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  • Updated 05.23.2023
  • Released 10.09.1997
  • Expires For CME 05.23.2026

Alcohol abuse and its neurologic complications

Introduction

Overview

The topic of alcohol abuse related to acute and chronic exposure covers a wide spectrum of neurologic syndromes involving the central and peripheral nervous system. Historical perspectives, clinical manifestations, clinical vignettes, etiology, pathogenesis, pathophysiology, epidemiology, prognosis, complications, and management are all discussed in this updated article. In addition, the authors discuss select mechanisms of cellular injury by alcohol.

Key points

• Alcohol intoxication has an acute and chronic symptomatology.

• The lethal dose of alcohol varies widely and depends on many external and internal factors. Tolerance develops with repeated exposures.

• Wernicke-Korsakoff syndrome is particularly found in the alcoholic population.

• Alcohol affects almost all areas of the nervous system.

• Alcohol affects the functioning of many systems in the body (heart, liver, muscle, nerve).

Historical note and terminology

Humans have consumed alcohol for thousands of years. Indeed, archaeologists have found evidence of nearly 11,000-year-old beer brewing troughs at a site in Turkey called Göbekli Tepe (69).

The term “alcoholism” was first used by a Swedish physician in 1849 to describe the adverse systemic effects of alcohol. Also, early psychiatry texts described a syndrome of alcohol-related deterioration characterized by intellectual and behavioral abnormalities (11).

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-Tr) defined alcoholism as “maladaptive pattern of drinking, leading to clinically significant impairment or distress” (12).

The definition of alcoholism by the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine is “a primary, chronic disease characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking” (193).

The role of alcoholism in the development of cognitive and functional decline was known in Ancient Greece (132) and has received serious study in Western medicine for more than 250 years.

In Greek mythology, Silenus was the frequently drunken companion and tutor of the wine god Dionysus. Artistic depictions of the drunken Silenus show him supported by satyrs or carried by a donkey.

Some Renaissance artistic depictions of the drunken Silenus show features of alcoholic cirrhosis, perhaps most fully in the painting Drunken Silenus (1626) by Spanish painter Jusepe de Ribera (1591-1652): evident signs of liver disease in this painting include parotid gland swelling, spider angioma (left parasternal area), gynecomastia, and ascites.

Giambattista Morgagni (1682-1771)
Italian anatomist and pathologist Giambattista Morgagni (1682-1771). Line engraving by G. Simoncelli. (Courtesy of the Wellcome Collection.)

A clinic-pathologic description of hepatic encephalopathy from alcoholic cirrhosis was described by Italian anatomist and pathologist Giovanni Battista Morgagni (1682-1771), Professor of Anatomy at the University of Padua, in his De sedibus et causis morborum per anatomen indagatis (Seats and Causes of Diseases Investigated by Anatomy) (192).

John Coakley Lettsom (1744-1815)
English physician and philanthropist John Coakley Lettsom (1744-1815). Lettsom described alcoholic neuropathy. Portrait attributed to Johann Zoffany (1733-1810), circa 1782.

Alcoholic neuropathy was documented at least as early as 1787 by English physician and philanthropist John Coakley Lettsom (1744-1815) (171), but other neurologic complications of alcoholism were probably not recognized until the end of the 19th century or later.

Alcohol-related deficits in memory and intellectual ability were reported in 1878 by British psychiatrist Robert Lawson (1846-1896) of the Wonford House Lunatic Asylum in Exeter (167; 166).

Subsequently, in a series of three articles from 1887 to 1889, Russian neuropsychiatrist Sergei Sergeievich Korsakoff (sometimes spelled Korsakov; 1853/1854-1900) gave a comprehensive description of the persistent amnestic confabulatory state now known as Korsakoff psychosis, occurring in conjunction with peripheral polyneuropathy, a combination he initially labeled either as “psychosis associated with polyneuritis” or “polyneuritic psychosis” (152; 151; 150; 309; 304; 305; 303; 159; 162; 163). Korsakoff based his conclusions on at least 46 patients, about two-thirds of whom were alcoholics, whereas the remainder suffered from a diverse group of disorders associated with protracted vomiting.

Carl Wernicke
German neuropsychiatrist Carl Wernicke (1848-1905). Photograph by J.F. Lehmann in Munich. (Courtesy of the U.S. National Library of Medicine, a public domain.)

Korsakoff was apparently unaware of the syndrome incorporating a confusional state, ophthalmoparesis and other oculomotor findings, ataxia, and neuropathic features, which had been described by German neuropsychiatrist Carl Wernicke (1848-1905) in 1881 and labeled as “Die acute, hämorrhagische Poliencephalitis superior” (acute hemorrhagic superior polioencephalitis) and is now generally called Wernicke encephalopathy (314; 145; 146). The clinico-pathologic overlap between Wernicke encephalopathy and Korsakoff psychosis was ultimately recognized in the late 1920s and early 1930s (92; 134; 42), and the two terms became linked as Wernicke-Korsakoff syndrome.

The term “alcoholic hallucinosis” (also known as “alcohol hallucinosis” and “alcohol-related psychotic disorder”) refers to a disorder of acute onset, with a predominance of auditory hallucinations (although delusions and hallucinations in other sensory modalities may also be present), no disturbance of consciousness, and a history of heavy alcohol consumption (96).

Paul Eugen Bleuler (1857-1939)
Swiss psychiatrist Paul Eugen Bleuler (1857-1939), circa 1900. (Courtesy of the U.S. National Library of Medicine.)

This syndrome has often been attributed to Swiss psychiatrist Paul Eugen Bleuler (1857-1939), who labeled it alcoholic hallucinosis (Alkoholhalluzinose) and considered it as an alcoholic madness (Alkoholsahnsinn) (31); Bleuler was also responsible for other psychiatric terms, including schizophrenia, schizoid, and autism. However, in his textbook, Bleuler acknowledged the earlier description by Wernicke, who labeled the disorder as “chronic hallucinosis in alcoholism” (chronische Halluzinose beim Alkoholismus) (315). Even earlier, in 1847, the French author Claude-Nicolas- Séraphin Marcel described a similar symptom complex under the label of folie d'ivrogne (ie, drunken madness) (181).

Although alcoholic intoxication was long recognized in art, portrayals of delirium tremens in caricatures (276) and health propaganda posters became particularly prominent in the early 20th century, in the years before and during Prohibition (1920-1933) in the United States.

Marchiafava-Bignami disease is a progressive alcoholism-related neurologic disease characterized by corpus callosum demyelination and necrosis and subsequent atrophy. The disease was first described in 1903 by the Italian pathologists Ettore Marchiafava (1847-1935) and Amico Bignami (1862-1929) in an Italian Chianti drinker (182). In the autopsy of this patient, the middle two-thirds of the corpus callosum were necrotic.

In the last century, through careful observation and description, American neurologist and neuropathologist Raymond Delacy (“Ray”) Adams (1911-2008) made the most prodigious contributions in understanding the neurologic complications of alcohol abuse, in conjunction with various protégés, notably Boston-born neurologist Joseph Michael (“Joe”) Foley (1916-2012) and, subsequently, Canadian-American neurologist Maurice Victor (1920-2001) (01; 02; 03; 04; 86; 05; 306; 305; 307; 301; 308). Foley began to work with Adams on the neurologic manifestations of liver disease in the late 1940s after Foley returned from his military service during World War II (165; 160). In a series of reports from 1949 to 1953, Adams and Foley described the clinical (neurologic), electroencephalographic, and neuropathologic features of alcoholic liver disease, including the clinical and electrophysiologic features of asterixis (01; 02; 03; 04; 86).

Social commentary on the neurologic degeneration and social decay from alcoholism. The neurologic disorders and social decay resulting from alcoholism were targeted by social reformers in many countries since at least the 18th century.

English engraver, pictorial satirist, and social critic William Hogarth (1697-1764) depicted the effects of alcoholism in his famous engraving, Gin Lane (1751).

Gin Lane (1751) by English engraver, pictorial satirist, and social critic William Hogarth (1697-1764)

Hogarth's engraving, published according to Act of Parliament on February 1, 1751 in support of what would become the "Gin Act," shows a poor London street (the area depicted is St. Giles, London) strewn with hopeless drunka...

Hogarth's engraving, published according to Act of Parliament on 1 February 1751 in support of what would become the "Gin Act," shows a poor London street (the area depicted is St. Giles, London) strewn with hopeless drunkards and lined with gin shops and a flourishing pawnbroker. The inhabitants of Gin Lane are being destroyed by their addiction to the foreign spirit of gin, with the engraving illustrating shocking scenes of child neglect, starvation, madness, drunken brawls, and death. Hogarth's illustration is filled with satirical humor: the pawnbroker's shop depicted is "S. Gripe pawnbroker;" the distillery is "Kilman distillery;" a gin shop sign reads "drunk for a penny, dead drunk for two pence, clean straw for nothing;" and a drunkard's paper is headed "the downfall of Mdam. gin."

A poem below the engraving reads as follows:

Gin cursed Fiend, with Fury fraught,
Makes human Race a Prey;
It enters by a deadly Draught,
And steals our Life away.

Virtue and Truth, driv'n to Despair,
It's Rage compells to fly,
But cherishes, with hellish Care,
Theft, Murder, Perjury.

Damn'd Cup! that on the Vitals preys,
That liquid Fire contains
Which Madness to the Heart conveys,
And rolls it thro' the Veins.

At that time, there was no quality control whatsoever, and gin was frequently adulterated (eg, with turpentine). When it became apparent that copious gin consumption was causing social problems, social reformers and the government made efforts to control the production of the spirit. The Spirit Duties Act (commonly known as the Gin Act of 1736) imposed high taxes on sales of gin, forbade the sale of gin in quantities of less than two gallons, and required an annual payment of £50 for a retail license. These measures had little effect beyond increasing smuggling and driving the distilling trade underground. The act was repealed by the Gin Act of 1743, which set much lower taxes and fees.

Similarly, the 4-part sequence of "A Drunkard's Progress" (1826) by American engraver and historian John Warner Barber (1798-1885) depicts the neurologic and social decay from alcoholism, complete with biblical admonitions. In the first image, "The Morning Dram," the father is drinking at 8 AM, ignoring his wife and children.

The Drunkard's Progress, or the Direct Road to Poverty, Wretchedness & Ruin: The Morning Dram (1826)

Hand-colored engraving by John Warner Barber (1798-1885), printed in New Haven, Connecticut. Biblical quotation above the image: "Wo unto them that rise up early in the morning that they may follow Strong Drink... Isa 5 C. 11v....

In the second image, "The Grog Shop," two men are drinking at a saloon, while two are brawling, one is vomiting, and one is unconscious on a bench.

The Drunkard's Progress, or the Direct Road to Poverty, Wretchedness & Ruin: The Grog Shop (1826)

Hand-colored engraving by John Warner Barber (1798-1885), printed in New Haven, Connecticut. Biblical quotation above the image: "Wo unto them that are mighty to drink wine, and men of strength to mingle Strong Drink... Isaiah ...

In the third image, "The Confirmed Drunkard," the father is intoxicated on the floor, while his wife and children are afraid, and the home is falling apart.

The Drunkard's Progress, or the Direct Road to Poverty, Wretchedness & Ruin: The Confirmed Drunkard (1826)

Hand-colored engraving by John Warner Barber (1798-1885), printed in New Haven, Connecticut. Biblical quotation above the image: "Who hath wo? Who hath sorrow? Who hath contentions? Who hath wounds without cause? ... They that ...

In the final image of the sequence, "Concluding Scene," there is an auction sign on the house, ordered by the sheriff. The family is evicted and departing with the wife in tears.

The Drunkard's Progress, or the Direct Road to Poverty, Wretchedness & Ruin: Concluding Scene (1826)

Hand-colored engraving by John Warner Barber (1798-1885), printed in New Haven, Connecticut. Biblical quotations above the image: "The drunkard shall come to poverty. Proverbs 23 Chap. 21 v." [Proverbs 23:21] and "The wages of ...

Social critics and reformers blamed both the alcoholic and those that manufactured or sold alcohol for the adverse outcomes on individuals and society. The responsibility of purveyors of alcohol for the negative effects was portrayed in various ways, but often with religious overtones. For example, the engraving titled "Illustration of the Rumseller's just doom and final exit" (1835).

Illustration of the Rumseller's just doom and final exit (1835)

The Latin expression "Facilis descensus Averni: sed revocare gradum, Hoc opus, hic labor est." is translated below as "The descent to Perdition is easy--but to retrace one's steps--this is labor--this a task severe." The work i...

A Latin expression serves as an epigram: "Facilis descensus Averni: sed revocare gradum, Hoc opus, hic labor est." ("The descent to Perdition is easy—but to retrace one's steps—this is labor—this a task severe.") The engraving depicts a man who is praying the rosary, about to be impaled by the devil, and struck by lightning bolts held in the hand of God. He is descending into Hell, portrayed by fire, smoke, a snake, and a fire-breathing serpent or dragon. A poem below the engraving reads as follows:

Behold! the soulless wretch—destroyer of his race—
In adamantine Chains—no more to show his face—
His Cup of Sin is full—fast flowing o'er the drim—
His light is quite extinct—there is no hope for him.

Companion of the worm—the victim of despair—
Lost to human sympathy—lost to Christian prayer—
Persued by wrath divine—hurled from the realms of light—
He sinks into the abyss—of one, eternal night.

Leading up to Prohibition in the United States, numerous forms of propaganda were used to convince people of the harms of alcohol (or of its relative safety by opponents of prohibition). One political cartoon of that era, "A sample room and its samples" (1902), for example, depicted a saloon keeper in front of a morbid saloon window display.

Toxic effects of alcohol: a sample room and its samples (1902)

A saloon keeper in front of a morbid saloon window display. The window display sign says: "SHOW WINDOW EXHIBIT. WHAT OUR LIQUORS CAN DO. GENUINE SPECIMENS MADE ON THE PREMISES." In the window display are five people, four label...

The window display sign says: "SHOW WINDOW EXHIBIT. WHAT OUR LIQUORS CAN DO. GENUINE SPECIMENS MADE ON THE PREMISES." The implications of this sign are displayed in the window in the form of five people damaged by alcohol, four of whom are labeled with their alcohol-induced problems: madman, tramp, convict, and idiot child (fetal alcohol syndrome). The fifth person, a woman, appears depressed or confused.

The 18th Amendment to the U.S. Constitution banned the manufacture, transportation, and sale of intoxicating liquors. The Volstead Act was ratified by the states on January 16, 1919 and went into effect on January 17, 1920, marking the beginning of the period in American history known as Prohibition. Despite an army of agents of the Bureau of Prohibition, Prohibition proved difficult to enforce; eventually, the illegal production and sale of liquor (“bootlegging”), the proliferation of illegal drinking spots ("speakeasies"), and the accompanying rise in gang violence and other crimes led to waning support for Prohibition by the end of the 1920s.

The 21st Amendment was ratified on December 5, 1933, repealing the 18th Amendment and ending Prohibition.

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