4. Middle Ages
After the fall of the Roman Empire, Greek-Roman medical culture had its new epicenter in Byzantium, where physicians inherited Galen’s science without making any significant innovations (the most famous was Paul of Aegina, 625-690 AD). Sometime before, Bishop Nestorius (381-451 approx.), who took refuge in the Middle East in an area between today's Iraq and Egypt, had brought with him his knowledge of classical science, contributing to the spread of Greek-Roman medicine in these areas.
The political events of the early Middle Ages caused a rupture between Christian Europe, with its auctoritas culture - in the hands of just a few scholars - and the Middle East of the Caliphs, where thanks to a climate of tolerance and cultural ferment, the texts of Hippocrates and Galen were translated and commented on in Arabic, becoming widespread and well-known [3].
In this context, two great scientists carry out their work : the Persian Avicenna (980-1037) [8, 9] and the Andalusian Jew Maimonides (1135-1204) [10]. Thanks to them, the legacy of Hippocrates and Galen is not only maintained, but spreads throughout Europe: the Reconquista of Spain (718-1492) and new contacts with the Near East bring important cultural exchanges, Avicenna’s Canon of Medicine and Galen’s Corpus are diffused along with the Latin translations ascribed to Gerard of Cremona (1114-1187), while Maimonides’ texts are disseminated in the Jewish world, along with other basic medical texts, thanks to translations by the Ibn Tibbon family (13-14th centuries). In particular, the medical schools of Salerno and Montpellier were vehiclesfor the dissemination of these works [11].
This was how Hippocratic concepts of melancholia and hysteria spread in late-medieval Europe, and in informed circles these diseases were treated according to what we shall call the “scientific” vision. In particular, this advocated the use of melissa as a natural remedy nerve comforter (melissa was considered excellent even in cases of insomnia, epilepsy, melancholy, fainting fits, etc.) [3, 12].
Besides the natural remedies, a sort of "psychotherapy" developed, practiced not only by Avicenna, but also for example by Arnaldus of Villa Nova (1240-1311). The latter, considered medieval Europe’s greatest physician, will be counted along with Galen and Avicenna in the inventories of physicians’ libraries throughout the Modern era [13].
It is also interesting to note that in the many treatises diffused at the time (Constantine the African’s Viaticum and Pantegni, but also the Canon of Avicenna and Arnaldus of Villa Nova’s texts) women were often not described as "patients" to be cured but rather as the "cause " of a particular human disease, defined as amor heroycus or the madness of love, unfulfilled sexual desire [8].
But we cannot talk about women' health in the Middle Ages without citing Trotula de Ruggiero from Salerno (11th century). While as a woman she could never become a magister, Trotula is considered the first female doctor in Christian Europe: she belonged to the ranks of famous women active in the Salerno School but discredited, among others, by Arnaldus of Villa Nova [14].
Called sanatrix Salernitana, Trotula was an expert in women' diseases and disorders. Recognizing women as being more vulnerable than men, she explained how the suffering related to gynecological diseases was “intimate”: women often, out of shame, do not reveal their troubles to the doctor. Her best known work, De passionibus mulierum ante, in et post partum, deals female problems, including hysteria. Faithful to the teachings of Hippocrates, Trotula was devoted to the study of women’ diseases, of which she tried to capture the secrets, without being influenced by the prejudices and morals of her time, also giving advice on how to placate sexual desire: in her work abstinence is seen as a cause of illness and she recommends sedative remedies like musk oil or mint [15].
Trotula works at a time when women are still considered inferior to men because of their physiological and anatomical differences. Hildegard of Bingen (1098-1179), German abbess and mystic, was another female doctor. Her work is very important for the attempt to reconciliate science with faith, that happens at the expense of science. Hildegard resumes the “humoral theory” of Hippocrates and attributes the origin of black bile to the original sin [16]. In her view, melancholy is a defect of the soul originated from Evil and the doctor must accept the incurability of this disease. Her descriptions are very interesting. Melancholic men are ugly and perverse, women slender and minute, unable to fix a thought, infertile because of a weak and fragile uterus [16]. In the ideology of Hildegard, Adam and Eve share responsibility with respect to original sin, and man and woman - sexually complementary - are equal in front of God and the cosmos [17].
The mainstream view of the time is one in which the woman is a physically and theologically inferior being, an idea that has its roots in the Aristotelian concept of male superiority: St. Thomas Aquinas’ (1225-1274) Summa Theologica Aristotle’s assertions that “the woman is a failed man” [18]. The inferiority of women is considered a consequence of sin, and the solutions offered by St. Thomas’ reflection leave no doubt about what will overturn the relationship between women and Christianity: the concept of “defective creature” is just the beginning. In question 117, article 3, addressing the possibility that the human soul can change the substance, St. Thomas says that “some old women” are evil-minded; they gaze on children in a poisonous and evil way, and demons, with whom the witches enter into agreements, interacting through their eyes [18]. The idea of a woman-witch, which we shall call the “demonological vision”, almost becomes insuperable: preachers disclose the Old Testament’s condemnation of wizards and necromancers and the fear of witches spreads in the collective imagination of the European population. The ecclesiastical authorities try to impose celibacy and chastity on the clergy, and St. Thomas’ theological descriptions regarding woman’s inferiority are, perhaps, the start of a misogynistic crusade in the late Middle Ages.
From the thirteenth century onwards, the struggle with heresy assumes a political connotation: the Church aims tat unifying Europe under its banner, so breviaries become manuals of the Inquisition and many manifestations of mental illness are seen as obscene bonds between women and the Devil. “Hysterical” women are subjected to exorcism: the cause of their problem is found in a demonic presence. If in early Christianity, exorcism was considered a cure but not a punishment, in the late Middle Ages it becomes a punishment and hysteria is confused with sorcery [19, 20].
Political and religious status quo in Europe is threatened by the first humanist ideas and the Church responds by intensifying inquisitions: the apogee is reached in 1484 with the Summis desiderantes affectibus, Innocent VIII’s Bull, which confirms the witch hunt and an obligation to “punish, imprison and correct” heretics [21, 22]. The German Dominicans Heinrich “Institor” Kramer and Jacob Sprenger are accredited with the publication of the famous Hammer of Witches, the Malleus Meleficarum (1486) [21, 22]. Although not an official Church manual, it takes on an official tone due to the inclusion of the papal Bull within the text. It is interesting to note that the title itself includes signs of misogyny: “Maleficarum” as witches, not “Maleficorum” as wizards… as if to say “evil is female/ evil origins from women”!
The devil is everywhere in these pages: he makes men sterile, kills children, causes famine and pestilence and all this with the help of witches. The compilers of the manual are familiar with the medicine of the age, and they investigate the relationship between sorcery and human temperaments: their descriptions rival those contained in the best psychopathology manuals [21, 22]. The text is divided into three parts and aims at proving the existence of demons and witches (warning the reader that anyone not convinced is also a victim of the Devil) explaining how to find and punish sorcery.
But what has this to do with women's health? It is quite simple: if a physician cannot identify the cause of a disease, it means that it is procured by the Devil. The inquisitor finds sin in mental illness because, he says, the devil is a great expert of human nature and may interfere more effectively with a person susceptible to melancholy or hysteria. Hysteria is considered a woman's disease, and who more than women are prone to melancholy? This disease is the basis of female delirium: the woman feels persecuted and the devil himself is the cause of this “mal de vivre”, which deprives the women of confession and forgiveness, leading them to commit suicide.
Obviously, the women most affected are elderly and single, in most cases they have already been in mourning or victims of violence. Sorcery becomes the scapegoat for every calamity and etymological explanations are also provided: for Sprenger and Krämer, the Latin word foemina is formed from fe and minus, that is “who has less faith”. This text is the worst condemnation of depressive illness and women to be found throughout the course of Western history: until the eighteenth century, thousands of innocent women were put to death on the basis of “evidence” or “confessions” obtained through torture [21, 22].
5. Renaissance
At the end of the Middleage, journeys along the coasts of the Mediterrinean sea contributed to a quick diffusion of Greek Classics, preserved and disseminated by the Arabians.
The humanistic movement (born with Dante, Boccaccio and Petrarch) emphasized a respect for the writings of the Antiquity. During these centuries, a new realistic approach to man as a person was born, which opposed the scholastics and introduced a fresh point of view about nature and man [19].
Italian philosopher Giovanni Pico della Mirandola (1463-1494) espoused the principle that each man is free to determinate his own fate, a concept that perhaps more than any other has influenced the developments of the last three centuries: only man is capable of realizing his ideal and this condition can, however, be achieved only through education [23]. Pico’s thesis was implemented by the Spanish educator Juan Luis Vives (1492-1540). His pragmatic orientation produced occasional flashes of insight; for instance, he thought that emotional experience rather than abstract reason detained the primary role in a man’s mental processes: in order to educate a person it is necessary to understand the complex functioning of his mind [19].
Up to this time the medical vision of hysteria, inherited from the Hippocratic-Galenic tradition, continues to dominate [24]. At the end of the 16th century, in European countries affected by the Counter-Reformation, the theological vision tends to overwhelm the medical community. During this period the most intense activity of the Roman Inquisition, in which magic has replaced the fight against heresy, is recorded. Thus in these states, a new generation of physicians emerges, which is destined to be subordinated to inquisitors [24]. It is precisely the physician and theologian Giovan Battista Codronchi (1547-1628) who, by criticizing the medical therapy of the time aimed at treating hysteria, give us a detailed description of them.
Codronchi said that midwives, recalling Galenus’ and Avicenna’s theachings, took care of the hysterical women introducing the fingers in their genital organs in order to stimulate orgasm and semen production [24]. The physician prohibited this treatment at all, an attitude due to the concern typical of that historical phase related to sex and sexual repression. The treatment for him must be practices by the spiritual guides [24]. And if Codronchi is also a proud supporter of the existence of demons, in favour of which he argued by referring to biblical and philosophical sources, the Italian Renaissance had already tried to condemn witch hunts and to give a “scientific” explanation of mental illness: among others, Girolamo Cardano (1501-1576) and Giovanni Battista Della Porta (1535-1615) were interested in sorcery and marginality, but did not see a demonic cause in them. They identified the origin of certain behaviors in fumes, in polluted water and in the suggestion (for Cardano) or in the acquisition of certain substances that induce “visions” and “pictures” (according to Della Porta) but both base most of their considerations on physiognomy [25]. Another important physician, the Dutch Johann Weyer (1515- 1588) intended to prove that witches were mentally ill and had to be treated by physicians rather than interrogated by ecclesiastics [19]. In 1550 he became the private physician of the Duke William of Cleves, who was a chronic depressive. The Duke observed that witches manifesedt many of the same symptoms as his relatives became insane. So, he sympathizes with Weyer’s theory that these women are really suffering from mental illness, but he cannot keep the witch hunter under control because of his transient psychotic episodes cause by an apopletic stroke [19]. In 1563, Weyer publishes De prestigiis Daemonum, which is a step-by-step rebuttal of the Malleus Maleficarum. He’s been called by his contemporaries “hereticus” or “insanus”, but his pages reveal that he’s not rebellious but that he’s a religious man [19].
However, for the doctors of that time, the uterus is still the organ that allows to explain vulnerable physiology and psychology of women: the concept of inferiority towards men is still not outdated.
Hysteria still remains the “symbol” of femininity [26].
6. Modern Age
The 16th century is a period of important medical developments, as proved by the writings of Andreas Vesalius (De humani corporis fabrica, 1543) and French surgeon Ambroise Paré (1510-1590).
These authors’ findings are the basis of the birth of modern medical science [24], combined with the "philosophical revolution", in which René Descartes (1596-1650) explains how the actions attributed to the soul are actually linked with the organs of the body, and also combined with the studies on the anatomy of the brain by physician Thomas Willis (1621-1675). Willis introduces a new etiology of hysteria, no longer attached to the central role of the uterus but rather related to the brain and to the nervous system [24]. In 1680, another English physician, Thomas Sydenham (1624-1689), published a treatise on hysteria (Epistolary Dissertation on the Hysterical Affections) which refers back to natural history through describing an enormous range of manifestations and recognizing for the first time the fact that hysterical symptoms may simulate almost all forms of organic diseases [19]. However, the author fluctuates between a somatic and a psychological explanation [27]. Sydenham demonstrates that the uterus is not the primary cause of the disease, which he compares to hypochondria: his work is revolutionary as it opposes the prejudices, but it will take several decades for the theory of "uterine fury" to be dismissed [26].
The scientific development does not mark a dramatic shift from a demonological vision of medicine, but progresses hand in hand with evolution of theories on exorcism. The written records tell us of several outbreaks of hysteria, the most famous of which is undoubtedly the one occurred in the village of Salem (Massachusetts) in 1692. The texts recall an episode in which a slave originally from Barbados talks about the prediction of fate and some girls creat a circle of initiation. This latter was formed by women yunger then twenty years of age and unmarried.The action of creating a circle of initiation was in itself an open violation of the precepts of the Puritans.
There is no record of the first stages of the disease: the girls result "possessed" since February 1692. The symptoms described were staring and barred eyes, raucous noises and muffled, uncontrolled jumps, sudden movements etc. The local doctor, William Griggs, referred the problem to the priest. The slave and two other women were summoned, and the former admitted witchcraft and pacts with the devil. Gradually they began to accuse each other. Eventually, 19 were hanged as "witches", and over 100 were kept in detention. Only when the girls accused the wife of the Colonial Governor of being part of this circle herself, the latter forbade further arrests and trials for witchcraft [27]. Marion Starkey, at the end of World War II, reports the case comparing it with more contemporary events [27]. Her explanation of classical hysteria is that the illness manifested itself in young women repressed by Puritanism, and was aggravated by the intervention of Puritan pastors, this leading to dramatic consequences. The incident proves thus that hysteria could be seen as a consequence of social conflicts [27].
Social conflicts do not occur exclusively in closed societies, such as small communities such as puritanical circles, but they also occur in more open and dynamic societies asbig cities. In 1748 Joseph Raulin published a work in which he defines hysteria as an affection vaporeuse and describes it as a disease caused by foul air of big cities and unruly social life. In theory, the disorder can affect both sexes, but women are more at risk for their being lazy and irritable [26].
Between the 17th and 18th centuries a trend of thought that delegated to the woman a social mission started developing. If from a moral point of view she finds redemption in maternal sacrifice that redeems the soul but it does not rehabilitate the body, from the social point of view, the woman takes a specific role. In 1775 the physician-philosopher Pierre Roussel published the treatise "Systeme physique et moral de la femme" greatly influenced by the ideas of Jean-Jacques Rousseau. Femininity is for both authors an essential nature, with defined functions, and the disease is explained by the non-fulfillment of natural desire. The excesses of civilization causes disruption in the woman as well as moral and physiological imbalance, the identified by doctors in hysteria [26]. The afflictions, diseases and depravity of women result from the breaking away from the normal natural functions. Following natural determinism, doctors confine the woman within the boundaries of a specific role: she is a mother and guardian of virtue [26]. In this context, the woman-witch appears more and more an artifice to secure the social order of ancien régime.
The Enlightenment is a time of growing rebellion against misogyny and sorcery becomes a matter for psychiatrists: in the Encyclopédie we read that sorcery is a ridiculous activity, stupidly attributed to the invocation of demons. And further: mental illness starts to to be framed within the "scientific view" and hysteria is indeed described in the Encyclopédie as one of the most complicated diseases, originally identified by ancient scientists as a problem related to the uterus. Even more interesting is the fact that the causes and symptoms of hysteria and melancholy are linked to the humor theory. Fortunately, the “demonological vision” of women's mental illness did not prevent previous medical theories from being maintained [28].
The last "witch" was sentenced to death in Switzerland in 1782, 10 years after the publication of the latest volumes of the Encyclopédie. Her name was Anna Göldi, and her memory was rehabilitated only in 2008 [29].
In the 18th century, hysteria starts being gradually associated with the brain rather than the uterus, a trend which opens the way to neurological etiology: if it is connected to the brain, then perhaps hysteria is not a female disease and can affect both sexes. But this is not such a simple shift as it may seem.
The German physician Franz Anton Mesmer (1734-1815) found in suggestion a method of treatment for his patients suffering from hysteria, practicing both group and individual treatments. He identified in the body a fluid called "animal magnetism" and his method soon became famous as "mesmerism". Indeed, it was thought that the magnetic action of the hands on diseased parts of the body could treat the patient, interacting with the fluid within the body. Only later we realized that this was a mere suggestion. Mesmerism had subsequent developments in the study of hypnosis [30].
The French physician Philippe Pinel (1745-1826) assuming that kindness and sensitivity towards the patient are essential for good care, frees the patients detained in Paris’ Salpêtrière sanatorium from their chains. Pinel's theory derives from ideas linked to the French Revolution: “mad” is not substantially different from “healthy”, the balance is broken by the illness and treatment must retrieve this balance. Nonethelsess, Pinel too considered hysteria a female disorder [19, 31]. Jean Martin Charcot (1825-1893) the French father of neurology, pushed for a systematic study of mental illnesses. In particular, he studied the effectiveness of hypnosis in hysteria, which, from 1870 onwards, is distinguished from other diseases of the spirit. Charcot argues that hysteria derives from a hereditary degeneration of the nervous system, namely a neurological disorder .By drawing graphs of the paroxysm, he eventually shows that this disease is in fact more common amongst men than women [32-36].
During the Victorian Age (1837-1901) most women carried a bottle of smelling salts in their handbag: they were inclined to swoon when their emotions were aroused, and it was believed, that, as postulated by Hipocrates, the wandering womb disliked the pungent odor and would return to its place, allowing the woman to recover her consciousness [34]. This is a very important point, as it shows how Hippocrates’ theories remained a point of reference for centuries.
7. Contemporary Age
French neuropsychiatrist Pierre Janet (1859-1947), with the sponsorship of J. M. Charcot, opened a laboratory in Paris’ Salpêtrière. He convinced doctors that hypnosis — based on suggestion and dissociation — was a very powerful model for investigation and therapy. He wrote that hysteria is “the result of the very idea the patient has of his accident”: the patient’s own idea of pathology is translated into a physical disability [35]. Hysteria is a pathology in which dissociation appears autonomously for neurotic reasons, and in such a way as to adversely disturb the individual’s everyday life. Janet studied five hysteria’s symptoms: anaesthesia, amnesia, abulia, motor control diseases and modification of character. The reason of hysteria is in the idée fixe, that is the subconscient or subconscious. For what concerns eroticism, Janet noted that “the hysterical are, in general, not any more erotic than normal person”. Janet’s studies are very important for the early theories of Freud, Breuer and Carl Jung (1875-1961) [35, 36].
The father of psychoanalysis Sigmund Freud (1865-1939) provides a contribution that leads to the psychological theory of hysteria and the assertion of a “male hysteria”. Freud himself wrote in 1897: “After a period of good humor, I now have a crisis of unhappiness. The chief patient I am worried about today is myself. My little hysteria, which was much enhanced by work, took a step forward” [37]. In 1889 he published his Studies on Hysteria with Joseph Breuer (1842-1925). The key-concepts of his psychoanalytical theory (the influence of childhood sexual fantasies and the different ways of thinking of the unconscious mind) have not yet been formulated, but they are already implicit in this text. Among the cases presented, we find the hysteria of the young Katherina, who suffers from globus hystericus. The text does not refer to the famous Oedipus complex, which emerges through the study of male hysteria, developed after this treatise [36-38].
We now reach a crucial point: until Freud it was believed that hysteria was the consequence of the lack of conception and motherhood. Freud reverses the paradigm: hysteria is a disorder caused by a lack of libidinal evolution (setting the stage of the Oedipal conflict) and the failure of conception is the result not the cause of the deasease [36-38]. This means that a hysterical person is unable to live a mature relationship. Furthermore, another important point under a historical point of view is that Freud emphasizes the concept of "secondary advantage". According to psychoanalysis the hysterical symptom is the expression of the impossibility of the fulfillment of the sexual drive because of reminiscence of the Oedipal conflict [36-38]. The symptom is thus a "primary benefit" and allows the "discharge" of the urge - libidinal energy linked to sexual desire. It also has the "side benefit" of allowing the patient to manipulate the environment to serve his/her needs. However, it is a disease of women: it is a vision of illness linked to the mode (historically determined) to conceive the role of women. The woman has no power but "handling", trying to use the other in subtle ways to achieve hidden objectives. It is still an evolution of the concept of "possessed" woman [37, 38].
During 19th Century, description of hysteria as a variety of bodily symptoms experiencedby a single patient is labeled Briquet’s syndrome. In 20th Century several studies are based on a particular presentation of hysteria’s symptoms: a loss or disturbance of function which does not conform to what is known about the anatomy and physiology of the body, as loss of speech but not of singing. Psychiatrists note that any function of the body can be affected by hysteria [34].
An analysis of the framing of these diagnoses in British medical discourse c. 1910-1914 demonstrates that hysteria and neurasthenia, although undergoing redefinition in these years, were closely connected through the designation of both as hereditary functional diseases. Before the war these diagnoses were perceived as indicators of national decline. Continuity, as well as change, is evident in medical responses to shell-shock [38].
The identification of hysterical fit, according to Pierre Janet’s theories, was for a long time considered impossible: an example of this diagnostic dilemma is provided by the Royal Free Disease, an epidemic of neurological, psychiatric and other miscellaneous symptoms which swept through the staff of the Royal Free Hospital in London between July and November 1955 and which affected a total of 292 members of staff. In the Medical Staff Report it was concluded that an infective agent was responsible [34]. In 1970 McEvedy and Beard put forward an alternative suggestion that Royal Free Disease was an epidemic of hysteria (for example the sensory loss affected a whole limb or part of a limb but the pattern rarely followed the distribution of nerves to the skin) and also pointed out that the spread of the symptoms, predominantly affecting young female resident staff, is characteristic of epidemics of hysteria, which usually occur in populations of segregated females such as girl schools, convents and factories. They wrote also that hysteria had a pejorative meaning in their society, but that should not prevent doctors from weighing the evidence dispassionately [34].
Besides defining the nature of hysteria, 20th Century psychiatrists also considered its history and geography. During World Wars hysteria attracted the attention of military doctors, and several authors have recorded their impressions on the frequency of hysteria in this period. Under battle conditions, the way in which hysterical symptoms provide a solution for emotional conflicts is particularly clear. A soldier torn between fear of facing death and shame at being thought a coward may develop a hysterical paralysis of his arm, sickness being a legitimate way out of the conflict [34]. For instance, in 1919 Hurst wrote that “many cases of gross hysterical symptoms occurred in soldiers who had no family or personal history of neuroses, and who were perfectly fit”. In particular, in 1942 Hadfield commented that the most striking change in war neurosis from World War I to World War II was “the far greater proportion of anxiety states in this war, as against conversion hysteria in the last war” [34]. But World War II not only allowed for a comparison with World War I in terms of patterns of neurotic symptoms, but also become a opportunity for cross-cultural comparisons between troops from widely differing cultural backgrounds [34].
Abse’s studies (1950) on hysteria in India during World War II demonstrate that, 57% of the 644 patients admitted to the Indian Military Hospital in Delhi during the year 1944, were diagnosed as suffering from hysteria and 12% were diagnosed as suffering from anxiety states. Abse also collected data from a British Military Hospital in Chester (June to October 1943) and he demonstrated the existence of a majority of anxiety states (50%) than hysteria cases (24%) [34].
Others studies confirm these data. In particular, in 1950 Williams demonstrated that Indian hysterics were often of high morale and were of all grades of intelligence, whereas among the British, gross hysterical reactions were the breakdowns of men with low stability and morale and usually of low intelligence [34]. Moreover, these studies demonstrate that from World War I to World War II there was a small relative decline of hysteria among British soldiers which was paralleled by a relative rise in anxiety states and by contrast, hysteria was still the most common form of neurosis among Indian soldiers in World War II. The contrasting patterns shown by soldiers suggest that hysteria and anxiety neurosis bear a reciprocal relationship, so that the decline of the former is compensated for by a rise in the latter [34].
But this also seems to demonstrate a different progress of hysterical disease in Western and non-Western societies. In the second half of the 20th century, we witness a “decrease” of hysteria (as response to stress, which represents the patient concept’s of bodily dysfunction) in western societies. Data of annual admissions for hysteria to psychiatric hospitals in England and Wales from 1949 to 1978 show that they are diminished by nearly two-thirds, with a marked decline in the proportion from 1971 onwards, and a similar decrease is recorded in a study conducted in Athens as well [34]. Hysteria was in fact a major form of neurotic illness in Western societies during the 19th Century and remained so up to World War II. Since then there appears to have been a rapid decline in its frequency and it has been replaced by the now common conditions of depressive and anxiety neuroses.
But the studies focused on Indian patients as well as on others non-Western countries as Sudan, Egypt and Lebanon [34] demonstrate that during the second half of 20th Century hysteria, as one of the somatic ways of expressing emotional distress, remained a prominent condition among psychiatric patients, although anxiety and depressive neuroses may have gained a little ground. Hence, psychiatrists supposed that it was an unstable transitional phase and predicted the disappearance of hysteria by the end of 20th Century [34].
There seems to be an inverse relationship between decreasing of hysteria and increasing of depression in Western society. The idea that depression was more likely to manifest itself in those born after the Second World War has been suggested in 1989 by Klerman [39]. More recently it has been documented by studies repeated over time in America and Australia, although there are exceptions in specific areas in relation to specific socio-environmental conditions and migration [40-44].
A systematic review of misdiagnosis of conversion symptoms and hysteria, based on studies published since 1965 on the diagnostic outcome of adults with motor and sensory symptoms unexplained by disease, demonstrate that a high rate of misdiagnosis of conversion symptoms was reported in early studies but this rate has been only 4% on average in studies of this diagnosis since 1970 [45]. This decline is probably due to improvements in study quality rather than improved diagnostic accuracy arising from the introduction of computed tomography of the brain [40].
We know that the concept of hysterical neurosis is deleted with the 1980 DSM-III: hysterical symptoms are in fact now considered as manifestation of dissociative disorders.
The evolution of this disease seems to be a factor of the social “westernization”. Several studies on mental diseases seem to validate this hypothesis. In 1978 Henry B. Murphy (1915-1987) [46] individuated the main causes of melancholy in social change and consequent socio-economic changes. A picture characterized by self-blame feelings, low self-esteem and helplessness. These features were described as being due to a rapid social change in two different social theatres: in those areas of England interested in turning the feudal economy into an industrial7at the centre of one at the end of the 17th century, and more recently in some areas of Africa affected by rapid economic development. In both cases the onset of psychopathological symptoms has been related to two main factors: on the one hand, the disruption of an enlarged family and the loss of a close emotional support for the individual, and on the other hand by a marked striving towards economic individualism. In this new psychological and external contest destiny and future will no longer be determined by fate, but menbuildtheir own destiny, an unknown and hard responsibility towards life [47]. In 1978 Murphy wrote that in Asia and in Africa these symptoms are rare, except among the Westernized persons, and that it could be useful to examine under what conditions these symptoms first became common in different societies [46].
From the expression of discomfort "hysteria" to the expression of discomfort "melancholy" the different conception of the self isessential. The world of hysterical manifestation is a world of "dissociation": something dark (trauma, external influences) affects a symptom not directly interpretable. From here the development in the West of hypnotic therapies (up by Mesmer to Freud and Janet) [36] and, in the West more than in non-Westernized world, it is the implementation of exorcism and purificatory rituals that mark the meeting with the groups: Tarantism and Argia in South Italy [47], Narval-Wotal practices of West African immigrants [48-52]. A world linked to a vision of women as a means unaware of evil forces, "out of control" from reasonableness or (in European Positivism) be an "immature" with manipulative behavior that seeks to achieve an improper position of power. Also the world of Melancholy is female, predominantly female since women suffer from depression at a ratio of 2.5 to 1 compared to men [48, 43]. But it is a reality in which, indeed, the patient (and therefore the patient woman) is aware of the conviction-conquest of being the master of its own destiny (and therefore to blame for their failures). We can see this passage in 1980s Africa.
