Markel, Howard. An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine. NY: Pantheon, 2011.

In the late summer of 1985, I stood in a long line in a stuffy hallway, deciding the rest of my life.   English or History? I was panicky, thinking about it. Up until that day, I’d assumed it would be English, like my mother and teachers thought it should be, like I told the newspaper for the scholarship announcement. It was a sensible choice with a pre-approved future. But there was History, the interloper, hanging out in the darker corner, rakish and probably in knee breeches, asking me what I really wanted. By the time I got up to the clerk, I knew it wasn’t scanning verse, literary analysis, or the Great American Novel. No, I wanted everything behind the pretty words–the sounds, the clothes, the smells, the emotions, the dirt, the people. I wanted the truth, close as anyone could get it. I wanted what was real. So it was, that when I began this blog, I thought I would take the occasional break from pastiche and review books that are simply “Holmes-related”–in particular, books on crime or history that I think shed a little light on the fog-covered alleys of Baker Street.

Markel isn’t, of course, writing about Holmes, or even Doyle, although he mentions both. Instead, he explores the early history of cocaine in Western medicine, as well as the beginnings of our modern understanding of addiction and recovery, using the experiences of two physicians whose lives were forever altered by it. His densely-packed, yet accessibly written account is, I think, essential reading for any Sherlockian who wants to better understand the scientific and medical milieu in which Sherlock Holmes worked…and learned to take cocaine.

The coca leaf’s stimulant properties were old news by the time the Spanish came upon it in the   days of the conquistadors. Chewing the leaves gave the native people in the Peruvian Andes (and other places where cuca grew) stamina, strength, and the ability to ignore cold and hunger. It didn’t take long for the Spaniards to make it a cash crop although, because it was notoriously hard to ship over long distances, they seem to have used it onsite to get more work out of native laborers. Still, there was always active interest in coca’s potential, and Markel describes the concerted efforts of “some of the best scientists, chemists, and physicians of the nineteenth century”* to first, import enough of the leaf to research its remarkable properties; second, to isolate the chemical compounds involved in said properties; and third, to use those compounds to create tonics and medications. We denizens of the 21st century aren’t the first to want to achieve far more in far less time, without the annoyances of hunger and fatigue.** The potential for fame and profit was, of course, lost on no one. In 1863, for example, Angelo Mariani concocted what would prove a very popular drink made from ground coca leaves in a Bordeaux solution. Vin Mariani gathered celebrity endorsements by the album-full, and made its creator a very wealthy man.*** The problem of shipping coca leaves in large quantities, however, remained. When University of Göttingen doctoral student Albert Niemann figured out how to isolate the leaf’s active ingredient in 1860, and explorer/physician Henry Hurd Rusby (on a mission from Parke Davis) suggested (c.1885) that this process be carried out in situ, as the alkaloid would ship better than leaves, the pharmaceutical world was ready.

Cocaine burst into a society in which medicine was, at last, undergoing rapid changes. In a century, physicians were transformed, from men who trained primarily as apprentices, talked about “humours” and “miasmas,” and performed procedures in bloody frock coats with no anesthesia beyond alcohol, into well-educated professionals (male and female) with at least a few effective drugs in their arsenal and–better yet–some knowledge of germ theory. The late 19th century was an exciting time to be a physician; the possibility that one might make a groundbreaking discovery was very real, and it appealed to both American surgeon William Stewart Halsted, and Viennese doctor Sigmund Freud.

Markel follows their careers and personal lives in what amount to short biographies, generally alternating between the two. He begins with Freud, discussing his family stresses, long engagement to Martha Bernays, and his struggles as a Jewish medical student at the prestigious University of Vienna, following a difficult program during an era when anti-Semitism was common and often overt.† An incredibly ambitious, brilliant man who cared deeply about his patients, Freud struggled a bit trying to discover the specialty in which he could make his mark, finally finding his niche in the psychiatric wing of the University’s Krankenhaus. Following long hours with patients in filthy conditions, Freud pursued greatness in the evenings, working on a paper which he hoped would be a definitive guide to medical cocaine. Not content with merely synthesizing the existing literature, he began to experiment with the drug, both on himself and a friend, the talented doctor Ernst von Fleischl-Marxow. Fleischl-Marxow’s experiences with neuromata on the stump of an amputated thumb had ended his surgical career and left him addicted to morphine. Freud believed cocaine might prove a cure for morphine addiction, a serious social problem of the day, and had seen accounts in medical journals (at least, the ones published by Parke Davis) of success with at least one patient in the U.S.. If he were correct, he would not only save his friend, but secure his own reputation. In the meantime, he tried cocaine himself, using topical applications (on the tongue, snorting) and was impressed by what it did for him in his frequently exhausted, discouraged, state. It’s 1884, and the drug will be his close companion for a dozen years. It won’t make his career (although some scholars wonder if it freed his mind enough to come up with psychoanalysis’ creative theories), but it will wreak havoc on his emotional and personal life and, at least once, place his career in jeopardy. It will, eventually, and in concert with morphine, kill his friend.

Markel points out that, as he was not a surgeon, Freud missed the significance of what proved to be cocaine’s most useful property–its ability to numb without injection, making it ideal for eye surgery. Although his monograph, Über Coca, was successful, it was overshadowed when a colleague, Carl Koller, described this revolutionizing application in a paper of his own. William Halsted, however, was a surgeon–an exceptionally gifted one–and intensely interested in anything that would allow him to invade the human body as painlessly as possible.  While Freud told Martha how cocaine made him more sociable at events and helped with his migraines, Halsted, his fellow surgeons, and his students, experimented with its anaesthetic properties by injecting various amounts of cocaine in solution, keeping track of injection sites, amounts, and effects, as well as using it topically to get them through exhausting days and nights on continual call. Freud, according to Markel, was able to keep his cocaine use /abuse above the level modern physicians might see as an addiction for quite awhile; Halsted was not so lucky. Along with others in his group, he was an addict “in a matter of weeks.”††

Reading about Halsted’s early career, it’s hard to see how he was created to be anything but a surgeon. Yet the time between the day he ordered his first shipment of cocaine from Parke Davis, to the day he walked out on a patient in the OR because he could no longer wield a scalpel was just about seven months. His career as a surgeon was all but destroyed in that instant, when he wasn’t yet thirty-three years old. If it had not been for close friends willing to confront him, and one, William Welch, who proposed a treatment plan and promised him a plum appointment at the new Johns Hopkins medical school if he got himself clean, he may have drowned horribly in a solution of cocaine hydrochloride. As it was, he would secretly relapse again and again, and was never the same open, gregarious man he was before the drug. Although his greatest professional accomplishments (sterile operating techniques, a radical breast cancer surgery, the invention of rubber gloves for the OR, hernia operations, etc.) were still to come, they were won as small skirmishes in a larger battle for control over his accidental addictions to both cocaine and morphine. Had his colleagues at Johns Hopkins been more observant, forthright, or honest (whichever applied in whichever case) he would never have achieved them at all.

Markel, a physician and medical historian who spent six years at the University of Michigan Addiction Treatment Service, does a phenomenal job in making the science behind cocaine  abuse and addiction understandable to those of us who had problems remembering to turn off the bunsen burner in high school chemistry.††† Because cocaine withdrawal is not as physically dramatic  as withdrawal from opiates, people once made the mistake of believing that, perhaps, it wasn’t addictive.‡ Markel points out, however, that cocaine withdrawal symptoms such as depression, fatigue, feelings of restlessness and suicidal ideation can recur months after one has taken the last dose, making it difficult for a cocaine addict to avoid relapse. One also must take into account that the inevitable stresses of life can lead a person to crave just a little cocaine vacation, believing that he has the control to stop, this time. As Markel makes clear, time and again in his book, whether it comes from family, coworkers, doctors, or oneself, denial is addiction’s best friend.

Denial also plays a part in how we treat addiction in our heroes. Halsted’s early biographers glossed over his lifelong problems with morphine and cocaine, pointing out his heroic early (supposed) recovery, but either not recognizing or not mentioning that problems may have continued. We’re only aware of them due to personal collegial memoirs that came to light after his death, but the evidence is clear. Freud was apparently able to put cocaine behind him–a process which Markel analyzes in depth–but afterwards tended to downplay the role it played in his life, an approach often adopted by his biographers. Markel, after pointing out that no one sets out to be an addict, and that addiction is an illness and not in itself a moral failing, argues that it does both men a disservice not to look at their problems with cocaine honestly, and is just as much of one to give the drug a greater role in their lives, achievements, and even failures, than it deserves.

(Granada photo)

So. Where does that leave Sherlock Holmes? Markel claims that Conan Doyle experimented with cocaine while bored in his fledgling Southsea practice.‡‡ I could find no mention of this in Andrew Lycett’s The Man Who Created Sherlock Holmes (Simon and Schuster (Free Press): 2008) and while Daniel Stashower, in his Teller of Tales (Henry Holt (Owl): 1999) believes that it’s possible, given Conan Doyle’s willingness to experiment on himself with gelseminum, as well as his eye surgery specialty, he writes that the evidence is just not there. Stashower points out that, even if he did experiment on himself, as did many doctors and researchers, there is nothing in Conan Doyle’s behavior to mark him as an addict. Still, Conan Doyle was a physician–one who studied eye surgery in Vienna, in which the ground-breaking research on cocaine’s anaesthetic properties was conducted–and an intelligent, perceptive man of the world. He knew about both the reality of drug use and the horrors of cocaine and morphine addiction, knowledge which Watson (an Army doctor) shares. Holmes’s use of substances makes sense in the context of his era and his personality, whether he was using due to boredom, or to self-medicate for deeper reasons. Like Halsted’s fellow physicians, Watson even believes that such a brilliant man could not possibly be under the influence until, at some point, the evidence is incontrovertible, and we have the famous scene in SIGN. As the perils of cocaine use become more apparent over time, Watson does the sensible thing and helps Holmes kick his habits, knowing all the while that relapse was ever a possibility. Because Holmes’s drug use is not the focus of the stories, we don’t get much more detail than that.‡‡‡ Still, it was fascinating to me to recognize elements of those habits and Holmes’ personality in both Freud and Halsted, particularly the latter. One has to wonder what Watson doesn’t say, out of his Victorian reticence and respect for his friend.

On Watson’s part, this desire to preserve a friend and patient’s privacy is understandable and laudable. As Sherlockians, however, I am not sure that we should fall into the trap of minimizing Holmes’s drug use, possible dependency, and the effects of such. In the two years I have been a part of this obsession, I have become vaguely aware of attempts to whitewash the situation, with claims that Holmes didn’t inject directly into the vein and therefore couldn’t have been an addict. That cocaine was legal, bought over the counter and appeared in soft drinks in Georgia, so it couldn’t be the scary stuff people kill each other over in Scarface. Perhaps only The Seven Percent Solution, with its theory that Moriarty was a figment of Holmes’s cocaine-addled imagination§ and Michael Dibdin’s dark (possibly over-the-top) foray into cocaine-induced psychosis, The Last Sherlock Holmes Story, probe the issue in  great depth, and when they do, it’s kind of disturbing. Why? We generally want our heroes to be true heroes, not people just as fallible, vulnerable, venial and incomprehensible as we are. Is this, however, honest or fair–to Holmes or to anyone? Isn’t it possible to admit that cocaine is, if not used in a narrow medical context, a dangerous, addictive substance (regardless of how it’s administered), and that while people fall into its trap for many reasons–experimentation, self-medication, recreation–no one intends to get caught?  Isn’t it simply acknowledging the realities of life to admit that abuse and addiction have negative consequences for everyone involved, no matter how functional the addict is, or believes herself to be?  Markel does an excellent job of showing how a scholar and writer can explore the darker crannies of his subject’s life, yet do so in such a way that the reader comes away with respect, compassion, understanding, and even affection for that individual. I finished the book with a distinct sense of melancholy, mingled with hope. Life is hard. None of us gets out of it clean; Halsted and Freud were not exceptions. White powder and injected solutions stole a great deal of joy from their lives, but they never stopped pursuing what mattered most to them–and what mattered most was not cocaine. It may have ruled the minutes, but never the hours.

An Anatomy of Addiction is available in hardback, paperback and eBook (Kindle, Nook, and Kobo). You can learn more about Dr. Markel on his website, www.howardmarkel.com, and he apparently has a FaceBook page.

I would like to know what you think about The Anatomy of Addiction, and/or about the subject of Holmes and cocaine. Leave your comments below, and on 12/22, I’ll do a random drawing for a free copy of this book.

Star Rating: 5 out of 5   “This is a wonderful book that gets it right.”

Footnotes:

*Markel, p. 52

**I’ll be back as soon as I get an energy drink from the fridge.

***Mariani provided a case free to a selected celebrity, and asked for a letter of endorsement in return. He received accolades from such luminaries as Edison, Rodin, Jules Verne, the Pope–and Arthur Conan Doyle.

†Which makes this quote from Markel particularly enjoyable: “But the obvious historical difference, of course is that these [anxious letters to Martha Bernays] were the career musings and worries of Sigmund Freud. Unlike countless other pupils who ruminate bitterly about real or perceived slights from their professor and mutter resentful vows of burying them with the attainment of fame and accomplishment, Freud actually did it.” (Markel, pp.30-31)

††Markel, p.100

†††I’d say that you only do that once, but actually, I did it at least three times.

‡This statement is made in an oft-mentioned book on Holmes and cocaine. It is incorrect. To give you an idea of what we are dealing with, I’d like to provide this chilling section from Markel’s book:

In time, cocaine abuse yields significant damage not only in the brain’s pleasure centers but also in the frontal cortex, the region of the brain that facilitates decision making. The extent of this neurological derangement was most starkly demonstrated during the late 1960’s. Scientists gave one set of laboratory rats ample food and water, and open access to heroin; the other group was given the same food and water but the bar was serving cocaine. The heroin rats certainly became addicted to their drug, but its narcotic effects curtailed their consumption to specific times during the day. Basically, they got stoned and fell asleep, awoke, drank water and ate, and then started all over again. On the other side of the caged neighborhood, the cocaine rats did nothing but consume more cocaine. At various points, some of these rats would collapse with nervous exhaustion, but once they awoke, they routinely pursued more cocaine. A month later, the heroin rats were surviving nicely, albeit addicted to narcotics; the cocaine rats were all dead. (Markel, p.105)

‡‡Markel, pp. 98-99. In his endnotes, Markel also cites Alvin Rodin and Jack D.Key’s Medical Casebook of Arthur Conan Doyle,  Jon Lellenberg et al., Arthur Conan Doyle: A Life in Letters, and an article by David F. Musto, “Sherlock Holmes and Sigmund Freud,” which appeared in the collection Cocaine Papers (NY: Stonehill, 1974).  I don’t have access to any of these currently, and so cannot tell you what they say about Doyle’s experience with cocaine.

‡‡‡There are, however, multiple fanfics devoted to withdrawal/relapse stories in both the Victorian and BBC universes which treat the issue with varying degrees of accuracy and detail. Look for them in the hurt/comfort or angst genres.

§Patently untrue, of course. Moriarty was real. It is interesting to note that in Meyer’s book, Freud alludes to Fleischl-von Marxow, but doesn’t say much about his own experiences with the drug, of which he was at that time an active user.