Two cla.s.ses of patients come to the physician complaining of lack of appet.i.te. The first and more important cla.s.s consists of those who are eating too little, who are consequently under weight, and who must be made to eat more. The other cla.s.s 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 cla.s.ses the physician is tempted to conclude that medicines should form the princ.i.p.al 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 Appet.i.te.--Appet.i.te, 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 quant.i.ty. 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 appet.i.tes 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. Appet.i.te grows by what it feeds on, and increase in appet.i.te 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 appet.i.te. 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 const.i.tution 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 appet.i.te 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 Appet.i.te.--The basis of the psychotherapy of the digestive tract is the fact that appet.i.te 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 appet.i.te 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 antic.i.p.ate the pleasure we are to have in eating it and with appet.i.te 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 appet.i.te 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 Appet.i.te_.--There is no need for a serious stomach condition to develop, to diminish, or eliminate appet.i.te. The sight of an accident on the street, especially if blood is shed, will entirely take away the appet.i.te 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 appet.i.te, not alone for the next meal, but sometimes for several days. Some people have no appet.i.te 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 circ.u.mstances. Even much less than this may serve to diminish appet.i.te. An offensive odor of almost any kind is quite sufficient to take away the appet.i.te 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 appet.i.te 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 appet.i.te of sensitive people.

We know all this very well, and yet we are p.r.o.ne to think of appet.i.te 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. Appet.i.te 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 quant.i.ty 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 appet.i.te is most needed. Anything that will increase the circulation in the stomach will usually add to appet.i.te; 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 appet.i.te, 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 gla.s.s of b.u.t.termilk 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 c.o.c.ktails, 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 appet.i.te.

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 appet.i.te. 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 appet.i.te. There are some people in whom a little taste of cheese serves the same purpose. Bitter tastes usually increase appet.i.te. Salt under certain circ.u.mstances 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 att.i.tude of expectancy. They have the reputation of being appetizers and so, though often at first somewhat disagreeable, they eventually prove to be helpful stimulants.

Appet.i.te 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 appet.i.te 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 appet.i.te 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 appet.i.te. 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 appet.i.te 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 appet.i.te 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.

_Appet.i.te and Food Preparation_.--There are many curious things with regard to the formation of the habit of eating that show how easily the appet.i.te or instinct is vitiated. Women, for instance, are nearly always p.r.o.ne 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 appet.i.te 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 gla.s.s 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 gla.s.s 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 quant.i.ties 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 Appet.i.te.--Nervous patients often say they have no appet.i.te, 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 quant.i.ty. 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 quant.i.ty. 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 circ.u.mstances 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 appet.i.te 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 appet.i.te, is that they should be made to realize that appet.i.te 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 appet.i.te 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 appet.i.te 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 const.i.tution, 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 appet.i.te 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 pa.s.sed 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 a.s.sociated with or developed on a basis of lack of normal weight.

CHAPTER V

CONSTIPATION

To judge by the frequency of advertis.e.m.e.nts for laxatives of various kinds, constipation must be an extremely common affection. At least one out of every three city dwellers suffers, it is said, from constipation. Proper regard for the taking of food calculated to help this important function, the formation of appropriate habits, and the proper disposition of the mind so as to relieve worry and anxiety, will cure the majority of these patients. There are some who need additional treatment, pharmacal or mechanical, but these are few.

Undoubtedly the mind plays the most important role in the therapeutics of the affection. It is influenced partly through instruction, {269} partly by the modification of unfortunate auto-suggestion, and partly through auxiliary favorable suggestions of one kind or another.

Prophylaxis.--What is needed in most cases is such instruction as will lead to a better observance of certain common-sense laws of health, rather than the addition of remedies which eventually only complicate conditions.

Many people believe that unless they have an ample movement of the bowels every day all sorts of serious results are likely to follow. If they do not have the expected movement before noon, they suffer during the afternoon from headache that is probably due more to worry than to any physical cause. Ordinarily it is quite out of the question that the retention of the contents of the lower bowel for a few hours should produce any such serious effects as these patients immediately begin to feel. Especially is this true when on the day previous there has been, as is often the case, a sufficient movement of the bowels, due to the use of medicine. Some people have become so anxious in the matter that they foster the development of feelings of discomfort both in their abdominal and intracranial regions.

This over-anxiety is all the more important because recent observations have made it clear that over-occupation of mind actually hampers peristaltic movements of the intestines, and thus prevents the muscular action which would gradually pa.s.s the excrement.i.tious material on to the lower bowel, to be evacuated in the normal way. _It cannot be too often repeated that nature resents too close surveillance of her functions and operations_. Just as soon as the over-anxiety is relieved, and patients are made to appreciate that if they do not have a movement to-day they may wait without serious solicitude till they have one to-morrow, the amount of medicine required to bring about movements of the bowels is at once reduced.

The Mind and Peristalsis.--a.n.a.logous to Pawlow's ingenious experiments, with regard to digestive secretion in the stomach, are Kronecker's experiments at Berne upon the motor function of the intestinal tract. Pawlow showed that the appet.i.te depended, not on physical conditions so much as on the mental state of the animal and its desire for a particular kind of food. Kronecker, by isolating a loop of intestine in which a metal ball was placed, showed that it was possible to modify peristalsis very materially by affecting the psychic condition of the animal. There was a distinct difference in the movements of the intestine, in the pa.s.sage of a metal ball, when the animal was called and expected to go for a walk with its master, than when it was threatened with punishment or rendered depressed for some other reason. In animals, the psyche plays a very subordinate role in inhibition and stimulation compared to that exercised by man's higher nervous system, since in him this portion of the organism is so much better developed than in the animal. The condition of the human mind in its possibilities of unfavorable influence over the intestinal function, is, therefore, extremely important.

The more one knows about the curious power of the mind even over so material a function as intestinal peristalsis and movement, the more is one convinced of the necessity for a properly disposed mind toward intestinal function, if it is to be accomplished with regularity and without disturbance. Many persons thoroughly under hypnotic influence, who are told that they will have a movement of the bowels at a certain hour the next day will have it. Indeed, this const.i.tutes one way of treating certain forms of constipation in nervous, {270} preoccupied people. There are many stories that ill.u.s.trate the influence of auto-suggestion upon the bowels. We have already mentioned Flaubert's suffering as a consequence of realistic absorption in "Madame Bovary's" poisoning by a.r.s.enic when he was writing that scene in the book. Boris Sidis has told the story of a man who used to have a disturbance of the bowels at every new moon, as the result of his memory, acting unconsciously, reminding him of his mother's habit of giving him a purgative about that time. These may be and doubtless are exceptional cases, yet they ill.u.s.trate the influence of mind and show how much it must be the effort of the physician to use this effective adjuvant just as much as possible in this very common and often obstinate affection in which drugs so often fail, or are unsatisfactory.

So-called Intestinal Auto-intoxication.--Those who are anxiously interested in the subject are likely to have read so much of intestinal auto-intoxications, of which a great deal has been written in recent years, that they will be quite sure the slightest delay in intestinal evacuation may be serious, or at least may profoundly disturb their economy. As a consequence, just as soon as the hour at which they should have a movement pa.s.ses, they begin to worry about it. In a couple of hours they feel tingly all over, and they know that there most be poisonous substances in their circulation. After two or three more hours, they begin to have a headache. Then they have to give up work, and still more devote themselves to concentration of attention on the disturbed condition. Their sleep will be disturbed, perhaps will be delayed; they wake unrested and fearful of the awful effects of intestinal auto-intoxication. In most people this state of feeling is entirely due to suggestion.

So much has been said in recent medical literature of the influence of absorption of poisonous substances from the intestinal tract--the so-called intestinal auto-intoxication--that it is a surprise to learn how little we know, definitely and absolutely, about this subject, and how many theories have come and gone. Arthur Hertz, in his "Constipation and Allied Intestinal Disorders" (Oxford Medical Publications, 1909), reviews the whole subject very interestingly but shows that we are entirely without any definite conclusive evidence for what has been talked about so much. The idea had often occurred, and been expressed vaguely, in medical literature in the old time, but began to have its great vogue when the high-sounding Greek term copremia (literally "excrement.i.tious-substances-in-the-blood") was invented, toward the end of the first quarter of the nineteenth century. Naturally this had a strong suggestive effect. Bouchard took it up a generation later, and then intestinal auto-intoxication, another mouth-filling term, came to occupy much attention as an explanation for various vague conditions, and especially nervous discomforts of many kinds. Bouchard's method of proving his theory by showing how much toxic material was reabsorbed from the intestines, using the urine for injection into animals, was open to many objections. Now it has been quite discredited.

Bouchard's disciples exaggerated and theorized even beyond their master, until intestinal auto-intoxication became the same sort of a refuge for the puzzled physicians of our time--like rheumatism or the uric acid diathesis, for those of a score of years ago. Various methods of demonstrating the toxicity of substances absorbed had a vogue for a time, but they have now lost their significance. There are only a limited number of people who seem to suffer {271} from the symptoms attributed to such reabsorption. Some people who are quite constipated have none of the symptoms at all, while a delay of an hour or two in the evacuation seems to affect other people very much. These latter are especially nervous persons. It now seems very clear that the liver acts as a safeguard against the absorption of poisonous materials from the intestinal tract, and that neither degenerate proteid materials, nor bacterial toxins, are allowed to affect the system to any serious degree. After all our study, as Dr. Hertz insists, we have as yet no evidence that poisons are absorbed.

Rea.s.surance as an Element in Treatment.--The most important element in the rational treatment of constipation is to make patients understand that under ordinary circ.u.mstances the symptoms of auto-intoxication, of which so much is said, do not develop until there has been long-continued acc.u.mulation of excrement.i.tious material and under conditions favoring absorption. Even then nature learns to protect herself against untoward conditions. We have some very striking examples of good health in spite of even very rare movements of the bowels.