THR THEORY OF THE TREATMENT OF DIABETES 91 



tion of ]3-oxybutyric acid in the processes of metabolism. It never fails to 

 occur in serious cases, and even in mild cases it appears quite often. 



Acetonuria and diaceturia are part of acidosis, for both substances, acetone 

 as well as acetoacetic acid (diacetic acid), originate from oxybutyric acid. I 

 must insist upon this view which has many evidences in its favor, among them 

 the fact that acetonuria and diaceturia orily occur when oxybutyric acid is also 

 found in the urine. I know very well that some prominent chemists have 

 maintained the direct opposite, but I also know that very prominent chemists 

 may be mistaken in their reports; for in the very eases in which they found 

 no oxybutyric acid in spite of the presence of acetone and acetoacetic acid, 

 and in the specimens which they kindly sent to me for examination in my 

 laboratory, I succeeded in demonstrating oxybutyric acid in the urine. 



Therefore, acidosis, including acetonuria and diaceturia, plays an impor- 

 tant role in diabetes. In twenty-four hours oxybutyric acid may be excreted 

 in amounts above 100 grams, and acetone -{- diacetic acid up to 15 grams. 

 As these substances are easily oxidized, their excretion in such large amounts 

 shows a deficiency in the power of oxidation possessed by the tissues in these 

 cases of diabetes mellitus. As regards this decrease in the power of oxidation 

 in the diabetic, the conditions are very similar to those involved in the in- 

 creased decomposition of albumin. Neither is primarily due to the diabetic 

 disturbances of metabolism, but since the albuminoid decomposition is only 

 increased when sugar is wasted and passes out unutilized in the urine, this 

 weakness of oxidation may be referred to the lack of oxidation of sugar. 



The oxidation of sugar, however, does not fail because the general power 

 of oxidation is diminished, but vice versa. Since for other reasons the sugar 

 is not oxidized, the general power of oxidation becomes lessened; of all the 

 products which are consumed in the organism, sugar is the most readily com- 

 bustible, and in the fire which thus arises in normal metabolism, other less 

 readily oxidizable substances are consumed, a process designated by physiolo- 

 gists as secondary oxidation. Owing to the facts just mentioned, the same 

 substances which produce acidosis may occur in other conditions — in non- 

 diabetic persons whenever carbohydrates and sugars are withheld entirely. 

 In the diabetic, too, they usually appear when the carbohydrates are excluded 

 from the food. They may be excreted, however, in severe diabetes, with 

 marked glycosuria, even when carbohydrates are eaten in large amounts. Here 

 acidosis indicates that the sugar metabolism of the body has fallen so low that 

 in spite of the plentiful ingestion of carbohydrate food, very little of it is 

 consumed. The fire which lights the secondary oxidation processes is almost 

 extinguished, and thus the total power of oxidation of the organism is dam- 

 aged. It must be remembered that this condition is due to the disproportion 

 between the products ready for oxidation in metabolism and the power of 

 oxidation. In diabetic patients tissue decomposition goes on too rapidly for 

 their power of oxidation ; their nourishment is both improper and too profuse, 

 yet by limitation of their metabolism and careful diet it is often possible to 

 restore to par the power of oxidation, and thus cause the acidosis to disappear. 



It has been necessary to discuss acidosis quite in detail because of its 

 r61e in diabetic coma. Acidosis is the only certainly known cause of this coma 



