Like that repulsive many-headed monster in Greek mythology, the myth about London's alleged suicide has survived despite repeated attempts to behead it. Not only the tabloid biographers but also many serious scholars have found it more fascinating than death from mundane natural causes. My own half-century of London study-as well as the research of other veteran London scholars like Russ Kingman and Dale Walker-has revealed no substantial evidence that Jack London deliberately took his own life. On the contrary, most of the reliable evidence undercuts the suicide theory. [1]

The rumor was apparently originated shortly after London's death by his erstwhile friend George Sterling, who told Upton Sinclair among others that Jack killed himself because he was desperately torn between his love for his Mate Woman Charmian and newfound passion for a beautiful (but nameless) Hawaiian woman. Sinclair bought the suicide notion but attributed it to London's alcoholism and deteriorating health. [2] A few years later C. Hartley Grattan, taking his cue from Sinclair, suggested that London had actually killed himself in despair over the tragic decline of humanity and civilization. The appearance of his article elicited vigorous denials from London's attendant physicians. [3]

It was not until Irving Stone's Sailor on Horseback was released in 1938 that gossip and fiction became widely accepted as fact; the canard has infected reference works and London biographies ever since. [4] All four physicians who worked trying to save London during his last hours-W. B. Hayes, W. S. Porter, J. W. Shiels, and A. M. Thomson-publicly attributed his death to natural causes. Twenty years afterward, Stone interviewed two of these physicians: Porter and Thomson. "He tried very hard to get me to say that death was due to other things than uremia," Dr. Porter wrote to Charmian London after the interview. "This he was unable to do. I am sure he wants to write a hot sensational thing, something to startle the public and sell." [5]

Stone allegedly had better luck with Dr. Thomson--even though Thomson had previously denied the rumor. According to Stone, on the floor of Jack's bedroom Thomson "found two empty vials labeled morphine sulphate and atropine sulphate [and] on the night table he found a pad with some figures on it which represented a calculation of the lethal dose of the drug." [6] In the "Acknowledgments" to Irving Stone's Jack London (1977), apparently having forgotten that the phantom vials had been empty thirty-nine years before, Stone claimed that Dr. Thomson "gave me one of the morphine sulphate vials, [as] he put it, for safekeeping. It still has four tablets left in it." [7] It is hard to imagine Thomson's jeopardizing his medical career by deliberately falsifying a patient's diagnosis, harder yet to imagine his pocketing evidence from the scene, and hardest of all to imagine his passing this evidence along to a virtual stranger "for safekeeping." Eliza Shepard wrote to Stone that she had been in the room with London and the doctors all day long but had neither seen any vials nor heard any remarks about suicide. [8] Stone's story was undercut further by an interview in the late 1930's when Barry Stevens and Yoshimatsu Nakata met with the first person to discover London on the morning of November 22, 1916--his valet Tokinosuki Sekine:

"Generally, I wake him up at six o'clock, and when he didn't get up as usual, I went in and shook him up and he didn't answer. . . There was a glass tube that he had dropped, it was a little under the bed, and I knew he had morphine. . . He usually has scratch pad in bag and everywhere, and there on the table was one of these scratch pads and he had figured something out on this. I knew he counted how much to take, so I tear it off and put it in my pocket. I picked up the tube and everything."

Sekine's competence as a medical diagnostician is highly questionable, but his devotion to Jack was beyond question: "Mr. London never scolded us," he told Nakata and Stevens. "I liked him very much . . . He was so friendly. I can talk to him about anything, almost. I never think he is my boss, but just like me. Sometimes his is my father." [9] It was Sekine who slipped the beautiful note into the breast-pocket of London's burial suit: "Your Speech was silver, your Silence now is golden." [10]

The questions surrounding Jack London's final hours may never be answered with total satisfaction; however the following medical analysis should clarify the factors leading to his death.

I have attempted to pull together information regarding London's death in a coherent fashion in order to make sense of various symptoms of illnesses he may have suffered, particularly through the last years of his life. In the literature I've been able to review there are some apparent physical signs as well as many descriptive references to symptoms suggesting more than one illness as causative with respect to his death.

In order for me to sort through all of the information available to me, I needed to either develop or co-opt a systematic format for collecting medical information. I realized that the system I needed was one available for all health-care professionals and particularly for those involved in direct patient care. I elected to use the same format physicians use when taking a history and performing a physical examination on a living patient. This approach would allow me to more accurately categorize London's maladies and in so doing create a clearer understanding of his death and the circumstances surrounding it.

Obviously all of the information regarding Jack London's health must come from information written previously or from photographs taken long ago. The information available is made even more difficult to sift through and draw conclusions from because much of it comes in the form of descriptions given from persons other than London himself. This does not, however, render it useless; indeed there appears to have been at least one very significant objective finding which lends validity to the claim that London suffered from renal disease. I will explain the significance of this later. In spite of the second-handedness of most of the information about London's health, I believe reasonable assumptions can be made about the illnesses he may have suffered from and how these constituted the true cause of his death.

Physicians use a sequence of questions when eliciting information from patients in order to ascertain the nature of their visit and to develop a plan for proper treatment. Initially the physician records, in the patient's own words, and usually in one sentence, what is known as the Chief Complaint. This is then followed by the History of the Present Illness, the Past Medical History (including allergies and medications the patient is currently taking), the Past Surgical History, the Family History, the Social History (current living conditions, marital status, drug, tobacco and alcohol use) and Psychiatric History. Subsequent to gathering this information, what is known as the Review of Systems is obtained: a systematic review of all of the body's physiologic systems. Once this information has been analyzed, the physician then develops an Assessment or Differential Diagnosis and Plan for treatment. This standard format provides a powerful tool for deciphering and conglomerating information that is sometimes obvious but nonspecific and widely distributed through multiple sources. This makes an organized and regimented approach especially useful in the case of understanding London's death.

Through my research I've used the aforementioned format to draw some conclusions about London's health prior to his death. The issues that I believe are important (in no particular order of importance) include his trips to the South Pacific and his use of "corrosive sublimate" to treat Yaws and the possibility of associated mercury toxicity as pointed out by Andrew S. Bomback and Philip J. Klemmer; the possibility that he may have suffered from Systemic Lupus Erythematosis (SLE) as suggested by Charles Denko coupled with Denko's assertion that casts in London's urine were noted at the time of an appendectomy performed on him in 1913; and the very real possibility that he may have suffered from both cardiovascular and cardiopulmonary disease brought about by his history of alcohol and tobacco use and by his diet. [11] In the following paragraphs I will elaborate on the effect these medical issues may have had on his system as a whole and how they may have acted in concert to contribute significantly to his death.

The first two assumptions in the preceding paragraph, that London may have suffered mercury toxicity from his use of "corrosive sublimate" and that he may have had SLE, lend support to the claim that he had renal disease. The authors of the articles I've referenced above make convincing medical arguments that London may have had these ailments, both of which cause renal disease. I would like to suggest here that London may have also been afflicted with something known as Polyarticular Gout, an assumption that draws support from the same observances made by Denko in his article as well as from descriptions of his joint afflictions made by others (for example his wife Charmian and London's own physician). This disease falls within the realm of rheumatologic disorders that may also afflict the kidneys. Significantly, London's diet, rich in protein, may have contributed to worsening renal function. The final suggestions regarding cardiovascular and cardiopulmonary disease in the preceding paragraph are linked to his renal disease, and stress on all three physiologic systems combined to render him very unhealthy. Indeed, diseases affecting all three body systems--renal, cardiac and pulmonary--interact in such a way as to create circumstances of worsening hypertension which in turn acts to cause a decline in the function of all three of those systems collectively.

It is worth noting here another of London's symptoms that may have erroneously been attributed to gastrointestinal (GI) distress. In more than one instance reference has been made to London's suffering from episodes of indigestion. While London's bouts of indigestion might have been representative of some GI disorder, it is well known in the field of medicine that indigestion might also be a harbinger of coronary artery disease (CAD). To wit, in London's case, he complained of indigestion the night prior to his death (and on other previous occasions) and prior to that also complained of palpitations in his chest. Chest palpitations are generally regarded as symptoms attributed to cardiac conduction abnormalities--another reason to suspect he may have had cardiovascular disease.

To elaborate on his cardiovascular and pulmonary function and the possible declination of function of those systems, one must also consider his history of alcohol and tobacco use, primarily smoking. In the field of medicine, to quantitate and therefore better understand a person's history of tobacco use, the patient's history of smoking is described in what are known as pack years. For example, use of one pack of cigarettes per day for twenty years, would equate to a twenty-pack-year history of smoking. It is the cumulative dose of tobacco that is important here. The sustained use of tobacco over the lifetime of the patient is directly related to the harmful effects of the drug. In our case, London has been described as smoking heavily throughout his adulthood. His favorite cigarettes were Imperiales, which came ten to the pack. Assuming he smoked three to five packs of cigarettes a day for twenty years, possibly longer, this would be the equivalent of a 30-50-pack-year history. [12] For a man as young as London, this represents an extraordinary amount of drug being ingested over a relatively short period of time. Currently we have the advantage of knowing the adverse effects of years of smoking and the havoc tobacco abuse in the form of smoking may inflict on the cardiovascular and cardiopulmonary systems of the body. In fact, cigarette-smoking may lead to hypertension as well. It is therefore reasonable to assume that London suffered some ill effects as a consequence of his tobacco abuse.

In addition to his tobacco use, throughout most of his life London consumed varying amounts of alcohol. While his use was heavier at times than others--particularly in his younger years and again later during the period he called "the Long Sickness" and until the last year or two of his life--he seldom stopped completely. Alcohol may act on the cardiovascular system through a number of mechanisms and may contribute to worsening hypertension; therefore, in its own way, his alcohol consumption could have acted jointly with his other afflictions in contributing to his generally worsening medical condition. [13]

I have already stated that London's other afflictions might lead to renal dysfunction (mercury causes renal toxicity, SLE leads to renal dysfunction, casts in the urine suggest renal disease). It is well known that hypertension alone, without other contributing illnesses, can cause deterioration of kidney function. One can see then that several problems may have contributed to London's declining renal function. Because blood pressure is controlled to a considerable degree by the kidneys-and this is a very important point-poor renal function leads to worsening hypertension which in turn leads to worsening cardiac and subsequently pulmonary function. It is now common knowledge that cardiovascular disease brought about by hypertension may lead to heart attacks, congestive heart failure and stroke. I believe that London's death may at least in part be attributed to one or more of these factors. Evidence for this assertion will be forthcoming.

However, first there remains the question of London's use of opiates and how and if their use may have played a role in his death. Here, the function and metabolic activity of the kidneys have a place in understanding what may have happened to London in his last hours. The enigma of the contribution of morphine to London's death has been well documented. It is also well known that London began using opiates at least since December of 1915. Alfred Shivers has clearly explained the metabolism of morphine through the kidneys and how its metabolism might be affected by worsening renal capacity. [14] London was said to have suffered from recurrent episodes of renal colic precipitated by calculi or kidney stones and that he may have dosed himself with morphine to alleviate this excruciating pain at some point during the night before his death. No one has been reported to have witnessed this act and therefore a definitive conclusion that he used any opiates the night before or the day of his death remains conjectural and speculative. Nonetheless, it is important to note that if London used morphine the night prior to his death, this drug has the kidneys as its place of metabolism and route of elimination from the body. Shivers's explanation is indisputable with respect to morphine metabolism and morphine toxicity. If London dosed himself with morphine, as has been previously suggested, a dose that normally might have been therapeutic might easily have been rendered toxic by his weakened renal condition. Death due to opiate toxicity is usually brought about through respiratory depression. However, as Shivers explains, the length of time required for someone to expire after ingesting a lethal dose of morphine cannot be accurately predicted. Furthermore, in London's case, the doctors in attendance reportedly administered the proper antidote to morphine toxicity without success. Whether the failure of the remedy for an overdose of morphine was related to an incorrect diagnosis (i.e., London was suffering from some other pathological event and not morphine toxicity), poor preparation or ineffectual administration of the antidote or sustained toxic levels of the medicine in his bloodstream because of his impaired kidneys, the fact remains that he did not respond completely to attempts to revive him. Without the availability of an autopsy report at the very least and current techniques in toxicological analysis, obviously unavailable at the time of his death in 1916, there is no way to know definitively whether the opiate morphine was contributory to his death. To make any assumption otherwise, to state as fact his death was suicide through an overdose of the drug, is at best hypothetical and at worst irresponsible journalism factually unsupported by the available literature.

In order to better understand why this is so, I believe it would be insightful to apply the modern psychiatric definitions of suicide and suicidal tendencies to London's case. In effect, I will use the system of medical history taking what I described at the outset of this piece as a psychiatric investigative device to help extrapolate from history London's state of mind prior to his death. Applying the medically accepted definition of suicide to London's case would help clear up some notions about his death.

Suicide has been defined as "the conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which the act is perceived as the best solution." Thus suicide is "not random or pointless, but a release from a problem or crisis inevitably producing intense suffering." [15] Predictive factors that may be considered high-risk include age over forty-five years, male gender, alcohol dependence, violent behavior, previous suicidal behavior, and previous psychiatric hospitalization. When a clinician evaluates a patient to assess his risk of suicide, an admission by the patient of a plan of action is considered an ominous sign. Eighty percent of people who eventually kill themselves give warnings of their intent. To my knowledge London never exhibited a desire to kill himself in the years just prior to his death. Furthermore, except for male gender and possibly alcohol dependence, none of the predictive items listed above may be considered applicable to Jack London in the time leading up to his death. Therefore, based upon what can be gleaned of his psychiatric history, his medical history and his medical examination, and given an established definition of suicide, it seems unreasonable to conclusively assume that he committed suicide.

Contrary to the assumption that Jack London committed suicide, it seems far more likely that London died naturally from the consequences of his poor health. The status of his physical condition concluded from the rational application of a system provided by modern medicine leads to a more mundane but reasonable explanation for the loss of this great American author. London was found semiconscious and poorly responsive the morning of his death. Significantly, it has been reported that he was unable to move his left arm in response to a verbal stimulus that should have elicited some motor response from that extremity. In light of this additional fact, suggestive of paralysis of that extremity, it seems far more likely that London suffered from a cardiovascular event that ultimately led to his demise. Paralysis of an extremity might be more indicative of an ischemic or a hemorrhagic stroke. I would suggest then, that London sustained a cerebrovascular accident which resulted in his death.

In sum, death caused by morphine self-administered in a dose with the intent to commit suicide seems less supported by the available facts than a multifactorial death caused by the breakdown of a combination of physiological systems in his body manifested as cardiopulmonary and renal disease and ultimately stroke or heart attack.