CHAPTER III
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.