The orderlies rushed the laborer into Bellevue’s accident room (the forerunner of today’s emergency departments) for examination and treatment. A compound fracture—the breaking of a bone so severely that it pokes through the soft tissue and skin—was deadly serious in the late nineteenth century. Before X-ray technology, it was difficult to assess the full extent of a fracture other than by means of painful palpation or cutting open the body part in question for a closer look. Discounting the attendant risks of infection and subsequent amputation, even in the best of surgical hands these injuries often carried a “hopeless prognosis.” At Bellevue, above the table on which these battered patients were placed, a sign painted on the wall suggested the chances of recuperation. It read, in six-inch-high black letters: PREPARE TO MEET YOUR GOD.
As the worker writhed in agony, one surgeon’s name crossed the lips of every staff member working in the accident room: Halsted. When it came to a crisis of the body, few surgeons were faster or more expert than he. Leg fractures were a particular interest of his in an era when buildings were being thrown up daily and construction workers were falling off them almost as frequently. One of Dr. Halsted’s earliest scientific papers assessed the surgical repair of fractured thigh, or femur, bones using a series of geometric equations based on how the leg adducted (drew toward) and abducted (drew away) from the central axis of the body. Such meticulous analysis was essential to repairing the break in a manner that accounted for the potential of the injured limb to shorten after the injury. Otherwise, the broken leg would heal in a manner that resulted in a decided limp or, given the intricate mechanics of the hip joint, much worse.
William Stewart Halsted at age twenty-eight, c. 1880. (photo credit prl.2)
An orderly was dispatched to find Dr. Halsted as soon as possible. Running through the labyrinthine corridors of the hospital, he shouted, “Paging Dr. Halsted! Fresh fracture in the Accident Room! Paging Dr. Halsted!” Down one of these halls, in a rarely used chamber, the surgeon was entering a world of mindless bliss. He heard his name but didn’t really care to answer. Yet something, perhaps a reflex ingrained by his many years of surgical training, roused him to stagger out into the hallway and make his way downstairs. The pupils of his eyes looked like gaping black holes, his speech was rapid-fire, and his whole body seemed to vibrate as if he were electrified.
Upon entering the accident room, Halsted was confronted with the acrid smell of blood and a maelstrom of doctors and nurses attending to the wounded worker. So intense was the pain that when Halsted gruffly demanded the patient move his leg one way or the other, the man screamed out an emphatic “No!” Passing a hand up and down the length of the laborer’s lower leg, Halsted could feel the sharp ends of a shattered shinbone, or tibia, thrusting its way through the skin. It was a gory mess requiring immediate attention.
An effective surgeon must be able to visualize the three-dimensional aspects of the anatomy he is about to manipulate. He must take great care in handling sensitive structures surrounding the area in question, such as nerves and blood vessels, to prevent cutting through or destroying them entirely, lest the procedure cause more problems than it corrects. Consequently, the surgeon needs to think several steps ahead of the maneuver he is actively performing in order to achieve the best results for his patient. But the cocainized Halsted was in no shape to operate.
Halsted stepped back from the examination table while the nurses and junior physicians awaited his command, mindful that in a moment bacteria could enter the wound and wreak havoc, perhaps leaving this laborer unable to walk again—or even to die from overwhelming sepsis. To their astonishment, the surgeon turned on his heels, walked out of the hospital, and hailed a cab to gallop him to his home on East Twenty-fifth Street. Once there, he sank into a cocaine oblivion that lasted more than seven months.
FORTY-FOUR HUNDRED MILES AWAY, Sigmund Freud, an up-and-coming neurologist, toiled away in the busy wards of Vienna Krankenhaus (General Hospital). Like Halsted, he was fresh prey for cocaine’s grip. On May 17, 1885, twelve days after Halsted hurried out of Bellevue, Dr. Freud boasted to his fiancée how a dose of pure cocaine vanquished his migraine and inspired him to stay up until four in the morning writing a “very important” anatomical study that “should raise my esteem again in the eyes of the public.” In reality, the publication proved to be nothing more than an extraneous footnote to his literary oeuvre.
A year earlier, Freud had published an extensive review exploring cocaine’s potential therapeutic uses. His central experimental subject was himself. But as impressive as his work was, Dr. Freud neglected to describe cocaine’s most practical application: it was a superb anesthetic that completely numbed a living being’s sensation to the sharp blade of a scalpel. In the fall of 1884, a few months after Freud’s monograph appeared in print, a young ophthalmologist successfully demonstrated the drug’s power to kill pain. The discovery excited the entire medical world, much to Freud’s chagrin.
In the spring of 1885, the preempted Freud made plans to flee Vienna and nurse his wounded ego with a prestigious neuropathology fellowship in Paris. In the months that followed, he engaged in discussions of brain disorders, witnessed dozens of demonstrations of women and men suffering from hysteria, participated in detailed scientific research, and, too frequently, self-medicated his anxieties away.
Cocaine thrilled him in a manner that everyday life could not. He wrote romantic, often erotic letters to his fiancée, dreamed grandiose dreams of his future career, walked about the streets of Paris, visited museums and theaters, and attended sumptuous soirees—all under the influence. Even on return to his beloved Vienna in 1886, eager to embark upon his own private practice and excited about the possibility of new medical discoveries and explorations, Freud continued to take increasingly greater doses of cocaine.
THE FULL-FLEDGED diagnosis of addiction did not really exist in the medical literature until the late nineteenth century. The earliest use of the word appears in the statutes of Roman law. In antiquity, “addiction” typically referred to the bond of slavery that lenders imposed upon delinquent debtors or victims on their convicted aggressors. Such individuals were mandated to be “addicted” to the service of the person to whom they owed restitution. By the seventeenth century and extending well into the early 1800s, “addiction” described people compelled to act out any number of bad habits. Those abusing narcotics during this period were called opium and morphine “eaters.” Alcohol abusers, too, had their own pejorative descriptors, such as “the drunkard,” but as their problem came to the attention of physicians, the condition was often indexed in medical textbooks as dipsomania or alcoholism.
All this changed in the late nineteenth century with the overprescription of narcotics by doctors to ailing and unsuspecting patients. One of the most striking measures of this era was the alarming number of male doctors who prescribed opium, morphine, and laudanum (a tincture of macerated raw opium in 50 percent alcohol) to ever greater numbers of women patients. Any female complaining to her physician about so-called women’s problems was all but certain to leave the doctor’s office clutching a prescription. For example, epidemiological studies conducted in Michigan, Iowa, and Chicago between 1878 and 1885 reported that at least 60 percent of the morphine or opium addicts living there were women.
Main entrance of the Vienna General Hospital, Allgemeines Krankenhaus, c. 1885. (photo credit prl.3)
Vial of cocaine hydrochloride produced by E. Merck and Co., Darmstadt, Germany, c. 1884. This was the product Freud used in his research. (photo credit prl.4)
Huge numbers of men and children, too, complaining of ailments ranging from acute pain to colic, heart disease, earaches, cholera, whooping cough, hemorrhoids, hysteria, and mumps were prescribed morphine and opium. A survey of Boston’s drugstores published in an 1888 issue of Popular Science Monthly documents the ubiquity of these narcotics: of 10,200 prescriptions reviewed, 1,481, or 14.5 percent, contained an opiate. During this period in the United States
and abroad, the abuse of addictive drugs such as opium, morphine, and, soon after it was introduced to the public, cocaine constituted a major public health problem.
NO EVIDENCE HAS BEEN found to demonstrate that William Halsted and Sigmund Freud ever met. Separated by physical and cultural oceans, their lives were, nevertheless, intricately braided and shaped by a handful of scientific papers on the medicinal uses of cocaine. For Sigmund Freud, the medical profession’s creation of so many morphine addicts led him to experiment with cocaine as a potential antidote. In the quest to obliterate the pain incurred by the surgeon’s craft, William Halsted explored the drug as a safer form of anesthesia. But because cocaine was such a relatively new drug during this period, neither Freud nor Halsted recognized its addictive and deleterious force until it was much too late. By using themselves as guinea pigs in their research, each became dependent upon a substance that nearly destroyed their lives and the work that ultimately changed how we think, live, and heal.
CHAPTER 1
Young Freud
ON A JUNE MORNING IN 1884, eleven months before William Halsted abruptly left Bellevue Hospital, Sigmund Freud took his usual seat on a richly upholstered banquette at the Café Landtmann, a pungently academic restaurant situated on Vienna’s Ringstrasse, then at its imperial peak. Freud had been studying medicine at the University of Vienna, directly across the street, since the fall of 1873, but his ascension in the arcane ranks of clinical privilege was slower than the healing of a festering wound. He was well-known to the café’s impeccably attentive waitstaff. Here, as in many Viennese kaffeehauses, physicians congregated and pontificated with artists, philosophers, painters, playwrights, scientists, and poets about the latest discoveries and controversies arising in the world of ideas they inhabited. The atmosphere was thick with the exhaust of cigarettes, cigars, and inspired minds. This particular morning, however, Sigmund seemed oblivious to the chatty guests as he stroked his bushy beard and rubbed a wet, reddened nose that was the direct result of consuming too much cocaine.
The University of Vienna, c. 1884. (photo credit 1.1)
The waiter asked for the doctor’s order. The medico, barely looking up, responded absentmindedly, “Einen kleinen braunen” (a short cup of espresso that was typically accompanied by a squat pot of cream and a glass of water). Dressed in a starched white shirt, black tuxedo jacket, and black bow tie, the waiter nodded affirmatively at the request while bending over to ignite one of the small cigars the doctor habitually smoked.
Alone, tired, and agitated, Dr. Freud spent most of his days and nights at the Allgemeines Krankenhaus—the vast and malodorous Vienna General Hospital, known throughout the world as the Parnassus of medicine. The physical plant was awesome for its day: a seemingly endless complex consisting of twelve interlocking quadrangles and courtyards situated on a 250-acre campus. It boasted dozens of clinical departments, institutes, and clinics stretched across miles of connecting wards, offices, laboratories, and amphitheaters, and contained more than four thousand beds. Enclosed by an imposing stone wall, the Krankenhaus was more medical village than edifice, with its own culture, hierarchy, and water supply. More important, it was host to a series of medical discoveries that profoundly changed and improved medical practice. One of the most famous was made by a Hungarian obstetrician named Ignaz Semmelweis, who in 1847 committed the revolutionary act of urging physicians and nurses to wash their hands before examining a patient to prevent the spread of infection.
Those in charge of transforming the young Sigmund from a bright, ambitious, and socially insignificant Jewish boy into a pioneering intellectual constituted a Teutonic hall of healing fame. His physiology professor, Ernst Wilhelm von Brücke, was one of the founding fathers of his field. Brücke, along with Hermann Helmholtz, Emil du Bois-Reymond, and Carl Ludwig, is credited with initiating a now accepted tenet of medical research: every action in the human body—from the flick of a wrist to one’s thoughts—has a chemical, physical, and biological foundation subject to the same laws and explanations as other physical phenomena.
In the dissection rooms, the anatomist Joseph Hyrtl elevated the preservation of human cadaver specimens to an art form by skillfully injecting wax and resins into blood vessels, lymphatic channels, and body parts. Thanks to these macabre talents, Hyrtl presided over the largest teaching collection of anatomical material on the planet. In the hospital basement, where the morgue was located, the world-renowned pathologist Carl von Rokitansky redefined his field as he performed or supervised more than thirty-two thousand autopsies, averaging two a day, seven days a week, for forty-five years.
Many mornings, Freud crossed a grand courtyard bounded by an arcade displaying busts of the University of Vienna’s greatest professors. Like every medical student who gazes at such monuments to his predecessors, Sigmund looked on the statues with admiration and envy. According to his biographer Ernest Jones, the young Freud even imagined the inscription his own bust would someday bear. It was a line from Sophocles’ Oedipus Rex: “who divined the famed riddle of the Sphinx and was a man most mighty.” From the courtyard, Dr. Freud walked across the busy Ringstrasse to the Café Landtmann with a load of medical journals, which he pored over as he sipped cup after cup of expertly brewed coffee.
Freud appeared alternatively bored and distracted, nervous and phlegmatic, subdued and preoccupied. He had little appetite for the cream-filled cakes proffered by the Landtmann’s pastry chef, which he had once happily consumed in two or three bites. Indeed, that pleasant June morning, Sigmund barely stomached the caffeinated beverage he had just ordered.
The waiters at Landtmann’s could not help but notice the harsh odors that clung to Sigmund’s black frock coat lately—sometimes, the nauseating scents of formaldehyde and ether from the laboratory; other times the aroma of sweat and disease from patients on the teeming wards. Previously, even as he’d immersed himself in the miasma of discovery and death, Sigmund had been tidy, if not splendidly attired. But on this particular morning, he looked as if he had not slept in days. It hardly required the trained eye of a Viennese physician to spot a nervous twitch or two along his jawline as he ferociously ground down on his already tender teeth.
A dedication of a plaque at the Sigmund Freud birthplace in Príbor, Moravia, 1931. The Freuds lived on the second floor of this building. (photo credit 1.2)
Freud as a six-year-old boy, 1862. (photo credit 1.3)
The twenty-eight-year-old Sigmund believed his ennui was a result of the ups and downs of his long-distance relationship with twenty-three-year-old Martha Bernays. Popular and pretty, she lived with her well-connected and well-educated Orthodox German Jewish family in Wandsbek, near Hamburg and more than five hundred miles from the Vienna city line. Like many young women of her generation, Martha centered her aspirations on raising a family and keeping a home in a comfortably bourgeois manner.
Sigmund’s family, on the other hand, was not nearly as distinguished. The Freuds were a mere trickle in the steady torrent of impoverished Ostjuden (East European Jews) emigrating west to Vienna during this period, a wave of migration that presented the city with the second-largest Jewish population in Europe after Warsaw’s. In 1855, Sigmund’s father, Jacob, a forty-year-old wool merchant with two adult sons from a previous marriage, married his third wife, the twenty-year-old Amalia Nathansohn. The following year, the Freuds left Brody, Galicia (now in the Ukraine), for Freiberg, Moravia (now Príbor in the Czech Republic), where Sigmund was born. Over the next ten years Amalia gave birth to another seven children. In 1859, the family moved to Leipzig and finally, in 1860, to Vienna, where they struggled financially, socially, and emotionally in the imperial city’s Jewish ghetto.
Father Jacob, age forty-nine, and son Sigmund Freud, age eight, 1864. (photo credit 1.4)
In his later life, Sigmund insisted that Jacob “allowed me to grow up in complete ignorance of everything that concerned Judaism,” perhaps as an exaggerated contrast to the more Orthodox ways of the Bernays family. Yet eve
n as a child, and certainly as a young man in mid-to-late-nineteenth-century Austria, Sigmund Freud was acutely aware of the outsider status his religious and cultural background imposed. The Freud family attended synagogue services, albeit irregularly, and engaged in Jewish rituals such as celebrating the Purim and Passover holidays. One of Sigmund’s most treasured heirlooms was the family’s bound Pentateuch (five books of Moses, or Old Testament) that his father inscribed in Hebrew with a “memory page” (Gedenkblatt). Jacob frequently read aloud from the family Bible, and Sigmund remained fascinated by Old Testament lore for his entire life.
On June 17, 1882, a mere two months after they met, Sigmund impetuously asked Martha to marry him, a nuptial event that would not, and financially could not, occur until six years later, when Freud first opened his practice. Even though Martha’s older brother, Eli, was engaged to Sigmund’s eldest sister, Anna, and would marry her in October 1883, Sigmund was initially not the favored choice to become Martha’s mate. Perhaps the most corrosive aspect of their affair of the heart was Martha’s powerfully opinionated mother. A widow deeply concerned about her daughter’s future, Frau Emmeline Bernays rarely missed the opportunity to inform Martha—and anyone else who would listen—about Sigmund’s financial unsuitability. In fact, Sigmund made his prospects even dimmer by electing to spend several years in the laboratory rather than ministering to the maladies of well-appointed and bill-paying Viennese.
The extended Freud family, 1878. Sigmund is in back, center, as a young medical student. (photo credit 1.5)
Martha Bernays, age twenty-one (left), and with her younger sister, Minna, age seventeen (Minna is seated), c. July 1882. (photo credit 1.6)
An Anatomy of Addiction Page 2