It is often said that this teaching as to the effect of the mind on digestion and its eminent usefulness for the treatment of dyspeptic conditions, is due to the attention that has been attracted to this subject as a consequence of the prominence of Eddyism, New Thought, Mental Healing, and the like. There are absolutely no good grounds for any such assertion. Here in America, more than twenty-five years ago, before there was any question of the modern mental healing movements, our greatest medical clinician, Dr. Austin Flint, expressed himself very emphatically with regard to mental influence over digestion, and to solicitude of mind as one of the most frequent etiological factors in dyspepsia.
Dr. Flint was thoroughly scientific in his medical observations, was no seeker after notoriety, and he was reading his paper before the older physicians of the period, and all of those who took part in that first meeting of the New York Medical Association strove to make their papers of scientific value. His words, then, must carry great weight:
Dyspepsia formerly prevailed chiefly among those who adopted, to a greater or less extent, the foregoing maxims [the finicky rules of dyspeptics which he deprecates and corrects as quoted later in this chapter]. It was comparatively rare among those who did not live in accordance with dietetic rules. The affection is much less prevalent now than heretofore, because these maxims are much less in vogue. The dyspeptics of the present day are chiefly those who undertake to exemplify more or less of these maxims. It seems to me, therefore, a fair inference, that dyspepsia may result from an attempt to regulate diet by rules which have for their object the prevention of the affection which they actually produce. It is to be added that an important causative element involved in the practical adoption of these rules is the attention thereby given to digestion. It is by introspection and constant watchfulness of the functions of the stomach, that the mind exerts a direct influence in the causation of this affection.
Dietetic Rules of a Former Day.—In order to make definite just what were the views of the olden times which he deprecates, he stated them briefly and forcibly:
The views generally entertained, at the time to which I have referred, largely by physicians and almost universally by non-medical sanitarians, may be summed up in a few maxims as follows: Eat only at stated periods, twice or thrice daily, and never between meals, no matter how great may be the desire for food. Never eat late in the evening or shortly before bedtime. In the choice of articles of diet, carefully select those which reason and personal experience have shown to be best digested; and never yield to the weakness of eating any article of food simply because it is acceptable to the palate. In order to avoid the temptation of overeating, let the articles of food be coarse rather than attractive, and eschew all the devices of the cuisine. Always leave the table hungry. Study personal idiosyncrasies, and never indulge in kinds of food which, although wholesome for most persons, are injurious to a few who are peculiarly organized. With reference to this last maxim, bear in mind that "what is one man's meat is another man's poison." In order to secure, as effectually as possible, a proper restriction in the quantity of food, it was recommended by some physicians and to some extent practiced, that every article be carefully weighed at meal times, and that a certain quantity by weight be never exceeded. Vegetarianism or Grahamism was advocated and practiced by many. Total abstinence from drink was considered by a few as a good sanitary measure, compelling the body to derive the needed fluids exclusively from fruits, vegetables, and other solid articles of diet. Restriction in the amount of drink, as far as practicable with regard to the power of endurance, was very generally deemed important, so as not to dilute the gastric juice.
When to his question, "Do you regulate your diet," the patient answered promptly and often emphatically in the affirmative, Dr. Flint insisted always: "This is a good reason for your having dyspepsia; I never knew a dyspeptic get well who undertook to regulate his diet." When the patient asks then, "How am I to be guided," the reply is, "Not by theoretical views of alimentation and indigestion, no matter how much they appear to be in accord with physiological and pathological doctrines, but by the appetite, the palate and common sense." He then goes on to answer certain other objections that patients are wont to urge, and says:
But the patient will be likely to say, "Am I not to be guided by my own experience and avoid articles of food which I have found to disagree with my digestion?" The answer is, that personal experience in dietetics is extremely fallacious. An article of diet which may cause inconvenience of indigestion to-day may be followed by a sense of comfort and will be readily digested to-morrow. A variety of circumstances may render the digestion of any article of food taken at a {257} particular meal labored or imperfect. As a rule articles which agree with most persons do not disagree with any, except from casual or accidental circumstances, and from the expectation, in the mind of the patient, that they will disagree. Without denying that there are dietetic idiosyncrasies, they are vastly fewer than is generally supposed; and, in general, it is fair to regard supposed idiosyncrasies as purely fanciful. Patients not infrequently cherish supposed idiosyncrasies with gratification. The idea is gratifying to egotism, as evidence that Providence has distinguished them from the common herd by certain peculiarities of constitution.
Dietetic Instructions.—Finally Dr. Flint has a series of instructions for those suffering from indigestion:
Do not adopt the rule of eating only at stated periods, twice or thrice daily. Be governed in this respect by appetite; and eat whenever there is a desire for food. Eat in the evenings or at bedtime, if food be desired. Insomnia is often attributable to hunger [italics ours]. In the choice of articles of diet, be distrustful of past personal experience, and consider it to be a trustworthy rule that those articles will be most likely to be digested without inconvenience which are most acceptable to the palate. As far as practicable, let the articles of diet be made acceptable by good cooking. As a rule, the better articles of food are cooked, the greater the comfort during digestion. Never leave the table with an unsatisfied appetite. Be in no haste to suppose that you are separated from the rest of mankind by dietetic idiosyncrasies, and be distrustful of the dogma that another man's meat is a poison to you. Do not undertake to estimate the amount of food which you take. In this respect different persons differ very widely, and there is no fixed standard of quantity, which is not to be exceeded. Take animal and vegetable articles of diet in relative proportions as indicated by instinct. In the quantity of drink, follow nature's indication; namely, thirst. Experience shows abundantly that, with a view of comfortable digestion, there need be no restriction in the ingestion of liquids.
Removal of Solicitude as a Remedial Measure.—Many dyspeptics have no subject that they occupy themselves with more seriously than their digestion, and they thus divert blood needed for digestive purposes as well as nervous energy that would help in it from the stomach to the brain, in order to exercise surveillance over the process. As has been well said, "Probably much more than half of the indigestion is really above the neck." This does not mean that there are not cases that need definite stomachic treatment, or even that patients who have succeeded in functionally disturbing their digestion by thinking over much about it, will not need gastric remedies.
The explanation of the many fads and remedies that cure indigestion, real or supposed, is exactly this tendency of the suggestive influence of such remedial measures to lessen the patient's solicitude about digestion. Any change in diet that carries with it the persuasion that for any reason digestion ought to be better, will, because of this, make digestion better. Any habit of taking warm or cold water before meals, or of chewing in a particular way, or of taking a particular kind of food different from what is usually taken—exclusively cereal, uncooked, largely fruit, vegetarian, etc.—will lift the concentration of attention on the digestive process, and so give the stomach a chance to do its work without interference from the brain.
Du Bois has quoted some striking testimony in this matter from Baras, who wrote on the "Gastralgias and Nervous Affections of the Stomach and the Intestines" as early as 1820. Baras had himself been a sufferer from {258} gastric discomfort, fullness after eating, eructations of gas, constipation, and general depression. He consulted most of the distinguished medical practitioners of his time. With one exception they were convinced that he was a sufferer from chronic gastro-enteritis. They added more and more to his concern about his stomach, and furnished him with numerous sources of autosuggestion. In spite of all that they did for him, his condition grew worse and worse, he lost in weight, and was sure that his case was hopeless. He was cured in a single day. His daughter was attacked with consumption, and "in the moment my attention," says Baras, "was centered entirely upon my child, I thought no more of myself, and I was cured."
Brain Workers and Indigestion.—Perhaps the best proof of how necessary it is that people should not continue to occupy their intellect seriously during the time when digestion is going on, is to be found in the frequency with which complaints of indigestion occur in literary folk. The complaints are heard most from literary folk because they are more likely to tell their stories. They have their work, and thoughts of it, always with them. So there is a constant call for nervous and mental activity and for much blood in the brain tissues. This subtracts from the nervous energy necessary for digestion, and makes it impossible to conduct it with that perfection which comes naturally to people who banish all other thoughts and keep their minds free for the pleasures of the table and social intercourse at meal time.
Nervous indigestion is so common among literary folk, teachers and scientific workers, that various causes have been suggested for it. Dr. George Gould, in his "Biographic Clinics," calls attention to it and suggests that the cause is probably the need of properly fitted spectacles. In our own time, when we are much more careful in the matter of eyeglasses, and when most writers and professors wear scientifically adapted glasses, the complaints still continue. The reason is evidently something associated with the almost continuous work that they do. Such people, too, are much more self-conscious than others. They think more about their digestion and what they eat. They often think that they differ from other people and have special idiosyncrasies for food. These thoughts are sure to culminate in nervous indigestion.
Food Faddists.—Literary folk and people who live the intellectual life are very prone to take up with fads of various kinds and find surcease from their sorrows in all sorts of out of the way dietaries, modes of eating, food limitations and specializations. They constitute a majority of the food faddists. Some of them—sure that they should not eat meat—are strenuous vegetarians. Others confine themselves entirely to food the life of which has not been completely destroyed by cooking. They are fruit faddists, nut faddists, milk-product faddists, and the like. Some of them try to persuade the world that it eats too much; others that it eats too frequently. Some of them take but a single real meal a day and have apologies for the other meals. All want to lead people to their particular mode of life, as if all the world had been wrong until they came to set it right. Some want the rest of the world to chew seventy-times-seven before they swallow and to adopt other exaggerations of attention to eating that are quite contrary to instinct, the most precious guide that we have in the matter of food choice and food consumption.
These intellectuals are always improved by their fads, no matter what they {259} may be. The reason is apparent. Their original digestive disturbance was due to over-occupation with intellectual work. Then they began to worry about their digestion and feared that nearly everything they ate would disagree with them. This fear and solicitude still further interfered with digestion. Next they acquired the new fad. They became persuaded that they could eat certain things in certain ways. They no longer disturb their digestion by anxiety about it, but, on the contrary, help it by favorable suggestion. Now under the new regime everything will surely go on well. Besides, they usually learn the lesson of not doing intellectual work close to their meals, and of spacing their work better. They learn to do a daily stint of work and no more. One of the fads that goes with most food fashions is abundant outdoor air. This always does good. Between the favorable mental influence, the lessened work, especially just after meals, and the increased outdoor air they get better and then they attribute it all to their special fad about food. The "cure" is due to psychotherapy and common sense, and not in any way to the special fad.
Worry.—Worry of any kind will have the same effect as the over-attention of the literary man or teacher to his work. Anyone who brings his business home with him is likely to suffer and, unless he has a superabundant supply of energy, will impair his digestive function as a consequence of attempting to do business after dinner, perhaps also stealing some of it in before and during breakfast.
The important rule with regard to the mental attitude of the patient toward uncomfortable feelings due to digestion must be, first to correct all other possible sources of the trouble, and only after these have been proved not to be factors in the case, should there be any question of modification of diet. This is just the opposite rule from that which obtains, and by which patients begin to meddle with their diet at the slightest symptom, or supposed symptom, of indigestion. My custom is to tell patients at once that there is probably something else besides their diet at fault. It is not that they eat too much, nor too great a variety, but that perhaps they eat too rapidly. Without reducing their diet, and above all without eliminating supposedly indigestible things from it, there should be formed a habit of eating more slowly. This will usually result in the reduction of the quantity eaten, but the variety of food should be the same, and the patient should not be permitted to limit his diet to a few supposedly bland, unirritating materials. In that event, constipation will assert itself, particularly if there is limitation of the amount of fluid taken.
Longevity of Dyspeptics.—There is one consolation that may be given to nervous dyspeptics, though in the midst of their worst symptoms they may not be sure whether it is a genuine consolation or not. It has been noted that many of those who live to extreme age tell the story of having suffered from nervous dyspepsia in middle-life. Their solicitude about themselves makes them safe against over-indulgences of many kinds in food or drink that might prove hurtful to them. Much of their discomfort is indeed due to the fact that they do not eat quite enough. If they succeed in avoiding the {260} pitfalls of the infectious diseases, and especially tuberculosis during their earlier years, and most of them are likely to because of the great care they take of themselves, they often live to old age. Certainly of two men, one of whom eats very heartily and the other very sparingly, the latter is much the more likely to attain old age. There are those who declare that the valetudinarian life, "half dead and alive," which even Plato satirized nearly 2,500 years ago, ever renews the question as to whether life is worth living or not. It is particularly dyspeptics who seriously discuss this question—yet with all their complaints, they actually do live longer lives.
Pharmaceutic Remedies.—This insistence on the importance of mind in the treatment of indigestion does not imply that tonic remedies, and especially such substances as strychnin, which stimulate appetite and add tone to the muscles of the stomach, should not be used when duly indicated. They are always helpful. Alone, these remedies give but temporary relief and after a short time the system becomes accustomed to them. If prescribed in connection with changes in the patient's habits, and especially such as divert his attention from his digestive tract, and from wrong persuasions as to food taking, the good they accomplish will be lasting. Nervous people usually have an increase of acidity. They are liable to overdo everything, and even the stomach overdoes its acid forming function. For this, alkaline remedies such as rhubarb and soda will do good. But, just as with strychnin, the benefit is but temporary unless the patient's habits and attitude of mind are modified so as to eliminate their solicitude as a constantly disturbing factor.
Circumstantial Suggestions.—There are many changes of habits that are of great value in the treatment of nervous and allied forms of indigestion. These changes often make a great difference in the general health of the patient and thus help to improve digestion. Besides their influence as alteratives, they are valuable from the mental influence which they exercise. It requires a definite exertion of will many times, perhaps, each day to bring about the omission or performance of certain actions, and this act of the will is accompanied by the repeated suggestion that this will cause improvement in the digestion. Many of the cures effected by special diet. Habits of exercise, health resort regimes and the like, owe their efficacy to this accompanying repeated suggestion of acts for the formation of new habits or the breaking of old ones.
Physiological Measures.—There are, of course, certain details with regard to digestion in which the patient's mental attitude needs to be changed by instruction rather than persuasion, by knowledge of physiology rather than by psychology. In the taking of food itself, chewing is, of course, the most important consideration after its good preparation by the cook. If patients are told to chew their food carefully, however, without further directions than this, it will usually be found that they begin to chew their meat a great deal and their vegetables scarcely more than before. It is, however, vegetables that must be chewed particularly. The meat-eating animals bolt their food. They have only cutting and tearing teeth. Their instinct is correct, for the saliva has nothing to do with the digestion of meat, and therefore no chewing is necessary. On the other hand, the vegetable-eating, and especially the grain-eating animals, chew carefully. Most of them are ruminants, that is, after a preliminary thorough chewing of their food, they swallow it, and then {261} afterwards at their leisure bring it up once more into the mouth and chew it again.
Mastication and the Stomach.—If food is not chewed well, and occurs in large masses in the stomach, not only is it not dissolved easily, but the work of passing it out to the intestine is delayed. The reflex which brings about the opening of the stomach and the ejection of food into the intestine is best brought about by the liquefaction of the stomach contents. During the mixing process all the food, as far as possible, becomes fluid and then is passed on. Large pieces of any kind are delayed, however, hamper the emptying of the stomach and interfere with stomach motility. The stomach is only a thin-walled membranous viscus which finds difficulty in dealing with food in lumps. It is different from the stomach of the hen, which, having no teeth, swallows grains of all kinds without chewing, but also by instinct swallows small stones which, in its thick-walled, muscular gizzard, are used for grinding up the food.
Exercise.—The taking of exercise is an important habit that needs to be changed in the case of dyspeptics. Many of those who live a sedentary life, and are much occupied with intellectual or business matters, are almost sure to take little or no exercise. If earlier in life they were accustomed to take much, the lack of it leads to serious disturbances of nutrition. They have formed certain habits as to the amount of food they eat, and these continue, so that they consume more heat-making material than they can use. In the process of dissipating it, there is likely to be much nervous energy wasted, usually to the discomfort of the patient. This is likely to be eventually reflected back to the stomach, with disturbance of appetite and digestion.
We now know that the motor function of the stomach is much more important than its secretory function. Its main purpose is to mix the food and pass it on in small quantities, at intervals, to the intestines. When patients have a sense of uncomfortable fullness in the gastric region after a hearty meal, or of discomfort after the taking of food, especially if much liquid is taken with it, they are prone to attribute these feelings to imperfect secretion not completing digestion as it should, and permitting fermentation with a production of gas and consequent stomach distention. The real reason for their discomfort is not secretory, but motor. It is due to a delay in passing on the food and to stomach distention because the gastric muscle is not in good tone.
People who have been used to taking exercises have their muscular system in good tonic condition. This includes the involuntary muscles, as well as the voluntary, and if they are neglecting air and exercise, the whole muscular system becomes flabby. Hence the uncomfortable sense of distention, because the stomach walls do not contract readily for the expulsion of food. A second important factor is also present—the muscles of the abdomen. Ordinarily they support the abdominal organs without any sense of effort. If by lack of exercise they have diminished in tone, however, when a hearty meal is eaten, the abdominal muscles have to support this additional weight since the stomach itself sags, and the consequence is a feeling of pressure on the left side of the abdomen about the level of the umbilicus. To relieve this feeling the tendency of the patient is almost always to lessen the amount eaten. If he is not distinctly overweight this will do harm rather than good. Instead he {262} needs to take sufficient exercise to tone abdominal muscles and reflexly also tone even involuntary muscles, and with them the gastric muscularis.
Air.—Almost more important than exercise is an abundance of fresh air, and without this muscles soon fail to respond to voluntary or involuntary impulses. If people do not spend two or three hours in the air every day, they are likely to develop an over-sensitive condition in which all nervous sensations are exaggerated. The reason men and women differ so markedly in their reaction to pains, aches and discomforts, is mainly that their habits of being out in the air differ correspondingly. Men are out much and, as a rule, stand discomfort better. Women are out little and are more sensitive to pains and aches. The more a man is out, the less is he likely to notice discomforts and aches that he would otherwise complain about.
Sleep.—Another important factor is the amount of sleep. Over and over again I have found that patients who were beginning to complain of discomfort, which they associated with the word indigestion, were taking too little sleep, and as soon as I persuaded them to add an hour or more to their sleep their gastric symptoms began to improve. It is easy in our large cities to acquire the habit of shortening the hours of rest. This is sometimes done so gradually that the individual scarcely realizes how much he has cut into his sleeping period. Some people who have to get up at seven or half-past seven in the morning go to bed about twelve, but really do not get settled for sleep until nearly one o'clock. Sometimes people read interesting books just before going to bed, or while in bed, and it is nearly two o'clock when they get to sleep.
Many people have the habit of reading themselves to sleep. This may be an excellent way to get rid of bothersome thoughts, provided the reading selected is not of too absorbing a character, and provided also as soon as sleepiness comes its call is heeded. Some write letters late at night. Writing always keeps one awake, though reading may be helpful for sleep. If this abbreviation of sleep becomes habitual, the first organs in the body to set up an objection is the digestive tract. It is one of the hardest worked systems in the body, having to dispose of its quantum of food three times every day, and if the organism does not receive due rest, the digestive tract suffers first. People who get insufficient sleep often have no appetite in the morning, and suffer from uncomfortable feelings in the gastric region. What they are too prone to do is to meddle with their diet, and this practice always does harm.
Two classes of patients come to the physician complaining of lack of appetite. The first and more important class consists of those who are eating too little, who are consequently under weight, and who must be made to eat more. The other class consists of those who eat enough but complain that they do not relish their food. Careful questioning usually elicits sufficient information to enable one to decide that most of these latter are eating too {263} much, or unsuitable food, and at too frequent intervals. They are usually overweight, and there is need to reduce the amount they eat. In both of these classes the physician is tempted to conclude that medicines should form the principal part of the treatment. We have a number of tonics and stimulants that undoubtedly initiate a desire for food, or at least so increase the circulation in the stomach that patients feel much more inclined to eat than they otherwise would. There are a number of remedies, also, the so-called anti-fat group, which produce a disinclination for food.
Power of Mind Over Appetite.—Appetite, whether in deficiency or in excess, is best regulated through the patient's mind. Patients frequently state that they cannot eat more than they do, that they have no inclination for food, and yet, after a little persuasion, they can be made to increase the amount they have been eating, and then that can be gradually raised until they are taking what is for them a normal quantity. There are many things that we swallow without caring for them. Most medicines we not only do not like, but positively dislike. We put them down, they accomplish their purpose, and food will act nearly in the same way. There are few cases where food is positively rejected. Patients can be persuaded to eat more, and after a time will be surprised to find that their desire for food increases with the habit of taking it. On the other hand, patients can be made to see that they are taking too much food really to enjoy its consumption. Their appetites are perpetually cloyed, and to them food has none of the pleasant flavor that exists when it is taken in moderation.
The Will to Eat.—In various parts of this book there is emphasized the necessity for the exercise of the human will in order to aid in the accomplishment of even physical functions. The basis of many nervous symptoms is a lack of sufficient nutrition to steady the nervous system. Some people not only lack will power, but also judgment in the matter of eating; they prefer to err on the side of insufficiency lest they should over-eat. For these people the important remedial measure is to dictate the amount that they shall eat, and gradually to increase it until they are eating enough for their nutritional purposes.
When this advice is given to patients, they are willing to agree that a gain in weight would be good for them, but they cannot understand how they can eat more since they are now eating all they can, or certainly all they care to. Appetite grows by what it feeds on, and increase in appetite is a function of the habit of eating.
But some patients, after having tried the prescription of eating more, are still in the same condition, and find that they cannot put on weight. What is needed in such cases is an inquiry into all the conditions of the daily life, their habits of eating and the amount of time that they take for their meals. They are probably eating one good meal a day, their dinner in the evening—but they confess that the other meals are not satisfactory. If their habits are rearranged, the will to eat does the rest. Sometimes they complain of uncomfortable feelings after eating and this makes them eat less at the next meal. There are various mental elements that disturb the efficacy of the will to eat, consequently these patients do not get on. What they need is emphatic insistence on the necessity for persistent effort in regular eating day after day, meal after meal, and it is not long before improvement comes not {264} only in weight, but also in appetite. I have known patients to gain five or six pounds a week after having tried weeks in vain to gain a single pound.
Sitophobia.—Many people read much of the possibilities of evil in overeating, and they conclude that a limitation of diet would be better for them. After a time some of these people of nervous constitution acquire an actual dread of over-eating and develop what has been called sitophobia, or dread of food. Before anything can be done with them, this dread must be removed. The problem is discussed more fully in the chapter on Weight and Good Feeling, but here it seems necessary to emphasize that it is often quite impossible by ordinary medical means to produce an appetite in these patients. Their mental persuasion with regard to food must first be removed. If it cannot be removed, improvement is usually out of the question. No medicines are sufficiently powerful to overcome a fixed unfavorable idea with regard to food. The same is true as to sleep, or any other natural function—it comes and must go through the mind.
Disturbance of Mind and Its Influence on Appetite.—The basis of the psychotherapy of the digestive tract is the fact that appetite is a function of the state of mind rather than of the state of body. We all know how easy it is to lose the appetite by emotional disturbance. We may come into the house after a brisk walk, when we know that dinner is going to be better than usual, quite ready to anticipate the pleasure we are to have in eating it and with appetite craving that dinner shall not be delayed, we find a telegram announcing the death of a friend or the illness of a relative or some other bad news, and in an instant our appetite has disappeared. It makes no difference to us for hours whether we eat or not. What we eat gives us no satisfaction. It will be taken entirely from a sense of duty and without pleasure and will digest slowly, even if it does not produce discomfort.
Feelings and Appetite.—There is no need for a serious stomach condition to develop, to diminish, or eliminate appetite. The sight of an accident on the street, especially if blood is shed, will entirely take away the appetite of many persons. Now that suicide beneath the wheels of subway trains has become a rather frequent way of going out of life, physicians note that nervous patients who happen to see these sad affairs have no appetite, not alone for the next meal, but sometimes for several days. Some people have no appetite at all if there is a dead body in the house where they live. I have known people who felt it almost a desecration to eat under such circumstances. Even much less than this may serve to diminish appetite. An offensive odor of almost any kind is quite sufficient to take away the appetite of many people. For some the odor of cooking food, if they have been in it for some time, is almost sure to cloy any desire for food.
Cooks suffer from loss of appetite for this reason. The sight of a disagreeable stain on a tablecloth, or of a waiter's thumb in the soup, or of some unpleasant characteristic of the waiter, may be quite enough seriously to disturb the appetite of sensitive people.
We know all this very well, and yet we are prone to think of appetite as something regulated by instinct, and representing the real needs of the organism in its cravings and the limitations of the necessity of food by its satisfaction. In our sophisticated modern life instinct will often fail entirely to fulfill these purposes. Appetite for those who live much indoors is a question of {265} habit and regulation rather than of instinct. It has to be voluntary to a large extent, not only as regards the quality but also the quantity of food. We eat the things that we care for, but how much of them we shall eat is another matter. That depends on how we happen to be disposed at the moment, and whether there is any good reason for eating more or less at the given time.
Appetizers.—There is a whole group of substances recommended as appetizers, most of which are effective, but their effect is likely to be temporary, and to fail particularly in those cases where an appetite is most needed. Anything that will increase the circulation in the stomach will usually add to appetite; consequently warm drinks, alcoholic liquors and spices of various kinds have this effect. In vigorous people, a dash of cold on any portion of the body, is followed by a strong reaction of the circulation. Cold drinks, therefore, will sometimes serve as an appetizer, especially in hot weather. Almost anything that has a certain peculiarity of taste, and that is taken with the definite suggestion that it will produce an appetite, will almost surely have that effect. All sorts of articles of diet have in various countries acquired a reputation as appetizers. Fermented mare's milk is effective in central Europe; a glass of buttermilk in Ireland; some very hot soup with one of the strong spiced sauces in it in England; and various curious combinations of fruit and other materials in the shape of what are called cocktails, in America. Anything that stimulates the stomach a little unusually, and is accompanied by the idea that it is likely to increase the taste for food, almost surely adds to appetite.
This question of appetizers is as yet a mystery to us. It is eminently individual and yet much depends on racial customs, the habits, the environments and the family training. It is surprising what curious materials serve to excite the appetite. Caviar, in spite of the distaste of "the general," is undoubtedly a good appetizer for many people. Bismarck herring, or kippered herring, acts in the same way. In the old days men used to take what were called red herrings and undoubtedly found in the eating of them a renewal of desire for food, when there had been absence of appetite. There are some people in whom a little taste of cheese serves the same purpose. Bitter tastes usually increase appetite. Salt under certain circumstances has a similar effect. Acid fruits sometimes stimulate a jaded desire for food. Nearly always the effect of these various appetizers is increased by the attitude of expectancy. They have the reputation of being appetizers and so, though often at first somewhat disagreeable, they eventually prove to be helpful stimulants.
Appetite and Habit.—For those who live an indoor life, and have that nervous disposition that disturbs instinct, the only safeguard for nutrition is a definite formula for eating which must be followed strictly, especially by those who are below the normal in nutrition. In the chapter on Weight and Good Feeling I discuss the failure of appetite following a diminution of the amount of food. The stomach may be described as unselfish, and in times of scarcity it gives up to other organs more of the nutrition that comes to it than it should. As a consequence, it is not so well able to fulfill its functions of digestion and of craving for food, which is part of its function, as it would otherwise be. It is the people who are eating a proper amount and have been eating it, whose digestive tracts are in a condition to crave the proper {266} amount of food. Those whose habits have unfortunately led them into eating amounts too small, also suffer in not having the proper desire for food.
Nervous people particularly are likely to lack appetite in the early morning. Those who are under weight will almost invariably confess that they take little breakfast. Their reason for so doing is that they have no appetite. For most of them what is really true is that in the early hours of the day their will has not yet taken properly hold of their economies and everything is in a depressed state. These patients usually confess that they wake feeling not rested but tired, fearing the day, and wondering now they will be able to get through it. Only toward the middle of the day do they feel like themselves, while towards evening they wonder how they could have been so depressed in the morning. What these people need is the rousing into activity of their functions. Occasionally, especially in summer, a cold sponge on rising in a room into which an abundance of air is admitted will do much for them. Often a walk of even ten minutes before breakfast will make all the difference between appetite and lack of it. Above all, however, they should be made to feel that if they want to eat they can eat—if they want to they can reestablish the habit of taking breakfast, and then it will be a pleasure instead of a burden.
Food and Caprice.—Those complaining of lack of appetite should learn not to let caprice rule them in the matter of eating. There are people who by habit eat too much. What they must do, as pointed out in the chapter on Obesity, is to unlearn the habit of overeating, and that is almost as hard to break as the habit of taking stimulants. Most nervous people undereat, but they must take themselves in hand, eat three meals a day, and reestablish the habit of taking as much at these meals as they ought. What each one should consume is eminently individual, depending altogether on the sort of heat engine that each one is. Family traits mean much in this. Some must eat much more than others to keep up their weight and strength, because they are wasteful heat engines. As a rule, tall, thin people must eat more in proportion to their weight than shorter individuals of stout build. They expose more surface for heat dissipation. In this each person must learn for himself his own necessities. When there is a question of regulating eating by reason, the rule must be remembered that there is a tendency in people living indoors to take too little rather than too much.
Appetite and Food Preparation.—There are many curious things with regard to the formation of the habit of eating that show how easily the appetite or instinct is vitiated. Women, for instance, are nearly always prone not to eat enough if they have to prepare their own meals. When a mother and daughter or two sisters live together, they usually prepare one good meal, but the other two meals are likely to be picked up any way. The presence of a man in the household makes all the difference in the world. Meals are prepared regularly for men. Even for a boy of five to fifteen, meals are regularly prepared, and, as a rule, the presence of a child makes for regularity in eating.
Habit of Overeating.—On the other hand, it is easy to form habits of eating that go quite beyond appetite and vitiate the desire for food quite as seriously in the opposite direction. Many stout people take snacks between meals; women, already too heavy, indulge in the afternoon tea habit with a surprising amount of substantial food taken with the tea; many a stout man {267} takes a glass of beer occasionally and never fails to take something to eat at the same time, mainly with the idea, as he says to himself, that by taking something to eat the beer will be less likely to do him harm. Stout children are likely to form the habit of eating too frequently. When they come home from school they have a piece of something; before they go to bed they have a glass of milk, and a piece of cake, and sometimes are encouraged in these bad habits by their parents. Any child who is more than ten per cent. above weight, should be kept strictly to its regular meal times, and should not be allowed to put on additional weight, for this will be very hard to get off in adult life. To carry more than ten per cent. of over-weight is a burden, and not a benefit.
Frequent Eating as an Appetizer.—Thin people should be encouraged to indulge in some of these between-meal privileges. Very often a thin person who has been accustomed to take comparatively small amounts at meal times, will find it easier to gain in weight by indulging in luncheons between meals than by increasing the amount of each meal. Large meals on stomachs unaccustomed to them, and somewhat less vigorous than they ought to be because of lack of nutrition, may be the cause of considerable discomfort if abundant meals are taken where small ones have been habitual. In this case, multiple feeding at shorter intervals will gradually increase tissue strength. After the patient has come up to normal weight, regular intervals between meals may be determined and sufficient quantities taken at each meal. Nearly all thin people sleep better, and are more comfortable if they take something shortly before going to bed. Most people will eat their breakfast better after such an indulgence than if fourteen hours elapse between the evening and the morning meal.
Nervous Loss of Appetite.—Nervous patients often say they have no appetite, that, even though they eat, their food has no taste. Such people have often lost their eating instinct to a certain degree. They eat merely from routine, or because food is placed before them. They would usually just as soon not eat and they have no instinctive directions as to quantity. If a number of courses are presented to them, they eat such as they care for and take a conventional amount of each kind of food presented, but they have no particular feeling to guide them in the matter of quantity. There are moods in which these patients care to eat. There are others in which eating seems a hard task. If they are in reasonably poor circumstances and have not to prepare a meal for others they are likely to neglect the preparation of one for themselves, take almost anything that happens to be at hand, and then consider that they have eaten.
Instinct and Natural Life.—If one expects the natural guidance of one's instincts then one must give these instincts a proper opportunity. Instinct is a part of our animal nature, and unless other portions of our animal nature are given rather free play, or at least the opportunities for their natural life, we cannot depend on any single one of the instincts to be a safe guide. Man was meant to live much outside. He was meant to take considerable exercise and to have to get his food by severe exertion. We have changed this. We live indoors to a great extent in an equable temperature, we very seldom tire ourselves by exercise, and it is not to be wondered at if we have not that craving for food that comes to the man who lives a more animal existence. The {268} Scotch surgeon, Abernethy, once said that the best possible tonic for the appetite was "to live on a shilling a day and earn it"—of course, he meant by manual labor. He talked at a time when the English workmen got but three shillings a day for fourteen hours of work.
Application of Principles.—What is needed for the mental treatment of patients with defective appetite, is that they should be made to realize that appetite is a function of habit, rather than of absolute natural craving in the conditions in which men and women live at the present time. The most important physical factor for appetite is not exercise, as has often been thought, because this, by consuming material, is naturally supposed to increase the craving for material to renew the tissue, but air, for it is oxidation processes that stimulate metabolism and make the call for a fresh supply of tissue-building material. People without an appetite must be made to understand that they should spend a considerable portion of the time between meals in the open air. Sitting in the open air is often even more effective than exercise under similar conditions, especially in weak people. The reason is exercise exhausts energy, and sometimes does not leave enough vitality for digestion, or even for the craving for food. Exercise is, of course, excellent for those of stronger constitution, and especially those who have been accustomed to it.
Those who need to eat more, must keep constantly before their minds the suggestion that if they want to eat they can, and that if they actually do eat more, satisfaction with eating grows, and appetite is restored to its normal place of influence. This is as true for those who are convalescing from some ailment, or who are in the midst of some progressive disease such as tuberculosis, as it is for the merely nervous persons whose lack of will and inefficiency of judgment have disturbed their eating habits. The will to eat is the most important appetizer that we have. The old Scotch physician's rule that if food stayed down it would do good, and that if the residue of it passed through the intestinal tract there was nothing very serious the matter with the patient, applies to the majority of patients who come to be treated for obscure ailments, especially of a chronic character, whenever they are associated with or developed on a basis of lack of normal weight.