D. Pellagra
IV. Diseases of uncertain pathogenesis associated with alcoholism
A. Cerebellar degeneration
B. Marchiafava-Bignami disease
C. Central pontine myelinolysis
D. “Alcoholic” myopathy and cardiomyopathy
E. Alcoholic dementia
F. Cerebral atrophy
V. Fetal alcohol syndrome
VI. Neurologic disorders resulting from cirrhosis and portal–systemic shunts (see Chap. 39)
A. Hepatic stupor and coma
B. Chronic hepatocerebral degeneration
VII. Traumatic brain lesions acquired during intoxication—subdural hematoma, cerebral contusion
The usual manifestations of alcohol intoxication are so commonplace that they require little elaboration. They consist of varying degrees of exhilaration and excitement, loss of restraint, irregularity of behavior, loquacity and slurred speech, incoordination of movement and gait, irritability, drowsiness, and, in advanced cases, sleepiness, stupor, and coma. There are several complicated types of alcohol intoxication, which are considered below.
As has been indicated, the symptoms of alcoholic intoxication are the result of the depressant action of alcohol on cerebral and spinal neurons. In this respect, alcohol acts on nerve cells in a manner akin to the general anesthetics and can cause coma. Unlike the anesthetics, however, the margin between the dose of alcohol that produces surgical anesthesia and that which dangerously depresses respiration is a narrow one, a fact that adds an element of urgency to the diagnosis and treatment of alcoholic coma. One must also be alert to the possibility that other sedative-hypnotic drugs may have potentiated the depressant effects of alcohol. Another treacherous situation is that of traumatic brain injury that is complicated by intoxication, a circumstance that is prone to misinterpretation because of uncertainty as to the main cause of stupor or coma.
Despite what has been said earlier, on rare occasions, alcohol has an exclusively excitatory rather than a sedative effect. This reaction has been referred to in the past as pathologic, or complicated, intoxication and as acute alcoholic paranoid state. Because all forms of intoxication are pathologic, atypical intoxication or idiosyncratic alcohol intoxication are more appropriate designations, nevertheless, the term pathologic intoxication is still used. The boundaries of this syndrome have never been clearly drawn. In the past, variant forms of delirium tremens and epileptic phenomena, as well as psychopathic and criminal behavior, were indiscriminately included. Now the term is generally used to designate an outburst of blind fury with assaultive and destructive behavior. Often the patient is subdued only with difficulty. The attack terminates with deep sleep, which occurs spontaneously or in response to parenteral sedation; on awakening, the patient has no memory of the episode. Lesser degrees are also known wherein the patient, after several drinks, repeatedly commits gross social indiscretions. Allegedly this reaction may follow the ingestion of a small amount of alcohol, but in some of the patients we have observed the amount has often been substantial. Unlike the usual forms of alcohol intoxication and withdrawal, the atypical form has not been produced in experimental subjects, and the diagnosis depends upon the aforementioned arbitrary criteria.
Pathologic intoxication has been ascribed to many factors, but there are no meaningful data to support any of them. However, an analogy may be drawn between pathologic intoxication and the paradoxical reaction that occasionally follows the administration of barbiturates or other sedative drugs. The few patients we have seen, mostly young men of college age or slightly older, have been docile and seemingly well adjusted when not drinking. Usually, they have avoided alcohol after a first episode of this sort, but there have been exceptions.