Matthew Warner Osborn. Rum Maniacs: Alcoholic Insanity in the Early American Republic. Chicago: University of Chicago Press, 2014. 280 pp. $48.00 (cloth), ISBN 978-0-226-09989-7.
Reviewed by Iain Smith (Gartnavel Royal Hospital)
Published on H-Disability (April, 2017)
Commissioned by Iain C. Hutchison
This book is a most welcome addition to a surprisingly sparse strand of research in the realm of medical history. The story of delirium tremens is undoubtedly a fascinating one. When this history is potentially fully mapped out, it will shine a light on the two-hundred-year history of the medicalization of the habit of heavy drinking and, in particular, its mental consequences.
The doctor of today is trained to identify alcohol dependence. The doctor believes that the existence of such dependence in a patient means that if they suddenly stop drinking they will be at risk of an alcohol withdrawal state. This alcohol withdrawal state can display a wide range of severity and potentially pass a threshold and become an alcohol withdrawal state with delirium. The latter term is not one that is widely used by the layperson. However, if they were to be told that this condition was previously known as delirium tremens, and by the abbreviation DTs, then recognition would be highly likely.
As Matthew Warner Osborn describes in this history of the condition, other names were in competition for the syndrome, both before and after its description and coinage as delirium tremens by the English physician Thomas Sutton (1767-1835) in 1813. Brain fever, mania a potu, mania a temulentia, delirium vigilans, and delirium potatorum were the main synonyms that did not stand the test of time beyond the end of the nineteenth century. By that point "delirium tremens" was common currency.
From the perspective of the British Isles, there is much to compare in relation to the detail in Osborn's account in Rum Maniacs: Alcoholic Insanity in the Early American Republic. Osborn's subtitle is a reference to a further synonym for DTs, namely, acute alcoholic insanity. However, in this nosologically confused area much chronic insanity was later to be attributed to alcohol in the world of the asylum.
Before discussing the rapid adoption of the diagnosis of delirium tremens by the medical schools and physicians in Philadelphia, Osborn presents us with the story of Dr. Benjamin Rush (ca. 1745/6-1813), signatory to the American Declaration of Independence, as an early pioneer in both the study of alcohol and its medical effects and as the "father of American psychiatry." Connection to Edinburgh of the Scottish Enlightenment era was strong for both Rush and for the subsequent American physicians who crossed the Atlantic in pursuit of medical knowledge around Europe. Medical journals and textbooks were little delayed in crossing from Europe to Pennsylvania, the state that is the main primary source of Osborn's research.
Osborn presents us with a thesis that the Philadelphian medical interest in delirium tremens, coupled with new concepts of mental science imported from Europe and based on physiology and on phrenology, went on to supplant the "republican system of medicine" of Rush and also to influence the popular culture of the time in a major way (p. 16). I was initially skeptical of the idea of such significant reach into the popular culture of the time, but Osborn amasses such detail that the case is convincing. The works of many novelists and writers are cited, including a long poem called The Rum Maniac (1851) from which this monograph derives its title.
The most famous example of such writers is Edgar Allan Poe (1809-49). The connection between Poe's dark romantic writings and the spectral illusions and hallucinations found in DTs is emphasized. Osborn also links Poe's death in 1849, at age forty, to his drinking by pointing out that he was in one of the beds reserved for inebriates in the Washington Medical College in Baltimore, Maryland. Certainly delirium tremens seems a likely contributor to his death along with other medical conditions that may have been at play.
We also learn of popular plays running night after night in many cities, such as Ten Nights Bar-room (1858). This play was adapted from the 1854 novel of the same name by T. S. Arthur (1809-85), a friend of Poe, and, it was performed throughout the United States for many decades as a warning against habituation to alcohol and the dangers of DTs. Ten Nights in a Bar-room and another play, The Drunkard, or the Fallen Saved! (first performed in 1844), were theatrical gold in the late nineteenth century. The stories could also be related using lantern slides, and the hallucinatory experience of DTs gave license for theatrical special effects.
Another finding from Osborn's research is that class, race, and gender differences existed in how the labels of delirium tremens and intemperance were applied over time to individuals in the antebellum period. These differences are found both in relation to causes of death and in regard to diagnoses given in private and hospital practices, which contrasted with the practice of the almshouse. These distinctions changed after the Civil War (1861-65). Large datasets of death records and admission records are analyzed to demonstrate that DTs was initially a diagnosis for the well-to-do and was given by physicians who were trained in the latest ideas arriving from Europe.
A certain degree of brain development, which was not to be found in the poor, was held to be necessary for the condition to develop. This differentiation between the rich and poor was later to dissolve as the middle classes became swayed by temperance ideology. DTs was then more likely to be applied to the poor.
Given the richness of detail in the book, it is difficult to cover all of its aspects in a short review. Osborn's ideas on the cultural meaning of the many narratives of DTs and intemperance, I will leave to one side. This has been well covered in earlier reviews of this work with an entirely favorable consensus emerging.
From my own perspective as a Scottish clinician treating patients presenting with alcohol withdrawal, and as someone who has read into the history of the disease, a few questions arise in my mind in relation to one important aspect of the story. I feel Osborn's book might have said more about this particular controversy, especially the issue of whether the condition is an intoxication phenomenon or a withdrawal phenomenon in individuals who are sustained heavy drinkers. One retelling of this history maintains that it was the intoxication hypothesis that predominated for over a century prior to the resolution of the issue in favor of a withdrawal aetiology by the famous human "guinea pig" experiment conducted by Harris Isbell and his colleagues in the Addiction Research Centre in Lexington, Kentucky. Osborn is aware of the controversy, but it is difficult from his account to know which view predominated in his period of study.
We learn that the Philadelphian physician Benjamin H. Coates (1797-1881) wrote about DTs in 1827, saying that "this disease is the result, not of the application, but of the sudden intermission, of the use of these articles" (p. 142). "These articles" were of course ardent spirits. However, if we move up to Boston, we find the physician John Ware (1795-1864) writing in 1831 that “it is a common belief, that Delirium Tremens is immediately occasioned by abstinence from ardent spirits. I feel very certain, that in a large proportion of cases, it has nothing to do with it.” And also that “the symptoms of this affection frequently ensue shortly after a course of excessive indulgence. In this case it is not that the discontinuance of the indulgence occasions the disease but that the access of the disease creates a distaste for liquor and is the occasion of the discontinuance of its use.” Osborn does not cite Ware, and, to be fair, the condition was written about frequently in North American medical journals. However, it would be useful to know more on the balance of this controversy at this time in North America.
Certainly in Europe the battle raged between professors. For example, Thomas Laycock (1812-76), Regius Professor of Medicine in Edinburgh, defended the intoxication hypothesis, or rather a variant of it based on the idea that substances other than alcohol in alcoholic beverages might be responsible for DTs, from an attack by the professor in Belfast who supported the discontinuation hypothesis. The theoretical position taken in relation to this argument had implications for treatment. Laycock advocated treatment without alcohol and without opium, and seemed to have much improved outcomes with a very low death rate at the Royal Infirmary of Edinburgh when compared to previous practitioners in the same hospital who used such "stimulants" and "narcotics" in treatment.
Osborn certainly leads us expertly into the murky area of death rates and of treatments administered, but it remains difficult to be sure of the true death rate from uncomplicated and untreated delirium tremens, which to this day is perhaps given as being at a higher rate than the evidence would support. Certainly, as Osborn shows us, the treatment could be worse than the disease. For example, from the early days, when the stomach was viewed as central to the condition of DTs, emetics were often administered. Klapp's cure, for instance, was taken to an extreme with the goal being that of getting the patient to vomit black or light brown material with the consistency of tar. This was older medicine and eventually such cures were suppressed by a flurry of concern over fatalities.
Other thoughts are on the transatlantic comparisons that Osborn allows us to make. Philadelphian physicians were quick to join the temperance cause, setting up early temperance societies in the state of Pennsylvania. In Britain, medicine lagged behind in this regard and doctors came much later to the temperance cause. This goes some way to explain why the United States led the way in relation to early medical treatment of inebriety. Dr. Samuel Woodward (1787-1850), an asylum superintendent in Worcester, Massachusetts, was seminal in arguing for separate inebriate reformatories as early as 1833. These reformatories were to address the habit of drinking rather than its consequences. Also seminal in the United States, and described by Osborn, was the Washingtonian self-help movement, which arguably was a prototype for Alcoholics Anonymous in the twentieth and twenty-first centuries.
Overall, the book is rich in published anecdotes, which in the early nineteenth century helped sustain the public fascination with DTs. The man in DTs who self castrated is a good example of why someone with this condition needs to be observed and safeguarded. The patient in the almshouse who cut off his hand to be given rum speaks to the potential force of compulsion in addiction.
For selfish reasons, I would have welcomed a bibliography, the valuable references provided by Osborn needing to be tracked down through the index and the endnotes. Despite this I would certainly commend this book as it takes us into an important area that has been poorly explored in the medical historical literature of the last seventy-five years. For example, John Romano's 1941 paper on the topic in the Annals of Medical History is difficult to access.
Archival resources exist to allow for similar studies to be conducted in other places for the nineteenth and early twentieth centuries. This may help us fill in some of the gaps that remain in understanding the history of DTs. In the meantime, Osborn has paved the way and revived this field of study.
. Harris Isbell, H. Franklin Fraser, Abraham Wikler, Richard Belleville, and Anna J. Eisenman, "An Experimental Study of the Etiology of Rum Fits and Delirium Tremens," Quarterly Journal of Studies on Alcohol 16, no. 1 (March 1955): 1-33.
. John Ware, Remarks on the History and Treatment of Delirium Tremens (Boston: N Hale's Steam Power Press, 1831), 7.
. Thomas Laycock, "On Delirium Tremens," The Dublin Quarterly Journal of Medical Science 52, no. 2 (November 1, 1871): 300-309.
. John Romano, "Early Contributions to the Study of Delirium Tremens," Annals of Medical History, ser. 3, no. 3 (1941): 128–139.
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Iain Smith. Review of Osborn, Matthew Warner, Rum Maniacs: Alcoholic Insanity in the Early American Republic.
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