MORE PRAISE FOR
JONATHAN KELLERMAN
AND HIS ALEX DELAWARE
NOVELS

Silent Partner

“A complex and haunting story of tangled personalities, deeply buried family secrets, and of violence lying thinly under the surface.”

—Los Angeles Times Book Review

“A most intriguing read … compelling.”

—New York Daily News

Time Bomb

“Though a time bomb is ticking away at the heart of this novel, readers will forget to watch the clock once they begin it.”

—Chicago Sun-Times

“Virtually impossible to put aside until the final horrifying showdown.”

—People

Private Eyes

“A page-turner from beginning to end.”

—Los Angeles Times

“Spellbinding suspense … Unforgettable.”

—Houston Chronicle

Bad Love

“Bad Love will have you looking over your shoulder before you turn out the lights.”

—Detroit Free Press

“By the end I was fairly racing through the pages.”

—Los Angeles Times

Self-Defense

“Exciting … loaded with tension and packed with titillating insights.”

—The New York Times Book Review

“Kellerman at his best.”

—USA Today

The Clinic

“Mines new realms of psychological terror … Holds the reader riveted.”

—Playboy

“Quite possibly the best of the series—and that’s saying quite a lot.”

—Chicago Tribune

Survival of the Fittest

“An original and gripping tale that is one of his best.”

—Chicago Tribune

“Why is it so hard to put down a Kellerman thriller …? It’s simple: the nonstop action leaves you breathless; the plot twists keep you guessing; the themes … are provocative.”

—Publishers Weekly

Monster

“Unsettling and thrilling … Right from the start of Monster, Jonathan Kellerman does everything right.”

—The Baltimore Sun

“Kellerman delivers … Get ready to sleep with the lights on.”

—Rocky Mountain News

Dr. Death

“Intriguing … Stylish … A brazenly clever denouement.”

—The New York Times

“[A] roller-coaster plot … Just what the doctor ordered.”

—People

BOOKS BY JONATHAN KELLERMAN

Fiction
DECEPTION (2010)
EVIDENCE (2009)
TRUE DETECTIVES (2009)
BONES (2008)
COMPULSION (2008)
OBSESSION (2007)
GONE (2006)
RAGE (2005)
TWISTED (2004)
THERAPY (2004)
THE CONSPIRACY CLUB (2003)
A COLD HEART (2003)
THE MURDER BOOK (2002)
FLESH AND BLOOD (2001)
DR. DEATH (2000)
MONSTER (1999)
BILLY STRAIGHT (1998)
SURVIVAL OF THE FITTEST (1997)
THE CLINIC (1997)
THE WEB (1996)
SELF-DEFENSE (1995)
BAD LOVE (1994)
DEVIL’S WALTZ (1993)
PRIVATE EYES (1992)
TIME BOMB (1990)
SILENT PARTNER (1989)
THE BUTCHER’S THEATER (1988)
OVER THE EDGE (1987)
BLOOD TEST (1986)
WHEN THE BOUGH BREAKS (1985)

Nonfiction
WITH STRINGS ATTACHED (2008)
SAVAGE SPAWN: REFLECTIONS ON VIOLENT CHILDREN (1999)
HELPING THE FEARFUL CHILD (1981)
PSYCHOLOGICAL ASPECTS OF CHILDHOOD CANCER (1980)

For Children, Written and Illustrated
JONATHAN KELLERMAN’S ABC OF WEIRD CREATURES (1995)
DADDY, DADDY, CAN YOU TOUCH THE SKY? (1994)

With Faye Kellerman
CAPITAL CRIMES (2006)
DOUBLE HOMICIDE (2004)

This is a work of fiction. Names, characters, places, and incidents either are a product of the author’s imagination or are used fictitiously. Any resemblance to persons living or dead, or places, is entirely coincidental.

A Ballantine Book
Published by The Random House Publishing Group
Copyright © 1993 by Jonathan Kellerman
Excerpt from The Conspiracy Club copyright © 2003 by Jonathan Kellerman

All rights reserved.

Published in the United States by Ballantine Books, an imprint of The Random House Publishing Group, a division of Random House, Inc., New York, and simultaneously in Canada by Random House of Canada Limited, Toronto. First published in hardcover by Bantam Books in 1993.

No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.

Ballantine and colophon are registered trademarks of Random House, Inc.

www.ballantinebooks.com

eISBN: 978-0-345-46379-1

v3.1

To my son, Jesse,
a gentleman and a scholar

Special thanks to Reuben Eagle,
Allan Marder, Yuki Novick,
Michael Samet, Dennis Payne,
and Harry Weisman, M.D.

Contents

Cover

Other Books by This Author

Title Page

Copyright

Dedication

Acknowledgements

Epigraph

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12

Chapter 13

Chapter 14

Chapter 15

Chapter 16

Chapter 17

Chapter 18

Chapter 19

Chapter 20

Chapter 21

Chapter 22

Chapter 23

Chapter 24

Chapter 25

Chapter 26

Chapter 27

Chapter 28

Chapter 29

Chapter 30

Chapter 31

Chapter 32

Chapter 33

Chapter 34

Chapter 35

Chapter 36

Chapter 37

Excerpt from THE CONSPIRACY CLUB

Ring out old shapes of foul disease;
Ring out the narrowing lust of gold.

—ALFRED, LORD TENNYSON

1

It was a place of fear and myth, home of miracles and the worst kind of failure.

I’d spent a quarter of my life there, learning to deal with the rhythm, the madness, the starched whiteness of it all.

Five years’ absence had turned me into a stranger, and as I entered the lobby anxiety tickled my belly.

Glass doors, black granite floors, high, concave travertine walls advertising the names of dead benefactors.

Glossy depot for an unguided tour of uncertainty.

Spring, outside, but in here time had a different meaning.

A group of surgical interns—God, they were taking them young—slouched by on paper-soled scrub slippers, humbled by double shifts. My own shoes were leather-bottomed and they clacked on the granite.

Ice-slick floors. I’d just started my internship when they’d been installed. I remembered the protests. Petitions against the illogic of polished stone in a place where children ran and walked and limped and wheeled. But some philanthropist had liked the look. Back in the days when philanthropists had been easy to come by.

Not much granite visible this morning; a crush of humanity filled the lobby, most of it dark-skinned and cheaply dressed, queued up at the glassed-in booths, waiting for the favors of stone-faced clerks. The clerks avoided eye contact and worshipped paper. The lines didn’t seem to be moving.

Babies wailed and suckled; women sagged; men swallowed curses and stared at the floor. Strangers bumped against one another and sought refuge in the placebo of banter. Some of the children—those who still looked like children—twisted and bounced and struggled against weary adult arms, breaking away for precious seconds of freedom before being snagged and reeled back in. Others—pale, thin, sunken, bald, painted in unnatural colors—stood there silently, heartbreakingly compliant. Sharp words in foreign tongues crackled above the drone of the paging operators. An occasional smile or bit of cheer brightened the inertial gloom, only to go out like a spark from a wet flint.

As I got closer I smelled it.

Rubbing alcohol, antibiotic bitters, the sticky-ripe liqueur of elixir and affliction.

Eau de Hospital. Some things never changed. But I had; my hands were cold.

I eased my way through the crowd. Just as I got to the elevators, a heavyset man in a navy-blue rent-a-cop uniform stepped out of nowhere and blocked my way. Blond-gray crewcut and a shave so close his skin looked wet-sanded. Black-frame glasses over a triangular face.

“Can I help you, sir?”

“I’m Dr. Delaware. I have an appointment with Dr. Eves.”

“I need to see some ID, sir.”

Surprised, I fished a five-year-old clip-on badge out of my pocket. He took it and studied it as if it were a clue to something. Looked up at me, then back at the ten-year-old black-and-white photo. There was a walkie-talkie in his hand. Holstered pistol on his belt.

I said, “Looks like things have tightened up a bit since I was last here.”

“This is expired,” he said. “You still on staff, sir?”

“Yes.”

He frowned and pocketed the badge.

I said, “Is there some kind of problem?”

“New badges required, sir. If you go right past the chapel, over to Security, they can shoot your picture and fix you up.” He touched the badge on his lapel. Color photograph, ten-digit ID number.

“How long will that take?” I said.

“Depends, sir.” He looked past me, as if suddenly bored.

“On what?”

“How many are ahead of you. Whether your paperwork’s current.”

I said, “Listen, my appointment with Dr. Eves is in just a couple of minutes. I’ll take care of the badge on my way out.”

“ ’Fraid not, sir,” he said, still focused somewhere else. He folded his arms across his chest. “Regulations.”

“Is this something recent?”

“Letters were sent to the medical staff last summer.”

“Must have missed that one.” Must have dropped it in the trash, unopened, like most of my hospital mail.

He didn’t answer.

“I’m really pressed for time,” I said. “How about if I get a visitor’s badge to tide me over?”

“Visitor’s badges are for visitors, sir.”

“I’m visiting Dr. Eves.”

He swung his eyes back to me. Another frown—darker, contemplative. He inspected the pattern on my tie. Touched his belt on the holster side.

“Visitor’s badges are over at Registration,” he said, hooking a thumb at one of the dense queues.

He crossed his arms again.

I smiled. “No way around it, huh?”

“No, sir.”

“Just past the chapel?”

“Just past and turn right.”

“Been having crime problems?” I said.

“I don’t make the rules, sir. I just enforce them.”

He waited a moment before moving aside, followed my exit with his squint. I turned the corner, half expecting to see him trailing, but the corridor was empty and silent.

The door marked SECURITY SERVICES was twenty paces down. A sign hung from the knob: BACK IN above a printed clock with movable hands set at 9:30 A.M. My watch said 9:10. I knocked anyway. No answer. I looked back. No rent-a-cop. Remembering a staff elevator just past Nuclear Medicine, I continued down the hall.

Nuclear Medicine was now COMMUNITY RESOURCES. Another closed door. The elevator was still there but the buttons were missing; the machine had been switched to key-operated. I was looking for the nearest stairway when a couple of orderlies appeared, wheeling an empty gurney. Both were young, tall, black, sporting geometrically carved hip-hop hairstyles. Talking earnestly about the Raiders game. One of them produced a key, inserted it into the lock, and turned. The elevator doors opened on walls covered with padded batting. Junk-food wrappers and a piece of dirty-looking gauze littered the floor. The orderlies pushed the gurney in. I followed.

General Pediatrics occupied the eastern end of the fourth floor, separated from the Newborn Ward by a swinging wooden door. I knew the outpatient clinic had been open for only fifteen minutes but the small waiting room was already overflowing. Sneezes and coughs, glazed looks and hyperactivity. Tight maternal hands gripped babes and toddlers, paperwork, and the magic plastic of Medi-Cal cards. To the right of the reception window was a set of double doors marked PATIENTS REGISTER FIRST over a Spanish translation of same.

I pushed through and walked past a long white corridor tacked with safety and nutrition posters, county health bulletins, and bilingual exhortations to nurture, vaccinate, and abstain from alcohol and dope. A dozen or so examining rooms were in use, their chart-racks brimming over. Cat-cries and the sounds of comfort seeped from under the doors. Across the hall were files, supply cabinets, and a refrigerator marked with a red cross. A secretary tapped a computer keyboard. Nurses hustled between the cabinets and the exam rooms. Residents spoke into chin-cradled phones and trailed after fast-stepping attending physicians.

The wall right-angled to a shorter hallway lined with doctors’ offices. Stephanie Eves’s open door was the third in a set of seven.

The room was ten by twelve, with institutional-beige walls relieved by bracket shelves filled with books and journals, a couple of Miró posters, and one cloudy window with an eastern view. Beyond the glint of car-tops, the peaks of the Hollywood hills seemed to be dissolving into a broth of billboards and smog.

The desk was standard hospital-issue phony walnut and chrome, pushed up against one wall. A hard-looking chrome and orange-cloth chair competed for space with a scuffed brown Naugahyde recliner. Between the chairs a thrift-shop end table supported a coffee maker and a struggling philodendron in a blue ceramic pot.

Stephanie sat at the desk, wearing a long white coat over a wine-and-gray dress, writing on an outpatient intake form. A chin-high stack of charts shadowed her writing arm. When I stepped into the room she looked up, put down her pen, smiled, and stood.

“Alex.”

She’d turned into a good-looking woman. The dull-brown hair, once worn shoulder-length, limp, and barretted, was short, frosted at the tips, and feathered. Contact lenses had replaced granny glasses, revealing amber eyes I’d never noticed before. Her bone structure seemed stronger, more sculpted. She’d never been heavy; now she was thin. Time hadn’t ignored her as she entered the dark side of thirty; a mesh of feathers gathered at the corners of her eyes and there was some hardness at the mouth. Makeup handled all of it well.

“Good to see you,” she said, taking my hand.

“Good to see you, Steph.”

We hugged briefly.

“Can I get you something?” She pointed to the coffee machine, arm jangling. Gold vermeil bracelets looped her wrist. Gold watch on the other arm. No rings. “Plain old coffee or real café au lait? This little guy actually steams the milk.”

I said no thanks and looked at the machine. Small, squat, black matte and brushed steel, logo of a German manufacturer. The carafe was tiny—two cups’ worth. Next to it sat a petite copper pitcher.

“Cute, huh?” she said. “Gift from a friend. Gotta do something to bring a little style into this place.”

She smiled. Style was something she’d never cared about. I smiled back and settled in the recliner. A leatherbound book sat on a nearby table. I picked it up. Collected poems of Byron. Bookmark from a store named Browsers—up on Los Feliz, just above Hollywood. Dusty and crowded, with an emphasis on verse. Lots of junk, a few treasures. I’d gone there as an intern, during lunch hour.

Stephanie said, “He’s some writer. I’m trying to expand my interests.”

I put the book down. She sat in her desk chair and wheeled around facing me, legs crossed. Pale-gray stockings and suede pumps matched her dress.

“You look great,” I said.

Another smile, casual but full, as if she’d expected the compliment but was still pleased by it. “You, too, Alex. Thanks for coming on such short notice.”

“You piqued my interest.”

“Did I?”

“Sure. All those hints of high intrigue.”

She half turned toward the desk, removed a chart from the stack, let it rest in her lap but didn’t open it.

“Yup,” she said, “it’s a challenging one, that’s for sure.”

Standing suddenly, she walked to the door, closed it, and sat back down.

“So,” she said, “how does it feel to be back?”

“Almost got busted on the way in.”

I told her about my encounter with the security guard.

“Fascist,” she said cheerfully, and my memory banks reactivated: grievance committees over which she’d presided. White coat disdained for jeans, sandals, bleached cotton blouses. Stephanie, not Doctor. Titles are exclusionary devices of the power elite.…

I said, “Yeah, it was kind of paramilitary,” but she just gazed at the chart in her lap.

“High intrigue,” she said. “What we’ve got is a whodunit, howdunit—a did-anyone-do-it. Only this is no Agatha Christie thing, Alex. This is a real-life mess. I don’t know if you can help, but I’m not sure what else to do.”

Voices from the corridor filtered in, squalls and scolding and fleeing footsteps. Then a child’s cry of terror pierced the plaster.

“This place is a zoo,” she said. “Let’s get out of here.”

2

A door at the rear of the clinic opened to a stairway. We descended to the first basement level. Stephanie moved fast, almost jogging down the steps.

The cafeteria was nearly empty—one orange-topped table occupied by a male intern reading the sports section, two others shared by slumping couples who looked as if they’d slept in their clothes. Parents spending the night. Something we’d fought for.

Empty trays and dirty dishes cluttered some of the other tables. A hair-netted orderly circulated slowly, filling salt shakers.

On the eastern wall was the door to the doctors’ dining room: polished teak panels, finely etched brass nameplate. Some philanthropist with a nautical bent. Stephanie bypassed it and led me to a booth at the far end of the main room.

“Sure you don’t want coffee?” she said.

Remembering the hospital mud, I said, “Already filled my caffeine quota.”

“I know what you mean.”

She ran her hand through her hair and we sat.

“Okay,” she said. “What we’ve got is a twenty-one-month-old white female, full-term pregnancy, normal delivery, APGAR of nine. The only significant historical factor is that just before this child was born, a male sib died of sudden infant death syndrome at age one year.”

“Any other children?” I said, taking out a note pad and pen.

“No, there’s just Cassie. Who looked fine until she was three months old, at which time her mother reported going in at night to check on her and finding her not breathing.”

“Checking because she was nervous about SIDS?”

“Exactly. When she wasn’t able to rouse the baby, she administered CPR, got her going. Then they brought her into the E.R. By the time I arrived she looked fine, nothing remarkable on exam. I admitted her for observation, did all the usual tests. Nothing. After discharge we set the family up with a sleep monitor and an alarm. Over the next few months the bell went off a few times but they were always false positives—the baby was breathing fine. The graphs show some tracings that could be very brief apnea but there are also lots of movement artifacts—the baby thrashing around. I figured maybe she was just restless—those alarms aren’t foolproof—and put down the first episode to some quirky thing. But I did have the pulmonologists look at her because of her brother’s SIDS. Negative. So we decided just to keep a close eye on her during the high-risk period for crib death.”

“A year?”

She nodded. “I played it safe—fifteen months. Started with weekly outpatient checkups, tapered off so that by nine months I was willing to let them go till the one-year exam. Two days after the nine-month checkup they’re back at E.R., middle-of-the-night respiratory problems—the baby woke up gasping, with a croupy bark. More CPR by mom and they bring her in.”

“Isn’t CPR kind of extreme for croup? Did the baby actually pass out?”

“No, she never lost consciousness, just gasped a lot. Mom may have been overreacting, but with her losing the first child, who could blame her? By the time I got to the E.R., the baby looked fine, no fever, no distress. No surprise, either. Cool night air can clear up croup. I ran a chest X-ray and bloodwork, all normal. Prescribed decongestants, fluids, and rest and was ready to send them home but the mother asked me to admit her. She was convinced there was something serious going on. I was almost certain there wasn’t, but we’d been seeing some scary respiratory things recently, so I admitted her, ordered daily bloodwork. Her counts were normal and after a couple of days of getting stuck, she was going hysterical at the sight of a white coat. I discharged her, went back to weekly outpatient follow-up, during which the baby would have nothing to do with me. Minute I walk into the exam room she screams.”

“The fun part of being a doctor,” I said.

She gave a sad smile, glanced over at the food servers. “They’re closing up. Want anything?”

“No thanks.”

“If you don’t mind, I haven’t had breakfast yet.”

“Sure, go ahead.”

She walked briskly to the metal counters and came back with half a grapefruit on a plate and a cup of coffee. She took a sip of the coffee and grimaced.

“Maybe it needs some steamed milk,” I said.

She wiped her mouth with a napkin. “Nothing can save this.”

“Least it doesn’t cost anything.”

“Says who?”

“What? No more free coffee for the docs?”

“Them days are gone, Alex.”

“Another tradition bites the dust,” I said. “The old budgetary blues?”

“What else? Coffee and tea are forty-nine cents a cup now. Wonder how many cups it’ll take to balance the books.”

She ate some grapefruit. I fiddled with my pen and said, “I remember how hard you guys fought to get the interns and residents in on the freebie.”

She shook her head. “Amazing what seemed important back then.”

“Money problems worse than usual?”

“Afraid so.” She frowned, put her spoon down and pushed the grapefruit away. “Anyway, back to the case. Where was I?”

“The baby screaming at you.”

“Right. Okay, again things start to look good, so again I taper off and terminate, set up an appointment in two months. Three days later, back in the E.R., two A.M. Another croup thing. Only this time the mother says the kid did pass out—actually turned blue. More CPR.”

“Three days after you terminated,” I said, making a note. “Last time it was two.”

“Interesting, huh? Okay, I do an E.R. checkup. The baby’s blood pressure is up a bit and she’s breathing rapidly. But getting plenty of oxygen in. No wheeze, but I was thinking either acute asthma or some sort of anxiety reaction.”

“Panic at being back in the hospital again?”

“That, or just the mother’s distress rubbing off on her.”

“Was the mother showing a lot of overt distress?”

“Not really, but you know how it is with mothers and kids—the vibes. On the other hand, I wasn’t ready to rule out something physical. A baby passing out is something to take seriously.”

“Sure,” I said, “but it could also have been a tantrum gone too far. Some kids learn young how to hold their breath and pass out.”

“I know, but this happened in the middle of the night, Alex, not after some power struggle. So I admit her again, order allergy tests, complete pulmonary functions—no asthma. I also start thinking of rarer stuff: membrane problems, an idiopathic brain thing, an enzyme disorder. They’re up on Five for a week, real merry-go-round, consults by every specialty in the house, lots of poking and probing. Poor little thing’s freaking out as soon as the door to her room opens, no one’s coming up with a diagnosis, and the whole time she’s in, there are no breathing difficulties. Reinforcing my anxiety theory. I discharge them and the next time I see them in the office, I do nothing but try to play with her. But she still won’t have anything to do with me. So I gently raise the anxiety issue with mom but she’s not buying.”

“How’d she take that?” I said.

“No anger—that’s not this lady’s style. She just said she couldn’t see it, the baby being so young. I told her phobias could occur at any age, but I clearly wasn’t getting through. So I backed off, sent them home, gave her some time to think about it. Hoping that as the baby approached one year and the SIDS risk dropped, mom’s fears would diminish and the baby would start to relax too. Four days later they were back in the E.R., croup, gasping, mom’s in tears, begging for an admit. I put the baby in but ordered no tests. Nothing even remotely invasive, just observation. And the baby looked perfect—not even a sniffle. At that point I took the mom aside and leaned more heavily on the psychological angle. Still no sale.”

“Did you ever bring up the first child’s death?”

She shook her head. “No. I thought of it but at the time it just didn’t seem right, Alex. Overloading the lady. I figured I had a good feel for her—I was the attending doc when they brought the first child in dead. Handled the whole post-mortem … I carried him to the morgue, Alex.”

She closed her eyes, opened them but focused away from me.

“What hell,” I said.

“Yeah—and it was a chance thing. They were Rita’s private patients, but she was out of town and I was on call. I didn’t know them from Adam but I got stuck doing the death conference, too. I tried to do some basic counseling, gave them referrals to grief groups, but they weren’t interested. When they came back a year and a half later, wanting me to take care of the new baby, I was really surprised.”

“Why?”

“I would have predicted they’d associate me with the tragedy, a kill-the-messenger kind of thing. When they didn’t, I figured I’d handled them well.”

“I’m sure you did.”

She shrugged.

I said, “How’d Rita react to your taking over?”

“What choice did she have? She wasn’t around when they needed her. She was going through her own problems at the time. Her husband—you know who she was married to, don’t you?”

“Otto Kohler.”

“The famous conductor—that’s how she used to refer to him: ‘My husband, the famous conductor.’ ”

“He died recently, didn’t he?”

“Few months ago. He’d been sick for a while, series of strokes. Since then, Rita’s been gone even more than usual and the rest of us have been picking up a lot of the slack. Mostly, she attends conventions and presents old papers. She’s actually going to retire.” Embarrassed smile. “I’ve been considering applying for her position, Alex. Do you see me as a division head?”

“Sure.”

“Really?”

“Sure, Steph. Why not?”

“I don’t know. The position’s kind of … inherently authoritarian.”

“To some extent,” I said. “But I’d imagine the position can adapt to different styles of leadership.”

“Well,” she said, “I’m not sure I’d make a good leader. I don’t really like telling people what to do.… Anyway, enough about that. I’m getting off track. There were two more passing-out episodes before I brought up the psych thing again.”

“Two more,” I said, looking at my notes. “I’ve got a total of five.”

“Correct.”

“How old’s the baby by now?”

“Just under a year. And a hospital veteran. Two more admits, negative for everything. At that point I sat mom down and strongly recommended a psych consult. To which she reacted with … here, let me give you the exact quote.”

She opened the chart and read softly: “ ‘I know that makes sense, Dr. Eves, but I just know Cassie’s sick. If you’d only seen her—lying there, cyanotic.’ End of quote.”

“She phrased it that way? ‘Cyanotic’?”

“Yup. She has a medical background. Studied to be a respiratory tech.”

“And both her kids stop breathing. Interesting.”

“Yes.” Hard smile. “At the time I didn’t realize how interesting. I was still caught up in the puzzle—trying to arrive at a diagnosis, worrying when the next crisis was going to be and if I’d be able to do anything about it. To my surprise it didn’t happen for a while.”

She looked at the chart again. “A month passes, two, three, still no sign of them. I’m happy the baby’s okay but I’m also starting to wonder if maybe they’ve just found themselves another doc. So I called the home, talked to mom. Everything’s fine. Then I realized that in the heat of everything, the baby had never had her one-year exam. I schedule it, find everything intact, with the exception that she’s a little slow vocally and verbally.”

“How slow?”

“No retardation or anything like that. She just made very few sounds—in fact I didn’t hear anything from her at all, and mom said she was pretty quiet at home, too. I tried to do a Bailey test, but couldn’t because the baby wouldn’t cooperate. My guesstimate was about a two-month lag, but you know at that age it doesn’t take much to tip the scales, and given all the stress the poor thing’s been through, no big deal. But brilliant me. Bringing up language development got mom worried about that. So I sent them over to ENT and Speech and Hearing, who found her ears and laryngeal structure one hundred percent normal and concurred with my assessment: possible mild delay in reaction to medical trauma. I gave the mom suggestions about stimulating speech and didn’t hear from them for another two months.”

“Baby’s fourteen months old,” I said, writing.

“And back in the E.R., four days later. But not with breathing probs. This time she’s spiking a temp—a hundred and five. Flushed and dry, and breathing fast. To be honest, Alex, I was almost happy to see the fever—at least I had something organic to work with. Then the white count came back normal, nothing viral or bacterial. So I ran a toxicology. Clean. Still, lab tests aren’t perfect—even our error rates are running ten to twenty percent. And that spike was real—I took the temp myself. We bathed her and Tylenoled her down to a hundred and two, admitted her with a fever-of-unknown-origin diagnosis, pushed fluids, put her through some real hell: spinal tap to rule out meningitis, even though her ears were clear and her neck was supple, because for all we knew she had one heck of a headache she couldn’t tell us about. Plus twice-daily bloodwork—she went bananas, had to be held down. Even with that, she managed to dislodge the needle a couple of times.”

She exhaled and pushed the grapefruit farther away. Her forehead had moistened. Swabbing it with a napkin, she said, “First time I’ve told it like this from the beginning.”

“You haven’t had any case conferences?”

“No, we don’t do much of that anymore. Rita’s basically useless.”

I said, “How did the mother react to all the procedures?”

“Some tears, but basically she stayed composed. Able to comfort the baby, cuddling her when it was over. I made sure she never was involved in holding the baby down—integrity of the mother-child bond. See, your lectures stuck, Alex. Of course the rest of us felt like Nazis.”

She wiped her brow again. “Anyway, the blood tests kept coming back normal but I held off discharge until she’d had no fever for four days running.”

Sighing, she burrowed her fingers through her hair and flipped through her chart.

“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?”

“Yes,” I said, “but in some cases the father turns out to be a passive accomplice. Any sign he suspects something?”

“If he has, he hasn’t told me. He doesn’t seem especially passive—nice enough. So is she, for that matter. They’re both nice, Alex. That’s one of the things that makes it so difficult.”

“Typical Munchausen scenario. The nurses probably love them.”

She nodded.

“What’s the other?” I said.

“The other what?”

“Thing that makes it so difficult.”

She closed her eyes and rubbed them and took a long time to answer.

“The other thing,” she said, “and this may sound horribly cold-hearted and political, is who they are. Socially. Politically. The child’s full name is Cassie Brooks Jones—set off any buzzers?”

“No,” I said. “Jones isn’t exactly memorable.”

“Jones, as in Charles L. Junior. Hotshot financier? The hospital’s primary money manager?”

“Don’t know him.”

“That’s right—you don’t read your newsletters. Well, as of eight months ago he’s also chairman of the board. There was a big shake-up.”

“The budget?”

“What else. Anyway, here’s the genealogy: Charles Junior’s only son is Charles the Third—like royalty. He goes by Chip—Cassie’s daddy. The mom is Cindy. The dead son was Chad—Charles the Fourth.”

“All Cs,” I said. “Sounds like they like order.”

“Whatever. The main thing is, Cassie is Charles Junior’s only grandchild. Isn’t that wonderful, Alex? Here I am with a potential Munchausen by proxy that could explode in everyone’s face, and the patient’s the only grandchild of the guy who took away the free coffee.”

3

We got up from the table and she said, “If you don’t mind, we can take the stairs-up.”

“Morning aerobics? Sure.”

“You hit thirty-five,” she said, smoothing her dress and buttoning her white coat, “and the old basal metabolism goes to hell. Got to work hard not to be lumpy. Plus, the elevators still move on Valium Standard Time.”

We walked toward the cafeteria’s main exit. The tables were completely empty now. A brown-uniformed maintenance worker was wet-mopping the floor, and we had to step gingerly to maintain traction.

I said, “The elevator I took to your office was converted to key lock. Why the need for all the security?”

“The official line is crime prevention,” she said. “Keeping all the street craziness out of here. Which to some extent is valid—there have been increased problems, mostly during the night shift. But can you remember a time when East Hollywood didn’t get bad after dark?”

We reached the door. Another maintenance man was locking it and when he saw us, he gave a world-weary look and held it open for us.

Stephanie said, “Reduced hours—another budget cut.”

Out in the hallway, things had gotten frantic. Doctors blew past in boisterous groups, filling the air with fast talk. Families traipsed through, wheeling doll-sized veteran journeyors to and from the ordeals wrought by science.

A silent crowd was assembled at the elevator doors, clumped like human droplets, waiting for any of three lifts that had settled simultaneously on the third floor. Waiting, always the waiting …

Stephanie moved through deftly, nodding at familiar faces but never stopping. I followed close behind, avoiding collision with I.V. poles.

When we entered the basement stairwell, I said, “What kind of crime problems have there been?”

“The usual, but more so,” she said, climbing. “Car thefts, vandalism, purse snatchings. Some muggings out on Sunset. And a couple of nurses were assaulted in the parking lot across the street a few months ago.”

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