Artificial or extrabuccal nutrition is frequently resorted to in our medical practice. As is well known, we possess four different methods of artificial nutrition, namely: (1) subcutaneous alimentation; (2) esophagogastral alimentation; (3) duodenal alimentation; (4) rectal alimentation.

It appears of interest to broach the subject of artificial nutrition with regard to its indications and also the special methods best suited.

With this object in view, cases in which artificial nutrition may be required can be divided into three groups:

1. Cases of subnutrition in which the digestive canal presents no obstacles to the passage of food.

2. Cases of difficult or impossible nutrition caused by obstacles to the passage of food along the digestive tube.

3. Cases in which absolute rest of certain portions of the digestive tract is imperative in order to effect a cure.

1 American Journal of the Medical Sciences, February, 1915, p. 165.

It will be best to discuss the above subject in each group separately.

Group I. Subnutrition With A Free Food Passage Along The Digestive Canal

Subnutrition can be observed in almost all acute and most chronic diseases. Ordinarily, however, the physi -cian, by rational instructions and an appropriate selection of foods, succeeds in introducing by the usual way (per os) an amount of aliment sufficient for the special case.

In rare cases the introduction of an adequate amount of food becomes difficult - if not entirely impossible - by a pronounced lack of appetite or marked aversion for food. But even then the usual mode of nutrition is persisted in, provided the difficulty of food ingestion is merely temporary, i.e., lasts a few days. So soon, however, as the insufficient nutrition is protracted, and attempts to overcome it by the diverse means at our disposal fail, the necessity of artificial nutrition makes itself felt. In complete abstinence from food artificial nutrition will be the more demanded.

As a whole, total food abstinence is met with principally in the insane and melancholics, also in several severe affections of the central nervous system, while insufficient nutrition is found in chronic diseases of the most various types.

With regard to the selection of the special kind of artificial nutrition in this group, the esophagogastral method will be selected. For the aliment is undoubtedly best utilized when subjected to the work of the entire digestive apparatus.

In case the repeated insertion of the stomach-tube is especially annoying to the patient, the duodenal tube may be used instead, provided the patient is not rebellious to treatment. In this instance the capsule at the end of the tube should best be made of gold, platinum, or hard rubber. The same method as that of duodenal feeding is applied with the difference that here the end of the tube with the capsule may remain in the stomach. The length of the tube in the digestive canal from the lips should be about 54 cm. The duodenal tube is, therefore, fastened in such a manner that mark II is situated outside the mouth. The thin tube does not molest the patient and is left in the digestive tract for about two weeks.

The food substances here used are, likewise, identical with those in duodenal alimentation, with the difference that larger quantities may be injected at each feeding.

Whereas in absolute food abstinence the total quantity of aliment is given through the tube, in insufficient nutrition one proceeds somewhat differently. As much food as possible is administered by the mouth, and what is still lacking is given by the tube. As soon as the patient ingests a sufficient amount of aliment by the mouth, artificial nutrition is stopped.