Freud's Patients, A Serial

A series of historical vignettes.

Ernst Fleischl von Marxow (1846-1891)

Freud's first therapeutic blunder and how he lied about it.


Simon Ernst Fleischl Edler von Marxow was born August 5, 1846 in Vienna.  He came from a prominent Jewish family that combined wealth and influence.  His father, the banker and businessman Carl Fleischl Edler von Marxow, was ennobled in 1875.  His mother Ida, née Marx, was an educated woman who surrounded herself with scientists, artists and journalists such as the archaeologist Emanuel Löwy and the novelist Marie von Ebner-Eschenbach.  One of his uncles, the famous physiologist Johann Nepomuk Czermak, is known among other things for having introduced the use of the laryngoscope. 

It was probably to follow his uncle’s example that Fleischl studied medicine with the intention of becoming a researcher. Exceptionally bright, full of original ideas, he obtained his doctorate in medicine in 1870 at the age of 24 and became assistant to Karl von Rokitansky in anatomopathology. The following year, however, he injured himself during an autopsy and the right thumb that had been infected had to be amputated. This resulted in extremely painful amputation neuromas which made his life unbearable and for which the surgeon Theodor Billroth operated on him several times with no lasting result.  Unable to continue his work in anatomopathology, he turned to physiology and became assistant to Ernst von Brücke at the Institute of Physiology.  There, despite his persistent pain, he conducted experimental research on the excitability of nerves and was able to show that the stimulation of the sensory organs causes variations in electrical potential on the surface of the corresponding areas of the cerebral cortex, a discovery that eventually would make possible the electroencephalogram.  He also invented various optical measuring instruments, such as the spectropolarimeter and the hematometer.

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Fleischl was not only an outstanding researcher, but also, according to all who knew him, an exceptional personality. Handsome, charming, witty, he was a brilliant conversationalist who was able to talk about literature and music as well as about the latest advances in physics. Very close to his colleague Sigmund Exner and to Josef Breuer, his circle of friends also included the writer Gottfried Keller, the urologist Anton von Frisch (the father of the Nobel Prize Karl von Frisch), the psychiatrist Heinrich Obersteiner, the composer Hugo Wolf, the philologist Theodor Gomperz, the gynecologist Rudolf Chrobak and the physician Carl Bettelheim.  Through Breuer and Gomperz, he entered the fashionable circle of the wealthy Todesco, Wertheimstein and Lieben families, and was for a while engaged to Franziska (Franzi) von Wertheimstein.  Drawing on experiments carried out by his uncle Czermak, he made, at a party at the Wertheimstein’s, a demonstration of hypnosis on a hen that deeply impressed the audience and contributed to the renewed interest in hypnotic states among scientists in Vienna in the early 1880s.  With his friend Obersteiner, he also carried out hypnotic experiments on himself.

At Brücke’s Institute of Physiology, Fleischl made the acquaintance of a young research assistant named Sigmund Freud who had started working there in 1876.  Freud greatly admired Fleischl who represented for him a sort of ideal and the two men gradually became very close, despite the difference in age and status.  Through Fleischl, Freud also became acquainted with his friend and physician Josef Breuer.  Together, Fleischl and Breuer supported financially their young protégé, who was regularly running out of money.

Having become intimate with Fleischl after leaving the Institute of Physiology in 1882, Freud discovered the tragedy that lay behind his mentor’s brilliance.  To calm his terrible pain, which often kept him up all night, Fleischl was taking morphine and had developed an addiction to it, like many others at the time.  It is in this context that Freud read in late 1883 an article by the army surgeon Theodor Aschenbrand on cocaine, an alkaloid synthesized in 1860 from coca leaves by Albert Niemann.  Aschenbrandt had added a little cocaine to the water served to his Bavarian recruits and found that the soldiers had become unusually resistant to fatigue and hunger (a well known effect of the coca leaf among the Indians of Peru).  Intrigued, Freud had inquired further and came upon a series of articles in the Detroit Therapeutic Gazette extolling the many virtues of cocaine, including its use in morphine detoxification.  

Freud does not seem to have noticed that the Gazette was actually a piece of promotional literature published by the pharmaceutical company Parke-Davis in Detroit, whose main product since 1875 had been cocaine. (George S. Davis, one of two founders of the company, was the Gazette’s editor.)  Eager to attach his name to some great scientific discovery that would bring him fame and fortune, Freud bought some cocaine from the manufacturer Merck in Darmstadt and began to try the product in oral doses on himself and a few people around him: his fiancée Martha Bernays, Josef Breuer and his wife Mathilde (for her migraines), and Fleischl.  Excited about the euphoriant properties of cocaine, Freud published in July 1884 an article “On Coca” in which he basically took up all the Gazette’s selling points.  Cocaine, he announced, was a stimulant and an aphrodisiac. It was good for dyspepsia, cachexia, sea sickness, hysteria, neurasthenia (what we would call today depression or chronic fatigue), melancholia (the depressive pole of manic depression), facial neuralgia (trigeminal neuralgia), asthma and impotence.  At the end of his article, Freud also suggested that cocaine had anesthetic properties that ought to be explored.  His friend Carl Koller did exactly that and discovered that cocaine could be used as local anesthetic in ophthalmology, thus becoming instantly famous in the place of Freud. 

Freud's article also contained a section on the use of cocaine in the detoxification of morphine. Freud relied almost exclusively on cases of successful demorphinisation alleged in Parke-Davis’ promotional Gazette, but he also claimed to have been able himself to detoxify a case of this kind. The weaning had been a success.  The patient had not been depressed, he “was not bedridden and could function normally.  During the first days of the cure he consumed [orally, that is] 3 dg of cocaïnum muriaticum daily, and after ten days he was able to dispense with the coca treatment altogether.”

As Carl Koller was to reveal in 1928, the patient in question was none other than Ernst Fleischl von Marxow. The cocaine treatment, which began on May 7, 1884 with Breuer’s assent, did not go exactly as Freud said in his article.  Although it had seemed promising during the first days, Freud wrote as early as on May 12 to his fiancée: “With Fleischl things are so sad that I cannot enjoy the cocaine successes at all.”  Cocaine, which Fleischl took “continuously” did not prevent him from suffering extreme pain and having “attacks” that left him nearly unconscious.  Freud added: “Whether in one of these attacks he took morphia, I do not know, he denies it, but a morphinist, even if it is Ernst Fleischl, cannot be believed”.  On May 19, cocaine having suppressed neither the pain nor the withdrawal symptoms, Theodor Billroth attempted at Freud’s request a new operation on the stump and recommended that Fleischl “take considerable amounts of morphia [...] and he was given he does not know how many injections” (May 23, 1884).

The detoxification had been an utter failure. Yet Freud set out to write his article “On Coca”, despite Breuer’s reservations (on June 12, 1884, he wrote to Martha Bernays: “Breuer absolutely does not want to tell me anything good about it”).  The article was submitted to the printer on June 18 and appeared on July 1.  It quickly aroused great interest in the United States, especially from Parke-Davis.  The company made a point to mention in a brochure the interesting work of “Professor Fleischl and Dr. Sigm. Freud of Vienna” which confirmed its own promotional literature.  (Parke-Davis also offered Freud $24 to compare the company’s cocaine to that of Merck.  Like a modern-day “key opinion leader”, Freud was glad to endorse Parke-Davis’ product and predicted that it “should have a great future”.)

The odd mention of “Professor Fleischl” comes from the fact that Freud had published anonymously reviews and abstracts of his own article in various American medical journals, using his prestigious patient and “collaborator” as scientific backing. In an article published in December 1884 in the St. Louis Medical and Surgical Journal, he wrote: “Prof. Fleischl of Vienna confirms the fact that muriate of cocaine is invaluable subcutaneously injected in morphinism (0.05-0.15 grm. dissolved in water) [...] a sudden abstinence from morphine requires a subcutaneous injection of 0.1 gram. of cocaine. [...] in 10 days a radical cure can be effected by an injection of 0.1 gram. of cocaine 3 times a day.” 

The dosage was the same as that indicated in the original article, but the method of administration was different (subcutaneous injection rather than oral administration).  Behind this little detail hid the fact that Fleischl not only had not stopped injecting morphine in spite of his “radical cure”, but had also begun to inject cocaine.  On July 12, 1884, shortly after the publication of his article “On Coca”, Freud mentioned in passing to his fiancée that his friend was taking cocaine “regularly”.  It is clear from Freud’s American articles that Fleischl had already switched to the syringe by October 1884.  Whether or not he did this initially against Freud’s advice, as the latter would claim in veiled terms in Chapter 2 of The Interpretation of Dreams, it is equally clear that Freud also adopted at some point this pharmacologically much more aggressive method of administration.  In January 1885, he announced to his fiancée that he wanted to see if one could relieve facial neuralgias by injecting cocaine directly into the nerve, adding: “and maybe even Fleischl can be helped. [...]  If only I could take away his pain” (January 7, 1885).  In a lecture published in early April 1885 and in which he again claimed that he had cured a morphine addict by giving him cocaine, Freud explicitly recommended the injection:  I have no hesitation in recommending the administration of cocaine for such withdrawal cures in subcutaneous injections of 0.03-0.05 g per dose, without any fear of increasing the dose.”

As any drug addict knows nowadays, the combination of an “upper” such as cocaine and a “downer” such as morphine or heroin is one of the most euphoriant and most dangerous (the painter Jean-Michel Basquiat and the actor John Belushi, among many others, died of it).  It is also the most irresistibly addictive combination.  Once hooked, Fleischl constantly increased the doses of cocaine to get the famous “rush”.  On his return from a trip to his summer residence in St Gilgen, in October 1884, his cocaine use had already become so significant that the manufacturer Merck asked him to inform him of the effects he observed.  In June of the following year, Freud wrote to Martha:  “Since I have given him the cocaine, he has been able to suppress the faints and he could better control himself, but he took it in such monstrous quantities (1,800 Marks for cocaine in three months, about a gram a day) that in the end he suffered from chronic intoxication” (June 26, 1885). Yet, in his article of April, Freud had written about his morphine patient: “No cocaine habituation set in; on the contrary, an increasing antipathy to the use of cocaine was unmistakably evident.”

Fleischl was in a state beyond description.  He went constantly from “the clearest despair up to the most exuberant joy over bad jokes” (April 10, 1885).  Breuer, Exner and Freud took turns spending the night with him. Freud took cocaine himself to stay awake:  “His talk, his explanations of all kinds of difficult things, [...] his manifold activities interrupted by states of the most complete exhaustion relieved by morphia and cocaine:  all that makes an ensemble that cannot be described” (May 21, 1885).  Fleischl’s friends felt the end approaching.  Freud, who had asked him once again to help him financially, wrote to Martha:  “I wonder if he will lend me anything.  If so, he may no longer be there when we need to think about paying back” (March 10, 1885).  In June, Fleischl began developing hallucinations characteristic of cocaine addiction but which Freud, in his ignorance, compared to delirium tremens:  Fleischl had the creepy sensation of insects or snakes crawling on his skin, a phenomenon known today as “formication” (or, more colloquially, “coke bugs”). 

In early August, Fleischl went to the family home in St Gilgen, accompanied by his younger brother Paul.  Freud wrote to him from Paris where he followed Jean-Martin Charcot’s lectures on hysteria, asking for money.  Fleischl did not answer.  Upon his return to Vienna, Freud told Martha that “Fleischl looks miserable, more like a corpse” (April 5, 1886);   “he hallucinates constantly and it will probably not be possible to let him remain in society for much longer” (April 7, 1886).  Freud resumed his night watches at Fleischl’s apartment, at least until the end of May 1886.  We do not know if he continued beyond that point, for his correspondence with Martha stopped shortly thereafter due to their marriage.

In July 1887, Freud published a reply to Albrecht Erlenmeyer, a morphine addiction specialist who had tested cocaine on his own patients. Erlenmeyer’s results contradicted those of Freud:  not only had the patients not given up morphine, but they had also developed an addiction to cocaine. Dr. Freud, concluded Erlenmeyer, had added to morphine and alcohol a “third scourge of humanity, cocaine”.  Stung, Freud responded by again invoking “the surprisingly favorable results of the first morphine withdrawal by means of cocaine carried out on the Continent. (It is perhaps well to mention at this point that I do not speak of experiments carried out on myself, but of another whom I advised on the matter.)” As for the negative results obtained by Erlenmeyer, they were due, according to Freud, to his administering the cocaine subcutaneously, not orally as Freud had prescribed -- a “serious experimental error” for which Erlenmeyer’s patients had paid the price.  After that Freud forgot his articles about cocaine, including the one in which he recommended the syringe.

Ernst Fleischl von Marxow seems to have lived his last years removed from “society”.  Did he ever manage to wean himself from cocaine? This is what Freud claimed in a letter he wrote in 1934 to the Viennese professor of ophtalmology Josef Meller:  “After a surprisingly easy morphia withdrawal, he [Fleischl] became a cocainist instead of morphinist, developed bad psychic disturbances and we were all happy when later on he returned to the earlier and milder toxic.”  However, we may have some doubts about this, for Freud’s mention of hallucinations in his letter to Martha of April 7, 1886 seems to indicate that Fleischl was at that date still taking cocaine (morphine does not cause this type of effects). 

After that?  In a letter written in 1891 to Franzi von Wertheimstein, Fleischl’s former fiancée, Breuer seemed to suggest that towards the end Fleischl had substituted chloral for morphine to relieve his pain:  “Aside from the pain, Ernst wasn’t even deeply unhappy when made drunk and half-stupid by the chloral he completely lost consciousness of everything and of himself.  Then there was the ongoing fight against his proclivity to excessive intake of chloral, in which he fell steadily, the terrifying hangover which resulted and which lasted one week, and then again the repetition” (28 October 1891).  Breuer doesn’t mention cocaine, but it seems unlikely that that the human wreck Fleischl had become would have found the strength to escape its grip.

Ernst Fleischl von Marxow died at last on October 22, 1891 in Vienna. Breuer wrote to Franzi von Wertheimstein: “I bemoan Ernst, as I have done for years, but I cannot say that I bemoan his death [...]. We all owe a death to Nature, but not suffering, not this pathetic crumbling of such a brilliant personality.”

                                           (Next post:  Mathilde Schleicher)



-  Crews, Frederick (2011)  Personal communication.

-  Exner, Sigmund (1893)  “Biographische Skizze”, in Ernst Fleischl von Marxow, Gesammelte Abhandlungen, Otto Fleischl von Marxow ed., Leipzig, p. V-IX.

-  Fleischl von Marxow, Ernst (1884-1885)  Letters to Sigmund Freud, Sigmund Freud Collection, Manuscript Division, Library of Congress, Washington, D.C.

-  Freud, Sigmund (1882-1886)  Letters to Martha Bernays, Sigmund Freud Collection, Manuscript Division, Library of Congress, Washington, D.C.

-  Freud, Sigmund (1934)  Letter to Professor Josef Meller, November 8, 1934, Sigmund Freud Collection, Manuscript Division, Library of Congress, Washington, D.C.

-  Freud, Sigmund (1974)  Cocaine Papers, Robert Byck ed., New York, Meridian Books.

-  Freud, Sigmund (1996)  Schriften über Kokain, Albrecht Hirschmüller ed., Frankfurt-am-Main, Fischer.

-  Hirschmüller, Albrecht (1989)  The Life and Work of Josef Breuer.  Physiology and Psychoanalysis, New York, New York University Press.

-  Israëls, Han (1993)  Het geval Freud. 1. Scheppingsverhalen, Amsterdam, Uitgeverij Bert Bakker.  [German translation:  Der Fall Freud: Die Geburt der Psychoanalyse aus der Lüge, Hamburg, Europäische Verlaganstalt, 1999.]

-  Kann, Robert A. (1974)  Theodor Gomperz:  Ein Gelehrtenleben im Bürgertum der Franz-Josefs-Zeit.  Auswahl seiner Briefe und Aufzeichnungen, 1869-1912, erlaütert und zu einer Darstellung seines Lebens verknüpft von Heinrich Gomperz, Wien, Verlag der Österreichischen Akademie der Wissenschaften.

-  Karch, Steven B. (2006)  A Brief History of Cocaine, Boca Raton, Florida, Taylor & Francis.



Mikkel Borch-Jacobsen, Ph.D. is professor of French and comparative literature at the University of Washington.


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