Two obdurate delusions of neuroscience (and neuroscientists) are illustrated by these books—that the contemporary position inevitably is the most scientifically advanced, and that medical science is set on an inexorable and more or less linear path to ultimate truth. The image is conjured of the scientist as stone mason, chipping away at the rock of ignorance uncovering the glorious forms of reason, but the trajectory of neuroscience of course is far less perfect. The awkward reality is that the march of science has an erratic course, veering up many culs de sac, and is a trajectory influenced by personality cult and by public fashion—today as much as ever.
It is with these central propositions in mind that the three books can be considered, involving as they do the history of the medical conceptions of hysteria. One (Enquist) is a quite brilliant novel, one (Maddox) an excellent biography and one (Faulks) a panoramic story. All three provide in their various ways an interesting take, from the perspectives of those closely involved, on the theories and treatment of hysteria of Jean-Martin Charcot and of Sigmund Freud. These theories (and treatments) dominated the subject in their times and had great cultural importance; yet they are notable today for their almost complete invisibility. Many exemplify discoveries, initially well-evidenced, which were then subjected to hyperbole and exaggeration and amplified to the level of nonsense and non-science, while their perpetrators were upheld as fashion icons (a common and still current tendency in the field of neuroscience for at least 150 years). Consider the many thousands of theses, papers, books and lectures devoted to these topics by numerous brilliant and learned doctors; now dismissed as scientific distractions. These were culs-de-sac up which drove most of the fashionable neuroscientists of their day.
Both Charcot and Freud enjoyed cult status, not least due to their gift for theatre and communication. Charcot's Tuesday lessons and Friday demonstrations were a magnet for physicians from around the world (Goetz, 1987). He founded seven journals and advised on four others. He contributed over 450 articles (116 on hysteria—twice as many as on any other subject). According to Axel Munthe, he was ‘the most celebrated doctor of his time … He rules supreme over the whole faculty of medicine’. His ambition was matched by his energy. His patient population was enormous (during 9 months in 1891 he had 3148 consultations, including 1913 new patients, of whom 806 were listed as hysteria or névroses). He undoubtedly made great and lasting contributions to neurological nosology, the neurological examination, the clinical approach (his famed anatomo-clinical method), and to epilepsy, muscle disease, syphilis, amyotropic lateral sclerosis, spinal cord disease and Parkinson's disease (Guillain, 1959; Goetz et al., 1995). Hysteria, however, was the contribution for which Dr Charcot was most famous—and upon which his public reputation was largely dependent. On the whole, it obscured his other work in the medical and especially public mind, but remarkably it is now his work on hysteria that has endured least and is indeed almost completely discredited.
Hysteria had been recognized since ancient times, but by the middle of the 19th century (actually much as now) it occupied a completely marginal position. This was soon to change with the work of Charcot, although in fact it was not he who initiated the revival. Charles Laségue (1880) and Pierre Briquet (1859) in France and Russell Reynolds (1869a, b) and Laycock and Todd in England were all acknowledged as predecessors by Charcot. When Charcot arrived at the Salpêtrière in 1862, ‘Burq's métallotherapie’ (Burq, 1859)—the application of various metals to the (usually naked female) skin—was in wide use, and impressed him. Charcot's chief influence though was his colleague Bourneville, whose practical and intellectual assistance (particularly in relation to publication) were vital. The publication (under Bourneville's editorship) of the first volume of the Iconographie Photographique de la Salpêtrière (1876–7) was a key element in the Paris-Hysteria cult (Bourneville & Regnard 1877). This mixed art and technology with clinical description and was irresistible (much as contemporary multicoloured graphical neuro-imaging). Therein were presented an array of clinical and laboratory measures, graphs and tables documenting the clinical course of the hysteria, often laced with lurid clinical descriptions of the subjects’ sexual fantasies (délire erotique) and photographs of women and girls in varied stages of hystero-epilepsy and undress. Its influence was immense although not to the taste of the British Medical Journal which wrote that the volumes were rendered ‘somewhat unsavoury reading by the introduction of long pages of the obscene ravings of delirious hysterical girls and descriptions of events in their sexual history’ (cited in Goetz et al., 1995). This established the Salpêtrière as the contemporary centre of hysteria, and into this circus entered Charcot as ringmaster.
Charcot applied his famed clinico-anatomical method (albeit without any pathological, but with plenty of living anatomy) to hysteria. He described and measured it, and then displayed and treated it. He viewed hysteria as an inherited disease which could be triggered by emotional or physical trauma and believed that there were definably pathophysiological pathways that could be activated by the physician under hypnosis (Charcot held that only hysterics could be hypnotized) and that activation might result in their resolution. He sought but never discovered the anatomical site of this disturbance. He viewed seizures as the central sign of an hysterical disorder, and defined the four stages of ‘grande hystérie’ (Goetz, 1987): the epileptoid phase (tonic and clonic, 1–3 min), the stage of ‘grandes movements’ (opistothonus and ‘clownisms’; 1–3 min), the stage of ‘attitudes passionelles’ (many erotic; 5–15 min), and then the final delirium (sometimes with wandering; a few minutes up to 1 h). He thereby tamed and catalogued hysteria as he had done with such success in other neurological spheres, and then embarked on treatment. He substituted magnets, solenoids, electrical shocks and then hypnotism and ovary compression in place of ‘Burq's métallotherapie’. He defined hysterogenic zones on the bodies of his patients, one inevitably close to the left breast, and systematized and medicalized the condition. He resuscitated hypnotism as a method of therapy, and his pretty, hypnotized, somnambulistic patients attracted international renown. Hysterics became three times more common in his outpatient clinic than tabetics; he became the world authority.
Now none of this hocus-pocus could have been possible without the complicity of his patients—and among the most famous was the beautiful and tragic Blanche Marie Wittman—known in her time as the ‘Queen of Hysterics’. Blanche was diagnosed with hysteria in 1878 and committed to the Salpêtrière for 16 years where she became the star turn in Charcot's demonstrations, and her ‘astonishing cataleptic, lethargic and somnambulistic feats were reported in detail throughout the Western medical world’. She was, as Enquist puts it, ‘a paragraph in the history of medicine … as Charcot's medium’. After his death, Blanche's convulsions stopped. She then worked as the laboratory assistant of Marie Curie, assisting in the discovery of X-radiation, and becoming one of Marie Curie's closest friends. Later, three limbs had to be amputated as the result of radiation damage and Blanche died as a limbless but beautiful torso.
Per Olav Enquist has written what is to my mind an almost perfect novel, at least in the sense that form and content are completely melded. It is poetic and charming—it provides the patient perspective. The Story of Blanche and Marie is based on the thoughts and memories of Blanche, mainly about Charcot and Curie, taken from her notebooks (three fictional volumes—‘The book of questions’), mixed in with the contemporary and very extensive documentary archive (real) which exists on the subject of both Charcot and Curie. The novel intertwines reality with fantasy, in a dreamy sequence, obscuring the boundaries of both—and thus is a brilliant evocation of hysteria itself. Blanche's notebooks allude to several selves (Blanche 1, Blanche 2, etc.), an allusion which is also in the title, mirroring Charcot's theories of the hysteric's multiple identities. It links the real events in Charcot's Salpêtrière to her inner life and in particular to her hysterical love for Charcot and Charcot's love for her (so convincing a fantasy that no doubt it was true). The book shows that the boundaries of fantasy and truth cannot be defined; and one cannot avoid the conclusion that this blurring of boundaries is one of the two fundamental pillars of the hysterical state (the other is the fantasy/reality that ‘love conquers all’). This novelistic interpretation of the real events surrounding the treatment of hysteria matches Pat Barker's Regeneration trilogy in its insight and medical interest.
It is Blanche who appears in the picture now hanging in the library of the Salpêtrière—much reproduced and probably the most famous picture in the history of hysteria (Fig. 1). As Enquist writes: ‘Our attention is drawn to the spectators’ faces … jealously curious, almost greedy … the motion of a falling body and the feminine resignation in Blanche. Loneliness and jealousy. Surrender, her blouse unbuttoned. Charcot turned towards the spectators … he opens his arms, like a savior’ (Enquist, 2006, p. 134). Incidentally, a lithograph of this painting by Brouillet hung above the couch in Freud's consulting rooms throughout his professional life. In her notebooks, Blanche describes Charcot's methods and the performances which had become wildly popular in Paris. As Enquist writes, it was rumoured that the experiments being conducted showed that: ‘Woman in a certain sense was to be regarded as a machine, that certain emotions could be evoked through mechanical influences, so that by pressing on specific points, ingeniously devised, the evocation of an emotional prolapse could be produced. These emotions could not only be evoked but could be repeatedly induced so that the hysterical and convulsive attacks thereby proved that Woman, precisely through her flight into hysteria and her scientifically monitored withdrawal from it, could be understood, the signs deciphered and examined’. It was possible: ‘to map the dark and unknown continent of Woman, in the same way that explorers such as Stanley! had mapped sections of Africa’ (Enquist, 2006, p. 28: not a bad analogy given the geographical nature of the hysteriogenic zones and also Jean-Baptiste Charcot's fame as explorer and cartographer). The rumour was fortified in a certain sense by the fact that these women ‘in their hysterical state displayed a nakedness, although this was scientifically motivated and not to be compared with indecency’ (Enquist, 2006, p. 28).
At the centre of the novel are the descriptions from her notebooks of Charcot's treatment—which are of great interest and so are cited here in some detail as they give a graphic picture of Charcot's methods. On the hysterogenic points (Fig. 2): ‘On October 3 1880, [Charcot] sketched for the first tune his scientific diagram on my body, which he partially uncovered, but not in an indecent manner so as to expose my breasts. The convulsions that I had suffered for many years, and that were not to be confused with epilepsy but that flung my body in an arc toward the darkening heavens, which lacked mercy, caused me to hiss as if with hatred or contempt at the God who did not exist. He punished me as if I were Job, not a butterfly that had escaped from heaven but a fallen angel subjected to vengeance. Charcot then prepared a rectangular road map in which he placed co-ordinates – I later learned the significance of the term – with specific designated points. He used a pen. I noticed that he did not select the points of desire which are usually viewed as having a connection with passion. When I later assisted with the work on Iconographie Photographique de La Salpêtrière, it was almost with humorous interest that I was allowed to designate on a diagram of a female figure the hysterogenic zones – on the front, eleven in number, on the back six. It was an illustration that actually described myself, though in graphic form. I could then record the image of a human being's puzzling emotional life in a sketch with simplified clarity. Not until later did it occur to me that this was me, a human being, and that I, instead of regarding myself as so contradictory and chaotic, had been able to simplify myself to this – I hesitate the use the word – purity … ‘Do you think that I’m a machine and not a human being, sir?’ I asked – ‘No’ … ‘But do you believe,’ I persisted, ‘that by touching these points you will have me in your power?’ He did not reply’ (Enquist, 2006, p. 138).
On hypnotism: ‘Charcot says that the first experiments with women are experiments with hypnotism. Augustine and Blanche are his first subjects. Blanche is told to look at the pendulum; to look only five to eight minutes before she seemed to grow drowsy … Augustine is placed on a bed. When Charcot raised her eyelids for several seconds, she reacted at once by stretching out her legs, a movement that made her nightgown slip to the side and reveal her naked pelvis with her sex exposed. Bourneville orders to cover the body … Blanche is now asleep. Charcot blew gently at her face. She remained in a cataleptic state. Charcot then used his hand to press on points near her ovaries [this is before Charcot had invented the ovary compressor] and she awoke and looked at Charcot with a strange smile … January 1886 – Jules Janet – when Charcot was ill – hypnotised her. She was then subjected to mesmeric passage but also taken further to a vague state that was assumed to be Gurney's deep state. Attempts were made to complement this with Azam's variant of total somnambulism, later with a combination of Azam and Sollier. But upon awakening twenty four hours later, Blanche remained in an inexplicably dissociated condition, which on her files was recorded as Blanche 1 and Blanche 2. During Blanche 1 she was very pliable and spastic, almost loving. During Blanche 2 she was very quiet and distressed, and pleaded to go back to Charcot’ (Enquist, 2006, pp. 94–95 and p. 159).
On the ovary compressor (Fig. 3) and the public demonstration of Blanche by Charcot on February 7, 1888 (the Tuesday lesson). Before the performance, Charcot in private shows her the ovary compressor. This is made of leather with metal screws affixed to it. The leather straps are fastened around her back and the screws, which have leather padding, are placed over the abdomen and then are slowly tightened causing the padding to squeeze the women's uterus. The ovary compressor is applied to Blanche's bare stomach and then pressed down towards the hysteric centre, to stop the attacks. Then the demonstration begins Charcot starts: ‘This patient who will be used for the demonstration is not a machine. I want to tell you that right from the start, and so the experiment may fail. The human being is less predictable than a machine, that's what makes us human … . This patient, who suffers greatly from hysteric attacks and convulsions, has a hysterogenic point on her back, another under her left breast, a third on her left leg. And the final phase in today's treatment, which is viewed as part of the healing process, may thus result in an extreme opisthotonus, meaning the classic arc-de-cercle. My assistant will first touch the point on her back. Blanche knew what would happen and she was prepared …. The assistant then touched the hysterogenic point, though not the one on her back as Charcot had said, but the one under her left breast. It didn't matter. She was ready, she had set off. … She is entering a forest …. She closes her eyes [and slips into her tonic phase] and walks through the forest. She met the boy … he would say she was a butterfly that had escaped from heaven … They lay down together by the grass … he unbuttoned her blouse. she allows him to caress her, she is allowed to caress him … she touches him and now he is lying completely naked beside her, and he curls up as if in spasm’. [Opisthotonus] … ‘Let us once again exert pressure on a few of the hysterogenic points … Patients often utter explanations such as ‘Mamma I’m scared’! … Note the emotional nature of the outburst and see here an arc … notice now the sudden calm, almost resolve, the static contracting stage is now dissipating’ (Enquist, 2006, pp. 163–171).
These descriptions, fictional as they are, are accurate depictions of the facts of Charcot's method and I would guess to their emotional impact. They seem to me very close to what Blanche was probably really experiencing. It is fascinating to read these beside the transcription of the Tuesday lessons (Goetz, 1987). From the perspective of medicine today, Charcot's methods seem absurd and frankly unethical—a mixture of magic and theatrics, served up with a dressing of not-so repressed sexuality. However, it is as a result of his work on hysteria that Charcot was raised to celebrity stature. He actively encouraged publicity, behaved as a showman and compère, and rapidly became a household name. It is said that on the days of his demonstrations, traffic jammed on the entire Left Bank as ‘students packed into tramways heading for the Salpêtrière lessons’ (Goetz et al., 1995). His lectures were attended by the laiety, philosophers and writers. Private showings of the beautiful and half naked Blanche (séances intimes) were arranged for selected influential laypersons and, particularly, journalists. As Goetz and colleagues (1995) coyly put it—‘Scholarly interest was difficult to disentangle from more sensational voyeuristic attraction’.
Like all celebrities Charcot attracted bitter criticism, not so much from the medical profession who themselves were essentially mesmerised by his theories (see the pages of Brain in the 1880s and 1890s to understand how topical hypnotism and hysteria were), but by novelists such as Tolstoy, Guy de Maupassant, Zola and Huysmans. In Tolstoy's novel, The Kreutzer Sonata (1887–9) Charcot epitomized the damage wrought by arrogant ‘priests of science’ whose medicalization of sexuality had destroyed modern civilisation's moral sensibility (cited by Goetz et al., 1995). Nevertheless, his worldwide private practice had a reciprocal relationship to his fame, contributing to and profiting from it.
Now let us turn more briefly to psychoanalysis and to Freud, whose scientific work was equally dependent on a cult of personality although this was not exhibited in the flamboyant way of Charcot, but rather by a more secretive manner. Often, dominance in fashion is due to a few devotees, working ferociously for the cause—and this was certainly the case in psychoanalysis, as the excellent biography of Ernest Jones by Brenda Maddox makes clear. Maddox documents the life-story of Dr Jones who was Freud's official biographer and himself a psychoanalist; and it is extremely well done. More interesting, perhaps, is the light it throws on the life-story of psychoanalysis—the cause. Psychoanalysis had its origins with Charcot. In late 1885, Freud went on a travelling fellowship to France and there spent 6 months watching Charcot treat hysteria with his theatrical demonstrations displaying ‘his patients on a darkened stage, twirling and sleepwalking’. Freud, like others, was greatly impressed by Charcot in spite of the fact that Charcot himself had no truck with the view that physical symptoms may have a sexual cause. Indeed, in 1911, Dejerine wrote that Charcot had ‘succeeded in taking from the psychiatrists a domain which they are attempting vainly to reconquer’ (Dejerine, 1911). Throughout his life Charcot believed that hysteria was due to a lesion in the brain, but the anatomical site continued to elude him. On his return to Vienna, Freud began to formulate his psychoanalytical theories which would in their turn profoundly influence the practice of psychiatry and indeed the whole of Western culture. Freud also learnt from Charcot that in the course of their treatment, his patients often fell in love with their therapists and developed a ‘magnetic passion’ (Pierre Janet's words). This process of ‘transference’ became a main instrument in psychoanalytical therapy evolved by Freud. What Freud also observed, it is perhaps possible perhaps from Blanche, is the importance of repressed sexuality in the production of hysteria or neurosis.
Maddox's book is fascinating, not so much because Jones has any particular claim to immortality, but because of what this biography of a biographer tells us of the rise and marketing of psychoanalysis so that it became a predominant fashion in 20th century intellectual life. Jones on the face of it seems a rather unlikely candidate to have championed psychoanalysis in the Anglo-Saxon world, and to have become its leading exponent. He was born into an ordinary religious baptist non-medical family in the valleys of South Wales. Jones, though, was a gifted boy whose interest in sexuality seems ahead of its times, and this may have played a part in his affinity with psychoanalysis as well as causing a certain amount of difficulty. He claimed to have had coitus at the ages of 6 and 7 years (apparently, he claimed a not uncommon practice in the Welsh valleys) and had two brushes with the law in his early years. In 1906 as a school medical officer, he was accused of exposing himself indecently to two mentally defective girls at a school for retarded children. He was exonerated when the testimony in court of the children was considered unreliable. In 1911, a woman patient accused him of having sexual relations, and Jones paid her $500 to prevent a scandal (nearly his whole year's salary). He was also early dismissed from his post as resident doctor in a children's hospital because of repeated absence without leave, and later from another hospital for asking a young girl about sexual advances from a boy. Jones is said to have recommended therapeutic masturbation or visits to prostitutes, and whilst married to Loe Kahn—a rich Dutch socialite, morphine addict and Freud's analysand—was also exercising his ‘droit de seigneur’ with her maid. He rather flagrantly allowed a number of influential (and rich) female patients to fall hopelessly in love with him.
It was from this shaky position that he became established as a leading defender of Freud and ‘the psychoanalytical cult’. This was a cult which was to dominate psychological therapy for three quarters of a century and was to change totally the attitude of Western Society and culture to mental functioning—particularly to attitudes to sex. Jones most attractive feature was his total loyalty to Freud, and Jones risked his own reputation when supporting Freud in various professional and personal battles. It was also Jones who personally managed to extract the 81-year old Freud and his family from Nazi-occupied Vienna on March 15, 1938. He chartered a plane, arrived in Vienna the day after Hitler, and pleaded and cajoled and succeeded in persuading the German and Austrian authorities to allow Freud to go; this was a singular achievement for which the whole world should be grateful.
It is perhaps also interesting to speculate whether the fashion for psychoanalysis and for sexualized theories of causation of neurosis were part of the reason for the divergence of neurology and psychiatry—the deleterious consequences of which are still felt today. Neurology is notoriously straight-laced, and the often shocking and radical path of the Freudian school was bitterly opposed by many leading neurologists. Babinski, Marie, Dejerine, Lhermitte all wrote on hysteria without mentioning sexual repression and their views led directly to the punitive ‘neurological’ approach to shell shocked patients in the Great War. It is worth recalling that Jones, like Freud himself, considered himself early on as a neurologist and had hoped to pursue a career in neurology. He was trained in neurology at the National Hospital, Queen Square, initially under Sir Victor Horsley (at whose house he held a party after the allegations of the retarded girls were dismissed), and then as the clerk of Dr C.E. Beevor. His notebooks show him an enthusiastic and energetic student, greatly influenced by John Hughlings Jackson and the Queen Square legacy, as well as the works of Charcot. His first paper in the Lancet concerned the cerebral localization of movements of the tongue in cases of hemiplegia. However, when he applied for the post of Clinical Assistant at Queen Square in 1906, he was rejected—despite backing from Horsley and Beevor—presumably on moral grounds, and this was the end of his neurological career. Freud, of course, too was trained in neurology—on the continent and not in England—and was influenced most by Charcot. He considered himself a neurologist, and wrote of Charcot that he had taught Freud that ‘theories, no matter how pertinent they are, cannot eradicate the existence of fact’ (sic!). In his early work on hysteria, Freud pressed on hysterogenic zones, hypnotized his patients and even believed with Fliess that sexual problems originated in the nose.
Psychoanalysis was a term coined by Freud in 1896 and defined as ‘psychology for neurologists’. Freud's original and long-lasting contribution though was of course his recognition that neurosis and particularly hysteria had their origins in childhood sexual conflict—a path upon which Charcot never embarked. He came rapidly to the conclusion that most of the patients’ symptoms were the result of repressed childhood sexual desires. Freud's early formulations considered hysteria to result from repressed memories of sexual seduction of the child by an adult, but later he abandoned this ‘seduction theory’ in favour of the hypothesis that hysteria depends upon repressed fantasies of childhood sexual desires. Freud evolved his theory of the Oedipus complex and considered this to be at the heart of the hysterical conflict. His theories of childhood sexuality shocked profoundly, and no doubt contributed to Freud's catapult to celebrity status.
Jones’ interest in Freud dates to 1906. Maddox notes that he had read the favourable review in Brain of Freud's ‘Studies in Hysteria’ (Breuer and Freud, 1895) in which was described for the first time the therapeutic benefit of the cathartic method of having the patient describe her sexual trauma. The review was by J. Michell Clarke (1896) from Bristol—a frequent contributor to Brain on matters hysteric and hypnotic, and someone who Jones may have known. Jones's first therapeutic endeavours were made using hypnosis, following Charcot and Janet, but he then moved on to the ‘cathartic method’ of Freud. In 1907 Jones met Jung. Then in 1908 he was invited to lunch with Freud and the two talked until two in the morning—a meeting of Berlin/Akhmatova intensity. Jones was captivated and Freud, on a more prosaic level, was delighted to have a Christian disciple—a son of a pastor no less! Jones was invited to join what Freud called ‘die Sache’—the Cause—and from then on remained close to Freud as a leading member of the psychoanalytic cabal. Indeed, Jones was the instigator of Freud's highly secret ‘Committee’ (of six, later seven members) set up in 1913. Freud referred to his henchmen as ‘Paladins’ and at the inaugural meeting of the Committee each was given a gold ring on which was mounted an antique Greek intaglio. The rules of the Committee were set out by Freud who emphasized that its existence should be kept secret but that the members should circulate weekly letters. This was really Secret Seven stuff.
Jones avidly took up the new cause, but one suspects with none of the insight and subtlety of Freud. He wrote widely—including a piece on Chess, in which he reminded readers that the act of ‘Check Mate’ was the killing of the King (father) in which the most potent assistance is provided by the Queen (mother), and that the neurosis of the grandmaster Paul Morphy was a substitute for the enactment on the chess-board of his taboo Oedipal conflicts. Jones was also deeply involved in Freud's split with Jung (Maddox reminds us that during the seismic power battle between the two, Freud fainted twice in the presence of Jung—rather like Blanche in the presence of Charcot—although Freud attributed the collapse to repressed homoeroticism) and the bitter battle between Anna Freud and Melanie Klein about the timing of the Oedipal complex and the development of the superego. All this seems faintly ridiculous to contemporary psychiatric theory, bound up as it is in receptor chemistry and functional neuroimaging (contemplate the mockery of this in future generations)—but it was a battle of ferocious intensity and importance at the time. Jones relentlessly promoted psychoanalysis, in both professional and public arenas, and was a key figure in the rise of public interest in the subject in the English speaking world. His clever choice of friends, articles, lectures and pronouncements all assisted in both elevating psychoanalysis and broadening its appeal. Maddox points out that ‘the jury is still out on Ernest Jones’. This is an interesting point, and reflects as much on the fate that has befallen psychoanalysis as on the rather dubious aspects of Jones’ life. It is indeed an extraordinary fact how far psycho-analysis has fallen from grace, from a position in which, even as recently as 30 years ago, it provided the predominant explanation for a wide range of psychiatric disturbances and more widely social, cultural and philosophical issues.
A brief mention now of Human Traces, the novel by Sebastian Faulks which follows the lives and fortunes of two fictional ‘mind-doctors’, Rebière and Midwinter, from 1870 to the late 1920s, with action spanning England, France, Austria, Africa and the United States. There are several set pieces at the centre of the novel, the most important being a description of Charcot's lessons and demonstrations—including those of Blanche. These have neither the poetry nor indeed the accuracy of Enquist (compare Enquist's, Faulks and Goetz's verbatim translations) and are derivative. Although Charcot dominates the novel, Freud surprisingly does not—although Rebière evolves theories which are clearly based on Freud, and pivotal to the story. The novel charts the clash between neurologically and psychiatrically-based therapies; and neurology wins because, it is implied, that finally much of psychiatry is pseudo-science. Why Freud is not specifically mentioned is interesting, and I may have missed the answer—and it is especially strange in view of Faulks's view (in 1994) that ‘Most people have a Freud shaped cavity in their minds which no other writer can satisfactorily fill. he offers intellectual excitement, literary pleasure, magical solutions’. Like Freud, Midwinter admits in the end that he has cured no-one; and surely as a reference to Freud's own early misdiagnoses, there are pages of Rebière's clinical notes on Katherina, whose mysterious debilitating pains he diagnoses as hysteria but then realizes are physical and so sends her for curative surgery. Charcot though clearly impressed Sebastian Faulks, and this novel is part of what really amounts to a current fashion for Charcot and a minor Charcot literary revival. Amusingly, in the novel, the ‘Senior Attendant, Ladies’, in Midwinter's English asylum, is named Miss Whitman.
Both Charcot and Freud were household names; Freud still is, and some would reckon him to be the single most influential individual in the 20th century. Both had a profound influence on wider society as well as medicine—and Freud's influence spread from science into art, philosophy, the humanities, politics, social policy and behaviour. Freudianism became an overwhelming intellectual cult. Yet, now, the really extraordinary theories of hysteria of both Charcot and Freud are largely confined to the neuroscience dustbin. These were theories which at the beginnings had genuine insight, but which were propelled by hype and extrapolation into unjustifiable exaggeration (from a scientific perspective), perhaps largely because of the vanity of the proponents, their potential gain in terms of fame and fortune (the latter at least for Charcot), and the low quality of public debate. Extreme positivists, always a tiresome curse on modern life, still view ‘the march of science’ as a linear striptease. Nothing changes and whole areas of expensive neuroscience, today seem to me likely to be equally transitory and equally essentially pointless. In fact, science—groan at the use of the term almost as a proper noun or near-religious concept—is, like life itself, often a porridge of random motion. These books relate that, from their particular perspectives, a history of science that is as much a history of shambles and of blur as is the history of any other human endeavour.