PSYCHOSOMATIC MEDICINE

The Early Canadian History of Anorexia Nervosa

1
David S Goldbloom, MD, FRCPC

Objective: To examine several early Canadian descriptions of anorexia nervosa (AN) in light of modern
understanding of the disorder.
Method: Two clinical reports of AN from the late 19th century and early 20th century in Canada are cited and
summarized. These original case descriptions are then compared with late 20th century knowledge of the disorder.
Results: Both of these early descriptions contain many astute and prescient observations on the etiology and
sequelae of AN and reveal a compassionate approach to patient care.
Conclusions: Canadian contributions to the medical literature on AN prior to 1970 merit both careful scrutiny
and appreciation in the world literature on this disorder.

(Can J Psychiatry 1997;42:163–167)

Key Words: anorexia nervosa, history, eating disorders

T he modern history of AN includes an extraordinary pan-

oply of investigations into the psychological, sociocultu-
ral, and biological determinants of this therapeutically vexing
disorder. In recent years, the evolution of eating disorders as
a field of academic inquiry has witnessed the proliferation of
comprehensive textbooks (1,2), subspecialty journals, such as
the International Journal of Eating Disorders, and clinical
research and treatment centres in Toronto, Vancouver, and
Montreal, as well as sites in Europe, the United States, Aus-
tralia, and Japan. For the past 2 decades, the media attention
focused on this disorder has perhaps contributed both to
public awareness of AN and to the misconception that it is
largely a disorder of our times reflecting a cultural preoccu-
pation with thinness and personal control in a context of food
abundance. This view not only ignores the extensive 19th
century documentation of the clinical features of AN in
Europe but also does disservice to early Canadian contribu-
tions to the description and study of this disorder. A substan-
tive academic historical literature documents the evolution of
Manuscript received December 1996.
1
Associate Professor of Psychiatry, Clarke Institute of Psychiatry and Uni-
versity of Toronto, Toronto, Ontario.
Address for correspondence: Dr DS Goldbloom, Clarke Institute of Psychia-
try, 250 College Street, Toronto, ON M5T 1R8
e-mail: goldbloomd@cs.clarke-inst.on.ca
Can J Psychiatry, Vol 42, March 1997
163
19th century and earlier forms of AN from a theoretical
perspective (3–5); this paper seeks simply to draw attention
to some relatively unacknowledged clinical descriptions by
Canadian physicians. These descriptions are not the result of
a systematic search or historical analysis of the medical
literature between 1895 and 1940 but simply are publications
of which the author has become aware through published
histories of this disorder.
For most historians of medicine, Sir William Gull
(1816–1890), physician to Queen Victoria, is regarded as the
physician who best described AN and gave it its name. He
was one of the preeminent physicians of Victorian England;
shortly after his clinical case series was reported (6), the
distinguished physician Ernest Charles Lasegue in Paris in-
dependently provided a rich clinical perspective on the same
disorder (7). The typical debate over who was the first to
describe AN persists to this day (8)—a conflict of culture,
language, and nations that seems particularly apt to Canadi-
ans in 1997. Before the 19th century drew to a close, however,
a detailed Canadian case report of AN was published by Dr
PR Inches in the Maritime Medical News of April 1895 (9).
A recent review of the history of AN in 19th century America
cites Inches’ report as the first Canadian publication on AN
but provides little commentary related to it (10). That report
not only reflects clinical acuity and an appreciation for the
psychological aspects of this disorder but also presages many
164 The Canadian Journal of Psychiatry
empirically confirmed dimensions of the context, clinical
features, and treatment of AN. Other recent and earlier 20th
century journal and textbook reviews of the history of this
disorder, however, fail to cite this 19th century publication,
and its influence must be presumed to be modest at best.
Dr Peter Robinson Inches was born of Scottish parents in
1835 in Canada and graduated from the University Medical
College of New York City in 1866. He underwent further
training in Edinburgh and subsequently at King’s College,
London, in 1868—the same year that Sir William Gull first
commented briefly on AN in a lecture at the annual meeting
of the British Medical Association (11). Inches became a
registered physician in New Brunswick in 1881 and served
on various committees of the Medical Council of New Bruns-
wick (12). He died in 1919.
Dr Inches acknowledges the initial description by Gull but
points out that he made notes on a similar case in his practice
prior to reading Gull’s 1888 Lancet report on AN (13). If true,
his observations reflect an extraordinary clinical acumen and
an opportunity for Canada to leap into the fray over where
AN was first observed.
The young woman described by Inches was noted by him
to have been premorbidly obese, now recognized as a risk
factor for eating disorders. He recounted the onset of secon-
dary amenorrhea in this patient at age 17 in the context of
separation from family while she attended boarding school.
This endocrine disturbance, typical age of onset, and psy-
chosocial precipitant are characteristic of modern descrip-
tions of the disorder. Dr Inches admits to having prescribed
emmenagogues without even seeing the patient—and there
was no observed benefit to either her amenorrhea or her
underlying clinical state. This medical approach to the relief
of peripheral manifestations of this disorder was to be revis-
ited a few decades later when AN was treated with pituitary
extract with similarly negative results.
Inches made note of her affective instability and her para-
doxical hyperactivity in the context of cachexia as well as her
denial of her illness: “She still would not allow that she was
ill, but could perform her ordinary house and social duties,
yet there was no change in the condition before described, her
weight was now 90 lbs. only” (9, p 74). Large clinical samples
of AN patients have borne out these observations. He identi-
fied as the most prominent symptom of her disorder “almost
complete refusal of food of any kind” (emphasis added; 9, p
74), which speaks to a distinction between this disorder and
a true anorexia, in which appetite is lost.
No other psychiatric disorder has the protean physical
manifestations of AN (14). Inches chronicled a number of
these which are now routinely listed in modern compendia of
the complications of this disorder, including bradycardia,
hypothermia, and acrocyanosis.
Vol 42, No 2
A consideration of family issues appears in Inches’ report.
While observing the detrimental effect of the illness on family
functioning, he adds that “during the early part of it, that is
while the diseased condition developed, these relations were
of the happiest nature and any disturbance of them took place
long after the disease existed and could not have caused the
inception of it, yet no doubt it was aggravated by such
circumstances” (9, p 74). While this may naively parallel
denial of family problems predating AN, it also points out the
erosive effect of the illness itself, which may confound cross-
sectional assessments of family functioning. Inches men-
tioned in passing that a younger sibling of his patient went on
to develop the same disorder; current knowledge confirms the
presence of an affected sibling as a risk factor for AN (15,16).
The etiology of AN remains unknown. Gull attributed it to
the broad rubric of perversions of the ego. Inches humbly
takes exception to this, preferring to attribute the symptoms
of AN “rather to the ill-fed cerebrum, and rather a conse-
quence than a cause” (9, p 75). We have subsequently learned
through natural and experimental studies of starvation that
this focus on symptoms as a reflection of starvation was an
appropriate one (17). Inches went on to postulate a linkage
between AN and neurasthenia, a 19th century term commonly
used to describe depression. It has subsequently been demon-
strated that the overlap between eating and mood disorders is
indeed high with regard to both comorbidity and longitudinal
vulnerability, although this association falls short of any
suggestion of AN being a depressive equivalent (18). Indeed,
Inches was once again prescient, commenting that “there is a
very important point of difference exhibited in the strong
willpower and continuous activity of the case I have de-
scribed, in contradistinction to the state of excessive want of
energy and weariness of neurasthenia” (9, p 75). His concep-
tualization of the symptoms being secondary to starvation
rather than purely the result of an ill-defined psychological
problem reflected an uncommon view.
The treatment of AN remains problematic and typically
multimodal (19). Inches observed that “the inutility of drugs
in the treatment of the disorder is evident” (9, p 75), a finding
that is essentially unchanged after a century of advances in
treatment research (20). He advocated “isolation from
friends, forced feeding, and massage” (9, p 75), which might
be interpreted as the need for rest, the importance of nutri-
tional stabilization, and consideration of the patient’s envi-
ronment. Modern treatment of AN, while taking a broader
appreciation of biopsychosocial determinants, remains rooted
in the importance of refeeding and has been the subject of
surprisingly little clinical research that would guide treatment
beyond clinical wisdom.
Inches concluded his report with an apology for taking up
the time of his audience with a subject “which may seem to
many of you as only one of that most common and fashionable
March 1997 The Early Canadian History of AN
of all complaints indigestion” (9, p 75). His comments may
reflect a perception of a continuing trivialization within the
medical community of AN as a disorder, despite recent evi-
dence of a long-term mortality up to 18% in some case
series (21).
The second phase of Canadian contribution to the under-
standing of AN came some 40 years later from the Toronto
General Hospital, which, half a century later still, was well
established as the leading academic research and treatment
centre for eating disorders in Canada. Dr HH Hyland, trained
in both neurology and functional nervous disease, was ap-
pointed to the staff of the Toronto General Hospital in 1930
and was a major figure there in neuropsychiatry for the next
30 years; Dr RF Farquharson, trained in internal medicine,
also enjoyed a long affiliation with Toronto General Hospital
and became the Sir John and Lady Eaton Professor of Medi-
cine and physician in chief there in 1947. Both men retired
from the hospital in 1960. During their tenure, they oversaw
the evolution of psychiatric services as an integral part of
medical wards, affiliating a neuropsychiatrist with each of 3
such wards. Between 1943 and 1947, 13 cases of AN were
documented among the 2469 public ward admissions with
psychiatric diagnoses at Toronto General Hospital.
In 1938, Drs Farquharson and Hyland published in the
Journal of the American Medical Association a case series of
8 patients with AN seen at Toronto General Hospital between
1932 and 1937 (22). The title of their report reflected their
perspective on both the etiology and sequelae of the disorder:
“Anorexia Nervosa: A Metabolic Disorder of Psychologic
Origin.” Their paper provided an important counterweight to
an increasingly popular view that AN reflected a primary
pituitary disorder similar to Simmonds’ pituitary cachexia.
While they acknowledged superficial similarities, they em-
phasized that its origins were psychological rather than endo-
crinological.
Among the cases they described, clinical details included
cognitive disturbances, impairment of normative satiety,
mood lability, obsessionality, the need for personal control,
the role of social prejudice against obesity, prodromal dieting,
perfectionism and dichotomous thinking, food preoccupation
and food rituals in parallel with food avoidance, problems
with the normal development of autonomy in adolescence,
emergence of binge eating, vomiting, and laxative abuse,
denial of illness, and ambivalence about hospital-based re-
feeding. All of these are intrinsic to the clinical descriptions
of AN in the late 20th century (23).
Farquharson and Hyland, however, wrote from perspec-
tives of internal medicine and neuropsychiatry; their case
series included metabolic studies and efforts at metabolic
treatment. There was careful documentation of glucose toler-
ance tests and basal metabolic rates and trials of pituitary and
thyroid extracts. They concluded that the low basal metabolic
165
rate seen in AN was a consequence of emaciation rather than
a primary disorder, that it normalized with improved nutri-
tion, and that thyroid extract was of no therapeutic value.
Similarly, while glucose tolerance tests were frequently ab-
normal in the untreated anorexic patient, there was tremen-
dous within-subject variability over time, and it seemed
“wiser not to attach too great significance to variation in the
curve” (22, p 1090). While fasting hypoglycemia was also
frequently evident, it was not as striking as in a number of
primary endocrinopathies, including Simmonds’ disease, and
was not associated with symptomatology.
Through their report, the authors kept returning to the
primacy of psychological factors in this disorder with multi-
ple medical manifestations. They drew attention to the par-
ticular nature of anorexia within AN, noting that “the anorexia
of anorexia nervosa is a morbid aversion to eating, whereas
in Simmonds’ disease there is loss of appetite unassociated
with emotion” (22, p 1091). This astute observation has
subsequently been ignored at times, and the conceptual mis-
understanding of food refusal in AN has led to fruitless trials
of appetite stimulants (20). Further, they observed a striking
difference between the mental state of AN patients and that
of people afflicted with Simmonds’ disease, with the former
reflecting liveliness, intelligence, sensitivity, and wilfulness.
They proposed a 2-step model of treatment: first, attitudi-
nal change of the patient toward food so that the emaciation
can be reversed through adequate nutrition; second, efforts at
relapse prevention “by eradication of the underlying mental
conflict” (22, p 1091). They felt the first task was best
achieved in hospital in a context of structure and supportive
professional staff, away from the environment in which the
disorder developed. Farquharson and Hyland advocated tak-
ing a detailed life history, with particular emphasis on the
interpersonal world of the patient and direct interview of
family and friends. The goal was in part to help the patient
see the connection between her psychological world and her
physical symptoms—the ultimate goal of psychosomatic
medicine. They recommended psychoeducation around bod-
ily adaptation to decreased food intake, for example, early
satiety with refeeding, to reduce patients’ fears around nutri-
tional rehabilitation. Tube feeding was seen as an exception
to this therapeutic norm and, as initially observed by Inches,
drugs were regarded as unnecessary and possibly even coun-
tertherapeutic “because permanent results are more likely to
be obtained if no artificial aids are employed” (22, p 1092).
Finally, they advocated occupational therapy both to divert
patients from their food preoccupation and to promote a sense
of achievement and self-confidence in an area of their lives
beyond eating and weight, thus presaging Hilde Bruch’s
classic description of a personal sense of ineffectiveness in
AN patients (24).
166 The Canadian Journal of Psychiatry
On its own, this 1938 paper remains a classic in the annals
of eating disorders. In 1966, however, these same authors
provided in the Canadian Medical Association Journal a
follow-up study of 15 AN patients treated 20 to 30 years
earlier (25). This represents one of the first longitudinal
studies of AN ever described. The sample consisted of 12
females and 3 males between the ages of 13 and 23 years at
the time of initial evaluation and with admission weights
ranging from 25 to 54 kg. All but one of these patients
experienced significant weight gain with treatment, and a
return of normal menstruation was documented in 10 of the
12 women, although one woman had secondary amenorrhea
for 13 years. One patient was subsequently diagnosed as
having paranoid schizophrenia and another suffered depres-
sive episodes requiring electroconvulsive therapy. Neverthe-
less, the sketchy details suggest positive social adjustment in
the wake of weight recovery. Nine of the 12 women married
and had children, and only 1 of the 3 men had married. The
clinical information is too limited for comparison with mod-
ern outcome studies, but the facts that over 80% of female
subjects had a return of menses and that the average weight
gain across all 15 subjects was 14 kg are impressive by
modern standards (26). The authors’ own estimation is that
10 of the 15 subjects made “good and sustained recoveries
from the initial illness, including one who relapsed on three
occasions over a period of two years” (25, p 418). They were
struck by the high-achieving, intellectual nature of their fe-
male subjects, in contrast with the less interactive and intel-
lectual males.
While acknowledging adolescence as a time of intense
emotion and at times turbulent change, they felt patients with
AN were distinct with regard to “a more fixed attitude with
an overwhelming desire to be thin . . . this desire, amounting
to a deeply seated passion, takes possession of their lives; it
overrides natural appetites and comes to dominate their whole
being” (25, p 418). Similarly, while recognizing that fear of
obesity or teasing about weight figured in the histories of the
majority of their patients, they doubted this could be the sole
etiological factor, otherwise AN would be a more common
disease. They suspected that anxiety and unhappiness from
other areas, including disturbances in the mother–child rela-
tionship, might be contributory.
In terms of treatment, they disparaged intensive psycho-
therapy or psychoanalysis as being either ineffective or even
exacerbating the condition; instead, they advocated support,
education, and weight gain as preconditions to greater self-
awareness and psychological change. The establishment of
trust in the physician was seen as a crucial factor, instilling
the feeling that “the doctor is on her side trying to help her,
and that he does not represent parental authority, although he
wishes to help the parents also” (25, p 419).
Vol 42, No 2
The pioneering contributions of Drs Inches, Farquharson,
and Hyland reflect not only extraordinary clinical acumen but
also a capacity for reflection on the mechanisms of disease
and the nature of suffering; above all, they speak to compas-
sion in the doctor–patient relationship as a cornerstone to
recovery.
Clinical Implications
• Historical clinical observation validates current clinical
research.
• Internists should continue their historical interest in anorexia
nervosa.
• Illnesses are understood in the context of the dominant medical
culture.
Limitations
• This article is a selective rather than an exhaustive review of
Canadian medical literature.
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Résumé

Objectif : Examiner plusieurs des premières descriptions de l’anorexie mentale qui ont été faites au Canada, à la
lumière des nouvelles connaissances acquises sur la maladie.
Méthode : Deux rapports cliniques sur l’anorexie mentale datant de la fin du XIXe siècle et du début du XXe siècle
sont cités et résumés. Ces premières descriptions de cas sont ensuite comparées aux connaissances connues sur
la maladie à la fin du XXe siècle.
Résultats : Chacune de ces deux descriptions renferme de nombreuses observations judicieuses et prescientes sur
l’étiologie et les séquelles de l’anorexie mentale et témoigne d’une approche compatissante en matière de soins.
Conclusion : Les travaux canadiens sur l’anorexie mentale publiés avant 1970 méritent d’être examinés avec soin
et de figurer parmi la documentation mondiale sur ce trouble.