History and epidemiology of alcohol use and abuse

From the earliest of times, alcohol is probably the first substance known to possess equal use as a potable liquid and/or drug. Presumably our remote ancestors discovered accidentally the natural fermentation processes of fruits and grains, thus producing a nonspoiling beverage. That this can be mere happenstance has also been supported by the instances in nature when one observes animals under the effects of alcohol, such as bears in Montana appearing “tipsy” after sampling fermented grain spilled in large amounts after a train wreck. Other examples include animals on a warm autumn day ingesting fermented fruits and showing diminished motor capability. Alcoholic beverages, primarily beers and wines, are best documented early in the cultural literature; they represent an important step forward in providing potable liquids that were portable. In traveling, local sources of water are always in question, and it is difficult or impossible to transport most other forms of liquids that are usually ingested, such as milk and juices. The transport of fruit juices very likely also resulted in natural fermentation, which slowly converted the juices’ fruit sugars to an alcoholic beverage, just as unpasteurized apple cider in the fall, when kept at room temperature, eventually ferments, forming Apple Jack (and ultimately vinegar). By definition, beers and wines are naturally fermented, with beer achieving a maximum alcohol concentration between 3% and 8%, and wine somewhat higher, between 8% and 12%. To achieve higher alcohol content, it is necessary to distill or fortify the particular beverage. With this, one can increase the content of wine by 20% or more, and with distillation, one can produce a menu of liquors such as whiskey, gin, and vodka by up to 50% alcohol. In regards to intake, each one standard drink—wine 6 oz., beer 12 oz., or 90-proof spirits 1.5 oz.—contains 12 grams of alcohol.1 The same process can be carried to completion through distillation, up to about 95% pure alcohol (ethanol); however, this would no longer be considered a beverage, but rather a reagent or solvent. Because of the ability of alcohol to absorb water, it is difficult to maintain ethanol solutions above the 95% level. Majno’s review of the history of medicine provides an important overview of the significance of alcohol and alcoholic beverages through the centuries.2 Nearly every society has found the means to produce an alcoholic beverage, from mead, to beer, to wine, and for many this provided the opportunity for easily preserved and safely potable beverages. Wine has perhaps one of the longest histories, at least in Mediterranean civilization. Wine has been used both as a beverage and as topical or systemic medicine. Majno points out that, although the 9–11% concentration of alcohol present in ordinary wines has little effect on bacteria by itself, wine has been used as mainstay in wound treatment ever since the Greek empire. Historically, the observation by Rabuteau of the apparent protection of wine drinkers in Paris during a cholera epidemic resulted in Rabuteau suggesting the importance of the use of wine to make drinking water safer. This was prior to the real understanding of the causation for both cholera and typhoid fever. Alois Pick, an Austrian military doctor, further studied the effect of adding cholera and typhoid bacilli to different flasks that had either water, wine, or 50/50 water/wine ratio. The organisms flourished in the water flasks, whereas Pick noted that wine, straight or diluted, killed Vibrio cholera within 10 to 15 minutes. It took longer for the typhoid bacilli to be killed, but wine also destroyed them within 24 hours. This further reinforced the general impression of the importance of safe and potable liquids with wine and other alcoholic beverages in much of Europe, serving them as the primary source for fluid ingestion. Ever since that time many observations have affirmed the benefits of wine, and in particular the superiority of red wine, in anti-infectious activities. While one assumes the alcohol plays a primary role in antisepsis, studies have shown that wine retains antiseptic characteristics after removal of the alcohol; moreover, studies comparing red and white wines versus 9.8% alcohol in culture growth of E. coli make it very clear that the wines have more activity and are more potent in this manner than is the pure alcohol. The exact molecules that are active remain obscure, but the mechanism operating here includes the possibility of the From the Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana. Address correspondence to Larry E. Millikan, MD, Department of Dermatology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112.