THE DRUNKARD AND HIS RESPONSIBILITY. BY HENRY P. STEARNS, M.D. THE DRUNKARD AND HIS RESPONSIBILITY. BY HENRY P. STEARNS, M.D. HARTFORD, CONN. : The Case, Lockwood & Brain ard Co., Printers. 1884. THE DRUNKARD AND HIS RESPONSIBILITY.* It will be my purpose in the following pages to discuss this subject, not generally or chiefly in its relations to society or the family, but rather in relation to the nature of the condition of drunkenness, and its influence upon the individual who may be affected by it. Indeed, if I mistake not, the point on which we are most interested is embraced in the last word of the heading, namely, the matter of responsibility. Is the drunkard responsible for continuing to remain one, or is he affected with such a form of disease as to free him from responsibility ? Again, has he a less degree of responsibility on account of his condition than others would have, or should he be held to full account for his misdemeanors ? This I conceive to be the point of largest interest at the present time concerning the whole subject, inasmuch as on its decision depends, in a measure at least, the course to be followed by society in its treatment of this class of its members. It also necessarily removes our discussion largely from the realm of morals and bears it over into that of disease; for if there is no disease, atld the individual still retains the full use of his physical and mental powers, then he must be held responsible to the same extent as others. If, on the other hand, he is diseased, the question is, to what extent is he so, and how does such disease modify responsibility ? It may be well, as preliminary to the discussion of these portions of the general subject, to prepare the way by making certain statements which will serve to prevent my being misunderstood, and also limit somewhat the range of the paper. First. I desire to restrict the use of the term drunkard so far as I shall introduce it in the following remarks. I assume that not all persons who are accustomed to become intoxicated can properly be called drunkards; that there are those who peri- odically become so because of a disordered condition of the nervous system. These are termed in medical language dipsomaniacs. They rarely inherit vigorous and well balanced nervous organizations. They are peculiarly susceptible, easily excited, intro- spective, or so sensitively organized, that when brought into trying circumstances, they almost instinctively contract the habit of endeavoring to fortify their nervous systems by the use of alcohol or some other drug. In other cases the nervous system has become disordered from the effects of injury to the head, by a blow, or railway accident, or by exposure to heat. In others the cause arises from disease existing in some distant part or qrgan of the body, the effects of which are reflected to the brain. When such conditions exist, a few indulgences only appear to be necessary in order to excite a morbid condition of the brain into activity, though it sometimes requires a considerable period of time before a deranged mental state occurs. Such persons may be considered as insane, and my experience leads me to believe that they are * Read before the “ General Conference ” of the Congregational Churches of Conn , at its meeting in Nor- wich, November 15,1883. 4 THE DRUNKARD AND HIS RESPONSIBILITY. more numerous than has been supposed by some medical authorities, but still they are few as compared with the whole number. Second. I wish to exclude from consideration persons who may be regarded as in the early stages of drunkenness, or who have not yet become confirmed drunkards. The majority do not become so until after a considerable period of the use of alcohol, and persons may use it and become inebriated many times in the course of years without there being developed any condition of the system which can be termed disease. There can therefore be no question as to their responsibility either in reference to society, or for a continuance of the habit of drinking, and they cannot properly be called inebriates. Third. We need have no question as to responsibility for acts done while in a condition of drunken automatism or trance; nor while an individual is in a condition of inebriation. I do not, however, exclude this last point from consideration, because I regard the condition of intoxication as one of disease in the ordinary accep- tation of that term. A person may imbibe alcohol and become stupefied by it just as he can inhale chloroform or sulphuric ether, or the bichloride of ethylene, or swallow opium and many other substances, but when they have become eliminated, the nervous system resumes its normal activity, and cannot be said to be diseased by such experience unless it is often repeated. The immediate effects of alcohol may not pass off so quickly as those of other substances; they may differ somewhat, physiologically considered, but may be regarded as of the same general character so far as relates to the production of disease by inducing intoxication. Our attention, then, shall be confined to the common, everyday, chronic drunkard, and only in respect of his disease and responsibility. 1. In reference to the question of disease. Diverse opinions have been and con- tinue to be entertained by medical authorities on this question, but I think, within the last few years, there has been a tendency toward a greater uniformity of opinion, and that the preponderance is in favor of the view that, in the large majority of cases of chronic drunkenness, tlmre does exist disease of brain to some degree. This opinion is held by nearly all who have made a special study of the subject. It is possible there may be a still more nearly uniform opinion on this point if all are agreed as to what constitutes disease. If we regard that only as disease which is an abnormal condition of some part or organism, and which is in an active state of dis- integration and wasting, it would hardly be claimed by anybody that such a condition exists in the brain of the drunkard ; but if, on the other hand, we broaden our defini- tion and include as diseased any part or organ whose function can no longer be norm- ally performed by reason of an impaired state of assimilation and nutrition, and consider it as including the grand total of disordered activities and functions of the body, which may have existed a considerable period of time, I think we shall have no difficulty in arriving at the conclusion that there exists a diseased condition of the brain of the chronic drunkard. I may frankly say that my own opinion is that in the large majority of cases where individuals have habitually or daily used alcohol as a beverage in any consider- able quantity, and so as to become frequently inebriated, that there is established an abnormal state of the brain which may perhaps be sufficiently enduring to be con- sidered as disease, and which may be transmitted to offspring; that this tifkes place through the elective action of alcohol affecting the vaso-motor portion of the nervous system, and through it the capillary portion of the circulation, and ultimately the cell THE DRUNKARD AND HIS RESPONSIBILITY. structure of the brain; that in consequence of this physiological action of alcohol upon the nervous system, when frequently and long used, there results a less sensitive and delicate condition of these constituent portions of brain substance, and that they become correspondingly less responsive to both objective and subjective impres- sions or influences, and that, therefore, there will result a less normal discharge of thought function in its various manifestations, both moral and intellectual. There can exist no doubt that the mind becomes less clear and accurate in its perceptions, and loses, in some measure, the nicety of its moral sense; it does not perceive the moral side of conduct so clearly and definitely as when the brain is free from the dis- eased effects of alcohol; it does not judge so perfectly in reference to the claims of friends and society; the sense of propriety as to personal conduct becomes obtuse, and ultimately the mind becomes weakened and its faculties more or less impaired. Such are the conclusions toward which a study of the physiological effects of alcohol upon the nervous system and mind, as it is commonly used by inebriates, points. If they are erroneous, the future and further observations will correct the error. 2. It now remains to inquire how far responsibility is modified by the presence of such disease, if at all. Responsibility presupposes, first, one who has in possession his natural powers of mind; second, one who is competent to choose his own course of conduct in relation to himself, society, and the law, to approve or disapprove, to follow or refuse to follow certain courses, the decision having been formed in the light of his own reason and free will. I think the law regards all members of society who owe it allegiance as possessed of the above named qualifications, with the following exceptions: 1, Child- ren under a certain age; 2, Imbeciles, or persons whose minds are imperfectly devel- oped; and 3, the Insane. With the first two of the above classes we need not concern ourselves. It may aid us to study the third. The insane are regarded as irresponsible, either because their mental operations are not of a normal character, or they have lost in a measure the power of self-control in their relations with other members of society. These conditions may be manifested by over-activity and sensibility, varying from slight excess up to active delirium, or by a diminution of mental function, attended with disordered reason. There may be delusions (false judgments), hallucinations or illu- sions (false sense perceptions), or that portion of the nervous system which is con- cerned in thought may become so convulsed or irregular in its activity that it passes from the control of the will power, and the individual experiences an irresistible impulse toward the committal of some act which may be criminal. It is in this last f orm of insanity that we sometimes find it most difficult to judge as to the actual con- dition of the individual. He may, and often does, have his moral faculties apparently intact and is able, at least in a measure, to reason in reference to the nature of his conduct. He fully disapproves and condemns it as repugnant to his ieelings and the convictions of his past life, and yet is seized with an impulse which becomes irresist- ible, to commit the act. Now, this is the only form of insanity with which we can compare the condition of the inebriate. In some respects there exists a resemblance; both can exercise reason in some measure ; both can appreciate the character and consequences of their conduct, and disapprove it, and both appear to be borne on by an irresistible impulse toward certain acts or lines of conduct. If the inebriate may claim irresponsibility on any ground it must be that of an irresistible impulse to indulge his craving for alcohol. 6 the drunkard and his responsibility. But with the insane, the irresistible impulse or tendency towards criminal acts is not the only indication of disease, and no court would hold one irresponsible on said grounds alone. There must exist other evidence of a diseased brain, and generally this is not far to find if we understand the full history of the individual. Such impulses may coexist with some form of epilepsy which may not have been suspected, and the criminal act wras the first observed evidence of such a condition. This has been found to be the case in some of the many unexpected crimes by persons who have before sustained good moral character. They also sometimes manifest themselves in the puerperal condition of mothers with newly born children. In some of these cases they give warning of their approach, and the mother will beg to have her child removed from her lest she may injure it, while with others the impulse comes on so suddenly, and is attended by such delusions, that the frenzied mother destroys her child in the most revolting manner, and will afterwards calmly tell how she has accomplished the horrible deed. Such impulses, also, occasionally arise in the system •when the individual is in a condition of drunken automatism, or trance, and he appears to be quite oblivious of what he has done. An instance of this kind is reported in the October number of The Journal of Mental Science. Or again, in persons affected with delusions or hallucinations, the evidence of which they endeavor to conceal. In such cases it frequently requires observation covering a considerable period of time in order to discover the true condition. It will be observed that in all the above named conditions, the impulse was only one of several indications which were confirmatory evidence of mental disease, and that such impulses may move in any one of many directions, that they impel towards the performance of acts which have little relation towards the subject himself, and may afford no satisfaction to him. In what respects, now, do inebriates resemble such cases of insanity as those outlined, or others of a similar character ? Simply in the one fact that in all there exists an impulse towards certain lines of conduct, and here the similarity ceases. The impulse of the inebriate strongly impels him to act in one direction only, and it is always towards gratifying his own desires. It is in the nature of a desire or craving, and if not relieved, or increased by Avhat has created and sustained it, tends in the process of time to become less, or to pass entirely away. There is no evidence that it is of a convulsive nature, or that the nervous system passes into any such state that it is beyond the control of the individual. In no degree can he be said to lose his consciousness either before or in the performance of his acts, or fail to understand what he is about. On the contrary he understands that his drinking is a wrong, both in relation to himself and society, and he intends at some future time to stop it. He has no delusions or halluciations, and he can reason not only concerning ordinary matters, but also in relation to morals in general and the vice of drinking in particular. He understands his own weakness, acknowledges it, and, -when under the influence of a satiety, like the libertine, he repents after a fashion of his conduct, but when the force of his passion for alcohol resumes its sway in his system, he persists in his course, but tells you he can stop drinking whenever he chooses to do so. We often hear it said that he is mistaken, that the impulse has become so strong that it cannot be controlled. If this is true, the individual has become insane and is no more responsible than other insane persons are. But the inebriate certainly comes short when we apply to him the tests of insanity aside from this impulse or craving for alcohol, and even this does not resemble very strongly the insane impulse, or THE DRUNKARD AND HIS RESPONSIBILITY. proceed from any such spasmodic action or convulsed condition of the nervous system, as would exist if it had passed from the control of the individual. It is in the fact that self-control is lost in some direction that irresponsibility rests. But it may be claimed that though there may not exist such conditions as those pertaining to the irresistible impulse of the insane, yet there does exist a moral ina- bility to resist the craving, and that in this way the freedom of will is impaired. This course of reasoning removes the discussion from the realm of disease and places it in that of morals. In this case the act of drinking either is, or is not, that of choice. Now no individual’s free will in an act of choice can be abridged except by disease. Every act of choice, consciously or unconsciously, originates in the inner sanctuary of his own being. External circumstances may hinder and prevent the execution of his choice, but not the act of choice itself. This is essential in any view of responsibility, and every person does choose or refuse in every moral act. If an individu al takes alcohol, it is because, all things considered, he chooses to do so. He mentally balances the act many times in his experience. On the one hand there are the claims of society, friends, wife, children, duty, competence, and the approval of his own sense of right, all of which protest against the continuance of his habit. On the other side, a craving of the system for something to lift the mind into a con- dition of excitement, and to more pleasing visions of its surroundings, and also the suffering and misery which always attend any efforts he may make to change his habit. These are the considerations on each side which present themselves to his mind, as motives, and he must and does choose which shall weigh the heaviest with him. And unless he overmasters his inclinations and reforms, he decides against the first named ones. If there exists any doubt about this, let us add some other conditions to the list and then see whether he will fail to be influenced by them. Let us suppose that in order to relieve the suffering of his craving he must take the liquor from a cup which will in some way inflict severe pain while holding it; or again, as conditional to his receiving it he must be publicly reprimanded. In the former case, duty, respect, health, love of wife and children, all did not outweigh in his choice the pleasure of relief from the pain which resulted from the craving of his system; but if we add to them considerations of another character, that is, the infliction of a greater suffering than arises from his want, we may be sure he will find enough of both freedom and ability of will-power to choose to resist, and his decision will be made with tolerable alacrity. It may be said that these are unfair conditions. I think not. But if they are so, impose any others which shall be of such a character as to produce a larger degree of suffering than arises from his craving, and the result will be the same. They simply illustrate, and it seems to me prove, beyond question, that the will-power, that is the power to execute a choice once made, is not largely impaired, but on the other hand is quite sufficient to serve its possessor promptly when he is to avoid suf- fering. I think it not too much to claim that ninety-nine in every hundred drunkards, unless there has become developed a condition of insanity, would reform at once and forever if the conditions of their continuing so were as above indicated. In the large majority of cases it would be perfectly safe to make the conditions additional to those already existing, of a much milder character. If, for instance, the drunkard should be obliged to walk five miles for every glass of liquor he imbibes, or if he should be obliged to take it in some public place and in the presence of large numbers of all classes of society and of both sexes, in my view these simple addi- tional conditions would prove to be quite sufficient with large numbers to so reinforce the power of resistance as to make it effectual in overcoming the impulse to indulge. 8 THE DRUNKARD AND IIIS RESPONSIBILITY. But after all does there not exist in the case of the drunkard an impulse or crav- ing for alcohol which, though not irresistible, is yet so strong that it excuses or palli- ates his indulgence? To answer this question let us refer to the conditions of the nervous system in connection with other vices. It is a well recognized fact that in the process of time and experience, it tends to crystalize around almost any line of conduct, good or bad, which an individual has followed, and that the longer any course is pursued the more difficult does any change from it become. The libertine who has given free scope to the indulgence of his passions for years finds it exceedingly difficult to govern or sub- due them. The impulses of his whole animal nature cry out in protest, and impel him on toward a continuance of his former habits, so that he is in constant danger of being overcome by their force in any effort at reform. The person who has for a long time given indulgence to explosions of temper on provocation, finds it more and more difficult on every succeeding recurrence to control it. The habitue of the gaming table at length developes a passion for the excitement attending its uncertain issues so powerful that it overrides almost all other considerations, and he sits within the charmed circle, oblivious of home and family, until he becomes a bankrupt both in property and reputation. We have, doubtless, all had occasion to observe how power- ful is the force of habit in those who have long been in the frequent use of profane language, and how it tends to control the individual even under the pressure of a public profession. Those who are familiar with the history of hardened criminals tell us that the majority are never reformed even by the experience of prison disci- pline, nor by the strongest inducements toward a moral life. These are simple illustrations, but they clearly indicate the fact that certain lines of conduct, when long followed out, tend to become woven into the very texture of the nervous system, and to remain there during life. They show that the inebriate is by no means alone in having to contend against strong impulses—impulses which become imbedded in the physical nature, and impel on in courses of conduct which the judgment condemns. Indeed a moment’s consideration shows that the tempta- tions to evil courses must be as diverse and vary as much as individuals themselves. No two are born into the world with nervous systems exactly alike in all respects and no two pass through it in exactly similar surroundings. The conditions inherited from long lines of ancestors, in respect to physical needs, cravings, and mental tendencies, early education and home influences during youth and while the brain is especially receptive and easily moulded, differ to the widest extent. The offspring of crime, who are reared in its midst, with no discipline of brain, or only one towards a violation of the laws of their own being and of society, experience thousands of impulses towards criminal acts, and the gratification of physical cravings, which are unknown, or nearly so, to those more highly favored as to inheritance and education. The susceptibilities of the brain, the ease and readiness with which it takes on or throws off influences which are morally injurious, are as diverse as brains themselves, so that we cannot positively decide just how much or how little of respon- sibility one may have in the sight of Omniscience. Human laws are clumsy and imperfect, and can only approximate towards justice in any case, when judging as to the degree of responsibility either of a drunkard or any other sinner. But though they are clumsy and imperfect in attaining anything like exact justice, yet they do reach out to certain great headlands in the boundless ocean. Society mnst exist (unless it is ready to commit suicide through the exercise of a weak sentimentality) and THE DRUNKARD AND HIS RESPONSIBILITY. consequently must demand from its members alike responsibility and obedience. Its laws do not pretend to attain full justice; they do not reach much below the surface, or penetrate the inner life, or make due allowances for the numberless weaknesses, inherited and acquired, which prey upon thousands of the less fortunate members of society; but they do and must demand that if individual members have not lost their free will by disease, and are not overcome by external force; if, in other words, they are of sane mind, and capable of self-guidance, they must be held responsible, not- withstanding they are influenced by physical impulses and weakened by physical disease. But again, does not the fact that the drunkard has a strong craving for alcohol, which is the outcome of his diseased condition, place him in a position in relation to society and its laws, which differs from that of others ? I reply by questioning the assumption contained in the question. It does not appear at all certain that the craving of the inebriate arises from the diseased condi- tion which I have admitted that he has. There certainly is no decisive evidence that it does, but, on the contrary, certain indications which point toward other causes for it. In the first place, this craving often appears during the early stages of drunken- ness, and frequently asserts itself after a short period of the occasional or irregular use of alcohol, and in many cases even before the individual has ever been once fully intoxicated. To be sure it is not so strong as it afterward becomes; it is much more easily controlled, but still it exists, and often proves itself quite sufficiently powerful to lead its possessor to continue the habit he is forming. Again, we have no evidence, nor have we any reason to suppose, that any dis- ordered condition of the ultimate structure in the brain exists when alcohol is only occasionally or irregularly used. 'Whatever of disease arises in consequence of its use comes after a considerable period, and from its inhibitory effect, that is, it impedes the normal physiological action of certain vessels and cells, until there results some defect of function. It is quite evident that long before any such patho- logical effects have become established the craving for alcohol exists and has made itself strongly felt. These considerations indicate that this craving does not have its origin in a condi- tion of disease, but on the contrary, that it arises from other causes which probably exist within the system itself and while in a condition of health. It does not by any means sustain a unique character, but appears, at least, to resemble cravings which arise from the disuse of other substances and physical experiences. The nervous system is so constructed or arranged in most persons that it very readily falls into habits of need as w7ell as habits of action. When it has once become accustomed to certain courses of action and articles of food, and especially to the use of substances which are of such a nature as to circumscribe the range of sensibility, thus inducing agreeable sensations, it soon begins to demand a repetition of this effect, and if not supplied it experiences a feeling of debility and a consequent crav- ing. Alcohol is by no means the only substance which acts in this manner upon the system. The bromides, chloral, hasheesh, and opium all act in a similar way, and so strong is the tendency of the system for the effects induced that there exists among almost all civilized nations some article which is used by large numbers to produce them. This is especially the case with opium, and most physicians have occasion to observe sooner or later in their experience how strong becomes the craving for this 10 THE DRUNKARD AND HIS RESPONSIBILITY. drug. I have in many cases witnessed suffering, amounting to an intense agony, in persons when endeavoring to abandon its use, and which have been apparently vastly greater than I have ever seen from such experience by any inebriate in giving up the use of alcohol. We observe the same thing in connection with the disuse of chloral, though to a less degree, and even with some articles of diet and habits of occupation. If either of these are radically changed at once, persons feel a want or a craving to return to former experiences. One who has been long accustomed to the activities of an out-door life becomes wretched and miserable if he is confined indoors and forced to breathe day after day an indoor atmosphere. The habits of his system have become so strong that if not indulged he may become actually ill from conditions which occa- sion no inconvenience to others who are accustomed to them. I refer to these simple every-day experiences to illustrate the fact that the human system is largely the slave of habit, and in many directions. The drunkard is by no means alone in his experiences of want, craving, and suffering. In all the departments of habit persons are able to change and overcome only by enduring the misery attend- ing such changes, and by the resolution of a will determined to do so. I therefore do not regard the craving of the inebriate as unique in its nature, or as due to a diseased condition of his brain, but rather as of the same general character as those wants which arise from the disuse of some other substances, and also from the abandonment of some habits of daily life long practiced. I readily admit that it becomes in process of time, and in the case of the chronic inebriate, very strong, indeed one of the strongest that arises from the disuse of any substance or the change of any habit to which the nervous system has long been accustomed ; but, nevertheless, I do not regard it as having a pathological origin. The final question then recurs, Does the disease which we admit exists in the case of the inebriate modify his responsibility ? I answer, that, in view of the fact that there are no indications of an active or progressive disease of the brain so far as appears from his mental condition, and that not even his craving for alcohol can be considered as due to whatever impairment of brain or mind he may have, he must be regarded as responsible, but may be ranked with other unfortunate classes of society in this respect. Thousands are born into the world whose mental endowments are of a low order, and other thousands, through neglect, ignorance, and vicious courses of conduct, never attain to that strength of wTill-power, intellect, and moral character which was possible for them ; yet they all have enough to enable them to obey the laws of society; they are all free from any disorder or derangement of mental activity, and for these reasons are held responsible. It matters not whether this weakness or disease is inherited or acquired, whether it exists through the fault of others or that of the individual himself. These are questions which as a physician I do not and need not ask. I have called the inebriate unfortunate. This may be regarded by some as altogether too lenient a term, inasmuch as he voluntarily induces and continues the disability under which he labors. But we must bear in mind that large numbers of other unfortunate classes of society resemble him in this respect, both as to physical and mental conditions. In fact, character itself, aside from its inheritance, is made up in this manner, whether it be good or bad. Moreover, all character has a physical basis of quality, because it is only through the nervous system that we can act even in thought. Every voluntary act or choice necessarily establishes a bias toward others of a similar nature, and in this way in the process of time and experi- THE DRUNKARD AND HIS RESPONSIBILITY. 11 ence both education and character become more and more ingrained in the nervous system. If choices and lines of conduct have been towards a violation of the laws of physical and mental health, then there becomes established a tendency towards deterioration and weakness, which renders opposite courses of conduct more difficult; if, on the other hand, these choices and acts have been in the direction of physical and moral health, there must result corresponding effects. The inebriate has less of intellect and judgment than he otherwise would have because he is diseased, but he has enough for self-guidance. He is not overborne by the force of his diseased condi- tion, so that he cannot act in such a manner as to avoid suffering and obey the laws of society. If he has, in consequence of disease and the force of temptations, vastly greater difficulty in so doing than others who are in better health, he shares these disa- bilities in common with other classes, and may claim, with them, from society, of which he forms a part, profound sympathy and the use of all practical measures to reclaim and restore him to a condition of health and usefulness, and no more.