203: Useful Occupations and Deceptions
L’Hôpital des Anges, Mother Hildegarde and Bouton! Claire is back in her element.
Claire proves her skill as a healer and earns Mother Hildegarde’s trust as she diagnoses a woman with diabetes and she does it in part by tasting her urine. Surprisingly, this is really how it was done!
Urinoscopy, or uroscopy, dates back to ancient times and involved examining the urine for color, clarity, thickness, sediment, odor, foam and taste. Initially this was employed to determine if the four humours were in balance (blood, phlegm, yellow and black bile). Later, physicians would diagnose diseases such as jaundice (noting a brown tint to the urine), kidney disease (with red or foamy urine), tumors of the urinary tract (with blood in the urine) and diabetes (with sugary, sweet tasting urine).
Diabetes was first described by the Egyptians around 1500BC as a disease causing rapid weight loss and frequent urination. Indian physicians around the same time called the disease “honey urine.” These early healers did indeed taste the urine of these patients and find it to be sweet, which at the time they blamed on excess food and wine.
The name reflects these early findings:
Diabetes “siphon” or “to pass through“
Indeed, diabetes does cause sugar in the form of glucose to be present in the urine and occurs in two primary forms: Type 1 and Type 2. In general, Type 1 diabetics do not have enough insulin. Type 2 diabetics have insulin resistance and their bodies are unable to use the insulin they have.
Type 1 diabetes is characterized by deficiency of insulin. Most commonly, this results from autoimmune destruction of the insulin-producing beta cells of the pancreas – the body’s immune system mistakenly destroys these cells. Normally, when we eat, the body breaks down starches and sugar into a simple sugar called glucose which the body uses for energy. The hormone insulin is needed to get the glucose from the bloodstream into the cells of the body. Without insulin, the cells of the body cannot access the glucose in the bloodstream and instead, glucose accumulates in the blood and the cells are left without that energy source. This leads to a number of dangerous problems:
1. Dehydration: Elevated glucose in the blood leads to increased glucose excretion in the urine. This excess glucose pulls more water out of the blood stream to be urinated, leading to dehydration.
2. Weight loss: Unable to use glucose as energy because of the lack of insulin, the body breaks down fat and muscle.
3. Diabetic Ketoacidosis (DKA): The cells of the body cannot access all of the glucose in the bloodstream, so instead the body begins to break down fat cells for energy. This creates chemicals called ketones to be circulating in the body and leads to fruity-smelling breath, vomiting, drowsiness, lethargy, significant dehydration and abnormal electrolyte levels such as potassium, sodium and phosphate.
4. Damage to the eyes, kidneys, heart and vascular system: Over time, high glucose levels in the blood harm the nerves and small blood vessels throughout the body, leading to loss of vision, kidney failure, hardening of the arteries, heart attack and stroke.
Type 1 diabetes is most often diagnosed in children, though 25% of cases are diagnosed as adults. The most often scenario is a patient presenting with complaints of polyuria (urinating excessively), polydipsia (excessive thirst) and weight loss. Also common is presentation already in DKA and other times, presenting silently, by the discovery of elevated glucose in the blood or urine.
Throughout history, a number of treatments were recommended. The ancient Greeks prescribed exercise, preferably on horseback. Healers of medieval Europe prescribed wine, opiates and even aphrodisiacs. On the other hand, in China, physicians advised avoiding sex and booze. In the 19th century, physicians discovered that periodic fasting and starvation did help to some extent, as it would lead to lower blood glucose levels, though this might only buy a few years. Type 1 diabetes would remain a death sentence until the 1920s.
Claire examines an ill woman in L’Hopital. The woman reports she has been very thirsty and very hungry, though “no flesh gathers on my bones no matter how much I eat.” She appears to be lethargic and dehydrated and in DKA (diabetic ketoacidosis). Claire then confirms her diagnosis by tasting the urine:
The vessel was brimming with a yellow fluid–urine, undoubtedly. I was mildly surprised; without chemical tests, or even litmus paper, what conceivable use could a urine sample be? Thinking over the various things one tested urine for, though, I had an idea.
I picked up the vessel carefully, ignoring Sister Angelique’s exclamation of alarmed protest. I sniffed carefully. Sure enough; half-obscured by sour ammoniac fumes, the fluid smelled sickly sweet–rather like soured honey. I hesitated, but there was only one way to make sure. With a moue of distaste, I gingerly dipped the tip of one finger into the liquid and touched it delicately to my tongue.
From Dragonfly in Amber by Diana Gabaldon, Chapter 12
Though Claire, nor anyone at that time, can cure this patient, Mother Hildegard is impressed by Claire’s assessment and promotes her from emptying chamber pots to helping tend to patients’ wounds.
The cause of diabetes remained a mystery until the late 19th century. A German medical student by the name of Paul Langerhans found in 1869 that the pancreas contained clusters of cells whose function was unknown. These would later be shown to be the insulin-producing beta cells and these clusters of cells would come to be named the islets of Langerhans in his honor. Germans Oskar Minkowski and Joseph von Mering showed in 1889 that a dog would develop diabetes if its pancreas was surgically removed, but if the pancreatic duct was simply tied off so that the digestive juices of the pancreas couldn’t reach the intestine, the dog did not develop diabetes. They showed that the pancreas had two functions:
- Exocrine function: production of digestive juices that are released into the pancreatic duct and into the digestive tract to break down food
- Endocrine function: production of a substance that regulated blood sugar and is released into the bloodstream.
Finally in 1921, Canadian surgeon Frederick Banting and his medical student assistant Charles Best began experiments showing that when a diabetic dog was injected with extracts of the tissue of a healthy pancreas, the symptoms of diabetes resolved. They went on to perform further animal testing, then injected themselves with the extract. Both felt weak and dizzy from it but they were not harmed. They worked to purify the substance, which they called “insulin” and in 1922 successfully treated 14-year-old diabetic Leonard Thompson successfully. Banting and his team patented their insulin extract but gave away all of their rights to the University of Toronto, paving the way for rapid adoption of the treatment worldwide.
Bouton lovers will appreciate this story about a modern day Bouton. 7 year old Luke has type 1 diabetes but is hypoglycemia unaware – he cannot tell when his blood sugar is dropping dangerously low. His Diabetic Alert Dog, Jedi, is able to sense when Luke’s blood sugar has dropped too low or has risen too high and he alerts Luke’s parents who can then give him he proper treatment. Amazing!