Sitophobia, meaning fear of food, is a condition which may last a long period of time and, if not successfully treated, may endanger life. It is therefore natural that this subject should command the full attention of the practitioner.

When I first used the term sitophobia I was not aware that Guislain2 had already employed the same word to designate the refusal of food which is so often encountered in cases of melancholia and in the insane. For this condition, however, the word introduced by SoIlier,3 namely, "sitieirgy," meaning refusing food, seems to be more appropriate. For, in the insane, the patients do not want to eat, not because they are afraid of the food, but for different reasons; either they are in a state of depression, unwilling to do anything, even eating, or they have suicidal ideas, or they have illusions that the food may be poisoned, etc. I may be, therefore, permitted to reserve the term sitophobia for those conditions only in which there is distinct fear of taking food on account of resultant bad consequences. Sitophobia in this sense has nothing to do with the insane and is found in mentally perfectly sound people.

1 Read before the New York Academy of Medicine, May 16th, 1901. Journal of the American Medical Association, June I5th, 1001.

2 Guislain: Eulenburg's "Realencyclopadie der Medicin," 1887, Bd. xii. p. 696.

3 Sollier: Revue de Medecine, aoflt, 1891. 36

In my paper, "The Diet of Dyspeptics,"1 I have already alluded to the importance of sitophobia and its management.

While, however, in the above article sitophobia is spoken of as occurring in cases of disorders of the stomach, principally those accompanied by pains, of late I had the opportunity to observe the same condition in persons who had no gastric symptoms whatever and in whom "the feal of food " was due to some intestinal difficulty. I shall, therefore, in this paper speak of the latter group of cases, or of "sitophobia of enteric origin."

A good illustration of the importance of this condition will be found in the following case, which I beg to describe:

William H -----, 28 years old, bookkeeper, had always been well up to two and a quarter years ago. At that time he became constipated, which condition gradually grew worse, occasionally alternating with diarrhoea. Off and on, mucus was observed in the stool. His appetite was good, but he suffered at times from headaches and disturbed sleep. Patient consulted me for the first time in March, 1900, and was given magnesia usta in conjunction with ferratin and olive-oil enemas, after which he improved for awhile. He went to the country, where his condition again became worse. On his return to the city, in August, patient was given podophyllin pills, which, however, did him no good. He then went to another physician, who ordered some medicine and injections of water.

These remedies not proving of benefit, patient again resorted to the podophyllin pills and injections every day, using both these means from September, 1900, to March, 1901. Often he would go without a movement of the bowels for seven to ten days. During all this time he ate much less than he was previously accustomed to, because he was afraid "that he would get entanglement of the bowel." His weight steadily grew less, and dropped from 138 to 101 1/2 pounds. He became exceedingly nervous, irritable, and hypochondriacal. Of late he felt so weak that he had to abandon his vocation. At this time (March, 1901) he again consulted me, looking very badly, and being hardly able to walk. After undressing he looked almost like a skeleton, every bone being visible, not unlike a Roentgen picture.

1 Max Einhorn: Medical Record, January 1st, 1898.

On examination, besides this extreme condition of emaciation, pronounced anaemia was found. The thoracic organs did not present anything abnormal, while the abdominal cavity appeared somewhat caved in (almost trough-like) and showed an "apparent tumor," situated above the navel to the left of the spine. There were no areas painful to pressure. The urine contained neither sugar nor albumin. The knee reflex was present.

The diagnosis of emaciation due to inanition without any organic trouble was made and the patient treated accordingly. He was advised to eat six times a day; a rectal injection of a half-pint of warm olive oil was ordered every night, and he was given internally calcined magnesia and ferratin. He was told to eat plain, wholesome food, plenty of fruit, bread, and at least a quarter of a pound of butter daily. He immediately improved; his bowels became regular, and hardly a month later he weighed 128 1/2 pounds, having gained on an average almost a pound every day. He now looks the picture of health, has ruddy cheeks, feels strong, and is able to take long walks without any fatigue.

Another case not unlike the one just described is the following:

Joseph W -, 23 years old, ladies' tailor, had been suffering for the last two years with digestive disturbances (fulness after eating and constipation3). Six months ago he consulted me, complaining principally of severe constipation. He was given tincture of rhubarb, but his condition did not seem to improve much. The appetite was not. especially good and the constipation became more obstinate. He was afraid to eat much, as he believed the more he ate the more he would be constipated and the sooner he would have to resort to a cathartic. He ate everything, but only in small quantities. He was also compelled to take a glassful of whiskey in the morning on an empty stomach and two to three times during the day in order to be able to do his work. He gradually became weaker, and lately lost fifteen pounds. His weight now is 110 pounds.

On examination, patient is found to be emaciated and pale. The thoracic as well as the abdominal organs do not reveal anything abnormal. The tongue is not coated. Urine contains neither albumin nor sugar. Patellar reflexes are present.

The diagnosis of habitual constipation with sitophobia was made and the patient treated accordingly.

In the two cases above detailed the sitophobia developed as a sequel to obstinate constipation. The patients were afraid to tax the intestinal tract with much food, as it was apparently unable to dispose of even small quantities of the most delicate aliments.

I have, however, seen instances in which chronic diarrhoea also gave rise to sitophobia. Of the many cases I have observed I will report only one.

Mrs. N. O -, about 33 years old, had been comcomplaining for the last four or five years of great flatulency and diarrhoea. She had four to six movements daily and one or two during the night - about 3 or 5 a.m. The dejecta were either watery or mushy, and always contained a considerable amount of mucus. Before an evacuation took place there was always a great deal of rumbling in the bowels, accompanied by slight colicky pains and passing of flatus. Her appetite was fair and there was no discomfort after meals. Patient, however, was very careful in her diet, taking principally mutton broth, scraped beef, and toasted bread, and of these very small quantities. She was afraid of aggravating her trouble by partaking of more food. Patient had constantly lost in flesh in the last two years, altogether about forty pounds. She feels weak, complains a great deal of dizziness, a dry sensation in her mouth, and restless sleep, and is unable to attend to her household duties.

The physical examination shows that a condition of enteroptosis prevails. The gastric contents do not reveal anything abnormal. The fecal matter contains some mucus and a considerable quantity of undigested food.

The diagnosis of enteroptosis and chronic enteritis is made. Patient is put on a liberal diet-salads, fruits, and coarse vegetables excepted - she is permitted to eat everything. She is also instructed to partake of kumyss, and bread and butter between meals. Besides the diet, patient is given tannigen (seven and a half grains three times a day). Under this regime she has steadily improved, gained considerably in weight, and her bowel trouble has yielded to a great extent, although it has not entirely disappeared.

Remarks

In the observations just narrated the sitophobia was marked and had its origin in the belief that the bowel trouble might become aggravated by partaking of nourishment to some extent. Nor are these cases rare. Sitophobia of a moderate degree is almost an everyday occurrence in various intestinal disorders.

Having emphasized the fact that sitophobia is met with in enteric affections, it does not appear superfluous to describe its dangers and also its treatment.

While in conditions accompanied by diarrhoea the avoidance of food may for a short while exert a beneficial influence upon the intestinal affection, it is quite different in most cases of habitual constipation. The latter condition becomes the more aggravated the less food is taken. The constipation growing more pronounced, the patient is still more afraid to partake even of the small quantities of food which he has hitherto managed to enjoy. Thus there is a circulus vitiosus: constipation causing sitophobia, which of itself aggravates the former affection.

But even in diarrhoea, with sitophobia causing an insufficient quantity of food to be ingested, there is, after a short interval of apparent improvement, a relapse. The deficient nutrition leads ultimately to an undermining of the constitution. The natural resources for combating disease are weakened; nervous symptoms manifest themselves. Thus the diarrhoea quite soon is again as bad as ever.

Moreover, sitophobia, no matter what be its cause, if left to itself is bound to endanger life. A person who habitually is taking an insufficient quantity of nourishment is slowly starving, and if there be no change in the mode of living, starving to death.

It is hardly necessary to dwell upon the symptoms which appear in this state of subnutrition. They are a host and hardly need any comment: general anaemia, and then anaemia of the brain, dizziness, dryness in the throat, extreme fatigue, insomnia, etc. Occasionally I have met with albuminuria, which promptly disappeared upon improving the nutrition.

Another important feature of sitophobia is the habit which the patient develops of eating minute portions. The condition which has led to sitophobia may have been remedied and thus the sitophobia as such may not exist any longer, still the acquired habit of eating very little may persist. This certainly can produce the same dangers to life as the original sitophobia.

Treatment

The patient must be made to eat sufficient quantities of food, no matter what is the underlying condition causing the sitophobia, and no matter how this is done. Sometimes persuasion alone is sufficient. Occasionally in very pronounced cases of subnutrition an ample diet cannot be adopted at once, but must be arranged gradually, accustoming the patient to more nourishment step by step. In some instances various medicaments will be helpful in carrying out this plan; thus the bromides in nervous conditions, or codeine in painful affections. Sufficient nutrition is the foundation upon which to build the structure of health. The former lacking, no matter what treatment may be instituted, the structure will sooner or later collapse. If a solid foundation is laid by a sufficient, diet, it is often quite easy to achieve perfect recovery, for the usual means of treatment will then prove successful in eradicating the primary disease.