r
one of drunkenness. It is scarcely necessary to say that a man who
smells of alcohol is not necessarily intoxicated; the drink may have
been given with the object of reviving him. It may be that one or
other of the above-named conditions has caused the patient to fall,
and in his fall he has incidentally sustained an injury to the head,
which, however, is in no way responsible for his unconsciousness.
Whenever there is the least doubt, therefore, the patient should be
admitted to hospital.

In the first instance, careful search should be made for any sign of
injury, especially on the head. The discovery of a severe scalp wound
or of a fracture of the skull, in association with the symptoms of
concussion or compression, will in most cases raise the presumption
that the unconsciousness is due to some traumatic intra-cranial
lesion. Examination of the fluid withdrawn by lumbar puncture may
furnish useful information (p. 338).

In the absence of evidence of a head injury, the stomach should be
washed out and its contents examined to see if any narcotic poison is
present. The urine also should be drawn off and examined for albumin
and sugar.

In haemorrhage due to the rupture of diseased cerebral arteries
(apoplexy), or to embolism, the symptoms are essentially those of
compression, and, in the absence of a definite history of injury to
the head, it is seldom possible to arrive at an accurate diagnosis as
to the cause of the condition. The history that the patient has
previously had "an apoplectic shock," and the fact that he is up in
years and shows signs of arterial degeneration and of cardiac
hypertrophy which would favour such haemorrhage, are presumptive
evidence that the lesion is not traumatic.

If a history is forthcoming that the patient is an epileptic, there is
a strong presumption that the symptoms are those of _epileptic coma_.

In _alcoholic poisoning_ the examination of the stomach contents will
furnish evidence. The patient is not completely unconscious, nor is he
paralysed; the pupils are usually contracted, but react; and the
temperature is often markedly subnormal. Improvement soon takes place
after the stomach has been emptied.

In _opium poisoning_ the general condition of the patient is much the
same as in poisoning by alcohol. The pupils, however, are markedly
contracted, and do not react to light. When the poison has been taken
in the form of laudanum, this may be recognised by its odour.