Anorrhexia amounting to disgust for food is conservative in many instances of acute gastric and intestinal disorders and should not be opposed. In prolonged fevers, notably typhoid, it becomes necessary to force the appetite. The term disgust requires qualification: sometimes there is genuine nausea and loathing: at other times the patient simply feels that he cannot eat but the thought or sight of food is not repulsive; again, the patient desires food but from experience, or prejudice which may amount to an insane delusion, feels that it would distress or harm him.

There are normally great differences in the appetite among different persons and in the same person at different times. Repression of the appetites in general, excessive self control and habits of abstinence, even amounting to obsessions, often lead to loss of enjoyment of food or, by resulting in contraction of the stomach, in actual inability to eat sufficiently except by careful restriction of diet to concentrated foods or by multiplication of the meals. The strength of the digestive organs as well as of the musculature generally, is reduced by prolonged insufficiency of diet, whether due to actual lack of food, poverty, preoccupation, grief and other mental states, or to faulty notions of the patient or his physician that have led to a preconceived plan of reduced nutrition.

In acute fevers and certain organic and serious functional diseases of the digestive organs, the best plan is to administer food like medicine, in definite dose, at definite intervals, without attempting to arouse the appetite though, of course avoiding disgust. If the patient cannot exercise, rest from mental cares or otherwise naturally create a sensation of hunger, as in convalescence from many diseases, surgical confinement and many neurotic states, dainty serving of food, moral suasion and an appeal to the appetite by unusual delicacies must be the strong points. If circumstances are such that the patient can have mental rest, change of scene and out-door exercise, such methods are superior to special preparation of food.

It should be remembered that diet-kitchen traditions are not always rational. Broths are often contraindicated by their excrement itious contents and they are never "nourishing" in the sense supposed but, on the contrary, exceedingly weak in nourishment. Pasty preparations, however flavored, are often too sweet and starchy for the invalid and they soon become disgusting. The dictum that the patient should never be asked what he would like to eat is also incorrect, though obviously the weak, wretched, anorrhexic patient is not in a condition to order his meals and he will usually prefer to take nothing. It is often advisable to consult his tastes and set him thinking about food. Sometimes some one article will suggest itself to him and, unless utterly irrational and harmful, it should usually be got, as the main point is to establish the appetite and habit of eating.

Hyperorrhexia or Boulimia is, in rather moderate grade, a frequent habit of comparatively healthy persons and may even be due to a wrong conception of the amount of food necessary to maintain life. There is also a popular impression that the individual standard of strength may be elevated or a reserve of vitality established by overeating, on the same general principle as financial wealth may be accumulated by getting more than one's normal share.

Diabetes, intestinal parasites (not because the worms consume any notable quantity of nourishment), states in which the stomach rapidly empties itself, various neurotic and insane states, especially certain forms of epilepsy and general paresis, sudden transition from want to abundance, may cause boulimia of high grade. In many cases, the patient seems actually to be kept thin by the labor imposed on the digestive organs and the resulting failure of digestion and assimilation. Sometimes boulimia seems to be purely a matter of indulgence of the grosser appetites, as, for example, in a young lady, otherwise dainty and refined, who would delibrately excuse herself from the table, induce vomiting by running her finger down her throat and return to eat another square meal. This method was also practiced by the Romans during the period of luxury.

The dietetic treatment of boulimia is obvious - regulation of the amount of food without particular reference to kind, providing the standard ration is established with sufficient accuracy - unless, of course, it occurs in diabetes, lithaemic cases etc., requiring special regulation.

Polydipsia is often indicative of diabetes melitus or insipidus but may be clue to local conditions causing dryness or bad taste of the mouth, to diarrhoea - which it tends to maintain - to excessive use of salt and sugar, requiring dilution, to labor, causing excessive loss of water by perspiration and, if of sudden development, it may indicate haemorrhage. In less marked form, it is due to habit, especially with regard to alcoholics and the xanthin-beverages. Excessive milk and water drinking are habits usually traceable to misconceptions of the hygienic value of nutriment or liquid. The old Jewish rule not to take milk with meat, though not literally correct, certainly should apply to the joint use of considerable quantities. Athletes sometimes produce gastric dilatation by endeavoring to strengthen themselves by the use of large quantities of milk.

A certain sort of health cranks - unfortunately including many physicians - become impressed with the value of water as an eliminant, or with the special virtues of some particular brand of mineral water or of distilled water and use it in excessive quantities with meals, interfering with proper gastric digestion, or between meals. The passage of large amounts of water free or nearly free from mineral salts, obviously interferes with osmotic processes generally by withdrawing salts from the blood and tissues, it induces an excess of circulatory and glandular - especially renal - work, and if pure water is used, its irritant effect on the gastric mucosa must be considered. It is possible that diabetes may be thus produced.

On the other hand, many persons, especially drinkers of concentrated tea and indolent or overworked middle aged and elderly women, habitually take too little liquid and develop a positive distaste for water. It is obvious that in such cases, all processes of secretion and elimination are interfered with.

The regulation of these dietetic vices needs no discussion.

Rumination or merycism is a peculiar condition, ordinarily considered a neurosis, in which the individual has the power of regurgitating food from the stomach, sometimes even claiming to be able to bring up any particular article swallowed. It is described as a pleasant habit, and seems, as a rule, to do no harm. However, the mere fact that the regurgitated morsel is described as retaining the original flavor, without sourness or bitterness, indicates a deficiency of acid secretion and peptonization or else some retention in the oesophagus, demanding investigation and proper treatment, including dietetic management.

Gastric regurgitation, whether occurring as water brash or otherwise, and with or without heart burn, etc., indicates a relative disproportion between endogastric tension and the competency of the cardiac sphincter. It is frequently due to the use of too much liquid with a meal, or to hasty swallowing, so that too much air is introduced, or to fermentation in the stomach. The strength of the cardiac sphincter is largely an individual characteristic and some persons can never stoop over soon after a meal, without regurgitating from the stomach.

Vomiting is largely a conservative process, to evacuate irritating or excessive gastric contents. Thus, animals such as horses (which do vomit occasionally), and persons that do not vomit readily, are more disposed than others to serious alimentary disturbances. Vomiting as an indication of gastric disturbance or of biliary disease, intestinal obstruction, peritonitis, pelvic disease etc., need not be considered. Hyperemesis gravidarum is discussed elsewhere.

Vomiting is often a nearly pure psychosis, due to disgust. This form is specially important from the dietetic standpoint, as the nutrition of many delicate patients depends largely upon the avoidance of unpleasant surroundings, and the preparation of food in a cleanly and dainty manner.

Hiccough, of brief duration, is usually a gastric or oesophageal reflex, more often the latter, spasmodic oesophageal peristalsis being set up by swallowing too hastily, or by swallowing too dry or too large boluses.

Prolonged singultus may be a psychosis or may be due to various reflex stimuli, as from biliary calculi, pelvic disease, etc. It is a very serious condition and an important - though not always successful - item in the treatment, is the establishment of normal oesophageal peristalsis by the use of bland food, usually of a liquid character. Theoretically such liquids should be given lukewarm but, often, extremes of temperature are of service. Chewing gum or allowing sugar or candy to melt in the mouth, and the sweet liquid to be swallowed, often gives relief in brief hiccough and sometimes in the severe grade. Various aromatic and alcoholic substances may be employed.

Aerophagia must be distinguished from eructation of gas due to the literal swallowing of air with food and drink, to the formation of gas by effervescence or fermentation, or by the action of gastric acid upon intestinal carbonates, with the pylorus relaxed. Genuine aerophagia is an exaggerated hiccough, with drawing of air into the oesophagus - probably rarely or never into the stomach - and its alternate expulsion. The term is not, therefore, literally correct. It is practically always a pure neurosis and manifestation of hysteria, and while it may be associated with gas in the stomach and may be excited by the causes of hiccough and somewhat relieved by the same treatment, it is amenable rather to moral suasion than dietetic treatment.