Anorexia nervosa The term "
anorexia nervosa" was first established by Sir William Gull in 1873. In 1868, he had delivered an address to the
British Medical Association at
Oxford in which he referred to a "peculiar form of disease occurring mostly in young women, and characterised by extreme emaciation". Gull observed that the cause of the condition could not be determined, but that cases seemed mainly to occur in young women between the ages of sixteen and twenty-three. In this address, Gull referred to the condition as
Apepsia hysterica, but subsequently amended this to
Anorexia hysterica and then to
Anorexia nervosa. Five years later, in 1873, Gull published his 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 17 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 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 observed 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 was the second case described in detail by Gull in his
Anorexia nervosa paper. She was referred to Gull on 8 October 1868, aged 18, by her family who suspected
tuberculosis and wished to take her to the south of Europe for the coming winter. 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 records the details in the last of his medical papers to be published. 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 to 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. that challenged the earlier understanding of the causes of chronic
Bright's Disease. The symptoms of Bright's Disease had been described in 1827 by the English physician
Richard Bright who, like Gull, was based at Guy's Hospital. Dr. Bright's work characterised the symptoms as caused by a disease centred on the kidney. Chronic Bright's disease was a more severe variant, where other organs are also affected. In their introduction, Gull and Sutton point out that Dr. Bright and others "have fully recognised that the granular contracted kidney is usually associated with morbid changes in other organs of the body" and that these co-existent changes were commonly grouped together and termed "chronic Bright's disease." The prevailing opinion at the time was that the kidney was the organ primarily affected, inducing a condition that would spread to other parts of the body and thereby cause other organs to suffer. Gull and Sutton argued that this assumption was incorrect. They presented evidence to show that the diseased state could also originate in other organs, and that the deterioration of the kidney is part of the general morbid change, rather than the primary cause. In some cases examined by Gull and Sutton, the kidney was only marginally affected while the condition was far more advanced in other organs. Gull and Sutton's main conclusion was that the morbid change in the arteries and capillaries was the primary and essential condition of the morbid state known as chronic Bright's disease with contracted kidney. They stated that the clinical history may vary according to the organs primarily and chiefly affected; the condition could not be expected to follow a simple and predictable pattern.
Myxoedema In 1873, Sir William Gull delivered a paper alongside his
Anorexia nervosa work in which he demonstrated that the cause of myxoedema is atrophy of the thyroid gland. This paper, titled
"On a cretinoid state supervening in adult life in women" was to be the better known of the two for many years. The background to Gull's work was research performed by
Claude Bernard in 1855 around the concept of the
Milieu intérieur and subsequently by
Moritz Schiff in
Bern in 1859, and who showed that
thyroidectomy in dogs invariably proved fatal; Schiff later showed that grafts or injections of thyroid reversed the symptoms in both thyroidectomised animals and humans. He thought the thyroid liberated some important substance into the blood. Three years earlier,
Charles Hilton Fagge, also of Guy's Hospital, had produced a paper on 'sporadic cretinism'. Gull's paper related the symptoms and changed appearance of a Miss B: After the cessation of the catamenial period, became insensibly more and more languid, with general increase of bulk ... Her face altering from oval to round ... the tongue broad and thick, voice guttural, and the pronunciation as if the tongue were too large for the mouth (cretinoid) ... In the cretinoid condition in adults which I have seen, the thyroid was not enlarged ... There had been a distinct change in the mental state. The mind, which had previously been active and inquisitive, assumed a gentle, placid indifference, corresponding to the muscular languor, but the intellect was unimpaired ... The change in the skin is remarkable. The texture being peculiarly smooth and fine, and the complexion fair, at a first hasty glance there might be supposed to be a general slight oedema of it ... The beautiful delicate rose-purple tint on the cheek is entirely different from what one sees in the bloated face of renal anasarca. A few years later, in 1888, this condition would be named
myxoedema by W. M. Ord.
Spinal cord and paraplegia Paraplegia is a condition usually resulting from injury to the
spinal cord. This was a long-term interest of Gull's dating back at least to his three Goulstonian lectures of 1848, titled
On the nervous system,
Paraplegia and
Cervical paraplegia – hemiplegia. Gull divided paraplegia into three groups: spinal, peripheral, and encephalic, where the spinal group related to paralyses caused by damage to the spinal cord; the peripheral group comprised disorders that occur when multiple parts of the nervous system fail simultaneously; and the encephalic group comprised partial paralyses caused by a failure of the central nervous system, possibly related to failure of the blood supply or a syphilitic condition. Gull's main work on paraplegia was published between 1856 and 1858. Along with the French neurologist
Charles-Édouard Brown-Séquard, his work enabled paraplegic symptoms to be understood in context with the prevailing, limited understanding of spinal cord pathology, for the first time. He presented a series of 32 cases, including autopsies in 29 instances, to correlate the clinical and pathological features. He acknowledged, however, that nothing was more difficult than "the determination at the bedside, of the causes". Pathologically softening and inflammation were sometimes evident, but in many instances no obvious aetiology was found. One might have to seek for 'atomical' as distinguished from 'anatomical' causes, he speculated. He described two types of partial lesions, one confined to a segment of the spinal cord, the other extending longitudinally in one of its columns. He noticed and was puzzled by degenerations of the posterior columns that could cause an 'inability to regulate motor power'. Gull recognised girdle pain as seldom absent from extrinsic compression, often signifying meningeal involvement. Paralysis of the lower extremities could, he thought, be consequent upon diseases of the bladder and kidneys ('urinary paraplegia'). The bladder infection was the source of inflammatory phlebitis extending from pelvic to spinal veins. Meningitis with myelitis was found and attributed to exposure to cold or fatigue. In five traumatic cases, the vertebral column was often but not invariably fractured and could compress the cord. He recorded one instance in a 33-year-old woman of a thoracic disk prolapse compressing the cord, without evident trauma. Tumours also figured in seven of his 32 patients; two were metastatic from kidney and lung. Two had intramedullary cervical tumours, and one, a Guy's Hospital nurse, probably had a cystic astrocytoma. Earlier work by the Irish physician
Robert Bentley Todd (1847),
Ernest Horn, and
Moritz Heinrich Romberg(1851) had described
Tabes dorsalis and noted atrophy of the spinal cord, but in an important paper, Gull also stressed the involvement of the posterior column in paraplegia with sensory ataxia [12]. ==Quotes==