MUNCHAUSEN BY PROXY may be the single most complex-and lethal-form of maltreatment known today. It is formally fefined as the falsi- fication or induction of physical and/or emotional illness by a caretaker of a dependent person. In most cases, the perpetrator is a  another and the victim is her own child. Baron Karl von Muchausen was a real historical figure, a soldier and an adventurer of the eighteenth century who became notorious for his outrageous stories. In 1951, a Bristish physician borrowed the baron's name and introduced the term Munchausen syndrome for peple who feign or produce illness in themseslves to gain sympathy, nurturance, and control over others. In turn, MBP was coined to describe those who use a substitute or "proxy" for tje same reasons. It's conservatively estimated that 1200 new cases of MBP are reported annually in the United States, with proportional numbers in other countries based on their populations. Howerver, many more cases go unreported—indeed, entirely undetected—due to the covert narure of the maltreatment. A recent study indi-cates that when a case of MBP is finally recognized, up to 25% of the sickened child's siblings have already died—most likely earlier victims of the perpetrator. Only when the same pattern of symtoms appears in the second child of the family, or the third or fourth or fifth l, have professionals and legal authorities been forced to realize that motherhood can twist into a strange illness-related type of abuse that, unlike battering or sexual violation, defies ready categorization. Even though the FBI has been vigilantly aware of MBP for several years, Muchausen by proxy is still a public health tragedy that, paradoxically, has been largely hidden from the public.
I entered the strange world of MBP begrudgingly. Having been primarily interested in Munchausen sydrome, I was reluctant to enter the difficult and troubling arena of child neglect and abuse. However, being a " Munchausen " expert meant attempting to master its variants; it meant wading into the waters of child protection despite the fact that MBP perpetrators almost invariably deny their actions, even when caught on tape. I have since consulted and testified nationally in numerous MBP cases, often before judges and juries who are dubious that such a bizarre form of abuse can even exist. I have discussed the syndrome in my own books and in chapters for books by others, & have answered over a thousand related inquiries through tele- phone, mail, and e-mail. I have worked in the field if MBP essentially everyday for over a decade, and it still breaks my heart.
One day, while trolling the Internet for links to expand my website, I came across a new and important perspective on MBP. A woman named shared aspects of her MBP victimization through vivid writing and moving photographs. She des-cribed her interest in writing a book and I e- mailed my encouragement, thus beginning a relationship that has culminated here.
In Sickened, we get an unprecedented look into the experience if MBP. There are over 500 clinical articles and books on the subject, but until now no one has told the full story of MBP from the inside. Julie Gregory grew up not in a playground among friends, but in the weirdly structured and antiseptic world of doctors's offices and hospitals. Her life was completely focused on the falsely constructed world of her various "illnesses", and the caregivers and doctors who might have nurtured her were co-opted into damaging both her body and her soul. Indeed, doctors are the unwitting accomplices in MBP, conditioned to have blind faith in what they are told by parents and families. It is undeniable that what a parent says is usually tge best guide to what's wrong with the child, so it takes an enormous shift in attiude for a physician to accept that the stories ring untrue, that the test result are normal, that no treatment ever works, that no amount of testing is ever "enough", and that the parent is more accurately called a perpetrator. Of course, the best lies are the ones that mix fact and fiction: children can show real symptoms, yet how they are created can remain conveniently undisclosed.
A parent can be ruthless in her quest to garner emotional satisfaction from the ailments of her child. She needn't be highly educated, only per-suasive. If MBP perpetrators find that interest is waning in their drama of "selfless" caretaking, they can move on to new audiences: new hospitals, new emergency ros. They often scour text-books or the Internet for medical information to enhance performances that could put any good actress to shame.
As Julie got older, it might seem to the reader that she colluded with her mother in misleading doctors. Did she? Never. She was simply over- powered. How can a child counter a mother's total self- absorption, an impenetrable world that is a whole unto itself? We know that even adult MBP victims may not disclose the true sources of their illnesses out of fear of abandonment OS punishment if they stop being sick. Other elements creep into the MBP picture, such as Stockholm syndrome, epitomized by Patty Hearst's adopting the cause of her violent abductors: Children often protect their abusers and resist making revelations to the very medical and social service personnel who could rescue them.

Sickened does not consist of unreliable mem-ories recovered through hypnosis or a therapist's leading questions, but of events hat were never forgotten-a blessing and a curse for Julie. They were further validated by Julie's compiling the whole messy, disturbing stack of her medical records. Itis from these records that we see how easily a mother's lies became insidiously trans-formed into medical fact.

Julie Gregory has a remarkable story to tell and a remarkable fortitude to share. She is also lucky to be alive. Author Philip Yancey has written, "Life is not a problem to be solved but a work to be made, and that work may well utilize much raw material we would prefer to do withou." Julie has a resilience only scarcely imaginable umder the cirrcumstances. That she has emerged not only with her sense of self intact but with enough clarity to write about it is amazing. I hope that her putting her life to paper in this searing and beautiful memoir can silence some of the demons of the past and help those still caught in the web of MBP maltreatment.

I expect Sickened to ignite a powder keg that brings MBP forever out of the closet, giving off a light that doctors, health care organizations, pro-fessional groups, child abuse workers,and the general public can never again ignore. Born of one of the darkest and most intractable of childhood situations, the words assembled here represent a monument, a genunie triumph of the human spirit.



                                                                                    Matc D. Feldman, M.D.

Department of Psychiatry anad Behavioral Neurobiology, University of Alabama, Tuscaloosa.