'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
