The Mask of Sanity. Hervey M. Cleckley

of two months. During this time of study he showed no evidence of a psychosis or a psychoneurosis and was discharged with a diagnosis of psychopathic personality. He was found to have tertiary syphilis, but neurologic examination and spinal fluid studies showed no evidence of neurosyphilis.

      Though at first cooperative and agreeable on this previous admission, he soon became restless and expressed dissatisfaction with the hospital. He was granted parole, but on his first pass into town he got into an altercation in which words were more prominent than blows and was held by the police for disturbing the peace.

      After losing parole he became constantly unruly in petty ways, often insulted the nurses and attendants, and several times egged on mildly psychotic patients to fight each other or to resist the personnel on the ward. On being questioned about this conduct by physicians, he glibly denied all and showed little concern at being accused. Since he was not considered as suffering from a real nervous or mental disorder, and since it was difficult to keep him on any ward except the closely supervised one among actively disturbed patients, he had been discharged.

      Records show that he sought hospitalization on other occasions after having been fined a half-dozen or more times for brawling on the streets and for petty frauds. There is every reason to believe, from the evidence of careful reports by the Red Cross and by social service workers, that when his troubles with the civil authorities became too discomforting he sought the shelter of a psychiatric hospital.

      Several months previously he had spent six weeks at a Veterans Administration hospital in Maryland after getting into similar trouble with the police in Wilmington, Delaware. He complained at the time of having spells during which he lost his temper and attacked people, often, according to his story, with disastrous results, since, again according to his story, he had at one time been featherweight boxing champion of England.

      According to the psychiatric history at the Maryland hospital, he had, in describing these spells, mentioned some points that would suggest epilepsy. As soon as he came to the hospital and was relieved of responsibility for the trouble he had made, the so-called spells ceased. His descriptions of them varied. Sometimes, when particularly expansive, he boasted of superconvulsions lasting as long as ten hours, during which he made window panes rattle and shook slats from the bed. After being in the hospital for several weeks and apparently beginning to grow bored, his talk of spells died down and he seemed to lose interest in the subject. He was discharged after the staff had agreed that the alleged seizures were entirely spurious, and the patient himself had all but admitted it. The diagnosis of psychopathic personality was made.

      Between his first visit to the present hospital and his recent return he had been in five other psychiatric institutions, each time following conflicts with the law or pressing difficulties with private persons. In all the records accumulated during these examinations and investigations, no authentic symptom of an orthodox mental disorder is noted. True enough, there are statements by wives and other interested parties about spells and opinions by the laity, such as the following which was quoted by his attorney on one occasion to shield him from the consequences of theft:

      I had occasion to be in Dayton, Ohio, recently and talked to the people running the… Loan Company at… Street, having stopped there for about an hour between trains en route for Chicago. I was informed by these gentlemen that he had wheels in his head.

      Statements such as the above, opinions that he is “undoubtedly goofy,” that he does not behave like a man in his proper senses, etc., abound in the ponderous stack of letters, medical histories, social service reports, records of court trials, and other material that has accumulated in this man’s wake. One who reads his strange and prolix story, and, even more, one who knows the hero personally is only too ready to fall into the vernacular and agree. Nevertheless, it was equally true on reviewing his record at the time of his new admission that no symptom impressing a psychiatrist had been manifested and that many groups of psychiatrists had, after careful study, continued to find him free of psychosis or psychoneurosis, in other words, sane and responsible for his conduct and even without the mitigating circumstance of a milder mental illness.

      Once during this period he had been sent to prison in a southern state for forgeries a little more ambitious than his routine practice. At the instigation of his second and legal wife, who consistently flew to his aid (despite her chagrin at the patient’s having meanwhile consummated two bigamous marriages), well-meaning officers of a veterans’ organization became interested and took up the cudgels.

      The patient, wearying sharply of prison, had for some time been talking on all occasions about a blow on the head which he had sustained while in service. This alleged incident, though absent from his military records, had cropped up frequently but not regularly during his hospitalizations. Sometimes the blow, which he had sustained accidentally from the butt of a gun that a companion was breaching, had merely left him dizzy for a moment. Again it had knocked him unconscious for a short period and necessitated several days’ rest in his tent.

      Max now became more specific about his wartime injury and explained that he had suffered a severe concussion, lying out stark and unconscious for some eight or nine hours. Attorneys pointed out his many periods of treatment in psychiatric hospitals. The governor soon agreed to parole him into the custody of a federal hospital in Mississippi.

      During his present hospitalization he was for several weeks happily adjusted on the admission ward, busy doing small favors for the physician, congenial with all the personnel, helpful and kindly toward psychotic patients. He was alert, quick-witted, nimble with his hands, entirely free from delusions, hallucinations, or any of the broader personality changes found in the ordinary psychoses. He was by no means “nervous,” even in the lay sense, and showed no emotional instability or signs of ungovernable impulse. Rather than an excess of anxiety, he showed the reverse, apparently finding little or nothing in his present situation or in all his past difficulties to cause worry or uneasiness.

      As the time passed he began, however, to grow restive. He became somewhat condescending toward the physician, frequently referring to himself as a man of superior education and culture and boasting that he had studied for years at Heidelberg.

      Shortly before the time set for him to come before the staff he demanded his discharge. This was denied. He now became involved in frequent altercations with attendants and sometimes fought desultorily with other patients. These fights always started over trifles, and Max’s egotism and fractiousness raised the issue. He never attacked others suddenly or incomprehensibly as does a psychotic person motivated by delusions or prompted by hallucinations. The causes of his quarrels were readily understandable and were always found to be similar to those which move such types as the familiar schoolboy bully. Usually his adversaries were patients also disposed to quarrel. No signs of towering rage appeared or even of impulses too strong to be controlled by a very meager desire to refrain.

      He always took care not to challenge an antagonist who might get the upper hand. During this period he talked much of his past glories as a pugilist, describing himself as former featherweight champion of all the army camps in the United States. The desire to show off appeared to be a strong motive behind many of his fights. As will be brought out later, he was indeed, a skillful boxer. These stories were not delusion but the exaggeration and falsifying, sometimes unconscious or half-conscious, that are often seen in sane people and not infrequently in those who are able, intelligent, and highly successful.{§§}

      He was often caught sowing the seeds of discontent among other patients whom he encouraged to break rules, to oppose attendants, and to demand discharges. He made small thefts from time to time. This trend culminated in his kicking out an iron grill during the night and leaving the hospital. He took with him two psychotic patients, and numerous others testified that he had tried to persuade them to leave also.

      The next afternoon he was returned to the hospital by the police after being arrested in the midst of a brawl that he had caused by cheating at a game of chance in a low dive. He had taken a few beers but was shrewd, alert, and well in command of his body and his faculties.

      He now insisted on his discharge from the hospital against advice and was brought before the medical staff. The diagnosis of psychopathic personality was again made. In his demands to be released he arrogantly