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"Everyone interested in anorexia nervosa . . . should skim this book or study it. It will make you realize how dependent upon culture the definition of disease is. I will never look at an anorexic patient in the same way again."—Howard Spiro, M.D., Gastroenterology
"[This] book is a first-class social history and is well-documented both in its historical and scientific portions."—Vern L. Bullough, American Historical Review
"A significant contribution to revisionist history, which re-examines events in light of feminist thought. . . . Bell is particularly skillful in describing behavior within its time and culture, which would be bizarre by today's norms, without reducing it to the pathological."—Mary Lassance Parthun, Toronto Globe and Mail
"Bell is both enlightened and convincing. His book is impressively researched, easy to read, and utterly fascinating."—Sheila MacLeod, New Statesman
RECOGNITION AND TREATMENT
ANOREXIA, from the Greek an (privation, lack of) and orexis (appetite), is a general term used to refer to any diminution of appetite or aversion to food. Everyone has experienced at least temporary anorexia, perhaps when a severe head cold interfered with the sense of smell or as a result of some emotional trauma. Often students cannot eat on the eve of a major examination and athletes may not be hungry as they anticipate the challenge of the big game. A host of somatic conditions, from blockages in the alimentary system to hormonal imbalances, may cause an aversion to food in general. Pregnant women regularly experience changes in food preferences that cannot be dismissed as caprice. A person who arises at 2:00 A.M. with an intense craving for spaghetti topped with strawberries and whipped cream is responding to a stimulus originating in or transmitted through the hypothalamus, that part of the brain which is the center of the autonomic nervous system. We cannot command ourselves to be hungry if we are not, nor to feel satiated if we are famished. The life-sustaining mechanisms of appetite, like the response to pain and the sexual drive, appear to be beyond the individual's control, at least for most people most of the time. Definition of the full range of activities controlled or affected by the hypothalamus is a matter for some disagreement, nor do we know precisely how this collection of nerve cells works, but unquestionably there are close links among the urges of fatigue, appetite, pain, and sexual desire. It is generally believed, although with less certainty, that the hypothalamus also plays a role in the nervous mechanisms underlying moods and motivational states.
"Anorexia nervosa" (aversion to food due to some personality disorder) is something of a misnomer. Many of those who suffer from the disease do not report a "loss of appetite," although obviously they do not eat enough to be healthy. Hungry or not, victims of anorexia nervosa voluntarily starve themselves to the point at which their lives are at risk, and reported mortality rates range from 10 to as high as 20 percent. Long-term follow-up studies show that a majority of those who undergo prolonged treatment for the disease never recover fully. Anorexia nervosa is far more common among females than males, by a ratio of ten or even twenty to one. The most frequent time of onset is adolescence and, although the poor are not immune to this disease, it appears to be the special preserve of well-to-do, white, Western girls. Among "high-risk" private school girls in England the reported incidence of anorexia nervosa is 1 in 200, and a recent survey of aspiring ballerinas suggests a rate of nearly 1 in 6, but estimates in the general population run from 0.6 to 1.6 per year per 100,000. Apparent differentials of gender, class, and age may be attributable in part to patterns for recognizing and treating the disease, and this question will be taken up presently. Earlier literature described the illness as hysterical, a term so vague and ultimately pejorative that it now is in total disfavor, and in many cases it was confused with other serious psychoses, including schizophrenia.
The currently accepted criteria for diagnosing the condition anorexia nervosa, published by J. P. Feighner and his associates in 1972, are as follows:
1. Onset prior to age twenty-five.
2. Lack of appetite accompanied by loss of at least 25 percent of original body weight.
3. A distorted, implacable attitude toward eating, food, or weight that overrides hunger, admonitions, reassurance, and threats; for example, (a) denial of illness with a failure to recognize nutritional needs, (b) apparent enjoyment in losing weight with overt manifestation that refusing food is a pleasurable indulgence, (c) a desired body image of extreme thinness with overt evidence that it is rewarding to the patient to achieve and maintain this state, and (d) unusual handling or hoarding of food.
4. No known medical illness that could account for the anorexia and weight loss.
5. No other known psychiatric disorder, particularly primary affective disorders, schizophrenia, obsessive-compulsive disorder, and phobic neurosis. (The assumption is made that even though it may appear phobic or obsessional, food refusal alone is not sufficient to qualify for obsessive-compulsive or phobic disease.)
6. At least two of the following manifestations: (a) amenorrhea, (b) lanugo (soft, fine hair), (c) bradycardia (persistent resting pulse of 60 or less), (d) periods of overactivity, (e) episodes of bulimia (binge eating), and (f) vomiting (may be self-induced).
Feighner's list of a set of symptoms is useful as a benchmark for a historical evaluation of the recognition and treatment of anorexia nervosa and at the same time as a reminder of how poorly the condition is understood. The symptoms he listed are derived from empirical observation and statistical frequency rather than from a rational ordering of causal mechanisms. The criteria for age and for weight loss merely reflect what has been observed most of the time; they are not arbitrary, but neither are they part of a logical chain of reasoning. The third symptom obviously is difficult to define in practice since it so heavily involves the observer's subjectivity, while the fourth and fifth conditions merely state what the disease is not. As with most psychiatric disorders, then, the syndrome of anorexia nervosa is known mostly by indirection. But the illness is there, and people die from it. Another immediate observation about Feighner's criteria is that they include both somatic or physical variables and psychic or attitudinal conditions. For many years the recognition and treatment of anorexia nervosa alternated between the extreme poles of somatic and psychic approaches, a bifurcation no more helpful for those who suffered from the disease than for the historian who would attempt to propose an explanation of holy anorexia.
The earliest known case of anorexia nervosa, or at least the one generally cited in the medical literature, is found in Richard Morton's Phthisiologia: or a Treatise of Consumptions. He described the plight of a twenty-year-old girl whom he treated in 1686. Her illness had begun two years earlier when
in the Month of July [she] fell into a total Suppression of her Monthly Courses from a multitude of Cares and Passions of her Mind, but without any Symptom of the Green-Sickness following upon it. From which time her Appetite began to abate, and her Digestion to be bad; her Flesh also began to be flaccid and loose, and her looks pale ... she was wont by her studying at Night, and continual pouring upon Books, to expose herself both Day and Night to the Injuries of the Air ... I do not remember that I did ever in all my Practice see one, that was conversant with the Living so much wasted with the greatest degree of a Consumption, (like a Skeleton only clad with Skin) yet there was no Fever, but on the contrary a Coldness of the whole Body ... Only her Appetite was diminished, and Digestion uneasy, with Fainting Fitts, which did frequently return upon her.
Morton grimly went on to describe how his patient refused every medication he had to offer (combinations of salts, waters, and tinctures) and how three months later she fainted and died. This seventeenth-century physician was the first to suggest concretely several of the symptoms typical of anorexia nervosa and to distinguish the disease clearly both from the vague diagnosis of consumption and from the specific ravages of tuberculosis. Scattered reports of self-inflicted emaciation appeared in eighteenth-century medical treatises, and Morton's perplexity in dealing with a patient who seemed to choose to starve gave way to consideration of the emotional or psychic basis of nervous disorders.
Among these very early precursors of Freud one of the most important is Giorgio Baglivi, who held the chair of medical theory in the Collegio della Sapienza in Rome by appointment of Pope Clement XI. Baglivi was thoroughly versed in physical medicine and, indeed, adhered to a school of thought that treated the body as a machine composed of many smaller mechanical parts. As Ilza Veith points out in her history of hysteria, however, Baglivi was far from narrowly mechanistic in his treatment of patients, and he believed that passions of the mind might even be the cause of various physical ailments. In his day the prevailing view was that overindulgence in food and drink were the sources of hysterical illness. On the contrary, the good doctor believed that persons of consequence, those of genteel breeding and more delicate emotional substance, mostly had "other things to think of than overcharging their Stomach with Gluttony or Drunkenness." Peasants and other "meaner sorts of persons" were less sensitive and better able to cope with grief and worry, but among Baglivi's clientele "a great Part of Diseases either take their Rise from, or are fed by that Weight of Care that hangs upon every one's Shoulders."
Already a class bias in diagnosis and treatment of nervous disease is evident. With his contemporaries, Baglivi held that mental illness almost invariably manifested itself in gastrointestinal symptoms. The physician believed that these followed on the decreased appetite and lack of interest in food he found so commonly among his patients, especially among young women unrequited in love. Baglivi frankly acknowledged that he could not explain the process by which emotional imbalances led to physical symptoms; he turned instead to therapeutic remedies. His medical regimen involved little more than encouraging the patient's self-recovery with the help of "a Physician that has his Tongue well hung, and is Master of the Art of persuading."
Although some of the symptoms referred to by Baglivi may have been indicative of anorexia nervosa, he did not identify this specific disorder. Rather, he, his predecessor Thomas Sydenham, and such eighteenth-century writers as Bernard de Mandeville, George Cheyne, Robert Whytt (who described fames canina, or voracious appetite), and William Cullen groped for general explanations of a baffling variety of physical disabilities that seemed to have a psychic origin. The terms melancholy, hysteria, hypochondriasis, lowness of spirit, nervous disease, English Malady, and affliction of vapors (perhaps emanating from an unhappy uterus as it floated upward and pressed upon the gastrointestinal organs) were used imprecisely in a literature that never fully escaped from the ancient Egyptian association of emotional disturbance in women with genital disease and the "wandering womb." In virtually all of the eighteenth-century medical literature it is impossible to distinguish anorexia nervosa from other "nervous" diseases. Only the recognition of a class differential remains constant, although in some quarters with an inversion of Baglivi's bias. From the American colonies Benjamin Rush, addressing a well-fed and probably sotted group of dignitaries at a conference on Indian diseases, lamented that the "HYSTERIC and HYPOCHONDRIAC DISEASES, once peculiar to the chambers of the great, are now to be found in our kitchens and workshops. All these diseases have been produced by our having deserted the simple diet and manners of our ancestors."
Even in the early nineteenth century writers describing symptoms typical of anorexia nervosa did so in the context of more general treatments of hysteria and the "genital neuroses of women." Philippe Pinel, head of the famous Salpétrière public mental hospital for women in Paris, identified a pattern of alternation between periods of anorexia (with concomitant amenorrhea) and what he called nymphomania. He described one such patient as being "in a state of sadness and restlessness; she becomes taciturn, seeks solitude, loses sleep and appetite, conducts a private battle between sentiments of modesty and the impulse towards frantic desires." Pinel goes on to tell how "voluptuous leanings" win the contest and the girl deteriorates from indecency and provocative solicitation to disgusting obscenity and finally to a violently maniacal condition. Shortly thereafter he relates a specific case history involving symptoms found in typical anorexia nervosa: female age seventeen, loss of appetite and even complete abstinence from food, amenorrhea, bulimia, bradycardia. Pinel also notes several symptoms often associated with anorexia nervosa even though they are not part of Feighner's diagnostic criteria (outlined earlier): disgust with daily life, frequent crying, taciturn behavior, inability to speak, facial discoloration, paralytic muscle spasms and body rigidity, constipation and limpid urine, hyperacuity, and depression. All these Pinel notes in reporting a classic and for him defining case of hysteria, one that may well have involved a patient who suffered from typical anorexia nervosa.
Specific recognition and nomenclature for the disease had to await the reports of William W. Gull and Charles E. Lasègue. As early as 1868 Gull had described a strange malady that seemed to afflict young women; they refused to eat even as they became extremely emaciated. He called the sickness apepsia hysterica, an appellation of dubious value since there is no necessary absence of pepsin and because the term "hysterica" at that time applied only to women, whereas self-starvation can occur also in men. Six years later Gull published a revised and updated set of findings and called the condition anorexia nervosa, the designation still used in England and the United States. Again he concentrated on the refusal to eat, extreme weight loss, and amenorrhea characteristic of the disease in young women. Moreover, he noted concomitant symptoms including constipation, low pulse rate, slow respiration, and the absence of somatic disease. Gull expressed some amazement at the highly active pace, even hyperactivity, of some of his anorexic patients. (This observation is especially important in terms of the analysis of "holy anorexia" that follows.) In a later report, enhanced with an engraving of the self-starved sickly body of one patient, he wrote about K. R., age fourteen, who walked long distances through the streets despite the fact that she was so obviously emaciated as to attract the stares of passersby. Even with "nutritive functions at the extreme ebb" she and her fellow sufferers persistently wished to be "on the move." Gull suggested that the illness resulted from a "morbid mental state" among young girls at an age when emotional distress was especially likely to affect the appetite. He asserted that the girl's relatives were "the worst attendants" but did not explore deeply the nature of the parents/daughter relationship and its causal or contributory role in the onset of anorexia.
At virtually the same time as Gull's second report in 1874, and apparently independently of it, Lasègue published a lengthy account, based on eight cases, of what he called anorexie hystérique. He carefully distinguished this disease both from "hysterical emaciation" and from the sudden weight loss associated with acute depression. None of his patients fasted absolutely, and whereas some developed an aversion to all types of food others objected only to certain items. Lasègue believed that the disease began with some emotional trauma, one the patient was inclined to conceal, usually in females in their later teenage years. He emphasized the relative happiness of his patients; they showed little concern about their extreme thinness and appeared positively to enjoy their condition. They alternated between being ill patients and capricious children, slowly and surely drawing their entire families into a trap in which eating and the refusal to eat became the sole topic of concern and conversation. Lasègue pessimistically observed that the families' responses, limited to entreaties and menaces, often with a confusing and unpredictable mixture of the two, were quickly exhausted and served as a touchstone to exacerbate the illness. Thus the physician tried to place "in parallel the morbid condition of the hysterical subject and the preoccupation of those who surround her." Negative as he was about the family's ability to bring its daughter to good health, he was certain of his own curative powers. Unlike Gull, who reported that at least one of his patients had died, Lasègue happily claimed a recovery rate of 100 percent.
Excerpted from Holy Anorexia by Rudolph M. Bell. Copyright © 1985 The University of Chicago. Excerpted by permission of The University of Chicago Press.
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