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
hese 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.