Prologue
 
On the morning of May 5, 1885, in lower Manhattan, a worker fell from a building’s scaffolding to the ground. A splintered bone protruded from his bloody trousers; a plaintive wail signaled his pain; and soon he was taken from the scene by horse-drawn ambulance to Bellevue Hospital. At the hospital, in the dispensary, a young surgeon named William Stewart Halsted frantically searched the shelves for a container of cocaine.
 
In the late nineteenth century, there were no such things as “controlled substances,” let alone illegal drugs. Bottles of morphine, cocaine, and other powerful, habit-forming pills and tonics were easily found in virtually every hospital, clinic, drugstore, and doctor’s black bag. Consequently, it took less than a few minutes for the surgeon to find a vial of cocaine. He drew a precise dose into a hypodermic syringe, rolled up his sleeve, and searched for a fresh spot on his scarred forearm. Upon doing so, he inserted the needle and pushed down on the syringe’s plunger. Almost immediately, he felt a wave of relief and an overwhelming sense of euphoria. His pulse bounded and his mind raced, but his body, paradoxically, relaxed.
 
The orderlies rushed the laborer into Bellevue’s accident room (the forerunner of today’s emergency departments) for examination and treatment. A compound fracture—the breaking of a bone so severely that it pokes through the soft tissue and skin—was deadly serious in the late nineteenth century. Before X-ray technology, it was difficult to assess the full extent of a fracture other than by means of painful palpation or cutting open the body part in question for a closer look. Discounting the attendant risks of infection and subsequent amputation, even in the best of surgical hands these injuries often carried a “hopeless prognosis.” 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.
 
As the worker writhed in agony, one surgeon’s name crossed the lips of every staff member working in the accident room: Halsted. When it came to a crisis of the body, few surgeons were faster or more expert than he. Leg fractures were a particular interest of his in an era when buildings were being thrown up daily and construction workers were falling off them almost as frequently. One of Dr. Halsted’s earliest scientific papers assessed the surgical repair of fractured thigh, or femur, bones using a series of geometric equations based on how the leg adducted (drew toward) and abducted (drew away) from the central axis of the body. Such meticulous analysis was essential to repairing the break in a manner that accounted for the potential of the injured limb to shorten after the injury. Otherwise, the broken leg would heal in a manner that resulted in a decided limp or, given the intricate mechanics of the hip joint, much worse.
 
An orderly was dispatched to find Dr. Halsted as soon as possible. Running through the labyrinthine corridors of the hospital, he shouted, “Paging Dr. Halsted! Fresh fracture in the Accident Room! Paging Dr. Halsted!” Down one of these halls, in a rarely used chamber, the surgeon was entering a world of mindless bliss. He heard his name but didn’t really care to answer. Yet something, perhaps a reflex ingrained by his many years of surgical training, roused him to stagger out into the hallway and make his way downstairs. The pupils of his eyes looked like gaping black holes, his speech was rapid-fire, and his whole body seemed to vibrate as if he were electrified.
Upon entering the accident room, Halsted was confronted with the acrid smell of blood and a maelstrom of doctors and nurses attending to the wounded worker. So intense was the pain that when Halsted gruffly demanded the patient move his leg one way or the other, the man screamed out an emphatic “No!” Passing a hand up and down the length of the laborer’s lower leg, Halsted could feel the sharp ends of a shattered shinbone, or tibia, thrusting its way through the skin. It was a gory mess requiring immediate attention.
 
An effective surgeon must be able to visualize the three-dimensional aspects of the anatomy he is about to manipulate. He must take great care in handling sensitive structures surrounding the area in question, such as nerves and blood vessels, to prevent cutting through or destroying them entirely, lest the procedure cause more problems than it corrects. Consequently, the surgeon needs to think several steps ahead of the maneuver he is actively performing in order to achieve the best results for his patient. But the cocainized Halsted was in no shape to operate.
 
Halsted stepped back from the examination table while the nurses and junior physicians awaited his command, mindful that in a moment bacteria could enter the wound and wreak havoc, perhaps leaving this laborer unable to walk again—or even to die from overwhelming sepsis. To their astonishment, the surgeon turned on his heels, walked out of the hospital, and hailed a cab to gallop him to his home on East Twenty-fifth Street. Once there, he sank into a cocaine oblivion that lasted more than seven months.
 
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Forty-four hundred miles away, Sigmund Freud, an up-and-coming neurologist, toiled away in the busy wards of Vienna Krankenhaus (General Hospital). Like Halsted, he was fresh prey for cocaine’s grip. On May 17, 1885, twelve days after Halsted hurried out of Bellevue, Dr. Freud boasted to his fiancée how a dose of pure cocaine vanquished his migraine and inspired him to stay up until four in the morning writing a “very important” anatomical study that “should raise my esteem again in the eyes of the public.” In reality, the publication proved to be nothing more than an extraneous footnote to his literary oeuvre.
 
A year earlier, Freud had published an extensive review exploring cocaine’s potential therapeutic uses. His central experimental subject was himself. But as impressive as his work was, Dr. Freud neglected to describe cocaine’s most practical application: it was a superb anesthetic that completely numbed a living being’s sensation to the sharp blade of a scalpel. In the fall of 1884, a few months after Freud’s monograph appeared in print, a young ophthalmologist successfully demonstrated the drug’s power to kill pain. The discovery excited the entire medical world, much to Freud’s chagrin.
 
In the spring of 1885, the preempted Freud made plans to flee Vienna and nurse his wounded ego with a prestigious neuropathology fellowship in Paris. In the months that followed, he engaged in discussions of brain disorders, witnessed dozens of demonstrations of women and men suffering from hysteria, participated in detailed scientific research, and, too frequently, self-medicated his anxieties away.
 
Cocaine thrilled him in a manner that everyday life could not. He wrote romantic, often erotic letters to his fiancée, dreamed grandiose dreams of his future career, walked about the streets of Paris, visited museums and theaters, and attended sumptuous soirees—all under the influence. Even on return to his beloved Vienna in 1886, eager to embark upon his own private practice and excited about the possibility of new medical discoveries and explorations, Freud continued to take increasingly greater doses of cocaine.
 
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The full-fledged diagnosis of addiction did not really exist in the medical literature until the late nineteenth century. The earliest use of the word appears in the statutes of Roman law. In antiquity, “addiction” typically referred to the bond of slavery that lenders imposed upon delinquent debtors or victims on their convicted aggressors. Such individuals were mandated to be “addicted” to the service of the person to whom they owed restitution. By the seventeenth century and extending well into the early 1800s, “addiction” described people compelled to act out any number of bad habits. Those abusing narcotics during this period were called opium and morphine “eaters.” Alcohol abusers, too, had their own pejorative descriptors, such as “the drunkard,” but as their problem came to the attention of physicians, the condition was often indexed in medical textbooks as dipsomania or alcoholism.
 
All this changed in the late nineteenth century with the overprescription of narcotics by doctors to ailing and unsuspecting patients. One of the most striking measures of this era was the alarming number of male doctors who prescribed opium, morphine, and laudanum (a tincture of macerated raw opium in 50 percent alcohol) to ever greater numbers of women patients. Any female complaining to her physician about so-called women’s problems was all but certain to leave the doctor’s office clutching a prescription. For example, epidemiological stud­ies conducted in Michigan, Iowa, and Chicago between 1878 and 1885 reported that at least 60 percent of the morphine or opium addicts living there were women. Huge numbers of men and children, too, complaining of ailments ranging from acute pain to colic, heart disease, earaches, cholera, whooping cough, hemorrhoids, hysteria, and mumps were prescribed morphine and opium. A survey of Boston’s drugstores published in an 1888 issue of Popular Science Monthly documents the ubiquity of these narcotics: of 10,200 prescriptions reviewed, 1,481,or 14.5 percent, contained an opiate. During this period in the United States and abroad, the abuse of addictive drugs such as opium, morphine, and, soon after it was introduced to the public, cocaine constituted a major public health problem.
 
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