Why Not You and I?

INTO WHOSE HANDS

Originally, back during the War (which Marlowe understood to be World War II), Graceland State Psychiatric Hospital had been an army base, and some of the old-timers still referred to the center as Camp Underhill. Marlowe was never certain whether there had been a town (named Underhill) here before the base was built, or whether the town had grown about the periphery of the base (named Underhill) at the time when it was carved out of the heart of the scrub and pine wilderness. Marlowe probably could have found out by asking one of the old-timers, had he ever thought to do so, or had he even cared to know. It was more to the point that no wing of the red brick hospital was of more than two stories; further, that each wing was connected to the next by a long corridor. This, so Marlowe had been told upon coming here, had been a precaution against an air raid — an enemy sneak attack could not annihilate the outspread base with its absence of central structures and its easy evacuation. Marlowe was uncertain as to the means by which an Axis blitzkrieg might have struck this far inland, but it was a fact that the center contained seven miles of corridors. This Marlowe had verified through many a weary weekend of walking to and fro and up and down through the complex, making rounds.

On this weekend Marlowe was feeding dimes into the slot of a vending machine, chained to the tile wall of one labyrinthine corridor. After judicious nudges and kicks, the packet of crackers was spat from its mechanical womb in a flurry of crumbs. Marlowe eyed the tattered cellophane sourly. An industrious mouse had already gnawed across the pair on the end. He should have tried the machines in the staff lounge, but that meant another quarter of a mile walk.

At his belt, the beeper uttered a rush of semi-coherent static. Marlowe, shaking the nibbled crackers onto the tile floor, thumbed the beeper to silence with his other hand and plodded for the nearest nursing station. He swiped a cup of virulent coffee from the urn there, washed the crackers from his throat with a gulp of boiling fluid, and dialed the number to which he had been summoned. “This is Dr Marlowe.”

“You have an involuntary admission on South Unit, Dr Marlowe.”

“I’ll be down once I finish one on North.”

The voice persisted. Marlowe sensed the speaker’s anxiety. “The patient is combative, Doctor. He’s delusional, obviously hallucinating. If you could give us an order….”

“What’s the problem? Do we know anything about this one?”

“This is his first admission here, and all we have are the commitment papers the deputies brought. He’s obviously psychotic. He says he’s Satan.”

“Hell, that’s my third this month. All right, seclude and restrain. I’m coming right down, and I’ll sign the order when I get there. ” Marlowe glanced at his watch. It was past ten, he still hadn’t eaten dinner, and the deputies from Beacon City were due to arrive on East with that adolescent runaway who’d slashed her wrists. Best take care of South Unit quickly. The coffee was sour in his stomach, and he regretted discarding the mouse-chewed crackers.

He was in North Unit, which was actually Central, since the northernmost unit was the Alcoholic Rehab Unit, but the walk was going to be a brisk five minutes in addition to the time lost in unlocking sectional doors. Marlowe, who showed a footsore limp under the best of circumstances, knew better than to wear himself out this early in the weekend. It was Friday night. Until 8:00 Monday morning he would be the only doctor on the grounds at Graceland. In that time he might have twenty to thirty admissions, on an average, in addition to the task of overseeing the well-being of some five hundred patients within the state hospital complex. A demanding situation under the best of circumstances, and impossible without a capable staff. Marlowe often wished for a capable staff.

He was tall and lean, with a profile that might have made a good Holmes if the haphazardly trimmed beard and randomly combed black hair hadn’t more suggested Moriarty. His eyes were so deep a blue as to seem almost black; one patient had told him he looked like Lord Byron, but many patients had called him many names. In a three-piece suit Marlowe would have fit the TV-romantic ideal of the distinguished young physician; however, around the hospital he favored open-necked sport shirts of imaginative pattern, casual slacks, and scuffed Wallabies. The crepe soles of these last were generally overworn to one side, giving him almost a clubfooted stance, but tile corridors are not kind to feet, and Marlowe liked such comforts as were permitted.

Lie unlocked an outside door, stepped out to cut across a courtyard. The summer night was hot and still. Behind electrified grates, ultraviolet lamps lured nocturnal insects to their doom; harsh crackles made the only sound other than the soft crunch of gravel beneath Marlowe’s crepe soles. There was a full moon, hot and electric itself, and Marlowe knew he would get little rest this weekend.

There was sound again when he unlocked the door to South Unit’s admission ward. The door to a seclusion room stood open, and inside three attendants were just fastening the padded cuffs. Spread-eagled on the bed, a young black man struggled against the wrist and ankle restraints and screamed curses. At the end of the hall way, several of the ward patients hovered anxiously, until a nurse’s assistant shooed them back to bed.

An attendant handed Marlowe the commitment papers. He glanced through them: 2 3-year-old black male, combative and threatening to life and person of family and neighbors since last night, apparently hallucinating, claimed to be Satan released from Hell. Today fired shotgun at neighbor’s house, subdued by officers; involuntary commitment papers signed by family, no previous history of mental disorders.

Marlowe entered the seclusion room, studying his patient. His dress was flamboyant, his appearance well-groomed; he was lean but not emaciated, with prominent veins standing out from the straining muscles of his arms. Marlowe’s initial impression was psychotic drug reaction, probably angel dust or amphetamines.

“Mr. Stallings, my name is Dr Marlowe. I’m your physician, and I’d like to ask you a few questions.”

“I am His Satanic Majesty, Lucifer God, Son of the Sun, Prince of Darkness and Power! Ye who seek to chain me in the Pit shall be utterly cast down! Bow down to me and worship, or feed the flames of my wrath!”

Marlowe played his stethoscope across his heaving chest. “Anyone able to get a blood pressure?”

The ward nurse handed him a sheet. “Don’t know how good these vital stats are — he’s been abusive and combative since the deputies brought him in. He’s strong as a horse, I can tell you.”

“These are about what they recorded at Frederick County when they examined him,” Marlowe said. “We still don’t have a chart on him?”

“First admission to Graceland, Dr Marlowe.”

The patient shouted obscenities, ignoring Marlowe’s efforts to examine him. Verbal content was a jarring mixture of street slang and religious phrases, frankly delusional. There seemed little point in continuing with the examination at this point.

Marlowe turned to the ward nurse, who was showing anger despite her experience with abusive patients. “Thorazine, 100 mgm IM.”

Two attendants held the patient on his side, pants drawn down, while she gave him the injection. The graveyard shift would be coming on shortly, and they had work to finish before they could go off. Marlowe observed the familiar ritual in silence, studying his patient’s reactions.

“Just make sure his blood pressure doesn’t drop out,” he told them. “I’ll write out orders for another 100 IM PRN q 4 hours, if this doesn’t do it. I’ll finish my examination once he’s quiet.”

“Thank you, Doctor.”

Marlowe’s beeper summoned him while he was writing orders. “That’s North Unit. Could you dial that for me, please?” He took the phone from the attendant and wedged it under his chin; one hand holding a Styrofoam coffee cup, the other scribbling an admission note.

“Dr Marlowe, we have an unauthorized absence from North Unit. The patient is Billy Wilson. He is an involuntary admission.” Marlowe sipped his coffee. “Chronic schiz from Jefferson County? I’ve had him on my service a couple times. Better call the family and local sheriff. He usually hitches a ride home and tells people he’s on the run from the CIA.”

“We also have a voluntary admission here to see you.”

“What’s his problem?”

“He says he’s depressed.”

“I’ll get over to see him when I can.”

Marlowe finished his coffee and the conversation, placed cup and receiver in appropriate niches. His beeper wondered if he might phone the ARU. Marlowe thought he might.

“Dr Marlowe, we have three unauthorized absences.”

“These are…?”

“Two voluntary, one involuntary. Jimmy Roberts and Willy Wilbertson from Adams County are voluntary; Freddie Lambert from Tarpon is involuntary.”

“Those first two always check back in together as soon as they’ve gone through their Social Security checks. Lambert usually winds up under a bridge with a gallon of skull-rot; better notify family and sheriff on him.”

He finished his admission notes, looked in on Stallings.The new admission was still raging against his restraints; shrill obscenities penetrated the seclusion room door. “Another 100 mgm Thorazine IM stat, I think,” Marlowe decided. “I’d like a quiet night.”

It was past midnight when Marlowe made it back to North Unit to interview the voluntary admission. As he sought to leave the nurse’s aide on South Unit had delayed him with a question about Dr Kapoor’s medication orders; the Pakistani resident had been eight weeks in the US and six weeks on South Unit, and still hadn’t discovered the distinction between q.i.d., q.d., and q.o.d. when writing medication orders. Marlowe made hasty corrections, ordered stat lithium levels on one patient, and swore a little.

The graveyard shift came on at eleven, and no one knew anything about his voluntary on North. The same, seated beside a flight bag in the office area, regarded Marlowe with politely contained anger.

He wore Nike running shoes, Levi jeans, and an Izod knit shirt, all of it just starting to slide past the comfortably well-worn stage. His beard had reached that scraggly sort of seediness that usually breaks the resolve of its wearer and brings the razor back out of the medicine cabinet. The black hairline was beginning to recede, but there were no flecks of grey. He had a complex digital watch toward which he pointedly glanced. The eyes behind the designer frames were red-rimmed and puffy, despite the effort of the tinted lenses to mask them. Marlowe guessed him to be a grad student or junior faculty from the state university campus at Franklin, some thirty miles to the north, and he wondered why the patient had not availed himself of the posh psychiatric unit at the medical school there.

“Hello, I’m Dr Marlowe. Sorry to keep you waiting.”

“Frank Carnell.” The handshake was accepted, but weak. “Would you care to step into my office, Mr Carnell?”

Each unit included an interview room for the on-call physician; however, as North Unit’s attending, Marlowe had an office of his own on the unit. He ushered his patient into the cheap vinyl-upholstered chair beside his desk and eased himself into the often treacherous swivel chair behind the expanse of pea-grey enameled metal littered with manila chart folders. The office furnishings were state-purchase, some of them going back to Graceland’s army camp days. A filing cabinet and a pair of unlovely metal bookcases of brownish-grey enamel housed a disarray of books, journals and drug company handouts. There was also a couch of cracked brown Naugahyde, a coffee table, two folding chairs, and a spindly rubber tree leaning against the Venetian blinds. Overhead fluorescent lamps hummed behind acoustic ceiling tiles and made all too evident the yellow wax-stains on the uncarpeted floor of worn asbestos tile. One wall boasted a plastic-framed imitation oil of a mountain landscape that might have been discarded by a Holiday Inn, but Carnell was devoting his attention to the framed diplomas and certificates that completed the room’s decoration.

“Impressive credentials, Dr Marlowe. I had the impression that our state hospitals were staffed entirely by foreign medical school graduates.”

“An exaggeration. I’m not the only American-educated psychiatrist here at Graceland.” There were, in fact, two others.

“From what I’ve seen, it makes me wonder what a psychiatrist of your training is doing here at Graceland State?”

“I think the question more properly, Mr Carnell,” said Marlowe evenly, “is why are you here?”

Carnell’s eyes, behind the tinted glasses, shifted to his chewed fingernails. He fidgeted with the flight bag on his lap. “I suppose you could say I’m depressed.”

“Depressed?”

“I haven’t been sleeping well. Can’t fall asleep until the late late show and half a bottle of vodka; sometimes I need pills. I wake up before dawn, just lie awake thinking about things that keep running through my mind. Tired all the time. No appetite. No energy. Used to jog to my classes; now I just cut them and lie about the apartment. Haven’t been able to study in weeks.” Carnell spoke slowly, and Marlowe sensed tears.

“When did all this begin?”

“This spring. I’m in journalism at State, trying to complete work on my doctorate before the funds all dry up. My wife said she’d had enough of floating around the secretarial pool to pay the bills while I played the eternal student. She’s shacked up with her old boss from central accounting, and the divorce is pending. I haven’t been able to adjust to that. My performance has been on the skids — I’m supposed to teach a class during summer session, but I’ve missed so many my students don’t bother either. I’ve been called on the carpet by the department twice. I’m broke, in debt, and now my fellowship has been canceled. It’s just that no matter how hard I try, it just keeps getting worse.”

Marlowe waited while Carnell worked to control his voice. “Mr Carnell, I certainly understand that you have good reason to be undergoing a great deal of anxiety and depression. However, since this appears directly related to your present life situation, I feel confident that this disturbance is a transient one. This is a painful crisis in your life, and I appreciate the profound distress you are experiencing. Under the circumstances, I definitely agree that you need professional counseling; however, I believe you would far better benefit from outpatient counseling rather than hospitalization at this time.”

Carnell fumbled with his flight bag. “Am I to understand that you are refusing me psychiatric care?”

“Not at all!” Marlowe had seen patients produce knives and an occasional handgun from unscreened personal belongings, but he doubted that Carnell was likely to turn violent. “I very strongly urge you to accept professional counseling. In my opinion you will derive considerably greater benefits through outpatient therapy than as a hospitalized patient here at Graceland.”

“In other words, in your opinion I’m better off seeing a shrink on the outside than I’d be if I entered Graceland State as a patient.” There was a certain triumph in Carnell’s voice. “Well, it happens that I’m broke. I can’t afford to be psychoanalyzed by some hundred-bucks-an-hour private shrink.”

“That isn’t necessary, Mr Carnell. If you wish, I can make an appointment for you to be seen on a priority basis this Monday at your community mental health clinic in Franklin; Dr Liebman there is an excellent therapist. Or if you prefer, I can make an appointment for you at the medical school to be seen by the psychiatric outpatient service.”

“I’m a tax-paying citizen of this state, Dr Marlowe. Why are you refusing me treatment in a state facility?”

“I’m not refusing you treatment, Mr Carnell. I frankly do not believe that hospitalization would be beneficial to you. If you would prefer to receive treatment at Graceland rather than in your local community, I will gladly make an appointment for you to be seen Monday in our outpatient clinic.”

“Suppose I don’t care to wait until Monday for medical attention.”

“Mr Carnell, you must understand that our facilities here are limited. Our primary task is to care for the severely disabled patient, the chronically ill. Patients whose problems can best be dealt with without hospitalization are directed toward more appropriate community programs.”

“Dr Marlowe, I can’t wait until next week for you to shuffle me off to some community agency. I can’t keep going on like I have these last weeks. If I don’t get help now I’m afraid…”

He paused to make certain Marlowe was giving his undivided attention.

“Well, I have quite a collection of sleeping pills. Tonight I feel like taking them all.”

“I have some papers you’ll need to sign,” Marlowe said.

After 2 am Marlowe let himself into the employees’ snack bar. It was nothing more than a cinder-block room, walled with vending machines, furnished with plastic tables and chairs about the color of tomato soup that’s been left too long to cool. It differed from the patients’ snack bar in that the plastic tables and chairs were not bolted to the tiled floor, spectators did not gape at the machines in slack-jawed hopefulness, and the drugs that changed hands were of better quality. There was also a microwave oven.

The oven was Marlowe’s solace during hungry nights on call. Underhill was a town too small to support a single fast-food franchise — something of a blessing in that otherwise Allen’s Eat Good Food would no longer be serving home-cooked meals at family prices (the last Blue Plate Special known to Marlowe), nor would the Ski-Hi Drive-Inn still be making malts out of real ice cream and frying greasy hamburgers made of hand-shaped patties (all in a decor that left Marlowe humming medleys of Andrews Sisters Hits). Underhill was also a town small enough to retain a blue law, and on Sundays even the Fast Fare convenience store was closed. The employees’ cafeteria, in any event, closed for the weekend, and the outer world was closed to Marlowe beyond range of his beeper. On occasion Marlowe might escape Graceland long enough to grab a meal at Allen’s or the Ski-Hi, but on Sunday, the day Marlowe hated above all days, if he were to have a hot meal, he must cook it himself.

There was a stove and refrigerator for staff in North Unit’s administrative section, but Marlowe was one of those bachelors for whom cooking was a forbidden art. Marlowe had only hazy memories of a youth before college and medical school, and whether the food put upon his plate was doled out or paid for, Marlowe regardless had had no thought to spare as to its conception. In his office Marlowe kept a hotplate and various cans, the sins of whose preparation were concealed by virtue of a large bottle of Tabasco sauce. With the microwave oven, Marlowe felt a competence somewhat akin to the laboratory.

For this weekend, Fast Fare’s frozen foods counter (Marlowe understood two classes of foods: canned or frozen) had supplied him with a carton of Western Steer’s Hungry Cowhand Rib-Eye Filets. These Marlowe had retrieved from North Unit’s refrigerator and now fed to the microwave. He punched buttons at random, drawing tired satisfaction as the blocks of frozen beef stuff turned a pallid grey and began to steam. A clatter of quarters excerpted the last two Reel-Keen Cheez-Burgers from a vending machine. Marlowe filled each stale bun with a partially thawed segment of Hungry Cowhand, placed his mutant creations within the microwave. The cheese-food was just starting to melt when his beeper interrupted.

Marlowe ignored its summons until the microwave’s buzzer announced the perfection of his cooking artistry, then picked up the snack bar phone and dialed. It was North Unit, and he’d just made the seven-minute walk from there.

“Dr Marlowe, this is Macafee on the admissions ward. I’m afraid we’re having some problems with that patient you just admitted.”

“Which one is that? ” Marlowe had had eight admissions tonight, and they began to blur together.

“Frank Carnell, sir. The suicide attempt from Franklin.”

“What’s the difficulty?”

Macafee was a Nam vet and continued to regard doctors as officers. “Sir, this patient is non-cooperative and abusive. He’s objecting to the suicide precautions you ordered, he claims someone has stolen a cassette recorder he had with him on admission, and he demands to speak with you immediately.”

“D/W he have a cassette recorder when he was admitted?”

“No sir. Only a small canvas bag containing clothing and personal articles.”

Marlowe tried a mouthful of steaming steakburger, decided it needed catsup. “I need to stop in at the med unit, then do an admission at the ARU. I’ll try to look in on you in between. Meanwhile it might be best to place Carnell under sedation and seclude if necessary. I believe I wrote a PRN for p.o. Valium?”

“Yes sir, you did. However, Mr Carnell has refused medication. ”

“Then write an order for Valium 10 mgm IM stat, then Valium 5 mgm IM q 3–4 hours times 48 hours PRN agitation and anxiety. I’ll sign it when I stop by. You already have a PRN seclusion order with the suicide precautions.”

“Dr Marlowe, Mr Carnell claims that as a voluntary patient he should not be on a locked ward and that we have no right to force him to take medications.”

“An argument the patient advocates have often raised,” Marlowe said. “However, Mr Carnell is an involuntary admission. I suggest you observe him carefully for further signs of delusional behavior.” Late at night Marlowe owned the corridors. They stretched in fifty-yard sections from brick unit to brick unit. After 11:00 pm only every third fluorescent ceiling fixture was left on, leaving the corridors hung with darkness in between the flickering islands of light. The corridors were entirely of tile: discolored acoustic tiles for the ceiling, glossy ceramic tiles for the walls, stained asbestos tiles for the floor. Marlowe wondered how such a manufactured environment could still stink of human filth and hopelessness.

Marlowe paused, not breathing. It was 4 in the morning, the hour of the cockroach, an hour before the keepers of the graveyard shift began to prompt their cares into a semblance of reality to greet their breakfast and the day shift at 7. He listened.

The roaches here were larger than any Marlowe had seen since an age when dinosaurs were but a fanciful gleam in a tree fern’s eye. He could hear them as they scuttled along the worn tiles of the long long corridor. Some, intent upon a smear of feces lodged within a missing bit of broken floor tile, were reluctant to flee his approach.

Marlowe stomped at them, withheld his foot at the last instant. The roaches scattered halfheartedly. It was, perhaps, an old game. Marlowe heard the silky rustle of their reconvergence as he silently passed by.

As he passed a snack vending machine, he could hear a mouse feasting within.

“Dr Marlowe never sleeps.”

“Can’t spare the time, Mr Habberly. Surely you’ve heard that there’s no rest for the wicked.”

Habberly chuckled. “Never going to sleep long’s you keep drinking my coffee.” He handed Marlowe his cup — a gift from the Sandoz rep, featuring a smiling yellow Happyface and the wish to “Have a Happy Day” from “Mellaril.” Pudgy and greying, Habberly was nearing state retirement age; he had been an orderly and later ward supervisor at Graceland since it opened. He and an aging male nurse, occasionally joined by a ward attendant on break, were the only inhabitants of North Unit’s administrative section during the graveyard shift.

“Careful, Doctor — that’s fresh poured!”

Marlowe ignored his warning and swallowed without looking up from his admissions notes. “Thank you, Mr Habberly.”

“Never could understand how some folks can drink coffee when it’s hot enough to scald your hand carrying it.”

“Practice deadens all feeling, Mr Habberly, and because there’s too little time to wait for it to cool. But I can still taste: you brew the best cup of coffee in Graceland.”

“Thank you, sir. Well, now, that’s practice again. I don’t fool with that big urn the day shifts use. Got me a three-four cup percolator just right for night shift. Been using it for years. And I don’t fool with state-purchase coffee.”

Marlowe finished his coffee and handed Habberly a sheaf of triplicate forms. “Here’s the commitment papers for tonight’s involuntaries. With luck you won’t have any more admissions until day shift comes on in an hour.”

Habberly thumbed through the forms, making certain that all had been signed and notarized as the law required. A patient could only be committed involuntarily if he constituted an immediate threat to others or to himself in the opinion of local magistrates and the admitting physician. Marlowe had had three involuntaries on North Unit tonight.

Habberly paused over the commitment papers for Frank Carnell. “Is this the patient who was causing the fuss about someone stealing his suitcase?”

Marlowe craned his neck to see which patient Habberly meant. “Yes. Which reminds me that I told Macafee I’d look in on him. By the way, you didn’t happen to notice whether Carnell had any sort of bag or anything with him when he was admitted, did you?”

“Why, no sir. He didn’t have any personal belongings with him at all. The deputies carried him up here straight from the emergency room at Franklin Memorial. I let them into the ward when they brought him here ’long about midnight.”

The admitting ward for each unit was a locked ward, and it was hospital policy that every patient admitted after hours or on weekends must be kept on the admissions ward until such time as the psychiatrist to whose service he was assigned had had an opportunity to interview him. The rule applied to voluntary and involuntary patients alike. Patient advocates complained that this rule was only intended to discourage voluntary admissions after office hours, but hospital administration pointed out that the rule had come into being after a Korean resident blithely admitted a seemingly depressed voluntary patient to an open ward one night, who quietly strangled and raped the retarded teenage boy who shared his room and passed it off the next morning as the work of Mafia hitmen.

Marlowe let himself into North Unit Admission Ward. It was, he reflected, a bit of a misuse of terms in that patients judged not suitable for the open wards might linger in a unit’s admission ward for weeks until proper disposition could be made. Graceland did not treat dangerous psychotics in theory; the state maintained a hospital for the criminal insane, now euphemized as a forensic psychiatric facility, in conjunction with the state penitentiary at Russellville. A patient who required long-term hospitalization at Graceland was either found suitable for an open ward or transferred to a chronic care ward, where long-term hospitalization usually meant lifetime.

Macafee nodded to him through the glass of the nurses’ station, unlocked the door to let him enter. “Good morning, sir. Almost 600 hours; we’ll be waking them soon. Care for some coffee, sir?”

“Yes, thank you.” Marlowe looked through the glass. The nurses’ station was a locked cubicle placed along one wall to give an aquarium resident’s view of the communal ward. Already several of the patients were beginning to shuffle about between the closespaced beds; it was close enough to breakfast, which arrived with the day shift, that minimal activity was permitted.

“Any problems?” Marlowe signed his telephone orders in the ward orders book.

“No sir. Not after we put Mr Carnell to bed.” Macafee sometimes confused the ward with training barracks, but it was usually quiet when he was on night shift, and Marlowe disliked disturbances.

“How is Mr Carnell?”

“Quiet, sir. Sawyer’s checking on him just now.”

“I’ll just take a look myself.”

A short hallway led from the communal ward to the outside corridors. Connected by a door to the nursing station was a small room for supplies and medications. There was an examining and treatment room farther along the hallway, then toilets, showers, a patients’ lounge, and several seclusion rooms. Carnell was lying-on the bed within one of these; a wooden night stand was the only other furnishing. Sawyer was just coming out of the room.

“Good evening, Dr Marlowe — or good morning, it’s getting to be.”

“And let’s hope it will be a good day, Mr Sawyer. How is Mr Carnell?”

“He’s been resting quietly. Starting to wake up now.” Sawyer had had ambitions of a pro-football career before a high school knee injury scrubbed that as well as hopes for a college scholarship. He was ten years younger than Macafee and a good audience.

Carnell was muttering to himself when Marlowe bent over him. “Good morning, Mr Carnell,” Marlowe said, since his eyes were open. “How do you feel?”

“Damn you, Marlowe!” Carnell sat up sluggishly. “I’ve been locked up, robbed, drugged, I don’t know what! Do you think you’re running some sort of prison camp? I demand to be released from this zoo right now!”

“I’m sorry, Mr Carnell. Have you forgotten why you came here?” Marlowe’s voice was patient. “Try to remember.”

Carnell’s face showed anger, then growing indecision. His eyes began to widen in fear.

“Mr Sawyer, could we have that IM Valium order stat?”

“Yes sir. Five mgm, was it, Dr Marlowe?”

“Better make it ten.”

The chronic care wards were always on the second story of Graceland’s far-flung units. Marlowe supposed this was because Graceland had no cellars. Presumably, had there been cellars, the temptation to wall them off would have been irresistible. Marlowe supposed Graceland had never had cellars.

There were two basic divisions among the chronics: the ambulatory and the nonambulatory. The ambulatory could be trusted to leave their locked wards, perform acceptably under controlled situations, and return to their locked wards. The nonambulatory could not be trusted to function within acceptable guidelines. They remained in their wards, often in their beds, often only a dream from the chronic med care unit; spoon-fed gobs of pasty slop, when they could no longer handle spoons; moved to the chronic med unit when they could only be fed through tubes and IV’s.

They fed the ambulatory chronics three times a day — breakfast, lunch, and dinner — the same as living souls. This meant they were herded from their wards three times a day, down the stairs (there was an elevator for each unit, and those who could walk, but not negotiate stairs, were granted this), and along the tiled corridors to the patients’ cafeteria. They moved along docilely enough, each regimented segment of quasi-humanity, herded along the long, long corridors by nurses and attendants.

Their clothes were shapeless garments that fit their shapeless bodies: not uniforms, only styleless wads of clothing donated by middle-class patrons who found salve for their consciences in charity bins for flotsam their guilt would not allow them to fling into trashcans. Some, who were habitually incontinent, might wear rubber (now vinyl) underpants, although it had been established with chronics that floors and clothing were more easily washed than could dermatitis and pustulant sores be cured; and so many, by chance or by choice, wore no underwear at all.

Marlowe, a microcassette recorder in one hand, a Powerhouse candybar in the other, alternately dictating and chewing, stood against one wall as the chronics shuffled past him on their way to be fed. Their faces were as shapeless as their bodies: some smiling, some grimacing, some frozen from the effects of too many shock treatments, too many drugs. A few seemed to recognize Marlowe, and waved or winked or muttered. Some, Marlowe thought, had been in Graceland longer than Marlowe, and that was forever. A grey-mustached grandmother in a shapeless polyester sack dribbled excrement as she shuffled past. The corridor stank of urine and feces and unwashed living dead, and no antiseptic nor disinfectant would ever cleanse it. Marlowe finished his candybar breakfast, waiting for them to pass before resuming dictation.

“If God exists,” a patient had once told Marlowe, “then what sort of sadist is he to curse the elderly with the indignity of loss of sphincter control?”

“An angry god,” Marlowe had replied with bitterness. “And vengeful.”

By midmorning Saturday Marlowe decided he had completed Friday’s tasks and it was time to recognize Saturday. He had contemplated napping on his couch, but there were two voluntary admissions waiting on West Unit, and the adolescent runaway on East had pulled her stitches out.

Marlowe dragged a toilet kit from his filing cabinet and paid a visit to the staff restroom, where he washed his face in cold water, brushed his teeth, gargled mouthwash, brushed his hair and beard. Returning to his office, he pulled off his red Hawaiian shirt, sprayed on deodorant, and changed into a blue Hawaiian shirt, also from his filing cabinet. Sleeping quarters were provided for on-call physicians in a cinder-block horror known as married residents’ housing, but this was detached from the hospital unit, and after a night when it took Marlowe twelve minutes to respond to a cardiac arrest from there, he decided to take calls from his office.

East and West Units cared for women patients, North and South Units for the men. Whatever symmetry had been intended by this plan had been completely obscured by the addition of the Adolescent Unit, the Med Unit, the Alcoholic Rehab Unit (again segregated by sexes and separated by a five-minute walk), and Central Administration — not to mention the semi-automonous Taggart Center for Special Children (once known as the State Home for the Mentally Retarded), the Crawford Training School (the state had seen fit to include a center for juvenile offenders within Camp Underhill’s disused facilities), and the R Everett Amberson Clinic (a former hotel refurbished as a drying-out spot for the less shabby class of alcoholics and pill addicts). It took new psychiatric residents a few months to find their way around, and a car was necessary to reach the outlying centers — a complication in that many of the foreign residents had licenses to practice medicine but not to drive.

Marlowe, who was not moved by tears and found them a bit bothersome, considered East and West Units more than a little bothersome. Granted that tears were nonverbal communication, women patients tended to use them as dramatic expression or as means to terminate an interview. A generalization, but an accurate one, for Marlowe had timed things. Even allowing for the additional time entailed by a pelvic exam on new admissions, as opposed to a quick grope and cough to check for inguinal hernia, it took half again as long on the average to complete any task on the women’s wards as on the men’s. Marlowe compared notes with several of the women psychiatrists and found their experience to be the same. Marlowe saw the basis of an article for the journals in this business of tears, but he left it unwritten as he hated the journals. The crucial point was that, given too many tasks and too little time to accomplish them, East and West Units demanded a disproportionate share of that nonexistent time.

Marlowe spent most of the day between East Unit and West Unit. It was a pleasant day, and families liked to carry their senile grandmothers and Valium-addicted aunts to the hospital on weekends. Everyone was off work, the children could come along, and it was a nice outing for Grannie or Noonie or Auntie or maybe Mom or Sis, who had begun to wander into traffic or seduce the paperboy after two bottles of vodka. Major holidays were worst of all, for then families liked to rid themselves of unwanted and incontinent organic old ladies, so they could enjoy Christmas or Easter without the pressure of an invalid. Graceland was cheaper than a rest home, and afterward, if conscience troubled, they could always take a drive and reclaim her. Best of all, on weekends they could drop a patient off and be miles away before the lone on-call physician had a chance to interview her. The worse the weather, the better Marlowe liked it: involuntary commitments might come in at any time, but it was unlikely that the family would decide to haul off Grandma when it looked like it might pour down all day.

By midnight Marlowe limped back to his office and collapsed on his couch. He had had fourteen admissions since morning, with more on the way. Most of the usual problems he had been able to deal with over the phone — too much medication, too little medication, extra-pyramidal reactions to the medications. Marlowe titrated and adjusted, switched from phenothiazines to Haldol or Navane or vice versa, dispensed Artane and Cogendn as required. Metal chains and straitjackets had required no such artistry, but the old-timers told Marlowe of how they used to scream and howl on nights of the full moon in the days before major tranquilizers, and Marlowe kept it quiet the nights he was on call.

Marlowe’s eyes stung. A Philippino resident had admitted a patient Thursday night and not noticed that he was a severe alcoholic; nor had the resident who inherited him in the morning and who transferred him to an open ward. When the patient went into DT’s with paranoid delusions, it took security two full cans of Mace to convince him to drop the table leg he was swinging like a club at anything, real or delusional, that came within reach. Marlowe had had to examine the patient once subdued, and Mace was still running like sweat off the man’s blistering skin.

The familiar coffee burn in his stomach reminded Marlowe that he hadn’t eaten anything except a candybar and a large tomato one of the nurses had carried in from her garden. Fast Fare had closed, even had Marlowe felt up to a short drive. Redeyed (“Remember—don’t rub your eyes,” security had warned him.), Marlowe pawed through his filing cabinet and uncovered a can of ravioli. He managed to open it without cutting himself, found a plastic spoon and fed himself cold ravioli from the can. He considered heating it on his hotplate, but lacked the time or ambition. He almost fell asleep while chewing, but his beeper reminded him who and where he was.

At 3 in the morning Willy Winslow on South Unit smashed the salt shaker he had stolen earlier and sawed at his wrists with the jagged glass. He was quite pleased when he flailed his bleeding wrists against the nurses’ station window, but neither the ward attendants nor Marlowe shared his amusement.

Winslow was a regular at Graceland, one of an undefined group of patients who enjoyed staying in state institutions, constantly admitted and readmitted, either voluntarily or involuntarily, and constantly discharged again. Winslow was well known to all the staff at Graceland; if he could not con a resident into a voluntary admission, he would gash his wrists and gain an involuntary commitment thereby During this, his seventeenth admission to Graceland, a concerned resident from one of the better private medical schools had devoted three months toward helping Winslow re-enter the community. Bolstered by an extensive outreach program, Winslow was to be discharged next week.

Marlowe, selecting from the suture tray, gazed at the masses of scar tissue upon each wrist and shook his head. “Mr Winslow, you managed to do this without anesthetic, and I don’t see why I should waste any in sewing you back together.”

Winslow’s eyes glittered, but he didn’t reply. It was, perhaps, an old game.

“And how many times do I have to tell you,” said Marlowe, drawing the curved needle with difficulty through the layers of scar, “cut lengthwise down your wrist, just here below the thumb — not crosswise.”

Frank Carnell was still in seclusion when Marlowe made rounds through North Unit on Sunday evening, but the ward attendants reported that he had been quiet throughout the day, and he appeared to be ready to come out into the ward. Marlowe found him sitting up on the edge of his bed, staring dazedly at his hands.

“Good evening, Mr Carnell. How are you feeling today?”

“I’m sorry — I’m bad about names. You’re Dr…?”

“Dr Marlowe. Dr Chris Marlowe.”

Carnell struggled to recall. “I remember seeing you, of course. When I was… upset. And when they brought me here from the hospital.”

“Do you remember coming here from the hospital?”

“I must have been completely irrational.” Carnell smiled sheepishly at the memory. “I seemed to believe I had come here as a voluntary patient. I had a cassette recorder, and I was going to take firsthand notes for my dissertation on the inadequacies of our state mental hospitals. I’m a journalism student at State, but then you know all that.”

“I’m sure there’s more than sufficient material there for a number of dissertations,” Marlowe agreed. “And was that actually your topic?”

“One of them,” Carnell confessed. “I had plenty of ideas, just never followed up on them. Guess that was just another of the things that helped my life slide downhill, until…”

He struggled to control his voice. “Well, until I finally pulled out all the pills I had on hand and gobbled them down like Al&M’s. I remember getting sick and passing out, and then I guess I woke up there in the emergency room.”

“You guess?”

Carnell frowned, trying to recall. “To tell the truth, my memory is pretty hazy for the last day or so — all those pills, plus whatever medications you’ve been giving me. There must have been a time there in the emergency room when they were bringing me around after I took all those pills…”

Marlowe waited patiently while he tried to remember.

CarnelPs face began to twist with fear. “Dr Marlowe, I can’t remember anything from the time I blacked out until when I was sitting there in your reception room and…Wait a minute, I was never brought here! I came voluntarily!”

“Indeed, you did,” Marlowe’s smile was almost sympathetic. “And voluntarily, I’m afraid, is unforgivable.”

Carnell started to rush for the door, but it was blocked by Macafee and Sawyer, and he was too weak to put up much of a struggle.

“Don’t worry, Mr Carnell,” said Marlowe soothingly, as the needle plunged home. “It does take time at first to understand, and you have plenty of time.”

It was past 5 am when Marlowe made rounds through South Unit. The sun would be creeping out soon, signaling the dawn of what Marlowe knew would be another Friday, and he would be on call.

“Dr Marlowe,” suggested Wygul, the ward attendant on South, “maybe when you finish signing those ECT orders, could you take a look in on Mr Stallings? He’s been a lot calmer tonight, and we haven’t had to restrain him since Saturday afternoon. I think he’s ready to be let out of seclusion now so we can see how he does on the ward.”

“Mr Wygul,” Marlowe finished his coffee, “I’ve never known your judgment to fail yet. Is the patient awake yet?”

“Yes, Doctor. He was sitting up in bed half an hour ago, and we’ll be waking everybody up in just a minute.”

“All right then, I’ll talk to him.”

Stallings gazed at Marlowe expectantly when he entered the seclusion room. He made no hostile moves.

“Good morning, Mr Stallings. I’m Dr Marlowe.”

“How do you do, Dr Marlowe.” Stallings’ manner was courteous, but in a friendly way, rather than cautious.

“Do you remember me from the night you came here, Mr Stallings?”

“Yes sir, I sure do.” Stallings laughed and shook his head. His hand seemed to want a cigarette to complete the gesture. “Man, I sure was out of my skull on something that night!”

“What do you remember?”

“Well, I remember being carried in here by the deputies, and being tied down and all, and I was cussing and telling the whole world that I was Satan.”

“And did you believe that?”

Stallings nodded in embarrassment, then looked earnestly into Marlowe’s eyes. “Yes sir, I sure did. And then you came into the room, and I looked into your face, and I knew that I was wrong, because I knew that you were Satan.”

“Mr Stallings,” Marlowe smiled sadly, “you appear to have made a rapid recovery”