PHYSICAL TREATMENT OF THE SUICIDAL DISPOSITION.
On the dependence of irritability of temper on physical
disease—Voltaire and an Englishman agree to commit
suicide—The reasons that induced Voltaire to change his
mind—The ferocity of Robespierre accounted for—The state
of his body after death—The petulance of Pope dependent
on physical causes—Suicide from cerebral congestion,
treatment of—Advantages of bloodletting, with cases—Damien
insane—Cold applied to the head, of benefit—Good effects of
purgation—Suicide caused by a tape-worm—Early indications of
the disposition to suicide—The suicidal eye—Of the importance
of carefully watching persons disposed to suicide—Cunning
of such patients—Numerous illustrations—The fondness for a
particular mode of death—Dr. Burrows’ extraordinary case—Dr.
Conolly on the treatment of suicide—Cases shewing the
advantage of confinement.
Medical men have not considered with that degree of attention
commensurate with its importance the relationship between physical
derangement and those apparently trifling mental ailments which so
often, if not subdued, lead to the commission of suicide. The origin
of self-destruction is more frequently dependent upon derangement of
the _primæ viæ_ than is generally imagined. Every one must, in his own
person, be aware of the influence of indigestion, and what is termed
bilious disorder, upon the spirits. An inactive condition of the bowels
is a common cause of mental disquietude. Voltaire, who was a man of
great observation, appears to have paid considerable attention to this
connexion. He advises a person who intends to ask a favour of a prime
minister, or a minister’s secretary, or a secretary’s mistress, to be
careful to approach them after they have had a comfortable evacuation
from the bowels. Dryden invariably dosed himself before sitting down
to compose. He says—“If you wish to have fairy flights of fancy,
you must purge the belly.” Carneades, the celebrated disputant of
antiquity, was in the habit of taking white helebore, (a purgative,)
preparatory to his refuting the dogmas of the Stoics. Lord Byron says,
in one of his letters, “I am suffering from what my physician terms
‘gastric irritation,’ and my spirits are sadly depressed. I have taken
a brisk cathartic, and to-morrow ‘Richard will be himself again.’” The
following anecdote is recorded of Voltaire:—“An English gentleman of
fortune had been sitting many hours with this great wit and censurer of
human character. Their discourse related chiefly to the depravity of
human nature, tyranny and oppression of kings, poverty, wretchedness,
and misfortune, the pain of disease, particularly the gravel, gout,
and stone. They worked themselves up to such a pitch of imaginary
evils that they proposed next morning to commit suicide together.
The Englishman, firm to his resolution, rose, and expected Voltaire
to perform his promise, to whom the genius replied, “_Ah! monsieur,
pardonnez moi, j’ai bien dormi, mon lavement a bien operé, et le soleil
est tout-à-fait clair aujourd’hui_.”
We knew a gentleman whose temper was not controllable if he allowed
himself to pass a day without his accustomed evacuation from the
bowels. Pinel records the particulars of the case of a man who had
fits of mental derangement whenever the action of the bowels became
irregular.
The blood-thirsty miscreant Robespierre is said to have been of a
“_costive habit, and to have been much subjected to derangement of
the liver_.” After death, it is said that “his bowels were found one
adherent mass.” It is indeed interesting to consider, both morally and
medically, how far these morbid ailments influenced this monster in the
bloody career in which he was engaged.
There can be no question but that the morbid irritability which
many of our men of genius have manifested was but the effect of
a derangement of the physical frame acting upon a mind naturally
sensitive to such impressions.
Much of the petulance, personality, and malignity of Pope was dependent
upon causes over which he had no control—viz., disease of the stomach
and liver, producing hypochondriasis. It has been well observed by
Madden, “Who knows under what paroxysms of mental irritation caused
by that disease (indigestion), which more than any other domineers
over the feelings of the sufferer, he might have written those bitter
sarcasms which he levelled against his literary opponents? Who knows
in what moment of bodily pain his irascibility might have taken the
form of unjustifiable satire, or his morbid sensibility assumed the
sickly shape of petulance and peevishness? Who knows how the strength
of the strong mind might have been cast down by his sufferings, when
‘he descended to the artifice’ of imposing on a bookseller, and of
‘writing those letters for effect which he published by subterfuge?’
Who that has observed how the vacillating conduct of the dyspeptic
invalid imitates the vagaries of this proteiform malady can wonder at
his capriciousness, or be surprised at the anomaly of bitterness on the
tongue, and benevolence in the heart, of the same individual?”[56]
That Pope was a severe sufferer from bodily disease will appear
evident from the following account given by Dr. Johnson of the poet.
He says, “Pope’s constitution, which was originally feeble, became so
debilitated that he stood in perpetual need of female attendance; and
so great was his sensibility of cold that he wore a fur doublet under
a shirt of very coarse warm linen. When he rose, he invested himself
in a bodice made of stiff canvass, being scarcely able to hold himself
erect till it was laced; and he then put on a flannel waistcoat. His
legs were so slender that he enlarged their bulk with three pairs of
stockings, which were drawn off and on by the maid, for he was not
able to dress or undress himself, and he neither went to bed nor rose
without help.”
His frequent attacks of indigestion made him at times a perfect picture
of misery and wretchedness. It clothed everything with a gloomy aspect,
made him quarrel with his friends and domestics, and he has been known
to say that he sighed for death as a reprieve from mental and bodily
agony. Sir Samuel Garth was frequently consulted when he had these
attacks; and it was only by exacting a strict attention to diet and
exhibiting medicine that he was enabled to restore the mind of the poet
to a healthy tone.
This physical ailment, as it often does when long continued, ultimately
affected the cerebral functions. At times he had symptoms of pressure
on the brain, or at least of an unequal and imperfect distribution of
blood to that organ. Spence says, he frequently complained of seeing
everything in the room as through a curtain, and on other occasions,
of seeing false colours on certain objects. At another period, on a
sick-bed, he asked Dodsley what arm it was that had the appearance of
coming out from the wall.
When the disposition to suicide is present, the physician should
carefully ascertain whether the patient is not labouring under cerebral
congestion, or a determination of blood to the head. The loss of
a small quantity of blood has frequently been known to remove the
propensity to self-destruction. A case is referred to by Schlegel of
a woman who was liable to periodical fits of suicidal mania whenever
she allowed a redundancy of blood to accumulate in the system. On two
occasions she attempted suicide. On the first indications of a return
of her delirium, she was generally bled, and relief was instantaneously
afforded.
A gentleman who had received, during the peninsular campaign, a sabre
cut in the head, felt for some years, whenever he was exposed to great
mental excitement, or allowed himself to over-indulge in the use of
spirits, a kind of suicidal delirium. Twice he was detected in the act
of attempting to commit suicide, and was fortunately prevented from
doing so. The local abstraction of blood from the neighbourhood of the
head was the only remedy which appeared to subdue the disposition.
The cases which are related in another chapter of individuals who were
insane at the moment when the act of self-destruction was attempted,
but who recovered the use of their reasoning after having inflicted
a wound attended with loss of blood, fully testify the importance
of general and local depletion in certain cases of cerebral disease
attended by this unfortunate propensity.
A blow on the head has been known to develope this feeling. The
affection of the sentient organ may remain latent for many years, and
then suddenly manifest itself. A man had received, when young, a kick
from a horse, which produced at the time no very urgent symptoms.
Six years after the accident, he, without giving any indications of
previous derangement of mind, cut his throat. Upon examining the brain,
it was found extensively diseased.
A man, feeling the suicidal disposition, bled himself from the arm, and
recovered.
It will not be proper in all cases to abstract blood; for the
destructive propensity has been known to exist where there has been
a deficiency of blood in the brain. The practitioner should examine
the condition of the patient thoroughly before he recommends active
depletion. Sixty per cent. of the cases of suicide will, however, be
found with cerebral disease either of a primary or secondary nature;
and to that organ the medical man’s attention should be particularly
directed.
The following case happily illustrates the benefits which are sometimes
derived from the local abstraction of blood in certain cases of
temporary insanity, accompanied with a disposition to commit suicide.
“A gentleman,” says Dr. Burrows, “of a very irascible and impetuous
disposition, with whom I was intimate, experienced in a public
meeting a rebuke which exceedingly mortified him, and made so deep
an impression upon his mind, that he was quite miserable. At night,
instead of going to bed, he roamed abroad; and at length, early in
the morning, without knowing whither he went, he found himself near a
sheet of water. The view of it at once determined him to drown himself,
and he accordingly plunged in. The action was perceived, and he was
rescued from the water, insensible, and immediately conveyed to a place
where means of resuscitation were adopted. As his address was found in
his pocket, a communication was directly made to his family, and Dr.
Burrows was called in to see the patient. He found him in a state of
insensibility. As soon as consciousness returned, he was dressed, put
into a coach, and Dr. B. accompanied him to his residence. As yet, he
had not spoken, neither did he appear to observe anything. The motion
of the carriage on the stones seemed to rouse him, and he looked about.
He took no notice of those who were in the carriage with him. He soon
became violent; his eyes were wild, and rolled in their sockets; his
face became flushed; the vessels of the forehead were excessively
distended, and all the symptoms of genuine delirium came on.[57] Dr.
Burrows ascribed the symptoms to a violent reaction in the vascular
system from the state of collapse it had sustained, and ordered the
oppressed vessels of the head to be relieved by the application of
cupping glasses, and the abstraction of sixteen ounces of blood;
the head to be kept cool, and enemata to be administered until the
bowels were well cleansed out. After these operations, he soon became
passive and disposed to sleep. He slept six hours, and awoke tolerably
composed, but not quite coherent. He took light nourishment, and at
night awoke perfectly collected, but exceedingly low. The next day he
was well, but languid. An explanation was given him, which removed the
impression that the offensive part of the speech had given him, and he
by degrees recovered his usual state of mind.”
We are inclined to believe, with D’Israeli, “that there are crimes for
which men are hanged, but of which they might easily have been cured
by physical means.” Damien, who attempted the assassination of Louis
XV., and who in consequence was subjected to the most refined tortures,
persisted to the last in declaring that if he had been bled, as he
wished and implored to be, the morning previously, he never would have
endeavoured to take the life of the king.
Gaubius relates the case of a lady of a too inflammable constitution,
whom her husband had reduced to a model of decorum by phlebotomy.
In the month of April, M. Delormel was called to Madame Chatelain,
at the Chateau de Armanvillers, who, according to the statement of
the physician in attendance, was “melancholic, hypochondriacal, and
insane.” She had made several attempts to commit suicide, and was
carefully guarded. She had been bled, purged, and well dosed with
anti-spasmodics, but to no purpose. M. Delormel examined the patient
very carefully, and came to a conclusion respecting her case very
different from that which had been formed by the other physicians
who had seen her. The lady was thirty-seven years of age, of a very
neuro-sanguineous temperament, active in body, and most amiable in
disposition. For more than two years she had complained of burning heat
in her stomach and bowels; digestion was painful, and constipation
habitual. The catameniæ were irregular; she was much emaciated, and the
symptoms of melancholia and hypochondriasis were well marked.
Madame C. could not bear to see her husband and children, to whom she
had, when in good health, been affectionately attached. Her chief
desire was solitude, and the predominant idea was the conviction of
approaching death. From an attentive examination of the case, it
was pronounced one of chronic gastro-enteritis. Eighty leeches were
applied to the abdomen, proper medicines were administered, her diet
regulated, and in less than a month she was completely restored to
health of body and mind.
When it is evident that the patient is suffering from cerebral
congestion, and yet general bleeding is inadmissible, the application
of cold to the head by means of a shower bath has often been productive
of much good. A young lady who laboured under the disposition to
suicide consulted an eminent living physician, communicating to him
the particulars of her malady, bitterly lamenting the unfortunate
feeling that was undermining her health. After trying various remedies
without effecting much relief, a cold shower bath was recommended
every morning. In the course of ten days, the desire to commit
self-destruction was entirely removed, and never afterwards returned.
A timely-administered purge has been known to dispel the desire of
self-destruction. Esquirol knew a man who was decidedly insane whenever
he allowed his bowels to be in an inactive condition.
A patient of Falret had well-marked suicidal delirium. So urgent were
the symptoms, that he was placed under restraint and carefully watched.
Active cathartics were administered, and Falret states that the
largest tape-worm he ever saw was evacuated. The idea of suicide soon
vanished, and the man was restored in perfect health to his friends and
family.[58]
Foderé examined the bodies of three persons in one family who fell
by their own hands, and in the three cases considerable disease was
discovered in the intestinal canal, which had been irritating the brain
and disturbing its manifestations.
In the instances just referred to, the indication of physical disease
of the _primæ viæ_ were but trifling during life.
Disease of the stomach and liver frequently incite to suicide; hepatic
affections notoriously disturb the equilibrium of the mind. Many a case
exhibiting an inclination to suicide has been cured by a few doses of
blue pill. The physician should direct his attention to the condition
of the uterine function and the state of the skin. During the puerperal
state, a tendency to suicide is often manifested.
A lady, shortly after her accouchement, expressed, with great
determination, her intention to kill herself. Her bowels had not been
properly attended to, and a brisk cathartic was given. This entirely
removed the suicidal disposition.
Any irregularity in the action of the uterine organ may give rise to
the same inclination. Under such circumstances, emmenagogues will do
much good.
German writers dwell much upon the connexion between suicide and
derangement of the cutaneous secretion. That this function should also
be attended to there cannot be a doubt, although we cannot call to
mind any cases of suicide which could be directly traced to suppressed
perspiration.
In some cases, a blister applied and kept open in the neighbourhood of
the head has effected much good. In other instances, issues have been
beneficial, particularly in persons subject to cerebral congestion.
There is, however, a condition of brain accompanying the suicidal
disposition which may be denominated a state of _cerebral irritation_,
in which bleeding or depletion would be injurious. In such cases,
friction on the spine, and the administration of anti-spasmodics,
gentle aperients, and alteratives, will be serviceable.
Sufficient attention is not paid to those precursory symptoms which
indicate the existence of a disposition to suicide. In two-thirds of
the cases that occur, the act is preceded by premonitory signs, which,
if attended to, will prevent the developement of the propensity.
With very few exceptions, the mental symptoms are those which are
principally manifested in these cases. Lowness of spirits, a love of
solitude, an indisposition to follow any occupation which requires
exercise of the mind, are generally exhibited. The person’s suspicions
become roused; he fancies his dearest friends are regardless of his
interests, or are plotting against his life. He takes no pleasure in
the family circle. He may be suffering from some evident physical
malady, acting through sympathy on the brain, and deranging its
functions; and then he will often refer to his disease, and express
his utter hopelessness of ever being cured. There is an expression
of countenance generally present in a person who meditates suicide,
which, if once seen, cannot easily be forgotten. Suicidal mania is
easily recognised by the experienced physician. The surgeon of a large
establishment in the environs of the metropolis informed me, that in
six cases out of ten he could detect, by the appearance of the eye, the
existence of the desire to commit self-destruction. A young gentleman,
a few days previously, had been admitted into the house as a patient.
The surgeon, after examining and prescribing for the lunatic, said to
one of the keepers, “You must watch Mr. —— carefully, for I feel assured
he will attempt his life.” Everything with which he might injure
himself, were he so disposed, was taken from him; but it appears that
he had resolved to make away with himself, and had carefully concealed
a penknife in his boot. On the evening of the day on which he was
admitted he made a dreadful gash in his throat, but failed in injuring
any large vessel. He confessed that he had determined to sacrifice
his life; he said, “It has been pre-ordained that I should fall by my
own hands, and I am only fulfilling my destiny by cutting my throat!”
Shortly after this he was removed; and as we have been subsequently
informed, sufficient care not being taken of him, he eventually
succeeded in killing himself.
How difficult it is for the medical man to persuade the friends of
a person who has evinced a disposition to suicide, of the absolute
necessity of his being confined and carefully watched! A physician,
dining with a friend, met by accident a young lady who had exhibited,
for a few days previously, a shrewdness of manner that attracted the
notice of those with whom she associated. He also observed a wildness
and incoherence about her ideas; but what particularly struck his
attention was, the peculiar expression of countenance which so often
denotes the presence of suicidal mania.[59] He felt convinced in his
own mind that the lady meditated self-destruction; and so firmly
persuaded was he of the fact, that he seriously spoke to the gentleman
at whose table he was dining on the subject, and urged him, as he was
intimately acquainted with the young lady’s family, to suggest the
propriety of having medical advice, and of carefully watching the
movements of the lady. This suggestion was treated with ridicule,
and of course the subject was not broached again. Two days after the
conversation took place, intelligence was brought that the lady had
taken a large dose of laudanum, and had died from its effects! A little
prudent caution might have saved the life of this poor unfortunate
being.
In cases in which the disposition to suicide has been evinced, the
patient ought to be carefully watched, and, under some circumstances,
placed under restraint. Men who talk loudly of the effects of moral
coercion, and who repudiate the idea of strait-waistcoats* &c., have
had but little practical experience of the treatment of the insane.
Moral discipline has done much good. Deeply should we regret to see
the system which has been in force within our own recollection again
introduced into our lunatic asylums. In endeavouring to avoid Scylla
we have fallen into Charybdis. How many lives are lost in consequence
of the patients not being properly secured when they have exhibited a
desire to commit self-destruction.
A lady who had attempted to destroy herself was very properly sent to
an asylum. Having expressed a determination to avail herself of the
first opportunity for carrying her intentions into execution, she was
most carefully guarded. She was never allowed to be out of sight; a
trustworthy nurse always kept by her side; and in the course of time
she was pronounced recovered. But as it was not considered prudent to
send her home at once, she was separated from the other inmates of
the house, and allowed to reside with the surgeon and matron of the
establishment. Even under these circumstances it was thought better
not to allow her to be wholly by herself, fearful that the disposition
might again suddenly develope itself. She resided with the surgeon
for some weeks, and appeared completely well. She expressed much
astonishment when told that she had attempted her own life; she was
apparently horrified at the idea. She was sitting with the matron
one morning after breakfast; the surgeon was going round the asylum,
when a child was heard to cry up stairs, as if it had received some
injury. The matron immediately left the room; she was not absent
three minutes, and when she returned she was astonished to find the
young lady had vanished. Immediate search was made for her, but she
was not to be found, when, looking behind the curtain in the parlour,
the lady was discovered hanging to the cornice! In that short space
of time she had succeeded in suspending herself, and was quite dead.
Of course we cannot determine whether she had recovered, and this
was but a sudden recurrence of the suicidal mania, or whether she
had cunningly concealed her ailment for the purpose of throwing her
attendant off her guard, and thus being enabled to effect her dreadful
purpose. We should be more disposed to accede to the latter solution
of the question, knowing the extreme cunning of such lunatics, and the
ingenious stratagems they often have recourse to in order to accomplish
any mischievous object they have in view.
A person who manifested indications of mental aberration was found
in the act of hanging himself. Upon being detected, he promised most
solemnly to abandon his rash resolution. He attempted a second time to
kill himself by cutting his throat, but the wound was not fatal. He was
now placed under the care of a gentleman who had devoted much attention
to the treatment of insanity; and, knowing his propensity, the
keeper received strict injunctions to watch his movements carefully.
Everything by which he could injure himself was removed from his room,
he was shaved every day by a barber, and no instrument of any kind was
allowed to be in his possession. He was confined for nine months; and
it appeared, from what afterwards occurred, that he had, during the
whole of this period, been absorbed in the one idea of how he should
contrive to commit suicide. He was discovered one morning hanging by
the neck from the bedstead, quite dead. How he got possession of the
cord which suspended him, puzzled everybody acquainted with the history
of the case. At last the enigma was solved. It appears that parcels of
books and newspapers had occasionally been sent to him by his family,
tied with twine; and he had carefully, and unknown to the keeper,
concealed each piece, until he had collected a quantity to constitute
a cord sufficiently strong with which to hang himself. For nine
months this idea had exclusive possession of his mind; and although
he exhibited no apparent symptoms of insanity, he had evidently been
contemplating suicide for the period already specified.
A female had made repeated attempts, during her residence in the
asylum at Wakefield, to hang herself, but had been so watched that she
had not succeeded. One evening, the servant, on going to remove all her
clothes out of her bed-room, thought she saw something bright on the top
of one of her under garments; upon examination, this was found to be
a pin. She had contrived just before bed-time to take off her garter;
and, knowing that her pockets as well as her clothes would all be
removed, she contrived to pin it within her dress, so high up that it
would not easily be perceived. Very providentially, the brightness of
the metal discovered it, and she was again prevented from accomplishing
her purpose. By degrees the propensity wore off; and after a residence
of eighteen years in the Hanwell Asylum, Sir W. Ellis found her a
few years ago, living, though upwards of eighty years of age, in a
comparatively tranquil state, waiting her removal in the ordinary
course of nature.
When persons determined on suicide find that they are unceasingly
watched, and so carefully secured that they have no opportunity of
executing their design, they will assume a most cheerful manner for
days and weeks together, in order to lull suspicion; and when a
favourable opportunity offers, it is never neglected.
A man who had long been in a state of despondency, and had made many
attempts to hang himself, but had always been prevented, very suddenly
appeared much better. He became apparently cheerful, and being desirous
of employment, was sent out with a large party into the hay-field.
He continued in this and other out-door occupations for some time,
gradually improving. One evening, on returning from the field, when
the rest of the party went in to tea, (which they were allowed when
hay-making,) he told the farming man that he did not feel thirsty, and
as it was very warm he would rather remain at the door. He was left
there. A short time afterwards his keeper came down to inquire for him,
and being told where he had been left, immediately exclaimed, “Then he
has hung himself!” It was also singularly impressed upon his mind,
that it was in one particular out-house that he had done it. There he
went, and found him suspended and dead, as he expected.
“A noble lord,” (says Dr. Rowley,) “whose family I had the honour to
attend, had received, it is said, some little reproof from a great
personage, concerning a military omission. It seized his lordship’s
mind so seriously, that on examination it was evident to me that
suicide was intended. All weapons and dangerous means whatever were
removed. It being a circumstance of delicacy, I sent for his lordship’s
son, then about eighteen, from Westminster school, communicated my
apprehensions, and requested his constant attendance on his noble
parent. This the young man executed for several days, and prevented
the commission of the crime apprehended. In my absence a few hours in
the country, a very eminent, learned, and indeed remarkably sagacious
physician, but my mortal and vindictive enemy, was called in. I had,
contrary to medical _etiquette_, enforced the necessity of promptly
bleeding a most noble lady in an apoplexy, which saved life, but
brought down invectives, hatred, and vengeance on me. Whether out of
opposition to my vigilance, or from malicious motives, it would be
difficult to determine, but the noble lord was liberated from all
restraint, and my apprehensions treated by injurious insinuations and
with contempt. Thirty-six hours had scarcely elapsed before the noble
lord put a period to his existence, by a sword he had concealed, which
had been a present from Prince Ferdinand: he wounded his breast in
two places, but the third thrust pierced his heart. Thus perished a
nobleman, whose liberality, feelings, and many virtues, did honour to
human nature, and who might, in all probability, have been now living,
had not medical arrogance and illiberality, merely from personal
ambition, dictated error, at the risk of human destruction! _Horridum!
valde horridum!_”
The physician should constantly bear in mind this important fact
connected with the suicidal disposition—viz., that those determined
upon self-destruction often resolve to kill themselves in a particular
manner, and however anxious they may be to quit life, they have been
known to wait for months and years, until they have had an opportunity
of effecting their purpose according to their own preconceived notions.
A man who has attempted to drown himself will not readily be induced
to cut his throat, and _vice versa_. A morbid idea is frequently
associated in the maniac’s mind with a particular kind of death, and
if he be removed from all objects likely to awaken this notion, the
inclination to suicide may be removed.
An old man, upwards of seventy years of age, who had a market garden,
near the asylum at Wakefield, consulted the late Sir W. Ellis as to
the best mode of destroying himself, as he had made up his mind not
to live any longer. He said he had thought of hanging himself, if Sir
William could not recommend an easier death. The physician talked to
him some time upon the heinousness of the crime he contemplated, and
endeavoured to shew him that hanging was a most horrible death, from
the suffocation that must be felt. His conversation was attended with
little success. Finding that the chylopoietic viscera were a good deal
disordered, he prescribed for him, and sent to inform his wife that he
ought never to be left alone. The medicine had the effect of restoring
the secretions to a healthy action, and he got better. Sir William
heard no more of him for some time, when he was at length informed that
he was discovered dead in a little shed in his garden, where he used
to keep his tools. But so fixed was the mode in his mind, by which he
was determined to accomplish his death, that, though the place was so
low he could not stand upright in it, and he had not a rope or a string
with which he could suspend himself, he contrived to effect his purpose
by getting a willow twig, and making it into a noose, which he fastened
to one of the rafters. He stooped to put his head through it, and then
pushing his feet from under him, suspended himself until he died. Now,
if he had not made up his mind to destroy himself in this particular
way, he might have accomplished it with much greater ease by drowning
himself in the pond in his garden, or by cutting his throat with his
garden knife, which he always had about him; but neither of these was
the mode he previously intended.
It may be practically useful to all who have the immediate care of
suicidal patients to bear this in mind; and if the medical man can find
out that any particular plan is contemplated, he ought to be especially
careful to remove the means of accomplishing it out of the patient’s
reach, and to prevent him having an opportunity of carrying it into
execution.[60]
“A medical friend,” says Dr. Burrows, “who had much enjoyed life,
and never met with any circumstances to occasion him particular
disquietude, when at the age of forty-five became very dyspeptic,
low-spirited, and restless. He gradually shunned society; but still,
though with great reluctance, pursued his professional avocations. This
depression increased so much that he often told his wife that he should
consult me. (He knew very well that both his father and grandfather had
destroyed themselves.)
“One morning he kept in bed much longer than usual, and a relation
calling, went up, without being announced, to see him. He seemed
composed, at length complained of being very faint, and upon
raising him up, blood was perceived on his hands. Upon examination
it was discovered, at the moment his friend entered the chamber,
he was employed in opening the femoral artery; that there had been
considerable hemorrhage from the small vessels he had divided. I saw
him within an hour afterwards. He had recovered from the syncope, and
expressed great sorrow for what he had done; described with minuteness
his case; lamented he had not seen me sooner, but that he could not
muster sufficient resolution; consented to place himself under my
superintendence; and, in fact, to follow all my directions.
“I placed him in charge of a careful keeper. It was agreed that he
should be removed into lodgings in the environs of town; and he
therefore submitted to the necessary medical treatment.
“He remained two days at home, till lodgings could be procured, during
which he was calm and rational; but there existed the suicidal eye,
which sufficiently denoted that he was not to be trusted.
“On the third morning, his keeper, having a violent attack of
rheumatism in his right arm, could not shave him, and another person
was obliged to be trusted. This person, unfortunately, laid the razor
on the dressing-table; and, while his face was turned away, and the
keeper was heating some water a few feet from the table, the patient
suddenly jumped up, seized the razor, and in a moment applied it to his
throat, and effectually divided the carotid artery.”
A case somewhat similar we find recorded by the same authority. Major——
had been wounded at the battle of Waterloo. He had since recovered
his health, but a great depression of spirits followed. The maniacal
diathesis was hereditary. By degrees he became more desponding, his
ideas wandered, and at length a suicidal propensity was evident. On
visiting him, Dr. Burrows strongly urged the necessity of placing
him under the supervision of an experienced keeper; but here, as in
too many cases, his family opposed this advice, and would not permit
proper restraint, but put him under the care of a nurse only. In the
evening, he retired early to bed. The nurse went to tea in his chamber,
supposing her charge to be asleep. The patient watched the opportunity,
jumped out of bed, seized a knife on the table, wounded, and would have
effectually cut his throat, had not the nurse interposed.
“A clergyman in Warwickshire told me,” says Dr. Conolly, “that he was
requested, some years ago, to interfere respecting certain measures
proper for securing a neighbour who had exhibited unquestionable
symptoms of insanity. His neighbour, however, was not to be met with
on the day when it was intended to remove him, and when he reappeared,
which was either the next day or in a day or two afterwards, he was
quite in a sound state, in which condition he has lived with great
comfort up to the present time. On the other hand, an instance came
under my own observation in which a gentleman had shewn many proofs
of disordered mind for the space of three or four months, and his
actions becoming dangerous, it was resolved to remove him. About
two hours before I was to call for him, he was so quiet and orderly
in a conversation with the old family-apothecary, that the latter
gentleman rode off to the relations of the patient, relenting all
the way concerning the proposed restraint, and purposing to solicit
its postponement; in which attempt he was only prevented by being
overtaken by a messenger before he had ridden half a mile, who came
to inform him that his apparently tranquil patient had nearly blown
up his house and his whole family with gunpowder, having for that
purpose thrown a pound and a half of it into the fire, sitting by to
see it explode. In another case, a gentleman had made repeated attempts
at self-destruction, but seemed to have got well, and was no longer
much looked after; yet after living comfortably at home for a little
while, and having passed a cheerful evening in reading to his wife, he
concluded it, when she had retired, by hanging himself in the parlour.
“These lamentable accidents are, of course, always productive of
disagreeable feelings in the mind of a practitioner; but never more
so than when he has been too confident of the absence of danger. It
is questionable, perhaps, whether there are not, in all these cases,
certain means of which prudence might avail itself, for the purpose
of ascertaining the exact state of the supposed convalescent’s mind,
as well as the existence of such intentions in a lunatic as are
inconsistent with the safety of other persons, or with the preservation
of his own existence. The lunatic may maintain a very guarded silence
on these matters so long as they remain quite unsuspected, but is
not very well able, in general, to prevent his intentions becoming
visible to those who have begun to suspect him. These intentions,
too, are generally associated with certain recollections, or certain
topics, or certain antipathies or prepossessions, which may be found
out and brought into the conversation; in which case, the lunatic can
seldom conceal his agitation, his superstitious belief, his anger, or
his inly-cherished hope of full revenge. Indeed, he is often in no
degree solicitous to conceal his feelings. There cannot be anywhere
a more harmless person than Jonathan Martin; his manners are mild,
his occupations are of the most peaceful description, his language
is strikingly simple and unassuming; but take up the Bible, and you
have touched the chord of his insanity; you find that, to destroy the
noblest monuments of ancient piety and munificence seems to him a work
to which God has especially called him. The effect of possessing a key
to the excited feelings of a lunatic is, indeed, always surprising to
those unaccustomed to their peculiarities. You walk with a man who
seems to delight in the simplest pleasures of a state of innocence;
he admires the flowers of the field and the beauty of the sky, or he
dwells with satisfaction on the contemplation of whatever is generous
and good; nothing can exceed the mildness of his manner: but a
single word calculated to rouse a morbid train of ideas, a name, the
reminiscence of a place, or any trifling inadvertency, will convert
this placid being into a demon; the tones of his voice, his gestures,
his countenance, his language, assume, in a moment, the expression of
a fiend; and you discover that opportunity alone is wanting to effect
some dreadful crime. The discovery of such a design is certainly not
always so easy, but wherever suspicion exists, strict superintendence
is warranted, or various degrees of restraint must be determined upon,
and steadily adhered to.”[61]
The following cases will shew the necessity of guarding a person
by the strictest surveillance from the moment that he evinces the
slightest symptom of mental alienation, when it manifests itself by
incongruous expressions or attempts at self-destruction. This precept
should be engraven on the mind of every medical man, and no feeling
of false delicacy should prevent his communicating his suspicions and
wishes the moment he considers measures of precaution necessary. In
these cases, the loss of an hour may make all the difference between
life and death.
M. Piorry was called to the Hôtel de Bibliothèque, where he found a
man of athletic form and military appearance in a state of complete
insensibility. He manifested all the indications of apoplexy or
epilepsy. Some time elapsed before the physician could ascertain
what was the matter; he could not obtain any satisfactory answers to
his repeated questions. At last the patient made Piorry understand
that he had swallowed a key. Professor Roux was sent for, who, after
considerable difficulty, succeeded in extracting the foreign body
from the œsophagus, along with an oblong piece of copper attached
by a chain to the handle of the instrument. On the succeeding night
he made fresh attempts to destroy himself; first by hanging with the
bed-clothes, and, on that mode not proving successful, he endeavoured
to strangle himself by squeezing two chairs against his neck. Thwarted
in effecting his design, he again swallowed the key, and he was nearly
dead when he was discovered, and the key extracted from his throat. He
was now confined in a strait-waistcoat, and was subjected to proper
medical treatment. In the course of a short period, all disposition to
suicide was removed, and his mind was restored to perfect integrity.[62]
A soldier, who was greatly beloved in his regiment for his exemplary
conduct and amiable qualities, became affected with suicidal
melancholy, and fired a pistol into his mouth. The havoc made was
dreadful; but by great exertions on the part of M. Petit, who attended
the case, his life was preserved. During his confinement, he manifested
great anxiety for his recovery, and expressed himself horrified that
he should ever have attempted to commit self-destruction. The surgeon
and his friends entertained every hope that all suicidal tendency
was dissipated. The result, however, proved that the whole was a
manœuvre on the part of the patient to lull suspicion to rest, and
when he had succeeded by this dissimulation in throwing his friends off
their guard, he put an effectual period to his existence whilst in the
wards of the hospital.
The following case exhibits some practical points exceedingly worthy
of record, and displays besides, in a remarkable degree, the control a
lunatic disposed to suicide acquires over himself, his conversation,
and conduct, when he wishes to lull suspicion to sleep. In this
instance, says Dr. Burrows, who relates the particulars of the case,
a most judicious physician, and those in whom he had confidence, all
experienced in the phases of this wonderful malady, insanity, and its
no less wonderful concomitant, suicide, were completely deceived.
A medical friend of the Doctor’s, travelling over Shooter’s Hill,
observed a gentleman walking up it, his carriage following him. When
opposite to each other, the stranger suddenly fell on his knees in
the dirt, and lifted up his hands, as if in earnest prayer. The
friend stopped his post-chaise at so extraordinary a sight, and soon
found by his looks and manners that the poor gentleman was insane. He
immediately accompanied him back to London, and placed him under Dr.
B.’s care till his relations were informed of his state.
The history of the case was this:—The patient was a cavalry officer
of rank, aged thirty-five, and had particularly distinguished himself
at the recent battle of Waterloo. On that occasion he had two horses
killed under him, and was himself wounded in four places. He was first
struck on the crown of his helmet by the splinter of a shell, which
wounded the scalp and stunned him; he was next shot through the fleshy
part of the thigh by a grape shot, which at the same time killed his
first horse; from these two wounds he lost much blood. Whilst lying
under his second horse, he was pierced in the groin by a lance; and
in this helpless condition he received from a French drummer, who was
rifling the dead and dying, a violent blow on the temple from the
butt-end of a musket, from the effects of which, he remained some time
insensible. He was afterwards conveyed in a most deplorable state as a
prisoner within the French lines, and though released the same evening
by the victorious allies, a long while elapsed before his wounds and
exhausted condition received any attention.
He inherited a predisposition to insanity, and was naturally reserved,
diffident, and taciturn, but affectionate and generous.
When he recovered from his wounds, he often complained of pains in
his head; and it was observed that his temper became fretful and
suspicious; that he slept ill, was depressed in spirits, and courted
solitude. These symptoms increased latterly. At length he imagined
himself the sport of his brother officers, and many other delusions
arose.
There was a moral cause likewise operating which, on a constitution
that had recently received so severe a shock, no doubt greatly
influenced his disorder. He had applied for promotion in consequence
of his sufferings in the service. This was withheld, as he thought,
ungraciously, and too long; and when he was raised a step, his mind was
already too much disturbed duly to appreciate it. The anniversary of
the glorious battle of Waterloo was just passed, and the recollection
of it was painful to him. In this state he came to town.
He was exceedingly sober and temperate by habit; but during the day
before, with a brother officer, he was persuaded to commit an unusual
excess in wine, with the hope of raising his spirits.
This proved a match to the mine. It exploded, and his intellects became
completely deranged.
Dr. Burrows found him with his countenance very wild, the eyes injected
and pupils contracted, pulse quick and weak, tongue white, and great
thirst. He had had no sleep for five nights. Sometimes exalted,
violent, and loquacious; sometimes depressed and taciturn. He was
rather languid, which was imputed to his having lost full twenty ounces
of blood from the rupture of an hæmorrhoidal vessel.
It is not necessary to detail the medical treatment adopted, but we
will proceed to those points in the case which are relevant.
He was placed in lodgings with a careful attendant. In about three
weeks he was nearly well, when unluckily a whitlow formed on his
finger, and as one of his delusions was that he was rotten in every
part, it was the cause, besides pain, of considerable irritation, and
it broke his rest; other delusions returned, but subsided with the pain
of the whitlow, and he again greatly improved.
In six weeks he was so well that the Doctor took his leave, advising
him to travel during the remainder of the autumn. The next day some
domestic occurrence occasioned violent irritation, and he again
relapsed into despondency, unattended by paroxysms of violence; but he
shortly recovered.
However, instead of going into the country and varying the scene, his
lady brought him into town and permitted unrestricted intercourse
with his relations, &c. He grew quarrelsome, suspicious, and very
low-spirited, and began to abuse his wife. It was then earnestly
recommended that he should be completely separated from all intercourse
with her and his connexions, but the advice was disregarded.
A boil now formed on his body. This irritated him more than the
whitlow, and his delusions about his rottenness were more prominent
than ever; but when the boil suppurated and discharged, his mind again
improved.
No persuasion could induce his friends to give him exercise or
diversion, or change the scene. He therefore sat all day brooding over
his fantasies, and reading religious books; for now there was added to
his delusions an impression that he was very wicked, and had neglected
his religious duties. His face, too, assumed the suicidal expression.
A month afterwards, a consultation with two eminent physicians
confirmed Dr. Burrows’ opinion of the treatment to be pursued. But,
notwithstanding this consultation, all remedial aid was neglected,
and he was allowed to follow his own inclinations, both in religious
matters and in totally secluding himself. In about three weeks all the
symptoms were so much increased that he was sent to a private asylum.
A few days afterwards, while walking out, he tried to drown himself,
but was rescued by his keeper. He continued in this desponding state
some months, when, rather suddenly, he appeared much better; and
continuing to improve, his physician thought him well, and he returned
home. Two days only had passed, when he called on the same physician,
acknowledged that he was as bad as ever, and entreated earnestly that
he might again be received into his house. He was so on that day. The
next day he poisoned himself and died.
It proved, that he had never abandoned the desire of committing
suicide; but he so well concealed it, and otherwise conducted himself,
as to lead to the conclusion that he had recovered. It was, in fact,
a scheme, the sole object of which was to get out and buy laudanum.
Having procured a sufficient quantity, but anxious to save his wife the
agony of witnessing the act he meditated, he preferred returning to the
asylum to execute it.
A few general principles have been laid down in this chapter to direct
the practitioner in the management of certain cases of suicidal
insanity. The success of the treatment will in a great measure be
dependent on the physician making himself acquainted with the minute
history of each case submitted to his professional care. No particular
rules can be adduced that will be applicable to all cases of this
description; much must be left to the judgment of the medical man. The
physician should, however, never forget that whatever apparently may
be the physical disturbance going on in the system, the brain, and the
brain alone, is the seat of the disease in all cases of suicide, and to
the condition of that organ most particular attention ought to be paid.