cod-liver oil. Nor is it by any means only in cases where there is general emaciation that the administration of fat does good; it is probable that the nutrition of the nervous tissues is directly improved by the treatment in many instances. The administration of iron is doubtless of great use to some anæmic patients, and sea-bathing frequently appears to exercise a very beneficial influence: but the first of these remedies is generally most efficacious when taken in the form of the chalybeate waters of some foreign spa; and there is good reason to doubt whether both mineral waters and sea-bathing do not owe most of their apparent power to the moral influences of travel and change of scene and mode of life. The more specific nervous tonics, such as strychnia, quinine, or phosphorus, seem to exercise but a doubtful and accidental influence.

The treatment of symptoms is a thing to be eschewed in hypochondriasis, with certain special exceptions. While, however, it is desirable to avoid concentrating the patient's attention on parts which are the apparent seat of mere morbid sensations, it is important to relieve him of the distress caused by real (though mere functional) disorders of the digestive system. Decided acidity of the stomach should be counteracted by the use of antidotes, of which none is more efficacious than magnesia ponderosa, in ten-grain doses thrice daily, or Brandish's solution of potash, ten minims three times a day, with gentian or cascarilla. The excessive or too long continued use of alkalies is, of course, to be avoided. The distressing flatulence, which is often one of the earliest, and also one of the most annoying symptoms, is greatly relieved by creosote (one drop in a pill twice or thrice a day) or the infusion of valerian. Alcoholic tinctures should be very cautiously employed, if at all; for there is a real danger of the patient coming to appreciate the comforting sensations given by the spirit so highly, that he gradually takes to drink; this is especially true in the case of hypochondriacal women, as it notoriously is in hysteria. We may add that it is particularly likely to occur in patients exhausted by masturbation or other venereal indulgence. The constipation, which is frequently so obstinate and troublesome, must be remedied, if it be anyhow possible,

without the use of drugs; for it is most dangerous to stimulate the patient's love of self-doctoring in the direction of the habitual use of purgatives. The prescription of fruit, green vegetables, &c., as articles of daily food, is a far more desirable mode of accomplishing our object; and the habitual practice of active bodily exercise is a powerful aid to the same end.

The question of the quantum et quale of physical exercise which may be beneficial in hypochondriasis forms a fitting subject with which to conclude our remarks on treatment, since this is a remedy which directs itself alike to the moral, the constitutional, and the symptomatic condition of the hypochondriac. The only rule, however, which it is possible to lay down for our guidance in this matter, is the direction to employ physical exercise in such a manner and to such an amount as shall fully exercise the muscles without ever producing severe fatigue, and shall also be amusing to the patient. It is a very dangerous error to carry exercise to the fatigue point; a short continuance of such malpractice will usually suffice to produce a profound deterioration of the vigour of the nervous system, and an aggravation of the hypochondriacal fancies.

ANOREXIA NERVOSA.

(APEPSIA HYSTERICA, ANOREXIA HYSTERICA.)1

IN an address on medicine, delivered at Oxford in the autumn of 1868, I referred to a peculiar form of disease. occurring mostly in young women, and characterised by extreme emaciation, and often referred to latent tubercle and mesenteric disease. I remarked that at present our diagnosis of this affection is negative, so far as determining any positive cause from which it springs; that it is mostly one of inference from our clinical knowledge of the liability of the pulmonary or abdominal organs to particular lesions, and by proving the absence of these lesions in the cases in question. The subjects of this affection are mostly of the female sex, and chiefly between the ages of sixteen and twenty-three. I have occasionally seen it in males at the same age.

To illustrate the disease I may give the details of two cases, as fair examples of the whole.

Miss A―, æt. 17, under the care of Mr. Kelson Wright, of the Clapham Road, was brought to me on January 17th, 1866. Her emaciation was very great (vide Fig. No. 1,3 p. 306). It was stated that she had lost 33 lbs. in weight. She was then 5 st. 12 lbs.; height 5 ft. 5 in. nearly a year. No cough. Respirations throughout normal. Heart-sounds normal. Resp. 12; pulse 56.

Amenorrhea for chest everywhere No vomiting nor

1 Reprinted from the Clinical Society's Transactions,' vol. vii, 1874,

p. 22.

2 Lancet,' August, 1868.

3 The woodcuts illustrating this paper are fac-similes of the original photographs exhibited at the time the paper was read.

diarrhoea. Slight constipation. Complete anorexia for animal food, and almost complete anorexia for everything else. Abdomen shrunk and flat, collapsed. No abnormal pulsations of aorta. Tongue clean. Urine normal. Slight deposit of phosphates on boiling. The condition was one of simple starvation. There was but slight variation in her condition, though observed at intervals of three or four months. The pulse was noted on these several occasions as 56 and 60. Resp. 12 to 15. The urine was always normal, but varied in sp. gr., and was sometimes as low as 1005. The case was regarded as one of simple anorexia.

Various remedies were prescribed-the preparations of cinchona, the bichloride of mercury, syrup of the iodide of iron, syrup of the phosphate of iron, citrate of quinine and iron, &c.,-but no perceptible effect followed their administration. The diet also was varied, but without any effect upon the appetite. Occasionally for a day or two the appetite was voracious, but this was very rare and exceptional. The patient complained of no pain, but was restless and active. This was, in fact, a striking expression of the nervous state, for it seemed hardly possible that a body so wasted could undergo the exercise which seemed agreeable. There was some peevishness of temper, and a feeling of jealousy. No account could be given of the exciting cause.

Miss A remained under my observation from January, 1866, to March, 1868, when she had much improved, and gained in weight from 82 to 128 lbs. The improvement from this time continued, and I saw no more of her medically. The woodcut No. 2, p. 306, from photograph taken in 1870, shows her condition at that time. It will be noticeable that as she recovered she had a much younger look, corresponding indeed to her age, twenty-one; whilst the photographs, taken when she was seventeen, give her the appearance of being near thirty. Her health has continued good.

It will be observed that all the conditions in this case were negative, and may be explained by the anorexia which led to starvation, and a depression of all the vital functions, viz. amenorrhoea, slow pulse, slow breathing. In the stage of greatest emaciation one might have been pardoned for assuming that there was some organic lesion, but from the point of view indicated such an assumption would have been unnecessary.

This view is supported by the satisfactory course of the case to entire recovery, and by the continuance of good

health.

Miss B-, æt. 18, was brought to me, October 8th, 1868, as a case of latent tubercle. Her friends had been advised accordingly to take her for the coming winter to the south of Europe.

The extremely emaciated look (vide woodcut No. 1, p. 308), much greater indeed than occurs for the most part in tubercular cases where