After-Cures.--I have said so much about the after-cure of alcoholism that applies directly to drug addictions also, that it does not seem necessary to repeat it here. Patients must be warned that if they become overtired, if they lose sleep, if they are subject to much excitement, if they put themselves in conditions of anxiety and worry, if any form of recurrent pain develops--headache, toothache, stomach-ache--they are likely to be tempted to take up their old habit. If they are in a position where they can easily get the drug it is almost inevitable that something will happen to make them feel that {713} they are justified in taking one or two doses and from this to the reestablishment of the habit is only a small step. Often these patients need a change of occupation. Some of them are over-occupied, some of them have not enough to do. In either case it is the doctor's duty to know enough about his patient to be able to give directions.

We do not treat a drug addiction with the hope of curing it, but we treat a patient suffering from a particular drug habit and we try so to modify that patient's life that after we have succeeded in getting him away from his habit, which is never difficult, he will not relapse into it. The after-cure is the more important of the two.

CHAPTER III

SUICIDE

In spite of the gradual increase of comfort in life and its wide diffusion--far beyond what people enjoyed in the past--there has been a steady progressive increase in the number of suicides in recent years. It is as if people found life less worth living the more of ease and convenience there was in it. This increase in suicide is much greater (over three times in the last twenty years) than the increase in the population. Surprising as it may seem, prosperity always brings an addition to the number of suicides. Stranger still, during hard times the number of suicides decreases to a noteworthy degree. It is not those who are suffering most from physical conditions who most frequently commit suicide. Our suicides come, as a rule, from among the better-to-do cla.s.ses of people. While suicide might seem to be quite beyond the province of the physician, it is a duty of the psychotherapeutist to prevent not only the further increase of suicides in general but to save particular patients from themselves in this matter. A careful study of the conditions as they exist, moreover, will show that he can accomplish much--more than is usually thought--and that it is as much a professional obligation to do so as, by the application of hygienic precautions and regulations, to lessen disease and suffering of all kinds and prevent death.

The same two modes of preventive influence that we have over disease in general can be applied to suicide. The physician can modify the mental att.i.tude in individual cases and thus save people from themselves and then he can, by his influence in various ways upon public opinion, lessen the death rate from suicide. For this purpose, just as with regard to infectious disease, it is important for him to appreciate the social and individual conditions that predispose to suicide, as well as the factors that are more directly causative. The more he studies the more will he be convinced that what we have to do with in suicide is a mental affliction not necessarily inevitable in its results and that may be much influenced by suggestion. Indeed, unfavorable suggestion is largely responsible for the increase in suicide that has been seen in recent years. Favorable suggestion might be made not only to stop the increase, but actually to reduce the suicide rate. For this purpose it is important to know just what are the conditions and motives that predispose to suicide and, above all, to realize that it is not the result of insufferable pain {714} or anguish, but rather of the concentration of mind on some comparatively trivial ailment, or exaggeration of dread with regard to the consequences of physical or moral ills.

Suicides are often said to be irrational; in a certain sense they are.

No one who weighs reasonably all the consequences of his act will take his own life. This irrationality, however, is nearly always functional and pa.s.sing, not of the kind that makes the commission of suicide inevitable, but only produces a tendency to it. This tendency is emphasized by many conditions of mind and body that the physician can modify very materially if he sets about it. Many of the supposed reasons for suicide are founded on the complete misunderstanding of the significance of symptoms and dread of the future of his ailments, often quite unjustified by what the individual is actually suffering.

Indeed, the desperation that leads to suicide is practically always the result of a state of mind and not of a state of body. It is exactly the same sort of state of mind which sometimes proves so discouraging in the midst of diseases of various kinds as to make it impossible for patients to get over their affections until a change is brought about in their ideas. This makes clear the role of psychotherapy with regard to suicide, and there is no doubt that many people on the verge of self-murder can be brought to a more rational view and then live happy, useful lives afterwards. For this purpose, however, it is important that the physician should come to be looked upon as a refuge by those to whom the thought of suicide has become an obsession.

A well-known social religious organization not long since established a suicide bureau, that is, a department to which those contemplating suicide may apply with the idea that they would there find consolation and perhaps some relief for their troubles and thus the idea of suicide might be dissipated. Many a suicide would be avoided if the reasons that impelled to it had been known to one or two other people beforehand, so that some relief might have been afforded to what seemed an intolerable condition. This suicide bureau is said to have done much good. There is no doubt that the mere act of giving one's confidence to another is quite sufficient of itself to diminish to a marked degree a burden of grief and trial. If anything in the world is true, it is that sorrows are halved by sharing them with another, while joys are correspondingly increased. The fact that there is someone to whom they might go, who would look sympathetically at their state of mind, who would appreciate the conditions, who had been accustomed to dealing with such cases, would be enough to tempt many people from that awful introspection and concentration of mind on themselves which, more than their genuine sufferings and trials, whatever they may be, make their situation intolerable.

There has always been a suicide bureau, however, in the office of every physician who really appreciates the genuine responsibilities of his profession. More than any others we have the opportunity to alleviate physical sufferings, to lessen mental anguish and to make what seemed unbearable ill at least more or less tolerable.

Unfortunately in recent years the change in the position of the physician in his relations to the family has somewhat obscured this fact in the minds of the public. The old family physician occupied to no slight extent the position of a father confessor, to whom all the family secrets were told, from whom indeed, as a rule, it was felt that they should not be kept; to whom father went with regard to himself and mother, to whom mother {715} went with regard to all the family as well as herself, to whom the boy confided some of his s.e.x trials and the girl some of the secrets that she hid from almost everyone else, so that to go to him for anything disturbing became the first thought. We must restore something of this old-fashioned idea of the doctor's place in life if all our professional duties are to be properly fulfilled. If those contemplating suicide learn to think of us as persons to be appealed to when all looks so black that life is no longer tolerable, we shall soon be in a position to confer increased benefits on this generation that needs them so much.

Physical Factors.--As a rule there is a physical element as the basis for nearly all suicides. With the unfortunate, unfavorable suggestion that has come from the supplying of details of pathological information--the half-knowledge of popular medical science--without the proper antidote of the wonderful compensatory powers of the human body for even serious ailments, a great many nervous people are harboring the idea that they have or soon will have an incurable disease. Physicians have abundant evidence of this. All sorts of educated people come to us to be rea.s.sured that some trivial digestive disturbance does not mean cancer of the stomach, or, when they are between forty and fifty, come to make sure that some slight disturbance of urination is not an enlarged prostate. Brain workers of all cla.s.ses come over and over again to be rea.s.sured that they are not breaking down because of organic brain disease, of which they show absolutely no sign. Sometimes they have been making themselves quite miserable for a long period by such thoughts. It is easy to understand, then, how many less informed people, yet provided with the opportunities of quasi-information that modern life affords, are apt to think the worst about themselves.

_So-called Insomnia_.--The correction of such preconceived notions will always greatly alleviate the mental sufferings of these patients.

For this purpose there are many chapters of this book which point out how various symptoms and syndromes that are often amongst the factors in the production of suicide may be managed. Perhaps one of the most frequent of these is so-called insomnia. Most people are insomniac, mainly because they are overanxious about their sleep. A few of them are wakeful because of bad habits in the matter of work and the taking of air and exercise. Essential insomnia is extremely rare and symptomatic; insomnia is not mental, but is usually due to some definite physical condition that can be found out and, as a rule, treated successfully. There is always some other symptom besides loss of sleep. If men will live properly and rationally there is no reason why insomnia should be a bane of existence, nor even any reason why the morphin or other drug habit should be formed which is so likely to come if inability to sleep is treated as if it were an independent ailment. In the forms in which it incites to suicide it owes its origin to a nervous superexcitement with regard to sleep in people whose daily life in some way does not properly predispose them for the greatest of blessings on which there is no patent right. Additional suggestions as to these insomniac conditions are made in the chapters on Insomnia and Some Troubles of Sleep which make it clear that suicide, because of insomnia is due to a delusion.

_Headache_.--Persistent supposedly incurable headache is another prominent feature of the stories of suicides and here once more we have to deal rather {716} with a delusion of over-attention of mind and concentration of self on a particular part than a real physical ailment. Most of the so-called headaches that are supposed to be so intractable are really not headaches but pressure feelings and other queer sensations in the head originally perhaps partaking of the nature of an ache but continued through over-advertence. Severe pain within the head occurs in cases of congestion and brain tumor, and without the head in cases of neuralgia, but most of these are only temporary and long-continued headaches are rather neurotic than neuritic or due to any real disturbance of the nervous system. This is discussed in the chapter on Headaches. People commit suicide who have for a long time been sufferers from headache because they fear that they may go crazy. There is absolutely no reason in the world to think this probable, and in the one case of continuance of severe intermittent headaches for years already mentioned--that of von Bulow, the Austrian pianist and composer, in which we have the autopsy record--it was found, after a long life, that his severe intracranial headaches were due to the pinching of a nerve in the dura and not to any organic change in the brain itself.

Mental Factors.--While physical factors enter into the suicide problem to a marked degree, it would be a great mistake to think that physical conditions or material circ.u.mstances are the main causes or occasions in suicide. It is supposed, as a rule, to be due to depression produced by incurable disease, oppressive weather, financial losses and the like. There is no doubt that these are contributing causes, but the physical conditions have very little influence compared with the att.i.tude of the patient's mind toward himself. As a rule, it is not those who are in absolutely hopeless conditions who turn to this supposed refuge of a voluntary exit from life in order to get out of trouble, but rather those who are momentarily discouraged and who have not sufficient moral stamina to face the consequences of their acts.

There was a time when it was considered brave to fight a duel and cowardly to refuse to do so. Looking back now, we know that they were the real brave men who dared to refuse when a barbarous civilization would force them into a false position and who, in spite of disgrace, ventured to be men and not fools. There are those who used to say that it was brave to take one's own life rather than bring disgrace on loved ones, but the mitigation, if there be any, of the disgrace that suicide brings with it, comes from that lowest of all motives, pity for the survivors, and the cowardly suicide leaves to others the thankless task of making up for his faults.

_Suicide and the Weather_.--An investigation of suicide records shows, as we have said, that it is not nearly so often bodily or material hardships that lead men to it as mental states. These mental states are not mental diseases, but pa.s.sing discouragements in which men are tempted beyond their strength and do irretrievable things for which there is no rational justification. It is not in dark damp weather that men commit suicides most, though this was supposed to be a commonplace in our knowledge of suicide. Recent investigations show that quite the contrary is true. Professor Edwin T. Dexter of the University of Illinois published a very important study of this question in a paper ent.i.tled "Suicide and the Weather." [Footnote 55] He followed out the records of nearly 2,000 cases of suicide reported to the police in the City of New York {717} and placed beside them the records of the weather bureau of the same city for the days on which these suicides occurred. According to this, which represents the realities of the situation, the tendency to suicide is highest in spring and summer and the deed is accomplished in the great majority of cases on the sunniest days of these seasons.

[Footnote 55: _Popular Science Monthly_, April, 1901. ]

His conclusions are carefully drawn and there is no doubt that they must be accepted as representing the actual facts. All the world feels depressed on rainy days and in dark, cloudy weather, but suicides react well, as a rule, against this physical depression, yet allow their mental depression to get the better of them on the finest days of the year. Prof. Dexter said:

The clear, dry days show the greatest number of suicides, and the wet, partly cloudy days the least; and with differences too great to be attributed to accident or chance. In fact there are thirty-one per cent. more suicides on dry than on wet days, and twenty-one per cent. more on clear days than on days that are partly cloudy.

What is thus brought out with regard to the influence of weather can be still more strikingly seen from the suicide statistics of various climates. The suicide rate is not highest in the Torrid nor in the Frigid zones, but in the Temperate zones. In the North Temperate zone it is much more marked than in the South Temperate zone. Civilization and culture, diffused to a much greater extent in the North Temperate zone than in the South, seem to be the main reason for this difference. We make people capable of feeling pain more poignantly, but do not add to their power to stand trials nor train character by self-control to make the best of life under reasonably severe conditions. With this in mind it is not surprising to find that the least suicides occur in the month of December, when the disagreeable changes so common produce a healthy vital reaction, though the many damp dark days that occur would usually be presumed to make this the most likely time for suicides. On the contrary, it is the month of June, the pleasantest in the North Temperate zone, that has the most suicides. It is important to remember this in estimating the role of physical influences on the tendency to suicide.

Social Factors that Restrain Suicides.--_War_.--A most startling limitation of suicide is brought about by war. For instance, our Spanish-American war reduced the death rate from suicide in this country over forty per cent. throughout the country and over fifty per cent. in Washington itself, where there was most excitement with regard to the war. This was true also during the Civil War. Our minimum annual death rate from suicide from 1805 (when statistics on this subject began to be kept) was one suicide to about 24,000 people, which occurred in 1864 when our Civil War was in its severest phase.

There had been constant increase in our suicide rate every year until the Civil War began, then there was a drop at once and this continued until the end of the war. In New York City the average rate of suicide for the five years of the Civil War was nearly forty-five per cent.

lower than the average for the five following years. In Ma.s.sachusetts, where the statistics were gathered very carefully, the number of suicides for the five-year period before 1860 was nearly twenty per cent. greater than for the five-year period immediately following, which represents the preliminary excitement over the war and the actual years of the war. This experience in America is only in accordance {718} with what happens everywhere. Mr. George Kennan in his article on "The Problems of Suicide" (_McClure's Magazine_, June, 1908), has a paragraph which brings this out very well. He says:

In Europe the restraining influence of war upon the suicidal impulse is equally marked. The war between Austria and Italy in 1866 decreased the suicide rate for each country about fourteen per cent.

The Franco-German War of 1870-71 lowered the suicide rate of Saxony 8 per cent., that of Prussia 11.4 per cent. and that of France 18.7 per cent. The reduction was greatest in France, because the German invasion of that country made the war excitement there much more general and intense than it was in Saxony or Prussia.

_Great Cataclysms_.--Even more interesting than the fact that war reduces the suicide rate is the further fact that a reduction of the number of suicides takes place after any severe cataclysm. The earthquake at San Francisco, for instance, had a very marked effect in this way. Before the catastrophe suicides were occurring in that city on an average of twelve a week. After the earthquake, when, if physical sufferings had anything to do with suicide, it might be expected that the self-murder rate would go up, there was so great a reduction that only three suicides were reported in two months. Some of this reduction was due to inadequate records, but there can be no doubt that literally hundreds of lives were saved from suicide by the awful catastrophe that levelled the city. Men and women were homeless, dest.i.tute, and exposed to every kind of hardship, yet because all those around them were suffering in the same way, everyone seemed to be reasonably satisfied. Evidently a comparison with the conditions in which others are has much to do with deciding the would-be suicide not to make away with himself, for by dwelling too much on his own state he is p.r.o.ne to think that he is ever so much worse off than others.

If life were always vividly interesting, as it was in San Francisco after the earthquake, and if all men worked and suffered together as the San Franciscans did for a few weeks, suicide would not end ten thousand American lives every year, as it does now.

Individual Restraints.--_Religion_.--It seems worth while to call to attention certain factors that modify the tendency to suicide and limit it very distinctly, because it is with the limitation of it that the physician must be mainly occupied. There seems to be no doubt that certain religious beliefs, which affect the individual profoundly and occupy his thoughts very much, furnishing, both by tradition and heredity as it were, sources of consolation for evils in this life by the thought of a future life, notably lessen the suicide rate. All over the world the Jews who cling to their old-time belief have perhaps the lowest suicide rate of any people. This is true in spite of racial differences. People who retain the confidence in prayer, that used to characterize members of all religions a century or more ago, are likely to be able to resist the temptation to suicide. This is true particularly for the more or less rational suicide. Oppenheim has recalled attention to the power of prayer against depression and in the insane asylums of England its efficiency in this way is well recognized.

It is well-known that Roman Catholics the world over have much less tendency to suicide than their Protestant neighbors living in the same {719} communities. It is true that where the national suicide rate is high many Catholics also commit suicide, but there is a distinct disproportion between them and their neighbors. The suicide rate of Protestants in the northern part of Ireland, as pointed by Mr. George Kennan, is twice that of Roman Catholics in the southern part. He discusses certain factors that would seem to modify the breadth of the conclusion that might be drawn from this, but in the end he confesses that their faith probably has much to do with it and that, above all, the practice of confession must be considered as tending to lessen the suicide rate materially. It is the securing of the confidence of these patients that seems the physician's best hope of helping them to combat their impulse and Mr. Kennan's opinion is worth recalling for therapeutic purposes:

In view of the fact that the suicide rate of the Protestant cantons in Switzerland is nearly four times that of Catholic cantons, it seems probable that Catholicism, as a form of religious belief, does restrain the suicidal impulse. The efficient cause may be the Catholic practice of confessing to priests, which probably gives much encouragement and consolation to unhappy but devout believers and thus induces many of them to struggle on in spite of misfortune and depression.

_Disgrace as a Restraint_.--It is curious what far-fetched motives, that appear quite unlikely to have any such influence, sometimes prove able to affect favorably would-be suicides and prevent their self-destruction. Plutarch tells the story, in his treatise on "The Virtuous Actions of Women," of the well-authenticated instance of the young women of Milesia. Disappointed in love, they thought life not worth living. Accordingly there was an epidemic of suicide among the young women and it even became a sort of distinction to prefer death to matrimony. Some perverted sense of delicacy entered into the feeling that prompted the suicides, as if s.e.x and its indulgence were something belittling to the better part of their nature. The authorities in Milesia must have been psychologists. They issued a decree that the body of every young woman who committed suicide would be exposed absolutely naked in the market-place for a number of days after her death. This decree, once put into effect, immediately stopped the suicides. The young women shrank from this exposure of their bodies, even though it might be after death, and the suicide fashion came to an end.

It might be thought perhaps that this incident represented ancient feeling and that a similar condition in the modern times would not have a corresponding effect. It so happens that something similar has been tried. In some of the cities of South Central Europe in which the suicide rate is almost the highest in the world, it was decided about a generation ago by the Church authorities of the towns that suicides would not thereafter be buried in the cemeteries near the bodies of those who died in the regular course of nature, but must be interred in a separate portion reserved for themselves. Strange as it may seem, just as in the case of the young women of Milesia, this proved a great deterrent to suicide. The suicide rate was reduced one-half the next year.

As a matter of fact, it only takes some reasonably forceful countervailing notion to set a train of suggestions at work that will prevent suicide. If those contemplating suicide are made acquainted with some of these curious facts we know, then the notion of suicide loses more than half its terrible {720} attraction by being stripped of all of its supposed inevitableness. Almost any motive that attracts attention, even apparently so small a thing as disgrace after death, makes these people realize the littleness and the cowardice of the act.

Favoring Factors.--_Psychic Contagion_.--A prominent factor in suicides that must constantly be borne in mind is the influence of example or, as we have come to call it learnedly in recent years, psychic contagion. It is discussed more in detail in the chapter on Psychic Contagion, but its place here must be emphasized. It has often been noted that certain peculiar suicides are followed by others of the same kind. If a special poison has been used, others obtain it and put an end to their lives in that way. Even such horrible modes of death as eroding the jugular vein by drawing the neck backward and forward across a barbed-wire fence have been imitated. If the story of jumping off a high building is told with lurid details, special care has to be taken in permitting unknown people to go up to the same place for some time afterwards. The imitative tendency is evidently a strong factor. Plutarch's story of the young women of Milesia brings this out, and it has been noted all down the centuries.

In any discussion of the prophylaxis of suicide the effect of newspaper descriptions of previous suicides must be looked upon as very important. The influence of suggestion of this kind on people who have been thinking for some time of suicide is very strong. There comes to them the impelling thought that the suicide's miseries are over and they wish they were with him. From the wish to the resolve and then to the deed itself are only successive steps when suggestion is constantly prodding the unfortunate individual. If we are going to reduce the suicide rate materially or, indeed, keep it from increasing beyond all bounds, this question must be squarely faced. Accounts of suicides are not news in the ordinary sense of the word and while they might find a place for legal and other purposes in a few lines of an obituary column, the present exploitation of them by the papers makes them a constantly recurring source of strong suggestion to go and do likewise. These suggestions come to persons already tottering on the edge of disequilibration in this matter, and it is like tempting children to do things that they know are wrong, but that look irresistibly inviting when presented under certain lights. The very fact that their death will produce a sensation and will give them so much s.p.a.ce in the newspapers attracts many morbidly sensation-loving people. Physicians must work as much for this prophylaxis as we have for the prevention of infectious diseases.

Child Suicides.--Probably the worst feature of the suicide statistics of recent times in all countries is the great increase of self-murder among children. Arthur MacDonald in discussing the "Statistics of Child Suicide" [Footnote 56] has shown that there is a special increase of young suicides everywhere. In France there are nearly five times as many suicides at the end of the nineteenth century as there were at the beginning of it. In England there is almost as startling an increase. Though the statistics are not as well kept, child suicide has increased not only in proportion to the increase of suicide among adults, but ever so much more. In Prussia the condition is even worse.

[Footnote 56: "Statistics of Child Suicide," _Transactions of American Statistical a.s.sociation_, Vol. X., pp. 1906-1907. ]

{721}

The French child suicide rate is especially interesting and disheartening. In the Paris Thesis for 1906 Dr. Moreau discusses the subject of suicide among young people and shows how rapid has been the growth of the number of such suicides in the last 100 years. The first statistics available for the purpose that, in his opinion, are exact enough to furnish a basis for scientific conclusions, are from 1836 to 1840. Altogether during that period in France there were 92 suicides under the age of seventeen years, 69 of whom were boys and 23 girls.

In 1895 this number had increased to such a degree that in a single year there were almost as many suicides (90) as there had been in five years, only fifty years before. In 1895 the proportion of suicides less than ten years of age was a little more than one in twenty of the total number of suicides in France. There are countries in Europe in which the suicide rate among such children is even higher than it is in France. In every country it has gone on increasing and the awful thing is that the suicide rate is increasing more rapidly among children than it is among adults, though among adults it doubles every twenty years.

_Causes at Work_.--The causes for the increase in suicide among children were pointed out even by Esquirol, the great French psychiatrist, nearly a century ago. They are the same to-day, only emphasized by the conditions of our civilization. He attributed it to a false education which emphasizes all the vicious side of life, makes worldly success the one object of life, does not properly prepare the child for constancy in the midst of hardships, nor make it appreciate that suffering is a precious heritage to the race, that has its reward in forming character and fixing purpose. He thought that there were two very serious factors for the increase of suicide among children not usually realized. They were in his time literature and the theater. He said: "When the theater presents only the triumphs of crime, the misfortunes of virtue, when the books that are in common circulation because of the low price at which they are issued, contain only declarations against religion, against family ties and duties towards our neighbor and society, then they inspire a disdain of life and it is no wonder that suicide rapidly increases even among the very young." He was commenting on the case of a child of thirteen who had hanged himself, leaving this written message: "I bequeath my soul to Rousseau and my body to the earth."

Cowardice of Suicide.--Of course, the strongest motive for dissuasion from suicide is the utter cowardice of the act. As a rule, the man who contemplates suicide is not a sufferer from inevitable natural causes, but one who for some foolish act has put himself into what seems to him an intolerable position out of which escape without disgrace is impossible, and he is afraid to face the consequences of his own acts.

It is from the fear of mental worry and of the condemnation of others rather than from any dread of physical suffering and pain that men commit suicide. The suicide leaves those who are nearest and dearest to him to face the battle of life alone, with all the handicaps that have been created by their foolishness. Running away in battle is as nothing compared to the cowardice of the suicide. The deserter is deservedly held in deepest dishonor, and if there is some little pity for the suicide, it is because of the supreme foolishness of his act and the feeling that it only can have been dictated by some defect of mental equilibrium. A frank recognition of these conditions in their real significance probably will do more than anything {722} else to make the prospective suicide realize the true status of his act better than anything else.