- Email: [email protected]
The Diagnosis and Treatment of Anorexia Nervosa
Medical Clinics of North America March, 1939. Baltimore Number
CLINIC OF DR. ERNEST S. CROSS CHURCH HOME AND INFIRMARY
THE DIAGNOSIS AND TREATMENT OF ANOREXIA NERVOSA ANOREXIA, or lack of appetite for food, is one of the commonest symptoms coming to the attention of the physician. Its significance is as varied as its cause, which may range from the most temporary indisposition to a fatal malady. Probably the symptom, anorexia, appears most frequently in abnormalities of the digestive tract, but hardly less frequently will it be found to be connected with some derangement of the nervous functions. Psychotic patients may refuse food through fear of poisoning in instances of delusion of persecution; melancholia cases may hope for death through starvation and thus develop marked anorexia; delirious states rob the patient of hunger or thought of food; some hysterical individuals may eat secretly and yet appear to be devoid of hunger. Psychoneurotic individuals often complain of poor appetite and many of these patients through hypochondriacal ideas, food phobias, dietary limitations, etc., present considerable grades of malnutrition. Within the psychoneurotic group is to be found a number of instances of almost complete anorexia with profound emaciation who present no organic lesions. The majority of these cases are amenable to proper treatment and recover completely and permanently. They present characteristic manifestations, knowledge of which may simplify an otherwise puzzling clinical picture. The term anorexia nervosa has been aptly applied to this condition. The symptom complex is found chiefly in girls and young women, less commonly in males, and as the name would imply 541
54 2
ERNEST S. CROSS
there is pretty generally a nervous or emotional background and consequently Dejerine applied the term "primary mental anorexia." Since the word mental may connote psychosis to some the term "nervous anorexia" is perhaps better and psychotic manifestations are not in any event properly grouped under this term. The cardinal and constant features are almost complete loss of desire for food, great emaciation, and in females amenorrhea. Thorough examination discloses various other fairly constant findings but no significant organic disease. Such patients may lose half their original weight and the desirability of prompt and correct diagnosis is stressed because such serious depletion naturally opens the way to superimposed infections, including tuberculosis, and even if infection is avoided gradual starvation may eventually bring a fatal result. Moreover, recognition of the condition may be a means of relieving much mental suffering in patient and family, and points the way to rational treatment. The following case history is presented as an example of anorexia nervosa: Miss B. U. D., a seventeen-year-old school girl, was brought by her parents on January 18, 1933, for consultation because of poor appetite and marked emaciation. Miss D. had been subject to a facial tic at times since her sixth year. She had bronchopneumonia in 1931. Her weight fifteen months before consultation was 110 pounds. The menstrual cycle had been established at thirteen and was normal until cessation about nine months previously. For some years she had been limiting sweets and fats to lessen oiliness of the skin with accompanying acne and this had been done at the advice of a dermatologist. In the spring of 1932, Miss D. joined with several of her companions in boarding school in a rigorous diet to reduce weight and with the added idea of improving her skin condition she gave up butter and cream entirely, with the result that she lost 10 to 12 pounds in a short time. During the summer of 1932 she was at home, quite active and apparently cheerful
ANOREXIA NERVOSA
543
and happy though eating very little. Frequent maternal urging to eat more had no effect as she had little or no appetite. The patient returned to boarding school in September, 1932, and not long after this time she was observed by a member of the family to be in a serious state of nervousness with accompanying weeping spells, eating hardly anything, and sleeping poorly. The patient expressed herself as convinced she was going to die and asked to be brought home where she seemed somewhat better, ate a little more, exercised vigorously without special fatigue, but continued to lose weight, which fell finally to a low mark of 70 pounds as compared with 110 pounds fifteen months earlier. Amenorrhea had been present for nine months. Physical examination on January 18, 1933, showed marked emaciation, the actual weight being 73Y:! pounds as compared with a height of 5 feet 3 Y:! inches. The skin was dry and there was slight enlargement of the axillary glands. The blood pressure was 80/55. Pulse was 72. The heart, lungs and abdominal organs were negative. There was no sign of thyroid or parathyroid abnormality. Hirci and crines were normal. There were no neurological abnormalities. The ocular fundi were negative. x-Ray studies of paranasal sinuses, skull, chest, gastrointestinal tract, kidneys and teeth showed no significant disease. The sella turcica was normal. There was no unusual shadow in the adrenal region but there were calcified shadows, presumably glands, in the pelvis. The lungs showed no evidence of tuberculosis though there were some small calcified shadows, like glands, along the mediastinal margins. Ophthalmological examination showed only astigmatism and muscle imbalance. Basal metabolism varied from 12.6 to 13.8 below the average. ,Laboratory investigations gave the following results: Red blood cells 4,888,000, hemoglobin 85 per cent, white blood cells 4400. Small mononuclear cells were increased, namely, 38.8 per cent. Nonprotein nitrogen, uric acid, calcium and
544
ERNEST S. CROSS
phosphorus of the blood gave entirely normal figures. Blood sedimentation was normal and the blood Wassermann was negative. The fasting blood sugar was 73 mg. per cent and rose to a maximum of 148 mg. one hour after the ingestion of glucose. Stool showed no abnormality and the urine contained only a trace of albumin and a few white blood cells. One hundredth mg. of tuberculin intracutaneously gave no response and 1/10 mg. evoked only a very slight reaction. The gastric juice showed a figure of 18 for free hydrochloric acid and 60 for the total acidity and was otherwise negative. The spinal fluid was negative, containing no visible cells and a sugar content of S9 mg. per cent. Fever was absent. The temperature in fact was low, averaging about 97 0 F. Psychological examination indicated an alert, responsive and apparently well-balanced personality, but the patient was considered nervous by her family and showed a recurring facial tic. She was overconscientious, particularly in her studies, and this was evidently extended to dieting for relief of a skin condition and later for slimming purposes. Reviewing the problem, we were dealing with an adolescent girl whose recurring facial tic under stress or fatigue suggested a somewhat nervous temperament. For some time she had limited certain foods to remedy a dermatological condition. The attack of bronchopneumonia two years before had caused her to lose some school work which she attempted to make up, a process which involved a good deal of extra work which was voluntarily assumed. Soon she joined her school friends in dieting to become thinner and the weight fell still further to the extent that her acquaintances commented on her appearance of ill health, and her religious teachers urged her to pray that her life might be spared. By this time, however, she had no appetite and she was frightened and panicky. Menstruation had ceased which was in itself a disturbing factor. Her weight dropped rapidly, 3S pounds or more in one year, and this process was probably accentuated by the fact that she
ANOREXIA NERVOSA
545
was very active physically, taking long walks in the open air but with no increase in appetite. Naturally, the thoughts of the family turned to the possibility of tuberculosis, endocrine disorders or some obscure wasting disease. The important results of the diagnostic study in the case were anorexia, emaciation, amenorrhea, low blood pressure, slow pulse, dry inelastic skin, retarded basal metabolism, hypoglycemia, subnormal temperature and of particular importance no evidence of significant organic disease. Further important considerations included the fact that the patient was a young unmarried girl whose general physical health had been good except for pneumonia two years earlier, and the evidence of some mild emotional reaction through the preceding months. On this basis it was considered legitimate to reassure the patient and her family, though to the father there was communicated the further fact that there was a bare possibility of organic disease of the pituitary gland which could not be revealed by any further tests at that time. This possibility was considered remote and advice was given to treat the case on the basis of anorexia nervosa. The advice was accepted and adequate treatment was carried out over several subsequent months with such a gratifying result that this young woman was able to enter college a year later and to complete her entire course without interruption and with steadily increasing weight and strength to the point of complete recovery. A considerable number of similar cases are to be found in medical literature. In Richard Morton's Phthisiologia, published in London in 1694, one reads two interesting reports. Morton received his medical degree from Oxford in 1670 and was a Fellow in the College of Physicians. He observed that in 1684 a Mr. Duke's daughter, eighteen years old, "fell into a total suppression of her monthly courses from a multitude of cares and passions of her mind." Her appetite for food was lacking and she wasted to a skeleton, without fever, cough or other indication of bodily disease, and finally died. Likewise about the same time a boy of sixteen years, son of a Mr. Steele, totally lost his appetite by hard study and "passions of VOL. 23-35
ERNEST S. CROSS
his mind," and went into a serious decline. Morton could discover no sign of organic disease and cough and fever were absent. In this instance Morton was able to persuade the patient to abandon his studies and to live in the country where great improvement followed an out-door life with horseback riding and the drinking of milk, especially asses' milk. Morton was writing of "consumption" (tuberculosis) and it is on that account more convincing and interesting that he sorted out certain cases in whom he could find no evidence of ')rganic disease but whose symptoms he considered to arise from "a preternatural state of the animal spirits and the destruction of the tone of the nerves." He called these conditions "nervous atrophy" or "nervous consumption" and believed they should be treated by a cheerful life, good air and a "delicious diet." In 1874, Sir William Gull of Guy's Hospital, London, reported 2 cases of anorexia, emaciation, and amenorrhea, with recovery and 1 fatal case. He chose the term "anorexia nervosa" as most appropriate, though in an earlier address on medical subjects he had called the condition "apepsia hysterica." He observed no adequate organic basis for the syndrome which he believed occurred mostly in young women, though it did also occur in males. He stressed the importance of differentiating tuberculosis, and of systematic management. Gull was sufficiently impressed with the importance of recognizing these cases that in the Lancet for 1888 he reported another case with favorable outcome, calling attention to their tendency to retain strength for considerable physical activity in spite of the appearance of serious emaciation. Ryle, in 1936, reported personal observations on 51 cases of anorexia nervosa, grouped as follows: (1) Young females (fifteen to twenty-nine years), 33 cases; (2) older females (thirty-one to fifty-nine years), 13 cases; (3) males (nineteen to thirty-four years), 5 cases. In all these cases the somatic and psychic characteristics were comparable. Thirty-seven of these cases were followed for some time and results were tabulated as follows: Recoveries, 21; improved, 6; unimproved, 6; deaths, 4.
ANOREXIA NERVOSA
547
T. A. Ross, writing in 1936, described 19 cases of anorexia nervosa, of which 16 did very well, though 5 required a second course of treatment to overcome relapse. One died in a relapse. The relapse cases had shown good physical improvement when they left the hospital but had secured little change in their mental attitude which was doubtless significant. DISCUSSION OF CLINICAL FEATURES
Loss of appetite, the most prominent symptom, is found to have various precipitating causes, most of which have more or less emotional content. (a) One set of causes includes voluntary reduction of food, as in slimming diet, which is carried too far. Religious fasting may be responsible in some cases and sometimes debility following an illness, and even restriction of food caused by poverty. (b) Outspoken emotional causes include crises of grief, disappointment, homesickness, unhappiness, maladjustment at home and in the social situation. There is no particular complaint of dyspepsia and in fact these patients do not regard themselves as really ill. They are merely lacking in desire for food as they see it. Emaciation advances steadily and may reach a degree which suggests the last stages of malignant disease or tuberculosis. In extreme cases the weight may decline to one half the original level and in such instances the outcome is apt to be unfavorable. The patient usually looks much older than her years and the skin is dry and lacking in elasticity. Basal metabolism is low and pulse and respiration are slowed, all of which are probably manifestations of malnutrition rather than the result of hypothyroidism. Amenorrhea is characteristic in female cases. Ryle believes it is of emotional origin equally with the anorexia. Malnutrition doubtless re enforces it and it is apt to be the symptom which persists the longest. Reestablishment of menstruation is to be considered as best evidence of relief of the whole symptom complex. DIFFERENTIAL DIAGNOSIS
Several observers state that differentiation of anorexia nervosa depends chiefly upon a little thought and knowledge
ERNEST S. CROSS
of the characteristic clinical picture. Since it occurs largely in the second and third decades of life, tuberculosis must be ruled out as well as any other organic disease, including cancer, by careful study. One condition in particular presents some difficulty and that is a syndrome described first by Simmonds in 1914, who observed at autopsy destruction of the anterior lobe of the pituitary gland. Clinically, these cases show emaciation, amenorrhea, appearance of age, gonadal atrophy, caries, low basal rate, etc. The clinical picture is strikingly similar to anorexia nervosa but there have been enough careful postmortem studies to establish a definite entity known as Simmonds' disease and depending upon destruction of the anterior lobe of the pituitary gland. For the most part the causal factor in anterior lobe disease is one which does not permit x-ray diagnosis. The usual causes are emboli and since the arteries of the anterior lobe are endarteries there is apt to be marked injury of tissue which is replaced by scar tissue. Other causes are metastatic ~ancer, syphilis, tuberculosis, and sometimes acute inflammation. A tumor of any size in the pituitary region would scarcely limit its effect to the anterior lobe of the pituitary and would cause more general signs of increased intracranial pressure, and there would be no opportunity for the development of the typical picture of "cachexia hypophyseopriva" or Simmonds' disease. The history should be carefully scrutinized for possible disease which would lead to involvement of the anterior pituitary lobe. The majority of cases of Simmonds' disease have been reported in older individuals, some of whom have had repeated pregnancies and some serious infections. The most constant characteristics are: (1) progressive loss of weight, (2) diminished sexual function, (3) low basal rate, (4) other findings somewhat variable including asthenia, premature senility, dry skin and hair, and some loss of the latter particularly in the axillary and pubic regions, dental caries, low blood pressure, slow pulse, hypoglycemia, etc. This clinical picture is of course very similar to that of anorexia nervosa and there is no test that will make the differentiation, but it is believed that in most cases
ANOREXIA NERVOSA
549
differential diagnosis can be made by attention to age, details of previous illnesses, psychological study, and thorough investigation of all parts of the body. The result of treatment is of course of the utmost importance for anorexia nervosa cases do respond in most instances, even though slowly, while the progress in Simmonds' disease is unfavorable even in cases where pituitary substitution medication has been tried. TREATMENT OF ANOREXIA NERVOSA
The principal and essential measures are rest, isolation, full feeding and analysis of difficulties. 1. Rest should be absolute, the patient remaining in bed constantly. If the condition is extreme the daily bath should be given in bed and physical activities reduced to a minimum until there is marked improvement. Gentle general massage may be given three or four times a week. Some of these patients feel inclined to exercise and they argue that inactivity will further diminish their depleted appetite, but they should be asked tp accept the principle of rest. Mental activity should be encouraged in a mild way and in gradually increasing measure by reading, games, music, simple hand work, leading on to sketching, modeling, painting, etc. At first the bed may be wheeled out of doors for sunshine and diversion but the process of resuming activity should not be considered until there has been a large gain in weight. 2. Isolation of the patient is in many instances of the utmost importance and should be insisted upon in all of the more extreme cases. The patient should be removed to a hospital or well arranged nursing home and provided with expert nursing care. Visits and letters from family and friends should be interdicted for some weeks and the patient should write no letters. Sufficient communication with the family can be maintained through the letters of the physician and the nurse. Isolation promotes mental and physical relaxation, lessens possibly long-standing stresses and gives the patient the opportunity for a new orientation less hampered by previous habits and reactions.
55 0
ERNEST S. CROSS
3. The method of feeding is important. From long disuse the alimentary processes are depleted and food must be given in small quantities at first and increased only gradually. If food is urged too liberally at the beginning the patient will feel she is asked to do the impossible and will be frightened. Vomiting is the usual result and is not to be considered as either perverse or hysterical in nature but as an indication to proceed more slowly. One may begin with 2 ounces of milk every two hours for eight feedings on the first day, doubling the amount on the second day, and on the third day prescribing 6 ounces every two hours. Fruit juice may now be substituted for one or two of the feedings, or meat broth if desired. On the fifth or sixth day salty crackers, dry toast or thin bread and butter may be added to alternate feedings. Milk should be increased to about 2 quarts in the twenty-four hours but part of it may be given in cream soups, custard and junket. Egg may be added, also pureed vegetables, stewed and fresh fruits, chicken, fish and meat until a normal diet is reached. When a fair amount of mixed food can be taken at regular meal times it is a good plan to teach the patient to swallow 1 or 2 raw eggs after the solid food and milk have been taken. At this time one may well consider whether or not food between the regular meals detracts from the appetite for the succeeding meal enough to lessen the total intake for the day. Milk and perhaps a few crackers can probably be taken anyway just before bedtime. The patient should be weighed once a week. The secret of gaining is to remain in bed and persist in eating liberally. It is often beneficial for the nurse to feed the patient and usually more food is taken this way. When the patient later begins to feed herself it is well for the nurse to remain in the room. When the responsibility for feeding herself alone is entrusted to the patient the weekly gain in weight must be scrutinized to guard against the possibility that food is secreted or thrown away. If necessary feeding may be resumed by the nurse. At the outset the patient may be so enfeebled and so lack-
ANOREXIA NERVOSA
55!
ing in ability to eat that intravenous injections of glucose may be required. The question of the use of insulin to promote gain is an open one in these cases. Hypoglycemia is frequently present, suggesting the advisability of administering glucose in fruit juice at the time of the insulin injection. 4. Analysis or discussion of difficulties must be undertaken in most of the cases if good results are to be obtained. T. A. Ross reports that in his series the relapses occurred in cases that improved physically but had not secured an altered attitude of mind. Frequently this discussion does not have to reach deep levels but there are some cases in which there is a serious underlying difficulty. Very often these patients are unaware of any connection between emotional reactions and physical symptoms. Hence some reeducation along these lines is important and may be the factor which determines the result. In an informal and conversational way one may be able to find and relieve some emotional condition arising through fear, anxiety, boredom, inferiority feeling, jealousy, resentment, etc. To obtain the confidence and cooperation of the patient is of course a great part of the battle. 5. Medication.-The use of insulin has already been mentioned. The usual finding of low basal metabolism might at first thought suggest the use of thyroid substance, but the author believes it is more apt to retard weight increase than to prove beneficial. One observer in discussing another disease warned against being caught in the "endocrine whirl" and we may apply that warning here, for in fact, none of the glandular products seem really serviceable in anorexia nervosa and this extends with particular force to the amenorrhea. Mild sedatives may be helpful. Vitamin reenforcement seems strongly indicated in view of the previous defective and scanty diet. Arsenic, especially in hypodermic form, is suggested. Examination of the blood will determine the advisability of administering iron, liver preparations, etc.
55 2
ERNEST S. CROSS
SUMMARY
Attention is called to a group of individuals, more commonly young females, who show extreme anorexia, emaciation, diminution of sexual functions, retarded metabolism, slow pulse, arterial hypotension, hypoglycemia, etc., the origin of which is referred to a functional nervous disorder and not to organic bodily disease. The symptom complex is ~ather typical, not difficult to recognize in general, and should be differentiated from the anorexia and emaciation of psychotics. The condition is closely simulated by Simmonds' disease which is associated constantly with destruction of the anterior lobe of the pituitary gland and has an unfavorable prognosis in contrast with a generally favorable result in anorexia nervosa. This particular differentiation calls for careful consideration. The essentials of treatment include rest, isolation, full feeding, psychotherapy and symptomatic management over a considerable period of time. BmLIOGRAPHY Calder, R. M.: Anterior Pituitary Insufficiency (Simmonds' Disease), Bull. Johns Hopkins Hosp., 50: 87-114, 1932. Dejerine and Gauckler: The Psychoneuroses and their Treatment by Psychotherapy, 1913. Gull, Sir William: New Sydenham Soc., London, 1894. Morton, Richard: Phthisiologia, London, 1694. Ross, T. A.: An Enquiry into Prognosis in the Neuroses, Cambridge University Press, 1936. Ross, T. A.: The Common Neuroses: Their Treatment by Psychotherapy. An Introduction to Psychological Treatment for Students and Practitioners, 2d ed., pp. 236, Wood, 1937. Richardson, H. B.: Simmonds' Disease and Anorexia Nervosa, Trans. Assoc. Amer. Phys., 52: 141-145, 1937. Ryle, John A.: Anorexia Nervosa, Lancet, 2: 893-899, 1936.
CLINIC OF DR. ERNEST S. CROSS CHURCH HOME AND INFIRMARY
THE DIAGNOSIS AND TREATMENT OF ANOREXIA NERVOSA ANOREXIA, or lack of appetite for food, is one of the commonest symptoms coming to the attention of the physician. Its significance is as varied as its cause, which may range from the most temporary indisposition to a fatal malady. Probably the symptom, anorexia, appears most frequently in abnormalities of the digestive tract, but hardly less frequently will it be found to be connected with some derangement of the nervous functions. Psychotic patients may refuse food through fear of poisoning in instances of delusion of persecution; melancholia cases may hope for death through starvation and thus develop marked anorexia; delirious states rob the patient of hunger or thought of food; some hysterical individuals may eat secretly and yet appear to be devoid of hunger. Psychoneurotic individuals often complain of poor appetite and many of these patients through hypochondriacal ideas, food phobias, dietary limitations, etc., present considerable grades of malnutrition. Within the psychoneurotic group is to be found a number of instances of almost complete anorexia with profound emaciation who present no organic lesions. The majority of these cases are amenable to proper treatment and recover completely and permanently. They present characteristic manifestations, knowledge of which may simplify an otherwise puzzling clinical picture. The term anorexia nervosa has been aptly applied to this condition. The symptom complex is found chiefly in girls and young women, less commonly in males, and as the name would imply 541
54 2
ERNEST S. CROSS
there is pretty generally a nervous or emotional background and consequently Dejerine applied the term "primary mental anorexia." Since the word mental may connote psychosis to some the term "nervous anorexia" is perhaps better and psychotic manifestations are not in any event properly grouped under this term. The cardinal and constant features are almost complete loss of desire for food, great emaciation, and in females amenorrhea. Thorough examination discloses various other fairly constant findings but no significant organic disease. Such patients may lose half their original weight and the desirability of prompt and correct diagnosis is stressed because such serious depletion naturally opens the way to superimposed infections, including tuberculosis, and even if infection is avoided gradual starvation may eventually bring a fatal result. Moreover, recognition of the condition may be a means of relieving much mental suffering in patient and family, and points the way to rational treatment. The following case history is presented as an example of anorexia nervosa: Miss B. U. D., a seventeen-year-old school girl, was brought by her parents on January 18, 1933, for consultation because of poor appetite and marked emaciation. Miss D. had been subject to a facial tic at times since her sixth year. She had bronchopneumonia in 1931. Her weight fifteen months before consultation was 110 pounds. The menstrual cycle had been established at thirteen and was normal until cessation about nine months previously. For some years she had been limiting sweets and fats to lessen oiliness of the skin with accompanying acne and this had been done at the advice of a dermatologist. In the spring of 1932, Miss D. joined with several of her companions in boarding school in a rigorous diet to reduce weight and with the added idea of improving her skin condition she gave up butter and cream entirely, with the result that she lost 10 to 12 pounds in a short time. During the summer of 1932 she was at home, quite active and apparently cheerful
ANOREXIA NERVOSA
543
and happy though eating very little. Frequent maternal urging to eat more had no effect as she had little or no appetite. The patient returned to boarding school in September, 1932, and not long after this time she was observed by a member of the family to be in a serious state of nervousness with accompanying weeping spells, eating hardly anything, and sleeping poorly. The patient expressed herself as convinced she was going to die and asked to be brought home where she seemed somewhat better, ate a little more, exercised vigorously without special fatigue, but continued to lose weight, which fell finally to a low mark of 70 pounds as compared with 110 pounds fifteen months earlier. Amenorrhea had been present for nine months. Physical examination on January 18, 1933, showed marked emaciation, the actual weight being 73Y:! pounds as compared with a height of 5 feet 3 Y:! inches. The skin was dry and there was slight enlargement of the axillary glands. The blood pressure was 80/55. Pulse was 72. The heart, lungs and abdominal organs were negative. There was no sign of thyroid or parathyroid abnormality. Hirci and crines were normal. There were no neurological abnormalities. The ocular fundi were negative. x-Ray studies of paranasal sinuses, skull, chest, gastrointestinal tract, kidneys and teeth showed no significant disease. The sella turcica was normal. There was no unusual shadow in the adrenal region but there were calcified shadows, presumably glands, in the pelvis. The lungs showed no evidence of tuberculosis though there were some small calcified shadows, like glands, along the mediastinal margins. Ophthalmological examination showed only astigmatism and muscle imbalance. Basal metabolism varied from 12.6 to 13.8 below the average. ,Laboratory investigations gave the following results: Red blood cells 4,888,000, hemoglobin 85 per cent, white blood cells 4400. Small mononuclear cells were increased, namely, 38.8 per cent. Nonprotein nitrogen, uric acid, calcium and
544
ERNEST S. CROSS
phosphorus of the blood gave entirely normal figures. Blood sedimentation was normal and the blood Wassermann was negative. The fasting blood sugar was 73 mg. per cent and rose to a maximum of 148 mg. one hour after the ingestion of glucose. Stool showed no abnormality and the urine contained only a trace of albumin and a few white blood cells. One hundredth mg. of tuberculin intracutaneously gave no response and 1/10 mg. evoked only a very slight reaction. The gastric juice showed a figure of 18 for free hydrochloric acid and 60 for the total acidity and was otherwise negative. The spinal fluid was negative, containing no visible cells and a sugar content of S9 mg. per cent. Fever was absent. The temperature in fact was low, averaging about 97 0 F. Psychological examination indicated an alert, responsive and apparently well-balanced personality, but the patient was considered nervous by her family and showed a recurring facial tic. She was overconscientious, particularly in her studies, and this was evidently extended to dieting for relief of a skin condition and later for slimming purposes. Reviewing the problem, we were dealing with an adolescent girl whose recurring facial tic under stress or fatigue suggested a somewhat nervous temperament. For some time she had limited certain foods to remedy a dermatological condition. The attack of bronchopneumonia two years before had caused her to lose some school work which she attempted to make up, a process which involved a good deal of extra work which was voluntarily assumed. Soon she joined her school friends in dieting to become thinner and the weight fell still further to the extent that her acquaintances commented on her appearance of ill health, and her religious teachers urged her to pray that her life might be spared. By this time, however, she had no appetite and she was frightened and panicky. Menstruation had ceased which was in itself a disturbing factor. Her weight dropped rapidly, 3S pounds or more in one year, and this process was probably accentuated by the fact that she
ANOREXIA NERVOSA
545
was very active physically, taking long walks in the open air but with no increase in appetite. Naturally, the thoughts of the family turned to the possibility of tuberculosis, endocrine disorders or some obscure wasting disease. The important results of the diagnostic study in the case were anorexia, emaciation, amenorrhea, low blood pressure, slow pulse, dry inelastic skin, retarded basal metabolism, hypoglycemia, subnormal temperature and of particular importance no evidence of significant organic disease. Further important considerations included the fact that the patient was a young unmarried girl whose general physical health had been good except for pneumonia two years earlier, and the evidence of some mild emotional reaction through the preceding months. On this basis it was considered legitimate to reassure the patient and her family, though to the father there was communicated the further fact that there was a bare possibility of organic disease of the pituitary gland which could not be revealed by any further tests at that time. This possibility was considered remote and advice was given to treat the case on the basis of anorexia nervosa. The advice was accepted and adequate treatment was carried out over several subsequent months with such a gratifying result that this young woman was able to enter college a year later and to complete her entire course without interruption and with steadily increasing weight and strength to the point of complete recovery. A considerable number of similar cases are to be found in medical literature. In Richard Morton's Phthisiologia, published in London in 1694, one reads two interesting reports. Morton received his medical degree from Oxford in 1670 and was a Fellow in the College of Physicians. He observed that in 1684 a Mr. Duke's daughter, eighteen years old, "fell into a total suppression of her monthly courses from a multitude of cares and passions of her mind." Her appetite for food was lacking and she wasted to a skeleton, without fever, cough or other indication of bodily disease, and finally died. Likewise about the same time a boy of sixteen years, son of a Mr. Steele, totally lost his appetite by hard study and "passions of VOL. 23-35
ERNEST S. CROSS
his mind," and went into a serious decline. Morton could discover no sign of organic disease and cough and fever were absent. In this instance Morton was able to persuade the patient to abandon his studies and to live in the country where great improvement followed an out-door life with horseback riding and the drinking of milk, especially asses' milk. Morton was writing of "consumption" (tuberculosis) and it is on that account more convincing and interesting that he sorted out certain cases in whom he could find no evidence of ')rganic disease but whose symptoms he considered to arise from "a preternatural state of the animal spirits and the destruction of the tone of the nerves." He called these conditions "nervous atrophy" or "nervous consumption" and believed they should be treated by a cheerful life, good air and a "delicious diet." In 1874, Sir William Gull of Guy's Hospital, London, reported 2 cases of anorexia, emaciation, and amenorrhea, with recovery and 1 fatal case. He chose the term "anorexia nervosa" as most appropriate, though in an earlier address on medical subjects he had called the condition "apepsia hysterica." He observed no adequate organic basis for the syndrome which he believed occurred mostly in young women, though it did also occur in males. He stressed the importance of differentiating tuberculosis, and of systematic management. Gull was sufficiently impressed with the importance of recognizing these cases that in the Lancet for 1888 he reported another case with favorable outcome, calling attention to their tendency to retain strength for considerable physical activity in spite of the appearance of serious emaciation. Ryle, in 1936, reported personal observations on 51 cases of anorexia nervosa, grouped as follows: (1) Young females (fifteen to twenty-nine years), 33 cases; (2) older females (thirty-one to fifty-nine years), 13 cases; (3) males (nineteen to thirty-four years), 5 cases. In all these cases the somatic and psychic characteristics were comparable. Thirty-seven of these cases were followed for some time and results were tabulated as follows: Recoveries, 21; improved, 6; unimproved, 6; deaths, 4.
ANOREXIA NERVOSA
547
T. A. Ross, writing in 1936, described 19 cases of anorexia nervosa, of which 16 did very well, though 5 required a second course of treatment to overcome relapse. One died in a relapse. The relapse cases had shown good physical improvement when they left the hospital but had secured little change in their mental attitude which was doubtless significant. DISCUSSION OF CLINICAL FEATURES
Loss of appetite, the most prominent symptom, is found to have various precipitating causes, most of which have more or less emotional content. (a) One set of causes includes voluntary reduction of food, as in slimming diet, which is carried too far. Religious fasting may be responsible in some cases and sometimes debility following an illness, and even restriction of food caused by poverty. (b) Outspoken emotional causes include crises of grief, disappointment, homesickness, unhappiness, maladjustment at home and in the social situation. There is no particular complaint of dyspepsia and in fact these patients do not regard themselves as really ill. They are merely lacking in desire for food as they see it. Emaciation advances steadily and may reach a degree which suggests the last stages of malignant disease or tuberculosis. In extreme cases the weight may decline to one half the original level and in such instances the outcome is apt to be unfavorable. The patient usually looks much older than her years and the skin is dry and lacking in elasticity. Basal metabolism is low and pulse and respiration are slowed, all of which are probably manifestations of malnutrition rather than the result of hypothyroidism. Amenorrhea is characteristic in female cases. Ryle believes it is of emotional origin equally with the anorexia. Malnutrition doubtless re enforces it and it is apt to be the symptom which persists the longest. Reestablishment of menstruation is to be considered as best evidence of relief of the whole symptom complex. DIFFERENTIAL DIAGNOSIS
Several observers state that differentiation of anorexia nervosa depends chiefly upon a little thought and knowledge
ERNEST S. CROSS
of the characteristic clinical picture. Since it occurs largely in the second and third decades of life, tuberculosis must be ruled out as well as any other organic disease, including cancer, by careful study. One condition in particular presents some difficulty and that is a syndrome described first by Simmonds in 1914, who observed at autopsy destruction of the anterior lobe of the pituitary gland. Clinically, these cases show emaciation, amenorrhea, appearance of age, gonadal atrophy, caries, low basal rate, etc. The clinical picture is strikingly similar to anorexia nervosa but there have been enough careful postmortem studies to establish a definite entity known as Simmonds' disease and depending upon destruction of the anterior lobe of the pituitary gland. For the most part the causal factor in anterior lobe disease is one which does not permit x-ray diagnosis. The usual causes are emboli and since the arteries of the anterior lobe are endarteries there is apt to be marked injury of tissue which is replaced by scar tissue. Other causes are metastatic ~ancer, syphilis, tuberculosis, and sometimes acute inflammation. A tumor of any size in the pituitary region would scarcely limit its effect to the anterior lobe of the pituitary and would cause more general signs of increased intracranial pressure, and there would be no opportunity for the development of the typical picture of "cachexia hypophyseopriva" or Simmonds' disease. The history should be carefully scrutinized for possible disease which would lead to involvement of the anterior pituitary lobe. The majority of cases of Simmonds' disease have been reported in older individuals, some of whom have had repeated pregnancies and some serious infections. The most constant characteristics are: (1) progressive loss of weight, (2) diminished sexual function, (3) low basal rate, (4) other findings somewhat variable including asthenia, premature senility, dry skin and hair, and some loss of the latter particularly in the axillary and pubic regions, dental caries, low blood pressure, slow pulse, hypoglycemia, etc. This clinical picture is of course very similar to that of anorexia nervosa and there is no test that will make the differentiation, but it is believed that in most cases
ANOREXIA NERVOSA
549
differential diagnosis can be made by attention to age, details of previous illnesses, psychological study, and thorough investigation of all parts of the body. The result of treatment is of course of the utmost importance for anorexia nervosa cases do respond in most instances, even though slowly, while the progress in Simmonds' disease is unfavorable even in cases where pituitary substitution medication has been tried. TREATMENT OF ANOREXIA NERVOSA
The principal and essential measures are rest, isolation, full feeding and analysis of difficulties. 1. Rest should be absolute, the patient remaining in bed constantly. If the condition is extreme the daily bath should be given in bed and physical activities reduced to a minimum until there is marked improvement. Gentle general massage may be given three or four times a week. Some of these patients feel inclined to exercise and they argue that inactivity will further diminish their depleted appetite, but they should be asked tp accept the principle of rest. Mental activity should be encouraged in a mild way and in gradually increasing measure by reading, games, music, simple hand work, leading on to sketching, modeling, painting, etc. At first the bed may be wheeled out of doors for sunshine and diversion but the process of resuming activity should not be considered until there has been a large gain in weight. 2. Isolation of the patient is in many instances of the utmost importance and should be insisted upon in all of the more extreme cases. The patient should be removed to a hospital or well arranged nursing home and provided with expert nursing care. Visits and letters from family and friends should be interdicted for some weeks and the patient should write no letters. Sufficient communication with the family can be maintained through the letters of the physician and the nurse. Isolation promotes mental and physical relaxation, lessens possibly long-standing stresses and gives the patient the opportunity for a new orientation less hampered by previous habits and reactions.
55 0
ERNEST S. CROSS
3. The method of feeding is important. From long disuse the alimentary processes are depleted and food must be given in small quantities at first and increased only gradually. If food is urged too liberally at the beginning the patient will feel she is asked to do the impossible and will be frightened. Vomiting is the usual result and is not to be considered as either perverse or hysterical in nature but as an indication to proceed more slowly. One may begin with 2 ounces of milk every two hours for eight feedings on the first day, doubling the amount on the second day, and on the third day prescribing 6 ounces every two hours. Fruit juice may now be substituted for one or two of the feedings, or meat broth if desired. On the fifth or sixth day salty crackers, dry toast or thin bread and butter may be added to alternate feedings. Milk should be increased to about 2 quarts in the twenty-four hours but part of it may be given in cream soups, custard and junket. Egg may be added, also pureed vegetables, stewed and fresh fruits, chicken, fish and meat until a normal diet is reached. When a fair amount of mixed food can be taken at regular meal times it is a good plan to teach the patient to swallow 1 or 2 raw eggs after the solid food and milk have been taken. At this time one may well consider whether or not food between the regular meals detracts from the appetite for the succeeding meal enough to lessen the total intake for the day. Milk and perhaps a few crackers can probably be taken anyway just before bedtime. The patient should be weighed once a week. The secret of gaining is to remain in bed and persist in eating liberally. It is often beneficial for the nurse to feed the patient and usually more food is taken this way. When the patient later begins to feed herself it is well for the nurse to remain in the room. When the responsibility for feeding herself alone is entrusted to the patient the weekly gain in weight must be scrutinized to guard against the possibility that food is secreted or thrown away. If necessary feeding may be resumed by the nurse. At the outset the patient may be so enfeebled and so lack-
ANOREXIA NERVOSA
55!
ing in ability to eat that intravenous injections of glucose may be required. The question of the use of insulin to promote gain is an open one in these cases. Hypoglycemia is frequently present, suggesting the advisability of administering glucose in fruit juice at the time of the insulin injection. 4. Analysis or discussion of difficulties must be undertaken in most of the cases if good results are to be obtained. T. A. Ross reports that in his series the relapses occurred in cases that improved physically but had not secured an altered attitude of mind. Frequently this discussion does not have to reach deep levels but there are some cases in which there is a serious underlying difficulty. Very often these patients are unaware of any connection between emotional reactions and physical symptoms. Hence some reeducation along these lines is important and may be the factor which determines the result. In an informal and conversational way one may be able to find and relieve some emotional condition arising through fear, anxiety, boredom, inferiority feeling, jealousy, resentment, etc. To obtain the confidence and cooperation of the patient is of course a great part of the battle. 5. Medication.-The use of insulin has already been mentioned. The usual finding of low basal metabolism might at first thought suggest the use of thyroid substance, but the author believes it is more apt to retard weight increase than to prove beneficial. One observer in discussing another disease warned against being caught in the "endocrine whirl" and we may apply that warning here, for in fact, none of the glandular products seem really serviceable in anorexia nervosa and this extends with particular force to the amenorrhea. Mild sedatives may be helpful. Vitamin reenforcement seems strongly indicated in view of the previous defective and scanty diet. Arsenic, especially in hypodermic form, is suggested. Examination of the blood will determine the advisability of administering iron, liver preparations, etc.
55 2
ERNEST S. CROSS
SUMMARY
Attention is called to a group of individuals, more commonly young females, who show extreme anorexia, emaciation, diminution of sexual functions, retarded metabolism, slow pulse, arterial hypotension, hypoglycemia, etc., the origin of which is referred to a functional nervous disorder and not to organic bodily disease. The symptom complex is ~ather typical, not difficult to recognize in general, and should be differentiated from the anorexia and emaciation of psychotics. The condition is closely simulated by Simmonds' disease which is associated constantly with destruction of the anterior lobe of the pituitary gland and has an unfavorable prognosis in contrast with a generally favorable result in anorexia nervosa. This particular differentiation calls for careful consideration. The essentials of treatment include rest, isolation, full feeding, psychotherapy and symptomatic management over a considerable period of time. BmLIOGRAPHY Calder, R. M.: Anterior Pituitary Insufficiency (Simmonds' Disease), Bull. Johns Hopkins Hosp., 50: 87-114, 1932. Dejerine and Gauckler: The Psychoneuroses and their Treatment by Psychotherapy, 1913. Gull, Sir William: New Sydenham Soc., London, 1894. Morton, Richard: Phthisiologia, London, 1694. Ross, T. A.: An Enquiry into Prognosis in the Neuroses, Cambridge University Press, 1936. Ross, T. A.: The Common Neuroses: Their Treatment by Psychotherapy. An Introduction to Psychological Treatment for Students and Practitioners, 2d ed., pp. 236, Wood, 1937. Richardson, H. B.: Simmonds' Disease and Anorexia Nervosa, Trans. Assoc. Amer. Phys., 52: 141-145, 1937. Ryle, John A.: Anorexia Nervosa, Lancet, 2: 893-899, 1936.