105 Pica

Pica is usually described as a pathological craving for nonfoods, although it can mean a craving for substances generally accepted to be food as well. Medical science has long been interested in this dis­order, for although it does not constitute a disease, it is often a symptom of disease and frequently is asso­ciated with nutritional deficiencies, especially those connected with minerals.

The word “pica” comes from the Latin for “magpie,” a bird that eats practically anything. The term was first used by Ambroise Pare in the 1500s, although references to pica consumption can be found in many ancient and medieval writings. M. H. Boezo, in his 1638 work De Pica, was the first to draw a distinction between “pica,” which he believed was an appetite for “absurd things,” and which was common in both men and women, and “malacia,” which referred to a vora­cious desire for normal food substances. He observed that the latter occurred most often in pregnant women, and believed the cause was a mental alter­ation caused by the pregnancy.

Classification

Probably the type of pica that has received the most scientific and lay scrutiny is the consumption of earth, called geophagy. This word was first applied by Aristotle, and it means, literally, “dirt eating.” Since that time, it has gone under many names, including allotriophagia (Sophocles), erdessen (medi­eval Germany), mal d’estomac (French), citta, and cachexia Africana. The last, from the Latin, mean­ing “the wasting away of Africans,” was a condition first noted by slave owners in the West Indies.

Still another type of pica is called papophagia, although some believe that it is not a disorder at all. The word is from the Greek and means “the eating of frost or ice,” and was coined by a U.S. Air Force doctor, Charles Coltman. Some modern weight loss plans recommend the chewing or sucking of ice as a method of appetite control, and those who work with people trying to quit smoking often suggest that smokers chew ice as a substitute.

Amylophagia refers to the consumption of laundry starch, which is almost exclusively associated with women. It was first noticed in the rural American South, and is believed to have begun with women who originally consumed clay, but switched to laun­dry starch. Hilda Hertz, in a 1947 article, observed that although the tastes of clay and starch are quite different, the texture is similar. Later research indi­cated that pregnant women ate starch because it relieved nausea, vomiting, and morning sickness. Local black culture held that if a woman consumed laundry starch while pregnant, her baby would “slide out” more easily during delivery.

Trichophagia is the ingestion of hair. Those suffer­ing from trichophagia and its associated problems are almost always young, English-speaking females with long hair who exhibit the nervous habit of chewing strands of it. It is usually related closely to “mouthing” behaviors (chewing on pencils, finger­nails, and so on but not swallowing them); if hair is accidentally ingested over a long period of time, “hairballs” can form in the stomach, causing serious gastrointestinal problems.

There are many other types of picas, including Iithophagia, the eating of rocks or pebbles.

Incidence

The reasons for the practice of pica are almost as numerous as its types. The interpretation of data on the disorder is complicated because definitions of pica are unreliable and because there is a natural reluctance on the part of practitioners to admit to the ingestion of nonfoods. This is especially true of geophagy, since “dirt-eating” is generally considered to be degenerate behavior.

Pica has been closely associated with women and pregnancy since classical times, and until recently it was believed that pregnancy caused mental instabil­ity in a woman, and thus provoked her cravings for both food and nonfood substances. Recent studies, however, have indicated that changes in sense of taste are not a constant in pregnancy, despite the desire for sharp-tasting foods. There have been many studies of the incidence of pica among preg­nant women in the United States since World War II, most carried out in rural areas. One of the most prominent of the few urban studies was done by Harry Roselle (1970), a New York medical doctor. He discovered that some of his nonpregnant patients consumed laundry starch or clay, and thought that this practice might be associated with iron-defi­ciency anemia. He prescribed iron for these patients, but their lack of cooperation did not allow him to form a firm generalization about the link between iron deficiency and pica. He did observe that hemo­globin values were unchanged while they were con­suming clay and starch, which led him to believe that pica was a symptom, rather than a cause, of the anemia.

Most medical investigations of pica tend to be most concerned with children. The practice is usu­ally associated with those in poverty, especially black children in rural areas or urban slums.

As babies explore their environment, they put a variety of things in their mouths. The actual inges­tion of nonfood substances seems to start as early as 6 months of age, but tends to decline with a develop­mental increase in hand-mouth activity and to drop sharply after the child reaches 3 years of age. Often, when pica is encountered after that age, the possibil­ity of mental disturbance is explored.

Pica is usually described as rare among adult males, although some claim that it is merely under­reported and the most common picalike practice among men - chewing tobacco - is not generally viewed to be pica. A study, carried out in Columbus, Ohio, in 1968 by J. A. Halsted found that 25 percent of 302 general patients admitted to eating clay, starch, or dirt at one time or another. Of these, only 24 percent (18 patients) were male.

Etiology

The causes of pica are not clear, and the search for them has been the subject of medical speculation since antiquity. Pica has been seen by most modern doctors and nutritionists chiefly as a means of allevi­ating nutritional deficiency. Similarly, most ancient and medieval scholars concerned with the subject stressed the importance of good nutrition and recom­mended fresh fruit and vegetables as a remedy. De­spite innumerable recent studies, however, no defi­nite connection has been established between pica and dietary imbalance. Nutrients in which pica prac­titioners are thought to be deficient include vita­mins C and D, phosphorus, calcium, zinc, and espe­cially iron. As early as A.D. 1000, Avicenna was treating pica with iron, and the search for the rela­tionship between iron deficiency and pica continues today.

Psychiatrists and psychologists often feel that both nutritional deficiencies and psychological disorders are linked in pica patients.

There is also a “cultural” etiology for pica. Anthro­pologists have long been searching the past for prac­tical reasons to explain why certain cultures and religions require the consumption of nonfood items. Symbolic geophagy was practiced in ancient times in Europe (so-called terra sigilata, or “sealed earth”), in the Middle East (consumption of a bit of dust from Mohammed’s tomb), and even among early Chris­tians. In parts of Africa it is thought that clay eating promotes fertility in women and lactation during pregnancy. John M. Himter (1973) has postulated a culture-nutrition hypothesis, which attempts to demonstrate how geophagy, a type of pica, evolved from a nutritional activity and physiological impera­tive into a cultural institution in some societies. Pregnant women in Nigeria consumed clay in a cul­turally acceptable way, purchased loaves in the mar­ketplace, and gained needed calcium and magne­sium as a result.

A last reason for pica is for pharmacological pur­poses.

History and Geography

Antiquity

Pica was well known to the ancients: Aristotle and Socrates both wrote of the practice of earth eating, and it is known that in Greece, as early as 40 B.C., the sacred “sealed earth” was used as a sort of magi­cal “cure-all.” The clays of the islands of Samos, Chios, and Selinos in the Aegean Sea were said to be especially effective. Galen took 20,000 lozenges of the clay from Lemnos back to Rome, and used them to treat poison victims.

Pliny the Elder noted that some residents of the province of Campania mixed white chalk with their porridge, to give it some color and texture. The chalk came from a hill called Leucogauem, which in Greek means “white earth.” Supposedly, Caesar Augustus ordered 20,000 sesterces to be paid yearly to the Neapolitans on behalf of the Campanians for the lease of the hill, without which, the Campanians claimed, they could not make their porridge. Pliny also noted a region in northern Africa where a simi­lar porridge was made with gypsum mixed in.

Many of the earliest medical writers tended to concentrate on the pica habits of pregnant women. In the sixth century, Aetius of Amida claimed that the urge to consume nonfoods was caused by a sup­pression of the menstrual flow, which in turn was caused by pressure from the fetus. He recommended exercise and fresh fruits and vegetables.

The Middle Ages

Avicenna described pica (although not by that name) and employed various iron preparations, among them iron dross steeped in fine wine and strained through a plant known as “Hippocrates’ sleeve.” Avicenna felt that an excessive appetite for sour and sharp-tasting foods was more easily remedied than one for dry things such as clay and charcoal. He further believed that pica in pregnant women was treatable by this method, but if the children of that pregnancy began practicing pica, they could not be cured of it. This disorder must have been fairly wide­spread, because Avicenna wrote of the need to con­trol it in young boys, and recommended imprison­ment if necessary, although pregnant women were to be treated more gently, for fear of damaging the infant.

Medical writers of the Middle Ages tended to view mental instability and food as important causes of pica. J. Ledelius, for example, stated that bits of left­over food in the stomach rotted and gave off four humors that ruined an individual’s sense of taste and caused the craving of all sorts of odd substances. H. Betten, by contrast, argued that the cause of pica was not foul humors in the stomach but weakness of the mind. An individual whose mind was controlled by emotion was far more likely to consume nonfoods than one whose mind was controlled by discipline. He concluded that this was the reason women exhibited pica symptoms more often than men. However, he did not advocate denying women the substances they craved, for to do so, he thought, would damage the fetus. He recommended that nonpregnant women be given stern lectures to strengthen their wills, and various prescriptions to strengthen their stomachs.

Famine was often the cause of pica use. During periods of famine in China, individuals would con­sume clays of various colors and types in place of rice. Usually grass, foliage, weeds, and tree bark were used as famine food, but in truly desperate times, such as the famine of 1640 in what is now Hunan Province, the people ate not only clay but also boiled shoes, leather, and wood.

Similarly, in Europe, during the Thirty Years’ War, while armies were ravaging the countryside and taking food from every village they encoun­tered, the peasants of Pomerania turned to baking bread with dough mixed with powdered earth. The practice of baking earth into bread was also ob­served in Germany during the War of the Austrian Succession, not only in peasant villages but even in the castle of Wittenberg.

Nineteenth Century: Pica, Exploration, and Empire

As Europeans began to explore Africa, Asia, and the Western Hemisphere, they discovered that pica seemed to exist, or to have existed, on almost every continent of the globe. Alexander von Humboldt and A. Bonpland (1804) found that some of the natives of South America engaged in pica. The Otomac Indian tribe, who lived along the Orinoco River, were par­ticularly fond of consuming an iron-rich clay during the lean months when the river overflowed its banks. Pica was also discovered among the natives of some mountainous regions of Peru, where powdered lime mixed with coca leaves was sold in the marketplaces. The Indians of the Rio de la Hacha, however, pre­ferred to consume the lime without additives, and usually carried it about with them in small boxes.

In central Africa, David Livingstone (1870) re­ported that some of the tribes were clay eaters. The Africans referred to the practice as safura; it was most notable among pregnant women of the area, but it was also practiced by males of all classes. The availability of food seemed to have no bearing on whether an individual chose to consume clay or not.

The literature of India indicates that geophagy was practiced on the subcontinent in ancient times; yet none of the early Portuguese or English ac­counts of India in the seventeenth and eighteenth centuries makes any mention of pica. By the end of the nineteenth century, however, British colonial physicians began to write about the earth eaters of India, believing that it was universal there. Native- born physicians also wrote about the subject, and one, Sarat Chandra Mitra (1904-7), thought it was a racial characteristic. Although he acknowledged that clay eating was practiced in many areas of the world, he thought that the Aryan and Dravidian races were unique in that they tended to use it for food on a regular basis, whereas other races ate it for sustenance only occasionally, or for pharmaceuti­cal reasons.

David Hooper and Harold Mann (1906) published a more extensive study of pica in India a year later, in which they took issue with Mitra’s assertion that clay eating was a racial characteristic. They be­lieved that the reason people in all cultures of India consumed clay was to alleviate the symptoms of dis­ease: gastric or intestinal irritation, anemia, even as a remedy for cholera.

Pica and Slavery

Plantation owners and managers in all areas of the slaveholding New World were concerned with the practice of pica by their slaves, because those who consumed earth appeared to become addicted to it, and the addiction was thought to be fatal. Planters referred to pica as a disease, calling it mαl d’estomac, cachexia Africana, stomach evil, or dirt eating. Con­temporary authors described the practice as wide­spread in the British West Indies. The dirt eaters usually became sick, suffering from stomach pains and difficult breathing. This was often followed by nausea and diarrhea, depression, and Iistlessness. Death followed within 2 or 3 months. Plantation owners and managers tried every means at their disposal to break the habit in those slaves who ac­quired it, but were generally unsuccessful.

John Imray, an Edinburgh-trained physician who resided in Dominica, wrote in 1843 that pica in the West Indies had become much rarer after the slaves were emancipated. He was convinced that a change in life-style was sufficient to cure earth eating. Slaves, in many cases, had been expected to feed themselves with their provision grounds, but be­cause they had been overworked by the sugar plant­ers, they had little energy left for their own crops. In desperation, they turned to earth eating. Freedom gave the blacks more time to grow and prepare their food. On the other hand, the diet and system of feeding slaves on the North American continent were much different from and nutritionally better than the diet and feeding system in the West Indies. Yet pica was also reportedly a serious problem among slaves in the southern United States.

Twentieth Century

The association of iron deficiency with earth eating, which we have seen since earliest times, has contin­ued into the twentieth century, as physicians came increasingly to believe that anemia was the cause of geophagy, and that iron preparations were the cure. At the same time, however, the dangers of the consumption of some kinds of pica materials were discovered.

In 1924 J. C. Ruddock suggested, in an article in the Journal of the American Medical Association, that lead poisoning was the result of some types of pica. As awareness of the dangers of the consumption by chil­dren of paint chips increased, the U.S. government moved to limit the lead content of commercially avail­able paints and plasters in the early 1940s. Unfortu­nately, pica continued to be a major cause of lead poi­soning in children. In New York City alone, there were about 52 reported cases of lead poisoning every year, with case-mortality rates ranging between 13 and 27 percent. The cause of the poisoning was almost always the ingestion of plaster and chips of lead­based paint in old, run-down tenements.

Geographic studies of pica, especially geophagy, began to appear in the late nineteenth and twenti­eth centuries. In Germany, R. Lasch (1898) wrote a preliminary study, which was the basis for Berthold Laufer’s larger study of geophagy, published by the Field Museum of Natural History in 1930. Laufer’s approach was different from previous works in that he surveyed every continent on the globe in which geophagy had been reported, and for the first time, information of the practice in ancient China was published in English.

Articles by physicians and nutritionists appeared in the late 1940s and early 1950s, as the practice of clay eating in the southern and urban areas of the United States was given a clinical examination. In their 1942 survey of black children in rural Missis­sippi, Dorothy Dickens and R. N. Ford found that of the 209 children in the sample, 25 percent of the girls and 26 percent of the boys had eaten either dirt or clay in the previous 2 weeks. Hertz (1947) ob­served the practice among pregnant black women in North Carolina, and because there were no reports of clay eating among the male population, she con­cluded that the practice was related to gender. Al­bert Whiting (1947), following up Hertz’s study in that same year, examined the types of clays used in pica, and reported on the consumption of soot from stove pipes. Pica users did not eat the soot directly, but placed it in bags and soaked them in water, making a sort of tea. In the 1950s, Cecile Hoover Edwards and her colleagues (1954, 1959) undertook a study of rural women in Alabama, examining why pregnant women craved certain nonfood items. They issued questionnaires to 47 health agencies and 91 individual health workers in the southeastern re­gion of the United States, and found that supersti­tion and oral tradition played a large role in the selection of pica materials. In a subsequent study, intending to determine the nutritive value of the clays consumed, they discovered that women who ate clay and cornstarch had diets that were other­wise low in calories, calcium, iron, thiamine, and niacin.

Two major studies of pica appeared in the late 1950s. In 1957 Marcia Cooper published a book­length study of pica, which included its history and association with mental and physical illness, physi­cal defects, and nutrition. According to Cooper, pica becomes established in children because they lack an understanding of dietary taboos. Poor nutrition leads them to practice pica with any number of sub­stances that might be mouthed or eaten. Cooper acknowledged that the exact causes of pica were not completely demonstrated by her work, but was cer­tain that more clinical studies in the future would elucidate them.

The other major work on pica, published by Bengt Anell and Sture Lagercrantz in Sweden in 1958, was focused on the geography of the disorder, and scruti­nized geophagy in Indonesia and Oceania, as well as among blacks in Afnca and America.

Throughout the century, most studies have as­sumed that a nutritional deficiency leads to pica, and, although iron deficiency is assumed to be the major cause, other trace elements, especially zinc, have also been investigated. Yet, despite the fact that the connection between iron-deficiency anemia and pica has been recognized for centuries, the ques­tion of whether pica is a cause or an effect of the anemia is still sometimes debated. Moreover, al­though both children and pregnant women engage in pica, there is no clear understanding of the physio­logical mechanisms that drive them to it. Thus, al­though pica has been recognized by practitioners of medicine since the beginning of recorded history, medicine seems little closer today to understanding its causes.

Brian T. Higgins

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