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MUNCHAUSEN'S SYNDROME
621
bleeding by these hormones so that higher doses of aminopterin can be administered. While the initial platelet-count is further depressed by the myelosuppressive agent, corticotrophin and cortisone protect against haemorrhage. I also feel that your conclusions with regard to of
hormonal treatment of Schonlein-Henoch purpura should be commented on in view of 9 cases we have treated in the past 4 years. The response of the disease to corticotrophin and cortisone is admittedly variable. When favourable, however, the improvement of the subjective symptoms of arthralgia, abdominal pain, &c., and the reversal of the skin lesion (as studied by serial biopsies) are very often too prompt to be exclusively due to spontaneous recovery. At times all symptoms recur when treatment is discontinued. Curiously enough, corticotrophin, in our experience, is much more effective than cortisone in this disease. The main purpose of this letter is not to disagree with, but rather to complement, the conclusions presented in your editorial. Corticotrophin and cortisone probably do not modify essentially the pathogenetic mechanisms of idiopathic thrombocytopenic purpura and might not modify that of Schonlein-Henoch purpura. Patients, however,often benefit greatly (even if aspecifically) from this form of therapy, as is indicated above. I feel, then, that it should not be denied to them when no coiltra-indications exist. New England Medical Center and Tufts College Medical School, Boston, Mass., U.S.A.
MARIO STEFANINI.
TOBACCO-SMOKING
SiR,ŃI thank Professor Adams for his charming tribute last week-the more appreciated because it was so unexpected. I congratulate him on his immediate complete cure from serious tobacco addiction, which cure must by now be well consolidated. I agree that there is no desirable substitute for smoking although some compensatory over-indulgence in sweets and other delicacies is, I think, permissible for a time, even at the risk of putting on weight. However, one has to learn to occupy one’s time in the same way as do those who have never smoked. I now think that smokers are emotionally inadequate -unable to bear with life’s joys and sorrows without continually dulling these with the quick-acting and fairly powerful analgesic, nicotine. LENNOX JOHNSTON. Wallasey, Cheshire. MUNCHAUSEN’S SYNDROME
SiB,ŃIn the correspondence which followed
Dr. on it article this condition interesting was emphasised that these patients may develop a genuine organic lesion ; the following case provides a
Richard Asher’s
good example. A man, aged 42, was admitted to Leith Hospital late on the night of Saturday, Aug. 15, 1953. He said that he had arrived at Leith earlier in the day on a ship sailing from Ireland, and shortly after going ashore he had been seized by a severe crushing pain which passed across his chest and down the left arm. He was smelling of alcohol, and his pulse was irregular; and, as the history was typical of coronary thrombosis, he was admitted by the house-physician and treated with anticoagulants. I saw him in the morning, and his glib account raised suspicions which were increased by the appearance of his abdominal wall; it was a veritable battlefield with no less than nine scars, caused, he said, by sixteen operations undergone in various parts of London and America. Electrocardiography confirmed the presence of auricular fibrillation but showed no sign of infaretion. In his pocket was found an insurance certificate dated four weeks previously in Edinburgh with a diagnosis of coronary thrombosis. It was discovered that, a few hours before coming to Leith, he had discharged himself from the Royal Infirmary, Edin1. Lancet, 1951, i, 339.
where he had been admitted in the previous week similar story and also under the influence of alcohol. Electrocardiography had shown no infarction and the rhythm was normal. It was later learnt that he had been in another ward in the Royal Infirmary in January of this year with a coronary thrombosis. The cardiograms taken at that time have been re-examined in the cardiology department and they show unequivocal evidence of an anterior myocardial infarction with auricular fibrillation. The day after his admission to Leith Hospital the patient’s cardiac rhythm became normal and further questioning produced truculent and evasive replies. A woman then appeared claiming domestic liaison with him and demanding his clothes which, she asserted, she had paid for. He was discharged at his own request after three days in hospital.
burgh,
with
a
This is a genuine case of the Munchausen syndrome in a man who has had a myocardial infarction and now has a paroxysmal fibrillation. Should he present himself at another hospital-as he almost certainly will-with a similar story, it would require a bold casualty officer to refuse him admission. CHALMERS DAVIDSON Leith Hospital, Edinburgh.
Assistant physician.
OCCUPATIONAL HEALTH SERVICE
SiR,ŃAt the present time there is a tendency by some clinicians to classify the medical profession into administrative doctors and doctors undertaking treatment, with an inference that the former have had no clinical training and possess no clinical ability of any sort. This attitude was emphasised from the platform during the recent meeting of the occupational health section of the Royal Sanitary Institute at Hastings. In considering occupational health-whether it is the minor group of special hazards or the much greater proportion of what may be called general health problems-there are two methods of approach. The one is the clinical approach to the individual, and the other is the communal approach to the occupational group : it makes no difference whether one is dealing with the narrow scope of industrial health, as applied to factories and places of work, or the wider implications of health applied to all occupations. It does not appear to be recognised that there is a communal approach to occupational health. It is not possible for any individual general practitioner or an industrial medical officer to know whether the factors which may be influencing the health of the individual patient or of the workmen in the factory are particular to that individual or that place of work. The doctor is to be commended for not merely accepting and dealing with a clinical problem, but for interesting himself in some preventive or remedial action. All the same, such practitioners are, perhaps,’too near to the individual. What is needed, to supplement their valuable services, is some form of observation of the general health of occupations so that a disproportionate sickness-rate in some special occupation is at once made obvious and preventive action taken. If in a town there are three factories all occupied in identical work under identical conditions and the sickness-rate of one factory is twice that of the other two, it is a fair comment to say that something unusual is happening in that factory. Who is to know this ? Who is to make the comment ? No individual practitioner and no industrial medical officer is in a position to have access to all places of work or all occupations, for all should be kept under simultaneous and continuous observation. In this town there are four separate motor-bus undertakings. As far as I am aware, there is no coordination of sickness statistics to show whether all have the same rates ; whether, for example, long-distance drivers vary from those employed on town routes, or whether certain schedules and timetables are associated with excessive sickness. It is this aspect which is so often forgotten. What is more, it must be realised that occupational health problems are tied up with general health problems. Inefficiency at work may have nothing to do with the job itself but may be directly due to anxiety about home troubles, with resultant inability to concentrate on the job in hand. What effect has the thought of an ailing wife or sick child left in unsuitable accommodation, or an exasperated departure to work after a spoilt breakfast following a marital tiff with a fretful wife driven to distraction by constant noise in an inadequately sound-insulated flat ? These are outside matters having a direct bearing on health in
bleeding by these hormones so that higher doses of aminopterin can be administered. While the initial platelet-count is further depressed by the myelosuppressive agent, corticotrophin and cortisone protect against haemorrhage. I also feel that your conclusions with regard to of
hormonal treatment of Schonlein-Henoch purpura should be commented on in view of 9 cases we have treated in the past 4 years. The response of the disease to corticotrophin and cortisone is admittedly variable. When favourable, however, the improvement of the subjective symptoms of arthralgia, abdominal pain, &c., and the reversal of the skin lesion (as studied by serial biopsies) are very often too prompt to be exclusively due to spontaneous recovery. At times all symptoms recur when treatment is discontinued. Curiously enough, corticotrophin, in our experience, is much more effective than cortisone in this disease. The main purpose of this letter is not to disagree with, but rather to complement, the conclusions presented in your editorial. Corticotrophin and cortisone probably do not modify essentially the pathogenetic mechanisms of idiopathic thrombocytopenic purpura and might not modify that of Schonlein-Henoch purpura. Patients, however,often benefit greatly (even if aspecifically) from this form of therapy, as is indicated above. I feel, then, that it should not be denied to them when no coiltra-indications exist. New England Medical Center and Tufts College Medical School, Boston, Mass., U.S.A.
MARIO STEFANINI.
TOBACCO-SMOKING
SiR,ŃI thank Professor Adams for his charming tribute last week-the more appreciated because it was so unexpected. I congratulate him on his immediate complete cure from serious tobacco addiction, which cure must by now be well consolidated. I agree that there is no desirable substitute for smoking although some compensatory over-indulgence in sweets and other delicacies is, I think, permissible for a time, even at the risk of putting on weight. However, one has to learn to occupy one’s time in the same way as do those who have never smoked. I now think that smokers are emotionally inadequate -unable to bear with life’s joys and sorrows without continually dulling these with the quick-acting and fairly powerful analgesic, nicotine. LENNOX JOHNSTON. Wallasey, Cheshire. MUNCHAUSEN’S SYNDROME
SiB,ŃIn the correspondence which followed
Dr. on it article this condition interesting was emphasised that these patients may develop a genuine organic lesion ; the following case provides a
Richard Asher’s
good example. A man, aged 42, was admitted to Leith Hospital late on the night of Saturday, Aug. 15, 1953. He said that he had arrived at Leith earlier in the day on a ship sailing from Ireland, and shortly after going ashore he had been seized by a severe crushing pain which passed across his chest and down the left arm. He was smelling of alcohol, and his pulse was irregular; and, as the history was typical of coronary thrombosis, he was admitted by the house-physician and treated with anticoagulants. I saw him in the morning, and his glib account raised suspicions which were increased by the appearance of his abdominal wall; it was a veritable battlefield with no less than nine scars, caused, he said, by sixteen operations undergone in various parts of London and America. Electrocardiography confirmed the presence of auricular fibrillation but showed no sign of infaretion. In his pocket was found an insurance certificate dated four weeks previously in Edinburgh with a diagnosis of coronary thrombosis. It was discovered that, a few hours before coming to Leith, he had discharged himself from the Royal Infirmary, Edin1. Lancet, 1951, i, 339.
where he had been admitted in the previous week similar story and also under the influence of alcohol. Electrocardiography had shown no infarction and the rhythm was normal. It was later learnt that he had been in another ward in the Royal Infirmary in January of this year with a coronary thrombosis. The cardiograms taken at that time have been re-examined in the cardiology department and they show unequivocal evidence of an anterior myocardial infarction with auricular fibrillation. The day after his admission to Leith Hospital the patient’s cardiac rhythm became normal and further questioning produced truculent and evasive replies. A woman then appeared claiming domestic liaison with him and demanding his clothes which, she asserted, she had paid for. He was discharged at his own request after three days in hospital.
burgh,
with
a
This is a genuine case of the Munchausen syndrome in a man who has had a myocardial infarction and now has a paroxysmal fibrillation. Should he present himself at another hospital-as he almost certainly will-with a similar story, it would require a bold casualty officer to refuse him admission. CHALMERS DAVIDSON Leith Hospital, Edinburgh.
Assistant physician.
OCCUPATIONAL HEALTH SERVICE
SiR,ŃAt the present time there is a tendency by some clinicians to classify the medical profession into administrative doctors and doctors undertaking treatment, with an inference that the former have had no clinical training and possess no clinical ability of any sort. This attitude was emphasised from the platform during the recent meeting of the occupational health section of the Royal Sanitary Institute at Hastings. In considering occupational health-whether it is the minor group of special hazards or the much greater proportion of what may be called general health problems-there are two methods of approach. The one is the clinical approach to the individual, and the other is the communal approach to the occupational group : it makes no difference whether one is dealing with the narrow scope of industrial health, as applied to factories and places of work, or the wider implications of health applied to all occupations. It does not appear to be recognised that there is a communal approach to occupational health. It is not possible for any individual general practitioner or an industrial medical officer to know whether the factors which may be influencing the health of the individual patient or of the workmen in the factory are particular to that individual or that place of work. The doctor is to be commended for not merely accepting and dealing with a clinical problem, but for interesting himself in some preventive or remedial action. All the same, such practitioners are, perhaps,’too near to the individual. What is needed, to supplement their valuable services, is some form of observation of the general health of occupations so that a disproportionate sickness-rate in some special occupation is at once made obvious and preventive action taken. If in a town there are three factories all occupied in identical work under identical conditions and the sickness-rate of one factory is twice that of the other two, it is a fair comment to say that something unusual is happening in that factory. Who is to know this ? Who is to make the comment ? No individual practitioner and no industrial medical officer is in a position to have access to all places of work or all occupations, for all should be kept under simultaneous and continuous observation. In this town there are four separate motor-bus undertakings. As far as I am aware, there is no coordination of sickness statistics to show whether all have the same rates ; whether, for example, long-distance drivers vary from those employed on town routes, or whether certain schedules and timetables are associated with excessive sickness. It is this aspect which is so often forgotten. What is more, it must be realised that occupational health problems are tied up with general health problems. Inefficiency at work may have nothing to do with the job itself but may be directly due to anxiety about home troubles, with resultant inability to concentrate on the job in hand. What effect has the thought of an ailing wife or sick child left in unsuitable accommodation, or an exasperated departure to work after a spoilt breakfast following a marital tiff with a fretful wife driven to distraction by constant noise in an inadequately sound-insulated flat ? These are outside matters having a direct bearing on health in