Acute insanity may result from overwork or severe mental strain, or from numerous diseases. It overtaxes the vital powers and causes wasting, inanition, and exhaustion. As the symptoms may result quite suddenly, often within a few hours after intense emotional strain or excitement, the digestive system is at first not necessarily disturbed to any considerable extent, although the appetite may be entirely absent. Subsequently various digestive disorders and malnutrition may supervene.

The insane, especially the melancholic, often refuse food absolutely, or can be induced to take it only very sparingly.

Forced Feeding

When food is absolutely refused by the patient, the question of forced feeding must be considered in order to tide him over the emergency and support life until confusional insanity or delirium subsides.

Concerning this problem opposite views are held. Some alienists regard the operation of compulsory feeding as good mental discipline, others decry it, and defer it as long as possible. It must be understood that the refusal of food may be either a complication or a symptom of the special form of insanity in which it occurs, and the patient should be carefully studied to determine which condition is present. As a complication, it may be caused by central nerve lesions that hinder deglutition, such, for example, as those found in either acute or chronic paralytic dementia. Or digestive disturbances, dyspepsia, or gastric catarrh may cause a loss of appetite which in the patient's disturbed mental state is exaggerated into a refusal of all food. Such local disorders may themselves cause hallucinations or delusions, giving rise to "sitophobia," or horror of taking food. Obviously in such cases cure of the complication may be sometimes effected by treating the local condition. Lavage will sometimes relieve it entirely.

When the refusal of food is purely a symptom of the disease, as it occurs in melancholia or delusional insanity, an attempt should always be made to learn the exact nature of the delusion, and to try if it cannot be dispelled or offset, as in the case of some paranoiacs. For example, the delusion may apply merely to food cooked in particular ways, or served in a certain manner or by certain persons, and the patient may have no real loss of appetite, but may even try to obtain food by stealth and be pleased at his success in that direction, and his food should be placed where he can find it unobserved.

Some patients will refuse all fluid foods who are willing to take solids, or vice versa, or they may refuse food offered by an attendant and yet accept it from a fellow-patient.

If their delusions take the form of suspicion of poisoning, they may sometimes be overcome by showing them eggs in the shell, unpeeled potatoes and fruits, which obviously can not have been poisoned beforehand, and which are then cooked in their presence. Some patients will only eat if left alone or after others have finished, because they feel unworthy to eat with them. Others who persistently refuse food will take it greedily if an apparent show of force is made in placing it within their mouths.

Patients with chronic or asthenic mania may refuse food from inattention, although able to eat if their surroundings are quiet and their attention can be momentarily obtained. If they can be induced to take but a few mouthfuls at a time they should be fed repeatedly at short intervals.

Food should be cooked and served as temptingly as possible, and the patient, if unable to keep himself in order, should have his mouth cleansed and clothing protected from soiling.

The appetite is seldom a safe guide in insanity, and when it fails completely forced feeding should not be postponed until the patient has become too exhausted to rally. Cases of depressive insanity are very apt to require it sooner or later, and sometimes it is practised continuously for a year or more. In acute mania, however, it may be only necessary to employ the method for a few days, after which the patient will eat of his own accord if given the opportunity.

In cases of melancholia, after one or two feedings with the stomach tube, I have often, by a little firmness and patience, satisfied the patient that swallowing a glass of milk for himself was more agree-ble than having it poured in through a tube. When voluntary starvation is the fixed intent, if the patient can be convinced that he has got to take food in some manner, he may yield to the inevitable and choose the lesser of what he regards as two evils. With a stomach tube in one hand and a glass of milk in the other the argument can be made very forcible.

The physician himself should always direct the passage of the tube for the first few times. Afterwards, if the patient is not refractory, an attendant may do it. Occasionally the aid of two or three assistants is necessary to overcome resistance. The patient should be made to sit down or lie upon his back, and either an oesophageal or nasal tube may be used, according to the directions given on p. 547. There are certain advantages in the use of each tube. The oesophageal tube does not so readily admit of regurgitation alongside of it as the nasal tube does (although occasionally patients can regurgitate through the tube itself). If it be filled before it is inserted, and if a little fluid be squeezed out of it when part way down the oesophagus, reflex swallowing occurs, which may be taken advantage of to further propel the tube. The disadvantage of this method of feeding is that the patient often struggles and must be gagged. A wooden gag shaped like a bit, with a central perforation through which the tube is passed, prevents it from being compressed by biting. But the gag is disagreeable, it may slip and break a tooth, and the head and arms must be rigidly held by two assistants.

I have known a refractory patient with melancholia to bite off and swallow eleven inches of stiff oesophageal tube, which remained in the stomach for eleven days before it was ejected by vomiting!

The nasal tube possesses the advantage that it can be more easily introduced with much less struggling, but it has the disadvantage that greater care is required to prevent passing it into the larynx, for the insane are sometimes strangely insensitive. The former difficulty can be obviated by getting the patient to speak, or by closing the tube after it has been inserted and before fluid is introduced, in order to make sure that breathing is not obstructed. This form of tube should be of as large a size as can be conveniently passed. A No. 8 catheter will serve.

For forced alimentation it is necessary to give food in fluid form, and a quart of milk, with one or two beaten eggs, either raw or slightly cooked or made into eggnog, may be prescribed two or three times a day. Nutritious meat broths, thickened with barley, rice, or vermicelli and strained, or potato puree, may also be given through a large tube. Cream and cod-liver oil should be added to the diet. In a case reported by H. C. Wood, for six weeks the patient lived with the greatest benefit on six pints of milk and sixteen raw eggs taken daily. If an ounce of malt extract be added to oatmeal or potato gruel in milk, it soon makes the mass sufficiently fluid to pass through the tube. As this method of feeding prevents the saliva from commingling with the food, there is additional advantage in giving malt or diastase to replace it.

For obstinate patients, feeding with the tube twice a day - at say 8 a. m. and 5 or 6 p. m. - is sufficient, and a quart of food can be introduced at once, but more feeble patients may require feeding three or four times a day. If gastric catarrh or dyspepsia is present, preliminary lavage may be employed, and then food and medicines may be poured through the tube.

Both hypnotism and primary anaesthesia under chloroform have been utilised in extreme cases to enable food to be given to the insane, but the latter method is only necessary or justifiable in very exceptional cases.

Nutrient enemata are of little value in the feeding of the insane who resist feeding, for if the patient realises their use he can make it more difficult to be nourished in this way than by the stomach or nasal tube.

Suralimentation

Suralimentation is to be recommended when feasible. (See p. 471).

Brush says: "In acute delirious mania, in melancholia with frenzy, and in some of the maniacal seizures incident to the aged, the great importance of a liberal persistent use of milk, eggs, and animal broths cannot be overestimated".

If patients will eat they should be given abundant nutritious food, such as tender meats, custards, cereals with butter, sirup, or cream, eggnog, thickened broths, purees, beef jelly, gruels, etc., which are made palatable to tempt the appetite, and the number of daily meals may be increased or nourishment may be given once in three hours. By diverting the blood current and nervous energy for digestive processes, the general nervous system and mental condition become soothed and quieted. Fresh fruit and fruit juices should be offered occasionally.

Special Precautions

In acute insanity there is a tendency for the body temperature to fall two or three or more degrees below the normal. This is especially true of those cases of primary dementia which are due to exposure and privation accompanied by severe mental strain, such, for example, as occur from shipwreck or from any form of severe sudden shock. While regulating the diet, therefore, attention must be given to the preservation of the body heat, and the patient should be surrounded by uniform temperature, to be maintained in an overheated room or by hot-water bottles and warm clothing. Sustaining the normal temperature will facilitate the digestive functions.

The insane must be closely supervised while eating. They often bolt their food, when given too much at a time, in a manner that soon destroys digestion. In such cases all food should be given in a state of fine subdivision or fluid or semifluid form. Patients with advanced general paresis or different paralytic diseases may easily suffocate by getting a piece of meat in the larynx. Patients with mania gravis, or suicidal melancholia, etc., should of course never be intrusted with knives or with plates or dishes which can be easily broken into sharp fragments with which to cut themselves.