An Anatomy of Addiction

by Howard Markel

  Even if Sigmund did not appreciate cocaine’s addictive properties, he did quickly realize that it was an expensive drug. Budgeting 33 kreuzer (nearly $3 in 2010) for his first cocaine purchase, the pfennig-pinching Sigmund was astounded when he received a bill from the Merck firm for 3 gulden, 33 kreuzer (roughly $30 in 2010). This sum represented a huge outlay for Freud. As a Sekundararzt, he earned 30 gulden a month (a little more than $90 in 2010), which barely paid for the cost of his meals. Additional expenditures would have to be covered by tutoring whining medical students who could not or would not commit their studies to absolute memory with rapid recall, a task that paid 3 gulden an hour. When he received his first shipment of cocaine in late April 1884, Sigmund allayed his financial worries by immediately ingesting 200 milligrams mixed into a glass of water. His bad mood was instantly transformed into one of cheerfulness; he was filled with the rare and incomparable feeling “that there is nothing at all one need bother about.”

  The title page of Über Coca, 1885. (photo credit 4.6)

  Like many inquiring doctors of his generation, Freud grounded his scientific studies by experimenting on himself. After consuming a few doses of cocaine, he was hopelessly enamored of its ability to cure indigestion, soothe aches and pains, and, perhaps more important, relieve depression and anxieties. Freud even purchased some to distribute to his friends, colleagues, and sisters. In May 1884, he sent several doses of cocaine to his fiancée to “make her strong and give her cheeks some color.” Around the same time, Sigmund expressed to Martha his high expectations for the drug and what it would do for his patients, his career, and their lives together:

  If all goes well I will write an essay on it and I expect it will win its place in therapeutics by the side of morphium and superior to it. I have other hopes and intentions about it. I take very small doses of it regularly against depression and against indigestion and with the most brilliant of success. I hope it will be able to abolish the most intractable vomiting, even when this is due to severe pain; in short it is only now that I feel I am a doctor, since I have helped one patient and hope to help more. If things go on in this way we need have no concern about being able to come together and to stay in Vienna.

  A few weeks later, on June 2, 1884, Sigmund exhibited both concern for Martha’s poor health and evidence of the drug’s sexually thrilling effects. He also demonstrates a loquacious, if not reckless, style of writing he adopted when under the influence during this period:

  Woe to you, my Princess, when I come, I will kiss you quite red and feed you till you are plump. And if you are forward you shall see who is the stronger, a gentle little girl who doesn’t eat enough or a big wild man who has cocaine in his body. In my last severe depression, I took coca again, and a small dose lifted me to the heights in a wonderful fashion. I am just now busy collecting the literature for a song of praise to this magical substance.

  During the summer of 1884 and after, Freud wrote many more cocaine-fueled encomiums to his fiancée. No matter what the reason, the need for relief from a migraine or a stomachache, an attack of sinusitis, the lows of his melancholia, or simply to daydream about his beloved Martha, Sigmund continued to use cocaine to make bad days good and good days better. The turmoil and uncertainty that framed his professional and romantic life demanded a potent tonic to calm his state of agitation and restore the stamina he desperately needed to make history. Ever sneaky and seductive, cocaine appealed to his psychic needs at his most vulnerable moments. And as his use of cocaine progressed, he required more of the stuff to satisfy his brain’s urgent pleas.

  Between April and July 1884, the young neurologist researched and completed what would become Über Coca (On Coca), a treatise filled with adulatory descriptions of the “magical drug” and his “most gorgeous excitement.” Freud’s biographer Ernest Jones described the text as “a remarkable combination of objectivity with a personal warmth, as if he were in love with the content.” Hyperbolic phrasing aside, the bulk of Über Coca is a well-written, comprehensive review of cocaine in concert with substantive, original scientific data on its physiological effects.

  The monograph signals a striking shift in Freud’s scientific modus operandi. No longer is he content to work exclusively on laboratory animals or the brains of cadavers. He now begins to explore living human beings or, as he tells the reader of Über Coca, “I have carried out experiments and studied, in myself and others, the effect of coca on the healthy human body.”

  Over the span of several weeks, Sigmund swallowed cocaine dozens of times, in doses ranging from .05 to .10 grams. From these experiences, he was able to compose an accurate précis of the drug’s immediate effects:

  A few minutes after taking cocaine, one experiences a sudden exhilaration and feeling of lightness. One feels a certain furriness on the lips and palate, followed by a feeling of warmth in the same areas; if one now drinks cold water, it feels warm on the lips and cold in the throat. On other occasions the predominant feeling is a rather pleasant coolness in the mouth and throat.

  In the pages that follow, the text becomes exclusively centered on how the drug altered his body and mind, including such effects as a rapid heartbeat, euphoria, and sleeplessness.

  Prior to his cocaine studies, Freud’s scientific work had focused on the quantitative, fact-based research he conducted in the laboratory. What was the precise relationship of one anatomic structure to another? How did manipulating that structure alter its function in terms of measurable criteria such as blood pressure or heart rate? These were the questions upon which Sigmund and his medical peers typically confined their gaze, if they were to have any hope of publishing their work, let alone impressing their teachers and the medical world at large.

  Yet the most striking feature of Über Coca is how Sigmund incorporates his own feelings, sensations, and experiences into his scientific observations. Throughout the monograph, Sigmund is careful to present his findings in language that generalizes the experience for a medical audience. But the “n of 1” in these experiments, the “one” who experienced these effects, was clearly Sigmund Freud. When comparing this study with his previous works, a reader cannot help but be struck by the vast transition he makes from recording reproducible, quantitatively measurable, controlled laboratory observations to exploring thoughts and feelings. In essence, Über Coca introduces a literary character that would become a standard feature in Sigmund’s work: himself. From this point on, Freud often applies his own (and later his patients’) experiences and thoughts in his writings as he works to create a universal theory of the mind and human nature. It was a method that for its time would prove scientifically daring, at times somewhat incautious, and, in terms of the creation of psychoanalysis, strikingly productive.

  The cocaine study first appeared in the July 1884 issue of Centralblatt für die gesammte Therapie, a medical journal published by Verlag von Moritz Perles of Vienna. By midsummer, Freud saw a financial return on his intellectual investment in the form of an offer of 60 gulden from Parke, Davis and Company to compare its product to Merck’s.

  ÜBER COCA SIGNIFIED MANY THINGS for Sigmund. It was his first major scientific publication. It boldly announced his industry and presence to the world of academic medicine. At the same time, it erroneously described the drug as an effective antidote to serious morphine and alcohol abuse. And it facilitated, if not encouraged, his consumption of the drug.

  Über Coca also represented a missed opportunity. As Sigmund raced to compile the drug’s history, uses, and therapeutic effects, he skimmed over cocaine’s most important clinical use as a local anesthetic. In a hurried last paragraph of his monograph—a postscript, really—Freud noted that “cocaine and its salts have a marked anesthetizing effect when brought into contact with the skin and mucous membrane in concentrated solution.” Without offering any additional data or experiments, Freud merely concluded that these properties “should make it suitable for a good many applications.”

  Carl Koller, the ophthalmolog
ist who bested Freud with his “discovery” of cocaine anesthesia, in 1884, when Koller was twenty-seven. (photo credit 4.7)

  It is not surprising that, as a physician specializing in nervous diseases and as the concerned friend of an addict, Sigmund focused primarily upon the uses of cocaine as a treatment for depression and morphinism. But it hardly required the genius of a Freud to inquire in detail why touching his tongue and lips with the smallest amount of cocaine powder created such powerfully numbing sensations; this is, after all, a key characteristic of ingesting cocaine. Considering his frequent use of cocaine, it is difficult to explain why Sigmund did not value this particular action of the drug as much as he did the drug’s ability to alter one’s mood, blood pressure, breathing rate, and any number of physiological and sensational parameters. Perhaps Freud was so preoccupied with completing his paper and rushing it into print that he simply neglected it. Perhaps his lack of interest in pain-inducing surgical procedures blocked his view to such a critical finding. An even more probable explanation might be that the deliciously exhilarating effects of cocaine—the high rather than the physical numbness—dominated his thoughts and actions. Whatever the precise reason, he made a colossal mistake by overlooking what would have been a historic description of the drug’s anesthetic properties.

  DISCOVERY, OF COURSE, is a relative term, especially when one is contemplating the world of science and medicine. As a rule, doctors and scientists are driven, determined, and obsessed with primacy of discovery. To the victors belongs more than mere mention in a textbook; discovering something represents a research investigator’s best shot at immortality. One wonders whether medical discovery would advance so quickly were doctors not all chasing their version of a holy grail that allows them to boast “I was there first.” Even the most cursory review of the historical record amply demonstrates that the quest to discover—and, at times, the outright bad conduct it can enable—is probably as old as scientific inquiry itself. As early as the second century A.D., the eminent physician and anatomist Galen of Pergamon derided his intellectual rivals as “lazy” and “ignorant” and refused to explain his discoveries to them because such knowledge would prove “as superfluous to them as a tale told to an ass.”

  The person who did capitalize on first reporting cocaine’s anesthetic properties was Sigmund’s colleague Dr. Carl Koller, an Aspirant in ophthalmology at the Vienna General Hospital. The two had known each other since medical school and, because of similar backgrounds and ambitions, tended to understand, envy, admire, and, alternatively, barely tolerate each other. On many occasions Sigmund considered his friend’s narrow devotion to all things optical tiresome. Carl, incidentally, was the young physician berated in Billroth’s clinic as a “Jewish swine” who’d inspired a touching defense from Freud in a letter to Martha. Yet while both of these men tasted cocaine on their lips, its ability to numb the mouth proved far more inspiring to the budding ophthalmologist than to the eventual founder of psychoanalysis.

  In July 1884, around the time of the publication of Freud’s cocaine paper, Koller began some experiments of his own, applying solutions of water and the white powder to the eyes of frogs, rabbits, and dogs before concluding it was an excellent anesthetic for operations on the human eye.

  As eager for professional accomplishment as Sigmund, Carl Koller scrambled to complete his experiments and prepare a formal address at the Ophthalmological Congress in Heidelberg slated to commence in early September 1884. After being awarded a prominent spot on the program, however, Koller ran into some difficulties not entirely biological in nature. Around this time, he was estranged from his father and stepmother (who apparently lived up to all the negative connotations of such a relation). As a result, Koller was subsisting solely on his paltry salary as a training physician at the Vienna General Hospital. Too poor to afford the travel expenses to the Heidelberg meeting, he asked a forty-nine-year-old ophthalmologist named Josef Brettauer to read the paper and demonstrate the experiments—a rather common practice in an era when travel was both expensive and arduous. The presentation was nothing short of spectacular.

  As the world’s most distinguished eye surgeons took their seats in the crowded and stuffy auditorium, Brettauer approached the podium and cleared his throat. He knew the data cold and was quite comfortable demonstrating cocaine’s effects before an audience. He enjoyed the advantage of knowing that it was not his career that teetered on the brink of this presentation’s success or failure; he was merely filling in for Koller, and this, no doubt, added to his confidence level as he began to speak.

  After explaining what Dr. Koller had been working on for the past few months, Brettauer snapped his fingers. On cue, a laboratory assistant wheeled in a large dog that had been waiting patiently in the wings of the amphitheater. Once on the stage, Brettauer displayed the mutt to the audience to show that the animal was alert, comfortably seated on a cushion, and loosely tied down to the gurney. He then picked up a carefully calibrated dropper full of cocaine solution, delicately held the canine’s left eye open with his thumb and forefinger, and introduced three or four drops of the elixir. Dramatically, the physician let one, then two minutes pass by in silence—a period that seems like a lifetime when giving a lecture before a crowded room. Once satisfied that the cocaine had taken effect, he thrust a forceps toward the dog’s eye. While the animal’s right eye blinked in response to such a threat, the left eye remained still. Deftly, Brettauer touched the canine’s left eye with the surgical instrument, and the results were astonishing: nothing happened! No whimpering, no barking, not even a flinch—that is, until the crowd sighed in relief that no harm had come to the dog and burst into uproarious applause.

  A month later, on October 17, 1884, Carl Koller read his paper before the prestigious Gesellschaft der Ärzte (Vienna Medical Society). But as Koller’s daughter Hortense recalled several decades later: “By this time, however, the news had already spread like wildfire (so great had been the need for this remedy) and experiments were under way all over continental Europe, England and across the Atlantic, wherever doctors gathered.”

  Freud, of course, was far from thrilled about Koller’s paper and its aftereffects. The fact that they both worked in the same hospital, where gossip of successes and failures traveled quickly, could not have been an easy cross for the always sensitive Sigmund to bear. Whenever the word “cocaine” came up in medical circles, it was Koller’s name and not Freud’s that generated great admiration. Consequently, Freud moped and complained about how still one more chance at medical immortality had passed him by.

  There are many different accounts of how Freud tolerated his usurpation by a junior colleague. In 1963, Koller’s daughter reported that Sigmund had taken the news in good stride. The historical record, however, reveals a more complicated tale. In late 1884, still possessed by what he misinterpreted as being scooped on the discovery of his career, Freud declared that he and several other medical scientists had long wondered about the drug’s anesthetic properties. Freud also claimed, without much evidence, that he and a Viennese eye surgeon named Leopold Königstein had been working on some unpublished investigations into cocaine’s pain-deadening effects on the cornea prior to Koller’s monumental announcement.

  Perhaps his most pitiful assertion of primacy occurred in early 1885. To several colleagues, Freud asserted that Carl Koller was present months earlier when he prescribed a 5 percent solution of cocaine to a Krankenhaus patient complaining of intestinal pain and that the administered drug produced a side effect of numbness to the lips and tongue. This episode, Sigmund insisted, was when Koller made his “first acquaintance” with the anesthetic properties of cocaine, which he then applied to his work as an eye surgeon. It was an attractive, but not widely accepted, version that Sigmund had great difficulty relinquishing from his mind.

  Another barometer of Freud’s feelings about his scientific rival can be summarized by his now famous contention that a joke is never really a mere joke. To Martha, in Januar
y 1885, Sigmund blithely dismissed the cocaine work as a scientific trifle he executed in the “chase after money, position and reputation.” Later, Freud was said to have inscribed a copy of his Über Coca to Koller with the words “To my dear friend, Coca Koller, from Sigmund Freud”; the mildly demeaning sobriquet, much to the ophthalmologist’s chagrin, followed him for the remainder of his life and extended well after his death in New York City in 1944.

  Nor did it end there. In 1895, Sigmund reported a dream that awarded him due credit for the medicinal uses of cocaine. It occurred at a time when his father was suffering from glaucoma and required an ocular operation. The dutiful Sigmund had just arranged the procedure for his father with the benefit of cocaine anesthesia. Sigmund later noted that in his unconscious reflections on these events, Koller congratulated both him and his colleague Leopold Königstein for being members of the medical triumvirate that introduced local anesthesia to the world. The dream may have been based on a real experience; more likely, it was merely a wish.

  Freud’s subsequent memories as recorded in his brief 1925 autobiography prove even more entangled. In that volume, he blames his failure to recognize cocaine’s anesthetic properties on the distracting influences of Martha. Acting more like a repressed patient than the acclaimed psychoanalyst he was, Freud recalled the events with great, albeit questionable, detail:

  I may here go back a little and explain how it was the fault of my fiancée that I was not already famous at that early age. A side interest, though it was a deep one, had led me in 1884 to obtain from Merck some of what was then the little-known alkaloid cocaine and to study its physiological action. While I was in the middle of this work, an opportunity arose for making a journey to visit my fiancée, from whom I had been parted for two years. I hastily wound up my investigation of cocaine and contented myself in my book on the subject with prophesying that further uses would soon be found. I suggested, however, to my friend Königstein, the ophthalmologist, that he should investigate the question of how far the anesthetizing properties of cocaine were applicable in diseases of the eye. When I returned from my holiday I found that not he, but another of my friends, Carl Koller (now in New York), whom I had also spoken to about cocaine, had made the decisive experiment upon animals’ eyes and had demonstrated them at the Ophthalmological Congress in Heidelberg. Koller is therefore rightly regarded as the discoverer of local anesthesia by cocaine, which has become so important in minor surgery; but I bore my fiancée no grudge for her interruption of my work.