46 Yet most established smokers: Robert H. Julien, A Primer of Drug Action: A Concise Nontechnical Guide to the Actions, Uses, and Side Effects of Psychoactive Drugs (New York: Holt/Owl Books, 2001), pp. 154–56.
47 Such quibbles aside: Freud to Fliess, April 19, 1894, and June 22, 1894, Complete Letters, pp. 67–69, 83–86.
48 “I would be endlessly obliged”: Freud to Fliess, June 22, 1894, Complete Letters, pp. 83–86; quote is from pp. 85–86. Sigmund wrote a similar letter on July 14, 1894, complaining of Fliess’s order that he stop smoking cigars; Complete Letters, pp. 87–88.
49 “I must hurriedly write to you”: Freud to Fliess, January 24, 1895, Complete Letters, pp. 106–07; quote is from p. 106.
50 “I need a lot of cocaine”: Freud to Fliess, June 12, 1895, Complete Letters, pp. 131–32; quote is from p. 132.
51 Freud began composing: Sigmund Freud, Project for a Scientific Psychology, in The Complete Psychological Works of Sigmund Freud, vol. 1, ed. and trans. J. Strachey (London: Hogarth, 1910); see also Masson, Complete Letters. Many scholars have noted that this project contains some precursor, or at least explanatory, sections of what ultimately became The Interpretation of Dreams.
52 He would then rewrite: Makari, Revolution, pp. 74–84.
53 And most important: Gay, “Freud: A Brief Life,” pp. xiv—xv.
54 As he had jovially informed Fliess: Freud to Fliess, April 16, 1896, Complete Letters, pp. 180–81.
55 In January, he told Fliess: Freud to Fliess, January 16, 1899, Complete Letters, pp. 340–41.
56 In mid-June: Freud to Fliess, June 16, 1899, Complete Letters, pp. 355–56.
57 A few weeks later: Freud to Fliess, June 27, 1899, Complete Letters, pp. 356–57.
58 That he did: Freud to Fliess, July 8, 1899, Complete Letters, pp. 359–60.
59 Eventually, Sigmund realized: Freud describes his drinking to Fliess as a “new vice” in early December 1898. December 5, 1898, Complete Letters, pp. 335–36; and Gay, Freud, p. 100.
60 “In the pages that follow”: Freud, Interpretation of Dreams, p. 57.
61 “The whole thing is laid out”: Freud to Fliess, August 6, 1899, Complete Letters, pp. 365–66; and Gay, Freud, p. 106.
62 Cradling a newly published copy: The book first appeared in print in November 1899, but its publication on the title page of the first edition was postdated into the new century, 1900. Freud, Interpretation of Dreams, p. 34.
63 “After last summer’s exhilaration”: Freud to Fliess, March 11, 1900, Complete Letters, pp. 402–04; quote is from p. 403. Decades later, Sigmund described The Interpretation of Dreams as his greatest work. In the preface to the third English edition of the book, published in 1931, Freud noted, “It contains, even according to my present-day judgment, the most valuable of all the discoveries it has been my good fortune to make. Insight such as this falls to one’s lot but once in a lifetime” (p. 56).
64 Despite Freud’s grand hopes: Gay, Freud, p. 3.
65 After all, The Interpretation of Dreams: Zaretsky, Secrets, p. 31.
66 “Do you think that one day”: Freud to Fliess, June 12, 1900, Complete Letters, pp. 417–18.
67 It was based on a series: Freud, Interpretation of Dreams, p. 187. As we shall see, this period coincides with the point when Freud was having so much difficulty with his nasal passages and sinuses that he underwent a surgical or cauterization procedure of the nasal turbinates performed by Fliess, following which “cocaine, in which Fliess was a great believer, was constantly prescribed.” See Jones, Life, vol. 1, p. 309; Harry C. Leavitt, “A Biological and Teleological Study of ‘Irma’s Injection’ Dream,” Psychoanalytic Review 43 (1956): 440–47; and Stanley K. Kaplan, “Narcissistic Injury and the Occurrence of Creativity: Freud’s Irma Dream,” Annual of Psychoanalysis 12 (1984): 367–76.
68 Immortalizing her as “Irma”: Some of the physical features of “Irma” are also based on another patient of Freud’s named Anna Lichtheim, and Freud always insisted that the figure of Irma was a sammelperson, or composite figure. Freud, Interpretation of Dreams, pp. 187, 192, 194, 197, 255–56, 259, 262, 297, 309, 387. Cocaine continued to be on Freud’s mind, or at least in his dreams. A few nights later he had a dream about his monograph on coca, the botanical nature of the drug, his father’s glaucoma operation, and the whole episode of Koller’s scooping him on the utility of the drug. Freud makes a point, in his interpretation of this dream, to again assert his role in the discovery. Even though he would never gain primary credit for realizing cocaine’s potential as an anesthetic agent, the monograph on dreams he was about to compose would be his greatest accomplishment. Freud, Interpretation of Dreams, pp. 256, 258–62, 387–88; and Siegfried Bernfeld, “Freud’s Studies on Cocaine, 1884–1887,” Journal of the American Psychoanalytic Association 1 (1953): 581–613. Many of the documentary details of the event, as recounted by Freud to Fliess, were so incriminating that Freud’s daughter Anna and two devoted colleagues redacted them from the first historical volume of the origins of psychoanalysis. See Sigmund Freud, The Origins of Psychoanalysis: Letters to Wilhelm Fliess, Drafts and Notes, 1887–1902, ed. Marie Bonaparte, Anna Freud, and Ernst Kris (New York: Basic Books, 1954); see also Malcolm, Freud Archives; Masson, Complete Letters; and Jeffrey M. Masson, The Assault on Truth: Freud’s Suppression of the Seduction Theory (New York: Harper Perennial, 1992).
69 “I was making frequent use”: Freud, Interpretation of Dreams, p. 187. Although Freud “slips” here in dating when he first recommended cocaine—it was 1884, not 1885—the friend he is referring to is, of course, Fleischl-Marxow.
70 Descriptions of scabrous turbinate bones: It was Fliess who taught Freud about this organic compound. Freud, Interpretation of Dreams, pp. 193, 401–2. Some scholars have also suggested that the smell of trimethylamine is similar to that created by burning coca leaves.
71 “this group of thoughts”: Freud, Interpretation of Dreams, p. 198.
72 “When the work of interpretation”: Ibid., pp. 198–99.
73 In many cases: For an elegant discussion of the triumphs and pitfalls of surgical decision making, see Atul Gawande, Complications: A Surgeon’s Notes on an Imperfect Science (New York: Metropolitan Books, 2002); and Atul Gawande, Better: A Surgeon’s Notes on Performance (New York: Metropolitan Books, 2007).
74 Upon leaving Vienna: Breger, Darkness, pp. 131–32.
75 Moreover, Emma’s nostrils: Freud to Fliess, March 4, 1895, Complete Letters, pp. 113–15.
76 “Before either of us had time”: Freud to Fliess, March 8, 1895, Complete Letters, pp. 116–18; quote is from p. 117. This is one of the most controversial letters in the Freud collections and for many years was suppressed and unpublished, perhaps because it presented the great Freud in such an unfavorable light. For the story of the discovery and publication of these letters, along with the downfall of the historian-archivist who uncovered them, see Malcolm, Freud Archives.
77 After the bloody event: Freud to Fliess, March 8, 1895, Complete Letters, p. 117.
78 He reassured Fliess: Ibid., p. 118.
79 Sigmund also informed Fliess: Freud to Fliess, March 28, 1895, Complete Letters, pp. 122–23; quote is from p. 123. 184 On April 20, Freud wrote Fliess: Freud to Fliess, April 20, 26, and 27, 1895, Complete Letters, pp. 125–26, 126–27, and 127–28.
80 “an unfailing means of rearousing”: Freud to Fliess, May 4, 1895, Complete Letters, pp. 185–86; quote is from p. 185.
81 A father’s death: Preface to the second edition, 1908, Freud, Interpretation of Dreams, p. 47.
82 Freud interpreted this: Freud, Interpretation of Dreams, pp. 428–29; this dream was reported by Sigmund to Fliess on November 2, 1898. In his book, Freud states the dream occurred the night before the funeral; in the letter to Fliess, he places it on the night after the funeral, which occurred on October 25, 1896; Complete Letters, p. 202. For a short time after his father’s death, Sigmund worried about if he was repressing a memory of Jacob sexually abus
ing him or his siblings. He later concluded that this was not the case. See, for example, D. Grubin (writer, director, and producer), Young Dr. Freud: A Film by David Grubin (New York: Public Broadcasting Service, 2002).
83 Distraught by his loss: Freud to Fliess, October 15, 1897, Complete Letters, p. 270.
84 It is the last extant letter: Freud to Fliess, October 26, 1896, Complete Letters, p. 201.
85 One assumes that Freud’s clinical experiences: Bernfeld, “Freud’s Studies on Cocaine, 1884–1887,” p. 611.
Chapter 10. “The Professor”
1 Decades later, a colleague recalled: George J. Heuer, “Dr. Halsted,” Johns Hopkins Hospital Bulletin, Supp. 90 (1952): 51.
2 “In Halsted’s little operating room”: The eminent internist Dr. William Sydney Thayer made this observation. See W. S. Thayer, “The Chief,” New England Journal of Medicine 207, no. 13 (1932): 563–70. Thayer hailed from a rather distinguished Massachusetts family that included several colonial settlers, Harvard professors, and clergymen. Among his most interesting distant relatives were Ralph Waldo Emerson; Ernest Thayer, author of the poem “Casey at the Bat”; and Scofield Thayer, a poet and editor of the famed Dial magazine and one of Sigmund Freud’s many patients. Thayer was an 1890 graduate of the Harvard Medical School and quickly rose at the Hopkins to be one of Osler’s favorite resident physicians and, ultimately, Osler’s successor as professor of medicine at Johns Hopkins. See also Edith G. Reid, The Life and Convictions of William Sydney Thayer, Physician (London: Oxford University Press, 1936), pp. 1–56; and Alex Beam, Gracefully Insane: Life and Death Inside America’s Premier Mental Hospital (New York: Public Affairs, 2001), pp. 100–108.
3 Virtually all of his now universally practiced techniques: William S. Halsted, “The Employment of Fine Silk in Preference to Catgut and the Advantages of Transfixing Tissues in Controlling Hemorrhage; Also an Account of the Introduction of Gloves, Gutta-Percha Tissue, and Silver Foil,” Journal of the American Medical Association 60 (1913): 1119–26.
4 Dr. William Mayo: Michael Bliss, William Osler: A Life in Medicine (New York: Oxford University Press, 1999), p. 212; and J. Scott Rankin, “William Stewart Halsted: A Lecture by Dr. Peter D. Olch,” Annals of Surgery 243 (2006): 418–25.
5 “[His] fingers are engaged”: Sherwin B. Nuland, “The Art of Incision: In Praise of the Greatest Surgeon Ever,” New Republic, August 13, 2008.
6 Those of us who are not surgeons: William G. MacCallum, “William Stewart Halsted,” Biographical Memoirs of the National Academy of Sciences of the United States of America 57 (1937): 151–70; and Fielding H. Garrison, “Halsted,” American Mercury 7 (April 1926): 396–401.
7 Given Halsted’s history: Heuer, “Dr. Halsted”; Sigmund Freud, Cocaine Papers, ed. Robert Byck (New York: Stonehill, 1974); William Golden Mortimer, History of Coca: The Divine Plant of the Incas (New York: J. H. Vail, 1901); and George Andrews and David Solomon, eds., The Coca Leaf and Cocaine Papers (New York: Harcourt Brace and Jovanovich, 1975).
8 Two years later: Samuel J. Crowe, Halsted of Johns Hopkins: The Man and His Men (Springfield, Ill.: C. C. Thomas, 1957), pp. 37–38.
9 At the opening of the twentieth century: Robert Aronowitz, Unnatural History: Breast Cancer and American Society (New York: Cambridge University Press, 2007), pp. 87–88. Aronowitz makes particularly good use of the W. S. Halsted Papers, Alan Mason Chesney Archives of the Johns Hopkins Medical Institutions, in documenting Halsted’s breast cancer work during the first two decades of the twentieth century, as well as the copious correspondence Halsted maintained with doctors around the world. The procedure Halsted developed, the radical mastectomy, removed so much tissue beyond the breast that it caused serious disability, lymphedema, and cosmetic problems. Still, Dr. Halsted predicted that his successors would find more precise and less debilitating treatments for breast cancer. He was right. Today, thanks to a host of new treatment modalities, the radical mastectomy is no longer performed. Even its less radical procedure, the “modified radical mastectomy,” is rarely performed as physicians and patients work to recognize signs of this terrible disease earlier and thanks to the development of new diagnostic methods in the form of frequent breast examinations and mammography, as well as improved treatments in the form of chemotherapy, radiation, and less invasive surgical procedures. That said, breast cancer remains one of the leading causes of death among women in the United States, and this battle is far from over. See also Ellen Leopold, A Darker Ribbon: A Twentieth-Century Story of Breast Cancer, Women, and Their Doctors (Boston: Beacon Press, 2000); and Barron H. Lerner, The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Career in Twentieth-Century America (New York: Oxford University Press, 2001).
10 During these years, he perfected: For example, goiter and hypothyroidism were among the leading causes for disqualifying young men from entering the U.S. Army in 1918. For a history of this once-common problem and its medical amelioration, see Howard Markel, “ ‘When It Rains It Pours’: Endemic Goiter, Iodized Salt, and David Murray Cowie, M.D.,” American Journal of Public Health 77 (1987): 219–29.
11 He also created: William G. MacCallum, William Stewart Halsted, Surgeon (Baltimore: Johns Hopkins University Press, 1930), pp. 84–93, 139–49.
12 As a result of his renown: Heuer, “Dr. Halsted”; MacCallum, Halsted, pp. 84–102; and William S. Halsted, Surgical Papers in Two Volumes, ed. Walter C. Burket (Baltimore: The Johns Hopkins Press, 1924). The papers Halsted wrote during the years 1889–95 are particularly helpful for understanding the variety of surgical problems he was encountering in the operating room. A huge collection of Halsted’s letters to his colleagues around the world can be found in the Halsted papers at the Alan Mason Chesney Archives of the Johns Hopkins Medical Institutions in Baltimore.
13 For procedures requiring local anesthesia: Heuer, “Dr. Halsted,” p. 47; according to an unsigned obituary published in Science in 1922 and likely written by Harvey Cushing, Halsted often used a simple salt solution, insisting that even water and sodium chloride could numb the skin; his residents preferred cocaine solutions. “William Stewart Halsted, 1852–1922,” Science 56, no. 1452 (1922): 461–64. Manuscript copy of this obituary can be found in George J. Heuer Papers, Box 2, File 19, Item 5, Weill Cornell Medical College, Cornell Medical Center Archives, New York. See also: James F. Mitchell, “Memories of Dr. Halsted,” Surgery 32 (1952): 451–60.
14 Such daily proximity: One of the strangest rumors about Halsted’s addiction is a purported reason behind his habit of sending his soiled shirts to Paris for laundering, on an annual basis. According to Heuer, Halsted did so because he considered the laundries in the United States to be inferior to the quality of those in France; Heuer, “Dr. Halsted,” p. 69. The rumor mill suggested that the French launderers sent along packets of morphine and cocaine in the return packages. The historian Peter Olch documents the scores of receipts for laundering of shirts in the Halsted papers but does not go as far as to state drugs were sent back to Baltimore for Halsted’s consumption; Rankin, “Halsted,” pp. 418–25. Indeed, this route seems especially fantastic when one considers that Halsted had such ready access to morphine and cocaine in his own operating room and surgical clinic. The drugs-with-laundry claim has appeared in several accounts over the years; see, for example, Ralph Colp Jr., “Notes on Dr. William S. Halsted,” Bulletin of the New York Academy of Medicine 60, ser. 2 (1984): 876–87.
15 The fastidious Dr. Halsted: Antiseptic surgery refers to methods where the surgeon kills germs before operating, such as by the use of strong disinfectants. In the decades that followed, surgeons developed aseptic techniques whereby all the instruments, drapes, and gowns were sterilized by means of steam, as opposed to the powerful antiseptics that not only destroyed microbes but also harmed living tissue. In aseptic surgery, as practiced in modern operating rooms around the world, living bacteria are not allowed near open wounds. For the techniques used in Halsted’s operating room, see Heuer, “Dr. Halsted,” pp. 46–53.
The permanganate tended to turn the skin a dark chocolate brown, the oxalic acid oxidized the permanganate and turned the skin back to its natural color, and the bichloride of mercury (1:1000) was known to be extremely rough on the hands and caused terrible dermatitis; for a more general discussion, see Gert H. Brieger, “American Surgery and the Germ Theory of Disease,” Bulletin of the History of Medicine 40 (1966): 135–45.
16 Armed with drawings of prototypes: MacCallum, Halsted, pp. 81–82; and S. Halsted, “The Employment of Fine Silk.” Several historians have presented evidence that Dr. Hunter Robb, an obstetrics-gynecology resident of Howard Kelly’s during this period, not Halsted, was the first to advocate the use of rubber surgical gloves for aseptic technique. Historians have parsed the discovery to note that Halsted developed them for his wife-to-be for avoiding dermatitis but Robb and, likely, Halsted’s chief surgical resident, Joseph Bloodgood, began using them for purposes of asepsis. Regardless, soon after their introduction, everyone in the operating room eventually adopted the gloves as routine practice, and it caught on across the globe. See Joseph C. Bloodgood, “Halsted Thirty-six Years Ago,” American Journal of Surgery 14 (1931): 89–148; A. C. Barnes, “A Comment on Historical ‘Truth,’ ” Perspectives in Biology and Medicine (Autumn 1977): 131–38; C. Proskauer, “Development and Use of the Rubber Glove in Surgery and Gynecology,” Journal of the History of Medicine and Allied Sciences 13 (1958): 373–81; and Rankin, “Halsted,” pp. 418–25.
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