"Thank you for seeing me, Mrs Caulfield. Let me introduce myself. My name is Dr Fletcher and I will be overseeing your son's recovery and rehabilitation. Is your husband not present? Oh, I understand. How long will he be in California? Hmm, if you would like me to send him a written report please do let me know. I assure you it will be no trouble."
"Now, I'm not the surgeon who carried out your son's surgery, that would be Dr Gelb. Have you spoken with him? No? Well let me just give you a quick overview of the situation with the surgery and then I'll tell you where we'll go from here."
"As I'm no doubt sure you're aware, your son was brought in to St Fillan's Hospital three days ago. He was found in Central Park in an agitated condition, and brought to us by the police as he showed no signs of physical illness. He was accompanied by a female minor by the name of...Phoebe? Yes, Phoebe Weatherfield Caulfield? No? Oh, well, but that's your daughter, is it not? I had the pleasure of meeting Phoebe and she is a very delightful little lady. You have a wonderful daughter, Mrs Caulfield. I performed the initial assessment on Holden and Phoebe very helpfully gave us a great deal of information about your son."
"I took the decision to admit Holden due to his condition, with the intention of monitoring him for a few days to see if the situation improved. I understand that you were informed of this when you came to collect Phoebe? Good. I'm sorry I couldn't see at the time but I had finished for the day."
"When we admit a patient it is routine to perform a physical exam to ensure that they are not suffering from any additional illnesses or other conditions that could interfere with our treatment. Naturally many of our patients cannot inform us directly of their needs, and we so we take this physical very seriously. We believe that both the mind and the body need to be healthy. Of course you can ask a question. Was Holden...oh, he was quite talkative, and certainly capable of expressing himself. He told us about an injury to his hand...yes, an old injury...and also some bruising to the stomach. No, I do not know where the bruising came from. Actually, I do. But it's not important right now."
"A doctor performs the exam to be sure that there isn't anything we're not aware of. Many patients are less responsive than Holden, but even those who are conscious and talking may mislead or lie...no, I'm not saying your son is a liar...patients in general simply may not be the best informants. Which is why we need to do the exam."
"The doctor performing the exam found Holden to be generally fit, but noticed a few worrying symptoms. Firstly, there was blood in his nose. Not a great deal, but suggestive that he had suffered a nosebleed recently. He was also incapable of modulating the volume of his voice with any precision. He spoke either in an almost inaudible murmur or shouted. Naturally this could be considered part of his agitated state, but as doctors we are taught to consider the possible underlying neurological causes of such a symptom. Lastly, upon inspection of his eyes Holden was found to have anisocoria and papilledema, which are classic symptoms of..."
"Oh, anisocoria is the unequal dilation of the pupils. One was significantly larger than the other. I am surprised that I failed to notice it at his initial assessment. Which obviously stresses the value of physically examining every admission. And...papilledema is, well, it's complicated to explain. Think of it as a swelling. No, not quite of the eye, but of the nerves and blood vessels behind the eye. His were very swollen."
"As I was saying, these are classic symptoms of a brain tumour. The examining doctor called up Dr Gelb that very evening to come in and see Holden. Yes, it was serious. The nosebleeds he had been suffering from suggested that it could deteriorate at any moment. Dr Gelb made a formal diagnosis and ordered x-rays of your son's cranium to be ready for the morning. When he arrived in the morning he made the decision then and there to operate. The brain tumour was small and easily accessible, and considering your son's condition he did not wish to lose any time."
"I understand that you would have wished to be informed and consulted, but time is of the essence with a tumour. I'm sure you can appreciate that. Dr Gelb is a father with a son the age of Holden and wanted the best outcome possible. The tumour was removed successfully so I don't think there is anything further for you to worry about. Afterwards he was placed in my care for his rehabilitation. Let me tell you about that now."
"Obviously we believe that the tumour was causing your son's agitation. The region of the brain in which it was growing is responsible for self-control. Yes, yes, it could cause all kinds of behavioural problems. Yes, that is a possibility. Yes, and that...look I don't think it's worthwhile trying to ascribe specifics but rather to look at the general picture. Four years you say? Yes, it could have been growing for that long. If you think his behaviour has worsened over four years, that sounds very reasonable."
"Yes, he mentioned his brother's death...Alexander? Yes, Allie. Usually we would consider something like that as a trigger for psychological problems. I am a psychologist by training. But our knowledge of his tumour suggests that the two are not strictly linked. Well, yes, if he was already suffering from poor self-control before Alexander's passing the trauma could have made it worse. You must remember that he's still a young man, just a young man with a brain tumour. Any normal and well-adjusted reaction to a sibling's passing at that age could be considered disruptive. There is no easy way for a teen to deal with such a thing. But for Holden it may have been worsened by his already loosening grasp on his self-control."
"Yes, I understand that the injury to his hand was caused by a destructive act at this time. How do I know? Let me tell me you what I have been doing in the past two days and it will become clearer."
"The physical recovery from brain surgery is extraordinarily slow. Most patients take months if not years to regain all the skills and abilities they had before the surgery. The deeper and bigger the tumour the worse the recovery will be, often with some permanent loss of function. No, your son is fine Mrs Caulfield, you can see him soon. Indeed, many tumours are inoperable because of the damage that the surgeon himself will cause in removing it. No, Mrs Caulfield, your son is fine. Please trust me."
"Yet Holden's tumour was so small and so shallow,that he was awake and talking just hours after surgery. He was talking a lot. Yes, I gather that's usually the case. He was talking a lot when he was brought in too. He understood that he had had surgery but was unwilling to rest. Usually I would provide a sedative, but he indicated that he would like to write and so I instead provided him with a pencil and paper. It is a good test to show that the patient has retained or recovered fine motor skills, which Holden clearly had."
"I encouraged Holden to write about his life. It would give me material, as a psychologist, to understand the tumour's effect on him and to assess his behavioural recovery in the future. He seems to have stayed up all night writing, which I must say I disapprove of. But the notes he provided are a wonderful insight. I read them with fascination yesterday. I could hardly pull myself away. His character shines through very clearly."
"No, he doesn't seem to have spoken much about his family life. I told him to start wherever he wanted, but he seemed uninterested in his early childhood. In fact, he spoke mostly of the last few days leading up to him being hospitalized. No, I think his long term memory is intact and he can remember the past well. His story included numerous digressions which suggest he has good recall over the period when the tumour has been affecting him. Before? I'm not sure. He recounts a few episodes that could well be before the tumour, but they are fewer and much less rich in description."
"Here's the thing, Mrs Caulfield. Your son was obviously badly effected by the tumour over the last few days. Or even over weeks and months. It's hard to tell. What he did in New York this last weekend suggests that he had lost almost all self-control and capability of judgement. If I may say he is very lucky to be alive. Oh, I mean that, and I don't mean it just to shock you. That is, of course, assuming it is all true. I cannot say whether or not any particular episode is real, or as real as he tells it. Indeed, he may not even know."
"Let me give you an example. He was observed to be writing an obscenity on a wall when the police arrived. What obscenity? Oh, it isn't fit to repeat. Yes, I can tell you, if you wish. He wrote 'Fuck You' on a wall in Central Park. I'm sorry, I did warn you. But in his account he speaks of simply finding such obscenities written by others and trying to erase them. It seems as though he has lost knowledge of at least some of his actions and believes they are the work of others."
"He also speaks of visiting his sister late at night and dancing with her in her bedroom. I believe this is simply a dream, a desire, one which caused him to pull her out of school the next day. You do? He says that you were there but... Yes, smoking. Did your daughter...Phoebe, mention it? No. Well, maybe it happened then, but it is hard to be sure what is real in his account."
"That's true. He clearly isn't better yet. The story he recounted is not just the history of a sick mind, but written by one who is still sick. But I wouldn't expect him to be better just yet, or even for some time. Rehabilitation takes a long time. The thought processes that his mind has created in the last few years are still his, even if they were ultimately caused by the tumour. So are his memories and his experiences. When he wants to think he does so through the mind of somebody who has been ill and the mind itself bears the impression of that illness. Holden will heal in time. But not immediately."
"How long? Well, I think that the next few months should be considered rest for him. Not physical rest but psychological. Certainly he cannot return to school until fall. Obviously we will discharge him before long. No, not before Christmas. Maybe soon after the New Year. Long enough so that we know he is on the road to recovery. But I want to see him every week for the next six months."
"Maybe he can return to school eventually and catch up. I'm sure that most schools would be very understanding about his past. I can write a letter if needed. Have you considered sending him out to California to be with his brother? No, not now, but later next year for school. It would be a new start for him. Let him be his normal self with people who don't know him. Well, I don't know what his normal self is, naturally. I haven't had chance to...that's true, if the tumour has been effecting him for a long time then he might not know what his normal...you might not either, yes. As he recovers the old Holden will disappear and a new one will emerge."
"No, please don't cry Mrs Caulfield, it's not that bad. The old Holden was sick and...oh, yes, he'll disappear. Almost certainly. No I can't make him go quicker, though I understand that you want a happy and healthy son as soon as possible. It must have been...yes I can understand, it must have been very trying. Don't bear him any ill-will Mrs Caulfield, it was all the tumour. But the tumour is gone now...yes, the old Holden will be gone soon too."
"I don't think I can destroy his manuscript, it is part of his medical case notes. I can let you read it...no? That's alright. Maybe you would like to see him now? Yes, he's still the old Holden for now. Please don't cry, he will get better soon. Mrs Caulfield, your son is getting better."