Evolution Of The Classification Of Diabetes

Over 2000 years ago two Indian physicians, Charaka and Sushruta1 were the first to recognise that diabetes is not a single disorder. Throughout history renowned scientists and physicians such as Galen, Avicenna, Paracelcus and Maimonides have made reference to diabetes2. During the eighteenth and nineteenth centuries a less clinically symptomatic variety of the disorder was again noted. It was identified by heavy glycosuria, often detected in later life and commonly associated with overweight rather than wasting. Under the present classification this would be regarded as type 2 diabetes.

A huge step forward in understanding the aetiology of diabetes was achieved through the experiments by Josef von Mering and Oskar Minkowski which led to the theory of pancreatic diabetes and were published as 'Diabetes Mellitus After Extirpation of the Pancreas' in 1889. The discovery was made after removing the pancreas from a dog which, although it survived the experiment, began urinating on the laboratory floor. Minkowski tested the dog's urine for glucose, as he did with clinic patients with polyuria, and found a high glucose content. This discovery inspired their work relating to the isolation of insulin from the pancreas for use in the therapy of diabetes, for which Banting and Best won the Nobel Prize in 1921.

In 1936, Harold Himsworth3 proposed that there were at least two clinical types of diabetes, insulin-sensitive and insulin-insensitive. He suggested that insulin-sensitive diabetics were insulin deficient and required exogenous insulin to survive, while the other group did not require insulin. This observation was based on clinical evidence, as at that time no assays were available for the measurement of insulin. The Australian scientist, Joseph Bornstein, who developed the first bioassay for insulin and was eventually awarded a Nobel Prize, initially gained little recognition for his work until he went to work in

London with Robin Lawrence4. Following the development of the bioassay for insulin and its measurement in individuals with diabetes, it became increasingly apparent that there were at least two major distinct forms of diabetes. With the help of the assay, these were now not only separable on the basis of age at diabetes onset, but also by the levels of endogenous insulin. The difference in age at onset led to the use of the terms 'juvenile-onset' and 'maturity-onset' diabetes which was thought to be largely consistent with their observed treatment differences described as insulin-dependent diabetes mellitus (IDDM) and non-insulin dependent diabetes mellitus (NIDDM).

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