The case of Emma Eckstein.

One of the most bizarre acts of medical malpractice took place over a hundred years ago, and happens to be one of the best documented. This is because the two doctors involved – a surgeon and a physician – corresponded at length about it, and the physician’s letters have been preserved. The case has important lessons for doctors, because it contains so many elements that still put patients at risk. These include idiosyncratic treatment, mistaking physical problems for psychological ones, negligence, blaming the patient, coverups, and flagrant sexism. The main perpetrator, Wilhelm Fliess, was a successful ear, nose and throat surgeon, who practised in Berlin in the late nineteenth and early twentieth centuries. He had a wide range of medical interests, including biorhythms and the phenomenon of bisexuality, which he believed to be universal. He was one of the first doctors to apply topical cocaine to the nasal mucous membrane, and was interested to find that his patients often improved in their general health as a result. On the basis of this, he conceived the idea that the nose was a far more important organ than had ever been recognised, and was intimately connected with the heart, respiration, digestion and the genito-urinary system, along with mental well-being. In a monograph published in 1892, he described a condition he called the “nasal reflex neurosis”. He argued that nasal infections or alterations in vasomotor function could lead, among other things, to menstrual disorders, infertility and miscarriages. Equally, he claimed, the therapeutic application of cocaine to specific areas of the nasal mucosa could be used to remedy these. Fliess had a good friend a few hundred miles away in Vienna who was a physician, specialising in neurology. The friend was later to become well known, but was struggling at the time to make a living in private practice, and had decided to specialise in some poorly understood disorders, including “neurasthenia” and “hysteria” – roughly the equivalent of what we would now term chronic fatigue and somatisation disorder. He had come up with his own explanations for these conditions, believing these to include masturbation, coitus interruptus, and sexual abuse in childhood. He was attracted to Fliess’s idea of nasal reflex neurosis, and curious about how these might apply to mental disorders. Among his patients was a beautiful young woman named Emma Eckstein, who appears to have suffered from irregular, heavy or painful periods, accompanied by difficulty in walking and sexual problems. He introduced her to Fliess, who came to Vienna in early 1895 to treat her.