Were Mrs. White's Visions due to Nervous Disorders? Part III
Modern Medical View of Epilepsy
Modern Medical View of Hysteria
The Hysterical Personality
Relation of Epilepsy to Hysteria
Modern Medical View of Schizophrenia
The Whole Life Picture Important
With Mrs. White's case history before us let us turn directly to the charge presented at the beginning of chapter 2. It is restated here:
Mrs. White's so-called visions were simply the result of nervous disorders. She suffered a blow on the head from a stone thrown at her at the age of nine that affected her nervous system. Medical works in the sections entitled Hysteria, Epilepsy, and Schizophrenia, describe her case exactly. Physicians who knew her well also thus described her.
The charge requires an answer to two questions:
1. Do medical works describe her case exactly?
2. How valid is the testimony of physicians who knew her well and diagnosed her as a mental case?
In this and the next chapter we shall seek to answer these questions.
First, what are the current medical facts regarding epilepsy, hysteria, and schizophrenia that a psychiatrist would have in his mind as he studied the case history of an individual. We shall set forth the principal facts that are strictly relevant to the charges before us. Let us start with epilepsy.
1. The formerly held idea that an injury to the head explains many cases of epilepsy, and also many other cases of abnormal mental states and behavior, is heavily discounted today. It would be shoddy diagnostic procedure to explain someone's queer ways simply by the fact that when he was a child he fell out of an apple
tree, or out of his crib, and landed on his head. It is estimated that probably between 5 and 10 per cent of those who suffer head injuries become epileptics.* Some authorities say not more than 5 per cent. On the whole question of head injuries in relation to mental diseases one medical work observes:
The opinion popularly entertained that injuries to the head are a frequent cause of mental disease is distinctly an error . Not over one-half of one per cent of admissions to hospitals for mental diseases are to be considered as traumatic [injury] psychoses in the correct sense of the term.Arthur Percy Noyes and Edith M. Haydon, A Textbook of Psychiatry, p. 126.
2. If the epileptic attacks have been frequent over at least five years of time, and no adequate medical care has been given, the chances of their cessation are poor.
3. Some authorities affirm that an epileptic may live a long life with little or no mental deterioration. But if the epileptic seizures begin in the teens, are frequent over a number of years, and the patient receives no adequate medical aid, most authorities hold that the outlook is very forbiddingthe patient almost certainly will suffer increasing mental deterioration.
4. There is some difference of opinion among authorities as to the temperament of an epileptic, but most doctors would agree with this description, given in a current medical work:
Between the attacks the patient's general physical and mental condition may be unimpaired. Very often one observes both intellectual and character changes which become more and more apparent as the disease progresses. The epileptic is frequently an unsocial, selfish, egocentric, suspicious, sensitive, pedantic, overscrupulous, hypochondriacal person. He is irritable and sometimes violent, but emotionally poor none the less. (It is possible that much of his unsociability and many of his reactions are the result of the general social attitude toward him. He is generally excluded from gainful occupations and not infrequently shunned.) The epileptic is hypersensitive to alcohol. Occasionally one observes paranoidal and other delusional trends and sometimes hallucinatory ideas and confusional states. He may become over-ceremonious and excessively religious as the disease progresses. Memory
* Modern neurological studies which more clearly delimit the motor area of the brain reveal that the chance that a head injury will result in convulsions, or fits, depends on the relation of the injury to the motor center. The head injury suffered by Mrs. White, when she was struck by a stone on the nose, was remote from this motor area.
defects, ethical depravity, other personality deterioration, and finally dementia may be observed.Israel S. Wechsler, A Textbook of Clinical Neurology, p. 625.
5. The epileptic attack, or fit, is generally one of two kinds: (1) a momentary loss of consciousness, though the patient makes no outcry, does not fall, and afterward has no memory of the incident. This, in medical language, is petit mal. (2) A violent attack, with foaming at the mouth, preceded by an outcry and sudden collapse, and followed by complete absence of memory of anything during the time of the attack. This, in medical language, is grand mal. Obviously Mrs. White's critic means grand mal when he declares that Mrs. White had an epileptic fit, for he emphasizes the fact that the fit is preceded by an outcry. Patently, petit mal could not provide the remotest analogy to a vision. Even a layman would have little difficulty in diagnosing correctly a true grand mal attack.*
Here are the medical facts regarding hysteria, so far as they have significance for the charge before us:
1. While the majority of hysterics are women, the malady is by no means confined to one sex, as the two world wars strikingly revealed.
2. True hysteria is today a much more sharply defined malady. (According to her critic Mrs. White must have had a case of true hysteria in order to fit certain of the specifications he set down.) In medical language it is known as one of a group of mental maladies called the psychoneuroses. The cause is not physical. Mary may fall out of her high chair in childhood, and years later may be a hysteric, but there is no relation between the two. Neither is there a relation between the glands of internal secretion and hysteria; in other words, the monthly cycle in women, affecting
* A medical authority, writing under the title, Psychiatry, Psychology and Seizures, speaks of the abrupt transitions from the normal to the acutely abnormal, in the case of an epileptic suffering a grand mal attack. At one moment a self-possessed, rational being, in the next moment a demon-possessed person out of all muscular control, both reason and consciousness gone.William G. Lennox, M.D., The American Journal of Orthopsychiatry, vol. 19, no. 3, July, 1949, p. 432.
ovaries and uterus, is not the cause or even a cause of hysteria a statement which, of course, requires the conclusion that the cessation of this cycle, known as the menopause, is not the true explanation for the subsidence of hysterical symptoms, which often takes place at mid-life. (See under No. 3.) The cause of hysteria is psychogenic; that is, it is caused by mental conflicts or other psychological factors.
3. The spectacular aspects of hysteriaswooning, various theatrical poses, anesthesias, and the likegenerally subside about mid-life, both for men and women. As a medical authority declares:
It is rare to see hysteria after middle life; the hysterics seem to flourish in youth and then in middle age they make adjustments and perhaps settle down to be queer or crotchety people.Stanley Cobb, Foundations of Neuropsychiatry, p. 217.
Excessive weeping, emotional upsets, fainting spells, that were formerly considered part of the symptom picture of hysteria, no longer require this explanation. They may be viewed, for example, as evidences of lowered physical and nervous vitality, and hence capable of being relieved, in many instances, simply by improving the bodily tone.
4. Most medical authorities speak of a hysterical personality. This is the way one current medical work describes it:
What characterizes the hysterical personality is the infantile reaction to life and the inability to adjust at the adult level of reality. The individual is hypersensitive, excessively irritable, self-centered (not altogether selfish), preoccupied with himself, impulsive and moody, and generally deficient in emotional control. He is enthusiastic and depressed by turns, often has out-bursts of crying, and sometimes of uncontrollable laughter. Like every child he craves attention and is querulous if he does not receive it, showing that he is considerably narcissistic [that is, sexually attracted toward himself]. He is shy, easily frightened, afraid to be alone, and he would dominate the stage, sometimes in true histrionic fashion. He is generally impatient and anxious, and not infrequently has acute attacks of anxiety. He exaggerates his complaints, keenly feels seeming neglect, is inordinately ceremonious, and
preoccupied with his bodily functions. He is affectionate and resentful at the same time (ambivalent), strongly attached to his family, yet incapable of loving very deeply. He is often cruel to the very people he loves best (sadistic trend). He injects his personality into everything and easily identifies himself with persons and things. He lives a life of childish phantasy and loves to indulge in day dreams (autistic thinking). Most characteristic is his extreme and abnormal suggestibility. Sexually he is immature . In short, the outstanding characteristics of hysteria are persistence of infantile trends and abnormal psychosexual development.Wechsler, op. cit., p. 711.
Dr. Wechsler immediately adds this important, qualifying sentence: Not every hysteric, of course, shows all the above mental traits; nor does the occurrence of one or more of them in an individual make of him a maladjusted neurotic.Ibid. Note particularly the last half of the sentence.
5. A hysterical episode, or what the layman might call a hysterical fit, can take a number of different forms. As one medical writer says: Hysteria is kaleidoscopic in its manifestations and may appear in the form of physical or mental disturbances.Arthur P. Noyes, Modern Clinical Psychiatry, p. 286.
To sum up the outstanding manifestations of a hysterical episode, or fit, as Dr. Noyes gives them: There may be disturbance of special sense organs, such as blindness, pains, headaches. Paralysis may be present in any one of several forms. There may be aphonia, in which the patient cannot phonate speech. But though the patient cannot speak he continues to cough. There may be hysterical vomiting. One of the commonest forms of mental disturbances in hysteria is amnesia, a blotting out of memory. There may be dramatic posturings and activities and an excessive flow of speech appearing nonsensical . Occasionally the hysterical patient spins fantastic stories. At times the patient suddenly leaves the place of his usual activity and without any apparent purpose travels to some remote point.
It is true that an epileptic may display, as a complication, the immature personality of the hysteric, and marked hysterical epiSodes may occur in a person who is also subject to epileptic
seizures. In fact, a person suffering an epileptic attack may also simulate certain hysterical symptomsthis is called an hysterical overlay. But the formerly held idea that hysteria and epilepsy sometimes co-exist or alternate or blend together so it is difficult to distinguish themwe are quoting an early critic who cites encyclopedias and medical statements of his dayis now rather generally abandoned. Hence the term hystero-epilepsy, which reflected that idea, is little used in medical literature today. Some medical authorities specifically term it a misnomer.*
Those who have written against Mrs. White need not have confined themselves to epilepsy and hysteria, as they have almost exclusively' done. Medical works present several distressing kinds of psychiatric maladies, with symptoms as varied and bizarre as the two discussed. And certainly among those symptoms some could surely be found to have at least the appearance of similarity to Mrs. White's state in vision. We have no desire to conceal this fact from our readers. On the contrary, we believe that the more we acquaint them with the facts the more easily can we provide them with a correct answer to the charge that her visions were the result of nervous disorders.
That is why we wish, now, to add a description of a third malady, schizophrenia. This fearsome-sounding term means split personality. As already remarked, some today, who indict Mrs. White's visions as manifestations of a sick mind, describe her, not as an epileptic or a hysteric, but as a victim of schizophrenia. We summarize briefly certain facts regarding this disease as found in a current medical work:
Schizophrenia (dementia praecox), says a medical textbook, is the most prevalent of all the major mental disorders, accounting
* Dr. William G. Lennox observes: I have passed my memory over patients seen in clinic or office who have come for the diagnosis and treatment of recurrent periods, characterized by impairment of consciousness and of muscular control. The inspection is confined to persons who have passed the first decade, and whose epilepsy is not complicated by an acquired structural alteration of the brain. My guess is that not more than per cent of these would have seizures purely emotional in origin and in character; no more than 4 per cent would have hystero-epilepsy. The remaining patients, 95 per Cent of the whole, represent those without hysterical seizures, either alone or combined with epileptic attacks.Op, cit., p. 444.
for about one third of mental cases in United States hospitals. Probably the majority of definite schizophrenic conditions arise in individuals who have always had a tendency toward withdrawal from ordinary activities. The onset of the malady usually appears before the age of twenty-five, and is as likely to appear in one sex as the other. Odd grimaces, contortions, mannerisms and stereotyped movements are also frequently seen.
After describing variant symptoms that accompany certain types of schizophrenia, the medical writer declares:
The course of the schizophrenic disorders follows no definite path. At times a schizophrenic episode may be followed by a spontaneous and apparently complete remission. This, unfortunately, is rather rare. More commonly, one sees a succession of schizophrenic episodes with periods of normal behavior of variable duration. In the great majority of cases the course is progressively downhill.Wallace Mason Yater, The Fundamentals of Internal Medicine, p. 900.
Let us summarize the generally accepted medical facts regarding schizophrenia:
1. A person experiencing a schizophrenic episode is, frankly, an insane person.
2. The period of insanity is not confined to minutes or hours the length of Mrs. White's visionsbut to days and weeks, generally over a course of years.
3. Complete return to normal, with no further episodes after a certain date, is rather rare.
4. In the great majority of cases the course is progressively downhill.
5. The personality of the schizophrenic is increasingly colored by his abnormal episodes.
The most important fact that stands out in this chapter, which has summarized the current medical view on epilepsy, hysteria, and schizophrenia, is not some particular symptom in connection with an attack, but the picture of the epileptic, the hysteric, and the schizophrenic as individuals. In mental maladies, perhaps more
than in any others, the whole life picture is important to the diagnosis. A person suffering with one of these maladies presents, generally, a well-defined picture as an individual in relation to society.
If Mrs. White is being viewed as an epileptic, then she must be viewed as a pronounced case, for she had many visions, and they began in her teens. Further, we shall have to view her as an untreated case, for modern medication for epilepsy was unknown in mid-nineteenth century. Now let the reader turn back a few pages and refresh his mind on what medical men today say about the usual social attitudes of such persons, and of the high probability that pronounced cases, if untreated, will suffer mental deterioration as the years go by.
If Mrs. White is being viewed as a hysteric, then she must be viewed as a pronounced case, and for the same reason that holds regarding epilepsy. She must also be considered an untreated case. Now let the reader turn back and read again the current medical description of the hysterical personality.
Let him note particularly the fact that the hysterical fit is the result of a particular kind of personality that seeks, through a fit, to secure certain ends or to give expression to certain moods and attitudes that were present before the fit and continue after it.
If Mrs. White is being viewed as a schizophrenic, she must be viewed as a pronounced case, and again for the same reasons that hold regarding epilepsy and hysteria. She must also be viewed as an untreated case.
The only reason that the nervous-disorder charge against Mrs. White sounds plausible to some who have read it is that they have never had opportunity to read the facts concerning her life, or the current medical findings concerning nervous and mental maladies.
Note:In the preparation of this chapter we have been greatly indebted to the critical assistance of several physicians who are specialists in the fields of psychiatry and neurology. Their names appear in the section entitled Acknowledgments on pages 5 and 6. See Bibliography for the list of current medical works consulted.