Diabetes was well recognized as a medical disorder more than 2000 years ago, and some well-known references are worth quoting. The ancient Egyptian Ebers papyrus, dating to 1500 bc, records abnormal polyuria; the Greek father of medicine, Hippocrates (466-377 bc), mentioned 'making water too often' and Aristotle also referred to 'wasting of the body.' Aretaeus of Cappodocia (ad 30-90) in Asia Minor (now Turkey) is credited with first using the name diabetes, which is Greek for a siphon, meaning water passing through the body: 'diabetes is a wasting of the flesh and limbs into urine - the nature of the disease is chronic, but the patient is short lived ... thirst unquenchable, the mouth parched and the body dry ...'. The famous Arabian physician Avicenna (ad 980-1027) recorded further important observations that maintained and extended the previous Greek knowledge through what became known in Europe as the Dark Ages: he described the irregular appetite, mental exhaustion, loss of sexual function, carbuncles and other complications. There are also references to diabetes in ancient Hindu texts (ad 500) as a 'disease of the rich, brought about by gluttony or over-indulgence in flour and sugar,' and in early Chinese and Japanese writings 'the urine of diabetics was very large in amount and so sweet that it attracted dogs.'1,2
After the European Renaissance the first physician to rediscover and record the sweetness of the urine in diabetes was Thomas Willis in London (1679), 'The diabetes or pissing evil ... in our age given to good fellowship and guzzling down of unalloyed wine,' and Mathew Dobson 100 years later in Liverpool first demonstrated chemically the presence of sugar in the urine of diabetic patients. The demonstration by Oscar Minkowski (1889) that removal of the pancreas in a dog unexpectedly resulted in uncontrolled polyuria - the urine sugar attracted flies in the laboratory to the puddles on the floor - was the significant observation that eventually led to the extraction of insulin from the pancreatic islets in Toronto in 1922.3 The story of the discovery of insulin is a remarkable record of disappointment: it was almost discovered in 1906 by Zuelzer in Berlin, and then in 1912 by Scott in Chicago, but was actually extracted by Paulesco in Romania in 1920. However, the world recognizes the story of the Toronto group - including Banting, Best, Collip and Macleod - as the definitive discovery and in 1923 the Nobel Prize for medicine and physiology was awarded to two of them, Frederick Banting and JJR Macleod.4 Until then the only effective treatment for diabetes had been dietary, and it was well known that restriction of food would ameliorate the symptoms. John Rollo had demonstrated this with his patient Captain Meredith in the army in Ireland in 1797, who obeyed his doctor's advice, documented the reduction in urine volume and subsequent weight loss, and even extracted sugar from the urine by evaporation. The dietary approach was carried to its logical extreme by the over-enthusiastic approach of FM Allen in New York (1919), whose starvation therapy often temporarily returned the blood glucose to normal, but only succeeded in extending life for a year or so in the severe juvenile cases, all of whom became skeletally thin. Dr Elliott Joslin is remembered as the Boston physician who bridged the period immediately before insulin's discovery and the exciting clinical demonstration of its effectiveness in the following decade.5 In London, Dr Robin Laurence, diabetic himself, on dietary therapy only in his early twenties, recorded how his life was saved in 1923 by a telegram from his doctor in King's College Hospital, 'I've got insulin, and it works - come back quick': he survived for many years and became the leading diabetes specialist in England.6
These two doctors, Joslin in Boston and Laurence in London, became the leaders of the revolution which would take place in both the opportunity for and the outcome of pregnancy in diabetic women.
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