CHAPTER XVII

THE PSYCHOSES WITH PSYCHOPATHIC PERSONALITY

The introduction of the term psychopathic personality is probably to be attributed to the description of "Die Psychische Minderwertigkeiten" by Koch in 1893. These were referred to by Morel[337] as "Psychopathic Depreciations," a group in which he says Koch included "a very large number of these psychical manifestations, so varied in their nature and intensity which, without belonging to the class of mental diseases proper, cannot, nevertheless, be reconciled with the idea of perfect mental sanity." These were described as being either congenital or acquired and including psychopathic predisposition, psychopathic defect and degeneration. To congenital defects were attributed the "Eccentrics, disequilebrated, overscrupulous and capricious persons, foolish, misanthropes, redressers of wrong, reformers of society, etc." In the degenerative processes he included mental deficiencies both intellectual and moral. Meyer,[338] who based his conception of "constitutional inferiority" largely on the work of Koch, says that the latter by "Psychische Minderwertigkeiten" "meant those little defects which constitute the inferiority of the individual in the whole strife of life, that inferiority which does not allow him to come up to an actually efficient balance in the struggle of life.... They were oddities, peculiar nicks in the personalities of the various people, and he designated those as constitutionally inferior." Koch in this grouping unfortunately included hysteria, psychasthenia and neurasthenia. Meyer eliminated these: "I wanted to do justice to the hysterias and psychasthenias which I could define as such, but I knew there was a whole group of cases in which the definition could not be pushed. I also knew that it was difficult to give the definition in the downward line towards imbecility, and since it was so very hard to give the definition in the individual cases, I thought that the least trouble would arise from making a relatively large group of 'inferiorities not sufficiently differentiated' and let those be entered under the heading of 'constitutional inferiority.'"

The original conception of this group was that it included intellectual defects which have subsequently been classified with the mental deficiencies, leaving only those cases showing purely psychopathic taints of a constitutional origin. There have been numerous other descriptions of these conditions. Ziehen[339] included under the psychopathic constitution "chronic, psychopathic conditions, which in their symptomatology and course not only involve defect of the affectivity but also of the intelligence, even though pronounced psychopathic symptoms, such as delusions, hallucinations, etc., do not intrude for any extended period. Where hallucinations and analogous symptoms do appear they are solitary and the patient retains insight into the condition." Ziehen's psychopathic constitution covers a very wide field, including not only hysteria and neurasthenia but epilepsy.

The psychopathic personalities as described today represent only a modern interpretation of conditions which have been given ample consideration in the psychiatric literature of the past. An early illustration of this fact is Pritchard's definition of "moral insanity" in 1835:—"A morbid perversion of the feelings, affections and active powers, without any illusion or erroneous conviction impressed upon the understanding; it sometimes coexists with an apparently unimpaired state of intellectual faculties." The psychopathic states were undoubtedly fully covered in Morel's description of the insanity of degeneracy in 1860. This he divided into cases arising from constitutional nervous temperaments, moral insanity, the feebleminded with or without morbid impulses, and those with criminal tendencies. This conception was well summarized by Diefendorf[340]:—"The disharmony of the intellectual and the moral faculties is one of the most striking features of degeneracy. As in the defects of the intellectual development, so in the moral sphere, the condition varies from a complete arrest of moral development to all forms of moral perversion and even to an abnormal development of the moral and emotional susceptibility. All of these conditions may exist, with a perfect development of the intellectual faculties.... The professional criminals should also, without doubt, be included in this class, as they present all possible varieties of moral perversions and anomalies, all of which may exist with preservation of the intellect and even with intellectual keenness."

Magnan described compulsions, impulsions and contrary sexual instincts as episodes of the insanity of degeneracy. The psychopaths were undoubtedly the "déséquilibrés" or ill-balanced individuals of Régis,[341] whose work on "Mental Medicine" included an exceedingly elaborate discussion of the so-called "borderline" conditions. "After maturity they are complex beings, heterogeneous, made up of disproportioned elements, contradictory qualities and defects, and as over-endowed in some directions as they are deficient in others. Intellectually, they often possess in a very high degree, the faculties of imagination, of invention, and of expression, that is to say, the gifts of speech, the arts, and poetry; on the moral side, they possess a singular emotivity, or rather, sensibility. What they lack, more or less completely, is good judgment, the moral sense, and especially continuity or logical consecutiveness, a unity of direction in intellectual production and the actions of life. It follows, that in spite of their often superior qualities, these persons are incapable of conducting themselves in a rational manner, of following regularly the exercise of a profession that seems well beneath their capacity, of looking after their interests or those of their families, of carrying on business prosperously or of directing the education of their children; their existence, therefore, constantly recommencing, is one long contradiction between the apparent wealth of means and poverty of results. They are the utopians, the theorists, the dreamers, who are enamored with the best things but accomplish nothing. The public which sees only the brilliant exterior looks upon these individuals as artists and superior beings. The medal is reversed, however, to those who are compelled to associate with them and share their existence; they see their defects, their incapacities and evil tendencies, of which they are not merely the witnesses, but also the victims. Aside from their lack of mental poise these individuals also display an excessive emotional sensibility and an enfeeblement of psychic energy that reveals itself by a noticeable predominance of spontaneity over reflection and volition. Hence their inability, their instability, and their irresolution; hence also their alternations of apathy and activity, of excitement and torpor, their violent attacks of passion and their cries of despair for the most trivial and slightest reasons." Régis divided the "psychic discordances" or disharmonies into the ill-balanced, the original and the eccentric. These were all included in the degeneracies of evolution. Clouston covers this same ground fully and in a somewhat similar manner in his "Unsoundness of Mind" (1911).

The insanities of degeneracy have also been given considerable space by such Italian writers as Lombroso, Bianchi, etc. Lombroso in "The Man of Genius" (1888) discussed this subject as follows:—"A theory, which has for some years flourished in the psychiatric world, admits that a large proportion of mental and physical affections are the result of degeneration, of the action, that is, of heredity in the children of the inebriate, the syphilitic, the insane, the consumptive, etc.; or of accidental causes, such as lesions of the head or the action of mercury, which profoundly change the tissues, perpetuate neuroses or other diseases in the patient, and, which is worse, aggravate them in his descendants, until the march of degeneration, constantly growing more rapid and fatal, is only stopped by complete idiocy or sterility. Alienists have noted certain characteristics which very frequently, though not constantly, accompany these fatal degenerations. Such are, on the moral side, apathy, loss of moral sense, frequent tendencies to impulsiveness or doubt, psychical inequalities owing to the excess of some faculty (memory, aesthetic taste, etc.) or defect of other qualities (calculation, for example), exaggerated mutism or verbosity, morbid vanity, excessive originality, and excessive preoccupation with self, the tendency to put mystical interpretations on the simplest facts, the abuse of symbolism and of special words which are used as an almost exclusive mode of expression."

Several other very elaborate works have been published on the subject of degeneracy. One of the better known of these perhaps is that of Max Nordau on "Degeneration" (1894). The book of Grasset[342] on the "Demifous et Demiresponables" has been translated into English and constitutes one of our most valuable contributions on this subject. Grasset credits Trélat with making the first comprehensive study of the semi-insane in his "La Folie Lucide," etc., in 1861. His classification of these conditions included imbeciles, the feebleminded, satyrists, nymphomaniacs, monomaniacs, erotomaniacs, jealous individuals, dipsomaniacs, spendthrifts, adventurers, the conceited or boastful, evildoers, kleptomaniacs, suicides and the inert and lucid manias. Grasset gives some interesting illustrations of the psychopathic traits of various men of genius. Tolstoï fell sixteen feet as a result of attempting to fly when eight years old, and whipped himself with ropes to become accustomed to pain. In school he chose a course in Oriental languages because everyone else was interested in law. Not being able to finish a college career in two years, he decided to go to a desert and live a purely animal life. It was necessary for him to resort to devices of various kinds to prevent suicide. Rousseau was at various times a clockmaker, music master, painter and servant in addition to studying medicine, music, theology, and botany. He dedicated a pamphlet "to all Frenchmen who were friends of justice" and distributed it on the streets. One of his acts was to write a letter "to God Almighty" and place it under the altar of Notre Dame. Persecutory ideas were entertained by him for years. Emile Zola was evidently a psychasthenic as well as a psychopath. He counted the gas jets on the street, the numbers on the doors, and the cabs passing by. These were added together. "For a long time the multiples of three seemed to him of good omen, then the multiples of seven were reassuring." "For a long time he was afraid he would not succeed in any proceeding on which he was about to enter if he did not leave the house with his left foot first." Balzac had an ambulatory mania and could not be found when called for military service. It is said that on one occasion "when he had put on a handsome new dressing gown he wanted to go out into the street with it on with a lamp in his hand to excite the admiration of the public." His father is said to have stayed in bed for twenty years without any reason for so doing, suddenly resuming his former mode of life at the end of that time. Schopenhauer broke a hotel proprietor's arm because he heard him talking outside of his room. He refused to pay a legitimate account because his name was spelled with two p's instead of one, on the bill. He often burned his beard instead of shaving and wrote his notes in Greek, Latin and Sanskrit for fear someone would read them. In his will he left all of his possessions to soldiers and to his dog. Goethe alternated between great joy and extreme depression and had unjustifiable attacks of anger. Frederick II had such a dislike for changing his coat that he had only two or three during the course of his life. When Schiller wanted to meditate he had a habit of putting his feet on ice and sniffing the aroma of fermenting apples. Nordau says "that Richard Wagner is accused of having a greater degree of degeneracy than all the degenerates that we have thus far seen put together." Mozart played the harpsichord at three years of age, composed concertos at five and made a concert tour at the age of six. He was extremely nervous and fell in love at fifteen with a girl of twenty-five. In the last months of his life he was obsessed with the idea that he had to prepare his own funeral mass. Lombroso's theory is that "genius is a true degenerative psychosis, belonging to the group of moral insanities which may temporarily spring from other psychoses and take their form, but always conserving certain special characteristics which distinguish it from the others." Although his conclusions may not be warranted it must be admitted that many men of genius have been psychopaths.

Kraepelin[343] in discussing the influence of heredity on psychoses and personalities, says, "Hence we may, perhaps, discriminate between congenital states of disease and morbid personalities, according as the disturbances are apparently the expression of the morbid conditions of past generations, or seem to be purely personal abnormalities, although it is certainly impossible to make any sharp distinction." In 1915, in the fourth volume of his eighth edition, Kraepelin devoted nearly one hundred and fifty pages to the subject of psychopathic personalities. These he divides into the excitable, the unstable, the impulsive, the eccentric, the liars and swindlers, the antisocial or enemies of society, and the quarrelsome.

A study of the "excitable" psychopaths in Kraepelin's[344] clinic showed the intellectual standard of these individuals to be above the average. Apprehension and judgment were unimpaired even when mental inferiority was not entirely lacking. Some complained of poor memory or absentmindedness, others of a feeling of fatigue. A definite mental activity was noted, usually of a happy mood, but occasionally with depressive tendencies. The characteristic feature was an emotional excitement, associated often with violent rages, without any adequate reason. The emotional reaction changed quickly to one of despair, anxiety, irritability or inaccessibility. The mood in a large number of cases was depressed and tearful, while others were cheerful and elated, laughing and joking, or erotic. Often without any apparent cause, irritability, pessimism, unsociability, weariness of life and thoughts of suicide appeared—more particularly during menstrual periods. The emotional state as a rule was kind, affable, good-natured, tractable, often religious, sensitive or sympathetic. The patients are often spoken of as well-liked, industrious, honest and substantial citizens. Some are timid, bashful or gloomy in disposition. Others are conceited, overbearing, tyrannical, rude, unsociable and quarrelsome. Many are childish, foolish or eccentric, highstrung and affected or untruthful. Some are unsteady, restless and over-occupied, full of schemes, rash, talkative, gossiping, and assuming striking mannerisms. Occasionally they are disinclined to any regular occupation, neglect their work, loaf around and are supported by their relatives. In sixty-two per cent of these cases the patients were brought to the clinic on account of suicidal tendencies. This was due to reduced circumstances in nearly fifty per cent of the men and in seventy-one per cent of the women. In the men marital troubles and love affairs were more common; sometimes loss of position, or death in the family, etc. Spurious attempts at suicide of a theatrical type were frequently reported. Next to suicidal inclinations as a cause for being brought to the clinic there were assaults, attacks of rage and outbursts of despair. In any stress or anger over a disagreeable occurrence these individuals are likely to become abusive, shout, scream, run around, strike the head against the wall, tear their clothes off, pull out their hair, etc. Some rush around all night in the streets in a senseless rage, improperly clothed. Occasionally they attack others unjustifiably and for no apparent reason. They are exceedingly susceptible to alcohol. During their excitements, consciousness may be clouded. Afterwards they say they were confused, not themselves, in a dream as it were, etc. Some have no recollection whatever as to what was done. These excitements rarely last more than a few hours. Thirty-two per cent of the men and less than ten per cent of the women were convicted of crime, usually for disturbing the peace, or criminal assaults, but occasionally for much more serious offenses. As a rule alcohol is a factor in these cases. The relations between the sexes are characterized by jealousy and quarreling. The women are particularly likely to have delusions of infidelity. Genuine hysterical attacks occur in a certain number of cases. They often see visions and may have dizzy spells or syncopes. Somnambulism may occur. Nervous symptoms often appear—headaches, unpleasant dreams, palpitations, tremors, increased reflexes, tics, etc. The excitable cases constituted nearly one-third of the psychopaths admitted at Kraepelin's clinic. Sixty per cent of these were women. The majority of cases were between fifteen and twenty-five years of age. Heredity appeared to be a factor in forty-seven per cent and many showed physical defects. Fifty per cent of the men were intemperate.

The "unstable" psychopaths are characterized by a dominating weakness of the will. In nearly one-half of the cases the intellectual endowment is normal, some having a surprising power of comprehension and ability to take up new things, with accurate observation of their surroundings and keen discrimination. These persons have no great persistence and do not exert themselves, are inattentive, tire easily and are distractible. They never go into things deeply and have only a superficial knowledge of events. They learn readily and forget quickly. The memory is poor and unreliable. The imagination is usually very active, with a tendency to exaggerate, dream of the impossible and relate great stories. There is an inclination to boast and fabricate, telling of wonderful but wholly imaginary deeds and accomplishments. They often represent themselves to be important personages. Some show artistic talent, write plays or fantastic poetry and discuss literary and dramatic problems. They are strongly inclined to become actors. The higher intellectual development is uniformly defective. Comprehension is not clear and judgment is immature and short-sighted. Their interests are devoted to frivolous matters without much attention to more important questions. They sometimes show great prospects in school but do not fulfill them later. The mood is cheerful and conceited, with a very high opinion of themselves and great ambitions. They blame their relatives for their lack of success and claim they are not understood or appreciated. Sometimes the emotional trend is more sad and gloomy. They complain of being unlucky, everything goes wrong. Occasionally anxieties appear, with a feeling of oppression, fear of being alone, of mental troubles or suicide. These feelings are, however, superficial in character, usually disappearing in a short time, to be followed by excitement, outbursts of anger or anxiety. They are often quarrelsome. The characteristic disturbance, however, is that of the will. They are entirely lacking in the capacity to stick to any one occupation. They are not punctual, are interfered with in innumerable ways and often change their work, looking for something more suitable. Hypochondriacal notions hamper their activities. Senseless journeys and trips are often undertaken. Some become vagabonds and tramps. They are much inclined to bad company and resort to immoderate use of tea, coffee, drugs and alcohol. Sixty-four per cent of Kraepelin's male cases and twenty per cent of the women were intemperate. The sexual habits are very often irregular and venereal diseases to be expected. Kraepelin found either gonorrhea or syphilis in twenty-two per cent of the women examined. Some exhibited homosexual tendencies. Many become spendthrifts, making extravagant and foolish purchases. They are inclined to speculate unwisely. Fifty-four per cent of the men and nearly a third of the women as a result of their moral deterioration come into conflict with the courts on account of thefts, assaults, quarrels, vagrancy, etc. Suicidal tendencies were shown in forty-eight per cent of the men and sixty-five per cent of the women in Kraepelin's clinic. In many cases these were induced by alcoholism, in other instances by family quarrels, etc. Often the reasons given were foolish. Hysterical attacks appear in a certain percentage of cases in the women. Some had hallucinations and confusional attacks or syncopes. Tremors, headaches, increased reflexes and other neurological symptoms occasionally appeared. The "unstable" group included about one-fifth of the psychopaths observed by Kraepelin. Thirty-six per cent of these were women. The majority of those admitted were between the ages of fifteen and twenty-five. Heredity was a factor in forty-nine per cent of the cases.

The "impulsive" psychopaths are characterized by a domination of the conduct by emotional impulses. The intellectual makeup of these individuals is usually good. They often have a special bent for art, music, poetry, etc. They frequently show a considerable mental activity and versatility. They express themselves well, make witty remarks and appear brilliant, although they may complain of absentmindedness or fatigability. They are always conceited, born to greater things and have a great future. There is an almost unbounded egotism in some cases. The emotional tone is good-natured, easygoing and accessible. Many are sensitive and visionary; others obstinate, inconsiderate, pretentious or quarrelsome. The mood is usually high-spirited and confident but variable. The patients are often depressed and hopeless, complaining of their luck. At other times they are sullen, surly, irritable and faultfinding. Many exhibit suicidal tendencies. An emotional irritability is exceedingly common, with violent outbursts of anger. Often they refuse to associate with others for a time and will speak to no one. The three common types are the spendthrift, the wanderer and the dipsomaniac. The spendthrifts usually indulge in alcohol and naturally soon contract enormous debts. They frequently have little insight into their condition or blame someone else for it. Many become wanderers and go aimlessly from one place to another—wherever their inclination leads them. The memory for these events is good. Some inadequate reason is always offered. These wanderers usually are children between the ages of ten and fifteen. The impulsive alcoholics may have attacks very rarely, sometimes only once a year. Debauches are preceded by restless and moody conduct. After constant drinking for days or weeks they sometimes have suicidal impulses. Sexual excitements may occur. They always show psychopathic traits between attacks. They are unsteady, unreliable, make sudden resolutions, change their occupations and residence and lead a wild existence with surprising adventures. Some have hysterical attacks, fainting spells, or even convulsions. The impulsive psychopaths constituted only two or three per cent of Kraepelin's cases. Practically all were over twenty-five years of age. There was a hereditary taint in seventy-one per cent of the cases.

The "eccentric" psychopaths are characterized by a lack of uniformity and consistency in the mental makeup. The intellectual endowment of these individuals is usually normal. They are often absentminded, forgetful and show a variation in productivity. Some are artists or devote themselves to inventions. Judgment is impaired and reasoning becomes distorted and onesided. There is a tendency towards exaggeration and extravagance in their viewpoints, with a leaning towards queer notions. They are often quickwitted, versatile and write long and wordy documents. Their mode of expression is bombastic and labored, and the content of speech or writing, verbose, desultory, flighty and full of meaningless expressions. They show a certain shrewdness and cunning, dissimulate, resort to all kinds of evasions, and are conspicuous in their conduct. Occasionally there is a tendency towards delusional ideas of a mild form. As a rule the mood is cheerful, although often depressed, suspicious or irritable. They are opinionated, boastful and better than others. Usually there is an emotional excitability. The patients are sensitive and irritated by small things, scold and complain. Sometimes they are sentimental and dreamy, with extravagant language. They often take sudden dislikes to brothers, sisters or other members of the family. They are capricious, quarrelsome, and faultfinding. Their conduct is aimless, contrary and incomprehensible. They lose all capacity for judgment of real conditions. They cannot proceed in any orderly way in things which they are really fitted for. They do not stick to anything long, changing plans and occupations frequently. They often go about at night talking, arguing and drinking. It is not unusual for them to quarrel with their wives or even commit assaults. The majority of these eccentric psychopaths were men over thirty-five and of degenerate families. This group constitutes only a small number of cases.

The "liars and swindlers" are characterized by an excitability of the imaginative faculties and a variable and uncertain will power. At first these individuals are likely to appear as unusually gifted persons. They are good-natured, present an excellent appearance and are apparently well informed on almost all subjects. They have a faculty for quoting foreign languages and sometimes are familiar with many tongues. Often they are brilliant conversationalists. On investigation their actual knowledge is found to be very superficial. They are inclined to art, poetry and literature. Many become interested in hypnotism or spiritualism. They are inclined to join religious sects or attach themselves to the Salvation Army. These individuals learn quickly but do not stick to things long. Their mental powers are not orderly or consistent. They have an extraordinary imagination but accomplish nothing. They are liars from birth, the falsifications usually being entirely useless. Many are anonymous letter writers. They are often unable to discriminate, themselves, between the true and the false in their own stories. These fabrications appear to be an emotional product, the imaginary occurrence practically always relating to the individual himself. They boast of their superiority in literary and scientific accomplishments and claim to be theologians, mathematicians, jurists, chemists, etc. In their imaginations and fabrications the patients always better themselves. In many instances they assume pretentious titles, represent themselves as counts, princes, etc. Sometimes they strongly suggest paranoia. In a small number of cases self-accusations appear and they confess to all kinds of imaginary crimes. As a rule they are elated and optimistic, but often affected and theatrical. Occasionally suicidal attempts are made. At times general depressions or anxious states appear. Some are coarse and deceitful. They are usually uncertain and capricious in everything. Some become spendthrifts. They are naturally cheats and swindlers; occasionally thieves. The swindling schemes resorted to are innumerable. The use of false names and assuming of uniforms and titles of various kinds is the most common. They make purchases of all kinds without any ability to pay or any intention of doing so. Many refuse to pay bills without any excuse whatever. Others attempt to marry rich women by deceitful means and misrepresentations. Some practice medicine without a license; others claim damages for imaginary injuries. Sexual offenses are common. If arrested they are often inclined to claim amnesia for the period of time when the act was committed. They occasionally have genuine psychoses and hysterical attacks. These simulate various diseases. The group of liars and swindlers constituted from six to seven per cent of the psychopaths in Kraepelin's clinic. Seventy-one per cent of the men were accused of crimes. The majority of cases were under twenty-five years of age. Heredity was a very important factor.

The "antisocial" psychopaths or enemies of society are characterized by a blunting of the moral elements of their makeup and a lack of adjustment to their environment. Kraepelin found that forty per cent of his cases were persons who had done well in school. They have a strong dislike for regular occupations and avoid them in every possible way. Their behavior is variable, with a tendency to be industrious occasionally and more often lazy. Frequently they appear queer, abstracted, inattentive, dreamy, sleepy or dull. When at their best they are not bright mentally and have no ambition or far reaching interest. They learn quickly and forget as rapidly. Their store of knowledge is very limited. They have no capacity for going into things thoroughly and cannot acquire a higher education. They are lacking in judgment, foresight and discrimination. Many have a weakness for cheap stories of adventure, pictures of crime, etc. In expression they are usually quick as well as verbose. A characteristic is their lack of truthfulness. They are liars and braggarts. The mood is usually cheerful and confident; sometimes arrogant, surly, moody, irritable and occasionally depressed or anxious. They change unexpectedly from one mood to the other. Irritability, with outbursts of anger, is common. They often become threatening and destructive. Eighteen per cent of Kraepelin's cases attempted suicide. At least one-third of these were theatrical attempts on account of fear of punishment. Childish vanity and conceit is a very common symptom, with boastful tendencies. A prominent feature is the lack of any deep emotional reactions. They do not react normally and properly to their surroundings. Another characteristic defect is their entire lack of sympathy for anyone else. They are likely to be cruel to animals as well as persons. They show little affection for parents, children or relatives and are lacking in a sense of decency and personal cleanliness. As children they are exceedingly troublesome in school. Some have to go to custodial institutions for care. Many are truants at school and run away from home, becoming wanderers and vagabonds. They are inclined to sexual excitement, irregularities and crimes of various sorts. Seventy per cent of Kraepelin's cases were thieves, beginning to steal as children; twenty per cent were embezzlers and twelve per cent guilty of fraud or forgery. Practically every variety of crime was represented. They exhibit an extraordinary tendency to revert to criminal habits. Prison life makes some submissive but starts others in a war against society. They often attempt violence or make passive resistance to the law. They occasionally develop hypochondriacal tendencies. Friendly advances are greeted with mistrust. Some are stubborn, sulky, unrepentant and have nothing to say, or lie and explain by putting the blame on others. Thus an opposition to all organized society develops. They often look upon themselves as martyrs. Others take the situation lightly and minimize the gravity of their position. Some seem to really see the error of their ways. The antisocial individuals sooner or later, like other psychopaths, are very prone to hysterical attacks, fainting spells, or even convulsions. Anesthesias and hyperesthesias may be noted. Some patients complain of headache, disturbed sleep, dreams, etc. The antisocial in Kraepelin's clinic constituted less than ten per cent of the psychopaths, of which seventy per cent were men. Half of the women were prostitutes. Over eighty per cent of the cases were under twenty years of age.

The intellectual makeup of the "quarrelsome" psychopath is usually fairly good. As a rule these persons show a narrowing of the intellectual sphere, with, however, a well-defined shrewdness which enables them to take advantage of others. Some show a tendency to pedantry and hair-splitting arguments. Memory is good but distorted by an emotional coloring. Judgment is warped and unreliable. They are credulous and accept statements without proof, but they look with suspicion on anything not in accord with their own ideas. The influence of these factors leads to an emotional excitability. They are always passionate, sensitive individuals who become excited over trivial matters. This is complicated by a marked self-confidence, minimizing their own failings. Quarrels are the inevitable consequence. Everything is exaggerated in importance. The conclusion is reached that the neighbors and others are all organized against them. Sometimes the feeling of enmity is transferred from one individual to another. The patient is constantly in trouble with someone. They are almost invariably of the male sex and usually of middle age or older when they come under observation.

For statistical purposes the differentiation of the psychopathic personalities has been described by the Association's committee as follows:—

"Under the designation of psychopathic personality is brought together a large group of pathological personalities whose abnormality of makeup is expressed mainly in the character and intensity of their emotional and volitional reactions. To meet the demands of current usage, the term for this group has been shortened from the older one "psychoses with constitutional psychopathic inferiority" with which it is synonymous. Individuals with an intellectual defect (feeblemindedness) are not to be included in this group.

"Several of the preceding groups, in fact all of the so-called constitutional psychoses, manic-depressive, dementia praecox, paranoia, psychoneuroses, etc., may be considered as arising on a basis of psychopathic inferiority or constitution because the previous mental makeup in these conditions shows more or less clearly abnormalities in the emotional and volitional spheres. These reactions are apparently related to special forms of psychopathic makeup now fairly well differentiated, and the associated psychoses also have their own distinctive features.

"There remain, however, various other less well differentiated types of psychopathic personalities, and in these the psychotic reactions (psychoses) also differ from those already specified in the preceding groups.

"It is these less well differentiated types of emotional and volitional deviation which are to be designated, at least for statistical purposes, as psychopathic personality. The type of behavior disorder, the social reactions, the trends of interests, etc., which psychopathic personalities may show give special features to many cases, _e.g._, criminal traits, moral deficiency, tramp life, sexual perversions and various temperamental peculiarities.

"The pronounced mental disturbances or psychoses which develop in psychopathic personalities and bring about their commitment are varied in their clinical form and are usually of an episodic character. Most frequent are attacks of irritability, excitement, depression, paranoid episodes, transient confused states, etc. True prison psychoses belong in this group.

"In accordance with the standpoint developed above, a psychopathic personality with a manic-depressive attack should be classed in the manic-depressive group, and likewise a psychopathic personality with a schizophrenic psychosis should go in the dementia praecox group.

"Psychopathic personalities without an episodic mental attack or any psychotic symptoms should be placed in the _without psychosis_ group under the appropriate subheading."

Unfortunately there are no statistics which show the incidence of psychopathic personalities in the community. A study of 70,987 first admissions to state hospitals shows that the psychoses associated with this condition constituted only 1.12 per cent of the total number. On the other hand, the reports of the Phipps Psychiatric Clinic show an admission rate for psychopaths of over six per cent during a five-year period. When they reach a state hospital it is usually owing to the development of manic-depressive insanity or some other well-defined psychosis. The important and troublesome cases from a social point of view are those that do not reach hospitals. A much larger percentage is to be found in institutions of the correctional and penal type. There is no greater problem today than the attitude of the state towards the psychopathic criminal. The influence of these individuals on the community at large is something that we have no means of estimating at the present time.