Devil's Waltz (3 page)

“Next fever spike: the kid’s fifteen months old, mother claims a hundred and six.”

“Dangerous.”

“You bet. E.R. doc records a hundred and four and a half, bathes and doses it down to a hundred and one and a half. And mom reports new symptoms: retching, projectile vomiting, diarrhea. And black
stools
.”

“Internal bleeding?”

“Sounds like it. That made
everyone
sit up. The diaper she had on did show some evidence of diarrhea, but no blood. Mom said she threw the bloody one out, would try to retrieve it. On exam, the kid’s rectal area was a little red, some irritation at the external edges of the sphincter. But no bowel distension that I can palpate — her belly’s nice and soft, maybe a bit tender to the touch. But that’s hard to gauge ’cause she’s freaking out, nonstop, at being examined.”

“Raw rectum,” I said. “Any scarring?”

“No, no, nothing like that. Just mild irritation, consistent with diarrhea. Obstruction or appendicitis needed to be ruled out. I called in a surgeon, Joe Leibowitz — you know how thorough he is. He examined her, said there was nothing that justified cutting her open but we should admit her and watch her for a while. We put an I.V. in —
great
fun — did a complete panel, and this time there was a slightly elevated white count. But still within normal limits, nothing that would jibe with a hundred and four and a half. Next day she was down to one hundred. Day after that, ninety-nine point two, and her tummy didn’t seem to hurt. Joe said definitely no appendicitis, call in GI. I got a consult from Tony Franks and he evaluated her for early signs of irritable bowel syndrome, Crohn’s disease, liver problems. Negative. Another tox panel, a careful diet history. I called in Allergy and Immunology again, to test her for some weird hypersensitivity to something.”

“Was she on formula?”

“Nope, a breast-fed baby, though by that time she was totally on solids. After a week she was looking perfect. Thank God we didn’t cut her open.”

“Fifteen months old,” I said. “Just past the high-risk period for SIDS. So the respiratory system quiets and the gut starts acting up?”

Stephanie gave me a long, searching look. “Want to hazard a diagnosis?”

“Is that all of it?”

“Un-uh. There were two other GI crises. At sixteen months — four days after an appointment with Tony in Gastro clinic — and a month and a half later, following his final appointment with them.”

“Same symptoms?”

“Right. But both those times, mom actually brought in bloody diapers and we worked them over for every possible pathogen — I mean we’re talking typhoid, cholera, tropical maladies that have never been seen on this continent. Some sort of environmental toxin — lead, heavy metals, you name it. But all we found was a little healthy blood.”

“Are the parents in some sort of work that would expose the child to weird pollutants?”

“Hardly. She’s a full-time mom and he’s a college professor.”

“Biology?”

“Sociology. But before we get off on the family structure, there’s more. Another type of crisis. Six weeks ago. Bye-bye gut, hello new organ system. Want to take a guess which one?”

I thought for a moment. “Neurological?”

“Bingo.” She reached over and touched my arm. “I feel so vindicated calling you in.”

“Seizures?”

“Middle of the night. Grand mal, according to the parents, right down to the frothing at the mouth. The EEG showed no abnormal wave activity and the kid had all her reflexes, but we put her through a CAT scan, another spinal, and all the high-tech neuroradiology video games, on the chance she had some kind of brain tumor. That
really
scared me, Alex, because when I thought about it I realized a tumor could have caused
everything
that had been happening, right from the beginning. A growth impinging on different brain centers, causing different symptoms as it grew.”

She shook her head. “Wouldn’t
that
have been a happy situation? Me talking psychosomatic and there’s an astrocytoma or something growing inside her? Thank God all her scans were totally clean.”

“Did she look post-seizural when you saw her in the E.R.?”

“In terms of being drowsy and listless, she did. But that’s also consistent with a little kid being dragged to the hospital in the middle of the night and put through the wringer. Still, it scared me — that there could be something organic I was missing. I asked Neurology to follow up. They did for a month, found nothing, terminated. Two weeks later —
two days ago
— another seizure. And I really need your help, Alex. They’re up in Five West, right now. And that’s the whole kaboodle, history-wise. Ready to give me some wisdom now?”

I scanned my notes.

Recurrent, unexplained illnesses. Multiple hospitalizations.

Shifting organ systems.

Discrepancies between symptoms and lab tests.

Female child showing panic at being treated or handled.

Mother with a paramedical training.

Nice mother.

Nice mother who might just be a monster. Scripting, choreographing, and directing a Grand Guignol, and casting her own child as unwitting star.

Rare diagnosis, but the facts fit. Up until twenty years ago nobody had heard of it.

“Munchausen syndrome by proxy,” I said, putting my notes down. “Sounds like a textbook case.”

Her eyes narrowed. “Yes, it does. When you hear it all strung together like this. But when you’re right in the middle of it… even now I can’t be sure.”

“You’re still considering something organic?”

“I have to until I can prove otherwise. There was another case — last year, over at County.
Twenty-five
consecutive admits for recurrent weird infections during a six-month period. Also a female child, attentive mother who looked too calm for the staff’s peace of mind.
That
baby was really going downhill and they were just about ready to call in the authorities when it turned out to be a rare immunodeficiency — three documented cases in the literature, special tests that had to be done at NIH. Moment I heard about it, I had Cassie tested for the same thing. Negative. But that doesn’t mean there isn’t some other factor I haven’t caught. New stuff keeps popping up — I can barely keep up with the journals.”

She moved her spoon around in her coffee.

“Or maybe I’m just denying — trying to make myself feel better for not seeing the Munchausen thing sooner. Which is why I called you in — I need some direction, Alex. Tell me which way to go with this.”

I thought for a while.

Munchausen syndrome.

A.k.a.
pseudologia fantastica
.

A.k.a. factitious illness disorder.

An especially grotesque form of pathological lying, named after Baron von Munchausen, the world-class prevaricator.

Munchausen is hypochondriasis gone mad. Patients fabricating disease by mutilating and poisoning themselves, or just lying. Playing mind games with physicians and nurses — with the health-care system itself.

Adult Munchausen patients manage to get hospitalized repeatedly, medicated needlessly, even cut open on the operating table.

Pitiful, masochistic, and perplexing — a twist of the psyche that still defies comprehension.

But what we were considering here was beyond pity. It was an evil variant:

Munchausen by proxy.

Parents — mothers, invariably — faking illness in their own offspring. Using their children — especially daughters — as crucibles for a hideous concoction of lies, pain, and disease.

I said, “So much of it fits, Steph. Right from the beginning. The apnea and passing out could be due to smothering — those movement artifacts on the monitor could mean she was struggling.”

She winced. “God, yes. I just did some reading, found a case in England where movement artifacts tipped them off to the baby being smothered.”

“Plus, with mom being a respiratory tech, breathing could be the first system she’d choose to mess with. What about the intestinal stuff? Some kind of poisoning?”

“Most likely, but it’s nothing the tox panel could come up with when they tested.”

“Maybe she used something short-acting.”

“Or an inert irritant that activated the bowel mechanically, but passed right through.”

“And the seizures?”

“Same thing, I guess. I don’t
know
, Alex. I really don’t
know
.” She squeezed my arm again. “I’ve got no evidence at all and what if I’m wrong? I need you to be objective. Give Cassie’s mom the benefit of the doubt — maybe I’m misjudging her. Try to get into her head.”

“I can’t promise a miracle, Steph.”

“I know. But
anything
you can do will be helpful. Things could get really messy with this one.”

“Did you tell the mother I’d be consulting?”

She nodded.

“Is she more amenable to a psych consult now?”

“I wouldn’t say amenable, but she agreed. I think I convinced her by backing away from any suggestion that stress was
causing
Cassie’s problems. Far as she’s concerned,
I
think the seizures are bona fide organic. But I did press the need for helping Cassie adjust to the trauma of hospitalization. Told her epilepsy would mean Cassie can expect to see a lot more of this place and we’re going to have to help her deal with it. I said you were an expert on medical trauma, might be able to do some hypnosis thing to relax Cassie during procedures. That sound reasonable?”

I nodded.

“Meanwhile,” she said, “you can be analyzing the mother. See if she’s a psychopath.”

“If it is Munchausen by proxy, we may not be looking for a psychopath.”

“What then? What kind of nut does this to her own kid?”

“No one really knows,” I said. “It’s been a while since I looked at the literature, but the best guess used to be some kind of mixed personality disorder. The problem is, documented cases are so rare, there really isn’t a good data base.”

“It’s still that way, Alex. I looked up sources over at the med school and came up with very little.”

“I’d like to borrow the articles.”

“I read them there, didn’t check them out,” she said. “But I think I still have the references written down somewhere. And I think I remember that mixed personality business — whatever that means.”

“It means we don’t know, so we’re fudging. Part of the problem is that psychologists and psychiatrists depend on information we get from the patient. And taking a history from a Munchausen means relying upon a habitual liar. But the stories they tell, once you expose them,
do
seem to be fairly consistent: early experience with serious physical illness or trauma, families that overemphasized disease and health, child abuse, sometimes incest. Leading to very poor self-esteem, problems with relationships, and a pathological need for attention. Illness becomes the arena in which they act out that need — that’s why so many of them enter health professions. But lots of people with those same histories
don’t
become Munchausens. And the same history applies both to Munchausens who abuse themselves and the proxies who torment their kids. In fact, there’s some suggestion that Munchausen-by-proxy parents start out as self-abusers and switch, at some point, to using their kids. But as for why and when that happens, no one knows.”

“Weird,” she said, shaking her head. “It’s like a dance. I feel I’m waltzing around with her, but she’s leading.”

“Devil’s waltz,” I said.

She shuddered. “I know we’re not talking hard science, Alex, but if you could just dig your way in there, tell me if you think she’s doing it….”

“Sure. But I am a bit curious why you didn’t call in the hospital Psych department.”

“Never liked the hospital Psych department,” she said. “Too Freudian. Hardesty wanted to put everyone on the couch. It’s a moot point, anyway. There is no Psych department.”

“What do you mean?”

“They were all fired.”

“The whole department? When?”

“Few months ago. Don’t you read your staff newsletter?”

“Not very often.”

“Obviously. Well, Psych’s dissolved. Hardesty’s county contract was canceled and he never wrote any grants, so there was no financial backup. The board decided not to pick up the cost.”

“What about Hardesty’s tenure? The others — weren’t Greiler and Pantissa tenured, too?”

“Probably. But tenure, as it turns out, comes from the med school, not the hospital. So they’ve still got their titles. Salaries are a whole other story. Quite a revelation for those of us who thought we had job security. Not that anyone fought for Hardesty. Everyone thought he and his guys were deadwood.”

“No more Psych department,” I said. “No more free coffee. What else?”

“Oh, plenty. Does it affect you, there being no Psych department — in terms of your staff privileges, I mean?”

“No, my appointment’s in pediatrics. Oncology, actually, though it’s been years since I’ve seen any cancer patients.”

“Good,” she said. “Then there won’t be any procedural hassles. Any more questions before we go up?”

“Just a couple of observations. If it is Munchausen by proxy, there’s some time pressure — the usual picture is an escalating pattern. Sometimes kids die, Steph.”

“I know,” she said miserably, pressing her fingertips to her temples. “I know I may need to confront the mother. That’s why I have to be sure.”

“The other thing is the first child — the boy. I assume you’re considering him a possible homicide.”

“Oh, God, yes. That’s really been eating at me. When my suspicions about the mother started to gel, I pulled his chart and went over it with a fine-tooth comb. But there was nothing iffy. Rita’s ongoing notes were good — he was perfectly healthy before he died and the autopsy was inconclusive, as so many of them are. Now here I am with a living, breathing child and I can’t do a thing to help
her
.”

“Sounds like you’re doing everything you can.”

“Trying, but it’s so damned frustrating.”

I said, “What about the father? We haven’t talked about him.”

“I don’t really have a good feel for him. Mother’s clearly the primary caretaker and it’s her I’ve been dealing with most of the time. Once I started to think of it as a possible Munchausen by proxy, she seemed especially important to focus on, because aren’t mothers always the ones?”