This picture has led any number of contemporary commentators astray. Aldo Carotenuto, who published the first cache of Spielrein’s rediscovered personal papers, has supposed that she suffered from a brief “psychotic episode” indicative of “schizophrenia.” Bruno Bettelheim, whose trenchant comments on Carotenuto’s book have since been added as a foreword to it, alternates between “either a schizophrenic disturbance or severe hysteria with schizoid features.”

Thus does one age misjudge the illnesses of another. The fact is that there is absolutely no warrant in all the numerous personal documents left behind by Spielrein, nor in any other known document pertaining to her, for going beyond the diagnosis actually given by her physician in his lecture—“psychotic hysteria.” Moreover, as will become clear in a later chapter, the whole point of that lecture, delivered under historic circumstances, was to illustrate a new approach to the specific syndrome of hysteria. The psychiatrist Anthony Storr, virtually alone among reviewers of Carotenuto’s book, has seconded the diagnosis of “hysteria” while adding that because of

Storr puts his finger on the problem: though such dramatic cases of hysteria are extremely rare nowadays, they were common enough at the turn of the century and had been well described, under a variety of labels, in the psychiatric literature. Krafft-Ebing, professor of psychiatry at the prestigious University of Vienna, had provided a comprehensive description of the phenomenology of such states in his Textbook of Insanity, for twenty years the premier psychiatric text in German-speaking Europe. Krafft-Ebing, anticipating his own subsequent researches into sexual pathology but confirming an ancient prejudice, rather stressed the role of erotic themes in the hallucinations of such patients. Jean-Martin Charcot, the legendary Parisian neurologist, had by contrast emphasized the theme of trauma. Charcot’s view was that such delirious states regularly marked the third stage in a fullblown hysterical attack, itself understood as a manifestation of an underlying neurological condition, and that the scenes which the delirious patient enacted might often refer to the specific incident that had triggered the onset of the condition. Theodor Meynert, professor of neurology at Vienna and a renowned brain anatomist, had thought enough of such confusional states to lend his own name to them (“Meynert’s Amentia”), a move that led a disgruntled former student of his, Sigmund Freud, to rename them yet again (“acute hallucinatory confusion”) in his own catalogue of nervous conditions. Meynert had stressed the wish-fulfillment aspect of such states and associated them accordingly with the mentation of childhood. Freud kept the wish-fulfillment hypothesis, but sought the context in a present erotic situation.

The truth is that physicians of that era knew both a lot more and a lot less about psychotic hysteria than today’s clinicians. They knew more because they had far more direct experience. Nowadays, an incipient hysterical symptom, whether a strange pain, or a cramp, or a dizzy spell, is likely to lead to a trip to an internist or family physician. There the patient will be prescribed Valium—one of the most widely prescribed medicines in the United States today—or the like, and sent on his or her way. Those who are persistent enough to return a second and third time, and to insist in the face of a negative diagnostic workup that their symptoms are getting worse, will eventually be sent off to a psychiatrist with the thought that obviously they are under a lot of stress. This unsympathetic regime, coupled with a widespread cultural dissemination of certain basic psychological principles, is sufficient to keep most cases from progressing very far along the hysterical path. It is rare nowadays for hysteric patients to reach the stage of delirium, and when they do, and are admitted to a psychiatric facility, interns and residents are rounded up from all around to see the syndrome in full flower. This on the basis that they may never be so lucky as to see such a case again.

At the turn of the century, however, matters were quite otherwise. The incipient symptom might lead straightaway to a trip to the local nerve specialist. There the patient would be interviewed with great curiosity and, depending on the doctor’s specialty, a regime of treatment would be instituted that might consist of cold showers (properly dignified as “hydrotherapy”), electro-galvanic massage (with the current strong enough to leave welts), or a trip to a local spa (one the physician usually was personally connected with). If the condition worsened, more severe remedies might be tried, including, ultimately, ovariectomies and clitoridectomies. In the meantime, it was up to the family to provide for the patient as best they could. But what were parents or spouse and children to do when the condition had already been sanctioned by a nerve specialist? In such a climate, hysteria flourished. So, too, did scientific knowledge of it.

The basic syndrome had, of course, been known to the ancients. Classical Greek theory had it that the seat of the disease was the uterus (hystera in Greek), hence the name “hysteria,” and the presumed cause was thought to be some sort of sexual or procreative frustration, for which the equally classical remedy of sexual intercourse might be prescribed. The Greeks knew, further, that a purely psychological cause might be sufficient, such as a secret passion that the patient would not reveal. The latter insight was subsequently amplified by the great medieval physician Avicenna for a related condition then prevalent in the Islamic world, “love sickness.” As part of the examination, Avicenna would take the patient’s pulse while inquiring if there were not perhaps a certain person that the patient had taken a fancy to. If the pulse quickened, the inquiry grew progressively more precise: did this person live in a certain city, a certain quarter, a certain street? And so on, until the identity of the secret love was revealed. At that point, to be sure, it was up to the families to see what could be arranged; only if marriage was out of the question did Avicenna institute other forms of treatment designed to strengthen the will.

The suspicion of concealed or frustrated eroticism continued to cling to hysteria—“the disease of nuns, virgins, and old maids”—almost down to the modern era, though each historical period speculated differently as to how best to conceptualize the physical mechanisms involved. In the mid-nineteenth century the work of two men, the ophthalmologist Richard Carter of London, and the French physician Paul Briquet, brought a sudden new clarity to the topic. Carter provided an entirely modern psychological portrait of the illness, a feature of which was his contention that the psychological motivations involved changed as the illness progressed. Briquet, meanwhile, put to rest the suspicions about sexual frustration by demonstrating that hysteria was far more common among Parisian prostitutes than among working girls in other professions. As to its causes, Briquet identified the “passions,” and he was especially compelling as to the role of psychic trauma in fomenting the disease.

At the time of Spielrein’s hospitalization, however, this clarity had been almost totally lost. The culprit, paradoxically, was an increase in scientific knowledge. For at the same time that Carter and Briquet were working out their psychological portraits of the illness, Louis Pasteur in France and Robert Koch in Germany were doing the far more important work of putting the final touches on the modern theory of disease. According to this new synthesis—we should pause to reflect on just how new it is—disease is caused by a disruption in the functioning of organs brought about by a specific pathogen, most often a bacterium or virus. Where the disease progressed to death, its impact upon the afflicted organs could be examined directly through postmortem anatomical examination. Otherwise, the physician could attempt to classify the disease according to the symptoms and clinical course, and then seek confirmation of his thesis by demonstrating through bacteriological study that a given pathogen was invariably present in such cases. The theory was both revolutionary and entirely sound. Moreover, since it provided a way of uniting all the relevant disciplines (clinical description, bacteriology, physiology, and postmortem anatomical examination), it almost instantly passed into universal acceptance. Koch and Pasteur ascended directly into the medical pantheon.

Unfortunately, applied to the great mass of psychiatric illnesses, the new synthesis was hopelessly premature. For in the vast majority of psychiatric ailments, excepting tertiary syphilis and a few dramatic neurological syndromes, postmortem examination could reveal no organic changes in the brain, the presumed seat of the illness. The search for pathogens was equally unavailing. To be sure, the study of the physiology of the nervous system began to make fitful if essential progress, as did knowledge of the localization of certain functions in the brain, but the only real consequence of these endeavors was that microscopic researches became part of a psychiatrist’s training.

Thus it happened that in the last decades of the nineteenth century, in a well-intentioned effort to be scientific, official psychiatry went off in a hundred directions at once. Clinical syndromes multiplied as physicians struggled to identify certain regular clusters of symptoms with little else to go on but direct observation. Psychiatric theorizing, meanwhile, entranced by the exciting discoveries being made concerning the nervous system, was increasingly preoccupied with extrapolating new explanations of mental disorder on the basis of a very rudimentary set of hypotheses about brain tracts, metabolic toxins, and the like— to the point where a few sharper minds realized that the whole field was degenerating into a kind of “brain mythology.”

Of the many theories put forth in this period, two concern our story directly: the theory of hereditary degeneration and the theory of “functional” changes in the nervous system. The theory of hereditary degeneration was a kind of speculative psychiatric attempt to align the discipline with the new concepts of Darwinian evolution. Specifically, it was contended that in certain families hereditary taint would manifest itself in progressively more severe conditions over successive generations. Thus, in the first generation, one might find only such mild disorders as nervousness and a general psychological eccentricity (perhaps manifest in unusual religious ideas or else in an artistic bent). In the next generation, more severe illnesses would emerge, such as epilepsy or severe hysteria. In the third generation, these in turn would be replaced by psychosis and overt criminality. And so on, until the line died out. The theory strikes the modern reader as quite odd, even if upon a moment’s reflection he or she will realize that it is based on a true-enough observation, namely that mental illness does indeed seem to run in families, with increasing pathology seen at least in some of them. Where we differ from the nineteenth-century view is in our predilection for attributing any progressive deterioration to psychological causes, and for seeing in bad parenting the causes of pathology in the next generation. At the turn of century, however, it seemed equally reasonable to assume that such psychological causes were supplemented by physical ones, that the familial protoplasm was deteriorating along with its mental health. And though sharper minds were beginning to object to this theory, too, its day was not yet done. Accordingly, one of the first duties of an admitting psychiatrist in a state psychiatric facility such as the Burghölzli was to take a family history.

The theory of hereditary degeneration also made its mark in fields other than psychiatry proper. For example, beginning with Krafft-Ebing’s pioneering work Psychopathia Sexualis, it was regularly invoked as an explanatory variable in the literature on sexual deviancy. Then, too, it enjoyed a very definite cultural vogue as social critics used it as a basis for attacking what they saw as degenerate trends in literature and the arts. Max Nordau’s enormously popular book Degeneration sought to portray any number of modern artists as variants on the criminal-genius type, with the notorious composer Richard Wagner as a prime example. But by far the most ominous development was the use of the degeneration idea to foster incipient theories of racial inferiority. This was a particularly sensitive matter for Jews, since it was then accepted as a simple medical fact by Jewish and Gentile physicians alike that rates of nervous illness were higher among Jews than among the other races of Europe.

The other prominent theory which concerns our story, and which would have been routinely applied to Spielrein’s case, was the doctrine of “functional” nervous disorders. This category of illness was a direct outgrowth of the recalcitrant peculiarity that the brains of nervous sufferers showed no anatomical changes at postmortem examination. Thus, by the early 1880s, it had became fashionable to theorize about “functional” changes in the nervous system, i.e., nonstructural changes, as the cause of “nervous illness,” or “neurosis” as it is now called. In trying to conceptualize how such functional change could arise, medical theories turned to the idea of a trauma: just as a magnet mysteriously loses its power of attraction if it is repeatedly struck by a hammer, so, too, it was thought that the nervous system might somehow alter its functioning in the face of trauma, whether external (such as being struck by a runaway carriage) or internal (in the form of an endogenous toxin such as might be produced by an overactive thyroid). It was readily understood that such a trauma might be sexual in nature, such as traumatic abuse in childhood, just as it was well understood that the physiological changes of puberty constituted a significant endogenous stressor that might evoke hysterical symptoms in the constitutionally predisposed. But such possible sexual causes were not especially privileged; the “functional” view, unlike that of earlier eras, understood that a wide range of precipitants might be sufficient to trigger hysteria. The real cause lay in the resulting alteration of the nervous system, itself only possible in the hereditarily predisposed.

Interestingly enough, roughly the same paradigm had also seemed to prove its worth, at least for a time, in the study of hypnotism. The juxtaposition of the two conditions, the hypnotic trance and hysterical “somnambulism,” was largely the work of Jean-Martin Charcot. Charcot had a legendary career. By the end of it, not only had he first identified all manner of valid neurological syndromes, including tabes dorsalis and poliomyelitis, but, having married into wealth and possessing a knack for sociability, he had also established his home as one of the most popular of all the salons of Paris. His Tuesday lectures at the Salpêtrière Hospital were attended not only by every foreign physician in town but also by the local Parisian literary and artistic elite. In the early 1880s, with Galli...