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January 25, 1994

Dr. Salvo and Tim

Ask Dr. Salvo

Dear Dr. Salvo,

I attended your lecture and discussion on Foucault's Madness and Civilization, given last week at Springhill College. I was proud of my teacher, Mrs. Margaret Davis, for her courage in bringing us a bona fide eccentric who made no bones about his preference for madmen for company. And, who openly admitted to being a psychiatrist. Since then I wondered to myself, "How did Salvo prepare for such an odd lecture? Indeed, how did he prepare to be a psychiatrist/or shaman/or guru, and why??

Dr. Salvo, please enlighten us.

Sincerely,
Lost in Admiration



Dear Lost,

In a way there is no way I could prepare for this discussion -- there is too much of it, as if I were requested to discuss gravity, or the common law.

In another sense, no preparation is necessary since I have been preparing all my life. As a child I was good friends with Isaiah, our gentle schizophrenic yard man. He hallucinated without embarrassment in my presence, but would never describe what he saw -- except to say, "See pretty things," and laugh.

A cousin, Lester, boarded with us -- thin, pale, cadaverous, withdrawn and idle. I now see him as probably a borderline schizophrenic along the lines of Bartleby the Scrivener. He looked at life, sniffed, and said, "I would prefer not to."

One friend of my mother's was brilliant but bipolar: On one occasion she left 10 dozen roses on the front steps, in apology for something intemperate she had said. On another occasion she brought a small revolver in her purse, in order to shoot my mother, my siblings and me, then herself. (This was to spare us the agony of living in such a bleak world.) My mother tricked the gun away from her, then called her daughter for aid while the angel of mercy was in the bathroom. The daughter, unruffled, replied, "You see, Miss Anna, I'm having this little Coke party?"

By age 16 or 17 I was visiting Searcy Hospital in the company of a good friend: Her uncle was the Superintendent. He would allow us to sit in the swing behind the Big House, and eat quantities of homemade ice cream while observing the patients. I suppose it was like a Londoner paying two shillings for a walk around Bedlam (Bethlehem).

On those days the patients were often loud, and profane, though some were mute. Catatonics were plentiful, some silently frozen in uncomfortable postures, some nude. (This sort of patient has almost disappeared.) The silly, "hebephrenic" patients were numerous too, their grotesque motions and expressions resembling those of the mimes so plentiful in California today. Many were organically deteriorated, i.e., brain-damaged because of uncontrolled convulsions. They were in large cages, since some were easily provoked to violence. As late as the 1940-50's, epileptic patients were somehow confused or equated with those who were psychotic; some brain damaged people are still treated as schizophrenic, especially if they hallucinate.

And of course there were many people inside the walls who were simply old and poor; just ignorant and uneducated; and quite a few mentally retarded. On these strange trips to the "insane asylum" I did not consciously choose or vow to come back and right all the wrongs I saw about us. Since age 5 I had known I'd be an orthopedic surgeon, but didn't know how I had chosen that specialty. Later, it was obvious: In order to cure my sister of her intractable bone disease.

My next encounter with madness came in 1946, when as a medical student I worked and lived at De. Paul Sanitarium, a private mental hospital in New Orleans operated by the Sister of Charity. There one of my cousins appeared one night as Pope Pius and offered to let me kiss his ring. I declined, mentally remarking, "He's manic, all right. I believe he was treated with electroshock and sedatives, and was out in a few weeks."

Lues, G.P.I. (general paralysis of the insane), and Tabes dorsalis were plentiful. Our resources were pitiful, in retrospect. There people suffered with syphilis of the central nervous system and were often far advanced when diagnosed. We had no penicillin, so we subjected them to tertian malaria, typhoid toxin and temperature elevation (in a hot box) to 104-105 degrees. We also gave them fearsome painful injections of arsenic and bismuth. All of this in the effort to kill the wily spirochete of tertiary syphilis. Spinal taps were standard for almost everybody, since on some days it seemed everybody had it -- even a priest with whom I became friends. By means of various colored thumb tacks he had made a model of his private solar system on the back of his door. It was to prove Galileo was wrong and improve on Copernicus, I believe, and was ingeniously described and defended. Today he could easily pass for a paranoid schizophrenic.

Those who had been labeled schizophrenic (or dementia precox) presented more serious difficulties. Not all of them responded to EST and sedatives. Some we calmed by prolonged immersion in a hot tub, or sedated by the cold wet pack, if they were in a frenzy. Some were even doused vigorously in the Scotch Douche -- an alarming looking large shower stall with multiple nozzles at all angles, all delivering powerful jets of ice-water. One could easily describe that experience as torture -- or at least aversive therapy. But, it seemed to me, most psychiatric treatments had always been painful or at best unpleasant. The most chronic psychotics, with poor therapeutic responses in the past and a dubious prognosis, were subjected to Insulin Coma. We actually gave them enough insulin to produce coma, kept them comatose for several hours, then awakened them with intravenous dextrose, and fruit juice later. This was a hazardous procedure and I seriously mistrusted it, but fortunately we didn't kill anybody the year I worked there.

In those days the patient who came in for E.S.T. was given a gag to bite upon, then four attendants held his arms and legs against the gurney (cart) he was lying on. He would have a full grand mal convulsion, which was then thought to be necessary. At times he would also have a dislocated shoulder, a compression fracture of the spine, or a long bone fracture. In spite of, or because of all the effort we spent to hold him down? One day a diminutive little grandmotherly patient was being rolled out, tinted blue, after he E.S.T. Her doctor, who was officiating, murmured absently to himself, "Who was that little lady?" Nobody replied.

The next year my paper on the hazards of E.S.T. was published in A.I.M.S. journal (interns' and medical students' journal) and sank without a ripple.

I suspect we would also have employed prefrontal lobotomy, but nobody in New Orleans knew how. Besides, a one-shot treatment didn't appeal to a doctor's pecuniary interests. Some psychiatrists discovered they could make more money shocking patients one or two mornings a week than they could by five days of doing all day psychotherapy. I forget whether this was the second or third psychiatric revolution.

Down at the small grubby establishment known as the City Hospital for Mental Disease, conveniently located right behind the Orleans Parish Prison, an extern's life was simple: We offered no treatment at all, except heavy sedation, restraint and seclusion for the violent; and we mainly served as a screen. That is, we screened in those whom we would refer to a hospital for treatment, and screened out those who belonged next door or back on the streets. A high percentage of our clientele were brought in fresh from the steamy gutters of Bourbon Street, unconscious, some with concussion. They all got a spinal tap the next morning, and sure enough, quite a few were syphilitic and others had blood in their spinal fluid, etc., so it was just as well our transient guests did have a spinal tap. The question of patient's informed consent never even surfaced during the year 1946-47 when I worked there as an extern.

In those days I was beguiled by Freud and read some of his work. Good entertainment, but no help for your grass roots daily work with largely uneducated madmen. This is still my view of Freud's work, except my regards for him has diminished still further since he has recently been debunked so thoroughly [ see Masson et al]

Formal training by way of three years of psychiatric residency was anticlimactic after my peculiar childhood and two years in a private, then a public madhouse. Add on 4 plus years of personal psychoanalysis along with 5 years of analytic training, and what do you get? An almost middle-aged, less- than-prosperous psychiatrist trained for private practice and a little teaching.

At the same time one who is moving away from psychoanalysis anyway, and moving toward public health psychiatry -- first in the public schools of Pittsburgh for four years, then in the Mental Health Department of Alabama. Beginning at the top of this department, after four years and a vigorous booting-out by the politicians, I began working my way toward the bottom. After a five year stretch at Searcy Hospital, sandwiched in between 4-5 years each in the Montgomery and the Mobile Mental Health centers, I felt I had covered the system pretty thoroughly and could begin working gradually toward retirement.

P.S. It is not true that success is attained by starting at the bottom, working hard, and saving one's pennies. One must also marry the Boss's daughter, as a close study of Horatio Alger will reveal. Well, I was married already and the boss had no daughter. Eheu fugaces.

Your mildly shopworn,
Salvo

January 25, 1994


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