His former chief residents Mont Reid and George Heuer, now prominent surgeons in their own right, entrained from Cincinnati to perform the procedure. Once he was out of the operating room on August 25, William’s course only became stormier. In early September, he developed pancreatitis, pneumonia, and a series of gastrointestinal hemorrhages. Despite multiple blood transfusions and valiant efforts by his physicians, he died on September 7, 1922.
At this point in the narrative, the evidentiary trail diverges somewhat. In Heuer’s biography, Dr. Mont Reid, one of the two physicians of record for Halsted’s last illness, insisted that he “was certain that [Halsted] was not addicted” to cocaine or morphine. Similarly, the nurses who took care of “the Professor” during his last illness are collectively quoted as stating that “he failed to show any deprivation symptoms.” The other doctor attending Halsted during his last illness, George Heuer, leaves no direct comment on William’s requirements for morphine or cocaine, perhaps feeling bound to his Hippocratic oath of never divulging the treatment of a patient to others.
Sometime in the early 1950s, the Johns Hopkins ear, nose, and throat surgeon Samuel J. Crowe peeked at Halsted’s final hospital chart while writing a book about his life and surgical legacy. Like Heuer’s book, it, too, was published posthumously. In this account, however, Crowe asserted that for the last three months of his life Halsted was self-administering a quarter grain (about 16 milligrams) a day of morphine, divided into four or more doses, for the painful biliary colic he was experiencing. Halsted, Crowe claims, brought an extremely dilute solution of morphine with him to Baltimore, and it appears that it was from this supply that his injections were derived during his hospitalization. Such a small dosage suggests that William was able to cut down his daily morphine requirement considerably over the years, especially when compared to the hefty three grains (195 milligrams) he was consuming daily in the 1890s when Osler wrote about him in his “Inner History.” Interestingly, as a practicing surgeon, Halsted worried about drug toxicity and addiction, always insisting that if morphine was to relieve postoperative pain, “a very small dose will do it just as effectively as a large dose and with less side effects.” Consequently, his patients at Johns Hopkins were rarely given more than one-tenth of a grain, or 6.4 milligrams, without his express permission. Conversely, there exists the possibility that as Halsted confessed his own doses to his Johns Hopkins physicians he minimized and obscured the exact amounts he was injecting.
In 1971, Emile Holman, a prominent professor of surgery at Stanford University, published yet another fascinating account of Halsted’s addiction. In it, Holman quotes the more than thirty-year-old memories of a urologist named David Sprong. In 1934, Dr. Sprong was a house officer (or training physician) at the Johns Hopkins Hospital taking care of William Henry Welch. Sometime before Welch’s death on April 30, 1934, Sprong reported, Welch had told him:
Although it has been widely reported that Halsted conquered his addiction, this is not entirely true. As long as he lived he would occasionally have a relapse and go back to the drug. He would always go out of town for this and when he returned he would come to me, very contrite and apologetic, to confess. He had an idea that I could tell what he had done. I couldn’t but I let him go on thinking so because I felt it was good for him to have somebody to talk it over with.
This, of course, is an astounding statement. Yet even if the words ring as true as a well-cast bell, it does raise a question: Why would Welch, who zealously protected Halsted’s secret for more than a half a century, make such a convicting admission to a junior physician?
Whether one believes that Dr. Welch made this last statement or not, after weighing all the evidence, Dr. Cushing’s posthumous diagnosis remains the most compelling: “The real truth of the matter is that he never conquered it.” Indeed, the biographical, archival, and clinical data strongly suggest that William remained an active morphine and cocaine addict until the final days of his life. Few would doubt that nearly thirty-eight years of morphine and cocaine exacted a harsh toll on his physical health. Less measurable at this late date are the psychic wounds he incurred by living a double life for such a long time. Every day, he was forced to spin a web of falsehoods obscuring the fact that the world’s greatest surgeon was a ravenous drug addict.
The Halsted cottage High Hampton, in North Carolina, c. 1920. (photo credit 12.7)
HALSTED, OF COURSE, had a vested interest in submerging his thoughts, urges, and actions about cocaine and morphine to avoid the slightest risk of dimming his lustrous reputation. Yet one can imagine that on many mornings he awoke hoping that this day would be different. That he would not succumb to his body’s desperate need for self-medication. That he would not have to lie to everyone he encountered about his clandestine drug abuse. That, instead, he would simply suit up in his white surgical scrubs and focus intensely, if not obsessively, on advancing the craft that would—and continues to—save millions of lives every year.
But every afternoon, when the clock struck four-thirty, William Halsted hurried home to his study. There, more times than not, he took out his own morocco case containing a syringe and a soothing dose of morphine. Ever the measured surgeon, he worked hard to calibrate his dosage to calm his jitters and angst but not cloud his senses or interfere with his medical judgment; on not a few occasions, however, he miscalculated and sailed off to narcotized oblivion, abandoning his responsibilities.
On many mornings after, he awoke to gnawing guilt, remorse, and a stomach full of acid. His hungover sensorium fueled his penchant for verbalizing the most curmudgeonly of thoughts and acting on his anger-filled impulses. And with each biting barb, he inexorably harmed personal relationships with those who cared for him. Later each afternoon, he returned to his home to repeat the same slow-motion cycle of self-destruction. There may have been days when Halsted could tell his demons to cease and desist or, at least, accept a smaller dose of morphine; but there were many, many more when he invited the demons into his locked study.
Most likely, William was able to abstain from cocaine for long periods of time, but he presumably pursued many prolonged binges in the years after he left Butler Hospital. These relapses probably coincided with his isolated summer vacations in Europe and North Carolina and his many frequent absences from the Johns Hopkins Hospital. Such episodes also may have included balancing the stimulant effects of cocaine with injections of morphine.
The long-term course for most active cocaine and morphine addicts is uniformly bad. Eventually, the limbic system telling such addicted brains to “go-go-go” for the immediate gratification of mind-altering drugs completely conquers the inhibiting frontal cortex, which would normally stop them from engaging in foolish or dangerous acts. The result is a constant search for and consumption of the addictive drug of choice and a steady downhill course toward death.
Halsted, on the other hand, was a remarkably high-performing addict for almost four decades. Armed with a controlling personality of epic proportions, more times than not the surgeon restricted satisfying his drug hunger to a precise schedule of furtive morphine injections. He also managed to contain his cocaine cravings to those safe periods when he was far away from the hospital and could afford to binge. What remains extraordinary about Halsted’s substance abuse was that he was able to escape on his morphine and cocaine holidays so well, so often, and for so long, while so few knew of his habit. Sadly, the ashamed, guarded, and lonely Halsted concealed this part of his life to the very end.
Epilogue
ADDICTIVE AGENTS, when taken chronically and copiously, can transform anatomy. Like an overloaded power switch, an insurgency of bad judgment and risky behavior hijacks the brain’s delicate circuitry, inducing temporary states of well-being and release from all inhibitions. Long after the high has disappeared, a neurologically mediated form of bondage forces the addict to pursue his own destruction. His body progressively demands greater amounts in exchange for briefer moments of escape amid a growing cascade
of physical and mental health breakdowns. In the end, for the witness it is death at its most repellent and for the addict at its most seductive.
For many people, the use of mind-altering drugs is nothing more than a guilty little pleasure that provides a brief, occasional reprieve from life’s emotional battles. But predictably, 5 to 10 percent of humans develop serious abuse problems after discovering their substance of choice. Imagine this susceptibility as a wheel of misfortune that includes wedges depicting risks related to genetics, environment, mode of administration, and emotional or physical trauma. The addict’s luck runs short when the wheel stops at the most harmful wedges.
When Freud and Halsted first became acquainted with their chemical bête noire, they fully expected cocaine to be the wonder drug of modern medicine. Neither had any idea of its potential to dominate and endanger their lives. Addiction as a bona fide medical diagnosis was not yet in the doctor’s lexicon, let alone his textbooks. Quite simply, these talented medical investigators studied the effects of cocaine by experimenting on themselves, consumed great quantities of it, and eventually encountered serious problems because they had done so.
Sigmund Freud with one of his beloved chow dogs in his London study, c. 1939. (photo credit epi.1)
Each man actively participated in the birth of the modern addict, and their clinical histories prefigure the ever-challenging spectrum of substance abuse, addiction, and recovery. Freud somehow escaped from his cocaine dependency even as he was plagued by periods of sexual turmoil, increased alcohol consumption, and depression. Decades after Halsted restricted his cocaine abuse to occasional binges, he still availed himself of daily morphine injections to quell his addictive urges, often with negative results.
In years past, some scholars have been eager to discount Freud’s and Halsted’s so-called cocaine episodes, citing their vast work output as evidence that cocaine posed only inconsequential problems, ignoring the reality that even fervent substance abusers can achieve greatness. Others have highlighted the accidental aspect of their maladies—as if anyone becomes an addict on purpose. Even at this late date, it is tempting for some to wonder why these two men’s brilliance, social position, specialized knowledge, or determination failed to immunize them against cocaine’s indiscriminate ravages. But in reality, their vulnerability to the disease of addiction demonstrates that the two intellectual giants were all too human.
Halsted’s formal portrait, 1922. (photo credit epi.2)
Cocaine failed to make either man more productive, happier, or smarter. They often recklessly practiced medicine while under the influence, and their most fallow professional years coincided with their most prodigious substance abuse. Each in his own fashion confessed regret over the physical and emotional tolls cocaine exerted, the valuable time it consumed, and the harm its abuse inflicted on others.
Yet cocaine no more explains the sum total of their lives and occupational achievements than a diagnosis of diabetes or hypertension would define others. Chronology alone does not imply a direct equation of causation between mind-altering drugs and creativity. Pharmacologically enhanced flashes of uninhibited thought alone do not result in intellectual progress over long periods of time; nor do they allow for the fine motor control one needs to conduct intricate surgical operations. Genius is not found in a bottle, pill, or potion. It arises from within and in most cases must be discovered and nurtured by others. The titanic legacies of Sigmund Freud and William Halsted were ground out page by page, stitch by stitch, patient by patient, insight by insight, day after day, year after year.
Today, neither man can claim the ultimate authority they held in their respective fields while alive. Long after Freud composed his last sentence, mental health professionals advanced, disputed, and replaced his theories and methods. In the decades since Halsted quit the operating room, surgeons have superseded his work in ways he could only have dreamed about. Still, none of us can approach an understanding of modern psychology or surgery without at least taking their work into serious consideration. Without fear of exaggeration, it can be said that each man changed the world.
History repeatedly reminds us that great accomplishments are often accompanied by great risks, just as personal tragedy often gives birth to inspirational growth. In their quest to change the course of medicine, Freud and Halsted imperiled their lives with cocaine, initially as a potential means to revolutionize science and ultimately from its abuse. In defiance of the malady that nearly destroyed them—or perhaps because of their struggle to overcome it—neither man ever lost his zeal for delivering his healing gifts to the world.
Notes
Prologue
1 The orderlies rushed: Allan E. Dumont, “Halsted at Bellevue, 1883–1887,” Annals of Surgery 172, no. 6 (1970): 929–35. The laborer’s case is logged into a volume of surgical records entitled “Bellevue Hospital Record Book, 1883–1897,” which is the basis of Dumont’s 1970 report. For similar contemporary accounts, see also William H. Rideing, “Hospital Life in New York,” Harper’s New Monthly Magazine, July 1878, pp. 171–89; and “The Bellevue of Today: Sights in the Wards of the Great Charity Hospital,” New York Times, November 23, 1884, p. 6.
2 Before X-ray technology: X-rays were discovered by the German physicist Wilhelm Roentgen in 1895. This remarkable technology has aided physicians and surgeons in diagnosing organic diseases ever since. Stanley J. Reiser, “Enigmatic Pictures: How Patients and Doctors Encountered the X-Ray,” Technological Medicine: The Changing World of Doctors and Patients (New York: Cambridge University Press, 2009), pp. 14–30; Stanley J. Reiser, Medicine and the Reign of Technology (New York: Cambridge University Press, 1981); Bettyann Kevles, Naked to the Bone: Medical Imaging in the Twentieth Century (New Brunswick, N.J.: Rutgers University Press, 1997).
3 Discounting the attendant risks: Allen O. Whipple, The Evolution of Surgery in the United States (Springfield, Ill.: Charles C. Thomas, Publisher, 1963), pp. 86–88; quote is from p. 87; J. C. O. Will, “On Fracture of the Tubercle of the Tibia,” British Medical Journal 1, no. 1360 (1887): 152–53; “Orthopaedic Surgery,” in The History of Surgery in the United States, 1775–1900, ed. Ira M. Rutkow, vol. 1, Textbooks, Monographs, and Treatises (San Francisco: Norman Publishing, 1988), pp. 243–86; Alfred R. Shands, The Early Orthopaedic Surgeons of America (St. Louis: C. V. Mosby Co., 1970); Mark M. Ravitch, ed., A Century of Surgery: The History of the American Surgical Association, vol. 1 (Philadelphia: J. B. Lippincott, 1981), pp. 34, 36, 118, 122, 124, 127, 129, 133, 137, 183, 203–04, 206; and G. H. Brieger, “A Portrait of Surgery: Surgery in America, 1875–1889,” Surgical Clinics in North America 67 (1987): 1181–216.
4 It read, in six-inch-high black letters: “The Bellevue of Today: Sights in the Wards of the Great Charity Hospital,” New York Times, November 23, 1884, p. 6.
5 Otherwise, the broken leg: William S. Halsted, “Adduction and Abduction in Fractures of the Neck of the Femur,” New York Medical Journal 39 (1884): 317–19. This paper was also reprinted in the Medical Record of New York (25 [1884]: 248) and in the Medical News of Philadelphia (44 [1884]: 288). It can be found more easily in William S. Halsted, Surgical Papers in Two Volumes, ed. Walter C. Burket (Baltimore: The Johns Hopkins Press, 1924), vol. 1, pp. 19–26.
6 an up-and-coming neurologist: Sigmund Freud to Martha Bernays, May 17, 1885, Ernst L. Freud, ed., Letters of Sigmund Freud (New York: Basic Books, 1960), pp. 145–46 (Letter 65). For a superb synopsis of Freud’s training and work as a neurologist and neuroanatomist between 1876 and 1896, see Oliver Sacks, “The Other Road: Freud as Neurologist,” in Freud: Conflict and Culture: Essays on His Life, Work, and Legacy, ed. Michael S. Roth (New York: Alfred A. Knopf, in association with the Library of Congress, 1998), pp. 221–34.
7 On May 17, 1885: Freud to Martha, May 17, 1885, Freud, Letters, pp. 145–46 (Letter 65). The paper Sigmund is referring to in this letter is “Zur Kenntnis der Olivenzwischenschicht” (Concerning the Knowledge of the Intermediary Layer of the Olive), Neurologisch
es Zentralblatt 4, no. 12 (1885): 268. The term “olive” refers not to the fruit but to a brain structure that has the shape of an olive, or, more specifically, the “inferior olivary eminence, a smooth oval prominence of the ventrolateral surface of the medulla oblongata (brainstem) corresponding to the nucleus olivaris,” as defined by Stedman’s Medical Dictionary, 23rd ed. (Baltimore: Williams and Wilkins, 1976), p. 977. Freud’s paper discussed his histological tracing of the acoustic nerve and the connection of the interolivary tract with the crossed trapezoid body.
8 Such individuals were mandated: The Oxford English Dictionary’s first entry under “addiction” defines it as a term from Roman law meaning “a formal giving over or delivery by sentence of court. Hence, a surrender or dedication of anyone to a master.” The Compact Edition of the Oxford English Dictionary, vol. 1 (Oxford: Oxford University Press, 1981), p. 26; John A. Crook, Law and Life of Rome (Ithaca, N.Y.: Cornell University Press, 1984), pp. 61, 172–76; Barry Nicholas, An Introduction to Roman Law (Oxford: Clarendon Press, 1962), pp. 2–15. I am indebted to my colleague Michael Schoenfeldt, professor and chairman of English literature and language at the University of Michigan, for introducing me to the word’s fascinating history.
9 Alcohol abusers, too: Such is the stark contrast to our current era, when the application of the word “addiction” has opened up significantly to include not only a large number of habit-forming drugs but also a number of behaviors ranging from excessive gambling to promiscuous sexual activity. See, for example, William Osler, Principles and Practice of Medicine (New York: D. Appleton, 1892), pp. 1001–07; David T. Courtright, Dark Paradise: A History of Opiate Addiction in America (Cambridge, Mass.: Harvard University Press, 2001), pp. 79–101; Sarah Tracy, Alcoholism in America: From Reconstruction to Prohibition (Baltimore: Johns Hopkins University Press, 2007). For engaging essays on the origins of terms for alcoholics, see, for example, H. G. Levine, “The Discovery of Addiction: Changing Conceptions of Habitual Drunkenness in America,” Journal of Studies on Alcohol 39 (1978): 143–74; William L. White, “The Lessons of Language: Historical Perspectives on the Rhetoric of Addiction,” in Altering American Consciousness: The History of Alcohol and Drug Use in the United States, 1800–2000, ed. Sarah W. Tracy and Caroline J. Acker (Amherst: University of Massachusetts Press, 2004), pp. 33–60; Timothy Hickman, “The Double Meaning of Addiction: Habitual Narcotic Use and the Logic of Professionalizing Medical Authority in the United States, 1900–1920,” in Tracy and Acker, Altering, pp. 182–202.
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