Over the Edge

14

IT WAS twelve-twenty when I got home, but Robin was still up, wearing a T-shirt over nothing and reading in bed.

"After you left, I went back to the shop," she explained. "Rockin' Billy phoned from New York; he's coming into town and wants another custom guitar."

I kissed the top of her head, undressed, and slipped in beside her.

"More fruit? What was it last time — a mango?"

"A six-stringed papaya." She laughed. "For the Tropical Dreams LP. No, this time he's gone high-tech. He's releasing a song next week called "Buck Rogers Boogie" and he wants a solid body shaped like a ray gun to take on tour — chrome paint, LED readouts, synthesizer interface, the works."

"Ah, art!"

"It's antiart, which is even more fun. Sometimes when I'm in the middle of one of his jobs and I start to feel silly, I pretend Marcel Duchamp is sitting in a corner of the shop, nodding approvingly."

It was my turn to laugh.

"I'd like to see the thing when it's done," I said, "risk my life and blast off a few chords."

"Come by when Billy picks it up. You might enjoy meeting him. Despite his looks, he's not your typical burned-out rocker. More of a long-haired businessman really."

"Maybe I should meet the guy. You spend enough time with him."

"Don't worry, darling, he's not my type. Too skinny." She grew serious. "How's Milo?"

I told her.

"Poor man," she said. "Down deep he's such a softy. Isn't there something we could be doing for him?"

"He knows he can come to us, but I think he's going to go the loner route for a while. And besides, getting together is awkward as long as we're working opposite sides of the Cadmus case."

"That's awful. How much longer will you have to be involved with it?"

"I don't know."

The noncommittal answer raised her eyebrows. She looked at me and let it ride.

"Speaking of which," she said, "a call came in on the service from Horace Souza. He insisted on leaving the message personally, so I took it. He's a charming old goat, isn't he?"

"I've never seen him in that light."

"Oh, but he is, honey. Very courtly, very old-world. Like a benevolent uncle. Some women go for that type."

"To me he's just manipulative and calculating. Everything he does is framed in terms of strategy, of winning the game."

"Yes, I could see that," she said. "But wouldn't you want someone like that defending you if you were in trouble?"

"I guess so," I said grumpily. "What did he want?"

"Dr. Mainwaring can see you tomorrow at ten. If he doesn't hear from you, he'll assume it's on."

"Okay, thanks."

She propped herself up and looked into my eyes. Soft, fragrant curls brushed across my cheek.

"Poor Milo," she said again.

I was silent.

"Are you cranky, Alex?"

"No. Just tired."

"Not too tired, I hope." The tip of her tongue grazed my lower lip. A jolt of pleasure coursed through my body.

"Never too tired," I said, and wrapped my arms around her.

In the daylight the high concrete walls of Canyon Oaks Hospital were a sickbed grey that had been rendered white by the mercy of darkness. They rose, like tombstones, out of the verdant hills.

Mainwaring wasn't in his office at ten, and his secretary implied that his absence was premeditated. She led me to a small reading room down the hall and handed me Jamey's chart.

"Doctor said to read this first. He'll be ready for you by the time you're through."

The room was pale and windowless, furnished with a tufted black vinyl sofa, an ersatz-wood end table, and an aluminium pole lamp. An ashtray on the table was filled with cold butts. I sat down and opened the chart.

Mainwaring's notes for the night of Jamey's initial admission to Canyon Oaks were detailed and punctilious. The patient was described as agitated, confused, physically assaultive, and unresponsive to the psychiatrist's mental status evaluation. Note was made of the fact that he'd been transported by an emergency ambulance and accompanied by the police. Mainwaring had conducted a gross neurological exam that had revealed no evidence of brain tumours or other organic abnormalities, though he'd included an addendum emphasising that the patient's lack of cooperation had made a comprehensive evaluation impossible. Plans for a CAT scan and an EEG were charted. Analyses for drug ingestion had ruled out the presence of LSD, PCP, amphetamines, cocaine, or opiates.

Psychiatric and medical histories had been taken from Mr. Dwight Cadmus and Mrs. Heather Cadmus, legal guardians, in the presence of Horace Souza, attorney-at-law. The medical history was unremarkable. The psychiatric history documented a pattern of progressive mental deterioration including delusions of persecution and probable auditory hallucinations combined with evidence of a premorbid schizoid or borderline personality type. The working diagnosis was "schizophrenic disorder with mixed features (paranoid type, DSM#295.3x, possibly evolving to undifferentiated type, DSM#295.6x)" for which Mainwaring prescribed hospitalisation and an initial regimen of chlorpromazine — the generic name for Thorazine — a hundred milligrams orally, four times a day.

Appended to the intake report were copies of the police report and court documents validating the hospital's right to hold the boy involuntarily for seventy-two hours and the subsequent long-term commitment, as well as a CAT scan conducted two days after admission by a consulting neuro-radiologist, which confirmed the absence of organic pathology. The radiologist recounted — with barely disguised irritation — how difficult it had been to administer the scan because of the patient's assaultive behaviour and stated that conducting an EEG wouldn't be advisable until the patient grew more cooperative. The brain wave test was unlikely to yield much of value, he added, because the patient was clearly psychotic and EEG tracings on psychotics were inconclusive. Furthermore, the patient had already been medicated; that would invalidate the exam completely. He thanked Mainwaring for the referral and signed off the case. In the note that followed, Mainwaring thanked the radiologist for his consultation, concurred with his findings and recommendations, and noted that the severity of the patient's psychosis had "dictated prompt chemotherapeutic treatment prior to encephalographic monitoring".

Past that point, the notes thinned considerably. Mainwaring had visited Jamey once or twice daily, but the contents of those contacts hadn't been recorded. The psychiatrist's remarks were brief and descriptive — "patient stable, no change" or "increased hallucinatory activity" — followed by orders to adjust drug dosages. As I read on, it became clear that Jamey's response to medication had been uneven and that adjustments had been frequent.

For a brief period following admission, he'd appeared to be reacting favourably to the Thorazine. The psychotic symptoms lessened in both frequency and severity, and twice Mainwaring recorded that "brief conversation with the patient" was possible, although he didn't specify what he and Jamey had spoken about. Soon after, however, there was an acute relapse, with Jamey growing highly agitated and lashing out physically. Mainwaring upped the dosage and, when the boy got worse instead of improving, kept increasing it steadily, searching for an "optimal maintenance dose."

At fourteen hundred milligrams daily there followed another period of improvement, although at this level of medication the patient was numbed and sleepy and progress was judged by the absence of unpredictable behaviours rather than by coherence. Then came another sudden relapse; the hallucinations this time were more "florid" than ever before, the patient so assaultive that full-time restraints were ordered. Mainwaring dropped the Thorazine and switched to other phenothiazine tranquillisers — haloperidol, thioridazine, fluphenazine. With each drug the fluctuating pattern repeated itself. Initially Jamey had appeared to grow sedate, the quiescent periods ranging from a few days to one or two weeks at a time. Then, without warning, he'd become intractably agitated, paranoid, and confused. Toward the end of the notes, repetitive movements of the lips, tongue, and trunk had begun to appear — symptoms of tardive dyskinesia similar to the ones I'd noticed at the jail. In addition to not responding favourably to the drugs, he was developing toxic reactions to them.

It was a baffling cycle, and at one point Mainwaring's frustration emerged through his curt prose. Faced with the latest relapse, he speculated that Jamey was suffering from a highly atypical psychosis, possibly related to some kind of seizure disorder — a "subtle limbic abnormality that would not be revealed by the CAT scam". The fact that dyskinesia had developed so quickly, he wrote, supported the notion of an abnormal nervous system, as did the patient's bizarre response to phenothiazines. Quoting journal references, he noted reports of success in other atypical cases through the use of anticonvulsant medication. Emphasising that such treatment was experimental in nature, he suggested a trial dosage of carbamazepine, an anticonvulsant, once written consent from the guardians had been obtained and an EEG had been conducted. But before this could take place, Jamey got better again, growing more calm and compliant than he'd been since admission and able once again to converse in brief sentences. Along with this came significant emotional depression, but this was deemed less important than the absence of psychotic symptoms. Mainwaring was pleased and kept him on the same medication.

Two days later he escaped.

The nursing notes weren't much help. Excretory fuctions, nutritional data, fluid intake, and temperature were dutifully recorded in the input-output log. Jamey was described by the nurses as either "nonresponsive" or "hostile". Only M. Surtees, LVN, had something positive to say, recording his occasional smiles and noting, proudly, his appreciation of the nightly back rub in a gaily corpulent cursive flow replete with bubble-dotted I's. But her optimism was invariably negated by the notes that followed on the next shift and ignored by the summation of the charge nurse, A. Vann, RN, who stuck to vital signs and avoided commentary.

As I closed the chart, the door opened and Mainwaring walked in. So precise was his timing that I wondered if I'd been observed. Standing, I searched the room for a hidden camera. None was visible.

"Dr. Delaware," he said, and pumped my hand. He wore a long white coat over a white shirt, a black tie, tweed trousers, and black suede oxfords. His jumpy brown eyes shone brightly in his thin, wolfish face as they examined me, head to toe.

"Good morning, Dr. Mainwaring,"

He looked at the chart in my hand.

"I trust you were able to decipher my penmanship."

"No problem," I said, giving him the folder. "It was very educational."

"Good. One does try to be thorough."

"I'd appreciate a photocopy for my files."

"Certainly. I'll have it mailed to you." He backed toward the door, opened it, and held it ajar. "Thoroughness notwithstanding, I assume you have questions."

"A few."

"Fine. Let's go to my office."

A short walk led us to the door with his name on it. The room was a monument to disorder, piled high with papers and books, and haphazardly furnished. He removed a stack of journals from a straight-backed chair, dropped them on the floor, and offered me the seat. Manoeuvering his way behind a simple wooden desk, he sat down, leaned forward, and reached for a circular pipe rack partially obscured by stacks of billing forms. Pulling a leather pouch from a coat pocket, he selected a bulldog briar, filled it, and went through a ritual of lighting, tamping, and relighting. Within moments the room was fogged with bitter smoke.

"So," he said, talking around the pipestem, "I suppose we'll be coordinating our reports."

I hadn't thought in terms of collaboration and avoided a direct answer by saying that it was a complex case and that I was far from being able to report anything.

"I see. Have you worked with many schizophrenics, Doctor?"

"It's not my specialty."

He sucked on the pipe and blew out an acrid plume. After following the smoke as it rose toward the ceiling, he lowered his eyes, then turned up his lips until they formed a wide slash of a smile. "Well, then," he said, "what is it that you'd like to know?"

"It's clear from the chart that Jamey was incoherent during most of his hospitalisation. But you did record a few lucid periods during which he could carry on a conversation. I'd be interested in knowing what kinds of things he talked about."

"Um-hmm. Anything else?"

"You recorded both auditory and visual hallucinations. Do you think that's significant? And during the hallucinatory periods how did he describe what he was hearing and seeing?"

He laced his fingers contemplatively. His fingernails were long, almost womanish, and coated with a clear polish.

"So," he said, "basically what you're interested in is content. May I ask why?"

"It might reveal something about what was going on in his mind."

It was the answer he'd expected, and the lipless smile reappeared.

"It's clear," he said, "that we're operating from very different theoretical backgrounds. Since we'll be working together, it's best that I lay my cards on the table. You're suggesting a classical psychodynamic approach: People's problems are caused by unconscious conflicts. Interpret the content of their ramblings in order to bring the unconscious to consciousness, and everything works itself out." Puff, puff. "Which is all very fine, I suppose, in cases of minor adjustment disorders. But not at all relevant to schizophrenia. The psychoses, Dr. Delaware, are essentially physiologic phenomena — chemical imbalances within the brain. What the patient has to say while in the throes of that imbalance has very little, if any, clinical significance."

"I'm not suggesting we psychoanalyse every nuance," I said, "and I respect the data on the biology of schizophrenia. But despite the fact that they sink into patterns, psychotics are as individual as anyone else. They have feelings. And conflicts. It can't hurt to learn as much as we can about Jamey as an individual."

"A holistic approach?"

"Just a thorough one."

"Very well," he said somewhat testily, "let's get on with it. What was it that you wanted to know? Ah, yes, visual and auditory hallucinations, do I think that's unusual? Statistically, yes. Clinically, no. An atypical pattern has been the hallmark of this case from the beginning. Are you suggesting hallucinogenic abuse?"

"It's the obvious differential."

"Of course it is, but it's been ruled out. I admit that when he was brought in, my first impression was that of a PCP user. The uncle and aunt were unaware of drug use, but that didn't impress me; one could hardly expect the boy to have told them about that kind of thing. However, the tests were clearly negative."

The pipe had gone out. He used the miniature spoon on his pipe tool to scoop out the top layer of ashes, tamped, and relit.

"No," he said, "I'm afraid this isn't a case of drug abuse. The diagnosis of schizophrenia is firm. While visual hallucinations are unusual in psychosis, they're not unheard of, especially in combination with auditory disturbances. Which leads me to an important point. The boy was typically incoherent and difficult to understand. He appeared to be hearing and seeing things, but I couldn't state with certainty that such was the case. All of it may very well have been auditory."

"What did he appear to be seeing and hearing?"

"Back to content, eh?" He removed the pipe from his mouth and played with it long enough for me to wonder if he was stalling. Finally he frowned and spoke. "To be frank, I don't recall precisely what he said."

"Souza told me he appeared quite sharp in the beginning, claiming the commitment was a mistake and being pretty convincing about it."

"Yes, of course," he said hastily. "At first there was the usual paranoid ideation: Someone was out to kill him; he was no crazier than anyone else. Then it deteriorated to wild accusations and vague mutterings about poisons and wounds — the earth bleeding, that kind of rubbish. Considering the diagnosis, nothing extraordinary. And not at all relevant to treatment."

"And the visual problems?"

"The visual part of it had to do with colour. He seemed to be seeing bright colours, with special emphasis on red." He smiled faintly. "I suppose one could interpret that as sanguinary imagery — that his perceptual field was awash with blood. In light of what's evolved, that would hardly be surprising."

"The lucid periods," I repeated. "What did he talk about?"

He shook his head.

"Excepting the period immediately following hospitalisation, lucid is an exaggeration. Minimally responsive would be more accurate. If I used the term conversation, it was in a very limited sense. The vast majority of the time he was unreachable — autistically withdrawn. When the medication took hold, he was able to answer simple yes or no questions. But he was never able to chat."

I thought back to Jamey's crisis call. He'd taken the initiative to reach me and, once we'd connected, had been able to report his location. While most of his speech had been jumbled, he'd maintained coherence for several isolated sentences. Far from normality but a lot more than answering yes or no. I raised the issue with Mainwaring, but he remained unmoved.

"During the last remission he began to grow more verbal. It renewed my hope that the latest medication would be the right one."

"Are you treating him with it now?

He scowled.

"In a manner of speaking. There's no one at the jail qualified to monitor his response, so I have to be extremely conservative about dosage. It's not treatment in the true sense, merely patchwork, and the pattern of uneven response has reappeared."

"That could explain what I saw when I visited him. The first time he was barely awake and showing signs of tardive dyskinesia. The second time he seemed a bit more alert and less neurologically impaired."

The psychiatrist cleared his throat.

"I'd like to suggest," he said mildly, "that you steer clear of terms like alertness and relative lucidity and that you don't even suggest the notion of voluntary drug abuse. That kind of thing can only play right into the prosecution's hands and dilute the picture we're trying to paint."

"Diminished capacity caused by paranoid schizophrenia. "

"Precisely. It's a difficult enough proposition for the layman to understand, without injecting needless complications."

For good reason, I thought and refrained from responding. He stared at me, then began sifting through the papers on his desk.

"Is there anything else, Doctor?" he asked.

"Yes. Ms. Surtees's notes seemed more positive than anyone else's. Do you see her as an accurate reporter?"

He leaned back and put his feet up on the desk. There was a hole in the sole of one of his wing tips.

"Ms. Surtees is one of those well-meaning, maternal types who attempt to make up for what they lack in intelligence and education by becoming personally involved with their patients. The other nurses viewed her with bemusement, but she posed no problem for them. I wasn't pleased at her employment, but the family was distressed and felt one-on-one care was important, and I couldn't see her doing much harm. In retrospect, perhaps I was too permissive."

Or impressed by dollar signs.

His jaws bunched as he chomped down on the pipe. He looked at me searchingly, requesting confirmation that he hadn't mishandled the case.

"So you don't have much faith in her credibility."

"She's a baby-sitter," he said brusquely, "not a professional. Now, if that's all—"

"Just one more thing. I'd like to talk with Mrs. Vann."

"Mrs. Vann is no longer with us."

"Was she dismissed because of the escape?"

"Not at all. She left of her own accord, just a few days ago."

"Did she say why?"

"Only that she'd been here for five years and wanted a change of scenery. I was disappointed but not surprised. It's difficult work, and very few last that long. She's a fine nurse, and I'm sorry to have lost her."

"So you don't blame her for what happened."

His eyebrows merged and created a mesh of creases in his forehead.

"Dr. Delaware, this is beginning to sound like an interrogation. My impression was that you came here to be educated, not to cross-examine me."

I apologised for coming on too strongly. It didn't appear to mollify him. Pulling the pipe out of his mouth, he turned it upside down and knocked it angrily against the rim of an ashtray. A small cloud of grey dust rose, then sank, leaving a film of soot on the paper disarray.

"Perhaps you're not aware of the enormousness of our task," he said. "Convincing twelve untrained individuals that the boy wasn't responsible for his behaviour will be no mean feat. The issue of blame is yet another irrelevancy that will impede us. We're expert witnesses, not judges. Why persist in digressing?"

"From where I sit, what's relevant and what's digression aren't all that clear."

"Believe me," he said with visible exasperation, "the issues aren't all that complex. The boy developed schizophrenia because of poor genetics. The disease disabled his brain and hence destroyed his so-called free will. He was programmed for disaster from birth, every bit as much a victim as the people he murdered. That's not speculation; it's based on medical data — the facts speak for themselves. However, because of the ignorance of the layman, it would be helpful to augment the argument with sociological and psychological theories. That is where, I strongly suggest, you should be directing your energies."

"Thanks for the suggestion."

"Not at all," he said airily. "I'll have that chart for you within a few days. Now let me see you out."

We rose and left the office. The corridors of the hospital were silent and empty. In the front reception room a well-dressed couple sat holding hands and staring at the floor. In the woman's lap was an unopened copy of Vogue. A cigarette dangled from the man's lips. They looked up at the sound of our footsteps and, when they saw Mainwaring, gazed up hopefully, as if at a deity.

The psychiatrist waved, said, "One moment," and walked over to greet them. The couple stood, and he shook each of their hands energetically. I waited several moments for the conversation to end, but when it became clear that my presence had been forgotten, I slipped through the door unnoticed.