_ CHAPTER X. THE WILL TO EAT
"If your will want not, time and place will be fruitfully added."
King Lear.
Eating is usually supposed to be entirely a matter of appetite which instinct directs to the best possible advantage of the individual. This is quite true for those who are living the outdoor life that is normal or at least most healthy for men, and when they are getting an abundance of exercise, and may I add also have not too great a variety of food materials in tempting form presented to them. Under the artificial not to say unnatural conditions which men have to a great extent created for themselves in city life, confined at indoor sedentary occupations, some of them--and they are much more numerous than is usually imagined--eat too little, while a great many, owing to stimulation of appetite in various ways, eat too much.
Eating therefore for health's sake has to be done through the will and as a rule by the formation of deliberate habits. It is easy to form habits either of defect or excess in the matter of eating and indeed a great deal of the ill health to which mankind is liable is due to errors in either of these directions. Having disturbed nature's instincts for food in modifying the mode of life to suit modern conveniences, we have now to learn from experience and scientific observations what we should eat and then make up our minds to eat such quantity and variety as is necessary to maintain health and strength in the particular circumstances in which we are placed.
While the greatest emphasis has been placed on the dangers to health in overeating, the number of people who, for one reason or another, eat too little is, as has been said, quite surprising. A very large proportion of those under normal weight are so merely because they have wrong habits of eating. Indeed, it may be laid down as a practical rule of health that wherever there is no organic disease the condition of being underweight is a symptom of undereating. A great many thin people insist that the reason why they are underweight is that it is a family trait and that father and mother, or at least one of them, and some of their grandparents exhibited this peculiarity; and thus it is not surprising that they should have it. A careful analysis of the family eating in such cases has shown me in a large number of instances, indeed almost without exception, that what my patients had inherited was not a constitutional tendency to thinness, but a family habit of undereating. This accrued to them not from nature but from nurture, and was acquired in their bringing up. Most of them were eating one quite abundant meal a day and perhaps a pretty good second meal, but practically all of them were skimping at least one meal very much. In some way or other, a family habit of eating very little at this meal had become established and was now an almost inviolable custom.
A great many thin individuals, that is persons who are somewhat more than ten per cent. under the average normal weight for their height, either do not eat breakfast at all or eat a very small one. It is not unusual for the physician analyzing their day's dietary to be told that the meal consists of a cup of coffee and a piece of bread. Sometimes there is a roll, but more often only part of a roll, though occasionally in recent years there may be some fruit and some cereal; the fruit will usually be a half of one of the citrus fruits which contains practically no nutrition and is only a pleasant appetizer, while more often than not the cereal will be one of the dry, ready-to-eat varieties which, apart from the milk or cream that may be served with them, contain in the usual small helpings very little nutriment. Such breakfasts are particularly the rule among women who are under weight. Sometimes lunch is comparatively light so that there are two daily apologies for meals. To make up for these, the third meal may be very hearty. City folk often eat at dinner more than is good for them. This may produce a sense of uncomfortable distention and overfulness followed by sleepiness which may be set down as due to indigestion, though it is just a question of overeating for the nonce.
It would be much more conducive to health to distribute the eating over the three meals of the day, but it requires a special effort of the will to break the unfortunate habits that have been formed. Particularly it seems hard for many people to eat a substantial breakfast and a determined effort is required to secure this. It would seem almost as though their wills had not yet waked up and that it was harder for them to do things at this time of day. It is especially important for working women, that is, those who have such regular occupations as school-teacher, secretary, clerk and the like, to eat a hearty breakfast. They can get a warm properly chosen meal at home at this hour, while very often in the middle of the day they have to eat a lunch that is not nearly so suitable. As a consequence of neglecting breakfast then, it is twenty-four hours between their warm, hearty meals. Even when they eat a rather good lunch, some eighteen hours elapse since the last hearty meal was taken, and one half the day's work has to be done on the gradually decreasing energy secured from the evening meal of the day before. With this unfortunate habit of eating, most of that was used up during the night in repairing the tissue losses of the day before, so that the morning's work has to be done largely "on the will" rather than on the normal store of bodily energy.
It is surprising how many patients who are admitted to tuberculosis sanatoria have been underweight for years as a consequence of unfortunate habits of eating. Not infrequently it is found that they have a number of prejudices with regard to the simple and most nutritious foods that mankind is accustomed to. Not a few of the younger ones who develop tuberculosis have been laboring under the impression that they could not digest milk or eggs or in some way they had acquired a distaste for them and so had eliminated them from their diet; some of them had also stopped eating butter or used it very sparingly. At the sanatoria, as a rule, very little attention is paid to the supposed difficulty of digestion of milk and eggs and perhaps butter. The patients are at once put on the regular diet containing these articles and the nurse sees that they take them even between meals, and unless there is actual vomiting or some very definite objective--not merely subjective--sign of indigestion, the patients are required to continue the diet.
It is almost an invariable rule for the patients of such institutions to come to the physician in charge after a couple of weeks and ask how it was that they could have thought that these simple articles of food disagreed with them. They have begun to like them now and are surprised at their former refusal to take them, which they begin to suspect, as the physician very well knows, to have been the principal reason for the development of their tuberculosis.
There are people who are up to weight or slightly above it who develop tuberculosis, but they do not represent one in five of the patients who suffer from the affection. In probably three fourths of all the cases of tuberculosis the predisposing factor which allowed the tubercle bacillus to grow in the tissues was the loss of weight or the being underweight. There is a good biological reason for this, for there are certain elements in the make-up of the tubercle bacillus which favor its growth at a time when fat is being lost from the tissues rather than deposited, for at that time more fat for the growth of the tubercle bacillus is available in the lungs than at other times. Often among the poor the loss in weight is due to lack of food because of poverty, or failure to eat because of alcoholism, but not infrequently among all classes it is just a question of certain bad habits of eating that might readily have been corrected by the will. It is surprising how many people who complain of various nervous symptoms--meaning by that term symptoms for which no definite physical basis can be found, or for which only that extremely indefinite basis of a vague reflex, real or supposed, from the abdominal organs--are underweight and will be found to be eating much less than the average of humanity. These nervous symptoms include above all discomforts of various kinds in the abdominal region; sense of gone-ness; at times a feeling of fullness because of the presence of gas; grumblings, acid eructations, bitter taste in the mouth, and above all, constipation. As is said in the chapter on "The Will and the Intestinal Functions," the most potent and frequent cause of constipation is insufficient eating, either in quantity or in variety. It is especially in the digestive tract of those who do not eat as much as they should that gas accumulates. This gas is usually thought to be due to fermentation, but as fermentation is a very slow gas producer and nervous patients not infrequently belch up large quantities, it is evident that another source for it must be sought. Any one who has seen a number of hysterical patients with gaseous distention of the abdomen and attacks of belching in which immense quantities of gas are eructated, will be forced to the conclusion that in such nervous crises gas leaks out of the blood vessels of the walls of the digestive tract and that this is the principal source of the gas noted. What is true in the severe nervous attacks is also true in nervous symptoms of other kinds, and neurotic indigestion so called is always accompanied by the presence of gas.
Apparently the old maxim of the physicist of past centuries has an application here. "Nature abhors a vacuum" and as the stomach and intestines are not as full as they ought to be, nor given as much work to do as they should have, nature proceeds to occupy them with gas which finds its way in from the very vascular gastrointestinal walls. This is of course an explanation that would not have been popular a few years ago when the chemistry of digestion seemed so extremely important, but in recent years, medical science has brought us back rather to the physics of digestion, and I think that most physicians who have seen many functional nervous patients would now agree with these suggestions as to the origin of gaseous disturbance in the gastrointestinal tract in a great many of these cases.
Besides the physical symptoms, there are a whole series of psychic or psycho-neurotic symptoms, the basis of which undoubtedly lies in the condition of underweight as a consequence of undereating. Over and over again I have seen the feeling of inability to do things which had come over men, and particularly women, disappear by adding to and regulating the diet until an increase in weight came. Extreme tiredness is a frequent symptom in those under weight, and this often leads to their having no recreation after their work because they have not enough energy for it; as every human being needs diversion, a vicious circle of influence which adds to their nervous tired condition is formed. I have seen in so many cases the eating of a good breakfast and a good lunch supply working people with the energy hitherto lacking that enabled them to go out of an evening to the theater or to entertainments of one kind or another, that it has become a routine practice to treat these people by adding to their dietary unless there are direct contra-indications.
Dreads are much more common among people who are underweight than among those who eat enough to keep themselves in proper physical condition. I have had a series of cases, unfortunately only a small one in number, in which the craving for alcoholic liquor disappeared before an increase in diet and a gain in weight. I shall never forget the first case in which this happened. The patient was a man of nearly sixty years of age who held a rather important political office in a small neighboring town. He was on the point of losing it because periodical sprees were becoming more frequent and it was impossible for him to maintain his position. He was over six feet in height and he weighed less than a hundred and fifty pounds. I had tried to get him to gain in weight by advice and suggestion without avail. Finally, I had to make a last effort to use whatever influence I had to save his political position for him, and then I succeeded in making him understand that he would have to do as I told him in the matter of eating, or else I would have nothing more to do with him.
It was not without some misgivings that I thus undertook to make a man of nearly sixty change his lifelong habits of eating. That is something which I consider no physician has a right to do unless there is some very imperative reason for it. Here was, however, a desperate case. It was in the late afternoon particularly that this patient craved drink so much that he could not deny himself. As he ate but very little breakfast and had a hasty scanty lunch, he was at the very bottom of his physical resources at that time, and at the end of a rather demanding day's work. We had to break up his other habits in the hope of getting at the craving. He had taken coffee and a roll for breakfast. I dictated a cereal, two eggs and several rashers of bacon and several rolls. I insisted on fifteen minutes in the open before lunch and then a hearty lunch with some substantial dessert at the end of it. This man proceeded to gain at the rate of a little more than three pounds a week. By the end of two months, he weighed about one hundred and eighty pounds and had not touched a drop of liquor in that time and felt that he had no craving for it. That is some ten years ago, and there has been no trouble with his alcoholic cravings since. He has maintained his weight; he says that he never felt so well and that above all he now has no more of that intense tiredness that used to come to him at the end of the day. Every now and then he says to me in musing mood,--"And to think that I had never learned to eat enough!"
For these very tired feelings so often complained of by nervous patients, once it has been decided that there is no organic trouble--for of course kidney or heart or blood pressure affections may readily cause them--there are just two things to be considered: These are flat-foot or yielding arch, and undereating. When there is a combination of these two, then tiredness may well seem excessive and yet be readily amenable to treatment. Persons with occupations which require standing are especially liable to suffer in this way.
Undereating in the evening is especially important for many nervous people and is often the source of wakefulness. It is the cause of insomnia, not so much at the beginning of the night, as a rule, as in the early morning. Many a person who wakes at four or five and cannot go to sleep again is hungry. There is a sense of gone-ness in the stomach region in these cases, which the patients are prone to attribute to their nerves in general, or some of them who have had unfortunate suggestions from their physicians may talk of their abdominal brain; but it is surprising how often their feelings are due simply to emptiness. Any thin person particularly who has his last meal before seven and does not go to bed until after eleven should always take something to eat before retiring. A glass of milk or a cup of cocoa and some crackers or a piece of simple cake may be sufficient, but it is important to eat enough. Animals and men naturally get sleepy after eating and do not sleep well if their stomachs are empty. Children are the typical examples. We are all only children of a larger growth in this regard.
When the last meal is taken before seven and people do not go to bed until nearly twelve, as is frequently the case in large cities, the custom of having something to eat just before bed is excellent for sleep. I have known the establishment of this habit to afford marked relief in cases of insomnia that had extended over years. The people in my experience who sleep the worst are those who, having taken a little cambric tea and some toast and preserves with perhaps a piece of cake for supper, think that this virtuous self-control in eating ought to assure them good rest. It has just the opposite effect. Disturbed sleep, full of dreams and waking moments, is oftener due to insufficient eating than to overeating. The people whom I know who sleep the best and from whom there are no complaints of insomnia, are those who, having eaten so heartily at dinner that they get to the theater a little late, attend the Follies or some late show for a while and then go round to one of the Broadway restaurants and chase a Welsh rarebit or some lobster a la Newburg, with a biscuit Tortoni or a Pêche Melba down to their stomachs and then go home to sleep the sleep of the just.
Just as there are bad habits of eating too little that are dangerous and must be corrected by the will so there are bad habits of eating too much that can only be corrected in the same way. While it is dangerous to be under weight in the early years of life, it is at least as dangerous to be overweight in middle life. With the variety and abundance of food now supplied at a great many tables, it is comparatively easy for people in our time to eat too much. The result is that among the better-to-do classes a great many people suffer from obesity, sometimes to such an extent that life is made a burden to them. There is only one way to correct this and that is to eat less and of course to exercise more. Reduction in diet means the breaking of a long established habit and that of course is often hard. The whole family may have to set a good example of abstinence from too great a variety of food and especially from the richer foods, in order that a parent may be helped to prevent further development of obesity and to lose gently and gradually some of the overweight that is being put on, and which now, by conserving heat and slowing up metabolism generally within the body, makes it so easy for even reduced quantities of food to maintain the former habit of adding weight.
In this matter of obesity, however, just exactly as in the case of tuberculosis for those who are underweight, prevention is much better than cure. The people who know that they inherit such tendencies should be particularly careful not to form habits of eating that will add considerably to their weight. After all, it is not nearly so difficult a matter as is often imagined. There is no need, unless in very exceptional cases, of denying one's self anything that is liked in the ordinary foods, only less of each article must be eaten. Even desserts need not be entirely eliminated, for ices may be taken instead of ice cream; sour fruits and especially those of the citrus variety--oranges and grapefruit--and the gelatine desserts may be eaten almost with impunity. The phrase "eat and grow thin" has deservedly become popular in recent years because as a matter of fact it is perfectly possible to eat heartily and above all to satisfaction without putting on weight. It is, of course, harder to lose weight, but even that may be accomplished gradually under proper direction if there is the persistent will to do it.
In recent years another disease has come to attract attention which represents the result of an overindulgence in food materials that can be limited without much difficulty. This is diabetes which used to be comparatively rare but has now become rather frequent. An authority on the disease declared not long since that there are over half a million people in this country now who either have or will have diabetes as the result of the breaking down of their sugar metabolism. It is not surprising that the disease should be on the increase, for the consumption of sugar has multiplied to a very serious degree during the last few generations. A couple of centuries ago, those who wanted sugar went not to the grocery store, but to the apothecary shop. It was kept as a flavoring material for children's food, as a welcome addition to the dietary of invalids and the old, and quite literally as a drug, for it was considered to have, as it actually has, to a slight extent at least, some diuretic qualities that made it valuable. A little more than a century ago, a thousand tons of sugar sufficed for the whole world's needs, while the year before the war, the world consumed some twenty-two million of tons of sugar. It is said that every man, woman, and child in the United States consumed on the average every day a quarter of a pound of sugar.
Our candy stores have multiplied, and while two generations ago the little candy stores sold candies practically entirely for children, eking out their trade with stationery and newspapers and school supplies, now candy stores dealing exclusively in confectionery are very common. There are several hundred stores in the United States that pay more than $25,000 a year rent, though they sell nothing but candy and ice-cream sodas. Corresponding with the increase in the sale of candy has come also the consumption of very sweet materials of various kinds. French pastries, Vienna tarts, Oriental sweetmeats, Turkish fig paste, Arabian date conserves, and West Indian guava jelly, are all familiar products on our tables. Chocolate has become one of the important articles of world commerce, though almost unknown beyond a very narrow circle a little more than a century ago. Tea and coffee have been introduced from the near and the far East and by a Western abuse consumed with such an amount of sweetening as make them the medium of an immense consumption of sugar.
There is no doubt that unless good habits of self-denial in this regard are formed, diabetes, which is an extremely serious disease, especially for those under middle life, will continue to increase in frequency. The candy and sugar habit is rather easy to form; every one realizes that it is a habit, but it is sometimes almost as hard to break as the tobacco habit. We were meant to get our sugar by the personal manufacture of it from starch substances. If a crust of bread is chewed vigorously until it swallows itself, that is, dissolves in the secretions and gradually disappears, it will be noted that there is a distinctly sweetish taste in the mouth. This is the starch of the bread being changed into sugar. We were expected by nature to make our own sugar in this way, but this has proved too slow and laborious a way for human nature to get all the sugar it cared for, so most people prefer to secure it ready made. Sugar is almost as artificial a product as alcohol and is actually capable of doing almost as much harm as its not distantly related chemical neighbor. It is rather important that good habits in the matter should be formed and we have been letting ourselves drift into very unfortunate habits in recent years. _