Table Of ContentTitles of Related Interest
JANKE, W.
Response Variability to Psychotropic Drugs
RACHMAN, S.
Contributions to Medical Psychology, 3 Volume Set
SANTOSTEANO, S.
Cognitive Control Therapy with Children and Adolescents
USDIN, E.
Biological Markers in Psychiatry and Neurology
WEISS, L., KATZMAN, M. & WOLCHIK, S.
Treating Bulimia
Journal of Related Interest
Journal of Psychiatric Research
Editor in Chief (UK): Merton Sandler
Editor in Chief (USA): Joseph J. Schildkraut
Founding Editor: Seymour S. Kety
The Journal of Psychiatric Research, which was founded in 1961 to report on the
latest work in psychiatry and cognate disciplines, has recently expanded its aims
and scope and will as a result now offer innovative and timely coverage of four
important areas of study:
* Clinical studies of all disciplines relating to psychiatric illness, as well as normal
human behavior, including biochemical, physiological, genetic, environmental,
social, psychological and epidemiological factors
* Basic studies pertaining to psychiatry in such fields as neuropsychopharmacology,
neurochemistry, neurophysiology, electrophysiology, genetics, psychology, sociol
ogy, epidemiology and behavioral medicine
* The growing application of clinical laboratory sciences in psychiatry including the
emerging field of psychiatric chemistry
* Advances in basic and clinical research methodology including the progress of
"technology transfer" — the applications of psychiatric research findings to the
clinical practice of psychiatry.
Commissioned reviews, news items, and conference reports will also be featured.
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RICHARD MORTON (1637-1698)
ANOREXIA NERVOSA
and
BULIMIC DISORDERS
Current Perspectives
Proceedings of the Conference on Anorexia Nervosa
and Related Disorders held at University College,
Swansea, Wales, 3-7 September 1984
Edited by
G. I. Szmukler, P. D. Slade, P. Harris, D. Benton
and G. F. M. Russell
PERGAMON PRESS
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Copyright © 1986 Pergamon Press Ltd.
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First edition 1986
Published as a special issue of the Journal of Psychiatric Research
Vol. 19, Number 2/3, and supplied to subscribers as part of their
normal subscription.
ISBN 0 08 032704 4
Printed in Great Britain by A. Wheaton & Co. Ltd., Exeter
PREFACE
THIS VOLUME comprises a selection of papers presented at the International Conference on
Anorexia Nervosa and Related Disorders held at University College, Swansea, Wales in
September 1984. The conference was organized by the Welsh Branch of the British
Psychological Society and the Institute of Psychiatry, London, with additional assistance
from the West Glamorgan Health Authority. Over 150 papers were presented at this
conference which attracted over 250 participants, a testimony to the remarkable amount
of interest in this field.
1984 marks the tercentenary of the onset of the illness in Mr. Duke's daughter, the
subject of the first medical account of anorexia nervosa by Richard Morton published in
1694. Morton attributed the illness to "a multitude of Cares and Passions of the Mind"
and had never before seen in his practice one "so much wasted with the greatest degree of
a Consumption (like a Skeleton only clad with skin)". Three hundred years later this
condition is common and appears to be becoming more common still. The exact nature of
the "Sadness and Anxious Cares" which contribute to the illness remains an area of
intensive study but this is only one part of the story of anorexia nervosa today. The
condition has assumed something of the nature of a paradigm of a 'psychosomatic'
disorder where its various aspects lend themselves to description and investigation at
virtually the entire gammut of conceptual levels employed in the study of disease. These
range from the socio-cultural to the biological. The conference provided a demonstration
that psychiatrists, physicians in internal medicine and psychologists, together with the
spectrum of ancillary disciplines and those related to the social sciences can find a common
ground in the study of this illness, a ground which is gradually being more extensively
illuminated although many mysteries are still concealed within the shadows.
Most sessions at the conference were introduced by review papers given by invited
speakers who covered broad aspects of the field. Among these was a set of three papers
in which authorities from separate treatment centres (Professor Crisp in England, Professor
Garfinkel in Canada and Dr. Vandereycken in Belgium) were asked to describe the
evolution of their treatment approaches and to comment in a less formal way than is
usual on what has been found useful and on what they have discarded. All of the review
papers have been included in this volume. The remainder of the papers presented were
free contributions and it has not been possible to reproduce them all here. A selection has
been made of those describing work not published elsewhere and which is innovative.
Interests which were prominent included the nature of bulimia (found by nearly all to be
increasingly represented in their clinical practice), the epidemiology of the eating disorders
and the assessment of different treatments. An awareness of an historical dimension was
ever present, partly related to an occasion associated with the name of Richard Morton
and partly also because of a sense that the clinical picture of anorexia nervosa is changing.
Somebody once defined a conference as a gathering of important people who singly can
do nothing but together can decide that nothing can be done. We hope that it will be
evident to the reader of this volume that these criteria did not apply to this particular
gathering.
J. psychiat. Res., Vol. 19, No. 2/3, pp. 83-88, 1985
Printed in Great Britain Pergamon Press Ltd.
RICHARD MORTON, 1637-1698,
LIMNER OF ANOREXIA NERVOSA:
HIS LIFE AND TIMES
A TERCENTENARY ESSAY*
JOSEPH A. SILVERMAN
Department of Pediatrics, Columbia University College of Physicians & Surgeons; and Babies
Hospital at the Columbia-Presbyterian Medical Center, 630 West 168th Street, New York,
NY 10032, U.S.A.
INTRODUCTION
IN 1689, Richard Morton, a fellow of the College of Physicians, published his magnum
opus, "Phthisiologia, seu Exercitationes de Phthisi". In this seminal volume, translated
into English five years later, and subtitled, "A Treatise of Consumptions", he outlined in
painstaking detail, the many disease processes that cause wasting of body tissues. All of
the material was based on his own clinical observations, with little reference to books.
The text, which is richly descriptive, is best known for his comments on tuberculosis. A
specialist in the treatment of this disease (OSLER, 1904; TRAIL, 1970), he was the first
physician to state that tubercles are always present in the pulmonary form.
Morton is best known today (BLISS and BRANCH, 1960) as the author of the first medical
account of anorexia nervosa, a condition that he referred to as "a Nervous Consumption",
caused by, "Sadness, and anxious Cares". The clinical description, printed in its entirety,
is as follows:
"Mr. Duke's daughter in St. Mary Axe, in the year 1684, and the Eighteenth Year of her Age, in the
month of July fell into a total suppression of her Monthly Courses from a multitude of Cares and
Passions of her Mind, but without any Symptom of the Green-Sickness following upon it. 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 extream and memorable cold Weather which happened 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 her self both Day and Night to the injuries of the Air,
which was at that time extreamly cold, not without some manifest Prejudice to the System of her Nerves.
The Spring following by the Prescription of some Emperick, she took a Vomit, and after that I know
not what Steel Medicines, but without any Advantage. So from that time loathing all sorts of Medicaments,
she wholly neglected the care of her self for two full Years, till at last being brought to the last degree
of a Marasmus, or Consumption, and thereupon subject to frequent Fainting Fits, she apply'd her self
to me for Advice.
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) yet there
was no Fever, but on the contrary a coldness of the whole Body; no Cough, or difficulty of Breathing,
♦First published in the Journal of the American Medical Association, 25 November 1983, Vol. 250, pp. 2830-
2832, reprinted with permission.
© 1983 American Medical Association.
83
84 JOSEPH A. SILVERMAN
nor an appearance of any other distemper of the Lungs, or of any other Entrail: No loosness, or any
other sign of a Colliquation, or Preternatural expence of the Nutritious Juices. Only her Appetite was
diminished, and her Digestion uneasie, with Fainting Fits, which did frequently return upon her. Which
Symptoms I did endeavour to relieve by the outward application of Aromatick Bags made to the Region
of the Stomack, and by Stomack-Plaisters, 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. Upon the use of which she seemed
to be much better, but being quickly tired with Medicines, she beg'd that the whole Affair might be
committed again to Nature, whereupon consuming every day more and more, she was after three Months
taken with a Fainting Fit and dyed."
(MORTON, 1694)
Almost three hundred years after the onset of Miss Duke's illness, it is appropriate to
acknowledge Morton's contributions and to examine what we know of his life, set against
the background of his times.
He was born in 1637 in the County of Suffolk, the son of a clergyman, Robert Morton.
The precise time and place of his birth are unknown. He was baptized on 30 July 1637 in
the parish of Ribbesford, Worcestershire, where his father was the minister of Bewdley
Chapel from 1635 to 1646.
He became a batler or commoner of Magdalen Hall on 17 March, 1653/4. [In England,
until 1752, for dates between 1 January and 25 March, (the latter from which the New
Year is reckoned) the double year date is given.] When Magdalen Hall was absorbed by
Magdalen College, Morton moved to New College from which he received the degree of
bachelor of arts on 30 January, 1656/7. Soon thereafter, he became chaplain to New
College. On 8 July, 1659, he was granted the degree of master of arts. By then, he was
already chaplain to the family of his cousin, Philip Foley of Prestwood, and vicar of the
parish of Kinver, in Worcestershire (WOOD, 1731; MUNK, 1878; FOSTER, 1891; DNB,
1909; TRAIL, 1970).
At that time (OGG, 1934), England was torn by religious controversy. The battles
between Puritan and Anglican, constantly seething, continued to erupt. The Puritan
believed his relationship with God to be personal. He believed that man, burdened by
original sin, faced certain damnation unless saved by grace. He thought that preaching
was important, and had little use for the Church of England and its emphasis on tradition,
set prayers, sacraments, and priests, all of which, to the Puritan, smacked of popery.
The Anglican strongly disagreed. To him, baptism did regenerate, and the Church with
its sacraments fulfilled an essential part in the process of salvation. The Anglican aimed
at securing, by the well-ordered ritual of the parish church, a reiterated acquiescence in
the established order of things.
Despite the fact that fewer than 3% of the population could be regarded as dissenters,
the Church of England with the help of Parliament and the crown, took draconian steps
between 1662 and 1665 to ensure its authority and primacy, and to destroy such dissent.
Among the steps taken were the following:
1. The Act of Uniformity (1662) required that all members of the clergy (1) be ordained
at the hands of a bishop; (2) give unfeigned assent to the Book of Common Prayer and the
Thirty-Nine Articles in their entirety; and (3) adopt the liturgy of the Church of England.
The statute further enacted that, after St. Bartholomew's Day (24 August, 1662), everyone
then in possession of a benefice and not already in holy orders by episcopal ordination
should (unless, meanwhile he submitted to such ordination), be disabled and deprived. All
MORTON: LIMNER OF ANOREXIA NERVOSA 85
those who refused to subscribe to the Act of Uniformity were dubbed, "nonconformists".
Richard Morton, one of almost 2000 men, or about a fifth of all the beneficed clergy, was
thus evicted from his parish and deprived of his income. (The Church, of course, lost
heavily by this unnecessary sacrifice of many of its best clergy, who were forced into
penury and embittered dissent. Equally serious was the loss of conscientious laymen who
followed their dispossessed pastors.)
2. The Conventicle Act (1664) made illegal all assemblies of five or more persons older
than 16 years of age under color of religion; for the first offense, a fine of £5 was imposed,
and after a third conviction, the penalty was transportation to a plantation other than in
Virginia or New England.
3. The Five Mile Act (1665) reaffirmed the obligation of all in holy orders to take the
prescribed oaths, and forbade all preachers and teachers refusing the oaths to come within
five miles of a corporate town or of the parish where they had taught or preached (OGG,
1934; KENYON, 1978; COOK and WROUGHTON, 1980).
Morton would not give unfeigned assent to the requirements of the Act of Uniformity,
and was ejected from his benefice and deprived of his income. Oxford was probably the
source of his nonconformist beliefs. Although the university as a whole, was more royalist
than was Cambridge, Magdalen Hall had definite Puritan leanings. Morton's election as
chaplain also suggests that the nonconformist element held sway at New College (ROBB-
SMITH, written communication, 1982). In 1662, ejected and dispossessed he was forced
to seek a new means of livelihood.
Virtually nothing is known about Morton between the years 1662 and 1670. Various
references shed little light on his movements or activities. Only vague statements can be
found: 1. "Having embraced the principles of the Nonconformists, he found it advisable
after the restoration of Charles II, to abandon the profession of divinity, and adopt that
of medicine', (MUNK, 1878); or 2. ". . . ejected from his living in August 1662, ... he
turned his attention to medicine" (DNB, 1909).
The decision to enter the field of medicine was neither unusual nor unwise. Although
the ministry was no longer a secure occupation for a nonconformist, medicine was a
relatively safe haven. Moreover, the medical curriculum was not sharply demarcated from
from that of the arts until the nineteenth century. In Morton's day, clergymen in country
districts, often had to act as physicians and therefore familiarized themselves with disease
and treatment (ROBB-SMITH, written communication, 1982). A total of 59 evicted clergymen
eventually became physicians (ROBB-SMITH, 1966).
One must assume that somehow, Morton found an influential person to persuade the
then 20 year old William, Prince of Orange, to recommend him for a doctorate by
"Creation". As a result, he "obtained the degree of Doctor (of Physic) of that faculty
an. 1670, at which time the Prince of Orange was entertained in Oxon, and when the
several Persons that were not well-wishers to the Church of England had degrees
conferr'd on them" (WOOD, 1731).
The M.D. by creation or royal mandate was awarded by Oxford to 39 persons between
the years 1651 and 1700 (ROBB-SMITH, 1966). This honorary degree could be granted to
distinguished persons who had no intention of practicing medicine. It also assisted those
worthy persons who wished to practice, but who, like Morton, might have difficulty in
fulfilling the orthodox prerequisites. In addition, the degree by creation did not require
86 JOSEPH A. SILVERMAN
the recipient to subscribe to the formularies of the Church of England (ROBB-SMITH,
written communication, 1982).
Having received his degree on 20 December 1670, Morton moved to London and
settled into the practice of medicine. He was admitted a candidate of the College of
Physicians on 20 March 1675/6, and a fellow on 23 December 1679 (MUNK, 1878). One
must assume that Morton's fund of medical knowledge was deemed satisfactory to be
awarded fellowship in the College.
In 1680 he was incorporated at Cambridge on his doctor's degree. One must speculate
about his reasons for incorporation. Why would a prominent, successful physician, with
an Oxford degree, fellowship in the College, and endorsement by the Prince of Orange
take this step? Perhaps Morton had two thoughts in mind: (1) He wished to replace his
honorary degree by creation with a straightforward Cambridge doctorate (still without
the need to subscribe to the formularies of the Church of England). (2) He anticipated
that the College of Physicians was likely to receive a new charter, and that, as an ejected
clergyman, his position was not secure. He hoped to insure his status by incorporating his
degree at Cambridge (ROBB-SMITH, written communication 1982).
On 11 March 1686/7, the College of Physicians received a new charter from the recently
crowned James II. In this document, the names of four of the existing fellows were
omitted, presumably having been struck from a list submitted by the College. Morton
was one of the four. The reasons for his removal are not known. Despite his excellent
medical reputation (DEWHURST, 1966), it is thought (CLARK, 1964) that his past as ejected
clergyman, and his presumed allegiance to William, the Prince of Orange, caused him
to be considered politically unreliable.
Morton was not restored to fellowship in the College until 1689. Subsequently, he was
made a Censor in 1690, 1691, and 1697. After the Prince of Orange became King of
England (MUNK, 1878; DNB, 2909), he appointed Morton to be physician in ordinary.
In addition to his Phthisiologia, Morton, in 1692, published two volumes on the subject
of fevers. Their titles are as follows: Pyretologia, seu Exercitationes de Morbis Universalibus
Acutis, and Pyretologiae Pars altera, sive Exercitatio de Febribus Inflammatoriis
universalibus.
All three volumes were widely used, enjoyed a high reputation, and are still occasionally
referred to in the medical literature. All were reprinted several times in continental
Europe. Morton's portrait (DNB, 1909), from a painting by B. Orchard, has been frequently
engraved and is prefixed to several editions of his works.
On 30 August 1698, Morton died. The cause of his death is not known. One might infer,
however, that tuberculosis would be among his afflictions. Morton himself wrote in 1694,
"I cannot sufficiently admire that anyone, at least after he comes to the Flower of Youth,
can die without a touch of Consumption,\ Eight days later, on 7 September 1698, he was
buried in the nave of Christ Church, Newgate Street. The flagstone over him, bore his
arms and the following inscription (MUNK, 1878):
H.S.J.
Richardus Mortonus M.D.
Coll: Med: Lond: Socius
Obiit XXX August \ Salutis MDCXCVIII
Anno / Aetatis LX
MORTON: LIMNER OF ANOREXIA NERVOSA 87
Those who wish to visit Morton's grave will be frustrated by the fact that Christ Church
was destroyed by German bombs in December 1940. Only the walls and tower remain
standing.
Little is known about Morton's personal life (DNB, 1909). He was married in or before
1668. His son, Richard, was born in 1669. He also had three daughters, Sarah, Mercy
and Honor. It is of interest that Morton's son began his education at Oxford on 16 March
1685/6, but left three years later to attend Cambridge. There, in 1691, he proceeded
B.A. and in 1695, M.D. per literas regias (DNB, 1909).
Morton's contributions are many and need little elaboration. His Phthisiologia was, as
stated, widely read, translated into other languages, and used for many years. During the
past three centuries, tuberculosis, Morton's main medical interest, has become better
understood and perhaps less of a problem.
Ironically, anorexia nervosa, to which he devoted a scant three pages, has not only
confounded physicians for 300 years, but has also reached epidemic proportions as the
20th century draws to a close.
The following statement accurately depicts the respect and admiration that should be
accorded Morton:
". . .the best way to appreciate the medical history of a disease is to take into account the circumstances
of the man who was studying it at the time of observation and to imagine one's self without any of the
aids since made available. To do this with reference to Morton and in the case of phthisis, one must
assume that the stethoscope does not yet exist, that the microscope is hardly more than the magnifying
glass of the child, that radiology is unheard of, that Auenbrugger has not yet introduced percussion
and that the knowledge now based on exact information, gathered little by little by all of these means,
has not yet been accumulated. Only then shall we be able to appreciate all the difficulties that Morton
had to contend with in the study of consumption. Nor was this all. He had also to accept or reject all
the theoretical errors as well as the practical successes from the time of Hippocrates onwards. In this
favour is the fact that he was not content to accept anything that he could not see or at least that he
could not explain in terms of what he had been taught...."
(CUMMINS, 1944)
Acknowledgement—William B. Ober, MD, and A. H. T. Robb-Smith, MD, gave advice and encouragement.
REFERENCES
BLISS, E. L. and BRANCH, C. H. H. (1960) Anorexia Nervosa: Its History, Psychology and Biology. Hoeber,
New York.
CLARK, G. (1964) A History of the Royal College of Physicians of London, Vol. 1, pp. 317-375. Clarendon
Press, Oxford.
COOK, C. and WROUGHTON, J. (1980) English Historical Facts 1603-1688. Macmillan, London.
CUMMINS, S. L. (1944) Some early British phthisiologists. Proc. R. Soc. Med. 37, 517-518.
DEWHURST, K. (1966) Dr. Thomas Sydenham (1624-1689) His Life and Original Writings, pp. 58, 78. The
Wellcome Historial Medical Library, London.
FOSTER, J. (IS9Ì) Alumni Oxoniensis, 1500-1714, Vol. 3, p. 1039. Parker, London.
KENYON, J. P. (1978) Stuart England, pp. 181-197. Penguin, Harmondsworth.
LEE, S. (Editor) (1909) Dictionary of National Biography, pp. 1054-1055. Macmillan, London.
MORTON, R. (1689) Phthisiologia, seu Exercitationes, dePhthisi. Smith, London.
MORTON, R. (1694) Phthisiologia: or, a Treatise of Consumptions, pp. 8-9. Smith and Walford, London.
MUNK, W. (1878) The Roll of the Royal College of Physicians of London, 1518-1700, pp. 398-399. The Royal
College of Physicians, London.
OGG, D. (1934) England in the Reign of Charles II, Vol. 1, pp. 189-218. Clarendon Press, London.
OSLER, W. (1904) The "Phthisiologia" of Richard Morton, M.D. Med. Lib. Hist. J. 2, 1-7.
