[From The Quarterly Journal of Inebriety, July, 1894.] 
DIFFERENTIAL DIAGNOSIS OF ALCOHOLIC 
COMA FROM OTHER FORMS OF COMA, WITH 
ESPECIAL REFERENCE TO THE CARE OF 
PERSONS FOUND BY THE POLICE ON THE 
STREETS IN A COMATOSE OR SEMI-COMA- 
TOSE CONDITION. 
By Lewis D. Mason, M.D., 
Consulting Physician Inebriates' Home, Fort Hamilton, N. Y. 
The differential diagnosis of alcoholic coma from other 
forms of coma is not unfrequently attended with much diffi- 
culty, and not only to those who have given little, if any, 
attention to the differentiation of the various forms of coma, 
but also to experienced practitioners and diagnosticians. It 
may be said that certain cerebral conditions are very similar 
to alcoholic coma in their general symptoms — and not un- 
frequently mistaken for it. This is especially the result 
when, as is not uncommonly the case, the person is taken 
sick or faint upon the street, and sympathetic bystanders 
administer the usual dose of whisky from the ever-present 
“ pocket flask.” Under such circumstances a cerebral lesion 
with its accompanying stupor, complicated with the smell of 2 
Differential Diagnosis of 
alcohol in the breath of the person, may well tax for the time 
being even the diagnostic skill of an experienced practitioner. 
A similar condition also pertains as when a person, we will 
say, returning from some convivial entertainment slightly 
intoxicated, falls and sustains a cerebral lesion. Here we 
have a decidedly mixed case, and unless the symptoms that 
accompany the cerebral lesion are well marked, such as are 
manifest in the case of a fracture of the skull with depression, 
or fracture at the base with aural hemorrhage, or a marked 
facial paralysis or hemiplegia, immediate diagnosis cannot 
be made, and we will of necessity have to delay the diagnosis 
until, it may be, some hours have elapsed and the effect of 
the alcoholic complication passed off 
It will be noticed that the difficulty of and the failure to 
make a proper diagnosis in these cases is first due to the 
great similarity under certain conditions of alcoholic coma 
and other forms of coma of cerebral or other origin ; and, 
secondly, to the fact that the person who attempts to make 
it is incompetent to do so, or is superficial, careless, or indif- 
ferent in arriving at his conclusions, or by force of necessity 
due to the urgency of the case, is forced, as it were, to decide 
hastily, and so literally “jump at” an erroneous conclusion. 
Take a hypothetical case. A person is found uncon- 
scious on the street by the police. The police are in doubt 
and call an ambulance. The ambulance surgeon detects the 
odor of alcohol, and other symptoms similar to alcoholic in- 
toxication— stupor, mental confusion, partial consciousness ; 
on being aroused, in a maudlin way the person may give his 
name and address, then lapse into unconsciousness. There 
is no apparent evidence of any cerebral disease or injury, or, 
indeed, of any other condition that could produce just these 
symptoms. Here is a case that certainly simulates alcoholic 
intoxication ; besides, there is the corroborative evidence — 
the alcoholic odor to the breath. The decision must be 
promptly made. The hospital has a standing rule that 
“ drunks ” must not be taken in, or, in the official language, 
they are “refused.” The ambulance surgeon must not break Alcoholic Coma from Other Forms of Coma. 
3 
this rule ; therefore, on what he thinks is good evidence, he 
“refuses to remove the case,” and in his desire naturally not 
to infringe the hospital rule, he gives the benefit of the doubt 
to the hospital, and the patient is removed to the station 
house. He is there received and registered as “drunk;” if 
at all demonstrative, “ disorderly.” He is placed in a cell. 
Some hours will elapse before his cas£ is disposed of, and in 
the meanwhile he will sleep off his “drunk.” 
In due time the cell door is unlocked, but the prisoner will 
never appear before an earthly tribunal. The “ dead drunk ” 
has slept his last sleep. Next in order a “ coroner’s case.” 
An inquest is held. The testimony is taken before the usual 
jury, and the cause assigned is “alcoholism and exposure;” 
but, unfortunately for the authorities and fortunately for the 
deceased, his friends are not satisfied with the finding of the 
coroner’s jury, and insist on an autopsy, and the actual cause 
of death is found to be fracture of the skull, or some other 
fatal cerebral lesion. 
A similar case occurred not long since in a prominent 
western city, and formed the basis of an editorial in one of our 
leading medical journals.* Calling attention to the evils that 
attend the present method of dealing with the class of cases 
under consideration here, it said : “ The intelligent coroner’s 
jury heard the testimony of the intelligent officers, and ren- 
dered the intelligent verdict that death was the result of acute 
alcoholism.” A second inquest held resulted in a verdict in 
accordance with facts — a fracture of the skull. The testi- 
mony further brought out the fact that the deceased was not 
a drinking man. 
We now desire to dwell more especially at first upon the 
differentiation of alcoholic coma from other forms of coma. 
Dr. J. Hughlings Jackson, F.R.C.P., in his article on “ Cere- 
bral Hemorrhage and Apoplexy,”—Reynolds System of 
Medicine, p. 902—thus writes under the caption “Special 
Diagnosis 
“Drunkenness.—The smell of drink must only lead us 
* Journal of the Amer. Med. Association. 4 
Differential Diagnosis of 
to a very careful examination of drunkenness, as patients who 
suffer cerebral hemorrhage may have been drinking, or may 
have taken spirits for premonitory symptoms. Oddly enough, 
patients soundly drunk, their real condition not being recog- 
nized, are now and then treated by doses of brandy and 
water. 
This shows in another way the difficulties of diagnosis. 
A drunken man may be in one of two conditions. ( i) He 
may be insensible without excitement; he may, indeed, be 
as deeply comatose as if he had extensive and fatal cerebral 
hemorrhage. This is so when the patient has been ‘ sucking 
the monkey,’ that is, sucking raw spirits out of a cask by aid 
of a gas piping, or when he has drunk off a large quantity of 
spirits for a wager or out of bravado. In these cases, from 
the condition of the patient alone we cannot make a diagnosis, 
although, fortunately, it is usually made for us by the history. 
If we hear that the insensibility began suddenly, or if the 
patient all at once staggered and fell insensible, cerebral or 
meningeal hemorrhage is almost as likely. 
Let us now suppose there is no history of the mode of 
onset, the patient being found in the street by the police. We 
try to rouse him, and we may get him to give his name or his 
address. There is, perhaps, some evidence that the case is 
not one of cerebral hemorrhage, but it had better be disre- 
garded, as patients comatose from fatal cerebral lesions of 
several kinds can be aroused so far. That he resists our 
endeavors to examine him or swears when aroused is of no 
value at all as excluding fatal lesion of the brain. The pa- 
tient may vomit (as he may in cerebral hemorrhage), and the 
vomit may reveal the nature of the case ; if he does not we 
are justified in doubtful cases in using the stomach pump. 
Then the drunken patient oftener passes his urine and feces 
than do other apoplectic patients. Again, we may find alco- 
hol in the urine. The mere presence of alcohol in the urine 
is not to be relied on to show that the apoplectic patient is 
suffering from a poisonous dose of alcohol only. 
As before said, a drunken man may owe his coma in part Alcoholic Coma from Other Forms of Coma. 
5 
at least to hemorrhage into the arachnoid cavity. However, 
Dr. Anstie tells me that it would be possible to recognize the 
presence of a poisonous dose of alcohol in the system if one 
drop of the urine itself added to 15 minims of a chromic acid 
solution* turned the latter immediately a bright emerald 
green. 
The other condition is one of excitement, of which there 
are all degrees. As we have seen, the patient, who, when 
left to himself, is insensible, may be aroused to resist and 
swear, but the main features of a case to which we are called 
may be one of ‘ uproariousness.’ If the patient be violent 
and struggle, he is probably drunk. 
A cautious man will still continue his examination for 
other causes, because it is certain that after severe and fatal 
injuries to the head the patient may struggle and swear, and 
even, as I saw in one of Mr. Hutchinson’s cases, make a 
definite reply, as, ‘What’s that to you about my tongue?’ 
when asked to put his tongue out. I have recorded a case 
supplied to me by Mr. Stephen Mackenzie, in which violence 
and swearing were the striking symptoms in a case hf death 
from meningeal hemorrhage. As in this case, we have often 
a history of a mode of onset under circumstances which ex- 
clude the diagnosis of drunkenness. But to make a diagnosis 
from the condition of the patient only is quite a different 
thing. We can only make a diagnosis by exclusion, and the 
most important thing is to exclude injury to the head. The 
young practitioner must not hastily conclude that a patient 
is ‘ only drunk ’ even if he be only confused, or if he swears 
or is violent, or if he lies on his back insensible, growling or 
swearing if disturbed. If he does, I am quite certain that he 
will have now and then bitterly to regret trusting to such 
circumstances. To have said that a patient was ‘ only drunk’ 
when a post mortem examination shows a fatal lesion of the 
brain is very painful to all concerned. Besides, deep intoxi- 
cation is itself a serious matter.” 
* Bichromate of potash i part, and 300 parts by weight of strong sulphuric 
acid. 6 
Differential Diagnosis of 
An article entitled “ Practical Differentiation of Inebriety 
from Coma, etc.,” written by Dr. John Morris of Baltimore, 
Md., was published in The Quarterly Journal of In- 
ebriety, June, 1879, also since appearing as a reprint.* This 
article is full of suggestion, and of so practical a nature that 
we are almost tempted to incorporate it in this paper, but we 
will endeavor to give an ample synopsis of it. 
“The frequent occurrence of blunders in mistaking brain 
diseases for drunkenness, and the serious reproach they 
bring on medical men, render it necessary that more earnest 
attention should be paid to the subject than heretofore, and 
that a higher knowledge should be obtained of the character 
of the dangers incident to these accidents. Unfortunately, 
drunkenness has not, save in a few instances, been studied 
as a disease, and consequently the manifestations pertaining 
to it are very little understood. This ignorance is particu- 
larly unfortunate when it is necessary to distinguish between 
it and brain troubles.” 
With this statement the author then enumerates the dif- 
ferent conditions resulting from disease or injury that may 
be mistaken for drunkenness. 
1. Fracture of the skull. 
2. Concussion of the brain. 
3. Cerebral hemorrhage. 
4. Embolism and thrombosis. 
5. Uraemia. 
6. Epilepsy. 
7. Narcotic poisoning. 
8. Heat apoplexy. 
“ In case of fracture of skull or concussion, in the absence 
of a history, the diagnosis is extremely difficult. Coma in 
these cases, frequently profound, simulates drunkenness. 
Alcoholic odor on breath is not a reliable guide, as a mod- 
erate quantity of alcohol, not enough to produce coma, may 
so affect the breath; also, alcohol is frequently given in case 
of accident, after the accident, before the physician arrives. 
* “The Disease of Inebriety,” E. B. Treat, publisher, New York, 1893. Alcoholic Coma from Other Forms of Coma. 
7 
“ The temperature, the condition of the pupils, the breath- 
ing, should be carefully noted ; but the true rule is to keep the 
patient under close and constant watch until a fixed diagnosis 
is obtained. I desire to emphasize the fact that there are 
conditions under which it is clearly impossible to draw the 
line between simple profound alcoholic coma and coma aris- 
ing from cerebral lesions ; or, on the other hand, to diagnose 
certain forms of cerebral lesions from alcoholic intoxication, 
until in both instances the case may have been under obser- 
vation some hours. In all cases look for wounds or bruises, 
or depression of skull, and the usual signs belonging to all 
forms of cerebral lesions, whether the breath of the patient be 
alcoholic or not!' 
Mr. Lawson, of Middlesex Hospital, reports a case as 
follows : 
“The patient was taken to the police cell as drunk; ex- 
amined by a physician ; recovered from his apparent semi- 
consciousness; was able to converse after a few hours ; severe 
cerebral symptoms came on ; was transferred to hospital; 
died on the thirteenth day ; autopsy revealed laceration of 
brain substance, extensive hemorrhage, and fracture or fissure 
extending into lambdoidal suture. A remarkable feature of 
this case was absence of paralysis notwithstanding severe 
cerebral injury; with the exception of loss of power over 
sphincters there was no paralysis whatever.” 
Cerebral hemorrhage is more frequently mistaken for 
drunkenness than any other trouble, for the reason that the 
symptoms are similar in several stages of the two conditions. 
There is a stage of noisy violence and uproar in both, 
and then a condition of complete coma. 
In ordinary cases of apoplexy we look for paralysis of 
one side or the other; but this does not obtain if the 
hemorrhage be into the pons or lateral ventricle. We may 
have convulsions in both diseases, but usually they are more 
severe on one side in apoplexy. 
“ The state of the pupil cannot always be relied on as a 
differential test!' Differential Diagnosis of 
8 
Doctor MacEwen of Glasgow says “ that the ordinary 
opinion that dilation of the pupils is found in alcoholic coma 
is incorrect, but that contraction is the rule. He acci- 
dentally discovered, that if a patient was shaken, or rudely 
disturbed, the pupils dilated, but very soon contracted 
again.” 
He therefore lays down as a rule, that an insensible per- 
son, who, being left undisturbed for ten to thirty minutes, 
has contracted pupils which dilate on his being shaken, 
without any return of consciousness, and then contract 
again, can be under no other state than alcoholic coma. Un- 
fortunately for this test, Dr. Reynolds has observed the 
same phenomena in patients suffering from acute softening 
under the same tests. 
The truth is that in cerebral hemorrhage the pupils 
present no fixed regularity. These conditions may even 
vary in different cases of the same lesion. 
Ingravescent apoplexy generally commences with delirium 
or convulsions, and coma comes on slowly and gradually. 
These are the cases that are frequently mistaken for 
drunkenness, provided the smell of alcohol is discovered in 
the breath of the patient. 
Embolism and Thrombosis. In embolism, coma is sud- 
den and transient ; in thrombosis, paralytic symptoms are 
marked. 
Urczmic coma. Generally preceded by convulsions — 
breath a peculiar odor urine albuminous — and other evi- 
dence of kidney disease — patient can be catheterized and 
urine examined. 
In cases of coma, where uraemia is suspected and there 
is suppression of urine, catheterization finding an empty blad- 
der will help confirm diagnosis. 
Urine may become temporarily albuminous from the 
inordinate use of alcohol — even when kidney disease does 
not exist, the urine and the action of the kidneys becoming 
normal after the effects of the alcohol have passed away. 
Epilepsy. Is often complicated with alcoholic intoxica- 
tion, as the results of it. Epileptic coma is, however, Alcoholic Coma from Other Forms of Coma. 
9 
usually of short duration. The tongue is bitten or bleeding. 
Where epilepsy follows an alcoholic debauch, the coma 
may be prolonged—possibly merge into an alcoholic coma, 
the patient sleeping off the effect in a few hours. 
Opium Poisoning. Coma from an overdose of opium is 
similar to alcoholic coma. The extreme contraction of the 
pupils, regarded as the distinguishing mark in opium coma, 
may also occur, though possibly to not so great an extent as 
in alcoholic coma, and according to Dr. Wilks in apoplexy 
seated in Pons varolii. Dr. Morris thinks that the breath- 
ing in opium coma is slower than in alcoholic coma. The 
smell of opium, particularly if laudanum has been taken, can 
be detected, and is an important aid to diagnosis. 
Heat Apoplexy— Sunstroke. “ Coma is often the result of 
sunstroke, and mental disturbance and outward violence not 
an unfrequent result of aggravated cases. One valuable 
diagnostic mark in sunstroke always present is intense heat 
of the head found in no other disease except yellow fever.” 
In cases of alcoholic coma, the temperature would be at or 
below normal. 
Method of Examination in Coma. 
First. Head for fracture or evidences of cerebral lesions 
scalp wounds or contusions, bleeding 
from ears. 
Second. Face —facial paralysis, congested or pale. 
Eyes — squinting, conjugate deviation. 
Eyelids — oedematous or not. 
Pupils — contracted, dilated, irregular. 
Mouth — bleeding, odor of breath, alcohol or 
opium. 
Tongue — for cicatrices, or recent tooth wounds. 
Body — hemiplegia or external or internal in- 
juries or convulsive movements. 
Bladder—note absence, condition, quantity of 
urine. IO 
Differential Diagnosis of 
Examine urine for albumen, casts, other evidence of kid- 
ney disease, and also for alcohol. 
In case of marked alcoholic coma use stomach pump, 
evacuate and examine contents of stomach, note alcoholic 
fumes, etc. In as far as possible, get a history of the case 
antedating the attack of coma. 
Note the rate and condition of pulse. 
Note the frequency and depth of the respiration. 
Note the temperature, whether elevated, normal, or sub- 
normal. 
Endeavor to arouse patient, ascertain degree of coma, 
and note any response to external impressions. 
“ In conclusion, observe close attention and watchfulness 
in all cases of coma supposed to be due to drunkenness. 
Many of these cases should be placed in the observation or 
reception ward of a hospital—in cases of doubt, a few hours 
will clear up the diagnosis, and determine whether the case 
is one of simple alcoholic coma or something more serious. 
After all, this is the only plan that can be followed in a cer- 
tain class of doubtful cases, and is far better than to make a 
hasty diagnosis, and have the usual deplorable results which 
a mistaken diagnosis is certain to include.” 
The system heretofore pursued has been most barbarous, 
both in this country and Europe, and is a reproach to our 
civilization. Dwelling on this subject, Dr. John Curnan 
pointedly says : 
“ I must enter a protest against the routine treatment of 
drunkenness too generally followed, viz.: Emetics or the 
stomach pump, cold effusion, flecking the skin with a wet 
towel, and then the interrupted galvanic current. 
“A patient having grumbled out a name and perhaps an 
address, is turned over to a policeman who speedily consigns 
him to a cold cell to sleep off his symptoms ; it cannot too 
often be insisted upon that a drunken man is suffering from 
acute poison and cannot be too closely watched. 
“ All police stations should have a regularly appointed 
medical officer in charge, and every case of sickness, or Alcoholic Coma from Other Forms of Coma. 
11 
aggravated case of drunkenness, should be put under his 
care. 
“ Certain necessary instruments and appliances should 
be on hand. When these precautions are taken, and when 
inebriety is added to the list of diseases and its treatment 
taught in our schools, many lives will be saved and much 
unhappiness spared the community.” 
We have taken the liberty to present the article of Dr. 
Morris so fully because it not only covers the subject under 
discussion, but shows that the abuses involved in the method 
of dealing with the class of cases under consideration has 
been before the public for many years, and the system, with 
some slight improvement, if any, is still in operation. We 
have also italicized those suggestions or facts in the article 
that we desired to emphasize and also amplified and modified 
somewhat the rules laid down for examination of a person 
in a comatose or semi-comatose condition. We may suggest 
also in this connection that the police might have some sim- 
ple instruction in “first aid” to such cases before medical 
aid can be had, such simple rules as opening the shirt collar, 
placing the body in a favorable position, and especially avoid- 
ing rough handling, clubbing the feet, cold water affusions, 
etc., before a correct diagnosis be made. The various 
cerebral-sedatives produce symptoms analogous to alcoholic 
intoxication — opium has already been referred to. But we 
desire to call particular attention to that condition which 
results from the long-continued exhibition of the bromides 
and is known as bromism. 
Bartholow describes it as follows : “Various mental symp- 
toms are in some subjects produced by the long-continued 
use of the bromides. Weakness of mind, without perversion 
of intellection, is a very constant result of the continued use 
of large doses — headache, confusion of mind, and a sort of 
intoxication, had long ago been observed to follow the use of 
bromide of potassium in even moderate doses (Puche). 
“ A form of mental derangement with hallucinations of a 
melancholic character has been observed by Hammond and 12 
Differential Diagnosis of 
others.” Indeed, so profound is the mental depression pro- 
duced that suicide has not been an uncommon sequence of 
this condition. “The disorders of voluntary gait, the appar- 
ent defects of co-ordination, are variously explained ; but 
they are doubtless made of several factors of which the cuta- 
neous anaesthesia is the most influential. The bromides 
possess the power to destroy or impair the irritability of the 
motor and sensory nerves, and the contractility of muscle, 
and to these effects must be attributed in part the disorders 
of voluntary movement.” Here we have a condition very 
much resembling alcoholic intoxication — confusion of mind, 
loss of memory, partial loss of co-ordination, a stumbling, 
uncertain gait — cutaneous anaesthesia. 
Hammond of New York reports a case in which a patient 
of his while under the full action of the bromides, was ar- 
rested because of his staggering gait and his mental con- 
fusion and inability to give an account of himself. This 
patient was taken to the station house and the justice was 
about to impose the usual fine of “ ten dollars or ten days,” 
when Dr. Hammond appeared, interceded for the prisoner, 
explained the cause of his apparent intoxication, and secured 
his release. 
A physician related to me his personal experiences while 
under full dosage of bromides — his memory seemed to fail 
him, almost completely ; he made a professional call and re- 
mained in the house two hours, when, as it was an ordinary 
call, ten or fifteen minutes would have been sufficient. He 
afterwards said the patient regarded him as intoxicated ; he 
also told me that he endeavored to read an article to a medi- 
cal friend, and was told that he repeated the reading of it 
several times, not conscious of the fact he had previously 
read it. 
Those who are at all familiar with intoxication from the 
bromides will at once see the similarity between that form of 
intoxication and intoxication from alcohol. 
In addition to the statements of so prominent an observer 
as Dr. Jackson, and the article of Dr. Morris, to which Alcoholic Coma from Other Forms of Coma. 
13 
we have already referred, we will give the testimony of 
two prominent observers—Dr. Norman Kerr of London, 
England, and Dr. A. Baer of Berlin, Germany, who, in reply 
to a request for information as to the method of dealing 
with the class of cases under consideration, courteously 
answered in the following communications : 
The London Police and their Procedure with Persons found 
“Dead Drunk ” on the Streets. By Norman Kerr, M.D., 
F.R.S., London, Eng. 
Strict injunctions are given to the metropolitan police 
force, and to the police force of Britain generally, to exer- 
cise the greatest caution in differentiating between drunken- 
ness and illness in cases of individuals arrested for pre- 
sumed drunkenness. 
In an address to police constables on their duties, 
on the 5th of June, 1882, one of Her Majesty’s judges, 
Sir Henry Hawkins, inculcatedon his hearers the neces- 
sity to be very careful to distinguish between cases of 
illness and drunkenness, as many serious errors had been 
committed for want of care in this respect. Yet the 
heading, “ Drunk or Dying,” appears every now and again 
in English newspapers. No later than the 26th of March, 
1894, the London Daily Telegraph reports the case of a 
girl of 15 years of age who was brought up before a 
police magistrate on a charge of having been found drunk 
on Sunday afternoon on the streets. The evidence showed 
that a serious mistake had indeed been made, the girl be- 
longing to a “ Band of Hope.” She had just left Sunday- 
school, and fallen down in an epileptic fit, having been sub- 
ject to such attacks for some years. The wrongly accused 
girl was discharged. In this case there ought not to have 
been so much difficulty in the diagnosis as in the case of a 
man with apoplexy, or with fracture of the skull. If the 
case was rightly reported by the Daily Telegraph, the police 
instructions do not appear to have been properly carried 
out. Colonel Howard Vincent, Q.C., M.P., in his “Police 14 
Differential Diagnosis of 
Code for the British Empire” (1889), says: “Persons 
found on the streets in fits should be carefully taken to the 
nearest hospital or registered medical practitioner.” I have 
seen several such cases at the request of the constable, and 
have immediately, when in doubt as to the diagnosis, advised 
the convulsed person to be taken to the nearest hospital or 
infirmary, which has been acted on by the constable, who 
was armed with my visiting card, on which was indicated 
the doubt and a request for admission as an urgent case. 
Regarding persons found insensible, Colonel Howard 
Vincent, who was a high police functionary, says : “ Insensi- 
bility is the suspension of the functions of animal life, ex- 
cept those of respiration and circulation. Insensibility is 
liable to be mistaken for drunkenness, and it must be re- 
membered that the conditions may be complicated with each 
other and with the effects of drink, and that no single sign 
can be relied upon in forming a conclusion on the condition 
of the patient. When a person is found insensible, the fol- 
lowing points must be observed : 
“a. The position of the body and its surroundings. 
“ b. The cause of insensibility. Place the body on the 
back, with the head inclined to one side, the arms by the 
side, and extend the legs ; examine the head and body, pass 
the fingers gently over the surface, search for wounds, 
bruises, swellings, or depressions ; ascertain the state of the 
respiration, whether easy or difficult, the presence or absence 
of stiffness, and the odor of the breath.” 
In the same volume in which Mr. Monro, Q.C., late Chief 
Commissioner of Police in London, in his preface, says that 
“ this code has been in use among the police force for sev- 
eral years,” we are told that “ persons are frequently found 
insensible on the streets in reality suffering from apoplexy 
or other natural causes, the symptoms of which give the 
sufferer very much the appearance of persons under the in- 
fluence of drink.” Such cases will require great caution, 
especially if there is no smell of drink. “ The police should 
be especially careful not to assume that a person is drunk, Alcoholic Coma from Other Forms of Coma. 
15 
save on sufficient and incontestable grounds ; for illness or 
the excitement of being taken into custody may at first con- 
tribute to such conclusion. In all such cases the first thing 
to do is to try to rouse the drunkard by gently shaking him. 
If that fails, the neckcloth and collar should be loosened 
and the head raised a little, by which means breathing is 
made easier.” It is also laid down that care is to be taken 
in conveying the apparently drunk and insensible to the 
station, and placing them in a proper cell. The practice of 
a constable, when a man is found drunk on the streets, is to 
take him to the police station, and in presence of an inspector 
apply certain tests. If the tests indicate suspicion of dis- 
ease, the divisional surgeon is sent for by the inspector, and, 
at his discretion, sends the individual to either the infirmary 
or a hospital. 
Though a part of the above “code of instructions” and 
of procedure seems proper enough, there can be little doubt 
that, probably from a levity begotten partly of the frequency 
of mere drunkenness, and partly of unacquaintance with the 
disease phenomena present in intoxication, the presence of 
drinking, as evidenced by the alcoholic odor of the breath, 
frequently so absorbs the attention as to throw the possibil- 
ity of disease into the background. 
A striking case recurs to my mind. A gentleman, aged 
55, was found staggering and apparently mumbling incoher- 
ently on the street. He had been suddenly attacked by 
paralysis, and attempted to utter the word “ Home,” with his 
address, but could not. The constable thought he was 
drunk, which irritated the sufferer, who was quite conscious, 
happily. He saw a friend passing, and held out his hand. 
His friend, knowing his complete sobriety, recognized the 
gravity of the case, and took the stricken gentleman home. 
Curious to say, speech was regained on reaching his house, 
but the symptoms proved to be the initiation of general 
paralysis, which was fatal in eighteen months thereafter. 
I have known a teetotaler treated, and very naturally so 
from the symptoms, as drunk, while insensible in an apoplec- 16 
Differential Diagnosis of 
tic fit and suffering from a fractured skull. Nor is such an 
error in diagnosis confined to constables. But a short time 
ago a man was charged with drunkenness who had been ex- 
amined and certified as “ drunk” by a surgeon who had been 
called to the station by the inspector in charge. 
The practice in London is to put no drunkard in a cold 
cell, and the instructions are to visit a drunken man in his 
cell every half hour. 
A similar mistake as that related has again and again 
been made by hospital surgeons, and apparently drunken 
cases have been refused admittance which afterwards ended 
fatally, simply because only intoxication was seen, and hos- 
pitals could not have accommodation for the immense num- 
ber of cases of drunken coma or insensibility. If there is 
a vacant bed, of course grave cases are never knowingly re- 
fused. 
In view of the difficulty of the diagnosis between simple 
uncomplicated alcoholic coma and injuries or other serious 
lesions, I have long come to the conclusion that all cases of 
alcoholic coma, whether apparently complicated with disease 
or not, should at once be taken to special wards, either in 
the police station or hospital or infirmaries, or some other 
receiving house or home. In my opinion, the fact of being 
found “ dead drunk ” should be sufficient warrant for a con- 
stable to take such procedure on his own responsibility, if 
the services of a surgeon cannot at once be procured. If 
taken to hospital, the public purse should be at the cost of 
such ward provision, duly appointed and kept at a tempera- 
ture not below blood heat. 
There would be considerable expense incurred, but an 
imperative duty owed by the State to every person, from 
whatever "cause found either unconscious or uncontrollable 
on the public way—a duty now very imperfectly paid in 
Britain — would be honorably fulfilled. I verily believe that 
not a few innocent lives would be saved, and that such a 
provision for the helpless and incapacitated would prove a 
true economy in the end. Alcoholic Coma from Other Forms of Coma. 
17 
Rules that govern the Berlin police in the case of persons 
found unconscious, etc., upon the streets. By Dr. A. Baer, 
Berlin, Germany. 
“ Every person found in coma or unconscious on the 
street, shall be brought immediately to a public hospital, in 
the first cab or carriage (droschke), or, if delay is possible, 
in a proper vehicle for the transportation of diseases. The 
policeman who finds a person in such condition shall trans- 
port said person on his own responsibility, without special 
order from his superior. In all cases, it makes no difference 
in the disposal of the case whether the coma be due to a cere- 
bral lesion, an apoplexy, or simple drunkenness. 
II. Every person who is found hurt or on the street in 
a helpless state shall be brought by the policeman (a) to his 
own house if he has one or (b) to a hospital if he has no 
lodging. In all these cases the policeman has to enquire the 
matter of fact and announce it to his superior police court. 
III. If a person is found drunk he shall be brought to 
his own house, even if he is also unconscious, if the house 
or domicile is known or can be ascertained. The drunken 
person must be brought to the hospital if he is unconscious 
or comatose, and if his lodging is unknown. 
A drunken person who is disorderly or scandalous is to 
be brought to the police station, and shall remain until the 
state of drunkenness has ceased. The name of this person 
is registered and then the person (having gotten over his in- 
toxication) is given his freedom. If this person has done 
some wrong or has injured other persons, the fact must be 
announced to the police court and the person is thereupon 
transported to the police prison. 
IV. All drunken persons brought to the police not quite 
unconscious, but in a helpless state, shall remain in the police 
room (station), which must be warmed, and a policeman 
shall see at short periods if the drunken person sleeps or 
what else he does. If there is a sign of dangerous illness a 
physician of the neighborhood is sent for, and if the con- 
dition is serious and the case urgent the patient is taken to 18 
Differential Diagnosis of 
the hospital, the case is registered and announced to the su- 
perior police court.” 
Drunkenness, without some injurious behavior, is not 
punishable in Germany, as with us, subject to fine and im- 
prisonment. 
The Parisian system is most complete and satisfactory, 
and has been in operation many years. The description of 
it I take from the preface of the English translation of Dr. 
V. Magnan’s work on “ Alcoholism,” translated by W. S. 
Greenfield, M.D., M.R.C.P., and published by Lewis of Lon- 
don, 1876. He writes : 
“The Bureau d’Admission of the Department of the 
Seine at St. Anne Asylum in Paris of which Dr. Magnan is 
one of the two physicians, is an institution to which no exact 
parallel exists in England (we may add, or elsewhere). To 
it are brought all the cases of insanity previous to their ad- 
mission to the various public asylums, and all cases of acute 
delirium and mania which fall under the care of the police of 
Paris. It is here that they are examined and their admis- 
sion or rejection decided upon ; if admitted they are drafted 
to the one or other of the asylums which is the most suited 
to the class of the patient or the form of his malady. 
“The Bureau d’Admission is quite distinct from the St. 
Anne Asylum itself, and under altogether different adminis- 
tration. In order to provide accommodation for the temporary 
lodgment of patients on their way to other asylums and also 
for the reception of the more acute cases, it is provided with 
about 50 beds, and is fitted up in every way as a small asy- 
lum. Here there are brought all the cases of delirium tre- 
mens and simple alcoholic delirium which fall under the 
notice of the police, and a large number from the lower and 
middle classes of society, and here they are treated until 
their recovery. Cases too, of fever with delirium are not 
infrequent, and it need scarcely be said that acute delirious 
mania is also often seen. Hence it comes to pass that a very 
large proportion of all the cases of delirium tremens occur- 
ring in Paris and its vicinity come under observation here. . . 
There is also an out-patient department to which not Alcoholic Coma from Other Forms of Coma. 
19 
only cases of mental derangement but all forms of nervous 
disorder, especially epilepsy, are gratuitously admitted, etc. 
The Parisian system is such that all cases of mental de- 
rangements, all cases of coma, all doubtful cases, which can- 
not be disposed of in any other way, such as taken to their 
homes or special hospitals, all such cases found by the police 
on the streets, in boarding houses, or in public resorts, are 
brought to a central bureau, to which is attached a hospital, 
a reception hospital, where they may remain until further 
disposed of. This system has the advantage that the case 
is promptly removed, and is without delay brought under the 
observation of competent medical men, and is at once placed 
under proper treatment, or assigned to such an institution as 
is suited to the class and nature of the disease of the patient. 
There is no unnecessary delay, no lack of prompt treatment, 
and the dangers of a “ mistaken diagnosis,” which is the 
opprobrium of medicine and surgery, are greatly lessened, 
if indeed it occur at all, because those who sit in judgment 
upon these cases are physicians of experience, and experts in 
their specialties, and have opportunities and a sufficient 
period of time to properly diagnose and treat the cases 
brought to them. There is no urgency because the case is a 
doubtful one, and therefore no occasion for a hasty diagnosis. 
In glancing over the English, German, and French meth- 
ods of dealing with the cases under consideration it will be 
noted that there are some points in common ; while the 
police of each nationality endeavor to secure medical aid for 
the person, the French by aid of the central hospital system 
invariably seem to secure that aid in the promptest and most 
direct manner. 
The Parisian method does not describe the conveyance 
of such persons, by what method, public or private. The 
German method refers to the privilege of hailing a passing 
cab or carriage, and thus getting its conveyance from a pri- 
vate source, a “disease wagon,” or one conveying sick per- 
sons is spoken of. 
Dr. Kerr informs me that in London they do not have 
any conveyance similar to our “ambulance system.” Cer- 20 
Differential Diagnosis of 
tainly it would seem the large European cities ought to have 
all the advantages derived from the telephone, the telegraph, 
and the “ ambulance service,” as we have it in all our large 
American cities, at least in New York and Brooklyn. Let 
me recommend to our transatlantic brethren the “ ambulance 
service,” susceptible of improvement, no doubt, and yet in- 
dispensable when promptness not only, but comfort to the 
injured are both combined. 
We believe, with the best features of the English, Ger- 
man, and French methods, incorporated with our American 
ambulance service, the best results could be obtained in care- 
ing for those who are taken sick, unconscious, or insane on 
the streets of our cities. 
It may be of interest to give a brief statement of the 
ambulance service of the city of Brooklyn for the year 1893 : 
During the year 1893 there were arrested for various 
specified offences, 33,748 ; of this number 23,307 were in- 
toxicated when arrested. The total “ ambulance calls ” were 
8,705, of these 399 were specified as “alcoholism.” 5,264 
“ambulance calls” were by the police, the balance by citi- 
zens or institutions, etc. It will be noticed that the ratio of 
the “ambulance calls” for cases of “alcoholism” in com- 
parison with other causes were about one in twenty-one or 
twenty-two. 
The disposition of the cases of “ alcoholism ” was as 
follows: 
Hospital. 
Precincts. 
Home. 
Not re- 
moved. 
No 
record. 
L. I. City Hospital, . . n 
Homeopathic “ . . 30 
Charity “ . . 6 
Norwegian “ . . 7 
East District “ . . 19 
St. Catharine’s “ . . 27 
St. Mary’s “ . . 14 
City . . 18 
Meth. Epis’pal “ . . 13 
12 
24 
198 
20 
Total, 14S 
12 
24 
198 
20 
Total cases, 399. Alcoholic Coma from Other Forms of Coma. 
21 
It will be observed that exclusive of those taken to hos- 
pitals, or precincts, or taken home, a large percentage were 
“ not removed,” that is, were considered ineligible cases for 
hospital treatment, so that if we include the 12 precinct 
cases, 210 persons of the 399 for whom the ambulance was 
called did not receive hospital treatment ; of the balance 24 
were taken home and as to the disposition of 20 there was no 
record. 
A more detailed record of the cases of “ alcoholism ”— 
from the time the ambulance was “ called ” until the final 
disposition of the cases, would render this department of the 
“ambulance service” more effective, and by a more accurate 
system of recording this class of cases be the means of pre- 
venting the errors to which the present method is liable, 
being also, from a statistical point of view, of value as the 
city increases in population. This branch of the “ambulance 
service” will increase also, and to be effective must be 
thoroughly systematized, and the average so-called “drunk ” 
be carefully examined by a competent medical officer and 
given, at least, the advantages that the “ ambulance service ” 
extends to the generality of the diseases and injuries. 
We believe, that by selecting and combining the best fea- 
tures of the English, German, and French methods, the police 
and medical authorities can secure a more perfect method of 
caring for the class of cases under consideration; we might 
almost add a perfect method, if we consider the advantage that 
the “ ambulance system ” gives us, in handling these cases 
with celerity and dispatch. 
With a view to enquire into, and if possible to remedy, 
the present method of dealing with persons who are found 
upon the streets by the police, said persons being in a condi- 
tion of complete or partial coma, or a state of mental aberra- 
tion from disease, injury, alcohol, or other narcotic drugs, a 
committee was appointed by the president of the “ Kings 
County Medical Society,” Feb. 20, 1894, on motion of Dr. 
J. H. Raymond. The committee submitted, May 28, 1894, 
the following report and recommendations to the society: 22 
Differential Diagnosis of 
Brooklyn, May 28, 1894. 
Mr. President, and Members of the Medical Society of the 
County of Kings: 
Gentlemen:—Your committee, appointed February 
20th, to report “ what means have been provided in the city 
of Brooklyn for the immediate care of persons found uncon- 
scious in the streets ” would respectfully present the follow- 
ing preliminary report. 
In the brief time which has elapsed since they were ap- 
pointed, they have had only time to make a superficial ex- 
amination of the subject, but they feel that they have already 
ascertained enough to warrant them in making this prelim- 
inary report, and also in suggesting some recommendations, 
which are based on facts which have come to their knowl- 
edge. 
They are not prepared to give specific instances which 
have occurred in this city, yet from their knowledge of the 
system in vogue and from the experience of cities where the 
conditions are not very dissimilar, they are satisfied that in 
Brooklyn there can be an improvement in the methods of 
managing such cases. 
Perhaps in no better way can these defects be shown 
than by narrating concisely some instances which have come 
to the knowledge of your committee, and as it is not their in- 
tention or desire to criticise individuals, but systems, the 
places in which the events occurred will be omitted. 
Case i. Man found unconscious in the area-way of a dwell- 
ing. Taken by police to station-house. Ambulance surgeon 
summoned. After examination, during which the smell of 
liquor was recognized in the breath, the diagnosis of “ drunk ” 
was made, and man left lying on the floor of the station- 
house. Later, a more experienced physician by chance came 
to the station-house and examined the man. He advised that 
the man be sent to the hospital, stating that it was impossi- 
ble for any one to tell whether he was suffering from alco- 
holic coma or from a fracture of the skull. His suggestion Alcoholic Coma from Other Forms of Coma. 
23 
was carried out, and the next day the man died, and the 
autopsy revealed an extensive fracture of the skull at the 
base. 
Case 2. Man found unconscious in the street. A well- 
wisher, who found him, rushed immediately to the nearest 
drug-store and obtained a glass of whisky, which he gave him. 
Ambulance surgeon was summoned and pronounced the man 
“ drunk ” and refused to take him to a hospital. The man 
subsequently died, and the autopsy showed a fracture of the 
skull, and the man’s history was ascertained to be that of a 
perfectly temperate man. 
Case 3. Man, aged 55, suffering from incipient general 
paralysis, was arrested for intoxication. 
Case 4. Girl, aged 15, attacked with epileptic coma, was 
arrested for intoxication. 
Case 5. Fracture with cerebral laceration treated for 
alcoholism. 
Case 6. Uraemic coma mistaken for alcoholism. 
Case 7. Man found unconscious, taken to hospital, 
where he was refused admittance on the ground that he was 
only a “drunk.” Was taken to the station-house, where he 
died. Autopsy revealed a fracture of the skull. 
Case 8. Man seen by a policeman to be reeling in the 
street. Was arrested on the charge of intoxication and 
locked up over night in a station-house. He was able to 
send word to his physician, a most eminent practitioner, who 
had great difficulty in convincing the police justice, before 
whom the man was brought, that his patient never drank, 
and that what the policeman took for evidence of drunken- 
ness was the result of poisoning from bromides. 
The following extract from the Journal of the American 
Medical Association is so much to the point that we venture 
to quote it: 
“The death of John Markey a few days ago in Chicago 
from a fractured skull, he having been run into by a street- 
car, and booked for drunkenness by the police, is another 
evidence of the stupidity of the average policeman, and the 24 
Differential Diagnosis of 
careless disregard for life that obtains in this country among 
police officers. An inquest was held. ‘ The intelligent 
coroner’s jury heard the testimony of the intelligent officers, 
and rendered the intelligent verdict that the death was the 
result of acute alcoholism.’ His wife was not satisfied, as 
she knew her husband was not a drinking man, and she in- 
duced the coroner to have a post-mortem made, when it was 
found that his skull was fractured. A second inquest was 
held, which resulted in a verdict in accordance with the 
facts. 
“A man is found in the streets unconscious, no matter 
whether it is due to apoplexy, fracture of the skull, or any 
lesion of the brain ; he is thrust into a cell to sleep off his 
supposed drunk (often to be found dead in the morning) or 
for the same reason not received at a hospital, when if he 
had been properly cared for his life might have been saved. 
In some cases, no doubt, there may have been evidence that 
the party had been drinking, and probably had received his 
injury while intoxicated, but this is no reason why he should 
be neglected. The police should be instructed, so that at 
least when in doubt a medical man be called to see the case. 
The judgment, “dead drunk,” is too often literally true. 
Instances of this character have often occurred, and within 
the last six months twelve cases have been noted in different 
cities, and it is high time that something should be done to 
stop it. Unfortunately, the police are not alone in this dis- 
regard of life, as two months ago two ambulance surgeons of 
New York committed the same mistake, we might almost 
say the same crime.” 
These instances are but samples, and they might be 
greatly multiplied; they undoubtedly indicate a deficiency in 
the public service in most cities, which, in the name of 
humanity, demands a remedy. 
The frequent occurrence of mistaken diagnosis makes it 
necessary that more earnest attention be paid to this subject 
than has hitherto been paid. The differential diagnosis be 
tween alcohol coma and cerebral conditions simulating it is Alcoholic Coma from Other Forms of Coma. 
25 
not easy, indeed, is sometimes impossible. Fracture of the 
skull, concussion of the brain, cerebral hemorrhage, embo- 
lism, thrombosis, uraemia, epileptic coma, narcotic poisoning, 
and heat apoplexy have all been mistaken for alcoholic coma. 
This is especially the case when an alcoholic condition has 
accompanied the other condition. Such mistakes have been 
made by well-informed medical men, and it is therefore not 
surprising that a policeman or a recent graduate of medicine, 
acting as an ambulance surgeon, should likewise err in 
diagnosis. 
Your committee do not at this time feel prepared to make 
a final report on the matter intrusted to them, but do, never- 
theless, feel justified in offering the following recommenda- 
tions, asking that they may be continued as a committee un- 
til such time as they are prepared to make a final report. 
Recommendations. First:—That while they believe 
that the system which exists in Paris is, perhaps, the most 
perfect, by which all persons found unconscious in the streets 
are taken to a special hospital where they have the most en- 
lightened treatment possible, still it is a question with them 
whether the distances are not so great as to make such a 
system impracticable in Brooklyn. They prefer, therefore, to 
keep this question under advisement for a longer time. 
Second. That all persons found upon the street in an 
unconscious or semi-unconscious condition, or wandering 
about in a state of mental aberration, shall be removed to 
their homes, or if they have no homes or their residence can- 
not be ascertained, then to the nearest hospital, and a visit- 
ing physician or surgeon shall be at once summoned. 
Third. That alcoholism or suspected alcoholism should 
not exclude such persons from the benefit of proper medical 
treatment, inasmuch as simple cases of alcoholic coma, par- 
tial or complete, are serioue and demand treatment, and again, 
alcoholism often obscures and is associated with serious 
cerebral lesions. In any event, therefore, such cases should 
have proper medical treatment. 
Fourth. If for any reason such cases cannot be taken 26 
Differential Diagnosis of Coma. 
either to their homes or to the hospital, and must be taken 
to a station-house, they should be placed in rooms properly 
warmed, and a physician should be summoned to examine 
them. If they remain in the station-houses, they should be 
visited every half hour by the watchman, and if any alarming 
symptoms supervene, a physician should be immediately 
sent for. The practice of locking in a cell for hours without 
inspection a person unconscious from alcohol, whether the 
same is complicated with injury or not, is inhuman. 
Fifth. In case of doubt, as between the police and the 
ambulance surgeon, a police surgeon should be summoned, 
and the disposition of the case should be determined by him. 
Signed by the committee. 
J. H. Raymond, M.D., Chairman, 
J. C. Shaw, M.D., 
L. D. Mason, M.D., Secretary. 
Those who are interested in the work of the Committee 
and desire to communicate with them on the subject, can do 
so by addressing the secretary, 
Dr. L. D. Mason, 171 Joralemon Street, Brooklyn, N. Y.