CHAPTER XXI.

THE PREVENTION OF SUICIDE, AND THE TREATMENT OF THE SUICIDAL TENDENCY IN THE INSANE.

It is a terrible thought that our much boasted civilisation and modern educational advantages bring with them a suicide rate which nothing so far has been found to check.

The struggle for existence, at our present high pressure, ends in the survival of the strongest and most able; the weaker in body, and the feebler in mind, get pushed aside and pass away before their due time by disease and self-destruction.

What can be done? the wheel of progress cannot be stopped because it crushes some victims in its onward course. The abolition of monopolies, and even the reforms of land holding, land conveyance, the refusal of special advantages to primogeniture, and the schemes of trade unionists, now being agitated, cannot do away with poverty. “The poor ye have always with you,” said Jesus, and He no doubt meant, “and always shall have,” in this probationary world. If only the grand principle of “moderation in all things” were more thoroughly followed out to its legitimate conclusion, many deaths due to the extremes which so many strive after, might be avoided; peace, health, and competence should be our aim, not wealth and extravagance; and the waves of commercial depression which so repeatedly occur are but the sequence of commercial exaggeration, and follow upon over-inflated markets.

However various may be the opinions regarding the mental state of suicides, there is no practical dissent from the acknowledgment of the desirability of preventing the commission of suicide.

For our purpose, then, it will suffice to consider, on the one hand, what means are necessary to restrain patients who are acknowledged to be insane; and on the other hand, what measures are permissible to dissuade and prevent those in trouble or pain from taking their own lives; such means will be equally available whether we think these sufferers sane in their deaths, or insane from the time when they attempt the destruction of their lives.

There are doubtless cases of suicide in which it is impossible to decide as to the mental state of the patient; no definition of insanity has ever yet been agreed to, and probably never will; and until medical science has advanced so far as to be able to estimate how much grief or pain a man can support without attempting to evade his sufferings, there always will be voluntary deaths of persons who are so notoriously sane as to forbid the application of restraint. Yet survivors will postulate a momentary insanity, when such persons shall have destroyed themselves to avoid the possibility of an error of judgment.

SUICIDE OF THE INSANE.

In a work such as this, intended not entirely for physicians, but also for students of Social Science, I do not think it fitting to enter into particulars as to the exact means of treating the suicidal propensity in such cases, nor do I suggest any definite medical prescriptions to relieve collateral symptoms; such may be safely left in the hands of the skilful physician. I have only to insist on the urgent necessity that exists for the immediate removal from society of any person exhibiting mind failure, who shows any tendency to self-destruction; and even if suicide be not definitely threatened, no time should be lost in commencing the care and treatment of a lunatic.

And, again, the means of treatment, and, if necessary, of coercion of those definitely of weak, or of unsound mind, fall to the alienist.

The whole question of Asylum treatment is now under consideration; whether any private establishments at all should exist, is debated with zeal; the further question of whether the treatment and care of the insane ought not to be begun and perhaps continued, just as is the treatment of bodily disease, without any formal certification, has also been broached of late, by an editorial in the “Lancet” of last year. These questions do not fall within the scope of a treatise on “Suicide as a fact.” The managers and attendants in English asylums may at any rate be congratulated on their care of their patients in this matter, for the rate of suicide in asylums is but 1 per 1,000 annually.

Many once popular modes of treatment of insane persons are now almost forgotten, just as many modes of treating bodily diseases have disappeared.

As a preventive of suicide in melancholia, the noted Avenbrugger recommended that the patient should be made to drink a pint of cold water every hour, whilst his feet were wrapped in flannel. Hufeland also advised the ingestion of plenty of cold water for mania. The eminent alienist Burrows recommended emetics, bleeding, and warm baths, accompanied by cold douche to the head, as measures fitted to remove the suicidal propensity. The means recommended by Brierre de Boismont for avoiding the suicidal propensity in the insane were the persistent use of morphia to ensure sleep, and the prolonged use of baths, the continuous immersion of the body for four, five, or six hours. Griesinger remarks that medication is of no use, and that mechanical restraint does not remove the tendency, even if it renders the act impossible for the time; nothing but constant watching is of any avail until the inclination passes off.

It has been suggested by many physicians that bleeding would remove the suicidal tendency in cases where it is associated with cerebral irritation, congestion, or inflammation.

Several cases of cut-throat are on record, in which the patient, who had just been raving, became sane after the bleeding which followed his act: Dr. Southwood Smith mentions this, see “Philosophy of Health,” vol. i., p. 109; and the elder Disraeli mentions that a surgeon narrated such a case to him. See “Curiosities of Literature.” The case of the late Sir Samuel Romilly was one example of this point; the bleeding restored his senses, and he did all in his power to check the hæmorrhage. See Wynter. “Borderlands of Insanity.”

Suicidal patients require most watching early in the morning; a good lunch often dispels the tendency for the day. During convalescence from mania, &c., relapses into suicidal condition are very common, and it is frequently in these remissions that nurses become less watchful just when they should be vigilant, and the act is committed.

When the tendency is the result of alcoholism, we are met by this difficulty; restraint is needed, and yet no one has the power to enforce restraint; the physician succeeds well enough in relieving the alcoholic delirium and coincident risk of suicide, perhaps time after time; but is powerless to prevent a succeeding attack. Unless a sufferer can be induced to volunteer his entry into a retreat, there are no means of saving him from himself. So long as a man is sensible when sober, be it only for an hour a day, he is beyond the reach of compulsory cure.

In the suicidal mania of parturition, on the other hand, the patient is happy in being already, from her state, under the practical control of her medical attendant, and hence such cases are almost always restrained successfully.

The essence of impulsive insanity is its occurrence without any warning; yet many such suicides might be prevented by a more careful observation on the part of the companions of a patient. Whenever there be any hereditary taint of insanity, or of dipsomania, or of chronic nervous disease, or epilepsy; if there be heredity of self-destruction, or if there have been a previous attack of insanity, or if there be insomnia, the slightest symptoms of mental alteration should be watched for; alterations of conduct, the attitude of suspicion, or of self-accusation, or of unnecessary melancholy. The facial expression will frequently raise the alarm; the restless uneasy eye, and ever varying play of the muscles of the face in one case; and the settled glare of the eye, and expressionless features in another, should warn observers of an approaching crisis of disordered intellect.

SUICIDE OF SANE PERSONS.

The suicidal tendency so often coexists, either with straightened circumstances, or sudden deprivation of income, that the very modes of treatment most likely to remove the tendency are by these very causes rendered impracticable. Temporary abstention from duty or business, coupled with change of climate and scene, would doubtless cure a very large percentage of cases, but it is exactly the inability to drop the chains of employment, and the absence of the monetary means for travel which are lacking.

The means of cure when they are practicable are obvious enough to any physician; a healthy and not too arduous employment; change of air, and scene; and of companionship; the improvement of the bodily health, the exhibition of nervine tonics; and last, but not by any means least, the exercise of every possible means of making sleep a certainty.

The continuous poring over one’s troubles, and contemplating one’s fate, without the definite lengthy intermissions given by healthy sleep, are most fertile causes of nervous breakdown and attempted self-destruction. The occurrence of a long night’s slumber frequently entirely removes the pernicious intentions at which an overwrought brain arrived over night.

I have already alluded to the debated question as to the tendencies of religion and education.

Statistics seem to point so clearly to development of the mind and mental tension as a cause of voluntary death, that it is probably of no use to look to education as a cure for the suicidal tendency in individuals.

The cultivation of a religious conviction of the sanctity of life, and the sin of a self-inflicted death is a more certain hindrance to suicide. Persons who are unable to obtain this mental conviction, are, I believe, more prone to take their lives in time of trouble, and beyond good advice and the care of their friends, I do not know that any means exist to restrain them. See Legoyt, Esquirol, Cazeauvieile and Descuret.

A man has a strong natural claim on his relations to take care of him when he meets with an accident, or is bodily ill, and it is always admitted; the same claim exists that he should be protected against himself, not only when insane, but when in great mental perturbation, misery or despair. Nothing but a constant watchfulness will suffice to restrain some persons from ending a life of present wretchedness, and enable them to experience the better times, which are very often in the future.

Among measures of precaution, the removal of suggestive weapons, and of books and papers likely to bring to recollection instances of crime or self-destruction, must not be omitted.

Every effort should be made to secure full occupation for the mind of a composing character if possible; ennui or tædium vitæ is an important predisposing influence.

Of the numerous French authors on suicide, the first rank is held by Brierre de Boismont; his suggestions for the prevention of suicide, among reasonable persons, _i.e._, not insane, are to avoid sadness, to procure a family, and to follow some business; and with regard to religion, he advises the confessional and the cloister. Ebrard also extols these two means of cure; of the latter remedy I have no experience, and the former is not likely to be much used in this country.

“We are attacked by many moral and social ills; there is much madness in our heads, and many evil passions, and weaknesses in our hearts; but the sources of purity are not dried up, the springs of human energy are not exhausted. Let us hope then, let us hope!”