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HENRY KAPLAN and the STORY of HODGKIN'S DISEASE
By Charlotte DeCroes Jacobs
Stanford University Press Copyright © 2010 Charlotte DeCroes Jacobs
All right reserved.
Chapter One Morbid appearances
Thomas Hodgkin was born on August 17, 1798, in Pentonville, just north of London. He was the first child of Elizabeth and John Hodgkin to survive infancy. John, a scholar and renowned master of calligraphy, made his living tutoring ladies from wealthy families. Elizabeth ran a strict Quaker household. The Society of Friends had a strong sense of community, strengthened by the public ridicule they suffered, such as being called "Quakers," because of the belief that members of the sect worked themselves into such a frenzy that they quaked. They lived by a rigid set of principles, "The Rules of Discipline," which included humble speech, plain dress, refusal to bear arms, and rejection of worldly pleasures. These Quaker beliefs, engrained in Thomas Hodgkin, along with the restrictions of the English middle class, shaped his future.
As a youth, Thomas was described as "sweetly docile" by some relatives and as "extremely volatile" by others. All agreed that he had an inquisitive mind. An avid student, he became fluent in five languages and excelled in the sciences. Young Thomas observed the Quaker dress code. In early nineteenth-century England, when fashionable young men donned velvet waistcoats, lacy shirts, and stovepipe hats, Thomas wore a black suit without a lapel and a flat, round hat with a wide brim. This Quaker attire, designed to be inconspicuous, had the opposite effect; outside the Society, he appeared peculiar. His clothing accentuated his pale face, thick eyebrows, deep-set eyes, and dour expression. In talking, he customarily used "thou" and "thine." His Quaker teachers had instilled rigorous standards of thought into him and sharpened his keen sense of observation, both of which contributed to his later achievements in medicine. They also fostered intolerance for imperfection and a righteous temperament.
When time came to select a career, Thomas favored medicine. But Quakers were prohibited from attending English universities. Besides, most physicians came from the upper class and had degrees from Cambridge or Oxford, which meant restriction to members of the Church of England. As an alternative, Thomas could become an apothecary. Tradesmen, mostly from the middle class, apothecaries were licensed to prescribe medicine following an apprenticeship and hospital experience. In his late teens, Thomas became apprenticed to John Glaisyer, a distinguished member of the Society of Friends. After working twelve-hour days in the apothecary's shop, Thomas read until the early morning hours. On his day of rest, he explored the countryside, often accompanied by his cousin, Sarah Godlee, a bright and amiable young woman. They traded books on botany and studied the geography of the local area. His family became alarmed at this budding romance, because the Society forbade marriage between first cousins.
In 1819, Hodgkin began his clinical experience on the wards of Guy's Hospital in London. At the time he enrolled as a twelve-month pupil, the ports of Great Britain were being guarded against entry of the plague. Outbreaks of scarlet fever and diphtheria decimated neighborhoods; four out of every ten children died before age five. Apothecaries treated syphilis with mercury and considered a theriac, a mixture of up to sixty ingredients, the remedy for most ailments. Surgeons performed operations without anesthesia, using nerve clamps and alcohol to dull pain. Unaware of the association between bacteria and infection, they operated in open amphitheaters while students in their street clothes gathered around to watch. Patients commonly died of postoperative infections. "At the beginning of the nineteenth century," one historian wrote, "medical knowledge consisted of nurses' gossip, sick men's fancies, and the crude compilations of a blundering empiricism." This was the medical environment in which Thomas Hodgkin, intolerant of the imperfect, began his medical studies.
Guy's Hospital was considered one of the finest medical establishments in England. "Guy's alone of all the schools in London," said an account of the times, "conducted organized teaching of Medicine and of the sciences on which it rests, and it was at Guy's that the scientific interests of the time were congregated." Much of this reputation was attributable to two men: its star surgeon, Sir Astley Cooper, and its treasurer, Benjamin Harrison, who assured the hospital's prosperity. "King Harrison," as he was called, ruled over Guy's for fifty years; no one dared contradict his decisions.
Hodgkin attended lectures for five hours daily. He soon discovered that empiricism and ignorance underlay most clinical practice, and the cause of death remained unknown in many cases. Only two or three autopsies were performed monthly at Guy's. Hodgkin thought that physicians would have to learn to discern the cause of disease before they could hope to design effective therapies. He became dissatisfied with his career choice; apothecaries could dispense drugs but not examine patients or participate in medical discovery. To change the status quo, Hodgkin needed to be a physician, but for a middle-class Englishman, this required a circuitous route. He had to leave England to earn an MD degree and, on return, pass a test administered by the Royal College of Physicians to obtain licensure. Even then, he didn't know how or if the medical profession would receive a Quaker.
Hodgkin enrolled at the University of Edinburgh, the foremost medical school in Great Britain. Given his academic inclinations, his professors encouraged him to spend time in Paris, where research was beginning to revolutionize the practice of medicine. There he studied at the Hôpital Necker in Paris with an eminent physician, René Laennec, who impressed upon Thomas his conviction that to unravel the mystery of disease, one must correlate physical examination with pathologic findings. At the bedside, Laennec used a novel instrument, the stethoscope, which consisted of an earpiece connected by a nine-inch wooden tube to a flat disc. When he held the disc on a patient's chest, Hodgkin could distinguish breath sounds of different maladies and hear heart murmurs clearly for the first time. He promptly wrote a paper for the Physical Society of Guy's Hospital introducing the stethoscope into England, but the medical community discounted the observations of the young Quaker student.
In 1823, Hodgkin received his MD degree from Edinburgh University and was commended on his thesis, De absorbendi functione, written in perfect Latin, which contained unique observations on the function of blood and lymph. With a stethoscope in his bag and a passion to understand disease in his soul, he then returned home. He easily passed his oral examination to qualify as a licentiate of the Royal College of Physicians. To pursue an academic career, however, he needed to secure a staff position at one of the teaching hospitals. Coveted for their prestige and financial reward, such posts were limited in number. "In the 1820's," one historian wrote, "appointments to hospitals were obtainable only by family or money influence." Having neither, Hodgkin feared that he might have to abandon his aspirations and establish a medical practice. But in 1825, dissension at Guy's Hospital proved advantageous.
Guy's and the adjacent St. Thomas's Hospital had been united for teaching purposes for forty-five years. When Guy's chief surgeon, Sir Astley Cooper, retired, he chose as his successor his nephew, Bransbury Cooper. St. Thomas's staff found the latter unacceptable, however, and a quarrel followed, resulting in dissolution of their association. The Museum of Pathology remained at St. Thomas's, so Guy's needed to establish its own. Hodgkin applied for the new post-inspector of the dead and curator of the Museum. Known to be a brilliant, recent graduate of Edinburgh University, he was offered the position.
Hodgkin found his early years at Guy's Hospital stimulating. Young researchers were beginning to approach disease in a scientific manner, challenging popular doctrines such as the pythogenic theory, which postulated an atmospheric source of fever, and accepted practices such as bloodletting. Hodgkin joined a notable group committed to the study of clinical medicine through postmortem examinations. "With the arrival upon the scene of that great triumvirate, Richard Bright, Thomas Addison, and Thomas Hodgkin," an account of the times said, "we seem to emerge from the remote past to the present." Addison was a talented researcher who first described adrenal insufficiency and pernicious anemia. Richard Bright, later known as the "father of nephrology," made significant contributions to the understanding of kidney diseases. Both felt hampered in their research by the difficulty of obtaining autopsies. "To connect accurate and faithful observation after death with symptoms displayed during life," Bright said, "must ... forward the objects of our noble art."
In their new curator, they found the solution to their dilemma. Thomas Hodgkin undertook his job with zeal, and in four years, he assembled one of the best collections of pathologic material in England. He arranged 1,677 specimens with clinical histories to demonstrate the effects of specific diseases on different organs. He published papers on the classification of malignancies, as well as some of the earliest descriptions of appendicitis and aortic insufficiency (an abnormality of a major heart valve). He encouraged physicians to use the stethoscope and the laryngoscope, a novel instrument that allowed examination of the throat and vocal cords. He co-authored a paper with Joseph Lister on a new microscope that provided greater magnification and better detail than any to date. And he taught one of the first courses in anatomic pathology. Had he been content building his museum and investigating disease, he probably would have been rewarded with promotions and honors. But he was not.
Thomas Hodgkin had a strong reformist inclination. "I quickly perceived," he said, "that to cure or alleviate actual sickness was not all that was necessary ... I saw that there were many causes constantly operating to disturb, ruin, and destroy [health]." To improve public health, he gave a series of community lectures on disease prevention. His superiors considered educating the masses unbefitting for an esteemed member of Guy's medical staff. In addition, Hodgkin disparaged contemporary medical education. He thought it absurd that after only six months of lectures at a medical school, physicians could begin to practice. He raised his voice for reform. Medical education was the province of senior physicians, however, and senior Guy's staff viewed him as a self-righteous agitator.
Meanwhile, Hodgkin continued to enjoy the company of his cousin, Sarah Godlee, against his parents' wishes. He hoped to persuade the Society of Friends to change its rule forbidding first-cousin marriages. But Sarah moved to Edinburgh to assist a distant relative, eighteen years her senior, who had recently been widowed, with two small children. A giving, selfless woman, Sarah eventually married him. Thomas, in his grief, turned to his work.
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On September 24, 1828, Richard Bright asked Hodgkin to conduct an autopsy on a ten-year-old boy named Ellenborough King, who had been admitted to Bright's care a month earlier. The child had been in good health when he suddenly developed enlargement of his glands and spleen. By the time he was brought to Guy's, the glands in his neck had become massive in size, and his abdomen was distended with fluid. A sizable ulcer on the abdominal wall marked multiple attempts to drain the fluid. Perplexed by this constellation of physical findings, Bright had not been able to save the boy. Now he was asking Hodgkin to elucidate the underlying cause of his death.
When Hodgkin opened the chest, he found inflammation in the lungs and large lymph glands, which he described as "equalling in size a pigeon's egg," surrounding the bronchial tubes. As he cut into the abdomen, a thick, purulent material spilled onto the table. The abdominal lymph glands were similarly enlarged, hard in consistency, and streaked with black material. The spleen was four times its usual size and covered with dark spots. The case reminded Hodgkin of a nine-year-old boy on whom he had carried out an autopsy two years earlier. That boy, too, had had enlarged lymph nodes and a spleen of unusual character. Here again were the same curious findings.
Fifteen months later, Thomas Addison asked Hodgkin to perform an autopsy on Thomas Westcott, a fifty-year-old carpenter who had recently died on the clinical ward. The patient had been transferred to Addison in a wasted state, blind in his left eye, confused, with enlarged lymph glands and a swollen abdomen. Before Addison could examine him, the patient was found dead in bed. At postmortem, Hodgkin recorded a "rose-red lump" in the right side of the brain, occupying a space about the size of a "crown piece." Throughout the body he found enlarged lymph glands, which he described as having the texture of a "testicle." The spleen had "an infinite number of small, white, nearly opaque spots which were seen pervading its substance."
Then, six months later, Hodgkin conducted an autopsy on Thomas Black, a fifty-year-old who had been admitted to Guy's with intermittent fevers and a swelling on the side of his neck. He, too, died before a diagnosis could be made. Hodgkin recorded numerous tumors in his chest and abdomen, varying in size "from that of a horse-bean to that of a hen's egg," which he noted to be of "semi-cartilaginous hardness." He realized he was observing a disease not previously described and informed his colleagues: "All these cases agree in the remarkable enlargement of the absorbant glands [which] appears to be a primitive affection of these bodies." At a time when the public regarded autopsies with suspicion, when politics and superstition dictated medical science, Thomas Hodgkin had detected a new disease.
On January 10, 1832, his paper, "On Some Morbid Appearances of the Absorbant Glands and Spleen," was submitted to the Medical and Chirurgical Society (which later became the Royal Society of Medicine). Inasmuch as he was not a member of the society himself, Hodgkin was prohibited from presenting his work in person. Instead, the society secretary read his manuscript. "The morbid alterations of structure which I am about to describe," the paper began, "are probably familiar to many practical morbid anatomists." His own six cases and others sent to him had similar pathologic findings: massive, firm lymph glands, unusual in their uniformity and absence of inflammation, and an enlarged spleen, "thickly pervaded with defined bodies of various sizes, in structure resembling that of the diseased glands." These abnormalities of lymph nodes and spleen had not previously been noted. Hodgkin thought they suggested a malignancy. "A pathological paper may perhaps be thought of little value," he went on to say, "if unaccompanied by suggestions designed to assist in the treatment, either curative or palliative. On this head, however, I must confess that I have nothing to offer." He did not advocate dosing with a theriac or bloodletting. Hodgkin didn't know the source of this malady, nor could he recommend therapy, but he had taken the first key step-recognition of a new disease and careful description of its presentation and progression.
Members of the Medical and Chirurgical Society received Hodgkin's presentation with indifference, and his manuscript lay forgotten in the volumes of Medico-Chirurgical Transactions. Unaware of the significance of the disease he had described, Hodgkin did not even give this "affection," later known as Hodgkin's disease, a name. He never knew how much his observations would aid mankind or that they would secure his place in medical history.
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Had Thomas Hodgkin focused his energy on research and teaching, he likely would have contributed even more to medical science. But with his Quaker upbringing, he felt compelled to bring about social reform. He spoke out against the medical establishment and its methods of selecting and remunerating physicians for attending the poor. Accusing many medical officers of negligence, he proposed that the post of medical officer be awarded through competitive examinations. An active member of the Anti-Slavery Society, he published several pamphlets such as On Negro Emancipation and American Colonization. He worked to relocate freed slaves to West Africa. He welcomed them into his home and rode with them in his open carriage through the streets of London, to the dismay of fellow lecturers at Guy's.
But of all Hodgkin's causes, the one that proved his downfall was his allegation of mistreatment of Native Americans, which brought him into direct conflict with King Harrison. A founder of the Aborigines' Protection Society, Hodgkin denounced methods employed to "civilize" Indians, and he reported to the House of Commons regarding abuse in the British colonies. In doing so, he revealed egregious practices by the Hudson Bay Company, including use of alcohol to domesticate Canadian Indians. Harrison served as a member of the Committee of the Hudson Bay Company. Hodgkin wrote to apprise him of the problems, stating that he knew Harrison would be concerned, since he had devoted his life to an institution whose sole purpose was the relief of suffering. He went so far as to suggest changes in company policy that would improve the Indians' situation.
Hodgkin developed a friendship with Chief Hesh-ton-a-quet, a Chippewa chief who had been invited to England with his wife and four other Indians, presumably as guests of the king of England. Upon arriving, their sponsor had put them on public display. Three died, and the chief was accused of child molestation. Hodgkin provided his bail, and in a highly publicized trial, the chief was acquitted. Following this, Hodgkin drove into the hospital square with an Indian many thought to be Chief Hesh-ton-a-quet in full costume beside him. He stopped in front of King Harrison's quarters. So angered was Harrison, the events that followed should not have been surprising.
In 1837, upon the death of a Guy's staff physician, the post of assistant physician became available. Such a position would allow Hodgkin to do more than teach and conduct autopsies; he would be able to admit patients to the hospital and help determine Guy's policies. Hodgkin felt confident that Harrison would grant him the post; after all, he had served as curator of the Museum and lecturer at Guy's Medical School for twelve years. Instead, Harrison appointed a clinician whose father had been on the staff at Guy's. Despite an outcry from students and staff physicians, King Harrison prevailed.
Excerpted from HENRY KAPLAN and the STORY of HODGKIN'S DISEASE by Charlotte DeCroes Jacobs Copyright © 2010 by Charlotte DeCroes Jacobs. Excerpted by permission.
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