The Psychopath as Physician:
from: The Mask of Sanity
25. The psychopath as physicianWhen first seen by me, he was still in his early forties. From the country town in which he was practicing medicine an inquiry came concerning his professional ability. Everyone regarded him as a brilliant man. His patients loved him, and while he was working regularly, his collections were more than adequate. It was often impossible to find him, for now and then, in the classic manner, he lay out in third-rate hotel rooms or in the fields semiconscious until he could be found and coaxed back home. This was tolerantly accepted as one of his idiosyncrasies by the rustic folk he attended. It was inconvenient, but like drought and the boll weevil, what the devil could one do about it? The community, in which not only social drinking but even card playing and dances were generally regarded as devices of Satan, intuitively sensed that the Doc's doings had little or nothing in common with the proscribed gaieties or frivolities. Although a man known to drink cocktails for pleasure and even a woman who smoke cigarettes might have been ostracized, local deacons and town gossips made no concerted attack on the doctor. The inquiry about his ability mentioned previously was prompted by the following incident: A patient whom he had been attending off and on for several weeks had noticed that he occasionally seemed glassy-eyed and slightly irrelevant. Neither she nor her family, however, was prepared for such a bedside manner as was his on the last visit. When the door was opened for the doctor, he swung in unsteadily with it, hanging desperately to the knob, which he apparently hesitated to relinquish. Breathing hard, he muttered inaudibly for a moment, winked inanely at three children who had withdrawn to a corner, gave several short, piercing cheers, and slipped to the floor. Retaining his instrument bag in one hand, he began, still prone, to crawl toward his patient's room. Switching his body from side to side, he made slow but spectacular progress, hesitating every few yards to give a series of hoarse, emphatic grunts or barks. This pantomime was taken by the family to represent an alligator slipping through a bog. In this manner he reached the bedside of the patient. This man's history shows a great succession of purposeless follies dating from early manhood. He lost several valuable hospital appointments by lying out sodden or by bursting in on serious occasions with nonsensical uproar. He was once forced to relinquish a promising private practice because of the scandal and indignation which followed an escapade in a brothel where he had often lain out disconsolately for days at a time. Accompanied by a friend who was also feeling some influence of drink, he swaggered into this favorite retreat and bellowed confidently for women. Congenially disposed in one room, the party of four called for highballs. For an hour or more only the crash of glasses, scattered oaths, and occasional thuds were heard. Then suddenly an earnest, piercing scream brought the proprietress and her servants racing into the chamber. One of the prostitutes lay prostrate, clasping a towel to her breast, yelling in agony. Through her wails and sobs she accused the subject of this report of having, in his injudicious blunderings, bitten off her nipple. An examination by those present showed that this unhappy dismemberment had, in fact, taken place. Although both men had at the moment been in bed with her, the entertainer had no doubt as to which one had done her the injury. Feeling ran strong for a while, but, by paying a large sum of money as recompense for the professional disability and personal damage he had inflicted, the doctor avoided open prosecution. Before a settlement had been made, the guilty man attempted to persuade his companion to assume responsibility for the deed. It would be less serious for the other man, he argued, since his own prominence and professional standing made him a more vulnerable target for damaging courtroom dramatics and for slander. His companion, however, declined this opportunity for self-sacrifice with great firmness. Less spectacular performances include locking himself in a hotel room alone where he would drink to stupefaction, arouse the management, break furniture, telephone his wife that he had decided to kill himself, drink more, and remain until taken by police or friends who broke open the door. He also contributed vividly to the liveliness of a dance some years ago. His older brother, whom he was visiting in a New England town and who was an officer in a country club where the dance was in progress, remonstrated with him, urging him to leave because his loud and disorderly behavior, having already attracted unfavorable attention, was now beginning to cause consternation. Whooping in indignation, he at once grappled with his elder on the porch of the club where they stood. The orchestra having stopped for intermission, a large number of ladies and gentlemen were strolling on the terrace below. Attracted by frantic outcries, reiterated curses, and the sound of scuffling above, these bystanders looked up to see the two brothers whirling dizzily in combat. The younger man, his strength finally prevailing, got the older against the banister and seemed about to throw him over. As observers ran to quell the tumult, our subject, having in his position of vantage breath to spare for oratory, caused the golf course to echo with his threats and insults. "You bastard! You goddamned - bastard! You son of a bitch! I'll kill you, bastard and son of a bitch that you are!" he yelled, pushing his brother back farther over the banister as the echoes returned his violent words. One wonders if the brother was observant enough at the moment to note the two-edged nature of the term with which he was being so loudly reviled. Rescuers soon interrupted the performance. Our subject could very probably have thrown his brother over before they came, but his intention apparently was to make a scene rather than to inflict serious injury. After one of his longest periods of regular work and apparently satisfactory adjustment, which lasted nearly a year, he attended the meeting of a regional medical society in a large city where an exploit brought him to the notice of local newspapers.
FOUND DRUNK ON HIGH ALTAR OF ST. PHILIP'S CHURCH
He often swears off drinking and expresses the intention of devoting himself to constructive and regular occupation but, despite all the serious troubles that his conduct has brought him, he actually continues as before. 26. The psychopath as psychiatrist In the group who show some fundamental characteristics of the typical psychopath but who make a good or fair superficial adjustment in society are sometimes found men who hold responsible positions. Lawyers, business executives, physicians, and engineers who show highly suggestive features of the disorder have been personally observed. Perhaps one would think that the psychiatrist, with good opportunity to observe the psychopath, would eschew all his ways. I believe, however, that a glimpse can be given of characteristics of the psychopath in such a person. Let us first direct our attention to him many years ago when, as an author of some papers on psychiatric subjects, he attracted the interest of several inexperienced young physicians then at the beginning of their careers. The articles, it is true, were marred by grammatical errors and vulgarities in English a little disillusioning in view of the suave and pretentious style attempted by the author. At the time, however, they impressed this little group of naive admirers as having all the originality that the author so willingly allowed others to impute to them, and, as a matter of fact, implied not too subtly himself in every line of his work. When seen later at a small medical meeting at which no experienced psychiatrists were present, this author seemed very grand indeed. The actual ideas expressed in his paper were, to be fair, culled from the primers of psychiatry and psychology, but he had an authoritative way of making them seem entirely his own, and marvelous, too. Despite his cool and somewhat commanding air, he succeeded in giving an impression of deep modesty. Everything seemed to accentuate his relative youth which, in turn, hinted of precociousness and of great promise. The effect he had on his audience, most of whom were general practitioners from small towns, was tremendous. An opportunity to meet this splendid figure of a psychiatrist and to sit at his feet during the rest of the evening was avidly welcomed by several of his new admirers. Dr. _____, though still in his middle thirties, enjoyed a wide and enviable reputation in a section of the country where psychiatrists were at the time almost unknown. After some work at hospitals in a distant state where he was born, he had come and set up as a specialist in his present habitat. He soon obtained a small institution in which he began to direct treatment of psychiatric patients. Reports indicate that it flourished and expanded greatly. It was generally agreed that his learning and ability were chiefly responsible for his rapid rise to local prominence. Ephemeral rumors hinted that the idolized Dr. ____ made a practice of treating by expensive and doubtful procedures any patient of means whom he could obtain for as long as the money lasted and of then dismissing him or sending him promptly to a state hospital. It was also heard that with female patients he sometimes suggested, or even insisted on, activities (as therapy) which are specifically proscribed in the Hippocratic oath. But what physician has not had similar things said about him? The impressive bearing of the man and his reiterated and rather eloquent appeals for higher scientific consecration on the part of his colleagues snuffed out these feeble stirrings of adverse criticism which were almost universally ascribed to jealousy. The lion of the evening seemed to put himself out in being gracious to his young admirers who were indeed nobodies on the fringe of the wonderful field which he seemed to dominate. His good fellowship was so hearty and yet so suave that one could scarcely bring himself to see the faint underlying note of condescension. The privilege of driving this relatively great personage out to a country place where hospitality beckoned was seized by one of the young physicians, In the car an attempt was made to turn the conversation to psychiatric questions which Dr. ____ had raised in his papers. He made a few stilted replies but soon drifted from the subject into talk that was hardly more than pompous gossip, His companion, fearing that such a learned man might be talking down to spare him the embarrassment of incomprehension, kept returning to psychiatry, trying to make it plain that no such embarrassment would discount the pleasure of hearing the master. Soon the replies of this alleged master left the young man in serious doubt not only as to the great one's knowledge, but even as to his interest in the subject. Dr. _____, in his more popular talks and articles, as well as occasionally in those directed toward rustic medical groups, often gave psychiatric interpretations of literature and art. One of his more recent efforts in this line touched briefly but ambitiously on the works of Marcel Proust. Being then in the middle of an earnest pilgrimage among the psychopathologic wonders of Remembrance of Things Past, the fledgling psychiatrist, perhaps hoping to make a good impression but also eager for enlightenment, ventured a question on this subject. The master at this time was calm and alert, but his remarks were so beside the point that his disciple wavered. Dr. _____ was perfectly self-assured, in fact politely pontifical, but the more he talked the clearer it became that he had not read the book at all. It finally became equally clear that even Proust's name was unfamiliar, and the disquieting suspicion dawned on his admirer that he had never encountered it except in the excerpt from some review which he had apparently come upon and used. He had not been sufficiently interested in what he plagiarized even to retain the name and was now imputing it to some imaginary Viennese psychiatrist. He followed this pretension only for a moment, however, and only as a stepping stone to banalities with which he was familiar and about which he spoke with such deliberation and assurance that they almost seemed marvelous. Never in all this persiflage did he show the least sign of confusion or timidity. Apparently he felt that he had kept intact his impressive front. Even at this stage of the acquaintanceship it was hard to avoid suspicion that any important distinction between such a front and more substantial things was not in the orbit of his awareness. With some remark about putting aside these grave and ponderous subjects, he sang a few lines of a surprisingly obscene ditty, clapped his companion on the back, and suggested with gusto: "When their social doings are over, let's you and I go get us a couple of good frisky chippies!" Despite the conviviality implicit in this remark (and no less in his tone), in some way hard to describe he still maintained the attitude of one who means to insist on his distinct superiority even while for a moment generously waiving certain restrictions of caste and allowing his companion a more respectable footing, It was only a quasi-equality that he offered, however-an indulgence such as an adult might allow a child who on some special occasion is permitted to sit up and play that he is grown. The friendship he seemed to offer was at best a morganatic one. His discourse during the rest of the drive, especially after he had stopped on the way for "a couple of quick ones," was coarse and humorless. It seemed impossible to strike a sincere idea from him on any subject. On arriving at the host's place, a merry but entirely civilized company was found drinking highballs, singing around the piano, or talking enthusiastically in small groups. The singing was in key, and the talking was not loose or aimless. For the most part the gathering was composed of people who, though lively, had some interest in general ideas as contrasted with the trivia of daily life, and a few slowly ingested drinks brought out humorous and interesting conversation. The house was not very large or the furnishing spectacular, but the place, like the men and women present, gave a strong impression to the newcomer that he was in orderly surroundings, among people of dignity and good will. A young, very good-looking married woman who had an amateur but genuine interest in psychiatric questions and who meant to be polite to the distinguished stranger, began talking to him with enthusiasm. He soon led her off into another room. A moment later, on passing through this room, one of the young physicians was hailed by a feminine voice and, responding, found the two in a nook, the lady pulling herself away from the doctor with some effort but with equanimity. It was plain that his crudely aggressive overtures were not welcome to her and she urged the other man, who was an old friend, to join them on the davenport. Apparently trying to start a conversation, she asked the celebrity about psychoanalysis, a subject on which he sometimes expounded to lay gatherings in such a way as to give the erroneous impression that he was a qualified analyst. "If I could get you out in a car I'd psychoanalyze you right now," he muttered, low but loud enough to be overheard, accompanying his words with a confident leer. The savant had evidently misread the spirit of the party. The lady rose, smiled quickly at her other companion as if to say she knew a disagreeable fellow when she saw one, and quietly rejoined a group. Dr. _____ now expressed the desire for straight liquor, making strong, derogatory remarks about highballs and those who drank them. Ordering his former disciple to come, he strode toward the kitchen. The former disciple, by this time feeling heavily responsible for the master, made haste to follow. In the kitchen Dr. _____ began to order the servants about in profane and petulant fashion. He had gulped one or two small whiskeys when several men wandered in looking for ice. One of these, an eager intern, expressed interest in the important investigative work which Dr. _____ had begun now, in loud, boastful tones, to announce himself engaged in. "If you want a job there, son, just lemme know," he thundered. Swaggering about, he made an all-embracing gesture. "At the ______ Institute I'm it. I'm the big cheese, I tell you." No one saw fit to dispute these claims. He began then a tirade on the subject of his executive ability, his scientific standing, his knowledge of the stock market, his sexual power, and his political influence. Having delivered himself of this, he pushed his audience aside and sauntered back into the sitting room. There he recognized an old acquaintance, a physician who had formerly been on the resident staff with him at some hospital but in an inferior capacity. This man, a newcomer, was talking with the hostess in the midst of a small group of men and women. "Why you old son of a bitch!" Dr. ______ shouted. "Come over here and set your goddamned a__ in this chair and talk to your chief." It was no time for vacillation. The newcomer and the young physician who had accompanied Dr. _____ to the party caught each other's eye and quickly hurried the celebrity to the door. He pulled back at first but soon came along satisfactorily as both companions sought so earnestly to cajole him that the words of each were lost to the other. Turning to his companions just as the door was gained, he shouted: "Chippies, did you say?" On the way to his hotel he began to protest. He was by no means confused from drink. "Be goddamned if I go there! What kind of dirty bastards are you anyway?" He became insistent - nay, even defiant - about going where he could obtain women. The new member of the party, who had seen him through many such episodes and who, to the other escort's relief, kindly assumed charge of the case, advised that he be humored. Dr. ____ himself, through an effervescence of obscene threats, muttered directions to the driver. Expecting to find an ordinary brothel, both of his companions were surprised to arrive at a large outdoor pavilion where an orderly dance was going on. Before a definite decision could be reached about what to do, Dr. _____ was out of the car. "Luke! Luke!" he yelled imperiously. A pleasant-looking man appeared. "You've got to get us a good piece of t___ and get it quick, boy!" he ordered. "We'll wait here and watch 'em dance by." The man called Luke, so far as could be learned, was under serious obligations to Dr. ____ and apparently meant to obey him. He confided that he had stood by his friend and benefactor in many such sprees in this town. Luke had pleasant manners and was not drinking. "God, that's one!" the savant muttered. "What an ____! Can you get that slut out here, Luke?" He was far enough away not to be overheard by the dancers. Luke smiled and shook his head. "There's one!" the doctor commented again with enthusiasm. "She's rutting! That one's rutting! I can tell it." His subsequent remarks can hardly be suggested even in writing on a medical subject. His two companions left him now in custody of Luke with instructions that he be brought back to the car when this was possible without violence. Luke had asked not to be left with sole responsibility. Some time later the doctor returned. It was difficult to judge whether or not he had gained all the satisfaction he sought. He made it plain that he had found a companion but despite his boastful garrulousness did not give the final details of the encounter. In view of his windy frankness, this caused doubt as to how far he had succeeded in his aims. Beyond question he had made considerable progress. He announced this much loudly, holding up a finger, sniffing it as he did so, and making a comment of such ingenious distastefulness that even his brother physicians blenched with revulsion. The new disciple could not but ruminate about what appraisals of woman and of human relationships, what attitudes toward basic goals, prevailed beneath this successful man's ordinarily impressive exterior. On the road back to his hotel he cursed truculently at other cars. He came in willingly. While going up on the elevator, he pinched the buttocks of the girl who ran the machine, apparently oblivious of several passengers. There was no gaiety or human touch in these actions, only a sullen, derogatory aggressiveness. He uttered vague challenges and threats emphasizing his combative prowess and his readiness to fight anyone who might take issue with him on any question. On entering his room, he immediately made for a whiskey bottle and began calling raucously for ice. He became loud and offensive when his companions sought to excuse themselves, banged the table with his fists, and offered grandiosely to fight and to fight at once. He was a tall, powerful man and by no means too drunk to put on a lively and embarrassing scene if crossed. He cursed the bellboy, who had arrived meanwhile, with such foul oaths it was incredible that he took them. Pouring himself a quick drink, he called for careful attention from his companions. Had he told them about his children? No. They must see pictures of them. He began to praise them extravagantly, to extol his love for them it, sickening terms of pathos, or pseudopathos. He spoke of his plans for their future. His entire manner began to change, and it was plain that he had determined notions about keeping all his children what he called pure. A surprisingly moralistic aspect of this psychiatrist began to appear. Cheap expressions of sentimentality fairly gushed from him. In a loosely emotional strain he recited rhymes by Edgar A. Guest about the little ones. Then he momentarily broke down and blubbered. Tears ran down his cheeks. The bellboy had brought ice and Dr. _____ insisted on pouring out drinks, swaggering about now in his earlier manner. When his companions insisted on leaving, he promptly announced that he would accompany them. He could not be persuaded to go to bed and quickly became overbearing when persuasion continued. Though he had, of course, taken a good deal of whiskey, he seemed to know perfectly what he was doing. In fact, he did not really seem drunk in the ordinary sense of the word. Both of his companions felt that this was not a person irresponsible for the moment who must be protected and prevented from doing things he would regret. On the contrary, one was strongly impressed that this was the man himself. Going down on the elevator he renewed his practices on the polite girl who operated it, becoming so annoying to her that his companions had to interfere. He called a taxi and insisted that all proceed at once to a brothel. Having had enough experience for one night in trying to be their brother's keeper, his companions were obdurate. He drove off, cursing them viciously as disgraceful specimens of humanity and making derogatory remarks about their virility. "What's the matter with him?" asked the younger. "Just a queer fellow that way," replied the one who knew him well. "He's cool and calculating, a good executive, and a rather pleasant man superficially during the week, though always a little arrogant. Even when on the job he's not to be trusted. Every time he gets a chance, he does just about what you've seen him do tonight. He keeps under wraps of outer dignity at the hospital and he's careful not to take them off under circumstances which would cause him to get in serious trouble. He passes as a great gentleman in polite but unsophisticated circles at home. But the cloak must be very uncomfortable. Almost every weekend he makes an opportunity to get it off, and he's always then just the man you saw tonight." "But won't his reputation suffer from what he did tonight?" "Probably not. He is a long way from home. Since the town is small, he evidently assumed that all the people he was thrown with tonight were country bumpkins who don't count for much and who would be overawed by him. He judges people only by superficial appearances of wealth and power, and he is seldom impressed except by gaudy display. He kept up a good front at the medical meeting. He is exceedingly shrewd, in a shallow sense, about where and when he behaves naturally. At home he often goes off into swamps with groups of men far beneath him in his own estimation and who are apparently flattered to be chosen. The trips are ostensibly to catch catfish or, in the winter, to shoot ducks; but actually it's merely to get rowdily drunk, boast and shout inanely, and sprawl about on the ground or in muddy boats around the camp. He wasn't drunk tonight. Out in the swamp he often passes through this obscene, blustering phase in an hour or two and reaches the sodden state that one might suspect is his goal. "Sometimes he wants women. It doesn't matter what women or under what circumstances. Some of the people who know him say that he prefers low, unprepossessing partners, but it has always seemed to me that there was no preference at all, and I've seen him often. A beautiful woman means no more to him than an imbecilic harlot, but on the other hand the harlot means no more than the beautiful woman. "Sometimes when the idea of sex is stirring him he gets too drunk to make much of his opportunities. I'll never forget one incident. It was about daybreak down in the swamps where we'd been fishing. He'd gone out on a sexual mission pretty drunk. We found him at a whitewashed shack. It was time to leave for home so another fellow and I rolled him off a fat illiterate washerwoman. She must have weighed two hundred pounds! "'Sakes, Boss,' she muttered, 'he's far gone dis time. Ain't done nuthin' yet!' It was my last fishing trip with him." The next morning with fresh sunlight streaming into the hotel, the youngest member of the group, having finished breakfast, met Dr. _____ in the lobby. He was emerging from a telephone booth. Tall, self-assured, clear-eyed, neat as a dandy, and fashionably dressed, he looked the fine figure of a man. He spoke affably. With a disarming, boyish smile he made some reference to the previous evening. His polite expressions and poised tone made clear the implication that it had been a pleasant occasion and had cemented friendships. The inconspicuous trace of condescension first noted on meeting him was now more obvious, but this somehow tended to make his cordiality seem more precious. He was as sober as a man can be and showed no signs of hangover. Indeed, as his other companion of the night had said, he must have been drinking very moderately. The former admirer of Dr. _____, who was an old friend of the lady whom he had offered to "psychoanalyze" in a parked car before, stopped at her house later in the day to say goodbye before leaving the city. "Come in. I must speak to you," she said. There was some indignation in her tone but more mischief and merriment. "What about your friend, the famous psychoanalyst?" she said, relishing, in all friendliness, the other's discomfiture. She was a person of some sophistication and poise. Being also pretty, vital, and desirable to men, she knew well how to take care of herself in ordinary company. She had been married for several years and gave a strong impression of being happy and in love with her husband. "Well," she continued, "I must tell you. You are interested in queer people." "Early this morning the cook came and woke me up. 'It's the telephone,' she said. 'Damn the telephone, Lou!' I told her. 'Don't you know I was up till all hours last night?' 'Yes'm,' she answered, 'but the gentleman says you'll speak with him, and it's important business.' "I picked up the phone, "'Good morning, Mary' said an unfamiliar, self-assured, masculine voice. I was wondering who it could be - knowing me well enough to use my first name and still so pompous. Then, just as I recognized the voic "'Mary, this is Doctor _____.' From his tone you'd have judged he thought I ought to sing for joy! " 'Yes indeed,' I said. He then baldly suggested that I make a date with him for this afternoon. He'd come out for me at 4 P.M. or, better still, he suggested, I could meet him at a drugstore downtown. "Really, there was something so superior about him, a sort of indescribably cool insolence, or I don't know what . about his manner, I mean ..and after last night! . not just the proposition itself . that I fairly turned white with rage. "I wanted so much to blast him with scorn that I was at a loss for words. When you get that mad it's easy to lose your head. The calm and effective expression of indignation by which ladies in Victorian novels squelched 'insults' is hard to put into the idiom of today. Trying not to make myself unnecessarily ridiculous, but trusting the reply would register as final, I said: " 'Is that so? Sorry, but I'm afraid I'll have to forego that pleasure.' "He then insisted, not like a lover or even like one who's making any decent pretense of being a lover, but coolly, almost arrogantly, like a fake gentleman who's after a servant girl. I must have succeeded in making myself a little clearer by this time, for he resigned himself about this afternoon. But I wasn't done with him. "He then began to say that he would be back in this city soon, probably every now and then. He'd like to see me on some of these occasions. He'd call me when he came. No, perhaps it would be better if he dropped me a note and let me know when he'd be here. Then I could call him! I was getting so vexed that I scarcely caught the implication that he didn't want to telephone and find George here. "For a moment I couldn't answer. Then I suddenly remembered the way he announced himself: 'Mary, this is Doctor _____!' The overwhelming effrontery of the whole farce came over me. It was too much! 'Mary, this is Doctor _____!' That priceless ass calling me by my first name and referring to himself as 'Doctor _____!' And under such circumstances! Why, he probably pictured us having our little bout of 'love' in the same strain. 'You're so lovely, Mary, do let me take off your pants!' 'Oh, Doctor - (blushing), you're so genteel and handsome!' "Can you beat it! I ask you as an old friend! The bumptious swine didn't even have enough delicacy in what he probably thought of as lovemaking to grant me the intimacy to call him Jack, or Harry, or Percival, or Happy Hooligan, or whatever else he's named. He's such an indescribable prig that he probably doesn't even allow himself to think of himself in terms of a first name. "I just had time to get out the words which must have come with something of a lilt: "'Yes, you just wait until I call you!' "I'm ashamed to confess they were almost lost in a burst of laughter. It wasn't ladylike at all the way I laughed. It was belly-shaking laughter. Homeric laughter. Rabelaisian laughter, maybe. I couldn't stop. "Lou, the cook, came back in and asked what was the matter. 'I can't explain,' I told her and went on laughing. "What sort of people are you psychiatrists anyway?" she now asked in her spirited, arch way, again enjoying her old friend's discomfiture which was now almost lost in wonder and amusement. "I bet that bat-house troubadour went away thinking I had become hysterical with delight at the opportunity he offered." "That might not be absurd after all," the friend murmured, remembering the self-possession and happy assurance with which Dr. _____ had emerged from the telephone booth that morning. This case is offered for what it may be worth. No diagnosis of psychopathic personality has been made. Occasional news of him over the next few years indicated that he was still outwardly well adjusted. I believe it likely that he continues to prosper and I have not the faintest notion that he will ever reach the wards of a psychiatric hospital except in the capacity of a physician and executive. He does not really succeed in impressing people of discernment, though he continues to think he succeeds in this. He impresses many people who are themselves essentially undiscriminating. He cannot tell these from others with sounder judgment and regards himself as a great success socially as well as financially. Such a personality shows suggestions of an inner deviation qualitatively similar to what is found in the fully developed sociopath. The shrewdness is typical. Unlike others, such as Max, whose cleverness brings only momentary success in objective dealing with the world, this man's similar cleverness is applied with enough persistence for him to advance continuously. He advances financially and, within limits, even professionally. He is a smart fellow and, in a very superficial sense, has a glib facility in medical activities. In relations with the public he shows an excellent knack, an artful sense of showmanship. For the more fundamental questions that immediately confront a person interested in psychiatry he apparently has no awareness, and therefore no concern. The problems of life that make up the chief and underlying interest for real psychiatrists do not exist for him. He is said to give many of his patients about what they feel they need. With relatively uncomplex and emotionally shallow persons his amazing self-confidence is perhaps more quickly effective than the deeper understanding, with its inevitable lack of certainties, that another sort of man would bring to his work. His patients are reported to show improvement that compares favorably with that shown by most of the patients treated by physicians whose aims are more serious. We must not forget that pseudoscientific cultists frequently succeed in relieving psychoneurotic patients of their symptoms by absurd measures. These practitioners, if they work in accordance with the fundamental principles of their craft, have no awareness of the real problems underlying such symptoms and little or no ability to help patients understand and deal with these problems. Such a man as this appears to be similarly limited. If one imagines his attempting pertinent psychiatric study of a seriously motivated person, of a person whose world is quite foreign to him, the picture becomes farcical. This man then, the traits already mentioned notwithstanding, is one who, unlike the obvious psychopath, succeeds over many years in his outer adjustment. Granting that the behavior just described is fairly typical and is persisted in, the conclusion follows that inwardly he is very poorly adjusted indeed, The quality of happiness he knows and the degree of reality in which he experiences so much that is major in human relations are such that, despite his superficial success, he must fail to participate very richly in life itself. Let it be pointed out that the drunkenness, immature sex attitudes, execrable taste, and deceit are not in themselves the basis for suspecting that this man is affected in some measure with the same disorder that affects the patients presented previously. Many readers would perhaps dismiss all this with the thought that our man might be more properly called a bad fellow and his status left at that. The significant points are these: His impulse to drink does not seem to be motivated by the hope of shared gaiety. His attitude in sexual aims is so self-centered as to give the impression that even when carrying out intercourse with women he is essentially solitary, isolated in evaluations so immature that what satisfaction he achieves must be in concepts of a phallic damaging and despoiling of the female with simultaneous reassurances to puerile concepts of his own virility. Such confusing and fragmentary achievement, common enough in a groping boy of thirteen, is a poor and pathologic substitute for fulfillment compatible with deep personality integration and is inadequate for one even remotely as near adult as what is implied by this man's outer surface. His lack of taste and judgment in human relationships seems inconsistent with his opportunity to learn and with his ability to learn in other modes of knowing where such values and meanings do not enter. His apparent hypocrisy is probably not a conscious element of behavior. At least he is unaware of how it would seem to others, even if he assumed all the facts were known to them. It has, perhaps, never occurred to him that there might be people in the world who had other fundamental aims than his own dominant aim to drop the disguise in which he has acted his part perhaps not too comfortably during the week, and plunge into what I would call activity more representative of perverse or disintegrative drives, of aims at sharp variance with everything his outer self seems to represent. I am well aware that many basic impulses appear in forms not socially acceptable, that they might be called immoral, vulgar, or criminal or be described by other unpleasant words. The person here discussed, when seen without his mask, seems not to be directed in any consistent and purposive scheme by these socially unacceptable tendencies but largely to blunder about at their behest. In his outer front he functions in accordance with all the proprieties, large and small, but here the reality is thin and personal participation halfhearted. He is somewhat like a small boy who succeeds in maintaining decorum and even in getting a good mark for conduct while in the schoolroom under teacher's watchful eye. Though he looks attentive, he is only shrewdly compromising, biding his time to get at what is to him more important. When the bell rings and he escapes from what he finds to be an artificial situation, an area of formalities and polite pretenses, he becomes natural and plays in accordance with what he takes to be the actual rules and real aims of existence. The small schoolboy learns eventually to reconcile what the classroom represented and what he sought in his hours of play. He finds in his work responsibilities and ways of celebrating much that is compatible, a core at least, that he can integrate into constructive, self-fulfilling, and, on the whole, harmonious expression of basic impulses. In such a man as the one we are considering, little harmony of this sort appears. Unlike those presented as clinical psychopaths, he has learned to carry out the formalities rather consistently and appears as actually living in a constructive and socially adapted pattern. Actually this is a surface activity, a sort of ritual in which not much of himself enters, For his more natural and inwardly accepted impulses he has found little reconcilable with what he gives lip service to. So he must turn to patterns of behavior so immature and (subjectively) chaotic that they mock and deny all that his surface affirms. The outer layers of socially acceptable functioning extend little deeper into affect than any other exercise empty of all but formality. He has apparently learned to carry out a lip service in matters that he finds unreal and tedious and to take pride in how well this is performed. As an alternative to the barren channels of formality, the inner man finds for the more valid fulfillment of real impulse only pathways or outlets that sharply deviate from the surface channels, that cannot in any way be integrated with them, and that in themselves remain relatively archaic, poorly organized, undirected toward any mature goal, and socially regressive or self destructive. It is confusing to interpret such a personality in terms of bad and good. From a psychiatric viewpoint, at least, such aspects of a maladjusted human being cannot be assessed authoritatively. Years after the incidents recorded in this report, some news of the good doctor was received which I believe would stand as "Paradox in Paradise." It was brought to the young psychiatrist who had accompanied Dr. _____ during the spree just cited by an earnest, middle-aged lady with a strong penchant for talking about psychology and psychiatry and psychoanalysis, about anything containing the prefix psyche for that matter. Striking at once for her hearer's closest interests, she began to talk about a wonderful lecture she had recently heard in a distant town at some woman's club or literary society which was fostering the cause of mental hygiene. The lecturer was marvelous, she insisted. He stirred up such enthusiasm that half the ladies present had begun to study psychology. And his subject! He talked about the queerest people! They were not exactly insane, but they really did the most fantastic things! They were even harder to understand than lunatics themselves! But the lecturer understood them, though he confessed in all modesty that some points about them were a puzzle even to one of his own experience. He was a most impressive person - so poised and authoritative, yet always quiet-spoken. He was such an intellectual person. A man of wide and profound culture. And such a gentleman! "I declare, I believe half of the women in our club wished they could exchange roles with his wife! With all that grasp of psychology, just imagine what a husband he must be!" She would like to learn more about these people . psychopathic personalities or psychopaths the doctor had called them. And the doctor's name . She uttered it in hushed tones of admiration.