MUNCHAUSEN'S SYNDROME
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639 Hedley Visick,3 later amplified by Hermon Taylor 4 and by Stead,5 suggests that some cases of perforation are better treated conservatively. It should also be realised that very early cases are in a state of acute shock ; lately Selye 6 has defined this phase in more precise biochemical terms, calling it the " damage phase of the alarm reac- tion." It is, of course, the wrong time for operation. Twenty-seven years ago Panuett 7 was teaching this ; he instanced the case of a man who perforated on the steps of the Royal Free Hospital. At first it was a matter for congratulation that he was rushed to the theatre within an hour, but he died soon after a straightforward operation. There are many obstacles which delay the progress of the " acute abdomen " from his home to the operating-theatre. One may speculate that these irri- tating difficulties must have saved thousands of lives. East London, South Africa. BERNARD GOLDSTONE. VACCINATION AGAINST SMALLPOX SIR,—Commenting on my letter published in your issue of Feb. 10, Dr. Millard (Feb. 24) writes : " I am also in favour of such people being inoculated against typhoid, but I do not think it necessary that everyone in this country should be similarly inoculated." I did not suggest that, because Dr. Millard favours vaccina- tion of all who visit the East, he should therefore advocate universal vaccination, but pointed out that, taking his argument to its logical conclusion, the vaccination of such travellers would increase the number of undetected cases of smallpox among them. Dr. Millard’s main argument against vaccination was that it is liable to render attacks so mild and atypical that they pass unnoticed and constitute a danger to others. He then recommended vaccinating the very people most likely to bring the disease into the country. There is surely an inconsistency here. At the same time Dr. Millard would leave unprotected those who remain at home and will be exposed to infection from the unrecognised case of smallpox in the vaccinated traveller. It is difficult to imagine a policy more calculated to increase the number and severity of epidemics. Arlesheim, Switzerland. A. M. WOOLMAN. SIR,—Dr. Millard’s deligl)tfully provocative article raises the question whether variola minor and variola major are the same disease and caused by the same virus. For the last six years in the Upper Nile province of the Sudan we have had a slowly developing epidemic of variola minor, with about 270 notified cases and 5 deaths. The disease was at first regarded as chickenpox, but after a few reported deaths it was diagnosed as variola major. Vaccination campaigns were organised, but because of the nature of the country they were largely ineffective, and vaccination was abandoned as soon as the disease was recognised as variola minor. The infection spread through the province slowly by traceable tribal contacts. On two occasions laboratory tests proved it was variola and not chickenpox. The clinical aspect of the cases, and the slow spread, gave the epidemic a totally different picture from that of variola major. The epidemic occurred in a comparatively primitive community of 80,000 people in an area of 90,000 sq. miles, and the number of cases notified was probably less than half the total. In one area where we instituted quarantine the people asked us not to do so because they knew that the disease was different from variola major and conferred immunity against variola major : in fact they welcomed its appearance. 3. Visick, H. S. Brit. med. J. 1946, ii, 941. 4. Taylor, H. Lancet, Jan. 6, 1951, p. 7. 5. Stead, J. R. Ibid, p. 12. 6. Selye, H. Stress. Montreal, 1951 ; p. 96. 7. Pannett, C. A. Personal communication. 1924. Contrast this slow epidemic with one seen in 1947 in a similarly primitive population at Yirrol in the Bahr el Ghazal province, where there were 280 cases with 117 deaths. It was a flare-up, rapid in growth, killing in its severity, and again rapid in its decline-thanks mainly to an intensive vaccination campaign. In the Upper Nile outbreak we abandoned vaccination on advice from laboratory specialists, and because climatic conditions and communication difficulties made it impossible to guarantee the supply of lymph vaccine regularly and in an active state. In some areas, owing to such difficulties, we had less than 15% " takes." I think there can be little doubt that there are two different diseases, both clinically and epidemiologically, and that the viruses are different. The distribution of the rash is the same, and the rash is in one stage ; but in variola minor it is less profuse, and not so confluent in the axillae and the groin, though confluent cases occur with facial distributions. The patient is not so seriously ill when the rash is in its pustular stage as in cases of variola major. The differentiation between variola minor and chickenpox is often difficult unless care is taken to examine the extremities and the rash itself. Generally mistakes are made most when the prodromal rash is not regarded as such, and the main disease is missed. The immunological reactions between vaccinia virus and the various geographical strains of the variola minor virus also vary.! There is yet no evidence to prove that variola virus strains change their virulence : the major runs true to type, and so does the minor virus. The differences are evident epidemiologically and clinically : variola minor gives a negligible mortality, rarely reaching 3%, compared with 20-30% for variola major. I suggest that the two diseases are entirely different entities, and that to confuse the two is to confuse the whole issue. Dr. Millard’s note that in the past inoculation used to be resorted to, and that inoculation was preferably from serious rather than mild cases is of historic interest. In the Sudan in the 18th century inoculation was also practised. A piece of rag was tied round the arm of a serious case and its price was haggled over. The person to be inoculated eventually bought it, having a guarantee not to get more than so many pocks. If he had a severe attack he claimed his money back, if he survived. Possible explanations are that the virus had " burnt itself out " in the serious case, or that the patient’s reactions had reduced its virulence. Malakal. J. F. E. BLOSS P.M.I. (M.O.H.) Upper Nile Province, Anglo-Egyptian Sudan. MUNCHAUSEN’S SYNDROME SIR,-A further example of the Munchausen syndrome was recalled to my notice today when a query arrived from the Royal Victoria Hospital, Folkestone, about a man’treated here last April. A few days after his irregular discharge from the Western Infirmary, Glasgow, early in May, 1950, he was admitted as an emergency to the West London Hospital. This man is 23 or 24, Irish, and of somewhat prognathous appearance. He claims to be aspiring to the priesthood ; and his complaints usually take the form of bleeding from nose, eyes, ears, and urinary tract, along with great pain of a renal- colic type. He has a rooted objection to cystoscopy or catheterisation, the threat of which leads to a demand for discharge. No cause can be found for his bleeding ; but sharp instruments may be found in his bed, and many of the blood- stained sites show no bleeding-point. He tends to ascribe his symptoms to trauma before admission, and is admitted following collapse in the street. I should be most interested to know if he has been an inmate of other hospitals. I feel sure that he has been in many in the past nine months. Western Infirmary, Glasgow. IAN A. SHORT. 1. Horgan, E. S., Haseeb, M. A., Satti, M. H. Brit. J. exp. Path. 1948, 29, 347.
Transcript of MUNCHAUSEN'S SYNDROME
639
Hedley Visick,3 later amplified by Hermon Taylor 4 andby Stead,5 suggests that some cases of perforation arebetter treated conservatively. It should also be realisedthat very early cases are in a state of acute shock ; latelySelye 6 has defined this phase in more precise biochemicalterms, calling it the " damage phase of the alarm reac-tion." It is, of course, the wrong time for operation.Twenty-seven years ago Panuett 7 was teaching this ;he instanced the case of a man who perforated on thesteps of the Royal Free Hospital. At first it was a matterfor congratulation that he was rushed to the theatrewithin an hour, but he died soon after a straightforwardoperation. There are many obstacles which delay theprogress of the " acute abdomen " from his home to the
operating-theatre. One may speculate that these irri-tating difficulties must have saved thousands of lives.
East London,South Africa. BERNARD GOLDSTONE.
VACCINATION AGAINST SMALLPOX
SIR,—Commenting on my letter published in yourissue of Feb. 10, Dr. Millard (Feb. 24) writes : " I amalso in favour of such people being inoculated againsttyphoid, but I do not think it necessary that everyonein this country should be similarly inoculated." Idid not suggest that, because Dr. Millard favours vaccina-tion of all who visit the East, he should therefore advocateuniversal vaccination, but pointed out that, taking hisargument to its logical conclusion, the vaccination ofsuch travellers would increase the number of undetectedcases of smallpox among them.
Dr. Millard’s main argument against vaccination wasthat it is liable to render attacks so mild and atypicalthat they pass unnoticed and constitute a danger toothers. He then recommended vaccinating the verypeople most likely to bring the disease into the country.There is surely an inconsistency here. At the same timeDr. Millard would leave unprotected those who remainat home and will be exposed to infection from the
unrecognised case of smallpox in the vaccinated traveller.It is difficult to imagine a policy more calculated toincrease the number and severity of epidemics.
Arlesheim,Switzerland. A. M. WOOLMAN.
SIR,—Dr. Millard’s deligl)tfully provocative articleraises the question whether variola minor and variolamajor are the same disease and caused by the same virus.For the last six years in the Upper Nile province
of the Sudan we have had a slowly developing epidemicof variola minor, with about 270 notified cases and5 deaths. The disease was at first regarded as chickenpox,but after a few reported deaths it was diagnosed asvariola major. Vaccination campaigns were organised,but because of the nature of the country they werelargely ineffective, and vaccination was abandoned assoon as the disease was recognised as variola minor.The infection spread through the province slowly bytraceable tribal contacts. On two occasions laboratorytests proved it was variola and not chickenpox. Theclinical aspect of the cases, and the slow spread, gavethe epidemic a totally different picture from that ofvariola major.The epidemic occurred in a comparatively primitive
community of 80,000 people in an area of 90,000 sq. miles,and the number of cases notified was probably less thanhalf the total. In one area where we instituted quarantinethe people asked us not to do so because they knew thatthe disease was different from variola major and conferredimmunity against variola major : in fact they welcomedits appearance.
3. Visick, H. S. Brit. med. J. 1946, ii, 941.4. Taylor, H. Lancet, Jan. 6, 1951, p. 7.5. Stead, J. R. Ibid, p. 12.6. Selye, H. Stress. Montreal, 1951 ; p. 96.7. Pannett, C. A. Personal communication. 1924.
Contrast this slow epidemic with one seen in 1947in a similarly primitive population at Yirrol in theBahr el Ghazal province, where there were 280 cases with117 deaths. It was a flare-up, rapid in growth, killingin its severity, and again rapid in its decline-thanksmainly to an intensive vaccination campaign.
In the Upper Nile outbreak we abandoned vaccinationon advice from laboratory specialists, and becauseclimatic conditions and communication difficulties madeit impossible to guarantee the supply of lymph vaccineregularly and in an active state. In some areas, owingto such difficulties, we had less than 15% " takes."
I think there can be little doubt that there are twodifferent diseases, both clinically and epidemiologically,and that the viruses are different. The distribution ofthe rash is the same, and the rash is in one stage ; butin variola minor it is less profuse, and not so confluentin the axillae and the groin, though confluent cases occurwith facial distributions. The patient is not so seriouslyill when the rash is in its pustular stage as in cases ofvariola major. The differentiation between variola minorand chickenpox is often difficult unless care is taken toexamine the extremities and the rash itself. Generallymistakes are made most when the prodromal rash is notregarded as such, and the main disease is missed.The immunological reactions between vaccinia virus
and the various geographical strains of the variola minorvirus also vary.! There is yet no evidence to prove thatvariola virus strains change their virulence : the majorruns true to type, and so does the minor virus. Thedifferences are evident epidemiologically and clinically :variola minor gives a negligible mortality, rarely reaching3%, compared with 20-30% for variola major. I suggestthat the two diseases are entirely different entities,and that to confuse the two is to confuse the whole issue.
Dr. Millard’s note that in the past inoculation used tobe resorted to, and that inoculation was preferably fromserious rather than mild cases is of historic interest.In the Sudan in the 18th century inoculation was alsopractised. A piece of rag was tied round the arm ofa serious case and its price was haggled over. The personto be inoculated eventually bought it, having a guaranteenot to get more than so many pocks. If he had a severeattack he claimed his money back, if he survived. Possibleexplanations are that the virus had " burnt itself out "in the serious case, or that the patient’s reactions hadreduced its virulence.
Malakal.
J. F. E. BLOSSP.M.I. (M.O.H.)
Upper Nile Province,Anglo-Egyptian Sudan.
MUNCHAUSEN’S SYNDROME
SIR,-A further example of the Munchausen syndromewas recalled to my notice today when a query arrivedfrom the Royal Victoria Hospital, Folkestone, abouta man’treated here last April. A few days after hisirregular discharge from the Western Infirmary, Glasgow,early in May, 1950, he was admitted as an emergency tothe West London Hospital.
This man is 23 or 24, Irish, and of somewhat prognathousappearance. He claims to be aspiring to the priesthood ; andhis complaints usually take the form of bleeding from nose,eyes, ears, and urinary tract, along with great pain of a renal-colic type. He has a rooted objection to cystoscopy orcatheterisation, the threat of which leads to a demand fordischarge. No cause can be found for his bleeding ; but sharpinstruments may be found in his bed, and many of the blood-stained sites show no bleeding-point. He tends to ascribehis symptoms to trauma before admission, and is admittedfollowing collapse in the street.
I should be most interested to know if he has beenan inmate of other hospitals. I feel sure that he has beenin many in the past nine months.
Western Infirmary,Glasgow. IAN A. SHORT.
1. Horgan, E. S., Haseeb, M. A., Satti, M. H. Brit. J. exp. Path.1948, 29, 347.
