On the Artificial Feeding of the Insane
98 Art. Yin.? BY HENRY SUTHERLAND, M.D. M.A. OXON., M.R.C.P. LOND.
Lecturer on Insanity to the “Westminster Hospital; Physician to Otto House and Blacklands House Private Lunatic Asylums; Physician to the St. George’s, Hanover Square, Dispensary; Late Assistant Medical Officer to the West Riding County Lunatic Asylum ; Member o? the Medico-Psychological Association, &c. &c.
The subject of the artificial feeding of the insane is one that has been already so fully discussed that it is felt necessary to offer some explanation of the writer’s object in drawing attention to a topic which, at first sight, appears to have been already exhausted.
The intention of the compiler of this paper is to endeavour to bring forward a resume of all that has been lately written on forcible alimentation ; and to give, as briefly as is compatible with clearness, a few practical directions for performing the different methods of artificial feeding.
As some division of the subject is necessary, it will be con- sidered under the following heads :?
I. Causes of refusal of food, as far as they relate to treatment.
Accessories to artificial feeding.
Moral treatment of the refusal of food.
Rules for feeding by the mouth or nose.
The position of the patient.
VI. Methods of opening the mouth, and of keeping it open.
Methods of feeding, and apparatus.
Formulae for diets.
IX. Indications for the different operations of feeding, and directions for performing them. X. Feeding by the rectum and by other means. I. CAUSES OF REFUSAL OF FOOD. The etiology of refusal of food can only be briefly glanced at, as the more immediate object in view is the treatment of symptoms dependent upon causation.
The causes may be roughly divided into moral and physical. Moral causes would include all emotional influences con- nected with a dislike to food, such as real grief, which the insane are sometimes quite capable of feeling when first separated from their friends; suicidal intention; and also delusions. Delusions may refer either directly to the patient’s self, as when he imagines that his bowels are stopped up, or indirectly to himself, as when he believes that his food is poisoned. Eeligious delusions are occasionally very troublesome to combat, as they may be sometimes founded upon some particular tenet which the patient is really bound to observe, as in the case of Jews, who will not eat meat unless it has been killed in a particular manner.
Physical causes would include dyspepsia; loss of appetite from constipation or from want of exercise; real obstruction in any part of the alimentary canal; and the repugnance often felt by new patients to the wholesale kind of diet afforded by a large asylum.
ii. accessories to artificial feeding. First amongst these must be ranked purgatives. A large proportion of patients are admitted into asylums with confined bowels. A successful attendant once told the writer that she always administered a black draught to all patients admitted to her ward, and invariably found that they were the better for it next day. Such indiscriminate treatment is not to be recom- mended, but the practical hint should not be disregarded. If the patient refuses medicine as well as food, an injection may be given, but such hurried measures are not usually neces- sary on admission.
Dyspepsia, organic disease of the stomach, or natural loss of appetite, must be subsequently treated by the usual medical remedies.
In cases of acute asthenic mania, the patient should be kept lying down as much as possible, and sleep is to be induced by darkening the room, and by appropriate sedatives.
MORAL TREATMENT OF THE REFUSAL OF FOOD.
The moral treatment of refusal of food would include that by persuasions, arguments, threats, influences causing shame to the patient, and occasionally by yielding to some delusion or peculiar manner of taking food, as may be judged necessary in exceptional cases.
New patients, who have not had any long experience of asylum life, may frequently be persuaded to eat by a clever attendant. In cases of religious melancholia or of fixed delusion, persuasion rarely succeeds. A man will often take food from a woman, and a woman from a man. Some patients will only take food from some particular person; others only after the attendant has tasted every mouthful that they eat; others-, ‘
100 ON THE ARTIFICIAL FEEDING OF THE INSANE.
again, demand that they should have only certain kinds of food, as a vegetable diet, or that particular biscuits should be bought for them at a certain shop, which they eat almost exclusively. Delusions are rarely overcome by argument, and in certain cases it is found to be to the advantage of both patient and attendant to yield to them.
Patients who suspect that their food is tampered with will sometimes eat eggs. Others will eat, if allowed to steal their food. Others will not eat when anyone is present, and must be left alone in a room with their food, or must be allowed to take their meals at a table separate from the other patients. Some will eat food if it is placed near them at night, and ladies, especially, may often be tempted by commencing with an anchovy sandwich, or some other dainty morsel. ‘L’appetit vient en mangeant,’ it is said; and when once the ice is broken, we frequently hear no more of this troublesome symptom. Threats and shaming the patient are sometimes useful. In cases of obstinate or hysterical melancholia the mere display of the feeding apparatus on a table is sometimes sufficient to induce the patient to eat in a natural manner. Another useful plan is to make one patient see another fed with the tube, and to inform him that he will be fed in the same way unless he takes his food. An enema of beef-tea administered to a strong man in the presence of others is a remedy that is sometimes successful. At the West Riding Asylum, where there were occasionally as many as six patients to be fed three times a day, and where time was of importance, the writer was in the habit of making the melancholiacs hold one another down to be fed in turn. After a few trials, the effect became so ridiculous that the patients used to laugh at one another, and eventually saw the folly of refusing food and took it properly.
One patient, under the observation of the writer, would never take his food unless he were allowed to lie flat on his back and were fed by the wife of one of the attendants, which was done day after day. A private patient of the writer always eats her food off a plate placed on the floor, as a dog would take his dinner.
RULES FOR FEEDING BY THE MOUTH OR NOSE.
In the first place, it must be stated that we ought never to feed a patient artificially if we can possibly persuade him to take his food in a natural manner.
The question as to how long a patient may be left without food is one of no little difficulty, and of course varies in each particular case. Speaking generally, it may be said that if a patient refuses three meals consecutively he ought to be fed. If the pulse is thin, weak, and either too fast or too slow, and if the patient has been long without food, active measures must be taken at once. On this last point, however, you are often deceived by the patient’s friends, who will sometimes state that no food has been eaten for days, and who do not consider that beef-tea, milk, or any other liquid should be called food. If the general condition is one of emaciation, if the stomach appears to have fallen inwards, if the lips and tongue are dry or covered with sordes, and, above all, if there is an unmis- takably foul smell in the breath, the indication is to feed as soon as possible.
There are two different smells in the breath of a patient who has refused food. One is the ordinary odour that is per- ceptible in any person’s breath who does not take proper exercise or whose bowels are habitually constipated. The other is more offensive and is dependent upon the action of the gastric juice upon the coats of the stomach, proving that actual decay is going on within. It is impossible to describe these stenches? they must be smelt to be appreciated.
In many cases, however, where the patient is robust and obstinate, starvation will effect a speedy cure. But if such treatment is to be adopted, the patient must not be left for a whole day unvisited. He should be seen at least every six hours until food has been taken.
There are some symptoms which, if they do not actually forbid us to feed, should at least be taken into serious consi- deration. One of the most anxious positions a medical man can be placed in is where a patient is dying from refusal of food, and is yet too weak to be fed without danger of syncope. These are generally cases of acute delirious mania, or of excitement in the course of general paralysis. The patient has, perhaps, been kept alive by the tube for some days. At last a change comes over him. The attendants try to feed with a spoon. The patient spits out all the food. The physician arrives to feed as usual, and finds that it is too late; he does not dare to do it, although wishing to do his best for the patient. The moribund condition should certainly make us pause before we administer food by any forcible method. Other symptoms 01* diseases may also considerably modify our determination to feed artificially. Such are disease of the heart, severe bronchitis or emphysema, the condition of preg- nancy, and especially hernise. In one bad case under the writer’s care, the straining and resistance of the patient to being fed caused an old rupture to descend to an alarming extent. A truss was procured and applied, and the feeding process was then conducted satisfactorily.
If you decide to feed when persuasion, threats, and all moral means have failed, you should feed at once, and not keep the patient in any unnecessary suspense.*
It may be well to examine the chest, if you have not already done so, and, if possible, the fauces should also be inspected, although this may be difficult until the actual feeding has commenced. If the tonsils are enlarged, a smaller tube should be used. False teeth should be removed from the patient’s mouth in a sitting posture, or they may be swallowed.
THE POSITION OF THE PATIENT.
This is a point upon which writers differ. When such high authorities as Drs. Bucknill f and Clouston J adopt the sitting posture in an arm-chair, we may conclude that there is some good reason for recommending it. It has this advantage : if the patient vomits, there is less danger of the liquid food pass- ing into the larynx and choking him. But Dr Lawrence has pointed out ? that there is really much less chance of vomiting taking place in the recumbent than in the sitting posture, as the abdominal muscles are then at rest.
It is the experience of the writer that it takes much longer to tie a patient into a chair than to throw a sheet over him when he is lying down on a bed; that the patient gets more bruised, and that the attendants are more likely ty) be injured, and that the patient can wriggle out of position much more easily in a chair than on a bed. Moreover, if the patient be sitting, the head cannot be held securely between the knees of an attendant as it could if he were lying down. There is thus more danger of the patient twisting his head round, and so getting the gag out of his mouth, an accident which exposes him to no little danger. There can be no doubt that the operator has far greater command over the patient in the recumbent than in the sitting posture, and for these reasons the writer usually feeds in that position.
A modification of the method of holding patients described by Dr S. W. D. Williams || is the one preferred by the writer. In ordinary case three attendants are sufficient, one for the head and one for each side. In extraordinary cases five are * Dr Sankey’s Lectures on Mental Diseases, p. 47. f Manual of Psychological Medicine, 3rd edition, p. 755. J Lancet, November 30, 1872. ? West Biding Asylum Medical Reports, vol. i. p. 26. II Journal of Mental Science, October 1864. ON THE ARTIFICIAL FEEDING OF THE INSANE. 103 necessary?one for the head, one for each arm, and one for each leg.
The patient is placed on his back on a firm mattress. The head is to be slightly raised on a pillow. If not undressed, the patient’s boots must be removed, and everything made loose round the neck. The operator should not feed till all are in position. A patient’s life has been sacrificed by his being held carelessly. In the case alluded to, the patient twisted his head round, the gag came out of his mouth, he bit off” the stomach tube, swallowed it and died. The attendant’s hands should be as bars of iron, but the doctor’s as springs of steel.
The most experienced attendant takes the head. He kneels at the head of the bedstead, on the pillow, and with his hands holds the patient’s head between his knees. A soft towel must be placed between the attendant’s hands and the patient’s head, to prevent the ears being injured. The attendant must spread out his hands with the fingers widely separated, pressing downwards and slightly inwards, and bringing the power of the knees in by pressing them against the backs of the hands, if necessary. The attendant’s thumbs should be pressed upon the patient’s forehead, and not upon the malar bones, or black eyes may be caused, for the insane are easily bruised. This attendant may usually be trusted with the gag, but in severe cases another person should hold it.
A strong sheet is then, or previously, thrown across the patient’s body. His arms should always be outside the sheet, or they may be accidentally knelt upon. The sheet is then drawn tightly down over him? especially at the knees, but not over the chest, which should be left unconfined. Two attendants (if there are only three) then kneel on the sheet, one on each side of the patient’s knees, so that the weight of their four knees is opposed to his two. The legs ^ are thus held tightly in their place without the least risk of injury. An attendant should never kneel upon any part of a patient, but this applies especially to the knees and elbows, which in general paralysis are liable to have enormous abscesses form on them from even slight pressure. Each of the attendants then grasps one of the patient’s arms, one hand is placed on the patient’s wrist, and the other presses down the shoulder.*
If five attendants are necessary, which seldom happens, the first takes the head. The second and third hold the arms, as above. The fourth and fifth kneel on the sheet at the knees, and use their hands to press down upon the legs of the patient, one hand being above and the other below the knee-joint.
Dr S. W. D. Williams, Journal of Mental Science, October 1864.
Holding the feet is useless and dangerous, as the smaller j oints afford but little hold and are more liable to be bruised and injured.
It is almost needless to remark that a man should never hold a woman down to be fed. The surgeon may show the attendants the proper positions, but should not assist at the actual feeding of a woman, except by passing the tube. The operator may or may not put on an apron to feed the patient, as he thinks fit.
METHODS OF OPENING THE MOUTH AND OF KEEPING IT OPEN.
Sometimes the patient suspects the intention of the doctor, and clenches his teeth. As Dr Williams says,* if the patient be a woman, the mouth is generally easily opened by getting her to talk.
In a difficult case of feeding under the writer’s care, in which the patient was a Jewess, with extraordinarily good teeth, the mouth was opened by pouring in a mouthful of beef-tea, which made her cough and choke, and, the teeth being parted in the act, the key was quickly slipped in between them, and the mouth was easily opened.
An attendant has shown the writer another method. The attendant kneels behind the patient. The thumb and first and second fingers of each hand are brought into play on each side of the face.
The thumbs compress the nose between them, the two fore fingers raise the upper lip; the two middle fingers are pressed down upon the lower gums ; and thus the mouth is easily opened.
Another way is by making pressure with the finger upon the gums at the back of the mouth, but in doing this the operator may be bitten. Either end of a spoon may be used as a lever to open the mouth, but the teeth may easily be broken by such a pro- ceeding.
The point of the ordinary screw-key may of course be used for the same purpose.
It has been found by the writer that, although these steel keys are the most ingenious contrivances we can use for opening the mouth and keeping it open, there is the objection to them that the prongs of the key are somewhat in the way, and often project towards the back of the mouth, and thus interfere with the passage of the tube. He has therefore designed a gag, intended to meet this objection.*
There are yet two instruments to be mentioned for opening the mouth.
One is the wooden wedge, which resembles the vent-peg of a beer-barrel, which was formerly used to open the mouth with. The other is the wooden gag, with a hole in it. The objections to the first are obvious, as it is a clumsy and brutal instrument. The wooden gag is objectionable, as it is very difficult to get it into the mouth. When there, the patient can easily put his tongue against the hole in it, and thus either prevent the en- trance of the tube or get his tongue injured. If you do succeed in passing the tube over the tongue, which may be done by prolonged and steady pressure, you are then working in the dark, you are pushing a straight tube backwards instead of a bent one downwards, and you cannot possibly tell where it is going. For these reasons the old wooden gag should be con- demned.
METHODS OF MAKING THE PATIENT SWALLOW.
In spoon feeding, when you have got the liquid mouthful into the patient’s mouth, he may be made to swallow by touching the back of the pharynx with the spoon, and at the same time compressing his nostrils. The nose, however, is easily abraded if this is done frequently.
METHODS OF FEEDING, AND APPARATUS.
Mouth feeding-. .Not entering oesophagus : 1. Single spoon. 2. Two spoons. 3. Spoon and feeding-cup. 4. Spoon and india-rubber enema bottle. 5. Funnel inserted behind the teeth. 6. Paley’s feeder. Entering oesophagus: i x 1. f without wooden end. 7. Stomach tube { ^ wooden end_ Accessories to stomach tube : Stomach pump. Funnel. Bottle, with movable valves.
To be obtained at Maw & Sons.
106 ON THE ARTIFICIAL FEEDING OF THE INSANE.
Nose feeding. Not entering oesophagus: 1. Feeding-cup inserted into nostril. 2. Funnel inserted into nostril. 3. Enema syringe inserted into nostril. Entering oesophagus: 4. Flexible oesophageal nasal tube. 5. Gum elastic catheter. Accessories to nasal tube: Funnel. Ear-speculum. Sponge bag attached to nasal tube. Other methods of feeding: By rectum. By absorption through the skin. Subcutaneously ? IX. FORMULAE TOR DIETS.* For feeding by the mouth : Breakfast. Beef-tea. One pint and three-quarters. Brandy. Two ounces. Castor oil. Half an ounce. Dinner (if fed three times a day). The same, without the castor oil. Tea. Milk. One pint. One egg. One teaspoonful of Liebig’s extract dissolved in cold water. For feeding by the nose:
Milk, beef-tea, eggs, brandy, and every kind of fluid food and medicine may be used. If any farinaceous material is required, pearl barley is most appropriate, as it passes easily through the narrow pipe of Paley’s feeder, or through the nasal tube.
Ground meat, meal, rice, sago, arrowroot, gruel, &c., may be passed through a large mouth tube, but not through the nasal tube.
Dr Sankeyt recommends that strong ale should be given through the tube, but this would not be suitable in cases of melancholia associated with derangement of the biliary secretion.
From Dr Crichton Browne, of the West Riding Asylum.
f Lectures on Mental Diseases, p. 47.
In private practice we must ascertain what the patient has been in the habit of taking in the way of food and stimulants. If he has been accustomed to high living, a milk or slop diet would in many instances be inappropriate. Where money is no object, champagne and turtle soup, concentrated chicken or oyster broths, and the strongest beef-tea that can be made, should be ordered.
Dr Learved’s apparatus * is probably the best that has been invented for making strong beef-tea.
Dr Henry Blanc f has described a method of administering raw beef in a palatable form to phthisical patients, which would probably be of great service in treating those suffering from so depressing a disease as insanity requiring artificial feeding.
Nutrient injection for the rectum .J Butter. One ounce. Port wine. One ounce. Beef-tea. Half a teacupful. Another: Brandy. Half an ounce. Beef-tea- Half a teacupful. Brandy injection in syncope: Brandy. One ounce. Water. One ounce.
X. INDICATIONS FOR THE DIFFERENT OPERATIONS OF FEEDING, AND DIRECTIONS FOR PERFORMING THEM.
In all cases where artificial feeding is necessary, the most simple method should be tried fiist. We should commence with apparatus not entering the oesophagus, as, of course, there is always some slight risk to be encountered in passing the stomach tube, although the danger of this proceeding has been much exaggerated. In cases of obstruction of the oesophagus, or where the patient is in robust health, and we wish to make the process as lono- and as disagreeable as possible, or if the operator is unskilled in the more difficult methods of feeding, spoon feeding is indicated.
Feeding by the single spoon requires no directions for its successful performance, but it may be remarked that the teeth are easily inj ured by a spoon if any force is used. In cases * Lancet, January 17, 1874. To be obtained at Maw & Sons. Lancet, June 13, 1874.
J From Dr Crichton Browne, of the West Riding Asylum. where the patient spits out the food, it may be well to put the left arm round his neck to steady the head, and the left hand may be used to press up the chin and keep the mouth closed till the food is swallowed. This method is useful for half- resolute melancholiacs, who fancy that there is no more powerful mode of forcing them to eat. It may be done in the sitting posture, and has the advantage that by it all kinds of food, solid and liquid, meat and bread, can be administered.
FEEDING WITH TWO SPOONS.
The patient may either sit or lie down. The supine posture is the best. The operator opens the teeth and keeps the mouth open, with the first spoon in his right hand. With the left hand he pours a spoonful of food (which must be liquid if the patient is lying down) from the second spoon into the first. He then gently touches the back of the pharynx with the first spoon. The patient’s nose is at the same time compressed by an assistant, and the mouthful is swallowed by reflex action. A common feeding-cup or an india-rubber enema bottle may be substituted for the second spoon in the above process. A funnel, with its tube bent at right angles, may be inserted behind the teeth, and liquid or semi-liquid food poured through it down the throat.
Paley’s feeder is only a funnel with a spout shaped like a goose’s bill. This spout is forced between the teeth, and when a spring is compressed the liquid flows down the patient’s throat, the stream being stopped when the valve is relaxed, at the will of the operator. A glass cover allows the surgeon to see through the top of the funnel and at the same time pre- vents the food being spilt. In a case of excitement in the course of general paralysis, the writer used Paley’s feeder. The patient shouted all the time, and the liquid nearly choked him by entering the larynx. The stomach tube was afterwards used successfully.*
APPARATUS ENTERING THE OESOPHAGUS.
The stomach tube for the mouth may or may not have a wooden end attached to it. This wooden end terminates in a cul-de-sac, and has two openings at the sides. The advantage of it is, that if the end of the tube when passed impinges against the wall of the stomach, the fluid is not prevented flowing on through the side holes, which are free. The * British Medical Journal, May 25, 1872. disadvantages of it are, that, not being an actual part of the tube, it might possibly become detached, and that, as the dia- meter of the holes is less than that of the tube itself, rice and other solid substances will not pass so easily as through a tube without a wooden end. If the tube without this appendage does impinge against the wall of the stomach, so that the food is stopped in its passage, this is easily remedied by drawing up a few inches of tubing. The tube without the wooden end is therefore to be recommended.
The stomach tube should be neither too narrow nor too broad The broader the tube the more difficult it is to pass, but the narrower the tube the greater danger there is of its enterino- the larynx. A tube measuring about 28 inches in length and of an inch in diameter outside, with a bore of of an ‘ inch,’is a good size. To the upper end of the stomach tube is attached a piece of gutta-percha tubing, about 15 inches in length, and to the upper end of this piece of tubing may be affixed a stomach pump, a bottle with movable valves, or a funnel holding about a quart.
In feeding with the stomach pump it must be remembered that you press down the valve with the left hand at the same time that you press down the piston with the right. The advantage of the stomach pump oyer the funnel is,that more solid food can be forced through it than will flow through the funnel by mere force of gravity. The disadvantages of the stomach pump are, that the food being squirted by it against the stomach wall may irritate it and cause vomiting, especially in dyspeptic subjects; and also that the proper management of the valves is somewhat confusing during an operation already sufficiently complicated.
The writer prefers the large funnel to the pump. Into this the basin of food is upset, and simply gravitates into the stomach The bottle with holes or valves appears to be a good arrange- ment, as by it you can regulate the flow of food, and stop the process if the patient vomits.
Before commencing to feed, the operator should ascertain that the food is not too hot or too cold, and also if it is of a proper consistency. Brandy or medicines are then added to the liquid, if necessary.
PASSING THE TUBE.
The surgeon first dips the end of the stomach tube in the warm liquid, which is better than oiling it, and takes it in his right hand. The last four or five inches of it should rest upon the palmar surface of the index finger. He then passes the finger and tube to the back of the pharynx, feels for the epi- glottis, passes the tube over it into the oesophagus, and pushes on the tube. Some operators pass the tube without putting the finger into the patient’s mouth. If this is done it is some- times advisable to bend the last two or three inches of the tube downwards before passing it. About eighteen inches of tubing should be passed, and it should not be done too quickly. About four inches should then be drawn up, to prevent the end adhering to the wall of the stomach. If this length of tubing has passed without any obstruction, the operator may be sure it is not in the larynx. It is a good plan to have a white line painted about sixteen inches from the end of the tube, to show when enough has been passed, and this may also be done on the nasal tube.
” In passing the tube there is sometimes a little pressure required to make it enter the oesophagus, on account of its having to follow a slightly obtuse curve, and coming in contact with the bodies of the vertebrse, which become prominent if the head is held far back. This pressure may be reduced to a minimum by directing the tube a little to the left side, as the oesophagus inclines to its left, in the upper third of its course, and by moving the head forwards when once the tube has reached the entrance to the oesophagus.” *
If the tube should be stopped in its course, it must be with- drawn and passed again. It should be remembered that occa- sionally there are real grounds for a delusion. In a case under the writer’s care the patient affirmed that he could not swallow because his oesophagus was stopped up. The tube was carefully passed and a stricture was found to exist. It was treated by passing the tube as far as the obstruction and gently pumping some liquid and oily food on to it by the stomach pump. The fluid gradually dilated it, and the patient ultimately recovered. A case of death from the use of the stomach pump has been recorded from the tube passing into a stricture of the oeso- phagus, probably malignant, in a patient who had attempted to poison himself by laudanum.f
The tube being passed, the fluid is upset into the funnel, or injected by the pump into the stomach.
The tube is then withdrawn. It is better to hold the funnel or a basin under the patient’s chin as this is being done, so that the end of the tube may fall into it, as some fluid always remains in the tube, which otherwise runs over the patient’s nightdress.
The patient should be kept lying down when the feeding is over, as the operation generally causes no little shock to the ner vous and circulatory systems. This is partly due to the struggle which almost always ensues to a greater or less extent and&to the anxiety which is frequently produced in the patient’s mind by the process ; and also partly to some obscure nervous con- nection between the stomach and the heart, through the medium of the pneumogastric and sympathetic nerves.
NASAL FEEDING. INDICATIONS FOR AND AGAINST FEEDING BY THE NOSE.
If the patient is a lady with a good set of teeth, it is very important that on her recovery she should not find that any of them have been chipped or broken. The risk of such an accident is entirely overcome by the use of the nasal tube. Its use is also indicated in certain cases of chronic passive melancholia where the teeth are clenched with great force, and where but little resistance is made to feeding by the nostril. In cases of severe bronchitis or emphysema, where there is much dyspnoea it would probably be preferable to feeding by the mouth, as’the mouth is capable of inhaling a larger quantity of air than the nose ;. and in feeding by the nostril the mouth is left free for respiration, whereas in feeding by the mouth it is partly blocked up by the tube, which is of course broader than the nasal tube Nasal feeding is contra-indicated in patients who possess an unusual amount ot co-ordination of their muscles In such cases it appears that the patient is able to contract the muscles at the back of the pharynx at will in such a manner as to direct the point of the tube into the larynx, and to cause alarming choking and blueness. In a case under the care of the writer, in which feeding by the nose was attempted the patient twisted his tongue backwards behind the tube brought it forwards between his teeth, and nearly bit it into two pieces Fortunately a loop of the tube was seen to project out of the mouth, and it was rapidly withdrawn. The patient was after- wards fed successfully with the stomach tube by the mouth In feeding with the nasal tube great difficulty is sometimes experienced m passing it. This is especially the case in persons who have a sharp aquiline nose and contracted nostrils. But as the septum ot the nose is on one side in most people, if we cannot pass it through one nostril we may frequently succeed with the other, without using any great force. The first passage of the nasal tube is always difficult. This is due to the accumulation of mucus within the nares. The attendant should therefore blow the patient’s nose before the tube is passed, and clear away as much of this obstructing matter as possible. At the first passage of the tube it often gets blocked up with mucus. If the food will not flow through it, it should be withdrawn, cleaned out, and re-inserted.
APPARATUS FOR NOSE FEEDING. NOT ENTERING THE (ESOPHAGUS. FEEDING-CUP INSERTED INTO THE NOSTRIL.
Dr Phillimore has published a paper * advocating the practice of feeding through the nose without the use of a tube, in which he states that no other method than that of feeding through the nostril has been practised in the Nottingham Asylum for years. The patient should be in the recumbent posture. He writes : ” My plan has been and is as follows. The surgeon stands on the right of the patient, and a little be- hind, holding in his right hand an ordinary earthenware invalid feeding-cup, containing the nourishment. He then places the nozzle into the left nostril, closing the right with the thumb, and the left nostril with the fingers of the left hand, steadying the head at the same time between his arm and side, the mouth being left perfectly free for respiration. The head being now slightly inclined to the patient’s left, the contents of the cup are allowed to*trickle along the left wall of the nasal cavity into the pharynx, and thence to the stomach. It will thus be seen that there is no restraining apparatus, nor gag, oesophageal tube, pump, other machinery, nor even an extra funnel required.” He concludes by saying, ” The process required care, but it was successful.”
FEEDING BY A FUNNEL INSERTED INTO THE NOSTRIL.
Dr Moxey has’published a paper t in which he recommends the following method : Gently introduce a small Wedgwood funnel wrthin, and only withm, one of the nostrils, holding it there lightly and without pressure during the entire adminis- tration, remembering that it is used merely as a convenient medium to supply the iood to the nostril.” * Lancet, November 2, 1872. f Lancet, May 31, 1873.
ON THE AKTIFICIAL FEEDING OF THE INSANE. 113 FEEDING BY ENEMA SYRINGE INSERTED INTO THE NOSTRIL.
Dr Hyslop has published a paper * in which he recom- mends for nasal feeding the use of ” a good clean pint enema bag, with the nozzle cut off within an inch of the shield, and the mouth-piece of a child’s feeding-bottle drawn over the nozzle.”
These two last methods of feeding by the nose stand inter- mediate between that of feeding by the nose with only a feeding- cup and that by the funnel and tube.
APPARATUS FOR NASAL FEEDING. ENTERING THE (ESOPHAGUS. FUNNEL AND TUBE.
To the upper end of the nasal tube may be affixed a funnel the size of a wine-glass or an ear-speculum. Dr Harrington Tuke has described a case to the writer in which he, having no other apparatus at hand, fed a lady through the nose with an elastic catheter having a sponge bag filled with fluid attached to the upper end of it.
The tube itself should be either a gum elastic urethral catheter of the size of number 3 or number 6, as recommended by Dr Harrington Tuke,f or a flexible india-rubber tube about 24 inches in length, and of an inch in diameter, with a bore of JL. of an inch. The thicker the tube the more difficult it is to pass, but the thinner the tube the more likely it is to get into the larynx and the less easily will the food flow through it.
Dr Harrington Tuke recommends that the gum elastic ca- theter should be slightly bent before it is used. It will facilitate the passage of the nasal tube if it is warmed and oiled before it is passed.
METHOD OF USING THE NASAL TUBE.
The patient is placed on his back. The tube is passed down one of the nostrils. If the patient chokes it is a sign that the tube is in the larynx. The tube should therefore be drawn up about an inch, and then pushed on again. When it passes on freely without obstruction, about fifteen inches should be pushed down the nose. The part of the tube remaining out of the nostril should then be held quite straight, in the vertical position, and there should be no bending or loops in it, or the food will not pass. The food is then poured into the funnel and allowed to find its way down the tube by the force of gravity. If the fluid will not flow on, about an inch of the tube should be withdrawn, as the point of it is probably resting against the wall of the stomach. If the liquid still will not pass, the tube must be withdrawn altogether and cleaned out, as it is probably blocked up with mucus.
When all the liquid has been successfully poured through the tube, the funnel may be placed under the nose as the tube is withdrawn, to catch the fluid which remains in the tube, which otherwise may run over the patient’s nightdress. The patient should be kept lying down for some little time after the operation, although there appears to be much less shock to the nervous system in feeding by the nose than by the mouth.
It may be mentioned that feeding frequently by the nasal tube causes some little swelling and tenderness of the lining mucous membrane, by which the process is rendered both pain- ful and difficult. The tube should therefore be as soft as pos- sible, should be well warmed and oiled, and should always be passed with the greatest gentleness and care.
There is one great disadvantage in feeding by the nose, which is, that by this method only liquid food can be adminis- tered, as the tube has a more narrow calibre than the stomach tube for the mouth.
OTHER METHODS OF FEEDING. BY THE RECTUM.
On this method of feeding Dr Bucknill* writes: ” Nutri- tive enemata are not of much use, so little, indeed, that they may well be dispensed with.” The writer agrees with this remark as far as it relates to the insane; but as it has come to his knowledge that a friend was kept alive solely by enemata for three weeks, who was suffering from enteritis, it must be acknowledged that it may be useful in certain extreme and exceptional cases.
Feeding by the rectum is indicated when the patient is in a nearly moribund condition, and where the resistance to feeding by the mouth would probably cause an immediately fatal ter- mination.
It may be used as an adjunct to feeding in other ways, and it is useful when it is desired to shame a patient into taking Ms food in the natural manner.
Manual of Psychological Medicine, 3rd edition, p. 757.
Piles, fistulse, or any disorder of the rectum, would probably contra-indicate this method of feeding.
FEEDING BY THE SKIN.
The only method of feeding by the skin that is likely to be of any real service is that mentioned by Dr Bucknill,* who writes : ” As an auxiliary resource we can recommend that the whole body should be well rubbed over twice a day with oil. We have known this resource of great service where inanition was threatened from constant vomiting.”
The writer has read in a novel of a bath of beef-tea being ordered for a shipwrecked mariner, who was nearly exhausted; and in some medical paper of whisky being subcutaneously injected; but having had no personal experience of these sen- sational methods of feeding, he is unable to recommend them. Such is the treatment of the insane by artificial feeding. No paper on the subject can teach its practice so well as actually performing the operations in the wards of a large asylum. Only general directions can be given, for almost all cases of refusal of food require different treatment; and their successful issue will depend no little upon the judicious selec- tion or combination of the methods we have endeavoured to describe.
Manual of Psychological Medicine, 3rd edition, p. 757.
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