Frederick M. (Frederick Madison) Allen.

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for example, any such thing as a longer retention of sugar in the



EXERCISE 471

corpuscles than in the plasma, equilibrium evidently was reached
within an hour, for analyses an hour or more apart failed to reveal
any such phenomenon. There was no tendency to any special eleva-
tion of blood sugar after it had been lowered by exercise, neither was
the lowering due apparently to mere delay in the absorption of food,
for the blood sugar remained lower at 8 p.m. and on the following
morning than after a day of rest.

After the morning experiment of August 21, the diet was abruptly
made almost carbohydrate-free (only 5 gm. in vegetables daily).
The patient continued at rest during the remainder of August 21 and
throughout August 22. The hours of eating were as before. With
this diet, slight but distinct ferric chloride reactions were continually
present, but the blood sugar by the morning of August 23 was found
normal. The graphic chart (Chapter III) shows some of the data,
but omits the 30 gm. glucose which were taken on 4 days as follows:

August 23, the patient exercised 10 to 10:50 a.m. as described in
Table II. Between 10:50 and 11 a.m. he ate 30 gm. Merck anhy-
drous glucose. Between 11 and 11 :45 a.m. he did 64 flights of stairs,
and between 11:45 a.m. and 12:45 p.m. 72 more flights, with the
usual walking between. He rested for the remainder of the day.

August 24 was a rest-day. Between 10 and 10:10 a.m. the patient
ate 30 gm. Merck glucose.

August 25, without exercise, the effect of low temperature was
tested, the point being of interest in connection with three questions:
(1) the hyperglycemia caused by cold environment according to re-
ports in the literature; (2) the clinical impression that diabetics do
better in warm weather and chmates than in cold ; (3) the conception
of diabetes as a defect of general metabolism, and the influence of
alterations in total metabolism upon the assimilative function. Ac-
cordingly, at 9:30 a.m. the patient entered a refrigerator room at a
temperature of 45°F., and sat there quietly in a chair until 12:45 p.m.
At 10 a.m. he ate 30 gm. glucose as usual. He was clad in thin
summer underwear, light khaki coat and trousers, thin socks, and
bath;room slippers. The change from the hot summer weather to the
cold room was about as great as could be borne without serious dis-
comfort or danger. The patient maintained muscular rest under
orders. He was uncomfortably chilly, complained especially of cold



TABLE n.
Patient No. 18.





Blood.


Urine
(24 hr.).


J


Date.


5


fi

fk


Corpuscle sugar.


1^


1


E




1




ter
cent


per
cent


per cent


per
cent


per
cent






°F.


Aug. 23 (exercise day) 10:00


0.083


0.083


0.083


102


39.1





+++


98.0


a.m.






(calc. 0.083)












10:50 a.m. Ate 30 gm. dex-


0.099


O.IOG


0.097


100


40.5






99.8


trose.






(calc. 0.096)












11:45 a.m.


0.154


0.200


0.143
(calc. 0.094)


. 92


43.6






99.8


12:45 p.m.


0.101


0.111


0.099
(calc. 0.081)


100


39.0


T




99.8


Aug. 24 (rest day) 9:15 a.m.


0.097


0.105


0.068


90


39.0


++


97.6








(calc. 0.077)












10:00 a.m. Ate 30 gm-. dex-


0.097


0.099


0.092


88


36.0








trose.






(calc. 0.094)












10:50 a.m.


0.192


0.222


0.178














11:45 "


0.170


0.213


0.117
(calc. 0.090)


80


33.0








12:45 p.m.


0.169


0.196


0.170
(calc. 0.123)


81


36.5








Aug. 25 (low temperature)


0.077











42.0


T


++


98.0


9:15 a.m.


















9:30 a.m. (entered cold room).
















98.3


10:10 a.m. Ate 30 gm. dex-


0.100


0.103


0.095


90


41.6








trose.






(calc. 0.095)












10:50 a.m.


0.164


0.196


0.116
(calc. 0.124)


90


45.0






97.5


11:45 "


0.175


0.196


0.149
(calc. 0.142)


85


38.0






98.0


12:45 p.m.


0.170


0.178


0.152
(calc. 0.175)


85


42.0






97.8


Aug. 26 (exercise day) 9:15


0.091


0.096


0.090


103


40.0





++


98.4


a.m.






(calc. 0.082)












10:00 a.m. Ate 30 gm. dex-


0.092


0.092


0.092


103


38.1






99.6


trose.






(calc. 0.092)












10:50 a.m.


0.143


0.156


0.127
(calc. 0.111)


103


34.2






100.0


11:45 "


0.095


0.095


0.095
(calc. 0.095)


100


38.7






100.5


12:45 p.m.


0.052


0.058


0.049
(calc. 0.043)


103


42.0






99.5


2:15 "


0.102


0.121


0.050


80


33.1












(calc. 0.066)













4.77



EXERCISE 473

feet, and shivered slightly toward the close of the experiment. He
was comfortable immediately upon leaving the cold room, and went for
a street-car ride after lunch.

August 26 was another exercise day. After the blood sample was
taken at 9: 15, the patient did 64 flights of stairs, with the usual walk-
ing, up to 10 a.m. Between 10 and 10 : 10 a.m. he ate the usual 30 gm.
glucose. Then, bet?ween 10:10 and 10:50 a.m., he covered 72 flights
of stairs; between 10:50 and 11:45; 72 more flights; between 11:45
a.m. and 12:45 p.m., another 72 flights. He then ate lunch as usual
(12 :45 to 1 : 20) and remained at rest thereafter. An additional blood
sample was taken at 2 : 15 p.m., to give an idea of the behavior of the
blood sugar after eating and rest on an exercise day.

The observations recorded in the table show the following effects of
exercise in this case.

Blood Sugar. — The repression of hyperglycemia by exercise is very
evident. No uniform law of distribution of sugar between plasma
and corpuscles is discernible; if one gains or loses sugar in advance of
the other, the process is not revealed under the conditions of the
experiments.

Blood Volume. — The hemoglobin and hematocrit readings are rather
irregular. It is known that these methods are subject to errors.
Also discrepancies between the two, seemingly not accidental, are a
not unusual experience in carrying out long series of parallel deter-
minations; e.g., at 11:45 on August 23 the percentage of hemoglobin
is diminished and the percentage of corpuscles increased. The im-
pression obtained is that as the individual corpuscles were subject
to change in volume. In general, the hemoglobin readings indicate
slight dilution of the blood with hyperglycemia on August 23, 24,
and 25. An opposite process must be borne in mind; m., the concen-
tration of the blood by exercise, as noted under Table I. These two
processes may be expected to neutralize each other in varying de-
grees, and possibly at the same time to be associated with unknown
changes in the volume of individual corpuscles. The one definite
demonstration is that, as far as hemoglobin and hematocrit determin-
ations can decide, the changes in blood sugar are not accounted
for by simple dilution or concentration of the blood.

Body Temperature. — Slight elevation of temperature, up to 99.8°F.,
was produced by exercise on August 23, and up to 100.5° by the live-



474 CHAPTER V

Her exercise on August 26. In this respect the human experiments
serve as a useful control to those on dogs. Since in the former the
pyrexia is so shght and in the latter so extreme, while the repression
of hyperglycemia and glycosuria is similar in both, the conclusion can
be drawn that elevation of temperature is not the sole or essential
cause of the improved utilization of sugar.

Acidosis. — Though the diet was poor in carbohydrate and rich in
fat, and the heavy exercise must have depleted body glycogen con-
siderably, no acidosis was produced in this diabetic patient to the
extent of any cHnical symptoms or any perceptible change in the ferric
chloride reaction.

The Influence of Cold. — It appears that the environment of 45°F.
raised the blood sugar from 0.077 to 0.100 per cent. Nevertheless it
must be recognized that this level of blood sugar in the cold at 10 a.m.
on August 25 is not significantly higher than that at summer tempera-
ture at 9 : 15 on the previous morning (August 24) . The patient's body
temperature was not appreciabty affected. The differences in blood
sugar after glucose ingestion on the two days are perhaps within the
limits of accidental variation, especially since the possibiKty of a slight
alteration of assimilation by repeated doses of glucose or by the con-
tinuance of carbohydrate-poor diet cannot be wholly excluded. If
any real difference exists, it is in favor of the cold environment, and
might indicate that increased muscular tone, shivering, and the stimu-
lation of metabolism sHghtly facilitated sugar combustion. Though
no harmful effect was here demonstrated, a brief experiment of this
sort in no wise opposes the belief in a harmful influence of cold upon
diabetes.

Observations on Patient No. 34.

This case represented a slightly more severe stage than the preced-
ing, and the tolerance was somewhat lower. The diet consisted of 50
gm. protein, 20 gm. carbohydrate, and 1300 calories, taken in three
meals, 7:30 to 8 a.m., 12:30 to 1 p.m., and 5:30 to 6 p.m. On this diet
there was a decided tendency to hyperglycemia during digestion, as
shown first by the blood sugar of 0.147 per cent at 3:05 p.m. on Sep-
tember 3. On this day a preliminary experiment was performed as
shown in the table, and the marked lowering of blood sugar found at
4:10 p.m. must be attributed to the exercise.









TABLE in.














Patient No.


34.






Blood.


Urine.




Date.










i,


i




§■


Remarks.




i


5 "


Corpuscle sugar.


o
u

per
cent


k

per
cent


u

per
cent


i






mis


per
cent


per
cent


per cent




Sept. 3


















Blood taken after


3:05 p.m.


0.147






56.7


111


41.4








lunch at 12:30


4:10 "


0.100






38.5


111


41.4






p.m. 3:05 to 4:10
p. m. exercised,
climbing 88 flights
stairs, walking
corridors between
times.


S;ept. 12


















No exercise; fast-


2:40 p.m.


0.128


0.139
0.121


0,128
(calc. 0.108)


56.7


97


36.1








day.


Sept. 13


0.105


0.105


52.3


96


36.1








No exercise.


Before






(calc. 0.076)














breakfast. .




















Sept. 14


















No exercise.


11:20 a.m.


0.210


0,200


0.180

(calc. 0.228)


50,4


95


35.5










2:40 p.m.


0.191


0.195


0,191
(calc. 0.184)




95


37.1








5:20 "


0.200


0.195


0.211
(calc. 0.210)


53.8


92


34,0










Sept. 15








Light work in fore-


11:20 a.m.


0.119


0.118


0.119
(calc. 0,090)


47.6


95


34.0





+


noon.
11:20 a.m. to 12:20


12:20 p.m.


0.100


0.103


0,105
(calc. 0,097)


29,0


86


36.0






p.m. Climbed 72
flights stairs and


2:40 "


0.105


0.105


0,102
(calc. 0,105)


42,2


85


37.0






walked as usual.
12 :20 p.m. Lunch.


4:20 "


0.122


0.122


0,122
(calc. 0.125)


50.3


85


32.0






Rested until 1 :50
p.m.


5:20 "


0.100


0.091


0.118

(calc. 0.115)


37.6


86


33.8






1:50 to 2:40 p.m.

Climbed 80 flights

stairs besides

walking.
2:40 to 4:20 p.m.

Rested.
4:20 to 5:20 p.m.

Climbed 88 flights

stairs and walked

in addition.



475



476 CHAPTER V

September 12 was a fast-day. It is seen that the high blood sugar
was still persistent at 2 : 40 that afternoon, but by the following morn-
ing had come down to a high normal level. Marked hyperglycemia
was present on the rest-day of September 14. On the next day after
breakfast the patient was engaged in duties involving light continuous
exercise, and an effect is apparent in the decidedly lower blood sugar
found at 11:20 a.m. Thereafter, heavy exercise reduced the blood
sugar to normal and held it there during the exercise periods, but
during the resting period from 2 :40 to 4 : 20 p.m. the tendency to hyper-
glycemia manifested itself plainly. The most striking feature of the
experiment is the immediate lowering of blood sugar by exercise as
compared with the slow reduction by fasting.

Acidosis. — The trace of ferric chloride reaction which appeared on
September 15 is presumably attributable to the exercise, for this reac-
tion had been negative for over a month preceding on practically the
same diet. The plasma bicarbonate was reduced by exercise on each
occasion. At 12 :20 p.m. on September 15 it was down to 29 per cent,
which is as low as in many patients close to coma; yet the dyspnea was
very transient and the patient entirely comfortable, with none of the
weakness, malaise, and other symptoms generally found in diabetic
acidosis. With rest, the rise of blood bicarbonate was rather rapid
but not immediate; for example, in the period of rest between 2 :40 and
4:20 p.m. on September 15 the CO2 capacity of the plasma rose from
42.2 to 50.3 per cent.

Observations on Patient No. 46.

From the history and graphic chart (Chapter III) it will be seen that
this patient was a frail little man, whose diabetes, though only moderate
in severity, was accompanied by weakness and prostration, more marked
in the subjective feelings than in actual strength tests. Beginning
September 1, this patient fasted (with whisky) through September 5.
On September 6, 3 gm. carbohydrate were given, and on September
7, 6.5 gm. At this point, when the weak patient had been through
practically 7 days of fasting, and glycosuria and acidosis had only
recently subsided, he was subjected on September 8 to a day of exer-
cise to the full hmit of his strength. He could not run rapidly like the



EXERCISE



477



n







a


o

NO (O

"^ ^*

fO

s is

=>!














.d

g

■4-J

3 'ffi

8 s

.>^ "
o


9:40 to 10:50 a.m. Exercise.

10:50 a.m. to 12 m. Rest.

Exercise to limit of strength con-
tinued afternoon and evening.

Total day's work 176 flights
stairs and considerable walking.




1




O


o


o


O


O


o


O


+


+




•mSng


6 °


o


o


O


+


+


+
+


to

CN






1


■spsndi03


per
cent

35.2
43.8
41.0

41.0


1


1


1


1


1


1


1


42.0
42.0
37.0




■mq
-oiSoniajj


per
cent

118
120
117

115


1


1


1


1


1


1


1


On ■«— 1 T-l
O ■^ tH




'00


vol. per
cent

50.0
31.9
39.5

53.8


1


1


1


1


1.


1


1


59.4
42,2
51.3




Corpuscle sugar.


per cent

0.137
(calc. 0.180).

0,143
(calc. 0.136)


1


1


1


1


1


1


1


0.200
(calc. 0.071)

0.143
(calc. 0.117)

0.143
(calc. 0.107)




•jBSns


per
cent

0.154
0.134
0.182

0.166


1


1


1


1


1


1


1


0.371
0.193
0.167




•iBSng


per
cent

0,161
0,139
0.179

0.156


1


1


1


1


1


1


1


0.244
0.161
0.147




.s
a


■IOI[ODIV


gm.
22.5


o
o


o
d

CN


cs

CN


O

d

CN


CN

CN


CN

CS


lO

cs

CN






-XqoqKO


gm.

12.7


en

fa


o


o


o

to


O

NO


o

lO


g


O




•?^£


O


5i


NO


CM
NO

On


On
CN


lO


CD


o




■msjoaj


CO

a ■*


NO


On


O

8


o

g


O

8


O

1— 1


o

d

o




*S3T10|^3


• NO
CO
CN




o
c^


1


ON


8

CN
CN


00
CN


CN






4


Sept. 8
2 :30 p.m.
3:30 "
4:30 "

5:30 "


00
1/3


On


o

(/3


CN


CN

&


PO
CN

4-J

1/3


CN


Sept 25
9:40 a.m.

10:50 "

12.00 m.



478 CHAPTER V

preceding patients, but he plodded faithfully up and down stairs and
by sufl&cient exertion covered a surprising number of flights. The
experiment was useful as a control to those upon diabetics of the sever-
est type, because this patient was as weak as many of the latter. Also,
the effect of marked strain and exhaustion was thus tested. These
have been feared and warned against, as tending to injure assimilation
and create serious danger of coma in patients with anything like a
severe form of diabetes, and it was conceivable that there might be an.
actual influence of these factors, particularly through the nervous
system. Also, from the standpoint of acidosis, it was of interest to
observe the effect of exercise upon a patient who had recently had a
considerable acidosis, whose plasma bicarbonate was still below nor-
mal, and whose glycogen reserves were supposedly depleted by gly-
cosuria and fasting with only a trivial carbohydrate intake.

It is seen in Table IV that during the hour of exercise the blood
sugar fell unmistakably, but in the succeeding hour of rest rose de-
cidedly higher than at the outset. At the end of a second hour of
rest it returned to near its original level. Therefore no benefit is per-
ceptible from exercise at this stage of treatment. If exhaustion was
possibly responsible for the hyperglycemia to any extent, it at least
did no appreciable harm from the standpoint of acidosis. The ferric
chloride reaction was negative. It is not improbable that the traces
present on September 9 and 10 were due to this exercise on September
8. The plasma bicarbonate fell during the hour of exercise from 50 to
3.1.9 per cent, a figure generally indicative of severe acidosis; but there
were no threatening symptoms and no distress beyond that of any very
tired person. The CO2 capacity then rose steadily, until after 8
hours of rest it was 53.8 per cent, or slightly higher than before the
exercise.

Period from September 19 to 25. — In this period the patient was
placed on a fixed ration of protein, carbohydrate, and alcohol, with
daily increase in fat (see graphic chart) . Starting with a total intake
of 1147 calories on September 19, sugar and ferric chloride reactions
were negative. A traceof glycosuria appeared with 1640 calories on
September 21, and increased slightly with 1916 calories onSeptember
22 and 2200 calories on September 23. Then, with 2438 calories on
September 24, heavy glycosuria developed suddenly to the extent of



EXERCISE 479

27.75 gm., and at the same time a faint ferric chloride reaction ap-
peared. On September 25, the fat was still further increased to make
2687 calories, and exercise was employed to the limit of strength.
The purpose of the experiment was to test the effect of exercise upon
such a condition brought on by overfeeding with fat.

As shown in the table, there was a remarkable drop in glycosuria,
down to 2.77 gm. The blood sugar fell in the exercise period 9:40 to
10:50 a.m. from 0.244 to 0.161 per cent, and then on resting till 12 noon
fell further to 0.147 per cent. The patient was slightly stronger than
before, but the factor, of overstrain was still present. This in itself
seemed to have no demonstrable importance. The initial blood sugar
was higher than on September 8, but this was merely incidental to the
diet. The actual diabetic condition was better in consequence of the
longer treatment. The better assimilation was indicated by the far
greater fall of blood sugar during exercise, and by the continued dimi-
nution during rest.

In Table IV, as in Table III, the hemoglobin and hematocrit figures
permit no uniform interpretation, aside from the fact that the changes
in blood sugar are not accounted for by changes in blood volume so far
as these methods can reveal. Also it is not possible to distinguish
any rule governing the distribution of sugar between plasma and
corpuscles.

Though the condition had been produced by feeding fat, and the
exercise presumably depleted the carbohydrate supply, there was no
appreciable tendency to acidosis. The existing faint ferric chloride
reaction was unchanged. The fall in the plasma bicarbonate from
59.4 to 42.2 per cent during the exercise period 9:40 to 10:50 is no
greater than ordinary, and in the rest period up to 12 noon there was a
rise as usual, up to 51.3 per cent. The patient recovered easily from
his weariness and experienced no unpleasant symptoms.

The impression is given that the condition created by excessive
calories was in large measure relieved by the increased combustion
due to exercise. It is evident also that the same patient can react
differently to exercise at different stages of treatment.



480 CHAPTER V

Observations on Patient No. 2.

This patient was an Italian girl aged 17 years, whose diabetes at
the time of these observations was somewhat more severe than any of
the preceding cases. At the same time her strength was such that she
could carry on heavy muscular labor continuously without difi&culty.
Two new features were tested here : (1) a comparison of fast-days with
and without exercise in a case of this severity; (2) the effect of heavy
exercise upon the tolerance over a long period of time (8 months).

First may be mentioned the comparison of the two fast-days, Septem-
ber 12 and 16. The former was a day of practically no exertion. It
may be that the sUght activity and excitement of the street-car ride
and visit were responsible for the slightly higher sugar in the afternoon,
immediately after returning from the trip, as compared with the fore-
noon. The blood and plasma sugars before breakfast oii September
13 were practically identical with those on the morning of September
12, showing no perceptible influence of the single fast-day toward re-
ducing h5^erglycemia. The regular diet being slightly in excess of the
true tolerance, the plasma sugar on the morning of September 16 had
reached 0.172 per cent, as compared with 0.139 per cent on September
12. It is observed that exercise on this day was effective in reducing
the h3rperglycemia, to 0.151 per cent in plasma at 10:50 a.m. and to
0.120 per cent at 12 : 10 p.m. But the patient bore the exercise on this
fast-day badly, and was compelled to sit or lie down the entire after-
noon. The sugar then rose to 0.128 per cent at 3:50 p.m. and to the
notably high level of 0.220 per cent at 5:10 p.m. The symptoms of
weakness and dizziness were characteristic of acidosis, and this was
verified by the CO2 capacity of the plasma. This fell as usual during
the heavy exercise between 9:15 and 10:50 a.m., and rose somewhat
as usual during the lighter exercise up to 12 : 10 p.m'. Then, instead of
rising with rest, it continued to fall as the blood sugar rose, so that at
5:10 p.m. the plasma bicarbonate was only 40 per cent. After a
night's rest, however, it was found on the next morning that matters
had adjusted themselves. The blood sugar was distinctly lower and
the plasma bicarbonate a trifle higher than on the morning of Septem-
ber 16. There had been a temporary upset from the exercise; in
particular, this patient's usual tendency to acidosis on fa-st-days had



EXERCISE 481,

been increased; but the final outcome of the fast-day with exercise was
a diminution of hyperglycemia, while a fast-day without exercise had
not reduced hyperglycemia. It cannot be supposed, however, that
this effect upon the blood sugar was worth the disturbance and risk
under the conditions.

Turning to the general and prolonged features of the experiment,
it can be seen by reference to the patient's graphic chart (Chapter III)
that between May 27 and July 24 she was on a carbohydrate-free diet
of 1500 to 1800 calories. This was in excess of the tolerance, for
ferric chloride reactions were almost continuous and glycosuria alto-'
gether too frequent. The plasma sugar of 0.208 per cent on the
morning of the fast-day of July 25 may be taken as typical of the
hyperglycemia produced by this diet. After the carbohydrate toler-
ance test which ended August 9, carbohydrate-free diet was resumed
with 1400 to 1600 calories daily. Again on September 4, it is seen in
the table that the plasma sugar was 0.238 per cent. The patient per-
formed moderate exercise for an hour, then rested 15 minutes; there
was a very marked reduction of sugar, to 0.152 per cent in the plasma.
No discomfort or acidosis symptoms resulted, and any lowering of
plasma bicarbonate during the moderate exercise was corripensated in

15 minutes of rest, for the carbon dioxide capacity was the same at
12:30 as at 11:15.

Thereafter the comparison of the two fast-days of September 12 and

16 was carried out with the results above described. The acidosis
resulting on a fast-day in contrast to a feeding day may again be
mentioned.

Another feature was incidentally noticed, the significance of which is
unknown. On September 17 the patient weighed 38.3 kilograms
without edema. With the beginning of heavy exercise on that day,
there was an immediate rise in weight to 40 kilograms on September



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 53 of 76)