The Cambridge Theorem (23 page)

“No, don't get up, officer,” he said as he pulled out a packet of cigarettes and sat down opposite him. “Mind if I smoke?” He tossed the folder down lightly on a small formica table.

Smailes' preference was apparently academic, since Kramer lit a cigarette without looking further at him. He inhaled deeply, protruding his tongue as he did so. He was the most unsavory-looking doctor Smailes had ever seen.

“You want to talk to me about Simon Bowles, I gather.” The psychiatrist had settled back into his chair and was regarding Smailes pleasantly. “We were all very sorry to hear the news. A number of us remember Simon quite well.”

“How did you hear the news?”

“Well, one of the orderlies spotted the notice in the paper, and brought it to work next day. Then I had a call from the coroner's office. I understand I may be called at the inquest. Which is quite understandable. Unfortunately it's a duty I have had to perform before. Is that why, ah, you need to interview me?”

“Not entirely. I'm with Cambridge CID. We normally conduct our own investigation in the case of unusual deaths. The coroner's officer will probably contact you directly about your testimony at the inquest.” Smailes shifted his weight and the plastic chair gave a sharp squawk.

“Were you surprised at the news that Simon Bowles had taken his own life?”

“Yes, yes I was,” the psychiatrist began, prefacing his remark with his unsettling tongue movement. “Simon seemed absolutely fine when he left here, and since we had heard nothing in the interim, one always assumes the best. Of course, he had technically attempted suicide before, and there is an unfortunately high relapse rate among patients who have suffered a major depression.”

“Why do you say ‘technically'?”

“As I recall, and I did take the opportunity to review the file after the coroner's people called, Simon was not trying to harm himself when he jumped out of his window. He was in the grip of a powerful delusion in which snakes were entering by the door of his bedroom. He chose the logical way to escape them, by leaping from the window. He landed on his feet, quite deliberately so, and broke an ankle, I believe. There were also a couple of crushed vertebrae, because we were unable to administer ECT, which would have been the treatment of choice. We had to rely on drugs, which worked quite well, actually.”

“ECT? What's that?”

“Electroconvulsive therapy. More commonly known as electric shock treatment.”

Smailes shuddered inwardly at the image of some unfortunate wretch strapped to a table while an orderly wired up his skull to an electrical socket. He could not believe such practices survived in modern hospitals. Lucky Bowles and his crushed vertebrae. It seemed Kramer was able to sense his distaste, for he crushed out his cigarette and continued amiably, “And the most commonly misunderstood and maligned practice in modern psychiatry, I might add.”

“How so?”

“Well, I think I detect in your expression the usual impression that ECT is some barbarous and primitive practice, a violation of individual rights, a mistreatment of the mentally ill, that sort of thing.”

“Perhaps. But I don't really know anything about it.”

“Precisely, officer. Precisely. I concede that we don't quite know how it works ourselves, except that it rapidly alters brain chemistry in a way that alleviates depression almost immediately. It is quite safe, harmless, and has few lasting side effects now that we are able to administer the charge to the nondominant side of the brain. You probably have the image of a struggling patient held down as his body convulses uncontrollably. That is all wrong, all wrong.”

Kramer's tone had become more urgent. He lit another cigarette.

“The patient is given anesthesia and a skeletal muscle relaxant. The voltage that is administered is quite low and usually causes only a slight contraction of the digits. The patient wakes up with little discomfort, and whatever fears he may have had allayed. Most patients will show significant improvement after one or two treatments. The majority will recover completely.”

Kramer reclined in the chair and made an expansive gesture with the hand that held the cigarette.

“Fortunately in Simon Bowles' case, the modern anti-depressants worked quite quickly and well, so there was significant improvement within a few weeks. But I stress, with ECT we would have expected improvement within days.”

Smailes said nothing for a few moments. “Perhaps we could go back to that time two years ago, when Bowles was admitted. You may be able to help reconstruct the young man's state of mind the night he killed himself.”

“Well, it is some time ago, but the case was somewhat unusual, and it was also one of the first I handled after I became a resident here. I've also been looking at the file, as I mentioned. One of the most vivid dietary defaults I've ever seen.” Kramer reached down for the manila file, removing his glasses by the taped hinge as he did so.

“I'm sorry?”

“Oh, I thought you would have known that. Simon Bowles' psychotic episode, you know, the delusional thinking, was caused by violation of the dietary restrictions of the medication he was taking. He had been put on one of the older generation of drugs—they are generally slower-acting, and have more potential side effects. He obviously did not understand the seriousness of not strictly following the dietary constraints that applied.

“The snake hallucination was really quite powerful at first. He was brought here from the Royal Cambridge after the emergency room set his ankle and then realized that he should be in a, well, more appropriate environment. By the time he was admitted here he could not move his limbs—you see, he thought he had become a snake himself.”

“Really?”

“Yes, poor chap.”

“Excuse me, doctor, I'm not trying to be clever, but he must have seemed really crazy when you first saw him.”

“Quite. With such severely disturbed individuals, our policy is to administer a major tranquillizer to encourage any delusions to subside. Then we proceed with discussions with the patient and his clinicians to try and arrive at a diagnosis, and a course of treatment. Of course, we would not have considered administering ECT as a treatment until we discovered that Simon was depressed, which became clear quite quickly.”

“It sounds a lot worse than that.”

“Not really. Through his family we quickly found out which doctor had been treating him, and with which medications. One does not like to criticize a professional colleague, but it really was surprising to find that Simon had been prescribed an MAO inhibitor as an anti-depressant. A little old-fashioned, one might say. Although not entirely surprising that a practitioner of family medicine might be a little behind the psychotropic times, so to speak.

“Simon's hallucinations subsided quite quickly, and he was able to describe them quite candidly, although with considerable embarrassment, the file notes.”

Kramer had become quite animated and was about to quote further from the file when the detective held up his hand. He kept his eyes on his notepad.

“I'm sorry, doctor, you've lost me with some of these technical terms. You'd better try and explain them to me, if you can. Just tell me in layman's terms what happened to Simon Bowles two years ago.”

Kramer studied the file for a few moments, flicking through its pages impatiently. Smailes suspected he actually enjoyed this appeal to his professional abilities.

“Yes. Okay. Well, Bowles had sought treatment from a family doctor for anxiety and depression. This was in March, two years ago, about six weeks before his Finals, I think. This alone is significant. We regularly see an increase in undergraduate admissions here around exam time. The stress, you know.

“According to the file, he was put on an anti-depressant, one of the monoamine oxidase inhibitors, as I mentioned.”

“What's that?”

“Well, how technical do you want me to get?”

“Not very,” said Smailes, evenly. “I just want to get a sense of what happened to him two years ago, and whether what happened was some kind of repeat performance.”

“Okay. When Simon saw his doctor, and described his symptoms, which I gather were sleeplessness, loss of appetite, anxiety, and ah, gloomy ruminations, he was diagnosed, I believe correctly, as suffering from depression. What was incorrect perhaps was the prescription of Parnate.”

“Why so?”

“This family of drugs—the MAO inhibitors—works to counteract a chemical deficiency in the brain which we are now sure plays a significant role in depression. Unfortunately, it can have serious side effects on the cardiovascular system and the liver. It can also have most unpleasant consequences when ingested in combination with certain common foods—notably fish and cheese. So its use needs to be carefully monitored. Since a much safer and more effective drug family—the tricyclics—has been discovered, most physicians would only turn to the earlier drugs if other methods had failed. One of these drugs helped Simon recover quite nicely, we found.

“What we found out was that the night of his admission, Simon had eaten a cheese sandwich, the only thing he had eaten that day. So he was either unaware of the restrictions that applied, or did not take them sufficiently seriously. The psychotic episode, I am convinced, was obviously a direct response to this, although Simon, poor fellow, was convinced that he had gone quite mad. Naturally, we took him off this medication and substituted one of the more sophisticated drugs, as I mentioned.”

Smailes was silent for a moment as he caught up with his note-taking, and then studied the psychiatrist's face. He was obviously an oddball, but then he supposed you would have to be to choose this kind of work. Despite his appearance, he obviously knew his stuff. The detective was aware that he was laboring under a strong prejudice, a severe distrust of this man's profession and its efficacy in the treatment of simple human unhappiness. Look at young Bowles and the muck they had pumped into him. His next question emerged somewhat involuntarily.

“How are you defining depression, in Mr. Bowles' case?”

“Well, depression is an organic condition whose symptoms include profound feelings of sadness and worthlessness, inability to sleep or eat properly, loss of interest in sex, and, intense feelings of guilt and self-blame.”

Smailes shifted uncomfortably in his chair. There had been times in his life when that description pretty well summed up his own state of mind, particularly after his divorce. Uncannily, the doctor seemed to sense his discomfort.

“This should not be confused with normal feelings of sadness or despondency, which everyone experiences. Depression in the psychiatric sense is a disease, which can be treated as a disease quite successfully, thank goodness. But clinical depression should not be confused with simple loss of spirits. Depression is a loss of all perspective, where the sufferer cannot conceive that life will ever improve. He cannot recall ever having felt contentment or joy, and will revive all manner of ancient memories to confirm his sense of worthlessness and inadequacy. For the depressed person, suicide becomes a real threat, which is such a tragedy since depression is one of the simplest psychiatric disorders to treat.”

“We classify depression as an affective disorder, that is, a disorder of mood, but since as humans we are biopsychological organisms, as it were, there are changes in brain chemistry that accompany such severe mood alterations. They may not have caused the depression initially, but they reinforce its tenacity. Studies tell us that untreated, ah, depression will lift organically in say, six to eight months. What our modern drugs do is to accelerate the recovery process, by restoring the chemical balance in the brain so that our natural resilience, the tendency of our organism to heal itself, can take over. The first indication is often the restoration of sense of humor. Incidents that previously confirmed a patient's sense of shame or worthlessness can be seen as funny or absurd. I remember in Simon's case this was the first indication of recovery. One morning in group he said that if he were not allowed to speak first, he would jump out of the window again. He had a big smile on his face, and most people appreciated the joke, if only because we only have the ground floor here.”

The Oriental orderly Smailes had already met stuck his head around the door and told Kramer he had a phone call. The detective flicked back through his notes, and then tapped his top lip as he tried to absorb all this information. You ate a cheese sandwich, then turned into a snake. It didn't seem to add up. Could this delusion return, spontaneously? When Kramer returned, Smailes steered him in this direction.

“This business of the snakes. What's all that about?”

“Well, a panic delusion often takes the form of the thing that an individual finds the most distasteful or upsetting. So Simon saw snakes. Then, because he was ashamed of this, he thought he had become one himself. It makes sense that you imagine yourself as something rather nasty if you are upset with yourself.”

Smailes marvelled at Kramer's understatement.

“Could this hallucination, whatever, recur spontaneously?”

“Most unlikely. You see, a major depressive episode is really a traumatic response to a sustained period of stress. Simon's psychotic incident happened within the context of a longer-lasting trauma, that of his depression, which is in itself a terrible stress, quite a terrible stress. But depression does not come on suddenly, like the flu. It is something that seems to gather strength gradually, often following some unfortunate life event. Of course, I have no information on what Simon's psychiatric history may have been immediately preceding his suicide. It is possible that he had become depressed again. Quite possible. But I think it is most unlikely that the particularly frightening delusion about the snakes would recur without some specific event which precipitated it. Simon Bowles' illness was a neurotic disorder, not a psychotic one.”