Chapter 3

WANT OF APPETITE AND INDIGESTION

The mind of the child is so unstable and yet so highly developed, that symptoms of nervous disturbance are more frequent and of greater intensity than in later life. Only rarely and in exceptional cases do certain symptoms, common in childhood, persist into adult life or appear there for the first time, and then usually in persons who, if they are not actually insane, are at least suffering from intense nervous strain. We have already mentioned the symptom of negativism and noted its occasional occurrence as an accompaniment of mental disorder in adult life, and its frequency among children who are irritable or irritated. Similarly, we may cite the digestive neuroses of adult life to explain the common refusal of food and the common nervous vomiting of the second year of life. Thus, for example, there exists in adult life a disturbance of the nervous system which is called "anorexia nervosa." A boy of nineteen was brought to the Out-patient Department of Guy's Hospital suffering from this complaint. He was little more than a skeleton, unable to stand, hardly able to sit, and weighing only four and a half stones. His mother, who came with him, stated that he had always been nervous, and that lately, after receiving a call to join the army as a recruit, his appetite, which had for some time been capricious, had completely disappeared. In spite of coaxing he resolutely refused all food, or took it only in the tiniest morsels, although at the same time it was thought that he sometimes took food "on the sly." A careful examination showed absolutely no sign of bodily disease. He was admitted to a ward for treatment by hypnotic suggestion, but before this could be begun he endeavoured to commit suicide by setting fire to his bed.

A girl of twenty-four years of age had become almost equally emaciated. Constant vomiting had persisted for many years and had defied many attempts at cure. It had even been proposed to perform the operation of gastro-enterostomy in the belief that some organic disease existed. In suitable surroundings and with the energetic support of a good nurse, who spent much time and care in restoring her balance of mind, the vomiting ceased, and she gained over two stones in weight. Work was found for her in some occupation connected with the War, and she left the Nursing Home to undertake this, bearing with her four pounds which she had abstracted from the purse of another patient.

Those who have not opportunities of observing how all-powerful is the effect of the mind upon the body, and especially perhaps upon the process of digestion, may find it hard to believe that these distressing symptoms and profound changes in the aspect and nutrition of the patients were due entirely to mental causes and were symptoms in accord with the attempted suicide or the theft of the money. In nervous little children we shall not often find such complex actions as suicide or theft, although they do occur, but combined with other evidence of nervousness we shall meet commonly enough with a persistent setting aside of appetite and refusal of food and with continuous and habitual vomiting, from nervous causes.

The experiments of Pawlow and others have explained the dependence of digestion upon mental states. They show that even before the food is taken into the mouth, while the meal is still in prospect, there has been instituted a series of changes in the wall of the stomach, which gives rise to the so-called psychic secretion of gastric juice. These changes are preceded by the sensation of appetite, which is evoked not by the presence of food in the stomach--for the food has not yet been swallowed--but by the anticipation of it, by the sight and smell of food, as well as by more complex suggestions, such as the time of day, the habitual hour, the approach of home, and so forth.

Emotional states of all sorts--grief, anger, anxiety, or excitement--put a stop to the process or interfere with its action, so that the sense of appetite is absent, and the taking of food is apt to be followed by discomfort or pain or vomiting. No doubt good digestion leads to a placid mind, but it is equally true that a placid mind is necessary for good digestion. Therefore we civilised people, living lives of mental stress and strain, try to increase the suggestive force of our surroundings and to provoke appetite by all devices calculated to stimulate the æsthetic sense. The dinner hour is fixed at a time when all work and, let us hope, all worry is at an end for the day. The dinner-table is made as pretty as possible, with flowers and sparkling glass. We are wise to dress for dinner, that with our working clothes we may put off our working thoughts.

In the treatment of adult dyspepsia we seldom succeed unless we can place the mind at rest. We may advise a visit to the dentist and a set of false teeth, or we may administer a variety of stomach tonics and sedatives, but if the mind remains filled with nameless fears and anxieties we shall not succeed.

In adult life the nervous person when subjected to excessive stress and strain is seldom free from dyspeptic symptoms of one sort or another, and what is true of adult life is even more true of childhood, when the emotions are more poignant and less controlled. Then tears flow more readily than in later life, and tears are not the only secretions which lie under the influence of strong emotion. Emotional states, which would stamp a grown man as a profound neurotic, are almost the rule in infancy and childhood, and may be marked by the same physical disturbances--flushing, sweating, or pallor, by the discharge of internal glandular secretions as well as by inhibition of appetite, by vomiting, gastric discomfort, or diarrhoea. Naturally enough, mothers and nurses are wont to demand a concrete cause for the constant crying of a little child, and teething, constipation, the painful passage of water, pain in the head, or colic and indigestion are suggested in turn, and powders, purges, or circumcision demanded. There can be no doubt that nervous unrest is capable of producing prolonged dyspepsia in infancy and childhood--a dyspepsia which, while it obstinately resists all attempts to overcome it by manipulation of the diet, is very readily amenable to treatment directed to quiet the nervous system.

Where a primary dyspepsia exists for any length of time, the growth and the nutrition of the child is clearly altered for the worse. The character of the stools, their consistency, smell, and colour, is apt to be changed because the bacterial context of the bowel has become abnormal. Rickets, mucous disease, lienteric diarrhoea, infantilism, prolapse of the rectum, and infection with thread-worms are common complications. No doubt children with primary dyspepsia are often nervous and restless, and the elements of infection and of neurosis are frequently combined. Yet often we meet with cases in which the gastric or intestinal disturbance comes near to being a pure neurosis. The nutrition, then, seldom suffers to any very great extent, or to a degree in any way comparable to that which is characteristic of dyspepsia from other causes. Emaciation, wrinkling of the skin, dryness and falling out of the hair, decay of the teeth, are not as a rule part of the picture of nervous dyspepsia. The child may be slim and thin and nervous looking, but as a rule he is active enough, with a good colour and fair muscular tone, so that one has difficulty in believing the mother's statements, which are yet true enough, as to the trouble which is experienced in forcing him to eat, or as to the frequency of vomiting.

In early childhood the difficulty of the refusal of food often passes or diminishes when the child learns to feed himself with precision and certainty. To teach him to do so, it is not wise to devote all our attention to making him adept at this particular task. The fault is that the brain centres which control the movements of hands, mouth, and tongue have not been developed, because his activities in all directions have not been encouraged. It is much less trouble for a nurse to feed a little child than to teach him to feed himself, and if he is not given daily opportunities of practice he will certainly not learn this particular action. But the fault as a rule lies deeper. The child who cannot feed himself cannot be taught until fingers and brain have been developed in the thousand activities of his daily routine, by which he acquires general dexterity. A child who is still too young to feed himself is learning the dexterity which is necessary as a preliminary in every action of the day. If he can carry the tablecloth and the cups and saucers to the tea-table, imitating in everything the action of his nurse, it will be strange if he does not also imitate her in the central scene, the actual eating of the food. If, on the other hand, he is waited upon hand and foot, if he is restrained and confined, sitting too much passively, now in his perambulator, now in his high chair, now on his nurse's lap, his imitative faculties and his tactile dexterity alike remain undeveloped. The child who is slow in learning to feed himself shows his backward development in every movement of his body. One may note especially the stiff, "expressionless" hands, indicating a general neuro-muscular defect. I have seen many children of eighteen months or two years of age in whom the movements necessary for efficient mastication and swallowing had failed to develop satisfactorily. In some a pure sucking movement persisted, so that when, for example, a morsel of bread or rusk was put in the child's mouth, it would be held there for many minutes and submitted only to suction with cheeks and tongue. Attempts to swallow in such a case are so incoordinate that they give rise frequently to violent fits of choking, which distress the child and produce resistance and struggling, while at the same time they alarm the mother or nurse so much that further attempts to encourage the taking of solid food are hastily and for a long time abandoned. In this helpless condition the other factors which tend to develop what we have called negativism have full play. The want of imitation and the lack of dexterity is not the sole or perhaps the main cause of the child's refusal of food and of the apparent want of appetite, but it is the cause of the failure to learn to feed himself, which places him in a condition which is peculiarly favourable to the operation of other factors. If only we can teach the child to feed himself, the difficulties of the situation become much less formidable.

The first of the factors which encourage the persistent refusal of food is the extreme susceptibility of the child to suggestion. A particular article of diet may be refused on one occasion, perhaps in pique, because another more favoured dish was hoped for or expected, or perhaps because the taste is not yet familiar. Then if on this occasion a struggle for the mastery is waged, and a painful impression is made on the child's mind connecting this particular dish with struggling and tears, from that day forward the child may persistently refuse it on every occasion it is offered. Matters are made worse if the nurse, anticipating refusal, attempts to overcome the resistance by peremptory orders, or by excessive praise extolling the delicious flavour with such fervour that the child's suspicions are at once aroused. Previous experience has made him connect these excessive praises with articles which have aroused his distaste. If these fads and fancies on the part of the child are to be avoided, it is essential that we should do nothing to focus his attention on his refusal. It is better that his dinner should be curtailed on one occasion than that taste and appetite should be perverted perhaps for years. Every nurse or mother should cultivate an off-hand, detached manner of feeding the child, and should patiently continue to offer the food without uncalled-for comments or exhortations. Let her always remember the force of suggestion on the child's mind, and that a confident manner which never questions the child's acceptance will meet with acceptance, while a hesitating address, from fear of the impending refusal, will be apt to meet with refusal. Sometimes a still worse fault manifests itself, when nurse and mother speak before the child of the smallness of his appetite, and of his persistent refusal of this or that article of diet. The suggestion then acts still more powerfully on his mind. He is aware that the whole household is distressed by his peculiarity, and he grows to identify it with his own individuality, and to regard himself with some satisfaction as possessing this mark of distinction. If there is any difficulty of this sort it is often directly curative to reverse the suggestion and to speak before him of his improving appetite, and to say that he begins every day to eat better and better, even if to do so we have to break a good rule never to say to the child what is not strictly true. Or once or twice we may take his plate away before he has finished, saying positively that he has eaten so much that he must eat no more. If in spite of every care antipathies to certain articles of food appear and persist, we must be content to bide our time. When the child grows of an age to reason, we should seize every opportunity to make him feel that his persistent refusal is a little ridiculous and childish. Little by little the seed is sown, and will germinate till one day we shall note with surprise that he has taken of his own accord that which he has neglected for so long and with such obstinacy.

But the force which is acting most strongly in producing this refusal of food is the force of which we have spoken in a previous chapter--the force which results in negativism, the force which is in reality the habit of opposition, the love of power, and the desire to attract attention. Here again the refusal of food, if due to this cause, is never the sole manifestation of the fault. Just as the delay in learning to swallow and to chew properly and to feed himself is part of a general want of dexterity and capacity manifested in all his actions, so it will seldom happen that the child's anxiety to oppose is only seen at meal-times. Watch a nervous child in the nursery before the dinner hour. He is cross and restless and inclined to cry. The nurse hands him a doll, and he throws it away saying, "No, no doll." At the same moment he may catch sight of his ball, and it too is violently rejected, "No, no ball." Everything in turn is treated in the same way. Finally he falls upon his nurse, crying and beating her with his hands, saying, "No, no Nurse." If that long-suffering woman at that moment summons him to dinner, it will be strange indeed if his attitude is not "No, no dinner," and "No, no" to every mouthful offered him. How strong this love of opposition may be is illustrated by the case of a little boy who was brought to me for refusal of food. Three weeks before, he had been taken in a motor-car to his grandfather's to midday dinner on Sunday, when his absolute refusal of food had spoiled the day and had occupied the attention and the efforts of the whole party. Doubtless he had enjoyed himself, for three weeks later, when he caught sight of the car which was to bring him to me, and which he had not seen in the interval, he at once said, "Not eat my dinner." This child's father told me that the sight or sound of the preparation of a meal was enough to bring on a paroxysm of opposition. Now this force of opposition, as we have seen, only develops into a serious difficulty when the child's own will has been opposed too much, when authority has been too freely exercised, and when the child has been urged and entreated and reproved with too great frequency. His opposition grows with all counter-opposition. And he is not really naughty, only irritable and restless from the thwarting of his natural impulses, and unable to express his thoughts and desires. Negativism will not often confine itself to meal-times. It will show clearly in all the actions of the child, and to get him to eat well and freely we must so change our management of him that negativism disappears or at least diminishes. There is no other way. No entreaty, no force, no threats of force will ever succeed, but will only make him worse, and, since negativism is due to mental unrest, the struggles and crying will only perpetuate the cause. The one way to banish negativism and overcome the opposition is to cease to oppose, and to practise this aloofness not so much at meal-times, for somehow by patience the child must be got to take his food, but in all our conduct to him. Repression and reproof, and thwarting of the child's will, and coaxing and entreaty must cease. There is no fear that we shall thereby make the child unduly disobedient. We have already, in another chapter, decided that negativism is not strength of will on the part of the child which must be broken, but is the result of constant attempts to oppose his nature, and the consequent nervous unrest. If we cease to oppose, the symptoms will tend rapidly to disappear, the child will become busy and contented and happy in his play, and we shall hear no more of his refusal of food. If sometimes it recurs for a week or two, we shall know how to deal with it.

In children, as with us, periods of nervous unrest and unhappiness are apt to recur in a sort of cycle. This cyclical character of mental disturbance is often a marked feature. We see it in epilepsy and in what the French have called Folie Circulaire. We see it in the dipsomaniac, in the intermittency of his craving for drink and of his periodical outbursts, and we see it in ourselves in those periods of depression which recur so often, we know not why. Little children too sometimes get out on the wrong side of their beds, and never get right the whole long day. Their own experience of the vagaries of mental states should lead mothers to be indulgent to the children in their days of cloud and to be particularly careful not to goad them by well-intentioned efforts into bursts of naughtiness and passion, each one of which tends to perpetuate the condition and increase the nervous unrest. We know how closely dependent is the sensation of appetite upon emotional states, and we must do all in our power--and the task is sometimes one of real difficulty--to keep the child's mind sufficiently at rest to preserve the healthy desire for food unimpaired. If there is no sign of appetite, but every sign of restlessness and irritability, we must seek in the management of the child until we find the fault.

If food is taken mechanically and without appetite, if the preliminary changes in the stomach wall which are necessary for adequate digestion do not take place, but are inhibited by the mental unrest, the meal is apt to be followed by gastric pain and discomfort, or, more commonly with children, the stomach may promptly reject its contents. At the worst, nervous vomiting of this sort may follow almost every meal, although, again, it is curious to note how little, comparatively speaking, the nutrition of the child suffers. The vomiting too, as in adults, comes very near being a voluntary act, and mothers and nurses will often remark that they get the impression that it can be controlled at will. If once the diagnosis is made that the want of appetite or the vomiting is of nervous origin, the treatment of the condition is clear. Sedative drugs directed towards quieting the nervous excitability may be of service, but tonics, appetisers, laxatives, and drugs with a direct action on the stomach will have but little effect. Nor is there as a rule anything to be gained by modifying the diet or by excluding this or that article of food. The frequency of the vomiting is such that it is apt to have brought discredit one after the other upon almost every article of food which the child can take, with the result that many useful and necessary foods have been abandoned for long on the ground that they are the cause of the dyspepsia. A permanent cure will only be effected when the faults of environment have been overcome, when the cause of the nervous unrest has been removed, and when the child's mind is at peace.

Nervous vomiting of this kind is not difficult to control, if those in charge of the children can be made to understand that the cause lies in the anxiety which they themselves show before the child, increasing his own apprehension or adding to his sense of power or importance. Once the child is convinced that his conduct excites no particular interest, the vomiting soon ceases. In more than one instance, vomiting which has persisted for many months has stopped at once after the matter has been fully explained to the parents. In the most inveterate case of this sort which has come under my notice, the child was regularly sick as soon as he caught sight of a white cloth being laid on the table for meals. Yet even this child never vomited when he was under the charge of a particular nurse who had to return more than once to the family, and on each occasion was successful in breaking the habit.