Many patients with Munchausen syndrome were also hospitalized when they were children. One theory is that they faced terrible abuse at home and were so relieved by the kindness shown them by doctors that they came to associate being sick with being safe. As adults they became dependent on using the sick role to numb their underlying emotional pain and keep distressing memories from surfacing-the same way drug addicts use heroin.
To treat Munchausen's, a psychiatrist must coax the patient to confront the original psychological trauma he or she has repressed. If that sounds simple, it isn't. People with Munchausen's will generally flee treatment to avoid any exploration of their underlying problems.
Trying to get Lilly to admit she had caused the infection would just make her shut down. The important thing was to let her know I understood that she was infected. Only one of the pathogens lived in dirt. The other-more toxic and invasive-lived in the remote recesses of her unconscious.
I pulled an armchair to the edge of the bed and sat down. "No one doubts that you're ill," I said. "Dr. Slattery least of all. He told me the infection is very severe."
Lilly didn't move.
I decided to tempt her by bending the professional boundary between us, offering her a little of the physicianly warmth she craved. I reached out and touched one of the black lines her surgeon had drawn on her thigh. "Stress affects the immune system. That's a fact."
Still no response.
I moved my hand to Lilly's hip and let it linger. "As a nurse, I would think you'd agree."
She rolled onto her back. If I hadn't moved my hand, it would have traveled to the lowest part of her abdomen. "Look, I'm sorry I jumped down your throat," she said, staring up at the ceiling. "I'm worn out. There's been one doctor in here after another. Medication after medication. I don't think I've been home five days in a row, between admissions." She let out a long breath. "Not exactly an extended honeymoon."
"You're newly married," I said. "I read that in your chart."
"I guess my life's just an open book," she said.
"I would guess you're as far from an open book as they come."
She looked at me.
"How long ago did you marry?" I asked.
"Four months."
"Is it everything you expected?"
She stiffened, maybe because I sounded too remote, too analytic, too much the psychiatrist come to diagnose her.
I offered up another bend in the doctor-patient boundary. "I've never tried the marriage thing myself."
"No?"
"Engaged once. It didn't work out."
"What happened?"
I pictured Kathy the last time I had seen her, in her room on a locked psychiatric unit at Austin Grate Hospital. "She wasn't well," I said. "I tried to be her husband and her doctor. I made a mess of both."
"I'm sorry," she said.
"Me, too."
Lilly relaxed visibly. "Paul's been a dream. He's been so understanding about this whole thing. About everything."
"Everything…"
She blushed like a schoolgirl. "We didn't have much time to be, you know…"
I shrugged and shook my head, even though I did know.
"Well, time to be"-she giggled-"newlyweds."
"Did you have any time at all?"
"The problem with my leg started right after we left for St. Barth. We ended up flying home early."
"But he understood."
"He's never pressured me," she said. "He's a very patient man. He reminds me of my grandfather that way. I think that's the reason I fell in love with him."
Sometimes a voice speaks at the back of my mind as I talk with patients. It is my voice, but it comes from a part of me over which I do not have complete control-a part that listens between the lines, even my own lines, then plays back what has gone unspoken. "Sex, pain, grandfather. When making love feels like being injected with dirt, you cut the honeymoon short and head for the hospital."
"Tell me about him," I said, wanting to let her decide which man to talk about.
"Grandpa?"
I just smiled.
"He's quiet and strong. Very religious." She paused. "My father died when I was six. My mother and I moved in with my grandparents."
"Are they still living?"
"Thankfully," she said.
"Do they know about the trouble you're having?"
She shook her head. "I haven't told anyone in my family."
"Not even your mother?"
"No."
I felt as though I had found a path into Lilly's psyche. I could speak of the infection in her leg as a metaphor for her childhood trauma. "Keeping a secret-especially a big one, like this-can add to your level of stress," I said.
"My grandparents are old now. And my mother's got her own problems to worry about. I don't want to burden them."
"But they care about you, and you're in pain."
"I can handle it," she said.
"After you've lost your father;" the voice at the back of my mind said, "you don't risk losing your grandfather, no matter what it costs to keep him close. Even if it costs you your innocence. Or your leg."
I kept speaking in metaphor. "It could be a long haul, getting to the bottom of this infection. You might want someone you can open up to. Someone outside your family." I glanced at the skin of her thigh where it stretched, tight and shiny, over the inflamed tissues below. "To release some of the pressure."
"They do the incision and drainage tomorrow afternoon," she said.
"Otherwise the infection has nowhere to go but deeper."
She gazed down at her leg. "I guess it's going to look pretty ugly once they open it up."
"I've seen… and heard… just about everything," I said.
She studied the leg a few seconds longer, then looked at me.
"If it's okay with you, I'll stop by after the procedure."
She nodded.
"Good." I squeezed her hand, stood up, then headed for the door.
That's what a little victory in psychiatry looks like. You slip into the shadows, dodging the mind's defense mechanisms, glad enough to take a half-step toward the truth. Behind the next word or the next glance may lurk the demon you seek, all in flames, desperate to be held, but set to flee.
As I left Lilly's room I caught the "-venger" part of my name being paged overhead. I stopped at the nurses' station, picked up the phone, and dialed the hospital operator. "Frank Clevenger," I said.
"Outside call, Doctor. Hold on."
There was dead air, then a deep voice said, "Hello?"
Even after two years I recognized North Anderson 's baritone. He was a forty-two-year-old police officer from Baltimore, a black man as intimate with the dark city streets as with the veins coursing through his perfectly muscled, weight trainer's body. We had become fast friends working the forensic case I had sworn would be my last. Plumbing the minds of murderers had finally worn my own psyche paper-thin. "It's been too long," I said.
"I would have called sooner, but…"
But we reminded each other of carnage. We reminded one another of Trevor Lucas, a plastic surgeon gone mad who had taken over a locked psychiatric unit, performing grisly surgeries, including amputations, on select patients and staff. Before we could convince him to surrender, which only happened after I went onto that locked unit with him, he harvested a grotesque sampling of body parts that still floated through my nightmares. Anderson couldn't be sleeping any better himself. "You don't need to explain," I said.
A few seconds passed. "You'll never guess where I'm working now."
Anderson was as tough and streetwise a cop as I'd ever met. "Gang unit?"
"Not even close."
"Vice Squad," I said.
" Nantucket," he said.
" Nantucket?"
"You remember how I like the ocean," he said. "They advertised for a chief of police; I sent in a resumed Been here sixteen months. I actually sailed North's Star up here myself."