Self-Starvation Through the Ages: Reflections on

the Pre-History of Anorexia Nervosa

Jules R. Bemporad
(Accepted 11 January 1995)

Recent publications have indicated that voluntary self-starvation is not a recently de-
veloped syndrome and that it has been reported throughout history. These prior forms
of inedia are summarized and related to their historical and cultural contexts. On the
basis of these data, some hypotheses are proposed regarding social influences on the
vulnerability to eating disorders. Objective: To document and describe forms of eating
disorders occurring prior to the formal medical description of anorexia nervosa in the
late 79th century. Method: Review of historical references to self-starvation, of recent
publications on the history of eating disorders, and of articles describing cases of eating
disorders occurring in the past. Results: Forms of eating disorders have existed since
ancient times varying in frequency, manifestations, and possible motivation. Discus-
sion: Certain sociocultural factors appear to foster or inhibit the frequency and type of
eating disorders. 0 7996 by)ohn Wiley & Sons, Inc.

It was long believed that anorexia nervosa came into existence in the late 19th century,
being described almost simultaneously by Leseque in France and Gull in England in
1873. However, the recent appearance of a number of publications (Brumberg, 1988;
Skrabanek, 1983; Vandereycken & van Deth, 1994) has revealed that various forms of
self-starvation had been practiced long before that. The occurrence of these behaviors
throughout most of recorded history should cause us to rethink whether eating disor-
ders are actually a product of our current social pressures rather than a deeper mode of
self-expression adopted by individuals in other epochs and other cultures. A look at this
"prehistory" of eating disorders may shed some light on this form of psychopathology
as it exists today by highlighting some commonalities, as well as differences, that may
be deciphered from a study of our anorexic ancestors. Because this literature has become
voluminous, detailed accounts of all recorded historical instances of self-starvation will
not be presented here and the reader is referred to more lengthy sources for that infor-
mation. Rather, the prevalent form of eating disorder at different epochs will be de-

Ides R. Bemporad, M.D., is Professor of Clinical Psychiatry, New York Medical College, Valhalla, New York.
Mailing address for reprints: 415 Toni lane, Mamaroneck, NY 10543.

international /ourna/ of Eating Disorders, Vol. 19, No. 3, 217-237 (1996)

Q 1996 by JohnWiley & Sons, Inc. CCC 027&3478/96/030217-21
218 Bemporad

scribed, illustrated by one or two paradigmatic cases. This expository material will be
used to formulate some tentative conclusions regarding a possible basis of eating dis-
orders.

ANCIENT TIMECTHE ROOTS OF GNOSTICISM

Prolonged inedia was essentially unknown in classical Greek or Egyptian cultures. No

instances of death or debility through voluntary self-starvation appear in the work of
physicians, historians, or writers of these times. There are numerous records of ritual
fasting for brief periods, usually 1 to 3 days, which served specific purposes. One was
fasting as a preparation to receive some sort of trance-like state, which was a medium for
sacred visions. Therefore, Moses fasted for 40 days before receiving the Ten Command-
ments, and Jesus and Elijah also fasted for 40 days before divine enlightenment. In this
case the extraordinary length of the fast, 40 days, might not be taken too literally as the
number 40 may have been selected because it was believed to have some sort of mystical
significance. (For example, the Jews wandered in the desert for 40 years after their
exodus from Egypt.) Fasting was also used as a means of penance or purification
through which the individual denied himself the pleasure of eating (often with absti-
nence of sexual behavior) to atone for prior transgressions against the deity. Finally,
fasting was used as a means of supplication to influence superior powers. In these
instances, the point of fasting appears to be the willful abstinence from a source of
pleasure to prove one’s devotion to the gods. There is less concern with depriving or
punishing one’s’corporeal self than with relinquishing a means of gratification. It would
seem unlikely that a culture whose maxims included “a sound mind in a sound body”
or ”moderation in all things” would foster severe self-deprivation. The closest behavior
to self-starvation to be found in classical Greece was that of the Pythagoreans who
abstained from meat of any sort. However, this dietary restriction resulted from their
belief in transmigration so that livestock might contain the soul of a departed human.
The situation was quite different in Eastern religiorls, where fasting was prolonged,
often to death, as part of a total withdrawal from a material world that was perceived as
essentially evil. A prominent example is Vardhamana, the founder of Jainism, who lived
in the 6th century B.C. and who died of voluntary fasting (Smart, 1967). The main
teaching of Jainism is that there exists a deep separation between the eternal soul and
transitory matter which includes the body. The goal of Jainism is to release the soul from
its corporeal bondage through austerity and extreme self-control, the epitome of which
is death through willful starvation in imitation of Vardhamana.
This admiration for the ascetic control of one’s body may also be seen in a Hindu myth
in which the goddess Uma attempts to seduce the god Siva in order to produce a son
who can destroy the demon Taraka (Mogul, 1980). Siva is immersed in profound con-
templation of the void of his own being so Uma cannot arouse his desire for her.
Attempts by the god of love to influence him are rapidly demolished by Siva, who
remains steeped in meditation. It is only when Uma renounces the material world and
starves herself for 36,000 years, that Siva finally is drawn to her. Buddha also went
through a phase of self-starvation, to the extent that he could touch his spine through
his abdomen, in the search for enlightenment (Mogul, 1980). He gave u p this form of
asceticism when it brought him no special knowledge or insight. These Eastern philos-
ophies gradually spread to the Mediterranean in the form of Gnostic sects. The unifying
theme of these ascetic sects was the gnostic thesis that the external soul has become
Starvation Through the Ages 219

separated from a god by the material world which is the source of evil (Jonas, 1958).
Humanity is made aware of this alienation of the soul from the deity by a selected
individual, who after some form of privation and temptation, informs the populace of
his knowledge (gnosis) of the true path to spiritual salvation. The gnostics, therefore,
were those who possessed this knowledge of the severance of the soul from the deity
and illusion of truth in material objects. Eventually, these Gnostic beliefs invaded the
religions of classical antiquity, taking root in Greece and Rome. The Greek scholar
Dodds (1970) argues that this transformation may have followed the decline of the
"polis," or city state which allowed a measure of active participation by its citizens in
favor of large, autocratic empires such as Alexander's which made its inhabitants feel so
politically helpless that they sought a measure of control within their own individual
existence rather than in civic matters. Others have found traces of gnosticism in Plato's
dialogues, particularly the Phaedo, written well before the Macedonian Empire. How-
ever, although Plato certainly differentiates the knowledge gained by the soul (abstract
thought) from that available through the body (sense perception), he merely places one
above the other in terms of accuracy and not in terms of morality. The senses may
confuse the soul in its search for truth but are not inherently evil.
The idea of the body as malevolent appears to have resulted from the spread of
gnosticism in the Hellenistic world and its incorporation into early Christian sects which,
in turn, infiltrated the civilized world around the Mediterranean.

EARLY CHRISTIAN ASCETICISM-GNOSTIC CULTS

The Gnostic elements of early Christianity together with a popular belief in the im-
minent end of the world led to a spread of asceticism, epitomized in celebrated hermits
who would abandon civilization for a solitary life of privation in rural seclusion. These
early holy individuals were predominately men, rather than women, who included
severe fasting as part of an overall rejection of their bodies and other material things. For
example, Hilarion, a 4th century ascetic, was originally intended for a brilliant career as
an orator in cosmopolitan Alexandria. However, at 15 he sought out the hermit Antony
in the Egyptian desert. After a 2-month stay with Antony, Hilarion returned home, only
to give away all of his belongings and live out his years in poverty and isolation. He is
reported as sleeping in a small hut of reeds and later in a cell less than 5 ft in height. His
diet was said to consist only of bread, salt, and some lentils. Hilarion was often con-
sulted by those in need as he was believed to be able to cure illnesses, in humans as well
as animals, and even to determine the victor of a race horse with his blessing (Fox, 1986).
As Hilarion may demonstrate the high regard accorded to self-deprivation, another
religious hermit, Saint Simeon Stylites, may be used to illustrate the disdain in which
these holy men held their bodies. Simeon tied a rope around his waist so tightly that it
ate into the flesh. The resulting abrasions were eventually infected and swarmed with
worms. As these fell from his body, Simeon replaced them in the putrefied wound,
saying "Eat what God has given you" (Wallman, 1967).
The essence of this ascetic doctrine is simply that bodily needs or desires are a source
of evil and are to be resisted at all costs to preserve the purity of the eternal soul
temporarily imprisoned in its corporeal habitus. This clear conflict between religious
aspirations and material necessity was behind the teaching of Eusebius Sophronius
Hieronymus, better known to history at St. Jerome, who translated the bible from
Hebrew to Latin but who also was the spiritual leader of a group of wealthy Roman
220 Bemporad

women in the late 4th century. He preached a life of abstinence and prayer, writing to
his pupil Eustochium, “Let your companions be women, pale and thin with fasting such
as daily, say with true earnestness, ’I have a desire to depart and be with Christ’ ”
(Ranke-Heinemann, 1990). Blessila, Eustochium’s younger sister took his message to
heart and departed this life at the age of 20 from malnutrition, thereby possibly being the
first young female in recorded history to expire from voluntary self-starvation. The death
of a high-born Roman girl aroused such animosity toward Jerome and what was termed
his ”detestable mob of monks” (Ranke-Heinemann, 1990), that they shortly escaped to
Bethlehem where he and his followers established a school and hostel for pilgrims.
The early centuries of the Christian era appear rife with ascetic cults rising up in rather
large and sophisticated cities and in opposition to their indulgent way of life, as ex-
pressed in Augustine’s confessions. The act of starvation has to be considered in the
context of a total renunciation of bodily needs or desires. One senses that social thought
at these times was plagued by a sense of a lost classical golden age and the rise of a
radical ascetic reaction to a hedonism and materialism that lacked an ethical foundation.

THE DARK A G E C S A T A N I C POSSESSION A N D SELF-LIBERATION

In contrast to the self-imposed, voluntary self-denial of the Hellenistic and Roman
worlds, the succeeding centuries seem to have exposed the same privations involuntar-
ily on the European populace. A series of disasters between the 5th and 10th centuries
did much to destroy any remnant of Greco-Roman civilization in Western and Northern
Europe. Among these devastations were the recurring invasions and settlements of
barbarians from the north, a severe plague that persisted for two centuries after its onset
in 542, and climatic deterioration which reduced agricultural production until the 9th
century (Brown, 1988). One of the most striking features of the so-called Dark Ages was
that cities simply disappeared. Even Rome, the center of civilization which had a pop-
ulation of several hundred thousand during classical times, had shrunk to perhaps
30,000 by the 6th century as the result of siege, famine, and plague. Vast areas of the city
were desolate and public buildings lay derelict or were used for construction materials
(Brown, 1988). Under such circumstances, everyday life appears to have been a struggle
against marauding armies, pestilence, and famine. It may not be surprising that in an
age when hunger was rampant, willful self-starvation seems not to have existed (or at
least not reported, since this era is comparatively poorly documented). Voluntary ab-
stinence from food would be a difficult way of expressing a psychological motive, if food
were a scarce commodity. Selvini-Palozzoli (1985) reports a similar situation centuries
later when she found anorexia nervosa to be nonexistent in Italy during World War I1
when severe food restrictions were imposed. Only as Italy returned to a certain level of
affluence did cases of anorexia begin to appear. It would appear that only when food
becomes abundant can voluntary denial of food serve a psychological purpose. It may
also be argued that in situations of prolonged scarcity, different aspects of femininity are
emphasized (as will be further discussed below). Nevertheless, there are a few reports
of self-starvation even during these difficult years. Two represent the role of satanic
possession, possibly reflecting the one cohesive social force in a relatively chaotic age:
the spread of Catholicism with its emphasis on the individual as caught between the
forces of good and evil. These two cases, one from the 5th century and one from the 8th
century are remarkably similar (Skrabanek, 1990). In both instances young women re-
fused to eat or drink because they were thought to have been possessed by the devil.
Starvation Through the Ages 221

Both were cured by exorcism; in one case, taking Holy Communion dislodged the devil,
whereas in the other visiting the holy tomb of a saint caused her to be freed of her
possessor. The theme of demonic possession as an explanation for anorectic behavior
recurs in the ensuing centuries. The most recent instance was less than 20 years ago,
when a Bavarian girl who was convinced she was possessed, died of self-starvation in
1976 after exorcism failed to cure her (Vandereycken & van Deth, 1994).
The third reported case of self-starvation during the Dark Ages also concerns itself
with Christian piety; so much so that the girl in question was elevated to sainthood. She
was the seventh daughter of a king of Portugal who ruled sometime between 700 and
900 A.D. This girl has been called St. Wilgefortis from the latin Virgofortis or strong
virgin, although she has also been worshipped as St. Ontcommer, St. Kummernis, or St.
Uncumber, as one who relieves the supplicant of burdens of encumbrances. Similarly in
France and in the Iberian peninsula, she was known as St. Liberata, the liberator. The
story of this princess who became a saint begins with her father promising her in
marriage to the Saracen king of Sicily (Lacey, 1982).The girl, however, had already made
a vow of virginity and of service only to God rather than to man. Upon the news of her
impending marriage, she prayed that she be stripped of her beauty and refused nour-
ishment. She lost her feminine contours and also grew hair all over her body, causing
her suitor to withdraw his offer of matrimony. As punishment, her father had her
crucified. While on the cross she asked that all remember ”the passion that encumbers
all women” (Lacey, 1982). In time, she became known as one who succeeded in liber-
ating herself from the physical and social discomforts that afflict womankind; menstrual
pains, childbirth, enforced sexual relations, and domination by males. She became the
patron saint for those who wish to be relieved of problems associated with procreation
or even by those who wish to free themselves from the control of others. This particular
history is of interest for it shows how self-starvation (and ultimately death) are seen as
a means of liberating oneself from the physiological burdens associated with feminity
and asserting one’s will in the face of social or political impotence. A similar situation
that occurred in the 13th century concerns St. Margaret, the daughter of a king of
Hungary who had pledged her to God if he could repel a Tartar invasion (Halmi, 1994).
After his victory the king built his daughter a convent where she excelled in her studies,
fasted, slept little, and performed exhausting menial work. When her father decided that
she should marry, Margaret intensified her fasting, dying of starvation at age 28. She
was canonized only 5 years following her death, attesting to the value placed on self-
denial in the name of God. Margaret is indicative of the alterations that transpired in the
13th century, in contrast to the preceding Dark Ages, which appear to have resulted in
a mini epidemic of anorexic behavior, at least in southern Europe.

THE LATE MIDDLE AGES A N D EARLY RENAISSANCE-HOLY ANOREXIA

In 1985, Rudolf Bell published a book called Holy anorexia, followed 2 years later by
Caroline Bynum’s Holy feast and holy fast; both works call attention to the existence of
self-starvation in a large number of European women from the 13th to the 17th centuries.
Although these historians do not state with any certainty that the behavior of these
women was illustrative of modern anorexia nervosa, they do document some similarities
to the disorder. This suggests that at this particular point in Western history, a syndrome
not so dissimilar from anorexia nervosa was frequently exhibited. Bell lists 261 docu-
mented cases of holy fasting that he discovered, beginning with St. Ubaldesca who died
222 Bemporad

in 1206, up to Maria Zonfrilli who expired as recently as 1934. Of these 261 instances of
self-starvation, 181 (or well over two thirds) occurred between 1200 and 1600 A.D. and
almost all in southern Europe. The paradigmatic example offered by Bell is that of St.
Catherine of Siena, and, in fact, many later holy fasters consciously took Catherine as
their model. Catherine was born in 1347, the 24th child of her mother and the only one
to be nursed by her. A twin, Giovanna, who was sent to a wet nurse, died in infancy.
Catherine is said to have been the favorite of her mother and of an older sister, Bon-
aventura, who served as a mentor to her younger sib. When Catherine was approaching
puberty, Bonaventura purposely starved herself as a means of reforming her dissolute
husband, a strategy that succeeded. However, when Catherine was 15, Bonaventura
died in childbirth, a loss that weighed heavily upon Catherine. She underwent a pro-
found psychological change, turning inward and shunning the everyday world. She
started to eat little, and to spend much of her time in prayer. At this same time, Cathe-
rine’s parents began to search for a suitable husband for her, to which Catherine re-
sponded with an intensification of asceticism and religiosity. In the midst of this conflict,
Nanna, Catherine’s younger sibling also passed away. This additional loss further
pressed Catherine to a life of devotion to God. She cut off her hair, began lengthy
meditations, and secretly flagellated herself in imitation of Christ‘s passion. Her family
dealt with these new behaviors by a determined effort to break Catherine’s will and force
her to resume a normal life. Catherine assumed the heavy and humiliating tasks im-
posed upon her without relinquishing her desire to serve only her God. Finally, she
confronted her family with her wish to become a nun and they relented, allowing her to
become a ”Mantellata.” This choice appears somewhat peculiar, for this order of nuns
was allowed to remain at home rather than reside in a convent. In any event, from this
point until her death from malnutrition at age 32, Catherine lived an austere, ascetic
existence. She ate almost nothing, often forcing herself to vomit the little she had
ingested. She seems to have had no limit to her energy, however, devoting most of her
waking hours to helping others. She slept very little, occupying a small room in the
parental home where she continued to punish her body by sleeping on sharp sticks, by
binding her body with a tight iron chain, and by daily flagellation. She became famous
for her tireless service to the poor and the sick and, later, for her influence in returning
the Papacy from Avignon to Rome. One apocryphal story may be worth retelling: When
Catherine was attending a woman dying from cancer of the breast, she involuntarily
recoiled at the sight and smell of the purulent mammillary organ devastated by disease.
Catherine was so angry at her own revulsion that she forced herself to drink a cup of the
exudate of the decaying breast. Catherine’s fame was increased by the appearance of her
biography, written only a few years after her death in the vernacular by her confessor
and possibly serving as an inspiration to other women. In time, the facts of her life
became embellished with performance of miracles, the ability to levitate, and the ap-
pearance of stigmata on her body.
Whether in response to Catherine’s example, or for their own reasons, numerous
other women began to fast to the point of death, to spend their lives in active support
of others, and to deny their corporeal needs, all in the name of sanctity. One possible
advantage of choosing this form of devotion is that it led to the belief that one could
communicate directly with God and thereby become superior to one‘s peers. Indeed,
many such women were elevated to sainthood, receiving an official stamp of approval
from the powerful church. Other possible reasons, mentioned by Bynum (1987), were
the ability to escape from an arranged marriage and the avoidance of childbirth and child
rearing, As such, these ”holy anorexics” ignored any demand of their bodies, indeed
Starvation Through the Ages 223

turning against their bodies with self-invented forms of torture, and also turned against
the accepted social female role. In return, they secured a sense of superiority in their
sanctity and the belief of belonging to Gods elect.
These forms of self-starvation continued beyond the Renaissance (a contemporary
example might be the philosopher-mystic Simone Weil), but their occurrence became
much less frequent. Bell (1985) speculates that the decline of religious self-starvation may
have been caused by a change in attitude on the part of the church. The official orga-
nization began to debunk individuals who claimed to have direct divine communication
and to insist that any commerce with the deity had to be through the intermediary of a
priest. The church was fending off the rising up of heretical cults, such as the Cathars,
who refused to grant the church its role of religious leadership and claimed that the
individual, on his or her own, could relate directly with divine powers. Therefore, later
holy anorexics could expect to be questioned by the Inquisition rather than be elevated
to sainthood. This retrenching of clerical power may have had a significant effect; how-
ever, other factors may be considered as well. The early Renaissance in southern Europe
appears to have been a time of sufficient affluence to allow for a return of an esthetic
sensibility with its own ideal of feminine beauty and behavior (Whitton, 1988). It was
also time, according to Burckhardt (1944), that women were approaching equality in
education with men. These forces seem to conflict with the actual role of women in
everyday life, in which they were forced into arranged marriages and expected to have
numerous offspring, because a good percentage of these never lived to adult life. The
decline of the Renaissance saw a return of more difficult economic realities for the
populace. With this general impoverishment, there arose a new domination by males
within the church as well as among the laity. Male priests were the only ones who could
intervene with God and also became the church's intellectual elite in the form of the
Jesuits, who excluded women from their ranks.

THE 17TH AND 18TH CENTURIES-THE MIRACULOUS MAIDS

The interpretation accorded fasting women in the centuries between the Renaissance
and the modern era was transformed gradually. In the Reformation, these starving
women were thought to be possessed by the devil, later they were thought to be frauds
seeking notoriety and, lastly, they were seen as either physically or mentally ill (Brum-
berg, 1988). The case histories of these women follow a fairly typical pattern: They were
usually young, of humble origins; they ate only delicate objects such as rose petals (or
as in one case, a woman existed only by the smell of a rose [Brumberg, 19881) adding to
their sense of purity and ethereal nature. They commonly became famous in their
surroundings and were visited by delegations of priests, doctors, or political represen-
tations who put them through a series of investigations to determine the cause of their
inedia. One such case, Eva Fleigen, mentioned by Brumberg (1988), was put to the test
by being taken to a garden and induced to taste exotic fruits. It was reported that as a
result of tasting only one cherry Eva became ill and nearly died. As printing became
more available to the general public, news of these cases became more widespread,
possibly influencing other girls to become anorexic. Soon Protestant as well as Catholic
women were affected and the wealthy as well as the poor showed signs of self-
starvation.
One such case is frequently cited (Bliss & Bruch, 1960)because her description appears
in a letter by the philosopher Thomas Hobbes, written in 1669. This fashionable girl lost
224 Bemporad

her appetite completely and was said to exist only by wetting her lips from a feather
dipped in water. Hobbes describes her as totally emaciated, so that her belly touched her
backbone. She was visited by the curious (as well as by officials) who offered a small
payment for the privilege of seeing her. Apparently the girl refused these offerings, but
her mother accepted them. Hobbes makes no conclusion regarding the cause of the girl’s
affliction, nor does he inform us as to her eventual fate. Such individuals appear to fulfill
criteria for primary anorexia nervosa as currently diagnosed. Little is known as to cir-
cumstances surrounding the initiation of self-starvation or the eventual fate of the vic-
tims. These cases appear to be infrequent, however. Because only those individuals who
aroused public notoriety have been reported, it is impossible to know the actual inci-
dence. Many such women may have developed the disorder and either died or recov-
ered, in obscurity.
One case of self-starvation is Martha Taylor who is historically important for prompt-
ing John Reynolds to write “Discourse on Prodigious Abstinence,” an essay attempting
to demolish arguments of supernatural causation and suggesting a medical etiology
(Brumberg, 1988). Therefore, this document may be interpreted as exemplifying the
transition in thought from religious to secular models of explanation. Reynolds argues
against the proposal that Martha was fed miraculously by angels by questioning why
such a favor should be bestowed on a person of “no known sanctity.” He finds it
incredulous that God should select such an irreligious young woman who is so devoid
of spirituality. Reynolds uses the same argument against demonic possession, stating
that the devil would not waste his powers on so modest a trophy as Martha. Therefore,
Reynolds concludes, the self-starvation of this woman has no grand purpose and its
cause should be sought in medical rather than religious realms. He then offered a theory
of ”fermentation” based on the works of Thomas Willis (of neuroanatomical fame) who,
in turn, were influenced by William Harvey’s demonstration of vascular circulation. In
brief, Reynolds proposes that Martha’s internal organs create food by fermentation and
release nutrients into the circulatory system, so that the individual can exist on his or her
own resources, without need of external food supplies. Actually, Reynolds’ theory
attempts to explain how it may be possible for a person to survive self-starvation rather
than why a person should wish to do so. The best clue to the reason for fasting that he
offers is his speculation that most anorexic behavior occurs between the ages of 14 and
20, when “the seed hath so fermented the blood, that various distempers will probably
ensue without due evacuation” (cited in Brumberg, 1988, p. 54) Therefore, the illness is
due to an abnormal condition of the blood.
The exact details of Reynolds’ formulations are of little importance; what is significant
is his use of a medical model to explain anorexic behavior. In this more secular age,
abnormalities of behavior brought to mind physiological malfunction rather than either
sainthood or demonic possession. Anorexic women were treated more and more as
physically ill and subjected to various treatments based on prevailing theories of disease.
For example, Bliss and Bruch (1960) discovered nine doctoral theses on the subject of
anorexia (in the historical collection of the Armed Forces Medical Library) written be-
tween 1685 and 1770. The existence of these documents certainly suggests that anorexic
behavior continued to appear despite the fact that the affected individual was considered
sick at best, and a fraud at worst. One of these monographs, written by Hardenus in
1703, explained the illness as due to insufficient bathing of the gastric nerves by bodily
fluids. In other instances, when the individual was grossly disturbed, anorexia was
believed to be due to the brain’s insensitivity to messages from the stomach. Almost all
of the nine dissertations did ascribe at least a minor role to emotional factors. One thesis,
Starvation Through the Ages 225

by Glado, written in 1696, cites one woman who became ill when she learned of the
death of her beloved brother. The subsuming of anorexic behavior under the heading of
medical disorders allowed Richard Morton to include it in his treatise on the various
forms of consumption in 1689. This major work was one of the first systematic treatises
on tuberculosis and was widely read, going through many editions, some being trans-
lated into English from the original Latin. Morton’s description of two cases, one an
18-year-old boy, has been considered the first complete and modern description of
anorexia nervosa. Morton describes a “nervous atrophy” or a wasting away of the body,
without concomitant fever, cough, or shortness of breath but accompanied by a want of
appetite and bad digestion, leading to the “falling away of flesh every day more and
more” (cited in Brumberg, 1988). Among the causes of this condition, Morton mentions
violent passions of the mind, intemperate drinking, and unwholesome air, which de-
stroy the tone of the nerves throughout the body. Morton also observes that he has seen
this form of consumption most frequently in individuals who come to England after
living in Virginia. Morton’s female patient died after tiring of his medical treatment but
the boy seemed to be recovering after giving up his studies, going into the country, and
starting on a milk diet.

THE NINETEENTH CENTURY: DIFFERENTIAL DIAGNOSIS

The 19th century was a time when medical description became more precise with a
listing of the constellation of symptoms which, when clustered together, produced a
wealth of syndromes bearing either their discover’s name or a translation of the more
blatant manifestations into Latin or Greek. Numerous instances of eating disturbances
were described in detail which allow us to decide whether these really met the criteria
for anorexia nervosa as we would now diagnose the disorder. For example, Shorter
(1994) described two 19th century cases of eating disorders that highlight the difference
in associated symptomatology, etiology, and course.
The first case is a 16-year-old girl who was forced to break off a romance with a man
with whom she had fallen in love. At the moment she was told to terminate this
relationship, she felt a heavy pressure on the lower region of her esophagus. This
symptom persisted until she was unable to eat, insisting that the ingested food was
becoming stuck in her esophagus. This girl also developed pain at the slightest pressure
on her sternum, anesthesia of one hand, and a dry cough. Later she complained of
hyperesthesia of her face and her facial muscles began to twitch. Eventually, she also
manifested spells resembling a sort of cataplexy during which she was conscious of her
surroundings but could not speak or move. Gradually, she was able to eat, but only in
the evening.
The other case is of a 17-year-old Italian girl who gradually ate less and less, claiming
food ”would simply not go down.” Concurrently her menses ceased and despite her
emaciation took long walks. She asked to enter a nunnery, a request her family granted,
and after 3 months died of malnutrition. Examinations by physicians revealed no phys-
iologic abnormalities.
The former case included food refusal as part of a complex of hysterical symptoms,
whereas the latter appears to represent true primary anorexia nervosa as described
repeatedly in various centuries. Therefore, hysteria not uncommonly presented with
alimentary symptoms resulting in an inability to eat, either because one could not
swallow or one felt a mass in one’s stomach or one suffered from gastrointestinal pains
226 Bernporad

after ingesting food. As Shorter (1994) proposed, these hysterical complaints seem to
have subsided once diagnostic tools such as X-rays could disprove the existence of a
gastric mass or esophageal paralysis that was held to be responsible by the patient for
her anorexia.
Other forms of self-starvation were described under the rubric of “sitophobia” (from
sitos, Greek for grain). This disorder, characterized by an ”intense dread of food,” was
found in inmates of psychiatric asylums, being reported by W.S. Chipley in the American
Iournal of Znsanity in 1859 (Brumberg, 1982). The anorexia of his patients was an integral
part of a serious psychiatric disorder and Chipley considered the refusal to eat as a
secondary problem. The two most prevalent forms of sitophobia were those where the
individual believed her food was poisoned and where a divine command or some other
supernatural force directed the individual not to eat. In these cases, food refusal may be
seen as a by-product of an underlying psychotic disorder.
Another form of eating disorder reported in the 1800s was ”chlorosis,” named for the
greenish tinge of the skin of its victims (from the Greek “chloros” for green), although
Loudon (1984) believes the term “green” was actually used to connote the immaturity of
the affected patients who were primarily young females. The symptoms of chlorosis, in
addition to a scanty or lack of appetite, included decreased energy, headache, shortness
of breath, and amenorrhea. After blood tests were included as part of a routine medical
evaluation, it was found that chlorotic girls were anemic, so that after 1870 the disease
was called chloro-anemia or just simple (as opposed to pernicious) anemia (Loudon,
1984).A history of the disease is presented by Loudon (1984), who traces descriptions of
the ”green sickness” back to the 16th century. At that time, it was called the “virgin’s
disease” and its cause was thought to be due to the absence of menses, leading to a
reabsorption of alleged toxins in menstrual fluid that had not been discharged. When it
was accepted (around 1800) that amenorrhea was compatible with perfectly good health,
other etiologies were proposed, including abdominal compression due to tightly laced
corsets, eventually culminating in hychrochromic anemia as the underlying cause. Al-
though quite common in the late 19th century, chlorosis essentially disappeared after
World War I.
Loudon speculates that chlorosis was actually a group of diseases of adolescent fe-
males that were lumped together on the basis of some common features. His major
division is between chloro-anorexia and chloro-anemia. The former was found in
younger wealthier girls in whom loss of appetite, social withdrawal, depression, pica,
and amenorrhea were prominent features, and anemia appeared late in the disorder as
a secondary characteristic. The latter was found in older, working class women who did
not manifest anorexia, pica, or psychological symptoms, but did present with severe
anemia. The chloro-anorexia group was thought to represent true cases of anorexia
nervosa, whereas the chloro-anemia group was considered a nutritional deficiency or a
result of gastric ulcers or inflammation. This blurring of subtypes under the umbrella of
one disease entity testifies to the diversity of eating problems confronting the 19th
century physician as well as the difficulty in arriving at a definitive diagnosis in the
absence of laboratory data.
Another category of 19th century fasting women, who would not be classified as
anorexic, concerns individuals who probably claimed to exist without nourishment in
order to attract attention, make money, or both. The first famous instance of such fasting
was possibly Ann Moore of Tutbury whose fasting became public in 1807. By 1813, her
story was big news on both sides of the Atlantic, filling newspapers and culminating in
a likeness of her being exhibited at the Columbian Museum in Boston (Brumberg, 1988).
Starvation Through the Ages 227

Ann was a poor woman who was separated from her husband and supported herself by
domestic services or beating cotton. She also received a small allowance from the local
parish. Her fasting has been attributed to difficulty in swallowing and postprandial
stomach pains following her having to wash the bed clothes of a victim of scrofulous
ulcerations that gave off a disgusting odor. In addition to her fasting, Ann adopted a
religious attitude (in contrast to her formerly loose past that included two illegitimate
children), and beseeched God and the local clergy for salvation. This desire for redemp-
tion did much to endear her to her neighbors who supported her claim to exist without
food. She was the object of numerous investigations, all of which failed to discover any
secret source of nourishment. After 5 years of notoriety and considerable financial gain,
it was discovered that Ann’s daughter was surreptitiously supplying her with tiny
morsels of food through kisses and that Ann was also secretly drinking fluids. In 1814,
Ann was forced to recount and publicly declare her deception. However, for half of
decade she had assumed celebrity status, attracting a stream of visitors to her small
village who paid for the privilege of seeing her. For a long period after her deception was
discovered, however, Ann became a symbol of female cunning and was cited in medical
texts as an example of the fraudulence of both religious fasting and the ability to exist
without nourishment.
Ann Moore’s sorry fate did not deter a host of other young women to claim to exist
without eating or drinking. The attraction to make such pronouncements may have been
the striking public interest that such cases provoked. It is possible that such women were
used to reassure oneself against the growing philosophical materialism espoused by the
medical and scientific communities and to reaffirm the threatened belief in a spiritual
existence that defied this very materialism.
The story of these fasting girls has a recurrent Cinderella theme. They were often from
poor families with many children, living in small hamlets or farming communities. Their
fasting became noticed by local authorities and the news of their existing without nour-
ishment spread throughout the area. Soon they became local attractions with visitors
from everyday life as well as from the clergy and the medical profession. Not uncom-
monly, the girls became opportunities for theoretical arguments between the practical
physician who claimed them to be fraudulent and religious zealots who claimed them to
be ethereal.
Another such woman, Sarah Jacobs, became a celebrity in the British Isles and the
United States in the 1860s (Brumberg, 1988). One of seven children of a small farmer in
Wales, Sarah began fasting as her puberty approached, soon claiming to exist without
any food. Sarah was watched by the local vicars and medical examiners who not only
scrutinized any possible secret intake but also any passage of excrement that would
prove ingestion of some sort. No evidence of feeding was found. Soon, Sarah was
visited by hundreds of curious onlookers who brought her gifts or money. Sarah‘s family
participated in a circus-like atmosphere that had transformed their home. They dressed
Sarah in gaudy clothes and charged for the privilege of taking her photograph. Sarah,
like other fasting girls, became an object of heated debate between the scientific estab-
lishment and the religious populace. Finally, in 1869, four nurses were dispatched from
Guy’s Hospital in London to determine the truth of Sarah’s claims. According to an
agreement with Sarah’s family, she was isolated and the house searched for secret
hiding places where food might have been stored. The nurses took turns watching Sarah
day and night. Within the first 2 days, they reported seeing excrement on Sarah’s
nightdress. However, the father objected to Sarah being seen by a doctor at that time.
After 6 days of this continuous watch, Sarah had become visibly weaker, causing the
228 Bemporad

nurses to appeal that these observations be stopped and Sarah allowed to eat. Again her
father refused, even after doctors stressed the girl’s need for nourishment. Ten days
after the watch had begun, Sarah died of malnutrition. After Sarah’s death, her father
was charged with criminal negligence for not allowing his daughter to be fed or to be
removed to a hospital for proper care. An autopsy found fecal matter dating from prior
to the watch, proving that the girl was somehow able to obtain nourishment. Medical
opinion, at the time, concluded that Sarah suffered from hysteria and her fasting was
perpetuated by her family’s attention and later by the public acclaim she received. The
notoriety that she experienced was thought to have so confused Sarah that she even-
tually believed she could live without nourishment. A note of interest is that despite
Sarah‘s tragic end, the news of her fasting led to a flurry of fasting among young girls
throughout Great Britain (Brumbach, 1988).
A final form of 19th century fasting that should be mentioned in passing is that of the
professional hunger artists. These performers, made famous by Kafka’s short story of
the same name, consisted of individuals who publicly abstained from food as a show of
strength for monetary gain. It may be of interest that these professional fasters were
predominately male, in contrast with the more private, personalized female abstainer.
Some of these men were found to be cheating, others actually died of their prolonged
fasts, and possibly some had some underlying illness (e.g., Claude Seurat, a celebrated
French hunger artist, was found to have a 16-ft tapeworm at autopsy). These individuals
were exhibited as freaks at circuses and seemed to represent an egregious mode of
making a living rather than victims of a disorder (Vandereycken and van Deth, 1994).

RECENT CONCEPTUALIZATIONS: SEARCH FOR CAUSES

Anorexia nervosa was separated formally from other forms of disorders involving
self-starvation by Gull and Leseque within a few months of each other in 1873. Gull
claimed priority in first describing the disorder, solely on the basis of a passing reference
to “hysterical apepsia” in a paper on general medical diagnosis delivered in 1868. Ac-
tually, Louis-Victor Marce, a French physician who managed to write at least 8 books
and 17 monographs on psychiatric topics before his early death at 36, was the first to
publish a modem medical account of anorexia disorder (Silverman, 1989). In an 1859
address to the society medico-psychologue of Paris (which was summarized in the
English Journal of Psychological Medicine in 1860), Marce described a group of young
females who “arrive at a delirious conviction that they cannot or ought not to eat”
(Silverman, 1989) and who present with oppositionalism as well as an obsession with
food. He described certain patients who have died of malnutrition, cautioning physi-
cians to remove the patient from her family for forced feeding, if necessary, to restore
health. Finally, Marce recommended extended follow-up beyond initial recovery, be-
cause relapse was frequent.
Gull and Leseque added some additional symptoms to Marce’s pioneer description
(without acknowledging his contribution) rounding out the full clinical picture of the
disorder. Both mention, in addition to refusal to eat, the onset in early adulthood or
adolescence, restlessness, amenorrhea, and a lack of concern on the part of the patient
over her worsening condition. Both authors presented a rather optimistic prognosis,
with recovery being possible if the patient is given gradually increasing amounts of food
and is separated from her family who might interfere with the proper treatment.
The reports by Gull (1868/1964, 187311964) and Leseque (187311964) may be seen as
Starvation Through the Ages 229

initiating the modern concept of anorexia nervosa, laying the foundation for much of
what is known today about the disorder. Indeed, these manuscripts written over 12
decades ago appear currently relevant to the contemporary reader. Following their
description, anorexia nervosa became a familiar, if still rare, disorder to most practitio-
ners. Descriptions of anorexia were included in psychiatric textbooks so that by 1895,
Freud was able to state, in a letter to Fleiss, “the well known anorexia nervosa of girls
seems to me on careful observation to be a melancholia occurring where sexuality is
underdeveloped’ (Freud, 1959, p. 103).
The latter history of anorexia nervosa in modern times has been well documented by
others so that a very cursory outline can be presented here (Bliss & Bruch, 1960; Selvini-
Palozzoli, 1985; Beumont, Al-Alami, & Touyz, 1987; Brumberg, 1988; Vandereycken &
van Deth, 1994). The disorder was assumed to be of psychogenic origin because recovery
was possible if the patient could be dissuaded from her refusal to eat and because
autopsy findings revealed no organic pathology. This mainly descriptive approach con-
tinued until 1919 when Simmonds called attention to the similarity of the cachexia found
in anorexia nervosa and in women who were found to have atrophy of the pituitary
gland at postmortem examination. As a result of Simmonds’ discovery, the disorder was
considered a form of pituitary dysfunction, often being treated with a variety of endo-
crinological products (Brumberg, 1988). This orientation continued until the 1940s when
Sheehan and Summers (1948) made a carefully documented comparison of the signs and
symptoms of anorexia nervosa and pituitary atrophy. The significant differences noted
were that anorexics lose weight gradually during the course of the illness, whereas those
with pituitary insufficiency only do so late in the course of the illness, and that the
former are hyperactive and deny any personal discomfort, whereas the latter routinely
complain of exhaustion and conserve their limited energy. Also, anorexics, in contrast to
those with so-called “Simmonds’ disease,” do not lose their pubic or axillary hair and
may show a growth of fine hair on their extremities.
Sheehan and Summers’ article (1948) appears to have laid to rest speculations that
anorexia nervosa has an organic basis and returned the disorder to the domain of
psychiatric inquiry. Subsequently, anorexia was interpreted along orthodox psychoan-
alytic formulations that focused on possible unconscious motives behind the manifest
symptomatology. In a classic paper presenting this approach, Waller, Kaufman, and
Deutsch (1940) conceive of the illness as resulting from an oral fixation, poor adaptive
capacities making the transition through puberty particularly difficult, and the postpu-
bertal development of restriction of affect, obsessive modes of thought, and marked
repression of sexual wishes. If such a vulnerable girl received a narcissistic blow during
adolescence, she is said to regress to oral modes of fulfillment that include fantasies of
oral impregnation. The anorexic behavior is thus interpreted as a defense against and
guilt over gratifying this fantasied wish. Although these authors also note the secondary
gain afforded by the disorder, the unconscious wish for oral impregnation and the
patient’s extreme defense against this wish are seen as the crux of the disorder.
The oral impregnation hypothesis gradually diminished as other therapists were un-
able to confirm such hidden desires in their patients and as psychoanalysis, itself,
evolved to encompass the adaptive abilities of the ego and the individual’s relationships
at the expense of repressed unconscious wishes. Along these later themes, Selvini-
Palozzoli (1963) proposed an object-relations view of anorexia nervosa before shifting
her own approach to a familial-transactional model. In this earlier formulation, Paloz-
zoli-Selvini suggested that the anorexic has not differentiated her own body from the
psychic image of the maternal object due to the mother’s sabotaging of her daughter’s
230 Bemporad

normal individuation. The anorexic strives to control and protect herself against the bad
maternal object that is identified with her own body. Therefore, the anorexic is not so
much afraid of eating, but of her own body that must be kept in check by starvation and
exercise. The predisposition to the disorder resides partially in the future anorexic’s
sense of weakness and helplessness that is intensified during the increasing social and
psychological demands of puberty. The anorexic episode is seen as a monosymptomatic
psychosis in which the body is endowed with all sorts of malevolent powers that
threaten the fragile ego of the patient.
A not too dissimilar approach was described by Bruch (1973) who stressed the an-
orexic’s sense of helplessness and ineffectiveness and her disturbance of body image and
perception. Bruch described the future anorexic as lacking an independent sense of self
and as exhibiting a robot-like obedience to the dictates of the family. The patient is
therefore ill prepared for the psychological separation inherent in the tasks of adoles-
cence and grasps onto an extreme control of her body after feeling that she cannot
control anything else in her psychological environment. The anorexic behavior allows
the patient a modicum of security and power, the ability to control her family, and a
moratorium from the overwhelming psychosocial tasks of adolescence. Bruch (1985)
believes that these particular psychological features characterize cases of primary an-
orexia nervosa, in which the disorder is invented by the patient and may not apply to
“me too” anorexics who become ill in imitation of others. The major consequence of the
psychodynamic approach to anorexia nervosa was the emphasis placed on premorbid
relationships, the role of the family in initiating and maintaining the disorder, and the
distortions of the self and others exhibited by the patient. As a result, family therapy
(Minuchin, Rosman, & Baker, 1978), cognitive therapy (Garner & Bemis, 1985), and
traditional dynamic psychotherapy remain popular contemporary approaches to treat-
ment.

TRANSFORMATIONS IN RECENT DECADES

An overview of the alterations that have occurred in anorexic behavior over more
recent decades has been attempted by Russell (1985) and by Bruch (1985). Russell (1985)
cites (1) the increased incidence of the disorder, documenting various epidemiological
studies, (2) alterations in the central psychopathology of the illness, arguing that today’s
anorexics are more fearful of becoming fat rather than defending against sexuality or the
demands of adult responsibility, and (3)the emergence of bulimia nervosa as a frequent
form of eating disorder. This last disorder may or may not overlap with anorexic symp-
toms and seems to present a separate entity with its own characteristics and prognosis
(Herzog, 1994). Russell argues that the increased prevalence of eating disorders may
represent a shift in symptom choice of a population of vulnerable individuals who, in the
past, might have presented with hysteria, anxiety states, or other forms of psychopa-
thology. Russell cites instances of eating disorders that began when the individual read
about them in a magazine or was questioned about symptoms by her doctor, intimating
that suggestion may play a significant role in the spread of these disorders.
Bruch (1985) comments on the changes seen in anorexia nervosa in a review of her
own personal experience in treating this disorder for four decades. A major difference in
patient characteristics that Bruch notes is that those anorexic individuals seen early on
had “invented” their illness, having never heard about the disorder. While indepen-
dently developing anorexia nervosa, these individuals displayed a remarkably similar
Starvation Through the Ages 231

clinical presentation and psychodynamic characteristics. More recent anorexics who

developed the illness after some familiarity with it, appear different to Bruch. They seem
to lack the "passion" of the earlier patients who believed strongly that they were ac-
complishing some positive achievement via their illness and expressed the desire to be
special, unique, or extraordinary. In contrast to the self-isolating, independent early
anorexics, Bruch finds that more recent patients compete with or cling to one another,
seek out self-help groups or special programs, and do not seem as convinced or sincere
in their pursuit of thinness. Bruch comments that the disorder ultimately may lose its
psychodynamic meaning, so clear in older anorexics, as the symptoms become com-
monplace and are manifested by patients with a variety of personal issues. These "me
too" anorexics appear to be blurring the distinctions of what had once been a clearly
definable disorder. Bruch also maintains that the rapid increase in bulimia points to a
differentiation of eating disorders and that this particular syndrome bears little resem-
blance to primary anorexia nervosa although it may include some "me too" anorexics
who cannot maintain rigid control over their eating.

DISCUSSlON
This somewhat cursory review of eating disorders reveals that these illnesses are not
a recent phenomenon but have existed for at least the past seven centuries and well into
the ancient past, if Eastern civilization is included. The form these disorders took at
different historical epochs seems to have vaned as, perhaps, did the motivation behind
the behavior. While a persistent theme is that of a "hunger strike" used to coerce others
to comply with personal wishes, other forms of inedia probably reflect the different
status of women throughout history and the potential social roles available. As indicated
by Bynum (1987) the assumption of a religious life may have allowed medieval and
Renaissance women to escape from prearranged marriages, the fear of death in child-
birth, or the drudgery of and submissiveness that characterized the wife's ascribed role.
The culturally esteemed ideal of a "holy anorexic," to use Bell's term (1985),may have
attracted numerous women to a life of sanctity in imitation of previous individuals
whose self-starvation was highly prized. As the act of extreme fasting was conceptual-
ized as a sign of demonic possession or mental illness rather than as a symbol of
salvation, the incidence of anorexic behavior seems to have subsided, although the
disorder did persist despite these adversities.
A frequent pattern of voluntary fasting emerged shortly afterward in the form of
"miraculous maids" who claimed to exist without requiring nutrition. In a more secular
age, these women were treated more as side show curiosities than brides of Christ,
bringing notoriety to their villages and wealth for their families. The steady trickle of
such cases swells to a good-sized stream as the industrial revolution created a new style
of family and a new status for women. With the spread of factories, women were
increasingly admitted to the labor force, creating a possible conflict between economic
realities and the accepted picture of women as wives and mothers. This industrialized
era (which also saw the rise of the middle class, with its emulation of wealthier indi-
viduals and its importance as a market for mass-produced goods) created a variety of
eating disorders dominated by hysteric symptoms. More recent changes seem to have
engendered a desire for thinness (a symptom not mentioned in characterizations of
fasting women in other times) and a psychological connection between a slender body
and success, sophistication, and self-control.
232 Bemporad

Therefore, it seems that control of food intake and the image of the body have served
as the basis for the expression of female needs or of female psychopathology at least
since the Middle Ages. The relationship between femininity and the psychological use
or abuse of bodily functions, while easy to observe and repeatedly mentioned, still
escapes adequate explanation. This relationship is made more interesting because self-
starvation in women is not documented in historical record until after the spread of
Christianity in Europe. There is essentially no mention of female self-starvation in the
volumes of Greek and early Roman documents that have survived and have allowed
modern historians to reconstruct with certainty the most petty details of everyday life in
the pre-Christian era. Self-starvation or the pursuit of thinness does not seem to have
taken root in the psyche of pagan women. Certainly if anorexia nervosa had existed in
classical times, it would have been recorded by Hippocrates or Galen or at least by those
playwrights, historians, or poets who have allowed us to glimpse into that period. This
absence of eating disorders in ancient times parallels the current paucity of these ill-
nesses in nonindustrialized countries that have not felt the influence of Judeo-Christian
ideas. Therefore, it may be instructive to examine the social status of women as recorded
in ancient Greece or Rome as possibly revealing reasons why eating disorders were not
utilized by women in those cultures, just as most current rural Asian or African women
appear not to suffer from self-starvation.
Such an examination leads to one conclusion that female eating disorders do not
flourish in male-dominated societies. One factor that seems to predispose to eating
disorder is that of female choice in social roles rather than the enforced submission into
a stereotype that limited feminine aspirations to basic nurturant activities. The limita-
tions placed on female opportunities in classical times are apparent in the writings of the
period (Sissa, 1992). In his “Politics” Aristotle justifies slavery by stating that some
beings were superior and meant to rule, whereas others were inferior and meant to
serve. As an ”obvious example” of the inherent dichotomy Aristotle cites the “natural
inequality” between men and women. (Aristotle’s words are as follows: ”the male is by
nature superior, and the female inferior, and the one rules and the other is ruled; this
principle, of necessity, extends to all mankind” [Sissa, 19921.)
Therefore, women, believed to be inherently inferior, were meant to be dominated by
men (Sissa, 1992). In the Timaeus, Plato suggests that women are a degenerate mutation
that occurred in a previously all-male world: The souls of male cowards were reincar-
nated into the bodies of women. Hesiod’s Theogeny, the first systematized collection of
Greek myths, has two versions of the creation of women occurring after the existence of
men (Sissa, 1992). In one, Zeus punishes men by presenting them with women as an evil
gift; in the other, the first woman is Pandora who foolishly opens a box full of woes,
afflicting humankind from then on. Proper Greek women were supposed to leave their
homes as little as possible, and never alone, just as women in some contemporary
Moslem cultures. Based on a study of Greek vase paintings, Lissarraque (1992) con-
cludes that women are always portrayed indoors, performing household tasks. When
women are pictured outdoors, as when drawing water from a public fountain, they bear
tattoos marking them as slaves rather than respectable matrons.
Women did not fare much better in Roman times. A study of legal codes reveals that
a Roman wife was legally considered a daughter to her husband. Inheritance of property
went through paternal authority and not maternal succession. Maternal kinship was
viewed as a natural but not a legal bond (Thomas, 1992). Women were honored with the
title of “Mother,” which carried dignity and respect but no legal power, if they bore their
husbands a son or daughter (the requisite number according to Augustus was three
Starvation Through the Ages 233

children). The conclusion that evolves from the remnants of the classical past is that
women were valued primarily as homemakers and bearers of children in a chauvinistic
world dominated by men.
Similarly, women in non-Westernized and nonindustrialized societies appear bound
to traditional social roles that are characterized by subordination to males and restricted
opportunities. Women in such cultures that are offered little choice seem to be free of
eating disorders.
A second characteristic of societies that seem to produce a higher frequency of eating
disorders is affluence. Selvini-Palozzoli (1985) has also noted the correlation, basing her
conclusion on the absolute dearth of cases during the impoverished years of World War
I1 in Italy leading to a gradually increasing frequency parallelling the economic recovery
in that country. Selvini-Palozzoli (1985) believes that one can only display rigid self-
control by fasting when food is abundant. When food is scarce, every one is fasting.
Daily existence is consumed with survival and social intercourse is reduced to the most
rudimentary assignment of gender-specific roles. The fruition of esthetic sensibility or
speculative thought seems to require a certain degree of leisure or respite from the need
to sustain one’s biological existence. For a good deal of our human history, as in much
of the modern world, the requirements of survival crowded out other avenues of self-
expression. For those living in the ancient world and during most of the Middle Ages,
famines, wars, plagues, and high infant mortality were no strangers. It may be that
improvements in agriculture techniques in the 10th and 11th centuries created sufficient
abundance of material wealth to permit the Renaissance, with its magnificent accom-
plishments, to occur (Whitton, 1982). It was also at this period of relative affluence that
cases of self-starvation became more and more frequent.
Societies where starvation is rampant and survival of children unsure also appear to
place a much higher value on nurturant functions of women than do prosperous, in-
dustrialized nations. One example cited by DiNicola (1990) is of the Efik of Nigeria who
would send pubertal girls to ”fattening houses” in preparation for marriage and moth-
erhood. In these cultures, eating disorders of any form are the exception. Reviewing the
cross cultural literature on anorexia nervosa and bulimia in 1991, Dolan could find only
two reports of African women with anorexia nervosa, and of these, one had been raised
in England before returning to her native Zimbabwe.
However, affluence alone may not suffice to produce eating disorders, necessitating
other factors (such as the relative social liberation of women). Wealthy Moslem countries
that continue to exert extreme control over the female populace also seem to lack eating
disorders. A more basic factor relevant to the presence of eating disorders may have to
do with attitudes of women toward their bodies that are influenced by relative male
domination and degree of affluence. In societies characterized by female subordination
and threat to material survival, there appears to be a high regard for the biological
aspects of existence.
Women are (and were) esteemed for their capacity to procreate, to literally nourish
others (by breast-feeding or by food preparation), and to provide a haven for child
rearing and protection from the nonfamilial world. This view of women has been termed
chthonian, by Paglia (1991), meaning of the earth (actually of the earth’s bowels, not its
surface). Paglia (1991) adopted the term from Jane Harrison‘s study of early Greek
religion and uses it as a substitute for Dionysian, which has come to represent more of
a sense of revelry and wild sexual abandon. In essence, chthonic functions may be
defined as those that are important for the perpetuation and preservation of humankind;
procreation, feeding, and protection of the young. These refer to the most relevant
234 Bemporad

female behaviors of subhuman species throughout the phylogenetic spectrum. In op-

position to the chthonic aspect of human nature, Paglia (1991) poses Apollonian func-
tions, which deny or combat our basic rootedness in biology. Apollonian means esthet-
ics, order, culture. The chthonian modes of knowing are proximal (feel or touch, smell
and taste) and the Apollonian are distal (seeing and being seen, and hearing). Paglia's
point is that the chthonian represents the feminine, whereas the Apollonian is primarily
a masculine mode of negating these very chthonian aspects. Paglia further argues that
Western civilization has become increasingly Apollonian ever since the Greeks, and
women have accepted the values that these evolving cultures have espoused. The result,
states Paglia, is that women in Westernized (or Apollonian) societies are in conflict with
their chthonic nature. To quote her: "Western woman in an antagonistic relation to her
own body; for her, biological normalcy is suffering, and health an illness" (p. 10). Paglia
continues: "the more woman aims for personal identity and autonomy, the more she
develops her imagination, the fiercer will be her struggle with nature-that is, with the
intractable physical laws of her own body" (p. 19).
These physical laws inherently involve reproduction, selected by evolutionary forces
to perpetuate the species. Pagila writes, "The female body is a chthonian machine,
indifferent to the spirit who inhabits it" (p. 10). Paglia selects the Venus of Willendorf as
a plastic representation of the chthonian aspect of women. This small statuette, one of
many similar ones found throughout Europe, is believed to date from about 30,000 B.C.
It depicts a woman with huge thighs, buttocks, breasts (over which are carved thin,
puny arms), and an enormous protruding belly. The statue's face is covered with rows
of curls that encircle the entire head, obliterating any distinctive facial features. There are
no feet, possibly because the statuette was propped up by fitting to carved slots. As a
contrast to these bulbous, faceless earth mothers, Paglia selects the familiar bust of
Nefertiti as an early image of an Apollonian conceptualization of femininity. This statue
displays a regal head with a large crown hiding her hair and an elaborate necklace below
a long sleek neck. The facial expression is cold and ethereal, possibly superior. Accord-
ing to Paglia, the Venus of Willendorf is all body, Nefertiti is all head. The conflict
between the chthonian and Apollonian is that between body and head-between bio-
logical corporeality and cerebral esthetics.
Paglia does not consider anorexia nervosa in her book, whose aim is an exposition of
the sexual and psychological tensions underlying the portrayal of human beings in the
plastic or visual arts throughout Western history. However, her thoughts, derived from
a totally different context, are extremely similar to those expressed by Orbach (1986) in
her study of recent cultural conflicts, which she emphasizes as resulting in eating dis-
orders. Both perceive Western civilization as forcing women to turn against significant
parts of their inherent nature. In the search for social acceptance, women are said to
have to deny their basic biology in a world where the body has become a public repre-
sentation of the self. Therefore, an ultra thin body is seen as elegantly feminine and
simultaneously a rejection of traditional female attributes. To adjust successfully to
Apollonian culture, women have to disavow or denigrate their biological functions such
as pregnancy, menstruation, childbirth, lactation, and so on. Anorexia nervosa sup-
presses these very disagreeable aspects of female existence and may be seen as a cari-
cature of an Apollonian ideal of abstinent self-control, achievement, and denial of one's
corporeality.
Many of our contemporary anorexics may feel compelled to reject their bodies as
unwelcome reminders of a detested or feared part of the self. They may seek thinness
Starvation Through the Ages 235

as a personal and public demonstration of their strong-willed victory over their physi-
ology. As ballerinas, fashion models, or athletes, these women are content in controlling
their chthonian striving. Others, such as the writer Isak Dinesen, may have chosen
anorexia nervosa as a symbol of heroic power over the stifling prospect of middle-class
womanhood. According to her biographer Thurmann (1982), Dinesen threw her lunch
out of a window as an adolescent in order to know the heroic through hunger and
suffering. Thus began a quest for emaciation that finally took Dinesen’s life, persisting
for decades and augmented by the use of laxatives, arsenic, and amphetamines. Dine-
sen’s heroic struggle was against her own body and its requirements. In a manner
similar to the formulations of Selvini-Palozzoli (1963), Dinesen’s body appears as an
alien being that must be kept at bay, if one is to survive psychologically.
However, some anorexics have not sought out slenderness by their self-denial but a
form of saintliness. A modern illustration of this holy anorexia was Simone Weil, of
whom Coles has commented aptly, ”Her hunger was for God, not a slim waistline”
(Coles, 1987). For such anorexics, fasting appears to represent not simply an attempt to
master their corporeal selves but to achieve a sense of ethereal sanctity, an existential
status that is above the requirements of earthly nutrition. After a life of self-starvation,
denial of sexuality, bodily neglect, tireless activity, strident oppositionalism, and rigidity
(while always staying close to her family), Weil became converted to a personal mystical
Christianity, increasing her search for purity, other worldliness, and a rejection of all
material things. Weil died at 33 years of age of malnutrition and tuberculosis, while
attempting to convince the French government in exile in England to send her on a
suicide mission into Nazi-held Europe (McLellan, 1990).
Weil is an important paradigm of a primary anorexic, who exhibits the passion that
Bruch comments upon, and who bears a striking resemblance to the religious anorexics
of the Middle Ages. Therefore, Coles’ remark that her hunger was for God and not a
slender waistline. However, Weil in her own way, just as Dinesen in hers, expresses the
basic conflict between the passions of the spirit and the requirements of the body. As
indicated above, in an Apollonian culture, the body’s chthonic functions are viewed as
messy, primitive, and chaotic, necessitating control and vigilance. For the classical
Greeks, the body appetites interfered with the psyche’s appreciation of abstract truth
and beauty. Sense perception was an inferior mode of knowing or being but it was, at
most, a source of misinformation, not inherently evil. However, as Plato’s thoughts
merged with the pessimistic world view of the Gnostic religions during the early cen-
turies of Christianity, the body took on a more sinister character: that of temptation away
from spiritual salvation (Ranke-Heinemann, 1990). The body, and particularly sexuality,
became invested with intonations of a sinfulness and personal baseness unknown to the
Greeks. This further projection onto the body of malevolence added to the already
existing prejudice brought about by the Apollonian ideals of order, beauty, intellect, and
reason. We cannot be certain how this later pejorative characterization of corporeality
affected the women’s views of their own bodies or their own appetites. However, this
view of the body is to be found in the writings of holy anorexics from Catherine to Weil.
The progression to Apollonian culture does not appear to produce the same conflict in
men, suggesting a possible reason for the much higher frequency of eating disorders in
women. Chthonian functions in men seem fairly limited to insemination. Less affluent
cultures or less industrialized cultures may place a higher premium on physical strength,
aggressiveness, and courage in their male citizens but the suppression of these in more
sophisticated civilizations does not seem to pit the masculine body against the masculine
236 Bemporad

mind. Men may pay other prices for the security or satisfaction of advanced society such
as psychosomatic disorders, secondary to the suppression of primal instincts, but have
not had to wage a personal war against their natural corporeal selves.
These arguments would lead to the conclusion that eating disorders, in one form or
another, are the price paid for Western civilization. This is not a novel idea, being
adumbrated by Freud’s classic statement of the antithesis between biology and culture.
In Civilization and its Discontents (Freud, 1930), Freud proposes that while civilization
affords humanity a sense of security, order, and beauty, these blessings can only flour-
ish at the expense of our most basic instinctual urges. For Freud, the suppression of
sexuality results in neurotic symptoms while the suppression of aggression leads to
excessive guilt. Freud concludes that individuals become neurotic because they cannot
tolerate the degree of frustration that society imposes in the service of its cultural ideals.
Nor will this frustration ever end, for he writes, “We shall never completely master
nature; and our bodily organism, itself a part of that nature, will always remain a
transient structure with a limited capacity for adaptation and achievement” (Freud,
1930, p. 86). Therefore, in order to attain any sense of organized community, humanity
must sacrifice its freedom and happiness. In essence, Freud is stating that there can be
no allegiance, or even a truce, between the Apollonian ideals of culture and the chthonic
forces of biology. The only result is a general malaise at best and psychopathology at
worst.
The same formulation may be applicable to eating disorders which can be understood
as a necessary repudiation of those biological functions that are counter to the ideals of
civilization. Orbachs (1986) analysis of anorexia nervosa becomes more understandable
in this context. She proposes that the female body is simultaneously an object of beauty
for others (an Apollonian function) and a machine for procreation (a chthonian func-
tion). These differences cannot be reconciled, so that biological drives are feared and
suppressed. Orbach stresses that there is an “. . . implied directive to conceal the phys-
ically maternal side of oneself. Slimness is opposed to fertility” (p. 75) or again ”. . .
thinness bears witness to the attempt to deny human biology and the process of devel-
opment.” (p. 74).
Therefore, a search through the history of eating disorders suggests that these mala-
dies, taking various forms in different eras, may basically stem from a conflict between
chthonian and Apollonian means of existence for female members of the population. It
may be that primary anorexia nervosa may exist in any culture, representing a female’s
self-invented reaction to her corporeality secondary to familial or personal issues, and
may have escaped detection or be misdiagnosed as another disorder. However, the
popularity of these disorders at different points in time may reflect the degree to which
the dichotomy between desired Apollonian traits and dreaded chthonian characteristics
is exaggerated. These disorders may be reduced greatly if this dichotomy is reduced
significantly in our culture and its ideals.

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