Abstract
When Thomas Trotter retired from his long career as physician to the Channel Fleet in 1804, he published his earlier MD thesis—an essay on drunkenness. 1 While Trotter was not the first to recognise the problem of addiction, or to suggest potential treatments, his manuscript was the first book-length discussion on the subject—and the first to suggest that addiction was ‘a disease of the mind’. His seminal work probably had little impact at the time—the medical profession, and the general public, were more supportive of the moralistic tone promoted by Benjamin Rush in his 1785 pamphlet ‘Ardent Spirits’.2,3
However, as the nineteenth century progressed, the problem intensified, with the increasing availability of opium and sedatives such as chloral hydrate, followed by the introduction of anaesthetic agents and the development of hypodermic syringes. Medical professionals were particularly at risk; highly addictive substances, such as chloroform, morphine and later cocaine, were largely unregulated and doctors carried them everywhere, storing them in their homes at night. Not surprisingly, they often used these substances to treat their own physical and mental pains, leading to addiction in many.
For some the problem arose from an acute illness. In 1874, George Harley, a brilliant doctor and physiologist at University College Hospital, London, developed extremely painful sympathetic ophthalmoplegia after a retinal haemorrhage. For three weeks, he lay in a dark room with hot poultices on his eyes, blind and completely unable to sleep, resisting the morphine bottle provided by his physician colleagues. Eventually, in a moment of despair, he drained the whole bottle: ‘It lifted me from purgatory into paradise, and I made myself a vow never to be hard upon an opium eater after having myself tasted of its bliss’. 4 He deteriorated rapidly and within weeks was hopelessly dependent on morphine, physically wasting away. With the help of his wife, medical colleagues, and his ‘steely resolve’, Harley recovered and returned to his successful career—but he made no secret of the problem that had threatened to overwhelm him.
New York surgeon William Halsted’s cocaine addiction was also no secret—but it was accidental. When the local anaesthetic properties of cocaine were discovered in 1884, Halsted and his colleagues were quick to imagine ways of using it to perform major surgical operations under local anaesthesia. 5 Halsted conducted many of his experiments on himself, injecting diluted cocaine around various nerves, attempting to perfect his nerve blocks. 6 He became increasingly erratic and physically unwell, often suddenly drenched in perspiration with shaking hands. Recognising the problem, medical colleagues, William Welch and Thomas McBride, organised a sailing trip to the Windward Islands off the coast of South America, hoping to isolate Halsted from his source of drugs. Halsted managed to sabotage the trip, but on return admitted himself to the Butler Hospital on Rhode Island for treatment. 6 Unfortunately, that treatment substituted morphine for cocaine—leaving Halsted battling morphine addiction for much of his life. Despite this, he returned to work with the support of his friends, and by 1890 he was appointed chief of surgery at the Johns Hopkins dispensary, a position he held for 30 years.
Both Harley and Halsted benefited from understanding colleagues who recognised the problem was an illness, one that required supportive friends and effective treatment. Increasingly, that is how the problem was being seen. Inebriety became a recognised medical condition in the 1850s; initially the term referred to those addicted to alcohol, but rapidly came to include those with drug addictions as well. 7 Organisations sprang up dedicated to addressing the condition, with societies such as the American Association for the Cure of Inebriates, and in Britain, the Society for the Study and Cure of Inebriety. These in turn spawned professional journals—the Journal of Inebriety and the British Journal of Inebriety—still published now as Addiction.8,9 Treatment options appeared in many guises, ranging from religiously influenced inebriate homes to medically operated inebriate asylums; they could be respectably run establishments or opportunistic businesses pedalling fraudulent remedies. 10 Often it was difficult to tell the difference.
Dr Leslie Keeley and colleagues, at the Keeley Institute in Illinois, claimed they could cure all forms of addiction with their residential programme and the regular administration of ‘double chloride of gold remedies’. The remedy came in three colours, red, white and blue, administered four times a day by injection, along with an oral tonic second-hourly. The tonic was also available by mail order and each patient was given their own formula in beautifully crafted bottles. The contents were a carefully guarded secret. Suggested ingredients varied from aloe plant, willow bark, ginger and ammonia, to hyoscine, cocaine, opium and morphine. Gold was advertised as a vital ingredient, but it seems doubtful it was ever included in significant quantities. The programme was very successful—and extremely lucrative for its owners. Many of the patients were doctors; by the 1940s, the institute had treated over 1700 physicians. For a while, many of these recovered doctors were employed by the hospital, and in 1892 there were 100 former patients working as physicians at the institute. This practice eventually ceased due to professional criticism and some serious relapses among these doctors.
In other places, recovered doctors started their own practices, becoming specialists in addiction medicine, using their own experiences to treat others humanely. Oscar Jennings, a Paris-based British surgeon, freely discussed his own experiences, while making the extraordinary claim that ‘one in four medical men is a drug habitué’. 11 In his own practice, 75% of his patients were doctors. 12 Others were seeing similar numbers—J B Mattison, medical director of the Brooklyn Home of Habitues, noted ‘more cases of morphinism are met with among medical men than in all other professions combined… the subtly ensnaring power of morphia is simply incredible to one who has not had personal experience or observation’. 13
While these numbers are disturbing they represent not just the disease prevalence, but also the number of people seeking help—a first important step on the road to recovery. Behind the numbers are important personal stories. Some, like Harley and Halsted, had their stories narrated by others, but others like the Russian doctor, Mikhail Bulgakov, wrote their own—helping to explain and destigmatise the condition, giving voice to the many other hidden sufferers. As a young doctor, Bulgakov sustained abdominal wounds while working at the front during the First World War. 14 Later in the war he spent 18 months in a remote, poorly resourced dispensary in Smolensk. He was the only doctor there—inexperienced, under-resourced—and overwhelmed. He began using morphine to treat his abdominal pain—although it is clear the drug was helping him with many other issues. 15 Eventually, he recovered from his addiction but he never returned to medical practice, choosing instead to pursue a career as a writer. His short story, Morphine, first published in the 1920s, is a dramatic, semi-fictionalised account of his own struggles with morphine addiction. 16 It was intended to be informative, to educate others about the problem. In it, one of the characters debates whether to publish his colleague’s diary entries of drug addiction: ‘I cannot say with any certainty whether they are instructive or useful though I believe they are… should I publish the diary which was entrusted to me? I should. Here it is.’ 16
Writing is therapeutic—and while statistics and cold hard facts are important—it is the personal stories that resonate, which remain long after the facts have faded from our memories. Stories are powerful and effective—and as long as doctors continue to battle with addictive substances, we need those brave enough to write their stories so we remain alert to the risks—to our colleagues, to our patients—and to ourselves.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.