Anorexia Nervosa and Anorexia Mirabilis
Authors: James C. Harris
Journal: JAMA Psychiatry (2014)

In the autumn of 1868, Sir William Gull provided the first modern description of a severe eating disorder. In a lecture at the University of Oxford, in Oxford, England, he described “a peculiar form of disease occurring mostly in young women, and characterized by extreme emaciation.”1(p305) Six years later, he proposed the name anorexia nervosa in his seminal publication “Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica).”1 Gull provided 3 detailed case descriptions with woodblock illustrations based on photographs of the young women and discussed their outcomes. He noted that 1 case had a fatal termination. Despite this case, he wrote that none of the cases are hopeless as long as life exists. The final case that Gull described was that of Miss K. R— (Figure 1), a patient that he saw in consultation with another physician; hers was themost severe presentation. Gull noted that this case was so extreme that he had her photographed and accurately engraved for publication to make clear the severity of her illness. Fortunately, she responded to refeeding and, within 6 months, was “nearly well.” Seeking to trace thehistoryofanorexianervosa, somephysicians have retrospectively diagnosed the conditions of femalemedieval saints as anorexianervosabecause these saints wouldabstain fromeating food to suchanextent that, in some instances, they died.2-4 Virtuous self-abnegation and fasting havebeenreferredtoas“holyanorexia,”3oranorexiamirabilis,4 which is similar to anorexia nervosawith regard to the physiologyof starvationand its focuson seekingperfectionandpurity. However, it is in many ways distinct from anorexia nervosaandoccurred inanentirelydifferentsociocultural context. St Catherine of Siena, a patron saint of Italy, is the most prominent of the “holy anorexics.”3 Shewas amodel of virtue, and her excessive fasting was widely emulated. The Florentine baroque Italian painter Carlo Dolci illustrated the ascetic piety of St Catherine of Siena (Figure 2).5 She is shown in the habitofaDominicantertiarywithacrownof thorns.Thispainting refers tohervision inwhichChrist offeredher the choiceof a crown of gold or a crown of thorns. She chose the latter. The best-known contemporary portrayal of Catherine of Siena is a fresco (http://www.basilicacateriniana.com/storia _en.htm) by Andrea di Vanni, one of her many disciples. The fresco shows a gaunt St Catherine with a young female devotee kissing her hand. It was placed on one of the pillars in the Capella delle Volte (Chapel of the Veils), where Catherine prayed, in the church of San Domenico in Siena. Catherine (Caterina) Benincasa was born in Siena in 1347. When she was 6 years old, she is reported to have seen Christ in pontifical vestments above her neighborhood Dominican church. A year later, she made a vow of perpetual virginity. As a young girl, Catherine was familiar with fasting because she had observed her older sister’s food refusal as protest against her husband’s misbehavior. When Catherine was 15 years old, her older sister died in childbirth, and her parents sought to have Catherine marry her sister’s widower. Catherine’s response was to fast in protest, and she did not marry. Miss K. R—. Photograph for woodcut engraving by C. S. Ticehurst. Courtesy of Christine Ruggere, Department of the History of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.