L.-V. Marcé and the psychopathology of eating disorders

,069-

L.-V. Marcé and the psychopathology ofeating disorders

ANDREW BLEWETT* and ALAIN BOTTÉRO&dagger;

History ofPsychiatry, vi (1995), 069-085. Pnnted In England

Introduction

The objective of this paper is to review Marce’s role in the history of eatingdisorders. Marce’s work entitled in translation ’Note on a form of

hypochondriacal delusion consecutive to the dyspepsias and principallycharacterized by refusal of food,40 has not been thoroughly reviewed since itspublication in 1860. It is our contention that Marce sought to affirm a

specific alienists’ understanding of a group of eating disorders which

incorporate much of the modem syndrome of anorexia nervosa. His workwas both original and precocious, and has been underestimated not only asan important contribution to the understanding of anorexia nervosa, but alsoas an illustration of the early differentiation of psychological causes of diseasefrom their somatic substrate.Use of the term ’anorexia nervosa’ for the syndrome described by Marc6 is

to some extent anachronistic: for the purposes of this discussion our use ofthe term implies some equivalence with the syndrome as it is understood bycontemporary psychiatry. The more general term ’eating disorder’ is usedwith no reference to any particular era. The term ’anorexia’ is used todescribe a symptom, and is as far as posslble qualified in the text.

There is an extensive literature on the history of eating disorders. Authorscan be divided into those clinicians who have attempted to understand theevolution of the illness, as a means of grasping contemporary anorexianervosa, 10, 16, 22, 77 and non-clinicians who write with a perspective from socialsciences and academic history. 12 Medical history has seen recent progress inits level of integration and sophistication. There is both an awareness of the

address for correspondence: Andrew Blewett MRCPsych, Consultant Psychiatrist, RadcliffeClimc, 51 Hatton Park Road, Wellingborough, Northants NN8 3AH.

t Alain Bott6ro MD, 14 bis, rue Raynouard, 75016 Paris, France.

[Publisher’s note: Indicators to the References at the end of this article are numerical. Footnotes aremdicated alphabetically.]

at The University of Edinburgh on September 26, 2015hpy.sagepub.comDownloaded from

http://hpy.sagepub.com/

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intellectual and cultural context in which the physician is working, and awillingness to re-examine medical lore with rigour and impartiality.58

Marce’s work illustrates the diagnostic and therapeutic process prior towidespread recognition of anorexia nervosa after the publications of Gu1122and Lasègue.31 It illustrates nosographic and clinical issues which haverecurred in the subsequent literature. The modern concept of primaryanorexia nervosa is thought to represent a valid homogeneous entity whichcan be reliably diagnosed using established criteria. Atypical illnesses withsome of the characteristics of modern anorexia nervosa present greaternosological difficulties. This problem can also be foreseen in Marce’s work.

Throughout the history of eating disorders the diagnostic boundaries haveshifted. In the mid and late nineteenth century patients frequently presentedwith abdominal pain. Examples can be found in Marce’ and Lasegue’s work.This period saw the earliest attempts to separate anorexia nervosa from

hysteria, a heterogeneous group of disorders often conceptualized as

disturbances of the peripheral nervous system. While much of Marce’s effortwent into showing that the syndrome arose as an abnormal psychologicalprocess rather than as a disease of the stomach, this movement was

anticipated by Marc6 when he argued that his patients were clearly alienated.Parallel efforts to conceptualize eating disorders as manifestations of hysteriawere equally prominent, epitomized by the work of Briquet.’ Ultimately,Gull coined the term anorexia nervosa in preference to ’apepsia hysterica’; inFrance the enduring term ’anorexie mentale’ was popularized by Sollier in1895.’2 (a)

In the early part of the present century almost the entire diagnosis waserroneously subsumed under a putative endocrine abnormality treated withpituitary extract.38 In parallel, the psychoanalytic movement generated anaetiologically-based concept of anorexia nervosa in which symptoms arise asan expression of repressed forbidden wishes, classically for oral impregnation.’, 80These developments were post-Freudian and most prominent in the UnitedStates. The psychoanalytic concern with symptoms and process rather thanreliable nosography loosened the concept of anorexia nervosa as well as ofother psychiatric syndromes. Confusion arose with a variety of illnesseswhich might now be diagnosed as schizophrenia, affective illness, personalitydisorder, or neurotic syndromes, to the point where some clinicians doubtedits existence as a discrete entity.26 This was deplored by others who havesought to redefine a core primary anorexia nervosa group. 21The current positive criteria defining anorexia nervosa have left atypical or

secondary illnesses conceptually isolated. This has been resolved in one

a In turn of the century French texts the use of the term ’anorexie mentale’ was attributed to oneJolliet. The authors have not been able to identify this person: it seems possible that this is anerroneous spelling of Sollier whose paper on ’anorexie mentale’,72 was a landmark on the subject.The term has been associated with H. Huchard, although the authors have not yet found an originaluse of it in Huchard’s work.



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major group, many of whom have been described as ’thin fat people’, 11 bydefining a new diagnostic entity, bulimia nervosa.64 There remains a

disparate group of illnesses which straddle various diagnostic categories, ornone at all. These include disorders not fulfilling accepted criteria foranorexia nervosa or bulimia nervosa, and abnormal eating patterns describedin patients with, for example, multi-impulse disorders,3° and possibly a groupof functional gut syndromes of unknown aetiology.’4

Marce drew together a coherent illness concept which illustrates thetensions within the modem diagnostic scheme. It was the first clearformulation of a primary eating disorder as a psychiatric disorder, and waspart of the movement which generated the notion of functional mentalillness.

This paper is divided into seven sections, with the following aims:

1. To introduce Marce’s contribution to the nineteenth-century discussionon eating disorders.

2. To consider Marce’s paper in relation to the perceived modern history ofanorexia nervosa.

3. To place Marce’s work in the context of his life and career.4. To consider Marce’s paper and the issue of the psychological motivation

for fasting in anorexia.5. To review the clinical presentation of eating disorders described by

Marce.6. To compare the clinical syndromes described by Marce, Gull and

Lasegue.7. To conclude on the status of Marce’s work.

1. Marce’s contribution

Marce presented his report on two young women with psychologicaldisturbance associated with bizarre eating patterns and weight loss at a

meeting of the Societe Medico-psychologique in Paris in 1959, (b) the yearbefore its publication.The disorder affected young women and frequently occurred in the

presence of a predisposing psychological and somatic disturbance. Whatevertriggered the characteristic pattern of behaviour, Marce considered that itwas maintained by abnormal beliefs. Despite the profound and sometimesfatal deterioration in the subjects’ physical state, there was no evidence of aprimary structural lesion. Marce believed that the kind of relationship thatdeveloped between the patient and her family and friends made recovery

b Amongst those present were Brierre de Boismont, Cerise, Legrand du Saulle, Michéa,

Delasiauve, and Ferrus.3



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harder to achieve. This observation was the basis of much of his treatment, amixture of re-feeding, Cc) separation from family, a method later re-

emphasized by Charcot, 14 and the establishment of a close directive

relationship with the patient, which Marc6 called ’moral command’. (d)Finally, Marc6 thought that the condition was heterogeneous, and he

distinguished those who wanted to eat but felt they could not from those whohad a primary repugnance for food. He was not dogmatic about subtypinghis patients’ illnesses, but the distinction he made is of lasting theoreticalimportance.

2. Marc6 and the modern history of anorexia nervosa

Marce’s work predated Gull’s coining of the term anorexia nervosa by over adecade. It is comparable to modern descriptions of anorexia, and illustratesthe factors determining the form and content of modern anorexia, and itsdevelopment as a distinct nosological category.

There are many. individual accounts of eating disorders prior to thenineteenth century.69 The conflicts between ideas of sanctity, fraud and themedical notions of nervous disorder and hysteria are not within the scope ofthis discussion, but continued to give rise to celebrated cases of miraculousfasting girls until the mid nineteenth century. It is easier to analyse thesegirls’ social role than to understand their individual psychopathology. Priorto the late nineteenth century clinical descriptions had begun to

conceptualize abnormal eating as a symptom of another kind of illness. Pinel,for example, described symptomatic anorexia in some detail:

Anorexia [is the] significant or total loss of appetite ... [it belongs to] atype of neurosis of alimentary behaviour ... Amongst the most ordinarycauses ... [are] ... sadness touching the spirit, likewise ambitious

feelings, fears, jealousy ... excessive study and professional work; ecstasy,the joyful mysticism of the contemplative life ...59 [Authors’ translation.]A later example is the description of abnormal eating in hysteria published in

c Marcé advocated forced feeding in extremis, following the example of his mentor Baillarger.3 The subject receives thirteen pages in the Traité.

d Marcé discusses moral treatment in his Traité. For example, in the treatment of monomania,’moral treatment plays here without doubt a primary role, by moral treatment I mean especialyisolation and skilled, energetic direction. Isolation, of which we have studied the effects, breaks thedelusional pattern of the patient, bringing him involuntarily into a regular and disciplined lifestyle,and giving the doctor the moral ascendancy which necessarily arises from sole and uncontestedpower’.50 Further, he continues, ’The moral direction of hypochondriacs should differ little fromthat employed with other lunatics. If one wishes to gain their confidence, it is essential to know howto listen to them, and never forget that they really experience the distress and pain which theyconstantly recite: far from trying to persuade them that they are not ill, which irritates and

discourages them, one needs to accept some of their complaints and treat them seriously, liftingtheir mood and gradually enabling them to recognized improvement’51 (authors’ translations).



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1859 almost contemporaneously with Marce, by Briquet, who in his classicwork briefly referred to monomania, corresponding to Marce’s ’partialinsanity’:

Sometimes appetite is conserved, patients want to eat. but suffer as soonas food reaches the stomach. In other cases appetite is absent, ... thesmallest quantity of food ... provokes atrocious pains ... this form ofgastralgia is the the most serious ... Sometimes a sort of hypochondria ormonomania takes hold of their mind, holding them in a constant

preoccupation with their state of health.’ [Authors’ translation.]Although published almost simultaneously, Marce’s work differed from

Briquet’s in firmly attributing fasting to abnormal beliefs arising in a

pathologically weakened subject. Motives were a logical starting point fromwhich the illness developed. Hysteria was not invoked by Marc6, whounderstood the condition as a type of alienation with primarily mentalpathology, a monomania.

In the same year as its publication in France, an abridged version appearedin Great Britain. 17 This version has recently been republished. 71 Marce’swork did not excite controversy in either country, and there was none of theinterest which followed the later description of ’anorexie hysterique’ byLasegue and anorexia nervosa by Gull in the same year. Gull’s subsequentclaim to have described the syndrome first was based on a brief allusion to’hysteric apepsia’ in 1868.2’ Recent reviews of Gull’s claim have found it

wanting. 78In English-speaking countries the term ’anorexia nervosa’ has had a

continuous history since Gull’s paper, giving it a spurious historical unity, asthe symptom criteria for making the diagnosis have varied greatly, and asMarce’s work shows, can be identified earlier in the nineteenth century.

Distortions such as this may arise because of the status and influence ofindividuals such as Gull. Heroic notions of great men and their seminaldiscoveries have consistently appealed to the medical profession itself. Gulland Lasegue both commanded such a place. Perhaps as a result many writershave been reluctant to consider the wealth of earlier material as other than of

peripheral interest, lacking clinical significance, and incapable of generatingfresh insights.

3. Marc6’s life and career

Biographical information on Marce shows him to have been a prolific writer,clinician and theorist. He was also a keen administrator. Sources concerningMarce himself are limited, and to some extent parasitic on each other.28, 33, 60, 66Marce was bom in Paris in 1828. His father was a royalist rewarded with agovernment post at the restoration of the Bourbon regime. This was not asuccess: he married and published two volumes of poetry before dying in astate of poverty . Marc6, aged six, was sent to Nantes in the care of his uncle



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who taught in the medical faculty. Marc6 studied in the same universitybefore undertaking his internship in Paris. He wrote his doctoral thesis onspermatic cysts and funded himself by offering tuition. He taught in theCharite in the rue des Saint-Peres in Paris, a now defunct hospital in whichBriquet headed a department from 1846. In order to marry, he was forced tolook for a permanent post. According to Ritti,61 it was for this reason that heapplied for and got a position with Baillarger and Moreau (de Tours), botheditors of the Annales Médico-Psychologiques in which Marc6’s ’Note’ waspublished, and both former pupils of Esquirol, originator of the monomaniaconcept and founder of the celebrated Maison de Sant6 at Ivry-sur-Seine,where Marc6 joined them on the staff.Marc6 came first in the examination for the agregation in 1860, ahead of

Charcot. His thesis, ’Des Alterations de la Sensibilite’,44 included a

discussion on abnormal appetite without referring to his own work. A briefreference to anorexia suggests that he had it in mind:

Nothing is commoner than anorexia in nervous disorders of which it isboth the cause and the effect; it is to this [anorexia] that are attributablethe extraordinary facts concerning patients who can sustain life with

infinitely small quantities of food, without ever experiencing the leasthunger for it.45 [Authors’ translation.]

In the same year he was appointed to La Ferme St Anne and shortlyafterwards to the Hospice de Bicetre in Paris. Semelaigne records that hisrapid progress provoked objections, ’while at the same time affirming hismerit’.67 Marc6 lectured and published a textbook of mental illnesses, theTraite Pratique des maladies mentales.48 The Traite was a standard textbook forseveral decades after his death.

Marce’s output in the following eight years was impressive. His interestsincluded psychopathology, brain pathology and neurology, and medico-legalissues. He is probably best known now for his original descriptions of mentaldisorders in pregnancy and the puerperium. Semelaigne recorded an

extensive list of his published work (see Appendix) and he was in contactwith many of the remarkable figures of the time. One of his obituarists,Linas, comments that he sacrificed many of the ’comforts of home’.34Laborde, who described himself as one of Marce’s faithful students, calledhim a ’victim of his devotion to science ... a martyr’.29

In 1864, Marc6 stopped working and left Paris. The reason for his absenceremains unknown, he returned ’partially recovered’ but died shortlyafterwards. Linas described him as ’a victim of duty, who succumbed to thetask ... he loved his work too much, and it killed him.’35

4. Marc6 and the psychopathology of eating disorders

Marce’s work has two parts. The first is a general account of the disorder.The second consists of two case histories, Mlle A. B. and Mlle X. who



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experienced different forms of the illness. According to Marc6 their principalabnormality was their refusal to eat. Of his two cases only Mlle X.complained of appetite loss which Marc6 called her ’anorexie’. 41 Elsewherehe uses the synonymous term ’inappetance’.

Marc6 believed that many such patients (e) were being treated for supposedgastric disorders, making the point that failure to understand the

psychological basis for not eating could have a fatal outcome;... it is not the stomach which requires attention, because it functionswell and the problem is rather insufficient intake. It is the delusionalidea,« which constitutes both the point of onset and the essential qualityof the disease ...42

Marc6 emphasized two forms of ’dyspepsia’, a term corresponding to abroader disturbance of alimentation than is meant in current terminology.(9)In one form appetite was lost and there was a disgust for food, in the secondappetite was normal but the patient did not eat because of somatic symptomsprovoked by ingestion of food. (h) In England, Albutt made the samedistinction in 1884, after the introduction of the term anorexia nervosa. Healso considered that individuals who were anorexic and without pain hadoften fallen ill after an episode of gastrointestinal illness. This suggests thatthe clinical observations made by Marc6 were neither specific to Frenchculture, nor to the period before the term anorexia nervosa was coined. Thedistinction was later reproduced by authors who sought to identify a primary

e Marce insisted on the relative frequency of eating disorders, both in his ’Note’; in the Traité ;52and in his thesis ’Les Alterations de la sensibilite’.46

f ’l’idée délirante’: the translation of this expression has caused confusion. The earliest Englishversion of Marcé’s paper employed the term ’delirium’, which in English is now used to term anacute organic confusional state which may feature, amongst other phenomena, tenaciously heldfalse ideas. In modem French psychopathology the term ’délire’ means essentially the same as theterm ’delusion’ in English, although its meaning has been elaborated. In particular, a distinction hasbeen drawn between the ’idée delirante’ of chronic psychosis, being an unshakeable false ideationalsystem concerning the relation between self and the outside world; and the ’délire’ conceived of as’delirium’ or ’l’expérience délirante’ meaning a pervasive inner dream-like destructuration of mentallife in an acute psychosis.19 In early British texts the term delirium was used more broadly than isthe case now. Cullen, for example, distiguished two sorts of delirium: false ideas arising either withfever or ’comatose affections’ on the one hand, and without either on the other. The latter hetermed ’insanity’.

g An implicit reference to Beau’s ’Leçons sur la dyspepsie’,6 an extensive discussion of digestivedisorders which Marcé notes in both his agregation thesis, ’Des Altérations de la sensibilite’, and inthe Traité. Beau’s work was a source of cardinal importance, in which he argued that mentalsymptoms arose secondarily to dyspepsia, which was itself the result of ’impoverishment of theblood’. While acknowledging the negative effects of impoverished blood on the nervous system,Marcé turned Beau’s thesis on its head.

h In the Traité, Marcé comments: ’Nosomanie can originate with a purely imaginarypreoccupation, but it often proceeds from a real illness which, exaggerated and amplified by the sickbrain, become the point of origin of a host of delusional notions: for some, the délire is organizedaround ... stomach pains ... which, unimportant in themselves ..., concentrate all attention ... ,53(authors’ translation).



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or idiopathic syndrome from a more complex one in which anorexia

appeared to be a symptom of another psychiatric disturbance.Marc6 described a cognitive process which he believed led to a progression

to ’partial insanity The patient is ’impressed’(’) by her anorexia or

abdominal pain, arriving at an ’hypochondriacal delusion’, and then believesthat she ’must not eat, ... cannot eat’. The ’gastric neurosis’, composed ofsymptoms arising in the stomach, ’is transformed into a cerebral neurosis’,arising in the central nervous system.43 c’‘~ His explicit account of this processsuggests that he had not identified other beliefs maintaining the fast: indeedhe did not have to, as the concept of monomania invokes the idea of anabnormal idea arising directly from a dysfunctional brain. The question ofmotivation for fasting is important because recent criteria describe fat phobiaand distorted estimations of body size as the driving rationalizations behindfood refusal in anorexia nervosa.The work of mid nineteenth-century to early twentieth-century writers

illustrates the nonspecific and changing nature of the preoccupations ofanorexic patients, prior to the general acceptance of modem criteria of fatphobia as a necessary feature of anorexia nervosa.

Briquet’s account of eating disorder in his work on hysteria, emphasizingthe intense pain experienced when even small quantities of food were

ingested, implied that his patients ’don’t eat’ because they ’can’t eat’. Briquetbelieved that his patients developed hysteria as a result of traumatic

psychological experiences, fatigue, and often following severe somatic illness,usually in the context of a characteristic labile temperament present fromchildhood.39 Although his patients were clearly overwhelmed by painful

1 ’délire partiel’. This term used by Marcé was associated with the notion of ’monomanie’,introduced by Esquirol.18 In his Traité, published two years after the ’Note’, Marcé defined the term’délire hypochondriaque’ as ’a form of monomania in which the subject manifests false notions anddelusional concerns (des fausses conceptions et des préoccupations délirantes) on the subject of hishealth’ (authors’ translation).54 Marcé attributes the replacement of the Esquirolian ’monomanie’by the term ’délire partiel’ to Ferrus, made on the semantic grounds that the extent of the mentaldisturbance was frequently greater than the prefix ’mono’ allowed.55 In effect Marcé made the terms’monomanie hypochondriaque’, ’hypochondrie délirante’, and ’nosomanie’ synonymous. Before theend of the nineteenth century the monomanias had come to be seen as a heterogeneous groupwhich would now include paranoia, mania, depression, states such as Marcé’s ’délire

hypochondriaque’, and other states involving a core theme or impulse which appeared morbid tothe alienist in the mid nineteenth century. The term distinguished such disorders from thoseinvolving severe pervasive mental deterioration (see also fn. (e)). Marcé’s nosography is representedin Table 2 (p.83).

’

’impressionée’. The translation of this word can be misunderstood. According to the PetitRobert,62 it was used in physiology texts to mean ’affect an organ in such a manner as to produce asensation’ (authors’ translation) from the early nineteenth century. Marcé presumably had a

psychological equivalent in mind.The term ’névrose’ discussed in the Traité,56 was for Marcé little changed from the term’neurosis’ introduced by Cullen, and which he had acquired via Pinel and Esquirol. He included init all those forms of mental illness assumed to result from cerebral disorder but which did not have a

recognizable anatomical lesion.



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experiences, Briquet does not elaborate on any cognitive process evident inhis cases of eating disorder.

Lasegue described his patients’ reasoning in sufficient detail to suggest that’I can’t eat’ had changed to ’I don’t need to eat’:

The patient replies that her food is sufficient and moreover, she hasneither changed nor got thinner ... [Authors’ translation]

The position had moved from a somatic mode of suffering to a distinctlypsychological understanding of her distress, her denial being familiar tomodem clinicians. Thirty years later Sollier reasserted Marce’s thesis,without referring to it, in his famous paper on ’anorexie hysterique’:

[The term anorexia is unsuitable because] ... it signifies loss of the senseof appetite, or feeling of hunger, whereas in reality in the clinical sense,anorexia properly constituted requires something in addition: the

systematic refusal of food, which is very similar to the sitiophobia ~’~ of theinsane, but which differs most in its motives’.’3

Janet identified numerous motivating anxieties leading to fasting, Hedescribed fear of sexual maturity, fear of social embarrassment, fear relatedto the idea that the sufferer was unable to accomplish the act of ingestingfood, and numerous other ’scruples’ as well as fear of obesity constituting orarising from an abnormal core idea or idee fixe, which notion plays a

pathogenic role closely related to Marce’s ’partial insanity’. Janet scepticallydismissed the notion that all pathological fasting was precipitated by thesolitary problem of an intense morbid fear of being overweight.25 Theindiscriminate use of the term anorexia in a wide range of illness entities led

Dejerine and Gauckler 17 to draw a categorical distinction between primaryanorexia nervosa and those forms of the illness which manifested the

symptoms of anorexia nervosa in the context or another disorder, such asdepressive psychosis, or local organic disease. In this group of secondaryanorexias a variety of motives for fasting occurred, including for example awish to starve to death or a fear of pain.

5. Recent analysis of motivating factors in nineteenth-century anorexics

The fear of weight gain in anorexia nervosa was recognized in the last third ofthe nineteenth century in France, with no evidence that it was being seenelsewhere.(’) Habermas has argued that this was due to the personalinfluence of Charcot who was impressed by the chance finding of a patient

1 Sollier coined the term ’sitiergie’ in preference to other current terms used to describe anorexianervosa, derived from the Greek ’σiτoς’, food, and ’εiργω’, I refuse.

m This may not have been the case. The English physician Allbutt recorded cases of anorexianervosa in whom ’the fear of growing stout’ was a motivating factor.2



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who used a ribbon tied around her waist as a self imposed limit on her size,in order not to look like her mother. Habermas contends that fear of obesitywas likely to have been the core cognitive basis for excessive fasting, at leastfrom the descriptions of Lasegue and Gull onwards, but was missed orignored.23 He attributes early post 1873 differences between reports ofanorexia in European continental countries to differences in the sophis-tication of their respective psychiatric communities. 21

Habermas’s analysis implies that the reasoning displayed by Marce’s andother nineteenth-century patients was not a sufficient cognitive basis to

account for their behaviour. This view seems to us to be debatable.An alternative view has been advocated by Shorter .70 He argues that

recognizable anorexia nervosa like disorders became possible when theoriesof disturbed nervous system functioning developed, using concepts such asneurosis, introduced by Cullen in 1772.15 From the end of the eighteenthcentury it became potentially possible to understand eating disorder as adisorder of the ’nerves’, and the causes of weight loss could be localized inthis system. Case reports of young women suffering from vomiting andabdominal pain were gradually replaced by illnesses with complaints of lackof appetite. The evolution of ideas of obesity created an internally consistentjustification for fasting as it became less and less feasible for either the patientor her doctor to believe in a local gastrointestinal disturbance by the end ofthe nineteenth century. Increasingly sophisticated clinical theorizing affectedillness attitudes amongst potential anorexics and so the seat of the illnessshifted from the abdomen to the psyche.

Marce’s observations illustrate this position. While his primary concernwas to differentiate the disorder from the various forms of gastrointestinaldiseases causing wasting, his ’delire hypochondriaque’ was also clearlydistinct from the more diffuse concept of nineteenth-century hysteria, andcan be recognized as a primary psychiatric disorder.The problems in showing continuity in the core nature of the illness

described by Marc6 and contemporary anorexia nervosa is greater than theproblem of interpreting historical texts in their proper context. Russell andTreasure65 criticize the idea that the basic nature of neurotic illness remainsunchanged while the symptomatic ’picture’ alters, depending on socioculturalfactors. They point out that the definition of the basic disturbance inneurosis remains elusive. By implication the basic disturbance in eatingdisorders is equally elusive, and the changing motivations of fasting patientscannot be assumed to be epiphenomena. Most of the cases of eating disorderdescribed in the nineteenth and early twentieth century, including Gull’scases for whom the term anorexia nervosa was coined, lack the psychologicalabnormalities necessary to make the diagnosis using the strict operationalcriteria of DSM 3 R’9 frequently employed in modem research.4



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6. The syndrome of anorexia nervosa: Marc6, Gull and LasegueThe symptoms described by Marc6 are consistent with the reports of

Lasegue and Gull (Table 1, p.82). The physical and psychological effectsof starvation are clearly described. Marce’s patients showed profound weightloss of up to half normal body weight, changes in their skin and teeth,collapsed when they tried to walk, and complained of feeling cold. They hadamenorrhoea, a symptom long given diagnostic importance. Like Gull,Marc6 reported a mortality rate. Lasegue wrote that he had never seen a fataloutcome.

Possible causal or maintaining factors are described. Mlle A. B. had afamily history of alienation, and Marc6 thought that her eating disorder had ahereditary diathesis. (n) He emphasized the relationship with the onset ofmenstruation, the ’profound nervous disturbance which accompanies themenarche’. This was clearly thought by many of Marce’s contemporaries tobe a cause of mental illness in young women, although not so by Marc6, whobelieved that menstrual and mental disorders arose as associated factors witha common underlying disturbance in the nervous system.49 A premorbidhistory of somatic illness affecting digestion was considered significant. MlleA. B. had childhood typhoid fever with residual symptoms and an episode ofquartemary fever. Individual predisposing factors are mentioned by Marc6:Mlle. A. B. was ’spoilt and wilful’, and solitary in her habits. These aspects ofher temperament were carefuly recorded and clearly thought relevant.

Finally, the family environment was thought to both prevent effective

treatment, and to increase the likelihood of relapse. Mlle X. was less troubledby her symptoms while on cures away from her family.The cessation of the menses was identified from the sixteenth century as

the cause of chlorosis, another condition frequently identified in youngwomen with weight loss until the mid nineteenth century. The original formof this theory, echoes of which persisted into the mid nineteenth century,he:d that resorption of menstrual blood poisoned the patient. A disease ofyoung women, it was also characterized by refusal to eat, pallor, andemotional symptoms.36, 37,75Marc6 makes no mention of chlorosis, but may well have been influenced

by the chlorosis tradition. It was believed that the impoverishment of theblood in chlorosis was a common cause of a variety of mental disorders. Thepresence of ’congestions’ and other symptoms at the supposed time of MlleA. B.’s menses are discussed at length, and treated by placing leeches at thetop of her thighs.(’) He also gave his patients iron, the place of which was

n In his Traité, Marcé emphasizes the importance of heredity; ’heredity ... dominates thepathogenesis of mental illnesses’57 (authors’ translation).



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already established for the anaemia of dietary deficiency as well as chlorosis. 13Marce noted that amenorrhoea could predate weight loss, and that themenses could be delayed after weight gain, an observation frequently madein modern anorexia nervosa.63Motor disorders were described by Marc6 but he did not observe the

overactivity which impressed Lasegue and Gull. His account of behaviouraland motor abnormalities focuses on difficulties with the act of ingestion.Lasegue explained excessive activity and apparent well-being as denial,fending off arguments about the need to eat. Gull noted the same

phenomenon, but did not give an explanation. Marce’s cases show limitedand more contained overactivity: Mlle A. B wrote twenty-page letters to hermother detailing her meals and devoted energy and ingenuity to her peculiareating habit: Marce found bread hidden in her clothes.

Other behavioural changes were more characteristically mood-related. Herecords that Mlle A. B. threatened suicide early in the course of her illness,and later banged her head against the wall. Her distress related to attemptsto get her to eat resulted in her striking her abdomen, destroying her clothesand cutting her family’s food into pieces. Mlle X.’s bizarre meals weresurrounded by procrastination and ritual, including weighing her food andselecting an eccentric diet. She ’resisted energetically both her mother and others’.

7. Conclusions: Marce’s achievement and obscurityMarce was responsible for four significant conceptual advances in the earlyhistory of anorexia. Firstly, he distinguished a disorder previously not differ-entiated from the dyspepsias, in which there is no identifiable local anatomicalabnormality. Secondly, he identified a psychological basis for fasting, arguingthat his patients were primarily mentally disturbed, and were vulnerable tomisguided attempts to treat the stomach. Thirdly, he affirmed that the milieuof the patient was critical in promoting the mental pathology. Fourthly, hedescribed the heterogeneous nature of eating disorders, anticipating thedistinction between a subclassification of primary and secondary anorexianervosa. From a contemporary perspective, he defined a syndrome withrecognizable biological, psychological and social components which make hispaper an invaluable source of comparison with modem clinical case descriptions.The reasons behind the failure of the medical world to pick up on and

apply the unified concept of an eating disorder in 1860 remain unclear. Themost parsimonious explanation is that Marce’s syndrome made sense to himbut not to the rest of the medical establishment. This may have arisenbecause anorexia nervosa continued to be associated with hysteria until thelast quarter of the century. Hysteria was a broad neurological-gynaecologicaldisorder and not generally the province of alienists. Marc6 categorizedanorexia by applying the concept of the delire partiel or monomanie. Indescribing a typical eating disorder as an example of a heterogenous group of



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disorders such as the monomanias or delires partiels, Marc6 did not give to thecondition the nosological uniqueness, or terminological economy, achieved byGull with anorexia nervosa. He argued that these patients had a ’true partialinsanity’, but this concept was itself abandoned shortly afterwards.

Further reasons for Marce’s work passing into obscurity may lie in theambitions of his contemporaries. Marc6 died young, at a time when nosologywas advancing quickly. His obituarists had no doubt as to his genius andperspicacity, but never arrived at a synthesis of his ideas. The personalities andstyles of Lasegue and Gull left little room the for retrospective recognition ofMarce’s work: it is particularly hard to see why Lasegue ignored Marce’swork on eating disorders, as he would certainly have been familiar with it.Gull and Lasegue were keen to assert their respective claims to priority, andmay have chosen to ignore a younger rival who was anyway then dead.

It is probable that Marce’s syndrome did not achieve the impact that Gull’sanorexia nervosa did at the time of its publication because of the inadequacies ofthe nosological systems then in use. Marc6 needed to show that his patients werementally ill, and in so doing had no need to use the notion of hysteria. Heemployed empirical discriptive psychopathology characteristic of the generationof Esquirol and his pupils Baillarger and Moreau (de Tours). Interest in hysteria,a concept which appeared to offer explanatory power in eating disorders, wasabout to expand enormously, (the number of theses presented in France onhysteria increased from 23 in the decade 1861-70 to 111 l in the decade

1891-1900).~ Gull’s term ’anorexia nervosa’ is remarkable as an enduringmisnomer which has nevertheless got this form of eating disorder off thehook created by dividing mental disorders into nervousness and madness. Ithas perhaps survived because this conundrum remains unresolved.

APPENDIX

List of Marce’s work from P. Semelaigne 68Gangrene du cerveau (1856).Memoire sur quelques observations de physiologie pathologique tendant a montrer

1’existence d’un principe coordinateur de 1’ecriture, et ses rapports avec leprincipe coordinateur de la parole (1856).

Manie hysterique intermittente a la suite de sevrage (1857).Influence de la grossesse et de 1’accouchement sur la guerison de 1’alienation mentale

(1857).Observation de melancolie traitee et guerie par l’opium a haute dose (1857).Etude sur les causes de la folie puerperale (1857).Trait6 de la folie des femmes enceintes, des nouvelles accouchees et des nourrices, et

considerations medico-legales qui se rattachent a ce sujet (1858).Experiences sur l’oedeme du cerveau (1859).Double tumeur sanguine du pavillon de l’oreille chez un aliene melancolique.

Tumeur de meme nature a la paupière superieure (1859).Des hallucinations qui surviennent dans le cours de la choree aigud chez les adultes

(1859).De 1’etat mental dans la choree (1859).



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Note sur une forme de delire hypochondriaque consecutive aux dyspepsies et

caracterisee principalement par le refus d’aliments (1860).Des alterations de la sensibilite (1860).Note sur une espece particuliere de convulsions epileptiformes survenant chez les

paralytiques alienes (1860).Deux cas de demence consecutive a une serie d’attaques d’apoplexie, avec lesions

importantes de la couche corticale des circonvolutions (with Luys) (1861).Memoire sur la stupeur ( 1861 ) .Demence consecutive a de nombreuses hemorrhagies cerebrales; cicatrices du corps

strie et des couches optiques (with Luys) ( 1861 ) .Congestion cerebrale point de depart de certaines epilepsies (1861).Traite pratique des maladies mentales (1862).Recherches cliniques et anatomo-pathologiques sur la demence senile et sur les

differences qui la separent de la paralysie generale (1863).Delire ambitieux avec paralysie generale chez les sujets adonnes aux boissons

alcooliques (1863).Delire partiel, hallucinations, etat chronique tendant a la demence, eruption

pellagreuse, tuberculisation pulmonaire. Ramollissement de la moelle epiniere auniveau de la region lombaire (1863).

De la valeur des ecrits des alienes au point de vue de la semiologie et de la medecinelegale (1863).

Sur les alterations anatomiques de la paralysie genenerale (1863).Sur 1’action toxique de 1’essence d’absinthe (1864) and several encyclopaedia entries.

TABLE 1. Comparison of symptoms occurring in, or associated with, the syndromesdescribed by Marce, Lasègue and Gull

* Drawn from DSM 3 Revised



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TABLE 2. Mental illnesses from Marcg’s nosographic scheme, derived from hisTrait6 pratique des maladies mentaux, 1862

REFERENCES

1. Allbutt, T. C., On Visceral Neuroses (London: J. & A. Churchill, 1884), 53-5.2. Allbutt, T. C., op. cit., 58.3. Annales Medico-Psychologiques. Report on the proceedings of the Société Medico-Psychologique,

meeting of 31 October 1859, vi (1860), 276-94.4. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 3rd

Edition Revised (Washington DC: APA, 1987).5. Baillarger, J. ’De l’alimentation forcée des aliénés’. Annales Médico-Psychologiques, viii (1846),

352-8, and ix (1847), 1-26.6. Beau, J.-H. ’De la dyspepsie’. Leçons données à l’Hôpital Cochin, rédigées par Thibierge,

interne de service. Le Moniteur des Hôpitaux, vol. 1, Première Série (1853), numéros 74, 81,83, 86, 89, 92, 96.

7. Blitzer, J. R., Rollins, N. and Blackwell, A., ’Children who starve themselves: anorexianervosa’. Psychosomatic Medicine, xxv (1961), 5, 369-83.

8. Briquet, P. Traité clinique et thérapeutique (Paris: J.-B. Baillière, 1859), 251-63.9. Briquet, P. op. cit., 256.

10. Bruch, H. Eating Disorders (New York: Basic Books, 1973).11. Bruch, H. op. cit., 194-208.12. Brumberg, J. J. Fasting Girls (Cambridge, MA: Harvard University Press, 1988).13. Carrière. ’Revue thérapeutique pour le traitement des maladies du système nerveux’. Annales

Médico-psychologiques, iii (1851), 322-33.14. Charcot J.-M. Clinical Lectures, on Diseases of the Nervous System, Vol. 34 (London: The New

Sydenham Society. 1889), 211-14.15. Cullen, W. ’The Neuroses and Vesanae’, from First Lines of the Practice of Physic (Edinburgh:

Elliot, 1784.). In Hunter, R. and Macalpine I. (eds), Three Hundred Years of Psychiatry1536-1860 (London: Oxford University Press, 1963), 473-79.

16. Dally, P. and Gomez, J. Anorexia Nervosa (London: Heinemann, 1979), 1-10.17. Déjerine, J. and Gauckler, E. The Neuroses and their Treatment by Psychotherapy (London:

Lippincott, 1913), 2-11.18. Esquirol, J. E. D. Mental Maladies, A Treatise on Insanity by E. Esquirol. Translated and edited



84

by Hunt, E. K. (Philadelphia: Lee & Blanchard, 1845), in Hunter R. and Macalpine I. (eds),Three Hundred Years of Psychiatry 1536-1860 (London: Oxford University Press, 1963), 731-8.

19. Ey, H. Bernard, P. and Brisset, C. Manuel de psychiatrie (Paris: Masson, 1989), 127-28,286-87, 446-66.

20. Gethin Morgan, H. ’Fasting girls and our attitudes to them’. British Medical Journal, ii (1977),1652-5.

21. Gull, W. The address in medicine delivered before the annual meeting of the British MedicalAssociation, at Oxford. Lancet, ii (1868), 171-6.

22. Gull, W. ’Anorexia Nervosa (apepsia hysterica, anorexia hysterica)’. Transactions of the ClinicalSociety of London, vii (1874), 22-28.

23. Habermas, T. ’The psychiatric history of anorexia nervosa and bulimia nervosa: weightconcerns and bulimic symptoms in early case reports’. International Journal of Eating Disorders,viii (1989), 259-273.

24. Habermas, T. ’The role of psychiatric and medical traditions in the discovery and descriptionof anorexia nervosa in France, Germany and Italy 1873-1918’. Journal of Mental and NervousDiseases, clxxix (1991), 360-5.

25. Janet, P. Les Obsessions et la psychasthénie, Vol. I (Paris: Félix Alcan, 1903), 33-41.26. Kay, D. W. K. and Leigh, D. ’The natural history, treatment and prognosis of anorexia

nervosa, based on a study of 38 patients’. Journal of Mental Science, c (1954), 411-31.27. King, A. ’Primary and secondary anorexia nervosa’. British Medical Journal, cix (1963), 470-9.28. Laborde, J.-V. Éloge prononcé à la séance solennelle de la Société Anatomique, le 10 février

1865 (Paris: Moquet, 1865), 1-19.29. Laborde, J.-V. op. cit., 17.30. Lacey, J. H. and Evans, C. D. H. ’The impulsivist: a multi-impulsive personality disorder’.

British Journal of Addiction, lxxxi (1986), 641-9.31. Lasègue, E. C. ’De l’anorexie hystérique’. Archives Générales de Médecine, i (1873), 385-403.32. Lasègue, E. C. op. cit., 394 .33. Linas, M. ’Notice sur Monsieur Marcé’. Annales Médico-psychologiques, v (1865), 85-89.34. Linas, M. op. cit., 87.35. Linas, M. op. cit., 88.36. Loudon, I. S. L. ’Chlorosis, anaemia, and anorexia nervosa’. British Medical Journal, cclxxxi

(1980), 1669-75.37. Loudon, I. ’The disease called chlorosis’. Psychological Medicine, xiv (1984), 27-36.38. Lucas, A. R. ’Towards the understanding of anorexia nervosa as a disease entity’. Mayo Clinic

Proceedings, lvi (1981), 254-64.39. Mai, F. M. and Merskey, H. ’Briquet’s Treatise on Hysteria’. Archives of General Psychiatry,

xxxvii (1980), 1401-5.40. Marcé, L.-V. ’Note sur une forme de délire hypochondriaque consécutive aux dyspepsies et

caractérisée principalement par le refus d’aliments’. Annales Médico-psychologiques, vi (1860),15-28. Translated by Andrew Blewett and Alain Bottéro in History of Psychiatry, v (1994),274-83.

41. Marcé, L.-V. op. cit., 25.42. Marcé, L.-V. op. cit., 17.43. Marcé, L.-V. op. cit., 15-16.44. Marcé, L.-V. Des altérations de la sensibilité, Thèse (Paris: J.-B. Baillière, 1860), 70.45. Marcé, L.-V. op. cit., 70.46. Marcé, L.-V. op. cit., 70.47. Marcé, L.-V. ’On a form of hypochondriacal delirium occuring secondary to dyspepsia, and

characterised by refusal of food’. Journal of Psychological Medicine and Mental Pathology, xiii

(1860) 264-643. Marcé, L.-V. Traité pratiques des madies mentales (Paris: J.-B. Baillière et fils, 1862).43. Marcé, L.-V. op. cit., 142-3.50. Marcé, L.-V. op. cit., 392.51. Marcé, L.-V. op. cit., 395.52. Marcé, L.-V. op. cit., 197.53. Marcé, L.-V. op. cit., 373-4.54. Marcé, L.-V. op. cit., 370-1.55. Marcé, L.-V. op. cit., 351.



85

56. Marcé, L.-V. op. cit., 37.57. Marcé, L.-V. op. cit., 102-3.58. Marx, O. M. ’What is the history of psychiatry?’ History of Psychiatry, iii (1992), 279-92.59. Pinel, P. Nosographie Philosophique (Paris: Maradan, An vi, (1798).), 102-7.60. Ritti, A. ’Victor Marcé’. Eloge prononcé dans la séance publique anuuelle de la Société

Medico-Psychologique, le 24 avril 1882, in Histoire des Travaux de la Société Médico-psychologzque, et Éloges de ses Membres, Vol. 1 (Paris: Masson 1913), 111-36.

61. Ritti, A., op. cit., 117.62. Robert, P. Le Petit Robert: Dictionnaire Alphabétique et Analogique de la Langue Française (Paris:

Société du Nouveau Littré, 1967).63. Russell, G. F. M. ’Anorexia Nervosa’. Proceedings of the Royal Society of Medicine, 1viii (1965),

811-14.64. Russell, G. F. M. ’Bulimia nervosa: all ominous variant of anorexia nervosa’. Psychological

Medicine, ix (1979), 429-48.65. Russell, G. F. M. and Treasure, J. ’The modem history of anorexia nervosa’. Annals of the New

York Academy of Sciences (1989), 13-30.66. Semelaigne, R. Les Pionniers de la psychiatrie française avant et aprés Pinel, Vol. 1 (Paris:

J.-B. Baillière et fils, 1932), 129-38.67. Semelaigne, R., op. cit., 132.68. Semelaigne, R. op. cit., 137-8.69. Skrabanek, P. ’Notes towards the history of anorexia nervosa’. Janus, lxx (1983), 109-28.70. Shorter, E. ’The first great increase in anorexia nervosa’. Journal of Social History, xxi (1987),

69-96.71. Silverman, J. A. ’Louis-Victor Marcé, 1824-1864: anorexia nervosa’s forgotten man’.

Psychological Medicine, xix (1989), 833-55.72. Sollier, P. ’L’Anorexie mentale’, in Congrès des Médecins Aliénistes et Neurologistes de

France et des Pays de Langue Française, 6ème Session, Bordeaux, 1-7 août 1895. ComptesRendus, Vol. 2 (Paris: G. Masson, 1896), 360-72.

73. Sollier, P. ’Anorexie hystérique (sitieirgie hystérique), formes pathogéniques, traitement moral’.Revue de Médicine, xi (1891), 625-50.

74. Stacher, G., Kiss, A., Wiesnagrotzkil, S., Bergmann, H., Hobart, J. and Schneider, C.

’Oesophageal and gastric motility disorders in patients categorised as having primary anorexianervosa’. Gut, xxvii (1986), 1120-6.

75. Starobinski, J. ’Chlorosis - the Green Sickness’. Psychological Medicine, xi (1981), 459-68.76. Terisse, A. ’Une histoire des thèses de psychiatrie en France du début du dixhuitieme siècle à

la veille de la Seconde Guerre Mondiale’. In Postel, J. and Quétel, C. (eds), Nouvelle Histoire dela psychiatrie (Paris: Privat, 1983), 540-2.

77. Tolstrup, K. ’Incidence and causality of anorexia nervosa seen in a historical perspective’. ActaPsychiatrica Scandinavia Supplement, ccclxi (1990), 1-6.

78. Vandereycken, W. and Van Deth, R. ’Who was the first to describe anorexia nervosa: Gull orLasegue?’. Psychological Medicine, xix (1989), 837-45.

79. Van Deth, R. and Vandereycken, W. ’Was nervous consumption a precursor of anorexianervosa?’ Journal of the History of Medicine and Allied Sciences, xxxxvi (1991), 3-19.

80. Waller, J. V., Kauffman, R. M. and Deutsch, F. ’Anorexia nervosa: a psychosomatic entity’.Psychosomatic Medicine, ii (1940), 3-16.



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