Compulsion
Compulsion
Clevenger 03
by
Keith Ablow
Contents
"Come away, O human child!
To the waters and the wild
With a faery, hand in hand,
For the world’s more full of weeping
Than you can understand."
—William Butler Yeats
The Stolen Child
Saturday, June 22, 2002
Lilly Cunningham looked up. I melted. She was twenty-nine years old, with pale blue eyes to get lost in. Her blond, curly hair would make any man want to touch it. Her strong forehead predicted intelligence and was perfectly balanced by the gentle slope of her nose. Then there were her full lips, dimples in her cheeks, her long, slender neck. A simple gold cross on a delicate chain pointed toward the curves of her chest and abdomen, rising and falling under a white sheet.
Part of me wanted to let my attention linger on Lilly’s beauty, but the bigger part of me loves truth, which is almost always about something ugly. My eyes moved to her exposed thigh.
The flesh was inflamed from groin to knee. The skin had broken down in places, spreading like wet parchment, weeping pinkish fluid. Two serpentine black lines, in Magic Marker, each running twelve or fourteen inches through the muck, showed where her surgeon would make incisions to promote drainage.
A war was being fought. Battle lines had been drawn.
"I don’t believe we’ve met," Lilly said, her voice straining.
"Dr. Clevenger," I said, still focused on her thigh. I stayed several feet from the bed, which is my habit when first seeing patients.
"Hmm. Shaved head, jeans, cowboy boots. You don’t look like any doctor I’ve ever seen. Certainly not at Mass General."
I met her gaze. "What do I look like?"
She worked at a smile. "I don’t know. An artist, maybe... or a bartender." She laughed, but weakly. "You have a first name?"
"Frank."
"Okay, then, Dr. Frank Clevenger. What’s your line? Surgery? Internal medicine? Infectious disease?"
"I’m a psychiatrist."
She shook her head and turned toward the wall. "This is un-
fucking
believable."
I stood there a few moments, starting through the tangle of IV tubing that dripped amphotericin and vancomycin in Lilly’s subclavian vein. A window just beyond the hanging bottles looked onto Boston’s Charles River at dusk, its waters blue-gray and utterly still. I tried again. "Do you mind if I ask a few questions?"
"You can do whatever you want. I don’t care."
I heard a fusion of anger and surrender in her voice. And I sensed something more in the way she half-whispered, half-swallowed the word
care
. A hint of seductiveness. Her tone made me imagine that I could, quite literally, do whatever I wanted to her. I took a mental note of that feeling, wondering whether she provoked it in others — and why. I stepped closer to the bed. "Do you know why your doctors asked me to see you?"
"Probably because they keep screwing up," she complained, shaking her head and exhaling in exasperation. "They can’t figure out what’s wrong with me, so they’re calling me crazy."
That was half-right. Her doctors
were
calling her crazy, but they had figured out exactly what was wrong with her — at least, physically.
Drake Slattery, chief of the internal medicine department, had filled me in. He is a lumberjack of a man who wrestled for Duke, and the muscles of his crossed arms had begun to ripple as he spoke. "She presented about four months ago, fresh from her honeymoon on St. Bart’s. Mild fever, red blotch on her thigh. I’m figuring some tropical insect took a bite out of her, left her with a little cellulitis. Nothing to write home about. Like an idiot, though, I trash my whole schedule to get her worked up and started on antibiotics right away."
"Is she that pretty?" I had asked.
He looked offended. "Professional courtesy; she’s a nurse over at Brigham & Women’s."
"Fair enough."
"And she happens to be gorgeous."
I smiled.
"So I dose her up on ampicillin, which seems to work," he said. "But then, two weeks later, she’s back in the emergency room. The leg is puffed up twice normal size. She says she feels like someone’s jamming a red-hot knife into her thigh. And she’s running a fever of 103." His arms started rippling, again. "The ampicillin doesn’t seem to cut it anymore, so I add a chaser of Rocephin. And the swelling goes down pretty quickly. All’s well that ends well, right? Sometimes you have to go after the bugs with bigger guns."
Slattery was an avid hunter, which made it hard for me to like him, despite his rare combination of genius and dry wit. "You’re the shooter," I said.
He winked. "Five days later, she’s down in the ER again, bigger and redder than ever. Shaking like a leaf. Now I’m worried. I don’t know what to think. Lymphatic obstruction from a malignancy? Sarcoidosis? I even wondered about some weird presentation of AIDS. I never guessed what was really going on."
Over the next few months, Slattery admitted Lilly to Mass General four times, treating her with a dozen different antifungal and antibiotic agents. Some seemed successful, dropping her white blood cell count and stopping the chills and sweats that plagued her. But, inevitably, she would return to the emergency room within days, infected and feverish again.
A CAT scan of her leg showed no tumor. A bone scan revealed no osteomyelitis. Repeated blood cultures failed to turn up any offending bacterium. So Slattery finally had a surgeon biopsy the semitendinous and biceps femoris muscles of Lilly’s leg. He forwarded the tissue samples to the bacteriology laboratory of the National Institute of Infectious Disease in Bethesda, Maryland. The report came back in a week later:
Pseudomonas fluorescens
, a pathogen generally found in soil.
"We gave her husband the news first," Slattery had told me. "He broke down and admitted he’d found a frigging syringe caked with mud at the back of one of her drawers. Wrapped in a pair of her panties."
That image turned my skin to gooseflesh.
"Here we are busting our asses trying to keep this mental case from losing her leg," Slattery went on, "and it turns out she’s been injecting herself with dirt."
"That might say something about how she feels about herself," I said.
"To you, maybe. To me, it says she has no business being in the hospital. She’s stealing — my time, not to mention the hospital’s resources."
"I’d bet this case is all about stealing. But the key is to figure out what was stolen from
her
."
"You’re the poet," Slattery said wryly. "That’s why I called you in."
I looked at Lilly lying in bed, still facing the wall. The technical term for her condition was Munchausen syndrome, intentionally creating physical symptoms in order to get attention from doctors. The name derives from Baron Karl Friedrich von Münchausen, a Paul Bunyan-like storyteller. Research studies have shown that a high percentage of patients with the disorder, like Lilly, worked in the health care field.
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 for 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 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 so understanding about his 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. Bart’s. 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.
