454 METABOLIC ABNORMALITIES, AUTOINTOXICATION 



able acetone, the liver less than the other viscera ; the blood 

 contains less acetone than the urine of the same patient. 



Relation of Acidosis to Diabetic Coma. There 

 seems to be little room for doubt but that the typical diabetic 

 coma with "air hunger" depends upon an excess of these 

 substances in the blood i. e., is an acid intoxication for the 

 following reasons : (1) The coma appears when the amount of 

 organic acids in the urine is highest, and is absent when there is 

 little or none of them in the urine. (2) Because of the identity 

 of the symptoms with those of experimental acid intoxication. 

 (3) Because of the repeated demonstration of a reduced amount 

 of alkali in the blood, as determined by titration, 1 and a great 

 reduction of the amount of CO 2 carried in the venous blood 

 (from the normal 36 per cent, it may be reduced to 3.3 per 

 cent. Minkowski). (4) The marked improvement that often 

 results from the administration of alkalies (usually sodium bi- 

 carbonate). Associated with this improvement is an elimination 

 of greatly increased amounts of organic acids, indicating their 

 previous retention in the body because of lack of alkali with 

 which they could combine (or their liberation from combination 

 with proteids Landau). 



/9-oxybutyric and diacetic acid, according to many authorities, 

 seem to have no specific poisonous effects, 2 but act simply as 

 acids in the blood. 3 Acetone does not have this effect, not 

 being an acid, and seems not to be toxic to any considerable 

 degree ; doses of 4 grams per kilo cause effects similar to ethyl 

 alcohol in dogs, 8 grams per kilo being fatal, which corresponds 

 with a dose of 500 grams for an adult man. Of course a 

 diabetic suffers from the effects of other poisons than these 

 acids, and often the coma cannot be relieved by alkaline treat- 

 ment, and seems not to be due to the acids alone. But, in the 

 majority of cases, the acids seem to be the chief factor, as 

 shown by the marked effect of alkaline treatment. 



1 The actual alkalinity of normal blood, which means the number of free 

 OH ions, is but little greater than that of distilled water, and the condition is 

 quite the same in diabetic acidosis (Benedikt and T6r6k, cit. in Folia Hemato- 

 logia, 1905 (2), 454). 



2 Some, however, attribute to oxybutyric acid a considerable toxicity inde- 

 pendent of its acidity. 



3 The view advanced by Stemberg (Zeit. f. klin. Med., 1899 (38), 65) that 

 an antecedent of oxybutyric acid, namely, ammo-butyric acid, is responsible for 

 the intoxication, does not seem to have been generally accepted, although 

 Grube (Arch. f. exp. Pathol., 1900 (44), 349) found that o-amino-butyric acid 

 is toxic and produces symptoms similar to those of diabetic coma. Magnus- 

 Levy questions the possibility of sufficient amino-butyric acid being present to 

 account for the great amount of acid eliminated in the urine (Arch. exp. 

 Path. u. Pharm., 1901 (45), 389). 



