Insanity, Moral Insanity, and ADHD

Any behavior that was outside the established norm in the 19th century could have been construed as insane. Women, especially, seemed to fall prey to this diagnosis, given the common belief that women were at the mercy of their ovary-dictated bodies (hysteria was commonly applied to women, while men were subject to hypochondriasis). An opinionated wife could easily be seen as insane.

One of the causes believed to account for the escalating number of women’s diagnoses of hysteria was over-education or improper education (studying math beyond the simple additions and subtractions needed to run a household budget, or studying the sciences, for example). Mental disease in women seemed to always carry with it some sexual component or manifestation, and stressing the mind with too much thought or study was thought to dispose women to barrenness — too much energy spent in intellectual thought robbed a woman’s sexual organs of the capacity to conceive and bear children. Reading too many novels could also result in insanity. Novels fostered sentiment, “instead of cherishing real feeling, such as result from the performance of active benevolence, the sacred duty of ordinary life, and of religious obligations” (from the fourth annual report of the Mt. Hope Institution for the Insane [Baltimore, MD], by Dr. W. H. Stokes). Daughters, considered perfectly sane in all other areas, could be committed to “lunatic asylums” as morally insane for loving (and eloping with) lovers of whom the fathers disapproved.

A particular diagnosis, called moral insanity, included symptoms that today might be diagnosed as attention deficit disorder. The inability to control one’s behavior (including remaining focused on the task at hand or the conversation in progress) or to display proper sentiment was considered a moral failing, a moral insensibility. The early “cure” for this moral failing was often physical punishment. Children with this behavior problem needed to be beaten and such beatings (articles on just how to beat a child circulated) were seen as a social duty of the parents. By the early 1800s the “moral treatment” offered an alternative that was eagerly embraced by progressive doctors and social reformers. The moral cure encouraged patients to focus on moral and spiritual character development, gave patients meaningful labor and physical therapy, and promoted social interaction. The moral cure did not, of course, cure anything — mental disease often needs, in addition to counseling, effective medical, pharmacological intervention, which hardly exists even now — but it was a great step up from chains and other restraints and the brutal beatings of earlier treatment for the insane.

In the courtroom, moral insanity found a ready audience. “Mad doctors,” doctors who worked in lunatic asylums, suddenly found their expertise in demand and their status as physicians elevated. Newspapers in America wondered if there was really such a thing as crime anymore, if every person on trial could apply, successfully, to moral insanity as a defense. The most sensational cases involved murder among the upper levels of society, and it came to be believed that the “moral insanity dodge” could be purchased from doctors willing to peddle their testimony and sign certificates of insanity. (In 1865, however, a diagnosis of moral insanity by several prominent doctors, could not save Lewis Powell (aka Payne) from the gallows after he attempted to assassinate Secretary of State William H. Seward as part of the Lincoln assassination conspiracy.) On the other hand, while an insanity certificate could save one from the gallows or even prison time, a diagnosis of insanity could also be used to condemn someone to incarceration in a lunatic asylum. A troublesome wife, an embarrassing relative, the need to break an unfavorable will were all common reasons to have someone declared insane, a declaration that was amazingly easy to obtain and requiring little actual medical evidence of insanity.

ADHD in the early to mid-19th century

The medical profession may have first recognized what today is called ADHD in 1798. Scottish physician Sir Alexander Crichton first posited that attention disorders could possibly be a medical issue and not a mental, that is to say, an insanity or criminal issue. Crichton recognized that a person could be born with the disorder or develop it as “the effect of accidental diseases” [Crichton, “On Attention and its Diseases”]. It is interesting to note that Crichton only refers to inattention in his treatise and does not discuss the hyperactivity that is popularly associated with the disorder. This may suggest that Crichton’s subjects under observation suffered the recently recognized subtype of ADHD (inattention without hyperactivity). Crichton also was the first to suggest that the problem of inattention improved with age (today, that theory has been overturned — as many as 50% of ADHD sufferers carry it with them into adulthood).

In 1835, British physician James Cowl Prichard wrote “Treatise on Insanity and Other Disorders.” It was Prichard who coined the phrase “moral insanity,” to refer to mental disorders that did not carry with them hallucinations or delusions. “Moral insanity” became a widely used umbrella term in the 19th century that referred to several types of mental disorders that today would include the classifications of personality, affective and mood disorders. The wide and varying symptoms associated with the autism spectrum, including ADHD, may also have fallen under this diagnosis.

In the mid-1840s, German doctor Heinrich Hoffmann added his own observations on the subject. His children’s book Struwwelpeter (Shock-headed Peter) provided cautionary tales to (mostly) little boys about improper behavior and consequences. Among the stories in the book was one dealing with Fidgety Phil and his disruptive behavior at the family dinner table. Phil’s father, expecting his son to misbehave, asks Phil to behave like a “little gentleman” before dinner even begins, but Phil seems unable to pay attention or mind what his father says. As expected. Phil acts up, unable to sit still, and dinner ends in total chaos, with Phil falling over in his chair and pulling the tablecloth and all the dishes down with him. This story is interesting in that the father expected Phil to be disruptive, indicating this was Phil’s usual standard of behavior. Most children act up at one time or another and occasionally have trouble following direction, but a consistent pattern of this kind of behavior can indicate ADHD. Hoffmann referred to such behavior as hyperkinetic syndrome.

By the 1860s, at least one prominent expert on mental disease, British doctor Henry Maudsley, was uneasy with Prichard’s term “moral insanity,” which carried with it a censorious or disapproving tone, rather than reflect the objectivity that medical science requires. He saw the disorder(s) as a result of a lack of willpower, or ‘insane organization,’ that he increasingly believed was biologically based.

ADHD, it must be stated, is not a mental disease, but the expression of a normal variant in the human genome. Medication may help the problem of focus during increasingly long and packed school days or at work, but it doesn’t “fix” ADHD, anymore than a tinted contact lens “fixes” brown eyes.