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This volume owes a large debt to Dr. W. R. Houston, formerly Clinical Professor of Medicine in the University of Georgia School of Medicine, now of Austin, Texas. As my first teacher in psychiatry and still as a bracingly honest critic and a skeptical but always heartening guide, Dr. Houston's uncommon learning in many fields and his kindness have been an important support.

Most of all it is my pleasure to thank Dr. V. P. Sydenstricker, Professor of

Medicine in the University of Georgia School of Medicine, whose genuine human qualities no less than his specific achievements in medicine and his remarkable energy, have encouraged, year after year, scores of less seasoned and sometimes groping colleagues to do sounder work and to find joy that is the stuff of life in even those daily tasks that would in another's presence become mere routine. Real wisdom joined with real humor cannot fail to be expressed in a rare and discerning kindness. These qualities, all in full measure, have done more not only to deal with illness, but also to reintegrate at happier and more effective levels those who have worked with him than their possessor can realize. It is indeed difficult to express fairly the gratitude which informs this writer in mentioning the constant encouragement, generous help, and the major inspiration that have come from Dr. Sydenstricker to the Department of Neuropsychiatry.

HERVEY CLECKLEY Augusta, Georgia, 1941

1 Sanity-a protean concept, 3 2 Traditions that obscure our subject, 10 3 Not as single spies but in battalions, 17 4 Method of presentation, 20

SECTION TWO --- THE MATERIAL PART I -- The disorder in full clinical manifestations

5 Max. 29 6 Roberta, 46 7 Arnold, 5 8 Tom, 64 9 George, 70 10 Pierre, 7 1 Frank, 93 12 Anna, 102 13 Jack, 121 14 Chester, 127 15 Walter, 136 16 Joe, 146 17 Milt, 159 18 Gregory, 167 19 Stanley, 174

PART I -- Incomplete manifestations or suggestions of the disorder

20 Degrees of disguise in essential pathology, 188 21 The psychopath as businessman, 193 2 The psychopath as man of the world, 196 23 The psychopath as gentleman, 199 24 The psychopath as scientist, 203 25 The psychopath as physician, 205 26 The psychopath as psychiatrist, 208 xiv CONTENTS

SECTION THREE --- CATALOGING THE MATERIAL PART I -- Orientation

27 Conceptual confusions which cloud the subject, 225 28 Clarifying the approach, 237

PART I -- A comparison with other disorders 29 Purpose of this step, 244 30 The psychotic, 245 31 Deviations recognized as similar to the psychoses but regarded as incomplete or less severe reactions, 248 32 The psychoneurotic, 256 3 The mental defective, 259 34 The ordinary criminal, 261 35 Other character and behavior disorders, including delinquency, 267 36 A case showing circumscribed behavior disorder, 272 37 Specific homosexuality and other consistent sexual deviations, 286 38 The erratic man of genius, 293 39 The injudicious hedonist and some other drinkers, 306 40 The clinical alcoholic, 312 41 The malingerer, 316 42 Fictional characters of psychiatric interest, 316 43 The psychopath in history, 326

PART I -- A clinical profile

4 Synopsis and orientation, 337 45 Superficial charm and good "intelligence," 338 46 Absence of delusions and other signs of irrational thinking, 339 47 Absence of "nervousness" or psychoneurotic manifestations, 339 48 Unreliability, 340 49 Untruthfulness and insincerity, 341 50 Lack of remorse or shame, 343 51 Inadequately motivated antisocial behavior, 343 52 Poor judgment and failure to learn by experience, 345 53 Pathologic egocentricity and incapacity for love, 346 54 General poverty in major affective reactions, 348 5 Specific loss of insight, 350

CONTENTS xv

56 Unresponsiveness in general interpersonal relations, 354 57 Fantastic and uninviting behavior with drink and sometimes without, 355 58 Suicide rarely carried out, 358 59 Sex life impersonal, trivial, and poorly integrated, 359 60 Failure to follow any life plan, 364

PART I -- What is wrong with these patients?

61 A basic hypothesis, 367 62 The concept of masked personality disorder or defect, 376 63 Further consideration of the hypothesis, 388 64 Aspects of regression, 397 65 Surmise and evidence, 403

PART I -- What can be done?

6 Illness and misconduct, 416 67 Legal competency and criminal responsibility, 420 68 Treatment or control, 433

Section One ~ ~ AN OUTLINE OF THE PROBLEM

1 Sanity-a protean concept, 3 2 Traditions that obscure our subject, 10 3 Not as single spies but in battalions, 17 4 Method of presentation, 20

A millionaire notable for his eccentricity had an older and better balanced brother who, on numerous fitting occasions, exercised strong persuasion to bring him under psychiatric care. On receiving word that this wiser brother had been deserted immediately after the nuptial night by a famous lady of the theatre (on whom he had just settled a large fortune) and that the bride, furthermore, had, during the brief pseudoconnubial episode, remained stubbornly encased in tights, the younger hastened to dispatch this succinct and unanswerable telegram:

This, at any rate, is the story. I do not offer to answer for its authenticity. It may, however, be taken not precisely as an example but at least as a somewhat flippant and arresting commentary on the confusion which still exists concerning sanity. Although most patients suffering from one of the classified types of mental disorder are promptly recognized by the psychiatrist, many of them being even to the layman plainly deranged, there remains a large body of people who, everyone will admit, are by no means adapted for normal life in the community and who, yet, have no official standing in the ranks of the insane. The word insane, of course, is not a medical term. It is employed here because to many people it conveys a more practical meaning than the medical term psychotic. Although the medical term with its greater vagueness presents a fairer idea of the present conception of severe mental disorder, the legal term better implies the criteria by which the personalities under discussion are judged in the courts.

Many of these people, legally judged as competent, are more dangerous to themselves and to others than are some patients whose psychiatric disability will necessitate their spending their entire lives in the state hospital. Though certified automatically as sane by the verbal definitions of law and of medicine, their behavior demonstrates an irrationality and incompetence that are gross and obvious.

These people to whom I mean to call specific attention are not the borderline cases in whom the characteristics of some familiar mental dis-

4 THE MASK OF SANITY order are only partially developed and the picture as a whole is still questionable. Many such cases exist, of course, and they are sometimes puzzling even to the experienced psychiatrist. Certain people, as everyone knows, may for many years show to a certain degree the reactions of schizophrenia (dementia praecox) of manic-depressive psychosis, or a paranoia without being sufficiently disabled or so generally irrational as to be recognized as psychotic. Many patients suffering from incipient disorders of this sort or from dementia paralytica, cerebral arteriosclerosis, and other organic conditions pass through a preliminary phase during which their thought and behavior are to a certain degree characteristic of the psychosis, while for the time being they remain able to function satisfactorily in the community.

Some people in the early stage of these familiar clinical disorders behave, on the whole, with what is regarded as mental competency, while showing, from time to time, symptoms typical of the psychosis toward which they are progressing. After the disability has at last become openly manifest, enough episodes of deviated conduct can often be noted in retrospect to make the observer wonder why the subject was not long ago recognized as psychotic. It would, however, sometimes be not only difficult but unfair to pronounce a person totally disabled while most of his conduct remains acceptable. Do we not, as a matter of fact, have to admit that all of us behave at times with something short of complete rationality and good judgment?

I recall a highly respected businessman who, after years of outstanding commercial success, began to send telegrams to the White House ordering the President to dispatch the Atlantic Fleet to Madagascar and to execute Roman Catholics. There was at this time no question, of course, about his disability. A careful study revealed that for several years he had occasionally made fantastic statements, displayed extraordinary behavior (for instance, once putting the lighted end of a cigar to his stenographer's neck by way of greeting), and squandered thousands of dollars buying up stamp collections, worthless atticfuls of old furniture, and sets of encyclopedias by the dozen. None of these purchases had he put to any particular use. When finally discovered to be incompetent from illness, an investigation of his status showed that he had thrown away the better part of a million dollars. For months he had been maintaining 138 bird dogs scattered over the countryside, forty-two horses, and fourteen women, to none of whom he resorted for the several types of pleasure in which such dependents sometimes play a part. Aside from persons in the early stages of progressive illness, one finds

AN OUTLINE OF THE PROBLEM 5 throughout the nation, and probably over the world, a horde of citizens who stoutly maintain beliefs regarded as absurd and contrary to fact by society as a whole. Often these people indulge in conduct that to others seems unquestionably irrational.

For example, the daily newspapers continue to report current gatherings in many states where hundreds of people handle poisonous snakes, earnestly insisting that they are carrying out God's will.* Death from snakebite among these zealous worshippers does not apparently dampen their ardor. Small children, too young to arrive spontaneously at similar conclusions concerning the relationships between faith and venom, are not spared by their parents this intimate contact with the rattler and the copperhead.

It is, perhaps, not remarkable that prophets continually predict the end of the world, giving precise and authoritative details of what so far has proved no less fanciful than the delusions of patients confined in psychiatric hospitals. That scores and sometimes hundred or even thousands of followers accept these prophecies might give the thoughtful more cause to wonder. Newspaper clippings and magazine articles before the writer at this moment describe numerous examples of such behavior.

In a small Georgia town twenty earnest disciples sit up with a pious lady who has convinced them that midnight will bring the millenium. An elderly clergyman in California, whose more numerous followers are likewise disappointed when the designated moment passes uneventfully, explains that there is no fault with his divine vision but only some minor error of calculation which arose from differences between the Biblical and the modern calendars. During the last century an even more vehement leader had thousands of people, in New England and in other states, out on the hillsides expecting to be caught up to glory as dawn broke. Indeed, conviction was so great that at sunrise many leaped from cliffs, roofs, and silos, one zealot having tied turkey wings to his arms the better to provide for flight. Those who had hoped to ascend found gravity unchanged, the earth still solid, and the inevitable contact jarring. 268,283

Few, if any, who prophesy on the grounds of mystic insight or special revelation come to conclusions more extraordinary than those reached by some who profess, and often firmly believe, they are working within the methods of science. A notable example is furnished by Wilhelm Reich, who is listed in American Men of Science and whose earlier work in psychopathology

with new tongues; they shalltake up serpents and if they drink any deadly thing it shall not hurt

6 THE MASK OF SANITY is regarded by many as valuable.28 Textbooks of high scientific standing still refer to his discoveries in this field.79,129,188

It is indeed startling when such a person as this announces the discovery of "orgone," a substance which, it is claimed, has much to do with sexual orgasm (as well as the blueness of the sky) and which can be accumulated in boxes lined with metal. Those who sit within the boxes are said to benefit in many marvelous ways. According to the Journal of the American Medical Association, the accumulation of this (to others) nonexistent material is by Reich and his followers promoted as a method for curing cancer.59 A report of the Council of the American Medical Association lists the orgone accumulator with various quack nostrums under "Frauds and Fables." The presence of any such material as "orgone" impresses the physician as no less imaginary than its alleged therapeutic effects. The nature of such conclusions and the methods of arriving at them are scarcely more astonishing than the credulity of highly educated and intellectual people who are reported to give them earnest consideration.28

During the 1940's, crowds estimated as containing twenty-five thousand or more persons, some of them having travelled halfway across the United States, stood in the rain night after night to watch a 9-year-old boy in New York City who claimed to have seen a vision which he described as "an angel's head with butterfly wings."

A clergyman of the Church of England during World War I confirmed as a supernatural omen of good the reported appearance of a luminous cross in the sky near Ipswich. In our own generation men of profound learning have expressed literal belief in witchcraft and approved the efforts of those who, following the Biblical injunction, put thousands to death for this activity.300 These headlines from a daily newspaper deserve consideration:

My interest in this news does not indicate that I hold it to be impossible for a person with a serious psychiatric disorder sometimes to write good poetry or to achieve other worthwhile attainments.

The headlines nevertheless reflect a bewildering conflict of evaluation in which some of the paradoxical elements strongly suggest absurdity. They also bring to mind what sometimes seems to be a rapt predilection of small but influential cults of intellectuals or esthetes for what is generally regarded as perverse, dispirited, or distastefully unintelligible.5, 36,114, 253 The award of a Nobel Prize in literature to Andre Gide, who in his work fervently

AN OUTLINE OF THE PROBLEM 7 and openly insists that pederasty is the superior and preferable way of life for adolescent boys, furnishes a memorable example of such judgments.94, 198 Renowned critics and some professors in our best universities179, 282 reverently acclaim as the superlative expression of genius James Joyce's Finnegan's Wake, a 628-page collection of erudite gibberish indistinguishable to most people from the familiar word salad produced by hebephrenic patients on the back wards of any state hopsital. Let us illustrate briefly with the initial page from this remarkable volume:154

(Parte 2 de 7)

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