By Xiaotian Shen, M.P.H. Director of Clinical Training,
Academy of Oriental Medicine at Austin, O.M.D., M.D. (China), L.Ac.

In the first century AD, the Greeks described the disease as “a melting down of the flesh and limbs into urine.” Gradually the Latin word for honey, “mellitus,” was appended to diabetes because of its link with sweet urine. Aretaeus the Cappodician (“Aretaeus” is sometimes spelled “Areteus” or “Aretaios.”) was probably the first western doctor to name this disease as “diabetes” (Greek: διαβητς) around the second century. It is derived from the Greek διαβα íνειν, diabaínein that literally means “to go through”, “passing through,” or “siphon,” reflecting the early understanding of a disease that drained an excessive volume of urine.

Traditional Chinese Medicine (TCM) has had an awareness of this illness, as well as its diagnosis and treatments since ancient times. There have been discoveries of inscriptions in ancient oracles wherein 22 diseases had been recorded during the Shang dynasty from 1395 BC to 1122 BC. Included in these texts was an illness called “Urinary Disease”
but the description was too simple for people today to determine if it indeed referred to what we now call “Sugar Urine Disease” in China.

The understanding and descriptions of diabetes became more and more clear during the periods of Warring States (8th century BC to 3rd century BC) and in the early Qin Dynasty (3rd century BC).

In the 2nd century BC, the non-medical Chinese classic Huainanzi (“Great Words from Huainan”) written under the patronage of the nobleman Huainanzi, also mentioned “He married his daughter to a man who suffered from Xiao disease. After the husband died, his daughter had hard time.” Xiao disease, Xiao Ke, Xiao Dan, Xiao Zhong, Ge Xiao were all the terms used during Qin and Han dynasties to call diabetes. Xiao means wasting or emaciation. The term of “Xiao Ke” originated in The Yellow Emperor’s Inner Classic, written during that period, and is still used today for the TCM diagnosis of diabetes.

The description, analysis and treatment of diabetes in The Yellow Emperor’s Inner Classic were scattered in 14 different chapters. According to the Plain Questions (Su Wen), as a part of The Yellow Emperor’s Inner Classic, diabetes arises from eating too much rich food and it typically occurs among wealthy people: “this is usually caused by rich and tasty food. One (who has Xiao Ke) must have often eaten fatty, rich and sweet food. Fatty food generates heat in the interior and sweet food causes fullness, leading to Xiao Ke”. The authors of the book also pointed out that the medical treatment for diabetes is not likely to succeed without proper diet: “you ask them to refrain from a rich diet, advice which they resist.” Outside China, the first association between the occurrences of diabetes and obese individuals was in Hindu medicine during Brahman period around 500 AD.

One of the greatest ancient Chinese doctors in the history of Chinese medicine, Zhang Zhong Jin (150 AD – 219 AD), outlined the primary symptoms of Xiao Ke in his book Synopsis of Prescriptions from the Golden Chamber (Jin Gui
Yao Lue): “eating a lot with yet hunger, thirsty with a desire for water, frequent urination with constipation, loss of body weight”, which is very close to the modern description of diabetes. Based upon the pattern identifications, Zhang prescribed many formulas for Xiao Ke, which are still in use today. In the west, before the mid 1800s, treatment often consisted of bleeding, blistering, and doping, often doing more harm than good. Another early treatment was overfeeding to compensate for the loss of fluids and weight (Gordon 1959). Even in late 1850s, French physician, Priorry, still advised diabetes patients to eat extra large quantities of sugar as a treatment.

Another great clinician Sun Si Miao (581 AD – 682 AD) further offered systematic approaches to the prevention and treatment of diabetes. In his book of Important Formulas Worth a Thousand Gold (Qian Jin Yao Fan, completed in 650 AD), he had an entire chapter on diabetes. He believed that alcohol, sexual indulgence, salty food and starchy food, are the primary causes of diabetes, emotional imbalances also played a very important role in the occurrences of this disease. Sun also believed that treatment itself would not cure the illness if the patient does not put a restriction on his diet. He said: “a patient suffers from Xiao Ke will gradually get better and better with the herbal decoction.

But if he gradually eats more and more rich food while the symptoms are alleviated, he’s going to loss weight and get thinner and thinner, with dryness in his mouth and weakness in inhaling…” Sun clearly pointed out that “a man with Xiao Ke should keep himself off from alcohol, sexual indulgence, salty food and starchy food. If he can do this, his illness wound not bother him even without any medications; if he’s not able to do this, whatever medicine he takes, there’s not going to be any cure for him.” he also said “ for a patient with Xiao Ke, if there’s a cure or not, is really up to the patient himself. If the patient puts a restraint upon himself, there’s going to be a relief soon; if the patient is indulgent with his life, his death is coming soon.”

Sun also put a great importance in physical exercise and emotional balance for the cure of any diseases including diabetes. More than one thousand years later, restriction on grains and breads was introduced to the diabetic patients by the western doctors in England. Sun also points out in his book that “for a diabetic patient, (the doctors) should often be concerned about the occurrence of big abscess whether the other symptoms are better or worse”.

Around the same period, another Chinese doctor Chao Yuan Fang, in his book Discussion of the Origins of the Symptoms of Disease (Zhu Bing Yuan Hou Lun, completed in 610 AD), also emphasized the importance of exercise as a part of the treatment for Diabetes. He suggested that diabetic patients should take a walk for one hundred twenty to more than a thousand steps before he can eat his meals. He also pointed out that patients with Xiao Ke tend to have skin sores and abscess. Later in the Mideast and West, Avicenna (980-1037 A.D.), the most prominent of the Arab/Persian physicians, described diabetes based on Galen’s work adds details such as the presence of carbuncles.

Later, around 1000 A.D., Greek physicians prescribed exercises, preferably on horseback, to “employ moderate friction” and alleviate excess urination. (Bliss 1982) The first Chinese doctors who clearly documented the sweet quality of the urine in a diabetic patient were the Zhen brothers (Quan Zhen and Liyan Zhen) in the Shui Dynasty. In their book Records of Proven Formulas of the Past and Present (Gu Jin Yan Fang Lu) completed in 627 A.D, the authors said the patients would have intense thirst, emaciation, and enormous urine output. The urine could be oily or sometimes not and it tastes “as sweet as wheat”. Many books and documentation written after the Zhens also talked about the sweetness of urine in patients of Xiao Ke, such as a few decades later in Tang dynasty, Langzhong

Li in his Discussions on Xiao Ke Formulas (Xiao Ke Fang Lun) said “when a patient suffers from Xiao Ke, his urine’s always sweet.” Xianke Zhao of Ming Dynasty in his book Differentiation and Analysis on the Characteristics of Medical Theory (Yi Guan, completed in 1687 A.D.) also mentioned “A patient of Xiao Ke will urinate a sheng (a Chinese unit similar to a liter) right after he drinks a sheng of water. If one tastes his urine, it should be sweet instead of salty.”

In England, in a remarkable work Pharmaceutice rationalis of Tomas Willis was published in Oxford in 1674. Willis described the sweetish flavor of urine in diabetes mellitus, a fact not recognized since the time of early Hindu medicine. He also associated diabetes with “good fellowship and guzzling down of … wine.” His observations initiated a new era
of diabetes research in England. Matthew Dobson of England in 1776 evaporated diabetic urine and found substance like brown sugar in appearance and taste. He also found a sweetish taste of sugar in the blood of diabetics. In 1797, John Rollo also in England, successfully treated a patient with a high fat and protein diet after observing that sugar
in the urine increased after eating starchy food.

It’s considered the first significant approach to the treatment of diabetes.

In 752 A.D., the distinguished physician Wang Tao published his famous book Arcane Essential from the Imperial Library (Wai Tai Mi Yao), which was a comprehensive guide to medicine. In it, he stated that diabetes was indicated by sweet urine and he recommended the consumption of pork pancreas as a treatment, implying a conclusion that the pancreas was the organ involved in the disease.

Further, he suggested that the urine of diabetes patients should be tested for sweetness to determine the progress of the disease and its treatment. His discovery of the association between diabetes and pancreas was the first in the world.

In 1869, Paul Langerhans, a German medical student, found islet cells in the pancreas, but he was not able to explain their function. Twenty years later, Joseph von Mehring and Oskar Minkowski learned that diabetes developed when they removed the pancreas of dogs. As soon as the link between the pancreas and diabetes was recognized, research focused on treating the disease with pancreatic extracts.

The most persistent and important of the early “extractors” was Georg Ludwig Zuelzer, a young internist in Berlin. In the early 1900s, Zuelzer experimented with pancreatic compounds and in fact injected a substance he called “acomatrol” into a dying diabetic patient. The patient improved but later died when Zuelzer’s acomatrol supply was exhausted.

In the later dynasties, many traditional Chinese medical classics talked about almost all aspects of diabetes. Among these schools of thoughts, Wang Huai Yin (975 AD – 997 AD) and Ye Tian Shi (1667 AD – 1746 AD) further explained the theory of Xiao Ke’s pattern identification according to the San Jiao (Triple Turner). In the Comprehensive Recording of Imperial Medicine (Seng Ji Zong Lu, completed between 1111 AD – 1117 AD), compiled by the Imperial Medical Bureau, the authors documented their observations on pains and aches in the four limbs in the patients of Xiao Ke. Liao Xi Yong (1546 AD – 1627 AD) in his Extensive Notes on Medicine from the First Awakened Studio (completed in 1613 AD) suggested diabetic patients tend to have toothaches and tooth loss. Zhang Jin Yue (1563 AD – 1640 AD) emphasized the importance of emotional factors in the occurrences and treatments of diabetes.

Ancient Chinese people were one of the first, if not the very first pioneers in the fields of diabetes. In the early stages of human medical history, Chinese described the symptoms of diabetes including excessive drinking, profuse urine, sweet flavor in urine and loss of body weight. They analyzed the etiology and mechanism of diabetes, offered a systematic approach to treat this illness, including the use of herbs and acupuncture, as well as dietary care and physical exercises. They also emphasized the importance of diabetes prevention and made recommendations on healthy life styles and emotional balance.

They even talked about the association between diabetes and pancreas. They observed and treated the complications of diabetes, such as pains in the limbs and abscess. Their many discoveries and contributions were the first in the world in those areas. Some of Chinese experiences are still very useful today, such as herbs, healthy life styles and emotional care. But the texts and books in the west on the history of diabetes tend to ignore these facts, even not mentioning about what happened in the history of traditional Chinese medicine at all, which has made the history of the battle between diabetes mellitus and human beings incomplete and very inaccurate. Now it’s time to restore the picture.

REFERENCE
Bliss, M. (1982). The Discovery of Insulin. Chicago, University of Chicago Press.
Gordon, B. L. (1959). Medieval and Renaissance Medicine. New York, Philosophical Library.

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