Dr. Fliess' Patient

By 1895, Sigmund Freud's theories of psychoanalysis and the unconscious were still in the formative stage but his revolutionary "talking cure" for treating neurosis had already made him well-known. It seemed only natural that 27-year old Emma Eckstein should seek him out for treatment. She became one of Freud's first analytic patients and he viewed her as a special challenge with her complaints of menstruation-related depression, hysterical anxiety, and frequent nosebleeds. While he believed that Emma's Images[2] symptoms were psychogenic in nature, he was cautious enough to call in a specialist to rule out possible physical causes.

Enter Wilhelm Fliess. A prominent otolaryngologist who practiced in Berlin, Fliess had already formed a long friendship with Freud since they met at a conference in 1885. In addition to a shared interest in neurosis, Fliess had come up with several, unique, theories of his own which had gained him some fame. Along with his work on biorhythms, Fliess had also developed what he referred to as the nasal reflex neurosis. Essentially, Fliess regarded the human nose as being an important link to sexuality and that sexual problems could be cured by treatment to the nose. Fliess claimed that he could give patients temporary relief by anesthetizing their noses with cocaine but he also advocated a more radical solution with nasal surgery. This operation involved removing several key bones in the nose.

In Emma Eckstein's case, Fliess viewed her as suffering from nasal reflex neurosis brought on by masturbation. Whatever misgivings she might have had about the diagnosis or the radical nasal surgery that Fliess proposed were quickly overcome by Freud's recommendation that she have the surgery. It probably helped that Fliess had also operated on Freud's nose to resolve some cardiac symptoms that he was experiencing. Despite the fact that Fliess had performed few operations of this type in the past and that he would be doing the operation in Vienna where he would not have the chance to follow up on his patient, the surgery went on as planned. He removed the turbinate bone in Emma's nose and instructed Freud to follow up on her after he returned to Berlin.

Emma experienced post-surgery complications from the very beginning. Not only was there considerable pain and hemorrhaging, but pus also began coming from her nose indicating infection (this was in a pre-antibiotic age). Freud called in a specialist who inserted a drainage tube but the bleeding continued along with a "fetid odour". Another surgeon, Ignaz Rosanes, cleaned the infected area and then, as Freud later described in a letter, "suddenly pulled out a thread, and kept on pulling. Before either of us had time to think, at least half a meter of gauze had been removed from the cavity. The next moment came a flood of blood. The patient turned white, her eyes bulged, and she had no pulse." Rosanes was able to pack the cavity and stop the bleeding after a minute but Emma was left "unrecognizable". Seeing what had happened, Freud fled to another room to strengthen himself with a glass of cognac. After returning, "a little tottery" to the room, Emma dryly commented, "So this is the strong sex".

She would need that sense of humour in the months that followed.  Recovery from the near-fatal surgery was extremely slow and left her permanently disfigured. Freud found himself in an extremely awkward position. Not only had Emma been his patient, but he had referred her to Fliess and recommended the surgery that had nearly killed her. Freud was worried about his patient but he also wanted to protect his friend Fliess from accusations of medical malpractice.  In a letter that he wrote to Fliess afterward, Freud reassured his friend that "You did it as well as one could do it...Of course, no one is blaming you nor would I know why they should".

Freud's determination to protect Fliess took him to remarkable lengths. He wrote to Fliess some time later and concluded in his letter that Emma's bleeding episodes had been hysterical in nature and resulted from "longing, and probably occurred at the sexually relevant times. The woman, out of resistance, has not yet supplied me with the dates." The fact that much of the bleeding was due to the unnecessary surgery that Freud talked her into having seemed irrelevant. Amazingly, Emma Eckstein continued on as Freud's patient and she was the likely inspiration for some his later self-analyses (including his "Irma" dream).  It is a testament to Freud's reputation as a healer that Emma Eckstein viewed her treatment with him as being highly successful despite the disastrous surgery.

Although Emma recovered to some extent, she eventually relapsed and became a bedridden recluse. After seeing another surgeon and having a hysterectomy following treatment for a myeloma, Freud was furious at her belief that her condition was organic and that she had sought treatment from another doctor. In his opinion, this "ruined her for analysis", and he dropped her as a patient. Freud continued to be a significant influence in her life though and she would later recommend her nephew, Albert Hirst, to Freud for treatment in 1910. She also became a psychoanalyst in her own right and wrote a small volume on child sexuality.

While Freud's relationship with Fliess had long since soured, he continued to defend his decision to send Emma to Fliess and described her case as being one of his success stories. When Emma Eckstein died in 1924 at the age of 59, Freud blamed her later relapse and poor health on her hysterectomy. After Fliess' death in 1928, his widow contacted Freud and asked for the letters that Fliess had written to him. Freud tersely told her that he had destroyed them and tried to have his own letters to Fliess destroyed as well.  She sold the letters instead. Orthodox psychoanalysts have restricted access to these letters for decades until Jeffrey Masson succeeded in publishing the complete Freud/Fliess correspondence (he was later fired as Director of the Freud Archives as a result of his controversial works on Freud).

Since the Emma Eckstein case represents one of the few actual examples that Freud ever provided to prove the success of psychoanalysis, the fact that this success story was not such a success seemed an odd omission from Freud's later writings. The disastrous surgery that nearly killed her and the extent to which Freud concealed his own role in damaging her health was largely hidden for decades. The case of Emma Eckstein also represents a warning to health professionals about potentially harmful "fad" treatments that ultimately prove to be more harmful than the conditions they were meant to treat.


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