Suicide among the insane is perhaps the greatest source of anxiety to the practical psychiatrist.1
All forms of mental alienation may give rise to ideas of suicide, but the first place from this standpoint belongs to psychoses of the depressed form (involutional melancholia, depressed phase of manic-depressive psychoses, certain forms of alcoholism, etc.).
1 Viallon. Suicide et folie. Ann. med. psych., 1901.
Whatever the nature of the disease may be, ideas of suicide may result:
(a) From an imperative hallucination: a voice calls the patient to heaven, orders him to die in atonement for his sins, etc.;
(6) From a delusion: fear of death from starvation, of being afflicted with an incurable disease; some patients commit suicide to escape the imaginary persecutions of their enemies;
(c) From an unconquerable disgust for existence (tcedium vitce) or from an intolerable psychic pain;
(d) From a sudden impulse (catatonia);
(e) From a suggestion: family suicide, epidemics of suicide;
(/) From a fixed idea, the origin of which is inexplicable. Such is the case reported by Ferrari: An officer declared on several occasions that it was ridiculous to live beyond sixty years. On the last day of his sixtieth year, after having passed a merry evening with his friends, he announced his intention of committing suicide, went into his room, and shot himself with a revolver.
The smallest objects may become in the hands of patients deadly weapons which they may turn against themselves. Magnan reported a case of a melancholiac who perforated his heart by means of a needle measuring scarcely 3 centimeters in length. Some patients at times resort to procedures so horrible that their use cannot be explained otherwise than by the existence of marked anaesthesia; thus a patient of Baillarger's applied his forehead to a red-hot plate of iron.
In institutions, where the patients are not allowed to have in their possession any dangerous instruments, the means most frequently made use of is hanging, which fact is explained by the extreme simplicity of the pro cedure.
Together with suicide may be classed the self-mutilations which patients frequently commit.
Insane patients have been known to cut off their own fingers, lacerate or even cut off their genital organs by means of pieces of glass, open their abdomens, etc.
The treatment of suicidal tendencies is reduced to strict and constant watching, which should be instituted as soon as the existence of such tendencies is suspected, and continued for a long time after their apparent disappearance. As we have already stated above, isolation is absolutely contraindicated. Keeping the patient in an observation ward and rest in bed during the acute periods are very useful measures.