THE BAD MOTHER.

In 1977, Roy Meadow, a British pediatrician, published an account of two children whose symptoms had, for a time, baffled him. Initially, there seemed to be no similarity between the cases. Kay, a six-year-old, had what appeared to be a recurrent urinary-tract infection. In the course of consultations with sixteen doctors, she had been admitted to the hospital twelve times, catheterized, X-rayed, and treated unsuccessfully with eight different antibiotics. Charles, a fourteen-month-old, had suffered for more than a year with bouts of drowsiness and vomiting, which came on suddenly and without evident cause, and for which he, too, had been hospitalized on several occasions. He would arrive at the emergency room with weirdly high sodium levels in his blood, but his renal and endocrine systems showed no evidence of disease; as Meadow notes in his article, "between attacks, Charles was healthy and developing normally."

Kay and Charles, it turned out, did have something in common. Kay's mother had tampered with her daughter's urine samples to make her appear to be ill when she wasn't. Charles's mother made him sick by feeding him high doses of salt.

Meadow gave this previously unrecognized form of child abuse a name: Munchausen syndrome by proxy, for the eighteenth-century German baron who was infamous for telling tall tales. Doctors had already identified a Munchausen syndrome, which referred to patients who feign illness or harm themselves in order to secure attention and sympathy--unlike malingerers, whose fakery is motivated by material gain (receiving a disability check, staying home from work).

Meadow's landmark article, "Munchausen Syndrome by Proxy: The Hinterland of Child Abuse," which was published in The Lancet, is a brief, discomfited piece of writing. He clearly finds it awkward to tell physicians that they might be complicit in a form of child abuse, particularly if they order unnecessary, painful medical procedures. He cannot decide whether it is problematic for parents to be allowed to remain at the bedsides of their hospitalized children, knowing that in some cases they might do harm. His explanation for the mothers' behavior is modest, and does not try to resolve apparent contradictions. Shortly after telling his readers that Charles ultimately died from salt poisoning--an autopsy revealed gastric erosions, "as if a chemical had been ingested"--he remarks, without apparent irony, that Charles's poisoner was a "caring, home-minded mother." Indeed, both mothers "were pleasant people to deal with, cooperative and appreciative of good medical care, which encouraged us to try all the harder." He adds, "Some mothers who choose to stay in hospital with their child remain on the ward slightly uneasy, overtly bored, or aggressive. These two flourished there as if they belonged, and thrived on the attention that staff gave to them."

Meadow's deliberately tentative conclusion is that Munchausen mothers "were using the children to get themselves into the sheltered environment of a children's ward surrounded by friendly staff." He leaves as an open question whether the disorder was unknown because it was so rare or simply because it lacked a name.

By defining two instances of abuse as a syndrome, Meadow made a significant diagnostic leap. Since then, a number of writers on the subject have taken an even bigger and more questionable leap: they have turned a bizarre and uncommon form of child abuse into a distinct psychiatric disorder, with its own checklist of symptoms identifying mothers who suffer from it. By now, Munchausen syndrome by proxy, or M.S.B.P., has generated a substantial body of literature--more than four hundred journal articles, and numerous books and essay collections. The D.S.M. IV, the latest edition of the American Psychiatric Association's guide to diagnoses, includes an entry on the syndrome, under the name "factitious disorder by proxy."

After Meadow, the physician who has perhaps done the most to draw attention to the syndrome is David Southall, who practices at a hospital in Stoke-on-Trent, England. In the nineteen-nineties, he pioneered the use of covert video surveillance to catch M.S.B.P. abuse in hospital rooms. Other researchers adopted this controversial investigative technique, and British and American TV have broadcast some of these images: blurry black-and-white clips of mothers smothering their babies, who struggle against pillows; a mother disconnecting her daughter's oxygen tube; another jamming her fingers down her baby's throat. These women seemed intent on creating a facsimile of breathing disturbances sometimes associated with sudden infant death syndrome, and counted on a doctor's subsequently reviving their children--an appalling gamble. The thirty-nine abused children in Southall's original study had forty-two siblings, twelve of whom were found to have died unexpectedly. Confronted with the video evidence, four mothers admitted to having suffocated eight of the siblings.