BRITTLE DIABETES REVISITED - THE 3RD ARNOLD-BLOOM-MEMORIAL-LECTURE

In 1934 the Chicago physician R.T. Woodyatt suggested that 'The histor y of diabetes has been marked by recurrence of certain ideas which dec line and disappear; only to go through a similar cycle again in an alt ered form in a new generation'. This has been particularly true of the concept of brittle diabetes which Woodyatt himself introduced in the 1930s. He never wrote a paper on the subject but contemporaries unders tood it to refer to excessive fluctuations of blood sugar which could not be explained by patient or physician errors; the cardinal feature was unpredictability and unexpected hypoglycaemic reactions. Also in t he 1930s, practitioners of the newly formed psychosomatic movement too k an interest in the effect of emotional factors on the course of diab etes and, in particular, patients who were 'difficult' or 'refractory' . What marked 'difficult' patients was that they did not follow their doctor's instructions or had recurrent diabetic ketoacidosis. By the 1 950s the question was whether there were two distinct groups of patien ts; one whose lability could be cured by adjusting insulin, diet, and exercise, and another whose lability had an emotional origin. Did prop onents of the organic school have patients (unreported) in whom labili ty had an obvious emotional cause or, conversely, were the psychosocia l problems which the psychiatrists unearthed a consequence rather than a cause of the instability? My experience with a patient with factiti ous hypoglycaemia which remained undetected for weeks in a clinical re search unit suggested that neither close observation nor screening by a psychiatrist could rule out factitious disease. Therefore in 1977 I suggested that the definition of brittle diabetes should be a patient whose life was 'constantly disrupted by episodes of hypo- or hyperglyc aemia, whatever their cause'. This was widely accepted and there was a subtle shift towards regarding brittle diabetes as synonymous with re current ketoacidosis. In the 1980s two English and one American group investigated large series of such patients, using new methods to try t o uncover a biochemical basis such as defective insulin absorption, ac celerated degradation at insulin injection sites, and inappropriate se cretion of various counterregulatory hormones. Most of these patients were young overweight women and the eventual conclusion was that in mo st the instability was self-induced. In the 1980s recurrent, often war ningless, hypoglycaemia was recognized as a problem in its own right b ut in this new generation was reborn as a problem of insulin pharmacok inetics as Woodyatt originally conceived it.