The Maryland Club, where Halsted and Welch dined nightly, c. 1890s. (photo credit 8.7)
Regardless of inspiring impulses, Welch had an unerring eye. For the next four decades, the crème de la crème of American medical and public health schools, foundations, and research institutes all came from the successive litters of students he lovingly referred to as “Welch’s Rabbits.” Of all these professorial and, perhaps, closer relationships, Welch immediately grasped that William Halsted was one of his greatest discoveries.
Welch assumed the role of William’s protector and arranged for the surgeon to reside in his suite of two furnished rooms on the third floor of a boardinghouse at 20 Cathedral Street that he rented for $35 a month. There, about a mile away from the hospital, Mrs. Thomas Simmons, a Civil War widow and landlady in rather reduced circumstances, and her unmarried daughter doted on the two gentlemen bachelors. Having little choice in the matter and worried by the constant threat of returning to his wildly addictive ways, Halsted readily agreed to his prescribed living arrangements. One of Welch’s many custodial tasks was to closely monitor the surgeon’s cash flow to make sure he did not have enough money to purchase cocaine. On most evenings as they dined together at the venerable Maryland Club, before they retired for the night, and again in the morning, as they readied for another day of work, Welch patiently coached Halsted on how to earn the trustees’ respect and endeavored to boost his shaky confidence.
BALTIMORE WAS SMALL IN SCALE and acreage and southern in temperature and temperament. Welch and Halsted lived in the “better” part of town, which included several prominent neighborhoods along Charles, St. Paul, and Cathedral streets, extending to and beyond Millionaire’s Row, on Mount Vernon Place. Elegant brownstones, limestone mansions, and red-brick row houses with marble stoops fronted tree-lined, cobblestoned pavements. If you were wealthy and white, Baltimore was a most amiable town, communal by nature, busy with social events, and, as the pathologist W. G. MacCallum described it, “a delightful, friendly place to live and one was happy.”
Traveling closer to the hilly neighborhood where the Johns Hopkins Hospital was situated, however, one encountered shabbier homes, unsavory tenements, a teeming mass of immigrants from Italy and Eastern Europe, African Americans, Irish Americans, and other charter members of the American urban poor. The streets reeked of manure and human refuse. Baltimore did not offer the “modern conveniences” of indoor plumbing and adequate sewage systems for all its residents until well into the twentieth century, a status that went a long way toward explaining why the “Charm City” once had the highest rate of typhoid fever in the United States.
Early each morning, a horse-driven carriage took Halsted from his leafy neighborhood to a squat, red-brick building situated behind the developing skeleton that would ultimately become the hospital. In subsequent years, this structure came to be called the “Old Pathological Laboratory,” and it was where Halsted toiled at some of his most important experiments. As he made his way to East Baltimore, his nervously twitching eyes elicited far less attention from the pedestrians he passed than did his formal dress. He adorned his muscular frame with bespoke suits made from the finest woolens on London’s Savile Row, hand-sewn linen shirts and silk neckties from Charvet, impeccably crafted leather shoes from Paris’s best cobblers, and, as MacCallum described it, “a glistening high silk hat when no one else wore one … not done in any air but only because it was his habit.”
The Old Pathological Building at Johns Hopkins, c. 1886; Halsted’s laboratory was on the second floor. (photo credit 8.8)
Upon arrival to the Old Pathological, William bounded up the stairs and thrust open the door to his poorly ventilated laboratory. After hanging his hat and coat on the pegs behind his door, he focused on his scientific tasks with intensity and purpose. These long days satisfied both his obsession for surgical perfection and the design of his recovery program. Hardly a debtor or a criminal like the original “addicts” of ancient Rome, William, nevertheless, was acutely aware of his bondage to cocaine.
Abstinence is a monumental challenge for any addict, even for one as motivated and disciplined as Halsted. Heroin addicts have an odd slang term called “jonesing,” which refers to the strong cravings one experiences even after quitting the drug. The addicted brain, after all, has an excellent memory for the substances it has learned to love. With time, treatment, and patience, the urges tend to subside or, at least, the successfully recovering addict is taught how to tame them and take the necessary steps not to act upon them. Such seductive and destructive thoughts, which can crop up at any time in a recovering addict’s life, are among the many reasons so many well-intentioned addicts relapse. To allay his potent waves of addictive desire, Halsted remained fixed to his workbench, and it was not uncommon to see the gaslights burning in his laboratory well into the next day’s early morning hours. Resolved to repay Welch for his support and reclaim his position in the medical profession, William confined himself to perfecting surgery.
Halsted found himself among the extremely good company of young, obsessive, eager scientists determined to make their own healing discoveries. His laboratory, which he shared with the brilliant anatomist Franklin P. Mall, was in the southeast corner of the building, directly across the hall from Dr. Welch’s southwest corner office. Elsewhere on the second floor were William T. Councilman, Welch’s associate pathologist, who in 1892 was appointed the Shattuck professor of pathological anatomy at Harvard Medical School; George Sternberg, who wrote the first major American textbook of bacteriology and eventually rose to become the surgeon general of the U.S. Army; Maude Abbott, a pathologist who pioneered the field of congenital heart defects; Christian A. Herter, a pathologist, biochemist, neurologist, and pharmacologist who in 1905 would cofound the prestigious Journal of Biological Chemistry; Walter Reed, who became internationally famous in 1900 for his elucidation of the role mosquitoes play in spreading yellow fever; and many other budding leaders in the fields of bacteriology and pathology.
Unlike during his hurried clinical days and nights in New York, Halsted now had the dedicated time, as professors like to say, to think the great thoughts. Restricting himself to dogs, which he treated with all the attention and care he’d once offered to his human patients, Halsted explored their intestines. Working with Franklin Mall, he operated on these canines employing a number of different suture, or stitching, techniques. This was no mere exercise in idle sewing. To operate successfully on a patient’s guts, the surgeon had to know which layer of the intestines would hold the stitch the best and not come apart once he completed the procedure and closed the incision. Anything less might invite a bout of peritonitis, the spilling of fecal material and the bacteria it carries into the abdomen; this disastrous surgical complication often resulted in the painful death of the unfortunate patient incorrectly put back together. These detailed and exacting studies demonstrated Halsted’s creativity, acute observational skills, and intense patience as he searched for new ways to extend the surgeon’s reach. Eventually, he concluded that the critical place to rejoin severed ends of the intestines was the submucosal layer, a monumental discovery that allowed surgeons to safely invade the gastrointestinal tract and emerge victorious.
Franklin P. Mall, professor of anatomy and colleague of Halsted’s at Johns Hopkins, 1893. (photo credit 8.9)
THERE EXISTS A CAPTIVATING ACCOUNT about a winter afternoon in 1889 when Dr. Welch invited the sweaty, bloodstained surgeon into his office. At the meeting, perhaps over a cup of tea, Welch repeated how he was engineering the appointments of the professors both of medicine and of gynecology at the soon-to-be-opened medical school. But, he confided to Halsted, neither he nor the trustees had yet designated a professor of surgery for Johns Hopkins. That person, Welch said as he leaned over his desk, was to be William Stewart Halsted. Once the toast of New York’s elite medical circles and now merely a dog surgeon, William protested that such a prestigious appointment could never be his. Without knowing the specifi
c details of his illness, many had heard about Halsted’s abandonment of a patient on the examining table four years earlier. William’s crime, in the eyes of many, was the unforgivable moral equivalent of a sea captain abandoning his sinking ship.
The always confident Welch dismissed Halsted’s objections with a principle that remains a cornerstone of drug rehabilitation: a recovering addict needs to learn to trust himself and his ability to resolutely say no when cravings hit him. That hardly meant Halsted had to go it alone, Welch added in his plummy voice. William could always come to him for guidance and, if need be, figurative hand-holding. Confidence, good faith, and hard work, Welch insisted, would help William conquer his addiction and deliver his healing gifts to all humankind.
At the end of this discussion came one of many details that strain credibility: Welch handed Halsted a small vial containing cocaine—a measure physicians today would hardly contemplate, let alone act upon. Welch instructed William to carry the vial at all times but never to break into it; to delay the opening of the vessel for another day; to, in essence, gain experience in saying no to his addiction. Once he achieved mastery over his cocaine cravings, Welch predicted, William’s confidence—a critical personality trait for anyone who earns his living cutting people open while the motor is still running—would return. And it was then, the pathologist gently said as he placed his ample hand on one of the surgeon’s shaking shoulders, that the hospital trustees would appoint him surgeon-in-chief over the most important surgical empire ever created on American shores.
Even if we discount many of the details and assertions of such a tale, it is certain that there were many painful conversations between Welch and William about the destructive force of cocaine. The precise details of those conversations are, sadly, lost, making it impossible to measure their effect and consequences. Predictably, William’s cocaine addiction proved to be the stronger combatant. In keeping with the remitting, relapsing, and chronic nature of his illness, Halsted would never maintain total abstinence, even under the watchful eye of his mentor. In April 1887, for example, William confessed to Welch that his problem had returned with a vengeance. It is unknown how William acquired a supply of cocaine—but this was not a terribly difficult task for a physician with such easy access to the drug in his surgical laboratory or at any local pharmacy. Regardless, Halsted did relapse around this time and was quickly hustled back to Butler Hospital, in Rhode Island, for more intensive therapy. There he remained, along with 3 other addicts and 171 mentally ill patients, for nine months of therapeutic seclusion and morphine. He was discharged on December 31, 1887.
When he returned to Baltimore in January 1888, he appeared much stronger and was eager to return to his laboratory. Halsted immersed himself in a series of important experiments on wound healing, antisepsis, and the surgical treatment of thyroid gland disease, breast cancer, and several other serious maladies. By most accounts, he was abstaining from cocaine. Yet all who knew him well fretted over how much he had changed from his boisterous and bold days as an operator in New York. With his now cloistered life as a surgical scholar, he seemed older, more guarded, remote, and cautious in his demeanor and actions, less friendly with others, even downright caustic and rude. The once-sociable Halsted now took great pains to avoid close relationships with anyone save Welch, a difficult feat when working in the company of dozens of lonely, twenty-five- to thirty-five-year-old men whose lives were bounded by the walls of the hospital and laboratory.
Already the recipient of several second chances, Dr. Halsted could not afford another encounter with cocaine. Every morning he awoke to the realization that relapse meant shameful discovery, readmission to Butler Hospital, and a career that even the redoubtable William Henry Welch could not resurrect. The intense pressure to succeed must have come at a huge emotional price for William Halsted. On many days, and not a few evenings, fighting to establish his hard-won sobriety, the increasingly isolated surgeon walked around the grounds and corridors of Johns Hopkins as if he was a condemned man. His body smarted from the long hours of leaning over the anesthetized dogs on his operating table. His posture sagged as if he were Atlas carrying the weight of the world on his shoulders. And always on his mind was the fear of cocaine’s absolute power to ruin everything—his health, his reputation, his career, and, as it turned out, the future of modern surgery itself.
CHAPTER 9
The Interpretation of Dreams
ON APRIL 25, 1886—Easter Sunday—the Vienna Neue Freie Presse ran a small news announcement that likely received little attention. In an agate font, the squib heralded, “Herr Dr. Sigmund Freud, Docent for Nervous Diseases at the University, has returned from his study trip to Paris and Berlin and has consulting hours at [District] I, Rathhausstrasse No. 7, from 1 to 2:30.” Freud announced to his corner of the world that he was no longer a mere physician-in-training; he had officially cast his hat into the ring of the Viennese medical profession.
Such a declaration demanded that he raise a steady stream of clinical revenue, a task that he initially found to be quite difficult. The shabby appearance of his frayed frock coat revealed that he was subsisting on the fringe, scrimping so much to make ends meet that often he could not afford cab fare for his obligatory house calls. Still, that September, Sigmund threw all caution to the wind and finally married Martha Bernays; a few months after the nuptials, the Freuds were expecting their first child, whom they would name Mathilde, after Josef Breuer’s wife.
Toward the end of his life, Sigmund wrote, “In the time span of 1886 to 1891, I did little scientific work and published almost nothing. I was occupied in finding my way in my new profession and in securing material subsistence for myself and my rapidly growing family.” He was being either modest or forgetful. Among his publications during this era were some illuminating investigations on aphasia (an inability to speak because of damage to the language centers of the brain) and infantile cerebral palsy, the latter based on his thrice-weekly pediatric neurology clinics at the Erstes Öffentliches Kinder-Krankeninstitut, (the Vienna First Public Institute for Sick Children).
More important, this period marks when Freud shifted from the anatomic-, structural-, and lesion-focused research of his medical training to the introspective, analytic inquiries that would make his name. And because of the trailblazing but introspective questions he chose to ask, he became, by necessity, his primary analytical subject. Indeed, these were the years when Freud began pondering what would become his signature ideas on neuroses, sexual conflicts, and the “talking cure,” with the express goal of mitigating the psychological foibles that drive many of us slightly mad.
IN FREUD’S LETTERS OF THIS PERIOD, the major chord struck is of the great effort required to establish his private practice. On too many mornings, he awoke to too many open slots in his appointment book and too much red ink in his bank ledger. Such precarious finances forced Sigmund to obsequiously court established physicians who might send well-to-do, mentally disturbed patients his way. At the same time, however, the ambitious Dr. Freud remained on the lookout for a stunning medical discovery.
Specializing in the nascent arena of debilitating neuroses, Freud employed newfangled and, in Viennese medical circles, poorly regarded “French techniques” such as hypnosis and electrotherapy. Several Krankenhaus physicians heatedly criticized these unorthodox methods as quackery, eventually forcing him to abandon them for fear of gaining a reputation as shatter-pated.
Day after day, Freud pandered for new patients while Martha worried about paying the stack of bills sent by their grocer, their butcher, and the tradesmen who serviced their brand-new, fashionable flat off the Ring at Maria Theresienstrasse 8. The flat leased for 1,600 gulden a month, but this actually represented a bargain in that the apartment building had been erected on the former site of the famous Ring Theater, which had burned to the ground on December 8, 1881, killing hundreds of people, and was considered by many superstitious Viennese to be an unlucky location.
The you
ng physician kept strict accounts of all monies received from his thin list of patients. Each evening, he turned over to Martha every check and cash payment for safekeeping in a strongbox. The following morning, depending on their requirements, Freud withdrew a precise amount of money, including about 10 cents for his daily allotment of cigars. As the new day progressed, he labored to replenish the strongbox before nightfall. There were many days when he was not successful at this task, a reality that forced Sigmund and Martha to all but ignore the gaiety of Vienna’s legendary cultural life and to postpone the purchase of furniture, let alone an elegant gold snake bracelet for her, a common gift university-affiliated physicians gave their wives to distinguish them from the spouses of less-accomplished doctors. After the arrival of their daughter Mathilde, the Freuds stretched Sigmund’s dribbling income even further. As the cultural historian Frederic Morton bluntly put it, “every kreutzer counted.”
The Ring Theater, which burned to the ground in 1881; built on its site a few years later was the apartment house where the Freuds first lived. (photo credit 9.1)
Despite his pecuniary travails, Freud still managed to scrape together the gulden to purchase cocaine. One way of raising cash involved his pen: translating Charcot’s French medical texts into German and—perhaps the lowest rung of academic hell—writing unsigned articles for a medical dictionary. He performed this work late at night, when he would have been better served by a decent night’s sleep. Aside from the money and what it might have been used to purchase, there was one virtue to his contract medical writing: the time spent thinking about and explaining complex concepts in neurology and psychology was an important early step in his becoming a masterful writer.
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