On World Diabetes Day (14th November), our attention is often drawn to the rise of the disease today or the 20th-century discovery of insulin as a treatment. However, the earliest reference to diabetes possibly goes back as far as 1500BCE in ancient Egypt, and we have been diagnosing diabetes ever since.
Around 6BCE, the Hindu physician Sushrata described a disease called ‘honey urine’. It was named not so much for the colour of the patient’s urine, but for the taste. He observed that ants were attracted to the urine because of it’s characteristically sweet taste.
The term diabetes came to us from the ancient Greeks, although it was not a common disease for them. Galen (129-210CE) focused on another symptom – excessive urination – and regarded diabetes as a kidney disease. He graphically referred to it as ‘diarrhoea of the urine’. The condition was very familiar to the Islamic physician Ibn Sina (980-1037CE), who provided a comprehensive list of symptoms. Among them he noted that, when evaporated, the urine left a sweet residue like honey.
In Europe, the sweet taste of urine as a symptom of diabetes was not recognised until much later. Perhaps the rarity of diabetes in Europe and Galen’s influence meant that it was not distinguished from other diseases with urinary symptoms. In any case, it was the 17th century before Thomas Willis noted that diabetes – also known as ‘the pissing evil’ – produced urine that was “wonderfully sweet, like sugar or honey”.
It is surprising that this was not more widely known in Europe, given the widespread diagnostic practice of uroscopy throughout the Middle Ages and beyond. For over 500 years images of physicians invariably depicted the physician with urine flask in hand. Urine was thought to reflect a person’s health because it had direct contact with all internal parts of the body, and its colour in particular was linked to the doctrine of the four humours. Urine itself was also used as a treatment for diseases such as gout and epilepsy, and played an important role in alchemy. In uroscopy, the colour, consistency, smell and taste of urine samples was carefully examined in a special flask and compared to a chart linking different urinary characteristics to specific ailments.
The practice of uroscopy became increasingly arcane and complex until eventually the physician required only the presence of the urine to make a diagnosis. From the patient’s point of view, it was much cheaper to send the physician a sample of urine than to have him make a house call. The popularity of uroscopy meant that it was taken up by quacks, charlatans and lay healers as well as physicians. By the 17th century, it had spiralled out of control. Practitioners claimed they could tell the age and sex of a patient from just their urine, as well as predicting the course of a disease. Some even claimed to predict the future in a related practice called uromancy.
Such abuse led to a backlash. In 1637, Thomas Brain published a book railing against the exaggerated claims for uroscopy and ridiculing those who practised it as “pisse prophets”. Brain was a qualified physician but had been in practice less than 10 years when he published The Pisse prophet or certain pisse-pot lectures. His book expressed many of the frustrations of a physician practising in the 17th century medical marketplace, where he was in competition with “quacks and empiricks” as well as other physicians, and constantly managing patients’ demands about the treatments they expected.
The attack by Brain and others sent uroscopy into decline after the 17th century, although urine analysis remained a valuable diagnostic tool for doctors. The irony was that, in the case of diabetes, the pisse-prophets may have had a point: the answer did lie in the urine. In 1772, Dr. Matthew Dobson of Liverpool Infirmary established that the sweetness in urine came from sugar. Fortunately for doctors, by the 19th century chemical analysis took over from tasting as a means of determining sugar levels in urine.
Despite the improvements in diagnosis and a greater understanding of the disease, the treatment for diabetes remained remarkably consistent from the earliest times until the 20th century, centring on control of the diet. Once the importance of sugar had been established, nutritional regimens such as that drawn up by Dr John Rollo, in 1797, became more about controlling sugar levels than balancing humours. Diet remains an important factor in the management of the modern disease, but people with diabetes had to wait for the discovery of insulin in the 20th century to get an effective treatment for their condition.
Author: Lalita Kaplish is a web editor at the Wellcome Library.
Find out more:
- Tattersall R. Diabetes: the biography. Oxford: Oxford University Press; 2009.
- Bush RB. “Urine is an harlot or a lier”. JAMA April 1969; 208(1):131-134.
- Armstrong JA. Urinalysis in Western culture: a brief history. Kidney Int. 2007; 71(5):384-387.