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^[28] 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.^[29]

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.^[30] In 1887, he also recorded the case of Miss K, in what was to be the last of his medical papers to be published.^[31]

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.^[32]

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.^[33]

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.^[31] 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 multiple nervous symptoms and an epileptic 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 97 °F. 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.^[34]

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.^[35]

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.^[29]

Gull–Sutton Syndrome (chronic Bright's disease)

In 1872, Sir William Gull and Henry G. Sutton, M.B., F.R.C.P. presented a paper^[36] 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^[37] 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^[38] 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.^[39]

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.^[40]

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.^[41]

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].^[41]

1895–1897 – U.S. newspaper reports

The earliest known allegation that links the Whitechapel murders with a prominent London physician (not necessarily Gull) was in two articles published by a number of US newspapers between 1895 and 1897.

The first article appeared in the Fort Wayne Weekly Sentinel (24 April 1895),^[42] the Fort Wayne Weekly Gazette (25 April 1895)^[43] and the Ogden Standard, Utah.^[44] It reported an alleged conversation between William Greer Harrison, a prominent San Francisco citizen, and a Dr Howard of London. According to Howard, the murderer was a "medical man of high standing" whose wife had become alarmed by his erratic behaviour during the period of the Whitechapel murders. She conveyed her suspicions to some of her husband's medical colleagues who, after interviewing him and searching the house, "found ample proofs of murder" and committed him to an asylum.

Variations of the second article appeared in the Williamsport Sunday Grit (12 May 1895);^[45] the Hayward Review, California (17 May 1895);^[46] and the Brooklyn Daily Eagle (28 December 1897).^[47] This article comments: "the identity of that incarnate fiend was settled some time ago" and that the murderer was "a demented physician afflicted with wildly uncontrollable erotic mania." It repeats some of the details in the earlier report, adding that Dr Howard "was one of a dozen London physicians who sat as a commission in lunacy upon their brother physician, for at last it was definitely proved that the dread Jack the Ripper was a physician in high standing and enjoying the patronage of the best society in the West End of London." The article goes on to allege that the preacher and spiritualist Robert James Lees played a leading role in the physician's arrest by using his clairvoyant powers to divine that the Whitechapel murderer lived in a house in Mayfair. He persuaded police to enter the house, the home of a distinguished physician, who was allegedly removed to a private insane asylum in Islington under the name of Thomas Mason. Meanwhile the disappearance of the physician was explained by announcing his death and faking a funeral – "an empty coffin, which now reposes in the family vaults in Kensal Green, is supposed to contain the mortal remains of a great West End physician, whose untimely death all London mourned." (This detail does not correspond with Sir William Gull, who was buried in the churchyard at Thorpe-le-Soken in Essex.)

The identity of the Dr Howard who is alleged to have provided the information for the first article was never established. On 2 May 1895, the Fort Wayne Weekly Gazette published a follow-up quoting William Greer [sic] as reaffirming the accuracy of the story, and describing Dr. Howard as a "well-known London physician who passed through San Francisco on a tour of the world several months ago".^[48] A further follow-up article in the London People on 19 May 1895, written by Joseph Hatton, identified him as Dr. Benjamin Howard, an American doctor who had practised in London during the late 1880s. The article was shown to Dr. Benjamin Howard on a return visit to London in January 1896, prompting a strong letter of denial published in The People on 26 January 1896:

In this publication my name is dishonourably associated with Jack the Ripper – and in such a way – as if true – renders me liable to shew cause to the British Medical Council why my name with three degrees attached should not be expunged from the Official Register. Unfortunately for the Parties of the other part – there is not a single item of this startling statement concerning me which has the slightest foundation in fact. Beyond what I may have read in the newspapers, I have never known anything about Jack the Ripper. I have never made any public statement about Jack the Ripper – and at the time of the alleged public statement by me I was thousands of miles distant from San Francisco where it was alleged that I made it.^[49]

1970 – Criminologist article (Thomas Stowell)

Dr. Thomas Eldon Alexander Stowell, C.B.E., M.D., F.R.C.S. published an article in The Criminologist entitled "'Jack the Ripper' – A Solution?"^[50]

Stowell was a junior colleague to Dr Theodore Dyke Acland, Gull's son-in-law. He alleges that one of Gull's patients was the Whitechapel murderer. He refers to the killer as "S" throughout the article without ever identifying him, but the identity of "S" is widely presumed to be Prince Albert Victor, Duke of Clarence and Avondale, Queen Victoria's grandson and heir presumptive to the throne. Stowell writes,

"S" was the heir to power and wealth. His grandmother, who outlived him, was very much the stern Victorian matriarch... His father, to whose title he was the heir, was a gay cosmopolitan and did much to improve the status of England internationally. [At 21, he was] gazetted to a commission in the army... He resigned his commission shortly after the raiding of some premises in Cleveland Street, which were frequented by aristocrats and well-to-do homosexuals."

Stowell apparently devised his theory using Sir William Gull's private papers as his primary source material. However, this cannot be confirmed as Stowell died a few days after publishing his article and his family burned his papers. Gull (who was named in the article) supposedly left papers showing that "S" had not died of pneumonia, as had been reported, but of tertiary syphilis. Stowell states that "S" caught syphilis in the West Indies while touring the world in his late teens and it was this illness that brought on a state of insanity which led to the murders.

He goes on to allege that "S" was certified insane by Gull and placed in a private mental home, from which he escaped and committed the last, and most brutal, murder of Mary Jane Kelly in November 1888. He then recovered sufficiently to take a five-month cruise before his relapse and death "in his father's country house" of "bronchopneumonia".

1973 – "Jack the Ripper" (BBC mini-series)

In 1973, the BBC broadcast Jack the Ripper, a six-part mini-series in the docudrama format. The series, scripted by Elwyn Jones and John Lloyd, used fictional detectives Detective Chief Inspector Charles Barlow and Detective Inspector John Watt from the police drama Softly, Softly to portray an investigation into the Whitechapel murders.

The series did not reach a single conclusion, but is significant for its inclusion of the first public airing of a story propounded by Joseph "Hobo" Sickert, alleged illegitimate son of artist Walter Sickert. This theory alleges that the Prime Minister, Lord Salisbury, conspired with Queen Victoria and senior Freemasons, including senior police officers, to murder a number of women with knowledge of an illegitimate Catholic heir to the throne sired by Prince Albert Victor. According to this theory, the murders were carried out by Sir William Gull with the assistance of a coachman, John Netley. Sickert himself later retracted the story, in an interview with the Sunday Times on 18 June 1978. He is quoted as saying, "It was a hoax; I made it all up" and, it was "a whopping fib."^[51][52]

1976 – "Jack the Ripper: The Final Solution" (Stephen Knight)

Stephen Knight was a reporter for the East London Advertiser who interviewed Joseph Sickert following the BBC series. He was sufficiently convinced by the story to write a book – Jack the Ripper: The Final Solution – which proposes the Sickert story as its central conclusion. The book provides the inspiration for a number of fictional works related to the Whitechapel murderers.

Knight undertook his own research, which established that there really was a coachman named John Netley; that an unnamed child was knocked down in the Strand in October 1888 and that a man named "Nickley" attempted suicide by drowning from Westminster Bridge in 1892. He was also provided with access to Home Office files, from which a number of contemporary police reports were made public for the first time.

Knight's claim that Sir William Gull, along with various others, was a high-ranking Freemason, is disputed. Knight writes:

It is impossible to find out if some of the lesser known people in Sickert's story were Masons. The chief characters certainly were. Warren, Gull, and Salisbury were all well advanced on the Masonic ladder. Salisbury, whose father had been Vice Grand Master of All England, was so advanced that in 1873 a new Lodge was consecrated in his name. The Salisbury Lodge met at the premier Masonic venue in England, the Freemasons' Hall in Great Queen Street, London.

This claim is refuted by John Hamill, former Librarian for the Freemasons' United Grand Lodge of England (subsequently the Director of Communications). Hamill writes:

The Stephen Knight thesis is based upon the claim that the main protagonists, the Prime Minister Lord Salisbury, Sir Charles Warren, Sir James Anderson and Sir William Gull were all high-ranking Freemasons. Knight knew his claim to be false for, in 1973, I received a phone call from him in the Library, in which he asked for confirmation of their membership. After a lengthy search I informed him that only Sir Charles Warren had been a Freemason. Regrettably, he chose to ignore this answer as it ruined his story.^[53]

Popular culture since 1976

In 1979, the fictional character Sir Thomas Spivey, portrayed by actor Roy Lansford, appears in Murder by Decree, starring Christopher Plummer as Sherlock Holmes and James Mason as Doctor Watson. Sir Thomas Spivey, a Royal physician whose character is based on Sir William Gull, is revealed as the murderer in a plotline based on Stephen Knight's Jack the Ripper: The Final Solution.^[54] Spivey is depicted as assisted by a character named William Slade, himself based on John Netley.

A fictionalised Sir William Gull appears in Iain Sinclair's 1987 novel White Chappell, Scarlet Tracings in a plotline based on Stephen Knight's Jack the Ripper: The Final Solution.

Sir William Gull is portrayed by Ray McAnally in 1988^[55] in a TV dramatisation of the murders, starring Michael Caine and Jane Seymour. The plotline reveals Sir William Gull as the murderer, assisted by coachman John Netley, but otherwise excludes the main elements of the Royal conspiracy theory.

From 1991 to 1996, a fictionalised Sir William Gull is featured in the graphic novel From Hell by writer Alan Moore and artist Eddie Campbell. The plotline depicts Sir William Gull as the murderer and takes Stephen Knight's Jack the Ripper: The Final Solution as its premise. Eddie Campbell records in his blog,^[56] that

I've always liked to imagine that our William Gull is a fiction who just happens to share a name with a real one who existed once.

The story "Royal Blood" told in John Constantine, Hellblazer (1992, DC Comics) mentions Jack the Ripper being Sir William Gull possessed by a demon called Calibraxis.^[57]

The fictional character "Sir Nigel Gull" appears in the 1993 novel The List of Seven by Mark Frost. "Sir Nigel Gull" is depicted as a Royal physician and appears to be based on Sir William Gull. The plotline has an occult theme that features Prince Edward, Duke of Clarence but does not reference the Whitechapel murders.

The 1997 TV series Timecop reveals Gull as the Ripper in its pilot, "A Rip in Time".

In a 2001 film adaptation of the graphic novel From Hell, Sir William Gull is portrayed by Sir Ian Holm.

Actor Peter Penry-Jones portrays Sir William Gull in 2004's Julian Fellowes Investigates: A Most Mysterious Murder – The Case of Charles Bravo – a dramatised documentary investigating the unsolved murder of barrister Charles Bravo in 1876.

Gull appears as a character in Brian Catling's 2012 novel, The Vorrh, where accounts of his relationship with Eadweard Muybridge and work on anorexia are blended into the fantasy narrative.