Miss A., æt. 17, under the care of Mr. Kelson Wright,  of the Clapham Road, was brought to me on Jan.. 17, 1866. Her emaciation was very great. It was stated that she had lost 33 lbs. in weight. She was the 5 st. 12 lbs. Height, 5ft. 5in. Amenorrhœa for nearly a year. No cough. respirations throughout chest everywhere normal. Heart-sounds normal. Resps. 12; pulse, 56. no vomiting nor diarrhœa. Slight constipation. Complete anorexia for animal food, and almost complete anorexia for everything else. Abdomen shrunk and flat, collapsed. No abnormal pulsations of aorta. tongue clean. Urine normal. Slight deposits of phosphates on boiling. The condition was one of simple starvation. There was but slight variation in her condition, though observed at intervals of three or four months. The pulse was noted on these several occasions as 56 and 60. Resps. 12 to 15. The urine was always normal, but varied in sp. gr., and was sometimes as low as 1005. The case was regarded as one of simple anorexia. …Occasionally for a day or two the appetitie was voracious, but this was very rare and exceptional. The patient complained of no pain, but was restless and active. This was in fact a striking expression of the nervous state, for it seemed hardly possible that a body so wasted could undergo the exercise which seemed agreeable. There was some peevishness of temper, and a feeling of jealousy. No account could be given of the exciting cause.

Sir William Withey Gull MD Bart, "Anorexia nervosa (apepsia hysterica, anorexia hysterica)," Transactions of the Clinical Society of London, 7, 22-8

What treatment was prescribed?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Various remedies were prescribed--the preparations of cinchona, the bichloride of mercury, syrup of the iodide of iron, syrup of the phosphate of iron, citrate of quinine and iron, &c.--but no perceptible effect followed their administration. The diet also was varied, but without any effect on the appetite.
 

What was the outcome?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Miss A remained under my observation from Jan. 1866 to March 1868, when she had much improved, and gained in weight from 82 to 128 lbs. The improvement from this time continued, and I saw no more of her medically. The Woodcut, Miss A., No. 2, from photograph taken in 1870, shows her condition at that time. It will be noticeable that as she recovered she had a much younger look, corresponding indeed to her age, 21; whilst the photographs, taken when she was 17, give her the appearance of being near 30. Her health has continued good…
 

How did Gull understand this case?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

It will be observed that all the conditions in this case were negative, and may be explained by the anorexia which led to starvation, and a depression of all the vital functions; viz., amenorrhœa, slow pulse, slow breathing. In the stage of greatest emaciation one might have been pardoned for assuming that there was some organic lesion, but from the point of view indicated such an assumption would have been unnecessary.…The want of appetite is I believe, due to a morbid mental state. I have not observed in these cases any gastric disorder to which the want of appetite could be referred. I believe, therefore, that its origin is central and not peripheral. That mental states may destroy appetite is notorious, and it will be admitted that young women at the ages named are specially obnoxious to mental perversity. We might call the state hysterical without committing ourselves to the etymological value of the word, or maintaining that the subjects of it have the common symptoms of hysteria. i prefer, however, the more general term of 'nervosa,' since the disease occurs in males as well as females, and is probably rather central than peripheral. The importance of discriminating such cases in practice is obvious; otherwise prognosis will be erroneous, and treatment misdirected.
    In one of the cases i have named the patient had been sent abroad for one or two winters, under the idea that there was a tubercular tendency. I have remarked …that these wilful patients are often allowed to drift their own way into a state of extreme exhaustion, when it might have been prevented by placing them under different moral conditions.
    The treatment required is obviously that which is fitted for persons of unsound mind. The patients should be fed at regular intervals, and surrounded by persons who would have moral control over them; relations and friends generally being the worst attendants.