An Anatomy of Addiction

by Howard Markel

  It is also telling that he does not reveal to Martha the precise amount of cocaine he was ingesting. In fact, throughout his notes during this period, Freud minimizes the amount and frequency of his cocaine dosage, using such terms as “a little cocaine” or a “bit of cocaine,” a tactic many substance abusers employ to avoid the disapproval or intervention of others.

  AS HIS FELLOWSHIP IN PARIS drew near a close, Freud finally relaxed in the presence of his great teacher and explored a few cases on his own. He was still wily enough to watch the interactions of the other young, ambitious doctors who crowded Charcot’s clinic and whose competitive maneuvering was an essential aspect of the academic medical merry-go-round.

  On February 9, a Viennese gentleman whom Freud described as “a truly dreadful fellow” arrived at the Salpêtrière. The doctor was trained in both neuropathology and hydrotherapy, the latter being a once-popular sect of medicine that proposed cures through warm baths in water sources rich in natural salts. Armed with a flattering letter of introduction from his mentor Wilhelm Winternitz, the director of a prominent hydropathic clinic in Kaltenleutgeben, near Vienna, the newcomer told Sigmund that it was only a matter of time before he was embraced by Dr. Charcot and advanced to the head of the class. He made “all kinds of condescending remarks,” Sigmund reported to Martha, “which I took in my stride, confident of imminent revenge.”

  Imagine Freud’s glee when Charcot read the applicant’s dossier and responded, like a café waiter, “À votre service, Monsieur.” Dr. Charcot quickly palmed the newcomer off onto Sigmund, adding sweetly, “Do you know Monsieur Freud?” Reflexively, both Austrian physicians clicked their boots together and lowered their heads in deference to the other, “he rather taken aback,” Sigmund explained to Martha, “I silently pleased.”

  A few days later, another foreigner arrived at the hospital. Sigmund described him to Martha as “a definitely Germanic type and yet somehow different.” As the students and doctors strolled over to the eye clinic, however, it became obvious that wherever he came from, the guest was no neophyte. There, the foreign physician conducted several examinations and offered his diagnoses with considerable authority and expertise. When he presented his card to the attending ophthalmologist, the latter responded with great deference and begged him to grace the clinic again the following morning. The visitor’s name was Hermann Jakob Knapp; New York City’s most prominent ophthalmologist, he was an early proponent of cocaine anesthesia in the United States and a colleague of William Halsted’s.

  The ambitious hydrotherapist, sensing a medical dignitary with whom he could network, sidled up to Dr. Knapp. “I heard you speaking German [and] I’d like to introduce myself,” he interjected while handing Knapp one of his richly engraved calling cards. Knapp graciously replied, “I am a German, but I emigrated to America long ago.” Freud, desperately wanting to be part of the conversation, fumbled through his coat to locate one of his own cards. Upon discovery of a particularly rumpled one, he was embarrassed to note that it stated only his name but neither his address nor his hospital affiliation. Knapp glanced at the card Sigmund timidly offered him and enthusiastically asked, “Could you be Dr. Freud from Vienna? I’ve known your name for a long time, from your publications, especially the one on cocaine.”

  The Viennese hydrotherapist condescendingly queried Freud, “Have you also written about cocaine?” Not waiting for Sigmund to answer, Knapp interjected, “Of course he has, it was he who started it all.” Sigmund told Martha, “I greeted [Knapp] accordingly and my bête noire stood there looking rather sheepish, first of all because he had failed to recognize the man, and second because he had again managed to make a fool of himself.”

  Young physicians, eager to get a leg up on their careers, spend inordinate amounts of time actively seeking the attention of their superiors. After all, one never knows when a senior man can help out a junior one. It is not rare during these reindeer games that the more callow let their desire to win acknowledgment overcome their intellectual prowess. The result is, invariably, an exhibition of bluff as the youngster overstates his medical skills and knowledge. The only joy for those forced to silently endure this process of one-upmanship is the rare occasion when the charlatan is found out by the possessor of the very hindquarters about to be kissed. For Sigmund, this was one of those wonderful moments.

  ON FEBRUARY 23, 1886, Freud left the Salpêtrière and Paris. He first spent a few weeks studying childhood neurological diseases under the great German Jewish pediatrician and later director of the Kaiser and Kaiserin Friedrich Kinderkrankenhaus, Adolf Baginsky. Soon after, he returned to Vienna to commence his private practice. At this point in his life, Freud would not be diagnosed as a cocaine addict according to modern medical definitions. Today, doctors imbue the terms “abuse” and “addiction” with separate meanings. “Substance abuse” implies use with adverse consequences, while “addiction” is defined by a loss of control and impairment of one’s mental faculties with continued use. Freud, it appears, was able to maintain some semblance of control over the timing and dosage of his clandestine cocaine consumption as he continued his medical studies. Nevertheless, by this point he was chronically abusing the drug and exhibiting signs of dependency.

  Sigmund never saw his inspirational teacher again, but he revered Charcot for the remainder of his life. On Freud’s last morning in the Salpêtrière Hospital neurology clinic, Charcot fondly bade him adieu. During their time together, the French neurologist had guided Sigmund toward studying hysteria, a strange and vexing disorder that defied physical and psychological boundaries. The sage teacher was also careful to warn his pupil, “Theory is all very well, but that does not prevent facts from existing.” Both this research interest and the advice were about to change the course of Freud’s life.

  CHAPTER 8

  Rehabilitating Halsted

  MODERN PSYCHIATRY WAS IN an embryonic state when Halsted admitted himself to Butler Hospital for the Insane. The hospital was founded in 1844 thanks to a large bequest from the Rhode Island industrialist Cyrus Butler and additional funds from the millionaire merchant, philanthropist, and benefactor of an eponymous university, Nicholas Brown Jr. In the decades that followed, the facility garnered an excellent reputation in treating the mentally troubled from America’s finest families but also, with the help of subsidies from the state’s treasury, many impoverished mentally ill Rhode Islanders.

  Situated a distance away from the bustle and stresses of downtown Providence, Butler Hospital’s buildings, rolling hills, ravines, trees, shrubs, and manicured gardens were designed to create a calming campus for psychic healing. Its therapeutic philosophy was centered on removing a mentally ill person from the social environment that appeared to cause his or her problems. Such enforced separation, the hospital staff believed, helped restore the troubled individual to sanity.

  The care of the mentally ill during this period often veered toward the cruel and punitive. Moral judgments abounded. Many doctors practiced harsh and even painful clinical methods that had remained unchanged for centuries. More broadly, Americans considered the insane to be a potential menace to society and mandated their warehousing in walled-off enclaves.

  Most asylums in the United States did not enjoy Butler’s lavish financial resources, and some struggled to put food on the table and doctors and nurses in the corridors. Such institutions were funded by sporadic contributions from the local communities that built them and occasional appropriations from state and municipal governments not known for their largesse in caring for the mentally ill. Short-staffed, often filthy, and overcrowded, many asylums were regarded as “snake pits” well into the twentieth century.

  Butler Hospital bedroom, c. 1886, similar to the one Halsted stayed in as a patient. (photo credit 8.1)

  Butler, to be sure, was very much an insane asylum of nineteenth-century sensibilities. But it was hardly Bedlam, the notorious London madhouse once considered so dangerous that the eighteenth-century physician William B
uchan described it as “more likely to make a wise man mad than to restore a madman to his senses.” By all accounts, the Butler Hospital’s staff and trustees labored to understand the disruptive force insanity and addiction imposed on their patients, and they devoted their working lives and fortunes to ameliorating such conditions. Hence, it is not surprising that their superlative work came to the attention of William Welch, who kept abreast of everything that was going on in clinical medicine. Without question, Butler Hospital was one of the best of its kind in the United States during the 1880s.

  WHEN HALSTED FIRST ARRIVED at Butler, he was unlikely to have taken much notice of the institution’s sumptuous grounds and residence halls. His nerves were jangled and his mood depressed by chronic cocaine abuse. He was also struggling with the realization that he had damaged his health and all but destroyed his career.

  Butler Hospital handicraft class. (photo credit 8.2)

  There were, of course, no effective medications for either mental illness or addiction in the 1880s. Even at the world’s major medical centers, where cutting-edge medicine was being sharpened each day with new discoveries and treatments, many American physicians considered mental illness to be an unfathomable spiritual, social, and physical imbalance. According to the Hippocratic concepts of humoralism, each person, and the organs residing within him, had their own composition, or krasis (mixture or temperament). Medical doctrine held that while there was a limited range of variation for such individuality, similar patterns of disease or disequilibrium appeared in many people. Achieving equilibrium in one’s thoughts, actions, demeanor, physical health, mental health, work, leisure, sleep cycle, emotions, environment, relationships, and diet was the quintessential therapeutic goal of physicians and patients alike.

  In the 1880s, medical professionals specializing in mental illness typically referred to themselves as “alienists.” This name has its roots in how insanity was understood in nineteenth-century American society. So “alienated” and separated from human society were insane individuals, so disjointed and unreal were their thoughts, feelings, and experiences, that only a trained specialist could restore their disordered world and bring them back safely to the realm of the sane and rational. One such practitioner was the creative and compassionate medical superintendent of Butler Hospital, Dr. John Woodbury Sawyer. Fortunately for Halsted, and unlike most asylum superintendents then working in the United States, Sawyer also had an abiding interest in facilitating the recovery of alcoholics and opium addicts.

  It is difficult, if not impossible, to re-create the precise treatment plan for a psychiatric patient from a distance of more than a hundred years. To begin, such records are often kept confidential, for all the obvious reasons. (This protection has only grown stronger in recent years with the passage of federal patient privacy acts.) More problematic is the current practice by some hospitals of destroying decades-old patient records and charts. Medical centers are prone to enacting such plans because of the exorbitant fees for storing them. One shudders when contemplating the priceless loss this burgeoning practice exacts upon the historical record. That said, the Annual Reports of the Trustees and Superintendents of the Butler Hospital for the Insane do exist, and from these yellowed and brittle pages we are able to garner a sense of the institution Halsted entered and, eventually, left.

  In 1886, when William was admitted to Butler, there were 186 patients, 82 men and 104 women, already residing there in altered states of mind. During the course of that year, another 83 patients were admitted (37 men and 46 women; one man and one woman required two stays during the same year). On a positive note, 103 patients were safely discharged that year to resume their daily lives. Thirty-six patients were thought to have been insane for less than three months; 23, for less than a year; 7, between one and two years; and 16, for more than two years. Thirty-one of the patients were married, 44 single, and 8 widowed; many were from New England, but 3 patients came from other states. Thirteen unfortunate souls never left the place and, instead, died from causes ranging from tuberculosis, heart disease, and stroke to exhaustion following acute mania and epilepsy. Three patients were not considered insane and were, instead, specifically admitted for addiction problems. One was William Halsted.

  The hospital’s annual report to the trustees for the fiscal year 1886–87 described in great detail the metrics and conditions of Butler’s insane patients. Predictably, in an era when substance abuse problems remained shrouded in secrecy, the report includes only a mere sentence about depicting the treatment of that year’s patients with addiction problems: “It has seemed to me best, also, in order that the statistics of insanity may be more accurate, to discharge those who have been treated for the opium and alcohol habits as ‘not insane’ rather than as ‘recovered.’ ”

  Nineteenth-century American alienists contended that severe mental illness was a “great leveler” among the rich, poor, educated, and illiterate, making them all suitable and congenial housemates. Yet in a culture rife with rigid social standings and distinctions, such egalitarian thoughts rarely worked out in practice. The Butler medical staff, for example, worked intensively to “quarantine” the “hopelessly demented” (read: impoverished ill) from the wealthier patients as a means of protecting the latter against the “depressing and unfavorable influence” of the former. And while the hospital certainly admitted the poor and insane of Rhode Island, the majority of its patients came from the upper classes.

  The desire (and financial need) to attract paying patients was the major impetus behind the Butler doctors’ intense lobbying for better and more luxurious facilities. In January 1888, for example, the medical superintendent unfurled an ambitious plan for improving the hospital’s physical plant that required a budget totaling over $80,000 (approximately $1.8 million in 2010). A year later, Butler Hospital boasted one of the most modern and spacious facilities of its kind along the eastern seaboard:

  Those who study these plans carefully, will see that there are rooms in suit[e], connected with which are all the conveniences and comforts which can be found in a first-class private house or hotel; and that beside a better classification of patients, afforded by a larger number of wards, there is found, also, the means of separation or isolation, so very important in the treatment of certain forms of mental disease; and the conveniences so needful to many patients accustomed to and able to pay for every comfort—persons whose mental balance is disturbed, without the loss of their tastes, or of desire for some of the companionships and even elegancies of life to which they have been accustomed.

  COCAINE ABUSE WAS AN ENTIRELY NEW phenomenon when William entered Butler. And while it is always treacherous for a historian to label a particular event or individual as the first of its kind, it seems safe to assert that Halsted was, at least, a charter member of the earliest cohort of cocaine addicts to come to the attention of medical professionals in the United States.

  As more and more people indulged in the chemically processed white powder hailing from South America, a growing number of doctors began reporting on the hazards of cocaine. Like many of today’s “new” medicinal agents that have ultimately proved dangerous, cocaine followed a specific and predictable track: doctors, scientists, and pharmaceutical companies first develop a new drug, then extol and massmarket its virtues and wonders. As a result, patients begin to clamor for it. In the worst scenarios, reports of adverse side effects or complications proliferate, accompanied by heated assertions to the contrary from doctors and patients refusing to acknowledge such risks. Typically, these pharmacological morality plays end with the drug relegated to the medical equivalent of the proverbial doghouse.

  Some of the earliest reports on cocaine’s dangers emerged in direct response to Sigmund Freud’s glowing advocacy of the drug as a treatment for morphine addiction. Over the summer of 1884, the editors of the St. Louis Medical and Surgical Journal commissioned a brief translation of Freud’s cocaine monograph for their December issue. To protect himself from some of the
charges he was hearing at medical meetings, Freud asked a still coherent Fleischl-Marxow to append a brief note describing his success with cocaine in treating his morphine addiction. Fleischl-Marxow’s addendum neglected to mention how much cocaine and morphine he was consuming at the time and erroneously concluded that abusing the two drugs simultaneously was “antithetical.” The morphine- and cocaine-addicted doctor went as far as to add that because of cocaine “inebriate asylums can be dispensed with.”

  The St. Louis Medical and Surgical Journal December 1884 issue in which Freud argues that cocaine is not addictive or dangerous. (photo credit 8.3)

  Among the most powerful salvos against cocaine was one from the highly respected Viennese neurologist Heinrich Obersteiner, a friend and colleague of both Sigmund’s and Fleischl-Marxow’s. On January 11, 1886, Obersteiner reported that “since the use of cocaine had become frequent, several cases of cocaine intoxication had occurred; their status is similar to the alcohol delirium and especially characterized by the hallucination of tiny animals crawling over the patient’s skin,” the very symptom Fleischl-Marxow experienced. A few months later, in May, Johann A. A. Erlenmeyer, a German physician, an expert on morphinism, and a vociferous critic of Freud’s work, published a paper declaring cocaine to be a scourge upon mankind because it was so dangerous, poisonous, and a definite cause of addiction. Sounding an alarm specifically meant for Freud and his supporters, Erlenmeyer wrote, “Today, I count myself fortunate for not having found it possible to recommend the use of cocaine in the morphine withdrawal cure.”