November of the Soul

by George Howe Colt

  IV

  SCIENCE: MORAL MEDICINE

  AND VITAL STATISTICS

  WHAT SEEMED BEAUTIFUL to Flaubert—and to other victims of what German poet Clemens Brentano called “hypertrophy of the poetic organ”—would soon be attributed to brain lesions, excess phosphorus, heredity, liver disease, madness, and masturbation. The assault of Enlightenment writers on the Church’s condemnation of suicide had cleared the way for a secular approach to the subject, while the rapid growth of science and medicine in the seventeenth century laid the foundations for the systematic study of suicide. For the first time self-destruction was discussed not primarily as a philosophical or moral dilemma but as a medical and social problem. The question was not whether suicide was right or wrong but why it happened. The scientific study of suicide had two strands. The statistical model, which would provide the basis for a sociological approach, located the cause of suicide in society. The medical model, forerunner to the twentieth-century psychobiological approach, located the cause of suicide in the body.

  Under the impression that suicide was primarily an English phenomenon, physicians explored the effects of climate on the body. Many believed that changes in temperature and precipitation affected the brain. In The English Malady: or A Treatise of Nervous Diseases of All Kinds, as Spleen, Vapours, Lowness of Spirits, Hypochondriacal, and Hysterical Distempers, etc., published in 1733, George Cheyne found that the English had more “nervous distemper” leading to suicide because they ate too many rich foods, did not exercise, and lived in large cities choked with pollution. In 1758, in A Treatise on Madness, William Battie, physician to St. Luke’s Hospital for Lunaticks, discussed weather and suicide: “Whatever may be the cause of Anxiety, it chiefly discovers itself by that agonising impatience observable in some men of black November days, of easterly winds, of heat, cold, damps, etc. . . . In which state of habitual diseases many drag on their wretched lives; whilst others, unequal to evils of which they see no remedy but death, rashly resolve to end them at any rate.”

  Like most eighteenth-century physicians who wrote on self-destruction, Cheyne and Battie seasoned their scientific theories with antisuicide bias. The first to separate completely the medical argument from the moral was a Frenchman named Merian, who, in 1763, in Mémoire sur le Suicide, stated that suicide was not a sin or a crime but a disease. All suicides are in some degree deranged, he said, otherwise they would not so completely contradict the law of nature. As for the cause of that derangement, each physician had his favorite culprit, according to his own theories of insanity: climate, the change of seasons, heredity, cerebral injuries, physical suffering, liver disease, melancholia, hypochondriasis, insanity, suppressed secretions, intoxication, gastritis, unnatural vices, and derangement of the primae viae, among others. Physicians conducted autopsies of suicides in search of physical clues. Some discovered lesions on the brains of suicides and suggested this was the cause. The French physiologist Pierre-Jean-Georges Cabanis believed suicide was caused by excess phosphorus in the brain. Franz Joseph Gall, the founder of phrenology, believed that the shape of the skull indicated specific characteristics: composers had a special bulge around the ear; suicides, he asserted, had thick craniums.

  More than a few physicians located the cause in another part of the anatomy. “Few, perhaps, are aware how frequently suicide results from the habit of indulging, in early youth, in a certain secret vice which, we are afraid, is practiced to an enormous extent in our public schools,” wrote one London physician. “A feeling of false delicacy has operated with medical men in inducing them to refrain from dwelling upon the destructive consequences of this habit, both to the moral and physical constitution, as openly and honestly as the importance of the subject imperatively demands.” Perhaps suffering from a chronic case of false delicacy himself, the good doctor continued, “The physical disease, particularly that connected with the nervous system, engendered by the pernicious practice alluded to, frequently leads to the act of self-destruction. We have before us the cases of many suicides in whom the disposition may clearly be traced to this cause.”

  While most physicians searched for a specific physical source of suicide, Jean-Étienne Esquirol, chief physician at the Royal Asylum at Charenton, maintained that suicide was not a disease per se. In his 1838 book, Des Maladies Mentales, he wrote, “Suicide presents all the characteristics of insanity of which it is but a symptom. . . . There is no point in looking for a unique source of suicide, since one observes it in the most contradictory circumstances.” Esquirol had reached a conclusion generally accepted by the medical profession today: Suicide is a symptom, not a disease. Accordingly, “the treatment of suicide belongs to the therapy of mental illness,” he wrote, “. . . and one has to have recourse to treatment proper to each kind of insanity in order to treat an individual who is propelled toward his own destruction.” In the early nineteenth century that might involve a variety of remedies. In his 1840 book, The Anatomy of Suicide, Forbes Winslow, a member of the Royal College of Surgeons in London, shared the following prescriptions:

  A lady, shortly after her accouchement, expressed, with great determination, her intention to kill herself. Her bowels had not been properly attended to, and a brisk cathartic was given. This entirely removed the suicidal disposition.

  Disease of the stomach and liver frequently incite to suicide; hepatic affections notoriously disturb the equilibrium of the mind. Many a case exhibiting an inclination to suicide has been cured by a few doses of blue pill.

  In certain diseases of the nervous system, particularly when associated with morbid conditions of the mind leading to suicide, the influence of music may be had recourse to with great advantage to the patient. . . . The monotony of the sound is supposed to have a soothing influence over the mind, similar to what is known to result from the gurgle of a mimic cataract of some mountain rill, or to a distant waterfall.

  Every physician had his pet cure. Leopold Auenbrugger suggested drinking cold water: “A pint every hour; and if continuing pensive and taciturn, forehead, temples, and eyes sprinkled with it until more gay and communicative.” While numerous physicians swore by this treatment—a Dr. Schonheyde even made his suicidal patients eat salt herring to work up a thirst—others urged temperance. “Once in a while this was hard on the patient, particularly if he had tried to drown himself,” noted Esquirol’s pupil Jean-Pierre Falret. “But one patient who had been cured by the copious use of water continued to drink it both through gratefulness and habit to the point that at the age of eighty he was drinking twenty-four to thirty pounds of water a day!”

  Some physicians found the plunge bath—sudden immersion into cold water—particularly effective in driving suicidal thoughts from the mind. (The plunge bath was discovered, according to Esquirol, when an insane carpenter threw himself into a pond; he was fished out half-drowned but fully sane.) Van Helmont advocated holding the patient under almost to the point of death, to ensure that self-destructive ideas were nipped at their root. Goethe’s physician Hufeland cited the benefits of the douche—buckets of cold water thrown from a height onto the patient’s head—in driving such thoughts from the mind. Johann Reil, known in Germany as the father of psychotherapy, suggested the insane and possibly suicidal patient be suspended by ropes from a considerable height “between heaven and earth,” while hospital attendants discharged firearms beside him or threatened to scorch his body with flames. In his 1803 Rhapsodies on the Application of Psychic Therapy Methods to Mental Disturbances, Reil also outlined a sort of psychodrama in which asylum personnel would act as a celestial jury; the preview of life in the next world was intended to shock patients into their senses in this one.

  Most suicidal patients, of course, received less dramatic treatment: bleeding, purging, and cupping, as well as drafts of mercury, bark, quinine, mineral waters, whey, and, occasionally, wine—“but its employment exacts much prudence,” warned Joseph Guislain in 1826. Some doctors swore that large doses of opium would restrain self-destr
uctive urges; others preferred morphia. What success these narcotics had with suicidal patients may have resulted from keeping them too drugged to act on their impulses. Tartrate of antimony, another popular remedy, kept them too nauseous. The rotary chair, a contraption in which the patient was whirled in circles as on an amusement park ride, led to copious vomiting and a submissive patient; the chair was recommended for those with “mental alienation with a suicidal propensity.”

  To restore the mind as well as the body, physical remedies were supplemented with “moral” treatment. Winslow suggested that “travelling, agreeable society, works of light literature, should be had recourse to, in order to dispel all gloomy apprehensions from the mind.” Falret, however, cautioned that gay spectacles tend to dampen the spirits of the suicidal. Maintaining that suicidal people think too much, Esquirol said that it was necessary to hinder them from reflection or to force them to think otherwise than they do think. Reasoning, he said, is of no avail. A protégé of Philippe Pinel, whose unchaining of the inmates at Bicêtre marked the beginning of the modern asylum, Esquirol advocated the use of gentle remedies, preferring warm baths and drinks to bleeding and the plunge bath. Of the latter he remarked, “I should as soon think of recommending patients to be precipitated from the third story of a house, because some lunatics have been known to be cured by a fall on the head.” He suggested that suicidal persons lodge on the ground floor in a cheerful setting where they could be watched by vigilant persons. He concluded that a little kindness goes a long way. “How many females have come to the Salpêtrière, whom misery or domestic grief has decided to end their days,” he wrote, “and who are cured by affectionate attention, consolations, the hope of a better future, and by good nourishment!”

  While the new view of suicide as a medical problem brought attention to the plight of suicidal people, it introduced a troubling theme. When the discipline of medical psychiatry emerged in the eighteenth century, it preserved the medieval assumption of a close relationship between insanity and suicide. The increased use of the insanity defense to avoid forfeiture and degradation of the corpse in suicide cases, however charitably intended, reinforced that link. Although Enlightenment writers had fought to establish the right to suicide as a moral, rational act, the argument in the nineteenth century was not whether suicide was moral but whether suicide could ever be rational. Physicians attempted to calculate what proportion of suicides were mentally ill. Estimates ranged from Brierre de Boismont’s 14 percent to the 100 percent of Esquirol and Falret. “As no rational being will voluntarily give himself pain, or deprive himself of life, which certainly, while human beings preserve their senses, must be acknowledged evils,” wrote a Dr. Rowley, “it follows that every one who commits suicide is indubitably non compos mentis.” Thomas Chevalier, professor of anatomy and surgery at the Royal College of Surgeons in London, came to slightly less sweeping conclusions: “I am far from supposing that all suicides are lunatics; but I must contend that from the facts I have stated, the onus probandi lies on those who deny the existence of insanity in such a case.” A suicide was a lunatic until proven rational.

  The insanity debate had terrifying implications. In nineteenth-century medicine, many types of mental illness were believed to be inherited, and some physicians maintained that suicide was the most hereditary type of insanity. Medical texts and histories of the period are studded with examples of intergenerational suicide. “Two cases have occurred, one in Saxony, the other in the Tyrol, in each of which seven brothers hanged themselves one after another,” reported one journal in 1891. The mere existence of such cases was accepted as proof that suicide was an inherited trait. “We know, as a fact, that there is no abnormal constitutional state more commonly transmitted from parent to child than this tendency to self-destruction,” asserted Samuel Strahan, a respected physician and lawyer, in Suicide and Insanity, published in 1893, “and that the major part of the annual increase of suicide, as well as of other degenerate conditions of which we have spoken, is due directly to propagation is absolutely certain.” Maintaining that self-preservation is the first law of nature, Strahan declared “the absence of this fundamental instinct . . . is per se irrefragable proof of unfitness to live.” He cited eleven family trees (many from his own practice) “showing how the offspring of the suicide and his contemporary relatives often sink so low in the scale of vitality that the stock becomes extinct.” Pursuing the thought to its ugly conclusion, he wrote, “The practical lesson to be drawn from these family histories is: that the unfit cannot be propagated indefinitely. If the experiment be persisted in, infantile death, sterile idiocy, barrenness and self-destruction will appear and extinguish the stock.”

  Over the course of the nineteenth century a new stigma emerged. “All the superstitious fear of the queer and the mad attached itself to suicide; the instinctive withdrawal of the sane from the tainted extended itself to cases of the calmest and most rational suicide,” wrote Henry Romilly Fedden in Suicide. “Finally, these new medical ideas hardened family prejudice against suicide: a suicide in the family became tantamount to insanity in the family, a stigma not confined to one member, but attaching jointly to the whole group and its descendants.” With the birth of the medical approach to suicide, self-destruction was no longer viewed primarily as a sin and a crime but as something abnormal and sick.

  While physicians searched for the cause of suicide by examining the body, social scientists searched for it by sifting statistics. The state had begun keeping track of the number of suicides in the Middle Ages, when the king of England needed to account for his taxpaying citizens. In 1215 the Magna Carta charged “the guardian of the crown’s pleas,” or coroner, with keeping written records of births and deaths in his area. The coroner was, of course, particularly interested in deaths by murder or suicide, in which case the dead man’s property was forfeited to the crown. The coroner’s “rolls” were the sole source of such information until 1527, when Bills of Mortality, periodic lists of deaths and their causes, were published in London. Thus, the bill of August 27, 1573, in the parish of St. Botolph Without Aldgate, finds that “Agnis Miller wieff of Jacob Miller who killed selfe with kniff was putt in the ground.” Common folk studied the bills for morbid tidbits of gossip, while the wealthy kept an eye on increases in death during times of plague to help decide whether it might be prudent to leave the city for a while.

  The first attempt to use these bills for anything more scientific was in 1662, when John Graunt, a London tradesman, published his Observations made upon the Bills of Mortality, in which he sorted the information into various categories, including cause of death. Thus, Graunt told us that 1,306 died of apoplexy, 998 of jaundice, 829 drowned, 279 of grief, 243 dead in the streets, 158 of lunatique, 136 of vomiting, 86 murthered, 74 of falling sickness, 67 of lethargy, 51 of head-ach, 51 starved, 26 smothered, 22 frighted, 14 poysoned, 7 shot, and 222 hanged themselves, among others. Graunt pointed out that while certain causes of death—plague, spotted fever, measles—claimed a varying toll from year to year, others—“consumption, dropsies, grief, men’s making away themselves”—remained fairly constant. Like an oddsmaker he estimated the likelihood of a person dying from a particular cause. “I dare ensure any man at this present, well in his Wits, for one in the thousand, that he shall not die a Lunatick in Bedlam within these seven years, because I finde not above one in about one thousand five hundred have done so,” he wrote. “The like use may be made of the Accompts of men, that made away themselves, who are another sort of Mad-men, that think to ease themselves of pain by leaping into Hell; or else are yet more Mad, so as to think there is no such place; or that men may go to rest by death, though they die in self-murther, the greatest Sin.”

  During the eighteenth century writers tabulated “moral statistics” in an attempt to measure social ills such as crime, divorce, illegitimacy, and suicide. In one of the most ambitious early studies, Brierre de Boismont gathered data on 4,595 French suicides between 1834 and 1842. He also inter
viewed 265 people who had planned or attempted suicide. While admitting that many suicides were caused by mental illness, de Boismont denied that all suicides were insane. In his list of causes he attributed 652 to mental illness, 530 to alcoholism, 405 to painful or incurable disease, 361 to domestic troubles, 311 to sorrow or disappointment, 306 to disappointed love, 282 to poverty and misery, 237 to ennui, 99 to indolence and want of occupation, and so on. Among the victims de Boismont noted a higher proportion of males, alcoholics, unmarried people, and the elderly. Like many investigators he remarked on the increasing suicide rate, which he attributed to the pressures of urban life. Suicide, he proposed, was a consequence of societal changes that led to disorder and alienation.

  This conclusion was shared by the swarm of statistical studies published over the following four decades, examining the distribution of suicide in relation to age, sex, marital status, occupation, social class, place of residence, education, degree of culture, race, religion, height, skull size, skin color, disease, intemperance, topography, weather, and lunar cycle.

  One of the first arguments these studies attempted to settle was that of nationality. Despite the assumption that suicide was “the English malady,” the statistical microscope revealed that England had no more suicides than Belgium and far fewer than France. Paris, in fact, had one suicide for every 2,700 people in 1836, compared to London’s one in 27,000 during 1834–42. (The purveyor of these suspiciously symmetrical statistics, it must be confessed, was an Englishman.) Berlin dwarfed both cities with one suicide for every 750 persons. At the opposite end of the scale, Palermo had only one in 180,000. Summarizing studies of suicide and nationality in his 1881 book, Suicide and the Meaning of Civilization, Thomas Masaryk, a philosopher who went on to become the first president of Czechoslovakia, concluded, “The evil frequently appears among the Danes, Germans, French, and Austrians, seldom among the Spaniards, Portuguese, Yugoslavians, Irish, and Scottish, moderately in England, Sweden, Norway, and the United States.”