The ‘Invention’ of Anorexia Nervosa

Prior to its diagnosis, anorexia, or loss of appetite, had been thought to be a symptom of another, primary disease. It was given the status of an independent condition by the eminent physician Dr William Withey Gull, who asserted that anorexia was distinct from the weight loss that resulted from a separate disorder such as organ disease or tuberculosis. Gull first introduced anorexia to the British Medical Association in 1868, referring to it as ‘apepsia hysterica’:

[a]t present our diagnosis is mostly one of inference, from our knowledge of the liability of the several organs to particular lesions: thus we avoid the error of supposing the presence of mesenteric disease in young women emaciated to the last degree through hysteric apepsia by our knowledge of the latter affection, and by the absence of tubercular disease elsewhere.

In his footnote to hysteric apepsia, Gull writes that ‘I have ventured to apply this term to the state indicated, in the hope of directing more attention to it.’ He did just this since five years subsequent to this address, on 24th October 1873, Gull presented a lecture to the Clinical Society of London, an elite group of medical consultants, entitled ‘Anorexia Hysterica (Apepsia Hysterica)’ in which the 1868 diagnosis of ‘apepsia’ was replaced by ‘anorexia’. Gull explained this substitution since ‘“what food is taken, except in the extreme stages of the disease, is well digested.”’ A paper based on this lecture, ‘Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica)’, was published the following year. In this report, the original title of the lecture, ‘Anorexia Hysterica’, was altered to ‘Anorexia Nervosa’ because Gull had come to believe that anorexia was nervous, rather than hysterical in origin given that ‘hysteria’ implied a gendered disease affecting only women:

we might call the state hysterical without committing ourselves to the etymological value of the word, or maintaining that the subjects of it have the common symptoms of hysteria. I prefer, however, the more general term “nervosa,” since the disease occurs in males as well as females, and is probably rather central than peripheral.

Two years after Gull’s publication, a paper delivered at the Royal College of Physicians was printed in The British Medical Journal that offered a detailed description of the symptoms of anorexia nervosa, concurring with Gull’s earlier diagnosis:

the appetite fails, food is not taken, and the body wastes to an extreme degree, the countenance has a distressed appearance, the eyes are sunken, the cheeks hollow, and the whole system impoverished: the body has fed upon itself, and all superfluous fat has become absorbed.

Similarly in France in April 1873, Dr Ernest Charles Lasègue published ‘De l’anorexie hystérique’ in the Archives Générales de Médicine, in which anorexia was described as ‘“hysteria of the gastric center”’. Although Lasègue believed that the condition derived from hysteria, ‘anorexia’ (lack of appetite) is used in place of ‘hysterical inanition’ since he states that anorexia ‘“refers to a phenomenology which is less superficial, more delicate, and also more medical.”’ In 1884, however, T Clifford Allbutt opposed the idea of a hysterical cause owing to the variety of symptoms produced by anorexia. Based upon six cases collected prior to the reports from Gull and Lasègue, Allbutt found that in some instances, ‘there is great pain on the ingestion of food; in others, there is no pain, but simply a distaste for food.’

In his account, Lasègue identified three stages of l’anorexie hystérique. During stage one, he reports that the patient experiences physical sensations, a ‘“vague sensation of fullness” and ‘“suffering after commencement of the repast.”’’ Certain foods are omitted from the diet and there is evidence of hyperactive behaviour. In stage two there is physical deterioration, yet the patient becomes the centre of attention owing to her food refusal and is thereby pleased with her condition and does not wish to ‘get better’. This is what Lasègue termed ‘“pathological contentment”’. In the final stage, he noted severe emaciation and amenorrhea and ‘“[t]he young girl begins to be anxious from the sad appearance of those who surround her, and for the first time her self-satisfied indifference receives a shock”’. From this report, it can be seen that since the anorexic girl is respondent to others, her family and friends act as a reflection of her own physical condition. The patient’s body image becomes distorted to such a degree that she only realises the extent of her emaciation when others exhibit signs of alarm.

By classifying the behaviour and symptoms of anorexia, Gull transformed an existing condition into a disease. Taking control of the patient’s volitional self-starvation, he translated the behaviour as a ‘mental perversity’ subject to treatment, indicating his wish to regulate undesirable female conduct by diagnosing it as an abnormality. This objective to manage disease is evident in Gull’s lectures and writings, the language of which is couched in terms of control. In his ‘Address on the Internal Collective Investigation of Disease’ delivered in 1884, he states that medical investigation requires a ‘combination of exact observation and record, with refined criticism and analysis’. Meticulous in his diagnosis, Gull advised his fellow physicians that:

we must, in many instances, have the life-histories of the parents or more remote ancestors, before we can fully unravel the course of irregular menstruation, hysteria, anorexia, uterine flexions, and the like.

Gull stressed the need for medical practitioners to carry out diagnoses in a uniform manner, in order that illnesses could be systematically classified and the problem of disease ‘settled’. Allbutt also suggests a way in which control should be exercised, especially in the case of anorexia which displays ‘objective symptoms’ that can be measured, treated and brought within patriarchal power: ‘[t]his anorexia nervosa is no whimsical malady, no inconsistent nor irregular indisposition, but is a definite complex, consisting, in part, of objective symptoms.’

. Firstly, its cause was problematic. Allbutt writes that ‘[s]ometimes, the distaste has taken its origin in a mere shirking of food – in the fear of growing stout, or in a nobler avoidance of self-indulgence’, while Lasègue believed that anorexia occurred ‘as the result of some “emotional cause” which the patient might either “avow or conceal.”’ These emotional causes outlined by Lasègue included ‘inappropriate romantic expectations, blocked educational or social opportunities, struggles with parents.’ Adding to this catalogue of possible origins for the condition, in an 1888 issue of the Lancet Gull attributed ‘perversion of the “ego” being the cause and determining the course of the malady’, crediting his patients’ refusal to eat to a psychological, rather than a physical affliction:

[t]hat mental states may destroy appetite is notorious, and it will be admitted that young women at the ages named [sixteen to twenty-three] are specially obnoxious to mental perversity.

Anorexia resisted Gull’s attempts at classification, however, thwarting his desire for a neat, methodical diagnosis.

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