“Canepeun: THE Inprcamons vor THE Ust o Ixsutne 189 prolonged, painful or laboured, often nausea, vomiting and abdominal pain, vertigo and a fmity odour on the breath, Drowsiness ap- pears and gradually becomes more marked while one may be misled by the marked anxiety, restlessness, and delirium which sometimes oc- cur. If the skin and tongue are dry and hard and the tension of the eyeball is reduced the patient is in imminent danger of coma and the ‘treatment should be vigorous. ‘The patient should be put to bed, kept warm, and encouraged to rest. Morphia is seldom indicated on account of the complicating factors it introduces, Warm drinks of all kinds should be provided liberally and the patient rust be continually urged to accept them. A cleansing enema is often useful. ‘The most im. portant part of the treatment, however, is insulin, 20 to 40 units, accompanied by a drink of orange juice, grape juice or diluted corn syrup, given as an initial dose and repeated every three to four hours until the symptoms disappear. Repeated examination of the urine to make gure that glycosuria persists will pre- vent any tendeney to hypoglycemia. Forty units of insulin per day, in divided doses, will keep most cases out of danger until the diet and insulin can be more suitably ad- justed. On the days immediately following an ‘acidosis the type of food most acceptable to the patient may be used and strict diet intro- duced gradually as recovery ensues. The use of sodium bicarbonate during the period of acidosis is hardly necessary, but 10 grams (150 grains) given by mouth does no harm and, in my opinion, accelerates the recovery. Coma Next let me repeat what has been said else- where: save for infection, coma is due to eare- lessness, usually on the part of the patient. All acidosis eases can be improved; not all comas can be cured. Coma is an emergency and must. be treated as such. The loss of one hour is an. inexcusable delay and the price is often the patient’s life. There cannot be the slightest doubt that insulin for emergeney use, like other biological preparations, should be readily avail- able, no further distant than the office of the nearest Medical Health Officer. Coma is best treated in hospital, but most cases could be saved by an initial dose of 60 units of insulin on diagnosis. If possible the patient should be made to take 2 to 3 ounces of corm syrup, diluted with water or coffee, by mouth, Many times this ean be swallowed when the patient appears completely comatose. I shall not dwell on the differential diagnosis of coma, but merely point out the possibility of coma, oven in diabeties, being due to another cause. This, however, is impossible if acetone is present on the breath, except perhaps in children. Children, in this connection, also present another unusual condition; in them a Giabetic coma may develop without dehydra- tion, Dehydration of some degree is, however, the rule in adults passing into diabetic coma, and probably contributes much to the severity of the condition, In the treatment of ad- vanced coma it is necessary to use not only insulin, the most important drug, but also to rectify the other abnormalities occurring. Cessation of Ketone produetion should be in duced by adequate provision of the calories required in foods other than fat. The meta- bolism should be reduced to the minimum by putting the patient to bed and keeping him warm. One hundred units of insulin, with 1,000 enbie centimetres of 10 per cent glucose solution, are given intravenously as soon as possible, Further doses of insulin and fluid may be given if necessary, but seldom are the subsequent doses so large. Perhaps 200 units in all are sufficient to overcome the coma com- pletely. Larger amounts may be given, if neces- sary, provided care is teken to balance the insulin given by adequate amounts of carbo- hydrate. I prefer to have the patient excreting sugar in the urine until he is able to fake an interest in his condition again, Further fluid administration will be required, but usually this can be given by mouth. An unknown quantity of insulin will be necessary to pre- vent relapse into acidosis as the patient is gradually introduced to more and more solid foods, but two doses per day of twenty units each will be found sufficient at first and the more accurate adjustment of dosage can be made as the evidence of its need accumulates. During the comatose state 15 to 20 grams of sodium bicarbonate, or its equivalent, may be given in divided doses. I have never known of any deleterious effects from such doses, and am convinced of their value in producing a more