Lecturer on Physical Diagnosis in the University of Pennsylvania, now
in the United States marine hospital service, has for several years
been on duty, most of the time, in Florida, the West Indies, and the
Gulf of Mexico. In answer to an inquiry made by me, he writes:
“Hysteria prevails with extraordinary frequency amongst the Cubans. It
presents itself in the shape of excito-motory and mental phenomena,
almost to the exclusion of all other manifestations. The motory
anomalies comprise the whole range from mild hysterics to the gravest
hystero-epilepsy. The latter is incomparably more frequent in Key West
than in Philadelphia. The confirmed hystero-epileptics are few, but it
is the rule for well-marked cases of hysteria to present occasionally,
often only once in the course of the disease, hystero-epileptic
seizures which may be of frightful intensity. By mental disorders I do
not mean only the acute attacks of excitement and delirium which
attend upon or take the place of convulsive attacks, but I mean also
to include the chronic form of hysterical insanity, which is generally
some variety of melancholia. These are the peculiarities of hysteria
as seen by myself in the Latin race in the tropics. My experience
teaches me that the Saxon race in the tropics shows the same
peculiarities to a less extent.”
In the region referred to by Guiteras it will be remembered there is a
mixed population composed largely of Spanish, French, and Portuguese.
Climatic and other local influences may have something to do with the
particular form which this disorder assumes in these tropical or
semitropical districts, but race would seem to be the most important
factor. In the section on Hystero-epilepsy I will speak of the
irregular type of this disorder, which has fallen most frequently
under my own observation.
Hysteria in the negro is of somewhat frequent occurrence, and is more
{218} likely to be of the demonstrative or convulsive than of a
paralytic or negative form. Hysterical convulsions, particularly of
the purposive kind, and hysterical mania, are often met with in the
colored population of our large city hospitals and asylums.
The influence which climate exerts, like that of race, is rather on
the type of hysteria than upon the disease itself. Hysteria is found
in every climate, but in warm countries the disorder seems more likely
to be mobile and dramatic than when found in the more temperate or
colder zones.
Season and meteorological conditions have some influence on the
production of hysterical attacks. It is well known that hysteria,
chorea, and other allied nervous disorders are more likely to appear
in the spring than at other seasons. This fact has been shown by
various observers.
Hysteria may occur in any rank of life. It is not, as has been held by
some, a disease of the luxurious classes. The American physician who
has seen much of this disorder—and that means every physician of large
practice—has met with hysterical cases in every walk of life. While
this is true, however, hysteria of certain types is met with more
frequently in certain social positions. Some of the remarks about race
and climate apply also here. It is the type of the disorder, and its
relative frequency among various classes, which are affected by social
position. Young women of the richer classes, who have been coddled and
pampered, whose wants and whose whims have been served without stint
or opposition, often pass into hysterical conditions which do not have
any special determining causative factor, or at least only such as are
comparatively trivial. Occasionally, in them hystero-epilepsy,
catalepsy, and the train of grave hysterical phenomena are observed.
We are more likely, however, to have the minor and indefinite
hysterical symptoms; or, if grave manifestations be present, they are
most usually ataxia, paralysis, contractures, or aphonia, and not
convulsive phenomena. Hysteria in our American cities is especially
prevalent among certain classes of working-people, as among the
operatives in manufacturing establishments. Dividing American society
into the three classes of rich, middle, and poor, hysteria is most
prevalent in the first and the last. It is, however, by no means
absent in the middle class.
The absence of occupation on the one hand, and, on the other, the
necessity of following work for which the individual is unfitted,
particularly irritating lines of work, predispose to the occurrence of
hysteria. It may be caused, therefore, either by no work, overwork, or
irritating work. As to the special occupations, hysteria would seem to
result most commonly in those positions where physical fatigue
combines with undue mental irritation to harass and reduce the nervous
system. In men it occurs often as the result of overwork conjoined
with financial embarrassment. It is met with not infrequently among
teachers, particularly those who are engaged in the straining and
overstraining labor of preparing children for examinations. A good
method of education is the best preventive; a bad method is one of the
most fruitful causes of the affection. The injurious effect of
American school or college life in the production of hysteria is
undoubted, and should be thoroughly appreciated. Our educational
processes act both as predisposing and exciting causes of this
disorder. Both in our private and public educational institutions the
{219} conditions are frequently such as to lead to the production of
hysteria or to confirm and intensify the hysterical temperament. In
our large cities all physicians in considerable practice are called
upon to treat hysterical girls and boys, the former more frequently,
but the latter oftener than is commonly supposed. Hysteria in boys,
indeed, does not always meet with recognition, from the fact that it
is in boys. Cases of hysteria in girls under twelve years of age have
come under my observation somewhat frequently. About or just
succeeding examination-time these cases are largely multiplied. The
hysteria under such circumstances may assume almost any phase;
usually, however, we have not to deal in such patients with convulsive
types of the disease.
Clarke[41] has considered some of these questions in connection
particularly with the physiological processes of menstruation, and its
bearing upon the inability of girls to maintain equally with boys the
stress of such competition.
[Footnote 41: _Sex in Education, etc._, by Edward H. Clarke, M.D.,
Boston, 1873.]
The cramming processes which are resorted to in order to force
children at fixed times from the lower to the higher grades of public
schools, and more especially from grammar to normal or high schools,
is a fruitful source of evil in this direction. It is not always so
much hard study as it is the badly-arranged and too numerous subjects
of study that make the strain. I have spoken of this in another
connection as follows:[42] “Our children are too largely in the hands
of those educationalists to whom Clouston refers,[43] who go on the
theory that there is an unlimited capacity in every individual brain
for education to any extent and in any direction. Children varying in
age and original capacity, in previous preparation, and in
home-surroundings are forced into the same moulds and grooves. The
slow must keep pace with the fleet, the frail with the sturdy, the
children of toil and deprivation with the sons and daughters of wealth
and luxury. A child is always liable to suffer from mental overwork
when the effort is made to force its education beyond its receptive
powers. Education is not individualized enough. The mind of the child
is often confused by a multitude of ill-assorted studies. Recreation
is neglected and unhealthy emulation is too much cultivated. In many
communities admissions to various grades of public schools are
regulated entirely by the averages obtained at examinations, instead
of on the general record of the pupils in connection with proper but
not too severe examinations. In consequence often, after the campaign
of overwork and confusion called an examination, we see children
developing serious disturbances of health or even organic
disease—paroxysmal fever, loss of appetite, headache or neckache,
disturbed sleep, temporary albuminuria, chorea, hysteria, and
hystero-epilepsy.”
[Footnote 42: “Toner Lecture on Mental Overwork and Premature Disease
among Public and Professional Men.” delivered March 19, 1884,
Washington, Smithsonian Inst., January, 1885.]
[Footnote 43: _Clinical Lectures on Mental Diseases_.]
The term students' hysteria has been applied to the neuromimetic
disorders from which medical students frequently suffer during their
attendance upon lectures. Some years since, when engaged in examining
students upon the lectures upon the practice of medicine delivered by
Professor DaCosta, I saw many illustrations of this affection, {220}
some of which were very amusing. In a paper on hysteria which received
the prize at the Physical Society of Guy's Hospital, P. Horrocks[44]
writes that during the fortnight following the death of the late
Napoleon, Sir James Paget was consulted for stone in the bladder by no
less than four gentlemen who had nothing the matter with them. “How
many students,” says Horrocks, “are there, of one year's standing or
more, who have not imagined and really became convinced that they were
suffering from some disease, generally a fatal disease?” In such cases
we have a combination of true psychical influence with overwork and
the unhygienic surroundings for which our medical colleges are
notorious.
[Footnote 44: _Med. and Surg. Reporter_, vol. xxxvii., Nov. 24, 1877.]
It has been my personal experience that comparatively few cases of
hysteria occur among female medical students. Not long since a thesis
was presented at graduation by a woman medical student[45] on the
curative effects of professional training in neurasthenic and
hysterical women. In this she shows that there are certain relations
of mind over body which enable it to modify bodily conditions and ward
off disease when other remedies appear almost powerless. She
illustrates the therapeutic power of mental impressions and
occupations by two cases in which a judicious and careful course of
study acted to cure severe nervous and uterine troubles. One of these
women, who had suffered with neurasthenia and general debility, severe
nervous headaches, and other symptoms, was able during her last year
at college to attend fifteen lectures a week, besides clinics, prepare
for examination on five subjects, and was seldom troubled with even
headache. She afterward was employed in hospital work, and could walk
five miles a day without discomfort. That women medical students know
when and how to take care of themselves during the menstrual period,
and that they can, if they see fit, cease work or lighten their labors
at that time, would partly account for their escaping from nervous
break-down.
[Footnote 45: “The Therapeutic Value of Mental Occupation,” by Hannah
M. Thompson, M.D., _Medical and Surgical Reporter_, November, 1883.]
That any form of irritation in a patient predisposed to hysteria may
act as an exciting cause in this affection has led Laségue to apply
the term peripheral hysteria to certain cases. One of his cases was a
girl fourteen years old, who, having suffered for a few hours with her
eyes because of some sand thrown into one of them by a playmate, awoke
the next morning with a spasm of the eyelid on that side, which
rendered it impossible for her to open that eye; and it remained
closed during four months. He considered that the irritation produced
by the sand was not the immediate cause of the spasm, but that its
long duration was an hysterical phenomenon. The patient afterward
became the subject of hysterical manifestations. In another complete
hysterical aphonia came on after a slight bronchitis. Another, after
an attack of indigestion, refused to touch either food or drink for
twenty-four hours, and later was troubled with regurgitation from
constriction of the pharynx or œsophagus which lasted for some weeks.
Anæmia and chlorosis are frequent exciting causes of hysteria in
children, particularly in girls.
Disorders of menstruation play a prominent part as exciting causes of
{221} special hysterical manifestations. The period of the
establishment of the menstrual function is one that is particularly
fertile in the production of hysteria, much more so than acquired
disorders of menstruation occurring later. Menorrhagia, dysmenorrhœa,
and certain local utero-vaginal disorders may act upon those
predisposed to hysteria as exciting causes. These conditions
themselves are, on the other hand, sometimes caused by nervous,
hysterical states in the individual.
With reference to the very common assertions that continence on the
one hand, and sexual over-indulgence on the other, are the most
prolific causes of hysteria, the true stand to take is that neither of
these positions is philosophically correct; for, as Briquet has shown,
nuns on the one hand and prostitutes on the other are frequent victims
of this protean disorder.
As affirmed by Jolly, sexual over-irritation, particularly that
induced by onanism, more frequently causes hysteria than sexual
abstinence or deprivation.
The occurrence of hysteria and hysterical choreas among pregnant women
has long been recognized. Scanzoni, quoted by Jolly,[46] states that
of 217 patients whom he had treated, 165, or 76 per cent. had been
puerperal, and that of the latter not less than 65 per cent. had borne
children more than three times. Cases of grave hysteria or
hystero-epilepsy have been aggravated by pregnancy and have led to
premature labor.
[Footnote 46: _Op. cit._]
Chrobak attacks the etiological problem of hysteria by referring its
causation to movable kidneys! He observed 19 such patients in Vienna,
16 being in Oppolzer's clinic.[47] Three times no subjective symptoms
accompanied the anomaly; eight times the trouble could be referred
either to the dislocation of the kidneys or to disease of the same;
and eight times the evidence of hysteria was unmistakable. Among the
latter eight cases neither vaginal, uterine, nor ovarian conditions
were recognized. He concludes that there is a direct nervous
connection between the kidneys and the genital organs, and between
both and hysteria.
[Footnote 47: _Medizinische-Chirurgische Rundschan_, quoted by _Boston
Medical and Surgical Journal_, 1870, lxxxiii. 430-432.]
In brief, the truth is that frequent or severe local irritation in any
part of the body in an individual of the hysterical diathesis may act
as the exciting cause of an hysterical paroxysm or of special
hysterical manifestations. Irritation or disease of the uterus or
ovaries may result in hysteria, as may the bite of a dog, a tumor of
the brain, a polypus in the nose, a phymosis, an irritated clitoris, a
gastric ulcer, a stenosis of the larynx, a foreign body in the eye, a
toe-nail ulcer, or a movable kidney.
Whatever tends to exhaust the nervous system will also cause hysteria,
but only in those who have some inherited predisposition to the
disorder. C. Handfield Jones[48] mentions heatstroke and severe
physical labor as such causes. One of the sequelæ of heatstroke
enumerated by Sir R. Martin, and quoted by Jones, is a distressing
hysterical state of the nervous system, with an absence of
self-control in laughing and crying, the paroxysm being followed by
great prostration of nervous power.
[Footnote 48: _Op. cit._]
{222} The effect of imitation in the production of hysteria has been
known in all ages. Most of the epidemics and endemics of nervous
disorders which have from time to time prevailed in various parts of
the world have either been hysterical in character or have had in them
a large element of hysteria. While it is impossible in a practical
work to devote much space to this branch of the subject, a discussion
of hysteria in its etiological relations would be imperfect without
some reference to these outbreaks. In ancient times, in the Middle
Ages, and within comparatively recent periods extraordinary epidemics
have occurred. No country within the range of medical observation has
been entirely free from them. Communities civilized and
semi-civilized, Christian and Mohammedan, Protestant and Catholic,
have had a fair share of the visitations. Some of them constitute
epochs in history, and, as Hecker,[49] their greatest historian, has
remarked, their study affords a deep insight into the work of the
human mind in certain states of society. “They are,” he says, “a
portion of history, and will never return in the way in which they are
recorded; but they expose a vulnerable part of man—the instinct of
imitation—and are therefore very nearly connected with human life in
the aggregate.”
[Footnote 49: _The Epidemics of the Middle Ages_, from the German of
J. F. C. Hecker, M.D., Professor at the Frederick William University
at Berlin, etc., translated by B. G. Babington, M.D., F. R. S., etc.;
3d ed., London, 1859.]
Some authors under hysteria, others under catalepsy, others under
ecstasy, still others under chorea, have discussed these epidemics—a
fact which serves to emphasize the truth that while these affections
have points of difference, they have also an easily-traced bond of
union. They are but variations of the same discordant tune. Briquet in
an admirable manner sketches their history from the age of Pausanias
and Plutarch to the time of Mesmer. Of American writers, James J.
Levick[50] of Philadelphia has furnished one of the most valuable
contributions to this subject.
[Footnote 50: “An Historical Sketch of the Dance of St. Vitus, with
Notices of some Kindred Disorders,” _Med. and Surg. Reporter_, vol.
vii., Dec. 21 and 28, 1861, p. 276, and Jan. 4 and 11, 1862, p. 322.]
In the year 1237 a hundred children or more were suddenly seized with
the dancing mania at Erfurt; another outbreak occurred at Utrecht in
1278.
As early as the year 1374 large assemblages of men and women were seen
at Aix-la-Chapelle affected with a “dancing mania.” They formed
circles and danced for hours in wild delirium. Attacks of
insensibility, of convulsions, and of ecstasy occurred. The disease
spread from Germany to the Netherlands. In a few months it broke out
in Cologne, and about the same time at Metz. “Peasants,” we are told,
“left their ploughs, mechanics their workshops, housewives their
domestic duties, to join the wild revelry, and this rich commercial
city became the scene of the most ruinous disorder.”
The festival of St. John the Baptist was one celebrated in strange
wild ways in these early days. Fanatical rites, often cruel and
senseless, were performed on these occasions. Hecker supposes that the
wild revels of St. John's Day in 1374 may have had something to do
with the outbreak of the frightful dancing mania soon after this
celebration. It at least brought to a crisis a malady which had been
long impending.
{223} The Flagellants afford another illustration of an early
religio-nervous craze. Self-flagellation was indulged in for
generations before the fourteenth century, but it then became
epidemic. A brotherhood of Flagellants was formed; they marched in
processions carrying scourges, with which they violently lashed and
scourged themselves. As late as 1843, Flagellant processions, but
without the whips and scourging, were continued in Lisbon on Good
Friday.
Strasburg was visited by the dancing plague in 1418. Those afflicted
were conducted to the chapel of St. Vitus, where priests attempted to
relieve them by religious ceremonies. The name St. Vitus's dance,
still so common as a synonym for chorea, has come down to us because
of the alleged wonderful doings of this saint in behalf of those
affected during some of the dancing epidemics. Both Hecker and
Madden[51] give interesting details of the personal history of St.
Vitus, who was a Sicilian, born in the time of Diocletian, and even in
childhood is said to have worked great miracles, and was delivered
from many sufferings and torments. He died about the year 303. His
body was moved to Apulia, afterward to St. Denys in France, and still
later to the abbey of Corvey in Saxony. A legend was invented that St.
Vitus, just before he bent his neck to the sword, prayed to God that
he might protect from the dancing mania all those who should solemnize
the day of his commemoration and fast upon its eve.
[Footnote 51: _Phantasmata; or, Illusions and Fanaticisms, etc._, by
R. R. Madden, F. R. S., London, 1857.]
Another strange disorder called tarantismus derived its name from the
fact that it was supposed to be caused by the bite of the tarantula, a
ground-spider common in Apulia, Italy. According to Hecker, the word
tarantula is the same as terrantola, a name given by the Italians to a
poisonous lizard of extraordinary endowments. The fear of the insect
was so general that its bite was much oftener imagined than actually
received. The disorder was probably in existence long before the
fifteenth century, although the first account of it, that of Nicholas
Perotti, refers to its occurrence in this century. Many symptoms
followed the bite or supposed bite: the individuals became melancholy,
stupefied, lost their senses, and, above all, were irresistibly
impelled to dance until exhausted and almost lifeless. It was believed
that the results of the bite could be cured, or at least much
benefited, by dancing to a certain kind of music. Tarantism was at its
height in the seventeenth century. To this day, in some parts of
Italy, dances called tarantellas are performed with intricate figures
to marked time.
Abyssinia was visited by a dancing mania called the tigretier, which,
according to Hecker, resembled the original mania of the St. John
dancers. It exhibited a similar ecstasy. Those affected with it were
cured by dancing to the music of trumpeters, drummers, fifers, etc.
Levick says that the dancing mania of the fifteenth century is still
kept in popular remembrance in some places by an annual festival,
especially at Echtermarch, a small town in Luxembourg, where a jumping
procession occurs annually on Whit Tuesday. In the year 1812, 12,678
dancers were in the procession.
The Anabaptists, a religious sect of the sixteenth century, exhibited
many of the wild and grotesque phenomena of hysteria or
hystero-epilepsy.
{224} The French Calvinists or Camisards, who appeared near the close
of the seventeenth century, were also the subjects of ecstasy and of
peculiar fits of trembling. These trembleurs experienced convulsive
shocks in the head, the shoulders, the legs, and the arms, and were
sometimes thrown violently down.
About 1731 and later great crowds frequented the tomb of Deacon
François de Paris, an advocate of the doctrines of Jansenius. It was
reported that miracles were performed at his tomb: the sick were
brought there, and often were seized with convulsions and pains,
through which they were healed. The subjects of these attacks are
sometimes spoken of as the Jansenist Convulsionnaires. The tomb was in
the cemetery of St. Médard, and hence those who visited the place were
also termed the Convulsionnaires of St. Médard. This disorder
increased, multiplied, and disseminated, lasting with more or less
intensity for fifty-nine years. Great immorality prevailed in the
secret meetings of the believers.
Hecker gives some remarkable instances of the effect of sympathy or
imitation exhibited on a smaller scale than in the epidemics of the
Middle Ages. One is of a series of cases of fits in a Lancashire
factory, the first one brought on by a girl putting a mouse into the
bosom of another. In Charité Hospital in Berlin in 1801 a patient fell
into strong convulsions, and immediately afterward six other patients
were affected in the same way; by degrees eight more were attacked. At
Redruth, England, a man cried out in a chapel, “What shall I do to be
saved?” Others followed his example, and shortly after suffered most
excruciating bodily pain. The occurrence soon became public; hundreds
came, and many of them were affected in the same way. The affection
spread from town to town. Four thousand people were said in a short
time to be affected with this malady, which included convulsions.