An Anatomy of Addiction

by Howard Markel

  7 “It was like a red-hot needle”: Florence Emily Hardy, Early Life of Thomas Hardy, 1840–1891 (New York: Macmillan, 1928), p. 200. Hardy is describing the experience of an old man he met on his travels in the early 1880s.

  8 “One can perhaps imagine”: William G. MacCallum, William Stewart Halsted, Surgeon (Baltimore: Johns Hopkins University Press, 1930), pp. 44–45.

  9 He performed the death-defying procedure: Ibid., pp. 43–44. Halsted discovered his mother to be suffering from the classic “Charcot’s triad” of gallstones: fever, right upper quadrant pain, and jaundice. This procedure has been credited by some historians of surgery as one of the first gallbladder removals, cholecystectomy, performed in the United States, although it is difficult to ascertain this definitively. Nevertheless, cholecystectomy became a standard surgical procedure Halsted was to perfect and report on in the years to come.

  10 He was especially perturbed: “Aseptic Surgery in New York in 1884,” in William S. Halsted, Surgical Papers in Two Volumes, ed. Walter C. Burket (Baltimore: The Johns Hopkins Press, 1924), vol. 1, p. 46.

  11 Convinced by Dr. Joseph Lister’s argument: Joseph Lister, The Collected Papers of Joseph, Baron Lister, 2 vols. (Oxford: Clarendon Press, 1909).

  12 Writing to a colleague in 1921: Letter from William S. Halsted to Rudolph Matas, May 30, 1921, Box 59, Folder 9, W. S. Halsted Papers, Alan Mason Chesney Archives, Johns Hopkins Medical Institutions, Baltimore; and Allan E. Dumont, “Halsted at Bellevue, 1883–1887,” Annals of Surgery 172, no. 6 (1970): 929–35.

  13 Yet when one of them: Simon Flexner and James T. Flexner, William Henry Welch and the Heroic Age of American Medicine (New York: Viking Press, 1941), p. 119; and Howard Markel, When Germs Travel: Six Major Epidemics That Have Invaded America Since 1900 and the Fears They Have Unleashed (New York: Pantheon, 2004), pp. 207–08.

  14 Welch, a frequent houseguest: Alan M. Chesney, The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine, vol. 1, Early Years, 1867–1893 (Baltimore: Johns Hopkins University Press, 1943), p. 111.

  15 Halsted’s demonstrable success: R. Dunglison and R. J. Dunglison, A Dictionary of Medical Science, new ed. (Philadelphia: Henry C. Lea, 1874), p. 874.

  16 Welch occupied his days: Welch was an intern at Bellevue beginning in 1876; Halsted joined the house staff in 1878. See Robert J. Carlisle, ed., An Account of Bellevue Hospital with a Catalogue of the Medical and Surgical Staff from 1736 to 1894 (New York: Society of the Alumni of Bellevue Hospital, 1893), pp. 333–34

  17 “The patient’s mouth filled with blood”: Transcript of a letter to William Osler from Halsted, August 25, 1918. Titled “Complete copy for Dr. J. F. Fulton of a handwritten letter of Halsted inserted by Osler in a reprint of Cushing’s ‘Some conservative jottings apropos of spinal anesthesia,’ ” New York Medical Journal 42 (1895): 483–85, and 488; no. 1800 in Bibliotheca Oslerania, 1929, where an abstract is printed; and George J. Heuer Papers, Box 2, File 14, Item 1, Weill Cornell Medical College, Medical Center Archives, New York, N.Y.

  18 Thanks to the surgeon’s quick packing: Wilder Penfield, “Halsted of Johns Hopkins: The Man and His Problems as Described in the Secret Records of William Osler,” Journal of the American Medical Association 210 (1969): 2214–18; and Lawrence K. Altman, Who Goes First: The Story of Self-Experimentation in Medicine (New York: Random House, 1987), pp. 53–85. See also William S. Halsted, “Practical Comments on the Use and Abuse of Cocaine,” Surgical Papers, vol. 1, pp. 167–77 (the quote regarding operating in his bedroom is on p. 172); and R. Hall, “Hydrochlorate of Cocaine,” New York Medical Journal 40 (1884): 643–44.

  19 Theater events, dances: MacCallum, Halsted, pp. 53–54.

  20 “Once we happened to speak”: [Sergius Pankejeff], The Wolf-Man by the Wolf-Man, ed. Muriel Gardiner (New York: Hill and Wang, 1991), p. 146; and M. Rohrwasser, Freuds Lektüren: Von Arthur Conan Doyle bis zu Arthur Schnitzler (Freud’s Reading: From Arthur Conan Doyle to Arthur Schnitzler) (Giessen: Psychosozial Verlag, 2005).

  21 “Sherlock Holmes took his bottle”: Arthur Conan Doyle, The Sign of the Four (1890), in The New Annotated Sherlock Holmes, ed. L. S. Klinger, vol. 3 (New York: W. W. Norton, 2005), p. 213. At his worst, according to Holmes’s second banana, Dr. John Watson, Sherlock self-injected cocaine three times a day for many months. Some have credited Freud’s papers on cocaine with inspiring Conan Doyle’s interest in using the drug as a literary device in his work. This is likely an overstatement. Conan Doyle probably read Über Coca, given his prodigious reading habits and propensity to keep up with the medical literature, but as noted earlier, cocaine was one of the hottest medical topics during this era, both before and after Carl Koller’s pathbreaking paper on the drug’s anesthetic powers. See also David F. Musto, “Sherlock Holmes and Sigmund Freud,” in Sigmund Freud, Cocaine Papers, ed. Robert Byck (New York: Stonehill, 1974), pp. 357–70; Alvin E. Rodin and Jack D. Key, Medical Casebook of Doctor Arthur Conan Doyle (Malabar, Fla.: Robert E. Krieger Publishing, 1984), pp. 249–99; Andrew Lycett, The Man Who Created Sherlock Holmes (New York: Free Press, 2007); Jon Lellenberg, Daniel Stashower, and Charles Foley, eds., Arthur Conan Doyle: A Life in Letters (New York: Penguin Press, 2007); and Howard Markel, “The Medical Detectives,” New England Journal of Medicine 353 (2005): 2426–28.

  22 “My dear Halsted”: R. J. Hall to Halsted, September 2, 1895. Box 11, Folder 3, W. S. Halsted Papers, Alan Mason Chesney Medical Archives, Johns Hopkins Medical Institutions, Baltimore. See also R. J. Hall, “Hydrochlorate of Cocaine,” New York Medical Journal 40 (1884): 643–44.

  Chapter 6. Cocaine Damnation

  1 The resulting chemical reaction: Dominic Streatfeild, Cocaine: An Unauthorized Biography (New York: Picador, 2001), pp. 271–323.

  2 Cocaine users soon flocked: National Institute of Drug Abuse, Research Report: Cocaine Abuse and Addiction, www.nida.nih.gov/researchreports/Cocaine/cocaine3.html (accessed May 28, 2009). A more dangerous form of freeing the cocaine from the salt was freebasing cocaine, a popular method of abuse in the early 1980s. When a user smoked the drug in a pipe containing ether, the alkaloid or base portion of the drug was “freed” from the chloride salt, resulting in faster delivery of cocaine molecules to the brain. But the mixture was highly flammable and explosive, leading to a number of injuries and deaths from its use by inebriated people. Most infamous were the severe body burns experienced by the comedian Richard Pryor in 1980; he was smoking freebase cocaine, drinking 150-proof rum, and experiencing a cocaine-induced psychosis.

  3 Cocaine can also wreak havoc: M. F. Weaver and S. H. Schnoll, “Stimulants: Amphetamines and Cocaine,” in Addictions: A Comprehensive Guidebook, ed. B. S. McReady and E. E. Epstein (New York: Oxford University Press, 1999), pp. 105–20; L. L. Cregler and H. Mark, “Medical Complications of Cocaine Abuse,” New England Journal of Medicine 315 (1986): 1495–1500; F. H. Gawin and E. H. Ellinwood Jr., “Cocaine and Other Stimulants,” New England Journal of Medicine 318 (1988): 1173–82; and F. H. Gawin, “Cocaine Addiction: Psychology and Neurophysiology,” Science 251 (1991): 1580–86.

  4 After arriving at the brain’s prefrontal cortex: M. D. Lemonick and A. Park, “The Science of Addiction,” Time, July 16, 2007, pp. 42–48; Richard F. Thompson, The Brain: A Neuroscience Primer, 3rd ed. (New York: Worth Publishers, 2000), pp. 168–75; Margaret Haney, “Neurobiology of Stimulants,” in The American Psychiatry Publishing Textbook of Substance Abuse Treatment, 4th ed., ed. Marc Galanter and Herbert D. Kleber (Washington, D.C.: American Psychiatry Press, 2008), pp. 143–55; and D. A. Gorelick, “The Pharmacology of Cocaine, Amphetamines and Other Stimulants,” in Principles of Addiction Medicine, 4th ed., ed. R. A. Ries, D. A. Fiellen, S. C. Miller, and R. Saitz (Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins, 2009), pp. 133–57. Others argue that the nucleus accumbens has more to do with the memory, anticipation, and motivation for reward than with appreciation for the reward itself. Hence, this frequent comment from addicts: “I don’t even feel that good
when I do it, but I cannot stop myself.”

  5 Under normal circumstances: To be neuroanatomically correct, the dopamine transporter proteins are located in the nucleus accumbens. They sit on the nerve terminals of neurons that originate in the ventral tegmental area and end in the nucleus accumbens; hence, the cocaine acts pharmacologically on or in the nucleus accumbens.

  6 A pharmacological version: Alan I. Leshner, “What We Know: Drug Addiction Is a Brain Disease,” in Principles of Addiction Medicine, 2nd ed., ed. Allan W. Graham and Terry K. Schultz (Chevy Chase, Md.: American Society of Addiction Medicine, 1998), pp. xxix–xxxvi; N. Volkow and T.-K. Li, “Drug Addiction: The Neurobiology of Behavior Gone Awry,” in Principles of Addiction Medicine, 4th ed., pp. 3–12; C. V. Dobrin and D.C.S. Roberts, “The Anatomy of Addiction,” in Principles of Addiction Medicine, pp. 27–38; Robert L. Dupont, The Selfish Brain: Learning from Addiction (Minneapolis: Hazelden Publishing Co., 2000); N. D. Volkow, J. S. Fowler, and G. J. Wang, “The Addicted Human Brain: Insights from Imaging Studies,” Journal of Clinical Investigation 111, no. 10 (2003): 1444–51; G. F. Koob and M. Le Moal, “Plasticity of Reward Neurocircuitry and the ‘Dark Side’ of Drug Addiction,” Nature Neuroscience 8, no. 11 (2005): 1442–44; P. W. Kalivas and N. D. Volkow, “The Neural Basis of Addiction: A Pathology of Motivation and Choice,” American Journal of Psychiatry 162, no. 8 (2005): 1403–13; and B. J. Everitt and T. W. Robbins, “Neural Systems of Reinforcement of Drug Addiction: From Actions to Habits to Compulsion,” Nature Neuroscience 8, no. 11 (2005): 1481–89.

  7 Ecstatic arousal and desire: Haney, “Neurobiology,” in Textbook of Substance Abuse, 4th ed., pp. 143–55; Gorelick, “Pharmacology of Cocaine,” in Principles of Addiction, pp. 133–57.

  8 Specifically, such crashes: F. S. Hall, X. F. Li, I. Sora, F. Xu, M. Caron, K. P. Lesch, D. L. Murphy, and G. R. Uhl, “Cocaine Mechanisms: Enhanced Cocaine, Fluoxetine and Nisoxetine Place Preferences Following Monoamine Transporter Deletions,” Neuroscience 115, no. 1 (2002): 153–61. I am grateful to my colleagues Dr. David McDowell, clinical assistant professor of psychiatry at Mount Sinai Medical Center of New York, and Dr. Kirk Brower, professor of psychiatry and medical director of the University of Michigan Addiction Treatment Service, for helping me sort out the complex neurochemistry of cocaine.

  9 In time, cocaine abuse: The frontal cortex also contains sensory, reinforcement, and associative circuitry that can be damaged by chronic cocaine abuse. See W. M. Freeman, K. Brebner, K. M. Patel, W. J. Lynch, D. C. Roberts, and K. E. Vrana, “Repeated Cocaine Self-administration Causes Multiple Changes in Rat Frontal Cortex Gene Expression,” Neurochemical Research 27, no. 10 (2002): 1181–92; C. A. Biggins, S. MacKay, W. Clark, and G. Fein, “Event-Related Potential Evidence for Frontal Cortex Effects of Chronic Cocaine Dependence,” Biological Psychiatry 42, no. 6 (1997): 472–85; and J. A. Matochik, E. D. London, D. A. Eldreth, J. L. Cadet, and K. Bolla, “Frontal Cortical Tissue Composition in Abstinent Cocaine Abusers: A Magnetic Resonance Imaging Study,” NeuroImage 19, no. 3 (July 2003): 1095–102.

  10 A month later: Streatfeild, Cocaine, p. 88; J. H. Woods and C. R. Schuster, “Reinforcement Properties of Morphine, Cocaine, and SPA as a Function of Unit Dose,” International Journal of the Addictions 3 (1968): 231–37; A. Etternberg, H. O. Pettit, F. E. Bloom, and G. F. Koob, “Heroin and Cocaine Intravenous Self-administration in Rats: Mediation by Separate Neural Systems,” Psychopharmacology 78 (1982): 204–09; and J. H. Woods, “Behavioral Pharmacology of Drug Self-administration,” in Psychopharmacology: A Generation of Progress, ed. M. A. Lipton, A. DiMascio, and K. F. Killam (New York: Raven, 1978).

  11 McBride was said to have spent: MacCallum, Halsted, pp. 45–46.

  12 It was likely a close and loving relationship: For social and cultural historical analyses of gender roles, masculinity, femininity, and sexuality during this era, see Gail Bederman, Manliness and Civilization: A Cultural History of Gender and Race in the United States, 1880–1917 (Chicago: University of Chicago Press, 1996); Carroll Smith-Rosenberg, Disorderly Conduct: Visions of Gender in Victorian America (New York: Oxford University Press, 1986); Michael Kimmel, Manhood in America: A Cultural History (New York: Free Press, 1996); E. Anthony Rotundo, American Manhood: Transformations in Masculinity from the Revolution to the Modern Era (New York: Basic Books, 1993); and John D’Emilio and Estelle B. Freedman, Intimate Matters: A History of Sexuality in America (Chicago: University of Chicago Press, 1997).

  13 After examining a laborer: Allan E. Dumont, “Halsted at Bellevue, 1883–1887,” Annals of Surgery 172, no. 6 (1970): 929–35; Wilder Penfield, “W. Halsted of Johns Hopkins,” Journal of the American Medical Association 210 (1969): 2214–18; and Allen O. Whipple, “Halsted’s New York Period,” Surgery 32 (1952): 542–50. The May 5, 1885, episode is described in detail in the prologue of this book.

  14 Instead, the editor lists: William S. Halsted, Surgical Papers in Two Volumes, ed. Walter C. Burket (Baltimore: The Johns Hopkins Press, 1924), vol. 1, p. 167. This short notice is followed by a series of letters and documents attesting to Halsted’s discovery of nerve blockade, the basis of modern painless dentistry. See also Halsted to Matas, May 24, 1921, Box 59, Folder 9; Halsted to Matas, May 30, 1921, Box 18, Folder 4; Halsted to Matas, July 10, 1921, Box 59, Folder 18; and Halsted from Matas, Box 59, Folder 11, W. S. Halsted Papers, Alan Mason Chesney Archives, Johns Hopkins Medical Institutions, Baltimore.

  15 “Neither indifferent as to which”: William S. Halsted, “Practical Comments on the Use and Abuse of Cocaine Suggested by Its Invariably Successful Employment in More Than a Thousand Minor Surgical Operations,” New York Medical Journal 42 (September 12, 1885): 294–95.

  16 In the summer of 1885: Halsted to Welch, July 14, 1922, Series II, Notes, Box 31, William S. Halsted Papers, Alan Mason Chesney Archives, Johns Hopkins Medical Institutions, Baltimore.

  17 To the end of his life: These events are recounted in a letter Halsted wrote to William Osler on August 23, 1918; it is reprinted in George J. Heuer, “Dr. Halsted,” Johns Hopkins Hospital Bulletin, Supp. 90 (1952): 21.

  18 Every time the urologist: A. P. Stout, “William Stewart Halsted,” Notes, Series II, June 9, 1924, Box 49, William Stewart Halsted Papers, Alan Mason Chesney Archives, Johns Hopkins Medical Institutions, Baltimore; Daniel B. Nunn, “Dr. Halsted’s Addiction,” Johns Hopkins Advanced Studies in Medicine 6, no. 3 (2006): 106–10; and Daniel B. Nunn, “William Stewart Halsted: Transitional Years,” Surgery 121, no. 3 (1997): 343–51.

  19 It was a short time: Howard Markel, “The Accidental Addict,” New England Journal of Medicine 352 (2005): 966–68.

  20 Regardless of the veracity: Arthur J. Beckhard and William D. Crane, Cancer, Cocaine and Courage: The Story of Dr. William Halsted (New York: Julian Messner, 1960). The authors interviewed a number of New York City doctors and members of the New York Academy of Medicine in the late 1950s who either knew Halsted personally or knew of him once removed (such as a friend’s spouse). Sadly, the authors do not list the book’s precise sources or the textual means for verification. Another title in this series of “juvenile biographies” is on Sigmund Freud: Rachel Baker, Sigmund Freud (New York: Julian Messner, 1952).

  21 Butler was a well-known insane asylum: MacCallum, Halsted, pp. 55–57, 58–71. Dr. Vander Poel first suggested Butler Hospital to Halsted a few months earlier, but such an intervention obviously failed.

  22 If he could only recover: Ibid., pp. 55–71.

  23 How lost and abject: Peter D. Olch, “William S. Halsted’s New York Period, 1874–1886,” Bulletin of the History of Medicine 60 (1966): 495–510; Peter D. Olch, “William S. Halsted and Local Anesthesia: Contributions and Complications,” Anesthesiology 42, no. 4 (1975): 479–86.

  Chapter 7. Sigmund in Paris

  1 Soon after its appearance: Ernest Jones, The Life and Work of Sigmund Freud, vol. 1 (New York: Basic Books, 1955), pp. 92–94.

  2 Around this same time: Sigmund Freud, “Contribution to the Knowledge of the E
ffect of Cocaine,” Wiener medizinische Wochenschrift, no. 5 (January 31, 1885): 130–33, in Cocaine Papers, ed. Robert Byck (New York: Stonehill, 1974), pp. 97–104.

  3 A mealymouthed Sigmund concluded: Sigmund Freud, “Addenda to Über Coca,” a revised and expanded reprint from the Centralblatt für die gesammte Therapie, Vienna, 1885, in Freud, Cocaine Papers, pp. 107–09.

  4 One of the most intriguing aspects: Freud, “On the General Effect of Cocaine,” Medicinisch-chirurgisches Centralblatt, no. 32 (August 1885): 374–75, in Freud, Cocaine Papers, pp. 111–18.

  5 In fact, Sigmund garnered: Jones, Life, vol. 1, pp. 92–96. Fleischl-Marxow, apparently, began injecting cocaine subcutaneously (under the skin) at the onset and may well have graduated to intravenous injections.

  6 At other times: Sigmund Freud to Martha Bernays, January 6, 1885—September 1, 1886, Ernst L. Freud, ed., Letters of Sigmund Freud (New York: Basic Books, 1960), pp. 131–218.

  7 Although this arrangement: His mentors Brücke, Meynert, and Nothnagel wrote strong letters of support on Freud’s behalf for this grant. See George Makari, Revolution in Mind: The Creation of Psychoanalysis (New York: Harper Perennial, 2009), pp. 26–27.

  8 Ever the scientific investigator: Freud to Martha, October 12, 1885; quoted in Jones, Life, vol. 1, pp. 183–84.

  9 Upon returning from her performance: Quote is from Jones, Life, vol. 1, pp. 177–78.

  10 Beyond Freud’s love: Peter Gay, Freud: A Life for Our Time (New York: W. W. Norton, 1998), p. 48.

  11 “possessed of a thousand demons”: Ibid., pp. 47–48; Freud to Martha, October 19, 1885, Freud, Letters, pp. 171–74 (Letter 81), and December 3, 1885, pp. 187–88 (Letter 87).

  12 In one of these dank hospital wards: Henry Sigerist, The Great Doctors: A Biographical History of Medicine (New York: W. W. Norton, 1933), pp. 276–82; P. Pinel, A Treatise on Insanity, trans. D. D. Davis (Sheffield, U.K.: W. Todd for Caddell and Davies of London, 1806); Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason (New York: Vintage, 1988), pp. 36–38, 72–74; Erwin H. Ackerknecht, Medicine at the Paris Hospital, 1794–1848 (Baltimore: Johns Hopkins University Press, 1967), pp. 150–51, 168–69; and Dora B. Weiner, The Citizen-Patient in Revolutionary France (Baltimore: Johns Hopkins University Press, 2001).