Timothy’s injured hand was able to write, but it was difficult and painful. This was not quite as bad a problem as it might otherwise have been, because Timothy was suspended from school for two weeks due to his outburst. He might have faced worse; he might have faced complete expulsion, had it not been for Mrs. Gibson going to bat for him, for the fact that he was otherwise an excellent and motivated student, and that his mother was able to bring up the fact that his outbursts were thought—by Dr. Putnam, at least—to be medical in nature. It helped that Earl had not been seriously injured. His personal soreness lasted a much shorter time than Timothy’s did.
Timothy’s schoolwork was brought to his home—not by Earl, but by another student who was more an acquaintance than a friend—and so he was able to avoid falling behind during the period of his suspension. He dedicated himself obsessively with doing at least as good a job on all the studying and homework while he was on suspension as he would have done when in school. Partly this was done as penance. He found the writing quite painful, and this pain served, in his own mind, as a punishment for his inability to control himself, to keep from lashing out at Earl. It was not the only cost he paid for that, but it was the most immediate one. He relished it, and this embrace of his own discomfort, if it did nothing else, at least made sure that he returned to school eventually with work that earned nearly uniform “A” grades.
His appointment with Dr. Putnam happened during his suspension, which would officially run out the following day, with Timothy returning to school the next Monday. He arrived at the doctor’s office with his brace on, though at home he sometimes eschewed it, welcoming the pain thus caused. Despite Dr. Putnam’s statements about how he sometimes ran a little late, Timothy was brought back to the exam room a few minutes before two. His mother had not accompanied him; she’d already lost too much time at work, and Timothy was more than confident in taking the bus. The city was hardly a hotbed of crime, particularly toward teenage boys during the day, but even if it had been…well, woe betide any but the most hardened criminal who would have tried to interfere with Timothy’s hopeful trip.
And it was a hopeful trip for him, despite the failures of the pheochromocytoma workup. Timothy hated his temper, hated the dark force of anger that episodically arose within him, beyond even his best attempts to control. It had always felt, to him—once he’d gotten old enough to think about it in such terms—to be a force rather than a state of his own mind. He felt ordinary frustrations on a day-to-day basis just as much as any other boy in a single parent home. Yet, oddly enough, these almost never instigated his uncontrollable rages. He had always complained as much as any child when told that it was bedtime, when told to clean his room, and he was irritated by such requirements as much as the next child. He’d thrown his share of minor tantrums over toys his mother refused to buy, pets he was not allowed to have, and all the typical, “character-building” deprivations of a typical childhood. These had almost never devolved into explosions of the extreme rage that led him to lose control of his reactions and seek to cause utter destruction.
Over the years, he thought he began to recognize some hint of a pattern in his furies, a common factor in most, but not all, of the instances in which his rage became a physical force that overwhelmed his ability to control himself. These were almost always in response to a perceived situation of victimization or injustice. The case of the two bullies trying to steal the backpack from the younger boy, which had led to his breakup with Allison, was almost prototypical in character. He later came to suspect that his attack on Earl had not really been triggered by the teasing Earl had done with his name, but by the fact that he had done so to try to impress the other group of boys nearby, victimizing Timothy—if only in the most minor of ways—to try to seem cool or funny to other high school boys.
Timothy’s recognition of this pattern, though, was years in the future. As he sat in the exam room, waiting for Dr. Putnam to arrive to remove his itching stitches, he was just hoping that the doctor might find some other physical cause to explain his problem, preferably something that could be treated.
Dr. Putnam walked into the exam room at seven minutes after two—Timothy confirmed this by looking at the cheap K-mart watch he wore then, and which had not suffered any damage in his outburst because it was on his left wrist. This was impressive, especially since the waiting room outside had been fairly packed with patients waiting to see either Dr. Putnam or his partner.
“Afternoon, Timothy,” the doctor said as he walked into the room, holding a medical chart. “It’s good to see you.” As he walked up to stand near Timothy, a thought seemed suddenly to occur to him and he asked, “Actually…do you prefer to be called Timothy, or would you rather it be Tim, or something else?”
Adults rarely asked such things, even of teenagers, so Timothy was mildly surprised. “Um…well, to be honest, I kind of like just Timothy better than Tim or anything else. Is that okay?”
“Of course, it is,” Dr. Putnam replied. “You’re the patient, and it’s your name. Heck, if you prefer a bit more formality, I’ll be happy to call you Mr. Outlaw.”
Timothy grimaced and replied, “Please, no. I…that always sounds like it’s supposed to be some stupid TV show or comic book character or something.”
Dr. Putnam gave only a mild chuckle and replied, “I suppose you could see it that way. And I will respect your wishes. So, Timothy…how’s the arm?”
Timothy shrugged, holding his right forearm up for the doctor to look at it, regarding it himself as well as he said, “It’s fine, I guess. I mean, the cuts are all fine, that’s for sure. They itch and stuff, but even that’s getting better.”
“How about your hand?” Dr. Putnam asked, tilting his head. “I had a look at the X-ray reports when the hospital sent over your records. That had to have hurt quite a lot. I imagine it still does.”
Timothy contemplated his hand, the back of which was marred with the greenish-turning-yellow residua of fairly extensive former black-and-blue patches. “Oh. Yeah,” he said, sounding quite dismissive even to his own ears. “It hurts, especially if I bump it on something. And writing hurts, too. But that’s a good thing.”
“Why do you say that?” Dr. Putnam asked, eyeing Timothy quite sharply.
Timothy felt embarrassed, for reasons that weren’t clear to him. “Do you think that’s wrong?” he asked in return. “I mean…do you think that’s weird?”
“Not necessarily,” Dr. Putnam replied. “I can think of many ways in which pain can be and is a good thing. But I’m curious as to why you think so.”
“Oh,” Timothy said. “Well…I guess it’s sort of like…like punishment, I guess. I mean, partly, it’s just…it’s just what I deserve for what I did. But also…I don’t know, maybe if it hurts enough, I won’t…won’t lose my temper like I did.”
“I see,” Dr. Putnam responded, nodding and smiling. “So, you’re hoping for some Pavlovian conditioning, is that it?”
Timothy had not known what the man had meant. If he’d been exposed to the concept before that day, he could not recall it. “Some what?” he asked.
“Sorry,” Dr. Putnam said with a shake of his head. “I’m sure they haven’t covered that yet in your biology classes. Or perhaps it would be psychology. But there was a scientist named Pavlov, and he demonstrated a thing called conditioned reflexes when he trained dogs to salivate…to drool…whenever he rung a particular bell.”
Timothy, confused, asked, “How would he do that?”
“Well, for quite a long time, he rang that bell whenever he was bringing the dogs food. Dogs’ mouths water when they anticipate eating something good—just like people. But pretty soon, with the bell always being there, just ringing the bell would trigger the drooling, even if there was no food coming.”
“Huh,” Timothy said, not quite getting the connection to his own situation. “That’s…interesting.”
Dr. Putnam smiled, and Timothy felt certain that the man recognized his confusion. “Well, that idea laid the groundwork for a…a framework of approach called ‘behaviorism,’ with the idea that all behaviors of all complex organisms are just such conditioned reflexes, and that they can be modified by the application of controlled rewards and punishments…reinforcement, treats, the giving and taking away of treats and the like. They did a lot of work with pigeons, interestingly enough, but they were convinced that every animal, including humans, acts as it does because of all those conditioned responses. And that behaviors can be encouraged or discouraged by careful and consistent application of rewards and punishments.
“So, I was saying, it sounds like you’re thinking along those lines. If you focus on the pain in your hand as the outcome of your rage, then—so the theory goes—you’ll be less likely to lose your temper in the future.”
Timothy brightened. “Yeah,” he said, “that’s kinda what I was thinking. Does it…well, I mean, if these guys all study this kind of stuff, does it work, that reward and punishment stuff?”
Dr. Putnam pursed his lips slightly, bobbed his head and shrugged, replying, “Well…sometimes, and to a certain extent, depending on what the cause of a behavior is. But it turns out that the behaviorists were a bit too simplistic. The causes of behavior are a lot more complicated than they thought. Though, of course, rewards and punishments do have effects, there’s no doubt about that. But they’re nothing like as absolute as they thought them to be.”
Timothy, feeling slightly glum in response to this revelation, asked, “So…what can make a difference?”
“Well, that would depend on what’s causing the problem,” Dr. Putnam said. “Here, let’s start getting your stitches out, and we’ll talk more about it while I do it.”
Timothy had already taken his brace off and hadn’t put any dressing on the wounds already for several days, the cuts having closed over quickly and cleanly thanks to the speed of healing in his still-growing body. Dr. Putnam grabbed a small paper-and-plastic kit of some kind from a cupboard. It looked vaguely similar to a microwaveable meal. Then the doctor had wheeled a portable, adjustable table up in front of Timothy and raised it to a level at which Timothy could comfortably rest his forearm, which he did after the doctor laid out a white paper sheet. Dr. Putnam next wheeled a rolling stool up in front and, after donning a pair of latex gloves, he peeled open his little kit, which contained some gauze, a pair of tweezers, and a pair of scissors.
“Is that, like, a ready-made thing for taking out stitches?” Timothy asked.
“Exactly,” Dr. Putnam replied. “It’s called a suture removal kit…which is almost exactly what you said.”
As the doctor reached out to pull Timothy’s arm gently toward him, Timothy asked, “Do you just…throw it away once you’re done with it?”
“More or less,” Dr. Putnam replied. “It may seem a little wasteful, but the benefit of avoiding the spread of infection outweighs the cost.”
“Oh. I guess that makes sense,” Timothy commented.
Dr. Putnam examined Timothy’s arm quickly but thoroughly, declaring that all the wounds looked as though they were healing beautifully. Then, starting with the largest of the cuts, he began carefully snipping the sutures and pulling them out. It felt strange to Timothy, but it was not uncomfortable, and certainly not painful, so he didn’t flinch even with the first suture removed.
After taking out several, and not looking up from his work, Dr. Putnam asked, “I was wondering if you’d ever heard of Charles Whitman, the Texas Tower shooter.”
“I don’t think so,” Timothy replied. Then unable to hold back a true and deep puzzlement, he asked, “Why would…why would someone shoot a tower?”
This brought a larger laugh than had Timothy’s earlier comment about his name, and Dr. Putnam said, “No, sorry. He didn’t shoot a tower, he shot from a tower. He was a man who, more or less out of the blue, one day went up into a tower at a university and, with a rifle, started shooting random people on the ground. He was a good shot—I think he’d been a Marine—so he hit quite a few. If memory serves, I think he killed about fourteen or fifteen people, and wounded many others, before the police finally killed him.”
“Holy crap,” Timothy said, carefully avoiding profanity in front of the doctor. “So, he was like those school shooter people, huh? At that one high school?”
“A little bit,” Dr. Putnam said, pulling another suture. “But this man had been a relatively well-adjusted adult, not a…well, not a poorly socialized high school loner. And he apparently left a note, talking about how he’d been having headaches and increasing fits of uncontrollable rage developing over recent time. He’d…well, he’d killed his wife and mother before shooting people from the tower, it turned out, but he couldn’t understand, himself, why he’d done it, and why he was doing what he was doing. He requested that his body be examined after his death, especially his brain—he was pretty sure he was going to be killed, I guess. And he was right.”
“Wow,” Timothy said, thinking with horror—and with slight anger—at what the man had done, particularly at the notion of killing his mother. Timothy had a powerful sense of loyalty to his mother, since she was the one who raised him, and he strongly disliked anyone who disrespected a mother.
“Yes,” Dr. Putnam said. He was now well over halfway done with the suture removal. “Well, the investigators followed his request, and they found that he had a brain tumor—I forget what type—that was pressing against a part of his brain called the amygdala. The name’s not really important, but what matters is that this particular part of the brain regulates things like fear and hostility…anger and aggression. So, it was pretty clear that the tumor was probably the cause of his increasing fits of uncontrollable anger, and what finally made him kill all those people.”
“Wow,” Timothy said. Then, suddenly, it occurred to him that Dr. Putnam wasn’t telling him this story just out of desire to share an interesting and morbid tale. After all, it didn’t seem like the sort of thing most doctors would discuss with their patients, especially young patients. Timothy made what he thought should have been the obvious connection from the first, and he asked, “Wait, do you think I might have a brain tumor? That…that that’s what might be making me get so mad all the time?” He had already become used to the notion of tumors when dealing with the search for the pheochromocytoma, so he was not resistant to the idea of some other kind in his body, though if he were honest with himself, the notion of a tumor in his brain was more disquieting than that of one in his body.
Dr. Putnam paused in the process of the suture removal, and he looked Timothy directly in the eye. “Well,” he said, “I think it’s something we should consider. I mean…you tell me. Do you think you have a tumor?”
Timothy thought this was a ridiculous question. Dr. Putnam was the doctor, not him. How should he know if he had a tumor? “I don’t know,” he said. “I mean, how could I tell?”
“Well, the only way to tell for sure is to look,” Dr. Putnam replied, now returned to the removal of the last few stitches. “But have you had any unusually bad headaches, vision changes, any…local weakness or sensory weirdness?”
Timothy didn’t really know what might constitute “sensory weirdness,” but he said, “I don’t know. I don’t think so. I mean, I get headaches every now and then, but nothing especially bad. And I haven’t had anything going on with my…my vision, I guess. Not that I’ve noticed. I don’t wear glasses or anything.”
Dr. Putnam finished with the last suture, had Timothy lift his arm, wrapped all but the metal implements up in the white drape and brought them over to the large, red metal waste receptacle, into which he threw them. The metal implements he dumped into a curious container on the wall, which was also red. Then he turned back to Timothy and said, “Well…maybe it’s not a tumor. Which, I suppose would be a good thing, when you get right down to it. No one really wishes for a brain tumor.”
Timothy wasn’t so sure he agreed. “But a tumor could be taken out,” he said, unable to disguise the hopefulness in his voice. “I mean…if my bad temper is caused by a tumor, they could take it out, and then I wouldn’t…wouldn’t hurt anyone anymore.”
Dr. Putnam regarded him seriously for a moment, then said, in a subdued voice, “Hurting other people worries you a lot more than hurting yourself, doesn’t it?”
“Sure, of course,” Timothy replied, surprised that anyone would have to ask such a question. “I mean…it’s kind of up to me if I hurt myself, right? I mean, it’s my body, I’m the one who’s gonna be in pain, so…so if I hurt myself, it’s my problem. But if I hurt someone else…I mean, that’s not right. It’s…I can’t just go around hurting other people.”
After the tiniest of pauses, Dr. Putnam asked, “Have you hurt other people?”
Timothy recalled that his mother had deflected the conversation in the ER away from the fact that he’d attacked Earl, and made it seem as though the only thing he’d done had been to hit the door. Even at the time, Timothy had suspected that Dr. Putnam had recognized that more had gone on than was being revealed, and he didn’t see any need to hide his shame. He also didn’t think he deserved to have it hidden.
“Yeah,” he replied, looking down. “I mean…I didn’t hurt him badly or anything, I don’t think, but I hit my friend Earl…hard. I hit him a bunch of times before the gym teacher started coming over and I was able to…to stop myself and to run over and hit the window instead.”
“Did you want to hurt your friend?” Dr. Putnam asked.
“No,” Timothy replied emphatically. Then, being more honest with himself, and more careful, he added, “Well, I mean…when it was happening, I wanted to hurt him. I mean, I wanted to hurt almost anything. I felt like I wanted to…to just hurt and break anything, everything. I wanted to…to break the whole world if I could, sort of. But that was only while I was…while I was flipping out. I’ve never really ever wanted to hurt him. I mean, he’s my friend, right?”
“Of course,” Dr. Putnam said. He smiled. “Believe it or not, that’s reassuring. There are people out there who wouldn’t care whether they hurt other people, who sometimes actually enjoy hurting other people. They’re called sociopaths. They use pain and fear in other people as a tool, to get what they want. But your situation is very different. It seems clear to me that you’re a normal, even an unusually good-hearted, young man who has this…this anger problem as a kind of…a bug of some kind. A factory defect, say.”
Timothy, a little slow at following Dr. Putnam’s point, said, “And you think it might be because of a brain tumor?”
Dr. Putnam shrugged and replied, “Well…maybe. But there are lots of other things around that can have similar effects. You’ve already ruled out the pheochromocytoma notion, I see, but that was always a bit of a zebra, anyway.”
This made no sense to Timothy. “A zebra?” he said, wondering if maybe it was Dr. Putnam who had a brain tumor.
Smiling indulgently, Dr. Putnam said, “That’s a bit of medical short-hand. When you hear hoof-beats coming down the road—in America, at least—if you look for their source, you expect to find a regular horse, not a zebra. It’s a way of saying that common things are…well, common. It’s a rule of thumb to keep us from getting too excited about possible wild tangents and carried away with the prospect of diagnosing exotic illnesses…which we sometimes do, especially early in our medical careers. Most of the time, though, the ordinary, run-of-the-mill diagnoses are the right ones. But of course, every now and then, there’s a slip-up at the zoo, and the zebras get loose, so you can’t rule them out entirely. But you have to weigh your estimates based on how common things are…and how one illness or process can masquerade as another.”
“Oh,” Timothy said. He thought he followed most of Dr. Putnam’s point but was far from sure.
Dr. Putnam seemed to realize that Timothy wasn’t keeping up with him quite as well as he might, and he stepped forward, patting Timothy on the shoulder before saying, “The point I’m making is, there are numerous things that could be causing your problems. Among the most common, for instance, depression can often present as anger and irritability. So can thyroid disease…though Dr. Barrett ruled that last one out pretty well with your blood tests. And of course—perhaps most common of all—some drugs can cause fits of extreme anger. So, I know they’ve gone over this with you before, but I want to get it straight from the horse’s mouth…or the zebra’s mouth, if you prefer. Do you use any drugs? Remember, everything you say is confidential between you and me, even from your mother, even from police. Unless you’re planning a murder, of course, which I seriously doubt. But…have you used any recreational drugs, especially cocaine, or amphetamines?”
Timothy, not bothered by the question, was able to shake his head and honestly reply, “No way. I haven’t even tried to sneak a beer or anything. I mean, mom doesn’t drink, because of my dad and all, and…well, because of my dad and because of me, I don’t want to screw around with anything that might make my temper worse. I’m really scared about that.”
Dr. Putnam smiled. “I think that’s a wise attitude,” he said. “Until we know more about what’s going on—if we figure it out—I think it would be very sensible for you to stay away from all drugs. Certainly, illicit drugs. Perhaps, in the future, there might be a place for modest amounts of medical quality marijuana, which might be useful in taking the edge off things, but…well, for now, even that particular generally benign substance should probably be avoided.”
Timothy was mildly surprised to hear even such a guarded endorsement of weed, but he didn’t dwell on it. Instead, he asked, “So, what do you think we should do?”
“Well, first I’m going to do a quick neuro exam, just to see if there’s any signs of anything focal, then we’ll decide what step to take next.” After saying this, Dr. Putnam proceeded to do a thorough set of checks on everything from how Timothy responded to lights in his eyes, to looking back and forth and up and down, checking his strength—he gave the grip strength a pass, he said, because of the state of Timothy’s right hand—checked his hearing, his peripheral vision, his reflexes in places Timothy hadn’t known there were reflexes, tested his ability to feel even light touches with a tiny plastic string on the bottom of his feet, his arms, his hands, his face…numerous things, the purpose for some of which Timothy couldn’t readily guess.
Then, smiling slightly, Dr. Putnam said, “Well, you’ve certainly got no focal neurologic deficits. Meaning, your exam is as good as a human could hope for. It doesn’t rule out a tumor, but it means that if there is one, it’s probably small. Which is good. And I already know that your blood work is as normal as can be. So, I think the next step is to set you up for an MRI.”
Timothy had heard the term but wasn’t too sure what it meant. “What’s that?” he asked.
“Well, it’s a little bit like the X-rays, in that it lets us see inside your body, but it’s much more sophisticated. It uses very strong magnetic fields and radio waves to take images inside your body…inside your brain, in this particular case.”
“Really?” Timothy asked, honestly curious. “How does it do that?”
Dr. Putnam tightened his lips a bit, then smiled mischievously before answering, “To be honest, I don’t really understand it myself. It’s something to do with quantum mechanics, and physics wasn’t my best subject as an undergrad. But it definitely does work. We can get incredibly detailed pictures of the insides of almost any part of a person’s body with it. Way better then X-rays.” He paused a moment, then asked, “You’re not claustrophobic, are you?”
Timothy, wanting to be clear and honest, said, “I…I know a phobia is a fear thing, but I don’t know which one that is.”
“A fear of enclosed spaces,” Dr. Putnam said.
“Oh,” Timothy said. “Well then, no. Not as far as I know, anyway. I mean, I don’t get in places like that for fun or anything, but I don’t think I’ve ever been bothered by them much.”
“Good,” Dr. Putnam said. “That’s good. That’ll make things easier.”
“Why?” Timothy asked.
“Oh, sorry,” Dr. Putnam said, “I didn’t realize I might’ve been a bit cryptic there. To do an MRI, you have to be kind of slid into a pretty narrow…tube, I guess, is the word. That’s to get the magnetic field particularly strong, I guess. Claustrophobic people can find it problematic.” After a moment of watching Timothy absorb this information, he said, “The only other problem is, it’s a bit loud.”
“Huh,” Timothy said, honestly more intrigued than worried. “That’s weird.”
“It is, a little,” Dr. Putnam agreed with a laugh. “I don’t know why it has to be so noisy, but I guess it really has to, because they always are.”
Little else of significance was said during that office visit. As Timothy left, Dr. Putnam’s office staff set him up for an appointment at a nearby MRI place, giving him a sheet with the location and the date of his appointment. Timothy noted that it was the following Wednesday, at two in the afternoon. Which meant he was going to miss still more school. He was glad that he’d worked hard on the assignments that had been sent home for him, so he was well-prepared to keep up. It was mildly irritating to have to miss school again, but if it could give him any clues about why he lost his temper so much, it was worth it. Even the prospect of brain surgery—which he was more than intelligent enough to realize would surely be the treatment of choice for a brain tumor—seemed far from worrisome.
In fact, that weekend, as he passed the time at home reading ahead on his schoolwork, as well as watching TV and movies, he went to some medical sites on the still-young internet, trying to see what he could learn about brain tumors. What he learned didn’t really help him much; it was far too general. Then he researched the “Texas Tower Shooter” Dr. Putnam had mentioned. He couldn’t recall the man’s name, but that title alone brought him to places where he could find out enough. It wasn’t Wikipedia, of which he would become a contributing fan later in his life, but there were some true crime sites already in existence, and he was able to get at least a rough idea of what the man in question had done.
He supposed he should have been sympathetic with Charles Whitman, the shooter. After all, the man really had been the victim of a brain tumor and had led a previously relatively normal and useful life, at least by the account Timothy read. However, rather than feeling sympathy or pity, Timothy found himself becoming angry, even disgusted by the man. Whitman had killed his wife and his mother before going up into the tower to start killing strangers…and had written some kind of note, which was effectively a suicide note. So, he had known that he was going to die. He had expected to die.
And this was what irritated Timothy, what had irritated him about the high school shooters in Columbine…and it worse than irritated him, it disgusted him, it filled him with vindictive ire. These people had known that they were likely to die, they had planned to die. But if they were willing to die, why the hell hadn’t they just killed themselves, which they could have done without harming, without killing, all those other, innocent people? They had been prepared to die, had been willing to die themselves, so there was absolutely no excuse for not simply killing themselves and saving the horrible steps in between. Timothy fantasized about being able to bring such people back to life and submitting them to torture, while screaming at them, “Why didn’t you just kill yourselves, you selfish pricks? You want to die now, don’t you? Well, you don’t get to. This is for what you did to everyone else!”
He tried not to think too explicitly about what he would like to do to them, because it got his anger going, and that wasn’t a good thing. Righteous—and even self-righteous—anger was far more insidious and tempting, far harder to keep under control, Timothy was to find, than spiteful or selfish anger. That made it particularly dangerous. It was only too easy to give yourself free rein if you were able to think of your victim as evil, as deserving of punishment. But ultimately, he decided early on, that was just an excuse people gave themselves. It was one he could not afford.
The example of the Texas Tower Shooter did clarify one thing to Timothy about himself, giving him a very important determination: if he were ever to come to the point where he thought he was not going to be able to control himself enough to avoid killing, or even just hurting, a bunch of innocent people…if that state ever seemed inescapable, then he would just kill himself, as all those other suicide murderers should have done if they’d had any balls at all. If he was ever so angry that he had to kill just anyone, then the choice of who that anyone should be was obvious.
It would be him.