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!”