Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (26 page)

Caroline was nothing if not opinionated. She was a country girl who made no effort to disguise her dislike for city life, and immediately after their marriage she began spending at least half the year at High Hampton. Halsted, too, was absent from Baltimore and Johns Hopkins from May to October, but he spent no more than two months
at High Hampton. What he did, and where he went, is the subject of conjecture. He regularly sent letters and postcards from capital cities and small villages, but he was always unaccompanied in his travels, and unless visiting European surgical friends, his whereabouts were loosely established and his routine unknown.

At High Hampton he made every effort to conform to the life Caroline had established. Though anything but a horseman, Halsted had great athletic ability and set about learning everything about horses, riding, and driving, until his skills were estimable. They purchased fine horses and shared long trail rides with the spaniels running before and beside them. Halsted even familiarized himself with enough veterinary practices to care for their ailments. Still, Caroline felt the world of horses was her domain and never quite accepted her husband’s increasing competence, just as she never considered herself able or worthy in the flip side of their lives together.

She wrote to Halsted, “I always could have ridden her [a mare in question] I think, but you did not think so. A person who does not ride never can understand how one who can ride does it as naturally as they breathe. You never understood either how crazy I always was to get out and away.”

Caroline believed herself entirely self-sufficient, and there is much evidence to support her contention. Though she was at times consumed with managing household servants and field-workers, outdoor physical work was central to her chosen lifestyle. She reveled in being alone at High Hampton in the periods when servants were not present: “The servants left this
A.M.
and I am happily entirely alone. My dinner has been served and I see no one until the milk comes at 6:30. My personal wants are few and I can always make myself comfortable.”

THE HALSTEDS WERE
treated with the respect afforded land-rich, moneyed outsiders, but people were not as oblivious to their habits as they seemed. Their comings and goings were noted, and there
was a good deal of “general talk” around Cashiers that both Dr. and Mrs. Halsted were addicted to drugs. On one occasion, an agitated Caroline Halsted confronted farm manager Douglas Bradley about a package she had been expecting from Parke-Davis, the manufacturer of morphine. When the package failed to arrive, she sent Bradley to the office of a local doctor. There he picked up a package similar to those received regularly from Parke-Davis or the local physicians.

Morphine was readily available without prescription until the Harrison Narcotics Tax Act of 1914. Chemically, morphine is an alkaloid, and the active ingredient in opium. It is extracted from the poppy plant and structurally very similar to its even more potent cousin, heroin. Morphine was first isolated early in 1804 but was not widely used for the next 50 years. Morphine, like cocaine, found its way into tonics and patent medicines. The passage of the Pure Food and Drug Act in 1906 required the identification of ingredients, but the availability and use of the drugs was not restricted.

Two nearly simultaneous events — the advent of the hypodermic syringe in 1853 and the American Civil War the following decade—were responsible for the first large-scale use and abuse of the drug. Wounded Civil War soldiers found merciful pain relief with morphine, and 400,000 were believed to have brought the habit home from the battlefield with them.

In addition to its primary application as a potent pain reliever, morphine was used to relieve anxiety, nervousness, and sleeplessness, and as an antidote for alcoholism. In the latter instance, the soporific and tranquilizing effects of the drug were seen in sharp contrast to the antisocial behavior associated with alcoholism, and were generally considered more acceptable. Morphine was also tried as a treatment for cocaine and opium addiction, but, as had been the case with Halsted, it proved ineffective. The actual chemical action of morphine is unknown, but specific receptors in the brain associated with the drug have been identified. It is thought to afford relief
from pain by preventing neurochemical release. Various studies indicate the involvement of substances such as acetylcholine, serotonin, and catecholamines.

In addition to pain relief, the effects of the drug include sedation, detachment, and a pleasant sense of well-being. Through its action on the medulla, it also suppresses the cough reflex and depresses respiration. Dry mouth, pinpoint pupils and decreased night vision, and constipation are common side effects at therapeutic dose levels.

Physical and psychological addiction to morphine occurs quickly. As tolerance to the drug grows, larger doses are required to achieve the same sense of euphoria, the reward that justifies the quest for the next dose. Barely eight hours pass between doses before the hunger is active again and soon thereafter, withdrawal begins. Starting with chills, nausea, sweating, and restlessness, it builds to the florid complex in 24 to 36 hours with goose bumps and involuntary leg movements, giving rise to the terms “cold turkey” and “kicking the habit.” To the addict, nothing is as important as the next dose. Managing the delicate balance becomes an all-consuming priority.

In the late 19th century, women were treated with morphine for depression, dysmenorrhea, and morning sickness, and they soon became habituated. By the early 20th century, the majority of new addicts were women. The term “southern addiction” was often used, which implied a population of middle- and upper-class women with nonspecific complaints who found relief from the ennui of life through use of the drug. Medical personnel with easy access to the drug also succumbed in large numbers, and at the turn of the century it was estimated that more that 10 percent of physicians were addicted. The prevailing philosophy was, “Though a morphine injection could cure little, it could relieve anything.”

Morphine is a respiratory depressant. It readily crosses the placental barrier and can result in fetal respiratory distress and neonatal addiction. The number of newborn addictions, birth deformities, and
stillbirths that resulted from the rampant use of the drug has not been calculated. As use of the drug became increasingly common, the debilitating aspects of its abuse were recognized and a more protective governmental attitude developed. Prior to legislation restricting its use in 1914, morphine addiction actually carried less social stigma than alcoholism. For a number of years after morphine was designated a controlled substance, it continued to be readily accessible. It was inexpensive and dispensed freely, and doctors maintained supplies on hand and made it available to their addicted patients. Morphine maintenance clinics were opened in many cities, and addiction remained manageable and lawful until 1919, when the United States Supreme Court ruled it illegal to dispense controlled substances to known addicts. When maintaining addicts was no longer legal, a black market in drug traffic blossomed, and narcotic usage soon became synonymous with the darker world of crime and violence. Procuring the next dose consumed and destroyed lives, and it extracted a painful human and economic price from American society.

As a physician, Halsted always had easy, legal access to morphine. He was thoroughly conversant with its effects and side effects and had the ability to accommodate his dosage to his daily routine—or perhaps, his routine to his dosage.

Osler’s concern at the time was Halsted’s dose management, and not his ability to function. In that regard, morphine was significantly less destructive than alcohol. Halsted’s condition, and his struggle to control it, were seen as both tragic and heroic, but not incongruent with a productive life. To Osler and Welch, Halsted was a professional equal with a chronic, but not debilitating, disease. Halsted announced his shame by working to hide all evidence of his problem.

Caroline Halsted fit the profile for “southern addiction” perfectly. She was socially withdrawn, often depressed and tearful, and suffered a decidedly low opinion of herself. Her marriage may have been unful-filling; she spent large periods of time alone at High Hampton and
often took to her suite at Eutaw Place for days on end. In all, she was a perfect candidate for relief from her sadness.

Caroline cannot have been unaware of her husband’s morphine use, and witnessing his revival each evening may have seemed just what she herself needed. Halsted’s frustration at his inability to extricate himself from addiction makes it highly unlikely that he encouraged her along the same path. Whatever the origin of her initiation, Halsted’s drug use and morphine’s ready accessibility certainly would have facilitated the process. Shared addiction is not an uncommon phenomenon. Where and when her involvement began are unknown, but the anxiety engendered by the missing Parke-Davis package places Caroline squarely in the picture.

CHAPTER TWENTY
The First Great Medical School

ON APRIL 4, 1892, HALSTED
was made full professor of surgery, which elevated him to equal academic status with his peers. Unfortunately, there was still no medical school. Its absence was keenly felt by the chiefs of service, who had been encouraged to expect a pool of young students from which they could cull the most promising as their resident staff.

After the successful opening of the hospital, it had become clear that the medical school endowment, dependent as it was on Baltimore and Ohio stock, was in deep trouble. The value of the stock plummeted, and with it hopes for the medical school. Soon troublesome rumors began to circulate that the hospital itself would attempt to build a medical school unrelated to the university and on the old model, supported by student fees and economic integration of the faculty of practicing physicians. This was exactly what the doctors were trying to avoid. A near insurrection among the medical staff ensued, and a truce was arranged with the board. Part of the compromise was for the hospital staff to give a series of lecture programs for outside physicians, but this proved unpopular and was quickly discontinued, with the fallout from the entire episode being the palpably urgent need to open the medical school. But the whole project was now in doubt,
and no one wanted to see the noble experiment drift backward into the sullied past of medical education.

Despite Johns Hopkins’s generous endowment, Francis T. King, president of the hospital board, wrote Daniel Coit Gilman, “Where is the man to endow the Medical School?”

As circumstances would have it, no man stood up and assumed the burden, but a group of women, including King’s daughter, Elizabeth, did. Four wealthy, educated, and unmarried young women, three of them the daughters of hospital trustees, hatched a scheme to save the medical school. The like-minded four—Mary Elizabeth Garrett, Carey Thomas, Mary Gwinn, and Elizabeth King, all lifelong friends—formed the Women’s Fund Committee. Their ostensible goal was to raise an additional $100,000 endowment, which they believed would allow the medical school to open. The trustees estimated the figure at $200,000, but since they believed little would come of the effort, the difference was not made an issue.

The women’s fundraising effort was well organized and attracted prominent women in New York, Boston, and Washington, D.C., including the first lady of the United States, Mrs. Benjamin Harrison. Perhaps some contributors were drawn by a desire to further medical education, but more likely the stimulus to contribute came from the committee’s demand that women have equal rights to admission to The Johns Hopkins Medical School.

In 1849, Elizabeth Blackwell was graduated from the Geneva College of Medicine and became the first American-trained female physician. The floodgates most certainly did not open, but things changed slightly for the better. Medical schools for women were established, and some of the existing proprietary schools began to admit women. Female physicians could be found in most urban communities, but the elite medical schools and most of the best hospitals still excluded women. Mary Elizabeth Garrett, perhaps the wealthiest member of the committee, was chronically ill and wanted to be
treated by female physicians. Other committee members shared this philosophy and believed the best schools should be open to the brightest women to provide the finest female physicians.

The four had been crusaders for other women’s causes and had helped found the Bryn Mawr School to provide better college preparatory opportunities for girls, who were excluded from the best schools. Carey Thomas, a member of the committee and an outspoken crusader for equal rights, became dean of Bryn Mawr and favored limiting the enrollment of Jewish girls at the prep school, entirely missing the hypocrisy of her stand. Unmarried, female-centric, and willing to speak their minds, the women used their family positions to enhance the effectiveness of their effort. The trustees agreed to meet with them only because Elizabeth King’s father was president of the board. After the meeting, the trustees assured university president Gilman that the women would never raise enough money to become a decision-making factor at the university.