CHAPTER XIV.

INSANITY IN RELATION TO SUICIDE.

It is not my intention in these pages to enter into a lengthened discussion of the once much debated question as to whether suicide be invariably a proof of pre-existing insanity.

It is sufficient for my purpose that a certain number of suicides are definitely insane, and that in these cases the act has been committed in consequence of some delusion from which the patient was suffering. Such a one may have been insane on a single point, and no other; or he may have been entirely demented.

But there certainly are other cases, in which no symptoms of mental disease can be discovered; either in the history of the deceased, or in his recent actions, appearance, or conduct. “There is no lunacy present where the sense of weariness of life is in exact relation to existing circumstances; where obvious moral causes exist which satisfactorily account for the deed; when the resolve has been fixed deliberately, and might have been abandoned had the circumstances become altered; and in which we discover, after honest and impartial search, no other sign or symptom of mental derangement. When a man prefers dissolution to a miserable or contemptible life, or one full of mental and physical ills, Morality and Religion must charge him with the deed; Insanity need not claim him for her own.”

The instinct of self-preservation is not so strong as to prevent men altogether from being tired of life, and seeking their own deaths. They may have exhausted all the available sources of pleasure, their business may have gone wrong, or their honour may have suffered, poverty and loss of position may be at hand, their difficulties may seem entirely beyond their power to surmount, and they calmly and deliberately arrange to leave behind them a life which has become unbearable; such an act may be unwise, and is certainly presumptuous, but it has in it no sign of disease.

And again, the existence of insanity cannot be affirmed in those suicides, which have taken place in every age of the world, and are not quite obsolete even now,─those cases of voluntary death among natives of uncivilized countries, which form a part of either their political, social, or religious institutions.

“Just as madness may exist, without any idea of suicide, so suicide may take place, the effect of a full and free determination, formed by a healthy mind, and executed with the coolness and complete system of precautions of the most perfect logic,” says Maudsley, and he carries with him the greater part of higher class medical opinion.

All our necessities, our desires, and our passions, produce a mental and bodily struggle; every want of man, though necessary to his perfection, involves victims to mental failure, and consequently either to crime or suicide. Even religion is frequently found to lead to disorder of intellect, from too great abstraction of thought from our earthly duties; while, on the other hand, mental failure is often shewn by religion becoming so absorbing a theme that it causes a patient to forget his worldly responsibilities.

The following authorities, who have specially studied the state of mind in cases of voluntary death, inclined to the doctrine that all suicides are insane: Esquirol, Falret, Bourdin, Winslow, Chevrey, Foderé, and Davey.

Forbes Winslow especially was the champion of this opinion; he distinctly wrote, no healthy mind ever permitted the act; but then in his time a wave of special tenderness to all criminals overshadowed the country; and exists even now, for our paupers are far less well cared for than our gaol birds.

M. Foderé, Professor of Medical Jurisprudence at Strasburg, used to say of voluntary death, “a suicide must be insane;” but this was a colloquial remark, rather than a medical dogma.

M. Falret, in his treatise on “Suicide and Hypochondriasis,” says, “suicide is necessarily an act of delirium;” perhaps it is to a medical man who considers hypochondriasis and hysteria to be insanity.

In the year 1777 this question of the coincidence of suicide with insanity was gravely argued before the Parliament at Paris, but the decision was put aside on a question of form, and never settled by them.

Dr. J. G. Davey read an essay before the Bath and Bristol Branch of the British Medical Association a few years back, in which he proved to his own satisfaction that “suicide is at all times, and under all circumstances, the effect of a positive brain disease;” but his arguments fail to explain the cases where two persons commit the act together; are we to suppose such disease of brain to be contagious? He mentions such a case, but without explanation. See Asylum Journal of Mental Science, vol. vii. 108, and xvi. 406.

It may be only a coincidence, but it is a fact, that almost without exception the supporters of the theory that all suicides are insane have been medical attendants in asylums.

Closely connected with unsoundness of mind is the disease epilepsy and its consequences; as is well known, the less violent forms, those in which the convulsive seizures are less obvious, are more liable to end in mental impairment, and thence in suicide, than are the more well-developed cases of convulsion. And among the modes of exhibiting its effects, it must not be forgotten that epilepsy is in some cases apt to show itself, not in a physical spasm but in a nerve storm, burst of passion, and what not: compare the opinion of Trousseau, in “L’Union Medicale,” 1861; he says:

“It may even safely be asserted that if a man who has presented no previous mental disturbance, or any sign of lunacy or furor, is not under the influence of alcohol, or any other drug, commit murder or suicide, he is epileptic, and has suffered a complete paroxysm, or has had epileptic vertigo.”

This very sweeping assertion does not commend itself to me, nor is it, so far as I can ascertain, generally accepted as reliable; it is too far reaching and dogmatic; it is one thing to believe epilepsy may be revealed by a burst of violence, and quite another thing to decide that every act of sudden passion is epilepsy, _i.e._, disease, and therefore blameless.

Blandford, in his work on “Insanity,” states: “That sane people commit suicide is a fact that must be apparent to every one who exercises _common sense_ in looking upon the subject. The hundreds of poor persons who are brought to our hospitals, half drowned, or with throats half cut, are _not insane_ in any medical sense of the word. Of course there are insane persons who are suicidal.”

M. Leuret epigrammatically sums up the causes of self-murder in the three words, madness, want, and crime.

The “Lancet,” in the autumn of last year, in an editorial article, remarked:

“Without hair-splitting, the great majority of suicides are perfectly well aware of the nature of the act they are performing, and do a deed with a so far intelligent purpose of escaping from a misery which seems unendurable, or because of some terror or shame that for the time overwhelms.

“It is heart-breaking and brain-tearing trouble that causes it, in the (hope or) belief that dying is sleep, or eternal oblivion.”

Dr. Gray, in the American Journal of Insanity, vol. xxxiv., writes, in regard to the United States: “Suicide is always an unnatural act, but in the large proportion of cases, if not in the majority, it is committed by sane people.”

Bucknill and Tuke, “Psychological Medicine,” state definitely, “it cannot be disputed that suicide may be done in a perfectly healthy state of mind,” ... “neither can it be doubted that it is the effect of a cerebro-mental disease in many cases.”

M. F. Dabadie, the author of a famous French work on Suicide, remarks, “if physiologists had endeavoured simply to establish that suicide was frequently a sign of madness, no one would have denied them; but to pretend, as some French physiologists have done, that every suicide is insane, is to _insult history and common sense_, and to expose oneself to ridicule.”

Des Etangs, in his work, “Suicide in France, from 1789 to 1860,” analyses and reviews the causation of 210,000 cases; he is fully convinced of the very large number of persons who kill themselves from sane motives, and with a sane mind.

He narrates numerous instances in which suicides have left their reasons for the act, written out at length, and these reasons, in most cases, shew “une lucidité parfaite.”

M. Littré remarks, “Quand un homme expose clairement les raisons qui l’empêchent de vivre plus longtemps, et quand ces raisons sont réeles et non pas imaginaires, quel motif y-a-t-il de lui denier la liberté morale, telle que nous la connaissons chez chacun de nous?”

In this place may suitably be mentioned the sad death of the Afghan surgeon Mahomed Ismail Khan, who had studied medicine in England, had taken his diplomas, and had then found all avenues to making a living in England closed to him on account of his nationality, colour, &c. (he could not return to his Indian home, having lost caste there); he, poor fellow, after making repeated efforts to obtain a situation that would support him, and after having exhausted his private means, drank prussic acid in bed at his lodgings. He left behind him a long and detailed history of himself, ending in a dissertation on suicide and its permissibility.

This essay, from its great medical and psychological interest, was offered to the editor of one of our leading medical journals for publication, but this was declined, on the ground that the arguments in favour of suicide were so delusive that it would be a public error to disseminate them. History repeats itself, for I find Voltaire narrates that he knew a professional man who, before killing himself, wrote an essay on suicide, and sent it for publication to the authorities of his native town, in 1769; the town council refused to publish it, assigning as their reason, that it would encourage men to quit a life, of which so much ill could be said.

It may be stated here, as a generalization, that whilst the medium course of life is the safest, the extremes of riches and indulgence, and their reverse, poverty and asceticism, both increase the suicide rate in about an equal proportion.

Post-mortem examination has not as yet disclosed any definite brain lesion, even in positive insanity, so that the discovery of a brain blemish associated with suicide is hardly to be expected. There have not been any large number of investigations into the post-mortem appearances of the brain in deaths from suicide in this country; in Wurtemburg, however, for two years, 1873-1875, a special examination was ordered in all cases of suicide in the insane, without any very valuable result being arrived at, viz., definite lesions of the brain existed in 45 per cent. of the cases, definite disease of other organs in 16 per cent., and negative results in 39 per cent.

Bucknill and Tuke divide insane suicides into three classes: 1. The monomania of self destruction; 2. In melancholia, death is chosen as the lesser evil; 3. Delusional, as when the sufferer hears a voice commanding him to act on its behests.

It must not be forgotten that the criminal law of England allows the possibility of a lunatic committing a murder in a lucid interval; and so also a lunatic may be held to _kill himself_ in a lucid interval.

THE FORMS OF LUNACY.

The special symptoms of each form of madness will on consideration be found sufficient to account for difficulties in forming anything like an accurate estimate of the relative amount of suicide in each of its forms. For example, in mania, sudden outbursts of violence may either end in instant self-destruction, or the sudden violence causes such precautions to be at once taken, that suicide is not practicable. In melancholia the chances of a self-inflicted death being allowed to occur, are much greater, because the patient is inoffensive, and the disease is of long continuance; the sufferer has often daily opportunities for months; and thus we find melancholia credited with the largest number. In monomaniacs, again, the project of suicide is often matured in their brains, whilst they hide their delusions; until a sudden outburst of suicide or crime startles the relations, who have only been saying to each other just before, “the patient is safe enough, the only thing the matter with him is the presence of a delusion.”

To imbecility, again, we do not find many cases allotted; the imbecile has not mind enough to feel his grievances sufficiently strong to make him exert himself to end them.

In the Reports of the English Lunacy Commissioners the cases of dementia are subdivided into two classes, ordinary and senile, each giving about as many cases as mania.

Abercrombie remarked, that the most striking peculiarity of melancholia is the propensity to self-murder; under a conviction of overwhelming and helpless misery, the feeling of life to be a burden, arises; and this is succeeded by a determination to quit it. A singular modification is sometimes seen, in which with the desire of death, there exists a sense of the sin of suicide; and to avoid this sin, another idea arises, viz., to bring about the death by committing a murder, and so to be executed. Several instances have been described, in which the insane murderer has distinctly avowed this process of reasoning, disclaiming any malice against the person he had killed, who by the way was generally a child, and in one case the reason for choosing a child was also explained by the lunatic, which was to avoid the risk of sending out of the world a person in a state of unrepented sin.

In the north-western and central parts of Europe madness and suicide coincide in intensity.

Osiander stated that the scale of madness among the European states has much resemblance to the comparative suicide rates.

On an approximate estimation I find that the Germanic stock has 2 madmen per 1,000 persons, the Celtic-Latin has 1 madman per 1,000 persons, the Slavonic has 0·6 only.

It is estimated that there are about 300,000 mad persons in the Old World, of whom Germany, France, and England, give the greater number.

The French and Italian statistics of insane suicides are not subdivided, and so are not available to show the relative proportions of the forms of insanity; the German numbers give the following result in recent years, 1875 _et seq._:─

─────────────────┬────────────────── │ Per Cent. FORMS OF LUNACY. ├─────────┬──────── │ Males. │Females. ─────────────────┼─────────┼──────── Religious mania │ 0·7 │ 0·6 Monomania │ 0·6 │ 0·5 Melancholia │ 68·7 │ 69· Brain fever │ 5· │ 2·8 Mania │ 5·1 │ 2·6 Imbecility │ 5·7 │ 5·0 Unnamed │ 14·2 │ 19·5 ─────────────────┴─────────┴────────

With regard to our own country, the last Report of the Lunacy Commissioners for England and Wales shows that of 13,581 patients admitted to the register of lunatics for 1882, 3,877 were stated to have a suicidal propensity, viz., 1,785, or 26·8 per cent. of the males; and 2,092, or 30·2 per cent. of the females.

The total number of lunatics in charge for the year 1882 was 76,765, and of these 17 committed suicide: 10 males and 4 females in asylums, 1 male before admission, and 1 male and 1 female while “on leave.” There were 17 suicides also in the year 1881. This small number of actual deaths speaks volumes for the care and attention which must be bestowed on the suicidal patients.

The proportion of suicidal tendency was higher among pauper than among well-to-do lunatics.

The highest rate of suicidal propensity was found in cases of melancholia, a proportion of 57, compared to mania 21, ordinary dementia 16, senile dementia 15, and idiocy 8.

The states of family life gave these proportions: marriage 32, celibacy 24, and widowhood 29, and of married persons, more females than males.

The Report also subdivides these cases with respect to the causes assigned for the insanity; the following were the most fertile causes, with the relative proportions:─

Domestic trouble, 9·7 (twice as many females as males); adverse circumstances, 6·0; overwork, worry, 7·5; religious excitement, 3·6; love affairs, 1·9; nervous shock, 1·4; alcoholic excess, 12·1 (nineteen males to six females); sexual excess, 0·5; sunstroke, 0·7; venereal disease, 0·3; self-abuse, 1·0; accidents, 3·2; pregnancy and parturition, 3·6; change of life (females), 2·9; privation, 2·0; old age, 3·0; bodily disease, 11·0; hereditary transmission, 22·8; and previous attacks, 15·8.

In England it is not practicable to form any reliable estimate of the true proportion of insane suicides, as compared with those occurring from disease and mental trouble. On the Continent an attempt is made in most States to assign the proportion; but it is easy to point out the difficulty of the task and the numerous errors that are liable to creep into such calculations. The following rates per 1,000 suicides have been published in the “Asylum Journal,” vol. 27: France, 300 insane per 1,000; Belgium, 470; Prussia, 333; Italy, 343; and Bavaria, 342.

M. Prévost, in a learned investigation of cases of voluntary death, estimated that 18 per cent. occurred in insane persons.

I have made careful investigation into all the cases of suicide which I have observed, and all those cases upon which I have held inquests, as the Deputy for Dr. Danford Thomas, in Middlesex, and I have found that in 20 per cent. only had the deceased ever exhibited symptoms of insanity obvious to the friends and relations.

The suicide rates of the great German lunatic asylums are higher than those of our English ones. Dr. Löwenhardt, of the great asylum at Sachsenburg, states that the average number of suicidal deaths in that institution is 5 per cent., a large proportion; for in the asylum of Illenau 3 per cent. only killed themselves, and in the asylum of Halle, only 1·7 per cent.

The varying rates of suicidal death in asylums depend very much on the qualities of the nurses on the staff, and on the relative number of patients attached to each attendant, for nothing but a constant and lynx-eyed survey will prevent the self-destruction of a large proportion of lunatics, when they have a wave of suicidal tendency passing over their minds.