Krishna Badami
Christchurch, New Zealand

Several years ago we saw a young woman who had an iron deficiency anemia, caused not by blood loss from menstruation (a common cause of iron deficiency anemia in females), but by repeatedly drawing her own blood by venipuncture and discarding it. This type of anemia caused by a specific self-harm behavior has been named the Syndrome de Lasthenie de Ferjol.

The French hematologist Jean Bernard and his co-workers described in 1967 a condition they called “Les anémies hypochromes dues à des hémorragies volontairement provoquées” or “Syndrome de Lasthenie de Ferjol.”¹ Twelve cases of factitious (from Latin: facere, “to make” or “to do”; facticius, “made by art”) iron deficiency anemia were described. All patients were women between the ages of twenty and forty-three who worked in paramedical professions. Olry and Haines have also described the history of this disorder.²

The name of the syndrome was inspired by the heroine of the story Une Histoire sans nom by Jules Amedee Barbey d’Aurevilly, a nineteenth-century French novelist (Figure 1). The story is about the young daughter of the Baroness of Ferjol, Lasthenie, who lived a sheltered life in a village in the Cevennes with her mother and their aged servant, Agathe Thousard. A Capuchin monk, Father Riculf, who stayed briefly with them during his travels, took advantage of Lasthenie’s somnambulism and, unbeknownst to her, had intercourse with her and made her pregnant. As the pregnancy became obvious, and unable to grasp how it had happened, Lasthenie grows increasingly melancholy with shame. Her son is still-born, and Lasthenie herself dies shortly after giving birth. Her mother and Agathe later discover Lasthenie’s blood-stained blouse, who had killed herself slowly by sticking needles around her heart.

Several reports of factitious anemia precede that of Bernard, et al.³ They have been mostly in women, usually young ones, but rare reports of the syndrome have occurred in pre-pubertal children, post-menopausal women, or in men—prisoners trying to get out of prison.

In literature and art, blood loss and anemia evoke notions of weakness, pity, and love. Here Lady Macbeth invokes the spirits to help thicken her blood in order to imbue her with precisely the opposite attributes—pitilessness and resolution:

Make thick my blood.
Stop up the access and passage to remorse,
That no compunctious visitings of nature
Shake my fell purpose, nor keep peace between
The effect and it! Come to my woman’s breasts,
And take my milk for gall, you murd’ring ministers . . .
—William Shakespeare, Macbeth, Act 1, Scene 5

Extreme pallor may have become passe, but the asthenic look (from Greek, asthenes meaning “weak”), with collarbones showing prominently, is still in vogue.⁴ In the past this led to the romanticization of tuberculosis, whose attributes include asthenia, anemia, and pallor.^5,6

Indeed, among the synonyms for tuberculosis are “phthisis” (Greek for decay or wasting), “consumption,” and “the white plague.” It is debatable whether the romanticization of tuberculosis stemmed from the fact that great artistic figures of the time such as Elizabeth Siddal, the model for John Everett Millais’ painting Ophelia (Figure 2), and the poet John Keats had the disease, or if it was the pallor that evoked feelings of beauty, purity, and high breeding, or of helplessness, pity, and love.

The Syndrome de Lasthenie de Ferjol or factitious anaemia is perhaps grounded in similar needs—the need to be appreciated, taken notice of, loved, and sometimes pitied. These needs are likely universal, although ways to engender these emotions (and the extent to which one will go to do so) vary. Blood-letting is the choice of a small inventive minority. Two cases from the literature are particularly striking. While not nearly as extreme as the fictional case of d’Aurevilly’s Lasthenie, factitious anemia is reported to have been attempted by the reinfusion of lysed blood in one case; in another, by laceration of the colon with a knitting needle!^1,3

Syndrome de Lasthenie de Ferjol should be regarded as a specific type of non-suicidal self-injury (NSSI). Broadly, NSSI is described as being most frequent in adolescents and young adults, with a slight preponderance amongst females. Etiologically, the relationship between NSSI and sexual abuse is said to be “contentious,” but both environmental and individual factors are believed to play a role.⁷

References

1. Bernard J, Najean Y, Alby N, Rain JD. Les anémies hypochromes dues à des hémorragies volontairement provoquées. Syndrome de Lasthénie de Ferjol. Presse Med. 1967; 14:2087–2090.
2. Olry R. Haines DE. Lasthénie de Ferjol’s syndrome: a tribute paid by Jean Bernard to Jules Amédée Barbey D’Aurevilly. Journal of the History of the Neurosciences. 2002, 11:181-182
3. Daily WJR, Coles JM, Creger WP. Factitious Anemia. Ann Intern Med. 1963; 58: 533 – 538
4. Van Paris C. Crop Top Abs Vs. Bare Shoulders! How the Hadid Sisters Flaunt What They’ve Got. https://www.vogue.com/article/gigi-hadid-bella-hadid-crop-top-abs-bare-shoulders-summer-beauty-skin-new-york-city
5. Mullin E. How Tuberculosis Shaped Victorian Fashion. https://www.smithsonianmag.com/science-nature/how-tuberculosis-shaped-victorian-fashion-180959029/
6. Newland C. The Prettiest Way to Die. https://lithub.com/the-prettiest-way-to-die/
7.  Cipriano A, Cella S, Cotrufo P. Nonsuicidal Self-injury: A Systematic Review. Frontiers in Psychology https://www.frontiersin.org/articles/10.3389/fpsyg.2017.01946/full