Mario and Nikolas

Recently I’ve been thinking a lot about a patient I’ll call Mario. He was a ministerial employee, happily married, and totally nuts. Under his façade of normality lay a vast web of paranoid delusions that linked his family, the Church, and both Cold War antagonists in a delicate equilibrium. All through the 1980s I prescribed antipsychotic medication under supervision, and he did just fine. But when the Berlin Wall fell in 1989 the web no longer held, the balance wobbled, the web fell apart, and Mario snapped. He first confessed vague violent fantasies, then disappeared from treatment, only to resurface in prison, after stabbing his cousin.

What reminded me of Mario in these last weeks was the rather similar story of Nikolas Cruz, the Parkland, Florida mass murderer. Both were deeply disturbed, both were armed, both were obsessed with fantasies of violence, and in both cases outside events – in Cruz’s case the death of his mother, in Mario’s the end of the Soviet empire – cut whatever inner restraints had prevented acting on those fantasies. What made the difference between one man wounded and 17 teenagers dead was the weapon: Cruz carried an AR-15, Mario a kitchen knife.

Nikolas walked into a Florida gun store, passed the laughable instant background checks, and walked out with his gun. In Italy you can’t buy a pistol, or carry any firearm on the street, without a license (porto d’armi) issued by the police.What you need to get that license:

1) A specifically authorized specialist physician (not me, and not your own General Practitioner) must certify your mental health. So much for Mario or Nikolas.

2) A specifically authorized physician must certify that you have no visual, hearing, or other physical problems that would interfere with proper use of a firearm.

3) You must have a clean criminal record, with no history of violent crimes or restraining orders.

4) You must not be an army deserter or a conscientious objector.

5) You must have had proper training in gun use and safety, either in the army or a certified two-month civilian course.

6) You must provide a list of all the people you live with.

7) You must demonstrate a specific reason for being at high risk of violent attacks – owning a jewelry shop or working as a security guard will do. Few people meet the test, and certainly not Mario or Nikolas.

You have to reapply for your carry license every year, and you can only own 200 bullets at a time.

If you only want a weapon firearm for sport* or hunting the process is easier – you can buy a few shotguns on the basis of just criteria one through six, with a license good for six years. But by law you have to report every acquisition of a weapon or ammunition to the police within three days. You must also store your guns in such a way that children, thieves, and household members who are mentally ill, alcoholics, or drug addicts can’t get hold of them; and transport them to and from the shooting range or game reserve unloaded and locked away. If a family member goes to the police about fights at home, the cops will come take away your guns.

Moral of the story: there are one tenth as many guns in Italy per capita as in the US. And one tenth as many gun deaths, even if you include suicides, accidents, and the Mafia.
*A reader has pointed out that air guns used for target practice can be purchased without a license.

entrance of my conference hotel in Louisville last week

Can’t Stop Talking About Italy…

The same Expatclic website that kindly featured Stethoscope On Rome as their Blog of the Month at the beginning of February has now published a nice interview with me about my life in Italy. The questions from an Italian woman living in Indonesia were very thoughtful, so it was fun to think about them and come up with answers. If you’re interested, you can read the whole interview here.

Foreskin Follies

I grasped his penis with both hands.

Urine was spraying into the air, while my fellow-intern at Morrisania Hospital in the South Bronx stood by holding a bladder catheter ready for use. Water retention due to heart failure had poor Mr. Jones’s body so swollen from the waist down that the business end of his urinary system was buried in edema, and the high-dose diuretic we had shot into his vein only made matters worse by turning him into a human fountain. My job, which I confess was complicated by spasms of laughter, was to squeeze away the excess fluid from his foreskin so my similarly incapacitated colleague could have a chance at finding the hole.

This may have been the only time I laughed out loud in three years of hospital duty as a resident specializing in internal medicine. A more typical form of emotional self-expression was crying in the stairwell.

We eventually managed to get the catheter in, stop giggling, and retire to our on-call rooms for a few hours sleep. It was only at morning rounds, presenting the case to our team, that we caught on to what was really going on with Mr. Jones. His problem lay as much in his isolation as in his heart: for weeks, while his legs ballooned progressively from human to elephant proportions, he had been holed up in his single-room-occupancy digs without any human contact, before his landlady happened to knock at his door, see the state he was in, and call an ambulance.

During my medical training in 1970s New York City we saw patients like that all the time, so bereft of social connections that they could slide downhill toward end-stage disease, or into the grave, without anybody pushing them to seek medical care. I’ll never forget one 17-year-old heroin addict, infected by a dirty needle, who lay in septic coma for five days on the floor of her studio apartment, before a sister chanced to stop by just in time to save her life. In Italy, where as Luigi Barzini said the only fundamental institution is the family, a teenager would never be abandoned like that to her own resources. Here, even junkies bring their dirty laundry home on Sunday for mamma to wash.

*****

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