A Note on MoralInsanity andPsychopathic Disorders F. A. WHITLOCK, Professor of Psychiatry, University ofQueensland, Australia Despite a good deal ofargument to the contrary (Maughs, today. The second patient was probably subject to attacks of 1941; Hunter and Macalpine, 1963; Walk, 1954; Walk and temporal lobe epilepsy with characteristic epigastric sensa­ Walker, 1961; Craft, 1965; Whitlock, 1967) it is still com­ tions rising into the neck and head, but without proceeding monly believed that Prichard's 'moral insanity' (1835) was to a grand mal convulsion. He was a man ofgood character, the forerunner of our present-day concept of psychopathic well aware of his tendency to violence during these episodes, (sociopathic) personality; the most recent example of this and made every effort to avoid harming others by warning appearing in the paper by Davies and Feldman (1981), who them of his attacks. The third patient, the one who was write: 'In 1801 Pinel described a condition termed by him liberated by a mob to whom he appeared rational, but then man;e sans delire, the notable feature of which was that the became infected by the prevailing excitement and laid about sufferer showed bouts of extreme violence but with no signs him with a sword with fatal effects, was almost certainly of psychosis ... Prichard confirmed Pinel's observation and suffering from mania as now understood. coined the term "moral insanity" which led to "a marked Prichard's cases were also diagnostically heterogenous. perversion of the natural impulses".' A number of modem They included cases of mania, manic-depressive psychosis, textbooks (Sim, 1974; Friedman el ai, 1975; Slater and epilepsy, obsessional neurosis, two possible schizophrenics Roth, 1977; Trethowan, 1979) also appear to regard moral and a 46-year-old man who almost certainly was showing insanity as the precursor of psychopathic disorder, although early signs of dementia. None of these patients had shown Trethowan correctly noted how the word 'moral' denoted life-long antisocial behaviour. The case descriptions abound 'affective' and was not being used in the usual ethical sense. in testimonials to the patients' previous good character-'a He went on, however, to write that Prichard described cases gentleman remarkable for the warmth of his affections'; 'her showing antisocial or even criminal behaviour. natural disposition was steady and industrious'; 'a man of A careful examination of the cases mentioned by Pinel sober and domestic habits'; and so on. Only one, a probable (1801) and by Prichard should make it abundantly clear that manic, could be said to have been aggressive and irascible. except for the first of the three patients cited by Pinel, there During his illness he assaulted a clergyman ofhis parish, but was not the remotest resemblance between their examples he made a complete recovery without residual defect. and what today would be classed as psychopathic per­ Faced by diagnoses of this kind one has to search for sonality. Nor do the authors' general delineations of the some common feature which united them under the rubric of disorder conjure up the picture ofpresent-day psychopathy. moral insanity. One thing is certain; antisocial, aggressive Why, one might ask, has the error persisted? One might and criminal behaviour were conspicuously absent in conjecture that few of the writers who maintain the identity individuals who, until their illnesses, had led blameless lives. of moral insanity and psychopathy have troubled to refer to Taking Pinel's concept of manie sans dilire as a guide, the original texts. Another source of confusion is the word Prichard was clearly describing individuals with major 'moral' as used in the early part of the 19th century. Walk affective ('moral') disturbances without 'any remarkable (1954) and Craft (1965) comment on how 'moral' was disorder or defect of the intellect, of knowing and reasoning employed in three ways: as psychological in, for instance, faculties, and particularly without any insane illusion or 'moral treatment' or moral causes ofinsanity; as affective or hallucination.' Their conduct is disturbed as well as their emotional as opposed to intellectual or rational; and in the feelings, but these symptoms are closely allied: 'Propensities ethical sense of right or wrong. Walk and Craft find that are so nearly allied to passions and emotions that they are Prichard used the term throughout his treatise to describe generally referred to the same division ofthe faculties. In my cases of insanity whose emotional and affective faculties classification, disorders of [both] are comprehended under were disturbed, and only later, and incidentally, used it in the the designation ofMoral Insanity.' ethical sense. 'It is hardly justifiable,' Craft writes, 'to In fact Prichard brings out this widely diverse sympto­ attribute the first description ofpsychopathy to Prichard on matology, with absence of intellectual disorder as the only the strength ofthis one passage.' common link, in the following passage: 'The varieties of Of Pinel's three patients given as examples of manie sans moral insanity are perhaps as numerous as the modifica­ dllire-'delire' here meaning delusion (or 'illusion' as tions of feeling or passion in the human mind. The most Prichard calls it}-the first appears to have had a life-long frequent forms, however, of the disease are those which are propensity for unbridled violence and impulsive behaviour characterized either by the kind of excitement already des­ originating in childhood. In the absence of any data on cribed or by the opposite state ofmelancholy dejection. One possible cerebral damage as a cause of this behaviour, it is of these is, in many instances, a permanent state, but there likely that he would be classed as an aggressive psychopath are cases in which they alternate or supersede each other ... 57 The prevalent character ofthe disorder is sometimes derived brain is furnished by the fact that its symptoms sometimes from the constitutional disposition of the individual, but precede for a time the symptoms ofintellectual derangement there are instances in which it is strikingly different from this in a severe case ofundoubted insanity as, for example, a case natural temperament.' Again, in his later book (1847) of acute mania or of general paralysis or of senile dementia'. Prichard wrote, 'The existence of moral insanity is palpable He continued: 'It is interesting indeed to notice that at least and easily recognized only in those instances in which it one of Dr Prichard's cases, on which he founded his descrip­ comes on, as it often does, after some strongly marked tion of the disease, was really a case of general paralysis'. disorder affecting the brain and the general state of health, Maudsley was probably incorrect, as the patient in question, such as a slight attack of paralysis and when it displays a who made a good recovery, was almost certainly suffering state of mind strikingly different from the previous habitual from mania. and natural character ofthe individual.' After elaborating further on the nature of the problem, he Moreover, in Prichard's view, if a patient suffering from wrote: 'In the most typical case of moral insanity which has moral insanity developed some delusional idea, the case come under my observation there had been previous attacks be.came one of monomania. He introduces such cases, of melancholia, and it is upon one of these that the moral classified as monomania, as being ones in which 'the actual derangement directly followed. Such cases commonly end in supervention of erroneous belief or illusion on a previously dementia, the disease of the mind passing into destruction existing moral insanity was clearly marked and admitted of thereof.' Here again the range of conditions this author des­ no doubt', and as illustrating 'the connection between the cribed can be diagnosed without difficulty as examples of two forms of diseases and the transition from one into the recognizable clinical disorders, for the most part devoid of other'. psychopathic features oflong duration. Thus it is clear that, with few exceptions, the cases of These comments bring up a second point ofimportance. It moral insanity described by Prichard, were individuals who, is quite clear that writers like Prichard, Maudsley and Hack until they developed behavioural and affective changes, had Tuke (1885; 1892) were convinced that moral insanity not been noteworthy for antisocial or other unacceptable generally devel~ped on a background of brain disease, behaviour. It would be rare for our contemporary including epilepsy or affective psychosis. Tuke wrote (1885) psychopath to be awarded such a character reference as 'the cases recorded ... afford examples of morbid cerebral those mentioned above--a far cry from the individual whose conditions in which the mental symptoms displayed are the propensities have often been observed in late childhood and emotional and the most automatic rather than those con­ adolescence and generally do not remit over a short period of cerned in cognition and may be referred to the form of time with full recovery ofnormal behaviour. mental derangement usually termed moral insanity, although For an account of the evolution of moral insanity into the moral sentiments may themselves be free from disease' psychopathic disorder the reader is referred to an excellent (my italics). one by Maughs (1941). However, some additional points are Tuke (1892), like Maudsley, was clearly puzzled by worth mentioning. examples ofmoral insanity diagnosed in individuals involved At the time when Prichard was writing, legal concepts of in criminal proceedings, but he warned against an excessive insanity required a demonstration of disturbances of reason preoccupation with its association with crime and went on to as shown by the presence of delusion. As Battie (1758) and discuss cases characterized by sudden attacks ofdepression Erskine in Hadfield's case (1800) remarked, 'Delusion is the for no cause as well as abnormal behaviour as the precursors very hallmark of insanity'.