An Anatomy of Addiction

by Howard Markel

  The meeting coincided with a difficult time in Freud’s life. He loved his wife dearly, but his discontent increased with the daily realization that she was far more interested in domestic orderliness than in his pioneering ideas. As he struggled to unlock the secrets of the mind, her chief concern centered on convincing Freud that their expanding family needed a larger flat. Four years later, in 1891, Sigmund finally was able to rent a new and larger abode he’d chosen at Berggasse 19, in the Ninth District of Vienna, a Jewish neighborhood near the Krankenhaus. This now famous second-story apartment served as Freud’s clinical, intellectual, and residential headquarters for the next forty-seven years.

  On November 24, 1887, a few months after delivering his neurology lectures and after Fliess had returned to Berlin, Freud sent the surgeon a mawkish note of admiration:

  My letter of today admittedly is occasioned by business, but I must introduce it by confessing that I entertain hopes of continuing the relationship with you and that you have left a deep impression on me which could easily lead me to tell you outright in what category of men I place you.

  Similar in age, religion, demeanor, and desire for success, they were also deeply enamored of creating new ways of understanding the connections among mind, brain, and body. Each had found in the other a soul mate, confidant, friend, and confessor with whom to discuss his desires, ideas, and, literally, dreams. As their novel notions garnered jeers, sneers, and hostility among their colleagues, the two young doctors only drew closer together.

  Fliess’s speculations about the human body, illness, and sexuality were considered by many physicians of the 1880s and 1890s to be astounding, if not entirely ridiculous. Specifically, Fliess posited that the nose was the major organ of the body, responsible for control of the delicate equilibrium between health and disease, and had a direct connection to the genitals. Moreover, he suggested that both the female body and the male body were governed by biological cycles of twenty-eight and twenty-three days, respectively. Careful nasal examinations at precise points of these cycles, Fliess insisted, would facilitate the diagnostic process as well as eliminate the need for artificial contraception.

  As with virtually every surgically inclined doctor since sharp instruments were first placed in their bold hands, it was not enough for Dr. Fliess merely to propose a theory of disease; he was also compelled to develop the means to manipulate or ameliorate the unhealthy circumstances that brought patients to his clinic. Fliess’s solution was to treat a compendium of gastrointestinal, neurological, and sexual disorders by applying huge doses of cocaine to the turbinate bones and sinuses of the nose, often followed by intricate, and potentially debilitating, operations on that sensitive region. These, in turn, were followed by more cocaine, for pain relief. Among the many who simultaneously endured and got high off Fliess’s misguided therapies was Sigmund Freud.

  For most of their relationship, the two men lived apart, Freud in Vienna and Fliess in Berlin, although they frequently met on gentlemen-only Alpine retreats they called congresses. Fortunately for the historical record, they left behind a voluminous correspondence detailing their work, ideas, and lives. Many of their letters were filled with sentiments of mutual admiration and intellectual and emotional support. At others times, they complained about their medical practices and trying colleagues. More intriguing, they explored Fliess’s nasal theories, Sigmund’s ideas about psychoanalysis and talk therapy, bisexuality, and the role masturbation, coitus interruptus, and condoms played in the development of neuroses.

  Freud, age thirty-four, and Wilhelm Fliess, age thirty-two, c. 1890. (photo credit 9.10)

  Freud also dropped clues about a possible physical relationship. In a few letters, he referred to himself as a young woman; in another, when the two were about to meet for a “congress,” he remarked that his “temporal lobe [was] lubricated for reception” and that he looked forward to the “introduction of a fertilizing stream.” In another still, he eagerly awaited the “thrusts and pushes” of their conversations but worried, “God alone knows the date of the next thrust.”

  FEW ADDICTS LEAVE BEHIND copious details of their patterns of substance abuse, for reasons ranging from shame, embarrassment, and secrecy to fear of getting caught and its repercussions. Barring an eyewitness or frequent body-fluid screening, it is difficult to document the amount of illicit drugs someone is consuming without complete openness and honesty from the person himself. Moreover, when the individual in question is a world-famous figure, revered by a legion of psychoanalysts, psychiatrists, psychologists, scholars, historians, philosophers, and the general public, there exists a host of reasons to suppress or, at least, gloss over habits or practices that might reflect poorly on the great man’s reputation.

  Yet in light of the physical symptoms Freud suffered during this period, in my medical opinion, there is ample evidence that he was abusing significant amounts of cocaine during the early 1890s and that he was using it in a dependent, if not outright addictive fashion. In fact, cocaine likely had a negative effect on virtually every aspect of Sigmund’s personal relationships, behavior, and health. We can make such a declarative statement because his letters to Wilhelm Fliess tell us precisely so.

  In May 1893, Freud suffered a bout of strep throat and tonsillitis resulting in a peritonsillar abscess, a painful and potentially fatal infection in those days before antibiotics. While recuperating, he wrote his “dearest friend” Fliess about the lack of progress he was making and his “incomprehensible disinclination to write (dysgraphia).” A few weeks later, Sigmund explained that he was suffering from a Fliessian syndrome of “crossed reflexes” of the nose, brain, and genitals that had led to severe migraine headaches. The excruciating pain, not surprisingly, could only be interrupted by the multiple doses of cocaine prescribed by Dr. Fliess. Freud reported feeling especially better after cocainizing the side of the nose that corresponded with the side of his head where the migraine originated, followed by generously cocainizing the other nostril as well.

  During the next few months, Freud does not mention cocaine explicitly to Fliess, but he does complain about severe nasal congestion. In late November 1893, Sigmund wrote Fliess:

  The last letter I was able to produce for you immediately thereafter was lost, as we say in Vienna, and then came a period in which I did not feel like writing, my nose was stopped up, and I could not get myself to do it. I again let myself be cauterized, again enjoy working, but otherwise am little satisfied with the success of the local therapy. I am not obeying your order not to smoke; do you really consider it a remarkable boon to live a great many years in misery?

  From a diagnostic standpoint, Sigmund’s nasal stuffiness is intriguing. The application of significant amounts of cocaine to the fragile mucous membranes lining the nose causes an intense constriction of the blood vessels feeding that region. Tissue death, copious mucus drainage, and bleeding often ensue. Shortly after, all that sticky detritus dries and hardens inside tortuous sinus passages and produces mucus plugs, which are eventually expelled into one’s handkerchief. Although smoking tobacco can set one up for sinus inflammation and infections, few things congest and disturb the nose more than the regular administration of cocaine. Sigmund’s need for cauterization—the placement of a hot knife against swollen, blocked nasal tissue to, literally, burn open a passage for air—in concert with his disinclination to write suggests serious cocaine abuse. Incidentally, it was not the last time he would consider resorting to the drastic measures of the cautery to relieve his cocaine-induced nasal congestion.

  In April 1894, after three weeks of abstaining from his black cigars, Freud revealed an even more distressing set of symptoms to Fliess:

  Less obvious, perhaps, is the state of my health in other respects. Soon after the withdrawal [from nicotine] there were some tolerable days and I began to write down the state of the neurosis problem for you; then suddenly there came a severe cardiac misery, greater than I ever had while smoking. The most violent arrhythmia, co
nstant tension, pressure, burning in the heart region; shooting pains down my left arm; some dyspnea [shortness of breath], all of it essentially in attacks extending continuously over two-thirds of the day; the dyspnea is so moderate that one suspects something organic, and with it a feeling of depression, which took the form of visions of death and departure in place of the usual frenzy of activity. The organic discomforts have lessened during the past two days, the lypemanic mood [morbid depression] persists, having the courtesy to let up suddenly—as it did last night and at noon today—and leave behind a human being who looks forward with confidence again to a long life and unlimited pleasure in resuming the battle.

  Initially, Sigmund diagnosed his problem as due to dilatation (abnormal enlargement) of the heart or a case of rheumatic myocarditis and prescribed digitalis, a powerful medication for congestive heart failure. The symptoms failed to abate, prompting Freud—who worried a great deal about premature death—to cease treating himself and seek another’s medical opinion. The physician he chose to see was his friend and collaborator the internist Josef Breuer. After a careful history and physical examination, Breuer explained away Sigmund’s symptoms as the result of nicotine poisoning.

  Freud aficionados know that one of the analyst’s greatest vices was cigars. By all accounts, he loved the taste, feel, and aroma of a well-rolled cheroot and was a heavy smoker. Too often, as Sigmund worked late into the night in his study on Berggasse 19, accompanied by his books and antiquities, he desired something to spur him on to complete his nocturnal tasks. Not content to sip multiple cups of coffee or tea, Sigmund often consumed twenty or more cigars a day.

  Nicotine, the active ingredient in tobacco, has long been valued as a stimulant that produces a mild sense of well-being and alertness. Highly addictive in its own right, nicotine is cherished for the relaxation and concentration it affords. Many a smoker will tell you that puffing on a cigarette or cigar before embarking on a complex task affords a useful sense of arousal and attention. Interestingly, in 1897, Freud characterized tobacco smoking—along with addictions to substances such as cocaine and morphine—as a mere replacement for the “primary addiction” of masturbation.

  Smoking too many cigars or cigarettes can increase the risk of panic attacks, nervousness, tremors, and an annoying awareness of the speed of one’s heartbeat. Yet most established smokers, like Freud, develop a tolerance to tobacco that allows them to avoid the unpleasant side effects of what was once termed “nicotine poisoning.” An overindulgence in cigars might cause chest discomfort and even anginal pain, especially in an older patient with preexisting atherosclerotic blockage of the coronary arteries. But Freud was a relatively young man, in his late thirties, when he began complaining of his chest pain. Such quibbles aside, nicotine poisoning remained an especially unlikely diagnosis given that he had abandoned cigars for nearly a month before experiencing these problems and was still not smoking in late April and early May, when he wrote Fliess.

  If forced to make a retrospective diagnosis, a physician today would be hard-pressed not to consider that Sigmund’s cardiac symptoms were related to his cocaine abuse. At first glance, Breuer’s failure to make this connection seems puzzling. One assumes that he was well enough acquainted with Sigmund to know something about his colleague’s experimentations with cocaine. Moreover, by 1894 the cardiac symptoms associated with cocaine use and the severe depression and headaches after its use—similar to what Sigmund was experiencing—were finally being reported in the medical journals of the day. Yet Dr. Breuer was hardly unique in missing the correct diagnosis. One of the most puzzling scenarios I have observed after a quarter century of medical practice is that physicians, past and present, deny serious signs and symptoms of substance abuse almost as frequently as patients and their family members do.

  Despite all the physical problems the drug was causing, Sigmund continued abusing cocaine because it made him feel temporarily better. Throughout this period, he self-medicated away his stomachaches, ennui, depression, fears, migraines, and chest pain with more doses of cocaine followed by the occasional administration of digitalis. Perversely, Freud continued to search for alternative explanations for his chest pain rather than seriously contemplate cocaine’s potential role in the matter.

  While discussing the issue with Fliess in June 1894, Sigmund again brings up tobacco as a cause but coyly dismisses it:

  I would be endlessly obliged to you, though, if you were to give me a definite explanation, since I secretly believe that you know precisely what it is, and that you have been so absolute and strict in your prohibition of smoking—the justification for which is after all relative—only because of its educational and soothing effects.

  Six months later, on January 24, 1895, Sigmund wrote Fliess a note singing cocaine’s praises:

  I must hurriedly write to you about something that greatly astonishes me; otherwise I would be truly ungrateful. In the last few days I have felt quite unbelievably well, as though everything had been erased—a feeling which in spite of better times I have not known for 10 months. Last time I wrote you, after a good period, which immediately succeeded the reaction, that a few viciously bad days had followed during which a cocainization of the left nostril had helped me to an amazing extent. I now continue my report. The next day, I kept the nose under cocaine, which one should not really do; that is, I repeatedly painted it to prevent the renewed occurrence of swelling; during this time I discharged what in my experience is a copious amount of thick pus; and since then I have felt wonderful; as if there had never been anything wrong at all. Arrhythmia is still present, but rarely and not badly.

  Later in the year, on June 12, 1895, Sigmund made a disturbing confession of sorts to Fliess about his cocaine consumption:

  I need a lot of cocaine. Also I have started smoking again, moderately, in the last two or three weeks, since the nasal conviction [the nasal origin of his cardiac symptoms] has become evident to me. I have not observed any ensuing disadvantage. If you again prohibit it, I must give it up again. But do consider whether you can do this if it is only intolerance and not etiology. I began it [smoking cigars] because I constantly missed it—after 14 months of abstinence—and because I must treat this psychic fellow well or he won’t work for me. I demand a great deal of him. The torment, most of the time, is superhuman.

  FREUD BEGAN COMPOSING a monograph he titled Project for a Scientific Psychology in the spring of 1895. In a final effort at appeasing his hidebound medical colleagues, he hoped to construct a theoretical model that would give psychiatry a physiological and quantitative basis. At the same time, he was struggling to clarify and expand his work on neuroses and the tools of psychoanalysis. That fall, Freud feverishly wrote up Scientific Psychology and, upon completion, posted it to Fliess for review. Within a few weeks, however, Sigmund reread the manuscript, found it to be grandiose but unrevealing, and buried it in the back of his desk drawer. The literary vehicle to take its place was one that advanced his name and reputation in ways even he could not yet imagine, The Interpretation of Dreams.

  The title page of The Interpretation of Dreams, 1900. (photo credit 9.11)

  Although Freud was unable to fully accept the physical and psychic consequences of his cocaine abuse, he was eager to begin a lengthy self-analysis of the subconscious thoughts expressed in his dreams. Freud was a dreamer in the most literal sense in that he dreamed a lot, could remember his dreams upon awakening, wrote them down, and then subjected them to intensive study. He would then rewrite and reanalyze those dreams, over and over again, theorizing that the changes in each version represented his own defenses and psychic conflicts. The more he thought through the meanings of his dreams, the more convinced he became that a careful, systematic interpretation would uncover the archaeology of the unconscious. It was among the ruins of the memory, he posited, where both he and the suffering patients who climbed the iron staircase leading to his consultation room would find a healing self-knowledge.

  “At the his
toric corner window”: Freud in his study at Berggasse 19, c. 1897. (photo credit 9.12)

  The Interpretation of Dreams forged the revolutionary path of considering our nocturnal visions as the fulfillment of wishes. It endeavored to describe how the unconscious mind translates these dreams’ sources into a fantasy that the awakened dreamer can recall and analyze. And most important, it detailed a novel and comprehensive theory of how the mind works. Sigmund may have begun plotting out his ideas as early as the summer of 1895, but, according to his letters, he did not begin composing the manuscript until late 1897. One reason for the delay, he complained to Fliess, was all the preliminary reading and research he was forced to complete before committing pen to paper. He was also frustrated, depressed, and contemplating leaving both his practice and Vienna.

  Freud appears to have curtailed his cocaine consumption beginning in the fall of 1896. During the first half of 1899, however, he briefly took up a more conventional substance of abuse: alcohol. Before and after writing The Interpretation of Dreams, he was known to have imbibed sparingly. As he had jovially informed Fliess in 1896, “any trace of alcohol makes me completely stupid.” Yet by 1899, he was often finding temporary solace in a wineglass. In January, he told Fliess of the “restoration” provided by a bottle of Barolo. In mid-June, Sigmund confessed that Martha was counting the bottles of “heavenly Marsala” in their house and “took charge of them lest in loneliness I succumb to the consolation of drink.” A few weeks later, he admitted, “I am gradually becoming accustomed to the wine; it seems like an old friend. I plan to drink a lot of it in July.” That he did, and in early July Freud informed Fliess that he could not “manage more than two hours a day without calling on Friend Marsala.” Eventually, Sigmund realized that his “new vice” was creating more problems than it was solving, and he gave up the libations altogether.