An Anatomy of Addiction

by Howard Markel

  Halsted’s medical school: the New York College of Physicians and Surgeons. (photo credit 2.5)

  The halls of the College of Physicians and Surgeons were hardly as austere or dignified as the decorous European medical schools. Within a four-story brick building on Twenty-third Street and Fourth Avenue (now Park Avenue South) in Manhattan, students were crammed chockablock into a series of stifling lecture rooms, amphitheaters, laboratories, and dissecting suites. The latter were always placed on the top floor of nineteenth-century medical school buildings to better ventilate the putrefying smell of the cadavers and, just as critical, to welcome in the natural daylight afforded by large windows and skylights. Yet all of the rooms at the College of Physicians and Surgeons, regardless of purpose, were smelly, smoky, dirty, and musty; in the winter months, the classrooms were blasted by the building’s powerful hot-air furnace.

  The medical students at the College of Physicians and Surgeons were notorious for the “cat-calls, whistles, and yells” they directed at professors as they entered the lecture hall. William scorned such sophomoric high jinks and instead hunkered down to his studies. His diligence paid off, and he rose with ease to the top of his class. Halsted delivered a sterling performance on his oral examinations, and his written thesis, “Contraindications to Operations,” was awarded an academic prize and a check for $100, or more than $2,000 in 2010 dollars. In June 1876, he graduated medicinae doctor (M.D.), cum laude (with honors).

  That autumn, Halsted would advance to an internship at Bellevue Hospital, a short distance on foot from his medical school. One of the oldest hospitals in the nation, it was named for a bucolic farm that once overlooked Kips Bay and the East River. Founded by a Dutch surgeon named Jacob Hendrickssen Varrenvanger in 1658, it began as an almshouse. In 1736, the Board of Aldermen of New York established a six-bed hospital. During the next century and a half, Bellevue’s physical plant and medical mission grew exponentially.

  Bellevue Hospital, 1879. (photo credit 2.6)

  Unlike today’s medical centers, nineteenth-century American hospitals were charitable enterprises devoted to the care of the urban poor, orphans, widows, seamen, soldiers, and immigrants. Consequently, hospital trustees spent a great deal of effort deciding which patient was morally worthy of the healing experience they offered and, thus, should be granted admission. Drunks, criminals, unwed mothers, prostitutes, and the so-called undeserving poor need not apply. In such an institutional atmosphere, the healing process was focused less upon therapeutic medications, diagnostic tools, and invasive operations than upon improving the unhealthy living environments of patients—and their godless ways—in the hope of effecting a spiritual, if not a physical, cure.

  The several blocks William traversed from his family’s well-appointed town house to the hospital afforded a stunning trip into the depths of late-nineteenth-century urban squalor. For example, an 1878 Harper’s Magazine essay explained to its well-to-do subscribers that Bellevue was situated amid a collection of ramshackle tenement houses and that entry was no simple matter:

  [The area was] plentifully dotted with shabby little stores and corner groggeries, where the garbage is piled up in the streets, the men are idle, the women slatternly, and the children as nearly nude as the weather permits.… The activity at Bellevue has no end. The keeper of the lodge at the entrance is continually besought for admission, and so worried by impossible requests that one can pardon his shortness of temper.

  Given the rudimentary state of medical education in this era, it was difficult for young physicians to gain the breadth of clinical knowledge and experience taken for granted today. American medical schools rarely, if ever, introduced their students to actual patients, preferring instead to pedantically lecture at them for a few years, followed by a lengthy apprenticeship with a practicing doctor. Worse, there were far more medical school graduates than there were internship slots at first-rate hospitals. Consequently, Bellevue was such a prestigious place to train that it required a rigorous entrance examination and selected interns from among the very highest-scoring students.

  Block Island, where the Halsted family summered. Halsted studied for his internship exam at Bellevue here during the summer of 1878. (photo credit 2.7)

  During the summer of 1876, William vacationed on Block Island, fourteen miles east of Montauk Point, Long Island, and thirteen miles south of the coast of Rhode Island. He devoted his mornings and evenings to cramming for his internship examination; his afternoons were spent swordfishing, swimming, and sailing in the Atlantic Ocean. William scored fifth among the competitive applicants and was awarded a coveted position on Bellevue’s fourth surgical division. He was one of only eight interns accepted that fall. What he found within its forbidding, protective walls was a busy complex of charity wards, laboratories, and an active morgue. Docked along the East River was a funeral ferry that transported unclaimed bodies up to Potter’s Field on Hart Island. Adjacent to the hospital was the Bellevue Medical College, filled to the rafters with well-dressed, well-off, young white men eager to learn how to be doctors.

  The river of human pathology at Bellevue had no end, and its sources were the slums and ghettos of New York. “The picture has many changes, no reverse,” William Rideing wrote about Bellevue in 1878, “it is pain, anguish, or death always. If the spectator is cynical, his morbidity is enlarged; but, if, without being an optimist, he can look at it with clear eyes, its gloom and sadness are relieved by a glimpse of the tenderness that blossoms in the hearts of the commonest poor.”

  Bellevue Hospital’s main gate, 1878 or 1879. (photo credit 2.8)

  Halsted’s internship class at Bellevue, 1878. Halsted, age twenty-six, is in the second row, fourth from the right, under the arch. (photo credit 2.9)

  From morning to late at night, year after year, the sick and needy pounded on the hospital’s doors, begging for admission—the victims of accidents in the building trades, the chronically and acutely ill, the hopelessly alcoholic, the insane, and the physically broken. The most desperately ill were transported in horse-drawn ambulances that received their calls through an independent telegraph wire that connected every New York City police precinct with the hospital. In 1876, 5,165 patients were admitted, most of them foreign-born; 2,215 of these patients were Irish, 1,680 American, 595 German, 256 English, and 56 French. Only 4,313 lived long enough to be discharged. With mortality rates of 16.5 percent, large numbers of former Bellevue patients were laid to rest in unmarked graves every year.

  There existed a clear chain of command at Bellevue; Halsted had to ascend through job titles such as interne, junior assistant, senior assistant, and, finally, house surgeon. Internes were required to reside fulltime in the hospital. Junior and senior assistants were allowed to go off duty each night at six p.m., unless an emergent case came in and the surgeon in charge felt compelled to call any and all in for help. The seven-day-a-week job (plus many nights) was “strenuous, exacting, and exhausting,” according to one of Halsted’s contemporaries, “but the experience was most varied and profitable.”

  Along the way, the impressionable young physician made medical rounds with such luminaries as Abraham Jacobi, the universally revered German émigré who established pediatrics as a bona fide medical specialty in the United States; the domineering internists Theodore Janeway and Alfred Loomis, whose textbooks and ideas on fever, practice, and therapeutics were absorbed, memorized, and communicated by generations of American medical students; and the prominent surgeons Alexander Mott, Erskine Mason, and Frank H. Hamilton. In later life Halsted noted that he learned little or nothing from the first two surgeons, while Hamilton became something of a mentor to him.

  Once Halsted completed his internship at Bellevue, he ventured uptown to New York Hospital, where he served an additional six months as house physician. There he briefly flirted with studying neurology under an inspiring teacher named Edward Seguin, the distinguished son of the even more prominent French neurologist Édouard Séguin. But at New York Hospi
tal, Halsted was biding his time for a far more important medical stepping-stone: two years of professional seasoning in the medical meccas of his day—Berlin, Würzburg, Leipzig, and Vienna.

  WILLIAM WAS HARDLY ALONE in such a pursuit. For decades, young American physicians aspiring to medical greatness traveled to Europe for advanced study. In the late eighteenth and early nineteenth centuries, enormous hospitals like Guy’s and St. Bartholomew’s in London and the Hôtel-Dieu in Paris were the destinations of choice. By the time Halsted embarked on his postgraduate medical training, however, the German and Austrian universities dominated virtually every aspect of science and medicine. These medical and research centers beckoned eager students from around the globe to learn disciplines that were then as new, exciting, and important as genomics and stem cell biology are today. Between 1870 and 1914, more than ten thousand doctors made the medical pilgrimage; or, as one historian has estimated, approximately 40 to 50 percent of all the American physicians born between 1850 and 1890 studied in Germany. As a result, auditoriums across Germany and the Austro-Hungarian Empire were crowded with eager students kneeling or sitting at the feet of the masters, innovators, and, in many cases, founders of the modern medical research enterprise.

  Like many young men who aspired to the elite ranks of academic medicine, William hailed from a wealthy family for whom money was never a concern. He simply declared his plans for the upcoming two years, drew a significant amount of money from his father’s bank account, picked up a first-class-passage ticket from the steamship company, and sailed off to Europe. He arrived in Vienna on November 4, 1878.

  Thereafter, for nearly a year, William stuck to a regimen of two German lessons each day so that he might better understand the countless lectures he attended at the Vienna Medical School. He focused most intently on learning about the vanguard discoveries being made at the operating table. Every evening, he washed down Tafelspitz with seidels of Märzen lager, exuberantly debating medical theories with his fellow students. His surgical aptitude soon caught the attention of Billroth’s aide-de-camp and assistant surgeon, Anton Wölfler, who invited William to work in his laboratory. There, Wölfler provided his American protégé with unlimited access to a superb collection of expensive, powerful, and finely polished microscopes, one of the principal technological tools employed in medical research of that era but hard to come by in the United States unless specially ordered from Germany. Finally, Dr. Wölfler introduced William to Vienna’s medical crème de la crème, including Theodor Billroth.

  In 1878 and 1879, Halsted and Sigmund Freud orbited the same tentacular campus that was the Vienna General Hospital and Medical School. For most of that period, Freud drudged over his laboratory bench at the Institute of Physiology, while Halsted made the medical equivalent of a grand tour. Sometime during his stay, William even initiated a private course in neuroanatomy with Dr. Theodor Meynert, the university’s professor of psychiatry, who a few years later would become such an important intellectual figure in Sigmund Freud’s life. Halsted’s tutorials were held daily at six a.m. in Meynert’s apartment. Each morning, Professor Meynert insisted on conducting the lesson from his bed while still in his rumpled pajamas. Decades later, in 1922, a still disgusted Halsted recalled that because “the lesson was given in his unsavory bedroom I soon released him from his contract.” Despite these near misses, no documentation exists to suggest that Freud and Halsted ever met.

  For the academic year 1879–80, William traveled to several German universities and medical schools. There, he heard some of the world’s leading authorities present lectures on embryology, histology (the microscopic anatomy of cells and tissues), and physiology. Until his dying days, William extolled the virtues of the German university system and its influence on his life and work. As his Johns Hopkins colleague William Osler later remarked, William returned to New York from this trip “very much verdeutsched.”

  Halsted also returned a superbly trained surgeon, perhaps the best of his generation, firmly committed to living much of his life within the confines of the operating room. He made his career choice precisely at the time when the field was just evolving from an ancient craft to an armamentarium of miraculous cures. Even as late as 1880, the surgical enterprise overflowed with danger, during both the procedure itself and the patient’s recovery thereafter. To be sure, great strides had been made with the advent of ether anesthesia, in the 1840s. But in an era before the universal acceptance of antiseptic surgery, infections ran rampant in surgical wards. Deadly surgical complications, including shock and hemorrhages, were so standard that it is little wonder some vaudevillian was inspired to remark, “The operation was a success, but the patient died!” At this point in medical history, only a consummate risk taker would devote his life to surgery.

  CHAPTER 3

  Über Coca

  AT FIRST GLANCE, a clump of cocaine appears pearly white, crystalline, and innocuous. Lurking within, however, resides the molecular power to inhibit the human brain’s uptake of dopamine, serotonin, and norepinephrine, chemical neurotransmitters essential to the governance of mood and many other mental activities. Along the way, cocaine suppresses one’s appetite, speeds up thoughts and actions, races the heart, and inspires a raucous euphoria that makes the brain hungry for more and more.

  There exists a long history of human encounters with cocaine’s vegetative source, a rather plain-looking bush that carries the elaborate Latin name Erythroxylum coca. A leafy shrub of six to eighteen feet in height, it grows most potently along the eastern slopes of the Andes Mountains descending into the Amazon basin, a moist, mountainous climate, at elevations of 1,500 to 6,000 feet. Its distinctive pale green, oval leaves have been harvested there for millennia. The local Peruvian Indians, or coqueros, who used it on a daily basis, called it cuca. Their Inca forebears venerated it as “the divine plant” and incorporated it into many religious rituals and initiation rites. So cherished a staple were these cuca leaves that virtually every man and woman in the region carried a small pouch filled with them, always ready for a chew and typically empty by nightfall.

  FREUD’S FIRST ENCOUNTERS with cocaine were on the written page. Ever the obsessive-compulsive scholar, Sigmund gathered stacks of papers and books on cocaine, many of which he borrowed from a distinguished Viennese pharmacologist named August Vogl, all neatly piled on the small worktable of his hospital quarters.

  He devoured every paragraph of these documents. Long fascinated by myths and saga, Freud thrilled while reading about Manco Cápac, Incan mythology’s son of the Sun God, who descended from the cliffs of Lake Titicaca to deliver his father’s light to the “wretched inhabitants of the country.” Manco Cápac’s other gift to humankind, as Freud later noted, was the “coca leaf, this divine plant which satisfies the hungry, strengthens the weak, and causes them to forget their misfortune.”

  Coca leaves (Erythroxylum coca). (photo credit 3.1)

  Sigmund also read about the explorers who traveled from Spain to the New World during the sixteenth and seventeenth centuries. In places we now know as Peru, Colombia, Bolivia, the Amazon basin, and the Andean mountainsides, the Spaniards raped, pillaged, and plundered for gold, silver, and other riches, proudly proclaiming themselves masters of all they surveyed. They brought with them many deadly infectious diseases, including measles, smallpox, and diphtheria. The result was an infectious, economic, and cultural devastation of these indigenous communities—a swift, fatal erosion, if not erasure, of centuries of progress and civilization. To make matters worse, the conquistadors subjugated those who survived into a brutal slavery, forcing them to labor in a wide range of agricultural, mining, and exporting ventures, all in the name—and for the profit—of the queen and king of Spain.

  Most conquistadors looked askance at the natives’ cuca habit. Those most faithful to the Catholic Church condemned its use as a sin. The indigenous people hardly listened, let alone cared. They had long since become accustomed to living in the glow of a mild euphoria and sense o
f purpose that chewing these leaves reliably produced.

  With the passage of time, however, many of the Spaniards who initially dismissed cuca as the work of the devil tried chewing a few, or a lot, of the leaves themselves. And they, too, became impressed by and reliant upon the plant’s powers. Those doing the governing and enslaving in the New World recognized far more practical reasons to encourage the Indians toiling in their mines to chew cuca: in higher doses, it has the remarkable ability to suppress hunger, increase tolerance for cold weather, and stretch the bounds of human endurance. An agent that encouraged a person to work harder was considered ideal for forcing others into physical labor in a high mountain climate where the oxygen content is palpably thin. The Spanish conquerors of Peru went as far as to create a legal framework for the sale and taxing of coca, insisting on a 10 percent cut of the sales of each crop. Such schemes helped set in motion an endless trail of misery for many involved in the cultivation, processing, and sale of its by-products and, more directly, for those succumbing to its pharmacological allure.

  At the beginning of the nineteenth century, several intrepid Europeans embarked on prolonged explorations of the New World in search of glory and fortune. Most of them wrote excitedly to their loved ones back home about the region’s beauty and natural riches. One of the adventurers Sigmund read about was the brave and curious German traveler Alexander von Humboldt. The twenty-nine-year-old Humboldt set out on a pathbreaking scientific expedition of the New World in early June 1799. As he sat in his cabin in a ship named the Pizarro, docked in the Spanish port of La Coruña before setting off across the Atlantic abyss, Humboldt wrote several farewell letters to his friends. Fearing that he might not return from the dangerous trip, he explained what motivated his peripatetic pilgrimage: “I shall collect plants and fossils and make astronomic observations. But that’s not the main purpose of my expedition—I shall try to find out how the forces of nature interact upon one another and how the geographic environment influences plant and animal life. In other words, I must find out about the unity of nature.”