The Anatomy of Suicide

by Forbes Winslow

What conclusion are we justified in drawing from the facts just related? Certainly, that there is in us all a disposition to destroy, which is in some wisely and providentially restrained. If this view of the matter be correct, we do not think that we should be wrong in concluding that by far the great majority of cases of suicide result from a morbid development of this natural feeling, consequent upon a primary or secondary affection of the brain. This subject is of great interest in a medico-legal point of view, and is well deserving of serious consideration.

Is the act of suicide an evidence of mental derangement? Before this question can be satisfactorily answered, it would be necessary for us to consider that vexata questio—what is insanity? Have we an unfailing standard to which to appeal; an infallible test by which we can ascertain, with anything like a proximity to truth, the sanity of any mind? Perhaps, if we were to assert that we considered it impossible to point out the line of demarcation which separates the confines of a sane and insane condition of the mind, we might lay ourselves open to an attack. Again, were we bold enough to proclaim our non-adherence to what is considered as the orthodox faith in this matter, and assert that we viewed every departure from a healthy tone of mind, whether in its intellectual or moral manifestations, as an evidence of insanity, we might still more expose ourselves to the merciless lash of the critic; yet these are the opinions to which we should feel most disposed to give our assent. We must make a marked distinction between insanity considered as a legal and as a medical question; and it is greatly owing to our not keeping this essential difference in mind that so much useless reasoning and vituperation has arisen. The man who is daily exposed to the kind and cheering influence of friendship, and who fancies himself alone in the world, without one human being to sympathize with him in his afflictions, is as essentially mad as he is who imagines himself to be made of glass, and is fearful of sitting down lest he should injure his brittle glutei muscles. A poet of antiquity wrote a book describing the miseries of the world, and destroyed himself at the conclusion of the task.

“No man who is oppressed with grief,” Crichton justly observes, “and who is constantly preyed on by mental and bodily pain, can be supposed capable of exercising his judgment at all times correctly; a fresh misfortune, imaginary or real, excites an irresistible desire of relief. Tired out, hopeless, dismayed by the threatening aspect of many a bursting cloud; discerning nothing, whichever way he looks, but a dreary and comfortless life, how can he be supposed capable of taking a clear, calm, and comprehensive view of the obligations he owes to his Creator or society, or of reflecting on the sudden vicissitudes which daily occur in human life, and on which every man may safely form some hope, even in the most distressed situation? The wretchedness of life is the only picture present to the mind of one in whom grief has terminated in such a state of deep melancholy; the only objects of comparison are the misery of existence on the one hand, and the relief he can obtain by withdrawing himself from it on the other.”

Insanity results from a disease of the brain. Although after death, in many cases, no appreciable structural lesion can be detected in the cerebral mass, it would be illogical for us to conclude that the sentient organ has not been physically affected. Derangement of mind is but the effect of physical disease, and, like all other diseases, it has an early as well as an advanced stage. Medical men have not paid sufficient attention to the premonitory indications of mental alienation. Having erected an arbitrary standard of derangement in their own minds, they have been disposed to consider no deviation from mental soundness as insanity, unless it exhibited the symptoms which their preconceived ideas had led them to suppose necessary, in order to constitute that disease. They have argued as if insanity were a specific disease invariably manifesting the same phenomena, and in this way definitions have been framed, by which the soundness of the intellect has been tested. It is hardly necessary to say how fallacious all such tests must be. The brain, like every other organ, is liable to a variety of diseases, in all of which the mental faculties are more or less affected. The danger of attempting to erect an arbitrary standard of insanity is this: it induces us to overlook the incipient symptoms of mental derangement, and to consider no deviation from soundness of intellect as insanity which does not come within the scope of our definition. The early symptoms of mental aberration are as much an evidence of the presence of insanity, as when the disease is more advanced, and the indications become so apparent that no one hesitates in pronouncing the individual mad. Medical men who have maintained that the act of suicide is not invariably the result of insanity have argued as if the mental ailment was always self-evident and easily detected; whereas, those who have had any experience in the matter know full well, that occasionally there are no diseases more difficult of detection than those which relate to a morbid condition of the mind. If an act of suicide has been committed, and the individual at the moment of perpetrating it did not manifest evident symptoms of insanity, the conclusion drawn is, that he was perfectly sane at the time. That the facts of the case do not warrant this inference must be apparent to those who consider the subject in an enlarged point of view. If we examine attentively the majority of cases of suicide, we shall find that the unfortunate persons have laboured, either for some time previously or at the very moment, under depression of spirits, anxiety of mind, and other symptoms of cerebral derangement. Very few cases of suicide take place in which you cannot trace the existence of previous mental depression, produced either by physical or moral agents. It may be said that lowness of spirits is not insanity; certainly not, according to the legal definition of the term; but we may always be assured, that if mental anxiety or perturbation be more than commensurate with the exciting cause, it may be presumed that the individual is labouring under the incipient indications of insanity.[64] This view of the case is strengthened if an hereditary predisposition to the disease should also be present.

“It will be said,” says Esquirol, “that there are individuals who, in the midst of affluence, grandeur, and pleasures, and in the full enjoyment of reason, have suddenly put an end to their existence, immediately after parting with their friends in good spirits, or after having written letters on business with perfect correctness. Can these be said to be insane when they commit suicide? Yes; most undoubtedly. Do not monomaniacs appear perfectly sane on all other subjects, till the particular idea is started which forms the burden of their hallucination? Are they not capable of curbing the expression of their delirium, and dissembling their aberration of intellect? It is the same with sane individuals, over whom the suicidal idea tyrannizes. A physical pain, an unexpected impression, a moral affection, a recollection, an indiscreet proposition, the perusal of a passage in writing, will occasionally revive the thought and provoke the act of suicide, although the individual the instant before should be in perfect integrity of mind and body.”

In general, most persons actually insane wish not only to be esteemed free from the malady, but to be considered as possessing considerable intellectual endowments; hence, real lunatics seldom allow the existence of their lunacy; but are always endeavouring to conceal from observation those lapses of thought, memory, and expression, which are tending every moment to betray them, and of the presence of which they are much oftener conscious than is generally apprehended or believed. Alexander Cruden, when suffering under his second and last attack of mental aberration, upon being asked whether he ever was mad, replied: “I am as mad now as I was formerly, and as mad then as I am now, that is to say, not mad at any time.”

Again, medical men who have reasoned against this opinion have forgotten entirely one peculiar, and a very remarkable feature of insanity—viz., the singular cunning of lunatics; how extremely difficult it is in many cases where we know the individual to be unquestionably mad, to make his delusion apparent. The case of the lunatic who indicted Dr. Monro for confining him in his asylum has often been cited. He brought an action against the Doctor at Westminster; and, although the man was subjected to a most severe examination and cross-examination, his insanity could not be detected. The trial was on the eve of being concluded, when Dr. Sims entered the court, and knowing the man’s peculiar delusion, he was requested to ask him a question. He did so, and his insanity instantly became apparent. He brought another action against Dr. Monro in the city of London, and, knowing that he had failed before by acknowledging his love for an imaginary princess, so remarkable a degree of cunning did he exhibit that one of the severest examinations to which a man was ever subjected in a court of justice could not induce the lunatic to disclose the delusion under which he was known to labour. This curious feature of insanity must be taken into consideration in forming an estimate of the presence of derangement in cases of suicide, and we must not hastily conclude, because insanity is not self-evident, that it does not exist.

A merchant, fifty-five years of age, of a strong constitution, although of a lymphatic temperament, mild and gentle in his disposition, the father of a numerous family, and who had acquired a considerable fortune in business, experienced some domestic troubles, not sufficiently serious, however, to affect any one of a resolute character. About a year ago, he formed a large establishment for one of his sons, and shortly afterwards became very active, and expressed, contrary to his usual habits, the delight which he felt at his increasing prosperity. He was also more frequently absent from his warehouse and business than usual. But notwithstanding these trifling changes, neither his family, nor any of his friends or neighbours, suspected any disorder of his reason. One day, whilst he was from home, a travelling merchant brought to his house two pictures, and asked fifty louis for them, which he said was the price agreed on by a very respectable gentleman who had given his name and address. His son sent away both the pictures and the seller. On his return, the father did not mention his purchase; but the children began the conversation, alluding to the roguery of the merchant, and their refusal to pay him. The father became very angry, asserting that the pictures were very beautiful, that they were not dear, and that he was determined to purchase them. In the evening, the dispute became warmer, the patient flew into a passion, uttered threats, and at last became delirious. On the next day, he was confided to Esquirol’s care. His children, frightened at their father’s illness, and alarmed at the purchase which he had made, looked through their accounts; and great was their astonishment at seeing the bad state of their books, the numerous blanks which they presented, and the immense deficiency of cash. This irregularity had existed for more than six months. Had this discussion not taken place, one of the most honourable mercantile houses would have been compromised in a few days; for a bill of exchange of a considerable amount had become due, and no means had been taken to provide for it.

A patient has been known to weep, and affect the deepest contrition for attempting suicide, when it has been proved that all the time he was meditating on the means of accomplishing his design. A workman was admitted into a French hospital, having a third time attempted his life. He appeared deeply mortified and broken-hearted that he should have suffered a relapse, and was much affected by the remonstrances of his physician. He promised faithfully, in tears, to abandon his rash resolve. Ten minutes afterwards, whilst on his road home, he perceived a piece of cord; he seized it, made a noose, put his head into it, and suspended himself from the branch of a tree, where he was found dead! Cases illustrative of the same fact are mentioned in another part of this work.

Again, we must bear in mind that insanity is often as much a disease of the moral as of the intellectual faculties, and that it is possible for the intellect to be perfectly sound, and yet for insanity to be present. Moral derangement has not met with that consideration from the profession which its importance demands. Insanity often consists in a vitiated condition of the moral principle, independently of any delusion of the intellect; and in many cases of suicide, if we investigate their history, we shall find that the alienation has been of this character. A man, whose disposition naturally disposed him to vice, fancied that he had been guilty of committing a nameless offence, and, whilst labouring under this idea, blew out his brains. In this case, the intellect was unaffected; the derangement consisted in a perversion of the moral powers. Senile insanity, which has been recognised in our courts of law, is a derangement of the moral constitution. In cases of this description, it is possible for the person to be conscious of his infirmity, and to confess, with great apparent regret, his inability to control his feelings. “I am impotent, and not fit to live,” said a man, and accordingly cut his throat. If we admit the existence of an insanity which consists solely in a perversion of the moral powers, then we should hesitate in pronouncing ex cathedrâ that insanity is not present because no derangement of the intellectual faculties can be perceived.