An Anatomy of Addiction

by Howard Markel

  Theodor Billroth, the famed professor of surgery at the University of Vienna, c. 1880. (photo credit 1.11)

  Freud probably had little or no contact with Billroth while serving on his clinical service, since the surgeon quit Vienna around this time for a summer holiday in Italy, leaving his chief assistant, Anton Wölfler, in command. An accomplished musician and a friend of Johannes Brahms’s, Dr. Billroth was also a vociferous anti-Semite who publicly declared that Jews had no place in medicine. Evidence suggests that he was hardly shy about expressing these opinions to his students. Worse, his pedagogic bigotry was mimicked by many of his surgical assistants. As an example of this behavior, a few years later, in January 1885, Freud wrote to Martha describing how one of Billroth’s assistants publicly berated a coreligionist as a “Jewish swine” because he failed to agree with the surgeon “about some minor technical matter.”

  Hermann Nothnagel, professor of medicine. In 1882, at age twenty-six, Freud began working for him and spent nearly a year on the internal medicine wards of the Krankenhaus. (photo credit 1.12)

  In early October 1882, Sigmund mustered the courage to petition Hermann Nothnagel for the position of Aspirant on the internal medicine wards. A learned professor and internist, Dr. Nothnagel was the author of a widely used dictionary of therapeutics and an authoritative textbook on brain diseases. He was also somewhat of a clinical tyrant who exacted a commitment of time and energy from his trainees that few young doctors would ever sign up for today. Famously, Herr Professor Doktor Nothnagel admonished his medical students, “Whoever needs more than five hours of sleep should not study medicine. The medical student must attend lectures from eight in the morning until six in the evening. Then he must go home and read until late at night.” Demanding he was, but Nothnagel also taught his pupils that “only a good man can become a great physician.”

  Freud served under Nothnagel for six and a half months, simultaneously impressing and ingratiating himself with the man who, along with the anatomist Brücke, would serve as his principal cheerleader as he advanced his career and earning power. But eventually, Dr. Freud began to appreciate that he had little interest in treating those admitted to Nothnagel’s ward, let alone in studying their physical maladies.

  WHAT DID INTEREST FREUD was the connection between mind and brain dysfunction. Accordingly, on May 1, 1883, he transferred from Nothnagel’s internal medicine ward to the psychiatric clinic, under the direction of one of his favorite medical school lecturers, Dr. Theodor Meynert. Freud called him “the Great Meynert in whose footsteps I followed with such veneration.” No wonder. Professor Meynert all but ruled the fields of neuroanatomy and psychiatry in Austria, even though his university’s charge to treat the mentally ill was slightly less prestigious than the chairs awarded in internal medicine or surgery. For the next five months, Freud cared for confused, psychotic, and senile patients in both the male wards (two months) and the female wards (three months). The most immediate advantage to Sigmund’s career shift, however, was his promotion to the position of Sekundararzt, a combination of what we might today call a senior resident and a very junior attending physician or instructor. With this advance, he wrote his fiancée, Martha, he might have a decent shot at a middling career in Vienna. With perseverance—and, of course, that seminal discovery that would make his name—perhaps he could advance to a steady income that would finance the marriage and family they could now only dream about.

  Theodor Meynert, director of the Second Psychiatric Clinic at the Krankenhaus. Freud worked under “the Great Meynert” for five months beginning in May 1883, at the age of twenty-seven. (photo credit 1.13)

  Freud as an Aspirant at the Krankenhaus, age twenty-six, 1882–83. (photo credit 1.14)

  In October, Freud segued to the hospital’s dermatology wards, which overflowed with the degenerating brains, hearts, noses, arteries, nerves, and skin of those stricken with syphilis. Dermatologists of the late nineteenth century were also known as syphilologists because their practice centered on treating the rashes and skin lesions associated with this deadly sexually transmitted infection. Sigmund complained that he saw patients only in the male wards and missed the opportunity to see the manifestations of neurosyphilis in women. He embarked on this clinical course because he knew the ability to diagnose and treat a variety of rashes was vital for a lucrative career as a general practitioner. But he also appreciated that syphilis represented one of the great puzzles of the nexus between organic and behavioral pathology. In the end, Freud did not find dermatology “a very appetizing field,” and the disgust he experienced while caring for the diseased and debauched permeated his letters and weighed heavily on his mind. Had he made the right choice? Was he wasting his youth? What would become of him? Such un comfortable questions plagued his thoughts as sharply as the spiral-shaped syphilitic microbes burrowed into the brains and hearts of his patients. With resolve and focus, he managed to stifle these disturbing notions as he plied his patients with industrial-strength mercury and iodide-containing concoctions.

  Vienna General Hospital, c. 1882. (photo credit 1.15)

  And rise he did. In his final full year at the Vienna General Hospital, 1883–84, Sigmund took charge of the inpatient nervous diseases ward, which comprised a typical census of 106 patients, 10 nurses, 2 junior Sekundararzt, and 1 Aspirant. Still, no aspect of his exhausting work—the long hours, the intense competition, the sordid plights of the patients he treated, his slow career progression, his self-doubt, prejudice in the workplace—could have been very soothing to Sigmund’s increasingly jarred psyche. If only he could relax, rest, and refresh himself, Sigmund likely thought during those long days and nights. But how?

  IN LATE JANUARY 1884, Sigmund wrote to his “Fraulein Martha” about a grand evening of papers and medical networking at the Vienna Medical Society. The still unknown physician planted himself in a seat directly behind the regal Herr Professors Billroth and Nothnagel. Sigmund silently watched and enviously stewed as they accepted the accolades and compliments of dozens of colleagues who had won their favor. To Martha, he confessed his unspoken thoughts of deep resentment: “Just you wait till you welcome me as you are welcoming the others now.”

  No wonder Freud was so cranky. After eleven years of training, he was facing many more years of grueling and unremunerative hospital work. A few months later, in April, the overburdened and melancholic Sigmund wrote his fiancée:

  You will certainly be surprised, my darling, to hear that I am sitting here again after having written to you as recently as Saturday from the same spot; this is the result of my having been absent through being laid up so long, and rather awkward it is too. I feel there is something altogether missing at the moment; I cannot work at the laboratory because of the prospering practice; work on the experiments, from which I expect little recognition, is lying idle. It gave me quite a turn today when the proofs of my paper on the Method arrived from Leipzig; since then, with the exception of two small discoveries, I have done no work, whatever.

  As downcast as he may have sounded to Martha, she knew long before the rest of the world that his drive for success was indefatigable. In the years to come she would profess that she was never much of a follower of psychoanalysis, but she always believed in her Sigmund.

  Sigmund Freud, age twenty-seven, and his fiancée, Martha Bernays, age twenty-two, c. 1883. (photo credit 1.16)

  In many respects, his feelings would be familiar to any medical student or doctor today. If we did not know the career trajectory of the author of these many letters to Martha Bernays, one might dismiss them as a young man’s means of quelling a troubled mind, literate but screaming pleas for escape from his medical Hades. But the obvious historical difference, of course, is that these were the career musings and worries of Sigmund Freud. Unlike countless other pupils who ruminate bitterly about real or perceived slights from their professors and mutter resentful vows of burying them with the attainment of fame and accomplishment, Freud actually did it.

&nbs
p; Many medical aficionados recall the name of Billroth; far fewer recognize that of Nothnagel or Meynert; yet nearly every college graduate today has some understanding of Sigmund Freud’s work. Early in his life, Freud understood that he was different from others and yet was highly desirous of being accepted into the mainstream of his professional and social sphere. Intellectually superior to many he encountered, Sigmund fantasized about greatness but had no clear idea how to achieve it. Such disquiet must have fueled his insecurity and, on many occasions, caused him to doubt the wisdom of his career choice. Sigmund was the type of genius who needed the glowing affirmation of others and yet was continually forced to hear his inner voice tell him that he was something far less. But aside from Martha, few were stroking Sigmund’s battered ego.

  Psychiatrists and other mental health experts have long debated the existence of what has been popularly labeled the addictive personality; yet if such characteristics could be uniformly relied upon as a diagnostic indicator, many professionals might consider Sigmund an ideal candidate. His particular constellation of bold risk taking, emotional scar tissue, and psychic turmoil would soon be put to the ultimate test. In the months that followed his experience of envy at the Vienna Medical Society, the young doctor’s scientific interests and runny nose turned increasingly to an exciting new drug called cocaine hydrochloride.

  CHAPTER 2

  Young Halsted

  LATE IN LIFE, William Stewart Halsted recalled that his childhood was overly restrictive and occasionally nightmarish. To be sure, his living arrangements at both his family’s town house on Fifth Avenue near Fourteenth Street in Manhattan and their country home in Irvington-on-Hudson, New York, were luxurious and comfortable. But even from the distance of more than a century and a half, his parents hardly seem warm or supportive.

  William Halsted with his mother, sister, and older brother, c. 1860. William is seated at left; he would have been four years old. (photo credit 2.1)

  His father, William Mills Halsted Jr., stern, hard-nosed, and preoccupied, ran a profitable dry goods firm in Manhattan and founded the Commonwealth Fire Insurance Company. Descended from an established lineage that had first immigrated to the United States from Great Britain in the 1660s, Mr. Halsted played in the highest circles of New York City society and wielded enormous influence as a member of the Board of Trustees of the College of the City of New York, the College of Physicians and Surgeons (now part of Columbia University), and several other charitable institutions and philanthropies. William’s mother, Mary Louisa Haines Halsted, was the daughter of William Sr.’s business partner, Richard Townley Haines, and hailed from a distinguished family tree that included the founders of Elizabeth, New Jersey.

  Both Mary Louisa and William Jr. relegated the daily upbringing of their four children to a retinue of governesses and servants. Sadly for Halsted and his siblings, his mother preferred the company of her coiffed and powdered peers; William Jr. was most interested in the cultivation of orchids in his well-stocked greenhouse. Perhaps the singular exception to this parental distance was the father’s nightly reprobation to William, filled with fire and brimstone drawn straight out of his Presbyterian code of morals, indicating disapproval of whatever his exuberant and rebellious son accomplished or avoided that day.

  In 1863, at the age of eleven, William ran away from a private school in Monson, Massachusetts, only to be “captured” in Springfield, a distance of twenty-four miles, and forced to return home. Despite these hints of unhappiness at school and at home, William was accepted to Andover in the fall of 1863, where he remained an indolent if not lazy scholar, much to Mr. Halsted’s chagrin.

  When William graduated from the preparatory school in 1869, the father adjudged the sixteen-year-old boy too immature to go off to college. Instead, Mr. Halsted kept William close at hand and hired a series of private tutors to coach the teenaged boy for the notoriously rigorous entrance examinations at Yale. These exercises were conducted twice a year, in the three days following commencement in late July (Sundays excluded) and, eight weeks later, three days before the fall term began. William crammed for a year in order to demonstrate a yeoman’s proficiency in Greek and Latin, a reading knowledge of Cicero, Virgil, Caesar, and Homer, and a fluid recall of arithmetic, algebra, geometry, English grammar, and geography. The test cost $10 ($170 in 2010 dollars), and roughly half of those taking it passed. Upon acceptance, the fathers of the fortunate 151 young men admitted to the class of 1874, including a beaming Mr. Halsted, were required to post bonds of $200 (a little over $3,400 in 2010 dollars) “to secure the payment of all charges arising under the laws of the College.”

  Halsted at about age fourteen, with his father, William Mills Halsted Jr., at the family’s country home in Irvington-on-Hudson, New York, c. 1866. (photo credit 2.2)

  Before the first term of his freshman year had closed, William had abandoned Odysseus and Euclid for the playing fields. Wiry, agile, compactly built, and muscular, William played shortstop on the college’s baseball team, tumbled with the gymnastics team, and rowed with the crew. In 1873, he served as the captain of Yale’s football team, which holds the distinction of being the first collegiate eleven-man squad ever fielded in the nation. William’s physical strength would serve him well throughout his career, being an essential attribute for the arduous life of a surgeon.

  At Yale, William was a member of all the right fraternities and clubs, became proficient in French, appeared in several dramatic productions, wore bespoke suits, was an excellent dancer, and steadfastly eschewed alcohol. His photographic portrait documents a good-looking young man with gentle eyes, strong features, and ears the size of jug handles.

  Halsted in 1868, at age sixteen, eager to go off to college. (photo credit 2.3)

  When combing through his college transcripts, one finds little to predict an incandescent intellectual curiosity. According to the university’s library records, he didn’t sign out a single volume between 1870 and 1874. Decades later, one of Halsted’s classmates described William’s scholastic record as singularly undistinguished: “He was generally popular with the student body and socially minded, but gave no evidence of unusual ability or of great ambition.”

  IN A LETTER WRITTEN TO HIS CLOSE FRIEND William Henry Welch on July 14, 1922, Halsted identified the precise moment of his intellectual awakening: “Devoted myself solely to athletics in college. In senior year purchased Gray’s Anatomy and Dalton’s Physiology and studied them with interest; attended a few clinics at the Yale Medical School.” The first volume William mentions was, of course, Anatomy: Descriptive and Surgical, the best-selling atlas of the human body by Henry Gray of London. The other book was an internationally well-regarded and authoritative physiology text, A Treatise on Human Physiology: Designed for the Use of Students and Practitioners of Medicine.

  Physiology is the science devoted to understanding the function of living organisms and the organs, tissues, and cells that compose them. During the mid- to late nineteenth century, the field was just hitting its stride as medicine’s central explanatory discipline. To put the long history of medical epistemology succinctly, one must first understand anatomy, or how the body is structured, followed by physiology, how a particular organ or structure works under normal circumstances at ever closer levels. From there, one can begin to approach studying diseased bodies and organs, what physicians call pathology, in order to assess what has changed because of a particular illness and try to develop the means to contain, treat, cure, or even prevent it.

  A Treatise on Human Physiology was written by Professor John Call Dalton of New York’s College of Physicians and Surgeons, a man credited as being the “first professional physiologist in the continental United States.” One of the book’s most glowing reviews, likely composed by the great Harvard anatomist and essayist Oliver Wendell Holmes Sr., exclaimed, “Dr. Dalton is one of the few native teachers of physiology who have made the discovery that an American has eyes, hands, organs, dimensions, senses, as well as a Ger
man or a Frenchman. He actually examines the phenomena he describes as they exist in Nature!” So persuasive were Dalton’s powers as a lecturer that the famed Philadelphia neurologist and novelist S. Weir Mitchell said that he had “the rare gift of making those who listened desire to become investigators.”

  Gaining admission to medical school in 1874 was hardly characterized by the cutthroat competition of today. At many American medical schools, one needed only a scintilla of intellectual achievement to justify a student’s berth. Few institutions even required a college diploma. But there also existed a clear-cut pecking order, from the finest academies, typically tied to established universities, such as Harvard, Yale, Columbia’s College of Physicians and Surgeons, Michigan, and Pennsylvania, to less prestigious, storefront proprietary schools run by enterprising practitioners subscribing to a polyglot of medical theories, including allopathy, homeopathy, herbalism, water therapy, and eclecticism. Nevertheless, it could hardly have hurt Halsted’s application to the College of Physicians and Surgeons, easily one of the best schools in the nation, to list as a reference his father, who served on the college’s board of trustees. In the late spring, William was informed that he would be admitted to the class of 1876. He also secured a coveted research assistantship under his new medical hero, John Call Dalton. Given the state of medical education in late-nineteenth-century America, Halsted would have found it difficult to land in a better position.

  Halsted at age twenty (top row, third from left) and the 1872 Yale football team—the first eleven-man football team fielded by a U.S. college. (photo credit 2.4)