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definiteness of this condtion I thought it was worth while to ask the question and attempt an answer, namely. What is meant by how much viagra can you take a gastric neurosis? It is generally admitted that the stomach, when not diseased in itself, is reflexly irritated through the autonomJc system. Embryologically, the liver, pan- creas, and appendix are offshoots from the primitive gut, all having the same nervous supply, largely through the s\Tnpathetic nen^es. But as the human species developed a cerebral nervous supply was superimposed upon this primtive nerve apparatus, and the disturbances of these two regulators, some- times working at cross purposes, produce many of the gastric neuroses. And so we find that the *Read before Mt. Sinai Hospital Clinical Society. Oct. 2, 1915] MEDICAL RECORD. 565 cerebral or psychic control of our gastrointestinal tract is interfered with by a disturbance in the sympathetic nervous system. Exhaustion of one or the other produces many symptoms not accounted for by any pathological condition. Thus in neuras- thenia, hysteria, and mental depression, we find that the stomach is involved. In a great majority of stomach patients who con- sult a physician no organic lesion exists, even after the most painstalcing diagnostic procedures have been employed in its discovery. Hence, they must be accounted for on other grounds than a chronic appendicitis, or latent gallstones or ulcer, as sur- geons would have us history of viagra in urdu believe. Let us designate these cases as neuroses. To be more specific, let us take up the various neuroses that I have seen myself in private and clinic practice : They are usually classed as sensory, secretory, motor, and psychogenic. The sensory neuroses include the anamolies of the sensation of hunger, such as anorexia, bulimia, and parorexia. The first is by far the most im- portant clinically, as we meet with it every day. Anorexia, the absence of the sensation of hunger, is a frequent accompaniment of many organic lesions of the stomach, notably cancer, gastritis, and later stages of ulcer. But it is frequently found as a pure neurosis accompanying neurasthenia and hys- teria. Nervous anorexia sometimes leads to very grave results in nutrition. The onset might have been some error in diet, or some particular aver- sion to certain foods, or mental strain. The patient begins to select his diet, will not eat enough, and meat will be the first article of diet to be discarded. With the irregularity of the daily meals, irregularity of the intestinal evacuation will set in, and this will become the most notably conspicuous symptom to the patient. Intestinal stasis will lead to head- ache, insomnia, flatulence, and even intestinal pains. Von Leube also described a clinical condi- tion which he called nervous dyspepsia, a condition in which the subjective symptoms are many and varied, but which do not harmonize with the phys- ical and chemical examination of the alimentary tract. Many writers have doubted the existence of such conditions as nervous anore.xia and nervous dyspepsia, but two cases under my present obser- vation convinced me of their existence. Case I. — Mrs. F., a lady of about 50 years, repeatedly complains that she has how much viagra can you take no appetite, and says she was treated for about a year for stomach trouble. It com- menced soon after the death of her husband; she lost considerable weight, and the numerous stomachics that other physicians prescribed did not help her. When I first saw her she was so weak that she was in bed, cried easily, and feared that she, too, was going to history of viagra in urdu die. On inquiry I found that she subsisted on a glass of milk and sometimes on less than that a day; while plenty of food was offered her, she partook of very little. On examination I found her rather emaciated, anemic, with a general viseroptosis. Before her husband's death she was up and about and attended to the household duties. It is evident that the mental worry and depression fol- lowing her husband's death also depressed the hunger center which is situated in the medulla oblongata near the nucleus of the vagus. Special nursing and forced feeding, as well as an assurance of no serious stomach trouble, helped her to recovery. Case II. — A woman of about forty history of viagra in urdu looks the picture of health, and yet all she eats a day is not enough to sustain a child. She complains that even milk history of viagra in urdu will produce epigastric pressure, make her vomit, cause her to feel bloated, and eructate: and she sometimes will go into collapse before vomiting. On the physical side, there is nothing discoverable that may produce reflex irritation in the stomach. She had a perineal tear and a slight retroversion of the uterus, both of how much viagra can you take which were corrected without however improving her condition. This patient is a profound neurasthenic or rather psy- chasthenic. In the hands of one who did not know pa- tient as well as I do, she would have been a subject for gallstone operation, appendectomy, or what not. For- tunately, I happened to strike her fancy and was able to observe her for two years. She has been a patient in various other hospitals, and of several private physi- cians. . , To say that a patient has neurasthenia and rest the diagnosis there is to fall into frequent error, because many organic diseases of the stomach, as latent ulcer or gall bladder disease, will in time produce nervous how much viagra can you take symptoms sufficient to brand a patient as neurasthenic, and surgery has demonstrated that many so-called neu- rasthenics really suffer from organic diseases, hence the witticism that it takes seven medical cures to dis- cover an ulcer. Therefore to make a diagnosis of nerv-