50 Magnan, Le Progrès médical, 1884.
Dipsomaniacs are apt to manifest precocious or retarded intellectual development. They are from infancy or childhood especially prone to convulsive or other paroxysmal nervous phenomena. They are often choreic, often hysterical. This association with instability of the nervous system is related to the fact that dipsomania is more common in women than in men.
DIAGNOSIS.—1. Acute Alcoholism.—The diagnosis of the ordinary form of acute alcoholism, with the exception of alcoholic coma, requires no consideration. The diagnosis of alcoholic coma from profound coma due to other conditions is, in the absence of the previous history of the case, always attended with difficulty, and is in certain cases quite impossible. It is therefore of great practical importance to obtain the history where it is possible to do so. The odor of alcohol upon the breath is of less positive diagnostic value than would at first thought appear. In the first place, sympathetic bystanders may have poured alcoholic drinks down the throat of one found unconscious, or, in the second place, individuals who have taken a certain amount of drink may be, and not unfrequently are, seized with apoplexy in consequence of the excitement thereby induced. The more common conditions with which alcoholic coma is confounded are apoplexy from cerebral hemorrhage and narcotic poisoning, especially opium-poisoning. To these may also be added uræmic coma and, under exceptional circumstances, sunstroke. In all these cases the circumstances under which the individual has been found are of diagnostic importance.
In alcoholic coma the pupils are more commonly dilated than contracted, the heart's action feeble, the respiration shallow, the muscular relaxation symmetrical, and the temperature low. There is a strong odor of alcohol upon the breath.
In apoplexy from cerebral hemorrhage the condition of the pupils will depend upon the location of the clot. They may be moderately dilated, firmly contracted, or unequal. The enfeeblement of the heart's action is, as a rule, less marked than in profound alcoholic coma. The pulse may be small or full and slow or irregular. It is usually slow and full. The respiration is often, although not invariably, slow and stertorous. Not uncommonly, the eyes and also the head deviate from the paralyzed side. If the coma be not absolute, the muscular relaxation is unilateral. The temperature is at first slightly below the normal, but less, as a rule, than in alcoholic coma; after several hours it rises to or above the normal.
In complete opium narcosis the insensibility is profound; the heart's action is slow or rapid, but feeble; the respirations slow and shallow or quiet or stertorous; the face at first flushed, afterward pallid and cyanosed; the pupils minutely contracted or dilated as death approaches; and the muscular relaxation complete, with abolition of reflex movements. In cases of doubt it is important to use the stomach-pump.
Uræmic coma is apt to be preceded by or alternate with convulsions. The pupils are more commonly slightly contracted than dilated, but are without diagnostic significance. The temperature is not elevated; it may even be low. The face may be pallid, pasty, and puffy, and there may be general anasarca if the nephritis be parenchymatous. On the other hand, in interstitial nephritis there is hypertrophy of the heart, without evidence of valvular disease, and some degree of puffiness of the lower extremities. In doubtful cases the urine should be drawn by a catheter and subjected to chemical and microscopical examination.51 Diabetic coma occurs suddenly without convulsions. This condition may be suspected when the emaciation is extreme or upon the recognition of sugar in the urine.
51 The following is the method recommended by Green (Medical Chemistry, Philadelphia, 1880) for the detection of alcohol in the urine: If its reaction be acid, the urine is exactly neutralized by potassium acid carbonate. It is then distilled on a water-bath in a flask or retort connected with a condensing apparatus. When about one-sixth of the liquid has passed over the distillate will, if alcohol be present, present the following characteristics: first, the peculiar alcoholic odor; second, a specific gravity lower than water; third, upon being mixed with dilute sulphuric acid and treated with a few drops of potassium bichromate solution the liquid becomes green, owing to the separation of chromic oxide; the odor of aldehyde may at the same time be observed. This reaction is not characteristic, but may serve to confirm other tests. Fourth, if dilute alcohol be shaken with an excess of solid and dry potassium carbonate in a test-tube, the greater part of the water will be appropriated by the potassium carbonate, and two layers of liquid will be formed. The alcohol constitutes the upper layer, and if sufficiently concentrated will burn upon the application of a flame. Finally, a small trace of alcohol may be separated from the urine without difficulty after the ingestion of alcoholic liquids by means of a good fractionating apparatus. Less than 1 per cent. of alcohol cannot be detected.
Sunstroke is characterized by dyspnœa, gasping respiration, jactitation, and intense heat of the skin. The pulse varies. It may be full and labored or feeble and frequent. The face is usually flushed. The pupils, at first contracted, are afterward dilated. The coma is apt to be interrupted by transient local or general convulsions.
It is impossible to lay down any rules by which the maniacal form of acute alcoholism may be at once diagnosticated from acute mania from other causes. For the characteristics of the convulsive form of acute alcoholism and those forms which occur in persons of unsound mind the reader is referred to the descriptions of those conditions. The diagnosis of acute poisoning by alcohol in lethal doses can only be established during life by investigation of the history of the case.