Daf Ditty Yoma 83: Bulmus and Anorexia

The term bulimia comes from Greek βουλιµία boulīmia, "ravenous hunger",
a compound of βοῦς bous, "ox" and λιµός, līmos, "hunger". Literally, the
scientific name of the disorder, bulimia nervosa, translates to "nervous
ravenous hunger".

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MISHNA: In the case of one who is seized with the life-threatening illness bulmos, causing him
unbearable hunger pangs and impaired vision, one may feed him even impure foods on Yom
Kippur or any other day until his eyes recover, as the return of his sight indicates that he is
recovering. In the case of one whom a mad dog bit, one may not feed him from the lobe of the
dog’s liver. This was thought to be a remedy for the bite, but the Rabbis deem it ineffective. And
Rabbi Matya ben Ḥarash permits feeding it to him, as he deems it effective.

RASHI

Our Mishna, he who is seized by bulmos (a disease) – This sickness seizes a person on account
of hunger, his eyes become dim and he is in danger of death.

When his healthy appearance returns, we know he is healed.

Steinzaltz

Jastrow

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And furthermore, Rabbi Matya ben Ḥarash said: With regard to one who suffers pain in his
throat, one may place medicine inside his mouth on Shabbat, although administering a remedy
is prohibited on Shabbat. This is because there is uncertainty whether or not it is a life-
threatening situation for him, as it is difficult to ascertain the severity of internal pain. And a case
of uncertainty concerning a life-threatening situation overrides Shabbat.

Similarly, with regard to one upon whom a rockslide fell, and there is uncertainty whether he is
there under the debris or whether he is not there; and there is uncertainty whether he is still
alive or whether he is dead; and there is uncertainty whether the person under the debris is a
gentile or whether he is a Jew, one clears the pile from atop him. One may perform any action
necessary to rescue him from beneath the debris. If they found him alive after beginning to clear

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the debris, they continue to clear the pile until they can extricate him. And if they found him dead,
they should leave him, since one may not desecrate Shabbat to preserve the dignity of the dead.

The Sages taught in a baraita: In the case of one who is seized with bulmos, one feeds him
honey and all types of sweet foods, as the honey and all types of sweet foods restore the sight
of his eyes. And although there is no clear proof for the matter, there is an allusion to the
matter. Jonathan said:

-‫ ֶאת‬,‫ ָעַכר אִָבי‬,‫ יוָֹנָתן‬,‫כט ַויּ ֹאֶמר‬ 29 Then said Jonathan: 'My father hath troubled the land;
,‫ִכּי ָטַעְמִתּי‬--‫א ֹרוּ ֵעיַני‬-‫ ִכּי‬,‫ָנא‬-‫ ְראוּ‬:‫ָהאֶָרץ‬ see, I pray you, how mine eyes are brightened, because I
.‫ְמַעט ְדַּבשׁ ַהזֶּה‬ tasted a little of this honey.
I Sam 14:29

“See, I pray you, how my eyes are brightened because I tasted a little of this honey”

The Gemara asks: And why does the baraita say: Although there is no clear proof for the
matter, when that verse is a strong proof? The Gemara answers: There, Jonathan was not seized
with bulmos, he was merely very hungry. Therefore, the episode provides no evidence that honey
or sweet foods are the remedy for bulmos.

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Rav Naḥman said that Shmuel said: In the case of one who is seized with bulmos, one feeds
him a sheep’s tail with honey, since the combination of the fatty meat and the honey helps greatly.
Rav Huna, son of Rav Yehoshua, said: Also, fine wheat flour with honey is a remedy. Rav
Pappa said: Even barley flour with honey is good for curing bulmos. Rabbi Yoḥanan said:
Once I was seized with bulmos and I ran to the east side of a fig tree and found ripe figs there,
which I ate. Figs on a tree do not all ripen at once but ripen first on the side where the sun rises, so
Rabbi Yoḥanan searched first for figs on the east side of the tree. And I thereby fulfilled the verse:

;‫ ְבֵּצל ַהָכֶּסף‬,‫יב ִכּי ְבֵּצל ַהָחְכָמה‬ 12 For wisdom is a defence, even as money is a defence; but the
‫ ַהָחְכָמה ְתַּחיֶּה‬,‫ְויְִתרוֹן ַדַּעת‬ excellency of knowledge is, that wisdom preserveth the life of him
.‫ְבָעֶליָה‬ that hath it.
Eccl 7:12

“Wisdom preserves the lives of those who have it” As Rav Yosef taught: One who wishes to
taste the flavor of the fig should turn to the east, as it is stated:

;‫שֶׁמשׁ‬ ָ ‫ ְתּבוּא ֹת‬,‫ יד וִּמֶמֶּגד‬14 And for the precious things of the fruits of the sun, and for
.‫ ֶגֶּרשׁ יְָרִחים‬,‫וִּמֶמֶּגד‬ the precious things of the yield of the moons,
Deut 33:14

“And for the precious things of the sun’s fruits” implying that the sun ripens fruit and makes
them sweet.

The Gemara relates that Rabbi Yehuda and Rabbi Yosei were walking on the road when Rabbi
Yehuda was seized with bulmos. He overpowered a nearby shepherd and ate the bread that
the shepherd had in his hand, since his life was in danger. Rabbi Yosei said to him: You have
robbed that shepherd. When they reached the city, Rabbi Yosei was seized with bulmos, and
all the people of the city surrounded him with jugs [lagei] and plates with all sorts of sweets.
Rabbi Yehuda said to him in jest: I robbed only the shepherd, but you have robbed the entire
city.

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§ It was taught that in the case of one whom a mad dog bit, one does not feed him the lobe of its
liver. The Gemara clarifies the concept of the mad dog.

The Sages taught in a baraita: Five signs were said about a mad dog: Its mouth is always
open; and its saliva drips; and its ears are floppy and do not stand up; and its tail rests on its
legs; and it walks on the edges of roads. And some say it also barks and its voice is not heard.

The Gemara asks: From where did the dog become mad? Rav said: Witches play with it and
practice their magic on it, causing it to become mad. And Shmuel said: An evil spirit rests upon
it.

Summary

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Some interesting concepts are introduced to us today. First, what do we do about a person who is
ill but insists on fasting on Yom Kippur? Well, we consult an expert - in this case, a doctor. If the
doctor agrees that this person can fast, then we allow him to fast. However, if the doctor says that
he should eat, we go with the opinion of the person himself, for we learn in Proverbs (14:10) that
"the heart knows the bitterness of its soul."1

Even if two or three doctors are consulted, we are walking close to the practice of court
witnesses. Again, the person who is ill has great power to make decisions in these circumstances. I
wonder whether this is true for both men and women. No distinction is stated. Generally speaking,
women's opinions about their own bodies and needs are not the primary determiners of what
happens in their lives.

1
https://dafyomibeginner.blogspot.com/search?q=yoma+84

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A new mishna considers a number of concerns:

1) when suffering from bulmos, it is alright to eat on Yom Kippur

2) when bitten by a rabid dog, it may or may not be permitted to use medicine to save one's life on
Yom Kippur

3) when suffering with a sore throat that may turn out to be life threatening, it is permissible to use
medicine

4) when a person is trapped under a landslide of rocks, it is permitted to move aside the rocks to
find that person, whether s/he is Jewish or Gentile; alive or dead. A live person must be moved to
save her/his life. If the person is dead, however, we do not desecrate our holy day to move rocks
or the person. This is because we do not break halachot of Shabbat/Yom Tov for the sake of
respect for a deceased person.

The rabbis consider illnesses, including confusion or tunba (seemingly senility or dementia), and
bulmos. Bulmos, which has the same root as bulimia (Ancient Greek for 'excessive hunger') is a
condition that includes symptoms of excessive hunger and loss of vision. The eyes recover first
as a person heals from bulmos. The rabbis tell a story of Rabbi Yehuda who is overcome with
bulmos while travelling with Rabbi Yosei. He grabs the bread from a shepherd's hand, devouring
it. This is allowed, as it saves his life. Rabbi Yosei says that Rabbi Yehuda stole that bread. Upon
returning home, Rabbi Yosei became ill with bulmos as well; he was surrounded by townspeople
offering him their food. Rabbi Yehuda quipped, you chastised me for stealing from the shepherd
and then you stole from the entire town!

The Gemara spends some time analyzing when we might break different prohibitions
strategically. For example if we are hungry with bulmos and we must eat, do we eat untithed food
or non-kosher food? Which halachot are Torah given and which are rabbinical in origin? Which
are punished with death and which with just a 'slap on the wrist'?

We end today's daf with stories about our rabbis that highlight their wisdom and their extraordinary
experiences in travel. The first finds Rabbi Meir protecting himself from theft through his
suspicions that the innkeeper is a bad person based on the meaning of his name. The second tells
us of an innkeeper who fed pork to a Jew because the Jew did not indicate that he was Jewish by
completing netilat yadaim before the meal.

This innkeeper would have fed the Jew kosher food had he known. And, as we know, eating food
forbidden by Torah law is punishable by death. So the innkeeper is responsible for killing the Jew.

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Our rabbis are incredibly focused upon finding the hair-width line between what is permitted and
what is prohibited. For people like me who do not believe that that line is all-important (except
when I prepare for Pesach, however, which is another story), is it worthwhile to study these
texts? I would argue that it is worthwhile. To understand the logic and context of our rabbis is
both fascinating and enlightening. And the studying does allow me to feel closer to my history.

FEEDING FORBIDDEN FOOD TO A SICK PERSON

Rabbi Mordechai Kornfeld writes:2

The Mishnah states that one is permitted to feed any type of food, even forbidden food, to one who is
afflicted with "Bulmus," a dangerous illness which results from hunger (Rashi). The Gemara cites a
Beraisa which says that when there is no permitted food available, and the only foods available are a
food prohibited by a very severe Isur and a food prohibited by a less severe Isur, one should feed to
the sick person the less severe Isur. For example, if the only foods available are a fruit of Tevel and
meat of Neveilah, one should feed the Neveilah to the sick person. Neveilah is forbidden only by a Lav
and is punishable with Malkus, while Tevel is punishable with Misah b'Yedei Shamayim. This
Halachah applies to any sick person in mortal danger.

A logical corollary to this rule should be that if the choice would be to feed a sick person Neveilah or
to desecrate Shabbos (in order to slaughter an animal properly), one should choose the Neveilah
because the desecration of Shabbos is punishable with Sekilah, a more severe punishment than Malkus.
However, the Rishonim rule otherwise. They rule that one should desecrate Shabbos and not feed him
Neveilah. (This is also implied by the Gemara in Chulin (14b) which permits one to slaughter an animal
for a sick person on Shabbos and does not specifically limit that allowance to a case in which there is
no Nochri available to kill the animal.) Why is Shabbos different?

(a) The RA'AVAD (cited by the ROSH and the RAN) explains that the allowance to feed an Isur to
a sick person applies only to the specific Isur which prevents him from eating. On Shabbos, when a
person needs to eat because of Piku'ach Nefesh, it is not the fact that a Neveilah is prohibited that
prevents him from eating. Rather, it is the Isur against slaughtering an animal on Shabbos that prevents
him from eating (because, if not for Shabbos, he would simply slaughter an animal and eat it).
Therefore, it is the Isur against slaughtering on Shabbos which may be pushed aside for the sake of the
sick person.

The RAN, however, takes issue with the Ra'avad's ruling. If the meat of Neveilah is available on
Shabbos, then both the Isur of Neveilah and the Isur against slaughtering on Shabbos stand in his way
of eating. Why should the Isur of Neveilah not be pushed aside? After all, it is less severe than the Isur
of Melachah on Shabbos.

Perhaps the Ra'avad means that an Isur which applies only at certain times (or in some other limited
way) is always pushed aside before an Isur that applies constantly. The limited Isur is viewed as the

2
https://www.dafyomi.co.il/yoma/insites/yo-dt-083.htm

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Isur which presently stands in his way, since, under other circumstances, it would not apply. Therefore,
the Isur against slaughtering on Shabbos must be pushed aside before the Isur of Neveilah.

(b) The ROSH, in an entirely different approach, says that the sick person might be so disgusted by
the Neveilah that he will not be able to eat it and his life will be in more danger. Therefore, it is better
to slaughter an animal for him.
(c) The RAN explains that in this case, the Isur of Neveilah is more severe than the Isur against
slaughtering on Shabbos. When the sick person eats Neveilah, each k'Zayis of meat that he eats
constitutes an additional Lav. A person who performs Shechitah on Shabbos transgresses the Isur only
once. Therefore, it is preferable to slaughter an animal on Shabbos for the sick person than to feed him
Neveilah.

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(1) The reason is because "the heart knows its own bitterness" (Mishlei 14:10), as Rav Yanai says.
(2) The reason the Choleh's opinion is disregarded is because perhaps, as a result of his illness, he has been overcome by "Tunba"
(Rashi: delirium).
(3) According to the unidentified opinion of the Gemara at the beginning of the Sugya (which may be the opinion of Rav Yanai),
the Choleh may not eat. According to Mar bar Rav Ashi, he may eat. Mar bar Rav Ashi holds that the logic of "the heart knows its
own bitterness" applies even against the opinion of two or more doctors.
(4) The reason is because of the principle "Safek Nefashos l'Hakel." This principle applies here because there is an equal number
of opinions for both sides (ROSH).
(5) The reason is because when it comes to a possible mortal danger, we do not follow the majority of medical opinions, and two
opinions are put on an equal basis with even 100 dissenting opinions. (This appears to be our Gemara's conclusion. However,
according to the SHE'ILTOS (cited by the ROSH, 8:13) and RASHI (84b, DH Al Pi Nashim), Mar bar Rav Ashi argues with this
view and maintains that we do follow the majority opinion in such a case - - see Insights to 84b.)
(6) ROSH 8:13. This may be learned by inference from the Mishnah, according to Rebbi Yanai. (Although the Mishnah is
discussing when two doctors support the Choleh and say that he should not eat, according to the Gemara's conclusion, nevertheless
the same should apply if one doctor supports him, since the Choleh with the doctor saying not to feed him override the doctor that
says to feed him.)

THE MAD DOG AND LASHON HA'RA

The Gemara quotes a Beraisa which lists five characteristics with which a person can identify a mad
dog: its mouth hangs open, spittle trickles down from its open mouth, its ears hang low, its tail rests
between its legs, and it walks along the far side of the road. Some add that it barks but its voice is not
heard.

Shmuel says that the danger of a mad dog is the Ru'ach Ra'ah that rests upon it. To support Shmuel,
the Gemara cites a Beraisa which states that one who attempts to kill a mad dog must do so only from
afar (such as by throwing something at it), so that he not be harmed by the Ru'ach Ra'ah. The Beraisa
continues and says that one who rubs against a mad dog is in danger, and the only remedy is to throw
off his clothes immediately and run away. The Beraisa adds that a person who is bitten by a mad dog
surely will die (Abaye, however, describes an antidote to the bite of a mad dog).

The CHAFETZ CHAIM (in SHEMIRAS HA'LASHON, Sha'ar ha'Zechirah, ch. 4) cites the
Midrash (Yalkut Shimoni, Parshas Ki Setzei) which compares a person who speaks Lashon ha'Ra to
one who is bitten by a mad dog. The Chafetz Chaim points out that just as there is no remedy for the
bite of a mad dog, there is no atonement for one accustoms himself to speaking Lashon ha'Ra. The
Gemara in Erchin (16b) says that one who habitually speaks Lashon ha'Ra has no atonement.

Why does the Midrash specifically compare a person who speaks Lashon ha'Ra to one who was bitten
by a mad dog?

The Chafetz Chaim, based on the Gemara here, describes how a person who speaks Lashon ha'Ra has
all of the attributes of a mad dog. The Ru'ach Ra'ah that rests on a mad dog causes it to have the
characteristics enumerated by the Beraisa. When the dog bites, the Ru'ach Ra'ah is transmitted to the
person who then develops all of the attributes of the mad dog. One who speaks Lashon ha'Ra also has
these attributes, as though a Ru'ach Ra'ah rests upon him. The Chafetz Chaim elaborates:

1. A mad dog's mouth hangs open. Similarly, the mouth of the person who speaks Lashon ha'Ra is
always open, waiting to find any listener with whom to share his gossip.

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2. Its spittle trickles down. The mad dog is always ready to attack anyone it meets, as indicated by its
constant flow of spittle. Similarly, the person who speaks Lashon ha'Ra is always eager to speak about
anyone whose name comes up in conversation. In addition, the spittle of a dog is most disgusting,
especially that of a mad dog. The dog leaves a path of saliva behind wherever it goes. Similarly, the
disgusting speech of the person who speaks Lashon ha'Ra leaves its impact wherever he goes.
3. Its ears hang low. By hanging its ears, the mad dog makes itself look uninterested in attacking
anyone, so that no one will be afraid to come near it. This tactic enables the dog to easily pounce on
its prey.
4. Its tail rests between its legs. For the same reason that it keeps its ears low, the mad dog walks slowly
and does not run excitedly. It gives the impression that it is harmless.
5. It walks along the far side of the road. The dog walks apart from the central flow of people and gives
the impression that it is uninterested in attacking anyone.
Some add that it barks but its voice is not heard. This is another guise that it engages to give the
appearance of a quiet, happy, kind-hearted canine, so that whoever sees it will assume that it is harmless
and will take no measure of caution. It then is poised to viciously attack its unsuspecting victim.

The person who speaks Lashon ha'Ra demonstrates these attributes as well. He walks humbly, away
from other people, so that they will think he is not interested in their affairs and that he does not spread
gossip. When he speaks Lashon ha'Ra, he does it in such a sly way that at first it is not evident that he
is speaking Lashon ha'Ra. His ears are down as though he is not listening to anyone else's private
conversations, and he walks along as though he is minding his own business, so that others will be
unprepared when he comes to attack with his vicious Lashon ha'Ra. Just as a mad dog barks and no
voice is heard, the one who speaks Lashon ha'Ra does damage that is not noticeable right away.

Finally, just as one who rubs against a mad dog must throw off his clothes and run away quickly, one
who comes near a person who is known to speak Lashon ha'Ra should run away immediately, even at
the cost of significant embarrassment.

Steinzaltz (OBM) writes:3

The Mishnah on our daf discusses circumstances when an illness would allow someone to eat non-
kosher food, and other cases when halakha would not allow non-kosher food to be eaten.

The first case discussed is bulmus – ravenous hunger. In this case the Mishnah teaches that he can
be fed anything that may cure him. The second case is that of someone bitten by a rabid dog. The
common cure in Mishnaic times, which was to have the victim eat from the dog’s liver, is forbidden
by the Tanna Kamma, although Rabbi Matya ben Harash permits it.

The “hunger sickness” of bulmus, is, apparently, connected to a drastic drop in blood sugar that is
caused by starvation or some other disease. As described in the Gemara, the sensation of hunger
comes together with a loss of awareness – the individual cannot see or cannot see clearly. The

3
https://www.ou.org/life/torah/masechet_yoma_7985/

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recommendation of the Sages is to feed the ill person sweet foods that can be easily digested as
quickly as possible.

The description of this condition is supported in the Gemara by a series of personal testimonies
from Sages who were witness to someone who had this condition or who had it themselves. Rabbi
Yohanan, for example, describes how he once suffered from bulmus, but was able to save himself
by applying his knowledge. He ate dates from the eastern side of a date palm to resolve his need
for sweet food.

Date palms are unique in that their fruit does not all ripen at the same time. From one day to the
next – and sometimes even through the course of a day, different fruits become ripe. Since the sun
rises in the east, it is logical to assume that the ripest fruits will be found on that side.

With regard to the bite of a rabid dog, the disagreement in the Mishnah would seem to be whether
the popular cure was, in fact, effective. The Rambam, however, understands that eating the rabid
dog’s liver is not a medical cure, but a segulah – a charm – which at best may be a psychological
support to the victim. He argues that the Tanna Kamma rejects the possibility that a Torah law
would be pushed aside for such an emotional support, even for someone who believes in it.

In his Sefer Shmiras Halashon (Sha’ar HaZechirah, Ch. 4, notes), R’ Yisroel Meir Kagan, zt”l,
expounds upon our Gemara using the insight of our sages who compare the habitual speaking and
listening to leshon hara to a situation of a mad dog that bites, and that such a wound does not heal.4

The Chofetz Chaim elaborates: The Gemara mentions five features in reference to a wild dog. Its
mouth is always open, its stench lingers, its tail hangs below its legs, its ears are long and hang
low, and it stalks along the edge of the street. Some say that it also barks, but its voice is not heard.
Each of these features can be understood in terms of the comparison which our sages make to one
who habitually speaks leshon hara. His mouth is constantly open, indiscriminately ready to share
his venomous tales with any person he meets.

The one who spreads slander possesses a foul and evil spirit, and his presumptuous nature and
angry character cause him to spread an unpleasant aura before himself and to leave behind a foul
odor to those he affects. The other three aspects of a wild dog come from his desire to lurk
undetected and to be prepared to pounce upon his unsuspecting victim. His ears are poised to hear
the approach of an appropriate target, and his tail is hidden between his legs as he walks along the
side of the road to remain out of sight until he is ready to strike. He remains quite careful, so that
he will be able to bite without warning.

4
https://dafdigest.org/masechtos/Yoma%20083.pdf

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This is the nature of the slanderer, as he spreads his tales to an unassuming listener. He casually
strolls about, and he unleashes his stories and aspersions about people without advance notice. It
is especially necessary for us to identify the nature of those who speak leshon hara in order to
protect ourselves from their attack. The danger and devastation of leshon hara can be avoided if
we steer clear of it before it happens.

Rambam (1) explains that Chachamim prohibited, even for medicinal purposes, the consumption
of non-kosher food when the curative effect of the medication has no basis in science (‫ ) סגולית‬and
has not been tested as an effective cure. Even if there are doctors who praise its therapeutic
properties it may not be used if its use would violate a prohibition.

Accordingly, there are Poskim (2) who question whether it is permitted for a person to take
homeopathic medications that are or may be non-kosher. One of the components of the question
is that in the manufacturing process it is soaked in alcohol and, depending on the place where it is
manufactured, it may be a wine derivative.

Rav Shmuel HaLevi Wosner (3) addressed the issue of whether homeopathic medication is
“natural” (‫( טבעית‬and its use would override prohibitions, or if they are not natural, and they may
not be used if their use involves violating prohibitions. He writes that the question is not whether
a medication is derived from natural ingredients or not; rather the central issue is whether it has
been demonstrated as an effective cure.

In other words, medications that are made from natural ingredients but have not been tested for
effectiveness are considered non-scientific –‫—סגולית‬and would be prohibited. Medications that are
not natural but have proven to be therapeutic are treated as “natural” – ‫– טבעית‬and are therefore
permitted. Other Poskim who address this issue also permit the use of homeopathic medication
even when all of its ingredients are not known based on principles derived from the halachos of
wine that is manufactured by a non-Jew (‫( ) יינם סתם‬4).

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Rabbi Elliot Goldberg writes:5

Fasting is a core element of the Yom Kippur experience. While challenging at times, fasting
contributes to the seriousness of the day and allows us to focus on our spiritual, rather than our
physical, needs.

But as we saw yesterday on Yoma 82, there are circumstances where it’s not only permitted but
obligatory to eat — particularly if a life is at stake. So how sick would you have to be in order to
eat? Would you seek out advice? From friends and family? A rabbi?

The Talmud addressed this question in a mishnah that we read a few days ago:

If a person is ill and requires food due to potential danger, one feeds him according to the advice
of medical experts who determine that he indeed requires food. And if there are no experts there,
one feeds him according to his own instructions, until he says that he has eaten enough and
needs no more.

Makes sense. If you are sick on Yom Kippur, you can eat if your doctor says you can. And if you
are unable to consult with a medical professional, you can use your own discretion. Sounds like
we are ready to move on to the next topic.

Not so fast. On today’s daf, the Gemara cites another source for us to consider: Rabbi Yannai
teaches that if a sick person feels the need to eat, they can eat even if their doctor says it is OK for
them to fast. Why? Because of the verse in Proverbs 14:10, which states: “the heart knows the
bitterness of the soul.” That is, a person understands their own condition even better than a doctor.

5
Myjewishlearning.com

15
Rabbi Yannai goes on to say that if a doctor says a person should eat and they choose not to, we
feed the person anyway based upon the doctor's advice. Why don’t we listen to the sick person in
this case? Because illness clouds judgement, so we rely on medical advice and insist that the person
eats.

For the Gemara, it’s problematic that Rabbi Yannai seems to be contradicting the mishnah by
allowing a sick person to eat based on their own assessment even when doctors are present. So the
Gemara suggests that the mishnah is talking about a case when a sick person wants to fast. In such
circumstances, experts can overrule the patient and require that they eat.

“But isn’t this obvious?” asks the Gemara. In matters of life and death we are lenient, so we don’t
need the mishnah to teach us that a doctor can instruct someone to eat if they are sick on Yom
Kippur.

So maybe the mishnah is talking about a case where a sick person wants to eat and its purpose is
to teach that experts, when they are available, are required to make eating permissible. But this
doesn’t sit well with the Gemara either, which cites an opinion that rejects this approach in even
stronger terms than Rabbi Yannai:

Any instance where an ill person says: I need to eat, even if there are a hundred expert doctors
who say that he does not need to eat, we listen to his own option and feed him, as it is stated: The
heart knows the bitterness of its soul. (Proverbs 14:10)

This conversation emerges, in part, from the fact that the mishnah differentiates between cases
when experts are present and when they are not, while Rabbi Yannai focuses on whether the sick
person wants to eat or fast. The Talmud is trying here to square two sources that are speaking about
related, but not identical, things. At the same time, the Talmud is motivated to codify into law that
which the mishnah does not specifically allow — permission for a sick person to self-determine
when they are too sick to fast.

In the end, the Talmud applies the first part of the mishnah to a case where the sick person wants
to fast and the latter to a case where a sick person wants to eat. Doctors can intervene in the former,
but the patient can determine the best course of action in the latter — no matter how many experts
weigh in on the matter.

So if you are sick on Yom Kippur and feel the need to eat, don’t worry about what others say. You
are free to do what you think is best. But if you choose to fast and a doctor instructs you otherwise,
listen to your doctor.

Rabbi Johnny Solomon writes:6

As part of our daf (Yoma 83a) discussion about the treatment of the sick of Yom Kippur, a stirring
pasuk from Mishlei is quoted to affirm that someone who feels that they need to eat on Yom Kippur
should do so - even in a situation where experts do not see it that way.

6
www.rabbijohnnysolomon.com

16
Specifically, the pasuk from Mishlei 14:10 states: ‫“ – ֵלב יוֵֹדַע ָמַרּת ַנְפשׁוֹ‬The heart knows the bitterness
of its soul”, which is understood to mean that we fully rely on an individual to assess how they are
feeling in order to determine their capacity to fast or need to break their fast - even more than a
medical expert who most likely has a better and a more objective understanding of their ability
and capacity to fast.

Yet while this pasuk is understood physiologically, it can also be understood psychologically. As
Hirsch explains, ‘no outsider can fathom the depth of a heart’s sorrow’ (From the Wisdom of
Mishlei p. 186). In fact, a phrase which is often overused but which can unintentionally upset or
frustrate those going through a crisis, is ‘I understand’, because in many cases, we don’t fully
understand what others are going through. At the same time, there are moments when the
experience of one person is sufficiently similar to another that they can bring them a unique form
of comfort.

A story along these lines, first told by Rabbi Ari Kahn and then later by Rabbi Paysach Krohn,
involves Professor Robert Aumann, the 2005 winner of the Nobel Prize in Economics, and Rabbi
Yisroel Zev Gustman (1908-1991), a brilliant Torah Scholar and Rosh Yeshiva who, having been
born in Lithuania and served as a Dayan in Vilna, then moved to Brooklyn and later on, to
Jerusalem where he delivered shiurim both to his yeshiva students and to the wider public, and
among the regular attendees of this shiur was Professor Aumann.

As Rabbi Krohn (in his ‘In the Spirit of the Maggid’ pp. 41-43) relates: ‘In June 1982, Professor
Aumann’s son, Shlomo, was a young father whose wife was expecting their second child. He was
a maggid shiur in a Jerusalem mesivta. When the first Lebanese War broke out, Shlomo was called
to duty at the front. Tragically, Shlomo was killed in action before his child was born. Rabbi
Gustman and all the bachurim of the yeshivah attended the levayah. Then they all accompanied
the yrosh yeshiva to the cemetery where they assisted in burying the young soldier. After the burial,
Rabbi Gustman walked among the gravesites of other Israeli soldiers killed in combat, his face
twisted in anguish. “They are all holy,” he said reverently, “every single one of them.” On the way
home, Rabbi Gustman asked that he be taken to the home where the Aumanns were sitting shiva.
He came in and sat down next to the grieving professor. “I appreciate that you came to the
cemetery, but now it’s time for the rosh yeshiva to be back in the yeshiva with his talmidim.” To
this, Rabbi Gustman said the following:

“I don’t know if you know this but I had a son named Meir. He was a beautiful little child. The
Nazis grabbed him from my arms and shot him in cold blood… My Meir is a kadosh, he is holy
– he and all the six million who perished are holy… I will tell you what is transpiring now in
the Olam HaEmes (the World of Truth) in Heaven. My Meir is welcoming your Shlomo into the
minyan and is saying to him, ‘I died because I am a Jew – but I wasn’t able to save anyone else.
But you, Shlomo, you died defending your fellow Jews.’ My Meir is a kadosh, but your Shlomo
is a shaliach tzidbbur – he served Klal Yisrael.”

Rav Gustman paused, lowered his voice and said to the bereaved father, “I never had the
opportunity to sit shiva for my Meir; let me sit here with you.”

17
Professor Aumann looked up at Rabbi Gustman and said with tears in his eyes and a lump in his
throat, “I thought I could never be comforted, but Rebbe, you have comforted me.”

Medicine & Law

Menachem Elon writes:7

PHYSICIAN'S DUTIES AND PATIENTS' RIGHTS

Initially, during the tannaitic era, it was established that it is permitted for a physician to heal.
The Talmud derives this from the verse (Exod. 21:19): "'He shall cause him to be thoroughly
healed' – This teaches that the physician is given permission to heal" (Bava Kamma 85a). This
implied rejection of the approach prevalent in various philosophies and religions at that time, and
later as well, even in some statements by Jewish thinkers, that one should not heal a person whom
God has made ill, because there should be no intervention in what Heaven has decreed (Rashi,
at BK 85a, S.V. Nitna reshut; Kitvei Ramban, Chavell ed. (Jerusalem 1964), vol. 2: Torat ha-

7
https://www.jewishvirtuallibrary.org/medicine-law

18
Adam, at 42). Other tannaitic halakhic rules established that an expert physician who inadvertently
caused damage is exempt, as a matter of public policy (Tosefta, Git. 4:6, Zukermandel ed.), for
otherwise physicians would be unwilling to perform their duties (Resp. Tashbez, vol. 3 no. 82).

During the period of the rishonim the view was articulated that the physician's work is not only
permitted, but is an obligation and constitutes the fulfillment of a commandment. Maimonides held
that this is based on the duty to save life found in Jewish law whereby a person is obliged to save
his fellow man who is in danger, "with his body, his money, or his knowledge (Yad, Nedarim 7:8).
According to Naḥmanides, "any physician who is knowledgeable is obligated to heal, and if he
refused to do so he is considered to have shed blood" (Sefer Torat ha-Adam, Kitvei ha-Ramban, ed.
Chavel, 2:41–42). Thus, the permission given the physician to heal also has the status of a
commandment (mitzvah), intended to dispel the physician's hesitation at the prospect of healing
others due to his fear of erring and injuring others (see Resp. Da'at Kohen, no. 140). Another
principle operating in the context of the physician and treatment in Jewish law is based on the
verse "Love your fellow as yourself." In Sharon v. Levi (CA 548/78, Sharon v. Levi, 35
(1) PD 735, at 755) Justice Elon wrote as follows:

It is instructive to observe how this basic right was viewed in Jewish law. "One who strikes a
blow causing damage less than a perutah (i.e., that did not cause any real injury) transgresses
a negative commandment (Sanh. 85a; Yad, Hovel u-Mazik 5:1–3). Even if the victim consents
to being struck, his consent has no validity.8 This being so, on what basis can one person let
blood of his fellow, even if it is necessary to do so in order to heal him? In the view of
the amora R. Matna (Sanh. 84b) permission to do so is not based on the consent of the patient,
whether expressed or implied, for the consent, as stated, is immaterial. Rather, it is a rule derived
from the verse "Love your fellow as yourself" (Lev. 19:18), from which one can infer, as Rashi
put it, that "each Jew was cautioned not to do to his fellow that which he does not want done to
himself".9

The philosophic-halakhic basis for permission to wound a sick person in order to cure him as
deriving from the fundamental Biblical command "Love your fellow as yourself" is cited by
Naḥmanides as a guiding accepted principle in the context of the physician and medicine in the
world of halakhah: "The person who wounds another to cure him (for medical treatment) is
exempt, and it constitutes the performance of a positive precept, as it states 'Love your fellow as
yourself'" (Toratha-Adam, ibid., p. 43).

Rabbi Eliezer Waldenberg, a leading contemporary authority in the area of halakhic-medical law,
wrote the following comment on these words of Naḥmanides:

We require that the commandment to heal be inferred from the verse ("Love your fellow as
yourself"), and it is insufficient to rely on the principle that "nothing stands in the way of saving a
life" to justify the physician's privilege to wound in order to heal (referred to by Naḥmanides, and
cited by the Tur and Shulhan Arukh), because the inference from "Love your fellow as yourself"

8
BB 92a; Sh. Ar., ḤM 420:1ff.; Shulhan Arukh Ha-Rav ḤM, Hilkhot Nizkei Guf ve-Nefesh ve-Dineihem 4; according to the
law, it is also forbidden for a person to injure himself – BK, Yad, ad loc.
9
(Rashi, Sanh. 84a, S.V. ve-ahavta le-re'akha kamokha; see also Kitvei ha-Ramban, Torat ha-Adam (ed. Chavell, Mossad ha-Rav
Kook), 41–42; M. Elon, "Ha-Halakhah ve-ha-Refu'ah ha-Ḥadishah," in: Molad, 4 (NS), 27 (1971), 228, 232

19
teaches that there is an obligation to heal even when there is clearly no danger to life, but only pain
or danger to a limb.

The Physician and the Judge

Both Naḥmanides and Rabbi Kook (Torat ha-Adam, ibid. p. 41–42; Resp. Da'at Kohen, no. 140
(Rabbi Abraham Isaac *Kook – the first chief rabbi of Israel)) drew an illuminating analogy
between the physician treating a patient and a judge presiding over a court. The judge's duty to
judge the people in each generation and in all matters is portrayed in the Talmud as giving rise to
a soul-searching dilemma, phrased as follows (Sanh. 6b):

The judges should know whom they are judging, before Whom they are judging, and Who will
exact punishment from them, for it is stated: "God stands amidst the community of God, in the
midst of judges (elohim) He will judge" (Psalms 82:1). Similarly, regarding Jehoshaphat it is
stated: "He charged the judges: Consider what you are doing, for you judge not on behalf of man,
but on behalf of the Lord" (II Chronicles 19:6). Perhaps the judge will say, "Why do I need this
anguish?" Therefore it is stated, "And He [God] is with you when you pass judgment" (Chronicles,
ad loc.; Rashi, Sanh. 6b – "For He is with your hearts, as your hearts incline as to the matter"). A
judge can only rule in accordance with what his eyes see. (Rashi adds, Sanhedrin, ad loc., "If he
attempts to render a just true judgment, he will not be punished.")

Similarly, the work of a physician imposes great responsibilities and corresponding demands on
his conscience, accompanied by much anguish. For this reason, Naḥmanides concludes that the
laws pertaining to a physician who is as careful as he should be when dealing with life-and-death
situations are the same as those applicable to a judge who seeks to render a just and true judgment.
If they are unaware that they have made a mistake, they are both exempt, by both human and divine
law.

Yet in one fundamental respect – which goes to the root of the matter – the physician's
responsibility is greater than that of the judge. If an authorized judge (one who judges "with the
permission of the court") becomes aware of his inadvertent mistake, he remains exempt even by
divine law. By contrast, if a physician becomes aware of his unintentional mistake, while he
remains exempt by human law, he is nevertheless liable by divine law. Indeed, if his mistake
caused someone's death, he is subject to the penalty of exile [to a city of refuge]. The physician
and the judge are partners to the heartbreak and ethical dilemmas inherent in their work. Each of
them attempts to ease these agonizing dilemmas by following his conscience, based on "what his
eyes see" or, as formulated by R. Menahem ha-*Meiri , by acting according to "what his eyes see,
his ears hear, and his heart understands" (Bet ha-Beḥirah, Ketubbot 51b). See also Maimonides
(Guide 3:34), who writes that the judge adjudicates in accordance with a general norm, whereas
the physician treats each patient in accordance with his own specific condition and sickness. This
is the essence of the physician's duty which obligates him to cure the specific ailment that confronts
him, according to the particular circumstances and condition of the patient.

Regarding the analogy between the physician and the patient, Justice Elon made the following
comments in the Shefer case (ibid., pp. 108–9):

20
It should be noted that the principles governing the professional behavior of the physician
intertwine law and ethics, compliance with the strict law and going beyond the law (lifnim mi-
shurat ha-din), the nature of the halakhah, and the nature of the world. Following the example set
by Naḥmanides' Torat ha-Adam, these principles appear in separate sections in the later halakhic
codes – Arba'ah ha-Turim of Jacob b. Asher and the Shulḥan Arukh of Joseph Caro (YD,
beginning of sec. 315ff.). Incidentally, it bears mention that Maimonides' Mishneh Torah does not
contain any codification of the laws relating to the physician. Maimonides comments on this matter
in the fourth chapter of Hilkhot De'ot, but only to deal with the proper regimen required to maintain
a healthy body. It is certainly instructive that these codifiers, who as a general rule do not include
in their codes those laws that have no practical relevance, and hence do not codify such laws as
those relating to the exile of an unintentional murderer to a city of refuge, nevertheless include the
rule that a physician who causes death and then becomes aware that he has erred should be exiled
(Tur and Sh. Ar, ḤM 425:1). They do so in order to demonstrate the deep responsibility born by
the physician, in that even when there is no legal sanction, he is liable, in cases of negligence, to
be exiled to a city of refuge, to grieve and to give an accounting of his life. This dilemma of medical
practice – where, on the one hand, there is the commandment not to refrain from healing others
while, on the other hand, there is the sense of "why do I need this trouble?" – has become greater
and more pronounced as a result of the tremendous advances in modern medicine and in light of
contemporary legal and philosophical thinking concerning fundamental rights and meta-principles.
Today – even more so than previously – both the judge and the physician continue to be partners
to this dilemma. Both carry the responsibility and both seek to do justice in their profession, each
in his own field – the judge to reach a truly correct decision and the physician to achieve true
healing. This guideline of searching out the essential truth – the full meaning of which will be
explained below – serves as a road-map – complex and difficult, yet indispensable – for resolving
the important, grave, and complex questions that lie at the doorstep of the physician and judge
alike. As is generally the case with regard to such basic questions, there are fundamentally different
approaches that create a profound sense of awe as one proceeds to grapple with and apply them.

The Patient's Obligation to be Healed and his Right to Choose Medical

Treatment

In the world of Judaism, just as the physician is obligated to heal, so too, as may be seen from our
above discussion, the patient is obligated to be healed. Moreover, one who refrains from being
healed violates the Scriptural verses "You shall guard yourselves well" (Deut. 4:15) and "For your
own life-blood I will require a reckoning" (Gen. 9:5). The obligation of a person to be healed from
a life-threatening illness takes precedence over almost all of the commandments of the Torah.
When a physician determines that to become cured one must desecrate the Sabbath, a patient who
refuses to accept treatment involving the desecration of the Sabbath "is considered to be 'a pious
fool,' …we compel him to do [what the physician has ordered]" (Resp. Radbaz, vol. 4, no. 1339;
Sh. Ar., OḤ 328:10, and commentaries ad loc.). In such circumstances, preferring observance of
the commandment over medical treatment is considered "a commandment performed through sin"
(Resp. Mahari Asad, OḤ no. 160). The patient's wishes are to be followed, however, when he seeks

21
to improve the medical care he is receiving, but the physicians disagree with him. This is based on
the verse "The heart knows its own bitterness".10

According to Jewish law, the patient is not only obligated to seek a cure, but he also has a basic
right to receive treatment from a physician of his choice whom he trusts. This rule is derived from
the teachings of the Sages, and became established halakhah in the Shulḥan Arukh, which rules
that "If Reuben vowed not to benefit Simeon, and Simeon fell ill, Reuben may treat him… even
with his own hand, even if there is another physician who can treat him" (Sh. Ar., YD 221:1).

In relation to this ruling, Justice Elon wrote the following in the Tamir case (APP 4/82 Cr. App.
904/82, State of Israel v. Tamir, 37 (3) 205–206:

It is well-established law, based on the principle of the personal liberty of every person created
in the image of God, that no person's bodily integrity may be infringed without his consent […].
This basic right includes the right to select the physician to whom his treatment will be
entrusted; making such a choice is integral to his fundamental right to maintain his bodily
integrity and mental well-being and not to be "harmed" thereby except with his consent […] An
instructive expression of this principle may be found in the teachings of our Sages.
The Mishnah states (Nedarim 4:4): "If one was forbidden to derive benefit from another
person… he may [nevertheless] be cured by him," i.e., when one person vowed not to benefit
from another person, or his fellow man vowed not to benefit to him, he may nevertheless benefit
from the medical services of the other person, for the duty to heal and the right to be healed in
body and soul "is a commandment" (Yad, Nedarim 6:8). The Jerusalem Talmud states that this
rule not only applies where there is only one physician available – i.e., the fellow from whom he
has vowed not to receive benefit – but even if another physician is available, and he may avail
himself of the medical treatment of the other physician, the patient may nevertheless choose to
consult the doctor from whom he vowed not to receive any benefit, for "not every person is able
to cure him" (Nimmukei Yosef to Rif, Nedarim 41a). This is in accordance with the codified
rule that "If Reuben vowed not to benefit Simeon, and Simeon fell ill, Reuben may treat him …
even with his own hands, even if there is another physician who can treat him." In medical
treatment, the personal trust between the patient and the physician of his choice is extremely
important, for which reason "even if there is another physician who can treat him, that
physician [i.e., the one from whom he vowed not to benefit], if qualified, is under a duty to treat
him, for the saving of life is sacred" (Ritba, to Rif, Ned. 41b).

OBLIGATION AND REFUSAL TO RECEIVE MEDICAL TREATMENT

The fundamental rule of Jewish law regarding the physician's duty to treat, and the patient's
obligation to be cured, is subject to a number of qualifications, which have proliferated in our
generations and which limit the possibility of treating a patient against his will. R. Jacob Emden,
one of the leading halakhic authorities of the 18th century (Mor u-Keẓi'ah, OḤ 322), laid down the
following conditions under which the patient is obligated to seek a cure and under which "he is
not listened to, if he rejects suffering and chooses death over life." Accordingly, the duty only
applies where the physician is familiar with the sickness "in absolute and clear certainty," the case

10
Prov. 14:10; Yoma 82a–83a; Sh. Ar. OḤ 618:1; A. Steinberg (ed.), Enẓiklopedyah Refu'it Hilkhatit, vol. 2, pp. 24–26, 443–45

22
concerns a patient who at that time was referred to as "a patient with a clear sickness and obvious
wound"; the treatment that the physician wishes to use was "definitively checked and certain"; and
the patient's life is in danger. In the event that these conditions do not exist, the patient's consent
is required for medical treatment, and he is permitted to refuse medical treatment. In contemporary
times, many posekim have dealt with these cases, enumerating additional cases in which the
patient's consent is required.

R. Moshe Feinstein, one of the great halakhic decisors of our generation,11 wrote that, when giving
treatment against a patient's will, in addition to the need for a high probability of success, account
must also be taken of the negative influence of treatment given against his will. According to
another opinion, if the patient can be expected to suffer even after the medical treatment, providing
grounds for assuming that he would not have agreed to such medical treatment before it was given,
then it cannot be administered in the first place without the patient's consent (ibid., 104). Another
view was that, given the large number of cases in which there was no certain medical opinion, all
non-consensual medical treatment should be avoided, unless there is a definite danger of death.12

EUTHANASIA

In recent years a number of factors have combined to bring the subject of *euthanasia to the
forefront of discourse in the world of medicine and halakhah. The awesome advancement in
science and medicine resulting from technological progress has facilitated the prolongation of
human life in its final stages. However, this prolongation has not always led to improvement in the
quality of life, and on occasion even sentences people to grave physical and mental pain. Doctor-
patient relations have also undergone a metamorphosis, from the paternalistic approach whereby
the doctor decides what is best for the patient, to an approach based on patient autonomy, whereby
the competent patient can decide for himself, and his informed consent is therefore required for
any medical proceeding. A large number of people are involved in the treatment of a terminally ill
patient, of different cultural backgrounds and outlooks, and consequently bringing with them
varied opinions as to how to treat the terminally ill patient. The general public today is also far
more concerned with moral problems pertaining to medicine in general, and specifically those
relating to the terminally ill. Limited medical resources do not always suffice to provide all
possible medical options for all those requiring it, and occasionally these, too, are considerations
in the decision making process in relation to these patients.

We shall now present the sources underlying the halakhic approach to this subject, and the manner
in which the halakhah relates to the subject in modern times in general, and in the State of Israel
in particular. In the Shefer case (Shefer v. State of Israel 48 (1) PD 87, 131–132), Justice Elon
wrote the following:

There have always been serious and complex moral problems regarding the end of one's stay on
this earth. Jewish law includes various rules dealing with the medical care to be given, as well as

11
see responsum of R. Moshe Feinstein quoted in Piskei Halakhah Refuah u-Mishpat, ed. S. Shachar (1989), p. 101)
12
A. Steinberg (ed.), Enẓiklopedyah Refu'it Hilkhatit, vol. 2, Informed Consent, p. 30, nn. 86–87; cf. Rabbi S. Raphael, "Kefiyyat
Tippul Refu'i al Ḥoleh," in: Torahshe-Beal Peh, 33 (Jerusalem, 1992)

23
other issues of civil and religious law, concerning the person who is terminally ill or dying
(= goses). Jewish law distinguishes between these states, but there are disagreements as to their
precise definitions and halakhic consequences. In any event, this is not the place to elaborate….
Regarding this terminal state, Jewish law emphasizes the importance of even ephemeral or brief
life (ḥayyei sha'ah), so long as "the candle flickers…" This is also true in non-Jewish cultures,
evidence of which we find as early as the Hippocratic oath, which states, inter alia: "I will not give
poison to any person, even if he requests it; and I will not offer it." Some cultures, however, did
not have this approach…

These medical-legal problems, involving fundamental questions of values, have grown more
complex and difficult in recent years, provoking much discussion and dispute in the medical and
legal communities, as well as among philosophers, clergymen, and the general public. On the one
hand, the awesome advance in science and medicine resulting from technological progress has
allowed the prolongation of life, by preventing the spread of disease and by various artificial
means; on the other hand, the prolongation of life has not always led to improvement of
its quality. At times, prolongation of life brings with it physical and mental pain, and the disruption
of day-to-day life. In addition, a patient in such circumstances today may find himself in a hospital
or other institution, attached to various machines which keep him alive, and not – as in the past –
within the walls of his own home, with his family and loved ones in the natural environment in
which he lived and flourished. Those who must deal with these problems are primarily the patient
himself and his family, in addition to physicians, legal scholars, clergymen, and philosophers. The
problems that arise involve grave and fundamental moral, religious, and ethical questions. The
basic question is: who understands all of these factors sufficiently to be competent to decide what
is the proper life span of a person and whether to shorten or to refrain from prolonging it.

The Bible

The prohibition on taking a human life is one of the gravest offenses in the Torah, and mankind as
a whole was admonished against this offense at the dawn of its history: "Whosoever sheds the
blood of man, by man shall his blood be shed, for in His image did God make man" (Gen. 9:6; see
at length in *Homicide , and *Noahide Law ). The Bible records a case which serves as a proof
text for the view that killing a man even where it is clear that there is no chance that he will continue
to live is nevertheless murder. At the end of the war between the Israelites and the Philistines
during the days of Saul, Saul understood that the Philistines were about to kill him, and therefore
decided to kill himself with his own sword. Scripture relates that Saul only injured himself after
this attempted suicide, and then asked an Amalekite youth to complete the act. Saul's condition at
that stage was analogous to that of a terminally ill patient, who clearly and lucidly requested the
hastening of his death in order to redeem him from his suffering. The Amalekite youth complied
with his wishes and killed him. Nevertheless, David subsequently ruled that the Amalekite youth
was liable for the death penalty as a murderer (I Sam. 31:3–4; II Samuel 1 and 16;
see Radak and Ralbag, ad loc.) From this Biblical story it emerges that that the active killing of a
person who is dying is forbidden, even under those conditions, and even if the patient requested it
(Ralbag, ibid., Sefer Ḥasidim, ch. 315; Ralbag and Radak further suggested interpreting that in fact
the youth did not actually kill Saul, but rather just said that in order to find favor in David's eyes).

24
In Talmudic Literature

As a rule, so long as the person's soul has not departed he is regarded as alive. The treatment of
the terminally ill is dealt with directly in tractate Semaḥot, which stipulates those actions that may
be performed on a dead person, and which are forbidden with respect to a living person: "A goses is
considered a living person in all respects… One may not bind his jaws… one may not move him…
one may not close the eyes of the dying [patient]. Whoever touches or moves him sheds blood…."
(Semaḥot 1:1–4; Shab. 151b).

The Mishnah in Tractate Yoma (8:6) states that "Any chance of saving a life takes precedence
over the Sabbath." Accordingly, in the event of a landslide, where there is a chance that a person
is trapped beneath the debris, the debris should be removed until it is certain that no living person
is trapped thereunder. Our Daf and Yoma 85a adds that, even if the person found under the debris
was mortally wounded, and it is clear that he will soon die, one continues to desecrate the Sabbath
to save him by removing the debris. Thus, this source indicates that even short-term life is
considered life. The halakhic decisors of the present generation disputed whether this source
implies that everything possible should be done to prolong life, even if only temporary, or whether
the laws of the Sabbath do not necessarily provide a basis for the duty to prolong life (Resp. Ẓiẓ
Eli'ezer, 5; Kuntres Ramat Raḥel, 28; Resp. Minḥat Shelomo, 91.24).

Regarding a person about to die and experiencing intense suffering, the aggadic sources adopt a
different attitude. The Talmud (Av. Zar. 18a) relates the story of R. Hanina b. Teradyon (second
century C.E.) who was taken to be executed by the Romans as punishment for publicly teaching
Torah. In order to ensure that the execution would be protracted and particularly cruel, the Romans
soaked pads of wool in water and placed them over his heart "to delay the departure of his soul."
When the executioner offered to stoke the flame and hasten his death by removing the pads, R.
Hanina agreed, and swore that by that act the executioner had secured his place in the World to
Come. The halakhic decisors offer a variety of explanations for the positive attitude taken by the
Talmud to this act, but the story itself indicates that when a person is about to die and experiencing
intense suffering, it is permitted to hasten his death even by way of a positive action – e.g.,
increasing the flame, and even by an act of "removing the impediment" – here, taking away the
sponges.

Another case cited by the Babylonian Talmud (Ket. 104a) describes the death of R. Judah ha-Nasi,
who towards his death was in unbearable pain. His students succeeded in preventing his death by
their incessant prayers for Heavenly mercy. His handmaid, noting the intensity of his suffering,
threw a jar on the ground, thereby momentarily causing them to cease praying, and at that moment
Rabbi Judah died. This story has been cited as proof that it is permitted to avoid prolonging the
life of a terminally ill patient (Iggerot Moshe, ḤM, vol. 2 no. 73.1).

Halakhic Rulings

The halakhic rulings sharply distinguish between the active hastening of death, which is forbidden,
and the removal of a life-prolonging impediment, which is permitted under certain conditions.

25
The various acts cited above as being prohibited in respect of the goses are enjoined because they
are liable to actively hasten the death of the terminally ill (see Sh.
Ar., YD 339:1; S.V. *goses; Talmudic Encyclopaedia (Heb.), 5, 393ff.).

Actively hastening death is forbidden even in cases where the patient is suffering acutely: "It is
forbidden to hasten his death, even if he is dying and both he and his relatives are suffering
intensely" (Ḥokhmat Adam, 91.14), "and even if we see that he is suffering intensely, and that it is
better for him to die, we are prohibited from performing any act to hasten his death" (Arukh ha-
Shulḥan, YD 339:1; Nishmat Avraham, YD 339:4).

This prohibition applies even where the patient himself requests it, an analogy being drawn from
Maimonides' ruling that one may not take ransom from a murderer in order to exempt him from
the death penalty, even if the blood avenger (i.e., the victim's relative who may exact the murderer's
life as retribution for the murder) agrees, because "the life of the victim is not the property of the
'blood avenger,' but rather belongs to God" (Yad, Roẓe'aḥ u-Shemirat ha-Nefesh 1:4).

On the other hand, the prohibition on passive euthanasia is not absolute and
the halakhah distinguishes between various forms of passive euthanasia, the prevention of
suffering to the patient being a paramount consideration. R. Judah he-Ḥasid (Ashkenaz,
12th century; Sefer Ḥasidim, ch. 723 (ed. Mossad ha-Rav Kook)) addresses the issue and rules that,
even though it is forbidden to perform any action that hastens death, there is no place for actions
that delay a natural death. "We do not act to delay a person's death. For example, if a person is
dying and there is a man chopping wood near his house so that the soul cannot depart, we remove
the woodchopper from there. Moreover, we do not place salt on his tongue to prevent his death.
But if he is dying and he says that he cannot die until he is placed somewhere else, he is not to be
moved from there (i.e., from where he is)."

According to this view, artificially delaying the soul's departure causes unnecessary pain and
suffering to the goses: "Do not feed the goses, for he is unable to swallow, but water should be put
into his mouth…and one does not shout at the time of the soul's departure, so that the soul does
not return and suffer unbearable pain…" (ibid., 234).

Joshua Boaz ben Simon Baruch (Italy, 16th century) in his glosses on Alfasi, MK 26b, in Shiltei
ha-Gibborim, in explaining this passage in Sefer Ḥasidim states that it is permitted to discontinue
an external act which prolongs the life of the goses, but it is forbidden to move him from his place
and place him elsewhere, or to do any other action in order to hasten his death (ibid., 234). This
opinion was codified and incorporated into the ruling of the Rema, at Sh. Ar., YD 339:1.

The life-preserving measures dealt with in these sources essentially reflect popular beliefs
prevalent in those days. The task facing contemporary authorities was to translate and apply these
examples to the life-preserving measures utilized by modern medicine. In that context, it was held
that an artificial respiration machine or other artificial life-support mechanisms are analogous to
the "grain of salt"; thus it was held that they can be removed in order to discontinue the artificial
prolonging of the dying patient's life.

26
Therefore, "once the physicians have determined that he cannot be cured (i.e., it is clear that he
will not recover), it is clearly permissible to disconnect the patient from the machine to which he
is connected." Furthermore, it was even held that "not only is it permitted to disconnect the
respirator, but there is an obligation to do so. For man's soul is the property of God and has not
God already taken the soul from this person, for as soon as the machine is removed he will die.
And quite the opposite, by using the artificial respirator we leave his soul inside him and cause it
(the soul, not the dying person) pain due to its inability to depart from the body and arrive at its
resting place" (Rabbi H.D. Halevi, bibliography). A similar ruling was given by R. Eliezer
Waldenberg (Resp. Ẓiẓ Eli'ezer, vol. 13, no. 89; cf. R. Solomon Zalman Auerbach, Resp. Minḥat
Shelomo, 91.24).

R. Ovadiah Hadayah (Resp. Yaskil Avdi, YD, vol. 7, no. 40) held that a goses is "any patient
regarding who all the physicians have given up hope and have determined that he will not recover
from his sickness."

In other responsa, Rabbi Moses Feinstein (Resp. Iggerot Moshe, YD, vol 2., no. 74, 73.1, 74.1)
and Rabbi Auerbach (Resp. Nishmat Avraham, Yad Vashem, 245) make additional distinctions
relating to this question, such as the distinction between medical assistance that actually alleviates
the patient's suffering (such as oxygen), which it is mandatory to administer to him, and
administering other medicines, and the distinction between standard medical treatment, which the
doctors are duty bound to continue administering to the patient, and nonstandard medical
treatment.

Summing up the position of Jewish law on this subject, Justice Elon wrote in
the Shefer case:

In Jewish thought, various overarching principles and values operate within the context of this
momentous and complex labyrinth of halakhah and medicine. Such principles include the sanctity
of human life, based on the meta-principle of man's creation in the image of God; the fundamental
precept to "love your fellow as yourself"; the alleviation of pain and suffering; the obligation of
the physician to cure and of the patient to be healed; the right of the patient to refuse medical
treatment; the decision-making approach of "her ways are pleasant ways"; the requirement that
"the laws of our Torah must accord with reason and logic"; as well as other principles discussed
above.

The point of departure in the extensive, difficult, and complex area of law and medicine is the
supreme value of the sanctity of life. This supreme value is based, as stated, on the meta-principle
of man being created in the image of God, with all that implies. Therefore, the standard of
the worthiness of a person does not exist, nor could it exist. The law for a physically or mentally
handicapped person is the same as that for a healthy person; we do not measure the degree of health
of the body or mind. Similarly, no standard exists with respect to the length of a person's life. The
same rules apply to a person who has only a short period to live and one who is expected to live a
long life: the flickering candle still burns and illuminates. Therefore, actively hastening death, or
acting to shorten life – even if termed "mercy killing" – is absolutely forbidden, even at the behest
of the patient. The obligation, in such situations, is to ameliorate the patient's pain and suffering in
every possible way.

27
The situation is different with regard to passive euthanasia, the non-prolongation of life, known in
Jewish law as the "removal of the impediment." Passive euthanasia is permitted and, according to
some authorities, even mandatory in certain cases, after taking into account such factors as the
fundamental principle of minimizing the patient's physical and mental pain and suffering, the
wishes of the patient, the negative consequences of treating the patient against his will, and the
various types of treatment – ordinary or extraordinary, natural or artificial, etc.

Similar considerations apply when considering the necessity for consent by the patient. In
principle, the obligation of treatment is incumbent upon both the physician and the patient,
especially when the treatment is necessary to save the person's life. However, apart from those
cases involving immediate danger to life, this principle has been progressively limited, and in
various situations the patient… may not be treated against his will…. The consideration of
individual autonomy in the decisions of the halakhic authorities came about largely as a
consequence of momentous developments in our generation in the field of medicine and the
struggle of the halakhic authorities to deal with them. At times, what is determinative is not the
opinion of the physician… but rather that of the patient himself, for it is forbidden to "actively
cause him to suffer." Great significance is accorded to the adverse effect that undesired treatment
may have on the patient: "The very fact that he is compelled [to undergo the operation] will further
endanger him." This illustrates the methodology of the halakhah – it develops and creates itself
through the process of case-by-case decision making.

All these and similar questions dealt with by a growing body of contemporary halakhic responsa
attest to the diversity of halakhic views on these difficult, tragic questions pertaining to the
relationship between the sanctity of life and prevention of pain and suffering, both mental and
physical, with all their implications.

In the State of Israel

The question of shortening, or failing to prolong, the life of a terminal patient has engaged many
scholars and writers in the realms of halakhah, medicine, philosophy, and law. Over the past few
years, with the development of new technological and diagnostic measures at the disposal of the
medical system, the courts are often required to decide on these questions. Section 309 of the
Israeli Penal Law criminalizes active euthanasia – i.e., an act that causes the shortening of a
patient's life – classifying it as murder. The Israel Supreme Court addressed the issue of the scope
and essence of this offense in the Shefer case (CA 506/98 Yael Shefer v. State of Israel, 48 (1) 87),
giving a leading judgment on the subject. The case concerned a little girl suffering from Tay-Sachs,
an incurable genetic disease, and it was undisputed that her days were numbered. Her request (filed
by her mother as her guardian) was that in the event of her condition deteriorating, the hospital
should refrain from administering life-prolonging treatment. Justice Menachem Elon dealt at
length with the aforementioned sources and analyzed the problem from the perspective of the need
to strike a balance between the Jewish values of the State of Israel and its democratic values. The
court held that, in that case, the mother's request to allow discontinuation of treatment could not
be granted, because on the basis of the medical testimony presented to the court, the child was not
suffering, her dignity was preserved and, as such, the sanctity of her life, even in its state of being

28
terminally ill, was the sole and determinant value, and any interference and harm to life
contravened the values of a Jewish, democratic state.13

In order to discuss and formulate a bill regulating policy in this area, the Ministry of Health
appointed a committee, headed by Prof. Abraham Steinberg (referred to as the Steinberg
Committee). In 2002, the Asher Committee published conclusions. The report discussed the moral,
religious, medical, psychological, social, and legal aspects of the problem, and formulated a draft
bill. This bill deals with the various categories of dying patients, including those who are legally
competent and those who are not, the different forms of treatment, the status of professional
caregivers and of the family, and establishes frameworks for the solution of individual problems,
as well as for adoption and review of decisions. The draft bill on the subject conformed with the
approach of Jewish law to this subject, and was adopted by the Israeli Legislature as binding law
in December 2005.

The section defining the purpose of the Terminally Ill Patient Law, 5766 – 2005 (Section 1)
stipulates as follows:

(a) The purpose of this law is to regulate the medical treatment of a patient regarding whom it was
determined that he is terminally ill, pursuant to the principles set forth in this Law, based on an
appropriate balance between the value of the sanctity of life and the value of individual autonomy
and the importance of quality of life.

(b) This law is based on the values of the State of Israel as a Jewish and democratic state, and
fundamental principles in the realm of morality, ethics and religion.

Basic Principle of the Law (Section 2):

In prescribing the medical treatment for a terminally ill patient, his medical condition, his will, and
the degree of his suffering are the exclusive considerations.

The law provides the following definition of a terminally ill patient (Section 6):

(a) An authorized physician may determine that a patient is terminally ill, if satisfied that the
patient is suffering from an incurable illness, and that his life expectancy, even upon receiving
medical treatment, does not exceed six months.

(b) An authorized physician may determine that a terminally ill patient is dying if satisfied that his
medical condition is such that a number of vital systems in his body have ceased to function, and
that his life expectancy, even upon receiving medical treatment, does not exceed two weeks.

The law explicitly prohibits active euthanasia, or assisted suicide, or discontinuation of ongoing
medical treatment:

13
For additional judgments dealing with this subject, see: OM 528/96 Bibes v. Tel Aviv-Jaffa Municipality (Tel Aviv District
Court); OM 2242/95 A.A. v. Kuppat Ḥolim Kelalit, 2 PDM, 1995, 235; OM 1030/95 Gilad v. Soroka (Beersheba District Court).

29
12. Nothing in the provisions of this law shall permit any act, even if constituting medical
treatment, that is intended to kill, or which will almost certainly result in death, irrespective of
whether or not it was motivated by kindness and compassion, and irrespective of whether or not it
was at the request of the terminally ill patient, or of any other person.

13. Nothing in the provisions of this law shall permit any act, even one constituting medical
treatment, that contributes to assisted suicide, irrespective of whether or not it was motivated by
kindness and compassion, and irrespective of whether or not it was at the request of the terminally
ill patient, or any other person.

14. Nothing in the provisions of this law shall permit the discontinuation of the medical treatment
of the terminally ill, which is liable to cause his death, irrespective of whether or not he is legally
competent […]

Nevertheless, the law does allow the physician to refrain from providing medical treatment to a
terminally ill patient (§8) or to refrain from the renewal of medical treatment (§14):

8 (a). Where a legally competent terminally ill patient does not want his life prolonged, his will
should be honored and medical treatment withheld […]

14. […] However, it is permitted to refrain from the renewal of medical treatment, which was
disrupted inadvertently or not in contravention of the provisions of any law, and it is similarly
permitted to refrain from the renewal of periodic medical treatment […]

The law also regulates the treatment of a terminally ill minor (§§19–21), and of a terminally
protected person. Moreover, the law regulates the methods whereby a terminally ill patient can
give advance living notice of his wishes concerning the medical treatment that he wishes to receive
(ch. 5 of the law). The law further appoints an institutional committee, comprising inter alia a
clergyman of the same religion as the patient, to rule on doubtful situations pertaining to the
treatment of the terminally ill patient.

BIBLIOGRAPHY:
PHYSICIAN'S DUTIES: M. Elon, Jewish Law: Cases and Materials (1999), 591–607, ch. 30; idem, "Medicine, Halakhah, and
Law: The Values of a Jewish and Democratic State," in: Jewish Medical Ethics (2004), v–xxxviii; CA 506/88 Yael Shefer,
Minor, v. State of Israel, 48 (1) PD 87; A. Steinberg (ed.), Enẓiklopedyah Hilkhatit Refu'it (1988–94), 1:70–74, S.V. "Bekhirah
Ḥofshit," S.V. Gilui Meda la-Ḥoleh; S.V. Haskamah mi-Da'at, 2:1–47; S.V. "Ḥoleh"; 2:437–67, 4:273–99, S.V. "Ne'emanut ha-
Rofe"; 4:613–42, S.V. "Sodiut Refu'it";6:688–122, S.V. "Rofe"; 6:624–45, S.V. "Torat ha-Musar ha-Yehudi." EUTHANASIA: M.
Elon, Jewish Law: Cases and Materials (1999), 637–95, ch. 33; idem, "Medicine, Halakhah and Law: The Values of a Jewish and
Democratic State," in: Jewish Medical Ethics (2004), v–xxxvii; J.D. Bleich, Judaism and Healing (1981, 2002), 134–45; H.D.
Halevi, "Nituk Ḥoleh she-Afsu Sikuyav Liḥyot mi-Mekhonat Hanshamah Melakhutit," in: Teḥumin, 2 (1981), 297; Z.N. Goldberg
and L.Y. Halperin, Emek ha-Halakhah – Assia, 64ff.; A. Steinberg (ed.), in: Enẓiklopedyah Hilkhatit Refu'it (1994), 4:343–
469, S.V. "Noteh Lamut"; D. Sinclair (ed.), Jewish Biomedical Law (Jewish Law Association Studies 15; 2005). ORGAN
TRANSPLANTATION: M. Elon, Jewish Law: Cases and Materials (1999), 697–731, ch. 34; A. Steinberg, Enẓiklopedyah
Hilkhatit Refu'it (1994), 2:244–191, S.V. "Hashtalat Evarim"; idem, ibid., 6:18–49, S.V. "Rega ha-Mavet"; LA 184/87,
698/96 Attorney General v. Anon., 42 (2) PD 661; D. Sinclair (ed.), Jewish Biomedical Law (Jewish Law Association Studies 15;
2005). ARTIFICIAL INSEMINATION: M. Elon, Jewish Law: Cases and Materials (1999), 625–35, ch. 32; A. Steinberg
(ed.), Enẓiklopedyah Hilkhatit Refu'it (1988), s.v. "Hazra'ah Melakhutit," 148–61; A. Walkin, Resp. Zekan Aharon, 2:97; Y.

30
Green, Hazra'ah Melakhutit bi-Pesika u-ve-Ḥakikat Medinat Yisrael; D. Sinclair (ed.), Jewish Biomedical Law (Jewish Law
Association Studies 15; 2005). IN VITRO FERTILIZATION: A. Steinberg (ed.), Enẓiklopedyah Hilkhatit Refuit, (1991), 2:148–
61, S.V. "Hafraya Hutẓ Gufi": FH 2401/95 (CA 5587/93) Daniel Nahmani v. Ruthy Nahmani et al., 50
(4) PD 661; CFH 2401/95 Ruthy Nahmani v. Danny Nahmani et al., 50 (4) PD 661; HC 2458/01 Mishpaḥah Ḥadashah v. the
Approvals Committee for Surrogacy Agreements (not yet published); D. Sinclair, Jewish Biomedical Law (Jewish Law Association
Studies 15; 2005).

Although diagnostic criteria for bulimia nervosa did not appear until 1979, evidence suggests that
binging and purging were popular in certain ancient cultures. The first documented account of
behavior resembling bulimia nervosa was recorded in Xenophon's Anabasis around 370 B.C, in
which Greek soldiers purged themselves in the mountains of Asia Minor. It is unclear whether this
purging was preceded by binging.
In ancient Egypt, physicians recommended purging once a month for three days to preserve health.
This practice stemmed from the belief that human diseases were caused by the food itself. In
ancient Rome, elite society members would vomit to "make room" in their stomachs for more food
at all-day banquets. Emperors Claudius and Vitellius both were gluttonous and obese, and they
often resorted to habitual purging.
Historical records also suggest that some saints who developed anorexia (as a result of a life of
asceticism) may also have displayed bulimic behaviors. Saint Mary Magdalen de Pazzi (1566–
1607) and Saint Veronica Giuliani (1660–1727) were both observed binge eating—giving in, as
they believed, to the temptations of the devil. Saint Catherine of Siena (1347–1380) is known to
have supplemented her strict abstinence from food by purging as reparation for her sins. Catherine
died from starvation at age thirty-three.
While the psychological disorder "bulimia nervosa" is relatively new, the word "bulimia,"
signifying overeating, has been present for centuries.
The Babylon Talmud referenced practices of "bulimia," yet scholars believe that this simply
referred to overeating without the purging or the psychological implications bulimia nervosa.
In fact, a search for evidence of bulimia nervosa from the 17th to late 19th century revealed that
only a quarter of the overeating cases they examined actually vomited after the binges. There was
no evidence of deliberate vomiting or an attempt to control weight.

31
Anorexia Nervosa and Bulimia Nervosa as Idioms of Distress: From
the Historical Background to Current Formulations
Eliezer Witztum, MD , Yael Latzer, DSc and Daniel Stein, MD, write:14

The aim of the present article is to understand the role of socio-cultural processes in the
predisposition to eating disorders (EDs) in the context of their historical background. For this
purpose we did a systematic literature search to investigate historical and contemporary
sociocultural perspectives relevant to anorexia nervosa (AN) and bulimia nervosa (BN).
Symptoms and syndromes of self-starvation have been observed for hundreds of years, being
interpreted according to the prevailing beliefs and cultural norms of each era. Our historical review
uncovers two central themes relevant to AN: an ascetic-religious aspect of fasting, in which self-
starvation serves as a means of purifying the body of the sins of the flesh, and a physical, esthetic
aspect focused on appearance and the ideal of beauty. By contrast, BN as it is currently defined is
a relative new syndrome that is not akin to descriptions of bingeing behaviors in previous eras that
have not included compensatory purging behaviors and fear of fatness. Our historical review
proposes that EDs can be regarded as an idiom of distress, in that in many (although not all)
societies and eras, they have served women as a mean to express their pain and to cope with issues
related to individuality, autonomy, equality, and social position.

14
International Journal of Child and Adolescent Health Volume1, Issue 4 2008

32
Anorexia Nervosa (AN) Historical Background

The survey of the historical background of EDs demonstrates that symptoms and syndromes of
self-starvation are not new, modern phenomena reaching epidemic proportions in young women
in recent years alongside the surge in the influence of the thin body ideal among women in many
Westernized cultures. Rather, they have been observed and known for many years, being
interpreted and understood according to the prevailing beliefs and cultural norms of each era. In
the following section, we will describe significant landmarks in the history of self-starvation, with
a specific emphasis on the motivations for self-starvation in different eras.

The Classical Period and Gnostic

Asceticism Interestingly, self-starvation was a virtually unknown phenomenon in the classical

world. Some descriptions of cases of vomiting after eating date from the Roman period, but no
behaviors reminiscent of anorexia nervosa are mentioned. It is only when European culture begins
to be influenced by Eastern religions that descriptions of extreme behaviors related to fasting and
self-starvation appear (3). These religions preached a dichotomy between the material world as
perceived by the senses, and an eternal, sacred reality of the soul, trapped as a prisoner within the
body. The body, with all its material attributes was seen as “essentially evil”, while the soul trapped
inside it was an entity representing the “eternal good”, which had become separated from the deity
at some point (4).

The Gnostic sects, who became particularly popular following the Roman conquest of Greece,
advocated this type of doctrine, claiming to possess the wisdom and knowledge (gnosis) that would
lead to the true road to salvation, in a world that was basically evil and corrupt. The Gnostic belief
in the dichotomy between the evil, corrupt material world and the inner spiritual entity had a
profound effect on the early Christians, who chose to withdraw from the sinful city life to remote,
secluded sites. The practice of self-starvation as a technique for purification and spiritual seeking
is found in descriptions of the lives of the first Christian monks, such as Hilarion and his
contemporaries.

Under Christian guise, Gnostic ideas infiltrated the Roman world. For example, St. Jerome,
translator of the Bible from Hebrew into Latin, became the spiritual ‘guru’ of a group of wealthy
Roman women in the fourth century AD. Records tell of a young Roman girl from an upper-class
family who fasted to her death as a result of the implementation of his extreme ascetic doctrine –
possibly the first documented instance of anorexia nervosa. Due to her death, Jerome was forced
to flee from Rome to Bethlehem (3). The Gnostic-Christian attitude of despising the material body
as a source of evil and an obstacle on the path to redemption left its mark on European culture for
hundreds of years, and remains significant even in today’s secular modern world.

The Early Middle Ages (5th – 10th Centuries)

The early middle Ages began as the Roman Empire collapsed and Hellenic culture declined.
Europe endured difficult times, beginning in the fifth century, marked by barbarian invasions,
disasters, and destruction, accompanied by plagues and famine. In the sixth century, the
population of Rome dwindled from several hundred thousand residents to 30,000. Over this

33
period, there are only a few reported cases (three) of young women starving themselves. Two
cases under similar circumstances, from the fifth and eighth centuries AD, were interpreted as
possession by the devil and cured through contact with sacred objects, leading to the ‘exorcism’
of the demonic agent (3,5).

The Late Middle Ages, the Renaissance, and “Holy Anorexia” (The 12th – 16th
Centuries)

Margaret’s story takes place in the thirteenth century, marking the beginning of an avalanche of
tales of voluntary self-starvation, particularly in southern Europe. In his book, Holy Anorexia, Bell
(7) collected 181 reported cases of ‘sainted’ young women who starved themselves, often to death,
between 1200 and 1600. In contrast to the rarity of these incidents during the early Middle Ages,
forms of anorexic behavior became common towards the end of the Middle Ages and during the
Renaissance. A considerable number of the women involved became ‘saints’, and their biographies
were circulated by their priest-confessors as an example to others.

One example of this pattern can be seen in the story of St. Catherine of Sienna, born in 1397, the
twenty-fourth daughter of a prosperous merchant family. Catherine began fasting at the age of 16
years subsequent to two tragic events that occurred in rapid succession – the death of a beloved
older sister in childbirth, and the death of a younger sister. Shortly afterwards, Catherine, who had
reached marriageable age by the standards of her time, was required by her parents to marry. She
refused; confronted with the objections of her family, she starved herself, spent long hours in
devout prayer, and punished her body with flagellation and other forms of self-abuse. Eventually
her parents relented and allowed her to retreat into life as a nun, outside the convent, until her death
from malnourishment at the age of 32 years.

During her lifetime, because St. Catherine was a prolific writer, much is known about her internal
experience of self-starvation. She refused to eat because she viewed herself as afflicted by an
inability to eat. Instead, she devoted herself to caring for the sick, the poor, and the miserable, in
complete self-negation and disregard for her own needs. Her need for absolute control can clearly
be seen in some of the stories about her, as well as the total suppression of bodily urges (7).

There were cases of other women who refused eating for “divine” reasons and were claimed as
saints. Despite the acceptance of divine intervention as the reason for self-starvation in these cases,
According to Bell (7) and Bynum (8), peers and superiors of the fasting saints repeated attempted
to induce these women to eat, sometimes even by force, to avoid the sin of vainglory, an inability
to engage in holy responsibilities, or the sin of suicide. The high rate of anorexic behaviors during
the Renaissance period may be attributable to the pervasive changes that were taking place in
everyday life and cultural values. These transformations have stemmed from the material
developments, wealth, and sophistication of the period. For example, inventions and progress in
agricultural techniques initiated in the eleventh century have gradually brought about a significant
improvement in the welfare and nutritional state of the general population.

Concurrently, trade with the East has developed, bringing cultural influences with it. Flourishing
city-states such as Genoa and Venice have emerged, with a social class of wealthy citizens who
cultivate esthetic values and the arts. Although women have remained subjugated to men,

34
performing the traditional roles of wife and mother, they could still enjoy a greater degree of power
and freedom of choice. Burckhardt (9), an acclaimed researcher of the Renaissance, believes that
women of the time have been provided with an education equal to that of men. The ideal of
feminine beauty has also changed during this period. The shift in perception is evident in paintings,
particularly in the portraits of partially nude women, surrounded by their toiletries (9). This is a
time reminiscent of our own, in which material plenty, opportunities, and greater freedom have
allowed women to rebel against their traditional roles, while engendering a heightened
preoccupation with external appearance.

Bingeing/Purging EDs Historical Background

In our review of the history of AN, we found over the years numerous examples of young women
engaging in self-starvation. What was different in diverse historical periods was the motivation
behind food refusal. In contrast, evidence of a bingeing/purging syndrome outside of its present
historical context is quite sparse (2).

Historical accounts of bulimia do not seem to preponderate in adolescent or young adult females.
In fact, prior to the nineteenth century, cases involved mostly adult men. Further, most historical
cases of bulimia actually represent binge-eating without compensatory purging behaviors. Russell
who was the first to relate to BN as a distinct clinical entity (28) also claimed that " It is not possible
to write a truly historical accounts of bulimia nervosa as the diagnostic term was coined as recently
as 1979, and there is therefore no true historical era available for study" (32).

Nevertheless, in a recent paper devoted to 25th Anniversary of BN (33), Russell considered the
claim that BN in its current definition is a new disorder (e.g., 2) as over inclusive, because in his
opinion the study of the history of BN has hitherto been neglected and subject to considerable
controversies. For these reasons we have decided to relate in our review to the history of
binging/purging EDs, rather than to the history of BN. Several authors have reviewed historical
cases of "bulimia" prior to its formal recognition in the late 1970th. Four cases have been described
before the second century CE, i.e., the Roman emperors Claudius (41–54 CE) and Vitellius (circa
69 CE). Most researchers (34,35) speculate as to whether these emperors have suffered from any
clinical disorder. This because excessive food intake among the elite in the Roman Empire
appeared to be based on intentional indulgence, with self-induced vomiting used as a means to
allow continued consumption. Nevertheless, a not entirely volitional pattern was apparently noted
in some cases (34).

In the eighth century CE, Avicenna prescribed self-induced vomiting to undo the ill effects of
overeating; however, he warned, that "to procure vomiting to an undue degree is injurious for the
stomach, thorax and the teeth . . . and may lead to consumption". According to the Arab medicine
at that time, the custom of some people who eat to excess and then procure vomiting is one of the
things that end in a chronic disorder (36).

From the twelfth to the seventeenth centuries, many of the fasting saints were reported to engage
in binge eating (e.g., St. Veronica) and self-induced vomiting (e.g., St. Catherine) (7). However,

35
these cases appear to fall within the current diagnosis of bingeing/purging AN subtype, rather than
presenting with true BN. In the seventeenth century, there appeared a description of a 50-year-old
man (1678) who experienced uncontrollable eating followed by vomiting 20 days each year, and,
following the 20- day bingeing/purging cycle, he fasted for 20 days and then resumed normal
eating throughout the remainder of the year (35). Dr. Richard Lower (1631–1691), in apparently
the first medical description of a bingeing or a bingeing/purging disorder, observed in the 17th
century “an uncommon hunger” (fames canina) among patients with hypochondria and hysteria
that produced in some cases “a great craving for food” [as cited in Silverman (37)], whereas in
other cases consuming large amounts of food was followed by vomiting (38). Parry-Jones and
Parry-Jones (39) reviewed 12 potential cases of BN from the seventeenth to nineteenth centuries.
Most of these cases, however, were apparently not associated with inappropriate compensatory
behaviors, and parasitic worms were found in some of them.

In the eighteenth century, Parry-Jones (40) detailed the case of Samuel Johnson from 1784 as
meeting criteria for BN. Johnson engaged in binge-eating episodes that caused him to be
significantly overweight. To control his weight, he engaged in fasting and used Senna's leaf as a
purging agent. However, Johnson’s use of fasting and purging seemed quite time-limited
compared with his longstanding pattern of compulsive overeating. In the 19th and early 20th
century, repeated medical descriptions have appeared of women who engaged with some form of
a mixture of bingeing, vomiting, and restricting behaviors. However, in most of these cases a clear
cut definition of BN could not be established. This because these women either suffered mainly
from binge eating behaviors, or the cycles of bingeing and purging were not concomitant, or their
weight was definitely reduced.

Discussion

Anorexia Nervosa Traditionally, AN has been conceptualized to represent a culture-dependent

syndrome (10), namely a syndrome that cannot be understood separated from its cultural context
(49) and that is restricted to a limited number of cultures by virtue of psychosocial factors (50).
Studies supporting this view have flourished since the 1960th, emphasizing that the increase in the
frequency of AN in young women in Western cultures in our era is the result of a similar increase
in the influence of socio-cultural norms such as the importance of slimness, youth, personal
achievement, individualism, and women’s self-definition (51).

More recent studies, however, cast doubt as to the definition of AN as culturally dependent, as its
current prevalence in many nonWesternized countries is often similar to that found in Western
countries, and the recent increase in its incidence in Western countries likely reflects greater use
of treatment facilities rather than being a genuine change (2).

Another line of conceptualization relates to the occurrence of AN in societies in transition that

undergo considerable socio-economic and sociocultural changes (52), or to its emergence in places
where it has not been described before (53). According to this conceptualization, what is
detrimental is not so much the maladaptive influence of a specific culture to predispose to an ED.
Rather, it is the changes that occur within a Westernized culture that idealizes thin physique (52),
or within cultures that are abruptly exposed to this ideal for the first time (53) that increase the risk
to develop disordered eating, as these may interfere with the cultural conditions required for the

36
development of a stable identity (54). In line with the relevance of socio-cultural changes in the
predisposition to AN, we propose that relating to the changes in the socio-cultural meaning of AN
over time as representing an idiom of distress, may be of additional relevance in understanding the
disorder from its historical perspectives.

Whereas the conceptualization of AN as culturally-dependent likely stands in contrast to the high

influence of genetic/biological determinants in the predisposition the disorder, conceptualizing AN
as an idiom of distress, as we propose, can be well -intergraded into genetic/biological
formulations. The term idiom of distress has been introduced for the first time by Nichter (55).
This conceptualization emphasizes that people in different cultures may express their distress and
deal with its consequences in different ways (55,56) that reflect the meaning that a culture gives
not only to the distress itself, but also to the mode in which it is expressed (57). Problems may find
their expression in a range of symptoms at the various levels of human experience: physical,
behavioral, emotional, experiential, cognitive, and interpersonal. Whereas the enactment of a
cultural idiom of distress may help to resolve or give meaning to one form of illness or distress, it
may cause or exacerbate other forms of suffering - depending on how it is used and articulated by
any given individual in any given society (57).

The use of physical symptoms and syndromes as an idiom of distress to overcome and give
meaning to emotional suffering has been described in a host of psychopathological disturbances,
including somatization disorders, psychosomatic disorders, depression (58), and anxiety (59). EDs
have served women as an arena in which they can express their pain, uniqueness, and individuality.
Although we have not found any reference to EDs as idioms of distress in an extensive review of
the literature, this type of expression is in our opinion of great relevance in the context of AN. The
culture participates in the construction of an idiom of distress in processes that shape the emotions
of an individual via a system of shared symbols, norms, and social institutions. Direct, free
expression of emotions such as aggression or sexuality or of emotions in general, is denied in
certain cultures.

The social, emotional, and mental distress of people may then be channeled, sometimes
neutralized, and directed towards alternative modes of expression that are legitimate and in line
with the values and expectations of the respective cultures. A common means of handling
expressions of distress is by redirecting them to the physiological plane (56), in our case self-
starvation and/or weight reduction. Our historical survey illustrates that the syndromes and
symptoms related to AN were observed and noted throughout human history, but were interpreted
in accordance with the beliefs and cultural norms of each era. Heightened rates of AN were seen
during periods without famine or food shortage – times of economic plenty, during which women’s
status was altered.

Traditional society changed, and women obtained education and greater freedom, which allowed
them to rebel against their traditional roles. Our historical review seems to uncover two central
themes relevant to AN: an ascetic-religious aspect of fasting, in which self-starvation serves as a
means of purifying the body of the sins of the flesh, and a physical, esthetic aspect focused on
appearance and the ideal of beauty. Similarly, Habermas (43) has argued that modern-day AN
extends to historical cases presented in the latter half of the nineteenth century by Gull, Lasegue,

37
and Marce, but not to the fasting found among medieval religious ascetics or Victorian-era fasting
girls.

Bulimia Nervosa

In contrast to AN, BN is still conceived to represent a culturally dependent syndrome. This because
numerous epidemiological studies have shown the occurrence of a sharp increase in the incidence
of the disorder in Westernized countries in the latter half of the 20th century. Moreover, the
appearance of BN in non-Westernized cultures is still infrequent, and almost always in the context
of some exposure to Western thin body-ideal norms (2).

One possible reason for this difference between AN and BN is that being a new syndrome, it might
take time for BN to spread to non-Western societies as well. Concerning our idiom of distress
model, BN represents one example in which the enactment of a cultural idiom of distress may
actually exacerbate rather than decrease suffering (57), as BN women often regard themselves as
unable to control neither their eating nor their weight. Keel and Klump (2) propose that in line
with the restraint hypothesis, in which bingeing may occur following extensive restricting, one
would expect that the fasting evident in medieval women diagnosed with “holy anorexia” would
result in binge eating in at least some of these young women. Consistent with this hypothesis, there
have been indeed isolated cases in which individuals have engaged in binge eating after a period
of restricted food intake.

However, the use of purging (or other forms of inappropriate compensatory behaviors) to
counteract or undo such bingeing episodes was lacking in most reported cases. The difference
between medieval and modern BN may be explained by the motivation behind food restriction. In
modern times, food restriction is often intended to achieve weight loss. When a binge episode
occurs, purging is motivated by the belief that it will prevent weight gain. Conversely, if fasting is
interpreted in a religious framework as has been the case in medieval times, then purging cannot
prevent the sin of gluttony once the binge episode has occurred (8). Keel and Klump (2)
additionally suggest that whereas modern AN may be the result of motivations related to weight
concerns, this has not been the case in the medieval ascetic-religious self-starvation. We propose
that preoccupation with weight in our era can be conceived as an idiom of distress in European
and North-American young women who are constantly exposed to and required to handle weight–
related socio-cultural pressures.

By contrast, self-starvation in women in living in the Far-East is connected to a significantly lesser

extent with weight-related concerns and body image disturbances (61). From a different
perspective, Keel and Klump (2) suggest that in contrast to AN, a bingeing/purging syndrome
predominantly affecting normal-weight women can emerge only in the context of fear of fatness.
Whereas historical and modern “bulimia” differ in the preoccupation with weight criterion (2),
such a dichotomy between AN and BN is in our opinion not always the rule. Many restricting
patients develop bingeing/purging behaviors within several years (62), and AN and BN present a
shared vulnerability in important aspects, including their genetic transmission or the resemblance
in enduring personality attributes in recovered patients (63).

38
Conclusions

EDs likely reflect complex, inter-dependent, multi-dimensional causalities (31). Dieting behaviors
may be propelled into a full-blown disorder by an interaction of antecedent genetic, biological,
psychological, familial and socio-cultural influences. EDs have been traditionally conceptualized
as sociocultural dependent syndromes, related primarily to the thin body ideal, and being of
relevance predominantly in wealthier industrialized Western countries (10).

More recent theories regard EDs as a cultural byproduct of modernity that cuts across geographic
and economic lines in vulnerable individuals, rather than being a strictly Western phenomenon
(52). EDs may, thus, be attributed to a combination of socioeconomic development, changing roles
of women, a socio-cultural emphasis on thinness, and a shift in eating patterns (52), that affect
predisposed women that share genetic, physiological and psychological vulnerabilities. The
paradigm of idiom of distress seems of particular relevance in translating these macro socio-
cultural processes into the suffering of each and every individual woman.

References
1. Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Curr Opin Psychiatry 2006;
19:389-94.
2. Keel PK, Klump KL. Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychol
Bull 2003; 129:747-69.
3. Bemporad JR. Cultural and historical aspects of eating disorders. Theoretical Med 1997; 18:401-20.
4. Jonas H. The Gnostic religion. Boston: Beacon Press, 1958.
5. Lacey JM. Anorexia nervosa and the beautiful female saint. BMJ 1982; 285:1816-7.
6. Halmi K. Princess Margaret of Hungary. Am J Psychiatry 1994; 158:1216.
7. Bell RM. Holy anorexia. Chicago: Univ Chicago Press, 1985.
8. Bynum CW. Holy feast and holy fast. The religious significance of food to medieval women. Berkeley: Univ Calif Press, 1987.
9. Burckhardt J. The civilization of Renaissance in Italy. New York: Oxford Univ Press, 1994.
10. Banks CG. Culture in culture-bound syndrome: The case of anorexia nervosa. Soc Sci Med 1992; 34:867-84.
11. Brumberg JJ. Fasting girls: The histories of anorexia nervosa. New York: Penguin Books, 1988.
12. Vandereycken W, Van Deth R. From fasting saints to anorexic girls: The history of self-starvation. New York: New York Univ
Press, 1994.
13. Bliss EL, Branch CHH. Anorexia nervosa: Its history, psychology, and biology. New York: Paul Hoeber, 1960.
14. Morton R. Pthisiologia: Or a treatise of consumptions. London: Smith Walford, 1694.
15. Liles EG, Woods SC. Anorexia nervosa as viable behavior: Extreme self-deprivation in historical context. History Psychiatry
1999; 10:205-25.
16. Lasegue C. De l'anorexie hysterique. Arch Gen Med 1873; 21:385-403.
17. Gull W. Anorexia nervosa. Trans Clin Soc London 1874; 7:22-31.
18. Chipley W.J. (1860). On sitomania. J Psychol Med Ment Pathol 1860;13:266–70.
19. Marce LV. On a form of hypochondriacal delirium occurring consecutive to dyspepsia, and characterized by refusal of food. J
Psychol Med Ment Pathol 1860; 13:264–6.
20. Habermas T. Historical continuities and discontinuities between religious and medical interpretations of extreme fasting: The
background to Giovanni Brugnoli’s description of two cases of anorexia nervosa in 1875. Hist Psychiatry 1992; 3:431–55.
21. Vandereycken W, Lowenkopf EL. Anorexia nervosa in 19th century America. J Nerv Ment Dis 1990; 178:531–5.
22. Vandereycken W, Habermas T, Van Deth R, Meermann, R. German publications on anorexia nervosa in the nineteenth century.
Int J Eating Disord 1991; 10:473–90.
23. Parry-Jones WL. Archival exploration of anorexia nervosa. J symptoms in early case reports.
24. Freud S. The origins of psychoanalysis. New York: Basics Books, 1959.
25. Walter JV, Kaufman MR, Deutsch F. Anorexia nervosa: A psychosomatic entity. Psychosom Med 1940; 2:3-16.
26. Bachar E. The Fear of Occupying Space. Jerusalem: Hebrew Univ Magnes Press, 2001.
27. Simmonds M. Uber embolische Prozesse in der Hypophysis. Arch Path Anat 1914;217:226.
28. Russell GFM. Bulimia nervosa: An ominous variant of anorexia nervosa. Psychol Med 1979; 9:429-48.
29. Strober M, Salkin B, Burroughs J, Morrell W. Validity of the bulimia-restricter distinction in anorexia nervosa. Parental
personality characteristics and family psychiatric morbidity. J Nerv Ment Dis 1982; 170:345-51.

39
30. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed, text rev). Washington, DC:
APA, 2000.
31. Halmi KA. Eating disorders in females: genetics, pathophysiology, and treatment. J Pediatr Endocrinol Metabol. 2002; 15(Suppl
5):1379-86.
32. Russell GFM. The history of bulimia nervosa. In: Garner DM, Garfinkel PE. Handbook of treatment for eating disorders (2nd
ed). New York: Guilford, 1997:11-24.
33. Russell GFM. Thoughts on the 25th Anniversary of Bulimia Nervosa. Eur Eating Disord Rev 2004; 12:139– 152.
34. Crichton P. Were the Roman emperors Claudius and Vitellius bulimic? Int J Eating Disord 1996; 19:203–7.
35. Ziolko HU. Bulimia: A historical outline. Int J Eating Disord 1996;20:345–58.
36. Nasser M. A prescription of vomiting: Historical footnotes. Int J Eating Disord 1993;13:129–31.
37. Silverman JA. Robert Whytt, 1714–1766, eighteenth century limner of anorexia nervosa and bulimia, an essay. Int J Eating
Disord 1987;6:143–6.
38. Stein DM, Laakso W. Bulimia: A historical perspective. Int J Eating Disord 1988; 7:201–10. 39. Parry-Jones B, Parry-Jones
WL. Bulimia: An archival review of its history in psychosomatic medicine Int J Eating Disord 1991; 10:129–43.
40. Parry-Jones B. A bulimic ruminator? The case of Dr. Samuel Johnson. Psychol Med 1992; 2:851–62.
41. Rosenvinge JH, Vandereycken W. Early descriptions of eating disorders in the Norwegian medical literature. Acta
Paedopsychiatr 1994; 56:279–81.
42. Habermas T. The role of psychiatric and medical traditions in the discovery and description of anorexia nervosa in France,
Germany, and Italy, 1873–1918. J Nerv Ment Dis 1991; 179:360–5.
43. Habermas T. The psychiatric history of anorexia nervosa and bulimia nervosa: Weight concerns and bulimic symptoms in
early case reports. Int J Eating Disord 1989;8:259–73.
44. Van Deth R, Vandereycken W. Was late-nineteenthcentury nervous vomiting an early variant of bulimia nervosa? Hist
Psychiatry 1995; 6:333–47.
45. Pope HG, Hudson JI, Mialet JP. Bulimia in the late nineteenth century: The observations of Pierre Janet. Psychol Med 1985;
15:739–43.
46. Binswanger L. The Case of Ellen West (trans. by Werner M. Mendel and Joseph Lyons) In: May R, Angel E, Ellenberger H.
Existence: A new dimension in psychiatry and psychology. New York: Basic Books, 1958:237-364.
47. Lindner R. "Solitaire -The Story of Laura". In: The FiftyMinute Hour. New York: Bantam Books, 1955:79-118.
48. Habermas T. Further evidence on early case descriptions of anorexia nervosa and bulimia nervosa. Int J Eating Disord 1992;
11:351–9.
49. Swartz L. Anorexia nervosa as a culture-bound syndrome. Soc Sci Med 1985; 20:725-30.
50. Prince R. The concept of culture-bound syndromes: Anorexia nervosa and brain-fag. Soc Sci Med 1985; 21:197–203.
51. Weisman MA, Gray JJ, Mosimann JE, Ahrens AH. Cultural expectations of thinness in women: An update. Int J Eating Disord
1992; 11:85-9.
52. Nasser M, Katzman MA, Gordon RA. Eating Disorders and Cultures in Transition. London: Brunner-Routledge, 2001.
53. Hoek HW, Van Harten PN, Hermans KM, Katzman MA, Matroos GE, Susser ES. The incidence of anorexia Nervosa in
Curacao Am J Psychiatry 2005;162:748-52
54. DiNicola VF. Anorexia multiforme: self-starvation in historical and cultural context. Transcult Psychiatr Rev 1990;27;245-86.
55. Nichter M. Idioms of distress: Alternative expression of psychosocial distress: A case study from India. Cult Med Psychiatry
1981:5A:379-408.
56. Witztum E, Goodman Y. Narrative construction of distress and therapy: A model based on work with UltraOrthodox Jews.
Transcult Psychiatry 1999; 36:403-36.
57. Hollan D. Self systems, cultural idioms of distress, and the psycho-bodily consequences of childhood suffering. Transcult
Psychiatry 2004; 41:62-79.
58. Keyes CLM, Ryff CD. Somatization and mental health: A comparative study of the idiom of distress hypothesis. Soc Sci Med
2003;57:1833-45
59. Greenberg D, Stravynski A, Bilu Y. Social phobia in ultra-orthodox Jewish males: Culture-bound syndrome or virtue? Ment
Health Relig Culture. 2004; 7:289-305.
60. Morgan JF, Marsden P, Lacey JH. “Spiritual starvation”. A case series concerning Christianity and eating disorders. Int J Eating
Disord 2000; 28:476–80.
61. Lee S. How abnormal is the desire for slimness? A survey of eating attitudes and behaviors among Chinese undergraduates in
Hong Kong. Psychol Med 1993;23:437–51.
62. Eddy KT, Dorer DJ, Franko DL, Tahilani K, ThompsonBrenner H, Herzog DB. Diagnostic crossover in anorexia nervosa and
bulimia nervosa: Implications for DSM-V. Am J Psychiatry. 2008;165:245-50.
63. Kaye W, Strober M, Jimerson D. The neurobiology of eating disorders. In: Charney DS and Nestler EJ. The neurobiology of
mental illness. New York: Oxford Press, 2004:1112-28.
Psychiatr Res 1985; 19:95–100. 24. Freud S. The origins of psychoanalysis. New York: Basics Books, 1959. 25. Walter JV,
Kaufman MR, Deutsch F. Anorexia nervosa: A psychosomatic entity. Psychosom Med 1940; 2:3-16. 26. Bachar E. The Fear of
Occupying Space. Jerusalem: Hebrew Univ Magnes Press, 2001.

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 Purging the Myth of the Vomitorium

Ancient Romans used the word, but pop culture has the concept all wrong

Stephanie Pappas writes:15

A Bacchanalian Revel before a statue of Pan, Nicolas Poussin, 1594-1665,

National Gallery, London

As far as pop culture is concerned, a vomitorium is a room where ancient Romans went to throw
up lavish meals so they could return to the table and feast some more. It's a striking illustration of
gluttony and waste, and one that makes its way into modern texts. Suzanne Collins' "The Hunger
Games" series, for example, alludes to vomitoriums when the lavish inhabitants of the Capitol—
all with Latin names like Flavia and Octavia—imbibe a drink to make them vomit at parties so
they can gorge themselves on more calories than citizens in the surrounding districts would see in
months.

15
https://www.scientificamerican.com/article/purging-the-myth-of-the-vomitorium/

41
But the real story behind vomitoriums is much less disgusting. Actual ancient Romans did love
food and drink. But even the wealthiest did not have special rooms for purging. To Romans,
vomitoriums were the entrances/exits in stadiums or theaters, so dubbed by a fifth-century writer
because of the way they'd spew crowds out into the streets. [Who Were the Barbarians?]

"It's just kind of a trope," that ancient Romans were luxurious and vapid enough to engage in rituals
of binging and purging, said Sarah Bond, an assistant professor of classics at the University of
Iowa.

VOMIT. VOMITUS. VOMITORIUM.

The Roman writer Macrobius first referred to vomitoriums in his "Saturnalia." The adjective
vomitus already existed in Latin; Bond told Live Science. Macrobius added the "orium" ending to
turn it into a place, a common type of wordplay in ancient Latin. He was referring to the alcoves
in amphitheaters and the way people seemed to erupt out of them to fill empty seats. [Photos:
Gladiators of the Roman Empire]

At some point in the late 19th or early 20th century, people got the wrong idea about vomitoriums.
It seems likely that it was a single linguistic error: "Vomitorium" sounds like a place where people
would vomit, and there was that pre-existing trope about gluttonous Romans.

Classically trained poets and writers at the time would have been exposed to a few sources that
painted ancient Romans as just the sort of people who would vomit just to eat more. One source
was Seneca, the Stoic who lived from 4 B.C. to A.D. 65 and who gave the impression that Romans
were an emetic bunch. In one passage, he wrote of slaves cleaning up the vomit of drunks at
banquets, and in his Letter to Helvia, he summarized the vomitorium idea succinctly but
metaphorically, referring to what he saw as the excesses of Rome: "They vomit so they may eat,
and eat so that they may vomit."

ROMAN FEASTS

Another classic was a first-century A.D. piece of satire called the "Satyricon," in which an
obnoxiously wealthy man named Trimalchio throws feasts in which he serves dishes like dormice
rolled in honey and poppy seeds, a rabbit with wings attached so that it looked like Pegasus, and a
huge boar surrounding by suckling pigs, which the guests could take away like party favors. (F.
Scott Fitzgerald was so inspired by this work that he originally titled "The Great Gatsby"
"Trimalchio in West Egg.")

Writer Aldous Huxley was similarly inspired, and wrote of vomitoriums as literal places to vomit
in his 1923 novel "Antic Hay."

42
"I think it caught on, probably because, A, it's very close to what we already have in terms of the
word vomit, so it was easily accessible linguistically and then, B, it already fit in with a cultural
perception" spread through works like the "Satyricon," Bond said.

The thing about the "Satyricon," though, is that it was satire—and probably exaggerated. Seneca
likewise had a "bad axe to grind about luxury," Bond said. Wealthy Romans and poor Romans ate
similar grain-based diets, said Kristina Killgrove, an anthropologist at the University of West
Florida, who has studied the diets of ancient Romans through molecular markers left in their teeth.
The wealthy ate more wheat; the poor more millet. Richer Romans also got to eat more meat than
poorer Romans.

The uber-wealthy did love a good feast, though, Killgrove said. Roman fine dining was a
community affair and would have included entertainment like dancers and flutists. Unlike ancient
Greeks, Romans included women at their upper-class functions, so crowds would have been co-
ed. Historical recipes show a penchant for fanciful presentations of food, particularly meats stuffed
inside other meats.

Myth busting Ancient Rome – the truth about the vomitorium

Caillan Davenport and Shushma Malik write:16

After gorging on a feast of sausages, blood pudding, young sow’s udder, sea bream, lobster, mullet,
Attic honey, and Syrian dates, all washed down with a few glasses Falernian wine, it is little
wonder that a Roman diner might begin to feel quite full.

It was once thought that a diner could, at this point in the meal, make a quick visit to the
vomitorium – a room adjacent to the dining room replete with a basin and feathers to tickle the
throat – in order to make room for the next course.

There is a delightful array of Latin words associated with the act of throwing up, from the verbs
vomo (“I vomit”) and vomito (“I keep on vomiting”) to the nouns vomitor (“one who vomits”)
and vomitus and vomitio, both of which can either refer to the actual business of chundering or the
yucky stuff itself.

The vomitorium is clearly part of this group, but no ancient source actually employs the word to
describe a place for post-prandial puking. It first appears in the Saturnalia of Macrobius, written
in the 5th century AD.

Macrobius uses the plural vomitoria to refer to the passages through which spectators could “spew
forth” into their seats at public entertainment venues. Vomitorium/vomitoria are still used today
by archaeologists as architectural terms.

16
https://theconversation.com/mythbusting-ancient-rome-the-truth-about-the-vomitorium-71068

43
Do experts have something to add to public debate?
We think so

Vomitoria in the Colosseum, Rome

This misconception of the vomitorium as a vomiting room is widely acknowledged in popular

culture. Our aim is to explore how the myth arose and why it has proved to be so persistent.

A vomitous history
In 1929, Aldous Huxley wrote in his comic novel, Antic Hay:

But Mr Mercaptan was to have no tranquillity this afternoon. The door of his sacred boudoir
was thrown rudely open, and there strode in, like a Goth into the elegant marble vomitorium of
Petronius Arbiter, a haggard and dishevelled person…

This passage is commonly cited as the first time vomitorium was misused to mean a room used
for vomiting. However, there are references in newspapers and journals that pre-date Huxley,
going back to the 19th century. They reflect the confusion about whether the vomitorium was a
passageway or a room for emptying one’s stomach.

In an 1871 account of Christmas in England, French journalist and politician Felix Pyat described
the holiday meal as “a gross, pagan, monstrous orgie – a Roman feast, in which the vomitorium is
not wanting.” By 1871, then, the vomitorium was already misunderstood as a chunder chamber.

44
In the very same year English writer Augustus Hare published his Walks in Rome, in which he
assumed that the chamber adjacent to the dining room in the Flavian Palace on the Palatine was
none other than a vomitorium, which he described as “a disgusting memorial of Roman life”.

In these rooms, Hare imagined, Nero poisoned his step-brother Britannicus, the concubine Marcia
drugged Commodus, and Pertinax received rumours of revolt. We can almost see the knowing
smile of the anonymous critic in an 1888 edition of Saturday Review when he described Hare’s
account of the vomitorium as a “delightful blunder”. Roman archaeology, our critic warned, is
after all too technical a subject to be dealt with by an amateur.

An illustration in a 1916 edition of The Washington Post got the myth slightly
wrong, showing bowls at the meal rather than a separate room.

Not to be left out, the Los Angeles Times ran two articles (in 1927 and 1928) mentioning Roman
feasting and the vomitorium, one of which was a precursor to the notable historian Will Durant’s
work The Story of Civilization.

Here, “graduate Epicureans” avail themselves of the vomitorium to “free themselves for more”.
By the time Huxley’s novel was published in 1929, therefore, a visit to the vomitorium was
entrenched in the popular imagination as an essential part of any Roman dinner party.

45
Gluttonous Emperors
Where did the idea of the vomitorium come from? Huxley’s novel alludes to the stories of
outrageous gluttony in the pages of Roman courtier Petronius’ Satyricon (written in the 1st century
AD). As it happens, Petronius’ novel doesn’t feature the vomiting room, merely an unfortunate
description of one character’s laboured bowel movements over dinner. For stories of dinner-time
barfing, we have to look elsewhere, to scandalous stories of imperial excess contained in
Suetonius’ On the Lives of the Caesars and Cassius Dio’s Roman History.

According to Suetonius, who was secretary of correspondence to the emperor Hadrian, the emperor
Claudius always finished his meals excessively bloated with food and wine. He would then lie
down so that a feather could be inserted down his throat to make him disgorge the contents of his
stomach.

Claudius’ excesses paled in comparison to the emperor Vitellius, who allegedly feasted four times
a day, and procured exotic foods from all over the empire to satiate his enormous appetite,
including brains of pheasants and flamingo tongues. He is said to have vomited between meals in
order to make room for the next banquet. The historian Cassius Dio memorably remarked that
Vitellius was “nourished by the mere passage of the food”.

Gold coin of Vitellius. Trustees of the British Museum, CC BY-ND

Suetonius and Cassius Dio included such stories not only to entertain their readers, but also to
make a point about the fitness of individuals to rule the Roman empire. Greed and gluttony
represented devotion to pleasure and the inability to maintain control over one’s desires. Claudius
and Vitellius are both said to have abandoned official duties for the sake of their next feast.

46
Suetonius claims that Claudius once left the courtroom when he caught a whiff of food cooking in
the temple next door and went to join in the banquet. When presiding over sacrificial rituals,
Vitellius is said to have gobbled up the sacrificial meat and cakes himself. Both these examples
constitute gluttonous derelictions of duties. Vomiting was the ultimate sign of profligacy and
wastefulness for an emperor, who was literally chucking up the wealth of his empire.

The morality and reality of food

Romans would have understood the moral messages contained in these anecdotes. A proper
Roman man was supposed to be devoted to the gods, his family, and to the state – not to his belly.
Excessive consumption of food was a sign of inner moral laxity.

The philosopher Seneca the Younger memorably remarked that if Roman men desired anything
more than basic food and drink for sustenance, they were fulfilling not their needs, but their vices.
He reserved particular criticism for those who spent their fortunes on exotic dishes:

They vomit so that they can eat, and they eat so that they can vomit. They don’t even consider the
dishes which they have assembled from across the earth worthy of digestion.
This statement, as with the stories of Vitellius and Claudius, does not reflect reality for most
Romans, least of all suggest that actual rooms were reserved for such decadent practices. It is a
moral criticism.

Vomiting was actually more commonplace in the Roman world as a medical treatment. Celsus
advised that vomiting should not become a daily practice (for that was a sign of luxury) but that it
was acceptable to purge the stomach for health reasons. The adjective vomitorius/a/um was
employed to describe emetics into the Victorian period.

47
 Bread seller in Pompeii mural

Most residents of the city of Rome could not be so cavalier about wasting their calories. Their
subsistence diets consisted mainly of cereals, legumes, olive oil, and wine, which had to sustain
them through their lives of manual labour. The food that Vitellius gobbled up at sacrifices to satiate
his enormous appetite would have been gratefully savoured by the people of Rome.

Such foodstuffs were carefully controlled. Even at religious festivals, the best sacrificial meat was
reserved for aristocratic participants or sold off, not distributed to the common people. The famous
“grain dole” provided to Romans was in fact a privilege confined to a mere 150,000 eligible
citizens out of the million plus residents of the city of Rome. Food was a privilege.

Of course, Macrobius’ own use of the term vomitoria was connected to vomiting, conjuring up the
image of the amphitheater spewing out people. The association between an architectural term and
lurid stories of vomiting Romans found in ancient texts easily led to the misinterpretation of the
vomitorium as a room for throwing up in the 19th-century imagination. Those who dined to excess
were regarded as similar to Romans, a people popularly known for their luxury and decadence.

The myth of the vomitorium has therefore been shaped by our fascination with the antics of
dissolute emperors and elites who loved a Technicolor yawn between meals. Since antiquity, we

48
have derived pleasure from hearing about and criticizing the overindulgent dining habits of others
as a sign of their moral laxity. (Mis)interpreting a suggestive word like vomitorium as a room
intrinsically tied to such decadence was a mistake waiting to happen.

Sacred Hunger
Rachel Mirsky writes: 17

17
https://www.yu.edu/sites/default/files/legacy/uploadedFiles/Academics/Undergraduate%20Studies/Stern%20College%20for%2
0Women/Departments%20and%20Programs/Undergraduate/Biology/About/Derech%20Hateva%2018.pdf#page=34

49
 Bulimia in the Talmud

Allan S. Kaplan and Paul E. Garfinkel write:18

18

50
51
 Bulimia Nervosa/Obesity A Historical Overview

Barton J. Blinder, M.D. and Karin H. Chao, B.S., M.A. write:19

Bulimia is derived from the Greek meaning ravenous hunger. Teenage or young women are most
likely to suffer from this eating disorder. The patient practices binge eating which consists of
uncontrollable, recurrent overfeeding most often outside of normal mealtime in a driven pre-
emptory pattern-disrupting routine daily activity. The compensatory behavior which occurs
subsequent to binge eating can include purging (mechanical or chemical self-induced vomiting,
19
Department of Psychiatry and Human Behavior University of California Irvine n [Understanding Eating Disorders]
Alexander-Mot Ed. Taylor and Frances, Washington, D.C.1994

52
ruminatory regurgitation, laxative and diuretic abuse) and non-purging (prolonged abstinence from
food, extreme vigorous exercise and the use or abuse of anorexic medication) techniques. The
patient's weight fluctuates, and unlike anorexia nervosa, a bulimic may not necessarily be
underweight. Studies show 70% of bulimics are within the normal weight range while 15% are
overweight, and 15% are underweight (De Zwaan and Mitchell, 1991).

Historical accounts of bulimia nervosa

Bulimia nervosa was not a new disorder. (Russell, 1979). There were scattered historical
references suggested bulimia and there have been detailed case histories over the last 60 years.
(Casper, 1983; Ziolko & Shrader, 1985; Blinder and Cadenhead, 1986).

Entries compatible with bulimia could be seen in the Latin writings of Aulus Gellius and Sextus
Pompeius Festus, grammarians of the 2nd and 4th A>D> respectively; and with the description of
"canine hunger" in the works of Theodorus Priscianus, a physician in the 5th century (Smith, 1866;
Lewis $ Short, 1900). Romans were known to tickle their throats with feathers after each meal to
induce vomiting thus allowing them to return to gluttonous feasting (Fischer, 1976). The Romans
did so to enhance the enjoyment of a wider selection of palatable foods. (In contrast Bulimis
patients have a narrow sterotyped food selection usually carbohydrates with the repetitive eating
of the same item). Galen, a 2nd century greek physician noted that an abnormal acid humor in the
stomach was the cause of "bulimis". Bulimis gave an exaggerated but false signal of hunger
(Siegel, 1973; Stein & Laakso, 1988). Powdermaker (1973) noted gluttony was an acceptable
behavior for primitive cultures. After months of hunger, hunting for food and finally preparing the
feast, one Trobriand Islander declared: “We shall be glad, we shall eat until we vomit." (Boskind-
White and White, 1986). In the Talmud (400-500 A.D.) the term "boolmut" was used to describe
an overwhelming hunger which impaired a person's judgment about food and on external event
(Kaplan & Garfinkel, 1984; van der Eycken, 1985; Blinde & Cadenhead, 1986).

The earliest English language example of bulimia occurred in the English translation in 1398 by
John Trevisa of Bartholomeus in Glanville's encyclopaedic thirteenth century work, De
Proprietativus Rerum (Parry-Jones, 1991). James (1743) described "true boulimus" which was
characterized by intense preoccupation with food and over eating at very short intervals,
terminated by vomiting (Stein & Laakso, 1988). Motherby (1785) studied three types of bulimia:
bulimia of pure hunger, bulimia associated with "swooning;" and bulimia terminated by vomiting
(Stunkard, 1990). Bulimia was recognized in the 1797 edition of the Encyclopedia Britannica
(Stunkard, 1990).

Case histories of bulimia before 1900's

In the 18th and 19th century binge eating and vomiting was considered worthy of medical attention
only if the overeating could be seen as a symptom of other disease. Gull (1873) noted in one
anorexic patient who "occasionally for a day or two, her appetite was voracious, but this was rare
and exceptional." He also saw another anorexic patient who, in order to induce vomiting, would
think of "putrid cat pudding." (Blinder & Cadenhead, 1986).

53
Lasegue (1873) noted that many anorexics reactively vomited after they had been forced to eat.
Janet (1919) commented that Lasegue's second phase of illness was when the period patient
learned to vomit what she swallowed. Briquet (1859) studied a woman who for months ate
normally, but then went into a phase of vomiting everything she ate (Habermas, 1989). Casper
(1980) and Garfinkel and Garner (1980) noted that significant occurrence of bulimic behaviors
and symptoms, approximately 40%, in anorexia nervosa patients.

During this period, different terms were coined to describe the overwhelming urge to overeat and
vomit (Habermas, 1989). However, none of them associated binging and purging with weight
control (Ziolko and Schrader, 1985). Blanchez (1869) termed "cynorexia" as a cycle of overeating
and vomiting. The cynorexic was literally possessed by the thought of food, and insatiable hunger.
Stiller (1884) described "hyperorexia" as a constant eating of small amounts of food in order to
counteract feelings of faintness. Soltmann (1894) documented a 17-year-old boy who ate
massively when he returned home from school. He was outraged when kept from eating. Soltmann
called such symptom "polyphagia" in which there was an absence of a feeling of fullness, leading
to a rather constant devouring of huge amounts of food. Speculatively, this might have been Klein-
Levin syndrome (Orlowsky, 1982; Sugar, Khandelwal, Gupta, 1990).

Secret eating and food stealing

Binging in secrecy and food stealing has been patterns seen frequently in bulimics (Habermas,
1989; De Zwaan and Mitchell, 1991). Janet (1908) noted his patient Nadia "from time to time
forgets herself to the point of devouring gluttonously anything she can get hold of. At other times,
she cannot resist the urge to eat something; she then secretly eats biscuits." Wulff's patient A (1932)
claimed she secretly binged on fodds such as sweets, pastries, and bread that were restricted
because of her obesity (Stunkard, 1990). She categorized foods by saying "This is good; the worst,
the better" (Habermas, 1989). Bergmann (1934) documented a young thin woman who hoarded
food from the pantry at night. Stunkard, Grace Wolff (1955) coined the term "night feeders" to
describe obese patients who consumed large amounts of food during the night. Other authors noted
secret eating and food stealing often associated with binge eating, and they suggested such
activities fell in the same category of binge eating (Casper, Ecker, Halmi, Goldberg, and DAvis,
1980; Densmore, 1988). Secret eating was usually planned in advance, and carried out late in the
day. It was all part of the isolating nature of bulimia nervosa. From a developmental and
psychodynamic perspective, secret eating and food stealing were suspected to express
impulsiveness, ambivalence or rebelliousness (Habermas, 1989; Schwartz, 1990; De Zwann and
Mitchell, 1991; Wilson, Hogan, Mintz, 1992).

1990-1940's

During the first half of this century, many of the studies on eating disorders were overshadowed
by Simmond's observation of pituitary insufficiency. Nevertheless, in a paper presented to the
German Psychoanalytic Society in 1932, Moshe Wulff described four cases of an eating disorder
in women characterized by uncontrollable, recurrent overeating, prolonged fasting, hypersomnia,
depressed mood, and irritability (Blinder and Cadenhead, 1986; Stunkard, 1990; Habermas, 1989).
All four went through the phase of binge eating, and two of the four vomited. Patient B described
the binge episodes as "circumstances of animal eating" in that she devoured everything in sight,

54
including orange peels and scraps of paper. Usually the patients binged on snacks or dessert foods
which were avoided at other times because these foods were fattening and calorie-rich. This phase
alternated with the phase of prolonged fasting. Patient D often went through 3- to 6-day-long fasts
that could extend to complete abstinence from food for the entire day. Patient C noted her
motivation to fast was to lose weight. During fasting, these patients selected fruits, vegetable, and
milk - a constricted cuisine. The fasting phase often ended with the onset of yet another phase of
prolonged binge eating episodes; such cycles brought these women a strong sense of disgust with
their own bodies, and the broken promises to never do it again.

Wulff characterized binge eating as "oral symptom-complex" in which the patient regressed to
obtain a "pure oral erotic satisfaction . . . almost a sexual perversion." He placed bulimia between
melancholia and addiction. From a psychoanalytic perspective what bulimia had in common with
above mental states was they all encompass a sense of loss or detachment leading to an "insult to
narcissism," the reaction to which culminated in binge eating (Blinder and Cadenhead, 1986;
Stunkard, 1990; Habermas, 1989).

Binswanger (1944) described the case of Ellen West who was a partially remitted anorexia who
began to struggle with bulimia. Her symptoms included binge eating, violent vomiting, and
laxative abuse. West's diary detailed her struggle for control over her emotions and her body
weight (Britt and Bloom, 1982; Casper, 1983; Blinder and Cadenhead, 1986; Stunkard, 1990;
Beumont, 1991).

Selling and Ferraro (1945) observed bulimia in refugee children between 1933 and 1939. Many of
these children came to the United States from Europe without their parents, and they fed
themselves frantically and excessively when they felt insecure. However, when these children
found new homes, they reduced their food intake (Casper, 1983). Waller and Kaufman (1940)
described two women who overate on candies, and then starved themselves in a defensive reaction
to an incestuous pregnancy fantasy involving father. Berkman of the Mayo Clinic (1930) reported
that out of 177 anorexia patients, 66% vomited. Most said they did it to relief the sensation of
fullness. Schottky (1932) noted a female patient who used a hose to empty out what she eaten
inducing vomiting (Habermas, 1989). It was also around this time that Nogue (1913) researched
the prescriptive use of laxatives or thyroid for the purpose of weight control. This brought about
the changes in the kind of laxatives used to lose weight; earlier, anorexics used vinegar to control
weight (Gungl and Stichl, 1892; Wallet, 1982; Janet, 1908).

Bulimia nervosa and anorexia nervosa

Many authors have described bulimia in nonanorexic patients. some characterized it as a rare
neurotic condition. Janet (1908) studied a 26-year-old male who was "withdrawn with a bizarre
character." This man's self-induced vomiting, as Janet noted, was a form of tic, and not as part of
anorexia (Habermas, 1989). Abraham (1916) described a patient who, instead of vomiting, binged
only on vegetables during bulimic attacks to counteract the weight gain. Abraham called it a
"neurotic hunger" in which the feeding and satiety signals originate from anxiety and internal
psychological conflict, not the emptiness or fullness of the stomach (Blinder, 1980; Blinder and
Cadenhead, 1986; Habermas, 1989). Abraham associated the bulimic condition with repression of
libido and likened it to an addiction dipsomania (alcoholism,) or morphinism (Blinder, 1980).

55
Wulff (1932) characterized the somnolence that followed the binges as a kind of "sleep
drunkenness" completing the bulimic cycle during which patients sought and fulfilled "oral erotic
stimulation." Lindner (1955) noted the case of Laura who binged but did not vomit. Laura's father
abandoned her and the family when she was young; Lindner suggested Laura's distended stomach
represented her secret wish to be impregnated by her father (Blinder and Cadenhead, 1986).
Kirshbaum (1951) used the term "Hyperorexia" as a manifestation to signify hypothalamic
insufficiencies.

However, modern history of bulimia first appeared in connection with patients who also suffered
from anorexia. Nemiah (1950) reported the case histories of 14 patients with this condition in
Massachusetts General Hospital (Stunkard, 1990). Four of 14 patients were suspected of bulimia
due to their abnormal eating pattern and vomiting. Many authors were aware of overeating,
laxative abuse, and self-inducted vomiting in anorexics, but considered bulimia as a variant of
anorexia nervosa, rather than a distinct syndrome (Bond, 1949; Nemiah, 1950; Bruch, 1962).
Abraham and Beumont (1982) viewed bulimia and anorexia as extremes of the same disorder;
whereas Russell (1979) described bulimia as an indicator of chronicity of anorexia. In separate
studies done by Casper (1980) and Garfinkel, Moldofsky, and Garner (1980) about half of patients
with anorexia demonstrated bulimic behavior; and in Mitchell's study (1985) 30 to 80% of patients
with bulimia had a history of anorexia. Blinder, Chaitin, and Hagman (1987) reported an increased
history of anorexia nervosa preceding bulimia and more extensive current eating disorder
symptoms in those bulimic patients who had co-morbidity for depression. Katz and Stinick (1982)
considered bulimia as a manifestation of the constant core syndrome of eating disorder. Comparing
bulimia and anorexia, a bulimic patient may not necessarily be underweight, and about 15% of the
time, she is overweight. Too, unlike anorexics, a bulimic patient may or may not have amenorrhea
(although oligomenorrhea, anovulatory cycles and occasional missed periods are common); a
bulimc patient possessed a greater premorbid weight, more affective instability, greater
interpersonal sensitivity; a bulimic patient is more extroverted, and was more likely to have a
personality disorder diagnosis (Russell, 1979; Casper, 1980; Garfinkel, 1980; Strober, 1980,
1981).

After 1940's

Some cases of bulimia before the 1940's mentioned the patient's concern with body shape and body
weight. Janet (1908) noted one of Charcot's cases of a young girl who wore a rose-colored ribbon
around her waist. She did this to ensure that her waist size never exceeded what she thought and
measured it to be (Brumberg, 1988). However, not until after the 1940's did the overconcern of
patients with body shape and self-image become a usual and constant feature (Casper, 1983). The
"desire and pursuit of thinness" theme started appearing more frequently in literatures, culminating
in the 1970's with what Bruch called "the pursuit of thinness," and Selvini-Palazzoli termed "the
desperate need to grow thinner." The idea of thinness was becoming a virtue, and it was a symbol
of independence, autonomy, self-control, and a moral grace. A combination of cultural, economic,
and psychological factors may have contributed to the vast and rapid emergency of bulimia
nervosa (Gordon, 1992). Culturally, following the Depression years, prosperity and increase in the
availability of foods led more girls to worry about overeating, being overweight, and being plump
(Casper, 1983). Fat was deemed disgraceful and indicative of a lack of self-control. Waller (1940)
saw patients who were "ashamed of being fat." Casper (1981) noted this dread of fatness came

56
from critical self-image which drove the patient to develop bulimia, and "escape into a controlled,
desirable, however, distorted and isolated thin existence." Bruch (1973) saw this development as
a compensatory mode of action covering over feelings of pervasive inadequacy.

Bulimia nervosa as a distinct syndrome

Toward the end of the 1970's, more focus was put on the occurrence of gorging in patients who
were at a normal weight. Bruch (1957) described a case of a patient who binged and vomited, but
he was neither obese nor emaciated (anorexia). Because these patients did not have an obvious
weight disturbance, it seemed necessary to define a new syndrome to encompass their disorder.
Boskind-White (1976) termed this "bulimarexia." This term described an eating disorder usually
in young women at a normal weight who alternated between binging and strict fasting.
Bulimarexics had low self-esteem, poor body image, and the fear of not being successful in
heterosexual relationships. Boskind-Lodahl and White (1978) noted "the importance of
sociocultural factors in female role definition and the view of bulimarexia as related to the struggle
to achieve a 'perfect' female image in which women surrender their self-defining powers to others."

with some initial caution, the concept of a distinct syndrome of bulimia nervosa came to be
accepted in DSM-III in 1980. Russell (1979) designated the term "bulimia nervosa" to describe a
subgroup of patients who, in contrast to eating restricts, have been found to have an older age of
onset, a more chronic outcome, and a higher incidence of premorbid and family obesity (Beumont,
George, Smart, 1976; Casper, Eckert, Halmi, Goldberg, Davis, 1980; Garfinkel, Moldofsky,
Garner, 1980; Strober, 1981; Strober, Salkin, Burroughs, Morrel, 1982). These patients manifest
greater anxiety and depression, report a higher incidence of impulsive behavior (substance abuse
and kelptomania), more evidence of premorbid instability, a greater body image distortion, and a
more extensive family conflict (Casper, et al., 1980; Garfinkel, et al., 1980; Katzman, Wolchik,
1984; Strober, 1980). According to DSM-IV (1993) the essential features of bulimia nervosa are
recurrent and uncontrollable episodes of binge eating; self-induced vomiting, the use of laxatives
or fiuretics, strict dieting, fasting, or vigorous exercise to prevent weight gain; and persistent
overconcern with body shape and weight. Binging usually precedes vomiting by about one year.
Bulimia is usually diagnosed in teenage or young women with the age of onset between 16 and
19. Less than 10% of men are affected by bulimia (Zwaan and Mitchell, 1991). In surveys of
college and high school populations (Halmi, Falk, and Schwartz, 1981; Hawkins and Clement,
1980; Johnson, Lewis, Love, Lewis, and Stuckey, 1984; Nagelberg, Hale, and Ware, 1984; Pyle,
Mitchell, and Eckert, 1981; Russell, 1979), a range of 4.1% to 13% of students met the criteria for
bulimia. Kendler, MacLean, Neale, Kessler, Heath, Eaves, in 1991 reported a 4% lifetime
incidence of bulimia nervosa in all women. In the long run, this disease is not easily cured, of the
45 patients with eating disorders reported by Bruch in 1973, 25% suffered from bulimic attacks;
however 12 years later, the number went up to 50% (Bruch, 1985).

OBESITY

Obesity is a condition characterized by the excessive accumulation of fat (when the body weight
exceeds by 20% of the standard weight listed in the usual height-weight tables) (Kaplan and
Saddock, 1991). Step variations in the magnitude of excessive weight have been delineated
according to increases in total body mass index (weight in kg/(height in m)2). The latter statistic

57
may be placed on a continuum so that a result over 25 (25 to 45) may signify the degree of obesity
from moderate to morbid, and reflect the level of accelerated mortality risk as a consequence of
the morbidity of anticipated medical complications (hypertension, cardiac and circulatory disease,
diabetes, orthopedic disorders). Fundamentally, it is a result of overnutrition. Obesity existed in
the most primitive and ancient societies. Portrayals of human forms during the Aurignacian era,
which dated some 20,000 years ago, showed rather plump and obese women. Some supposed fat
was admired during this period; obesity in a woman was looked upon as a sign of fertility, her
capacity to bear children, and her ability to endure the extremes of weather conditions (Beumonth,
1991; Bruch, 1973).

Attitudes toward obesity changed in the classical times as it was recognized as a problem.
Aristophanes, a fifth century B.C. Greek comedy writer, described in his work Plutus that obese
men were "bloated, gross, and pre-senile . . . they are fat rogues with big bellies and dropsical legs,
whose toes by the gout are tormented." The Greek goddesses such as Venus and Diana were plump
and matronly with round bodices. They glorified and portrayed the "mother earth" image (Boskind-
White and White, 1986). However, in their own daughters and wives the Greeks emphasized
slimness, and beauty in order to look seductive in revealing clothes. Greek physician Dioscorides
described radish, caper, and vinegar as substances that disturbed the bowel system. These were
prescribed as diuretics and emetics. Hippocrates described obesity in detail and advocated for
slimming exercise along with punitive measures such as sleeping on hard beds. The Cretans also
had drugs which allowed one to drink and to eat as much as one wished and remain slender. In
Sparta, people were customarily trained to survive in its military society. A spartan writer,
Xenophane, described diets as being sparse, strict at best, so its people could survive war times
and could enjoy better heath. Obese people were punished for their adiposity; youths were
examined in the nude for excess weight gain, and those who gained weight were subjected to
compulsory diets and scourging. The Romans frowned on obesity, and they were accredited for
inventing the vomitorium which allowed them to binge and to relieve themselves of the feeling of
fullness. To preserve their youthful figures, Roman wives and daughters often starved themselves
to the point of death. Galen prescribed diuretics to "make them thin as reeds" (Boskind-White and
White, 1986). The Egyptian men also chose wives who were young and slender.

In some religious circles, gluttony was considered a sin. For example, in the painting "The Last
Judgment," the sinners were fat and heavy but the disciples were slender. Bible verses also
discredited gluttony. Examples include the following, in Proverbs 23:21 "For the drunkard and the
glutton will come to poverty;" Deuteronomy 21:20 "He is a glutton and a drunkard, then all the
men stoned him to purge evil from mist;" Matthew 11:19 "Behold a glutton and a drunkard - a
friend of tax collectors and sinners. However, in an overtly ambivalent perspective, obesity was
also viewed as the "Grace of God." In works throughout the Renaissance, scenes of merry feastings
were depicted with great joy and vitality. Botticelli's Venus and De Vinci's works portrayed
women who round bodices and full figures (Bruch, 1973).

In other non-western cultures, obesity was looked upon as a favored trait. For some Plynesian
people, it was a privilege to be so well-fed and pampered that tone could be at such leisure to get
fat. Some Malayan kings were noted to be very large, and they were specially cared for with
massages and exercises to preserve their good health (Bruch, 1973). The girls of Banyankole of
East Africa underwent regimens to gain weight in preparation for marriage. It was a compliment

58
to the men who married plump women; it showed the men off as good providers (Boskind-White
and White, 1986).

Throughout the Victorian Age, obesity was associated with lower class status and poverty. Dress
designs of their period stressed full breasts and tiny waistlines; for instance, the "Gibson girl"
image of the last 19th century America. Women stayed away from food in order to be slim and to
create the hourglass shape. In 1864 Ebstein distinguished three types of obesity: stout, comical,
and severe (Beumont, 1991). Some poor immigrant mothers during the 1930's who suffered from
hunger in their childhood and youth did not see overweight in their children as negative. To them
plumpness meant security and success. Slenderness was at its peak during the 1960's with the
arrival of "Twiggy" (5'7", 92 pounds). Severe abstinence from food and various forms of weight
control were used to achieve a type of malnourished figure which was heralded as the standard of
beauty. It was of no surprise that during this time there was both an increase in medical and
psychiatric recognition of eating disorders and more women diagnosed as anorexic or bulimic.

Cross-cultural studies of white's and minorities' views on body type showed that blacks and other
minorities do not prefer the ultrathin body type (Huenemann, Shapiro, Hampton, et al., 1966;
Levinson, Powell, Steelman, 1986; Maddox, Black, Liederman, 1968; Stern, Pugh, Gaskill, et al.,
1982). Studies showed that black girls and their families were not as obsessed over being think or
losing weight (Wadden, Stunkard, Rich, et al., 1990; Dornbusch, Smith, Duncan, et al., 1984;
Sobal, Stunkard, 1989; Striegel-Moore, Silberstein, Rodin, 1986; Wadden, Foster, Stunkard, et al.,
1989). The latter attitudes contributed to a twofold increased prevalence of obesity in blacks
compared to Caucasian women (Van Itallie, 1985). Contributing to the latter difference in addition
to attitudinal and social value determinants would be differences in informed nutrition practices,
opportunities for regular exercise, and poverty-determined adverse health practices. Higher
socioeconomic status in females correlated to over body weight and a less chance of becoming
obese (Sobal, Stankard, 1989). Other studies showed that decline in educational level was related
to an increasing amount of body fat and obesity (Teasdale, Sorensen, Stunkard, 1992; Sonne-
Holm, Sorensen, 1986).

Obesity through the ages has been clearly influenced by prevailing social custom with both over-
valuation of its presence and severe derision and social ostracism. A plethora of methods for
slimming have been attempted and early observations were made of the adverse health
consequences of morbid obesity.

Reclaiming the Body: Anorexia and Bulimia in the Jewish

Community

59
Hannah Farkas writes:20

“To save one life is to save the world.”

The Talmud

“My filthy habit” kicked in again!” A tearful Naomi sank into the couch in my office. “I must be
crazy!” It was the day after the second Seder and she had been free from binging and purging for
several months. “The first Seder was a total pig out so I decided I’d stick to salad and vegetables
last night,” she said. But when she saw the pot roast and roast potatoes, the chicken and kugel, she
lost control. Although she ate only a mouthful of each, within moments, she excused herself from
the table, slipped into the bathroom where she proceeded to throw everything up. “I couldn’t help
it,” she said ruefully, “I felt so fat.”

Naomi, a 31 year old Jewish mother of six- year old twin girls, has struggled with food, weight
and her body since early childhood when she was labeled “chubby.” As an overweight teen, she
began dieting; by college, the relentless pursuit of thinness had spun into a full blown anorexia
nervosa. In response to feeling starved, she began binging. Next came vomiting. Before long she
was bulimic.

Naomi is not alone in her unhealthy relationship with food, eating and her body. From being
overweight to being anorexic and then bulimic, Naomi has spent most of her life battling with food
and her body. While most women do not have life threatening eating disorders, the majority of
females spend a lifetime feeling guilty about what they eat and agonizing over their bodies.

20
Judith Ruskay Rabinor, Ph.D. The American Eating Disorder Center of Long IslandOriginally published in the book “What May
I Do With My Body” Jewish Choices/Jewish Voices: Contemporary Ethics, Spirituality, and Identity. Published by the Jewish
Publication Society, editors, Elliot Dorff and Louis Newman

60
We are born hungry and forever, until we take our last breath, we must learn to nourish our
hungers, appetites and desires, our mind body and soul. How what has begun as a sacred right–
feeding ourselves–become, for so many women, a dreaded taboo?

I am a clinical psychologist who has spent over thirty years working with people—mostly
women—who have struggled with eating and body image disorders. These complex conditions
arise from a combination of behavioral, biological, genetic, emotional and socio-cultural factors.
While they are exacerbated by our culture’s obsession with weight loss, an eating disorder is
always about more than an obsession with dieting and one’s body. Starving, chronic dieting,
binging, excessive exercising and being preoccupied with “fat” thoughts are the tip of an emotional
iceberg. My work is always about helping people identify and nourish the unmet emotional,
psychological and spiritual hungers masked and expressed in these behaviors.

As many as 10 million females and 1 million males fight a daily battle with anorexia and bulimia,
life threatening eating disorder whose complications claim the lives of 5-10% of sufferers each
year. At any given time, 10 percent or more adolescent girls and adult women report disordered
eating—behaviors characterized by excessive dieting and exercising which, although not
diagnosable eating disorders, cause seriously impaired lifestyles. Once thought to effect
predominately teenage girls, anorexia and bulimia occur throughout the lifecycle and affect males
as well as females. In addition to anorexia and bulimia, more than 25 million people struggle with
binge eating disorder, often a precursor to obesity.

In the psychotherapy session that followed, Naomi and I explored her binge-purge. The middle of
five children, Naomi grew up feeling invisible, sandwiched between an older sister, known as “The
Brain,” and a younger sister who was the prettiest and most popular girl in the class.

“My mom’s Seder table brought up my old feelings of envy, competition and inadequacy,” she
realized. Feeling shamed, silenced and invisible, she turned to her tools of survival: binging and
purging. Unable to control unacceptable thoughts and feelings, Naomi used food to sooth herself.
Later, she distracted herself by throwing up. For Naomi, binging and purging were her tools of
emotional survival. Learning to identify, accept and talk about her shameful feelings rather than
stuff them down her mouth or deposit them in the toilet was the beginning of her healing journey.

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No one theory explains the development of eating and body image disorders. While the cultural
emphasis on thinness undeniably damages all women, only a small percentage develop
diagnosable eating problems. These disorders serve different functions for different people at
different stages. They generally help one avoid dealing with unacceptable feelings, moods and
thoughts by keeping obsessive “fat thoughts” and food related behaviors in the forefront of one’s
consciousness. They can be triggered by peer and family issues as well as a host of traumatic
events, including emotional, physical and sexual abuse. While they occur throughout the lifecycle,
onset is most often in adolescence when teens and young adults are faced with a host of new
physiological changes, cognitive demands and social and emotional pressures. Ultimately these
disorders have more to do with coping with one’s thoughts and feelings than with one’s body.

Jewish vulnerabilities

As a psychotherapist I try to help each person unlock the mysterious needs hidden behind their
eating problem. Learning how to truly nourish oneself is the goal of therapy. While women from
all countries and cultures develop eating disorders, Jewish women face unique challenges and
vulnerabilities:

Genetic predisposition

Like all Americans, Jews are exposed to pervasive media images pressuring women to achieve an
unachievable standard of thinness. On a daily basis we are bombarded with unrealistic images of
the female body in newspapers, television and magazine. These images promote eating and body
image disorders. Feeling fat is the norm for the majority of American women when compared to
images of ultra-thin models who are tall blond lean and lanky. For most females, and especially
Jewish women whose genes predispose them to being short, stocky and dark, making peace with
one’s body is especially challenging

The role of food and mealtime in Jewish life

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 “My binges began with the Hanukah latkas.”

“It was the Yom Kippur fast that led to my anorexia.”

The central role food plays in Jewish life creates a compounded vulnerability for Jewish women.
From fasting on Yom Kippur to over-eating on Shabbat and Passover, a cornerstone of Jewish
identity has always been rituals that involve family meals. For Jews, food has always had multiple
meanings of survival and resilience. Not only do unique Jewish dishes celebrate the cycles of life,
but mealtime itself tells the story of Jews as a persecuted, migratory people. Often forced by
pogroms to leave their homes on a moment’s notice, only what could be carried on one’s back was
taken. Often a pair of candlesticks and a tablecloth were all that remained of their vanished lives
and became the centerpiece of a new home and life. Mealtime was symbolic of resiliency in the
face of persecution. Even today, for many Jews, saying a blessing over bread and wine evokes
memories of loss, hope and simultaneously celebrates the continuity of life itself.

The Orthodox Community

Women in the certain sects of the Orthodox community face special risks. Strictly prescribed roles
often define their lives. They are under great pressure to marry early, and arranged marriages,
immediate childbearing and large families are the norm. For example, Orna was a young woman
who was pushed to start husband hunting at 17; feeling unready for marriage, the search triggered
a deadly diet. For young girls who are unprepared to start families, anorexia is a way to delay
puberty, put off childbearing and gain control of their bodies when their lives are out of their
control.

Because many psychological problems such as addictions, alcoholism and eating disorders carry
a stigma, often anorexics and their families keep their problems secret and avoid identifying the
problem or seeking psychotherapy until the problems are dangerously severe. One particularly

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upsetting experience with an Orthodox family stands out. Rifka, a 24 year old married woman with
five small children arrived at my office in a state of severe emaciation. She’d come in at the urging
of her mother, who suspected bulimia. Upon consultation, Rifkin admitted to being bulimic and
dated the onset of her bulimia to an unhappy marriage. She wanted to divorce her husband, but
feared her parents would carry out their threat to disown her if she divorced. Although I attempted
to educate her parents about the serious medical and emotional problems associated with her eating
disorder, her mother stood firm: divorce was taboo. “There are some things worse than bulimia,”
her mother stated flatly as she left my office, “and divorce is one.”

Issues of Identity: Dieting as a ritual of female identity

People develop a personal identify based on both a need for uniqueness and group affiliation (i.e.
familial, ethnic, religious and occupational.) Many Jews struggle with the tension between
assimilating with mainstream American culture and retaining a sense of Jewish identity. This
tension can be played out with food and/or with dieting. For example, dieting can have multiple
ways of strengthening one’s personal identity. Consider eighteen year old Rebecca, who developed
anorexia. It took many months of therapy before we were able to uncover the roots, hidden in her
past. Eventually Rebecca became aware that the origins of her feelings of “being unworthy to live”
came from an unconscious identification with her maternal grandmother, lost in the Holocaust.

Throughout time and across cultures, rituals help negotiate life’s transitions and strengthen one’s
sense of identity. Unfortunately, in contrast to rituals celebrating the male lifecycle, (circumcision,
bar mitzvah), few rituals in Judaism celebrate the seasons of a woman’s life. In mainstream culture,
especially at adolescence, dieting is one of the few rituals that bond women and, in a destructive
way, it has become a ritual of female identity: wherever women gather, there is inevitably talk
about weight loss. For Jewish women, excessive dieting may reflect a need to rebel against one’s
Jewish heritage and genetic endowment as well as separate from a family that centers itself on
food and eating.

Rituals of Renewal: How Jewish Practices can heal

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I am probably more of a practicing therapist than a practicing Jew, yet I am steeped in many Jewish
traditions that have enriched my life, and what enters my life, enters my work. Both Judaism and
psychotherapy embrace the concepts of courage, compassion and empathy as fundamental
building blocks of growth. I bring many Jewish concepts into my work as a way of bonding with
clients.

The Metaphor of the Mishkan

People with eating disorders are disconnected from themselves, others and the universe. They need
a safe place to reconnect and heal. When I begin therapy, I overtly invite each person into a
mishkan, a “sacred dwelling place,” where we can work together to reclaim the parts of themselves
lost to the relentless pursuit of thinness. In addition, people with eating disorders benefit from
being reminded that their bodies are sacred. Healing involves reclaiming one’s body as a mishkan,
a sacred dwelling place.

The Mi Shebairach

This prayer for healing in Debbie Friedman’s contemporary rendition reminds us, “Help us find
the courage to make our lives a blessing.” Many people who suffer from eating disorders benefit
from being using these healing words as daily affirmations. “I eat to fill the hole in my soul,” were
the words of Maya, a thirty-two year old woman who introduced herself to me as spiritually
bankrupt. Integrating meaningful spiritual concepts to sufferers can be a source of great spiritual
nourishment.

Rosh Chodesh

In the past few decades, a growing number of Jewish women have focused on developing rituals
honoring the feminine. One example is the revival of the ancient new moon ceremony, Rosh
Chodesh. From Talmudic times, Jewish tradition designated Rosh Chodesh as a special holiday

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when women gathered to feast, celebrate and pray. Today Rosh Chodesh groups create new rituals
as well as recovered neglected ones. Some groups celebrate biblical women such as Judith and
Miriam, others invent new rituals to celebrate unique aspects of womens’ lives, such as pregnancy,
labor and childbirth as well as to grieve losses such as miscarriages. New groups are tailored for
girls and teens, hoping to foster Jewish identity and boost self-esteem at a time when stick thin
models make many young girls feel bad about their bodies.

Holy Sparks

The kabbalah teaches us to search for our shattered sparks, the parts of us we have lost. This
concept is particularly useful for my work with people struggling with eating disorders. For
example, Rena, a former patient had been bulimic at twenty-one. She recalled a despairing moment
of her life. In a session where she had asked me, “Will I ever get better? Do you think I can
recover?” A quote from Rabbi Nachman of Breslov touched her deeply: “As long as a tiny flame
remains, a great fire can be rekindled.” I reminded her and gently drew her attention to many of
her inner resources. The mystics believed that we will attain wholeness by finding our holy sparks.
This concept is akin to a strength-based approach that guides my work as a psychotherapist.

Storytelling

One of my tools as a psychotherapist is also at the heart of Judaism. I encourage my patients to

think about and tell the stories of their lives. Jews have a deep respect for storytelling. Each year
Jews read the Torah from cover to cover, always certain that each rereading will offer new
meanings. Passover, the holiday most celebrated by Jews worldwide, is based on the retelling of
the story of freedom. Like Judaism, psychotherapy is based on the principle that each time a person
tells his or her story, new meanings are revealed. Certainly this has great relevance to eating
disorders, for binging and starving always contain a hidden story.

Forgiveness.

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One of the final steps of recovery often involves asking for forgiveness from oneself. I often initiate
the practice of selichot (petitions for forgiveness) into my work. Although this practice of asking
for forgiveness from those we have harmed usually occurs between Rosh Hashanah and Yom
Kippur, it can be practiced anytime. This practice teaches that if one asks three times for
forgiveness from someone one has harmed, forgiveness must be granted. It reminds us not to hold
grudges, that anger destroys. People with eating disorders tend to be perfectionists and often have
great difficulty forgiving themselves. The ritual of selichot can be used to encourage self-
forgiveness.

Conclusion

The world breaks everyone and afterwards, some of us are strong in the broken places.

Ernest Hemingway

The idealization of thinness damages all of us. It is about being who you are supposed to be instead
of being who you are. Judaism and psychotherapy teach people to celebrate life, value the present
moment, and honor what is holy/whole. Healing involves helping patients know that who they are
is enough. I remind my patients of an old Hassidic tale. Before his death Rabbi Zusya said, “In the
coming world, they will not ask me “Why were you not Moses? They will ask me, “Why were you
not Zusya.” The aim of psychotherapy is to try to help our patients become strong in the broken
places. The unexpected gift of being a therapist is that when my patients grow, I grow. This is the
essence of tikun olum: we are all always repairing a communal brokenness.

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