Moral insanity was a diagnosis that described a form of mental disorder consisting of abnormal emotions and behaviours in the absence of intellectual problems, delusions or hallucinations.
The physician James Cowles Prichard coined the term in 1835 in his Treatise on insanity and other disorders affecting the mind. He defined moral insanity as: "madness consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses, without any remarkable disorder or defect of the interest or knowing and reasoning faculties, and particularly without any insane illusion or hallucinations."[1][2][3]
The concept of moral insanity was indebted to the work of physician Philippe Pinel, which was acknowledged by Prichard. Pinel had described mental diseases of partial and affective insanity. His concept Manie sans délire (Latin - mania sine delirio; French - folie raisonnante or folie lucide raisonnante, monomanie affective; German - Moralisches Irresein[4]) referred to insanity without delusion, a form of partial insanity. That is, the sufferer was thought to be mad in one area only and that thus the personality of the individual might be distorted but his or her intellectual faculties were unimpaired.[5]
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Overall, Prichard defined insanity as a "chronic disease, manifested by deviations from the healthy and natural state of the mind." He then proposed four broad categories. Moral insanity was for disorders that only seemed to arise from a person's feelings and habits, not their intellect. The other three types involved increasing degrees of intellectual abnormality: a partial derangement that was limited to certain trains of thought; a full mania, by which was meant 'raving madness' regardless of topic; and lastly, a breakdown of any connections between ideas, referred to as incoherence or dementia.
Prichard considered that some early nosologists, namely Sauvages, Sagar and Linnaeus, had distinguished between medical conditions with hallucinations and those involving depraved appetites or feelings. But he credits Pinel as the first in psychiatry to clearly distinguish madness without delerium, in opposition to Locke's widely accepted axiom that insanity always stemmed from faulty intellectual connections or mistaken perceptions. Prichard also considered a complex categorical scheme developed by Heinroth, concluding that a number of disorders in different divisions of that scheme would be more simply gathered under the heading 'moral insanity'. He suggested the category could also be termed 'parapathia', or alternatively 'pathomania' by analogy with monomania.
The latter term had been introduced by the physician Esquirol, referring to a form of insanity where there is a fixation or abberation in only one area, thought to be caused by a split in the faculties of the mind. In Prichard's scheme, the first category of intellectual insanity was considered monomania. This meant that the symptoms of moral insanity could increase, causing a degeneration into monomania.[6] "On the surface, monomania can thus appear even more circumscribed a form of derangement than moral insanity."[7] However, Esquirol considered moral insanity to be only one form of monomania.[8]
Contemporary misunderstanding of the term derives from the double meaning of the word "moral" in the nineteenth century context. According to Erdmann Mueller (1899, author of a comprehensive treatise on moral insanity): "the word moral in the concept moral insanity is derived from the word affective in Esquirol's terminology, and the translation of moral as virtuous or ethical is the result of a misunderstanding due to the double meaning of the word."[9] According to Pinel, manie sans délire (mania without delusion) had no relation to the moral faculty.[10] Moral insanity was a form of mental derangement in which the intellectual faculties were unaffected, but the affects or emotions were damaged, causing patients to be carried away by some kind of furious instinct (instincte fureur).[10] Likewise the term moral treatment referred to a set of psychosocial techniques rather than ethical practice.[11] Under Pinel's guidance, patients were freed from chains and shackles.[12]
However, some did put a moral, in the sense of ethical, slant on it. Henry Maudsley saw it as a sign of poor moral willpower or sense. Daniel Hack Tuke asserted that while it may appear to stem from the emotions, it was often due to a weakening of the 'higher centres' of will, and he thus suggested a new name 'inhibitory insanity'. Moral insanity was also increasingly seen as a form of genetically-inherited degeneracy,[9] and toward the end of the 19th century and into the 20th century converged with ideas of moral imbecility and deficiency, as well as with an anti-vice moral hygiene movement.[13]
Both moral insanity and monomania were depicted in Victorian novels and movies of the time. They were similar in that they were both abnormalities of an otherwise normal mind, though the former was a systemic malfunction and the latter an isolated abberation.[14]
The context leading to the conceptualization of this diagnostic category was undoubtedly borne out of the frustration of alienists (the term is approximately equivalent to the modern day one of psychiatrist) by the definition of madness provided by John Locke in which delusional symptoms were required. In legal trials this definition had proved to be a great source of embarrassment to alienists because unless delusional symptoms could be clearly shown judges would not consider a plea of insanity.[15] It has been suggested that modern conceptions of responsibility have been forged in part through the medical and legal exchanges over moral insanity, including anticipations of the diagnosis in the writings of Benjamin Rush, in the context of religiously-framed common sense conceptions of free will.[16]
Several historians have entirely discredited the notion that the diagnostic category of moral disorder was a forerunner of psychopathic disorder. As stated by the historian F.A. Whitlock: "there [is] not the remotest resemblance between their examples [Pinel's and Prichard's] and what today would be classed as psychopathic personality."[15] Prichard's "moral insanity" was a catch-all term of behavioural disorders whose only feature in common was an absence of delusions: it is not cognate with the modern diagnostic category of antisocial personality disorder.[17]
The German psychiatrist Koch later sought to make the moral insanity concept more scientific, suggesting in 1891 the phrase 'psychopathic inferiority' (later renamed personality) be used instead. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent mental retardation or illness. The diagnosis was meant to imply a congenital disorder without moral judgement, though Koch has been described as deeply rooted in a Christian faith.[18] Toward the mid 20th century the terminology of the 'psychopathic' would become specifically associated with an aggressive and anti-social personality. A more general concept of character disorders came into use by psychoanalysts, and psychiatry later adopted the current terminology of personality disorders.[19]