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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 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

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 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

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 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 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 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 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.

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