Five years later, in 1873, Gull published his seminal work “Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica)", in which he describes the three cases of Miss A, Miss B, and a third unnamed case. In 1887, he also recorded the case of Miss K, in what was to be the last of his medical papers to be published.
Miss A was referred to Sir William Gull by her doctor, a Mr Kelson Wright, of Clapham, London on 17th January 1866. She was aged 17 and was greatly emaciated, having lost 33 pounds. Her weight at this time was 5 stones 12 pounds (82 pounds); her height was 5 ft 5 inches. Gull records that she had suffered from amenorrhoea for nearly a year, but that otherwise her physical condition was mostly normal, with healthy respiration and heart sounds and pulse; no vomiting nor diarrhoea; clean tongue and normal urine. The pulse was slightly low at between 56 and 60. The condition was that of simple starvation, with total refusal of animal food and almost total refusal of everything else.
Gull prescribed various remedies (including preparations of cinchona, biochloride of mercury, syrup of iodide of iron, syrup of phosphate of iron, citrate of quinine) and variations in diet without noticeable success. He noted occasional voracious appetite for very brief periods, but states that these were very rare and exceptional. He also records that she was frequently restless and active and notes that this was a "striking expression of the nervous state, for it seemed hardly possible that a body so wasted could undergo the exercise which seemed agreeable".
In Gull's published medical papers, images of Miss A are shown that depict her appearance before and after treatment (right). Gull notes her aged appearance at age 17:
It will be noticeable that as she recovered she had a much younger look, corresponding indeed to her age, twenty-one; whilst the photographs, taken when she was seventeen, give her the appearance of being nearer thirty.
Miss A remained under Gull's observation from January 1866 to March 1868, by which time she seemed to have made a full recovery, having gained in weight from 82 to 128 pounds.
Miss B, pictured around 1868 aged 18 (No. 1) and 1872 (No. 2). From the published medical papers of Gull
Gull noted that her emaciated appearance was more extreme than normally occurs in tubercular cases. His physical examination of her chest and abdomen discovered nothing abnormal, other than a low pulse of 50, but he recorded a "peculiar restlessness" that was difficult to control. The mother advised that "She is never tired". Gull was struck by the similarity of the case to that of Miss A, even to the detail of the pulse and respiration observations.
Miss B was treated by Gull until 1872, by which time a noticeable recovery was underway and eventually complete. Gull admits in his medical papers that the medical treatment probably did not contribute much to the recovery, consisting, as in the former case, of various tonics and a nourishing diet.
Miss K was brought to Gull's attention by a Dr. Leachman, of Petersfield, in 1887. He notes the details in the last of his medical papers to be published.[24] Miss K was aged 14 years in 1887. She was the third child in a family of six, one of whom died in infancy. Her father had died, aged 68, of pneumonic phthisis. Her mother was living and in good health; she had a sister who displayed various nervous symptoms and an eplieptic nephew. With these exceptions, no other neurotic cases were recorded in the family. Miss K, who was described as a plump, healthy girl until the beginning of 1887, began to refuse all food except half cups of tea or coffee in February that year. She was referred to Gull and began to visit him of 20 April 1887; in his notes, he remarks that she persisted in walking through the streets to his house despite being an object of attention to passers-by. He records that she displayed no sign of organic disease; her respiration was 12 to 14; her pulse was 46; and her temperature was 97ยบ. Her urine was normal. Her weight was 4 stone 7 pounds (63 pounds) and her height was 5 feet 4 inches. Miss K expressed herself to Gull as "quite well". Gull arranged for a nurse from Guy's to supervise her diet, ordering light food every few hours. After six weeks, Dr. Leachman reported good progress and by 27 July her mother reported that her recovery was almost complete, with the nurse by this time no longer being needed.
Photographs of Miss K appear in Gull's published papers. The first is dated 21 April 1887 and shows the subject in a state of extreme emaciation. The unclothed torso and head is displayed with the ribcage and clavicle clearly visible. The second photograph is dated 14 June 1887 in a similar attitude and shows a clear recovery.
Although the cases of Miss A, Miss B and Miss K resulted in recovery, Gull states that he observed at least one fatality as a result of anorexia nervosa. He states that the post mortem revealed no physical abnormalities other than thrombosis of the femoral veins. Death appeared to have resulted from starvation alone.
Gull observed that slow pulse and respiration seemed to be common factors in all the cases he had observed. He also observed that this resulted in below-normal body temperature and proposed the application of external heat as a possible treatment. This proposal is still debated by scientists today.
Gull also recommended that food should be administered at intervals varying inversely with the periods of exhaustion and emaciation. He believed that the inclination of the patient should in no way be consulted; and that the tendency of the medical attendant indulge the patient ("Let her do as she likes. Don't force food"), particularly in the early stages of the condition, was dangerous and should be discouraged. Gull states that he formed this opinion after experience of dealing with cases of anoerexia nervosa, having previously himself been inclined to indulge patients' wishes.( wikipedia ).
Read here : Acne in Anorexia Nervosa
