Under the term anorexia ( appetite) is understood a complete absence of the sensation of hunger, combined with loss of appetite. While anorexia is met with in almost all organic as well as functional disorders of the stomach, "nervous anorexia" may at times appear as a primary affection, unassociated with the conditions just mentioned. The cause of this primary anorexia may be either a depressed condition of the hunger centre or, according to Rosenthal, a kind of hypersestbesia of the gastric mucous membrane. As etiological factors are frequently found great mental depression, as after a death in the family, worry, anxiety, fright, etc.

Symptomatology

At first the patient complains of loss of appetite and begins to eat less. As a rule, all kinds of meat are first discarded from the bill of fare. Later on bread, butter, and afterwards most solid foods are avoided and the patient subsists only on a small quantity of milk and some soup. For quite a while the patients apparently maintain their healthy appearance and do not even seem to lose in weight. The small quantities of food the patient takes are now still further reduced. Even the encouragement on the part of the family to take more nourishment fails to have any effect; the patient, as a rule, obstinately refusing to do so. It was Sollier1 who laid particular stress upon this symptom, and suggested designating this condition by the name of "sitieirgy" ( food, and refuse). At this stage the patients lose considerably in weight and begin to look emaciated, have cold extremities, a slow pulse (50 to 60) and reduced temperature (95 to 96° F.); they grow anaemic and weak, and very soon are hardly able to leave their beds. The appearance of such a patient in this stage of the disease is very similar to that of a consumptive. The face is pale, the eyes sunken, the skin dry, the extremities slightly cyanosed, and the abdomen retracted. If the patient still continues to refuse food, the condition may terminate fatally. Such cases of nervous anorexia ending in death have been reported by Gull,2 Charcot,3 Rosenthal,4 and others.

Rosenthal's case was as follows: The patient, female, seventeen years old, had suffered for eighteen months from anorexia. After this period she took only 30 to 40 gm. of milk per day. The patient became emaciated and looked like a skeleton. She could not sleep and could not leave her bed. Isolation of the patient or forced alimentation could not be employed under the existing circumstances. Symptoms of rapidly progressing inanition appeared, in connection with shortness of breath, dysphagia, and alalia all indicating anaemia of the bulbar centres, the case terminating fatally.

1Sollier: Revue de medecine, aout, 1891. 2Gull. Lancet, 1868.

3 Charcot: "Oeuvres completes," t. iii., p. 240. 4 Rosenthal: l. c.

Diagnosis

After the development of nervous symptoms no difficulty is encountered in making the diagnosis of anorexia. It is necessary first of all to exclude organic affections of the stomach. The early stage of tuberculosis may at times be mistaken for nervous anorexia, especially if there exists no cough or if tubercle bacilli are absent in the sputum. One point, which is quite valuable in making the diagnosis of nervous anorexia, is the circumstance that patients with the latter condition are not in any way alarmed about their loss of appetite, while anorexia existing in organic disorders of the stomach, like cancer, etc., evokes fear and anxiety.

Treatment

In the early stage of the disease the treatment is quite easy. It is merely necessary to impress the patient with the idea that he must take sufficient food. The meals should be taken at regulated periods. The patient should be given food without any previous questioning as to whether he would like it or not. At meal-times he should be encouraged to take his entire portion. A liberal variety of foods is also of importance. In the way of medicines most of the bitter tonics, which stimulate the appetite, are indicated. Thus nux vomica, in the form of the tincture, may be given in doses of ten drops three times daily, or fluid extract of condurango, twenty drops three times daily. Boas recommends fluid extract of Peruvian bark, one teaspoonful three times daily. Orexinum basieum in doses of 2 to 3 dcgm., in wafers three times daily. is also useful. All these stomachics should be given about one-quarter of an hour before meals.

The longer the disease has existed the more difficult it becomes to combat it successfully. If it is already of long standing and has led to a high degree of emaciation and other pronounced symptoms of inanition, then treatment at the home of the patient is hardly ever successful. Charcot first laid stress upon the importance of isolating the patient from his surroundings. This plan of treatment has been still further advanced by Weir Mitchell1 in this country, and this method is known as the Weir Mitchell rest cure. The principle of this cure consists first in isolation of the patient from his family; secondly, in strict supervision by the physician, and by a constant attendant; thirdly, in ample feeding, so that a state of hypernutrition may be established; fourthly, in the application of massage and electricity, which may be considered as adjuncts to the above.

In cases in which food is absolutely refused, even after isolation, forced alimentation or gavage (feeding by means of the tube) becomes necessary. Frequently after having nourished the patient by artificial means for a few da)'s, he gains the conviction that his stomach is able to digest food and then begins to eat spontaneously. Good fresh air and an organic iron preparation like Gude's peptomangan or Pizzala's or Dietrich's albuminate of iron or Boehringer's ferratin may be advantageously administered, especially after the patient has begun to improve. Arsenic may also be administered, either alone or in conjunction with the above-mentioned iron preparations; thus Fowler's solution, two or three drops three times daily in water, or Levico or Roncegno mineral waters may be given, one to two tablespoonfuls daily, or cacodylate of sodium, half a grain t. i. d. As a rule, the patient should not leave the sanitarium until he has regained his former weight. In the latter instance there is no danger of relapses.

1 Weir Mitchell: "Fat and Blood," Philadelphia. 1884.