An Anatomy of Addiction

by Howard Markel

  That same year, in the United States, Dr. E. W. Holmes, once a strong proponent of using cocaine for treating hay fever, fatigue, and exhaustion, warned readers of the Therapeutic Gazette that the drug could be habit-forming and that the doctor self-prescribing cocaine was the equivalent of the lawyer representing himself in court: each had a fool for a patient or client.

  In the months that followed, Freud continued to fight back in print, contesting claims that cocaine was addictive. But by July 1887, with Fleischl-Marxow’s decline in full force, he employed an ever-shifting set of rationalizations in a paper on the craving for and fear of cocaine. Although Freud admitted that cocaine might not be the wisest course of therapy for those already addicted to morphine, he continued to assert that the drug was entirely safe for recreational users like himself. He also distinguished between injecting cocaine and ingesting it into the mouth or nose:

  All reports of addiction to cocaine and deterioration resulting from it refer to morphine addicts, persons who, already in the grip of one demon[,] are so weak in will power, so susceptible, that they would misuse, and indeed have misused, any stimulant held out to them. Cocaine had claimed no other, no victim of its own. I have had broad experience with the regular use of cocaine over long periods of time by persons who were not morphine addicts and have taken the drug myself for some months without perceiving or experiencing any condition similar to morphinism or any desire for continued use of cocaine. On the contrary, there occurred more frequently than I should have liked, an aversion to the drug, which was sufficient cause for curtailing its use.… I consider it advisable to abandon so far as possible subcutaneous injections of cocaine in the treatment of internal and nervous disorders.

  Unfortunately for Fleischl-Marxow, Halsted, and their peers who became addicted to cocaine between 1884 and 1886, such academic debates did little to stem the rising tide of cocaine use. In fact, it took several more years before the medical profession in Europe and North America gained a greater appreciation for cocaine’s rapaciously addictive dangers.

  What particularly startled those first doctors treating the earliest cocaine addicts were the rapid, degenerative changes in physical appearance and personality, especially when these patients were compared to those addicted to opium or morphine. The latter tended to simply nod off alone in their rooms when under the influence and often kept up their clandestine substance abuse for years before falling to pieces or being discovered by family members or coworkers; their color may have been pale and their bowel habits halting, but they nevertheless functioned. Active daily cocaine users, on the other hand, became haggard and haunted in a matter of weeks to months. Their mannerisms were jittery and nervous. They could barely sit still and often walked aimlessly. Incapable of participating in meaningful conversations, they spoke nonstop with little regard for their listeners, let alone control of word choice and sentence structure.

  In 1888, Charles Bunting, a physician who treated many alcoholics and addicts, reported how within months one patient was transformed “into an emaciated, hollow-eyed, bilious-faced, flat-chested, helpless limp of humanity—a very caricature of manhood, with a look like a hunted beast, the shrunken frame trembling.” Similarly, in 1891, a California physician named H. G. Brainerd described the speed with which such striking changes occurred: “Within a few months … the character of the cocaine habitué is changed, and he becomes unfitted for business.”

  An American physician named J. W. Springthorpe, who accidentally became a cocaine addict around the same time as Halsted, published a tortured memoir titled “The Confessions of a Cocainist” in 1897. Springthorpe poignantly recalled that “every part of the body seems to cry out for a new syringe … one syringe self-injected is absolutely sure to produce the fascinating desire for a second.”

  Only twelve months later, in 1898, C. C. Stockard of Atlanta portrayed the intense paranoia his cocaine-abusing patients exhibited after several days of use. For example, one of his morphinism patients ingested a rather large amount of cocaine to counteract the unadulterated agony of opium withdrawal. The resulting signs and symptoms Stockard describes perfectly capture the paranoiac hell of acute cocaine intoxication. The patient was convinced, he writes, that

  the people in the house were watching his actions and were talking about him and planning against him. The sparrows singing in the street were talking about him, the ticking clock was a telegraph machine of some sort, through which people were communicating about and plotting against him.

  That same year, Dr. T. D. Crothers unequivocally stated that “cocaine is probably the most agreeable of all narcotics, therefore the most dangerous and alluring.” Crothers also observed that the majority of the cocaine abusers he treated were professional men over the age of thirty who had already used alcohol and opium recreationally before turning to cocaine as a stimulant after a hard day’s work. Not coincidentally, more than 60 percent of the cocaine abusers in Dr. Crothers’s study were members of the medical profession.

  MOST AMERICANS OF THIS ERA considered substance abuse to be a vice, an evil habit that could be conquered by seeking out a new environment, building up a sound physical constitution and one’s willpower, and, depending on one’s religious beliefs, praying for divine intervention. It was a moral or character defect and only those favored (and forgiven) by God had any chance at success. A subtext to this thinking was a tendency to blame alcoholics and addicts for creating their own problems.

  With respect to cocaine, many physicians, including Freud, continued to argue that the drug was not addictive itself; rather, the person who took it to excess suffered from a personality or set of characteristics that put him or her at risk for abuse. This argument, often summarized by the label of the “addictive personality,” continues to resonate in the twenty-first century, although many critics decry it as a means of stigmatization. Like many clichés, this one has some elements of truth; certain types of people are more likely than others to become addicts, such as those who enjoy taking risks or have emotional difficulty enduring painful stimuli and delaying gratification. But it is also important to note that, at present, more than half of all adults diagnosed with substance abuse problems simultaneously suffer from one or more mental health problems, such as depression, mood disorders, or attention deficit disorder. Furthermore, evidence is being uncovered each day demonstrating the genetic basis of addiction and of a host of other mental illnesses. One doubts that these epidemiological trends were that much different in the late nineteenth century, even if the diagnostic categories existed under different names and rubrics. All of these personality factors, genetic attributes, and mental health disabilities can play significant roles in an individual’s decision to self-medicate his problems away with a drink, a joint, a syringe, or a line of mind-altering substance. Nevertheless, the notion of the addictive personality persists and thrives in the popular imagination.

  FROM MAY TO NOVEMBER 1886, Halsted surrendered to his alienists’ rigid prescriptions of seclusion, fresh air, exercise, healthy diet, and daily counseling sessions in order to achieve a gradual but determined withdrawal from cocaine. It would be anachronistic to call William’s treatment “talk therapy” in the Freudian sense. But Dr. Sawyer’s modus operandi for treating addicts and alcoholics was to gently converse with them, build up their self-confidence, suggest sober frames of reference for living the rest of their lives without the offending substance, and imbue them with an understanding of what would happen if they continued to abuse drugs. Dr. Sawyer wisely wasted no time berating Halsted for his failings or lack of self-control. Instead, he and his superb staff spent the next six months convincing William that the most productive part of his life and career was about to begin, provided he could get a handle on his illness.

  Most mornings, William ambled through the bucolic grounds of the hospital and spent time weeding the hospital’s fragrant flower garden and vegetable farm. He also attended weekly stereopticon lectures and, less frequently, Sunday church ser
vices. On many afternoons, he took the sun in the hospital’s conservatory, went horseback riding, and made visits to the well-stocked library to peruse the latest edition of the Graphic and other popular magazines of the era. Because of his social station and financial resources, it is highly doubtful that Halsted spent much time interacting with the asylum’s severely alienated inmates. In fact, William resided in a nicely decorated room in a building separated from the locked asylum wards by a lengthy corridor designed to muffle the sounds of the screaming patients at night.

  The Butler Hospital library, c. 1890. (photo credit 8.4)

  Butler Hospital musicale for patients in Isaac Ray Hall, c. 1887. (photo credit 8.5)

  Extreme agitation and unrelenting insomnia constituted William’s most troubling symptoms. So powerful were these unpleasant reactions that they were untouched by either soothing hot towels or sedative doses of chloral hydrate and bromides. William simply needed something stronger to counteract the emotionally draining symptoms of quitting cocaine. Disastrously for Halsted, the doctors at Butler succumbed to an urge that the profession has been victim to since well before the invention of the prescription pad. If one drug does not work, doctors are trained to substitute another, or simply combine a few new drugs. We have already seen how Sigmund applied such a therapeutic construct on his friend Fleischl-Marxow in Vienna.

  The intense withdrawal symptoms from morphine and alcohol compelled doctors of this era not just to stand there but to do something. For example, the withdrawing alcoholic who experienced intense hallucinations, or delirium tremens, and seizures was often calmed with doses of morphine; morphine addicts enduring painful narcotic withdrawals were given a few shots of whiskey or, better still, several strong hot toddies. Not surprisingly, William’s paranoia and agitation inspired his alienists to pull out a syringe filled with morphine and inject its soothing balm into his arm.

  Halsted’s doctors lacked a complete understanding of the dangers of their treatments. The psychiatrists at Butler Hospital were as kind, competent, and professional as any to be found in the world. But their reliance on the liberal use of morphine caused additional addictive problems for Halsted that lasted for the remainder of his life.

  Halsted made excellent progress in eschewing cocaine during his six-month stay at Butler, no doubt thanks to the emotional support he was getting from his doctors, the lack of access to cocaine, and the calming effects of his daily morphine injections. But before he was able to venture out of Butler’s safe haven to reclaim his surgical instruments, he endured two more traumatic events.

  On August 31, 1886, Halsted’s beloved roommate, Thomas McBride, was fatally struck down by an attack of Bright’s disease (as kidney failure was then known). The forty-year-old McBride was sailing home on the North German Lloyd’s steamship Aller, after a buoyant and activity-filled European jaunt, when he died; he was quickly buried at sea. Some have speculated that cocaine, and perhaps morphine, contributed to McBride’s early demise; others have waxed poetic on what this talented young physician might have accomplished had he lived longer. Less debatable was the enormous impact McBride’s death must have had on William when he was at his most psychologically vulnerable.

  Another emotional blow struck near the end of 1886, when Dr. Sawyer became severely ill with what was likely a severe streptococcal throat infection. One apocryphal account of their final lucid visit describes Dr. Sawyer urging William not to be discouraged by his addiction. “I’ve seen enough of drugs,” Dr. Sawyer reputedly said, “to know that it is not an easy thing to break off. Many more fail than succeed. In your case you are, at this moment, succeeding. Don’t let anything stop you from trying. You are young—is it thirty-four? Our profession needs you. Think of it that way and don’t let modesty interfere.”

  Whether his alienist told him this or not, it is clear that Halsted did summon the strength to tame his voracious beast of a disease. He actually got better, if not completely cured. Each day’s abstinence fortified his desire to rejoin the world at large. Like an unemployed actor hungering for a theater filled with adoring fans, Halsted desperately wanted to return to the operating room and, thereby, change the course of medicine. Such a magnificent destiny, however, was only accomplishable if he could stay healthy enough to seize it. By late November 1886, the medical staff at Butler agreed that he was well enough to leave the asylum, provided he submit to living under the watchful eye of his friend and benefactor William Henry Welch.

  TRUE TO HIS PROMISE, Welch took Halsted two hundred miles south of New York City and his cocaine-abusing cronies, to the homier Baltimore. There, Welch was charged by a group of energetic trustees and a magnificent endowment of $7 million (or more than $132 million in 2010 dollars) to design and populate what became the most important center of healing, education, and research of its day, one that would eventually rival, if not completely dominate Vienna, Berlin, Leipzig, Paris, London, and all of North America.

  It was to be named the Johns Hopkins Hospital and Medical School, after the wealthy but dyspeptic bachelor and Quaker merchant who forked over the funds for the enterprise. When Mr. Hopkins died, in 1873, his last will and testament explicitly called for the creation of a first-rate medical school and hospital as an integral part of a fully endowed research university. By 1887, the university had been up and running for twelve years, but the hospital and medical school were still being pondered and planned. Given Welch’s appreciation for all things deutsche, it is not surprising that he organized the medical school along the German model of research institutes and laboratories. The school was to be physically and intellectually connected to a magnificent hospital that not only served Baltimore’s destitute, as directed by Mr. Hopkins’s will, but also attracted ailing people from around the world as its doctors developed new ways to treat, cure, and prevent disease.

  The Johns Hopkins Hospital, early 1900s. (photo credit 8.6)

  The medical campus’s collection of buildings constructed of ferrous-red brick and West Virginia sandstone was designed by John Shaw Billings. A physician and surgeon, Billings served as officer in charge of the surgeon general’s library from 1865 to 1895 and initiated two major indexes of the world’s burgeoning medical literature, Index Medicus (1879) and the Index Catalogue of the Surgeon General’s Office (1880). In 1896, after a distinguished career with the United States federal government, he was named the first director of the stately New York Public Library on Fifth Avenue and Forty-second Street.

  For Johns Hopkins, Dr. Billings created a space of healing and discovery that was efficient and inspiring, practical and grand, topped by a magnificent slate-clad, copper-ribbed dome that could be seen from virtually every point of Baltimore and, on a clear day, from the head of Chesapeake Bay. Underneath its spire were well-appointed rooms for private patients, comfortable quarters for the resident medical staff, pristine operating rooms, spacious teaching amphitheaters, laboratories, workshops, and endless wards separated into pavilions in order to keep the spread of infection among the patients to a minimum.

  Although Welch possessed the loudest voice in selecting those who would participate in his greatest medical experiment, he still required the final approval of the university’s board of trustees. The mutton-chopped, frock-coated men who sat on this board were a powerful group of Baltimore businessmen who understood the need to create something entirely different and modern but were also bound, by custom and legal precedent, to protect the massive investment their late colleague had entrusted to their care.

  When Halsted arrived in Baltimore in December 1886, the medical campus was still a morass of muddy streets, wooden and iron scaffolding, and piles of bricks. The hospital would not formally open its doors until the spring of 1889, and the medical school did not embark on its teaching mission until 1893. Suitably impressed by Halsted’s facility with the scalpel and his potential to reinvent the science of surgery, Welch hoped to appoint his protégé as the first professor of surgery at Johns Hopkins. But Welch was nothing if
not politically savvy; he understood that in academia, as in so many other professional pursuits, timing was everything. Ever the benevolent puller of strings and manipulator of lives, Welch initiated William’s clinical reentry with the rather tenuous designation of “special graduate student” in his pathological laboratory. There, the surgeon could accrue additional time recuperating from what was euphemistically referred to as “health problems.”

  Welch was interested in supporting Halsted for many reasons. Foremost, Professor Welch loved helping young men. A lifelong bachelor who resided in a series of boardinghouses, Welch spent most evenings in the company of other successful men at the stuffy and tobacco-stained dining clubs then so popular in New York and Baltimore. In these richly paneled rooms as well as the amphitheaters and classrooms of Johns Hopkins, Welch’s eye was always caught, and sometimes bedazzled, by the promise of ambitious, younger physicians eager to climb the greasy pole of academic medicine.

  In recent years, many medical historians have speculated about Dr. Welch’s sexuality. His students, far less sophisticated, coined a few lines of doggerel verse hinting at the mysterious proclivities of the teacher they warmly nicknamed “Popsy” Welch:

  Nobody knows where Popsy eats,

  Nobody know where Popsy sleeps,

  Nobody knows whom Popsy keeps,

  But Popsy.

  From the distance of nearly a century, Welch remains an enigma of personality and appeal. Many of his rank-and-file medical students derided him as an aloof and indifferent lecturer. His family wondered about his solitary summer vacations to ocean resorts where he pursued sweets of all kinds, long naps on the beach, and wild rides at amusement parks. And not a few colleagues commented on how he spent the overwhelming majority of his time in the company of his young laboratory men, who remained loyal to their chief until their dying days. The historical documentation necessary to answer the questions posed by the “Popsy poem,” however, has been definitively removed from the table. Welch’s highly developed sense of privacy extended to what he saved for the archives and posterity.