The Prehistory of Anorexia Nervosa
Jules R. Bemporad, M.D
(New York)
Anorexia Nervosa usually has been considered a relatively recent disorder, being described almost simultaneously by Gull (l873) and Lesque (l973) in the latter part of the l9th Century. However, a number of scholarly works which have appeared in the last few decades (Skrabanck, l983, Brumberg, l988, Vandereycken, and Van Deth, l994 Bemporad, l996) present evidence of voluntary self-starvation dating back many centuries. The frequency of these acts of willful self denial seems to vary greatly in different certain periods of history, suggesting that certain combinations of social and economic factors may have facilitated or inhibited the expression of psychopathology through anorexic behavior, just as current anthropological studies have demonstrated marked differences in the rate of anorexia in disparate cultures (DiNicola l990, Dolan l99l.)
It may be in interest that, in Western culture, instances of self starvation do not appear until the Hellenistic era. There are no reports of anorexia from classical Greece, although instances of willful over-eating or voracious hunger are not rare (Ziolko, l996.) Many of these early abstainers were male hermits who renounced the entire material world as part of a general asceticism Various gnostic sects arose in the wake of the decline of independent city states which were submerged into large empires. The Greek scholar Dodds (l970) postulates that as citizens lost their sense of public effectiveness in the government of the "polis", they diverted their desire for control to the private sphere, including their corporal selves. It was at this time that Eastern religions influenced European through through the use of Gnosticism which proclaims, not only a special knowledge of God, but a dichotomy between spirit and body. (Jonas, l958). The body, as part of the material world, is considered evil while the soul, which is imprisoned in that body, is considered holy. This depreciation of the body was not confined to male recluses, but seems to have been adopted by wealthy Roman ladies. For example, St. Jerome became the spiritual leader of a group of high born Roman women, one of whom actually starved herself to death in 383 A.D., thereby becoming the first recorded death from anorexia and also forcing St. Jerome to flee for his life to Bethlehem (Ranke-Heinemann, l900.)
With the fall of the Roman Empire, there also appears to be a decline of self imposed fasting. During the ensuing "Dark Ages", everyday life reverted to its most basic biologic level with a premium placed on female physical stamina and procreative capability, as the population had to deal with recurrent famines, plagues, and attack by marauding armies (Brown l988.) Cities disappeared and with them the previous emphasis on culture and sophistication which had been guiding forces for the urban wealthy classes. Only three cases of anorexia have been reported during these centuries of privation: two were of young women who were thought to be possessed by Satan and cured by exorcism (Skrabanek, l990) while the third involved a princess who fasted when her father promised her in marriage to a Saracen king of Sicily (Lacey, l982). This devout girl, who wished to serve only Christ, managed to make herself sufficiently unattractive so that her suitor called off the wedding. As punishment, her father had her crucified, a martyrdom which resulted in her being canonized as a Saint (Lacey, l982.)
In contrast to the relative rarity of self starvation during the "Dark Ages", anorexic behavior seemed to have reached almost epidemic proportions during the Renaissance, particularly in Southern Europe where urban centers, and their concomitant sophistication and wealth flourished. (Bell l985, Bynum l987.) In his book, Holy Anorexia, Bell (l985) cites 26l cases of female starvation for religious reasons between 1206 and l934. Of these 26l fasting women, l8l (more than two-thirds) lived between l200 and l600 A.D. with many being elevated to sainthood. In addition to fasting (often to death) these "holy" anorexics castigated their bodies, refused offers of marriage and sought refuge in religious orders. Many were sanctified for their alleged ability to communicate with Christ (such as St. Catherine of Siena) and praised for their devotion to helping the sick and the poor at the expense of their own health and appearance. Their existence contrasted with the more typical Renaissance feminine ideal of an ethereal yet carefully clothed and made up fashionable lady who was educated to serve at her husband's side. Some forms of holy anorexia continued beyond the Renaissance (Simone Weil might serve as a contemporary example, Coles, l987, McLellan, l990) but once again this form of behavior diminished greatly as the more mundane world of the Reformation reshaped European values. One possible explanation for this relative disappearance of holy anorexics may be in an alteration of the attitude of the Church. In the attempt to reestablish it's authority, the Church mandated that the laity could only communicate with Christ via the intermediary of an ordained male priest, so that a young girl claiming to speak with Christ could expect a visit from the Inquisition as much as an invitation to sainthood. However, the centuries following the Renaissance also brought about an alteration in the social perception of the female's role in society. Women were once again prized for their biological rather that aesthetic qualities as the high civilization of Southern Europe was eclipsed by a pervasive puritanism.
In these simpler times, a few cases of self starvation have been reported as "miraculous maids" (Brumberg, l982) who claimed to be able to exist without nourishment. These girls have a "Cinderella" quality: they usually come from poor families in rural areas who became celebrities once news of their ethereal existence spread and who were visited by dignitaries, often for a fee paid to the family. Some of these girls were found to be frauds while others died of malnutrition. Many claimed a religious basis to their fasting so that they became the objects of debate between the church which espoused the possibility of a solely "spiritual" existence and the rising scientific materialism which doubted the ability to live without nourishment. A few of these "miraculous maids" gained international fame and some may have starved to death in obscurity.
This trickle of cases of anorexia swelled to a respectable stream of self starvation in the l9th century, leading to their description by Leseque and Gull in l873 (although Silverman (l989) has found a published clinical account of anorexia nervosa by Louis Victor Marce, a French physician, dating to l859.) At this time, the industrial revolution produced a return of a moneyed and urbane middle class with cultural and aesthetic aspirations. As Veblen (l899) noted in his Theory of the Leisure Class, a corpulent woman no longer was evidence of her family's prosperity. Since women were now joining the labor force, a frail, thin woman proved that she did not need to work because of her father's or husband's financial success.
The history of anorexia from Victorian days to our own era is well known and need not be repeated here in detail. Numbers of cases declined during the World Wars and the depression, only to reemerge with alarming frequency in the late sixties. Russell (l985) reviewed the changes in eating disorders since the turn of the century, noting an overall increase in incidence in the last few decades, the emergence of bulimia as a frequent manifestation, and possibly, a different motivation: fear of becoming fat rather than defending against sexuality or the demands of an adult life.
This very cursory overview of the relative frequency of self starvation may reveal a pattern regarding social factors which appear to influence it's use to express deeper psychological issues. It is of interest that self starvation was unknown in Western civilization until the emergence of Gnosticism which stressed not on the dichotomy of mind and body, but the relative evil of the body and it's desires. The denial or privation of the corporeal self seems to occur only after it has been separated and placed in opposition to the spiritual self. Even today, cultures which do not make this separation or that regard the body highly do not exhibit eating disorders (Dolan, l991 .) Another contributing factor is the creation of an affluent society where biological survival is assured. Those historical epochs characterized by privation did not produce anorexia. Selvini-Palozzoli (l985) found a similar occurrence in Italy during World War II. When food was scarce, there were no cases of anorexia. Only as the economy recovered in the post war period did such disorders begin to be reported.
Finally, only when women are regarded for their aesthetic , cultural or spiritual attributes are cases reported. Affluence alone, as in contemporary Arabic countries, does not result in increased incidence of self starvation if women are prized mainly for their biological functions. It may be that the confluence of wealth plus a degree of culture which rewarded more aesthetic aspects of femininity (at the expense of biological functions) against a Judeo-Christian background of mind-body dichotomy that may create a conflictual social role for women resulting in the development of eating disorders.
In her book on the modes of representation of the human form in Western Art, Camille Paglia (l99l) has singled out two opposing forces: the Apollonian, which emphasized the intellectual, aesthetic and spiritual, and the Chthonian which stresses the biological, preservative aspects. It may be that when cultures glorify the Apollonian and denigrate the Chthonian that eating disorders are seen. These would be more common in females since so much of their lives is tied to procreation and nurturance while men's role in evolutionary continuity seem limited to insemination. It is when vital functions such as child bearing, nursing, or menstruation are perceived as contrary to a desired feminine ideal that anorexia may be used as a means to deny a significant aspect of the self. Therefore, eating disorders may be the price paid by women for the achievements of Western Civilization. This is far from a novel idea, being clearly antedated by Freud's classic statement on the antithesis between biology and culture in Civilization and Its Discontents (l930). This is not to deny the role of particular family dynamics or of the development of the personality in childhood as significant determinants of later eating disorders. Treatment should address individual psychodynamics and the internal psychic world of each patient including the evaluation of self and others. However, these individual and family problems may be expressed through culturally determined modes so that the study of historical as well as cultural preferences for particular syndromes becomes a worthwhile endeavor.
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