It would seem that bulimia is not excited in this manner, for it may be quelled by food in the stomach before there has been time for its absorption, and the attacks are in no relation to the composition of the blood or to the needs of nutrition; but it should be remembered that sensations in the stomach may inhibit the hunger-center or they may excite it. There is nothing against the supposition that either peripheral or central causes may be present and active. Clinically, there is no doubt that this pathological, excessive, imperative hunger is expressed by sensations located in the stomach, and it may be accompanied by the very rapid evacuation of the contents of the stomach into the duodenum.

Clinical Description.-In the mild form, a sudden, strong desire for food may occur at any moment during the day or night, while the stomach is full and active, or in repose. There is a little discomfort and uneasiness, possibly a little headache or vertigo, a slight burning or gnawing sensation in the stomach, but the desire for food is not imperative, although it is exaggerated, and the attack passes off after a little food or drink is taken into the stomach, and, after intervals of very variable length, may return suddenly, unexpectedly, and inexplicably.

The severe form is a much more serious affection. The beginning is sudden, inexplicable, and violent, occurring soon after a meal, while the stomach is empty, during the day or night. The affection may be continuous, the only relief being obtained during a short period after eating; this clinical form may be accompanied by violent exacerbations, which are most frequent in the forenoon.

The attacks may also be irregular or periodical, and the course intermittent, with short or with very long intervals. This lawlessness, or absolute disregard for all rules, is a distinctive characteristic. If the desire is not satisfied, the peculiar, indefinable visceral sensations become more and more unbearable, there are burning and pain in the stomach, and there may be headache, ringing in the ears, and vertigo; or the face may become pale, the extremities cold, and the patient may faint. The desire may become so strong as to overpower the moral sense, and food be taken regardless of its quality or ownership or of the surroundings. After the taking of food the sensations subside, but the effect is independent of the quantity, the quality, and the nutritive value of the food. The attacks may be quelled by eating a little food, or very large quantities may be required to still the hunger. But often the bulimia soon returns, imperative in

its strength, and without apparent reason. In the intervals between the attacks the appetite may be normal, or the severe attacks may be followed by loss of appetite, the hunger-center being apparently exhausted or completely inhibited.

The functions of the stomach may be normal or the evacuation of the contents may be too rapid. The affection is frequently associated with excessive hydrochloric acidity, but this functional adenohypersthenia may alternate with normal secretion. At least one important functional disturbing influence is irregular and immoderate eating. The course of the affection is variable, and it may terminate in spite of the persistence of the causative disease or condition. It is rebellious when due to encephalic disease, and it may disappear spontaneously in hysteria. Bulimia is sometimes the cause of myasthenia gastrica, of gastritis, and of intestinal disease.

Differential Diagnosis.-Acoria, polyphagia, and bulimia are often confounded. In acoria, the food eaten does not satisfy; the patient never feels that he has enough, while the desire for food may be normal or less than normal. In polyphagia there is a good appetite associated with a delayed feeling of satisfaction; or, at least, the sensation of having eaten enough does not become so strong as to interfere with the enjoyment of eating more-this is common gluttony. In bulimia there is strong, imperative, often unbearable hunger, which may be satisfied. From the form of gastralgia which occurs only when the stomach is empty it is distinguished by the strong and imperative appetite which accompanies the pain, and by the occurrence of some of the attacks when the stomach still contains food.

Treatment. The etiological treatment is no less essential in bulimia than in the other nervous affections of the stomach. The hysteria or neurasthenia may demand a combined systematic cure, consisting of isolation, rest, diet, massage, electricity, hydrotherapy, and suggestive moral control. The other causative diseases require particular medication, a mere outline of which would here be out of place.

Both

Antipyrin, or a similar analgesic, may moderate the severity of the attack. Opium or codein may also be used. of these drugs are valuable in the diabetic form. The bromids of strontium and arsenic are palliative, and sometimes rapidly curative, remedies. Fifteen grs. of the strontium salt may be given three or four times a day, half an hour before eating, or tablets of the arseniate of soda ( of a gr.) should be given during the period of gastric activity. We have obtained the

best results from a combination of codein, extract of coca, and extract of hyoscyamus.

The intragastric douche may be of some service, and several glasses of hot water, given in the same manner as in the treatment of chronic gastritis, are sometimes beneficial.

The diet is determined in part by the associated disease, and should be sufficient to supply the needs of nutrition. Milk, finely-divided cereals, lean fish, the soft part of small, fresh oysters, the least excitant meats, dry toast, indifferently acting vegetables, etc., may be combined, and ordered in small and frequent meals. Sweets should be excluded, but enough fresh butter (unsalted) should be ordered to furnish the needed quantity of fat. The patient should live and exercise in the open air, and whenever subnutrition exists a very nourishing diet is absolutely essential.

II. ACORIA.

Acoria (a, privative, and zopévvopt, I have enough; or zópos, satiety) is a rare nervous affection of the stomach, characterized by loss of the special sensation of satiety. The patient never feels that he has eaten enough, whether the meal be small or very large. The appetite is no sharper than in health, indeed, it is often diminished, and the proper quantity of food to be eaten in order to avoid overloading the stomach must be estimated by reasoning.

Nature and Causation.-Some authors claim that the affection is a peripheral anesthesia, while others, whose views are upheld by autopsies, have found the trouble to be due to compression of the pneumogastrics and to softening of the nuclei of origin of their posterior roots. Acoria may be encountered in diabetes, but the large majority of cases occur in the neuropath, particularly after shock and depressing emotions (neurasthenia and hysteria). It may be produced by the crushing influence of a great sorrow. Acoria is an asthenic affection, and it is never associated with bulimia.

The sensation of satiety is not a mere negative sensation, as some contend, signifying the entrance of the hunger-center into a state of repose Acoria may coexist with anorexia. Neither is acoria a mere continuance of the hunger-center in a state of excitation, for the desire for food may, in this affection, disappear during the course of a meal in spite of the fact. that the patient does not feel that he has had enough. Some of the patients with acoria have no sensation of fullness and

weight from overloading the stomach with food or from strongly inflating it with air, but others complain of pain as well as fullness and heaviness in the abdomen. In one of our cases we were able to locate these latter sensations in the colon. It seems probable that the sensation of satiety is identical with a particular state of the gastric "muscular sense," and may be intensified by certain associated sensations, as weight, fullness, discomfort, and cessation of the appetite. Acoria, in keeping with this view, is a special gastric anesthesia, which may be central or peripheral in origin.

Diagnosis. The diagnosis consists in the detection of the symptom, and, when possible, also of its cause, the etiology serving as a guiding thread in the search. The only manifestation of acoria is the loss of the sensation of satiety, and the patient is exposed to myasthenia and gastritis from overeating.

Treatment. The treatment of acoria consists chiefly in moral management, hygiene, and excitant hydrotherapy. The intragastric cold douche may be tried, and the hot or cold needle-bath should be used to tone the nervous system. Galvanization of the vagosympathetic, the cathode over the stomach, and the anode moved over the cervical centers, in the manner described in the chapter on electric treatment, should be tried. Less active are intragastric and epigastric electrization. Strychnin is valuable, and it should be given in increasing doses to the full physiological effect, and then continued for some time in ordinary doses. Frequent and small meals should be given, for the anesthesia is not likely to be relieved by overdistending the stomach. The treatment must also be causative, and a systematic cure may be required by the neurasthenia or by the hysteria which so frequently accompanies acoria.

III. PAROREXIA.

Parorexia (napá, aside, and pets, appetite) is a nervous perversion of the appetite. Bulimia, anorexia, and acoria are quantitative variations of the special sensations of the stomach; but parorexia is qualitative.

The appetite may be selective, and there may be a craving. for special articles of the ordinary diet-pickles, sweets, ices, spices, condiments (malacia). This common perversion hardly deserves consideration in itself, unless accompanied by exclusion of the more nutritive foods; but it may play an im

portant part in the etiology of the diseases of the stomach. The appetite may be more seriously perverted, and nonalimentary, injurious, even disgusting articles may be eaten (pica). This form is common among the little plantation negroes of the South,-the so-called "dirt-eaters,"-and seems to be more prevalent in the spring and in malarial regions. It may be associated with bulimia, and the immediate prevention of the pernicious habit may cause great suffering, which is relieved by the administration of food. It is a popular belief that "dirt-eating" is a sign of intestinal worms, and the association often exists. The habit may seriously affect digestion and nutrition, and is a cause of gastro-enteritis.

Parorexia is most common in the chlorotic or neurotic girl, particularly during the menstrual period. It frequently accompanies pregnancy, and may be caused by sexual

excesses.

The insane and the hysteric may swallow all sorts of things-pins, needles, urine, feces; but this is a disease of the mind, and not a perversion of the appetite.

Treatment. It is difficult to formulate a general treatment of parorexia. It is an irritative affection, and sedation is the controlling indication, which should be combined with good digestive hygiene and with the management of the associated condition. The stomach of the " dirt-eater" should be thoroughly washed out, and the complicating excessive secretion, bulimia, hypersthenic gastritis, malaria, intestinal worms, enteritis, anemia, or inanition should be given proper attention.

IV. ANOREXIA NERVOSA.

Complete loss of appetite may be a symptom of a large number of diseases, and does not constitute anorexia nervosa, which is a very serious nervous affection of the stomach. The appetite in this disease may be completely lost, but the loss is associated with a systematic refusal to take food for a particular reason or motive. The mind is up in arms, and with rare composure excludes all but a little food, and seems satisfied with the result. The loss of appetite is the only gastric symptom. The other symptoms are mental and those that result from the voluntary starvation.

Etiology. Anorexia nervosa is a disease of the adult neuropath, but it may also develop in persons who are neither neurotic nor nervous. It is most frequent between fifteen