The Mask of Sanity. Hervey M. Cleckley

      PREFACE TO THIRD EDITION

      Since the last edition of this book was prepared, many additional psychopaths have been observed pursuing their vivid patterns of maladjustment. A few encouraging reports of successful therapeutic measures have emerged. The number of patients concerned is, however, too small to furnish substantial evidence that a regularly effective means of dealing with the psychopath’s disorder has been discovered. It is my increasingly strong belief that the immediate and practical goal of all concerned with this problem should be to promote a general understanding that these people have a social disability that is real and extremely serious. Adequate means must be provided to control legally these severely disordered patients like those long ago provided, and available today, for far less incompetent patients of other types. Even if a truly curative therapy is never devised, perhaps half the damage, crime, waste, useless disorder, and sorrow caused now by psychopaths could be eliminated by a reasonably wise use of such legal measures for control.

      In the present revision I have attempted to make clearer my concepts of the psychopath’s confusing and paradoxical disorder. It is not easy to convey this concept, that of a biologic organism outwardly intact, showing excellent peripheral function, but centrally deficient or disabled in such a way that abilities, excellent at the only levels where we can formally test them, cannot be utilized consistently for sane purposes or prevented from regularly working toward self-destructive and other seriously pathologic results. Impressed by its effectiveness as used by Henry Head to distinguish a complex and deep type of aphasia, I chose the term semantic to indicate my concept of a personality disorder which appears to have, at least hypothetically, some important similarities.

      In previous editions I evidently failed to convey accurately or adequately the concept I had formed. From correspondents, from reviews of the book, and from comments in studies on the psychopath published by others, I find I did not make my intended meaning sufficiently clear. Some readers were misled by my use of the term semantic to believe I claimed that the basic pathology in this disorder, or its cause, is deficiency in the understanding of speech or some other linguistic difficulty. Some comments, on the other hand, gave me the impression that it was assumed I had found fault with the psychopath because he could not achieve a final and absolute understanding of life’s meaning at levels more or less eschatological. I have restated my concept with the aim of making it more explicit, with the hope of being more articulate.

      A sweeping revision of our whole nomenclature of psychiatric illnesses has been made since the last edition. This has encouraged me in the task of trying to set off and delineate more clearly other types of personality disorder that may be compared and contrasted with that of the psychopath. I find I have had to deal not only with my primary subject but, in order to do so satisfactorily, to comment also on nearly all the material treated in general textbooks of psychiatry.

      It is a privilege to acknowledge the help of Dr. Lester Bowles, whose wisdom and fine human qualities have enriched the Department of Psychiatry and stimulated my own efforts.

      I also wish to thank Dr. Fred B. Thigpen, Dr. B. F. Moss, and Dr. W. P. Robison. As residents in psychiatry, their excellent clinical judgment and genuine spirit of inquiry have contributed substantially to the material presented here.

      Dr. Corbett H. Thigpen, my medical associate of many years, has played a major part in the development and the revision of this work. His observations and his thought, available to me during innumerable pleasant and stimulating hours of discussion, have assisted and profoundly influenced my own conclusions to a degree that amounts to real collaboration. Without his limitless generosity in relieving me over long periods of heavy and urgent responsibilities in teaching and in clinical activity, it would have been impossible for this volume to be written. My debt to him in this, and my gratitude, I can acknowledge but cannot fittingly express.

      HERVEY M. CLECKLEY

      PREFACE TO FIRST EDITION

      The present volume grew out of an old conviction which increased during several years while I sat at staff meetings in a large neuropsychiatric hospital. Many hundreds of such cases as those presented here were studied and discussed. The diversity of opinion among different psychiatrists concerning the status of these patients never grew less. Little agreement was found as to what was actually the matter with them. No satisfactory means of dealing with them was presented by any psychiatric authority, and meanwhile their status in the eyes of the law usually made it impossible to treat them at all. They continued, however, to constitute a most grave and a constant problem to the hospital and to the community.

      Since assuming full-time teaching duties at the University of Georgia School of Medicine, I have found these patients similarly prevalent in the wards of the general hospital, in the outpatient neuropsychiatric clinic, and in consultation work with the various practitioners of the community and with the hospital staff. The overwhelming difficulty of finding facilities for their treatment has been no less urgent than the yet unanswered question of what measures to use in treatment. How to inform their relatives, the courts which handle them, the physicians who try to treat them, of the nature of their disorder has been no small problem. No definite or consistent attitude on the part of psychiatric authorities could be adduced in explanation; no useful legal precedent at all could be invoked, and no institutions found in which help might be sought by the community.

      I should like here to express my appreciation for their encouragement and guidance about this and about other neuropsychiatric problems to Dr. R. T. O’Neil, Dr. William M. Dobson, Dr. M. K. Amdur, Dr. O. R. Yost, and Dr. M. M. Barship. To all of them as colleagues, and in varying degrees as teachers, during my years with the United States Veterans Administration, I am sincerely grateful.

      Dr. John M. Caldwell, of the U.S. Army Medical Corps, Dr. Cecile Mettler, Dr. Phillip Mulherin, Dr. F. A. Mettler, Dr. Lane Allen and Dr. Robert Greenblatt, all of the faculty of the University of Georgia School of Medicine, I should like to thank for their interest and helpful criticism in the preparation of this work. Nor can I fail to mention here the kindness and active co-operation of other departments in the School of Medicine which, though less directly related to the present study, have been a valuable and constant support to the Department of Neuropsychiatry. Though I name only a few, I should especially like to express appreciation to Dean G. L. Kelly, Dr. J. H. Sherman, Dr. C. G. Henry, Dr. E. E. Murphey, Dr. Perry Volpitto, Dr. R. F. Slaughter, Dr. R. H. Chaney, Dr. W. J. Cranston, Dr. H. T. Harper, Dr. Lansing Lee, and Dr. J. D. Gray. The interest and understanding shown by these and others in the problems of the newly organized full-time Department of Neuropsychiatry have been more helpful than they know.

      To Dr. Lawrence Geeslin, Dr. C. M. Templeton, Dr. Joe Weaver, Dr. Alex Kelly, and Dr. DuBose Eggleston, all of the Resident Medical Staff at the University Hospital, I am grateful for their fine and wise efforts to make neuropsychiatry an effective influence on the wards of a general hospital.

      It is hard to see how the present manuscript could have reached completion without the understanding and energy contributed to its making by my secretary, Miss Julia Littlejohn.

      Mr. Berry Fleming and Mr. Donald Parson, one as a distinguished novelist and one as a poet, but both sharing the psychiatrist’s interest in human personality, have kindly made available to me their valuable points of view.

      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 enheartening 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