Book Reviews -- Samples
AN ANATOMY OF ADDICTION - Sigmund Freud, William Halsted, and the Miracle Drug Cocaine
By Howard Markel
Illustrated. 314 pp. Pantheon. $28.95.
Reviewed by Kate Scannell, MD, Syndicated Columnist
First published in print: 10/23/2011--Bay Area Newsgroup Newspapers
After injecting himself with cocaine, the acclaimed New York surgeon -- who would come to be known as the "Father of Modern Surgery" -- proceeded to the trauma room where he'd been summoned by hospital staff. Awaiting his arrival was a construction worker with life-threatening bone fractures who was "writhing in agony." But, rather than picking up a scalpel and treating the laborer, the surgeon, Dr William Halsted, "turned on his heels, walked out of the hospital, and hailed a cab to gallop him to his home. ... Once there, he sank into a cocaine oblivion that lasted more than seven months."
Meanwhile, across the Atlantic and 12 days after Halsted fled the hospital, the Viennese physician who would become the "Father of Psychoanalysis" began composing love letters -- about cocaine -- to his fiancée, Martha. In those letters, Sigmund Freud wrote about his self-experimentation with "this magical substance" -- the way it lifted him "to the heights in a wonderful fashion." Two months later, he would publish his legendary monograph, "Über Coca" -- a "song of praise" to cocaine.
Through compellingly told stories of these two physicians, author and medical historian Howard Markel takes us on a sometimes-cringing tour of the medical establishment during the late-19th and early-20th centuries -- and, as we discover, much of what we encounter seems hauntingly familiar today. In his new book, "An Anatomy of Addiction -- Sigmund Freud, William Halsted, and the Miracle Drug Cocaine," Markel also tells a timeless and over-arching tale about medical practice "under the influence" of commerce and happenstance.
From the author's vividly detailed research, we learn that Halsted and a group of colleagues began to self-experiment with cocaine in 1884, hoping to discover new anesthetic techniques that would allow safer, tolerable and more successful operations. At the time, the medical profession had just discovered how to use narcotics to alleviate pain, but no one truly appreciated the addictive potential of "miracle drugs" like cocaine.
Fortunately, Halsted did discover how to use cocaine to block the spinal cord and numb nerves, thus giving rise to modern surgical and dental anesthesia. He also promoted cleanliness and sterility in the operating room -- a radical notion at a time when "surgeons who did subscribe to the germ theory of disease still numbered in the minority." Furthermore, he developed novel surgical methods for operations on the breast, intestines, gallbladder and thyroid.
Unfortunately, as a consequence of self-experimentation, "in a matter of weeks, Halsted and his immediate circle were transformed from an elite cadre of doctors into active cocaine abusers." Despite some inglorious public displays of grossly unprofessional behavior, Halsted -- described by Markel as a "remarkably high-performing addict" -- continued to work, never breaking his addiction through the time of his death in 1922.
In contrast, Markel suggests that Freud stopped using cocaine in his lifetime, by 1896 and just prior to launching his psychoanalytic legacy. However, he would frequently ruminate over the death of a close friend whose morphine addiction he had misguidedly tried to "treat" with cocaine. And years would pass, during which he'd obsessively yearn for professional recognition as an authority on cocaine's (purported) clinical powers.
Drawn to the particulars of these men's lives, we also get a good (or, sometimes, bad) view of social norms and Western medical practice, imbued with the Victorian enthusiasm for experimenting with mind-altering drugs in the latter half of the 19th century. This may surprise many readers who link the beginning of "the" drug culture to the 1960s.
But in the mid-to-late 1800s, "controlled substances" did not exist, —... 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." Self-dosing with nitric oxide (laughing gas), hashish and narcotics was common and legal. "Energy-boosting" commercial beverages and "tonic" wines contained cocaine.
Caught in the hype, physicians began recommending cocaine products as a cure-all to their patients for ... well, anything. Here, Markel underscores the attendant hazards when physicians sacrifice sound scientific principles to the gods of popular culture in a cautionary tale involving a Corsican chemist named Angelo Mariani.
From 1863 through the turn of the century, Mariani mass-marketed "Vin Mariani" -- a "tonic wine" concocted from ground coca leaves and Bordeaux, each ounce containing at least six milligrams of cocaine. Advertisements proclaimed, "It nourishes, fortifies, refreshes, aids digestion, strengthens the system ... it is a stimulant for the fatigued and over-worked body and brain, it prevents malaria, influenza and wasting diseases."
Mariani's cocaine-enhanced tonic was enjoyed by Queen Victoria and two U.S. presidents -- Ulysses S. Grant and William McKinley. Celebrity endorsements were obtained from Thomas Edison, Auguste Rodin and Robert Louis Stevenson. Even Pope Leo the 13th permitted his name and face to be featured in a Mariani ad.
Angelo Mariani also became a prototypic pharmaceutical salesman. He marketed his elixir directly to physicians, offering free samples to initiate patient treatment. As Markel summarily notes, "Mariani predated by more than a century and a half the unholy alliance of pharmaceutical houses and too many practicing doctors, a partnership that continues to conspire, inundate, and overmedicate us all in the 21st century."
As a sign of the times, Markel further notes: "... the alarming number of male doctors who prescribed opium, morphine, and laudanum ... 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."
Halsted's and Freud's cocaine promotion both reflected and reinforced prevailing societal norms. But, as physicians -- and their great medical contributions not withstanding -- they also bore a responsibility to temper their personal enthusiasms for the greater good of science and the patients they served. As Markel pointedly concludes: "Each man actively participated in the birth of the modern addict, and their clinical histories prefigure the ever-challenging spectrum of substance abuse, addiction, and recovery."
In the light of current day and in the giant shadows of these men, it is sobering to acknowledge that our two celebrated "Fathers of Medicine" were both drug addicts. It is discomforting to witness familial resemblances in us 21st century offspring, we modern-day American physicians who, with our patients, helped to create Prozac Nation and run up $240 billion in annual prescription drug costs.
Markel's engaging book reminds us that the practice of medicine has always been both cultural and scientific in nature. And through his vivid portrayals of two legendary physicians' lives, we are also reminded that its practitioners are all too human.
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Kate Scannell is a Bay Area physician and syndicated columnist. Her books include the memoir "Death of the Good Doctor" and the novel "Flood Stage."
Copyright 2011, Kate Scannell
The Immortal Life of Henrietta Lacks
By Rebecca Skloot
Crown Publishers, New York, NY, 2010, 369 pages, $26.00.
Pre-Print copy for the Journal of Legal Medicine
Reviewed by Kate Scannell, M.D., F.A.C.P.*
ENCOUNTERING HENRIETTA LACKS
Journalist Rebecca Skloot’s new book is a gripping read that embodies all abstractions about research ethics in a compelling tale about Henrietta Lacks – a woman whose microscopic cancerous cells shook the world’s medical establishment in 1951.
Doubtless, before the publication of this book, few people outside of medical or research circles would have recognized that name. But for many of us insiders, “Henrietta Lacks” routinely and mysteriously figured into our witnessing of major medical advances within the last six decades, into ground-breaking discoveries about cancer treatments and the Salk polio vaccine, into the daily routines of many lone scientists sitting endless hours at their research benches in companionship with her “immortal” cells.
I first “encountered” Henrietta Lacks in the early 1980s – more than three decades after she had died from cervical cancer in 1951. I had been asked to assist a fellow researcher with his experiment, by concocting various broths and “prepping” the cells he would require. Eager to avoid the tedium of my own research project, I dutifully assembled the requisite ingredients and glassware. And, as he had recommended, I met with “The Guy” who oversaw our cell cultures so I could learn how to handle them properly.
“These are HeLa cells,” he informed me as he gently handed over a culture bottle on which was scrawled various numbers and initials. He explained that the cells were from an “eternal” human lineage – faithfully and perpetually reproducing for decades, generously providing researchers around the world with a standardized and plentiful supply of cells for experimental purposes.
His astounding description left me awestruck. I had been taught that all human cells were programmed to die – it was part of the natural order. What unique biophysical property did these undying cells possess? What separated these immortal cells from claims of the divine?
“The Guy” couldn’t answer these questions. But he did offer that the cells had been so-named with the initials of the woman from whom they’d been taken: “Henrietta Lacks.”
The following hour or so that I spent under a sterile hood prepping those HeLa cells affected me deeply. And though mesmerized by the cells’ disembodied immortality, I was more powerfully preoccupied with their personification. I became intensely curious about Henrietta Lacks – the person whom those cells had survived. Regrettably, however, I could find no illuminating information about her in the medical texts available to me back then.
“. . . ON THE BANKS OF THE RIVER OF DEATH”
It is now 2010 and, sorting through the new arrivals at my local bookstore, I stumble upon “The Immortal Life of Henrietta Lacks” by Rebecca Skloot. On its dust jacket is an arresting photograph of a beautiful and clear-eyed woman who seems to be looking straight through time, to the precise moment in which I look at her. The cover text below the book’s title reads: “Doctors took her cells without asking. Those cells never died. They launched a medical revolution and a multi-million dollar industry. More than twenty years later, her children found out. Their lives would never be the same.”
I purchased the book and read it in one day. And, although made newly aware of many vital details characterizing Henrietta’s life, still, I keenly felt her abiding absence. Indeed, having left no words or first-person narrative of her own, her story was wholly reconstructed through the second-hand accounts of family members and doctors. In the end, she remained – immortally – without a voice that we could hear, without an identity of her own making.
Tellingly, even Henrietta’s name was often misrepresented within various medical and lay publications about HeLa cells. She died without an obituary [p. 89] and was buried in an unmarked grave. [p. 121]
In 1999, the book’s author visited Henrietta’s birthplace in Virginia – located off Route 360, “just past Difficult Creek on the banks of the River of Death.” [p. 76] There Skloot hoped to find and interview any family members still living in the mile-long subsection of the area known as “Lacks Town.” She drove past an unpainted shack that marked its entry and soon encountered Cootie, Henrietta’s first cousin. He told Skloot: “Everybody in Lacks Town kin to Henrietta, but she been gone so long, even her memory pretty much dead now. . . . Everything about Henrietta dead except them cells.” [pp. 79-80] Ten years later, when Skloot revisited the town where Henrietta grew up tending gardens and “planting tobacco behind mule-drawn plows,” [p. 19] it was virtually gone and ". . . it felt like everything related to Henrietta’s history was vanishing.” [p. 306]
The historical invisibility of women, blacks, and impoverished Americans is a figurative “river of death” that courses through this book. It is not only Henrietta’s life that is submerged, but also the lives of her community and family members. A profoundly heartbreaking example of this involves Elsie, one of Henrietta’s two daughters, who was committed with the problematic diagnosis of “idiocy” to the Crownsville State Hospital – known formerly as the Hospital for the Negro Insane. In 1955, four years after Henrietta’s death, Elsie died at the age of fifteen in that gruesome asylum all alone and unbeknownst to her sister, Deborah, through whom much of Henrietta’s story is told. [p. 45; p. 117]
In 2001, the author accompanied Deborah to Crownsville to fulfill her promise to help “figure[e] out what happened to Elsie.” [p. 268] They met a hospital director who informed them that most of the medical records from that time period had been contaminated by asbestos and “carted away in bags and buried.” [p. 271] Still, because of some personal “habit of collecting potentially historic documents,” [p. 271] he was able to locate an autopsy report and photograph of Elsie that he had stored in a closet near his desk. In that photograph, Elsie “stares somewhere just below the camera, crying, her face misshapen and barely recognizable” and she “appears to be screaming” while her “head is twisted unnaturally to the left, chin raised and held in place by a large pair of white hands.” [p. 273] In the end, the “picture” of Elsie we are left holding is one of terrible deafening silence, literalized by hands around her small throat.
RESEARCH QUESTIONS LEFT UNANSWERED
The medical research establishment figures prominently in this book, primarily in the ways it regarded Henrietta Lacks and HeLa cells. With a mostly even-hand, Skloot holds up a lens through which she views the doctors and researchers who populated not only the hospitals and research labs where Henrietta and her cells resided, but also the urgent medical questions that were left unanswered for the Lacks family.
Yet, for this reader, it is the brief side-trip to Crownsville that provides the most vividly distilled impression about the research establishment. Skloot, while trying to learn what happened to Elsie, uncovered troubling information about ostensibly covert research activities at Crownsville. The hospital director shared his private trove of documents and newspaper clippings with Skloot, allowing her to determine that, while Elsie was at Crownsville, “scientists often conducted research on patients there without consent.” [p. 275] Research sometimes included the insertion of “metal probes into patients’ brains” or pneumoencephalography – a painful (and now archaic) procedure in which holes are drilled through a person’s skull, and spinal fluid is replaced with air in order to obtain clearer X-ray images of the brain. [pp. 275-6] The hospital director evaluated the data at his disposal and made a calculated guess that Elsie had been studied. [p. 276]
As affecting as they are, still, these haunting images and alarming reports concerning Elsie and Crownsville do not take center stage under the hot lights cast upon the research establishment. For that, we are transported to Baltimore; it is 1951, and Henrietta Lacks is seeking medical care for cervical cancer at John Hopkins Hospital – a charity hospital with a segregated ward for black patients. Before she receives caustic radium treatment, two “dime-sized” samples of her cervical tissue are removed, allegedly without her permission. The samples are given to George Gey, a tissue-culture scientist who for years had struggled to develop a continuously reproducing human cell line that could facilitate and advance cancer research.
As it turns out, Henrietta would die several months later, at 31 years of age. Her cancerous cells, however, would survive her and proliferate wildly in Gey’s lab, “with mythological intensity.” [p. 40] He would freely distribute them to scientists throughout the world who, in turn, would often make amazing medical discoveries. Over time, for-profit cell banks and biotech companies would enter the picture and launch a “multimillion-dollar” industry from a “dime”-sized sample of Henrietta’s cervix.
Meanwhile, Henrietta’s children would struggle financially – some of them unable to afford basic health care – and they would not even learn about their mother’s scientific legacy for decades to come. In fact, when they were first contacted by John Hopkins officials in 1973, they willingly complied with requests for their blood sampling because they'd come to understand that the doctors wanted to test them for cancer. As Henrietta’s husband later recounted: “They said they got my wife and she part alive. . . . They been doin experiments on her and they wanted to test my children see if they got that cancer killed their mother.” [p. 182] But, as the family grimly discovered, there’d been an abysmal misunderstanding – the doctors only wanted the family’s samples in order to conduct further HeLa cell experimentation. This painful revelation arrived as a shock for Deborah who for days had been phoning Hopkins for her “cancer results,” dreading that she may have inherited her mother’s fatal disease. [p. 185]
The family’s formidable distrust of researchers and doctors only expanded when in 1976, reading an article in Rolling Stone magazine, they also learned about massive commercial profiteering from HeLa cells. [p. 193] As Deborah remarked, “. . . if our mother cells done so much for medicine, how come her family can’t afford to see no doctors? Don’t make no sense. People got rich off my mother without us even knowin about them takin her cells, now we don’t get a dime.” [p. 9]
A SPECIMEN’S RED TOE NAILS
Yet, above all else, it is the doctors’ casual disregard and thudding incuriosity about the family’s interest in their mother as a human being that destroyed any last vestige of their trust. When Skloot made her initial phone contact with Deborah and proposed writing a book about her mother, Deborah eagerly responded that such a book would be “great.” Deborah--only one-year old when Henrietta died--had tired of everyone’s focus on her mother as though she were just some dehumanized assortment of cells. “Everything always about just the cells and don’t even worry about her name and was HeLa even a person.” [p. 52] She asked, “You know what I really want? I want to know, what did my mother smell like? For all my life I just don’t know anything, not even the little common things, like what color she like? Did she like to dance?” [p. 53]
For decades, no researchers informed or consulted with the Lacks family about the nature and scope of their experimentation with Henrietta’s cells. Instead, popular media bombarded the Lacks siblings with disturbing and weirdly evocative depictions of their mother whose early death had left them with few memories of her. Deborah saw “a Newsweek article called PEOPLE-PLANTS that said that scientists had crossed Henrietta Lacks's cells with tobacco cells” which made her fearful that “they’d created a human plant-monster that was half her mother, half tobacco.” [p. 196] Hearing that scientists had used HeLa cells to study viruses like AIDS and Ebola, Deborah imagined “her mother eternally suffering the symptoms of each disease: bone-crushing pain, bleeding eyes, suffocation.” [p. 196] She was horrified to read that some people had even tried to kill HeLa cells. [p. 196]
Even while Henrietta lay dying a painful and agonizing death in the hospital, doctors wrote in the medical record: “Henrietta is still a miserable specimen.” [p. 66] Later, during Henrietta’s autopsy, one of Gey’s assistants who was charged with collecting additional pathology samples gasped when she suddenly noted that “Henrietta’s toenails were covered in chipped bright red polish.” [p. 90] Recounting that episode years later, the assistant explained: “I nearly fainted. I thought, Oh jeez, she’s a real person. I started imagining her sitting in the bathroom painting those toenails, and it hit me for the first time that those cells we’d been working with all this time and sending all over the world, they came from a live woman. I’d never thought of it that way.” [pp. 90-1]
A STORY MANY-STORIED
This story is many-storied: not only about “HeLa cells and Henrietta Lacks, but of Henrietta’s family – particularly Deborah – and their life-long struggle to make peace with the existence of those cells, and the science that made them possible.” [p. 7] Their colossal struggle also intimately involves issues of race, gender, poverty, class, and healthcare inequality. It raises substantial questions about medical practice and research ethics, about societal care of the mentally ill, about the moral conduct of journalistic inquiry into other peoples’ lives. It ignites legal and ethical debates about tissue ownership and the commercialization of human biological materials.
And when the struggle is fueled by the depersonalization and dehumanization of Henrietta Lacks and her family, we also wrestle with great philosophical disturbances; at this level, the book sounds a cautionary note about the valorization of medical and scientific “objectivity.” We see how claims to such objectivity can actually derive from the denial of someone’s subjectivity. How the “progress” of scientific research can depend upon dehumanizing the body and its parts which hauntingly reside as “specimens” within the freezers of commercial biobanks and unregulated storage facilities scattered throughout the country.
But underneath all of this – stripped bare of scientific mind, of political and ideological counsel, of celestial advisement and legal consideration, of professional belonging and identity – I would have to say that the book tells a remarkably simple story infused with a very old theme. In essence, the story is a fiercely human tale about the importance of seeing one another in the clarifying light of each other’s unique and radiant mortal being. We are reminded that this sometimes requires faith and forgiveness, the acute notice of a corpse’s painted toe nails, or a road trip to Crownsville. But, always, it requires a basic respect for persons that calls on us to seek each other out with curiosity and compassion, rejecting utilitarian yardsticks to measure our humanity or the value of others’ lives. There is a moral to the story, and it is captured by Elie Wiesel in the book’s epigraph:
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Kate Scannell is a physician, syndicated columnist, and the author of the memoir, "Death of the Good Doctor." Her new novel is "Flood Stage."
This is a preprint of the article submitted for publication in the Journal of Legal Medicine (c) 2010 [copyright Taylor & Francis]. The
Journal of Legal Medicine is available online at:
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The Anatomy of Hope—How People Prevail in the Face of Illness
By Jerome Groopman
The Annals of Internal Medicine - Medical Writings: Book Notes
By Kate Scannell, MD, 2005
Groopman J. 248 pages. New York: Random House; 2004. $24.95. ISBN 0375506381
A STRUCTURED REVIEW:
Fields of medicine: All.
Format: Hardcover book.
Audience: All physicians, medical students, and patients.
Purpose: To remind us of the exquisitely particular ways that hope emerges between a doctor and a patient who faces a serious illness. To journey deeply into the art of clinical decision making with an articulate and seasoned guide.
Content: Through finely rendered prose, the physician–author recounts the stories of 5 of his patients with cancer, each of whom illuminates “another dimension of the anatomy of hope.” The sixth chapter concerns his personal struggle with disabling back pain and the hope that finally arrives as a catalyst for his own healing. Chapters 7 and 8 present the author's attempt to construct “an authentic biology of hope” from scientific research espousing the influences of the human mind on the body. The book concludes with “Lessons Learned,” a reflective personal essay in which the author integrates his insights about hope into a refined notion of the art and science of his medical practice.
Highlights: The author avoids the smooth surface of sentiment, instead choosing to delve into the messy and complex depths of hope that are plumbed by any serious clinical inquiry into the process of medical decision making. The stories draw us into the lived experiential dimension of hope that is expanded and contracted by doctors and patients as they negotiate a medical decision among clinical uncertainty. We see hope as a multidimensional process that unfolds between a doctor and a patient, making its sometimes wayward path through a thicket of human frailties and overarching statistics. The language is inclusive and generous, making the book accessible to both clinicians and patients.
Limitations: None, except leaving this reader with an appetite whetted for more. It will be interesting to see how further exploration of hope is nuanced in terms of patient experience (Is “hope” sometimes a search for meaning, or the desire to conclude one's life in some particular way?), how hope stretches across varied sociocultural frameworks, and how hope reaches beyond the focused goal of eradicating illness or increasing lifespan.
Related reading: During my own cancer treatments, I found hope for a future in various writings that made me feel connected to something larger than the outcome of my disease. These included Pema Chodron's When Things Fall Apart—Heart Advice for Difficult Times (Shambhala Publications, 1996) and the poetry of Rainer Maria Rilke and Mary Oliver.
http://www.annals.org/content/141/2/164.2.full?sid=13329713-46ad-46b1-b9fe-58bb788eed8e