ALKALINE TREATMENT OF DIABETIC COMA 441 



in very large amounts (twenty to thirty grams in the 

 course of twenty-four hours). In cases of coma the forma- 

 tion of this acid rises to an abnormal level, and coincidently 

 there is a lowering of its combustion. Under such circum- 

 stances enormous quantities of the substance may appear in 

 the urine (as much as 160 grams in twenty-four hours). In 

 the body of subjects dead from diabetic coma one or two hun- 

 dred grams of the acid may be found. The coma is regarded 

 as an acid intoxication, in which, it would seem, all the indi- 

 vidual phenomena are dependent either directly or indirectly 

 upon the accumulation of acid. As the supply of alkali which 

 the system keeps ready for the neutralization of the acids 

 permeating it is not large, these acids (oxybutyric acid, 

 diacetic acid) are for the most part neutralized by ammonia, 

 which is thus withdrawn from urea formation. In these 

 cases, therefore, the urinary ammoniacal elimination serves 

 as an approximate index of the acid excretion. 24 



Alkaline Treatment of Diabetic Coma. Oxybutyric acid, 

 the sites of production of which may be looked upon as 

 the liver and muscles and perhaps other tissues as well, pro- 

 duces in case of diabetic coma, as indicated by the observa- 

 tions of Minkowski, F. Kraus and others, a lowering of the 

 alkalescence of the blood and of the amount of carbonic 

 acid fixed thereby in the blood. 25 For this reason it is alto- 

 gether logical that in the coma, which in French's opinion is 

 the most serious menace to the life of the diabetic subject 

 (aside from pulmonary phthisis), efforts be made to an- 

 ticipate it by a prophylactic alkaline treatment. Umber 

 believes that in those cases of diabetes in which persistence 

 of diacetic acid in the urine can be recognized by the ferric 

 chloride reaction, enough alkali should be given daily to 

 give the urine an amphoteric reaction. "This frequently 



24 A. Magnus-Levy, Die Oxybuttersaure und ihre Beziehungen zum Coma 

 diabeticum, Leipzig, J. C. Vogel., 1899, p. 83. 



25 G. Embden and L. Lattes (Frankfurt a. M.), Hofmeister's Beitr., 11, 327, 

 1908; H. C. Geelmuyden (Christiania), Zeitschr. f. physiol. Chem., 58, 253,, 

 1909. 



