Manteno State Hospital, population 8,000, was a city unto itself, with more than one hundred red brick buildings neatly laid out over a campus of some two hundred acres. From afar, Manteno looked like a Midwest college campus. Each of the hospital buildings bore the name of a famous psychiatrist; some familiar to me, others not at all. But one name, Sigmund Freud, I knew far better than any of the others. Undergraduate college students, medical students, as well as University faculty and practicing clinicians, all thought of Freud as a creative psychiatrist whose genius distinguished him from his many peers. Needless to say, a psychiatric treatment unit at Manteno bore his name. The inhabitants of the Freud unit, usually about eighty in all, were disheveled, zombie-like creatures, each quietly trapped in a private world of hopeless insanity as he or she wandered around or sat in silence apparently waiting for who could only guess what.
     The H-shaped floor plan of the Freud building was divided into two identical wings with the crossbar of the H used jointly for dining by the patients who lived in each of the building’s two subsections. One half of the H, called Freud II, consisted of a line of three huge and stark warehouse-like rooms—a dormitory housing forty or more women, a dormitory for forty or more men, and a large connecting common room almost the size of the dormitories. Each dormitory had four identical rows of ten cream-colored, badly chipped metal beds, all in need of repainting and repair. The common area, used during the day, was furnished only with a hodge-podge of wooden chairs, a never-used untuned piano and a TV set somehow attached to the ceiling.
     Amazingly, Freud II, crowded with all of these zombie-like creatures, had just become my unit, my workplace, and, in a strange way, my new living place in another world. And all of the eighty very sick people who called Freud II their home had just become my patients.
     Although I’d had several months to prepare myself to live at Manteno, the reality I encountered on my arrival was astoundingly different from anything I had expected. No amount of reading textbooks and scientific journals can prepare you for some things. While no one had tried to describe what Manteno was going to be like, I doubt that anyone could have done it justice. My first days on Freud II, which I will describe in more detail a bit later, were a surrealistic blur. From the moment I arrived on the hospital campus, I felt dazed. And a few hours later as I entered Freud II for the first time, I thought I was looking at the world through a thick pane of glass. I frequently struggled with the urge to pinch myself to be sure this wasn’t all a bizarre non-stop dream. Here I was suddenly cast into an unbelievable role—to my complete astonishment, as if I knew what I was doing—with my own charge of seriously ill mental patients. Because of my interest in the field of psychiatry and through a determined effort I had been assigned—while a junior medical student at the University of Chicago and still with almost no training in psychiatry—to become the on-site research assistant on Freud II. What I had not been told was that by virtue of that assignment, all of the more than eighty committed patients barely living their lives on Freud II had instantly, somewhat miraculously, become my patients.
     Incredible! How could I, who had never written a real order for any patient’s care, suddenly have responsibility for a whole ward of seriously ill psychiatric patients? Wasn’t there some other doctor who worked there who would tell me what to do? No one had told me it was going to be this way. Any ward attendant’s knowledge of schizophrenia was at least ten times greater than mine. And each morning during my first few weeks living at Manteno I would awaken with a start, bolting from bed with a confused sense that I ought to be doing something—even though I did not know what it was that I was supposed to be doing. Just seeing Freud II and the patients imprisoned there was overwhelming. I felt that I was alone on another planet, inhabited by almost silent aliens who spoke a language I had never heard before or who, more likely, communicated through thought transmission.
     I know that sounds a little crazy, but it gives a flavor of how lost I felt.
     Fortunately for me, I had Esther there to guide me. She was a kind, mid-forties matronly person who took me under her wing from the first day I arrived on Freud II. She seemed to have all of the answers to almost everything. Esther was a vibrant person, very much in the real world, animated, beaming, and authoritative. While she was designated as the Freud II unit secretary, she actually ran the place. The attendants, whose job it was to take care of the patients, took their orders from Esther. And it was Esther who patiently answered most of my questions about how things worked on Freud II. I was grateful that she seemed happy to share her treasure trove of information with me. She told me about each patient and the cast of characters involved in that patient’s care. Esther was the one who explained to me most of the procedures involved in the day-to-day operation of the unit.
     After my first few stunning days of trying to become used to this bizarre new world, I began to wonder what went on in the rest of the one hundred red brick buildings that comprised the campus of the hospital. Were they all like Freud II? Seen from outside, the whole hospital complex appeared thoughtfully designed, a planned city, its buildings functionally arranged in rows that were both efficient yet peaceful and appealing to the eye. Each morning as I walked from the doctor’s residence hall to Freud II, I puzzled over what was going on in each of the buildings I passed. While most of the buildings appeared alike, I knew that the apparent uniformity of the outsides was deceptive. My Freud II staff told me that what went on inside the many buildings differed significantly from one to the next. Some were for certain kinds of patients. Others were for specific types of treatment.
     Day by day my curiosity grew. I felt a growing need to find out what went on in those other units. It was more than idle curiosity. I reasoned that if I knew what was going on inside those other buildings, I could gain some perspective to help me understand how Freud II fit into the universe of mental health treatment, or at least the universe of psychiatric treatment as provided here at Manteno. How were the other units so very different from Freud II? What kinds of treatment were going on?
     Toward the end of my first week of getting used to life on Freud II, I queried Esther about taking a tour of the rest of the hospital. She was surprised at my request. She acknowledged that the other units were quite different from Freud II, or so she thought, though she couldn’t exactly explain how the other units differed. She had worked at the hospital for more than six years, yet she herself hadn’t seen the insides of most of the other buildings. She knew that no one ever visited the other hospital treatment units, and pointed out that no previous research assistant had ever even asked to visit them. Esther was unclear as to why visiting was prohibited. It had just never occurred to her to question why no one ever was allowed to visit the other Manteno treatment units.
     Finally, as a result of my nagging, she reluctantly called the hospital superintendent, Dr. Chermak, to help me gain access to the other units. Dr. Chermak’s secretary was a road block who immediately refused Esther’s request. The secretary firmly reminded Esther of the hospital policy that the patients on the other units were not to be disturbed by outside visitors. Esther then relayed my plea that I was not just any outside visitor, that I was the research assistant to Professor Nathan Apter from the University of Chicago, and that I deserved to be exempt from the hospital no-visit policy, even if only for a single day. Pulling rank had some effect, and the matter was referred to Dr. Chermak. A day later Dr. Chermak’s secretary called Esther, grudgingly granting permission for me to see some of the other hospital buildings. She gave Esther a list of ten or so units that I could visit. As far as I could tell, that sounded like an adequate number.
     I awoke extra early on the morning of what I didn’t know would become a day that would change my life. The darkness outside did little to dampen my enthusiasm. I was very excited and couldn’t fall back asleep. I put on my shirt and tie and my white coat, itself a badge that I was a member of the medical staff. While I didn’t have a clue as to what I was about to see, I knew it was going to be different than anything I had read or could even imagine, even more strange than life on Freud II. I was so ignorant and bewildered about what was going on out there. But I was hopeful, and I expected to learn a good deal. There was great comfort in knowing that my visit to each of the units on my list had been announced to the attendant staffs by Dr. Chermak’s secretary. It would be like having instructors or tour guides at each of my stops. Or so I thought. I couldn’t have guessed that I was about to begin a hospital horror tour, a day when I would be exposed to incredibly ghastly sights in real life. The first building on my tour list was the “men’s combative unit.” Shouldn’t the name itself have alerted me? But I was too naïve to be suspicious of what I was to encounter. To my surprise the two attendant staff members who met me at the door were not the least bit friendly. Where were my smiling tour guides? In fact they were ugly characters, both suspicious and surly. They didn’t have a clue that I was coming to visit. Dr Chermak’s secretary had wreaked her revenge for having had her authority over-ridden by “forgetting” to let anyone know I was coming. To address their hesitation to even let me into the building, I had to explain who I was and why I was there. My white coat did little to reassure them that I had a legitimate claim to visit. They clearly didn’t believe me. It struck me that they thought I was there to spy on them and report back to Dr. Chermak about their performance deficiencies.
     Meanwhile, the staff was the least of my surprises. The locked door on the face of this attractive red brick building opened onto a non-stop riot. I was immediately bowled over by waves of the stench of stale sweat and deafened by the din of shouted obscenities and screams from everywhere in the unit. The inside of the building was identical to the large gray warehouse I had discovered at Freud II, but was much more crowded. Its nearly two hundred tightly packed residents all wandered around aimlessly. For no apparent reason other than their proximity to one another, fights between patients broke out every few minutes. A squad of husky attendants could be seen flying to break up some—but not all—of the fights. The attendants were amazingly skilled, and they worked as a disciplined team with set team member assignments to subdue patients and prevent injury. Fights calmed as quickly as they had started, often with minimal attendant intervention. It seemed to me that at least half a dozen fights were ongoing at any one time, many of which the attendants seemed to ignore.
     An attendant told me that occasionally someone was seriously hurt, and that some patients had died as a result of injury. But major injuries or deaths were rare. Patients with prolonged violent behavior were commonly transferred to another building for yet more intensive treatment. Later in the morning, I was to see first hand what that actually meant.
     No one ever came here to visit, the attendants angrily explained, suggesting that I had violated a sacred code, and that I, myself, was crazy to do so. I interpreted their comments as a warning that my safety was at stake. Perhaps they were right. But, uncomfortable as I was, I couldn’t wimp out now. Despite their gross displeasure at my presence, in response to my repeated requests to be shown around, three of the attendants escorted me through the unit. As we walked, a number of screaming, raging men unpredictably ran up fully intending to attack us, but then were expertly repelled by the attendants. Although they hated my being there in the first place, I was suddenly grateful that the attendants shielded me. Nothing touched me beyond a barrage of foul language. Twenty minutes later I escaped from the unit unharmed, but not without my heart pounding and my eyes as wide as saucers. I actually thanked the attendant staff for showing me around. In my head I was confused at thanking people who apparently hated me yet seemed to be saving my life. Was this for real? I was immensely relieved when the door closed behind me, and I felt safe again although shocked and bewildered. I had to wait a few minutes to calm down.
     Next on my list, just a few buildings away, was the “women’s geriatric unit.” The locked door was opened a crack by an attendant who, while less hostile than those on the previous unit, seemed puzzled at my presence. Even before I could explain who I was and the purpose of my visit, I was overwhelmed by the sickening smell of urine and feces. When the door to the unit finally swung open, there before me was a sea of beds, each occupied by a frail, obviously malnourished elderly woman. Some of these women were in restraints. Most were dressed in hospital gowns. Some had torn off their gowns and lay naked on their beds. Unearthly demented shrieks, cries, croaks, and groans made me feel I was not in the presence of human beings but of strange witch-like creatures. These patients were still alive, but seemingly their souls had departed from what was left of their bodies. I wanted to turn around and run away. But I didn’t. I reminded myself that I was a doctor in training, and that I must learn what I could, no matter how horrible it was.
     An attendant on the unit told me in a very matter of fact way that all of these people were waiting to die, and that all would die fairly soon. And then others would be admitted to take their places. He wasn’t sure where they came from, only that they kept on coming. No one ever got better. No patient from this unit was ever transferred to a medical unit for treatment if her condition deteriorated, which invariably, eventually, it did. Twenty to thirty patients a month died on this unit alone, some within a few days after they had arrived. An equal number died on the men’s geriatric unit next door. It was a rare day when someone on the unit didn’t die. The attendant staff made some effort to clean the patients, change their linen and give fluids— either water or a thick milk-like drink. The staff knew—and I soon figured it out—that these were token efforts at patient care.
     When finally I looked back over my shoulder at the lovely red brick building I had just left, I couldn’t believe what I had just seen inside. I felt numb and weak, detached from everything. I wanted to crumple into a soft comforting chair, turn on some music, reach for a romance or adventure novel and pretend this wasn’t real. I needed to declare that I had seen enough, that my tour was over. But my mind couldn’t turn off the pictures I had just seen. With horrible images at every turn, this was some kind of a nightmare movie on an endless loop. I recalled some newsreel footage I had seen as a kid showing Allied soldiers liberating a concentration camp. The skeletal images with glazed eyes that did not blink, the announcer explained, were still alive but were beyond hope.
     I stood still for a few minutes to try to recover. What happened when these patients died? I looked over to another building a few hundred yards away. Its fifty foot smoke stack revealed that it must be an incinerator of some sort, cremation probably being one of its functions. Did the attendants move the bodies by day, or did they wait till nightfall? I envisioned laundry carts loaded with dead bodies being trundled off to the crematorium, like the death carts during a medieval plague. I guessed that when patients died, social workers sent out notification letters. The families may have forgotten who the patients were, or perhaps had moved far away—emotionally if not geographically. Perhaps, driven by shame, guilt, or frustration, they had wanted to forget, even to hide the existence of their mentally ill family members from other family and friends. Probably most of the Notification of Death letters were returned to the hospital as ‘undeliverable’. Were the notices ever sent early—when the barely live patients had become mere remnants of people? Once they died, they became names and numbers on a list filed someplace in a drawer that was never again opened. It was as though they had never existed.
     I pressed onward to another somewhat larger building that housed some of the more “intensive treatment” units. I didn’t even know what that meant, but Esther had told me that it included a unit for the administration of electric shock treatments. I’d read someplace that electric shock treatment was like kicking a Swiss watch to make it work. No one really understood it; yet it had been demonstrated to be effective in treating certain types of serious mental illness. From hearing about it and reading about it, shock treatment sounded barbaric. But I needed to see for myself what it was really like.
     I arrived at the electric shock unit in time for the morning treatments. I had never seen any kind of a grand mal epileptic seizure before, let alone an artificially induced convulsion. Dr. Asher, in charge of the unit, looked short and smug, his face a frozen smile. He asserted that electric shock treatment seemed to help most people whether they were schizophrenic, manic, or depressed. In clipped, precise words he added that it was also good for sociopaths, obsessive-compulsives, disturbed adolescents, and alcoholics—just about everyone with any kind of problem. In essence, he explained that electric shock treatments worked by confusing people, and that this confusion enabled them to forget their troubles. Asher made such extravagant claims that I could hardly believe anything he said. Except I could see he was in dead earnest. He proudly boasted that his delivery system enabled him to give seventy shock treatments in an hour and a half. He said I was lucky and would get to see his system in action. Next to us a line of expressionless patients, both men and women clad in gray pajamas, stood in silence as they faced a hospital gurney. All seemed resigned to whatever was to be their inevitable fate. Asher stood at the head of the gurney. A small black box lay on a table to his side. He held what appeared to be a pair of ice tongs attached by wires to the black box. At Asher’s command, the first patient in line climbed onto the gurney like a well-trained dog jumping onto a familiar couch. Without another word, the next four patients came forward two on each side of the gurney. They covered the patient on the gurney with a sheet and held down the corners, flattening the patient to keep him or her from wriggling. Asher then placed the tongs on each side of the patient’s head and pressed a button on the black box.
     Suddenly the patient emitted a loud whooping noise, stiffened up with an arched back and began a series of rhythmic, jerking movements which the other patients attempted to dampen by pulling on the corners of the covering sheet. The patient did not breathe during the convulsion, and his color changed from red to blue. I thought he would never breathe again. But finally he did, and after a few more minutes his normal color returned.
     Holding the patient down, Asher explained, helped reduce injury to the neck or back during the course of the treatment. Injuries had been common prior to this attempt at seizure modification, and the induced convulsions were severe enough to produce spinal fractures. The treated patient now looked bewildered but awake. On Asher’s signal, the four attending patients rolled the gurney out of the treatment room to transfer the patient onto his bed in another room. The team of four helpers then returned with the empty gurney. To my surprise one of the four helpers climbed onto the gurney for her treatment, while the next patient in line took a place on the helper team. I watched half a dozen treatments.
     Impulsively I asked Asher if I could have a shock treatment “just to get an idea of what it is like.” What in the world was I thinking? Asher seemed to give my request more serious consideration than it deserved. But finally he declined, commenting slowly, “Perhaps that isn’t such a good idea.” Instantly I realized that I had made a preposterous request, even a dangerous one, and I felt like a fool. I could envision the whole medical staff, plus Dr. Chermak and Dr. Apter all hearing about my inane statement and having a good laugh. The well-respected Nathan Apter, Professor of Psychiatry at the University of Chicago, might have second thoughts about having chosen me as a research assistant. This underscoring of my stupidity made me feel yet more fragile and uncertain than I’d felt every day since I had arrived at Manteno. Wondering what dumb thing I would do next, I resolved to try to at least appear a little more composed, even though it would all be a pretense on my part.
     My next stop was the colonic irrigation room. “High colonic irrigation is used to wash out the poisons that cause schizophrenia,” the attendant explained. I wanted to laugh out loud at the absurdity of his pronouncement. But he was dead serious. His voice had a ring of intense certainty, the kind of certainty necessary for someone who has no facts or solid information and who is reciting a carefully memorized slogan. No one was being flushed at the time of my visit, though I was told that the treatments were being given daily. The frequency of treatment for each patient was prescribed by the unit doctor and ranged from two to four times per week. The unit itself contained five minimally screened tables, each with the necessary tubing and plumbing. The toilets were in an adjacent room. I was not disappointed at having missed the colonic treatments of the day. Even imagining a group of people simultaneously receiving mega-enemas and evacuating made me feel nauseous.
     In another area of the same building I discovered that what was called the “Scotch Douche” treatment had nothing whatsoever to do with douches. “This treatment gets rid of the devils and demons in the patient’s brain,” explained the husky attendant who proudly regarded this unit as his special place. As he talked, I could only think about how all of the attendants seemed to look alike—Caucasian, mid-forties, big, slightly overweight.
     The Scotch Douche room at Manteno looked like a parabolic curve lined with grey tile. At one end of the room four high pressure fire hoses were securely attached to floor-to-ceiling metal posts. At the other end of the room was another floor to ceiling pillar. Here extremely violent patients were tethered while they were sprayed by streams of water from the high pressure hoses. The idea was that up to several hours of high pressure hosing would leave the once violent patient exhausted and much more manageable. “It always works,” the attendant happily boasted.
     While I was getting my lecture from the attendant, the door to the room burst open, admitting two burly attendants dragging a large man, thrashing and screaming, struggling against the straight jacket that bound his arms to his body. His wild kicks at the attendants didn’t come close to landing on their targets.
     Within almost no time at all, he was tightly secured to the metal post at the end of the room opposite the fire hoses. Aimed directly at him, the hoses were turned open full blast, and high pressure streams of water hit him from different angles. Assaulted by forceful torrents, he cursed and threatened for a minute or two and then began screaming and moaning. After a very long five minutes he slumped to the floor, now a silent and limp rag doll.
     This patient, I was informed, had committed the unpardonable sin of injuring an attendant. And according to the injured attendant’s coworkers, he would have to pay the price for it. After a five minute interval the hoses were turned on again even though the patient appeared to have become docile.
     It may have made difficult patients more manageable, but I realized that this inhuman procedure was not treatment. This was torture! Part of me didn’t want to believe such things could really be taking place. But it was happening, right there before my eyes! I wanted to scream! I wanted to report all of this to some authority to get it stopped—maybe even call the police. Yet there was no one at the hospital, or perhaps any place, to whom I could protest or appeal. Even if I had tried to protest to Dr. Apter or Dr. Chermak, it wouldn’t matter. No one, I soon realized, would listen to me anyway. When it came to the mentally ill, Manteno was the authority.
     I’m not sure how I got to the next room. My legs felt paralyzed, and I had no sense of walking. Was I actually floating? It was a stupid idea, but it gave me the comfort of a momentary distraction.
     This room, tiled in gray like the others, contained sixteen oversized bathtubs—each covered by a canvas secured by ropes attached to the sides and bottom of the tubs. In each canvas the head of a man or woman protruded through a hole. No one seemed to care that the men and women were being soaked in the same room. In these circumstances gender didn’t matter. Above the loud sound of running water came occasional cries, shrieks or curses. I couldn’t make out the words. What I heard was more like a discordant chorus of groans.
     I was disappointed that Dr. Kalkhofen, the unit chief, wasn’t there. In his absence, one of the friendlier unit attendants offered an explanation of the procedure: “They come in wild—screaming and cussing and all trussed up in leather. The cold water calms them down. They stay in leather for a few days after they get here.” Patients were taken out of the tubs at night and returned to the tubs in the morning. They received hydrotherapy for anywhere from a week to a month. Remarkably, it seemed to work. If patients had been violent and raging when they were first put into the tubs, after a time they seemed to lose all of the energy that had gone into their raging. Even for those who still had some fight in them, the sounds of running water drowned out most of the noises they made. I was trapped watching the likes of a Frankenstein movie that I had seen at a cheap near-campus movie house. In this horror film, however, there was nothing to separate me from one grisly scene after another. Clearly this was not entertainment, and there was no happy ending. And I couldn’t just leave the theater to get back to my real life as a college student on campus. Manteno had now become my real life. Next door to the hydrotherapy room was the “wet pack” room. Because the room was so very quiet, I felt like I should be tip-toeing along instead of walking. Here approximately fifteen blue-gray-looking pajama-clad men and women were strapped to tables with leather restraints.
     They all looked dead. Was I in a morgue? A year earlier I had visited the morgue at Cook County Hospital, where the previous night’s crop of dead bodies, mostly harvested from the streets, lay waiting to be cut up by the feelingless pathologist.
     This place didn’t seem much different. Coldly professional attendants mechanically covered each patient’s body with cold packs. The patients were then further covered over by the same gray canvas cloth I had seen earlier. Every few hours the cold packs were changed. This was another form of treatment used to reduce violent behavior. No attendant on duty at the time seemed to know why certain patients were given the cold pack treatment while others were sent to the hydrotherapy tubs.
     I was overjoyed to leave what could only be called a torture factory. Once outside the intensive treatment building I breathed some fresh air. I stopped for a few minutes to settle down and regain my pretense at composure. I had to keep acting the way I thought a doctor should be acting, interested and analytical. By now I truly dreaded continuing my tour. But I had to see as much as I could, whether my heart burst out of my chest or not. I had to learn whatever I could! I kept going, and the nightmare continued. Another red brick building contained the insulin coma unit. Dr. Lowell was a pleasant young physician, someone I had never seen in the medical staff dining room. She explained that she lived off the hospital campus but came daily to supervise insulin coma treatment and to attend patients on the acute medical unit. Unlike the strange cast of characters posing as medical staff who lived in the doctor’s dorm, she seemed like a real person with whom I could talk. At the insulin treatment unit there were mostly women in various stages of coma, all of whom had been given injections of large doses of insulin earlier in the morning; the patients occupied all of the twenty beds. I had studied about insulin coma treatment, but had never seen anyone in a coma before. Lowell was kind enough to teach me about it. Yet for all her willingness, it was not easy for me to concentrate. While she calmly described different coma levels, in the background many of the comatose patients were experiencing one epileptic seizure after another.
     The seizures were the result of the injected insulin precipitously dropping patients’ blood sugar levels to the point where they went into coma. What amazed me was that in any other setting coma or repeated epileptic seizures, called status epilepticus, were seen as urgent medical emergencies demanding immediate, intensive treatment. Yet Lowell paid no attention to the nonstop perilous seizures going on around her. Here at Manteno, I realized, these dangerous events were considered desirable. It was a treatment that required a patient to visit the outskirts of death itself. In my mind I began hollering and arguing. It was all so backwards, almost as though from an earlier age. This was the twentieth century version of Bedlam. Was I the one who was crazy? My anxiety and confusion must have shown. When I talked to Dr. Lowell, all that came out of my mouth was a shaky-sounding question about the possibility that some patients in status epilepticus might die. Lowell patiently insisted, however, that there were very few deaths from the procedure: “Perhaps one-to-three percent,” she said. I was stunned. While she was calmly trying to reassure me, she was actually confirming my worst fears. How could a procedure with a one to three percent mortality rate be considered an acceptable medical practice? Later, in a review of the psychiatric literature, I would discover that this disturbing mortality rate also occurred at other large state mental hospitals throughout the United States.
     If a patient did not become sufficiently comatose or failed to experience seizures, a higher dose of insulin was injected the following day. For young women with acute paranoid schizophrenia, Dr. Lowell reaffirmed, insulin coma was the treatment of choice. Many of this group responded dramatically, she explained. They became less paranoid and delusional; and over time, she emphasized, many returned to reality. Most patients received a series of fifty treatments—fifty brushes with death.
     Some precautions were taken. An energetic nurse walked briskly around the unit quickly and confidently, shoving a large tube into the mouths and down into the stomachs of some of the comatose patients whom she had judged were seizing too much. She poured a thick, syrupy fifty percent glucose solution into a funnel at the upper end of the tube. After a few minutes, the patient’s epileptic seizures diminished in frequency and finally stopped. At the end of an hour in coma, all patients were tubed and given the syrupy solution to elevate their blood sugar levels. I watched a few patients begin to sit up and stare quietly around the room in a confused way. They truly seemed as though revived from the dead. I felt relieved. It was, indeed, like watching one of those old zombie movies, only this time the movie had come to life and I was in the middle of it.
     Dr. Lowell and I then walked into the catatonic feeding room next to the insulin coma treatment unit. Patients with catatonic schizophrenia were stiff and mute. Some with catatonic schizophrenia did not eat or drink; if left to nature, they would die of dehydration or starvation. In the catatonic feeding room I watched a nursing staff attendant push a cart with a five gallon jug full of a milky fluid from one bed to another. Painfully thin, silent, catatonic patients in various grotesque postures lay in every bed; crumpled, emaciated mannequins each staring into another world. In a procedure similar to what I had observed in the insulin coma unit, thick rubber tubes were forced into each patient’s stomach. The milky fluid was poured into funnels at the top of the tubes. I was happy to see that no one was drowning as a result of an incorrectly placed tube pouring fluid into a patient’s lungs rather than into his or her stomach. After a feeding of only a few minutes the tube was withdrawn and the cart moved on to the next bed.
     Catatonic patients were fed twice daily. I left the unit wondering if each patient got a clean feeding tube; or whether the same tube was used for everyone. Just the thought made my own stomach knot up. I needed my hospital tour to end. I had long ago passed a state of sensory and emotional overload. Looking down at my list, I took dim comfort to see that I had only one more unit to endure. I mechanically stumbled toward my last stop.
     The last stop on my tour was far less upsetting but almost equally bizarre. All patients at Manteno who had a diagnosis of tuberculosis were segregated and quarantined to one special unit. The layout of their unit was the same as the configuration of Freud II, two large dormitories with a day room in between. But here the crowd of some one hundred patients milling around was more boisterous and more active than my Freud II patient group.
     I was told that many of the tuberculosis patients were receiving the new antituberculosis drug, Marsilid, which really seemed effective in arresting their lung disease. However, it also affected their behavior. The patients grew more alert, sleepless, irritable, happy, silly, and possibly more psychotic.
     As I walked through the unit, I was struck by the way people chattered at one another in nonsensical conversations. Some chattered at me, and then bounced away without expecting a response. It was just as well. By now I was feeling numb and couldn’t answer anyway. I felt like I was attending a very noisy cocktail party where everyone else had had too much to drink. The Marsilid this group of patients received to treat their tuberculosis was the first monoamine oxidase inhibitor drug in common use, later to be recognized as a family of powerful antidepressants. But at that time we did not think much about antidepressant drugs. It was as though using drugs to treat depression was a foreign concept to us. Depression seemed to be such a minor illness compared to the devastating catastrophe of schizophrenia.
     When I finally got back to Freud II, I was emotionally drained but incredibly relieved that my tour was over. Freud II, even though a part of Manteno, now looked great compared to what I had seen. For the first time, I noticed the streams of light coming through the windows into the gray caverns of the warehouse that now felt like my home. Here was Esther, smiling at me the way my mother had greeted me when I got home from grade school. The Freud II patients, as crazy as they seemed to be, suddenly appeared as models of mental health being treated in a civilized, humane way. I began to experience warm feelings welling up inside me along with a greater sense of acceptance that the Freud II patients were my very own patients. They needed my help and my protection from the gruesome torturers masking as treatment staff in other parts of the hospital. My efforts might actually make some difference in their lives. Not only was I going to protect them, I was going to help at least some of them to get well. I clung to this soothing feeling. Esther asked if I had learned anything on my tour. “Yeah,” I said. “It was great!” I knew I was lying, but I didn’t have the strength to get into what had really happened.
     This had truly been one of the most remarkable days of my life. A few hours later I slowly walked back to my room in the medical staff building to rest and regroup. I couldn’t face the medical staff in the dining room that night. Besides, the idea of eating was far from my mind. Lying in my bed had much more appeal. I had seen first hand what I could not have dreamed existed. It all felt unreal. Perhaps it was then that the idea of a diary of Manteno crossed my mind— to help me to remember, to help me to organize my thoughts, to help me to plan, and to help me recover. I got up and began to write.
     That night, as on many nights thereafter, I wrote for a long time. I was so eager to record everything I had seen, what I had learned, and to raise questions for myself about what different things meant. As I wrote, I tended to obsess about what I planned to do the next day or on other days to reach my goal of helping some of my patients to improve.
     There was little sleep the night after the horror tour. When I did sleep, I dreamed I was being pursued by some crazed maniac who held tongs or an ice pick or a butcher knife—I wasn’t sure what—as I ran down a dark unlit corridor with a wall straight ahead of me. There was no way out for me, either.
     On Friday, riding back to Chicago with Jim Sachs, a psychology grad student, I tried to talk about everything I had seen. Of all people Jim should have been the one most likely to have had a similar experience, the one who could really understand. Jim provided my transportation to Manteno on Mondays and back to my apartment on the weekends. Although he did psychological testing on some of the Manteno patients, his job was in an office in the administration building, and the patients brought to him were those few in sufficiently good condition as to be able to cooperate with psychological testing procedures. Except from a distance, Jim did not see the very sick patients I had seen. He explained that during the eighteen months he had been working at Manteno, he had never had a tour even remotely resembling mine.
     My patients and the others I had seen were not nearly as healthy as Jim’s, yet I was surprised he did not appear to grasp what I was telling him. He shared a part of my experience, yet was ignorant as to what was going on in most of those red brick buildings. He was so close to what was going on; yet he knew so little. He had never asked to look behind the stage set building fronts to see the ugliness inside. And if people like Jim in the psychiatric profession had practically no sense of what was going on in those red brick buildings, how much would the general public be likely to know, or care.
     Back in Chicago that evening I couldn’t wait to get to Jimmy’s, my favorite off-campus bar for endless hours of fun. Over my years as a college student, I’d had countless numbers of happy times at Jimmy’s. Jimmy himself tended bar. I liked him, and he had always been kind to me. He was an astute judge as to which under-age college students he could serve without risking trouble with the law. Jimmy, along with a group of my friends all welcomed me this time, just as they had on countless other occasions. Art, Lynn and Harry, all students in other areas of study, had been my friends for years. They knew how much I had been looking forward to my first week at Manteno, and they were curious about what had happened. At first they clustered around my table waiting to hear the story of my first Manteno week. And I was more than eager to tell them about it. In fact I couldn’t stop talking about it. But after a few minutes of my relating what I had seen, Lynn went off to the rest room and then settled at another table, making no effort to return. Art looked puzzled and then made some nervous and grossly inappropriate jokes. He then remembered some minor chore which gave him the excuse to flee. Harry politely listened the longest, but before long his eyes looked glazed; I could tell he really wanted to be anywhere but listening to me.
     I began to feel as though I were talking to myself. There was no point in my continuing. I didn’t blame any of the others for lack of interest or understanding. How could I fault my friends for becoming uncomfortable when I tried to get them to listen to me? It was no wonder that they wanted to flee. What I was describing to them, in horrible detail, would have been equally inconceivable and equally upsetting to me only a week earlier.
     As always at Jimmy’s bar, people milling around me were laughing, joking, and drinking. Tonight I was not one of them. Nothing anyone else said sounded funny or interesting and a few beers didn’t help. A thick glass wall separated me from the others around me. I left Jimmy’s early and went back to the quiet of my apartment. Usually I listened to music. But tonight I seemed to want no distraction from the audiovisual tapes in my head, all playing the events of my first week at Manteno.
     A girl I barely knew came over later, announcing she wanted casual sex. She made it clear she didn’t want to talk much about anything—especially my week at Manteno. But I wanted to talk, and Manteno was all I wanted to talk about. Her mind was in a very different place. We squabbled, and she left in an unhappy mood.
     Over the rest of the weekend I didn’t leave my apartment. I was preoccupied by mental replays of everything I had seen. Any form of music or anyone talking seemed loud and irritating. My answers to all of my friend’s phone calls were terse and perfunctory – even rude. I was unaware of being hungry, but I mechanically ate cold cut sandwiches or stuff out of cans. It was as though I wasn’t really there. Part of me was elsewhere – back at Manteno – with visions of an unreal world and a heavy feeling that an enormous, ill-defined task lay before me. What was I doing, and what had I gotten myself into? Yet I couldn’t envision trying to back out.