An Anatomy of Addiction

by Howard Markel

  When William returned to New York in early January 1886, his friends noticed worrisome changes in his behavior. Once modest and self-effacing, he was now abrupt, spoke incessantly, and cared little for the responses of those he was speaking with. Dr. George Brewer, a Baltimore urologist who visited Halsted around this time in search of a position at Roosevelt Hospital, complained that from early afternoon until long after it turned dark he could not get a word in edgewise. Brewer later remembered that Halsted was “very excited and talked constantly about everything under the sun from the transit of Venus to gonococci.” Every time the urologist tried to beat a hasty retreat out of Halsted’s house, the cocaine-fueled surgeon “would start up again.”

  William probably rationalized his cocaine consumption as being in the service of scientific inquiry. But long after he concluded his experiments, he abused the drug for the same reasons shared by most addicts: to simply feel better, to numb himself, to escape from the painful lows of depression, frustration, rejection, and a hundred and one other slings and arrows of life.

  In late January 1886, a worried William Henry Welch took it upon himself to institute an ad hoc treatment plan to arrest Halsted’s dire condition. Welch refused to accept the dogmatic pronouncements of the day dismissing alcoholics and drug addicts as hopeless, morally flawed wrecks of human beings. The pathology professor was determined to save his talented colleague from cocaine damnation. Intervening with two other concerned friends, Drs. George Munroe and Samuel Vander Poel, Welch invited Halsted into his office and offered him a potential way out of the abyss he was facing.

  Welch laid all his cards on the table. He began by revealing that he knew what was going on with respect to Halsted’s relentless cocaine abuse and that it needed to stop, posthaste. The solution Welch suggested was a rejuvenating sea voyage, then considered therapeutic for men of means suffering from a broad range of maladies. Convinced of the wisdom of this suggestion, Halsted joined Welch during February, March, and April of 1886 on a schooner named the Bristol bound for the Windward Islands in the Caribbean. Recognizing that William’s previous cold-turkey attempts to stop using cocaine had failed abysmally, the two physicians developed a rigorous treatment plan featuring a large supply of cocaine to be doled out by Welch while gradually cutting down William’s dosage to nothing before the trip’s end.

  A pile dwelling where Caribbean islanders lived in the Windward Islands at the time of Halsted’s restorataive ocean voyage. (photo credit 6.3)

  For much of the voyage down the Atlantic seaboard, things worked out rather well; but Halsted was still taking daily, albeit progressively smaller, doses of cocaine. By the time the bow pointed toward the Carribbean, he’d begun experiencing uncomfortable feelings and emotional states of the sort that bedevil any addict trying to break free of this drug. Just as the use of cocaine brings on great feelings of euphoria and exhilaration, the cocaine-starved brain complains and rebels vociferously. With smaller and less frequent doses, William’s brain must have screamed to him, “Where is my drug? Feed me my tonic! If only I had some more cocaine, all would be well.”

  It has long been observed that cocaine abusers who abruptly stop their drug of choice do not suffer the full-blown physical symptoms seen in those who suddenly quit morphine or alcohol. Such findings formerly encouraged physicians to insist that there was no withdrawal syndrome associated with cocaine. In more recent conceptions of addiction and withdrawal, however, experts have verified a set of nasty psychological symptoms that creep in after a cocaine abuser attempts to quit, including depression, intense fatigue, unpleasant dreams, restlessness, disturbances of appetite, and even suicidal thoughts. This awful state of mind can last for many months after discontinuing use of cocaine and contributes to the high relapse rates among those seeking recovery. To be sure, the effects of withdrawing from opiates and alcohol are much more intense, physical, and acute than those involving cocaine. Yet, as Halsted surely could have testified, cocaine maintains the ability, long after it has taken its corporal leave, to communicate with the addict’s brain, luring him back to partake once again, with the flimsy promise that all will be well—at least for a few moments.

  Despite careful projections, Halsted could not satisfy his cocaine hunger. He grew steadily more agitated as he estimated that he would completely run out of the drug long before returning home. Late one night, miles out at sea, the cocaine-obsessed Halsted lay awake, nervously rocking in his hammock while listening to the scratching and snoring of his bunkmates. Audibly assured that they would not bear witness, he snuck out of the cabin and prowled about until he located the captain’s medicine chest. It was a short time before this scion of privilege was reduced to breaking into the locked container for a much-needed dose.

  A fascinating, likely embellished, and difficult to verify biography of Halsted was published in 1960. The book was written as part of a series on famous doctors and scientists for an audience of young teenagers. In it, we are told that at this point of the journey Drs. Welch and Halsted explored the island of Santa Lucia only to find a desperate doctor, a moribund patient, and an appendix doing its best to burst in the latter’s abdomen. Like a fireman’s horse hearing the bell, Halsted diagnosed acute appendicitis and recommended an emergency appendectomy. The island doctor vociferously disagreed, insisting that the patient’s problem was the result of eating a plate of poisonous roots. William took command and insisted on beginning the operation. But first, he administered a dose of cocaine from the ship’s store to both the patient and himself. The patient, of course, required the drug to avoid feeling the pain of being cut open. William, the authors claim, needed cocaine to quell his raging urges. Halsted’s diagnosis turned out to be correct, and the patient enjoyed a speedy recovery from his appendectomy. Regardless of the veracity of this tale, let alone the improbability of operating well while under the influence, there still remained the pressing problem of the depleted cocaine supply Halsted needed so badly.

  Santa Lucia, the Windward Islands, where Halsted is said to have performed an appendectomy during his attempt at rehabilitation (photograph c. 1890). (photo credit 6.4)

  William consumed all of the cocaine before the ship approached Florida, and it was then that he entered the most harrowing part of his oceanic journey. Plagued by nightmares, exhaustion, irritability, outright suspicion of his fellow travelers, and, because he was clenching his muscles relentlessly, aching limbs, William felt lousy. Somehow, Dr. Welch got the cocaine-starved Halsted back to New York Harbor in one piece in late April 1886. Before disembarking, Welch offered Halsted his best diagnosis: the surgeon needed far more intensive treatment than that afforded by a mere sea voyage; Halsted would have to admit himself into Butler Hospital.

  Butler was a well-known insane asylum in Providence, Rhode Island, under the direction of Dr. John Woodbury Sawyer, a psychiatrist who was having a degree of success treating morphine addicts. This was hardly a palatable choice for the surgeon-in-exile. In William’s defense, prolonged confinement to an insane asylum was not a fate any self-respecting or self-preserving late-nineteenth-century American chose voluntarily.

  The benevolent Welch did make sure that Halsted had a nugget of hope to take with him to Providence. Once successfully treated and released from Butler, Halsted could join him in Baltimore, where Welch was assuming command as professor and dean of the newly established Johns Hopkins University School of Medicine. Halsted quickly grasped that the invitation was a golden opportunity to make medical history. If he could only recover from his addiction, if he could only rid himself of this deadly habit, he might revolutionize the teaching and practice of surgery. Before surrendering to Welch’s generous offer for recovery, however, Halsted stalled and begged for some time to think things over. Predictably, a few hours later, he was back in his town house, high on cocaine.

  The next morning, Dr. Welch came knocking on Halsted’s door with a list of nonnegotiable demands that began and ended with commitment to Butler Hospital. The sober p
athologist and the drug-addled surgeon sat across from each other and took up their conversation where they’d left off the evening before. Halsted desperately tried to rebuff the hard evidence that cocaine was destroying his body, his social relationships, and his career. Such outlandish denials distinguish the disease of addiction from mere dabbling or recreational substance use. The addict’s brain truculently conspires against common sense and the instinct for self-preservation, urging its possessor not to quit. And it often backs up this hypnotic neurochemical spell with quarrelsome force. Quite simply, the active cocaine addict feels decent enough when the drug is coursing through his bloodstream and manipulating his central nervous system but feels downright awful when it is not.

  Butler Hospital, Rhode Island. (photo credit 6.5)

  Welch’s wheedling demands somehow inspired a watershed moment in Halsted’s life. A few hours later, Welch tucked him into a Pullman car leaving Grand Central Station and bound for Providence. Of all the negative thoughts running through William’s troubled mind upon entering the sumptuous, marble-clad lobby of Butler Hospital, it is safe to assume that the dominant chords sounding were shame, remorse, and regret. At the registration desk, a clerk presented the surgeon with an ornate hospital register and pen. How lost and abject this proud surgeon must have felt as he timidly signed the ledger as “William Stewart” and drew a long, inky slash where “Halsted” should have been entered.

  CHAPTER 7

  Sigmund in Paris

  NO MATTER HOW HE COGITATED on the events of 1884, Freud knew somewhere between the ventricles and atria of his heart that he had been bested by “Coca” Koller. His failure to recognize cocaine’s anesthetic properties aside, a small but steady stream of respectful reviews of Über Coca began to trickle into print. Smelling still more academic gold to quarry, he continued to pursue his scientific investigations. His second impulse, perhaps even more powerful, was to continue abusing cocaine.

  Freud proved rather adept at self-promotion. In January 1885 he convinced a reporter for the Viennese metropolitan daily Neue Freie Presse to write a feature story about his work on the new miracle drug. Soon after its appearance, the piece was translated and published by hundreds of American and European newspapers. This flush of fame, the equivalent of a young medical researcher today finding his work profiled on National Public Radio or in the New York Times, no doubt encouraged Freud to invest in five hundred reprints of the coca monograph in early 1885, which he distributed to professors and doctors who had the connections to sharpen his professional trajectory.

  Around this same time, Freud published a study of cocaine’s effects on the motor power of specific muscle groups and psychic reaction time in the January 31, 1885, issue of the Wiener medizinische Wochenschrift. He followed this up with a brief series of addenda to his Über Coca, which closed with a casual acknowledgment of Koller’s anesthetic discovery (one he insisted that “countless others” had been working on as well). A mealymouthed Sigmund concluded that while this application was, indeed, exciting, “the present still artificially high price of the drug is an obstacle to all further experiments.” A little more than a month later, in March 1885, he published a paper in the Medizinischchirurgisches Centralblatt summarizing his findings on cocaine’s general effects on the human body. One of the most intriguing aspects of this paper is how Freud briefly mentions the success he had in treating acute morphine withdrawal in an unnamed addict we now know was Fleischl-Marxow, who was, by this time, no longer doing so well on cocaine: “He took about 0.40 grams of cocaine per day,” the paper prematurely boasted, “and by the end of 20 days the morphine abstinence was overcome.” Throughout the winter and early spring of 1885, Sigmund saw to it that all of his lectures on cocaine at prominent medical societies were abstracted and reprinted in a variety of journals.

  THE BIOGRAPHIES OF FREUD and Halsted contain many odd coincidences of fate, scientific interests, and even the fact that both were rambling about the wards of the Krankenhaus in 1878 and 1879. But one of the great temporal ironies in their medical histories occurred in 1885. While Halsted was injecting himself, students, and patients with cocaine solutions, Sigmund briefly attempted to inject the drug into the trigeminal nerve of a patient with terrible facial pain. Like Halsted, Freud practiced such injections on his own arm.

  He would later claim that his old boss Franz Scholz taught him how to use a hypodermic needle. Scholz had prided himself on his exemplary sterile technique in administering subcutaneous injections. It is difficult to ascertain how adept Freud was at using a needle-loaded syringe. Given his choice of medical specialty and the lack of regular opportunities to practice injection techniques, however, it is safe to wager he was less than proficient.

  Tracing the lithe trigeminal nerve as it traverses a person’s face, the ropy ulnar nerve as it slithers along the path of the arm, or a spongy blood-filled vein bulging beneath the skin, let alone isolating those structures long enough to accurately insert a needle, requires real skill. Halsted clearly possessed that ability, and his deft injections led to the advent of local anesthesia, one of the greatest gifts to modern surgery and dentistry. Both men were unabashed medical geniuses, but Freud would never be able to claim the manual dexterity of a surgical virtuoso like Halsted. In fact, Sigmund garnered lackluster results with the cocaine injections and soon abandoned the method.

  Freud’s clumsiness may well have saved him from Halsted’s landslide fate. The surgeon’s reliance on rehearsing this technique on himself provided a faster, more intense high but also increased his tolerance and desire, if not outright compulsion, for more of it. Halsted’s path from scientific investigator to full-blown addict required only a few months; Freud’s cocaine abuse, which centered on the application of the drug into his mouth or nasal passages, continued for years in a somewhat more measured manner.

  Regardless of the route of entry, in 1885 and 1886 Freud was self-medicating with greater and more frequent doses of cocaine. On too many days and nights, at social occasions and alone in his quarters, when the pain of being Sigmund was simply too great to bear, he availed himself of some of the “magical drug.” At other times, as while writing to his beloved Martha, cocaine served as an aphrodisiac, unleashing flowery and uninhibited words of love.

  IN MARCH 1885, while waiting to be appointed Privatdozent at the Vienna General Hospital, Sigmund applied for and received the University of Vienna’s prestigious Jubilee Fund travel grant. Awarded annually to the training doctor deemed to be most worthy of additional medical study in another country, it came with a stipend of 600 gulden and the stipulation that half was given to the winner before embarking, with the balance to be paid upon his return and presentation of a formal report to the medical school. Although this arrangement meant Sigmund would have to be extremely miserly with his expenditures, he made immediate plans to leave for Paris to study neurology under Jean-Martin Charcot, the world-famous neurologist, pathologist, and clinician. A leading light of the Paris clinical school, Dr. Charcot held court at the Salpêtrière Hospital, on the Left Bank of the river Seine. Scheduled to begin his fellowship in the fall, Sigmund first took a brief summer visit to Martha’s country home in Wandsbeck, near Hamburg. After a teary farewell, he was off for France.

  Freud’s initial days in Paris were lonely and trying. In one early October 1885 letter to Martha, he records every expense, from stationery to matches, in view of the tight budget forcing him to squeeze every centime to its maximum value. Freud managed on 300 francs (or $60) a month for meals, room, and books. He dutifully sent home any extra monies to his mother, excepting the one month he splurged on purchasing a complete set of the journal Charcot’s Archives for 80 francs. His hotel accommodations at the Hôtel de la Paix in the Latin Quarter were cheap, 55 francs a month, but woefully dingy. His second address, Hôtel du Brésil on the Rue de Goff, was a far better bargain at 155 francs a month for both room and board. On one occasion, Dr. Freud of the famously filthy Krankenhaus was disgusted to discover th
at the curtains surrounding his hotel bed were green and menacing. Ever the scientific investigator, before retiring that night, he made a trip to the local chemist and brought back a parcel of chemical reagents to test his room for arsenic. The inquiry, fortunately, proved to be negative.

  As Sigmund began to explore the City of Lights, he found it to be “magnificent and charming,” a delightful place of “magic.” Freud reveled in the beauties of the winding Seine. He visited the Louvre Museum’s Egyptian and Assyrian collections and ogled the Venus de Milo. So enchanted was he by the grand museum’s ancient collections that he neglected to wander into the famed picture galleries. On many nights, he climbed the twisting stairs of Paris’s theaters, where he made do with “shameful pigeon-hole loges.” These were the only seats he could afford but well worth it for the chance to watch the legendary Sarah Bernhardt in Victorien Sardou’s Théodora. Upon returning from her performance, Sigmund raved about the actress to Martha: “But how that Sarah plays! After the first words of her vibrant lovely voice I felt I had known her for years.… I believed at once everything she said.” Sigmund also attended productions of Hugo’s Hernani, Sophocles’ Oedipus Rex, Beaumarchais’s Le Mariage de Figaro, and Molière’s Tartuffe. Beyond Freud’s love of the stage, there was a practical reason for his frequent theater attendance: the performances served as valuable French lessons.