During the Middle Ages, self-starving practices were commonly undertaken by both sexes as a form of religious
observance, particularly during Lent where the control and reduction of food intake was culturally institutionalised. This provided women with the means of experiencing bodily suffering through spiritual fasting. Both Caroline Walker Bynum and Rudolph Bell have explored the role which women assumed in divine practices that involved abstinence from bodily desire. Bynum relates that nourishment was derived by means of prayer and the Eucharist rather than from earthly sustenance as women ‘fasted in order to prepare themselves for Christ’s body and blood.’[1] However, this religious potential for volitional female suffering became largely unobtainable in Britain with the advent of the Protestant Reformation. Worship of the saints was abolished and extreme, publicly demonstrative forms of female adoration such as ‘[t]he renunciation of food, once experienced and explained as a form of female holiness, was increasingly cast as demonical, heretical, and even insane.’[2]
This repression of what were deemed to be irrational forms of mortification attained a new dimension with increasing medicalisation of the female body. The first medical account of self-starvation is credited to the seventeenth century physician Richard Morton who distinguished rejection of food from the loss of appetite that was symptomatic of other illnesses such as tuberculosis and chlorosis, the latter of which Morton commonly terms as ‘Green-Sickness’.[3] In his Phthsiologica – or a Treatise on Consumption (1694), Morton described the case of an eighteen year old girl, resembling ‘“a skeleton only clad with skin”’[4] who
fell into a total Suppression of her Monthly causes from a multitude of Cares and Passions of her Mind, but without any Symptom of the Green-Sickness following upon it. From which time her Appetite began to abate, and her Digestion to be bad; her flesh also began to be flaccid and loose, and her looks pale.[5]
Even though Morton established a specific pathology of self-starvation, the condition would not be formally named for almost two hundred years.
By the nineteenth century, the social status and power of the physician increased as medical authorities had grown secure in the scientific validity of their own assumptions. Unchallenged, physicians increasingly began to compel the subjective experience of their patients to accord with their own doctrine. This was particularly noticeable with female patients and it was at this point in 1873 that an official medicalisation of appetite was elicited when anorexia nervosa was simultaneously diagnosed in England and France by Sir William Withey Gull and Ernest Charles Lasèque. While Lasèque named the condition anorexie hystérique, the term anorexia nervosa was coined by Gull whose description of the malady first appeared in Transactions of the Clinical Society of London (1874).[6] In an 1888 issue of the Lancet, Gull attributed ‘perversion of the “ego” being the cause and determining the course of the malady’,[7] crediting his patients’ refusal to eat to a psychological, rather than a physical affliction as he stated
[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.[8]
Yet, in the processes of coercing patients’ subjective experience, while Gull noted the psychological cause and imension of anorexia, he chose not to engage with his patients’ subjective nuances. By concentrating upon the organic effects, rather than psychological causes, Gull failed to acknowledge the existence of the emotional states of his female patients, treating them as ephemera unworthy of the masculine empiricism upon which the evolving medical discourse was founded.
Even when Huchard and Deniau divided anorexia into the two sub-conditions of anorexie gastrique and 
anorexie mentale in 1883 – describing patients with the former as ‘those with many digestive complaints, in whom hysteria was believed to cause a physiological disturbance leading to impaired gastrointestinal absorption and function,’ and the latter as those with ‘“pure” psychiatric conditions and involved mental rather than digestive problems’[9] – this did not significantly alter treatment, or the way in which female mental phenomena were regarded. Patients diagnosed with anorexie mentale were still treated by controlled or forced feeding in order to overcome the physiological effects, rather than by engaging with the underlying causes that instigated the behaviour.
Yet, while the authority of medical discourse was used to justify the coercion and restriction of female experience, self-starving behaviours continued to create uncertainty within this form of patriarchal control. Gull’s diagnostic security was undermined by the fact that a number of nineteenth century ‘conditions’ shared similar symptoms with anorexia nervosa including bulimia, pica, chlorosis, hysteria and neurasthenia:
“[b]ulimia, pica, and strange longings are morbid modifications of the appetite,” Thomas Laycock wrote in 1840, “and belong to the same class of phenomena as …anorexia…and, like it, are characteristic of the pregnant, chlorotic, and hysterical female.”[10]
Far from being derivations of anorexia, a number of these conditions were theorised and diagnosed prior to the work of William Gull. In 1838, thirty five years before the formal characterisation of self-starvation, the medical adviser in The Penny Satirist described a common disease ‘to which the tender sex is subjected, particularly in the large towns of over-refined countries’, which was identified as ‘chlorosis or green sickness.’[11] The masculine medical establishment responded by perceiving this susceptibility as a female trait and as further evidence that women were the ‘tender sex’. As the advisor continued to observe:
[y]ou can scarcely take a walk in the streets of large towns without meeting young ladies with a pale yellow complexion, mixed with a peculiar greenish tinge, a bluish circle around the eyes, an air of languor and debility.[12]
The cause of such symptoms was thought by Clark to result from the ‘capricious’[13] appetite of the patient, who often exhibited symptoms of pica during which they ‘craved strange substances such as chalk, dirt, ashes, or vinegar’,[14] yet at other times they lost their ‘appetite altogether, sometimes refusing to eat.’[15] As with anorexia, while the psychosomatic nature of chlorosis was noted, arising from ‘one principal source, namely, bad physical and moral education’,[16] the result of ‘[w]ant of proper exercise, improper dress, tight lacing, too much sitting, improper development of the imagination at the expense of the reasoning faculties, boarding-school education, play-going, and novel-reading’,[17] such observation disparaged female subjective experience and trivialised female activities. A further undermining of diagnostic certainty was caused by chlorosis and anorexia occurring within girls of a similar age, with Clark writing that there is ‘frequent occurrence of anaemia or chlorosis in girls between the ages of fourteen and twenty-four’,[18] compared to Gull’s theory of anorexia arising between sixteen and twenty-three. In addition, in cases of chlorosis the Lancet (1887) reported that ‘sometimes there is amenorrhoea’,[19] a symptom also associated with anorexia.
Confronted with such etiological confusion, physicians attributed this uncertainty to a consequence of dealing with the unpredictable, irrational and hysterical female, thereby evading questions regarding the clarity and consistency of the empirical science that formed the foundation of medicine.
[1] C. Walker Bynum, Holy Feast and Holy Fast: The Religious Significance of Food to Medieval Women (Berkeley, 1986), p.117, James of Vitry, Life of Mary of Oignies, AASS, June, vol.5, p.517
[2] J.J. Brumberg, Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease (Cambridge: Harvard University Press, 1988), p.49
[3] R. Morton Phthisiologica: Or a Treatise of Consumptions 2nd edition (London, 1720), pp.8-9, in R. M. Bell, Holy Anorexia (London: University of Chicago Press, 1985), pp.3-4
[4] ibid, pp.3-4
[5] ibid, pp.3-4
[6] E.L. Bliss and C.H. Hardin Branch, Anorexia Nervosa: Its History, Psychology, and Biology (New York: Paul B. Hoeber, 1960), p.13
[7] W. Gull, ‘Clinical Notes’, The Lancet, March 17 (1888), p.517
[8] W. Gull, ‘Anorexia Nervosa’ (apepsia hysterica, anorexia hysterica), Transactions of the Clinical Society of the London 7 (1874), p.25, in J.J. Brumberg, Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease (Cambridge: Harvard University Press, 1988), p.118. Gull identified anorexia nervosa as a disease in its own right, rather than a symptom of another disease since upon examination one patient ‘was found to be extremely emaciated, but there were no signs of organic disease.’ W. Gull, ‘Clinical Notes: A Fatal Case of Anorexia Nervosa’, in Lancet, Jan 19 (1895), p.149
[9] E.L. Bliss and C.H. Hardin Branch, Anorexia Nervosa: Its History, Psychology, and Biology (New York: Paul B. Hoeber, 1960), p.18
[10] T. Laycock, A Treatise on the Nervous Diseases of Women (London: Longman, Orme, Brown, Green and Longmans 1840), p.73, in A. Krugovoy Silver, Victorian Literature and the Anorexic Body (Cambridge: Cambridge University Press, 2002), p.2.
[11] Anon., ‘The Medical Adviser’, The Penny Satirist, iss.43 (London, 1838)
[12] ibid
[13] A. Clark, ‘Observations on the Anaemia or Chlorosis of Girls, Occurring More Commonly Between the Advent of Menstruation and the Consummation of Womanhood’, Lancet, vol.130, issue 3351, 19 November (1887), 1003-1005, p.1003
[14] Victorian Literature and the Anorexic Body, p.2, Noted by Samuel Ashwell, in A Practical Treatise on the Diseases Peculiar to Women (Philadelphia, PA: Lea and Blanchard, 1845)
[15] ibid
[16] Anon., ‘The Medical Adviser’, The Penny Satirist, iss.43 (London, 1838)
[17] ibid
[18] A. Clark, ‘Observations on the Anaemia or Chlorosis of Girls, Occurring More Commonly Between the Advent of Menstruation and the Consummation of Womanhood’, Lancet, vol.130, issue 3351, 19 November (1887), 1003-1005, p.1003
[19] ibid
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