A CASUALTY OF COCAINE

THE BALTIMORE SUN

In his later years, the eminent doctor wore a tall silk hat, ordered his suits from a London tailor and his shoes from a Paris boot maker. In the fireplace of his mansion on Eutaw Place, he burned only hickory logs cut on his summer estate in North Carolina and aged at least three years. He was a dignified and meticulous man with a long, white mustache, pince-nez and the slightly reproachful look of a Victorian gentleman.

As the first surgeon-in-chief of Johns Hopkins Hospital, Dr. William Stewart Halsted had helped transform surgery from a brutal business for amateurs to a delicate science.

A founding father of Hopkins, Halsted had developed or improved operations for breast cancer, hernia, aortal aneurysms, thyroid and gallbladder trouble. He had pioneered the use in America of silk sutures, surgical clamps and rubber gloves. He had corresponded with the greatest medical minds of Europe, operated on the rich for mind-boggling fees and trained a generation of surgeons who preached his gospel all over the country.

And he had kept his astonishing secret to himself.

Only a few of his closest associates knew that as a young surgeon experimenting with anesthesia, Halsted had become one of America's first cocaine addicts. The habit derailed and nearly destroyed his career, sending him twice to a mental hospital before he finally managed to get off cocaine -- by getting on morphine. Fewer still knew that he took time each day from the busy schedule of a Hopkins Medical School professor to shoot up with morphine, probably to the end of his life at the age of 70 in 1922.

"He fell into this not realizing the effect it could have on his life," says Dr. Daniel B. Nunn, a Florida surgeon and historian for the Halsted Society, a surgical honor society. "He was a true victim."

Today, on some of the rough streets in the shadow of Hopkins Hospital, cocaine is sold around the clock. The wonder drug of a century ago has become a scourge. Young men shot in the drug trade regularly land in the surgical intensive-care unit in the hospital building that bears Halsted's name.

Theirs is a world one presumes would be unfathomable to the stiff, wealthy patriarch who worked at Hopkins a century ago. But Dr. Nunn, who is working on a biography of Halsted, says the surgeon understood the insidious power of cocaine.

"He would be very much upset and appalled, but I'm not sure he'd be surprised," he says. "He was very much aware of what drugs could do to people."

The story of Halsted's cocaine habit, which can be pieced together from old medical journals, letters in the Hopkins archives, and the findings of a few scholars, is more than a Baltimore mystery tale or a footnote to medical history.

It is a glimpse at the very beginning of America's ruinous entanglement with the white, powdery alkaloid derived from the leaves of the South American coca plant.

The story begins in New York City, where Halsted was born in 1852, the son of a prosperous merchant. He was taught at home by a governess until the age of 10, graduated from prestigious Phillips Academy in Andover, Mass., and from Yale University, where he was a bon vivant and captain of the football team. When he went on to the College of Physicians and Surgeons in New York, which would become Columbia University's medical school, he applied himself to his studies and compiled a superb record.

After a surgical internship and two years of study in Europe, Halsted returned to New York, where he quickly established a reputation as a tireless, innovative surgeon. He operated seven days a week at six different hospitals, ran an outpatient service for the poor and still found time to offer classes for medical students -- from 9 p.m. to midnight.

Once, when his sister dangerously hemorrhaged after giving birth, he grabbed a syringe, drew his own blood and injected it into her vein, a daring move that may have saved her life. On another occasion, he performed pioneering gallbladder surgery on his own mother.

He later would describe these first five years of practice as the happiest years of his life. Friends described him as an outgoing man with a busy social life, and associates saw him as headed for a stellar career.

Then, in October 1884, Halsted saw in the Medical Record a report of a paper presented at a conference of German ophthalmologists on the anesthetic properties of cocaine. For some years, cocaine had been an ingredient in popular tonics, but its medical use was minimal. Halsted was intrigued by its promise: "Within a week or two, at most, of the arrival in this country of [Vienna ophthalmologist Carl] Koller's first paper announcing the anesthetic effect of cocaine on the conjunctiva we began active experimentation with the drug, hoping that it might prove of use in general surgery," Halsted wrote in a letter many years later. "By 'we' I mean twenty-five or thirty students . . . who registered with me as their preceptor. At the evening quizzes we began our injections into nerves."

Halsted was not the only interested doctor. The Squibb pharmaceutical company received 300 cocaine orders from physicians and researchers in the month after the Medical Record report. The price rose from $2.50 a gram to $7 and kept climbing.

Even as they experimented with injections on the job, some doctors started using cocaine after hours.

"It became rather the fashion to snuff [cocaine] at the theater, where it seemed to add color to the play," wrote Dr. W. G. MacCallum, Halsted's first biographer.

One of the experimenters, Dr. J. K. Bauduy, wrote eloquently to the New York Medical Journal about the allure of the drug: "As soon as a medicinal dose of cocaine has reached the circulation, a feeling of well-being is experienced, all sense of physical and mental fatigue which may have been present disappears as if by magic; the mind becomes excessively clear; ideas constantly flow and the faculty of speech seems especially exalted. So long as these effects are continued, sleep is impossible: no fatigue is experienced from continued muscular movements, no matter how prolonged. . . . "

But by the time Bauduy's letter was published in 1885, Halsted and a number of other doctors already had found that the "magic" of cocaine could spiral into a disabling obsession.

Bauduy described the drug's dark side in bitter, emotional terms:

"The most alarming poisonous effects of the drug are: debasing and enslavement of the will, a general demoralization which is as diabolical as it is indescribable, and which tends rapidly toward depravity and to the development of everything that is degrading and ignoble in human nature. Habits of the most detestable character, a settled indifference to every interest in life, destruction of the most noble affections and affiliations; the utter death of friendship and of all the nobler qualities, complete disregard of all social and domestic duties, of even pressing family necessities and the common interest of daily life; the radical extinction of every previous religious spark that had enlivened the soul; the development of the most intense selfishness -- these are the certain results of indulgence in this the most powerful and devilish drug which it has ever been the misfortune of man to abuse."

Halsted wrote about his own cocaine problem only in glancing, euphemistic references, but the record of his own career reveals the drug's shattering impact on his life. By early 1885, he and at least three of his closest associates were addicted to the drug. He had stopped attending New York Medical Society meetings and was having trouble coping with surgery and teaching.

Late in 1885, Halsted published his own scientific paper on cocaine. But his spare, clear writing style had been transformed by the drug to rambling incoherence, which is conveyed by its opening lines: "Neither indifference as to which of how any 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 anesthetic, had been supposed, if not declared, by most so very sure to prove, especially to them, attractive. . . ."

An aside in the paper refers to the author's "poor health." It was a weak phrase for the catastrophe that had occurred.

A student, Thomas Southworth, wrote of his mentor that "the extreme nervousness engendered by the taking of cocaine became unbearable. . . . This drug addiction did not decrease his interest in medicine but it decreased his powers to such an extent that he was threatened with professional extinction."

Halsted was invited to give a series of lectures in a competition for the chair of surgery at the College of Physicians and Surgeons, but his work was so erratic that he was forced to drop out.

In February and March of 1886, he took a sea voyage to the Windward Islands in the Caribbean -- a common tactic at the time for people trying to escape alcoholism or addiction. But he defeated the trip's purpose by breaking into the ship's store and stealing a supply of cocaine, according to Dr. Nunn, the Halsted society historian.

A couple of months later, a young physician who came to see Halsted about a job found him "very much excited," talking rapidly and incoherently about a wild range of topics.

A few days after this encounter, Halsted committed himself to Butler Hospital, a well-reputed mental hospital in Providence, R.I. He used the pseudonym William Stewart and remained for more than six months. Discharged at the end of 1886, Halsted was invited to move to Baltimore by an old friend, Dr. William Welch, a pathologist and bacteriologist and one of Hopkins' four founding doctors. Welch was doing research on animals in the pathology laboratory that would ultimately become part of the Hopkins medical complex. In part as an act of charity, he gave Halsted work and got him a room in a Cathedral Street boarding house.

The arrangement apparently worked reasonably well, and Halsted was in sufficient condition to lecture in New York and Harvard in the spring of 1887. But by April, he had relapsed and was back at Butler Hospital, this time for an eight-month stay. Some researchers have speculated that while at Butler, Halsted got off cocaine and onto morphine, a painkiller and like heroin, a highly addictive derivative of opium.

Secretly self-medicating with morphine, Halsted returned to Baltimore and resumed his work in Welch's lab. Eventually, convinced that Halsted had conquered the drug problem, his colleagues oversaw his gradual return to surgery. In 1889, the year Johns Hopkins Hospital opened, Halsted became associate professor of surgery, and in 1892, at 40, he was promoted to full professor of surgery and surgeon-in-chief at the hospital.

One day about six months after Halsted's promotion to the top surgical post, Dr. William Osler, another of Hopkins' founding physicians, surprised the surgeon "in a severe chill" -- a symptom of withdrawal from morphine.

"He had worked so well and energetically that it did not seem possible that he could take the drug [morphine] and do so much," Osler wrote of the incident. "This was the first intimation I had that he was still taking morphia.

"Subsequently I had many talks about it and gained his full confidence. He had never been able to reduce the amount to less than three grains daily [about one-fifth of a gram]; on this he could do his work comfortably and maintain his excellent physical vigor -- (for he was a very muscular fellow)."

Osler, a revered teacher and historian of medicine, recounted the tale in his "Inner History of the Johns Hopkins Hospital," which he sealed before his death in 1919, directing that it not be published until the hospital's centenary in 1989. Curiosity overcame his successors, who asserted that his instructions were ambiguous and approved the history's publication in 1969. In it they also found Osler's scribbled footnote on his description of Halsted's drug use: "Subsequently, 10 Jan. 1898, he got the amount down to 1 1/2 grains, and of late years (1912) has possibly got on without it."

Apparently Osler's surmise was incorrect. On his death bed in 1934, Hopkins co-founder William Welch revealed that Halsted had continued to use morphine periodically to the end of his life.

During relapses in later life, "Halsted would leave town and, upon his return, come to [Welch] contrite and apologetic to confess," wrote the late Dr. Peter D. Olch, a physician and medical $H historian who studied Halsted's drug habit. Olch also tracked down the caretaker of Halsted's summer home in North Carolina, who related stories of the surgeon's continuing drug use.

In Baltimore, during the 30 years between his appointment as surgeon-in-chief and his death in 1922 of complications from gallstone surgery, Halsted's reputation as a surgical thinker and teacher solidified.

"He secured a very good income from a very few patients as his fees were enormous -- at least they were so regarded," Osler wrote.

He married a surgical nurse, Carolyn Hampton. They had no children and kept largely to themselves.

"The Chief and his wife are certainly queer people," wrote Harvey Cushing, a resident under Halsted from 1897 to 1900 and later a prominent neurosurgeon. He visited the mansion at 1201 Eutaw Place, where Halsted had an extensive surgical library on the first floor, and found it "a great, magnificent, cold stone house, full of rare old furniture, clocks, pictures and whatnot in topsy turvy condition, cold as a stone and most unlivable."

Halsted's standoffish manner in Baltimore was a striking contrast with his outgoing, social style in his pre-cocaine days in New York.

Osler traced Halsted's withdrawn nature directly to the drugs: "The proneness to seclusion, the slight peculiarities, amounting eccentricities at times (which to his old friends in New York seemed more strange than to us) were the only outward traces of the daily battle through which this brave fellow lived for years."

After his appointment as full professor, Halsted stayed away from research that would require any contact with cocaine and even avoided mentioning the topic. When Harvey Cushing proposed experiments with cocaine anesthesia to Halsted, the elder man never mentioned his own previous extensive research. Cushing first learned of Halsted's work many years later.

While Halsted battled to keep his career on course, some of his colleagues in the cocaine experiments also struggled.

His closest associate, Richard Hall, saw his promising New York career --ed by cocaine. He moved to the relative obscurity of Santa Barbara, Calif., where he struggled for several more years with addiction before possibly beating the habit. In 1895, Hall wrote to Halsted that he was "pulling myself together after a period of long misery, the causes of which I do not need to describe."

Years later, in a letter to an old friend, Halsted wrote that in addition to Hall, "two other assistants of mine acquired the cocaine habit in the course of our experiments on ourselves -- injecting nerves. They all died without recovering from the habit."

In the years after Halsted traded cocaine for morphine, cocaine found a market far beyond the elite world of medical experimentation.

As early as 1903, a Baltimore grand jury report remarked on an emerging street trade in the drug. "The 'Cocaine' habit promises to be a serious evil. It is practised by those incapable of knowing that its continued use must result in mental and physical wreck," the report said.

In 1906, the grand jury recorded 28 cases brought against cocaine sellers and added a prescient comment.

"A nefarious trade which shows a retail profit of several hundred percent cannot be suppressed by the penalties imposed by the present laws," the grand jury reported. "A fine of $25.00 against the seller of these drugs for the first or second offense is not sufficient punishment when his profits amount to $40.00 or $50.00 per day."

Nearly nine decades later, more severe laws have filled the nation's prisons to overflowing with cocaine dealers and users. But drug profits continue to defeat the best efforts of law enforcement.

For Halsted himself, there was a poignant postscript. In 1920, the National Dental Association appointed a committee to investigate a dispute over who had first discovered neuroregional anesthesia -- the fact that by injecting anesthetic into a nerve, a doctor could block feeling to an entire region of the body.

At the conclusion of its research, the committee gave the credit to Halsted. In his ill-fated New York cocaine experiments of 1884, it said, he had been the first to discover the principle of nerve blocking.

On April 1, 1922, five months before his death, Halsted was honored by the dental association in a banquet at the Belvedere Hotel.

"As a man, as an inspiring teacher and as a scientific surgeon, he stands without a peer today," said Dr. John M. T. Finney in one of many encomiums.

The next night, Halsted, in a reflective mood, wrote to thank one of the organizers of the banquet, making a rare reference to his own battle with cocaine some 38 years before.

"The reaction from this great joy seems to be setting in tonight," ++ Halsted wrote, "and my happiness is tinged with regret for the lost opportunities -- for the time wasted from loss of health."

SCOTT SHANE is a Sun reporter.

The Early History Of Cocaine

Cocaine is a drug obtained from the leaves of the coca plant, a shrub indigenous to several South American countries. Since ancient times, native cultures of that continent have chewed coca leaves for mental stimulation and to alleviate hunger, seemingly without ill effect. European explorers in South America encountered this use as early as the 16th century.

1859 -- Austrian explorer Karl von Scherzer brings coca leaves from South America to Europe for study.

1860 -- Austrian scientist Alfred Niemann extracts an alkaloid from coca leaves and calls it cocaine.

1872 -- Scottish neurologist Alexander Hughes Bennett reports anesthetic properties of cocaine in a medical thesis.

1884 -- In June, in a love letter to his fiancee, Martha Bernays, Sigmund Freud writes: "In my last severe depression I took coca again and a small dose lifted me up to the heights in a wonderful fashion. I am just now busy collecting the literature for a song of praise to this magical substance." He publishes a paper, "On Cocaine," recommending it for fatigue, nervousness, alcoholism and morphine addiction.

1884 -- In October at a conference in Germany, Freud's ophthalmologist friend, Carl Koller, presents his findings on the use of cocaine as a local anesthetic. A report of the paper is printed in the Medical Record in New York. William Halsted, like many other doctors, obtains a supply and begins the anesthesia experiments that cause his addiction.

1885 -- The New York Times reports that cocaine is being used successfully to treat a variety of complaints, from hay fever to seasickness. The Medical and Chirurgical Society of Maryland reports "cocaine took up much attention" at its annual meeting, where five papers on the drug are presented. The Parke-Davis pharmaceutical company calls cocaine "the most important therapeutic discovery of the age."

During the 1880s, cocaine becomes a key ingredient in tonics and elixirs, nasal sprays and even hemorrhoid remedies, despite growing evidence of the drug's addictive and toxic properties. One cocaine-based tonic called Vin Mariani wins worldwide popularity as a cure-all and is praised by Thomas Edison and Pope Leo XIII, among others.

1886 -- Atlanta pharmacist John Pemberton creates a tonic called Coca-Cola from a secret formula of coca leaves, kola nuts and a small amount of cocaine. In 1891, Asa Chandler obtains the formula and founds the Coca-Cola Co.

1887 -- Freud publishes a paper called "Craving for and Fear of Cocaine" that revises his earlier views on the drug. In retrospect he refers to 1885, when he inadvertently got a friend addicted to cocaine, as "the least successful and darkest year of my life."

1902 -- Street trade in cocaine has become well-established in many American cities, which begin to pass regulations limiting its sale. A medical textbook reports that "Cocainism is a new disease of civilization, falling most heavily on the extremes of LTC society -- the wealthy and the pauper classes." In 1904, the Coca-Cola Co. bows to public pressure and removes the cocaine from its formula.

1914 -- Congress passes the Harrison Narcotics Act, culminating a period of tightening regulation in response to a growing awareness of the hazards of drug abuse. By requiring detailed records of the production, import and sale of cocaine and other drugs, the act greatly reduces the sale of pharmaceutical cocaine to abusers and essentially drives the trade underground, where it remains 80 years later.

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