The Addicted Surgeon

For 19th century medicine, there were few new drugs that were welcomed more enthusiastically than cocaine.   Though coca leaves had long been recognized for their analgesic properties, it was not until 1860  when Albert Niemann published his doctoral dissertation describing the purification process that extracted the colourless alkaloid that he christened "cocaine."   Almost from the beginning, the prospect of a safe and non-addictive alternative to opium-based medications such as morphine seemed too good to be true.  

And so it turned out eventually.

In the meantime however, eminent medical doctors and neurologists across Europe and North America began experimenting with cocaine, both on themselves and on patients seeking to be cured of their morphine addictions.   It also seemed like the ideal anesthetic with doctors and dentists using the drug on their patients for various medical and tooth extraction procedures.    Sigmund Freud was an early cocaine advocate who recommended its use in treating various addictions. 

Though cases of cocaine intoxication were reported as early as 1885, physicians were still skeptical about the idea of cocaine being as addictive as morphine.   And they were right, since it eventually proved to be even more addictive.  Not only was it useless in helping morphine addicts cure their addiction, but they often developed a joint cocaine-morphine habit.    Episodes of cocaine psychosis began being reported and an 1886 editorial in the New York Medical Journal would comment that "no medical technique with such a short history has claimed so many victims as cocaine."   Friedrich Albrecht Erlenmeyer, a German physician who became best known for his in-depth description  of the symptoms of cocaine intoxication, denounced cocaine as "the third scourge of mankind" after alcohol and morphine in his 1887 monograph, "Cocaine in the Treatment of Opiate Addiction."   

By 1890, more than 400 cases of cocaine addiction were reported in the medical literature, and physicians gradually realized they had unleashed a new social problem on society.   Even Freud turned against cocaine and openly regretted his early support which had led to many of his patients becoming addicted.   Lack of reliable statistics makes it hard to chart the actual rise of the cocaine epidemic since cocaine addicts rarely used that drug alone but tended to combine it with other addictions, including alcohol.     Despite the medical warnings, it would take time for drug laws to catch up and many commercial products containing cocaine or coca leaves were widely available and often legal.  Even the popular soft drink Coca Cola had coca leaves as one of its ingredients (it was removed in 1903 in favour of caffeine).   

Ironically, while physicians were the first to document the dangerous addictive properties of cocaine, they were also in danger of becoming addicts themselves.   By 1901, an estimated 30 percent of cocaine addicts in the United States alone were physicians or dentists.   Since they had easy access to cocaine,  which was widely used as an anesthetic and even more popular than morphine, addiction became an occupational hazard.   

Which brings us to William Stewart Halsted.... 250px-William_Stewart_Halsted[1]

One of the most eminent surgeons in the United States and a champion of anesthetic medicine, Halsted was a founding professor of the John Hopkins Hospital when it first opened in 1889.  Along with his work with anesthesia, he conducted one of the first gall bladder operations in the United States (on his own mother, no less) as well as the first radical mastectomy.   After reading an 1884 research paper in a European medical journal describing how cocaine could be used as a safe alternative to morphine in anesthesia, Halsted decided to conduct his own experiments.  Along with his medical students and several fellow physicians, he injected cocaine into himself and others and developed the first practical nerve block method to eliminate pain during surgery.   Unfortunately,  Halsted had no idea that cocaine was dangerously addictive.    As his student, Wilder Penfield, would later describe, "cocaine hunger fastened its dreadful hold on him" which was then followed by a "confused and unworthy period of medical practice."    To save his career and to avoid becoming a danger to his patients, William Halsted was sent to the Butler Sanatorium in Providence, Rhode Island.

Though he stayed at the sanatorium for a year,  his doctors had no real experience dealing with cocaine addiction (actual cases were still rare at the time).   In what seems like a bizarre strategy today, Halsted's doctors decided to cure his cocaine addiction by having him become addicted to morphine instead.   All that accomplished was to give their patient two addictions rather than just one.    After leaving the sanatorium and taking a cruise to recover, Halsted returned to his medical practice though, as observer pointed out, "the brilliant and gay extravert seemed brilliant and gay no longer."   There would be more hospitalizations and he eventually stopped using cocaine but his addiction problems were hardly over.  

According to a manuscript written by his colleague, William Osler, which only became public in 1969, Halsted continued to take three grains  (200 mg) of morphine a day secretly.   While this was eventually reduced to one and a half grains, William Halsted would "struggle against the dreadful discomfort of drug hunger" for the rest of his life.  In a letter that he wrote to Osler in 1918, Halsted would comment that three of his assistants also became addicted to cocaine and eventually died without ever overcoming their dependence.    He lated admitted that some of the New York Medical Journal articles he published between 1884 and 1885 on cocaine anesthesia were largely written while he was under the influence of cocaine.   Referring to them as "not creditable", he acknowledged that he was "not in good form" when he wrote them. 

Certainly his writing style when he was under the influence of cocaine was very different than his usual standard.   The first sentence of one of these papers seems to reflect the "cocaine influence" on grammar and syntax:

Neither indifferent as to which of how many possibilities may best explain, nor yet at a loss to comprehend, why surgeons have, and that so many, quite without discredit, could have exhibited scarcely any interest in what, as a local anaesthetic, had been supposed, if not declared, by most so very sure to prove, especially to them, attractive, still I do not think that this circumstance, or some sense of obligation to rescue fragmentary reputation for surgeons rather than the belief that an opportunity existed for assisting others to an appreciable extent, induced me, several months ago, to write on the subject in hand the greater part of a somewhat comprehensive paper, which poor health disinclined me to complete.

Despite the blow to his reputation stemming from his drug abuse, Halsted managed to recover enough to function as a surgeon.   While still suffering from physical dependence on morphine,  he was able to conceal the signs of his addiction from his colleagues and patients.  As one of the founders of John Hopkins Hospital and a major pioneer in surgical education, he was widely praised for his expertise by the time of his death in 1922 from pneumonia.    Obituaries described his medical achievements at length though his addictions remained a well-guarded secret in the John Hopkins medical community. 

While warnings about cocaine addition spread rapidly, so did its popularity.  Though very much an "upper-class" drug at first, cocaine became more widely available as people discovered the various ways it could be ingested, whether mixed in alcohol or snorted in powder form.    Enterprising salesmen even sold it door-to-door in some places and many pharmacists dispensed cocaine over the counter to anyone wanting a stimulant to work long hours.    Though laws surrounding cocaine became more rigid, at least to the point of requiring a prescription, finding a willing source was rarely that hard.   

As cocaine became more of a social problem, police and legislators began cracking down in earnest.  Pharmacists refused to carry it and police chiefs began publicly linking cocaine to crime.   Not surprisingly, given the time period, there was also a definite racial tinge to the health warnings as newspapers and social reformers talked about "negro cocainists" who were readily influenced by the drug along with other "lower classes."    The spread of cocaine use among African-Americans is probably not that remarkable since many employers freely offered it to workers as a stimulant to make them work longer hours.   Fears of drug use among African Americans led to at least one race riot in 1906,  Still,  Federal legislation restricting cocaine manufacture in the United States was only passed in 1914 (a full ban would not take place until 1922).  Though similar bans existed on heroin and other opium-based medications, morphine would still be available to medical doctors, even if heavily restricted.

Actual statistics relating to physicians and dentists addicted to drug such as cocaine and morphine during those early years of prohibition are hard to find considering the stigma surrounding drug use.   While William Halsted is the most well-known early case of cocaine and morphine addiction in a medical doctor, he was hardly the only one.  His life story and the struggle he went through to cope with his addiction still resonates today given the 0ngoing problem faced by physicans addicted to prescription medications.   Not to mention the stigma that often prevents them from getting help before it's too late.     For many medical doctors and dentists coping with addiction, the world hasn't really changed that much since William Steward Halsted's day.






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