An Anatomy of Addiction

by Howard Markel

⊕ Rating: 7/10
Read: March 10th, 2022
Pages: 336
Year: 2012
ISBN: 1400078792

Summary & Review

A look at Sigmund Freud, William Halsted and the birth of cocaine. It explores how the two men were enraptured by the promise of the new miracle drug but how ultimately its clinical application was limited, while the personal usage by the two men was unlimited. Freud seemingly shook off his cocaine addiction, Halsted never quite did. But both spent plenty of time using rather heavily and the author explores what effect it had on the men and their work.

Freud would use the drug as a social lubricant (both at parties and for writing verbose love letters) and as a tool for staying up late working. Halsted initially tried to continue to work as a surgeon whilst using, until one day the shakes and the pressure got to much and he walked away from the patient whilst still on the operating table. He took a sabbatical to get clean and returned as one the “Big Four” physicians at the founding of Johns Hopkins Hospital. However, it looks like he never quite got clean. Though he seemingly did manage to separate his professional life and drug usage. Each day at 4:30pm he would go home and use in private, never seen or available again until the following morning.

This is a short, quick read and has plenty of images throughout – as a visual person, something I always appreciate. The second half doesn’t quite come together and it ends a little abruptly. But hey, the book never overstays its welcome at least. And if you have any interest in Freud, Halsted or cocaine I would say this is worth a read. And this is my second time reading the book in fact and I enjoyed it both times. – March 10th, 2022

Highlights & Notes

Note: I highlight using an app and its OCRing isn’t always 100% accurate. If there’s any spelling or grammatical errors that’s likely why.

At Bellevue, above the table on which these battered patients were placed, a sign painted on the wall suggested the chances of recuperation. It read, in six-inch-high black letters: PREPARE TO MEET YOUR GOD.

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.

Opium was the first global pharmaceutical agent in the history of medicine. It is a sticky, bitter brown sap produced by the poppy (Papaver somniferum), a red wildflower that flourishes in Turkey, Afghanistan, China, India, and the Middle East. The plant may have originated along the western Mediterranean near southern France and Italy. By the Roman era, however, it had been transplanted in Egypt, and its use as a pain medication soon spread from the Middle East to Asia and Europe. Although highly valued by physicians of the Middle Ages, opium fell out of favor, its use in Europe declining precipitously during the Renaissance and the Inquisition. Why did such a miracle drug - and one of the few drugs around - fall out of favour in the Middle Ages?

Beginning in the early sixteenth century, however, the seafaring Portuguese reaped great fortunes by importing opium from India. Britain’s expanding imperial influence in India during the seventeenth and eighteenth centuries, its growing wariness of and competition with nearby China, and a burgeoning opium trade ushered in the infamous Opium Wars of the nineteenth century. During the mid-1800s, opium was, once again, the doctor’s drug of choice for treating all forms of severe pain. (Page 71)

Sigmund Freud: “As you know, an explorer’s temperament requires two basic qualities: optimism in attempt, criticism in work.” (Page 75)

Sigmund Freud: “The bit of cocaine I have just taken is making me talkative, my little woman. I will go on writing and comment on your criticism of my wretched self.… I believe people see something alien in me and the real reason is that in my youth I was never young and now that I am entering the age of maturity I cannot mature properly. There was a time when I was all ambition and eager to learn, when day after day I felt aggrieved that nature had not, in one of her benevolent moods, stamped on my face with that mark of genius which now and again she bestows on men. Now for a long time I have known I am not a genius and cannot understand how I ever could have wanted to be one. I am not even very gifted; my whole capacity for work probably springs from my character and from the absence of outstanding intellectual weaknesses. But I know that this combination is very conducive to slow success, and that given favorable conditions, I could achieve more than Nothnagel, to whom I consider myself superior, and might possibly reach the level of Charcot. By which I don’t mean to say that I will get as far as that, for these favorable conditions no longer come my way, and I don’t possess the genius, the power, to bring them about. Oh, how I run on!…You know what Breuer told me one evening? I was so moved by what he said that in return I disclosed to him the secret of our engagement. He told me he had discovered that hidden under the surface of timidity there lay in me an extremely daring and fearless human being. I had always thought so, but never dared tell anyone. I have always thought I inherited all the defiance and all the passions with which our ancestors defended their Temple and could gladly sacrifice my life for one great moment in history. And at the same time I always felt so helpless and incapable of expressing these ardent passions even by a word or a poem. So I have always restrained myself, and it is this, I think, which people must see in me.”

“Here I am making silly confessions to you, my sweet darling, and really without any reason whatever unless it is the cocaine that makes me talk so much.” (Page 125)

In 1889, one of the Hopkins surgical nurses caught William’s eve Her name was Caroline Hampton. A tall woman with piercing eyes.

She hailed from a distinguished family of planters that included her uncle Wade Hampton III, a decorated Confederate general. A photographic portrait of Caroline in her nurse’s uniform exhibits a bright air of confidence and a prematurely pear-shaped figure. Robust and horsey, Caroline was especially good at maintaining the various mechanical gadgets then in use at the hospital. By some accounts, she was difficult, spirited, prone to haughtiness, and high-strung. But Dr. Halsted saw her worth and appointed her to be the head nurse in his operating room.

The abrasive chemicals Caroline doused her hands in every day rendered her skin rough, cracked, and marred by red, angry rashes. None of these traits appealed to either the southern belle or the surgeon pursued her. As the dermatitis traveled up her fingers and hands and extended to her forearms, a besotted William grew determined to do something therapeutically definitive and sweetly chivalrous. In the winter of 1889-90 (in later years he could never recall precisely when), the who took a train up to New York and met with an executive at surgeon the Goodyear Rubber Company. Armed with drawings of prototypes, he asked the rubber man if he would kindly manufacture “two pairs of thin rubber gloves with gauntlets.” Soon after, all the surgeons and nurses in his operating room donned them. William’s invention may have begun as a means to win Caroline’s heart, but it ultimately changed the way doctors operate, much to the benefit and safety of their patients. (Page 194)

In later years, colleagues would comment on Dr. and Mrs. Halsted’s distant marriage. Theirs was a type of relationship that was rather common in the late nineteenth and early twentieth centuries: spouses lived together and shared emotional connections but pursued activities that did not include the other. Some criticized her mannish dressing style and his general avoidance of any close contact with her. It was well known in Baltimore that the Halsteds occupied separate floors of their enormous town house at 1201 Eutaw Place. He lived on the second floor, with his books, papers, and a secretary desk stocked with boxes of freshly filled fountain pens, Pall Mall cigarettes, cigarette holders, and eyeglasses. She resided on the third floor, with their beloved black dachshunds, Sisly, Fritz, Nip, and Tuck. The union produced no chil dren. They supped as a couple, followed by a brief conversation of the day’s events and withdrawal to their separate quarters. According te those familiar with the couple’s domestic routine, they never e breakfast together. (Page 195)

As exacting about his home environment as he was about his operating room, William made the sort of incessant demands that proved particularly grating for Caroline. The surgeon’s Turkish coffee had to be ground and brewed just so; the table linens were always to be freshly laundered and flatironed. He typically interfered with the management of dinner parties by insisting on ordering groceries from nearby Lexington Market, planning the menu, arranging the flowers and china, and, even though he rarely drank, selecting the wines. William’s ceaseless search for perfection often exhausted the migraine-prone Mrs. Halsted.

In 1898, Harvey Cushing, then a surgical resident of Halsted’s and soon to be a founder of modern neurosurgery, wrote his mother that William’s “stone-cold” lair reminded him of Charles Dickens’s Bleak House. The house overflowed with antiques, Oriental rugs, blooming dahlias, leatherbound books, telescopes, knickknacks, and an intricate telephone system linking each room in the house and connected to an outside line, the latter strictly guarded by servants ordered to tell any callers that the Halsteds were unavailable. It was an unwritten law among his residents at the hospital that the chief was not to be disturbed at home, no matter how dire the situation. Once his castle’s heavy door was slammed shut for the evening, William intended it to stay that way.

Even at his healthiest, Dr. Halsted did not operate often: three mornings a week at the most and rarely more than one patient in a single morning. In the latter years of his career, he operated far less frequently. The cases he chose were selected from among the many patients seeking care at the Hopkins’s surgical clinic, but Halsted limited his practice to the conditions he was studying at the time.

Those days he did operate, he left the surgical theater promptly at the stroke of noon. From there he beat a hasty retreat to his rooms on the second floor of the hospital for a light and solitary luncheon. This suite was where he’d lived in 1889 and 1890, until he’d married Caroline. William was so finicky about the decor of his pied-à-terre that he ordered the painting of its walls to be done over and over again until the color suited his aesthetic sensibilities. Equally central to the setting was a marble-manteled fireplace that was kept well stoked by an orderly assigned to fulfilling his every wish. The small suite of rooms, with its overstuffed Victorian furniture and a large photograph of Michaelangelo’s Madonna of Bruges, was his refuge from the tumult and stress of his surgical world. (Page 196)

Three grains, incidentally, is equal to 195 milligrams of morphine, a robust amount that speaks volumes about the level of drug tolerance Halsted had developed because of his chronic and frequent use On a surgical ward, the typical dose ranges from 5 to 20 milligrams every four hours, depending on the severity of the pain experienced by the patient. For moderate to severe pain (after a major operation, for example), the optimal intramuscular dose is 10 to 20 milligrams per 70 kilograms (154 pounds) of body weight every four hours. (Page 212)

Most recovering addicts insist that two touchstones of a successful recovery are daily routines and rigorous accountability. Fortunately for Freud, Martha managed the household at Berggasse 19 with precision. She may have complained of relentless domestic tasks, but her close attention to the schedules, meals, and virtually every activity in their spacious flat allowed Sigmund to focus exclusively on his work and patients. Because he conducted most of his career in a set of three rooms directly attached to the family quarters, Martha orchestrated reliable but controlled contact with his children, whom he numbered among the great joys of his life.

From Monday through Saturday, during his working life as a psychoanalyst in Vienna, Freud rose from his bed promptly before seven a.m., bathed, partook of a light breakfast and coffee, and sat for a daily trim of his beard and hair by a barber who made house calls. At eight a.m., Freud greeted his first patient and began a fifty-five-minute analytic session. Once his practice started to flourish, Sigmund saw twelive of more patients a day. He typically took a break from one to three p.n enjoying a family lunch and a walk to clear his head before returning to his consulting room with the famous couch and more patients to analyze. There were also brief visits with colleagues and his children, trips around the corner to the tobacconist for his daily fix of cigars, perhaps another cup of coffee for energy, University of Vienna, and an evening meal with the entire family. Virtually every week, he attended meetings of the Vienna Medical Society and the Vienna B’nai B’rith men’s lodge, as well as gatherings of his like-minded colleagues and acolytes eager to discuss psychoanalysis.

This overflowing agenda does not even begin to account for the time he spent each night, and well into the early morning, reflecting on his psyche and those of others. These were the critical hours when he composed and ruminated over the many books and papers containing his claim to intellectual immortality. From fall to late spring, he limited his recreation to Saturday nights, attending lectures and plays or playing cards and chess, although later in life he claimed to find the latter too stressful a leisure activity. Sundays were supposed to be a sacrosanct day of rest in the company of his beloved children, mother, wife, and friends. More often than not, he managed to steal a few hours away ffom his self-imposed, secular Sabbath to write a few pages of his latest manuscript. Every summer, Sigmund and his family took a lone v tion filled with restorative hikes in the mountains, playful activition with his children, and reading for pleasure.

With Freud’s intense work schedule and the daily demands he mad on his mind and body, one could easily argue that there was little roorm for cocaine abuse. Cocaine may have briefly picked him up and given him energy during the early years of his career, but, especially as he aged, his body began to rebel against the intensely draining peaks and valleys of mood the drug instigated. Cocaine highs resulted in a disjointed prose that was best relegated to the wastebasket. The lowS of cocaine abruptly halted the productive commitment of pen to paper and thwarted his ability to complete useful thoughts about the complex topics he tackled. The ever-driven Sigmund, one of the most prolific and persuasive intellectual authors of the twentieth century, simply did not have the time for cocaine’s hour-stealing and rapidly debilitating effects.

All of these exercises-the never-ending demand for new manuscripts, students and patients to see, friends and colleagues to talk with, thinking about his mental health as well as the mental health of others, packaged in predictable routines and demanding constant accountability to so many-served as the ideal therapeutic program he required for his recovery from substance abuse. Admittedly, the precise means Freud used to keep his mind off cocaine were markedly different, if not unique, when compared to the methods of the overwhelming majority of recovering addicts.

One only wishes that he’d had similar fortitude to put down his addictive and cancer-producing cigars, which, beginning in 1923, at a sixty-seven, robbed him of an intact, functioning mouth and force him to undergo multiple painful surgeries and wear ill-fitting prosthe ses. On September 21, 1939, a year after he fled Nazi-dominated Austria for London, a cancer-riddled Freud asked his physician Max Schu to a fatal dose of morphine to end his life. Freud was said, “Schur, reported to have you remember our ‘contract’ not to leave me in the e sense.” Dr. Schur administered a large naps a third) dose was given the following day, and Freud wen coma from which he did not awake. He died at three a.m. on September 23, 1939. (Page 222)