and without living came an incredible dignity, and incredible power of cells and a feeling of capable feeling we're just hand and i will make something out of this life. what was taken the tools away. so the people are still here. and i are in st. louis and oakland and they are laid off concrete finishers in vermont and they are everywhere. in this book is about time is for them.

it just happened to be in my backyard was a microcosm, the counselor tried to tell. and they don't have any champions. they are as close to forgotten as anybody i know. >> so what did the mill closing two to their sense of self if they take so much pride in building and working with your hands? what did the mill closing due to them quick >> one what to wreck out of this mix cat food. a lot of the older folks just retired. they did not mill around going well with me. they cut firewood. they found a way to make a living. they are very capable. there's a difference in getting by in making a living.

they are getting by. and again, a lot of them landed in jobs that pay the bills, just barely and give them insurance, which is key to everything. but if you ask them if they're still caught in the heart, they will tell you no. but if you say whether he a million of it of course not. but if you go in his closet and open up, all these texts he was awarded for per the tenants are working without missing a day pushcart i.q. if you open one of his tours it is packed with t-shirts for mastering amends and company

picnics. he doesn't wear them anymore. i think is incredible pride in these jobs like there was that being a steel worker and mining coal, building houses, driving the truck were. there's incredible pride in these things. my brother sam said a beautiful thing. if a man supposed to be the one that deals with word. he is supposed to be the one that's capable and he told me once, reproducing the only thing going to make this country will be money and he does figure it takes a lot of people to do a job like that. so i think he's got a good point.

pingback next on the tv, howard marco recounts the father of psychoanalysis and william alston said early in the writer in the field of modern surgery. the respect of addictions to cocaine. this is an hour and 15 minutes. command good evening, everyone and welcome to the university of michigan authors for him. jointly hosted by the hatcher library where we are sitting on the institute for humanity which i am the director and the ann arbor book fair and also the college of literature status of the earth has been involved as

well. we are delighted tonight to be speaking with professor tash dr. professor, howard markel who is speaking about his extraordinary book, anatomy of addiction. william halstead and the miracle drug cocaine. just a couple words by way of introducing the author. first let me say because in my particular culture have come from yours began talking about yourself under any circumstances , which is related to freud by the way. in any case, it is called narcissism. in any case, i'm about two to fly off to venice after this. i'm going immediately to the airport to take the waters to find myself addicted to strawberries, which is coming back with tuberculosis which is not related to professor markel's wonderful first two books. the first of which was the

award-winning quarantine come east european jewish immigrants in the new york city epidemics of 1892, which johns hopkins published in 1987 and then his completely marvelous wind turns travel, six major epidemics that have invaded america since 1900 the fears they've unleashed. also the publisher of the anatomy of addiction. i'm delighted to tell the barnes & noble bookstore first of all is still in existence, which in health deserves a round of applause and second laws the book back at the table and it can be purchased afterwards and so forth. professor howard markel distinguished professor and has tremendous and, professor of pediatrics, professor of history to a professor of health management and policy, professor of psychiatry and director of

center for history and a sense at the university of michigan. the ending was very thin strips on a military uniform to present over public on the ministry of health, president of the center. [laughter] the versatility is extraordinary. and what it told me with professor markel is not only a practicing clinician, but also historian, pediatrician and indeed has worked for many years with adolescents who have suffered from both of addiction. so dr. markel isn't only tripled in the way he approaches this topic of two completely luminous figures paired forward william alston who will hear a cat, both of whom are reaching attics at one time in their life.

and the point is dr. markel approaches this nominally from the point of view of a fantastic storyteller. he and elegant prose and is at its own extraordinary story of that in this case together as a work of genius. secondly he approaches to the point of view of historian, scholar, but also a clinician with an experience if you will of the seduction of wonder drugs. what it means to work in clinical culture where when new drugs come in the techniques are discovered, people feel the sense of trying to use them wisely and understand how far they can go and what they'll do. for example one radiology was first brought into being, what it produced was the speech of disasters with radioactive and couldn't get through airport security and a more good anyway, be that as it made the fact of the matter is there's very few people who can combine a real

clinical experience in a sense of the medical culture research and desire for a care of the sons of new technologies and wonder drugs and their real history of the archive and a wonderful storyteller, which all combine to give us some story forward in all said. many say before we start. many say before we start these things. he's consulted widely through the history of medicine on pandemic influenza preparedness, pleading for united states department of defense along with his associate director of the center, professor alexander stern answered 2006 until the present users as principal historical consultant on pandemic or peritonitis for the u.s. centers for disease control prevention. he contributed 200 articles to scholarly publications and popular periodicals from journal of medicine, "wall street journal," written in "the new york times" regularly and he has been on all manner of television

programs and later to tell you this program is taped by c-span for the booktv weekend shall until police during catch if you want to watch it a second time this season is for instance the magnificent character of my introduction and want to watch it again or whatever you want to look at, please c-span.org and you can find it. let's hope it doesn't compete with michigan football speaking of other cultural addictions. a couple of minor points. please if your cell phones or uncommon now is the time to change that. secondly, when we get to questions after a brief conversation where going to open this up. there is a mike in the middle, so please get yourself in mind to just ask a question from the night. that is an artifact and then third i want to mention that professor markel was john rich

professor at the institute for humanities, where this book was originally conceived in early drafts are produced in 2006. so professor markel, let me call you howard now if i may. for those aren't familiar, maybe especially with all said, tell us about the setup of these these two addicts. what brought you to think about these people and put them in one book? >> well, when i started i wanted to write a cultural history of addiction. you know, addiction is a rather new concept in medicine and medical history. the original meaning of the word came for a room at the peak of the it meant antiquities if i had you a great deal of money i could not pay you back it would take me before a judge and make them your at it or slave and i would say to you until he could pay restitution i love that. the concept of being enslaved to

something extraneous to you is really remarkable. but it wasn't until the 1820s or 30s that dock or started thinking about addiction. moderate definition is using a substance that can be a behavior as well, but using a substance not only with great and grave consequences but a loss of control so you know it's going our new and still do it anyways different in substance abuse, we can abuse it to harm the ethos that control. morphine and opium started the ball rolling and doctors look to describe morphine and opium because it is an incredible painkiller. but nobody knew they would be creating all these because they call the morphine theaters are opium eaters or people with more feminism. once the hypodermic syringe was invented, the cow without the

barn door and more addicts are produced. when the 1880s there was interest in or in new drug called cocaine hydrochloride. coca leaves have been used by aboriginals and south americas for millenniums. but finding out the way to chemically take those leaves and come out with a powder that is measurable, weibel, defensible come for scribble took quite some time and not have been in 1884. it was touted in medical journals of the day two other great that there's as the miracle cure. it's going to cure everything. tuberculosis, dyspepsia and even morphine addiction. a young man named sigmund freud who is not yet sick and forward even though that was his name, he was studying to become a neurologist in vienna and was working at autumn unscreened canal scum and the vienna

general hospital, which was the parnassus of medicine at that time. that was the place and all the world, the greatest art fairs, wasn't so great if you're a patient. it was more of a place for the diagnosis is key rather than the treatment because we didn't have a lot of treatments back then. either way, also place where handwashing was first discovered to be an important issue. some contractors are still working on learning. before it became very interested in now. he did so not only because he thought this could make my name. he had to become not only a great physician if you want to ever become a professor at the university of vienna of medicine or neurology, he had discovered something really great. i love learning about that because he was an ambitious medical student, very eager to please and very dear to succeed and somehow i could identify. i remember being a medical

student very well, which is the down the street. and i remembered that inks and desire to succeed and not always knowing i would. or if i ever have. and he also had a very good friend and play shall mark so come a talented physiologist who is also a talented physician but while contacting a cadaver he cut his thumb and develop such a raging infection, many of us as before antibiotics and wound healing as we know it, some with amputated and he developed a terrible germond, which is a narrow tumor that causes phantom pain of unimaginable levels. ..

>> it was a great irony there because freud was on cocaine as he wrote "on cocaine." [laughter] but he missed a critical issue of cocaine. it's a wonderful anesthetic. you ever see a cop show where they look at a pile of cocaine, they put their finger in it and touch their gum? it'll numb the gum. it'll numb anything. so freud missed that. whether he was too high or too anxious or what, or he wasn't attuned to that issue because he wasn't a surgeon. but a friend of his, carl kohler, who freud used to call

coca kohler, the idea that you could have a local anesthetic that would numb you effectively was, literally, front-page news around the world. it wasn't just medical school school stuff or doctor stuff. and the man who read about that across the ocean shortly after it was reported was a man named william halstead, and that's probably not a name that is familiar to you. he became the greatest surgeon ever. he was then the boy wonder of new york. he was working at bellevue as what is now columbia college of physicians and surgeons as well as several other hospitals. he had brilliant ideas about wound healing, about antisepsis and operating under a clean circumstance which seems, well, yeah, of course, but back then surgeons were wearing old frock coats smeared with blood and pus, they were draping or dripping their elbows into the

surgical wound, interns would hold sutures in their mouth and then hand it to them. so it brings up the old vaudeville joke, you know, the operation was a success, but the patient died because they got super infected and died. so halstead was always looking for perfection in his operative craft, and he read the paper about its anesthetic properties. i've got to get something. he bought it, started doing experiments, and the problem is most people did experiments on themself. freud did, halstead did. but halstead was injecting it. freud often took it with water or sniffed it. halstead was injecting it to find out how far he could go with the numbing, and within a matter of weeks, he became a nor rid cocaine addict as did most of his fellows and assistants who helped work on this. and it came to a head where halstead stopped going to meetings, you know, medical meetings, he stopped going to

classes. by the way, i forgot to mention, halstead invented the surgical rubber glove, the iconic symbol of surgery, modern surgery. if that's not a detail important enough. and halstead was called down to the operating room, the stent room to see -- the accident room to see a patient who had broken their tibia bone so badly that it was coming out of the skin. that's called a compound fracture. back in the 1880s that was something you rarely survived because of infection. and he was so high on cocaine he walked away from the table and said, i can't do this. and he went home, and he skittered away the next several months high on cocaine until his friends read him the riot act and tried to do an intervention. but i was so enchanted with these two men's stories for all the reasons you enumerate. they were remarkly high-performing addicts and brilliant people which disproves the notion, well, you should have known better. it's a human disease, and smart

people, rich people, poor people, all people are prey to this terrible disease. they fought so hard to break it. it had to do with a miracle drug that was supposed to help people, not harm people. they were accidental addicts because everybody's an accidental addict. nobody says i'm going to take this heroin and become a raging addict. they're going to beat the odds. every addict is the author of his own story, but they never write it correctly. and he was, the idea of all of this, well, i became addicted to the story. >> yeah. >> and while i was thinking of writing about other people, i was on a hilltop in tuscany one day -- i thought i'd work that in. [laughter] and, to hell with it, if i'm that compelled by this, surely somebody else must be, and i hope the readers are. but it was just so fascinating, i became -- i knew these gentlemen even though i've never

met them, and likely they never met, by the way. i understood where they came from, i understood what their ambitions were, i understood what their foibles were, and i had great empathy, and i felt for them, and i want today document their stories. but as a broader issue, to agnat poise addiction as a human disease. it's not a joke, it's not a sensation, it's not the stuff of cable tv even though it is the stuff of cable tv. it is a very serious problem for the individual, for the families and people who love that individual. and for the society at large. it's one of the greatest public health problems facing the world today. >> you know, um, for somebody who's not a physician, not part of the medical establishment, another thing the book does, and i alluded to this earlier, but i'll say it again. it gives one a lens on the seductions of clinical practice, on what it means to be living with something that really is new, that's untested, whose limits are not yet -- and i'm

wondering if you could talk a little bit more about that. because in a way i think that's why it's so beautifully organized with two medical people as opposed to a number of other people. i know you've written on writers and so forth, so i'm wondering if you could talk about that. >> well, it's an exciting milieu that is not well known to most people even though it's on tv quite a bit. but the academic atmosphere isn't on television as much or movies. and it's a very exciting place to be if you're a young man or young woman or if you're an old man or old woman. there is the thrill of discovery even when you don't have a shot at it. there's always the snooping around, how can i make this better both for the patient and for society, but also for me as a discovery. hospitals are filled, filled to the rafters with ambitious young men and women and old ambitious young people -- ambitious old people who really want to change the world. and so you're always looking for

something. and yet none of us seem to be aware of this old morality play that plays itself out over and over and over again of the miracle cure, the miracle procedure, the miracle this that doesn't turn out quite so miraculous. and we only learn that after using it on quite a few people and looking at reactions to it. and, in fact, that happened with cocaine rather quickly even though the 1884 it was a miracle drug. by the 1890s in the medical literature, it's filled with wrecks of human beings who are florid addicts. but that thrill of discovery both for popular consumption and personal advancement is the engine that drives the temples of health that we all benefit from today. >> um, liechtenstein himself is another story, actually, once said that the way in which we come to find out there's a limit to understanding is by bumping our heads against it, and only by bumping your heads against the limits of understanding like

a wall do you realize there's a limit there. >> right. no, i think it's very true. and i remember moments in my own career where we'd do things that seemed outlandish, and i'd have people confront, how will we learn? that's where the separation comes from, the healer with the patient in front of you versus the scientist doctor, the medical scientist. and it's a huge issue. there's another thing we didn't bring up that one of halstead's colleagues who's in this book quite a bit, the great internist said what separates man from the animals is a desire to take drugs. [laughter] and it's true. it's true. we all want something that will make our lives better. that would make my sciatic pain less. that would make us less nervous. that would cure an infection -- we all want a simple pill. pop it, gone. and i think that's a very human phenomenon that also conspires into all of this.

the quest to heal ourselves with some kind of a drug, a pill. >> so part of what makes this a fantastic read, really one of the best i've had in a decade, actually, is the way that you carry out these two different characters and their differences. um, and i'm wondering if you could tell us more about it. halstead seems to have been constantly on and off the wagon, if you will, whereas freud at a certain point stops or seems to. >> yeah. >> so tell us about those differences. >> well, that was another wonderful coincidence. you can't find two people in a hospital more at odds, more different than a psychiatrist or a psychoanalysis and a surgeon. they are different species. now, my medical school report card says howard is not a surgeon. and i didn't realize for years that was not a compliment. but it's a certain approach, it's a certain being that is very different than a psychiatrist or psychoanalyst. freud was a young jewish fellow

in a very anti-semitic country and was told frequently, was given anti-semetic slurs were thrown at him at different points during his training. and he did experiment quite a bit with cocaine, and he nearly killed a patient. he and a colleague nearly killed a patient. and to me, i interpret that as his bottom. he wrote about it in the interpretation of dreams that actually became the model dream. it's called "irma's dream." and this irma, which was really a woman named emma, he and a friend of his, wilhelm fleece, was an ent man who had a theory that all physiological imbalances are due to the nose and can be cure with the a removal of bones in the nose and healthy supplies of cocaine. one of his patients, by the way, was sigmund freud. taking quite a bit of cocaine to the point that he had

stuffiness, he had to have a hot, heated knife to burn a hole in his nasal tissue so he could breathe. is they treated emma this way, and fleece left a sponge in the surgical wound. he left for berlin, and emma nearly died. freud had a dream about this, and the way he interpreted it is that i'm such a good physician, i'm so conscientious about this that when my patients go sour, i feel bad for them. dreams are wish fulfillment. and he was telling himself as you've told me the same big lie that addicts tell themselves every day, my addiction's not that bad, by problem's not that bad. and yet at some level he must have known that not only did he almost kill somebody, but his career would have been ruined. it's not too much to say that would have been malpractice as the time. and it was around this time that he had this dream and his father died. he wrote to fleece, by the way,

i put the cocaine brush aside. and there is no evidence in his letters, and freud's fun to write about because he writes so many letters, and he's telling you what he wants you to know about himself. so he probably stopped using cocaine in october of 1896 and lived until '39. he had another addiction, cigars, which led to his death in 1939. hall halstead, on the other hand, who committed himself to insane assignment twice -- now, this wasn't rehab in malibu. going to an insane asylum back then was a very scary place, and he even signed his name on the register, he was so ashamed, he was so demoralized, he signed william stuart and then an ink slash where his last name should have been because he was so embarrassed. and that's one of the, sadly, one of the major symptoms of this disease; shame, hiding, secrecy. and he was brought to johns

hopkins hospital by his friend, william welch, who was going the found the greatest medical school in the world. they had tons of money, about seven-odd million dollars given by the philanthropist johns hopkins which was a huge amount of money, and he said to halstead, welch did, i'm going to bring you with me to baltimore, but you're going to live with me, i'm going to be your minder, i'm going to follow you, and so he did. and halstead was not a surgeon in his first few years at hopkins. he was operating on dogs. but he was working on all sorts of experimental things. how does a wound heal? what type of suture will help that? how do you cut the intestines apart but then sew it back together so it doesn't leak? everyone who's ever gotten off an operating table safely has william halstead to thank for that. and he was figuring this out, improving himself. and he must have had the weight of atlas on his -- the world, like atlas, on his shoulder because he knew he could never resurrect his career again.

another thing happened, by the way, that i neglected to mention. when he was at butler hospital, the insane hospital, insane asylum, they decided to treat him with another drug to get him off cocaine, and that was morphine. >> oh, jeez. >> the reverse of -- [inaudible] so he actually became a cocaine and morphine addict. he never stopped using morphine probably on a daily basis for the rest of his life. and there are times where his hands would be too shaky to operate, or he'd be too stoned to operate. you could never get ahold of him after 4:30 in the afternoon because he'd get home with his morphine dose. and there's very good evidence to suggest that he'd go on cocaine binges off and on for the rest of his life. and yet he had to live this double life of literally the world's greatest surgeon that every doctor in the world, what does halstead say about x? what does halstead say about y? and yet he had this secret, i'm a raging drug addict, and i cannot control myself.

and so that was their two not-so-parallel lives. and yet they had problems as a result of their substance abuse for most of their lives. >> halstead, if i remember from the book, actually at certain moments was shaking so much he had to ask his assistants to sew the patient up. >> absolutely. now, halstead was famous for being such a meticulous operator, so slow to close that will mayo, the mayo brother, said, you know, the patient tends to heal three hours before halstead closes a wound. [laughter] but there were times that halstead was so shaky -- now, whether he was on cocaine and that will give you a tremor, or he was withdrawing, he didn't take enough morphine that morning, so he was withdrawing, or he was hungover, that's hard to figure out from the distance of 100 years. but his surgical colleagues, his residents loved it because they got to operate more. the chance, the chance to cut is the chance to heal as many surgeons have told me. and they blamed it on his

cigarette consumption. he used to smoke a lot of cigarettes, but that doesn't seem very likely. in fact, one of his chief residents said, you know, we didn't like when he stopped smoking cigarettes because we didn't get as much o.r. time. it was probably because he was cutting down on his substance abuse. and there's minutes in the johns hopkins medical school archives that the trustees are meeting, where's halstead? and he would have been fired under any circumstances like that if he was anybody else. and yet whether people knew or didn't know or chose not to look very closely, he was enabled to continue this path for the rest of his career. >> let me go beyond the book for a second. you've written elsewhere about f. scott fitzgerald and a number of other. so this issue arises deep in the book about the relationship between addiction and talent. um, it's not, obviously, one doesn't want to row hasn't size

addiction, you know, that somehow it's purely an artifact of opium and it allows the imagination to soar and this and that and the other, but on the other hand, there's a lot of wonderful material that you've alluded to, especially about freud about the way in which ambition is also so unsettling. i mean, the young freud coming from, as you put it, this position of being cursed in vienna, if you will, and having neither money, nor status and the wrong religion, everything else. absolutely certain that he had something there as yet and having not discovered it, waiting to find out and so forth. so i'm wondering, now i'm asking you also not just in terms of your work as a writer but also a clinician, what about this relationship between ambition, talent? >> well, as a clinician i've met many untalented addicts, and i've known many. ambition, angst, sensitivity, an inability to tolerate pay

whether it's psychic or physical, um, perfectionism, all sorts of psychic scars that many of us carry are risk factors. i don't want like to use the term addictive personality, but it is risk factors if you, indeed, meet the wrong drug at the wrong time. there's good science about genetic predisposition. you may not have a problem with this drug, but you may turn on that frankenstein switch in your head the minute you touch another substance. i sort of describe it as four wheels of misfortune; genetics, psychic trauma or physical trauma, the drug itself and the mode of administration. because some ways shooting up, injecting is far more addictive than sniffing or tasting that drug. and the addict falls short on all four wheels. in terms of talent, i absolutely

reject the notion that the drug abuse causes the greatness. greatness that these two men came by stitch by stitch, thought by thought, dream by dream, page by page, patient by patient. in fact, i write in this book it was really in spite of the addiction, the struggle to be free of the addiction that i think their true greatness and genius comes from. there may be a spark of an idea whether it's the interpretation of dreams or a really neat rock song or whatever. but then to carry it out, that it becomes that work of art or work of brilliance, that's work. >> yeah. >> and the addict, the practicing addict can't do that because he or she is too busy taking their drug to their, to their ruin. it's death at its most repellant and its most seductive. >> uh-huh. >> it's a game, a cat and mouse game that the addict plays with him or herself. so what is interesting is there's a lot of talented people

that seem to have a lot of issues of angst and great ambition. who could become a great artist or a great mind in such a competitive, difficult world unless, a, they felt a -- sorry. a, they felt they had some greatness in them, they had some ambition in them, and they had this upsetting and angry voice always saying you haven't done enough. you've got to do more. it's sad that, but you do need that. well, i'm not great, but i assume you need to have that to achieve greatness. and that's what i think these two had, and a lot of the addicts and alcoholics i have read about and written about over the years. >> um, before we open it up, i've got a couple more questions that go a little bit beyond the book into other things you've written in your clinical experience as a physician. so the first one is, um, if you could talk more generally about the different, how you specify what addiction is as opposed to a culture of dependency, you

know, mad men. everybody's drinking all the time. they're not all raging addicts, some of them are and whatever. here's another example, the advertising world which i know fairly well for various reasons. it's 2:00 in the morning, you have a presentation due at 6, you haven't got an idea. cocaine is there to even you out for the presentation. how does one from the medical point of view distinguish these broader themes of dependency from actual addiction? >> well, if you read the definitions and they're problematic, and everyone argues about them, is that if you are using the substance to abuse to the point that not only are there bad consequences and in all those examples that you've mentioned like the "mad men" show, those characters have had bad consequences. but also that you've lost control, that you still do it knowing it's going to harm you, you still seek it out despite all the warnings you have had, that is what, how psychiatrists would define it. a very hard thing.

it's sort of like pornography. you know it when you see it, but it's hard to describe it. but i've met many people who have spent too much time denying it because nobody wants to say i'm an addict. nobody wants to say i'm an alcoholic. but if you're starting to think about it, if you're starting to each utter the words -- even utter the words in your secret part of your brain, you probably have a problem. so when i see patients or i talk with others -- friends, peers and so on -- there's a problem here. let's take the word "addiction" off the table. let's take substance abuse off the table. but surely you must admit taking cocaine five times a day to finish your ideas or some patients i've had smoking marijuana from morn until night, drinking several six-packs a day. that is a problem. that's not what normal earth people do. >> uh-huh. >> and so that's how i like to look at it. >> uh-huh. >> when you start putting

negative words on it like "addict," and like it or not it's not a positive word for many people, um, then you get into the defensiveness. and defensiveness, denial, lying, these are the cardinal symptoms of addiction because you want to protect your addiction. that's your best friend. that drug, that alcohol, that's whatever. you don't want anyone to interfere with your best friend. that helps you make it through the day. and so i try to look at it as a problem and talk with people that way. >> so, um, one is perfectly prepared to believe that in some sense clinical practice is an art in the way you describe. >> it's a complete art. >> but then there's another question about the science. by their specific brain pathways, changes, what kind of things, what can you actually see biochemically going on? >> well, i talk about that in the book, and some of the most interesting stuff that's going on in science right now is neurochemistry and addiction

vaccines that were written about very recently in "the new york times" that would form an antibody to the drug so you don't get high, other neuropathways because you literally change the anatomy of the brain. there's a pleasure center in the brain that's called the limbic system. you know, the brain is not that big a space. the limbic system is even smaller. i used to always say to some of my friends, there brain is each that big of a space. but once you start rewiring it, there's sort of a circular loop, get high, get high, get more, get more because the drug, particularly a drug like cocaine, fools the neurons into secreting enormous amounts of dopamine which is the neurotransmitter that tells us to smile on a sunny day, to enjoy an accomplishment, to enjoy our spouses, what have you, our children. and it's a trojan horse, if you will, because it presents so much dopamine that you feel

positively euphoric. and then nothing else can match that chemically-mediated euphoria. and to i crudely, the wires actually change. and there's wonderful imaging studies to show this, that an addicted brain each ten or more -- even ten or more years after recovery, just showing recovering addicts pictures of cocaine, for example, that part of their brain lights up on a pet scan. so you've really changed the biology of that individual which is one of the many reasons that treating this disease is so difficult. there is a lot of art, there's a lot of finagling, there's a lot of patience, and there are a lot of patients. that makes it very difficult to treat the disease. >> okay, following that extreme description, this is my last question before i'll ask you if you want to talk and so on. 21st century has from talk show, if you will, like us to

newspaper to everything else claimed an endless spate of new addictions. >> uh-huh. >> a whole generation addictioned to the internet and cell phones and god knows what else and so on. how do you think about that from the medical point of view? >> well, it's been very evolving, the idea of new addictions, what used to be behaviors of come pulses. you know, the old definition was not only an exogenous substance, but a substance that you physically withdraw from. so alcohol and heroin, you'll physically withdraw to the point where you could die, particularly alcohol. cocaine was not considered addictive long ago because they didn't see physical withdrawal although there's quite a lot of withdrawal and a lot of psychological withdrawal. marijuana when i was in medical school was not considered addictive because they didn't withdraw. well, they do, it stays in the fat cells, and you withdraw over a much slower period of time. but that has changed. and now each behaviors like hypersexuality, gambling, too much playing on the internet, you know, i had a medical school

professor who used to say everything in moderation, including moderation. and i think we all have to be careful not to unleash the addict within. and there's many things that could -- too much exercise, too much -- so it's really an evolving puzzle that we're frantically trying to understand, and yet there's so many new culprits every year that our youth and the rest of us are subject to whether it's a behavior or a drug or what have you. there's so many enemies out there looking for us to pull us in. >> before i open it up to everyone here, um, is there something i didn't want ask you, some piece of the book, something like that -- >> no, you clearly read the book. i give you -- [laughter] but i'd love to hear what people -- >> and i reread the book. it's a great book. [laughter] please, um, we have -- no, let me just remind you, um, because of the nature of the taping, if you would go up to the mic and just, please, be at liberty to go form a line up there if you

want to ask something. i'm sorry to do this in a somewhat cumbersome way, but it's for the taping, so -- >> two very different kinds of questions. first, could you say something about halstead's family life, his family of origin as well as whether he married and what their involvement one way or another was in his addiction? >> sure. hall -- >> let me ask -- >> okay. but i'll ask you to repeat the second because i'm not so good as remembering. >> i've forgotten the other one. [laughter] >> well, if you think of the second one -- halstead came from a very patrician family on both sides. his mother was an old new jersey family, and his father was of an

old new york family. theylyed a very wealthy life on madison avenue, were actually nearby neighbors to theodore roosevelt's family. his father, william halstead's father, was a her chant, textile merchant but on many charitable boards. he was also a trustee of the college of physicians and surgeons which helped halstead get in to medical school because he was not the best student when he was at yale. he rarely cracked a book, if ever. his mother and father seemed to ignore him and the other children quite a bit, and they were in the care of governesses. his father was very religious presbyterian who would read him fire and brimstone sermons of what he did wrong every night. halstead referred to his childhood as, quote, nightmarish. he even ran away at one point. so it was a very cold, distant, difficult relationship there.

halstead did marry. he had several close relationships with men, roommates with men and loving relationships that are very hard to define 100 years after the fact. but he did marry a woman who was his o.r. nurse. carolyn hampton. and she was developing -- back then when she caught his eye, doctors were still dipping their hands in corrosive chemicals like carbolic acid and magnesium which were very caustic to the skin. and she developed a terrible skin rash all the way up from the fingertips to the elbows. and, in fact, that was the inspiration for the rubber glove. halstead went up to new york to the goodyear company, gave a design for his and her rubber gawpt lets. then the other doctors saw it and said, hey, this could be really good for aseptic surgery. but they had a very odd relationship. they lived on separate floors of the house, they had dinner

together but never breakfast. she was considered very odd and difficult herself. they went away every summer to her family's estate in north carolina, and no one really knows what went on there. he didn't have many close friends. he didn't have many dinner parties because he was so fastidious about everything. the coffee had to be ground and brewed just so. the table cloth had to be ironed just so, that he drove mrs. halstead quite crazy. and so it was a very singularly lonely life that he led. and particularly after his addiction was discovered, he changed from quite a gregarious man to an extremely difficult and caustic man who hated to have eye contact with people. now, medically that's fascinating to me because if you're high on cocaine, it'll blow up the pupils of your eyes so they look like doll's eyes. they'll be all black. and if you're high on morphine,

it'll make them pinpoint. and i wonder, i can only speculate, didn't want to make eye contact. there are a lot of very smart doctors in that hospital, johns hopkins hospital, might have figured it out. >> i remembered my second question. when did the government, any government, first assume some responsibility for regulating individuals' use of drugs? >> yeah. that's an excellent question. and i talk about this quite a bit in my book, that the regulation of drugs, what we call controlled substance, was not in anyone's imagination back then. you could get opium, laud numb, morphine, cocaine, morphine at the druggist's without any prescription whatsoever, and you could do that for many, many years in this country until 1914 where there was such an alarming epidemic of drug abuse and addiction that the congress passed what's called the harrison narcotic control act of

1914 which started the ball rolling of prohibition and controlled substances as we understand them today. that's only been refined in the decades since. but even by the 1890s there's a lot of medical literature of the problems of morphine addicts, cocaine addicts and on and on and on and on. so it didn't begin until relatively late in the history of these substances. >> who else would like to ask something? please, please. and by the way, don't wait. if you want to ask something just, please, go back and get in line. >> i'll feel badly if you don't ask questions. >> well, my question is sort of from the other end of the spectrum, but it does relate to your last answer. my understanding is that the research i've done is that african-american men in the late 18 and late 19th century, i'm

sorry, the 1880s, the time period we're talking about, dock workers were given cocaine to increase their productivity in terms of working on the docks. and i'm wondering if, um, this all came about through a conversation about, you know, drugs in the black community. but in this particular instance, um, as i said, you have these workers who have been given cocaine to increase their productivity, and then they are left with this addiction that they are unleashing on a commitment. and i -- on a community. and i wondered if you could speak to that a little bit. >> yes. >> did the company, like, give them cocaine? how did this work? have you come across that? >> yes, quite a bit. the idea of giving workers cocaine or maybe coca leaves or coca teas, what have you, coca beverages, we didn't talk about that, there were many coca beverages that were very popular.

one was a bordeaux wine with coca leaves, and angelo mariani became the first cocaine millionaire on earth. and can the other is coca-cola. but a lot of not just african-american dock workers, but other laborers -- this is particularly true in south america as well and goes way back before there was cocaine hydrochloride. you'll see con keith doers giving aboriginals, mine workers, farm workers as much coca leaves as they can because it improved their endurance, it allowed them to tolerate high altitudes. it doesn't do anything for the blood oxygen, it just makes you less aware of it. and there's all of these issues of medicating, and that's what it is, your workers, your slaves to work harder and causing enormous problems not just for those individuals, but for the society at large. very short-sighted stuff here.

no matter how you define it. and, yes, it was rather common to do that. women, women in america were more likely to become morphine addicts than men, about six to four odds. and that's because for every so-called woman's complaint from menstrual disorders to postpartum depression as we might call them today a so-called well meaning doctor would, here you go, take some of this in a paternalistic way, and they created many, many, many addicts that way. one of the most famous was written about in a wonderful play called long day's journey into night by eugene o'neill. that's about his family, and that's about his mother who became a morphine addict accidentally after the birth of eugene o'neill when she went into postpartum depression and could never get that monkey off her back. so there was a lot of -- i don't want to judge, well, in the case of the bosses on docks i will,

but in the case of the doctors, i don't want to judge them, but they weren't really thinking it through, and they didn't have enough information based on what they were doing, and they unwittingly or wittingly created an epidemic of substance abuse that we've never recovered from. >> thank you. >> yes, well, thank you for this wonderful book, and, um, i'm wondering what you do with the question of what influence did addiction have on freud's theories. >> uh-huh. >> both in terms of his working productivity and how much he put out, the time in which he produced them, and then also the kind of work that he produced. so it's very interesting to me, for example, that freud is a lot about psychic boundary management. so it's about the ego and the superego and the id, it's all about compartmentalization. >> right. >> and you talked so eloquently about halstead and his living a double life. so i think that's an intriguing

question. on the other hand, i know if your book you -- in your book you seem to very carefully and astutely avoid making these kinds of causal arguments because they are just kind of, they're dangerous -- >> right. >> -- and they're too tempting. but i'm sure you get this question, and i'm just wondering how do you answer it, and do you think there's any value in thinking about the role of his addiction in his literary and psychoanalytic work? >> i think there is, but i think you can go too far. it's never one plus one equals two with human beings. it's always one plus one equals 57, and then you have to figure out the other 55 -- [laughter] there are issues in freud's life that i talk about in the book that cocaine really sparked some interesting ideas. and he writes about this to his then-fiancee and later who becomes his wife, martha. for example, when he's in paris learning about neurology under a great neurologist, he's also

taking a great deal of cocaine. he's saying he needs it to unleash his tongue, to feel more comfortable at these parties where he's trying to impress people. he also says, i feel so strong, i could knock down the gates of the temple. what a wonderful metaphor for a jew from vienna, trying to break into academic medicine. but he also says i find it fascinating that when i do take cocaine, it unleashes ideas that i thought were locked away in my brain forever. sounds like free association and thought therapy. yet i think when you look at his letters and the examples he had, because he turned -- [inaudible] into a cocaine and morphine addict, and he died. he nearly killed emma eckstein. i think at some point he got the idea this substance is too toxic to achieve those ends. i've got to come up with something else. and that was talk therapy and free association.

um, that said, freud was incredibly compartmentalized about his own substance abuse. he had reasons to do that. it was a very shameful activity back then. it might have harmed his career, and he was very career-oriented. but he never came to grips, i think, with understanding -- remarkable for a man who was so understanding of so many people and so many ideas. he had his own blind spots, and to me that tells me that he is just like every other addict. maybe smarter, maybe more accomplished, but the notion of an inability to come to grips with this is something we see all the time in the world of addiction. so did it have an influence? to be sure. it's part of his life just as his background, his love of books, his love of antiquities. but to have a reductionist idea that all ideas flowed from a long line of cocaine i reject. it's simply too simplistic, and

i don't think it's intellectually appealing to me. >> but, howard, one thing a reader can get from your book, actually, i think, another reason to the answer of this is you tell the story so well, it looks like freud's own partial but incomplete mastery of his addictive personality contributes unconsciously to his formulation of the theory of sublimation. >> yes, yes, it does. >> because it's the that it's something that wreaks havoc because it's primitive and basic and in the unconscious when it's raised up to a higher level of functioning, and in a way that's what happens. >> yes. and the interpretation of dreams. the first dream is a cocaine dream. it's a using dream. so his substance abuse is part of the story of freud. what i hesitate and what i always worry about is when i have patients who do this. i had up with kid say to me, hey -- one kid say to me, hey, man, i am such a better writer when i'm high. >> right. that means he doesn't know how to write.

>> and i said, bring it in the next day, and let's go over it. or i'm a were the driver when i'm high. >> oh, yeah. for sure. >> it may seem that way to you at the time, but that's not really how it works. but to be sure, there's parts of this. itthis is part of his story. and that was so interesting to me, so many historians and freudians, because it's addiction. it's substance abuse. it's cocaine. want to rub that under. no, we need to understand that. one of the reasons i wanted to write this book is i wanted to understand the influence. and there is, to be sure, an influence. is it the only influence? no. it's just too complex a story. but it is part of the story. >> sure. >> could you, please, speak to the idea of food as an addiction including the part where it's the one substance you cannot give up completely? >> yeah. well, this is -- food is an addiction, and this is why i've always had a problem with that notion, because we all must eat to survive. you do not need to take cocaine to survive. quite the opposite.

you don't need to smoke cigarettes to survive, etc., etc. and a lot of fuddy-duddy doctors like myself had problems with that. now, what we are finding in the neurochemistry and the neuroimaging is that the very similar pathways and similar lighting-up areas of the brain are there, but how do you control that in a certain way is a very different challenge. and very difficult. it's just an extra load of problems for addiction medicine and for people who suffer from it. and we're desperately trying to figure it out, and there's a lot of obese people who are really desperate to figure this out. so i don't have an answer for you. but it's something i've really evolved in my own thinking that ten years ago that's not part of it. i think there's many, many things we're going to find out that are addictive, and we may not each call it addictive but that cause some serious problems for people. >> thank you very much.

howie. i'm very amazed at the different disciplines you have mastered and how you -- >> that's debatable, ask my colleagues. [laughter] >> and we have met before in daniel's humanities institute, so i have a lot of appreciation for what, you know, you have done. and, um, this is just a very brilliant presentation. and i'm thankful to you. steve jobs has just died, and the whole world is mourning including my friends in nigeria who have the iphones, the ipod, la lax lax. now, one of them has said to me, look, father, we heard steve

jobs took some drug, you know, when he was young, and he has come out to say it's one of the three greatest things he did in his life. >> yeah. >> father, have you seen that drug in the u.s.? they're asking as if i could get -- [laughter] so this could be the incarnate of steve jobs. um, is it, is it possible that, or is it even useful for people who want to be successful to go in, you know, go and try drugs, you know, hoping something would come out of this? and if you have tried something like this in your past, how do you, how do you reap the rewards having escaped from -- >> you, that's a tough -- wow, that's a tough question. steve jobs, may he rest in peace, used lsd which is supposedly, i don't know, not an

addictive drug, but a very dangerous drug nonetheless. and for every story of a wonderful acid trip, i have heard 20 or 30 of really detrimental experiences with lsd. i don't know everything, and i don't have a lock on the truth. i only know what i read, what i see, what i've experienced and what i have seen in my -- what i treat. and i have seen so many more train wreck stories, wreckage of human life, of human relationships, of work, of all sorts of things through substance abuse that those singular stories i hear don't mean much to me. and they certainly don't make me want to recommend to anyone that that's a path for success. that may have worked for him, he

may believe that's what did it. he may be wrong too. but that was what made steven jobs steven jobs. he also was a remarkable worker when you think of all his life was apple. and i doubt that he was on acid trips during much of that greatness. and so people attach certain things, it's not exactly an experiment, it's not a controlled study, but i will tell you from too many sad stories and too much experience that the perfect experiment is substance abuse to the point of addiction because it always comes out bad. the results are always the same, and the results are always reproducible. i cannot predict that you or you will not have a problem with substance, a, but you or you with substance b or all of you will or all of you won't.

but i do know as a physician who wallets the best for you and -- who wants the best for you and your health that if you don't play with it, i can guarantee you won't have a problem with it. so that's how i have approached it as a physician. and as a writer and as a historian as well as a physician, i've just seen too many train wreck stories that make me comfortable -- i read that in the o obituary of jobs, and i just shook my head. i was very uncomfortable. [laughter] >> thanks, howard, for a wonderful discussion. i, i ask this question with some trepidation, but since you raised the question of a public health issue on an international scale and by what i understand about statistics is that we are the main users of narcotics. do you have any feeling, and you

don't have to answer this if you don't want, but do you have any feeling or opinion about the legalization of drugs? >> that's a tough one, but you are right. the united states of america is the biggest consumer of illicit drugs in the world. and, um, while marijuana is the most commonly abused illicit substance, cocaine is number two. that doesn't even begin to account for the legal drugs -- smoking cigarettes, nicotine, and alcohol. nor does it account for a new epidemic of prescription drug abuse, of opiates that are overprescribed and sedatives and on and on and on. every time minute buys an ill -- somebody buys an illicit drug, they are harming many people they never see because it is a whole industry of slavery, criminality, bloodshed and tragedy. and so the guy who's snorting a

line on a football saturday -- i'm feeling good -- has harmed people without even knowing it or without even acknowledging it. legalizing drugs is a very thorny issue, and prohibiting drugs is an equally thorny issue. we've tried prohibition in many shapes and forms in this country, not just with alcohol most famously with the value ted act -- value stead act in the early part of the 20th century, but also with the controlling of substances as well, of narcotics, as you said, or cocaine or marijuana. and even the data places where they are legalized like the netherlands and such, it's not a disneyland there either. there's a lot of claddal damage. collateral damage. and yet at the same time we're facing this problem, as i said earlier, what separates humans from the animals is a desire to take drugs. the desire to escape. to feel good.

and so i think it's a much deeper social question and debate that we all have to have. americans and people around the world, how do we want the handle this public health crisis in a thoughtful, nonpunitive, medically-correct, caring way? as well as a legal and social issue. and i don't think we've come even close to having that conversation. it's not a pro, not a con, it's a lot of gray area in between, and i thank you for bringing up that question, because i think we need to have it all the time. >> um, so my question relates to, like, you talked about cocaine comes out, and it's this heralded, very powerful drug, the wonder drug. and after some of this addiction it's, basically, been -- my understanding is completely disappeared from clinical use. but, obviously, it had some powerful qualities. my question is, in your

professional opinion are there, like, appropriate applications of cocaine in a clinical setting that have been lost because of some of the misuse in the past? is. >> well, actually, cocaine is still used to this day as a local anesthetic, frequently by ear, nose and throat doctors. a similar drug, lidocaine or novocain are synthetic versions of that that don't cause the euphoria. but anyone who's been to a dentist has cocaine to thank for that because it's the same process that, in fact, william halstead discovered and wrote about called nerve blockade, that it blocks the nerve sensation the pain. so we have wonderful synthetic versions, but there are still to this day at the university hospital down the street, i'll bet, there was one ear, nose and throat procedure where they used a liquid cocaine solution to payment the area they were -- paint the area they were operating on. so we haven't lost that.

the problem isn't -- no one, no one went into a raging cocaine bitch because of anesthesia. it was for other reasons, and that's the issue. it's such a seductive drug, by the way, but the wonderful experiment years ago where they had a group of rats and they had buttons and they could press for pellets of morphine or heroin, and they'd get high and they'd fall asleep. they'd wake up, they'd get some water, and they'd get high again, but they lived. the cocaine rats died. and this goes to this trojan horse. it is so powerful a drug on the system of neurochemistry, of fooling the brain into a yee foric -- euphoric sense that it wants again and again that it's a very dangerous substance to play with.

>> dr. markell. >> hey. >> regarding the legality or illegality of drugs or setting aside that, the availability of it i could probably go within ten blocks of where we're sitting and find any drug in the world that's available. >> yeah. >> so the problem is probably as bad as it can be from a medical or societal standpoint. therefore, making it legal probably wouldn't increase the number of add addicts -- >> yeah. >> but it might do away with a lot of the social problems that are attendance to it being illegal. >> yeah. >> the other thought i had in mind was freud analyzed himself. he never analyzed his drug use? >> no. that's a wonderful question. and that's where, in fact, i remember having this conversation with danny, and i stole a line of his and put it in the book, that he was subject to the same big lie that every

addict tells him or herself every day. i don't have a problem. you have a problem, i don't have a problem. and he never came to terms with that. for him the principle addiction was masturbation. which, that's the only times i hear the words i love you and i believe them. [laughter] but he never came to grips with what cocaine did to his relationship with his wife, with his children, the fights he had. boy, he was famous for loving -- he said this in "interpretation of dreams," i often love and hate the same perp but not necessarily at the same time. really rancorous fights with his former teachers, his colleagues. carl jung, most famously. on and on and on of disruptive behaviors and could never say in a moment of truth, huh, maybe i

had something to do with it. maybe my substance abuse had something to do with it. and so he had all these layers of denial and explanation to compartmentalize as alex just said, to compartmentalize that away which is death to the addict. if you can put it away and only take it out in secret, it causes a lot of problems. so here's the irony. the man known if history as the searcher for self-truth never, in my opinion, was able to delve into that particular truth of his life. yes, ma'am. >> um, yes. i read somewhere that -- [inaudible] had observed addiction. he, of course, first treated gladiators and then under marcus aurelius, he was the official doctor for the roman army.

do you -- i can't remember his exact words, but he said something to the effect that it was better for people to endure pain than to become addicted to -- >> he did. >> -- to drugs. and if you could, do you know what drugs he was observing? >> it was probably poppy. sap from a poppy plant which becomes opium and then becomes morphine and all the rest that we've had since then. but it was probably that. um, and there have been many doctors and many observers who worried about all of these substances in realtime whether it was, you know, a first or second century a.d. or the 1500s or the 1700s, worried about the grip that these substances would have. but they were lone voices. they were quiet voices in a deafening roar of let's go for it, and that was the problem. that's been the problem. >> could you say something

about, um, the use of substances by soldiers? i'm sure you're aware -- >> by? >> soldiers. >> uh-huh. >> you're aware of the use of doll teens, i believe they were called, by the nazis during the third like. do you have any knowledge of that? >> huh-uh. >> they were -- i've just read this numerous places, that the german soldiers were given a superamphetamine which was discovered by nazi doctors -- >> that i've -- >> through europe. it's a widespread, i also read somewhere that napoleon's soldiers were given a ration of vodka, so there seems to be a sort of longstanding use of drugs by soldiers. >> yes. >> for one purpose or another. if you could just comment on that. >> well, better living through chemistry has been with us for a