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 popula ion. 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.