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A hundred years ago: Diabetes and insanity

By Theo B. Hyslop, M.D.

Senior physician, Bethlem Royal Hospital; Lecturer on Psychological Medicine, St. Mary's Hospital

By Theo B. Hyslop, M.D.

Senior physician, Bethlem Royal Hospital; Lecturer on Psychological Medicine, St. Mary's Hospital

Extracted from the July 1907 issue of The Practitioner

The relationship of diabetes to insanity is manifold, and there are various questions of extreme interest which occur to the medico-psychologist. Savage, in a paper read before the Medical Society of London in 1890, stated that diabetes and insanity alternate in families (one generation being diabetic, and the next insane, or vice versa); and also in individuals, acute diabetes being replaced by acute melancholia, this latter giving place again to diabetes, which was again replaced by temporary mental depression. In two cases, elderly men suffering from diabetes, melancholia appeared shortly before the fatal termination, and the sugar disappeared. Besides patients with diabetic relatives, Savage had ten patients in Bethlem, who were both insane and diabetic. He found nearly all the cases of insanity with diabetes were melancholiacs. My experience coincides with that of Savage, but, of late years, I have seen several cases in which the symptoms were those of actual cerebral degeneration and dementia.

In my experience, diabetic insanity is more common in males than in females, and the age is usually between 50 and 60 years. In addition to external injuries where the head has been the seat of injury, there appears sufficient evidence to believe that mental anxiety, emotional strain, shocks, and even violent passions may be followed by diabetes.

From the clinical standpoint there would appear to be several relationships of diabetes to insanity. These are:

1) Alternating states of diabetes and insanity. Sometimes the periodicity of the disordered metabolic processes gives rise to a coincidental periodicity in mental phases, and I have seen several cases, in which there was a tendency to psychorhythm, or so-called circular insanity.
2) Conditions of melancholia, not necessarily chronic and incurable, in which the melancholia may be an incident in the course of the diabetes, or the diabetes may be incidental to the melancholia.
3) Dementia, when it does occur in relation to diabetes, is usually a sequel to repeated and long-continued psychical shocks, albuminuria, vascular degeneration, and renal disease.
4) Dementia paralytica, or general paralysis of the insane in association with, or due to, diabetes, is extremely rare. I have seen one case of a man, aged 52, who, without a history of syphilis or alcoholism, gradually became confused, exalted, amnesic, and unable to control his excitement, whilst physically there was some degree of paresis of accommodation, and retinitis, absence of wrist jerks and knee jerks, but the plantar, abdominal, and epigastric reflexes were readily obtained. The presence of sugar in the urine proved the case to be one of the pseudo general paralytic type. Subsequently, symptoms of diabetic coma supervened, with dyspnoea, cyanosis of the hands and extremities, and death.
5) Delusional states, without obvious melancholy or exaltation, sometimes occur. The metabolic defects may be attended by confusion of the mental faculties, with inability to interpret correctly the impressions derived through the special senses. The delusions, therefore, have a sensory origin, and when they do occur, they usually have reference to some bodily state. In one case, there was mild optimism, confusion of ideas, and subsequent delusions that the ground was soft and therefore dangerous to walk upon. There was no polyuria or great thirst, but the knee jerks were absent, and there was anaesthesia and analgesia of the distal extremities of the arms and legs, this probably (as in tabes) giving rise to defect of static and pressure sense, whereby the feet seemed to be coming into contact with soft material.
6) In some cases of acute mania, there may be considerable glycosuria, which may improve, or entirely disappear. Traumatic mania of an impulsive and violent kind may exhibit glycosuria, but I have never seen this condition followed by actual diabetes mellitus.
7) The psychopathic temperament with defective inhibition, convulsive tendencies, paroxysmal attacks, and mental infirmity, may be the expression of a psychosis in the offspring of a diabetic parent without any evidence of actual diabetes in the offspring.
8) Various forms of paralysis, with or without aphasia, sometimes of a transient nature, may form a prelude to uraemic or diabetic coma. It is important to note that the auto-intoxication sometimes occurs suddenly, and the danger is subsequently enhanced by too rapid changes of food, stoppage of opium or codaeia, any moral or physical shock, over-fatigue, alcoholic indulgence, etc. When coma and dyspnoea occur in an insane patient, together with true diabetes, the prognosis is extremely grave, although I have seen some amelioration of the symptoms, and in one case there was sufficient improvement in the mental state to permit the completion of a will which was held to be valid.

M. Chauppe reports a case in which aphasia was a passing symptom in the course of diabetes insipidus; he was fatigued by walking, became comatose, and when found was aphasic, but produced a hospital ticket, on which were the words ‘polyurie simple.' About ten minutes after having drunk nearly two litres of water, he recovered his speech, and M. Chauppe attributed his aphasia to simple dehydration of the blood, and this possibility must be held in view in ordinary diabetic cases, in which the blood is sometimes remarkably sticky and dehydrated, even without the presence of acetone.

The occurrence of aphasia with hemiplegia was, in one of my patients, attended by an uncontrollable tendency to weep whenever spoken to or approached in any way, but there was no sensory defect, perception was normal, and, for a period of nearly ten years, the symptoms remained stationary. There was perfectly sound disposing capacity, and, in spite of the physical and emotional instability, this patient was, in my opinion, quite competent to make a will.

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