SUMMARY Bile acid levels were measured in the sera, cerebrospinal fluid (CSF), and brain tissue of 10 patients immediately after death from fulminant hepatic failure (FHF). Serum bile acids in FHF were predominantly conjugated, and total bile acid levels were higher in all 10 patients than in normal controls (85-9 ± SE 8-4 compared with 5.7 ± 0'4 nmol/ml, P < 0 001). Small but significant amounts could be detected in CSF (range 1 2-5-3 nmol total bile acid/ml) and brain biopsies (1-0-18-8 nmol/g wet weight) of FHF patients, whereas none could be detected in CSF and brain biopsies of patients dying without evidence of liver disease. There was no relationship between serum, CSF, or brain levels and duration of coma, or presence of cerebral oedema found in five FHF patients at necropsy. However, serum bile acid levels were similar in FHF to those found in chronic liver disease without encephalopathy and lower than those found to inhibit brain respiration in vitro. A primary role for these compounds in the pathogenesis of coma in FHF therefore seems unlikely.

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The discussion on the freedom to commit suicide and on medical assistance to suicide is a challenge for psychiatry to consider critically the ethical aspects of suicide prophylaxis and of the present jurisdiction on suicide. Suicide research has shown that most acts of suicide are not carried out as free acts of will. The increase in clinic suicides and the high frequency of suicides after in-patient psychiatric treatment clearly show the limits of the therapy of suicidal patients and force us to reflect critically on new developments of psychiatry and special forms of therapy. The decision on the necessity and the duration of compulsory measures can always be made only for each individual case. The danger of renewed acts of suicide can never be excluded. Especially great demands are made on the doctor-patient relationship. Suicide prophylaxis is a humanitarian obligation of society and the medical profession, especially of psychiatry, an obligation which must not be jeopardised by one-sided propagations of the right to "voluntary death".

The psychopathology of 301 patients aged between 45 to 65 admitted to psychiatric hospitals because of endogenous depression between the years 1920 and 1982 was investigated and compared within 4 consecutive time periods. Among other things, an increase in physical and vegetative complaints, disturbances of vital feelings, feelings of guilt towards partner and family, as well as feelings of insufficiency and attempts of suicide was observed. Within the last decade, the duration of phases was considerably longer. Conflicts during prodromal periods of depression, particularly with regard to the partner, the family and the professional occupation were exceedingly more frequently. Historical influences such as a lifestyle orientation towards success, optimal health and wealth might be significant for this development. Pharmacotherapeutic factors will be discussed, and the necessity for further transsectional and longitudinal studies based on clear diagnostic criteria and exploratory techniques will be pointed out.

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