We may notice in the next place the acts of self-mutilation and self-destruction so often committed by the insane. If we walk round the wards even of a small asylum, we shall rarely fail to find some one or more patients who have tried, with more or less success, to do damage to themselves. They may be labouring under suicidal melancholia, or other forms, as that which is called suicidal monomania or suicidal impulse. Critics and writers on the subject vary greatly in opinion, some thinking that all who commit suicide are insane, others that delusion must be ascertained before we can pronounce any suicidal or homicidal patient to be of unsound mind. I have coupled suicidal and homicidal patients, for the condition of the one is often closely allied, or even identical, with that of the other class. The same patient often commits both homicide and suicide, or at one time is homicidal, at another suicidal; and so, in reducing to a number of heads the patients who are homicidal, we find that we can range in almost identically the same divisions those who are suicidal. It is of the latter that I shall first speak.

That sane people commit suicide is a fact that must be apparent to every one who exercises common sense in looking upon the subject. The hundreds of poor creatures who are rescued from the Thames, or brought to our general hospitals half poisoned, or with throats half cut, are not insane in any medical sense of the word. Putting these aside, let us look at the insane who are suicidal.

I. First, we have the melancholic patient, who has been noticed by his friends to be a little low-spirited, but nothing more. They have not heard of any delusions; he has not done or said anything that could warrant their calling him insane. He has only appeared changed in spirits and capacity of enjoying himself, and this they have thought it better not to notice; so he blows his brains out, or jumps from the top of the house, and then they are extremely anxious that he should be called insane, and not felo de se. This is pure suicidal melancholia, insane tædium vitæ, where, without any marked or overwhelming delusions, the whole feeling of the individual makes him look on life as not worth the keeping. He is perplexed and annoyed with everything and everybody:

“Weary, stale, flat, and unprofitable
Seem to him all the uses of this world.”

And so he ends them. We see the insanity of the man in that he is entirely changed from what he was; there is no cause for his depression, but perhaps there is cause for his insanity, his suicidal melancholia.

II. The malady may still be fitly called suicidal melancholia; but the desire to commit suicide may be directly prompted by delusions, e.g., that he is going to be horribly tortured; or he hears a voice commanding him to kill himself; or thinks that by this he shall gain heaven; he is ruined, and shame and poverty are staring him in the face; or he sees visions of the departed beckoning him to come to them. This form is easy of diagnosis, and the prognosis is favourable if the general health be not much broken. Of this I shall have to speak when I come to the subject of melancholia.

III. In almost any case of acute insanity – in delirium tremens, in epileptic mania – suicide may be committed in fear, in a paroxysm of rage, or a general outburst of destructiveness; or in attempting to escape a man may jump from housetop or window without any definite idea of self-destruction. In all cases of acute insanity, as acute delirium, acute mania, and the like, this must be borne in mind, and opportunities of self-harm removed from a patient. Many at this time are subject to paroxysms of ungovernable fury, and will then try and hurt themselves as well as others, will dash their heads against a wall, bite their arms, or even do more serious mischief if they have the chance. We cannot say that they are suffering from suicidal melancholia or suicidal mania. Suicide is like breaking the windows, or tearing in pieces their clothes or furniture – a mode in which their vehement destructiveness finds vent. Of the insanity of such persons there is, of course, no doubt, and the prognosis is not affected by the fact that suicide has been attempted.

Source: Fielding Blandford, Insanity and Its Treatment: Lectures on The Treatment, Medical and Legal of Insane Patients (Edinburgh: Oliver and Boyd, 1892), 190-193

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