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 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 from them and take action to have “lunacy warrants” drawn against them, not wanting to be restricted, they 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,181 among others,252, 279 has so effectively pointed out, not only were the irrational considered fully culpable, but also young children and idiots. 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, hanged. He is committed to a psychiatric hospital for the protection of society and for his own best interests, 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.
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 medico-legal 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, school teachers, 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 which 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 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 work 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.33
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, one finds tucked away at the end of a large volume an obscure chapter 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 half-hearted, but even this is nearly always involved with personality types or disorders which bear little or no resemblance to that with which we are now concerned. While it is true that these other conditions are officially placed in the same category with the one discussed here, and which we believe is a clinical entity, it is hard to see how any student unfamiliar with the latter will profit by encountering it vaguely placed in a company of assorted deficiencies and aberrations which are by no means basically similar.
It is my earnest conviction that, classified with a fairly heterogeneous group under a loose and variously understood term, a type of patient exists who could, without exaggeration, 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 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. Present 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.
CHAPTER 3. NOT AS SINGLE SPIES BUT IN BATTALIONS
An 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 neuropsychiatric 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 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.{††} Over a period of twenty-nine months 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 who, I believe, for reasons brought out in the appendix, were nearly all fundamentally like those diagnosed as psychopaths, the addiction and other complications 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.
These statistics from one psychiatric institution cannot, of course, be taken as proof that the disorder is so prevalent everywhere. One must not overlook the fact, however, that each of these patients was accepted despite rules specifically classifying him as ineligible, and often as a result of conduct so abnormal or so difficult to cope with that he was considered a grave emergency. Another factor worth mentioning is the psychopath’s almost uniform unwillingness to apply, like other ill people, for hospitalization or for any other medical service. The survey at least suggests that these patients are common and that they constitute a serious problem in the average community and a major issue in psychiatry.
I have been forced to the conviction that this particular behavior pattern is found among one’s fellow men far more frequently than might be surmised from reading the literature. If the nature of the disorder
