Spirits From the Past: Stigma in Historical Medical Literature on Alcohol Addiction and Implications for Modern Practice

Prominent 19th century American physician, Benjamin Rush, wrote on "habitual drunkenness" (2–4) in An Inquiry Into the Effects of Ardent Spirits Upon the Human Body and Mind (circa 1784) (5). He attributed alcohol addiction to loss of control over drinking and described it as a clinical and moral disease (5). He also advocated for abstinence as the only cure (5–7). Indeed, Rush detailed morality as a faculty of the body and mind. He named nine innate faculties of the mind: three intellectual faculties (imagination, understanding, and memory), three moral faculties (the moral sense, the conscience, and the sense of deity), and three miscellaneous faculties (the will, the passions, and the principle of faith). Derangements of any of these faculties could result in disease (8). For example, delirium was considered an insult to the intellectual faculties and could be caused by fluctuations of blood flow to the brain (hence connecting mind and body). He characterized moral pathology as "anomia," or complete absence of moral action (unrelated to the neurologic condition of anomic aphasia) (8, 9).

An Inquiry pointed to liquor as the driver of moral corruption, and this commentary sparked broader societal discourse. Rush's analysis of morality was meticulous, but he associated addiction with depravity. His preoccupation with moral deficit overshadowed his clinical observations and contributed to mounting stigma against those with alcohol addiction.

Such stigma manifested at the Philadelphia Hospital where Rush served. The hospital did not treat intoxicated patients, though Rush tried, albeit unsuccessfully, to build a unit to meet this need (10). Although Rush devoted much of his early work to discussing addiction in the context of morality, he spent the last few years of his life advocating for improved access to care for those with addiction. Despite his efforts, these patients were relegated to inferior facilities, such as the overcrowded and poorly ventilated Philadelphia Almshouse, which also housed yellow fever patients (11). Rush's emphasis on right versus wrong clouded his views on addiction. His words are striking, not simply as historical artifact but also for their medical authority and influence. In a similar manner, autopsy reports published by physician Thomas Sewall, a contemporary of Rush, interwove religious rhetoric and pathology findings.

Thomas Sewall conducted autopsies of chronic drinkers and illustrated tissue damage attributed to excess alcohol use. His findings yielded tangible evidence of addiction as a medical condition. Like Rush, Sewall used clinical acumen to educate the public on the dangers of excess alcohol use. He described a nondrinker's stomach as having "the internal or mucous coat of the stomach in a health state, which in [color], is slightly reddish, tinged with yellow" (12). He contrasted this with "The stomach of the habitual drunkard [where] the mucous or internal coat [is] in a state of irritation, with its blood vessels, which are invisible while in a health state, [are] distended with blood."

Sewall observed what we now know to be gastric varices, a progression of portal hypertension that can be caused by liver cirrhosis (13). Although Sewall presented objective findings, he also evoked religious undertones that appealed to the broader society. He noted, "wine is a mocker, and science confirms it. Its use is a sin against the God of Heaven" (12). Although medical literature of the 19th century widely cited a moral cost associated with alcohol consumption, a shift in focus to delirium tremens intensely captured the public's attention and, eventually, its imagination.

Delirium tremens is an acute disruption in cognition and attention occurring in the setting of alcohol withdrawal (14). Notorious for insidious onset and potentially fatal outcomes, delirium tremens warrants close monitoring even today, with mortality rates ranging from 5% to 15% (14, 15). Delirium tremens was first described in 1813, at a time when medical writing mirrored growing cultural enchantment with hallucinations associated with alcohol intoxication and withdrawal. The rise of the American Gothic literature genre and its characteristic supernatural narratives gripped the public (3, 10, 16). Well-known works from the time, such as those by Nathaniel Hawthorne, Edgar Allen Poe, and Ambrose Bierce, carried themes of supernatural phenomena, alcohol intoxication, and self-destruction (16). Case reports of delirium tremens similarly shaped public perception of alcohol addiction, particularly as bizarre and grotesque descriptions of hallucinations were reported (10). What began as clinical observation, soon burgeoned into a form of creative enterprise. Storied apparitions and supernatural phenomena filled medical journals of the 19th century and eclipsed objective documentation of withdrawal.

In 1813, physician Samuel Pearson described a patient's withdrawal presentation in theatrical detail while also detailing his management of alcohol withdrawal in his publication, "Observations on Brain Fever'" (17). "A full dose of opium should be immediately administered in a glass of wine and repeated in smaller doses for several hours successively; the quantity of which should be regulated by the constitution of the patient." Of note, this guidance resembles a rudimentary form of modern day Clinical Intoxication Withdrawal Assessment (14, 18). Pearson was likely referring to laudanum, a tincture of opium mixed with alcohol originally popularized by Thomas Sydenham circa 1660 (19).

Pearson also described a patient in alcohol withdrawal as haunted by phantoms. The patient had delusions that he had committed murder and believed his crime was uncovered by these spirits. These delusions persisted despite increased laudanum dosing. Though innocent, the patient suffered from guilt until taken to the gravesite of his alleged victim (17). Despite Pearson's earlier guidance on treating alcohol withdrawal, he conceded that in some cases, the cure lies in confronting a patient's delusions (even if it warrants a graveyard visit). Pearson's storytelling likely resonated with readers already fascinated by supernatural literature. He highlighted to the public the significant risks of withdrawal. Unfortunately, the patient's suffering portrayed as caricature also worsened the perception of those with alcohol addiction.

Stigmatizing language in medical literature on addiction persisted well beyond the era of Rush, Sewall, and Pearson. In 1955, Isbell et al. (20) studied alcohol withdrawal in subjects with a history of alcohol and opiate addiction. This study gained notoriety for its controversial treatment of subjects, who were administered alcohol for prolonged periods and monitored for withdrawal seizures. Subjects were defined in derogatory terms, with their behavior described as "typical of that of any group of former morphine addicts." Intoxication was described as "debauch" and suggested moral deviance. Moreover, supernatural themes emerged in descriptions of delirium tremens, such as visions of snakes rising from the floor, disembodied faces, and the screams of a man being killed (20). The narrative components of delirium tremens did not provide substantial clinical data, nor did they humanize the subjects. Once again, spectacle overshadowed science.

Physicians such as Rush, Pearson, and Sewall gave medical credence to what was previously considered a largely social and religious issue. Although their work brought alcohol addiction to the forefront of public discussion, their language formulated patients through a theatrical lens. The voices of these early physicians introduced a potent negative image of addiction that echoed in later works, such as that of Isbell et al. (20). Modern medicine reframes addiction as the biological brain disease that it is, thereby supporting discussions of morbidity and mortality over morality. Today's clinicians are empowered by the rise and reach of online publications and social media. However, history bears testimony that language used by medical authority outlives its authors and affects public perception for generations to come. In many ways, medical literature of the past serves as a cautionary tale. Indeed, sometimes the most compassionate lens is an objective one.