An Anatomy of Addiction

by Howard Markel

  17 “I know that you will be astounded”: Halsted to Franklin P. Mall, March 25, 1890, Box 28, Folder 20, W. S. Halsted Papers, Alan Mason Chesney Medical Archives, Johns Hopkins Medical Institutions, Baltimore. Booker refers to William D. Booker, a physician and physiologist who helped organize the clinical pediatrics service at Johns Hopkins in 1889 and served as the chair of clinical pediatrics there for six years. He later became a prominent Baltimore pediatrician and a member of the hospital’s advisory board. Semi-Centennial Volume of the American Pediatric Society, 1838–1938 (Menasha, Wisc.: George Banta Publishing, 1938), p. 20.

  18 Before the nuptials, Caroline resigned: MacCallum, Halsted, p. 82.

  19 Theirs was a type of relationship: For elegant discussions of separate spheres, sexuality, and companionate and same-sex relationships during this era, see Caroll Smith-Rosenberg, Disorderly Conduct: Visions of Gender in Victorian America (New York: Oxford University Press, 1986); and John D’Emilio and Estelle B. Freedman, Intimate Matters: A History of Sexuality in America (Chicago: University of Chicago Press, 1998).

  20 According to those familiar: Nip and Tuck were the Halsteds’ most famous dogs, most likely because of their charming names. In some accounts, Sisly’s name is spelled Sisley. See MacCallum, Halsted, pp. 119–20; Heuer, “Dr. Halsted,” pp. 65–70; and Judith Robinson, Tom Cullen of Baltimore (London: Oxford University Press, 1949), p. 237.

  21 William’s ceaseless search: MacCallum, Halsted, pp. 106–07; Colp, “Notes,” pp. 876–87; Sherwin B. Nuland, Doctors: The Biography of Medicine (New York: Vintage Books, 1988), pp. 415–16; and Daniel B. Nunn, “Caroline Hampton Halsted, an Eccentric but Well-Matched Helpmate,” Perspectives in Biology and Medicine 42, no. 1 (1998): 83–93.

  22 In 1898, Harvey Cushing: Harvey Cushing to his mother, Betsey Cushing, February 20, 1898, Harvey Cushing Papers, Microfilm Reel 15, p. 03, Sterling Library, Yale University, New Haven; Michael Bliss, William Osler: A Life in Medicine (New York: Oxford University Press, 1999), p. 254; Michael Bliss, Harvey Cushing: A Life in Surgery (New York: Oxford University Press, 2005), p. 116; and MacCallum, Halsted, pp. 103–20.

  23 Once his castle’s heavy door: Heuer, “Dr. Halsted,” pp. 61, 67–70. Although the telephone was initially conceived of as a business tool, by the 1920s, more and more American homes contained the new invention. Leading the way in this new market were wealthy families and the homes of physicians. See C. S. Fischer, “Telephone,” The Oxford Companion to American History, ed. P. S. Boyer (New York: Oxford University Press, 2001), p. 769; and D. J. Boorstin, The Americans: The Democratic Experience (New York: Random House, 1973), p. 391.

  24 The small suite of rooms: MacCallum, Halsted, pp. 81–82.

  25 Rigorous, entirely exhausting: William S. Halsted, “The Training of the Surgeon,” Bulletin of the Johns Hopkins Hospital 15, no. 162 (1904): 267–75. The typical time frame for training included six years as an assistant followed by two more years as house surgeon. Halsted added in his report that “I know from applications which have been made to me this year that men of the desired quality would gladly serve 10 years on the surgical staff in order to obtain the experience which the house surgeonship and the training leading to it affords.” For a recent review on the state of residency training in the United States after the reforms in duty hours, see Institute of Medicine, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety (Washington, D.C.: Institute of Medicine/National Academies of Science, 2008).

  26 His visits might last: Heuer, “Dr. Halsted,” pp. 53–60.

  27 But even among the very rich: Ibid., pp. 56–58.

  28 Years later, in 1940: Harvey C. Cushing, The Medical Career and Other Papers (Boston: Little, Brown, 1940), p. 225.

  29 At the dawn of the Gay Nineties: H. L. Mencken, Happy Days (New York: Alfred A. Knopf, 1940), p. 55.

  30 Before the century turned: Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (New York: Basic Books, 1985); The Education of American Physicians, ed. Ronald L. Numbers (Berkeley: University of California Press, 1980); Thomas N. Bonner, Becoming a Physician: Medical Education in Great Britain, France, Germany, and the United States, 1750–1945 (New York: Oxford University Press, 1995); Ronald L. Numbers, ed., The History of Medical Education (Los Angeles: University of California at Los Angeles, 1970).

  31 Almost immediately, the Hopkins: Alan M. Chesney, The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, vol. 1, Early Years, 1867–1892 (Baltimore: Johns Hopkins University Press, 1943).

  32 At the laboratory bench: This organism, if ingested or introduced into an open wound, can cause damage to the gut or gas gangrene in the wound. Ubiquitous and found in decaying vegetation and marine sediment, this bacterium is currently known as Clostridium perfringens.

  33 Every year until his retirement: Simon Flexner and James T. Flexner, William Henry Welch and the Heroic Age of American Medicine (New York: Viking Press, 1949); Donald Fleming, William H. Welch and the Rise of Modern Medicine (Baltimore: Johns Hopkins University Press, 1987); Alan M. Chesney, The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine, vol. 2, 1893–1905 (Baltimore: Johns Hopkins University, 1958); and A. M. Harvey, G. H. Brieger, S. L. Abrams, and V. A. McKusick, A Model of Its Kind, vol. 1, A Centennial History of Medicine at Johns Hopkins (Baltimore: Johns Hopkins University Press, 1989), pp. 19–22.

  34 Once there, he approached: Audrey W. Davis, Dr. Kelly of Hopkins: Surgeon, Scientist, Christian (Baltimore: Johns Hopkins Press, 1959), pp. 142–74; and “Testimonial Dinner to Howard Atwood Kelly on his 75th Birthday,” Bulletin of the Johns Hopkins Hospital 53, no. 2 (1933): 65–109.

  35 In 1926, Kelly wrote: Howard A. Kelly, A Scientific Man and the Bible (Philadelphia: Sunday School Times Co., 1925); and H. L. Mencken, “Fides Ante Intellectum,” American Mercury 7, no. 26 (1926): 251–52.

  36 In discussing Kelly’s dual devotion: John F. Fulton, Harvey Cushing: A Biography (Springfield, Ill.: C. C. Thomas, 1946), p. 681.

  37 “effulgent as an X-ray tube”: Quoted in Bliss, William Osler, p. 215.

  38 The undisputed star of the faculty: Howard A. Kelly, “Osler as I Knew Him in Philadelphia and in the Hopkins,” Johns Hopkins Hospital Bulletin 30, no. 341 (1919): 215–16; and Harvey Cushing, The Life of Sir William Osler (Oxford: Oxford University Press, 1925).

  39 He was always impeccably dressed: Howard Markel, “Dr. Osler’s Relapsing Fever,” Journal of the American Medical Association 295 (2006): 2886–87; and Bliss, William Osler, pp. 208–58.

  40 Having gathered this critical intelligence: Harvey et al., Model of Its Kind, vol. 1, pp. 23–25.

  41 By insisting that his pupils observe: John Dewey, Democracy and Education: An Introduction to the Philosophy of Education (New York: Echo, 2007); Ludmerer, Learning to Heal, pp. 43–71; and Henry M. Thomas, “Some Memories of the Development of the Medical School and of Osler’s Advent,” Bulletin of the Johns Hopkins Hospital 30, no. 341 (1919): 214–15.

  42 After greeting them: T. M. Boggs, “Osler as Bibliophile,” Bulletin of the Johns Hopkins Hospital 30, no. 341 (1919): 216.

  43 But he always concluded: William Osler, “Books and Men,” in Aequanimitas, with Other Addresses to Medical Students, Nurses and Practitioners of Medicine (Philadelphia: P. Blakiston’s Sons, 1904), pp. 209–15; quote is from p. 211.

  44 “part of the permanent hospital record”: Heuer, “Dr. Halsted,” pp. 26–28; Harvey et al., Model of Its Kind, vol. 1, pp. 36–38; quote is from Heuer, p. 26.

  45 “it was an impressive demonstration”: Heuer, “Dr. Halsted,” p. 28.

  46 Other medical students: Bliss, William Osler, p. 215.

  47 Rarely, if ever: “Johns Hopkins Hospital Board of Trustees Minutes,” December 10, 1895–March 10, 1896, Alan Mason Chesney Medical Archives, Johns Hopkins Medical Institutions, Baltimore; Welch to Mall, January 11, 1896, Franklin Mall Papers, Alan Mason Chesney Medical Archives, Johns Hopkins Me
dical Institutions, Baltimore; Chesney, Johns Hopkins Hospital, vol. 2, pp. 38, 81–83; and Bliss, William Osler, pp. 209, 214–15.

  48 During many of the Friday afternoon dry clinics: Bliss, William Osler, p. 215.

  49 Halsted gruffly stated: Heuer, “Dr. Halsted,” pp. 33, 56–68.

  50 Indeed, many seasoned Johns Hopkins doctors: R. Matas, J. T. F. Finney, W. H. Welch, and M. Reid, “Memorial Meeting for Dr. William Stewart Halsted, Late Professor of Surgery in the Johns Hopkins Medical School,” Bulletin of the Johns Hopkins Hospital 36, no. 1 (1925): 1–59.

  51 In fact, Halsted’s absenteeism: “The Matter of Dr. Halsted’s Absence,” a list of hospital board minutes regarding Halsted’s absences from the Johns Hopkins Hospital, Box 69A, W. S. Halsted Papers, Alan Mason Chesney Archives of the Johns Hopkins Medical Institutions, Baltimore. One bone of contention between Halsted and the board had to do with his annual summer vacations, from June 1 to about October 1. The Halsteds escaped the humid heat of Maryland for High Hampton, Caroline’s family estate in North Carolina, where she attended to her stable of fine horses. There are also multiple letters in the Halsted papers where, as early as 1891, William requests leaves of absences because of “poor health.” His colleagues were also concerned about his appearance during this period. For example, William D. Booker wrote Franklin Mall on May 3, 1891, “He was looking dreadful when he left, but recent letters from him are very encouraging”; Booker to Mall, May 3, 1891, Franklin P. Mall Papers, Series I, Correspondence, Alan Mason Chesney Archives, Johns Hopkins Medical Institutions, Baltimore. For a superb summary of Halsted’s many absences, see Daniel B. Nunn, “William Stewart Halsted: Transitional Years,” Surgery 121, no. 3 (1997): 343–51. See also Heuer, “Dr. Halsted,” pp. 70–78.

  52 The flimsy excuse Halsted offered: Bliss, William Osler, p. 213.

  53 “with the scalpel in his hand”: Heuer, “Dr. Halsted,” p. 25; a similar account of this behavior was expressed by Roy D. McClure, the surgeon-in-chief at the Henry Ford Hospital in Detroit and one of Halsted’s former chief residents, in a letter to Heuer on October 22, 1948; George J. Heuer Papers, Box 2, File 13, Item 8, Cornell Medical Archives, Weill Cornell Medical School, New York.

  54 “This gave me an extraordinary amount”: H. L. Mencken, The Diary of H. L. Mencken, ed. C. A. Fecher (New York: Alfred A. Knopf, 1989), p. 10 (diary entry for January 14, 1931). In a biography of the Hopkins obstetrician Thomas Cullen, published nearly two decades later, Mencken noted that Halsted “would start an operation, go on for a bit, then seem to get tired and say to his assistant, ‘You see what I want to do, you finish it,’ and walk away. But Max Broedel [a medical illustrator and a great friend of H. L. Mencken’s], who worked with them all, always said Halsted was the pick of the Big Four. He knew things”; Robinson, Tom Cullen, p. 238. Joseph Colt Bloodgood came to Johns Hopkins as an assistant resident surgeon in 1892 and stayed there, rising to the rank of clinical professor of surgery, until his death in 1935. He was also chief of surgery at Baltimore’s St. Agnes Hospital. For a surgical memoir of Bloodgood’s tenure under Halsted, see Joseph C. Bloodgood, “Halsted Thirty-six Years Ago,” American Journal of Surgery 14 (1931): 89–148.

  55 The volume was elaborately bound: William Osler, “The Inner History of the Johns Hopkins Hospital,” ed. D. G. Bates and E. H. Bensley, Johns Hopkins Medical Journal 125 (1969): 184–94. For descriptions of the fabled Osler Library, which contains the bulk of William Osler’s extensive rare book collection, see C. Lyons and D. S. Crawford, “Whatever Happened to William Osler’s Library?,” Journal of the Canadian Health Library Association 27, no. 1 (2006): 9–13; C. Gray, “The Osler Library: A Collection That Represents the Mind of Its Collector,” Canadian Medical Association Journal 119 (1978): 1442–45; and Bibliotheca Osleriana: A Catalogue of Books Illustrating the History of Medicine and Science (Oxford: Clarendon Press, 1929); see also Colp, “Notes,” pp. 876–87.

  56 Some have speculated: For fascinating accounts of this medical librarian’s life, see Thomas E. Keys, “Osler’s Librarian, Dr. W. W. Francis,” in The Persisting Osler, ed. J. A. Barondess, J. P. McGovern, and C. G. Roland (Baltimore: University Park Press, 1985), pp. 213–22; and Marian F. Kelen, “Memories of My Librarian Father, W. W. Francis, M.D.,” in The Persisting Osler, pp. 223–27. Francis died in 1959.

  57 The historical record trumped privacy: Osler, “Inner History,” pp. 184–94.

  58 The speech was widely reported: William Osler, “The Fixed Period,” in Aequanimitas, with Other Addresses, pp. 375–93; and Bliss, William Osler, pp. 321–28.

  59 Not surprisingly, he waxes a tad envious: Osler’s substantial income is discussed in W. Bruce Fye, “William Osler’s Departure from North America: The Price of Success,” New England Journal of Medicine 320 (1989): 1425–31.

  60 He did add, however: Osler, “Inner History,” pp. 184–94; nineteenth-century dollars were converted into 2010 values using a formula based on the consumer price index from the economic history–focused website Measuring Worth, www.measuringworth.com/index.html (accessed February 25, 2010).

  61 “He had never”: Osler, “Inner History,” p. 190. On the original manuscript, after the word “daily” there is an asterisk, but no elucidating comments or writing follow. See also John L. Cameron, “William Stewart Halsted: Our Surgical Heritage,” Annals of Surgery 225, no. 5 (1997): 445–58; and Peter D. Olch, “William S. Halsted: The Antithesis of William Osler,” in Persisting Osler, pp. 199–204. One can only speculate here, but I believe Welch knew about these issues all too well.

  62 “Subsequently he got the amount down”: Osler, “Inner History,” p. 193, footnote 32. The notation of 1912 is especially curious; given the date of the amendment, one wonders if it was an error for 1902 or actually refers to the later date.

  63 At such moments: This sentiment was best expressed by the noted physician, author, and director Jonathan Miller with respect to cigarettes and nicotine addiction. See D. Cavett, “Why Can’t We Talk Like This?,” New York Times, May 29, 2009, http://cavett.blogs.nytimes.com/2009/05/29/why-cant-we-talk-like-this/?apage=8 (accessed May 4, 2010).

  Chapter 11. Dr. Freud’s Coca Coda

  1 A year later, Freud admitted: Freud to Fliess, August 7, 1901, Jeffrey M. Masson, ed., The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887–1904 (Cambridge, Mass.: Belknap Press of Harvard University Press, 1985), pp. 446–48; quote is from p. 447. In this letter, Freud expresses resentment of Fliess’s wife, who is jealous of the two men’s relationship; Josef Breuer, for planting such a seed of jealousy in her mind; and Fliess’s habit of taking sides against Freud in terms of criticizing his work.

  2 Taken immediately to the Krankenhaus: Fliess to Freud, July 20, 1904, Complete Letters, p. 463; Peter Gay, Freud: A Life for Our Time (New York: W. W. Norton, 1998), pp. 101–02, 154–56; Otto Weininger, Geschlecht und Charakter: Eine prinzipielle Untersuchung (Vienna: Wilhelm Braumüller, 1903); and Wilhelm Fliess, Die Beziehungen zwischen Nase und weiblichen Geschlechtsorganen (In ihrer biologischen Bedeutung dargestellt) (Saarbrücken: Verlag Dr. Müller, rpt. ed., 2007).

  3 Sex and Character is a sprawling, racist treatise: Chandak Sengoopta, Otto Weininger: Sex, Science, and Self in Imperial Vienna (Chicago: University of Chicago Press, 2000), p. 1.

  4 Consequently, in the summer of 1904: Fliess to Freud, July 20, 1904, Complete Letters, p. 463.

  5 Astoundingly, Freud went as far as to imply: Freud to Fliess, July 23, 1904, Complete Letters, p. 464. Freud denies Fliess’s claim that Swoboda was one of his students; rather, he rationalizes a bit by introducing him as a patient. In a subsequent letter, he does call him a student, and, of course, Fliess picked up on this slip rather angrily.

  6 “I believe,” he wrote angrily: Fliess to Freud, July 26, 1904, Complete Letters, pp. 465–66. The source who told Fliess was Dr. Oscar Rie, the Freud children’s pediatrician and a colleague of Sigmund’s at the Vienna First Public Institute for Sick Children. Dr. Rie’s wife was the sister of
Ida Bondy, who married Fliess in 1892.

  7 “I do not believe”: Freud to Fliess, July 27, 1904, Complete Letters, pp. 466–68.

  8 Some historians have generously suggested: Complete Letters, p. 460. Freud admits that he borrowed one of Fliess’s concepts on bisexuality for his book The Psychopathology of Everyday Life, but there he curiously refers to Fliess only as a “friend with whom I used at that time to have a lively exchange of scientific ideas.… Since then I have grown a little more tolerant when, in reading medical literature, I come across one of the few ideas which my name can be associated, and find that my name has not been mentioned.” Sigmund Freud, The Psychopathology of Everyday Life, part of The Standard Edition of the Complete Psychological Works of Sigmund Freud (New York: W. W. Norton, 1990), pp. 143–44. This book is also the volume that introduced an explanation of verbal slips and lapses now known as the “Freudian slip.”

  9 In her dotage, Anna Freud: Complete Letters, p. 4.

  10 “The friendship with Fliess”: Quoted from Bonaparte’s unpublished notebook in Complete Letters, p. 3; Marie’s paternal grandfather was Pierre Napoleon Bonaparte, who was the son of Lucien Bonaparte, one of Napoleon’s younger and less cooperative brothers, who was eventually disinherited. For this reason, Marie was not considered a member of the branch of the family that made claim to the French throne. Her maternal grandfather, François Blanc, was one of the chief real estate developers of what became Monte Carlo, and this was the source of Marie’s immense fortune. See Célia Bertin, Marie Bonaparte: A Life (New Haven: Yale University Press, 1982). To Freud’s request to destroy the letters, Princess Marie responded, “How much would be lost if … the Platonic dialogues had been destroyed just to protect the reputation of Socrates, the pederast!” Quoted in Gay, Freud, p. 614.