(Parte 4 de 7)

In recent years a contrary tendency has become prominent in psychiatry, a tendency to make, on the basis of symbolism and theoretical postulates sweeping and unverifiable assumptions and to insist that these prove the

* The ease with which defective heredity may be found in any case in which one looks for it is well known. A study published in 1937 revealed that 57 percent of a group of normal people showed a positive family history of "neuropathic taint.

AN OUTLINE OF THE PROBLEM 13 cause of obscure personality disorders to lie in specific infantile, or even intrauterine, experiences.82, 166, 238 This practice has become exceedingly popular and has, in my opinion, led to many fanciful and absurd pseudoscientific explanations of the psychopath and of other psychiatric problems. Let us bear in mind that the currently prevalent psychodynamic theories are of such a nature that they can be glibly used to convince oneself of the truth of virtually any assumption, however implausible, that one might make about what is in the unconscious but what is never brought to consciousness or otherwise demonstrated. Let us not mistake these easy and unsupported assumptions for actual evidence.

After many years of work in psychiatry as a member of the staff in a closed hospital devoted to the treatment of mental disorders, and after many other years in charge of the psychiatric service in a general hospital, I believe that these curious people referred to as sociopaths or psychopaths, in the vernacular of the ward and the staff room, offer a field of study in personality disorder more baffling and more fascinating than any other. The present work has been attempted because of an ever-growing conviction that this type of disorder is far less clearly understood than either the well defined psychoses or the neuroses and that this lack of understanding is, furthermore, not sufficiently recognized and admitted. Although I do not pretend to achieve a final explanation of so grave and perplexing a problem, it is hoped that a frank and detailed discussion may, at least, draw attention to the magnitude of the problem.48

The chief aim of this study is to bring before psychiatrists a few of these cases, typical of hundreds more, who have proved so interesting to the writer, so difficult to interpret by the customary standards of psychiatry, and all but impossible to deal with or to treat satisfactorily in the face of prevalent medicolegal viewpoints. Many of these cases have been classified consistently as psychopaths by not one but a number of expert observers, usually by several staffs of psychiatrists, and nearly always with unanimity. Others are so similar and so typical that few, if any, experts could find grounds to question their status. It is my belief, however, that this diagnosis, as it is authoritatively defined and as it is generally understood, fails to do justice to the kind of patients considered here.

It is hoped that such a presentation may be of interest to physicians in general practice and, perhaps, to medical students, as well as to those whose work is confined more specifically to personality disorders. It is, indeed, the physician in general practice who will most often be called on by society to interpret the behavior of such patients as these and to advise about their treatment and their disposition. These people, whom I shall usually call psychopaths for want of a better

14 THE MASK OF SANITY word, are, as a matter of fact, the problem of juries, courts, relatives, the police, and the general public no less than of the psychiatrist. Referring to such patients, Henderson says:128

It is often much against his better judgment that the judge sentences a man whose conduct on the face of it indicates the action of an unsound mind to serve a term of imprisonment. But he is almost forced to do so because, according to our present statutes governing commitment, the doctor may not feel that he is justified in certifying the individual as suitable for care and treatment in a mental hospital.

It is important that the average physician at least be aware that there is such a problem. According to the traditional standards of psychiatry, such patients are not eligible for admission to state hospitals for the psychotic or to the numerous hospitals of the same type maintained by the federal government for veterans of the armed services. They are classed as sane and competent and, theoretically at least, are held responsible for their conduct. Being so classed, none of the measures used to protect other psychiatric patients (and their families and the community) can be applied to bring them under any sort of treatment or restriction, even when they show themselves dangerously disordered. By many psychiatrists they have in a technical sense, been considered to be without nervous or mental disease. There are many arguments that can be brought forward in support of these beliefs, particularly if one adheres strictly to the traditional and currently accepted definitions of psychiatry and minimizes or evades what is demonstrated by the patient's behavior.

It is difficult, however, for society to hold these people to account for their damaging conduct or to apply any control that will prevent its continuing. Those who commit serious crimes have a history that any clever lawyer can exploit in such a way as to make his client appear to the average jury the victim of such madness as would make Bedlam itself tame by comparison. Under such circumstances they often escape the legal consequences of their acts, are sent to mental hospitals where they prove to be "sane," and are released. On the other hand, when their relatives and their neighbors seek relief or protection from them and take action to have them committed to psychiatric hospitals. They, not wanting to be restricted, are able to convince the courts that they are as competent as any man.

It is pertinent here to remind ourselves of the considerable change that has occurred during recent centuries in the legal attitude toward antisocial conduct and punishment. Formerly, all who broke the laws were considered fit subjects for trial, and penalties were inflicted without regard to questions of responsibility or competency. As Karl Menninger,210 among others,275,300 has emphatically pointed out, not only were the irrational considered fully

AN OUTLINE OF THE PROBLEM 15 culpable, but also young children and idiots. It has also been said that at an earlier date, animals and even articles of furniture, a tree (or a stone), were brought to trial, fantastic as it seems to us now, and sentenced to legal penalties.

Today the murderer who hears what he believes is God's voice telling him to kill is not, as a rule, considered legally responsible for his crime. He is likely to be committed to a psychiatric hospital for the protection of society and for his own best interest, but not as a punishment. This legal attitude has become so axiomatic, so familiar to the man on the streets, that it is well for us to remember it is relatively new.

Since publication of the earlier editions of this book much more drastic changes have been called for and, to some degree, have occurred in popular and even in legal attitudes toward serious antisocial activity. Some of the demands made in behalf of what is often called permissiveness are based on false assumptions, often on truly absurd assumptions. Among these, apparently, is the relatively popular conviction that those who perpetrate heinous and brutal crimes should not really be blamed or, at the most, not be blamed greatly, or seriously punished. Another assumption is that psychiatry has discovered an effective means of curing even the most vicious criminals, and that they should not be sentenced to prisons but regularly sent to psychiatric hospitals. This concept is indeed flattering to psychiatry in view of our record with its woeful lack of evidence that we possess any means of this sort whatsoever.

Popular among some groups who consider themselves progressive is the belief that society instead of the criminal should be held responsible for the unprovoked murders, brutal rapes, and other outrages that blight our civilization. Another factor that sometimes seems to play a part in the doctrine of permissiveness is the popular psychiatric theory that crimes are often carried out in order to obtain punishment for unconscious feelings of guilt weighing on the tender conscience of the criminal. Referring to a sane man convicted of murdering in cold blood and without provocation, eight young women some years ago, one psychiatrist was quoted as expressing the conviction that this murderer should be regarded as being just as free from guilt as any of his victims.

We might also bear in mind that once only obvious irrationality was regarded as personality disorder, as disability. Medically we recognize the fact that many less obvious disorders are more serious and incapacitating than those with gross superficial manifestations that can be readily demonstrated. In our attempts to appraise the psychopath and his disorder, it will be helpful to bear these facts in mind and not to forget that our present medicolegal criteria are based on knowledge that is far from complete.


These people called psychopaths present a problem which must be better understood by lawyers, social workers, schoolteachers, and by the general public if any satisfactory way of dealing with them is to be worked out. Before this understanding can come, the general body of physicians to whom the laity turn for advice must themselves have a clear picture of the situation. Much of the difficulty that mental institutions have in their relations with the psychopath springs from a lack of awareness in the public that he exists. The law in its practical application provides no means whereby the community can adequately protect itself from such people. And no satisfactory facilities can be found for their treatment. It is with these thoughts especially in mind that I seek to present the material of this book in such a manner that the average physician who treats few frankly psychotic patients may see that our subject lies in his own field scarcely less than in the field of psychiatry. After all, psychiatry, though still a specialty, can no longer be regarded as circumscribed within the general scope of medicine.35

In nearly all the standard textbooks of psychiatry the psychopath is mentioned.

Several recent textbooks have indeed made definite efforts to stress for the student the challenging and paradoxical features of our subject. Often, however, tucked away at the end of a large volume, an obscure chapter is found containing a few pages or paragraphs devoted to these strange people who take so much attention of the medical staffs in psychiatric hospitals and whose behavior, it is here maintained, probably causes more unhappiness and more perplexity to the public than all other mentally disordered patients combined. From some textbooks the medical student is likely to arrive at a conclusion that the psychopath is an unimportant figure, probably seldom encountered even in a psychiatric practice. Nor will he be led to believe that this type of disorder is particularly interesting. Not only is the chapter on psychopathic personalities often short and sometimes vague or halfhearted, but even this until fairly recently was nearly always involved with personality types or disorders which bear little or no resemblance to that with which we are now concerned. Although it is true that these other conditions were for many decades officially placed in the same category with the one discussed here, which I believe is a clinical entity, it is hard to see how any student unfamiliar with the latter could profit by encountering it vaguely placed in a company of assorted deficiencies and aberrations that are by no means basically similar.

It is my earnest conviction that, traditionally confused with a fairly heterogeneous group under a loose and variously understood term, a type of patient exists who could, without exaggeration, still be called the forgotten man of psychiatry. If this patient can be presented as he has appeared so clearly during years of observation, if some idea can be given of

AN OUTLINE OF THE PROBLEM 17 his ubiquity, and, above all, if interest can be promoted in further study of his peculiar status among other human beings, I shall be abundantly satisfied. It is difficult to contemplate the enigma which he provokes without attempting to find some explanation, speculative though the attempt may be. My efforts to explain or interpret are, however, tentative and secondary to the real purpose of this volume, which is to call attention to what may be observed about our subject.

3. Not as single spies but in battalions

In attempt to determine the incidence of this disorder in the population as a whole is opposed by serious difficulties. The vagueness of officially accepted criteria for diagnosis and the extreme variation of degree in such maladjustment constitute primary obstacles. Statistics from most psychiatric hospitals are necessarily misleading, since the psychopath is not technically eligible for admission and only those who behave in such an extremely abnormal manner as to appear orthodoxly psychotic (that is to say, as suffering from another and very different disorder) appear in the records. If the traditional legal and medical rules were regularly followed, statistics from state hospitals and from the federal psychiatric institutions would show no psychopaths at all. Let it also be noted that these institutions contain a vast majority of the patients hospitalized in the United States for mental disorder. Most statistical studies, therefore, cannot be regarded as even remotely suggesting the prevalence of this disability in the population.

These facts notwithstanding, it is still impressive to note what the records of a typical psychiatric institution reveal during a period of twenty-nine months shortly before the first edition of this book was published in 1941.* During this period 857 new patients were admitted to one federal hospital, where a staff of ten psychiatrists, including myself, classified them after careful examination and study. Of this group, 102 received the primary diagnosis of psychopathic personality, being considered free of any other mental disorder that could account for the difficulties that led to their admission. This group, comprising nearly one-eighth of all those admitted, indicates that the disorder is far from rare. The records also show 134 other patients classified under alcoholism or drug addiction, many of whom I believe, for reasons brought out in the appendix, were fundamentally like those diagnosed as psychopaths, the addiction and other complications

* See Appendix for details of this survey.

18 THE MASK OF SANITY being secondary. If even one-half of these are considered as psychopaths, we arrive at a figure of 169, or almost one-fifth of the total.

(Parte 4 de 7)