One of the many eye-opening experiences for us in medical school was seeing beer on our teaching hospital’s formulary. It’s a holdover from the days before current withdrawal regimens. Indeed, the interaction between the medical establishment and the beer world goes way back.

Today we’ll dwell primarily on one aspect of this interaction — a Prohibition-era skirmish over a physician’s right to serve beer. That’s right: long before the debate on medical marijuana, there was … medical beer.

According to the Smithsonian, medical beer was a wedge issue in the early days of Prohibition — supporters of alcohol tried to exploit a loophole in the Volstead Act:

… the 18th Amendment to the U.S. Constitution did not amount to a complete “prohibition” on all forms of alcohol. It banned only the manufacture, sale or transportation of alcohol “for beverage purposes” – in other words, for the pleasure and delight of socializing and inebriation. This directive covered a substantial proportion of the nation’s imbibers, to be sure, but it also left open certain loopholes for the framers of the Volstead Act, the federal law that finally put the amendment into effect. It excluded all alcohol-mainly sacramental wines-consumed for religious purposes. Hair tonics, perfumes, toilet waters and other cosmetic products were similarly exempt. Not least, it excluded alcohol prescribed by physicians as a treatment for any number of acute and chronic ills. It was in the context of this last exemption that the fight over “medical beer” unfolded.

It’s a little surprising brewers chose the medicine route, rather than exploiting the religious-sacrament loophole (religious practices being less open to scrutiny and evidence). Nevertheless:

…On March 3, 1921, shortly before his last day as attorney general, Palmer issued an opinion declaring that the “beverage” clause of the 18th Amendment entitled doctors to prescribe beer at any time, under any circumstances and in any amount they saw fit. Wholesale druggists could take charge of selling beer. He also suggested that commercial drugstores could sell it from their soda fountains-though “never again beer over the saloon bar or in the hotel dining room.”

But rather than settling the debate, Palmer’s opinion set off a new round of court challenges, squabbles and questions. “Will the druggists become bartenders and the drug store a saloon?” the New York Times asked that November. “Will the doctors become beer dictators and be overwhelmed by those who are thirsty because they are sick, or merely sick with thirst?”

Beer-makers, unsurprisingly, were sure that Palmer had hit upon a perfect fusion of virtue and science. “Brewers Jubilant over ‘Medical’ Beer,” the New York Times reported on March 11.

If it had continued, the relationship between physician and patient might have been fundamentally changed in the US. But it was not meant to be:

Within months of Palmer’s decision, Congress had taken up the so-called beer emergency bill (officially, the Campbell-Willis bill), which limited wine and liquor prescriptions to not more than a half pint in ten days, and banned beer altogether.

The doctor-as-dealer paradigm would live on, of course, but in a more limited capacity. However, in an era where the lethal effects of alcohol withdrawal were not generally appreciated (and the best withdrawal therapy — benzodiazepines — still decades away) prohibition of alcohol was a potential death sentence.

Some doctors recognized this in the 20’s and 30’s, and, as a consequence, to this day, a significant fraction of hospitals have beer on their formularies, for this very purpose.

What about those new studies about the health benefits of beer — for the heart, and for bones? Sure, there’s some new evidence. But lest anyone get the wrong idea, from our perspective in the hospital, beer seems to cause more health problems than it corrects. A nice, relatively recent historical overview of the subject was written by Klatsky in the Annals of the NY Academy of Science. He succintly summarized his findings thusly:

The basic disparity underlying all alcohol-health relations is between effects of lighter and heavier drinking.

So true — and worth reflecting on, as we head into the weekend. Be safe, and return on Monday for more Medgadgets!

