Kartini Clinic Blog

Judgement and consequences: where to hospitalize an eating disordered child

2012-04-27T23:50:00+00:00

It is understandable for parents to hope treatment for their ill child could be as close to home as possible - and to wish for as little disruption to family life and work as could be managed - but I for one am very unhappy about what I see as a lack of judgment on the part of many physicians when it comes to hospitalization for a very ill eating disordered child.

Hospitalists, who would under any other circumstances adamantly decline to do surgery for which they were not trained - or with which they had no experience - commonly agree to take care of a child with an eating disorder simply because of a family’s wish to have it done in their home town. Hospitalization at inexperienced centers is also often carried out in response to the parents’, general pediatrician’s or therapist's desire to have such care done close to home, even when such a patient clearly should be transferred elsewhere.

Transferred where you might ask? Put bluntly: to a eating disorder treatment facility where they know what they are doing.

Is that too much to ask?

Children with recalcitrant weight loss, repeated hospitalizations, profound bradycardia (sometimes as low as 28-29 BPM), hypophosphatemia and other symptoms well delineated by the Academy of Pediatrics and the Society for Adolescent Medicine, need expert care. Why does it make sense to some people to send patients to a specialist hospital for surgery (including, ironically, weight loss surgery) but not for Anorexia nervosa, with a mortality of 10%? Why are doctors so cavalier about the risks?

We doctors deliver to loving parents difficult news they don't want to hear all the time. So why do we then find it so hard to tell parents of a medically unstable eating disordered child that it’s not appropriate to put convenience and closeness to home ahead of adequate treatment?

It’s clearly about judgment; let’s hope it’s not about consequences.

The Evidence Is There, Now Make It Work

2012-04-13T18:29:11+00:00

Jacques, a friend and parent advocate, sent me an online summary of an article discussing the current evidence base for the use of Olanzapine in anorexia nervosa. Keep in mind as you read the summary that, regardless of the evidence base for efficacy and safety of Olanzapine in general and with anorexia nervosa in particular, this is still an off label use of this drug. Off label means it is a drug approved for one condition which is used by physicians to treat a different condition in a novel way. This kind of use is extremely common throughout medicine and especially in psychiatry.

It’s all very well (and highly desirable) to have an evidence base for any treatment we use in children, however, no medication works unless it is actually taken. And although this sounds like “duh!”, you have to know that compliance with medication is somewhere around 50% under the best of circumstances. Even though this dismal statistic is widely known, providers are still very reluctant to take the bull by the horns and advocate for directly observed, no-option medication administration in children, adolescents and young adults. Why?

In the article quoted here, Dr Daniel LeGrange, a highly respected eating disorder treatment provider at the University of Chicago, is quoted as saying: “One challenge is finding a medication that patients with anorexia nervosa will agree to take regularly…… Patients are almost uniformly very skeptical and very reluctant to take any medication that could lower their resolve to refrain from eating……there are long-standing resistances, and I think researchers and clinicians have been very reluctant to embark on that course, since it's just littered with obstacles."

Agree to take?

We seem to have finally achieved a consensus opinion among those of us who practice a family-based approach to the treatment of eating disorders: that parents should be in charge of no-option re-feeding. So why are we so reluctant to extend this approach to medication? Food is medicine and…medication is also medicine! The article quotes Stephanie Dulawa, PhD, assistant professor of Psychiatry & Behavioral Neuroscience at the University of Chicago and senior author of the study as saying "Anorexia nervosa is the most deadly psychiatric disorder…” Surely if that is true we should take very, very seriously the administration of a medication known to help? No doses should be missed.

I have discussed this issue elsewhere and detailed how we manage this at Kartini Clinic. What have the rest of you (parents, parent advocates, patients and providers) experienced? What do you think?

Wrong in too many ways to count

2012-03-30T13:00:58+00:00

I follow Laura Collin’s blog almost all of the time—but some personal medical issues have kept me from reading lately, until today. I scanned her recent entries and saw this.

Good God. But it does raise a few questions/issues; in fact, way more than a few.

1. Parents don’t cause eating disorders. Since we founded the Kartini Clinic we have been saying loudly, unequivocally and clearly: Parents don’t cause eating disorders and children don’t choose to have them.

Do we say this to ingratiate ourselves with parents? Hardly. Do we put it like this because we are “black and white thinkers” and “dogmatic”? Well, if you think the statement “the world is not flat” is black and white and dogmatic, then maybe. We proclaimed this initially, in the 1990’s, based on our overwhelming clinical experience and we continue to say it based on the evidence, both genetic, clinical and now, neurobiological.

You see, not only do parents not cause eating disorders they couldn’t cause them if they wanted to.

Why would anyone want to cause an eating disorder in their child, you ask? Well, the article quoted by Laura—if true on the face of it—shares the story of a sad little girl and an obsessed, neurotic, misguided woman who apparently believes it is better to be dead than fat. Certainly she must think it is better to be anxious and unhappy than fat. Whatever fat is, in this context.

I have recently seen two cases of what I feel may be Munchhausen by proxy—where a parent is vested in their child’s having an illness (in this case an eating disorder) to the extent that the parent will fabricate symptoms and even starve the child while claiming “he won’t eat”. Nasogastric tubes get placed, unnecessary medical procedures are performed, etc. It is incredibly sad, in fact, criminal. And yet, even these parents, by anyone’s standard disturbed, have not been able to cause anorexia nervosa in their child.

2. Epigenetics as subtext? I have begun to wonder whether or not the fashionable focus on “epigenetics” in the mental health world is not partially a back door way to place blame for causality on parents and families. I’m just going to toss that one out there and invite comment.

3. The Obesity “Epidemic”. The whole obesity thing makes me want to stand on a very high peak and shout “Cease this madness!” Presumably in previous eras “we” were not as fat as we are now. And yet we ate cupcakes. We even ate Twinkies. But our mothers did cook at home---a difference between “now” and “then” that doctors are reluctant to discuss. It is far easier to blame children and insist they “learn to make healthy food choices” than it is to talk painfully and frankly with parents who will do almost anything to avoid preparing and sharing family dinners. OK. Comment invited here too.

4. Paging the Doctor! And then this Vogue article about the seven year old child who lost 16 pounds—did her pediatrician finally then wake up? That is terrible weight loss in a young child (even though it still doesn’t mean she has an eating disorder). It reminds me of something a family physician friend of mine once told me, and which many of you have heard me quote: “Julie,” he said, “if you want to be shot out of a cannon into a bed of granola there is always some doctor out there who will willingly oblige.”

Re-training the brain and modifying behavior in eating disorder treatment

2012-03-18T00:11:03+00:00

Ah the brain, it's so complex; we are so complex! What of our behavior is under our control? What is amenable to cajoling, influence and even coercion? Does this change with age? How is general willingness and ability to learn affected by a specific brain disorder, or can we generalize?

These issues quite frequently come to the fore during the treatment of food phobia, and even infrequently in the treatment of early onset anorexia nervosa.

Some percentage of our young food phobia patients are able to achieve “bite, chew, swallow” once we have them on the seemingly magical dose of 7.5 mg Olanzapine, have sufficiently re-fed their brains with nasogastric feeds, released them from the anxiety of being presented with food for a while, and have taught them that they have nothing to fear from us. But some are not able to get there without a final “push”, and that push is the incentive/disincentive system whereby they win a visit from their parents only by eating their food.

This incentive/disincentive system, somewhat inaccurately referred to as behavior modification (“behavior mod”, shorthand) is something we do with great reluctance. It is supremely hard on parents, especially mothers, something we at Kartini Clinic can easily understand as most of us are parents and the majority of us are mothers. Yet we do it when we need to, because it works. And we are all about outcome.

In the rare case of childhood anorexia nervosa where the child is unable to face food even when adequately supported by nutrition, medication, team and family, we enlist this extra “push” by requiring them to eat in order for their parents to visit. This is done on a meal by meal basis, so that the reward is immediate. We have framed this for our young patients as “re-training the brain”--- showing the brain “it’s hard, but I can do it. I can do it for my mother. I can do it for my father. Watch me!” But it can’t be done in a vacuum and almost never from day one. There is a delicate balance between doing what you need to in order to move forward, to re-train behaviors, and punishment. It can never be punishment. All other incentives and motivators should be tried first, the child should not be in a malnourished state (in other words, use NG feeds to nutritionally restore the brain first if necessary), and the team should be familiar to them and comfortable with this intervention. The team must also be prepared to do a great deal of hand-holding and comforting -- of the parents.

Children respond to “re-training the brain” differently, according to temperament, but are unlikely to be the limiting factors in the success of this intervention. The limitations are set by the ability to tolerate this intervention on the part of us, the parents.

A child’s parents must first believe it can work, and second they must know that their child’s team is NOT interested in punishing their child, and finally this technique must never be done -- and cannot be done -- without parental sign-off and support. It’s not unlike leaving a sobbing toddler at daycare every day, even when you know they are playing happily once you have been out of sight for ten minutes. Painful. Very painful. But with some children it is necessary to help them realize they can stand on their own feet, that adults are in charge to keep them safe, that love never wavers, even when that love must do what is hard in the moment.

Exercise and the Severely Anorexic Patient

2012-03-02T22:15:04+00:00

On February 18 I attended the annual conference of the Columbia River Eating Disorder Network (CREDN) and heard Dr Ken Weiner of ERC speak there. Ken spoke about the uselessness, hopelessness and mirage of dieting, but he also spoke about some of the issues pertinent to managing the patient with anorexia nervosa.

In Dr. Weiner’s experience, and the experience of his colleague Dr Craig Johnson (founding editor of the International Journal of Eating Disorders and founding member of the Eating Disorder Research Society), patients for whom compulsive, compensatory over-exercising has been a prominent feature of their illness, once weight restored, will experience 50% relapse rate if returned to their sport.

50% is a very high relapse rate. Very high. It is therefore their recommendation that such a person not be returned to their sport -- typically running, but not just running -- after successful remission. Ever.

This is a tough recommendation to make and one that is often not received well at all, and not only by the patient. In the case of young patients, parents can be as invested as the child is in sport and exercise. (“Running is what she looks forward to” “it’s her stress reliever” “it’s her main source of self-esteem”, etc.). In some cases, academic scholarships can depend on it. Hard to argue with all that…. and yet, let's think what’s at stake: an illness with a ten percent mortality rate. Children really do die of this disease. Far too many, in fact. If you have had the wrenching experience of standing next to parents who have lost their child to anorexia nervosa, you will be humbled … and terrified.

I remember a boy, about 17 years old, whose mother brought him to me for an assessment. They were late to the appointment because he had to “go to the bathroom” just before. When he did not emerge from the bathroom for a long time his mother became concerned and finally went in. She found him on the floor, tears streaming down his face, doing push-ups and mumbling “eighty-five, eighty-six…Mom…please stop me…please help me stop.”

I remember a day I was giving a lecture to the medical students about eating disorders. The lecture room looked across a courtyard towards the windows of the pediatric wards. One of the residents looked up and cried out: a young girl of fourteen could be seen doing desperate jumping jacks in the window well after the nurse had cleared away her meal.

Every clinician who has evaluated patients with severe eating disorders knows how confused parents can be when told how ill their child in fact is -- despite obvious warning signs such as bradycardia, wasting, social isolation and even fainting -- because only the day before they were running around playing soccer, training for a marathon or competing in gymnastics. “If she’s so sick” the father of a young woman -- with a BMI of 15, terrible wasting, and a heart rate of 38; in other words very dangerously ill -- asked me once, “how come she was able to run with her track team yesterday?”

The answer is, you are able to function until suddenly you are not. You’re driving along until you run out of gas…and with a broken gas gauge, who’s to know?

And if your cancer doctor told you that you could increase your cancer’s chances of relapse to 50% from less than 10% if you did “X”, would you do X? Would you allow your child with cancer to do so?

Why Weight Restoration in Eating Disorder Treatment Must Come First

2012-02-13T17:46:03+00:00

I (among other people) have recently been challenged by Laura Collins to get the message out that weight restoration is critical to psychological recovery in anorexia nervosa. Some authority, Laura says, must declare definitively that psychological recovery is tied to weight restoration.

Some authority….ok…but who?

Since the late 1990’s the AAP (American Academy of Pediatrics) has issued guidelines for hospitalization (after all, a serious intervention) based on medical parameters and weight gain. They are a bit dated now, but still extremely useful in our quest to (a) keep children with anorexia nervosa safe and (b) force insurance carriers to cover such inpatient restoration and the induction of re-feeding. The sad thing is that many, many, MANY therapists and doctors ignore these guidelines and continue to treat patients in an outpatient setting with insufficient weight restoration, even though a patient would clearly meets AAP guidelines for hospitalization e.g. orthostatic or bradycardic or less than 75% of their former weight, or (in the case of very young children) not growing along their former trajectory and are being stunted.

What to do about this? AED (Academy for Eating Disorders) has issued their own guidelines for medical restoration, which are helpful in that they have a target readership of more than just pediatricians (the target readership of the AAP guidelines). Kartini Clinic received a grant several years ago to produce and distribute Spotting the Tiger, with it’s strong emphasis on weight restoration, to all pediatricians, pediatric nurse practitioners and family doctors in Oregon, Idaho and Washington. The result: a resounding silence. Not many watched this DVD, as far as I can tell—those physicians and nurse practitioners who have called me for help over the years have never reported opening it or having read it. And although I know that I am not “the authority” Laura seeks, I have written extensively about the critical role of weight restoration in full remission/recovery in my book Give Food A Chance and in my blogs.

So why the heck do people seem so impervious to the message that without weight restoration you get nothing? And I do mean nothing: no physical recovery AND no psychological recovery. Remember: psychological recovery is about the brain. The brain is an organ of the body; like all other organs it needs fuel to replace broken or used-up cells, and for functioning cells to communicate with each other. Starvation is as bad for children and for any other living thing. This takes no great leap of intellect: you can’t become psychologically normal in a state of malnutrition. You don’t (or shouldn't) need access to all “latest science” to know this. What happens when you starve any other mammal? Think about it.

Why the resistance to this simple message?

I postulate that it is yet another leftover from the days when the treatment of anorexia nervosa was the sole purvue of psychiatry. Even today, the adolescent psychiatric unit at our own hospital makes little attempt to re-feed patients who come to them for reasons but who also have an eating disorder. They’re “not set up for it” they tell me, and they “don’t believe that food should be forced” because they are not the “food police” and because they believe in motivational interventions that are precluded when the patient is not “vested in their own recovery”. They often tell us that unless the patient is “motivated” to get well no intervention is going to be meaningful. The excuse offered is that “ideal body weight is controversial” and can’t be determined accurately anyway. In keeping with this (mistaken) belief psychiatrists—and others—chronically underestimate a child’s goal weight.

Folks, it’s just not that hard to set a biologically meaningful goal weight for a child or adolescent; a little complex perhaps - like much of medicine - but certainly not too difficult or impossible.

In this country, as horribly broken as our system of medical care/insurance/access is, we are still largely able to vote with our feet. If your doctor or therapist doesn’t understand how critical complete weight restoration is to your child’s full recovery, find another one who does. My friend Charlotte from the UK tells me that “voting with your feet” is simply not possible in the system they have over there, and I can only believe her. With sorrow.

And you know what? In the US voting with your feet is not the sole purvue of the educated elite. In this country even folks of simpler background are on the Web every day, searching Craigslist, communicating on Facebook, networking socially, shopping for deals, selling on Ebay, and they can also search for care for their children on sites like NEDA, or EDReferral.com. Families from all over can read everything written on approaches to their child’s illness: so get informed, get powerful, and don’t accept “what’s always been done” for no other reason than that it’s always been done that way or because the provider who does it this way happens to be conveniently located near you. Start a discussion thread relevant to your life, and above all read and share discussion groups/resources already out there such F.E.A.S.T., Kartini’s blog, Sarah Ravin’s blog, Carrie Arnold’s blog, Xtra normal’s films by Bushesbre, and many more. Most of these blogs will have a list of recommended sites for further reading.

That great leveler, the Web, is on your side.

Coming from afar

2012-02-03T13:00:44+00:00

This week I have had the privilege of treating a young person whose parents moved heaven and earth to fly them across the entire United States to seek what they believe to be the best care available anywhere.

Can you imagine how humbling that is for us? To be thought the best care by parents who are entrusting you with the most precious thing they have: their child? It’s not that they come with stars in their eyes and “yes doctor, whatever you say” written cross their foreheads—far from it, usually. They typically come after hours of conversation with our intake coordinators, asking questions, challenging, arranging insurance, arguing with disbelieving family members (“surely there’s the best care in the world in New York/Chicago/Seattle….”) telling their stories, crying, debating and taking a deep breath at the magnitude of a decision to put their lives on hold, fly three thousand miles and dive into the deep end of the pool of family-based treatment, Kartini style.

Typically those who come from afar have tried many things first, and “failed”. It never ceases to amaze me what parents go through in their quest for adequate treatment. Yes, in those urban centers where one would assume the best and most advanced medical care in the world resides, parents come to us having been told that their child is “untreatable” or “spoiled” or “a result of family dysfunction” or “struggling with autonomy issues from an overbearing family system”. Some have been in treatment for many months or years, with wholly inadequate weight gain; some have been medicated with medications from a previous century or another field (benzodiazepines, sleeping pills, laxatives…..), some have endured psychiatric hospitalization and separation from their loved ones “for their own good”.

The stories are diverse and scary. Maybe some of you have a few?

A wolf in sheep’s clothing

2012-01-20T13:00:09+00:00

Every researcher in the field of eating disorders tries their best to reduce the burden of suffering for patients. They try to contribute to the meaningful scientific discussion. Having said that, however, I am going to proceed to critique an article by Natalie Godart, Sylvie Berthoz, Florence Curt and colleagues at the Institut Mutualiste Montsouris in Paris, France; the French National Institute for Health and Medical Research; King’s College, London Institute of Psychiatry; the Department of Biostatistics, Necker Hospital, Paris; and the Institute of Mental Health Research, University of Ottawa. I must thank Chris Berka, former board chair of FEAST (US), for making me aware of this article, although it resulted in a huge headache given how much was wrong with it.

I call this article a "wolf in sheep’s clothing" because, while it purports to report more favorable outcome for “treatment as usual (TAU)” when “family therapy (TAU+FT)” is added, what it really does is imply that faulty family dynamics are what sustain or cause anorexia nervosa, and –worse—it states that “our study design made it possible to rule out the hypothesis that the key ingredient for family therapy effectiveness in AN is that it places ‘greater emphasis on getting patients to eat well and maintain a healthy weight’”.

Leaving aside that “treatment as usual (TAU)” as they defined it (“sessions for the patient alone as well as sessions with a psychiatrist for the patient and her parents”) is so inadequate, if this is “treatment as usual” in France, they had better strongly consider joining the 21st century. So what could possibly be improved by adding “family therapy sessions targeting interfamilial dynamics, but not eating disorder symptoms” ? The answer seems to be “not much”, as the reported outcomes were so bad that I would quit my job if that were all that we were able to achieve for children at Kartini Clinic.

Good and intermediate outcome groups (Morgan and Russell Outcome Categories) were lumped together and defined as those patients who achieved a “healthy weight” and sometimes resumed menstruation. Now let’s look at what they considered a healthy weight. They state (emphasis mine):

Regarding weight status assessment, in view of the patients' age, we considered the Ideal Body Weight (IBW) (which is classically defined as the average body weight of the general population over 15 years of age) to be a less relevant index than BMI percentiles. Hence, to take the ages of our patients into account, we referred to the INSERM (French National Institute for Health and Medical Research) weight curves for the French female population [47], in which a BMI<10th percentile indexes AN [48]. We defined the outcome categories as follows [16], [49]:

1) Good outcome : weight >10th BMI percentile and regular menstruation

2) Intermediate outcome: >10th BMI percentile but amenorrhea (i.e. the absence of menstruation for at least the past three months)

3) Poor outcome: weight <10th BMI percentile and/or presence of bulimic symptoms.

As they melded the “good” and “intermediate” outcome groups into one acceptable group for analysis and contrasted that melded group to the “poor outcome” group, to belong to the successful group a patient could be amenorrheic (no menses) and weigh any number above—even slightly above—the 10th percentile for age. AND, if I am reading their tables correctly, by eighteen months (!!) only slightly more than 17% had achieved this modest outcome in the TAU group and about 40% in the TAU + family therapy (TAU+FT) group.

Now, that’s some damned poor outcome after a very long time. A closer look (see table 3) shows that only about 27% of the TAU group achieved a BMI greater than the 10%tile for age and 53% in the TAU+FT. Worse, about 65% in the TAU group were still amenorrheic and a third were still amenorrheic in the TAU+FT group. I would not publish this data if I were them, unless I wanted to blow the whistle on a national disgrace.

From my Kartinian point of view I struggled with two main issues of the authors’ approach to pediatric eating disorders:

Their definition of a healthy weight is so flawed as to be malpractice. How can one define a healthy weight for a given child/teen as “that weight which is above the 10th percentile for their age?” Have they had no clinical experience with eating disordered children? How about normal children? Surely it matters what the starting point was? A child who grew happily along the 50th percentile prior to their illness could not be said to have achieved a “healthy weight” if they have been returned to a weight which represents the 15th pecentile for age. Who cares about the average BMI centile for age? Individual healthy weights will fluctuate wildly with Tanner stage (SMR), genetics and menstrual history. This lack of understanding of the crucial role of weight restoration and individual healthy weights is no doubt why they got such abysmal results.

Although I am aware that even people who agree with me up to this point may now depart from my analysis, this article is a perfect example of why I cannot agree that all that is “evidence-based” is gold. There is a lot of so-called “evidence” out there that is misleading and even demonstrably false. And an even larger pile of “evidence” that has been erroneously interpreted. This article is a perfect example of the latter: drawing the wrong conclusions from the data, probably a result of bias in concept to begin with. This research represents a randomized controlled study (RTC), considered to be the gold standard for evidence. I say: caveat emptor! Let the buyer beware!

Richard Morton’s Description of Anorexia Nervosa in a Young Man

2012-01-06T13:00:36+00:00

This is the second and final case presentation Dr. Morton makes of two illustrative examples of anorexia nervosa. This time it is a young man. He mentions that the patient is the son of a friend—so imagine how motivated he was to establish the correct diagnosis and find a successful treatment! First Morton discusses the differential diagnosis, establishes the correct diagnosis, discusses failed treatments and finally discusses his successful treatment of what, to him, is a chronic disease.

The Son of the Reverend Minister Mr. Steele, my very good Friend, about the Sixteenth Year of his Age [I remember a time when everyone spoke of anorexia nervosa as if it was unusual to present this “early”, whereas as it has been our experience that sixteen would be a high-average age of presentation], fell gradually into a total Want of Appetite, occasioned by his studying too hard [excessive preoccupation with studies is common, although parents are not usually displeased—at first]), and the Passions of his Mind, and upon that into an Universal Atrophy [he means by this that the visible wasting was over the entire body not just any certain part; he is talking to other physicians reading this and building a case that this affliction arose from the nerves and not, say, from syphilis], pining away more and more for the Space of two Years, without any Cough, Fever, or any other Symptom of any Distemper of his Lungs [so it’s not tuberculosis], or any other Entrail [for example cardiac wasting]; as also without a Looseness, or Diabetes [remember that there was no cure or effective treatment for diabetes and it would have presented with wasting and a sweet urine], or any other Sign of a Colliquation [the degeneration of bodily tissue to a liquid state], or preternatural [a supernatural-seeming phenomenon which nonetheless has a rational—but unknown—explanation] Evacuation. And therefore I judg’d this Consumption to be Nervous, and to have its seat in the whole Habit of the Body, and to arise from the System of Nerves being distempered [so it is a brain disorder, arising from the nervous system]. I began, and first attempted his Cure with the Use of Antiscorbutick [anti-scurvy medication, e.g. vitamin C], Bitter, and Chalybeate of Medicines [Iron containing supplements], as well Natural as Artificial, but without any Benefit; and therefore when I found that the former Method did not answer our Expectations, I advis’d him to abandon his Studies, to go into the Country Air, and to use Riding, and a Milk Diet (and especially to drink Asses Milk) [the milk of a female donkey is considered the closest to human breast milk that is available in the animal kingdom] for a long time. By the Use of which he recover’d his health in a great measure, though he is not yet perfectly freed from a Consumptive State; and what will be the Event of this Method, does not yet plainly appear [the chronic nature of this disease is re-iterated, even when great improvement is seen].

As far as I am concerned, having read and re-read this case history of a young man with anorexia nervosa in the seventeenth century, the take-home message is that neither vitamins nor supplements did any good until he was re-fed (with asses milk!).

Anorexia Nervosa Case Report, Circa 1684

2011-12-23T22:50:28+00:00

As promised, here is the first patient case report by Richard Morton in his 1689 book, Pthisiologia. My comments are in regular italics and his original text in bold (with original, Stuart England grammar and spelling!).

History 1

Mr. Duke’s Daughter in S Mary Axe (a medieval parish in London memorialized by a modern London street of that name) in the year 1684. and the Eighteenth Year of her Age, in the month of July fell into a total Supression of her monthly Courses from a Multitude of cares and Passions of her Mind -- It certainly makes sense that her presenting symptom would be amenorrhea—lack of menstruation-- although here it seems to have preceded her weight loss and wasting. This has been reported off and on in the literature since Morton’s observation but largely ignored, as it seems counter-intuitive. Apparently, with Mr Duke’s daughter, the Mind (brain) had shut off the hormones even before she lost weight. Morton seems astonishingly clear that suppression of the menses was caused by the mind/brain, even without the benefit of our intervening 300 plus years of physiological and biochemical research. -- but without any Symptom of the Green-sickness following upon it. In distinguishing this presentation from that of "green sickness" or hypochromic anemia, Morton is building a case for his colleagues that this consumptive disease is not like the many others they more frequently saw. Per Wikipedia: “Hypochromic anemia was historically known as chlorosis or green sickness for the distinct skin tinge sometimes present in patients, in addition to more general symptoms such as a lack of energy, shortness of breath, dyspepsia, headaches, a capricious or scanty appetite and amenorrhea.” From which time her Appetite began to abate and her Digestion to be bad. Her Flesh also began to be flaccid and loose and her Looks pale, with other Symptoms usual in an Universal Consumption of the Habit of the Body, and by the extreme and memorable cold Weather which happened in the Winter following, this Consumption did seem to be not a little improved, for that she was wont by her studying at Night, and continual poring upon Books, to expose herself both day and Night to the injuries of the Air, which was at that time extremely cold, not without some manifest Prejudice to the System of her Nerves. If this idea that vapours and cold air could cause major illnesses seems laughable to you, remember that physicians of Morton’s time did not even have the benefit of the germ theory. Robert Koch’s formal postulates regarding the existence of germs and their role in disease causation lay far in the future (1890), and Darwin’s work only a bit before that; the father of genetics Gregor Mendel did his (overlooked) work in the 1850’s though its importance was not recognized until the twentieth century.

The Spring following, by the Prescription of some Emperick, she took a Vomit (I think by this he means an emetic, i.e. something to make her vomit therapeutically), and after that I know not what Steel Medicines (some form of iron supplementation), but without any Advantage. So from that time loathing all sorts of Medicaments, she wholly neglected the care of herself for two full Years, (wow! a great description of "denial of the seriousness of the illness" which is reported in modern systems of classification for anorexia nervosa) till at last being brought to the last degree of a Marasmus (wasting), or Consumption, and therefore subject to frequent Fainting-Fitts, she apply’d herself to me for Advice (remember what he said about late advice in these cases, from his introduction and discussion).

I do not remember that I did ever in all my Practice see one, that was conversant with the Living so much wasted with the greatest degree of a Consumption, (like a Skeleton only clad with Skin) how often I have made this observation to medical students when caring for our most severely wasted patients yet there was no Fever again he is differentiating this illness from the Other consumptive illness of the day: TB, but on the contrary a Coldness of the whole Body; no Cough or Difficulty of Breathing, nor an Appearance of any other Distemper of the Lungs, or any other Entrail: no Looseness, or any other sign of a Colliquation, or Preternatural Expence of the Nutritious Juices -- over-exercise? Only her Appetite was diminished, and her Digestion uneasy, with Fainting-Fitts (fainting is still a very common way for eating disordered children to present to the general pediatrician or family doctor), which did frequently return upon her. Which Symptoms I did endeavor to relieve by the outward Application of Aromatick Bags made to the region of the Stomach, and by Stomach-Plaisters (this was done as recently as my grandfather’s day) as also by the internal use of bitter Medicines, Chalybeates, and Juleps made of Cephalick and Antihysterick Waters, sufficiently impregnated with spirit of salt Armoniack, and Tincture of Castor, and other things of that Nature (ick!). Upon the use of which she seemed to be much better; but being quickly tired with Medicines, she beg’d that the whole Affaire might again be committed to Nature, whereupon, she was after three months taken with a fainting-Fitt and died.

And preventing these deaths are what it’s all about.