Hysteria in the United States assumes almost every form, probably because we have here represented almost every race and nationality, either pure or mixed. While it cannot be clearly shown that certain races are much more prone to hysteria than others, the type of this disease is doubtless much influenced by racial and climatic conditions. Certain phases of the disease prevail in certain sections more than in others. Mitchell's40 experience is that the persistent hystero-epilepsies, and the multiple and severe contractures which Charcot and others describe, are rare in this country among all classes, and especially uncommon in the lowest classes, among which Charcot seems to have found his worst and most interesting cases. He says that while his own clinic furnishes numerous cases of neural maladies, and while he has examples of every type of the milder form of hysteria, it is extremely uncommon to encounter the more severe and lasting forms of this disease. When Mitchell's Lectures were first published I was inclined to regard hystero-epilepsy of the grave type as of rare occurrence, and so stated in answer to a communication from him. Recently, as the result of a longer experience, I have become persuaded that some irregular forms are met with somewhat frequently in various sections of our country. It remains true, however, that in the Middle and Northern sections of the United States the graver hysterias of the convulsive type are not nearly as frequently observed as in the southern countries of Europe.
40 Op. cit.
Dr. Guiteras, formerly physician to the Philadelphia Hospital, and 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 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 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.
Clarke41 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.