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18, with marked visible edema of face and ankles. The edema passed
off within a few days and the weight remained approximately what it
was before. It will be observed in the table that the hemoglobin and
hematocrit readings after September 17 showed a fall decidedly beyond
any possible experimental error, and the former values were not re-
gained until September 29. In other words, the blood appeared to be
diluted during the period of edema. Accidentally or otherwise, the



482



CHAPTER V















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EXERCISE



483



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Blood taken after breakfast and 32
flights stairs; has exercised large part of
each day since Sept. 17; 33 flights
stairs.


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to lunch; 32 flights stairs and 60
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EXERCISE 485

edema was coincident with the beginning of exercise. The changes in
hemoglobin and corpuscles were not parallel to alterations in the sugar
concentration. There have been no other observations on diabetic
patients to indicate whether the blood volume is ordinarily increased
in the period of edema to which such patients are often readily subject.
The regular diet through this time remained at 1450 to 1600 calories.
After September 16, increasing exercise was carried out daily as the
patient's endurance improved with training. Only on fast-days
moderate exercise or none at all was required. It is seen in the table
. that on September 17, after walking, the blood sugar on this same diet
was lower than it previously had been, without exercise. On Septem-
ber 21, after heavy exercise, it was lower still. On September 22, it was
the lowest yet observed. On September 25, with the blood sugar
approximately normal (0.118 per cent) just before lunch, the experi-
ment was performed of adding 25 gm. carbohydrate in the form of
wheat flour to the noon lunch. Although this patient had previously
been subject to repeated glycosuria on carbohydrate-free diet with the
same protein and total calories, glycosuria remained absent with this
quantity of carbohydrate with heavy exercise, and the plasma sugar
at 4:45 p.m. was only 0. 162 per cent, in contrast to the above mentioned
values of 0.208 and 0.238 per cent observed on fasting before exercise
was inaugurated. The use of carbohydrate was continued, but the
form was changed to green vegetables. On September 29, with 25
gm. carbohydrate in the diet, and after breakfast had been taken about
7:30 a.m. as usual, the plasma sugar at noon was 0.128 per cent. The
hyperglycemia of 0.357 per cent in the plasma on Octobei: 29 was the
result of the carbohydrate tolerance test at that time, with 140 gm.
carbohydrate in the diet and glycosuria present. The diet up to this
time had involved slight undernutrition, especially in view of the
exercise. This was evidenced by the weight, 41 .3 kilograms on June
27, 40.4 kilograms on October 30. After October 30 the carbohydrate
allowance was diminished to 10 gm., and the attempt was made to
build up weight by steady increase of total calories. The exercise at
the same time was pushed to a maximum, with the idea that the patient
might be made to lose fat while building up her muscles to the greatest
possible size and functional power on a diet abundant in protein and
total calories. Her day's work frequently consisted of 200 flights of



486 CHAPTER V

stairs, walking 75 blocks, 30 minutes roller-skating, and 30 minutes
hard work with the medicine ball. In addition she carried on minor
activities, so that she was fully resting only during the hours of sleep.
The strength was greatly increased by this program. The patient
had the full strength and endurance of the most vigorous working
girl and could outdo the average normal girl. It is evident from
Table V, however, that the attempt thus to use exercise to compensate
for an excessive caloric ration was a failure. As the calories were
increased, the blood sugar rose in proportion, and the rise was not
checked by omitting all carbohydrate after November 24. Glycosuria
also became rather frequent, as shown in the graphic chart. The ulti-
mate outcome was that the patient was dismissed on February 2, 1916,
weighing only 39.2 kilograms, on a carbohydrate-free diet of 75 gm.
protein and 1500 calories; i.e., a reduction in both weight and food.
No blood sugar analyses were performed later than January 15, but in
view of the glycosuria present as late as January 29, it is certain that
hj^erglycemia was persistent.

Reference may be made also to the three formal tests of carbo-
hydrate tolerance performed during this period (July 26 to August 9,
October 11 to 30, December 13 to 20). The point to be determined
was whether the building up of the muscles in mass and function
would bring about any noteworthy improvement in the carbohydrate
tolerance. It was clearly evident that the patient gained in size and
power of her muscles, but it is also evident from the history and the
graphic chart that the carbohydrate tolerance by accurate tests re-
mained unchanged. In addition, it can be observed from the graphic
chart that the attempt to introduce as much as 30 gm. carbohydrate
in the diet in January was borne for a few days by virtue of hard exer-
cise, but terminated in marked glycosuria. The tolerance meanwhile
was injured, since glycosuria resulted thereafter from smaller quanti-
ties of carbohydrate, so that on January 26 to 29 glycosuria was pres-
ent on diets of 77 gm. protein, 25 to gm. carbohydrate, and 1200 to
1400 calories.

The behavior as respects acidosis is also of interest. Some of the
fluctuations in the plasma bicarbonate in this period, shown particu-
larly in the graphic chart, were due to exercise. In general this curve
remained close to the lower border of normal. The ideas concerning



EXERCISE 487

the carbohydrate supply and the glycogen reserve as governing acidosis
are so firmly intrenched in the literature that attention may profita-
bly be called to these results with prolonged heavy exercise on diets
always poor in carbohydrate and completely free from carbohydrate for
months at a stretch. The ration of approximately 100 gm. protein
could furnish approximately 60 gm. potential carbohydrate, but it is
known that normal persons generally exhibit more or less acidosis, at
least temporarily, when placed upon diets of this character. Two ques-
tions maybe raised. First, what effect will exercise haveuponthe acid-
osis of carbohydrate-free diet? Second, if the introduction of carbohy-
drate into the diet is made possible by exercise, will this carbohydrate,
which is consumed by the exercise, have the usual effect in diminishing
acidosis? Contrary to some existing preconceptions, it will be seen that
exercise produced no perceptible tendency to acidosis, except on the
fast-days as above mentioned. The evidence on the point is as fol-
lows: (a) Practically continuous ferric chloride reactions had been
present throughout the earlier months in the hospital. They were
■ thus present on the carbohydrate-free diets of 1600 calories or more
prior to August, and on the lower carbohydrate-free diets, viz. about
1500 calories, they had ceased in September, shortly before exercise was
begun. Exercise did not bring back such reactions; on the contrary,
they were negative or limited to indefinite traces on the carbohydrate-
free diet of 2500 calories, November 24 to December 4, and entirely
negative on the carbohydrate-free diet of 2000 calories December 6 to
11. There was thus if anything a diminution of ferric chloride reac-
tions after exercise as compared with the period before exercise. (&)
The data for ammonia nitrogen are best seen by a glance at the graphic
chart. It is evident that the ammonia determinations after Decem-
ber 2 show no striking tendency to acidosis as compared with those
before June 25. The question of the usefulness of carbohydrate
in lowering acidosis during exercise cannot be answered from the data
in this record. With the same number of calories in the diet there is
no essential difference in the ammonia excretion on December 31 and
January 6 with 30 gm. carbohydrate and on January 15 without
carbohydrate, but here the proper utilization of the carbohydrate is
made questionable by the glycosuria and marked hyperglycemia.



488 CHAPTER V

B. The Efpect upon Carbohydrate Tolerance and Glycosuria.

It was noted in several of the above studies that glycosuria was
either prevented or checked after it had begun, and this rule applied
also to the glycosuria resulting from carbohydrate-free diet or (patient
No. 46, Table IV) from simple addition of fat to a diet.

From the standpoint of clinical experience, patients may be divided
into three groups on the basis of their reaction to exercise: I, those
showing more or less improvement in food tolerance; II, those show-
ing little or no change in tolerance; III, those in whom the effect is
injurious.

I. A number of tests were performed of which the following is typi-
cal. Patient No. 34 (see Table III above; see also graphic chart.
Chapter III) was started on a carbohydrate tolerance test on Octo-
ber 11. With a steady increase of 10 gm. daily in the carbohydrate
intake, glycosuria appeared with 200 gm. carbohydrate on October
28, and increased slightly with 210 gm. carbohydrate on October 29.
The patient had been at rest up to this time. The daily increase of
carbohydrate was continued, but exercise was imposed in the form
of 72 flights of stairs and 30 minutes lively rope-jumping daily. The
glycosuria ceased immediately, and reappeared only with 260 gm.
carbohydrate on November 3. A similar observation is described in
the history of patient No. 49. This improvement in tolerance belongs
to the milder cases, and may practically be said to vary with the
degree of mildness. It is well known that diabetics of milder type
than those represented in this series may assimilate much larger quan-
tities of carbohydrate with exercise than without, and this fact has
been counted as an advantage in the dietetic management of patients
of the poorer class, who must live by hard manual labor. As was
shown above (patient No. 46, Table IV) the reaction to exercise
varies with the time and degree of treatment. Patients with active
diabetes may show no improvement of assimilation, and only injuri-
ous and perhaps dangerous consequences from exercise, but later,
after a sufficient period of sufficiently thorough treatment, may reach
the condition in which exercise is clearly beneficial.

II. Patient No. 26 (see graphic chart, Chapter III), a girl of 14
years, began a carbohydrate tolerance test on October 6. A trace of



EXERCISE 489

glycosuria appeared with 130 gm. of carbohydrate on October 19.
Exercise was then introduced in the form of stair-climbing and rope-
jumping to the point of exhaustion daily. The glycosuria continued,
and increased sUghtly on the ensuing days up to October 23 as the
carbohydrate was slightly increased. Even with exercise, two par-
tial fast-days (October 24 and 25) were necessary to abolish it. This
instance is typical of cases in which exercise shows no appreciable
effect upon the tolerance one way or the other.

Patient No. 43 (see graphic chart, Chapter III), a young woman of
27 years, beginning August 1, 1915, took a diet of 100 gm. carbohy-
drate and 2150 to 2500 calories. On this she remained free from gly-
cosuria during the week ending August 7. In the following week
(August 9 to 14) she was sent on long walks, as much as 8 miles
daily, which, though taken slowly, were enough to tire her thoroughly.
On August 10 and 11, she happened to have crying spells which brought
on glycosuria. A walk was taken immediately after the one on
August 10, and it was found that the urine became immediately free
from sugar. Nevertheless glycosuria recurred from time to time
subsequently; viz., on August 19 to 20, 23 to 25, and September 11.
After the fast-day of "September 12 exercise was temporarily discon-
tinued, to determine the effect of the omission upon the tolerance.
Traces of glycosuria occurred on September 14 to 15.

On September 16, blood was taken at 9:15 a.m., as shown in Table
VI. The patient then ate breakfast and went for a walk of 54
blocks. The marked rise in blood sugar found upon her return at
12:20 p.m. may be attributable to the breakfast; the walking had not
availed to prevent this increase of hyperglycemia. The hemoglobin
and hematocrit readings seemed to indicate that the exercise was
sufficient to concentrate the blood appreciably. Notwithstanding
the hyperglycemia, however, the glycosuria which had been present
on the two previous days ceased promptly with this exercise, and re-
mained absent as exercise was continued on the succeeding days.
The data do not permit decision whether the cessation was due to a
simple diminution of renal permeability or (as is more probable) at
liqast partly to a slight lowering of blood sugar (as compared with
corresponding hours on the preceding days, when no analyses were
made).



490



CHAPTER V



In the 3 weeks between September 19 and October 10, severe exer-
cise was discontinued, and the patient took only a short walk daily.
Nevertheless glycosuria was fully as rare as before,' the only trace in
this period being on the last day. Mild exercise was employed dur-
ing the carbohydrate test, October 11 to 30, and, as evident from the
graphic chart, the assimilation was not quite so high as shown in the
previous test in July. The slight difference between the tests may be
attributed to the unduly high diets of the intervening period. It is
evident that exercise failed to build up the tolerance or to prevent
the injury resulting from such diets. On the whole, the influence of

TABLE VI.
Patient No. 43.





Blood.


Urine (24 hr.).


Date.


Sugar.


Plasma

sugar.


Corpuscle sugar.


CO2


Hemo-
globin.


Corpus-
cle.


Sugar.


FeCli
reac-
tion.


1915
Sept. 12, 11:30 a.m.


per cent
0.154


per cent
0.154


per cent

0.154

(calc. 0.154)


per cent

37.1


percent
101


per cent
46.0


gm.






Sept. 16,9:15 a.m.
12:20 p.m.


0.167
0.185


0.164
0.188


0.137
(calc. 0.173)

0.147
(calc. 0.180)


39.2
42.0


88
95


33.0
38.8









exercise upon the tolerance of this patient was so slight as to be
barely recognizable.

Occasional ferric chloride reactions were present both before and
after the inauguration of exercise. Their occurrence was not gov-
erned solely by the quantity of carbohydrate in the diet, as may be
seen by comparing the periods July 27 to 31, August 26 to 28, and No-
vember 7 to 25 in the graphic chart. Exercise had no perceptible
influence in this respect. The plasma bicarbonate is seen also to hold
generaUy a normal level. Nothing can be concluded beyond the fact
that exercise failed to produce any appreciable tendency to acidosis,
and as far as carbohydrate served to prevent acidosis, it was appar-
ently as effective with exercise as without.



EXERCISE 491

III. No observations have been recorded which show the injurious
effect of exercise in patients with the severest diabetes. The injuri-
ous effect easily demonstrable in cases even of milder type under
inadequate treatment is, as above mentioned, another matter. The
carbohydrate tolerance of the patients properly belonging in this
group is practically nil, even under the most rigorous treatment.
Their tolerance for protein and total calories is likewise excessively
low. Experience has clearly and repeatedly demonstrated that their
tolerance cannot be built up by exercise. Experiments such as de-
scribed in patient No. 46 (Table IV above) will have different and
sometimes dangerous results if performed upon these severest cases.
In view of their great proneness to glycosuria, it is a difficult matter
to show conclusively that a given patient of this type has glycosuria
on exercise, and is free from glycosuria at rest. The existing evidence
is of two kinds:

(a) The demonstrable changes in the blood sugar, which can be
shown to be increased instead of diminished by exercise, as above
mentioned.

(b) The general clinical experience that patients of this sort are
badly affected by heavy exercise. They are weak and worn out, nerv-
ous and unwell on even moderate exertion. Those with diabetes
even of a somewhat milder type sometimes reach this condition tem-
porarily when they overdo exercise without supervision. Such pa-
tients have been treated with complete bed-rest for periods of one to
several weeks continuously, and the effect of such rest has been good,
certainly upon the general health and seemingly also upon the
tolerance.

C. The Use of Exercise in Various Classes of Patients.

From the standpoint of practical usefulness, the experience with
exercise in the present series of diabetic cases may be expressed by
grouping patients into the following six classes.

1. It is obvious that some patients are received in very critical
condition and die before there can be any possible use of exercise.
There were six such cases in the present series; viz., Nos. 11, 15, 30,
38, 45, and 71.



492 CHAPTER V

2. Exercise is necessarily limited or impossible in the youngest and
the oldest patients, also in those with organic disability of some

■kind. In the present series, Nos. 55 and 68 were infants too young
for any considerable exercise, and not much was possible for patient
No. 73, a girl of 3 years, already weak with advanced diabetes. Senile
patients have, as a rule, not been taken. Therefore patient No. 17,
with arteriosclerosis and tendency to gangrene, and No. 58, senile
and nearly blind, are the only ones falUng in this category. The only
ones exempted from exercise for complicating disease were patients
Nos. 25 and 61, whose cardiorenal conditions were far more serious
than the diabetes. Milder disabilities in other patients have not
prevented prescribing exercise in keeping with their capabilities.

3. Exercise is sometimes inadvisable, as mentioned, because of the
actual severity of the diabetes. In the great majority of cases this
applies only to a transitory stage, and under proper treatment exer-
cise later becomes feasible. The cases in this series which were too
severe for the use of any important amount of exercise from the time
they were received, are Nos. 8, 54, 69, and 75. A number of other
patients in the series have shown downward progress, so that they have
finally reached this stage in which exercise is impracticable on account
of the severity of the diabetes and the accompanying weakness. In



Online LibraryFrederick M. (Frederick Madison) AllenTotal dietary regulation in the treatment of diabetes → online text (page 54 of 76)