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.