A FEW YEARS LATER, while reading the 1931 biography of his life by Fritz Wittels, Freud still felt a need to deny cocaine’s negative impact on his career. As he read the passage describing the cocaine episode, where Wittels suggested that Sigmund had “thought long and painfully just how this could have happened to him,” the psychoanalyst wrote an ink-stained “False” in the book’s margin. Almost a decade earlier, in 1923, an irritated Freud had written to Wittels, “I know very well how it [the cocaine episode] happened to me. The study on coca was an allotrion [an idle pursuit that takes one from the fulfillment of serious responsibilities] which I was eager to conclude.”
Regardless of the compliments Freud might pay to Carl Koller or the altered versions of events and finger-pointing he would later concoct for the sake of his future biographers and students, Freud completely missed recognizing the most important therapeutic use of cocaine, and it upset him greatly.
CHAPTER 5
The Accidental Addict
IN 1844, AFTER MORE than a decade of perfecting a long-distance communication device he called the telegraph, Samuel F. B. Morse convinced the U.S. government to fund the construction of a line of wires between Washington, D.C., and Baltimore. At the system’s official opening on May 24 of that year, Morse sent the most famous telegram in history: “What hath God wrought!” In the decades that followed, his technological marvel of hardware, dots, and dashes, along with new developments in wire insulation and conductor materials, led to the creation of a thick, sinewy network of cables stretching across vast swaths of countryside, extending far beneath the surface of the Atlantic and Pacific oceans, and connecting villages, towns, and cities around the world. This vast complex of wires and electronics transmitted rivers of information, which were rapidly heralded by the largest and most varied print press in our nation’s history. Forty years after Morse’s triumph, in the fall of 1884, this was precisely the path taken by the news of cocaine.
For months, cocaine led the discussions in the clinical societies and hospital rounds in Vienna, Paris, London, Berlin, Boston, Philadelphia, New York, and other great medical capitals. The primary focus, of course, was Koller’s announcement of the drug’s anesthetic potential. One of the most energized readers of these dispatches was William Halsted, the up-and-coming New York surgeon who had committed to filling his days with the pursuit of a single goal: the perfection of the art of surgery.
On October 11, 1884, a few weeks after Koller’s lecture by proxy in Heidelberg and within days of his formal presentation in Vienna, Halsted sat in the library of the New York Academy of Medicine on West Forty-third Street. He was reading the latest issue of the New York Medical Record, a publication that reliably gathered medical news from around the world and reprinted the medical society lectures of New York’s most prolix doctors. The scientific details of cocaine’s anesthetic properties fired his imagination. Before the day drew to a close, William resolved to purchase some cocaine to begin an investigation of his own. And like Freud in Vienna a few months earlier, William spent a great deal of money on this brand-new pharmaceutical wonder. On October 29, 1884, the New York Times published a story about the cocaine craze sweeping the medical profession. The price of cocaine, the reporter noted, was $420 per ounce and $6,720 per pound (or $9,157 per ounce and $146,512 per pound in 2010 dollars).
It is critical to appreciate how dependent the advancement of surgery was on the physician’s ability to render a patient unconscious to the pain of the scalpel. Modern medicine is simultaneously blessed and cursed by an endless cornucopia of pharmaceutical-grade painkillers, anxiety squashers, and pepper-uppers. But for most of human history, the mere extraction of a tooth, let alone anything that demanded invasion of the body, was a most risky business. The 1846 discovery of ether as an anesthetic and the subsequent development of antiseptic surgery allowed its practitioners to probe deeper and deeper into the recesses of the body in search of diseased organs and tissue to extirpate. Nevertheless, ether and chloroform, the primary anesthetic drugs of Halsted’s era, were not without their failings. Noxious, nauseating, and heavily sedating, they rendered patients groggy and unaware of their surroundings for hours. Consequently, the development of an agent that could be safely injected under the skin, leaving a patient completely awake yet insensate to the surgeon’s pointedly sharp manipulations, was earthshaking. In fact, the news captured the attention of just about every doctor keeping abreast of the medical literature.
That Koller the ophthalmologist became so interested in cocaine anesthesia was a direct result of the operation he most frequently performed: cataract removal. Although practiced since the days of antiquity, it had long remained a dreaded procedure. After all, without pharmaceutical assistance, cataract removal is not only excruciating; it packs the extra punch of requiring the patient to watch as the surgeon literally pokes him in the eye. Many observers have described this awful ordeal, yet few re-create the immediacy of the moment as well as the British novelist Thomas Hardy: “It was a like a red-hot needle in yer eye whilst he was doing it. But he wasn’t long about it. Oh no. If he had been long I couldn’t ha’ beared it. He wasn’t a minute more than three quarters of an hour at the outside.”
With the advent of ether and chloroform in the mid-nineteenth century came great hopes for making cataract removal less painful. But these anesthetics often induced vomiting in patients—and this, in turn, created a cascade of alarmingly high pressures in the abdomen, chest, and head, which are not conducive to performing delicate eye surgery.
IN LATE OCTOBER 1884, when cocaine first captured Halsted’s attention and time, he was making quite the name for himself in New York medical circles. Upon his return from Vienna in 1880, he joined the faculty of the College of Physicians and Surgeons and soon after assumed important surgical posts at several New York City hospitals. While simultaneously serving as attending surgeon at the Charity Hospital on Blackwell’s Island, the Emigrant Hospital on Ward’s Island, and the Roosevelt, Bellevue, and St. Luke’s hospitals in Manhattan, Halsted demonstrated his talents as an operator on a daily (and often nightly) basis. “He worked with superhuman energy and endurance of ten men,” wrote one biographer, the Johns Hopkins pathologist W. G. MacCallum. So frenetic was Halsted’s daily schedule between 1880 and 1885 that it led MacCallum to ponder:
One can perhaps imagine the extent of the task with the outpatient department of Roosevelt occupying the morning, five other hospitals demanding his services in the wards and operating room at any time, and especially at night, with regular hours of teaching in the dissection rooms at the College and with his quiz of sixty-five or more students at his house. What leisure he could ever have with his programme it is hard to tell.
By all accounts, Halsted had found his true calling. In 1881 his sister had delivered her first child. While visiting her, Halsted found her to be “ghastly white, pulseless, and unconscious.” So, focused on his craft and smooth in professional demeanor, Halsted used a hypodermic needle to withdraw blood from his own arm and transfuse his moribund sibling. Luckily for her, in an era before the discovery of blood groups and blood incompatibility, Halsted’s and his sister’s blood type matched perfectly, and he saved her life. A year later, he removed his ailing mother’s gallbladder after diagnosing a potentially fatal case of gallstones and ascending cholangitis (an inflammation and possible infection of the bile ducts caused by blockage). He performed the death-defying procedure on the family’s kitchen table at two in the morning, with his father and siblings as assistants.
The gregarious William enjoyed a long waiting list of students eager to learn from him. His formal lectures on surgery at the medical school were fully subscribed. In addition, each academic year he held special “quizzes,” or tutorials, on surgery at his home for those pupils desperate to master the many arcane questions their professors would ask them on the examinations that determined class rank and, in a real sense, their careers. And to sate his own scientific curiosity, the young surgeon was co
nstantly searching for ways to apply the medical miracles unfolding in Vienna, Berlin, Leipzig, and elsewhere to his operating room.
The Bellevue Hospital grounds, c. 1880. (photo credit 5.1)
A surgical operation at Bellevue Hospital under less than hygienic conditions, c. 1880. (photo credit 5.2)
William’s principal workshop, Bellevue Hospital, was a place filled with disease, discussion, and doctoring. It contained more than eight hundred beds and admitted more than twenty thousand patients per year. When he returned to Bellevue from Vienna in 1880, the ethos of saving the poor from themselves still permeated the wards, but so, too, did the spirit of discovery and medical professionalism. Without question, Bellevue was internationally known as a first-rate medical center. Yet the permanently unsatisfied William found it a far cry from clinical perfection. He was especially perturbed by the horribly unsanitary practices in the operating room, including the reuse of dirty instruments, the improper preparation of the catgut needed to sew patients back together, ligatures handed to the operator from the mouth of an intern, and even nurses dragging their sleeves through the bloody surgical field.
Convinced by Dr. Joseph Lister’s argument that antiseptic surgical procedures eliminated infectious germs from the operative site and afforded better results for patients, Halsted complained publicly at medical meetings about Bellevue’s filthy customs. But unlike many of his colleagues who contented themselves by merely grousing, he actually did something about this problem. In 1883, he persuaded his bosses to allow him to construct a giant pavilion, a tent, with sealed flaps and an easily washed, varnished oaken floor. William’s antiseptic operating theater was the first of its kind in New York City. Writing to a colleague in 1921, the year before he died, Halsted recalled the uphill battle he’d waged and eventually won: “Operations [were] performed in a large tent which I built on the grounds of Bellevue Hospital having found it impossible to carry out antiseptic precautions in the general amphitheatre of Bellevue Hospital where the numerous anti-Lister surgeons dominated and predominated.”
Halsted was hardly exaggerating. Bacteriologists and doctors of this era were just beginning to appreciate the role microbes played in dreaded contagious diseases as well as their propensity to ruin the best-laid surgical plans to close an open wound or amputate a gangrenous limb. Those surgeons who did subscribe to the germ theory of disease still numbered in the minority. As a result, things remained pretty grim for those forced to submit to the surgeon’s knife. At this point in medical history, there were still far too many physicians with blood and dirt on their hands trolling the wards of Bellevue, much to the disgust and alarm of the eager young bucks like William who would devote the remainder of their careers to applying the advances of bacteriology and medical science to create the life-saving methods of antiseptic surgery.
William H. Welch, age thirty, as a young professor at Bellevue Medical College, c. 1880. (photo credit 5.3)
An event in the amphitheater of the Bellevue Medical College illustrates the debate between those physicians who denied the existence of disease-causing microbes and those who embraced the concept. One spring afternoon in 1882, a favorite young professor of bacteriology and pathology at Bellevue, William Henry Welch, lectured to his medical students about Robert Koch’s monumental discovery of the tubercle bacillus as the cause of the white plague of tuberculosis. Welch’s students ran to Bellevue’s senior professor of medicine, the redoubtable and bespectacled Alfred L. Loomis, to tell him about this remarkable information. A few days later, Dr. Loomis, the author of scores of medical textbooks that had made his name, if not exactly a household word, then certainly famous among students and practitioners, ascended the lecture platform of the Bellevue Hospital amphitheater, looked merrily about the vast room, and declared: “People say there are bacteria in the air, but I cannot see them.” Many of the medical students laughed uproariously at Loomis’s witty denunciation, as students are wont to do whenever their professor makes the slightest attempt at humor. Yet when one of them later told Welch about the episode, Welch was said to have shaken his head and noted his colleague’s obsolescence with an equal mixture of remorse and humor: “That’s too bad. Loomis is such a nice man.”
It was around this time that Welch began his long and productive friendship with Halsted. Both were junior professors in a tight-knit medical community. Welch, a frequent houseguest and dinner companion of Halsted’s, grew steadily impressed with William’s novel views on antisepsis, wound healing, and advancing surgical techniques. Halsted’s demonstrable success was all the more fantastic in an era when postoperative hospital wards were redolent with the stink of multiplying bacteria, or what surgeons of the day misguidedly referred to as “laudable pus” and “pus of a good quality” because they thought its appearance was a sign that the body was healing itself. In reality, laudable pus was just the chemical and cellular detritus of a festering wound, one likely worsened by multiple infections.
Welch occupied his days teaching pathology and conducting bacteriological research. As a result, the bulk of his income came from the lecture admission tickets he sold to his adoring students, a once common practice in nineteenth-century medical education. Halsted, on the other hand, was already generating bountiful revenues from his surgical practice in addition to his teaching fees. Regardless of finances, they shared an intense determination to import the German research ethos into their clinical backyards and, thus, transform American medicine.
BY THE LATE FALL OF 1884, William was devoting whatever spare time he could marshal to a series of meticulous experiments using solutions of cocaine he procured from Parke, Davis and Company and water he obtained from his kitchen tap. And just as with Freud’s experimental inquiries, Halsted’s principal guinea pig was himself. By injecting the topmost layers of his own skin and, thence, probing deeper and deeper into muscle and nerve tissue, he carefully assembled the evidence to demonstrate how cocaine safely numbed a patient during mildly invasive procedures, such as the removal of a tooth or the closure of a skin wound with sutures, all the way to much more involved surgical operations.
One of Halsted’s earliest attempts at performing major surgery with cocaine anesthesia came close to turning disastrous. In early 1885, his roommate and colleague, Thomas McBride, asked him to surgically remove the interior dental nerve in a wealthy and prominent woman suffering from trigeminal neuralgia, an inflammation of the maxillary and mandibular branches of the facial nerve. Because the stabbing pain that afflicts the cheek, nose, lips, teeth, and jaw is so intense that it causes an involuntary wincing, or tic, doctors referred to the malady as tic douloureux. Halsted agreed to operate, “in a bedroom in my house.” The 4 percent cocaine solution worked perfectly, but the “final snip” of Halsted’s scissors nicked the internal maxillary artery. Thirty-three years later, Halsted dramatically recalled the event: “The patient’s mouth filled with blood as if poured in by cupfuls. Tom McBride, whose patient she was, rushed out of the room not wishing, he told me afterwards, to be present at the death.” Thanks to the surgeon’s quick packing of the wound with gauze, several days of around-the-clock nursing with Halsted constantly at her bedside, and the remarkably adept clotting mechanisms of the human blood system, the woman recovered from the mishap without serious complications.
Undeterred by this setback, Halsted recruited others to help him with his pathbreaking cocaine research. Every evening, his students and assistant physicians clambered to his doorstep outfitted with pencils and notebooks, offering arms to be injected with cocaine for the purpose of figuring out where to apply the anesthetic and how much should be given. Alas, not every dose of cocaine was administered strictly in the cause of advancing science. Increasingly, Halsted—and the others—began sneaking topical applications of the stuff onto their tongues or sniffed it into their nostrils for a quick and easy means of obliterating fatigue.
Halsted and his colleagues were quick to appreciate the sheer fun of ingesting cocaine. Theater events, dan
ces, and even bowling matches at the University Club, a mere block away from Halsted’s home, were brightened by the white powder. And like many other medicos who read of Koller’s great discovery, Halsted and his associates focused only on the positive aspects of the drug as they inadvertently became drawn into its clutches, particularly after graduating from frequent oral or nasal applications to the much more direct and rapidly addicting route of injecting cocaine first into the muscular tissue of their arms and later perhaps even directly into the bloodstream.
ACROSS THE ATLANTIC, just as Halsted was making his unintentionally bad decision to inject cocaine, a young general practitioner struggling to build a practice in Southsea, Great Britain, became enchanted with cocaine’s charms. During the long stretches between patients, the doctor occasionally experimented with the drug. On more occasions, however, he took up his fountain pen and wrote beautiful essays, stories, and even novels.
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