Refusal of food l may result from:

(a) Delusions with or without coexisting hallucinations: fear of being poisoned or of not being able to digest the food; hypochondriacal ideas;

(6) The desire to starve to death;

(c) An unconquerable disgust for food;

(d) Negativism (catatonia, general paralysis).

Refusal of food may be partial or complete. Some patients will accept only certain kinds of food, often because these appear to them to be the safest or because "the voices" order them so. One patient lived solely on eggs, the shell seeming to him to be the only impenetrable barrier to the mysterious agencies used by his persecutors. One precocious dement would take no nourishment other than stale bread because a voice from heaven commanded him to do penance by fasting.

It may be also absolute or relative. Often with a little perseverance one may persuade a melancholiac to accept a sufficient quantitity of nourishment in a convenient form. Some catatonics refuse what they have been offered and several minutes later devour their neighbor's meal without there being any delusion to explain their conduct. Others refuse to eat, but when food is placed in their mouth they swallow it without trouble. Many even submit with the best grace to being fed with a spoon or with a feeding cup.

1 Pfister. Die Abstinenz der Geisteskranken und ihre Behandlung. Freiburg, 1899.

When refusal of food threatens to have a bad effect upon the health of the patient, as is shown by loss of weight determined by regular weighings, one must resort to forced feeding or "tube-feeding."

Tube-feeding may be accomplished in two ways: by the mouth and by the nose.

Tube-feeding by the mouth is the less painful and less dangerous procedure for the patient as well as the more convenient one for the physician.

The necessary instruments are a mouth-gag, a stomach-tube, and a funnel of glass or rubber.

The operation itself is performed in four stages:

(1) Opening the mouth; . (2) Introducing the tube into the stomach;

(3) Attaching the funnel to the tube and ascertaining the proper penetration of the tube into the stomach;

(4) Introducing the liquid food.

The first stage presents several difficulties due to the resistance of the patient, which is sometimes very great. However, by dint of patience and by taking advantage of little interstices between the jaws it is usually possible to accomplish this.

The introduction of the tube is usually easy. The end entering the pharynx sets up reflexly the movements of deglutition, so that the instrument of itself enters the oesophagus. A gentle push suffices to make it enter the stomach.

Although the large size of the tube renders a false passage almost impossible, the purpose of the third stage is to ascertain that the tube is well in place and has not entered the trachea. Two procedures are used to make sure of this: auscultation at the opening of the funnel and introduction into the tube of several drops of pure water. If the noise produced by the gases of the stomach is heard, and if the water runs down freely, the tube is in place and is not obstructed. Otherwise the tube must be withdrawn and cleaned and the operation recommenced.

The liquid nourishment should always be introduced at a low pressure. Its composition may vary according to individual cases. Milk, eggs, beef-juice, peptones, or vegetable soups usually constitute the basis.

Tube-feeding through the nasal passages presents several inconveniences:

(1) It is painful;

(2) It often causes irritation and inflammation of the nasal mucosa;

(3) The small size of the tube renders its penetration into the larynx liable to occur, and does not allow the use of any but perfectly liquid food.

This method of feeding should, therefore, not be resorted to except in special cases, such as those of buccal affections interfering with the introduction of the tube by the mouth. In such cases a properly sterilized nasal tube or large-sized catheter is used; its end is lubricated with sterilized vaseline, and the operation is then accomplished in three stages:

1. Introduction of the tube through the nasal fossae; this is effected without difficulty. No force should be used, one nasal fossa may be found to be obstructed owing to a deviation of the septum, a growth, or swelling from any cause: the tube may then be introduced through the other nostril.

2. Passing the end of the tube through the pharynx. This is a most delicate procedure. Owing to reflex contractions or to voluntary efforts on the part of the patient the tube is very apt to become coiled up in the throat, eventually to be expelled by way of the mouth; it must thou be withdrawn and the operation recommenced. This can, in a measure, be prevented: as the end of the tube enters the pharynx a little water may be poured either into the funnel or into the patient's mouth; this starts up movements of deglutition by which the end of the tube is directed into the oesophagus. As stated above, the tube may enter the larynx and trachea: as soon as that happens all groaning and talking stops and with each respiratory act air rushes in and out of the tube with a sucking and blowing noise; the tube must then be partly withdrawn, until the end is released from the larynx. This is not so apt to occur if the patient's head is raised by two pillows: in that position the direction of the pharynx is more nearly in line with that of the oesophagus, whereas when the head is hyper-extended the direction of the pharynx is more nearly in line with that of the larynx and trachea; even the voluntary act of swallowing is, in this latter position, as everyone knows, difficult.

3. Descent of the tube down the oesophagus and its penetration into the stomach. The small size of the tube renders it liable to be expelled by an effort of vomiting. This does not happen with a stomach tube such as is used in tube-feeding by the mouth. By using a tube which is sufficiently stiff this can usually be prevented.

Not infrequently after tube-feeding the patient rejects the contents of the stomach either spontaneously or by a voluntary effort. This may often be prevented by throwing a few drops of water in his face. In cases of obstinate vomiting the irritability of the stomach mucosa may be diminished by introducing with the liquid food several drops of a solution of cocaine.

It may be useful to precede the feeding by lavage of the stomach.