Previous Investigation.

Transcription

1 THE INFLUENCE OF SUBCUTANEOUS INJECTIONS OF LARGE QUANTITIES OF DEXTROSE ON THE METABOLISM IN THE DOG. By JAMES STT, M.D. (Fromt the Laboratory of the Royal llege of Physicians of Edinburgh.) THE question of the part played by the increased amount of sugar in the blood and tissues in diabetes has been fruently discussed. Some have concluded that the symptoms of the disease are due simply to the withdrawal of sugar from the metabolism, while others consider that there is evidence that sugar or some derivative of sugar exercises a toxic action upon the tissues of the body. The following investigation' was undertaken as a contribution to the study of this question. Sugar may be introduced into the body either by the alimentary canal, by intravascular inijections, or by subcutaneous injections. The last metd was emnployed in the present observations since it appears most closely to imitate the condition in diabetes, because the sugar has time to act upon the tissues and is not directly dealt with by the liver as when it is taken by the mouth, or so rapidly excreted by the kidneys as when injected into the blood. Previous Investigation. Voit2 records a series of experiments on the subcutaneous injection of various monosaccharids in the human subject, in which he sws that very large quantities can be administered witut causing any disturbance, and that only a very small proportion is excreted in the urine. These results are in accord with the previous investigations of Leube', w found that in dogs the injection of 5 c.c. of a 5 per cent. 1 The expenses of this research were defrayed by a Grant from the British Medical Association. ' Deutsches Arch.f. klin. M11ed. LVIII. p Quoted in Voit's paper.

2 18 J. STT. solution dextrose caused no glycosuria. The disaccharids he found were entirely excreted by the kidneys. V. Harleyl swed that when grape sugar is injected into the jugular vein of a dog, it causes an] augmentation in the lactic acid in the blood, the quantity of acid steadily increasing until it reaches its maximum in about three urs after the injection. Harley confirms the results of Limpert and Falk2 as well as tse of Brasol that the greater part of the sugar injected into the vein of a living animal is not excreted by the kidneys but is decomposed in the organism. Kossa' found that after the subcutaneouis administration of doses of cane sugar from per cent. of the weight of the body, there was a marked increase in the total amount of nitrogen, urea, and ammonia in the urine, both in the dog and rabbit, which continued for dome time after the administration of the sugar, and that this was iissociated. by great emaciation of the animals. Cane sugar administered subcutaneously has, therefore, no effect in sparing the proteid, but acts in the opposite way by increasing its disintegration. J. Munk' observed that a 5 per cent. solution of sugar in the blood increases the rapidity of the circulation through the kidney by one-third, the excretion of urine as much as eight times, and also the excretion of solid constituents in the urine. Munk supposes that the sugar directly irritates the secreting epithelial cells of the kidney. M. J. Arrows5 found that 15 grms. of glucose could be injected intravenously in the rabbit witut producing toxic effects. Much larger doses were ruired to produce toxic symptoms. GENERAL PLAN OF INVESTIGATION AND METHODS. Two bitches, one weighing about 2 kilos and the other about 28 kilos, were used, and as a preparation the perineum was split under full anaesthesia to allow of catheterisation. Before each experiment they were fed for some days on a fixed diet of oatmeal-porridge and milk in order to establish nitrogenous uilibrium. I This Journal, xii. p Limpert and Falk. Vircw's Archiv, ix. p Brasol, Archiv f. Physiol., p Pfliiger's Archiv, LXXV. pp Centralblatt f. med. Wissensch., p. 438, 1886; Vircw's Archiv, cvii. p mptes rendus hebdomadaires des 8sances et memnoires, p

3 DEXTROSE AND METABOLISM. 19 The urine was collected by keeping the animals in a cage with a sloping zinc floor under which a suitable vessel was placed. The floor was kept scrupulously clean and faeces were removed as soon as possible after they were passed. The urine was never contaminated with feces except on one occasion when it was not examined. When the animal came into nitrogenous uilibrium it was deprived of food for one day, and a definite quantity of dextrose injected. A similar diet was again given for several days, and the animal again fasted for one day as a check on the effect of the sugar. The urine was collected daily at 1 a.m. and the bladder was emptied by the catheter. Urine. The reaction and specific gravity were taken. The quantity collected was noted and the urine diluted to a convenient volume. The amounts of the following ingredients were determined by the metds enumerated, duplicate analyses being made in all cases and the mean of these taken: 1. Total nitrogen by Argutinsky's modification of Kjeldahl's metd. 2. Urea nitrogen by Bohland's metd by precipitating all nitrogen, not urea, with psptungstic (Merck's) and hydrochloric acids. The ammonia nitrogen is thus completely precipitated. 3. Nitrogen of ammonia by Schiossing's metd. 4. Total sulphur as S3 by igniting with caustic potash and nitre, and precipitating with barium chloride. 5. Oxidised sulphur as SO3 by heating with weak hydrochloric acid and precipitating with barium chloride. 6. Pspric acid as P25 by titrating with uranium nitrate. The nitrogen not in urea (non-urea nitrogen) was calculated by difference. The percentage of nitrogen in urea and not in urea, the percentage of sulphur fully oxidised and not fully oxidised, were calculated by difference. 7. Albumin was tested for by cold nitric acid, and by heat and acetic acid. 8. Sugar was tested for by Fehling's solution, by phenylhydrazin, and by fermentation with yeast. Fceces. These were treated with dilute sulphuric acid and the nitrogen estimated by Argutinsky's modification of Kjeldahl's metd.

4 11 J. STT. FOOD ANALYSES. Analyses of the food given to the dogs swed the amount of nitrogeni to be: Milk / nitrogen. Oatmeal Experiments L and 11. Daily diet: 7 c.c. milk = 2-56 grms. nitrogen 4 grms. meal = c.c. water 15 grms. salt Total intake of N. per diem = Experiment III. Daily diet: 5 c.c. milk = 1 83 grms. nitrogen 2 grms. mueal = 4'3,. Total intake of N. per diem = 6-13 Exp. I. For this and for the next experiment a llie was used. On Nov. 22nd, 19, at 12.3 p.m. the bladder was emptied by the catheter. 13 grms. dextrose dissolved in 4 c.c. water were sterilised and injected subcutaneously, under aseptic precautions, in the region of the neck, massage being applied to diffuse it. This amount of glucose is ual to 6'5 grms. per kilo of body weight. The dog received no food all that day, and after the injection it lay in its cage in a quiet condition. On the following morning (23rd Nov.) at 1 a.m. the bladder was emptied by the catheter. The total amount of urine excreted since the injection was 29 c.c. Before dilution this urine was examined for sugar and albumin by the metds described on p. 19. There was only '5 grm. dextrose in the 29 c.c. No albumin. The urine was then diluted to 1 c.c.-the amount used in the examination for sugar and albumin being allowed for. ExP. II. On the 17th Dec. 191, at 12.3 p.m. 13 grms, dextrose dissolved in 4 c.c. water were injected subcutaneously, under aseptic precautions, in the left side, massage being applied to diffuse it. As in Exp. I. the bladder was emptied before injection. The dog received no food all day. After injection it lay in a quiet condition. At 2 p.m. 38 c.c. urine were drawn off and swed faint reduction with Fehling. At 6 p.m. 1 c.c.,,,,,, marked,. On the 18th at 1 am. 55 c.c. urine were drawn off,.....

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6 112 J. STT. 4) 2 co P4 Io lb. 4o 2 4) Cs r-o to Q cc 4o f zo i 4 "., ho _- co "4 co ;O ~-4 ~-4 4) 4) p24 h44 4 Io 4) C: I CD 9 ;q co ch " ce r uz~ "4 m c q cq "4 o * ) ":4 D L* cq km cq 14 ) co :o CQ C9 C "4 t- co C* ~ o co "4 C'- cq I:- i,o 2 _I D "m cq ew cq " C- t4 t " e qc. " 4X OD eo Cq 4 CD oc' o co rc h CD C'- "4 C'- "4 CQ Cq ro 9 c) N "-4 o "4 e q co "4 a "4t' C'-o "4 4 "-4"r4 "4 "4 "4 " r- "-4 C- l o "4 ) C'- "-4 "4 4 "4 "-4 "-4 "4 cq ci C Sz z o 4).41 4) 19 g 4 4._ l.4 4) Go co ;4 4

7 DEXTROSE AND METABOLISM. There was oinly 175 glrn. sugar in the 13 c.c. urine as comnpared with 5 grm. sugar in Exp. I. No albumin was present. The urine was then diluted to 6 c.c., the amount used in the examination for sugar and albumin being allowed for. Exp. III. A retriever bitch weighing 28 kilos was used, and the perineum was split as in the former experimeints. In this experiment the nitrogen excretion in both uirine and feeces was examined. The experiment was begun on 7th Nov. anid ended 23rd Nov On Nov. 15th at 1 p.m. the bladder was emptied by the catheter. No food was given that day. 2 grms. dextrose dissolved in 5 c.c. water were sterilised and injected subcutaneously in the left si(de. This amount of dextrose is ual to 7 grms. per kilo of body weight. Massage was applied and quickly diffused it. Feeces were passed just before the injection was given. On the following morning (16th Nov.) at 1 a.m. the bladder was emptied by the catheter. The total amount of urine excreted since the injection was 15 c.c. Before dilution the urine was examined for sugar and albumin. There was only -87 grm. glucose in the 15 c.c. urine. No albumin. The urine was then diluted to 5 c.c. for further examination. 1. Total nitrogen excreted. TABLE II. Efects of injection of dextrose and fasting on the output of total nitrogen comnpared with the effects of fasting alone. Exp. I. Exp. II. Exp. III. intake Output Intake Output Intake Output (food) (urine) (food) (urine) (food) (urine) grms. grms. grms grms. grnis. grms. First Period 11' ' 6'1 4'82 Day of injection O st day after injection ' nd,,,,,, ' rd,,,,,, ' '26 Day of fasting ' st day after fasting nd,,,,,, '6 11' '12 In the first two experiments the intake of nitrogen and the output by the urine were alone studied. The amount of nitrogen excreted by other channiels was large, and it was possible, tugh improbable, that the change in the excretion of nitrogen in the urine was due to alteration in the arrmount of that element absorbed. In the third experiment the excretion of nitrogen in the fieces as well as in the urine was estimated. PH. XXVIII

8 114 J. STT. TABLE III. Exp. III. Nitrogen ba2ance. Output Intake. Total Date (food) Urine Fac output From 9th to 15th. Food on 4 days From 15th to 2th. Food on 4 days From 2th to 23rd. Food on 3 days 18-39_ Balance All three experiments sw a very marked increase of the excretion of nitrogen under the administration of dextrose, and the third indicates that this is due to an increased disintegration of proteids in the body and not to any alteration in the absorption of proteids. 2. Distribution of nitrogen of the urine. TABLE IV, Distribution of nitrogen in urea and in other compoundls. Exp. I. Injection and fasting Fasting Urea N Non-urea N First Period grnms. grms. Normal period average Day of injection Day of fasting 1st day after injection st day after fasting 2nd,,,,,, nd,.,. 3rd,,,,,, First Period Normal period average Day of injection lst day after injection 2nd,,.. 3rd, I.. Exp. II. Injection and fasting Urea N grms Non-urea N grin. 4' Exp. III. Injection and fasting Day of fasting Day after fasting Urea N grms. Non-urea N gms Fasting Urea N grn Non-urea N grms Fasting Urea N Non-urea N Urea N Non-urea N First Period grms. gms. grim grms. Normal period average 3, Day of injection Day of fasting lst day after injection I it day after fasting nd,,,,,, i d,,,,,,

9 DEXTROSE AND METABOLISM. 115 TABLE V. Percentage of urea nitrogen. First Period Normal period average Day of injection 1st day after injection 2nd, it.. 3rd,... Day of fasting 1st day after fasting 2nd,..... Exp. I. Exp. II. Exp. LII. 84 / 84 / 83 / In the second experiment the fall in the proportion of urea nitrogen is the same on the day of fasting as on the day of fasting with the injection of dextrose. But in the first experiment it is distinctly, and in the third experiment very markedly lower on the days of injection. TABLE VI. Nitrogen in preformed ammonia. Injection and fasting Fasting Exp. L. Exp. II. Exp. IIl. Exp. I. Exp. II. Exp. III. First Period grnis. grms grms. grms. grmi grns. Normal period average Day of injection 35 15,17 Day of fasting st day after injection 96 A st day after fasting '27 2nd,,,,,, '65 '7 46 2nd,,,,,, Urine alkaline 3rd,,,,,, TABLE VII. Percentage of ammonia N. to total N. Injection and fasting First Period Exp. L. Exp. II. Exp. IlL Normal period average 1/ 1/ 6 / Day of injection st day after injection nd,,,,,, Day of fasting 1st day after fasting 2nd,.... Fasting Exp. L. Exp. II. Exp. III. 1 / 1 /, 6 / In the second experiment there was no rise in the proportion of nitrogen in ammonia after the inijection, but in the first experiment a slight rise appeared, while in the third experiment the rise was very marked indeed

10 116 J. STT. The increased excretion of ammonia in diabetes is very fully dealt with by von Noord en1. The very i-arked rise observed in two of the experiments recorded, supports the view that an acid or acids are produced in the decomposition of the dextrose as indicated by Harley (loc. cit.), or that the increased proteid disintegration is accompanied by the liberation of acids. Nitrogen in other combinations. Table VIII. includes the N. in such compounds as creatinin, uric acid, purin bases, cynurenic acid, hippuric acid, ammonia, etc. It is practically impossible to estimate the quantities of each of these separately, because the metds of determining their amounts are laborious and unsatisfactory. Their collective quantities, wever, are indicated by the amount of N. excreted in the urine in forms other than urea, less the ammonia nitrogen given in Table VI. TABLE VIII. Percentage of non-urea N. not in ammonia to total N. Injection and fasting Fasting First Period Exp. L Exp. IL Exp. IIL Exp. L Exp. IL Exp. III. Normal period average 9/ 9/ 12/ 9/ 9 / 12/ Day of injection Day of fasting st day after fasting nd,,,,,, The increase of these bodies on the day of injection is greater than upon the day of fasting alone in the first and in the third experiment. 3. Excretion of sulphur. The total excretion of sulphur and the excretion of sulplhur in the oxidised and unoxidised state swed no alteration of importance. TABLE IX. Percentage of total sulphur as SO. to total nitrogen. Exp. I. Exp. II. Normal period average 24x6 / 24X6 / Day of injection st day after injection nd,,,,,, rd,,,,,, 2 22 Day of fasting lst day after fasting nd,,,,,, 22 XXth Century Practice of Medicine, ' Diabetes Melitus,' p. 92.

11 DEXTROSE AND METABOLISM. On the day of injection of dextrose the percentage of sulphur to nitrogen was distinctly higher than on the day of fasting. The reason of this is not apparent. 4. Excretion of psprus. TABLE X. Percentage of P2 to total nitrogen. Normal period average Day of injection lst day after injection 2nd,. it.. 3rd,..... Day of fasting 1st day after fasting 2nd,. it.. Exp. I. Exp. II. Exp. III. 34 / 34 / 28 / The excretion of pspruis in proportion to the nitrogen is diminished on the day of injection, but no further alteration of importance was demonstrated. Day of injection lst day after injection 2nd is I.. 3rd,.... Day of fasting 1st day after fasting 2nd, Excretion of water. TABLE Xl. Exp. I. c.c Exp. II. c.c Exp. III. c.c The injection of large quantities of dextrose caused a temporary retention of water followed by an increased secretion. 6. Excretion of sugar. TABLE XII. Proportion of sugar excreted in the urine. I Exp. I. Exp. II. Exp. III. Amount injected grms Grms. per kilo body weight Total amount excreted grms. 6-5 '5 5' Percentage excreted '4 117

12 118 J. STT. NCLUSION. The chief results of these experiments is to sw that the in*jection of large quantities of dextrose, from 5 to 7 grms. per kilo of body weight, subcutaneously, so that it is as far as possible acted on by the general tissues of the body and not dealt with by the liver or at once excreted by the kidneys, causes a marked increase in proteid metabolism. In fact dextrose or more probably an acid derivative of dextrose under such circumstances acts like such toxic agents as psprus, etc. poisoning the protoplasm. A diminution in the proportion of nitrogen built into urea is also caused, and in this respect the administration of dextrose produces an effect similar to that induced by giving diphtheria toxinel or such drugs as sulpnal' which interfere with the metabolic processes. 1 This Joumal, xxiv. p This Journal, xxv. p