Monday, January 5, 2015

Freud & The Cocaine Episode in Context

Coca in Context: From The Andes to Paris & Atlanta
An early documentation of the use of the medicinal properties of the coca plant came from the Spanish friar, Vincente de Valverde, reporting on the importance of the coca tree to the Incas:
"...coca, which is the leaf of a small tree that resembles the sumac found in our own Castile, is one thing that the Indians are ne'er without in their mouths, that they say sustains them and gives them refreshment, so that, even under the sun they feel not the heat, and it is worth its weight in gold in these parts, accounting for the major portion of the tithes."1
 It was not long until quantities of the medicinal plant were being exported from South America to Europe and the United States, where Western "medicine men" began making coca infused beverages and tonics. Historian Howard Markel points to an 1817 article published Gentleman's Magazine to illustrate the European fascination with coca:
"[The Indians] masticate Coca and undergo the greatest fatigue without any injury to health or bodily vigor. They want neither butcher nor baker, nor brewer, no distiller, nor fuel, nor culinary utensils."2
According to Markel, the article called for immediate scientific research to uncover the wisdom of the power of Coca.

By the mid-nineteenth century, coca leaves were being analyzed for their chemical structure. In Germany, Albert Niemann earned his doctorate by developing a method for extracting the coca alkaloid from the leaf in 1860.3  As academics and pharmaceutical laboratories were investigating the chemical properties of coca, medicine men of a different sort were developing tonics and a variety of coca-infused beverages. One of the most popular and successful of these libations was Vin Mariani, a coca wine developed by the French chemist Angelo Mariani. By the turn of the century, Vin Mariani had become the choice intoxicant of many celebrities and artists. Mariani published a collection of celebrity endorsements for his wine in a book entitled Portraits from Album Mariani.4

In 1859 the influential Italian neurologist and fiction writer, Paolo Mantegazza, published an influential paper On the Hygenic and Medicinal Virtues of Coca.5  Sigmund Freud was an avid reader of Mantegazza's fiction.6

The most famous of all cocaine drinks of the 19th century did not appear in France, but rather, in the United States. John Smith Pemberton, a disabled, Civil War veteran had developed a severe addiction to morphine, the standard pain medication of the day. Having read a number of research studies on the use of Cocaine to overcome morphine addiction, Pemberton developed a Vin Mariani spinoff that he marketed as French Wine Coca. Pemberton's cocaine infused wine tonic enjoyed a short-lived popularity when, in 1886 Fulton County, Georgia, banned the sale of alcohol. Because Pemberton's manufacturing plant was located in Fulton County, he substituted the alcohol with kola nut extract, patenting Coca-Cola as a health drink to be sold in pharmacies. Coca-cola contained cocaine until 1903 when the manufacturer began using spent coca leaves which had the cocaine extracted.7 

By the early 20th century, cocaine was widely used as an anesthetic. It was eventually replaced for use in surgery with Novocaine, a new (novo) anesthetic that did not have the euphoric, addictive qualities of cocaine.

Using the Google Ngram viewer, we can see that the word "coca" entered the published literature in the 16th century. The word "cocaine" appeared in publication in the mid 19th century. This is partly due to the development of the manufacturing and sales of refined cocaine powder by the Parke, Davis & Co. pharmaceutical manufacturers. The powdered cocaine produced by Parke, Davis & Co. was applied as a topical anesthetic (a paste brushed on to the desired area), or dissolved in water to taken orally. Cocaine injections were used to deliver the anesthetic in surgery and became more widespread in recreational use in the late 19th century. "Snorting" the cocaine powder did not become popularize until the mid-20th century.

By the 1880s cocaine was a popular additive in beverages, toothache powders, teas, as well as a variety of other products. It was hardly unknown by the public in both Europe and the United States. What was unclear was that it had addictive properties.

The Young Dr. Freud's First Medical Publications
In 1883 the 27-year-old Dr. Sigmund Freud, a newly minted medical doctor, was serving as resident physician at The First Psychiatric Clinic of the Vienna General Hospital, in Austria. He was engaged to be married; his letters describe an eager, young, professional who harbored dreams of scientific fame and a desire to establish himself financially in the anticipation of marriage and a family. His love letters to his betrothed, Martha Bernays, reveal the young doctor's enthusiasm for research, discovery, and learning. According to his biographer, Ernest Jones, the first mention of cocaine was found in a letter written to Martha on April 21, 1884.
"I have been reading about cocaine, the essential constituent of coca leaves which some Indian tribes chew to enable them to resist privations and hardships. A German has been employing it with soldiers and has reported that it increases their energy and capacity to endure. I am procuring some myself and will try it with cases of heart disease and also of nervous exhaustion, particularly in the miserable condition after the withdrawal of morphium (Dr. Fleischl). Perhaps others are working at it; perhaps nothing will come of it. But I shall certainly try it, and you know that when one perseveres, sooner or later one succeeds. We do not need more than one such lucky hit to be able to think of setting up house. But don't be too sure that it must succeed this time. You know, the temperament of an investigator needs two fundamental qualities: he must be sanguine in the attempt, and critical in the work."8

The letter to Martha shows a young professional who is eager to establish himself professionally and

to begin a family with his fiancé. We also take note of his mention of Dr. Fleischl's morphine addiction treatment. Dr. Ernst von Fleischl-Marxow was a colleague and friend of Sigmund's who had accidentally sliced his thumb while conducting an autopsy. Freud's biographers point out that the young Doctor Freud's interest in the mystical coca plant was not only driven by a strong desire for professional security and scientific notoriety, but also a devotion to help his friend, Dr. Fleischl, through a debilitating morphine addiction.

Sigmund had previously attempted a scientific breakthrough with using gold chloride to dye tissue slides for microscopic viewing. Having failed to achieve the professional renown that was necessary for both his scientific and family plans, he turned his eye to investigating the uses of the Incan plant for the treatment of morphine addiction and depression. Freud first ordered one gramme of cocaine hydrochloride from the pharmaceutical company Merck of Darmstadt, Germany in 1884. As was a common research practice of the time, Freud tried one-twentieth of a gramme (Coca-Cola originally contained about 4.3 milligrams per six-ounces)9 of cocaine, the equivalent to about five, 12-ounce bottles of Pemberton's Coca-Cola drink) on himself. Jones reports that Freud "found it turned the bad mood he was in into cheerfulness and gave him the feeling of having dined well 'so that there is nothing at all one need bother about,' but without robbing him of any energy fro exercise or work."10

Sigmund's research was reported in his first major medical article Über Coca published in 1885. The article praised the uses of coca for depression, morphine addiction, and hastily mentioned cocaine's anesthetic qualities, which would become the primary medical use for the drug. Freud's first patient was his friend, Dr. Fleischl-Marxow. Markel describes that the initial results were "nothing short of miraculous," and that by the end of the month-long "cocaine therapy" Fleischl's morphine use was gone. Unfortunately, the addictive qualities of cocaine were only then trickling-in through the scientific community and Fleischl develop a cocaine addiction, which he then gave up and returned to morphine. Dr. Ernst von Fleischl-Marxow eventually died at the young age of 45.

From Medicine to Psychoanalysis 
Ernest Jones tells us of Freud's lifelong regret for prescribing cocaine to his close friend. While Freud regretted that he could not help his friend overcome his morphine addiction, he also seems to have attributed the addictive quality of cocaine and other substances more to the individual than to the drug. A theme that remains in psychodynamic addictions treatment today is the idea of an "addictive personality," which explains why some people become addicted to substances while others do not. Freud viewed his friend Dr. Fleischl as someone who had an addictive personality, and thus could not be treated with cocaine nor morphine. Perhaps in a classic example of denial, Freud did not see himself as the addictive type, despite the fact that he smoked up to 20 cigars a day.

Although his enthusiastic praise of cocaine quickly disappears from his love letters to Martha, he does mention using cocaine in 4 of nearly 300 letters that he wrote to his main confidant of this time, Dr. Wilhelm Fliess. In a letter to Fleiss dated May 30, 1893 Freud mentions using cocaine to successfully treat a headache. On January 24, 1895, Freud described using "a lot of" an anesthetic cocaine paste to treat the pain and swelling associated with nasal infection. In letters dated April 26 and 27, 1895, he again briefly mentions using cocaine to treat pus that was forming in his nasal passage due to a chronic infection. Finally, on October 26, 1896, Freud tells Fliess, "incidentally, the cocaine brush has been completely put aside." This is in reference to using the brush to apply the cocaine paste as an anesthetic. No mention of cocaine use was made again in any of Freud's correspondence, many of which where much more intimate in nature than any censorship of cocaine use would have warranted. The last word on cocaine was 1896 four years before his first publication on psychoanalysis, The Interpretation of Dreams.

When one searches The Standard Edition of the Complete Psychological Works of Sigmund Freud, one finds that "cocaine" occurs about 26 times in Freud's writings. Most of these references occur in his seminal psychoanalytic text, The Interpretation of Dreams. The mention of cocaine in The Interpretation of Dreams comes from the retelling and analysis of a dream that serves as the book's central topic of analysis. It is known as Irma's Injection.11

Irma's Injection is the "model dream" Freud used to illustrate the process of psychoanalytic dream analysis. To understand the dream analysis, one must also understand the real-life scenario that played-out between Drs. Freud and Fliess, and their patient, Emma Eckstein. It is important to note that Irma's Injection has little to do with cocaine, which had been used as an anesthetic during her surgery and as a post-operative pain management, and had a lot to do with the guilt Freud felt for malpractice with both Eckstein (Fliess forgot to remove the surgical gauze after surgery and nearly killed his patient) and his friend, the now deceased, Dr. Ernst von Fleischl-Marxow.

Presentism & Yellow Scholarship
Freud's Cocaine Episode has been the topic of discussion in university classrooms for over a century. For reasons that are sometimes rather superficial, it seems that some professors and authors exaggerate and sensationalize topics in an attempt to make them more appealing to students, or to promote a certain attitude. With Sigmund Freud, the two most common cliches have to do with cocaine addiction and sexual perversion. When professors and authors, many of whom might be relying solely on secondary source materials and biased opinions of their own teachers, exaggerate or sensationalize the scholarship for dramatic effect they are doing a disservice  not only to the theorist they present to their students, but also to their students themselves.

Reviewing the current evidence, there is little basis to promote the theory that Sigmund Freud was addicted to cocaine. There is evidence that he used cocaine between 1884 and 1895 for either stimulation, mood enhancement, or pain relief. In the context of 19th century writers and thinkers, the use and abuse of cocaine by artists and thinkers was the practice, rather than the exception. One must be careful of presentist attitudes when critically evaluating historic episodes. All evidence suggests that Freud had stopped using cocaine for any purpose in 1895, which predates any of his psychoanalytic writings by four to five years.

During the newspaper circulation wars of the early 20th century, the practice of sensationalism and crude exaggeration was used to sell more newspapers. Scholars have a term for this practice;  yellow journalism. It seems that we too, in academics, need a term to describe the misrepresentation of academic research in the attempt to "sell" an idea. I propose the term yellow scholarship, and put forth the story of Freud's cocaine episode as one of its foremost examples.

Freud, Sigmund. The Standard Edition of  the Complete Psychological Works of Sigmund Freud. Translated by James Strachey. London: Hogarth, 1986.

Freud, Sigmund. The Letters of Sigmund Freud. New York: Dover, 1992.

Gay, Peter. Freud: A Life for Our Time. New York: Norton, 1988.

Jones, Ernest. The Life and Work of Sigmund Freud. New York: Pelican, 1953.

Markel, Howard. An Anatomy of Addiction. New York: Pantheon, 2011.

Masson, Jeffrey Moussaieff. The Complete Letters of Sigmund Freud to Wilhelm Fliess 1887-1904. Translated by Jeffrey Moussaieff Masson. Cambridge, MA: Belknap Press, 1985.

Direct questions, comments, & corrections to Matthew Giobbi.