Psychological Medicine, 1992, 22, 561-571 Printed in Great Britain
Pagophagia, or compulsive ice consumption: a historical perspective BRENDA PARRY-JONES1 From the Department of Child and Adolescent Psychiatry, University of Glasgow SYNOPSIS Pagophagia, or the excessive consumption of ice or iced drinks, is popularly regarded as a novel manifestation of pica, which has emerged, predominantly in the USA, over the last 30 years. However, a sampling of historical sources reveals that not only are there warnings in the writings of both Hippocrates and Aristotle concerning the dangers of excessive intake of cold or iced water, but a series of medical works, from the sixteenth century on, incorporate discussion and illustrative case histories about the detrimental effect of immoderate usage of cold water, ice and snow, frequently in the context of disordered eating.
INTRODUCTION Pica is a form of appetite disorder characterized by an abnormal or excessive craving either for a particular food item or items, or for bizarre non-nutritive substances, both solid and liquid. The condition acquired its name by reason of the colourful resemblance observed between the indiscriminately acquisitive behaviour, in relation to both food and non-food items, which is displayed characteristically by the magpie (in Latin, Pica) and the ingestion of an extraordinary range of.substances by human subjects afflicted with this disorder. Pica was referred to by Galen as early as the second century A.D. and was described, although not by name, in both Latin and English texts during the Middle Ages. The term itself can be traced in continuous medical usage, in the English language, from 1563 onwards (Parry-Jones, 1991). There is evidence that, historically, pica was regarded as a symptom of other disorders, including anorexia and bulimia, rather than a separate condition (Parry-Jones & Parry-Jones, 1992). The principal populations affected by pica over the centuries were pregnant women; pubescent girls and young women with chlorosis (otherwise known as greensickness or virgin's disease) which 1 Address for correspondence: Mrs Brenda Parry-Jones, Department of Child and Adolescent Psychiatry, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ.
could incorporate a form of anaemia; the mentally retarded, autistic subjects and certain categories of the mentally disordered; males, females and, particularly, children infested with intestinal worms; primitive tribes in which geophagy [dirt-eating] was a cultural norm and, in the present century, malnourished or emotionally deprived infants and toddlers, chiefly from the lower socio-economic groups. Predictably, over so long a timespan, involving such a varied population, a wide range of craved substances is reflected in the historical literature. During the 1960s and 1970s, a number of case reports (e.g. Reynolds et al. 1968; Coltman 1969a; Brown & Dyment, 1972; De Silva, 1974; Crosby, 1976) concerning a form of pica involving the compulsive consumption of an abnormally large volume of ice cubes or iced drinks featured in the American medical literature, together with a brief communication concerning its occurrence in seven South African Blacks (Speirs & Jacobson, 1976). The earliest American papers to utilize the term pagophagia were those of Reynolds etal.(\ 968) and Coltman (1969a). Coltman's published article was a sequel to an oral report delivered, in February 1966, at the Annual Meeting of the Society of Air Force Physicians at San Antonio, Texas, concerning the ice-eating compulsion, and an explanatory footnote to his paper, written from a Texan United States Air Force Base, clarified that, 'The term pagophagia was conceived by
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David J. Kudzma M.D. " a local Greek scholar'". A precedent for such a construct may be seen in the use of the term pagoplexia for frostbite. Haubrich (1984) defined pagophagia as 'a perverted craving for the eating of ice. The term incorporates the Greek pagos "anything stiffened or hardened, such as frozen water", and phagein, " t o eat "...and is symptomatic of iron deficiency'. Although there are entries for pagophagia in a number of American medical dictionaries from about 1978 on, and a full definition, almost identical with that of Haubrich, is incorporated in the International Dictionary of Medicine and Biology (1986), pagophagia is significant by its absence from the latest edition (1989) of the Oxford English Dictionary and, perhaps more surprisingly, it is not yet included in the 1990 editions of either the Oxford Medical Dictionary or Black's Medical Dictionary. The latter fact, together with the almost complete lack of references to excessive ice eating in contemporary British medical literature, suggests that the practice is either extremely rare, slower to develop, or is, as yet, unidentified in the UK. It would appear that climatic and cultural conditions, coupled with the widespread, easy availability of ice, constitute major contributory factors in the development of the ice-eating habit in the USA.
HISTORICAL BACKGROUND The use of ice, both as a luxury item and in medical practice, is a very ancient tradition. Hippocrates (460-361 B.C.) set a precedent which was to remain influential in medical lore for centuries when, in his 51st Aphorism, Section II, he stated;' It is dangerous to heat, cool, or make a commotion all of a sudden in the body... Why should any one run the hazard in the heat of summer of drinking of iced waters, which are excessively cold, and suddenly throwing the body into a different state... producing thereby many ill effects? But, for all this, people will not take warning, and most men would rather run the hazard of their lives or health than be deprived of the pleasure of drinking out of ice' (cited in Masters, 1844). Another version of the Aphorisms (Coar, 1822) emphasized that 'Whatever is done gradually is safe, but if the transition should be from one extreme to the other, it is
dangerous'. Similarly, in the medical section of the Secreta secretorum (c. 1128-1130), one of the most popular medieval works, the content of which is attributed, though not entirely incontrovertibly, to Aristotle (384-323 B.C.), specific advice was given concerning the dangers of 'drynkynge Waters with a colde stomake fastynge'. Shock cooling of the system should be avoided and the reader was advised 'to drynke colde water in somer and warme water in wynter and not contrary wyse' (Copland, 1528). A subsequent section of this work, headed ' How pure water ought not to be dronke', stressed the adverse effects on digestion and physique of consuming cold water with a meal and advised 'If thou must nede drynke water alone, take it moost temperatly, and as lytel as thou mayst' (Copland, 1528). Another authoritative medieval work, De proprietatibus rerum, delivered a similar caution, '... who that drinkyth oft colde water, shall not escape frome colde sycknesse, namely in his age.... And water molten of snowe and of haiel is erthly and worste of all' (de Glanville, 1535). Unlike the text from Hippocrates, the Secreta secretorum appears to refer to cold water ingestion rather than ice consumption, but it is likely that its cautions applied also to the use of water cooled artificially by the addition of snow or ice, which, contrary to popular opinion, was an established tradition in both ancient Greek and Roman cultures. Trenches or pits were dug out, packed with snow brought down from the mountains by slaves, and overlaid with protective branches. At this early period, melted snow itself was drunk and snow was added to wine as a coolant. Masters (1844), in his comprehensive history of ice, noted that in sixteenth century Constantinople it was customary to preserve snow and ice for the entire summer for use in cooling drinks. Among the Europeans, the Spaniards and the Italians were the first to cool their wine by the addition of snow brought down from the mountains, a practice which was denounced as ' unhealthful' by the astonished French physician Symphorien Champier (1472-1540). By the end of the sixteenth century, however, ice had begun to come into use as a luxury item at the French court. Masters (1844) also referred illuminatingly to 'L'Isle des Hermaphrodites', a satirical account of high-living at the fin-de-siecle court
Pagophagia: a historical perspective
of Henry III, in which it was ordered that 'large quantities of snow and ice should everywhere be preserved, in order that people might cool their liquors with them, even though they might cause extraordinary maladies, which, it seems, were then apprehended'. Despite warnings of its possible ill-effects, ice culture increased rapidly during the seventeenth century, as methods for ice preservation in dry, well-drained dug-outs, insulated by covers of chaff, straw or reeds, were succeeded by more sophisticated receptacles, such as the French glaciere (ice-chest) and lakeside ice-houses on the landed estates of the English gentry, whose subterranean stock of ice provided year-long supplies. By the end of the seventeenth century ice, snow and iced liquors had come into common usage in France and these were followed, in the eighteenth century, by iced lemonade, iced fruit juice and finally, ice creams, the latter of poor quality initially. Ice creams were procurable in England from the mid-eighteenth century, and both iced drinks and ice cream became routine embellishments in social gatherings and outdoor occasions throughout Europe during the course of the nineteenth century. Any consideration of the medical implications of abnormal or inappropriate ice consumption can be made only with an awareness of the prevailing socio-cultural background and of the various coolants available in different countries at different periods.
MEDICAL ACCOUNTS OF THE USE AND ABUSE OF COLD WATER, ICE AND SNOW The sixteenth and seventeenth centuries In an early work on the diseases of women, Trois livres de la sante, fecondite et maladies des femmes (1582), Jean Liebault, a Montpellier physician, discussed, in some detail, various appetite abnormalities, including pica. A handwritten early seventeenth century English translation of his work (Hunterian MS. U.6.21) included, in a section dealing with abnormal hunger states, such as 'boulimos' (bulimia) and 'dogges' (canine) appetite, an interesting reference to the frequent occurrence in 'young maides' of an excessive consumption of cold water and 'acqua borax' (borax water), 'wherewith they stuffe themselves everie hour', causing
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suppression of the menses and various 'hypochondriacall' affections. It is unclear from this text what underlay the girls' penchant for borax water. Borax (sodium biborate) had medicinal, cosmetic and industrial uses and possessed a bitter, slightly caustic, flavour. The latter might perhaps offer an explanation for its attraction to girls with pica, a proportion of whom, throughout the long history of this condition, displayed considerable liking for sharp, bitter and acidic flavours. Medicinally, borax was utilized as an aperient salt and as an emmenagogue and its saline properties were' recommended for making the skin smooth and free from Asperities' (James, 1747). A little later, the eminent French Royal physician, Lazarus Riverius (1589-1655) made two very significant references to the consumption, not only of cold water, but also of snow and ice by women and young girls suffering from pica and chlorosis, in his popular work, Praxis Medica (1640). In an English edition published in London, in 1658, Riverius defined pica as 'a depraved Appetite; by which evil, unprofitable, and hurtful things are desired'. Some of the desiderata in pica listed by Riverius were ' Earthy, Dry and burnt things, as Cloves, Cinnamon, Nutmegs and other spices, Salt, Ashes, Chalk, and the like', but a contrasting compulsion to consume sour things 'sharp, bitter and very cold', leading to 'the continuall use of unripe Fruits, Vinegar, Juyce of Lemmons, Pomegranates, and Orenges, cold Water, Snow, Ice and the like' was identified. In a separate section, on greensickness and chlorosis, Riverius (1658) attributed suppression of the menses specifically to an 'evil' diet, 'for these Virgins drink great draughts of water at bed-time, or in the morning fasting, or eat Vinegar, Herbs, unripe Fruits, Snow or Ice', leading to a loss of their natural body heat. This latter reference has been cited by Fairbanks et al. (1971) as an early example of pagophagia. John Archer (1673), court physician to Charles II, introduced a more general caution: 'Waters of Snow and Ice are condemned because they are thick and hurt the Stomach, and Stir up grievous Symptomes, and Diseases of the Joynts, Nerves, and Bowels'. Riverius' works achieved such popularity that they ran through several editions, translations and revisions. The English edition of a revision by Francois Calmette, also a Montpellier physician, was published in 1706 under the title
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Riverius Reformatus or the Modern Riverius. Under the heading 'Of longing and strange Lusts call'd Pica or Malacia', Calmette included two important references to the consumption of water, ice and snow. Among the external causes of pica he listed 'the immoderate use of water', and elaborated on this point by explaining that this was the reason why almost all the young girls of Montpellier, and a great many of the married women, who, by nature and by custom 'are very abstemious [i.e. temperate, in the avoidance of wine] are so much troubled with this Distemper'. Like Riverius, he observed that some pica sufferers 'have a mind to Mortar, others to Coals, Iron, Salt, Water, Snow, Ice, Vinegar, Verjuice [i.e. the liquid from sour grapes], unripe Fruits, Leather etc' (Calmette, 1706). However, he put forward a much more advanced theory of causation by suggesting that this depraved appetite was attributable less to ' the variety... of bad humours abounding in the Body and Stomach, as from the various Imaginations, Phansies, and Prejudices; either inborn or acquired elsewhere'. As an example of the former, he quoted an instance known to him personally of the hereditary transmission of a particular craving from a mother to her young son, but the acquired behaviour Calmette attributed to a process which would be termed, in modern idiom, as the influence of peer group pressure. Such strange perversions, he maintained, could be 'induced by others, as often happens in Maids, that create one another an Appetite to certain things by persuading them, that by taking such things they formerly have made themselves look fair and handsome; with which the Mind being struck, afterwards, when occasion serves, longs for the like' (Calmette, 1706). This quotation is of outstanding significance, both in providing a very early and unequivocal statement concerning the wishes of young girls to conform to the prevailing pattern of female beauty, a theme which is discussed more fully elsewhere (Parry-Jones & ParryJones, 1993) and for the implication that this ideal of beauty was achievable by the consumption of either non-foods or low or noncalorific substances, which included fruit, water, snow and ice. This latter interpretation is lent support by some current case-histories, such as that by McLoughlin & Hassanyeh (1990), which describes a form of pica involving the con-
sumption of 40 ice cubes per day, accompanied by small amounts of frozen soft fruit, in a female patient with confirmed anorexia nervosa. Cooper (1957), in her comprehensive historical survey of pica, refers to a group of ten Latin theses on this subject, written by European authors from the sixteenth to the eighteenth century. One of these, by Hubrigkt (1562), included among examples of pica, the 'craving for snow in summer', and another thesis, submitted in 1691 by Christiani, referred to the occurrence of cravings for ' unusual drinks, such as excessive amounts of water, iced drinks, etc' (cited in Cooper, 1957). The eighteenth and nineteenth centuries
The result of drinking snow and ice water was, according to the French physician Lemery (1704) and several fellow practitioners, to 'hinder Digestion, injure the Stomach, cause wind and crudities, provoke Coughing, hurt the Breast, coagulate the Liquors, oppress the Spirits, and produce many other ill Effects', some of which could be fatal. However, he conceded that 'the use of Ice may be wholsome in hot Countries, because the Air being very much heated with the Sun Beams, the Body requires a Liquor that can stop the violent Motions of the Humours, and make them a litle of a thicker Consistence'. There was, however, no justification for ice-use in temperate climes. Francis de Valangin, a native of Switzerland, who practised in London for many years, devoted a substantial section of his Treatise on Diet (1768) to the consideration of the virtues and vices of water ingestion. While acknowledging that moderate water intake assisted digestion, he warned that it might produce ' bad Effects...when drank to an excessive Quantity. ... All waters made of Snow, though nothing but harmless frozen Rain and those made of Ice, are found to be pernicious... The Coldness of Water, or the Use of Ice, will have pretty near the same Effect as that of the inspired cold Air.... In some countries, and for some constitutions, the prudent and moderate use of Ice may sometimes be proper, but in general it produces more ill than good Effects. In the southern parts of Europe, where, on account of the Heat of their Climate, they indulge themselves with the deceitful pleasure of drinking out of Ice, they often pay for it with the Loss of their Lives. In
Pagophagia: a historical perspective
our temperature Climate, though the Inducement is not so great, yet Luxury has introduced the use of those sorts of Drinks, and of divers Sorts of Ice-Creams, which are pernicious and dangerous in the Heat of Summer; for every thing that is excessive is an Enemy to Nature' (de Valangin, 1768). With suitable deference to the pronouncements of Hippocrates on this subject, de Valangin concluded that 'it cannot be safe to throw the Body all of a sudden, when it is hot, into a quite different state, by taking into the Stomach those Things which are excessively cold'. The latter theme, therefore, shows a considerable degree of continuity from the classical period into early modern writings, although the actual ill-effects of the unnaturally cold ingestae reported varied in form and severity, ranging from generalized bodily weakness and digestive disturbances to specific conditions, such as amenorrhoea, anorexia, diarrhoea and even death. A number of illustrative case histories were put forward on this subject. Thomas Umfreville, for example, listed (1743) a series of cases in which the copious drinking of cold water after exercise was believed to have been instrumental in causing death or serious illness. One of these cases was derived directly from the works of Hippocrates; another was extracted from the writings of the reknowned Swiss physician, Fabricius Hildanus (1560-1634) concerning John Cassellanus of Aventicum, who, having overheated himself during a journey, drank quantities of cold water, fell into a fever, became reduced to a skeleton and, finally, died. The centre-piece of Umfreville's account was the detailed history of John Ferguson of Argyll, Scotland, whose case was sufficiently curious to merit notice in the Philosophical Transactions of the Royal Society (Campbell, 1743). At the age of 18 years,this young cowherd ' overheated' himself crossing mountainous terrain in pursuit of his cattle near Kilmelford; thereupon, he drank excessively from the icy waters of a mountain stream, fell asleep, awakened feverish and with complete loss of appetite. For 18 years he took no nourishment except small amounts of water and whey and no deception was found when a close watch was kept over him in a locked room for twenty days. At the age of 36, his diet unchanged and his person 'meagre', he continued his herding duties. Umfreville, with
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acknowledged adherence to the counsels of Hippocrates, utilized this sequence of cases to illustrate the changes to the constitution which it was believed could be effected by an abnormal ingestion of cold water. In Ferguson's case, he believed the abstinence from food to be due to ' a morbid State created by that great Error of drinking cold Water when hot, causing a change in nature', which prevented the subject 'from being able to enjoy the Aliment he before used' (Umfreville, 1743). However, in somewhat contradictory fashion, Ferguson's survival as an abstainer was attributed solely to his limited intake of water and whey. Another example of the dangers of excessive body-cooling was given by de Valangin (1768), who quoted the case of a nobleman who was 'a great Advocate of the Cold-Bath, and in general for every Thing that could harden the Body; and imagined that Cold applied internally must be as salutary as when applied externally. He often drank Liquors out of Ice, and eat plentifully of Ice-Creams of divers Kinds; After having one Day taken a greater Quantity of these than usual, a fatal Inflammation, which at once affected the Stomach, the Intestines and Kidnies,... made him fall a Victim to his favourite Opinion'. Lemery (1704) identified this unfortunate casualty as Gonzagues, Duke of Mantua. Sinclair (1807), whose discussion of the various sources of water included a section on 'snow-water', made no reference to its being unsalubrious, merely commenting on its vapidity and air-lessness and rejecting a former theory connecting the prevalence of goitre in inhabitants of the Alps with their year-round derivation of water supplies from melted snow. In his popular work, 'The maintenance of health. A medical work for lay readers' (1874), Fothergill reiterated the same cautions about excessive intake of cooling agents: ' There is a popular prejudice against drinking freely of cold fluids when heated, and no doubt death is sometimes so induced; but the consumption of cold and even chilled drinks is now much on the increase. Ice is no longer regarded as a mere luxury, it has become a necessity of life in hot weather, and its addition to a beverage adds much to its agreeableness'. Fothergill goes on to discuss the direct effects of ice ingestion on body temperature, pointing out that as much heat is extracted from the body' as is requisite to
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raise the temperature of the chilled fluid... from about 32° to 99°'. He observed that' the quantity of the chilled fluid has much to do with the effect, and a pint will take twice as much heat to raise its temperature as will half a pint. Consequently, it is not unimportant to the imbiber what the amount of his fluid is, as well as its temperature'. Fothergill noted that in contemporary society. 'At all entertainments, dancing and other, where the heat becomes great, ice, both as a beverage and in the more solid form of ice-cream forms now the essential matter of the refreshment table, and is very acceptable'. He warned, however, that 'free indulgence in iced fluids is very apt to induce a sharp diarrhoea in many persons'. Most relevantly to the twentieth century concept of pagophagia, Fothergill commented on the compulsive character of ice intake; 'the free consumption of ice has not unfrequently the effect of creating even a stronger craving than ever for fluids, from the same action upon the throat that snowballs have on boys' hands - the persistent cold causes a free flow of arterial blood to the part' (Fothergill, 1874). From a strictly medical angle, however, Fothergill commended the use of ice in febrile illness to relieve parched lips and to lower body temperature and he recommended the utilization of chips of ice in 'the hiccough and sickness which accompany the final stage of many diseases'. With the development of methods of artificial ice production in the nineteenth century, ice was employed increasingly as a refrigerant, in staunching haemorrhages and in antiphlogistic treatments. The value and versatility of ice in its varied stages was recognized, particularly in medicine, and, as Masters (1844), himself the designer of an ice-making machine, claimed, 'It is at once stimulant and sedative, diaphoretick, sudorific and diuretic, excitant and refrigerant, emollient and roborant, astringent and relaxant'.
The twentieth century
In the late 1960s and early 1970s, a number of cases of compulsive ice eating were reported in the USA. Reynolds et al. (1968) studied the prevalence of different forms of pica in 38 consecutive patients with iron deficiency anaemia, seen in 1966-7 at a United States Air Force
Base in California. Enquiries about their ingestion of unusual quantities or types of food led to the discovery that 23 patients were compulsive ice eaters. These patients consumed five or six glasses (approximately 240 ml per glass) of crushed or cubed ice daily and also concealed ice cubes in drinks and among salad vegetables. The ice was chewed and swallowed in small pieces and this behaviour appeared to be unrelated either to season or to temperature; nor was it caused at that time in any of these patients by pregnancy, although three women in the group recalled the onset of ice-eating episodes during previous pregnancies. While some patients claimed to be unaware of the extent of their ice consumption, others confessed that they had been unwilling to admit to it 'because of fear of underlying psychiatric disease' (Reynolds et al. 1968). As is the case with some other forms of disordered eating, such as bulimia and rumination, most subjects were secretive, self-conscious and unwilling to disclose their habits and, consequently, the incidence of such disorders always appears to be far lower than it actually is (Parry-Jones, B. 1992). Significantly, it was reported that treatment of the iron deficiency led to the disappearance of the ice craving in all but one of Reynolds' pagophagics. Coltman, who originally opened up the topic of compulsive ice consumption in his oral report of 1966, provided in his paper (1969 a) clinical observations on 25 cases of iron deficiency 'associated with an unusual perversion of appetite characterized by the ingestion of extraordinary amounts of ice', referring to this compulsion as pagophagia. His 25 patients, like those of Reynolds et al. (1968), were United States Air Force personnel, or members of their families, and in Coltman's case, were stationed at the Lackland Base, Texas. He defined pagophagia in his patients as 'the purposeful ingestion of at least 1 ordinary tray of ice daily for an excess of 2 months', and an average ice-tray was estimated to contain approximately 710 g of ice. In a subsequent letter (Coltman, 19696), further details were quoted about the quantity of ice ingested: 'The dose was calibrated in each patient to the "nearest cube" and based upon examination of a representative tray from each of the subject freezers'. Eighteen of the 25 subjects consumed between 2 and 13 trays of ice
Pagophagia: a historical perspective
each day and this 'clearly represents behavior which could be considered unusual in any setting!' (Coltman, 1969a). In a third communication, Coltman (1971) described five additional pagophagic patients, including the first compulsive ice eater ever to come to his attention, an 18-year-old Negro girl. This patient presented in a panic-stricken state after ' she had been convinced by her father that she would die of cancer unless she stopped her ice-eating. In spite of her absolute conviction that her father was correct, she had an ungovernable ice consumption'. Her mild iron lack anaemia responded, within one week, to orally administered iron sulphate. Not only did her ice craving disappear, but she firmly believed her life had been saved. Coltman's second patient, a 35year-old woman whose considerable liking for beer was matched by a deep-rooted ice craving, revealed that an enforced choice between the two commodities would lead her to abandon her beer rather than reduce her ice intake. A third female patient utilized ice ingestion as a device to postpone her chain-smoking habit and a fourth subject sought treatment for her pagophagia to prevent the re-occurrence of the considerable financial burden of replacing her artificial dentures, two sets of which she had already destroyed by chewing chipped ice. A fifth female patient, following the successful treatment of her pagophagia, presented to Coltman, as a commemorative trophy, her icetray ' severely pockmarked by the ice pick which she used to crush her ice'. Crosby (1971) referred to ice eating observed in two women hospital employees while at their work. Both of them proved to have iron depletion; the first had recently been rejected as a blood-donor, owing to her anaemia; and the second was discovered to be suffering from a bleeding duodenal ulcer. Crosby also recorded an example of two-generation pica; a woman, who had successive pica for green salads, croutons and then chewing gum during periods of anaemia, confided that her late mother had been an ice eater:' She would carry around with her a cup of chipped ice to eat. We couldn't keep Mother in ice' (Crosby, 1971). In another communication, Crosby (1976) noted that pica, as a symptom of iron deficiency, occurred in over 50% of his patients with iron deficiency anaemia and estimated that about half of his pica
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sufferers were compulsive ice eaters. De Silva (1974) referred to a case of pica for cigarette ash and soil (geophagia) in a 33-year-old Puerto Rican woman and noted that she had suffered from recurrent pagophagia in the course of several pregnancies, when a lowering of her haemoglobin levels might have been anticipated. Brown & Dyment (1972) provided an interesting discussion of pagophagia in relation to iron deficiency anaemia in adolescent girls, in order 'to bring to the attention of those physicians caring primarily for children, the association of pagophagia... and iron deficiency anaemia', a subject not previously dealt with in paediatric literature. Case material regarding four girls was presented, two Negro sisters aged 12 and 14 years and two Caucasian girls aged 13 and 15 years. All four were seen within a two-month period, by the paediatric service of a United States Army Hospital in Texas, with a diagnosis of microcytic hypochromic anaemia, presumed to be due to menorrhagia. Their respective haemoglobin levels ranged from 8-2 g per 100 ml to 10-4 g per 100 ml; they each consumed between 4 and 10 glasses of ice per day and, in all four girls, pagophagia disappeared within 1-8 weeks of oral iron therapy. Brown & Dyment (1972) emphasized the advisability, during casehistory taking with adolescents, to include a query concerning ice consumption, and if the practice was confirmed, to proceed with the appropriate tests to exclude iron deficiency. Speirs & Jacobson (1976), writing from a Johannesburg hospital, with an awareness of the American cases of pagophagia reported by Reynolds et al. (1968) and Coltman (1969 a, b), drew attention to the fact that ice eating symptomatic of iron deficiency among Blacks had not yet had any publicity. Accordingly, they reported on two pagophagic South African patients and briefly mentioned another five subjects with ice eating compulsions. The first patient, a nursing sister, admitted with severe iron deficiency anaemia, described her unusual craving, but had no awareness of any association between the pagophagia and the iron deficiency. She referred to two nursing acquaintances 'whom she knew to be regular raiders of the freezer' (Speirs & Jacobson, 1976), and, although both were asymptomatic, marked and mild iron deficiency respectively was discovered in each of them on investigation. Their second patient
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attended a gynaecological clinic for menorrhagia, where she received treatment for her iron deficiency and the ice craving was discovered. Two other ward sisters 'with a reputation for unusual ice-eating habits' were also found to be iron-deficient and a nursing assistant, who consumed large quantities of ice to soothe a recurring sore-throat, described the onset of this habit following heavy blood loss due to an incomplete abortion. All these subjects consumed 2-3 bowls of ice daily, over a long period, with increased amounts during pregnancy; all were Black South Africans and had had some hospital nursing experience. Several of them referred to a previous desire to eat soil, which was abandoned on learning of the possibly harmful effect of bacteria and the dangers of worm infestation, whereupon ice-eating was, apparently, take up as an alternative. McLoughlin & Hassanyeh (1990) provided the only British case report discovered to date of twentieth century pagophagia in their description of a middle-aged, anorexic patient, who admitted to eating up to 40 ice cubes daily over the period of 2 years, in conjunction with a generally bizarre diet. Her ice consumption was the same throughout all seasons, but she denied having eaten ice during childhood or pregnancy and stated that she had never known anyone with a similar compulsion. This patient did not chew the ice, merely allowed it to melt in her mouth, making' a refreshing drink without much volume of liquid', and she found sucking ice relieved her sore lips, mouth and tongue. 'She has also started to freeze soft fruit, which she eats iced, deriving much pleasure from the small amounts of food and... says she would not eat these foods uniced...and becomes upset when none is available'. Shortly after the patient developed this habit 'her haemoglobin level was found to be low' (McLoughlin & Hassanyeh, 1990).
DISCUSSION From this literature sample it appears that the over-use of cold water, ice or snow has been regarded, consistently, as hazardous to health and well-being and there have been indications that the teaching of Hippocrates against rapid cooling of the body remained operant, in some
contexts, into the nineteenth century. In the classical and medieval texts (with the exception of the Secreta, which suggested that the digestion might be weakened), the adverse implications of ingesting excessive amounts of cold substances were described, in very general terms, as having 'many ill-effects', being 'unhealthful' or causing 'extraordinary maladies'. The excerpts from Liebault, Riverius and Calmette all classified excessive cold substance use under depraved or abnormal appetite and they were in agreement that 'young maides', 'virgins' and young girls and women were the chiefly vulnerable population. While Liebault associated this phenomenon with suppression of the menses and ' hyponchondriacall' affections, Riverius linked it with greensickness and chlorosis and Calmette interpreted the practice more widely, as having connections with the aspirations of young girls to look 'fair and handsome'. De Valangin (1768) supported the appropriateness of ice in certain circumstances, while indicating that its effects could also be undesirable and even fatal. Approaching the twentieth century, when ice as a commodity was much more widely available, Fothergill (1874) accepted as inevitable the social role of coolants, although he pointed out that over-use could loosen the bowels and, perhaps most relevantly to the present study, he alluded to the fact that over-indulgence in ice could create, 'not unfrequently', an even stronger craving for it. The twentieth century contributors were under no misapprehensions concerning the compulsive nature of the ice-taking habit, but the interesting fact is that, with one exception (McLoughlin & Hassanyeh, 1990) the patients on whom they reported did not actually come to their attention owing to their compulsive appetite. The patients seen by Reynolds et al. (1978) and Coltman (1969 a) all presented with iron deficiency at haematological clinics and their pagophagia was discovered incidentally during history-taking. Similarly, the teenage pagophagics reported by Brown & Dyment (1972) were under investigation for anaemia presumed due to menorrhagia and the two South African patients described by Speirs & Jacobson (1976) presented with iron deficiency anaemia and menorrhagia respectively. It is interesting, and probably permissible, to speculate that a similar connection might have appertained between ice-eating and iron
Pagophagia: a historical perspective
deficiency in some of the young girls with pica and amenorrhoea reported in sixteenth to eighteenth century medical texts. Historically, pica was almost universally regarded as symptomatic of chlorosis in both girls and young women, and chlorosis came, increasingly, during the nineteenth century to be viewed as a form of anaemia ('chloroanaemia'), which could be treated effectively with iron preparations. Similarly, pregnant women over the centuries, exhibited pica at a period of natural depletion of their haemoglobin levels, for a range of substances, including ice. In view of the fact that the evidence suggesting a relationship between iron deficiency and ice ingestion had been observational rather than experimental, Woods & Weisinger (1970) set out to test the hypothesis using 12 albino rats, which had been trained to eat crushed ice. Six rats were made anaemic by withdrawal of blood to the level of 5/6 g per 100 ml, at which level pagophagia had been observed in humans. 'The anaemic rats showed a significantly increased preference for ice, and, as a group, satisfied 96 % of their water needs for the day by ice-eating' (in contrast to only 4 5 % for the controls) (Woods & Weisinger, 1970). When, after an interval of two weeks, the haemoglobin levels of the six experimental rats had returned to normal levels, it was observed that their preference for ice had decreased correspondingly. Woods & Weisinger stated, at the conclusion of their investigation, that it 'lends experimental support for the speculation based on clinical data that iron deficiency tends to cause ice-eating, but gives no explanation for this phenomenon', thereby corroborating the view of Reynolds et al. (1968) that 'the exact mechanism of pagophagia in anaemia remains obscure'. In geophagia, another common form of pica, it is possible to relate the development of iron deficiency directly to the properties of the ingestae, since 'certain clays bind dietary iron in complexes that cannot be absorbed through the intestinal wall' (Hudson, 1977). No comparable theory has been put forward to date in relation to the iron depletion engendered by abnormal ice intake, for, as Crosby (1976) has pointed out, 'Ice does not displace any dietary factors nor water prevent the absorption of iron'. Crosby, therefore, viewed the pagophagia as a consequence and not a cause of iron deficiency. Facts which did, however, emerge clearly
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from the uncertainties, surrounding pagophagia were that short periods of iron therapy almost invariably eliminated the pagophagia and that its cessation was more rapid with parenterally administered iron (Reynolds et al. 1968; Coltman, 19696; Crosby, 1971). An editorial (1969 a) discussing the findings of Reynolds & Coltman, drew attention to the puzzling fact that in some cases the ice craving ceased when the amount of iron actually administered was ' in doses insufficient to correct the anaemia or to replenish body stores'. This naturally raises the question whether there were other, specifically psychological, influences behind the abnormal substance intake and if the mere fact of receiving treatment was sufficient to satisfy an underlying need, leading to rapid physical recovery and the abandonment of the ice abuse. The accounts of the twentieth century pagophagics, with one exception (McLoughlin & Hassanyeh, 1990), were published in general medical, not in psychiatric journals, and include no discussion of possible psychological reasons for the abnormal eating patterns. In fact, Brown & Dyment (1972), in their case presentation of four teenage pagophagics, dismissed as 'sheer speculation' any suggestion 'that the attention paid to these children by their family and physician as a result of the discovery and treatment of the anaemia might relieve some anxiety and thus diminish the symptoms'. Coltman (1969 a), utilizing a group of seven pagophagic patients, demonstrated that their iced-craving remained unchanged when they received medical attention and a placebo injection, but that in six of the seven, the pagophagia ' stopped completely... within seven days of a single blind injection of parenteral iron'. Nevertheless, it has to be acknowledged that pica, which has puzzled and fascinated observers and theorists for centuries, is being viewed increasingly as being dependent on an admixture of social, cultural, biological, behavioural and psychological factors and that it is not simply a manifestation of a chemical or nutritional deficiency (Parry-Jones & ParryJones, 1992). In the twentieth century, for example, manifestations of pica in young children have been attributed, increasingly, to emotional deprivation and the lack of social stimulation. In the midst of so many unresolved questions about the causes of pica and its
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association with iron deficiency, where there are descriptions of iron-deficient subjects who do not exhibit pica and pica sufferers who are not iron-deficient, there does seem to be a fairly consistent correlation between pagophagia and iron-lack. However, the small number of reports of pagophagia to date, and their limited geographic distribution, allows only tentative conclusions to be drawn. It would be valuable, for example, to investigate whether any subjects presenting with iron deficiency in haematology departments in the UK were compulsive ice eaters, or whether this is a phenomenon which relates predominantly to twentieth century American culture. It would also be interesting to establish whether the occurrence of most of the reported cases either on US Air Force bases or in a US Army Hospital bore any relation to particularly easy and unsupervised access to icemachines by these subjects. Unless selected expressly for its cooling properties, ice constitutes an unusual substance choice, being tasteless, odourless and ephemeral. An editorial (19696), discussing the relationship between pagophagia and anaemia, makes the point that the unlikely substances that have been craved by pica sufferers over the centuries have been determined by 'local custom, social acceptance, easy availability and perhaps other psychological factors. What more likely agent in our modern life of electrical appliances for everyman than the ice cube?'. In the modern USA it is customary and socially acceptable to use ice extravagantly and it is freely available in most domestic and commercial settings. However, ice is certainly not the only commodity available for compulsive ingestion and its abnormal use by pica sufferers is selective and not enforced. In an age of fitness, health consciousness and the prevalent slim body image, it is possible to interpret that the appeal of ice to a certain proportion of its consumers, lies in its lack of calories, an interpretation that has been strengthened in recent personal discussions with a number of American acquaintances, and a hypothesis that has been in no way invalidated by the historical sample. This brief investigation has demonstrated positively that there were significant historical antecedents to the 'new version of pica, pagophagia' proclaimed in an editorial (19696) of the Nutrition Reviews, and that the mechanism of pica and its
frequent association with iron deficiency has yet to be fully explained.
REFERENCES Archer, J. (1673). Every Man his Own Doctor. For the author: London. Black's Medical Dictionary (1990). A. & C. Black: London. Brown, W. D. & Dyment, P. G. (1972). Pagophagia and iron deficiency anemia in adolescent girls. Pediatrics 49, 766-767. Calmette, F. (1706). Riverius Reformatus or the Modern Riverius; containing the Modern Practice of Physick. Set down in a method very near that of Riverius.... Printed for R. Wellington: London. Campbell, R. (1743). A letter concerning a man who lived eighteen years on water. Philosophical Transactions of the Royal Society of London XL11, 240-242. Coar, T. (transl.) (1822). The Aphorisms of Hippocrates (special edn, 1982, The Classics of Medicine Library). L. B. Adams: London. Coltman, C. A. (1969a). Pagophagia and iron lack. Journal of the American Medical Association 207, 513-516. Coltman, C. A. (19696). Pagophagia and iron lack. Nutrition Reviews 27, 244. Coltman, C. A. (1971). Letter concerning pagophagia. Archives of Internal Medicine 128, 472^73. Cooper, M. (1957). Pica. A Survey of the Historical Literature as Well as Reports From the Fields of Veterinary Medicine and Anthropology. C. C. Thomas: Springfield, III. Copland, R. (transl.) (1528). [Aristotle] Secreta Secretorum, (facsimile edn, 1970). Da Capo Press: Amsterdam. Crosby, W. H. (1971). Food pica and iron deficiency. Archives of Internal Medicine 127, 960-961. Crosby, W. H. (1976). Pica a compulsion caused by iron deficiency. British Journal of Haematology 34, 341-342. de Silva, R. A. (1974). Eating cigarette ashes in anemia. Annals of Internal Medicine 80, 115-116. de Valangin, F. (1768). A Treatise on Diet, or the Management of Human Life; By Physicians called the Six Non-Naturals. For the author: London. Editorial (1969a). Pica and iron deficiency. Journal of the American Medical Association 207, 552-553. Editorial (19696). Pagophagia and anemia. Nutrition Reviews 27, 52-54. Fairbanks, V. F., Fahey, J. L. & Beutler, E. (1971). Clinical Disorders of Iron Metabolism. Grune and Stralton: New York. Fothergill, J. M. (1874). The Maintenance of Health. A Medical Work for Lay Readers. Smith, Elder and Co: London. Glanville, Bartholomeus de (1535). De proprietatibus rerum (English transl. (1398) by John Trevisa). T. Berthelet: London. Haubrich, W. S. (1984). Medical Meanings. A Glossary of Word Origins. Harcourt Brace Jovanovich: San Diego. Hildanus, G. F. (1646). Opera Omnia. Frankfurt-on-the-Main. Hubrigkt, J. F. (1562). De Appetito Depravalo Pica Dicto. Altdorff. Hudson, R. P. (1977). The biography of disease: lessons from chlorosis. Bulletin of the History of Medicine 51, 448-463. Hunterian, MS U.6.21 (17th c ) . Trois Libres appartenant aux Infirmilez et Maladies des Femmes. (English translation of J. Liebault Trois livres de la same, fecondite et maladies des femmes, published in Paris, 1582). (Department of Special Collections, University Library, Glasgow.) International Dictionary of Medicine and Biology (1986). J. Wiley and Sons: New York. James, R. (1747). Pharmacopoeia Universalis or a New Universal English Dispensatory. For J. Hodges: London. Lemery, L. (1704). A Treatise of Foods, In General. Printed for J. Taylor: London. Liebault, J. (1582). Trois Livres de la Same, Fecondite el Maladies des Femmes. Paris.
Pagophagia: a historical perspective McLoughlin, I. J. & Hassanyeh, F. (1990). Pica in a patient with anorexia nervosa. British Journal of Psychiatry 156, 568-570. Masters, T. (1844). The Ice Book: Being a Compendious and Concise History of Everything Connected with Ice from its First Introduction into Europe as an Article of Luxury to the Present Time; with an Account of the Artificial Manner of Producing Pure and Solid Ice. Simpkin, Marshall and Co: London. Oxford English Dictionary (1989). Clarendon Press: Oxford. Oxford Medical Dictionary (1990). Oxford University Press, Oxford. Parry-Jones. B. (1991). Historical terminology of eating disorders. Psychological Medicine 21, 21-28. Parry-Jones, B. (1992). Merycism or rumination disorder: a historical investigation and assessment. (In preparation.) Parry-Jones, B. & Parry-Jones, W.LI. (1992). Pica: symptom or eating disorder? A historical assessment. British Journal of Psychiatry 160, 341-354. Parry-Jones, B. & Parry-Jones, W.LI. (1993). Fashions in Fasting: A Historical View of Self-inflicted Starvation. Basil Blackwell: Oxford. (Due to be published in 1993.)
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Reynolds, R. D., Binder, H. J., Miller, M. B., Chang, W. W. Y. & Horan, S. (1968). Pagophagia and iron deficiency anemia. Annals of Internal Medicine 69, 435-440. Riverius, L. (1658). Four Books of that Learned, and Reknowned Doctor, Lazarus Riverius. ...All Englished by Nicholas Culpeper, Physitian and Astrologer. These Histories and Observations are often mentioned and referred unto, in these Seventeen Famous Books of Riverius, called The Practice of Medicine. Printed by P. Cole: London. Sinclair, J. (1807). The Code of Health and Longevity: or a Concise View of the Principles of Health and the Attainment of Long Life (4 vols.), 5th edn. Sherwood, Gilbert & Piper: London. Speirs, J. & Jacobson, R. (1976). The consumption of ice as a symptom of iron deficiency. South African Medical Journal 50, 1742. Umfreville, T. (1743). The Case of Mr John Ferguson of Argyleshire. Printed for W. Reason: London. Woods, S. C. & Weisinger, R. S. (1970). Pagophagia in the albino rat. Science 169, 1334-1336.
Pagophagia, or compulsive ice consumption: a historical perspective BRENDA PARRY-JONES1 From the Department of Child and Adolescent Psychiatry, University of Glasgow SYNOPSIS Pagophagia, or the excessive consumption of ice or iced drinks, is popularly regarded as a novel manifestation of pica, which has emerged, predominantly in the USA, over the last 30 years. However, a sampling of historical sources reveals that not only are there warnings in the writings of both Hippocrates and Aristotle concerning the dangers of excessive intake of cold or iced water, but a series of medical works, from the sixteenth century on, incorporate discussion and illustrative case histories about the detrimental effect of immoderate usage of cold water, ice and snow, frequently in the context of disordered eating.
INTRODUCTION Pica is a form of appetite disorder characterized by an abnormal or excessive craving either for a particular food item or items, or for bizarre non-nutritive substances, both solid and liquid. The condition acquired its name by reason of the colourful resemblance observed between the indiscriminately acquisitive behaviour, in relation to both food and non-food items, which is displayed characteristically by the magpie (in Latin, Pica) and the ingestion of an extraordinary range of.substances by human subjects afflicted with this disorder. Pica was referred to by Galen as early as the second century A.D. and was described, although not by name, in both Latin and English texts during the Middle Ages. The term itself can be traced in continuous medical usage, in the English language, from 1563 onwards (Parry-Jones, 1991). There is evidence that, historically, pica was regarded as a symptom of other disorders, including anorexia and bulimia, rather than a separate condition (Parry-Jones & Parry-Jones, 1992). The principal populations affected by pica over the centuries were pregnant women; pubescent girls and young women with chlorosis (otherwise known as greensickness or virgin's disease) which 1 Address for correspondence: Mrs Brenda Parry-Jones, Department of Child and Adolescent Psychiatry, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ.
could incorporate a form of anaemia; the mentally retarded, autistic subjects and certain categories of the mentally disordered; males, females and, particularly, children infested with intestinal worms; primitive tribes in which geophagy [dirt-eating] was a cultural norm and, in the present century, malnourished or emotionally deprived infants and toddlers, chiefly from the lower socio-economic groups. Predictably, over so long a timespan, involving such a varied population, a wide range of craved substances is reflected in the historical literature. During the 1960s and 1970s, a number of case reports (e.g. Reynolds et al. 1968; Coltman 1969a; Brown & Dyment, 1972; De Silva, 1974; Crosby, 1976) concerning a form of pica involving the compulsive consumption of an abnormally large volume of ice cubes or iced drinks featured in the American medical literature, together with a brief communication concerning its occurrence in seven South African Blacks (Speirs & Jacobson, 1976). The earliest American papers to utilize the term pagophagia were those of Reynolds etal.(\ 968) and Coltman (1969a). Coltman's published article was a sequel to an oral report delivered, in February 1966, at the Annual Meeting of the Society of Air Force Physicians at San Antonio, Texas, concerning the ice-eating compulsion, and an explanatory footnote to his paper, written from a Texan United States Air Force Base, clarified that, 'The term pagophagia was conceived by
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David J. Kudzma M.D. " a local Greek scholar'". A precedent for such a construct may be seen in the use of the term pagoplexia for frostbite. Haubrich (1984) defined pagophagia as 'a perverted craving for the eating of ice. The term incorporates the Greek pagos "anything stiffened or hardened, such as frozen water", and phagein, " t o eat "...and is symptomatic of iron deficiency'. Although there are entries for pagophagia in a number of American medical dictionaries from about 1978 on, and a full definition, almost identical with that of Haubrich, is incorporated in the International Dictionary of Medicine and Biology (1986), pagophagia is significant by its absence from the latest edition (1989) of the Oxford English Dictionary and, perhaps more surprisingly, it is not yet included in the 1990 editions of either the Oxford Medical Dictionary or Black's Medical Dictionary. The latter fact, together with the almost complete lack of references to excessive ice eating in contemporary British medical literature, suggests that the practice is either extremely rare, slower to develop, or is, as yet, unidentified in the UK. It would appear that climatic and cultural conditions, coupled with the widespread, easy availability of ice, constitute major contributory factors in the development of the ice-eating habit in the USA.
HISTORICAL BACKGROUND The use of ice, both as a luxury item and in medical practice, is a very ancient tradition. Hippocrates (460-361 B.C.) set a precedent which was to remain influential in medical lore for centuries when, in his 51st Aphorism, Section II, he stated;' It is dangerous to heat, cool, or make a commotion all of a sudden in the body... Why should any one run the hazard in the heat of summer of drinking of iced waters, which are excessively cold, and suddenly throwing the body into a different state... producing thereby many ill effects? But, for all this, people will not take warning, and most men would rather run the hazard of their lives or health than be deprived of the pleasure of drinking out of ice' (cited in Masters, 1844). Another version of the Aphorisms (Coar, 1822) emphasized that 'Whatever is done gradually is safe, but if the transition should be from one extreme to the other, it is
dangerous'. Similarly, in the medical section of the Secreta secretorum (c. 1128-1130), one of the most popular medieval works, the content of which is attributed, though not entirely incontrovertibly, to Aristotle (384-323 B.C.), specific advice was given concerning the dangers of 'drynkynge Waters with a colde stomake fastynge'. Shock cooling of the system should be avoided and the reader was advised 'to drynke colde water in somer and warme water in wynter and not contrary wyse' (Copland, 1528). A subsequent section of this work, headed ' How pure water ought not to be dronke', stressed the adverse effects on digestion and physique of consuming cold water with a meal and advised 'If thou must nede drynke water alone, take it moost temperatly, and as lytel as thou mayst' (Copland, 1528). Another authoritative medieval work, De proprietatibus rerum, delivered a similar caution, '... who that drinkyth oft colde water, shall not escape frome colde sycknesse, namely in his age.... And water molten of snowe and of haiel is erthly and worste of all' (de Glanville, 1535). Unlike the text from Hippocrates, the Secreta secretorum appears to refer to cold water ingestion rather than ice consumption, but it is likely that its cautions applied also to the use of water cooled artificially by the addition of snow or ice, which, contrary to popular opinion, was an established tradition in both ancient Greek and Roman cultures. Trenches or pits were dug out, packed with snow brought down from the mountains by slaves, and overlaid with protective branches. At this early period, melted snow itself was drunk and snow was added to wine as a coolant. Masters (1844), in his comprehensive history of ice, noted that in sixteenth century Constantinople it was customary to preserve snow and ice for the entire summer for use in cooling drinks. Among the Europeans, the Spaniards and the Italians were the first to cool their wine by the addition of snow brought down from the mountains, a practice which was denounced as ' unhealthful' by the astonished French physician Symphorien Champier (1472-1540). By the end of the sixteenth century, however, ice had begun to come into use as a luxury item at the French court. Masters (1844) also referred illuminatingly to 'L'Isle des Hermaphrodites', a satirical account of high-living at the fin-de-siecle court
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of Henry III, in which it was ordered that 'large quantities of snow and ice should everywhere be preserved, in order that people might cool their liquors with them, even though they might cause extraordinary maladies, which, it seems, were then apprehended'. Despite warnings of its possible ill-effects, ice culture increased rapidly during the seventeenth century, as methods for ice preservation in dry, well-drained dug-outs, insulated by covers of chaff, straw or reeds, were succeeded by more sophisticated receptacles, such as the French glaciere (ice-chest) and lakeside ice-houses on the landed estates of the English gentry, whose subterranean stock of ice provided year-long supplies. By the end of the seventeenth century ice, snow and iced liquors had come into common usage in France and these were followed, in the eighteenth century, by iced lemonade, iced fruit juice and finally, ice creams, the latter of poor quality initially. Ice creams were procurable in England from the mid-eighteenth century, and both iced drinks and ice cream became routine embellishments in social gatherings and outdoor occasions throughout Europe during the course of the nineteenth century. Any consideration of the medical implications of abnormal or inappropriate ice consumption can be made only with an awareness of the prevailing socio-cultural background and of the various coolants available in different countries at different periods.
MEDICAL ACCOUNTS OF THE USE AND ABUSE OF COLD WATER, ICE AND SNOW The sixteenth and seventeenth centuries In an early work on the diseases of women, Trois livres de la sante, fecondite et maladies des femmes (1582), Jean Liebault, a Montpellier physician, discussed, in some detail, various appetite abnormalities, including pica. A handwritten early seventeenth century English translation of his work (Hunterian MS. U.6.21) included, in a section dealing with abnormal hunger states, such as 'boulimos' (bulimia) and 'dogges' (canine) appetite, an interesting reference to the frequent occurrence in 'young maides' of an excessive consumption of cold water and 'acqua borax' (borax water), 'wherewith they stuffe themselves everie hour', causing
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suppression of the menses and various 'hypochondriacall' affections. It is unclear from this text what underlay the girls' penchant for borax water. Borax (sodium biborate) had medicinal, cosmetic and industrial uses and possessed a bitter, slightly caustic, flavour. The latter might perhaps offer an explanation for its attraction to girls with pica, a proportion of whom, throughout the long history of this condition, displayed considerable liking for sharp, bitter and acidic flavours. Medicinally, borax was utilized as an aperient salt and as an emmenagogue and its saline properties were' recommended for making the skin smooth and free from Asperities' (James, 1747). A little later, the eminent French Royal physician, Lazarus Riverius (1589-1655) made two very significant references to the consumption, not only of cold water, but also of snow and ice by women and young girls suffering from pica and chlorosis, in his popular work, Praxis Medica (1640). In an English edition published in London, in 1658, Riverius defined pica as 'a depraved Appetite; by which evil, unprofitable, and hurtful things are desired'. Some of the desiderata in pica listed by Riverius were ' Earthy, Dry and burnt things, as Cloves, Cinnamon, Nutmegs and other spices, Salt, Ashes, Chalk, and the like', but a contrasting compulsion to consume sour things 'sharp, bitter and very cold', leading to 'the continuall use of unripe Fruits, Vinegar, Juyce of Lemmons, Pomegranates, and Orenges, cold Water, Snow, Ice and the like' was identified. In a separate section, on greensickness and chlorosis, Riverius (1658) attributed suppression of the menses specifically to an 'evil' diet, 'for these Virgins drink great draughts of water at bed-time, or in the morning fasting, or eat Vinegar, Herbs, unripe Fruits, Snow or Ice', leading to a loss of their natural body heat. This latter reference has been cited by Fairbanks et al. (1971) as an early example of pagophagia. John Archer (1673), court physician to Charles II, introduced a more general caution: 'Waters of Snow and Ice are condemned because they are thick and hurt the Stomach, and Stir up grievous Symptomes, and Diseases of the Joynts, Nerves, and Bowels'. Riverius' works achieved such popularity that they ran through several editions, translations and revisions. The English edition of a revision by Francois Calmette, also a Montpellier physician, was published in 1706 under the title
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Riverius Reformatus or the Modern Riverius. Under the heading 'Of longing and strange Lusts call'd Pica or Malacia', Calmette included two important references to the consumption of water, ice and snow. Among the external causes of pica he listed 'the immoderate use of water', and elaborated on this point by explaining that this was the reason why almost all the young girls of Montpellier, and a great many of the married women, who, by nature and by custom 'are very abstemious [i.e. temperate, in the avoidance of wine] are so much troubled with this Distemper'. Like Riverius, he observed that some pica sufferers 'have a mind to Mortar, others to Coals, Iron, Salt, Water, Snow, Ice, Vinegar, Verjuice [i.e. the liquid from sour grapes], unripe Fruits, Leather etc' (Calmette, 1706). However, he put forward a much more advanced theory of causation by suggesting that this depraved appetite was attributable less to ' the variety... of bad humours abounding in the Body and Stomach, as from the various Imaginations, Phansies, and Prejudices; either inborn or acquired elsewhere'. As an example of the former, he quoted an instance known to him personally of the hereditary transmission of a particular craving from a mother to her young son, but the acquired behaviour Calmette attributed to a process which would be termed, in modern idiom, as the influence of peer group pressure. Such strange perversions, he maintained, could be 'induced by others, as often happens in Maids, that create one another an Appetite to certain things by persuading them, that by taking such things they formerly have made themselves look fair and handsome; with which the Mind being struck, afterwards, when occasion serves, longs for the like' (Calmette, 1706). This quotation is of outstanding significance, both in providing a very early and unequivocal statement concerning the wishes of young girls to conform to the prevailing pattern of female beauty, a theme which is discussed more fully elsewhere (Parry-Jones & ParryJones, 1993) and for the implication that this ideal of beauty was achievable by the consumption of either non-foods or low or noncalorific substances, which included fruit, water, snow and ice. This latter interpretation is lent support by some current case-histories, such as that by McLoughlin & Hassanyeh (1990), which describes a form of pica involving the con-
sumption of 40 ice cubes per day, accompanied by small amounts of frozen soft fruit, in a female patient with confirmed anorexia nervosa. Cooper (1957), in her comprehensive historical survey of pica, refers to a group of ten Latin theses on this subject, written by European authors from the sixteenth to the eighteenth century. One of these, by Hubrigkt (1562), included among examples of pica, the 'craving for snow in summer', and another thesis, submitted in 1691 by Christiani, referred to the occurrence of cravings for ' unusual drinks, such as excessive amounts of water, iced drinks, etc' (cited in Cooper, 1957). The eighteenth and nineteenth centuries
The result of drinking snow and ice water was, according to the French physician Lemery (1704) and several fellow practitioners, to 'hinder Digestion, injure the Stomach, cause wind and crudities, provoke Coughing, hurt the Breast, coagulate the Liquors, oppress the Spirits, and produce many other ill Effects', some of which could be fatal. However, he conceded that 'the use of Ice may be wholsome in hot Countries, because the Air being very much heated with the Sun Beams, the Body requires a Liquor that can stop the violent Motions of the Humours, and make them a litle of a thicker Consistence'. There was, however, no justification for ice-use in temperate climes. Francis de Valangin, a native of Switzerland, who practised in London for many years, devoted a substantial section of his Treatise on Diet (1768) to the consideration of the virtues and vices of water ingestion. While acknowledging that moderate water intake assisted digestion, he warned that it might produce ' bad Effects...when drank to an excessive Quantity. ... All waters made of Snow, though nothing but harmless frozen Rain and those made of Ice, are found to be pernicious... The Coldness of Water, or the Use of Ice, will have pretty near the same Effect as that of the inspired cold Air.... In some countries, and for some constitutions, the prudent and moderate use of Ice may sometimes be proper, but in general it produces more ill than good Effects. In the southern parts of Europe, where, on account of the Heat of their Climate, they indulge themselves with the deceitful pleasure of drinking out of Ice, they often pay for it with the Loss of their Lives. In
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our temperature Climate, though the Inducement is not so great, yet Luxury has introduced the use of those sorts of Drinks, and of divers Sorts of Ice-Creams, which are pernicious and dangerous in the Heat of Summer; for every thing that is excessive is an Enemy to Nature' (de Valangin, 1768). With suitable deference to the pronouncements of Hippocrates on this subject, de Valangin concluded that 'it cannot be safe to throw the Body all of a sudden, when it is hot, into a quite different state, by taking into the Stomach those Things which are excessively cold'. The latter theme, therefore, shows a considerable degree of continuity from the classical period into early modern writings, although the actual ill-effects of the unnaturally cold ingestae reported varied in form and severity, ranging from generalized bodily weakness and digestive disturbances to specific conditions, such as amenorrhoea, anorexia, diarrhoea and even death. A number of illustrative case histories were put forward on this subject. Thomas Umfreville, for example, listed (1743) a series of cases in which the copious drinking of cold water after exercise was believed to have been instrumental in causing death or serious illness. One of these cases was derived directly from the works of Hippocrates; another was extracted from the writings of the reknowned Swiss physician, Fabricius Hildanus (1560-1634) concerning John Cassellanus of Aventicum, who, having overheated himself during a journey, drank quantities of cold water, fell into a fever, became reduced to a skeleton and, finally, died. The centre-piece of Umfreville's account was the detailed history of John Ferguson of Argyll, Scotland, whose case was sufficiently curious to merit notice in the Philosophical Transactions of the Royal Society (Campbell, 1743). At the age of 18 years,this young cowherd ' overheated' himself crossing mountainous terrain in pursuit of his cattle near Kilmelford; thereupon, he drank excessively from the icy waters of a mountain stream, fell asleep, awakened feverish and with complete loss of appetite. For 18 years he took no nourishment except small amounts of water and whey and no deception was found when a close watch was kept over him in a locked room for twenty days. At the age of 36, his diet unchanged and his person 'meagre', he continued his herding duties. Umfreville, with
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acknowledged adherence to the counsels of Hippocrates, utilized this sequence of cases to illustrate the changes to the constitution which it was believed could be effected by an abnormal ingestion of cold water. In Ferguson's case, he believed the abstinence from food to be due to ' a morbid State created by that great Error of drinking cold Water when hot, causing a change in nature', which prevented the subject 'from being able to enjoy the Aliment he before used' (Umfreville, 1743). However, in somewhat contradictory fashion, Ferguson's survival as an abstainer was attributed solely to his limited intake of water and whey. Another example of the dangers of excessive body-cooling was given by de Valangin (1768), who quoted the case of a nobleman who was 'a great Advocate of the Cold-Bath, and in general for every Thing that could harden the Body; and imagined that Cold applied internally must be as salutary as when applied externally. He often drank Liquors out of Ice, and eat plentifully of Ice-Creams of divers Kinds; After having one Day taken a greater Quantity of these than usual, a fatal Inflammation, which at once affected the Stomach, the Intestines and Kidnies,... made him fall a Victim to his favourite Opinion'. Lemery (1704) identified this unfortunate casualty as Gonzagues, Duke of Mantua. Sinclair (1807), whose discussion of the various sources of water included a section on 'snow-water', made no reference to its being unsalubrious, merely commenting on its vapidity and air-lessness and rejecting a former theory connecting the prevalence of goitre in inhabitants of the Alps with their year-round derivation of water supplies from melted snow. In his popular work, 'The maintenance of health. A medical work for lay readers' (1874), Fothergill reiterated the same cautions about excessive intake of cooling agents: ' There is a popular prejudice against drinking freely of cold fluids when heated, and no doubt death is sometimes so induced; but the consumption of cold and even chilled drinks is now much on the increase. Ice is no longer regarded as a mere luxury, it has become a necessity of life in hot weather, and its addition to a beverage adds much to its agreeableness'. Fothergill goes on to discuss the direct effects of ice ingestion on body temperature, pointing out that as much heat is extracted from the body' as is requisite to
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raise the temperature of the chilled fluid... from about 32° to 99°'. He observed that' the quantity of the chilled fluid has much to do with the effect, and a pint will take twice as much heat to raise its temperature as will half a pint. Consequently, it is not unimportant to the imbiber what the amount of his fluid is, as well as its temperature'. Fothergill noted that in contemporary society. 'At all entertainments, dancing and other, where the heat becomes great, ice, both as a beverage and in the more solid form of ice-cream forms now the essential matter of the refreshment table, and is very acceptable'. He warned, however, that 'free indulgence in iced fluids is very apt to induce a sharp diarrhoea in many persons'. Most relevantly to the twentieth century concept of pagophagia, Fothergill commented on the compulsive character of ice intake; 'the free consumption of ice has not unfrequently the effect of creating even a stronger craving than ever for fluids, from the same action upon the throat that snowballs have on boys' hands - the persistent cold causes a free flow of arterial blood to the part' (Fothergill, 1874). From a strictly medical angle, however, Fothergill commended the use of ice in febrile illness to relieve parched lips and to lower body temperature and he recommended the utilization of chips of ice in 'the hiccough and sickness which accompany the final stage of many diseases'. With the development of methods of artificial ice production in the nineteenth century, ice was employed increasingly as a refrigerant, in staunching haemorrhages and in antiphlogistic treatments. The value and versatility of ice in its varied stages was recognized, particularly in medicine, and, as Masters (1844), himself the designer of an ice-making machine, claimed, 'It is at once stimulant and sedative, diaphoretick, sudorific and diuretic, excitant and refrigerant, emollient and roborant, astringent and relaxant'.
The twentieth century
In the late 1960s and early 1970s, a number of cases of compulsive ice eating were reported in the USA. Reynolds et al. (1968) studied the prevalence of different forms of pica in 38 consecutive patients with iron deficiency anaemia, seen in 1966-7 at a United States Air Force
Base in California. Enquiries about their ingestion of unusual quantities or types of food led to the discovery that 23 patients were compulsive ice eaters. These patients consumed five or six glasses (approximately 240 ml per glass) of crushed or cubed ice daily and also concealed ice cubes in drinks and among salad vegetables. The ice was chewed and swallowed in small pieces and this behaviour appeared to be unrelated either to season or to temperature; nor was it caused at that time in any of these patients by pregnancy, although three women in the group recalled the onset of ice-eating episodes during previous pregnancies. While some patients claimed to be unaware of the extent of their ice consumption, others confessed that they had been unwilling to admit to it 'because of fear of underlying psychiatric disease' (Reynolds et al. 1968). As is the case with some other forms of disordered eating, such as bulimia and rumination, most subjects were secretive, self-conscious and unwilling to disclose their habits and, consequently, the incidence of such disorders always appears to be far lower than it actually is (Parry-Jones, B. 1992). Significantly, it was reported that treatment of the iron deficiency led to the disappearance of the ice craving in all but one of Reynolds' pagophagics. Coltman, who originally opened up the topic of compulsive ice consumption in his oral report of 1966, provided in his paper (1969 a) clinical observations on 25 cases of iron deficiency 'associated with an unusual perversion of appetite characterized by the ingestion of extraordinary amounts of ice', referring to this compulsion as pagophagia. His 25 patients, like those of Reynolds et al. (1968), were United States Air Force personnel, or members of their families, and in Coltman's case, were stationed at the Lackland Base, Texas. He defined pagophagia in his patients as 'the purposeful ingestion of at least 1 ordinary tray of ice daily for an excess of 2 months', and an average ice-tray was estimated to contain approximately 710 g of ice. In a subsequent letter (Coltman, 19696), further details were quoted about the quantity of ice ingested: 'The dose was calibrated in each patient to the "nearest cube" and based upon examination of a representative tray from each of the subject freezers'. Eighteen of the 25 subjects consumed between 2 and 13 trays of ice
Pagophagia: a historical perspective
each day and this 'clearly represents behavior which could be considered unusual in any setting!' (Coltman, 1969a). In a third communication, Coltman (1971) described five additional pagophagic patients, including the first compulsive ice eater ever to come to his attention, an 18-year-old Negro girl. This patient presented in a panic-stricken state after ' she had been convinced by her father that she would die of cancer unless she stopped her ice-eating. In spite of her absolute conviction that her father was correct, she had an ungovernable ice consumption'. Her mild iron lack anaemia responded, within one week, to orally administered iron sulphate. Not only did her ice craving disappear, but she firmly believed her life had been saved. Coltman's second patient, a 35year-old woman whose considerable liking for beer was matched by a deep-rooted ice craving, revealed that an enforced choice between the two commodities would lead her to abandon her beer rather than reduce her ice intake. A third female patient utilized ice ingestion as a device to postpone her chain-smoking habit and a fourth subject sought treatment for her pagophagia to prevent the re-occurrence of the considerable financial burden of replacing her artificial dentures, two sets of which she had already destroyed by chewing chipped ice. A fifth female patient, following the successful treatment of her pagophagia, presented to Coltman, as a commemorative trophy, her icetray ' severely pockmarked by the ice pick which she used to crush her ice'. Crosby (1971) referred to ice eating observed in two women hospital employees while at their work. Both of them proved to have iron depletion; the first had recently been rejected as a blood-donor, owing to her anaemia; and the second was discovered to be suffering from a bleeding duodenal ulcer. Crosby also recorded an example of two-generation pica; a woman, who had successive pica for green salads, croutons and then chewing gum during periods of anaemia, confided that her late mother had been an ice eater:' She would carry around with her a cup of chipped ice to eat. We couldn't keep Mother in ice' (Crosby, 1971). In another communication, Crosby (1976) noted that pica, as a symptom of iron deficiency, occurred in over 50% of his patients with iron deficiency anaemia and estimated that about half of his pica
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sufferers were compulsive ice eaters. De Silva (1974) referred to a case of pica for cigarette ash and soil (geophagia) in a 33-year-old Puerto Rican woman and noted that she had suffered from recurrent pagophagia in the course of several pregnancies, when a lowering of her haemoglobin levels might have been anticipated. Brown & Dyment (1972) provided an interesting discussion of pagophagia in relation to iron deficiency anaemia in adolescent girls, in order 'to bring to the attention of those physicians caring primarily for children, the association of pagophagia... and iron deficiency anaemia', a subject not previously dealt with in paediatric literature. Case material regarding four girls was presented, two Negro sisters aged 12 and 14 years and two Caucasian girls aged 13 and 15 years. All four were seen within a two-month period, by the paediatric service of a United States Army Hospital in Texas, with a diagnosis of microcytic hypochromic anaemia, presumed to be due to menorrhagia. Their respective haemoglobin levels ranged from 8-2 g per 100 ml to 10-4 g per 100 ml; they each consumed between 4 and 10 glasses of ice per day and, in all four girls, pagophagia disappeared within 1-8 weeks of oral iron therapy. Brown & Dyment (1972) emphasized the advisability, during casehistory taking with adolescents, to include a query concerning ice consumption, and if the practice was confirmed, to proceed with the appropriate tests to exclude iron deficiency. Speirs & Jacobson (1976), writing from a Johannesburg hospital, with an awareness of the American cases of pagophagia reported by Reynolds et al. (1968) and Coltman (1969 a, b), drew attention to the fact that ice eating symptomatic of iron deficiency among Blacks had not yet had any publicity. Accordingly, they reported on two pagophagic South African patients and briefly mentioned another five subjects with ice eating compulsions. The first patient, a nursing sister, admitted with severe iron deficiency anaemia, described her unusual craving, but had no awareness of any association between the pagophagia and the iron deficiency. She referred to two nursing acquaintances 'whom she knew to be regular raiders of the freezer' (Speirs & Jacobson, 1976), and, although both were asymptomatic, marked and mild iron deficiency respectively was discovered in each of them on investigation. Their second patient
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attended a gynaecological clinic for menorrhagia, where she received treatment for her iron deficiency and the ice craving was discovered. Two other ward sisters 'with a reputation for unusual ice-eating habits' were also found to be iron-deficient and a nursing assistant, who consumed large quantities of ice to soothe a recurring sore-throat, described the onset of this habit following heavy blood loss due to an incomplete abortion. All these subjects consumed 2-3 bowls of ice daily, over a long period, with increased amounts during pregnancy; all were Black South Africans and had had some hospital nursing experience. Several of them referred to a previous desire to eat soil, which was abandoned on learning of the possibly harmful effect of bacteria and the dangers of worm infestation, whereupon ice-eating was, apparently, take up as an alternative. McLoughlin & Hassanyeh (1990) provided the only British case report discovered to date of twentieth century pagophagia in their description of a middle-aged, anorexic patient, who admitted to eating up to 40 ice cubes daily over the period of 2 years, in conjunction with a generally bizarre diet. Her ice consumption was the same throughout all seasons, but she denied having eaten ice during childhood or pregnancy and stated that she had never known anyone with a similar compulsion. This patient did not chew the ice, merely allowed it to melt in her mouth, making' a refreshing drink without much volume of liquid', and she found sucking ice relieved her sore lips, mouth and tongue. 'She has also started to freeze soft fruit, which she eats iced, deriving much pleasure from the small amounts of food and... says she would not eat these foods uniced...and becomes upset when none is available'. Shortly after the patient developed this habit 'her haemoglobin level was found to be low' (McLoughlin & Hassanyeh, 1990).
DISCUSSION From this literature sample it appears that the over-use of cold water, ice or snow has been regarded, consistently, as hazardous to health and well-being and there have been indications that the teaching of Hippocrates against rapid cooling of the body remained operant, in some
contexts, into the nineteenth century. In the classical and medieval texts (with the exception of the Secreta, which suggested that the digestion might be weakened), the adverse implications of ingesting excessive amounts of cold substances were described, in very general terms, as having 'many ill-effects', being 'unhealthful' or causing 'extraordinary maladies'. The excerpts from Liebault, Riverius and Calmette all classified excessive cold substance use under depraved or abnormal appetite and they were in agreement that 'young maides', 'virgins' and young girls and women were the chiefly vulnerable population. While Liebault associated this phenomenon with suppression of the menses and ' hyponchondriacall' affections, Riverius linked it with greensickness and chlorosis and Calmette interpreted the practice more widely, as having connections with the aspirations of young girls to look 'fair and handsome'. De Valangin (1768) supported the appropriateness of ice in certain circumstances, while indicating that its effects could also be undesirable and even fatal. Approaching the twentieth century, when ice as a commodity was much more widely available, Fothergill (1874) accepted as inevitable the social role of coolants, although he pointed out that over-use could loosen the bowels and, perhaps most relevantly to the present study, he alluded to the fact that over-indulgence in ice could create, 'not unfrequently', an even stronger craving for it. The twentieth century contributors were under no misapprehensions concerning the compulsive nature of the ice-taking habit, but the interesting fact is that, with one exception (McLoughlin & Hassanyeh, 1990) the patients on whom they reported did not actually come to their attention owing to their compulsive appetite. The patients seen by Reynolds et al. (1978) and Coltman (1969 a) all presented with iron deficiency at haematological clinics and their pagophagia was discovered incidentally during history-taking. Similarly, the teenage pagophagics reported by Brown & Dyment (1972) were under investigation for anaemia presumed due to menorrhagia and the two South African patients described by Speirs & Jacobson (1976) presented with iron deficiency anaemia and menorrhagia respectively. It is interesting, and probably permissible, to speculate that a similar connection might have appertained between ice-eating and iron
Pagophagia: a historical perspective
deficiency in some of the young girls with pica and amenorrhoea reported in sixteenth to eighteenth century medical texts. Historically, pica was almost universally regarded as symptomatic of chlorosis in both girls and young women, and chlorosis came, increasingly, during the nineteenth century to be viewed as a form of anaemia ('chloroanaemia'), which could be treated effectively with iron preparations. Similarly, pregnant women over the centuries, exhibited pica at a period of natural depletion of their haemoglobin levels, for a range of substances, including ice. In view of the fact that the evidence suggesting a relationship between iron deficiency and ice ingestion had been observational rather than experimental, Woods & Weisinger (1970) set out to test the hypothesis using 12 albino rats, which had been trained to eat crushed ice. Six rats were made anaemic by withdrawal of blood to the level of 5/6 g per 100 ml, at which level pagophagia had been observed in humans. 'The anaemic rats showed a significantly increased preference for ice, and, as a group, satisfied 96 % of their water needs for the day by ice-eating' (in contrast to only 4 5 % for the controls) (Woods & Weisinger, 1970). When, after an interval of two weeks, the haemoglobin levels of the six experimental rats had returned to normal levels, it was observed that their preference for ice had decreased correspondingly. Woods & Weisinger stated, at the conclusion of their investigation, that it 'lends experimental support for the speculation based on clinical data that iron deficiency tends to cause ice-eating, but gives no explanation for this phenomenon', thereby corroborating the view of Reynolds et al. (1968) that 'the exact mechanism of pagophagia in anaemia remains obscure'. In geophagia, another common form of pica, it is possible to relate the development of iron deficiency directly to the properties of the ingestae, since 'certain clays bind dietary iron in complexes that cannot be absorbed through the intestinal wall' (Hudson, 1977). No comparable theory has been put forward to date in relation to the iron depletion engendered by abnormal ice intake, for, as Crosby (1976) has pointed out, 'Ice does not displace any dietary factors nor water prevent the absorption of iron'. Crosby, therefore, viewed the pagophagia as a consequence and not a cause of iron deficiency. Facts which did, however, emerge clearly
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from the uncertainties, surrounding pagophagia were that short periods of iron therapy almost invariably eliminated the pagophagia and that its cessation was more rapid with parenterally administered iron (Reynolds et al. 1968; Coltman, 19696; Crosby, 1971). An editorial (1969 a) discussing the findings of Reynolds & Coltman, drew attention to the puzzling fact that in some cases the ice craving ceased when the amount of iron actually administered was ' in doses insufficient to correct the anaemia or to replenish body stores'. This naturally raises the question whether there were other, specifically psychological, influences behind the abnormal substance intake and if the mere fact of receiving treatment was sufficient to satisfy an underlying need, leading to rapid physical recovery and the abandonment of the ice abuse. The accounts of the twentieth century pagophagics, with one exception (McLoughlin & Hassanyeh, 1990), were published in general medical, not in psychiatric journals, and include no discussion of possible psychological reasons for the abnormal eating patterns. In fact, Brown & Dyment (1972), in their case presentation of four teenage pagophagics, dismissed as 'sheer speculation' any suggestion 'that the attention paid to these children by their family and physician as a result of the discovery and treatment of the anaemia might relieve some anxiety and thus diminish the symptoms'. Coltman (1969 a), utilizing a group of seven pagophagic patients, demonstrated that their iced-craving remained unchanged when they received medical attention and a placebo injection, but that in six of the seven, the pagophagia ' stopped completely... within seven days of a single blind injection of parenteral iron'. Nevertheless, it has to be acknowledged that pica, which has puzzled and fascinated observers and theorists for centuries, is being viewed increasingly as being dependent on an admixture of social, cultural, biological, behavioural and psychological factors and that it is not simply a manifestation of a chemical or nutritional deficiency (Parry-Jones & ParryJones, 1992). In the twentieth century, for example, manifestations of pica in young children have been attributed, increasingly, to emotional deprivation and the lack of social stimulation. In the midst of so many unresolved questions about the causes of pica and its
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association with iron deficiency, where there are descriptions of iron-deficient subjects who do not exhibit pica and pica sufferers who are not iron-deficient, there does seem to be a fairly consistent correlation between pagophagia and iron-lack. However, the small number of reports of pagophagia to date, and their limited geographic distribution, allows only tentative conclusions to be drawn. It would be valuable, for example, to investigate whether any subjects presenting with iron deficiency in haematology departments in the UK were compulsive ice eaters, or whether this is a phenomenon which relates predominantly to twentieth century American culture. It would also be interesting to establish whether the occurrence of most of the reported cases either on US Air Force bases or in a US Army Hospital bore any relation to particularly easy and unsupervised access to icemachines by these subjects. Unless selected expressly for its cooling properties, ice constitutes an unusual substance choice, being tasteless, odourless and ephemeral. An editorial (19696), discussing the relationship between pagophagia and anaemia, makes the point that the unlikely substances that have been craved by pica sufferers over the centuries have been determined by 'local custom, social acceptance, easy availability and perhaps other psychological factors. What more likely agent in our modern life of electrical appliances for everyman than the ice cube?'. In the modern USA it is customary and socially acceptable to use ice extravagantly and it is freely available in most domestic and commercial settings. However, ice is certainly not the only commodity available for compulsive ingestion and its abnormal use by pica sufferers is selective and not enforced. In an age of fitness, health consciousness and the prevalent slim body image, it is possible to interpret that the appeal of ice to a certain proportion of its consumers, lies in its lack of calories, an interpretation that has been strengthened in recent personal discussions with a number of American acquaintances, and a hypothesis that has been in no way invalidated by the historical sample. This brief investigation has demonstrated positively that there were significant historical antecedents to the 'new version of pica, pagophagia' proclaimed in an editorial (19696) of the Nutrition Reviews, and that the mechanism of pica and its
frequent association with iron deficiency has yet to be fully explained.
REFERENCES Archer, J. (1673). Every Man his Own Doctor. For the author: London. Black's Medical Dictionary (1990). A. & C. Black: London. Brown, W. D. & Dyment, P. G. (1972). Pagophagia and iron deficiency anemia in adolescent girls. Pediatrics 49, 766-767. Calmette, F. (1706). Riverius Reformatus or the Modern Riverius; containing the Modern Practice of Physick. Set down in a method very near that of Riverius.... Printed for R. Wellington: London. Campbell, R. (1743). A letter concerning a man who lived eighteen years on water. Philosophical Transactions of the Royal Society of London XL11, 240-242. Coar, T. (transl.) (1822). The Aphorisms of Hippocrates (special edn, 1982, The Classics of Medicine Library). L. B. Adams: London. Coltman, C. A. (1969a). Pagophagia and iron lack. Journal of the American Medical Association 207, 513-516. Coltman, C. A. (19696). Pagophagia and iron lack. Nutrition Reviews 27, 244. Coltman, C. A. (1971). Letter concerning pagophagia. Archives of Internal Medicine 128, 472^73. Cooper, M. (1957). Pica. A Survey of the Historical Literature as Well as Reports From the Fields of Veterinary Medicine and Anthropology. C. C. Thomas: Springfield, III. Copland, R. (transl.) (1528). [Aristotle] Secreta Secretorum, (facsimile edn, 1970). Da Capo Press: Amsterdam. Crosby, W. H. (1971). Food pica and iron deficiency. Archives of Internal Medicine 127, 960-961. Crosby, W. H. (1976). Pica a compulsion caused by iron deficiency. British Journal of Haematology 34, 341-342. de Silva, R. A. (1974). Eating cigarette ashes in anemia. Annals of Internal Medicine 80, 115-116. de Valangin, F. (1768). A Treatise on Diet, or the Management of Human Life; By Physicians called the Six Non-Naturals. For the author: London. Editorial (1969a). Pica and iron deficiency. Journal of the American Medical Association 207, 552-553. Editorial (19696). Pagophagia and anemia. Nutrition Reviews 27, 52-54. Fairbanks, V. F., Fahey, J. L. & Beutler, E. (1971). Clinical Disorders of Iron Metabolism. Grune and Stralton: New York. Fothergill, J. M. (1874). The Maintenance of Health. A Medical Work for Lay Readers. Smith, Elder and Co: London. Glanville, Bartholomeus de (1535). De proprietatibus rerum (English transl. (1398) by John Trevisa). T. Berthelet: London. Haubrich, W. S. (1984). Medical Meanings. A Glossary of Word Origins. Harcourt Brace Jovanovich: San Diego. Hildanus, G. F. (1646). Opera Omnia. Frankfurt-on-the-Main. Hubrigkt, J. F. (1562). De Appetito Depravalo Pica Dicto. Altdorff. Hudson, R. P. (1977). The biography of disease: lessons from chlorosis. Bulletin of the History of Medicine 51, 448-463. Hunterian, MS U.6.21 (17th c ) . Trois Libres appartenant aux Infirmilez et Maladies des Femmes. (English translation of J. Liebault Trois livres de la same, fecondite et maladies des femmes, published in Paris, 1582). (Department of Special Collections, University Library, Glasgow.) International Dictionary of Medicine and Biology (1986). J. Wiley and Sons: New York. James, R. (1747). Pharmacopoeia Universalis or a New Universal English Dispensatory. For J. Hodges: London. Lemery, L. (1704). A Treatise of Foods, In General. Printed for J. Taylor: London. Liebault, J. (1582). Trois Livres de la Same, Fecondite el Maladies des Femmes. Paris.
Pagophagia: a historical perspective McLoughlin, I. J. & Hassanyeh, F. (1990). Pica in a patient with anorexia nervosa. British Journal of Psychiatry 156, 568-570. Masters, T. (1844). The Ice Book: Being a Compendious and Concise History of Everything Connected with Ice from its First Introduction into Europe as an Article of Luxury to the Present Time; with an Account of the Artificial Manner of Producing Pure and Solid Ice. Simpkin, Marshall and Co: London. Oxford English Dictionary (1989). Clarendon Press: Oxford. Oxford Medical Dictionary (1990). Oxford University Press, Oxford. Parry-Jones. B. (1991). Historical terminology of eating disorders. Psychological Medicine 21, 21-28. Parry-Jones, B. (1992). Merycism or rumination disorder: a historical investigation and assessment. (In preparation.) Parry-Jones, B. & Parry-Jones, W.LI. (1992). Pica: symptom or eating disorder? A historical assessment. British Journal of Psychiatry 160, 341-354. Parry-Jones, B. & Parry-Jones, W.LI. (1993). Fashions in Fasting: A Historical View of Self-inflicted Starvation. Basil Blackwell: Oxford. (Due to be published in 1993.)
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Reynolds, R. D., Binder, H. J., Miller, M. B., Chang, W. W. Y. & Horan, S. (1968). Pagophagia and iron deficiency anemia. Annals of Internal Medicine 69, 435-440. Riverius, L. (1658). Four Books of that Learned, and Reknowned Doctor, Lazarus Riverius. ...All Englished by Nicholas Culpeper, Physitian and Astrologer. These Histories and Observations are often mentioned and referred unto, in these Seventeen Famous Books of Riverius, called The Practice of Medicine. Printed by P. Cole: London. Sinclair, J. (1807). The Code of Health and Longevity: or a Concise View of the Principles of Health and the Attainment of Long Life (4 vols.), 5th edn. Sherwood, Gilbert & Piper: London. Speirs, J. & Jacobson, R. (1976). The consumption of ice as a symptom of iron deficiency. South African Medical Journal 50, 1742. Umfreville, T. (1743). The Case of Mr John Ferguson of Argyleshire. Printed for W. Reason: London. Woods, S. C. & Weisinger, R. S. (1970). Pagophagia in the albino rat. Science 169, 1334-1336.
