Quite sane: the true syndrome of Baron Munchausen; and a case report of Ophthalmic Munchausen syndrome

their weekly shopping but this was not adequate. Now there is a budget which is held by the nurse, but the patients plan their meals for the week and then buy from the super market. The team is allowed a budget of up to Â£4,500per year, half of which comes from the catering budget. The sum of Â£ 15per person per week was allocated for food and this appeared realistic in relation to the Social Security Benefit likely to be received. (d) The small size of the group, rarely more than four, allows no one to get lost and appears to enhance cohesiveness, mutual support and personal growth. It can be encouraging to see the development of warmth, kindness and humour in people who had apparently little interest in others before. (e) Occasional treats such as a meal in a restaur ant, or other outing, is regarded as educative. Maddocks and Maddocks

(b) It is necessary to have designated nursing staff, but the pull from the acute side is difficult to resist when staffing is short and there are par ticularly acute cases. The personalities of the staffare as important as their qualifications. (c) A budget is essential; initially the patient would "shop" from the hospital stores for their weekly shopping but this was not adequate. Now there is a budget which is held by the nurse, but the patients plan their meals for the week and then buy from the super market. The team is allowed a budget of up to Â£4,500 per year, half of which comes from the catering budget. The sum of Â£ 15per person per week was allocated for food and this appeared realistic in relation to the Social Security Benefit likely to be received. (d) The small size of the group, rarely more than four, allows no one to get lost and appears to enhance cohesiveness, mutual support and personal growth. It can be encouraging to see the development of warmth, kindness and humour in people who had apparently little interest in others before. (e) Occasional treats such as a meal in a restaur ant, or other outing, is regarded as educative.
both in learning, budgeting for it and in social behaviour. Visiting an ex-patient's social club is an activity which can be continued after dis charge, and many patients continue to see each other in unofficial self-help groups offering support and friendship. (0 Occupational therapist's time is essential, as is social worker help with placement. Ultimately rehabilitation is only as good as the aftercare and, while some patients need sheltered group living, others are better living alone. We are very fortunate that Slough Council is sympathetic to the long-term mentally ill and will rehouse them in single person accommodation. There are several staffed group homes, and unstaffed half way houses and group homes are in our area, some of which are jointly managed by a voluntary organisation, Social Services and Health. A network of care has been built up which consists of monitoring by general prac titioners and in out-patient clinics, support from com munity psychiatric nurses and social workers, social interaction in day centres and befriending by volun teer workers and with good communication between all of these. When no better facilities are available, it is possible to rehabilitate people successfully from an acute ward in a District General Hospital. Psychiatric Bullelin(\992), 16,[432][433][434] Sketches from the history of psychiatry  (Asher, 1951) many different clinical presentations have been described, including the abdominal, by proxy, dermatolÃ³gica!, neurological, psychiatric and pyrexial variants (Blackwell, 1968). By contrast, virtually no attention has been paid to the medical history of Raspe's eponymous hero (Raspe, 1775), some authors suggesting that this was not recorded (Wingate, 1951;Sjoberg, 1951). While the fictional Baron's supposed memoirs are unreliable, sketchy and recorded by different hands, they do shed some light upon his health and attitude to physicians.
Outlined below is the recorded medical history of the fictional Baron Munchausen. A case of Ophthalmic Munchausen's syndrome, which shares some features of the Baron's story is reported for the first time.
Quotations and page numbers, shown in square brackets [], are from Carswell (1948), whose scholarly return to the earliest editions provides an invaluable corrective to other modern editions which are usually selective and confused.
From the third edition, the Adventures are intro duced with the remark that the tales were recounted "over a bottle" [170]. This is confirmed when, intro ducing the Sequel to his tales, the Baron argues that the truthfulness of his stories. "All that I have related before, said the Baron, is gospel; and if there be any one so hardy as to deny it... I will condemn him to swallow this decanter, glass and all perhaps, and filled with kerren-wasser (a kind of ardent spirit distilled from cherries ...)" [93].
Another valiant defence of his honesty gives a further indication of prevailing levels of alcohol consumption in the Baron's circle. "If any gentleman will say he doubts the truth of this story, I will fine him a gallon of brandy and make him drink it at one draught" [39].
The Baron's own consumption is not systemati cally recorded, but during a particularly dangerous trip he drinks half a pint of liquid that resembles "a fine pure liquor like Holland's gin" which he "could not distinguish ... from the best mountain wine." He describes being "greatly refreshed" but his drinking companions, two eagles, stagger and fall asleep on both exposures to the stuff. He takes more than two gallons with him on his continuing journey [80]. Whatever the true nature of the beverage it is strong enough to deprive a bear of sight when squirted into its eyes [83]. Some editions also identify the Baron as the victim of a story in which his parents meet by accident "in consequence of their both being intoxicated" [34].
With such historical evidence, the contemporary Bulletin reader's mind will already be considering the part alcohol played in the Baron's creativity.

Baron Munchausen 's medical history
Most of the Baron's recorded travels were perilous as well as improbable, but surprisingly few injuries were recorded.
Hunting was not a fortunate pastime. Early in the first edition he recalls: "A large pond not far off was, as it were, covered with wild ducks. In an instant I took my gun from the corner, ran downstairs and out in such a hurry that imprudently I struck my face against the doorpost. Fire, light and sparks flew out of my eyes ..." [10] The Baron claimed to have subsequently fired his damaged flintlock, using such hallucinatory sparks, by deliberately striking himself in the face twice more.
Hunting polar bears on ice, he speaks of how: "Unfortunately, at the very instant I was presenting my carbine, my right foot slipped, I fell upon my back, and the violence of the blow deprived me totally of my senses for nearly half an hour" [47].
During another escapade, the Baron recalls: "I felt my chariot sinking under me. I attempted to drive on,

43.1
Mr M with some of his collection of spectacles, as he appeared in a local newspaper. but the ground, or rather immense vault, giving way, my chariot and all went down precipitately. Stunned by the fall, I was some moments before I could recollect myself..." [155].
Two more unusual head injuries seemingly did not result in concussion.
Trapped and tied up by American Savages, the Baron tells of how "they took my three unfortunate companions and myself, and scalped us. The pain of losing the flesh from my head was most horrible ..." [148].
When the Baron's ship strikes a whale, the shock waves are so great that the Baron's "head particu larly was pressed into my stomach, where it con tinued some months before it recovered its natural situation" [25].

Baron Munchausen and doctors
The only doctor mentioned in the books is a ship's surgeon named Mr Crawford, who checked the Baron's pulse before the captain would accept a wager. The surgeon duly "reported me in perfect health." and perhaps more surprisingly disagreed with the ship's captain as to the Baron's state of mind. The surgeon reportedly said: "I am of a different opinion; he is quite same ..." [58].
The only treatment for the Baron's ills follows his descent into the active heart of Mount Etna. "Vulcan himself did me the honour of applying plasters to my wounds, which healed them immediately" [65].
Ought this clean bill of health, authenticated by the medical profession, and apparent safe escape from their hands be taken at face value? I think not. The following incident suggests to me extensive, bitter, experience as a patient. The Baron cheerfully recalls lifting the London College of Physicians from the earth, by balloon, during their annual dinner. He comments: "Though this was meant as an innocent frolic, it was productive of much mischief to several respect able characters amongst the clergy, undertakers, sextons, and gravediggers: they were it must be ack nowledged, sufferers; for it is a well-known fact that during the three months the college was suspended in the air, and (the members) therefore incapable of attending their patients, no deaths happened." [44] The different editions of the Adventures therefore provide suggestive evidence that Munchausen's true syndrome comprised: (a) unlikely stories told after alcohol (b) a history of multiple head injuries, some highly improbable (c) post concussional visual disturbance (d) a low opinon of doctors. Presented here is a man who demonstrates some similar features.

Case report
Mr M, a divorced, unemployed 45-year-old, was referred for psychiatric assessment because of poor memory and "pressure" in his head. He attributed these symptoms to impaired eye sight. He said that he was blind in the right eye and partially sighted in the left, following an assault four years previously, for which he had received interim compensation. In fact he had presented similar problems to psychiatrists nine and seven years previously.
Local casualty records revealed 42 attendances. Of 11 "head injuries", trauma was evident in only five. Seven skull x-rays were all normal. "Head in juries" were always accompanied by complaints of asthenopia and variously, diplopia, anosmia, vomiting and collapse. These symptoms were also presented during attendances for other reasons. These included 12 haemorrhagic episodes; eight per rectum, three haematemeses and one epistaxis, none of which were substantiated.
Mr M had visited eight local ophthalmic surgeons and at least nine opticians, amassing 18 pairs of spectacles. A recent eye test had shown his corrected vision to be: right eye 6/9, left eye 6/12. The family practitioners committee had banned him from further tests.
Mr M denied heavy drinking, but an inde pendent forensic history included alcohol-related convictions. His Gamma GT was 87 IU/1. Mr M's appearance was neglected. He was not wearing spectacles. There was no evidence of anxiety, depressed mood or psychosis, his belief about his eyesight being an overvalued idea. Cognitive testing revealed no abonormality, his intelligence being in the low normal range. He requested referral to an ophthalmologist but declined psychiatric follow-up.

Discussion
I have been unable to trace a previous report of a case of Munchausen's syndrome where spectacles, rather than scars, have been collected and would therefore add the relatively benign Ophthalmic Munchausen's Syndrome to the list of other varieties. In Asher's seminal paper, Muchausen himself was not identified as a possible example of "Neurologica Diabolica". Asher claimed legitimacy to the title on the grounds of the Baron's exaggeration, breadth of travel and the lack of an alternative title. In truth the Baron probably under-recorded his medical history, and Mr M's case shows that with appropriate symp toms long journeys are unnecessary. Industrious medical neologists have disposed of the last reason by coining over 20 alternative titles. Why then might a learned man like Asher have chosen the name?
The founder of Raspe's University was a Munchausen [xi], but Raspe fell from grace and took to mocking great institutions through Munchausen, his best known creation. By contrast Asher was an esteemed fellow of his own Alma Mater when he wrote his best known paper. Is it too fanciful to suggest that the line of Munchausen was cursed with an eponymous affliction by Asher because of that September evening, in the late 18th century, when Baron Munchausen took the London College of Physicians for a ride?