It may appear daring to speak of a special treatment of intoxication with the acetone bodies, inasmuch as this form of intoxication, according to our views, is no independent disease picture, but is merely a symptom complex that accompanies a variety of morbid conditions and is dependent on the nutritive disturbances that are the result of these conditions. Nevertheless, the toxic symptoms of acidosis occupy a more or less independent clinical position and call for treatment that is not always identical with the treatment of the primary disease. Even the mild forms of acidosis that are seen in non-diabetic subjects are worthy of the most careful study, because this form of poisoning constitutes a source of danger in an organism that is already diseased. The acidosis of diabetics, of course, is still more important, for it constitutes the foundation of future attacks of coma. Very frequently the condition of acidosis must be combated more than the glycosuria, even at the risk of increasing the glycosuria temporarily or even permanently, provided, of course, that this is the only way to obviate the dangers incident to acidosis.

Generally speaking, there are at our disposal:

Two Means for Combating Acidosis

1. Means directed towards limiting the formation of the acetone bodies, i. e., towards favoring their oxidation.

2. Means directed towards disintoxicating the ace tone bodies circulating through the tissues and towards accelerating their elimination.

In all non-diabetic cases the first measure invariably leads to the goal. In all such cases the daily addition of 150 grm. of carbohydrate to the diet suffices to reduce the acetonaemia and to prevent the appearance of Gerhardt's ferric chloride reaction in the urine. Where this reaction is already positive the same amount of carbohydrate is sufficient to cure the acidosis in one or at most two days. We have frequently had occasion to verify the correctness of this statement and have given a few examples of such cases above. If it becomes necessary to work quickly and if in cases, for instance, of severe gastro-enteritis, rapid absorption of the carbohydrates from the stomach cannot be produced, monosacharides may be injected subcutaneously or intravenously (dextrose or levulose); the disacharides (cane sugar and milk sugar) are, as we know, not disintegrated if they enter the organism through other channels than the intestine (F. Voit). As an example, mention may be made of a case of acute gastro-enteritis with violent vomiting and diarrhoea that was treated by von Noorden in the summer of 1903 and in which the ferric chloride reaction of the urine disappeared within three hours after the intravenous infusion of a litre of a physiological salt solution to which had been added 10 per cent, of dextrose.

In diabetes mellitus the matter is much more difficult. There are cases, of course - and happily these constitute the majority - in which the degree of acidosis is insignificant and in which the ordinary dietetic treatment that is employed to reduce the glycosuria produces the desired result. In other cases, again, in which large quantities of the acetone bodies appear in the urine on a moderately strict diet, or even when the carbohydrates are completely excluded, the problem is more difficult. It is hard to say what amount of acetone bodies one would consider as "large." In the majority of cases one can probably speak of "large quantities" if more than 1 grm. of acetone is continuously excreted every day. Under these circumstances the acidosis is at least as important as the glycosuria. Some authors recommend adding carbohydrates or substances that are similar to carbohydrates to the diet, for in this way, it is argued, the acetonuria is decreased, while at the same time the glycosuria is not greatly increased. A substance answering this purpose would seem to be levulose. Unfortunately, however, as von Noorden has repeatedly shown, this sugar is useful only in mild cases, for in the more severe cases levulose seems to increase the glycosuria as much as other carbohydrates (amylum, etc.). In severe cases, on the other hand, levulose presumably exercises the same effect on the glycosuria as starch, and the latter substance is more useful because it offers more variety to the patient and is more agreeable to take than levulose. For these reasons we employ levulose only in those cases in which we desire a very rapid result and in cases in which - as for instance in incipient coma, - only a liquid diet can be taken. Under these circumstances, levu lose frequently exercises a very excellent effect and aids in warding off impending danger. We know from clinical experience that the administration of 50 to 100 grm. of levulose a day rapidly produces a great decrease in the excretion of oxybutyric acid (Weintraud, Hirschfeld, von Noorden, Mohr and Loeb). - Glycerine in doses of from 50 to 100 grm. has also been employed with fair success, but this remedy increases the glycosuria much more than levulose.

Recently L. Schwarz, basing on the idea that certain disintegration products of dextrose are presumably oxidized by diabetic subjects, advised the administration of saccharic acid and of glyconic acid in acidosis. In his clinical experiments he found that the acetonuria was reduced by the administration of 50 to 60 grm. of glyconic acid. In diabetic coma he witnessed a transitory "recovery" in two cases after the administration of large quantities of glyconic acid together with large quantities of bicarbonate of soda. We have tried this plan in a number of severe cases of diabetes but have been unable to corroborate the prompt effect of glyconic acid described by Schwarz. He has written in another place that the good effects that Schwarz obtained in these cases of coma were presumably due to the large quantities of alkalies that he administered.

A number of authors, basing on recent investigations described above, have advanced the idea that in cases of acidosis the administration of fats must be reduced in order to prevent the accumulation of acetone bodies. This treatment should only be instituted if one could be persuaded that the reasons for the exclusion of fat were cogent, for fat is of paramount importance in maintaining the nutrition of diabetics. It is, as von Noorden has said, our "sheet anchor" in all severe cases of diabetes. Although it is probable that the acetone bodies are formed from fat and although the production of acetone bodies can be increased by the administration of fat and particularly of fatty acids, we are nevertheless not justified in excluding fats from the diet of diabetics. From a number of investigations that von Noorden has performed in conjunction with Dr. Loeb and Dr. Satta in numerous cases of diabetes, it has been shown that butter, for instance, does not cause an increase of acetone bodies until quantities larger than 150 grm. a day are given. If more than this amount is administered, the total quantity of acetone bodies excreted in the urine is increased, but only by a few grm., and much less rapidly than would correspond to the increased amount of fat that is administered. Butter gives the highest values for acetone excretion of all the fats that we eat. von Noorden has called attention to the fact that this deleterious influence that large quantities of butter exercise can be reduced if the butter is first thoroughly washed with cold water, for in this way the lower fatty acids are removed and they exercise the greatest influence on the acetonuria (paper read before the Association of Naturalists in Carlsbad, 1902). If the butter is thoroughly washed, quantities as large as 180 or even 200 grm. can be given without causing any appreciable increase in the acetone excretion and we will hardly ever be tempted to give more fat than this. The practical question, therefore, whether or not fat is to be administered is hardly touched by the interesting and important studies on the origin of acetone bodies from fat.

The most efficient means for combating acidosis in diabetes is the abundant administration of carbohydrates. The best plan of all, of course, is to promote an improvement in the diabetic condition in general - an improvement that is quite commonly brought about, von Noorden has repeatedly recommended allowing diabetics with much acidosis a certain amount of carbohydrate during certain periods irrespective of the fluctuations in the glycosuria that result. During the carbohydrate periods the acidosis decreases, and the external sign of this improvement is the disappearance of the ferric chloride reaction from the urine. This improvement is often maintained for a long time, for weeks or even months, after the amount of carbohydrates is gradually reduced to the old low standard. A very important method of treatment, particularly in severe and obstinate cases of acidosis is the institution of the so-called oatmeal cure that von Noorden recently warmly recommended (Berl. klin. Wochen-schrift, 1903).