An Anatomy of Addiction

by Howard Markel

  For decades, almost all the skilled physicians of the Johns Hopkins Hospital failed to put his actions together, diagnose his continued use of morphine and cocaine, or find a means of keeping him away from patients. Even William Osler, who did suspect that something was amiss early in their professional relationship, was hesitant to speak his mind freely about Halsted’s problem. Public knowledge of his addiction would destroy Halsted and seriously injure the reputation of the Hopkins. Instead, Osler honored Halsted’s need for privacy and, in proper historical fashion, left behind an intriguing volume of notes, which was sealed for fifty years. In fact, it contains one of Dr. Osler’s most startling clinical discoveries: Halsted’s continuing and active addiction to morphine.

  William Osler, c. 1888. (photo credit 10.12)

  OSLER’S MEMOIR HAS LONG reposed in the library bearing his name at McGill University, in Montreal. Bound in black leather, tied with a red ribbon, originally sealed with wax and a now broken silver lock, the text makes the hearts of medical historians instantly beat faster. The “secret” manuscript was willed by Osler to his wife, Lady Grace Revere Osler, in 1919 and, upon her death, in 1928, to her sister and executrix, Susan Revere Chapin. Mrs. Chapin, in 1931, donated the manuscript to the care of W. W. Francis, the dean of Osler’s alma mater the McGill Medical School and Sir William’s bibliographical protégé. It has been cherished by the McGill faculty ever since.

  Titled “The Inner History of the Johns Hopkins Hospital,” the memoir is jam-packed with sensitive revelations about the early days of the Hopkins. As a result, Dr. Osler instructed his survivors to neither discuss nor open the manuscript “until preparations are being made to celebrate the hospital’s centenary in 1989.” Dr. Osler cleverly concealed his furtive essay in a “dummy” copy of a fictional journal he titled Archives of Medical Sciences and produced as a practical joke in 1893. The volume was elaborately bound, embossed, and included a fake table of contents listing “articles” by William Welch, Howard Kelly, William Halsted, and himself, under the nom de plume “Egerton Y. Davis.”

  Some have speculated that Mrs. Chapin and Dean Francis broke the original seal of the manuscript for a prolonged peek sometime in 1928. Whether they read the manuscript or not, we do know that the manuscript was resealed around this time by Mrs. Chapin and that Francis kept his oath of confidentiality. As soon as he died, in 1959, however, scholars began agitating to study and publish the memoirs. The historical record trumped privacy in 1969, and “The Inner History” appeared in the Johns Hopkins Medical Bulletin, a full twenty years ahead of the hospital’s centennial.

  Osler may have composed his stunning observations as early as the 1890s or as late as 1902 to 1905, but the physician did not leave behind enough evidence for a more precise dating. For example, Osler offers an amendment to his remarks about Halsted that is dated January 10, 1898, suggesting that the manuscript may have been written before that date. Seven years later, in 1905, when delivering his valedictory, and inadvertently scandalous, address “The Fixed Period” before leaving Hopkins for a prestigious post at Oxford University, Osler cursorily mentioned that he had recently written about the early days of the hospital. The speech was widely reported in newspapers across the nation, but not because of his announcement of a secret history of the Johns Hopkins Hospital; instead, it was Osler’s humorous comment on how men do their best work before the age of forty and how society might be better served if all men over sixty were “chloroformed” that created a media maelstrom.

  Dr. Osler probably wrote his “Inner History” late at night in his library on West Franklin Street, at the sturdy, polished library table he’d had imported from England. When he got around to discussing Halsted, Osler began by noting the surgeon’s “sharp tongue and a very cynical manner.” The epitome of every pupil’s most adored professor, Osler could not have appreciated Halsted’s refusal to play to the gallery or welcome the medical students into his home. Osler complained that Halsted could be quite “standoffish” until one got to know him personally and detailed his tortured relationships with the local medical community of Baltimore, amicable interactions being an essential aspect of attracting goodwill and patient referrals for the fledgling hospital.

  Osler loved a crisp dollar and what it could buy. Not surprisingly, he waxes a tad envious when describing the fees Halsted charged his wealthy patients. After referring one dowager to the surgeon for removal of bile duct stones, Osler complained that Halsted had had the gall to submit a bill for $10,500, or almost $260,000 in 2010 dollars. He did add, however, that the woman recovered from both her financial and her surgical extractions quite nicely.

  During the winter of 1893, however, only six months after William’s surgical coronation as a Johns Hopkins professor, Osler witnessed telltale signs that his colleague’s addiction was active and thriving. Somewhere in the hospital, perhaps in the stairwell, in the library, or along the corridor to his rooms, Osler noticed Halsted shivering as if stricken by a “severe chill.” Suffering from neither a cold nor a physical response to the last thrills of a mildly snowy season, Halsted was withdrawing from morphine. He either had run out of the drug he’d first been introduced to at Butler Hospital in Rhode Island or had miscalculated his last dose and was in desperate need of another. This was Osler’s “first intimation” that his colleague was “still taking morphia,” a habit he’d previously been certain Halsted had abandoned because “he had worked so well and so energetically that it did not seem possible that he could take the drug and do so much.”

  The benevolent physician took it upon himself to win Halsted’s “full confidence” and gain a better understanding of his affliction. After many candid conversations, Osler confirmed his worst suspicions. “He had never,” Osler wrote in his secret diary, “been able to reduce the amount to less than three grains daily; on this he could work comfortably and maintain his excellent physical vigor (for he was a very muscular fellow). I do not think that any one suspected him not even Welch.” Three grains, incidentally, is equal to 195 milligrams of morphine, a robust amount that speaks volumes about the level of drug tolerance Halsted had developed because of his chronic and frequent use. On a surgical ward, the typical dose ranges from 5 to 20 milligrams every four hours, depending on the severity of the pain experienced by the patient. For moderate to severe pain (after a major operation, for example), the optimal intramuscular dose is 10 to 20 milligrams per 70 kilograms (154 pounds) of body weight every four hours.

  One final but puzzling clue demands to be recounted: on an otherwise blank page of the manuscript, dated January 10, 1898, Osler noted, “Subsequently he got the amount down to 1.5 grains, and of late years (1912) has possibly gotten on without it.” On the basis of Osler’s recollections, it seems likely that, at a minimum, Halsted was injecting himself with morphine at relatively high doses between the autumn of 1893 and 1898, and probably for much longer than that.

  After his intense struggle for resurrection, why did Halsted continue to abuse drugs? Everything he had hoped and worked for was now at his fingertips to enjoy, savor, and perpetuate. Why couldn’t he simply stop? For addicts’ loved ones this is a familiar quandary. Those fortunate not to have any firsthand knowledge of addiction may never understand it. As for millions of drug addicts, it was never a question of morals, character, intellect, or physical stamina for Halsted; by all accounts he was among the most honorable, vigorous, and hardworking of men. Still, as Dr. Osler attested, at least once a day the surgeon was compelled to satiate his constant hunger for morphine.

  Surgeons are consummate risk takers. They never really know, after ordering a patient to be anesthetized, whether or not that person will awaken, let alone recover from the operation about to be performed. The surgeon needs to deny all those risks. He must banish them from his mind in order to muster the courage to invade a patient’s body and fix the problem at hand.

  Addicts are accomplished at denial and risk taking, too. For William the addict, intoxicating injections
of morphine (and, less frequently, cocaine) loomed far more important to his sense of well-being than all of his surgical accomplishments, medical titles, accolades, scientific papers, students, patients, and considerations of personal health and professional reputation combined. Just as they deadened physical pain, his drugs of choice placed his troubled mind at ease. Halsted routinely gambled his life and career on whether a morphine or cocaine dose might yield a high or permanent oblivion. Perhaps better than any physician alive, he could explain the long-term ravages of addiction on the body and its predictable path to ruin and death. As a consummate medical scientist, he prided himself on being scrupulously honest about a particular technique or medical statement. But William the addict remained unconvinced that the dose he was about to take might bring about his demise. At such moments of intense drug craving, he simply did not care. The unenlightened might demean Halsted’s behavior as dishonest; those more acquainted with addiction know that the denials and outright lies—to himself and others—were sentinel symptoms of his illness.

  Halsted, impeccably dressed while relaxing in North Carolina with his dogs, c. 1904. (photo credit 10.13)

  CHAPTER 11

  Dr. Freud’s Coca Coda

  IT WAS INEVITABLE that Freud’s relationship with Wilhelm Fliess would end badly. Although their once-amiable accord began to fray before the publication of The Interpretation of Dreams, a thunderstorm of animosity erupted in August 1900 when the two met for a “congress” at the Achensee, a lake near Innsbruck. During the trip, they fought constantly. As happens with many good friends who descend into hatred, the taunts and criticisms each hurled at the other were perfectly pitched. Fliess scored his most brutal points by questioning the scientific validity of Freud’s psychoanalytical theories. The thin-skinned Sigmund fumed at such impudence, refusing to see Fliess again in person and sharply curtailing their legendary correspondence. A year later, Freud admitted his intellectual debts to Fliess but cruelly reopened their rift: “There is no concealing the fact that the two of us have drawn apart to some extent.… [You] have come to the limit of your perspicacity.”

  The final winds blew on July 20, 1904, after Fliess picked up a copy of a recently published book titled Sex and Character. Its author, Otto Weininger, was a twenty-three-year-old convert from Judaism to Protestantism with a Ph.D. from the University of Vienna. Depressed over the tepid reviews his book initially inspired, on October 3, 1903, Weininger retired to his room in the same house where Beethoven had died decades earlier and shot himself in the heart. Taken immediately to the Krankenhaus, he succumbed the following day. Otto’s melodramatic end appears to have improved his royalty statements; soon after his funeral, the book became the talk of Vienna’s literary and intellectual salons.

  The famous Dr. Freud, 1910. (photo credit 11.1)

  Sex and Character is a sprawling, racist treatise in which Weininger espoused that women and Jews were bereft of a rational and moral self and, therefore, were unequal to Aryan men and undeserving of simple liberty. Far more troubling to the egocentric Fliess, however, was that Weininger’s tome speculated about bisexuality in a manner strikingly similar to what he had discussed with Freud but not yet published. Consequently, in the summer of 1904, Fliess confronted Sigmund about the book.

  Freud denied Fliess’s charges and described Weininger as “a burglar with a key he had picked up.” While he did admit to telling a troubled young man named Hermann Swoboda about Fliess’s theories on bisexuality, Freud denied all responsibility and suggested, instead, that Swoboda had conveyed these ideas to Weininger, who’d then incorporated them into his book. Astoundingly, Freud went as far as to imply that Weininger’s suicide was “out of fear of his criminal nature.”

  Fliess subsequently heard from a mutual friend that Weininger had shown Freud an early version of his manuscript and that Sigmund had declared it to be “nonsense” and advised against publishing. Refusing to be placated by even this explanation, Fliess complained that his intellectual property had been stolen and accused Sigmund of being the fence. “I believe,” he wrote angrily on July 26, 1904, “in this case you should have called his attention and mine to this ‘burglary.’ ”

  A somewhat disingenuous Freud admitted the next day that while he had “forgotten” about meeting with Weininger and regretted handing “over your idea” (via Hermann Swaboda),

  I do not believe…that I should have shouted “Stop, thief” at that time. Above all, it would have been no use because the thief can just as well claim it was his own idea; nor can ideas be patented. One can withhold them—and does so advisedly if one sets great store by one’s right of ownership. Once they have been let loose, they go their own way.

  Their now famous correspondence ends at this point. Some historians have generously suggested that Freud felt guilty about this episode as well as a subsequent instance when he appropriated some of Fliess’s thoughts on bisexuality for his popular 1901 book, The Psychopathology of Everyday Life. Still, one wonders how Freud would have responded if the tables were turned and Fliess had helped himself to some of Sigmund’s ideas without proper credit. Certainly, Sigmund’s long-held grudge over Carl Koller’s primacy in discovering cocaine anesthesia suggests that he would not have reacted terribly well. In later years, Freud rarely, if ever, mentioned Fliess’s name; nor was he willing to fully acknowledge the role his once-cherished companion played at the dawn of psychoanalysis. In her dotage, Anna Freud, Sigmund’s daughter and the zealous defender of his intellectual legacy, revealed that her father “never talked to her about Fliess.”

  ANOTHER SOURCE FOR DISSECTING the Fliess-Freud split is Princess Marie Bonaparte. One of Sigmund’s favorite analysands and followers, Princess Marie was a disinherited relative of Napoleon Bonaparte’s who, thanks to her mother’s family fortune, had the funds to pay the ransom for Freud’s escape from Nazi-occupied Vienna to England in 1938. She initially consulted Dr. Freud in 1925, her chief complaint being an inability to achieve orgasm while in the missionary position. Historians better recall Princess Marie as the woman who bought and preserved for posterity the Freud-Fliess letters, despite Sigmund’s strenuous objections and desire for their destruction. In an unpublished notebook she composed near the end of her long life, Marie wrote:

  Wilhelm Fliess, c. 1904. (photo credit 11.2)

  The friendship with Fliess began to decline as early as 1900 … when Freud published the book on dreams. Freud had not realized this! I taught it to him. His friendship with Fliess made him reluctant to impute envy to Fliess. Fliess could not bear the superiority of his friend. Nor could he tolerate, this time according to Freud, Freud’s scientific criticisms.… Ida Fliess, moreover … out of jealousy, did everything possible to sow discord between the two friends, whereas Martha Freud understood very well that Fliess, according to Freud, had as passionate a friendship for Freud as Freud had for Fliess.

  Princess Marie offers an insightful analysis of the ultimately corrosive relationship. Doctors are a competitive breed. Few things irritate and disturb a physician’s internal balance more than being left behind by the professional successes of a close colleague. These were the years when psychoanalysis was just beginning to be accepted by a small but enthusiastic body of practitioners and patients. Only a decade later, Freud’s name would be internationally recognized, albeit often during conversations shrill with controversy and contention. Dr. Fliess simply could not compete with his intellectual juggernaut of a friend. Envious of such medical greatness, Fliess must have grasped that Sigmund’s lofty accomplishments would never be his, which likely rankled him. At the same time, Freud seemed incapable of fully acknowledging the important role Fliess played in helping him to articulate so many of his ideas.

  Freud, with Marie Bonaparte and U.S. ambassador to France William Bullitt, fleeing Nazi-dominated Vienna via Paris to London, 1938. (photo credit 11.3)

  Others have speculated about the precise boundaries of Fliess and Freud’s relationship, one that may have extended into a ph
ysical realm that could not even be discussed, let alone reconciled, in early-twentieth-century Vienna. On October 6, 1910, years after the Freud-Fliess dissolution, Freud wrote a confession of sorts to his colleague and acolyte Sándor Ferenczi:

  You have not only noticed, but also understood, that I no longer have any need to uncover my personality completely and you correctly traced this back to the traumatic reason for it. Since Fliess’s case, with the overcoming of which you saw me occupied, the need has been extinguished A part of homosexual cathexis has been withdrawn and made use of to enlarge my own ego. I have succeeded where the paranoiac fails.

  A little more than a week later, Freud wrote Ferenczi, “You probably imagine that I have secrets quite other than those I have reserved for myself, or you believe that my secrets are connected with a special sorrow, whereas I feel capable of handling everything and am pleased with the greater independence that results from having overcome my homosexuality.” The following year, Freud wrote Ferenczi, and made his final mention of Fliess in his copious correspondence: “I have now overcome Fliess, about whom you were so curious.”