Discussion

In our search of the literature, the oldest case reports of suicidal death by throat-cutting appeared in the late 1800s and early 1900s.^{Reference Anderson5,Reference Millard6} The case presented here is the earliest case of suicide by cutting the throat that we are aware of. The appearance of discussions of suicide in the medical literature coincides with the rise of the movement to incorporate moral treatment of the mentally ill in Europe.^{Reference El-Mallakh7} In the 18th and 19th centuries, care for mentally ill individuals was provided for a fee (paid by family members) by private asylums for the insane.^{Reference El-Mallakh7} Indigent care was generally made available by charitable, faith-based organisations.^{Reference El-Mallakh7} Psychiatrists were not required to be physicians and were frequently just administrators, called alienists. Furthermore, suicide was illegal, and patients attempting suicide were frequently charged with attempted murder.^{Reference Millard6} Many institutions refused to treat patients who had attempted suicide that were brought to them, sometimes with fatal results. The history provided to Dr Bell was that this young man bled for 3 h before dying. The known time interval suggests that this patient would have been observed during this process but not treated. Laws criminalising suicide remain active in many countries but were abolished and not enforced from the mid-19th to the mid-20th centuries.^{Reference Lew, Lester, Mustapha, Yip, Chen and Panirselvam8} Criminalisation or decriminalisation does not alter the risk of suicide.^{Reference Lew, Lester, Mustapha, Yip, Chen and Panirselvam8}

In modern times, throat-cutting is more often associated with homicidal acts than suicide, although such suicide attempts are more common in rural settings.^{Reference Anas, Mannan and Khan3} Forensic pathologists frequently distinguish suicide from homicide by the presence of ‘hesitation wounds’. Patients attempting suicide will frequently make multiple cuts (Fig. 2).^{Reference Ozdemir, Celbis and Kaya9} One exception is ‘honour killings’, in which the number of cuts may be five times greater than in typical homicides.^{Reference Ozdemir, Celbis and Kaya9}

The case presented here is over 200 years old. We believe it is the oldest documented case of suicide by cut throat. Suicide did not become a topic in the medical literature until the appearance of moral treatment in psychiatry in the late 18th and early 19th centuries. Early descriptions of suicide focus on the medical aspects of treatment or pathologic identification of injuries. The museum notes of the case of this young man include descriptions of the wound and aberrant thyroid anatomy but no information about the psychiatric or psychological issues surrounding the death. Furthermore, the description suggests that the man was allowed to die when sufficient time was available to stop the bleeding or otherwise prevent his death.