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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 classes 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 attitude 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 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 passing, 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 went with regard to all the
family as well as herself, to whom the boy confided some of his sex
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 reassured 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 classes come over and over again to be reassured 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 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 Buelow,
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 circumstances 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 attitude 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 passing 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 entitled "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 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 Massachusetts,
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 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,
destitute, 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 prone 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
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 sex 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 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 space 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 Association, Vol. X., pp. 1906-1907. ]




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 else to
make the prospective suicide realize the true status of his act better
than anything else.

Men sometimes seem to persuade themselves that it is a brave thing
thus to face death. The shadowy terrors of what may come after death
are too little realized to deter a man from his act when compared with
the real disgrace that he is so familiar with and that he has often
witnessed in actual life. It is the man, as a rule, who has most
condemned others when something has gone wrong, who has found no
sympathy in his heart for the slips of his fellows, who discovers no
courage in himself when he has to face disgrace. He does not realize
that for most men there are so many extenuations of any evil that a
man may do, that the large-minded man is ready to forgive and
eventually to forget almost anything that happens. "To know all is to
forgive all," and the more we know of men the readier we are to
forgive them. Little men do not forgive and cannot forget the failings
of their fellows and they think that everyone else looks upon men's
failings in the same way. It is only the small, narrow man who
contemplates suicide as a refuge from disgrace, and the fact that he
can complacently plan the abandonment of others not only to the
disgrace which he himself is not ready to face, but to all the
suffering consequent upon it, is the best proof of his littleness of
soul. The utter pusillanimity of suicide is the best mental antidote
for the temptation to it.

Besides, the thought that deterred Hamlet may well be urged:

There's the rub;
For in that sleep of death what dreams may come.
When we have shuffled off this mortal coil,
Must give us pause;
. . . who would fardels bear,
To grunt and sweat under a weary life;
Cut that the dread of something after death.--
The undiscovered country, from whose bourn
No traveller returns.--puzzles the will;
And makes us rather bear those ills we have.
Than fly to others we know not of?

It is sometimes said that this is the argument of a coward, but such
cowardice is as reasonable as the dread of touching a wire that may be
carrying a high charge of electricity. Besides it is only such an
argument that will properly suit the man who, in his cowardice, is
ready to let others bear the brunt of his disgrace, flying from it
himself. [Footnote 57]

[Footnote 57: Is life worth living? How old this argument as to
suicide is can perhaps best be appreciated from the fact that it is
discussed very suggestively in a papyrus of the Middle Kingdom the
date of which is probably not later than 2500 B. C, which is now in
the Berlin Museum and is recognized to be the most ancient text of
its kind that has been preserved in the Nile Valley. I have referred
to this in the initial historical chapter. I think that I have more
than once turned men's thoughts from the serious contemplation of
suicide--always a dangerous thing--by discussing with them this
fact that men have at all times in the world's history argued just
the same way on these subjects. Men prefer not to resemble the dead
ones, and a motive is all that is needed. ]

There has sometimes been an erroneous tendency to confuse suicide and
heroism, but Chesterton, in "Orthodoxy," [Footnote 58]
has well expressed the difference:

[Footnote 58: "Orthodoxy" by Gilbert K. Chesterton, New York, John
Lane Co., 1909. http://www.gutenberg.org/ebooks/130]



A soldier surrounded by enemies, if he is to cut his way out, needs
to combine a strong desire for living with a strange carelessness
about dying. He must not merely cling to life, for then he will be a
coward, and will not escape. He must not merely wait for death, for
then he will be a suicide, and will not escape. He must seek his
life in a spirit of furious indifference to it; he must desire life
like water and yet drink death like wine. No philosopher, I fancy,
has ever expressed this romantic riddle with adequate lucidity, and
I certainly have not done so. But Christianity has done more: it has
marked the limits of it in the awful graves of the suicide and the
hero, showing the distance between him who dies for a great cause
and him who dies for the sake of dying. And it has held up ever
since above the European lances the banner of the mystery of
chivalry: the Christian courage, which is a disdain of death; not
the Chinese courage, which is a disdain of life.

The feature of incidents in life that bring with them disgrace and
punishment which needs to be insisted on for those to whom the thought
of suicide comes, is that the sensation which the revelation of such
acts causes is but a passing phase of present-day publicity, and that
after all it is not even a nine-days' wonder, but a two- or
three-days' wonder, and then it is forgotten and replaced by something
else. The facing of the condemnation for the moment may seem an
extremely severe trial. The world's blame, however, is largely a
bogey, a dread that is phantom-like and that disappears, or at least
diminishes, to a great degree as soon as it is bravely faced. Besides,
as practically every man who has been carrying around a guilty secret
with him for years is free to confess, there is an immense sense of
relief once the worst is known. At last the effort at concealment, the
nervous tension, the fear of the moment of exposure are all past and a
new set of thoughts can be allowed to come. Those may be unpleasant
and yet they are not so bad as the dread of discovery that hung over
the unfortunate. If a man can be braced up to meet exposure, usually
he will find in a very few days that there are sources of consolation
that make it much easier for him to live than he thought possible
before.


Real Suffering a Tonic.--Probably the best remedy for a man or a woman
who talks of suicide and seems to fear lest the temptation should
overcome them is, if possible, to give them an opportunity to see some
real suffering. I have on a number of occasions had the opportunity to
note the effect on a discouraged man or woman of the sight of a cancer
patient suffering severely, yet bearing the suffering patiently,
wishing that the end might come, yet ready to wait until it shall come
in the appointed order of nature. Suffering, like everything else,
becomes much more bearable with inurement to it. The old have learned
the lesson of not only not looking for pleasure in life, but of being
quite satisfied with their lot if no pain comes to them, and they even
grow to consider that they have not much right to murmur if their pain
is not too severe. It is not among those who have to suffer severe
pain that one finds suicides as a rule. It is true that young, strong,
healthy persons who suddenly find that pain is to be their lot for a
prolonged period may grow so discouraged and moody over it as to take
their lives. The patients that I have seen suffering from incurable
diseases have expressed no desire at all that their life should be
shortened, except during the paroxysms of their pain, unless they feel
that they are a serious burden on others when they may express the
wish to be no more.


Euthanasia.--Every now and then there is a discussion in the
newspapers of the justifiableness of euthanasia, that is, the
giving of a pleasant death to those who are known to be incurably ill
and who are doomed to suffer pain for most of what is left of their
existence. The question usually discussed is whether patients have the
right to shorten their own existence and then, also, whether their
physician might have the right or, even as some people say, the duty,
to lessen human suffering by abbreviating existence for such incurable
cases. The discussion has always seemed to me beside the realities of
things, because physicians do not see many patients, I might almost
say any patients, who really want to shorten their lives or would want
to have them shortened. I have known many physicians die of cancer,
but very seldom is it that one tries to shorten his own existence, or
that even his best friend in the profession would consider that he was
justified in doing this for him. This, it seems to me, should be the
test of the problem. It is true that not infrequently, in the midst of
their paroxysms of pain, patients wish they were dead, but there come
intervals of surcease from discomfort to some degree at least that
make life quite livable for a time again and even occasionally there
is real happiness in these intervals, deep, human, natural happiness
in heroic forbearance and example.

We can recall AEsop's fable of the old man who, gathering wood for the
fire in the winter that he needed so much, finds the burden of his
labor and the wood too much for him and calls loudly for death to come
to him. Promptly Death makes his appearance and asks what the old man
wants. "Oh! nothing," is the reply; "only I would like you to help me
to carry this bundle of sticks." This is the attitude of mind of
practically all who have grown old in suffering. They have learned to
bear with patience, and that patience gives even something of
satisfaction. After all, it is not so often the pleasant things in
life that we look back on and recall with most satisfaction as the
difficulties and trials. Virgil said long ago, "Forsan et hoc olim
meminisse juvabit"--perhaps at some future time we shall recall
these, our trials and pains, with pleasure. It is the conquering of
difficulty that means most for men and even the standing of pain is
not without an aftermath, if not of pleasure, at least of broad human
satisfaction. When we talk about euthanasia, then, it would be well to
ask some of these old people whether they want it or not. Seldom will
the answer be found to be that which is so often presumed, by those in
good health and strength, to be inevitable under such conditions.

Physicians have all seen incurable cancer patients who were
approaching their end inevitably and with the fatal termination not
far off, have hours and days of alleviation of suffering and even of
enjoyment that made up for the prolongation of life almost in the
midst of constant agony. The distinguished New York surgeon who had
the pleasure a few years ago of listening once more to his favorite
singer and fairly seemed to get renewed life from the inspiration of
her voice and who for days after had the pleasant consciousness of
smooth running life in improvement so characteristic of convalescence,
is a typical example of what may happen under such circumstances. I
shall not soon forget Dr. Thomas Dunn English, the well-known author
of "Sweet Alice, Ben Bolt," saying at an Alumni dinner of the
University of Pennsylvania, that, like Bismarck, he used to think that
all the joys of life's existence were in the first eighty years of
life, but of late years he had found that many of them were also
in the second eighty years of life. He was at the time 83. He made the
most joyous and happiest speech on that occasion. He was quite blind,
was almost deaf, had been reported dying some months before, and had
gone through prolonged suffering, yet he was by his cheeriness and
whole-hearted gaiety on that occasion a joy and inspiration to all the
younger men at the table.


Dread of Suicide.--There are patients who come to the physician worked
up because they fear they may commit suicide. Every now and then the
thought comes to them that some time or other they will perhaps throw
themselves out of a window, or be tempted to drop in front of a
passing train, or over the side of a steamboat, or impulsively take
poison. Some nervous people become quite disturbed by these thoughts.
Every physician is sure to have some patients who must be reassured,
every now and then, that they are not likely to commit suicide. Their
nervousness over the fear of this may serve to make them supremely
miserable and it evidently becomes the doctor's duty to reassure them.
It is not difficult to do this, as a rule, provided the physician will
be absolutely confident and unhesitating in his declaration that there
is no danger that they will commit suicide, since it has almost never
been known that patients who dread it very much and, above all, those
who dread it so much that they take others into their confidence in
the matter, take their own lives. The very fact that the thought
produces so much horror and disturbance in them is the best proof that
they will not impulsively do anything irretrievable in this way.

Prof. Dubois has discussed this subject in his usual thoroughly
practical way and his words serve as an authoritative confirmation of
what has been already said, though as a matter of fact the expressions
and experience of nearly every nervous specialist thoroughly justify
the position here assumed. Besides, it must be realized that this
confident assurance is the best possible prop that doubting patients
can have with regard to the actions they dread, and by positive
declarations the physician will accomplish more than in any other way.

There are patients who are subject to strange obsessions. They are
afraid that they will throw themselves out of the door of a car, or
climb over the parapet of a bridge. They are afraid that they will
throw their relatives out of a window, or will wound somebody with a
knife or a gun. There are some with a strong impulse to open their
veins. But if there is a certain attraction in such things, it is
really a phobia. It tends to make one shrink back and not to act.

Nothing quiets these patients like the frequently repeated statement
that they will not do anything. It is necessary to show them the
vast distance there is between the impulse toward suicide and murder
and the phobia which, however distressing it may be, is a safeguard.
One must keep at this education of the mind with imperturbable
persistence and use the most forceful and convincing arguments that
one can think of to correct the judgment of his patient, in order to
make the strings of moral feeling and reason vibrate in unison.

It is through lack of courage and perseverance that we err in the
treatment of these psychoneuroses. We wait too long to distinguish
the morbid entities that bear on a certain etiology or a different
prognosis. We do not see clearly enough the bond which unites these
different affections.

It may seem to some physicians as though they would be assuming too
much responsibility in giving patients such positive assurance that
their dreads will not be fulfilled, but as a matter of fact the
experience of physicians is quite sufficient to justify the confident
statements here suggested. It is true that occasionally a person who
afterwards commits suicide talks the matter over and hints at the
possibility of taking his own life. He does not, as a rule, speak of
it with dread, however, but as one of the alluring solutions of his
difficulties that he sees ahead of him. He is much more likely to
write a letter to his physician telling him that all his arrangements
are made and that by the time this letter reaches him he will be
already dead. The prospective suicide is usually quite secretive about
this purpose, not only to friends, lest he should be prevented from
accomplishing it, but even with his physician, in whom he has had
absolute confidence and to whom he has told practically everything
else. The patients who fear the possibility of committing suicide, who
tell how much they dread the horror of it, and who rush to consult the
physician to help them against themselves, show by the very fact the
unlikelihood of action on their part.


The Physician and Suicide.--By mental influence, then, the physician
may lessen the tendency to suicide in the individual and in the
community. To do this is to save suffering and to help in the solution
of one of the most serious social problems in modern times. It can
only be accomplished by a sympathetic attitude towards the whole
subject and a tactful understanding of each individual case. Every
effort in the matter, however, is well worth while, for there is no
more hideous blot on our modern civilization than the startling
increase of suicide. It is particularly important to bring about
improvement in this regard among young suicides, and fortunately it is
here that the influence of the physician for good is likely to be most
felt. The saving of life is the noblest part of the mission of the
physician and nowhere, perhaps, can this be accomplished more
successfully than with regard to some of these patients whom a rash
resolution, due to a momentary fit of depression and a sense of
suffering exaggerated out of all proportion to their actual pain, is
hurrying out of life.





Next: Grief

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