The Mask of Sanity. Hervey M. Cleckley

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.

      THE MASK OF SANITY

      SECTION 1. AN OUTLINE OF THE PROBLEM

      CHAPTER 1. SANITY: A PROTEAN CONCEPT

      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 pseudo-connubial episode, remained stubbornly encased in tights, the younger hastened to dispatch this succinct and unanswerable telegram:

      WHO’S LOONEY NOW?

      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. While 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 too many physicians 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.

      MATERIAL TO DISTINGUISH FROM OUR SUBJECT

      These people to whom I mean to call specific attention are not the borderline cases in whom the characteristics of some familiar mental disorder 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 of 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, one can often, in retrospect, note enough episodes of deviated conduct 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 rationality and good judgment?

      *****

      I recall a highly respected business man 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 attic-full’s 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 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 relation 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 hundreds 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 millennium. 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.245, 258

      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 is regarded by many as valuable.25 Textbooks of high scientific standing still refer to his discoveries in this field.79, 112, 165

      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) non-existent material is by Reich and his followers promoted as a method for curing cancer.52 A recent