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Then they discovered that Kay's mother had been doctoring the girl's urine samples; in fact, Kay was never sick at all. Charles' mother, meanwhile, had been force-feeding her baby excessive doses of salt to make him sick.
In a 1977 article in the international medical journal The Lancet, Meadow dubbed this peculiar form of child abuse "Münchausen syndrome by proxy." Münchausen syndrome — also coined in The Lancet, in 1951 — is a psychiatric condition in which a patient concocts illnesses or injures himself solely to draw attention or sympathy. (The condition is named after an eighteenth-century German baron notorious for his exaggerated storytelling.) A mother who maimed her children for no tangible gain, Meadow theorized, would be looking to earn sympathy and to portray herself as an indefatigable caregiver in the face of adversity.
In 1979 California prosecutors brought Münchausen by proxy into the courtroom, citing it as the motive in a murder case against Priscilla Phillips, who had steadfastly cared for her ailing adopted daughter until the girl died of unexplained causes. Suspicions were raised when a second daughter came down with similar symptoms, and a doctor discovered that Phillips was spiking the child's infant formula with toxic quantities of baking soda. Found guilty of second-degree murder and child endangerment, Phillips served four years in prison.
Prosecutors in Texas, Florida, Delaware and at least three other states subsequently used the Münchausen-by-proxy motive to win guilty verdicts, and law enforcement officials have suggested the condition as a possible explanation in hundreds, if not thousands, of unsolved cases in which mothers were deemed potential suspects.
But many in the medical community remain unconvinced.
The abuse can be hard for doctors to discern, notes Dr. Marc Feldman, a clinical professor of psychiatry at the University of Alabama at Tuscaloosa who serves as an expert witness in Münchausen cases — and who believes the condition is a valid diagnosis. Warning signs: more than one child in the same family who falls ill with similar, unexplained symptoms; no overt signs of abuse (such as cuts or bruises); a mother who appears to be an ideal parent; symptoms that only appear when the mother is present.
"Suffocation is very common," Feldman elaborates. "There's also bleeding by creating the illusion of bleeding: A mother may bloody the child's diaper in some way, such as using her own tampon, which forces a wide array of intrusive medical procedures on the child. We see a lot of vomiting induced by ipecac. There's diarrhea due to surreptitious use of laxatives. Alternatively, some mothers give the child constipating products."
Feldman says he's aware of cases in which mothers injected feces into a child's IV line. "Every time I think I've heard the last possible variant of Münchausen by proxy, I hear about something new," he says. "It really boggles the imagination."
According to Feldman, most Münchausen-by-proxy victims may continue to be subjected to the abuse — and the medical consequences — for a long time, "but 90 percent of them don't die as a result."
"Look, I'm not somebody who doesn't believe people hurt their kids," says Mart, who in 2002 authored Münchausen's Syndrome by Proxy Reconsidered, a critique of the diagnosis. "But they do it for a million reasons: because they're drunk, because they're angry, because they have mental problems, because the kid is causing trouble. Do we say that all rapists are exactly the same? No. Are all murderers exactly the same? No. I think it's misleading to a jury to say there's a scientific profile that differentiates these mothers from anybody else."
Mart adds that the logic law-enforcement officials and psychologists apply to their argument is disconcertingly circular: "They say, 'OK, why would she do such a thing? Because she has Münchausen by proxy.' You ask, 'How do you know she has Münchausen by proxy?' They say, 'Because she did it.' You have to differentiate between clinical lore and things that have been empirically proven. A lot of this hasn't been proven."
Indeed, few studies have been conducted worldwide. In the American Psychiatric Association's clinical manual — considered by most psychiatrists to be the diagnostic bible — the syndrome is mentioned only in the appendix, as a condition "that requires further research and study."
Ten years ago it looked as though a group of forensic examiners from across the nation, including Marc Feldman, might have had the opportunity to perform a unique study on a woman convicted of what has been called the largest maternal infanticide in American history. Marie Noe of Philadelphia confessed in 1998 to murdering eight of her ten children between 1949 and 1968. (The other two died of natural causes as infants.) As part of her criminal sentencing, a judge ordered Noe to submit to an extensive psychological examination.
One court-appointed psychiatrist subsequently ruled out Münchausen by proxy in Noe's case, but the judge called off the more thorough study. Feldman says he personally appealed to the judge to reconsider, "and he never responded."