Unequivocal cases of FAS observed to date have occurred only in infants born to severely alcoholic mothers (many of them with delirium tremens and liver disease) who continued to drink heavily throughout pregnancy. It is important to state that a relationship to lesser degrees of alcohol intake is far less secure. Data derived from the collaborative study sponsored by the National Institutes of Health indicate that about one-third of the offspring of women who are heavy drinkers have FAS. Abel and Sokol have estimated that the worldwide incidence of FAS is 1.9 per 1,000 live births and have pronounced it the leading known cause of mental retardation in the western world. The degree of maternal alcoholism that is necessary to produce the syndrome and the critical stage in gestation during which it occurs are still vague. The various teratogenic effects described earlier are estimated to occur in the embryonic period, that is, in the first 2 months of fetal life. Other nonteratogenic effects appear to be related to periods during gestation when the fetus is exposed to particularly high alcohol levels.
A comprehensive and not outdated account of alcohol-related birth defects and the controversial issues surrounding this subject is contained in a special issue of Alcohol Health and Research World, published by the National Institutes of Health (Vol. 18, 1994).
Neurologic Complications of Alcoholic Cirrhosis and Portal–Systemic Shunts
This category of alcoholic disease is discussed in Chap. 39, in connection with the acquired metabolic disorders of the nervous system.
Treatment of Alcohol Dependence
Following recovery from the acute medical and neurologic complications of alcoholism, the patient still must face the underlying problem of alcohol dependence. To treat only the medical complications and leave the management of the drinking problem to the patient alone is shortsighted. Almost always, drinking is resumed, with a predictable recurrence of medical illness. For this reason, the medical profession must be prepared to deal with the addiction or at least to initiate treatment.
The problem of excessive drinking is formidable but not nearly as hopeless as it is generally made out to be (see review of O’Connor and Schottenfeld). A common misconception among physicians is that specialized training in psychiatry and an inordinately large amount of time are required to deal with the addictive drinker. Actually, a successful program of treatment can be initiated by any interested physician, using the standard techniques of history taking, establishing rapport with the patient, and setting up a schedule of frequent visits, although not necessarily for prolonged periods. Our position on this matter was reinforced by a controlled study of problem drinkers in whom treatment was equally successful whether carried out by general practitioners or by specialists (Drummond et al). O’Connor and Schottenfeld summarize the various approaches to the patient who has a drinking problem but is not yet alcohol dependent. They favor brief and focused interventions that point out the problem in unambiguous terms and offer empathetic advice; the physician is often the central person in this interaction.
It appears that the requisite for successful treatment is total abstinence from alcohol; for all practical purposes, this represents the only permanent solution. There are alcohol addicts who have been able to reduce their intake of alcohol and eventually to drink in moderation, but they represent only a small proportion of the addicted population. Alcoholic patients must be made fully aware of the medical and social consequences of continued drinking. They must also be made to understand that because of some constitutional peculiarity (like that of the diabetic, who cannot handle sugar) they are incapable of drinking in moderation. These facts should be presented in much the same way as one would explain the essential features of any other disease; there is nothing to be gained from adopting a punitive or moralizing attitude. Yet patients should not be given the idea that they are in no way to blame for their illness; there appears to be an advantage in making them feel that they are responsible for doing something about their drinking.