My Two Minutes of Fame

If you would like to see me run and (for better or worse) hear what I sound like (yes, I do have a pretty significant Cleveland accent), here’s your chance.

Running Jenny

Make sure you watch the video, of course. Enjoy!

One thing that didn’t make it into the video that I want to say is thank you to my doctor and the nurses and staff at Fairview Hospital and the Moll Cancer Center. In eight months of constant contact with the medical profession, I didn’t run into one bad person. Someone had to have a bad day in there, but they never let it show. I am thankful such smart and compassionate people choose such a tough field as oncology.

A Brief History of Mr. Hodgkin and His Horrible Disease

(I am sticking this in the Civil War category, although it has almost nothing to do with the Civil War. It’s very much a history related post, however.)

There seems to be something a bit ironic about a student of history being diagnosed with a type of cancer with as long and as interesting a history as Hodgkin’s Disease. Being a history buff afflicted with this particular malignancy, I thought it might be interesting to give … drum roll … a brief history of both Dr. Hodgkin and his horrible disease.

(You know, my first interest was medical school — maybe you’ve seen my website on Civil War medicine. But desire and interest and actual talent are different things, so I ended up a lawyer. Still anatomy in particular fascinates me so I enjoyed flipping through some of the really disgusting pictures I found on the web that Hodgkin included in his books.)

Dr. Thomas Hodgkin

Hodgkin’s Disease is one of the best known medical eponyms. The fellow who’s name got attached to this relatively rare¹ cancer especially known for attacking younger people² was named Thomas Hodgkin. Hodgkin was born in to a Quaker family in Middlesex, England on August 17, 1798. In 1819, he entered medical school at St. Thomas’s and Guy’s Medical School (affiliated today with King’s College in London). In 1823, he earned his M.D. Two years later, Dr. Hodgkin was appointed lecturer in morbid anatomy and curator of the Pathology Museum at Guy’s Hospital Medical School.

Physically, Hodgkin was dark haired, with a slight and wiry build. He had a hot temper, but was greatly appreciated as a lecturer. Hodgkin’s passion seems to have been pathology. In 1829, Hodgkin published a work that became a classic in pathology, The Morbid Anatomy of Serous and Mucous Membranes. This work focused on unexpected intra-thoracic and intra-abdominal tumors and how cancer spread.

In 1832, Dr. Hodgkin described the disease that now bears his name in a paper entitled On Some Morbid Appearances of the Absorbent Glands and Spleen. The paper was published in the journal of the Medical and Chirurgical Society in London. The disease would be rediscovered in 1865 — right as the Civil War ended — by Dr. Samuel Wilks who recognized Hodgkin’s work and named the disease after him in a paper entitled Cases of enlargement of the lymphatic glands and spleen, (or, Hodgkin’s disease) with remarks.

Hodgkin was one of the early advocates of preventive medicine, publishing On the Means of Promoting and Preserving Health in 1841.

Although the most brilliant pathologist of his day, Hodgkin was an abject failure in business. After staying up all night caring for a very rich patient, Hodgkin received a blank check for his work. He filled in the blank with 10 pounds, then added insult to injury by saying that the patient didn’t seem to be able to afford more. Many of his friends were reluctant to ask him to consult on their cases because he would refuse to charge them.

Hodgkin was a social progressive. He opposed slavery, advocated for reforms in medical education, and founded the the British and Foreign Aborigines Protection Society. His liberal views along with his hot temper made him enemies in the medical profession.

Dr. Hodgkin died of a terrible illness sadly familiar to many Civil War soldiers — dysentery — on April 5, 1866 in Jaffa, Palestine. His grave reads: “Here rests the body of Thomas Hodgkin M.D. of Bedford Square, London. A man distinguished alike for scientific attainments, medical skills and self-sacrificing philanthropy.”

Hodgkin’s Disease - The Early Years

Dr. Hodgkin was the first to note that Hodgkin’s Disease seemed to form in the intra-thoracic region and would spread through contiguous lymph node chains. He also noted that involvement of the spleen seemed a symptom of advanced disease.

Dr. Hodgkin also recognized that the “father of microscopical anatomy,” Marcelle Malpighi published the first actual recorded description of Hodgkin’s disease in his paper De viscerum structuru exercitatio anatomica in the year 1666. Hodgkin’s Disease was not the first cancer discovered,³ but it was among the first and one of the first to be accurately described.

Hodgkin only examined his disease grossly; he did not undertake to use the primitive microscopes of the day to explore the tissue further. As previously mentioned, a year before his death, Dr. Wilks assigned Hodgkin’s name to the disease. Hodgkin’s Disease proved to be interesting because it was difficult to classify — was it an infection? a cancer? an inflammatory process? The disease additionally attracted much attention and infamy due to it’s frequency in young adults.

Several pathologists who followed Hodgkin and Wilks did examine biopsies of Hodgkin’s Disease under the microscope, but it was Dorthy Reed (1874-1964), a fellow at Johns Hopkins, who first classified the unusual giant cells unique to Hodgkin’s Disease. Dr. Reed failed to recognize that they represented a neoplasm, however, thinking they were inflammatory. The unique giant cells that make up Hodgkin’s Disease are today known as Reed-Sternberg cells (Dr. Carl Sternberg (1872-1935) had also done work describing them independently in Germany in 1898).

Pathologists were eventually able to tie the giant Reed-Sternberg cells⁴ to the malignant process. Hodgkin’s Disease is a cancer,⁵ sometimes called Hodgkin’s Lymphoma. ⁶

Reed-Sternberg cells are interesting because they only make up 1 to 2% of a Hodgkin’s Disease tumor. Hodgkin’s Disease is the only malignancy where the size of the masses aren’t a result of the number of cancerous cells. ⁷ (This is one reason why there is so much inflammation with Hodgkin’s Disease and often scar tissue).

In 1925, Hodgkin’s Disease, Non-Hodgkin’s Lymphoma, and the leukemias were finally differentiated officially as different diseases.

Hodgkin’s Disease: The First Curable Cancer

Although early pathologists did not recognize that Hodgkin’s Disease was a malignancy, it’s ability to kill was well known. Ninety percent of people with Hodgkin’s Disease would die within three years time; almost all would die within five years.

Through the early 20th century, doctors experimented with using radiation to try and control Hodgkin’s Disease. They had limited success. They began to then experiment with nitrogen mustard. Now my military readers are probably asking mustard? Isn’t that the stuff that was so terrible and killed so many in WWI? Yes. Ironically, the development of the nitrogen mustard drug used in Hodgkin’s disease stemmed from the use of mustard compounds during World War I and from a terrible explosion during World War II in Bari, Italy that exposed servicemen to toxic effects. The Bari incident showed that nitrogen mustard could cause suppression of the bone marrow and of the lymphatic system. By the mid-1940s, doctors were beginning to control Hodgkin’s Disease and shrink the tumors.

The big breakthrough came in the middle 1960s. By 1964, doctors had come up with a combination chemotherapy regimen that utilized the mustard known as MOPP. MOPP consists of cyclophosphamide, vincristine, methotrexate, and prednisone.

The current staging system was also set up by the mid-1960s. The Ann Arbor Staging for Lymphomas also applies to Hodgkin’s Disease. Stage is closely associated with prognosis. The stages for lymphoma are:

• Stage I indicates that the cancer is located in a single region, usually one lymph node and the surrounding area. Stage I often will not have outward symptoms.
• Stage II indicates that the cancer is located in two separate regions, an affected lymph node or organ within the lymphatic system and a second affected area, and that both affected areas are confined to one side of the diaphragm - that is, both are above the diaphragm, or both are below the diaphragm.
• Stage III indicates that the cancer has spread to both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen.
• Stage IV indicates diffuse or disseminated involvement of one or more extralymphatic organs, including any involvement of the liver, bone marrow, or nodular involvement of the lungs.

To this letters are often appended:

• A or B: the absence of constitutional (B-type) symptoms is denoted by adding an “A” to the stage; the presence is denoted by adding a “B” to the stage. The B symptoms include night sweats, fevers, and weight loss of 10% of more. Many symptoms associated with Hodgkin’s Disease (itching, pain on drinking alcohol) are not official B-symptoms.
• E: is used if the disease is “extranodal” or has spread from lymph nodes to adjacent tissue.
• X: is used if the largest deposit is >10 cm large (”bulky disease”), or whether the mediastinum is wider than 1/3 of the chest on x-ray.
• S: is used if the disease has spread to the spleen.

(So if you assigned your author all the different letters that applied to her case, she would have Stage III-AEXS Hodgkin’s Disease.)

By the way there are also four known sub-types of Classical Hodgkin’s Disease:

• lymphocyte predominance (approximately 5% of cases)
• nodular sclerosis (approximately 70%)
• mixed cellularity (approximately 20%)
• lymphocyte depletion (5%)

(Your author had the NS sub-type.)

By 1967, the results from MOPP were coming in and they were astounding: an 81% complete remission rate. In 1968, Adriamycin ⁸ became available for the first-time and in 1972 Dacarbazine ⁹ was approved for use. Because MOPP caused severe side effects (including sterility and severe suppression of the bone marrow leading to secondary leukemias), in 1972-73 a group from Italy led by Bonadonna came up with the current “gold standard” for Hodgkin’s Disease: ABVD Chemotherapy. ABVD combined a vinca-alkaloid known as Vinblastine ¹⁰ (similar to Vincristine in MOPP), an anti-tumor antibiotic called Bleomycin, and Adriamycin, and Dacarbazine. In head to head trials, ABVD proved not only less toxic, but also provided superior rates of cure.

The last major step in treating Hodgkin’s Disease came in 1992 when a German group came up with a new regimen for highest risk patients known as BEACOPP. Along with the Stanford V regimen (a combination chemotherapy and radiation regimen), these two treatments are now sometimes used in place of ABVD in advanced disease.

With modern chemotherapy, sometimes combined with radiation to areas of disease, about 80% of patients with Hodgkin’s Disease can today be cured.

As you would expect, Hodgkin’s Disease is still an evolving field, especially in terms of treating patients who have relapsed disease. Much of the work currently involves effective treatments for Hodgkin’s Disease that reoccurs despite first-line therapies. Also, there has been focus on trying to predict which patients are most likely to relapse. The use of radiation remains an issue as does attempting to lessen the toxicities from chemotherapy.

A Few Famous Hodgkin’s Disease Survivors You’ve Probably heard of

• Paul Allen
• Mario Lemieux
• Arlen Specter
• and a host of wonderful people you’ve never heard of, but are just as important, and just as valuable

So there you have it — a brief history of Dr. Hodgkin and his disease.¹¹

1. The incidence of Hodgkin’s Disease is about 3 cases per 100,000 people per year, and it accounts for less than 1 percent of all cases of cancer in the United States. The American Cancer Society states: “The American Cancer Society estimates that in 2007 there will be about 8,190 new cases of Hodgkin disease in this country. And about 1,070 people will die of the disease. Because of better treatment, death rates have fallen by more than 60% since the early 1970s.” [↩]
2. Hodgkin’s has a biomodal distribution; it is most often seen in people aged 15 to 34 or over the age of 60. In young adults, it is the most common kind of cancer. [↩]
3. Cancer is an ancient disease. Bone remains of mummies have revealed growths suggestive of bone cancer. The Edwin Smith Papyrus found in Egypt that dates back to 1600 BC actually describes 8 cases of tumors or ulcers of the breast that were treated by cauterization, with a tool called “the fire drill.” The writing explains that there was, “no treatment.” [↩]
4. R-S cells are the major thing that differentiate Hodgkin’s Disease from non-Hodgkin’s Lymphoma. The R-S cell is very large and often has more than one large nuclei. [↩]
5. Hippocrates used the terms carcinos and carcinoma to describe non-ulcer forming and ulcer-forming tumors. He used the word that referred to a crab because crab the disease often presented with finger-like spreading projections from a cancer called to mind the shape of a crab. [↩]
6. A lymphoma is a cancer of the lymphatic system, a set of interconnected organs and tissues that helps the body fight diseases and infections. There are two major types, the much more common Non-Hodgkin’s Lymphomas and Hodgkin’s Disease. Connected along the thin network of vessels of the lymph system are groups of small, bean shaped and sized organs called lymph nodes. Lymph nodes are found in the neck, chest, armpits, abdomen, and groin. The lymphatic system also includes the tonsils, thymus, spleen, and bone marrow. [↩]
7. Most of the Hodgkin’s Disease mass consists of benign inflammatory cells including small T lymphocytes, histiocytes, plasma cells, eosinophils, and neutrophils. The inflammation is produced by cytokines which are in turn produced by the tumor cells. [↩]
8. Adriamycin is the red drug. It is used for many different kinds of cancers. It’s generic name is doxorubicin. Adriamycin is in the class of chemo drugs known as Anthracyclines. [↩]
9. Dacarbazine is also known by it’s brand name, DTIC. Dacarbazine is an alkylating antineoplastic agent. It is used mainly now for Hodgkin’s Disease and for certain kinds of melanoma. [↩]
10. Vinblastine is a mitotic inhibitor. It derives from the perwinkle plant. [↩]
11. The World Health Organization in 2001 tried to officially name Hodgkin’s Disease, Hodgkin’s Lymphoma. Personally, I think Hodgkin’s Disease sounds better and my doc uses the term “Disease”, so I am going to keep referring to it as Hodgkin’s Disease. [↩]

grateful

As a cancer patient, I am grateful that kind, smart, funny, caring people choose to become oncologists, chemo nurses, or to otherwise work in the field of oncology. Yes, this is their job, yes they are compensated for the work that they do. But I’m still grateful that my medical team chose one of the most difficult (if not the most difficult) areas of medicine — intellectually and emotionally — in which to specialize. If you want to make a lot of money or just earn prestige, there are a lot easier ways to go about it than working in a rigorous field like oncology. I don’t know how people can work in oncology, but I am grateful there are so many good people in the field.

That’s all. :)

the unusual case of R.S. Andrews

Even before being diagnosed with Hodgkin’s Disease — an occurence that caused me to spend a lot of time learning about medicine — I have had an interest in the medical aspects of the Civil War.  In fact, my screen-name when I was a member of American Online was CWSurgeon0.  And I even have a website about a Civil War surgeon named Hunter McGuire.  You probably know Dr. McGuire best as Stonewall Jackson’s medical director.  He was actually a lot more than that and although he is probably best remembered for failing to save Jackson, he had an extremely distingushed medical career.

As usual I digress.  The point of this post was to tell the story of Snowden Andrews.  Most of the material for this post comes from Krick’s excellent book, Stonewall Jackson at Cedar Mountain.  I warn you ahead of time that this is graphic and not to be read while eating (unless you are the twisted type who likes to eat and read about horrific battle wounds).

Robert Snowden Andrews (1830-1903) was a 31 year old architect from Maryland.  He survived one of the worst wounds of the Civil War at the battle of Cedar Mountain.  Remarkably, he was coming off a prior wound; Andrews had suffered a leg wound during the Seven Days and as such was not quite yet up to par health wise at the time of the battle. It was said “Anyone not of his temperament would have been away in a hospital or on sick leave.”  But being on sick leave wasn’t Andrews style.

Thus, the 31-year old found himself on the Cedar Mountain battlefield in August 1862 as part of Stonewall Jackson’s command.  As Charles Winder’s chief of artillery, Andrews commanded cannons on the field near what is termed the “Crittenden Gate,” near the center of the battlefield. (This is also very close to where Jackson would try to draw his sword — it had rusted into its scabbard! — and make the famous rally of his troops).

It was while commanding and directing his guns with “success and gallantry,” that Andrews rode into the path of an exploding artillery shell. The result was catastrophic. A sharp piece of the projectile sliced open the right side ofhis abdomen, nearly cutting him into two pieces. Andrews threw one arm across the gaping hole and slid off his horse and onto his back. (Falling forward would have caused the Major to have almost certainly been disemboweled.)

Such wounds were almost universally fatal in the Civil War.  Any Civil War buff can tick off a litany of officers who died of “belly wounds,” perhaps the most famous case of all being dashing Confederate cavalry commander Jeb Stuart.

So it is no surprise that General Taliaferro, who lauded Andrews four days later in an official report, sadly opined of his being wounded “I fear mortally.” Almost all who saw Andrews thought he was to surely die. In fact, this wound was very much like the one that Andrews chief, General Charles Winder, took in the same battle, except that Winder’s wound was to his left side and Winder did not survive. (Winder died quietly near sun down.)

My man General A.P. Hill at some point passed Andrews lying on the battlefield and promised to send help for him. Help arrived in the form of Dr. Hunter McGuire, Jackson’s medical director. (Yes, the same McGuire I referred to in the beginning of my post.)  McGuire, well-known for his bluntness and candor, told Andrews that there was simply no hope and nothing he could do. Andrews, who had already been seen a few other surgeons at this point, retorted “Yes, that’s what you fellows all say.” McGuire detailed two Georgia brothers, Drs. Thomas and William Amiss, to take care of Andrews.

The surgeons later described the injury thusly: Andrews was “completely disemboweled, his intestines covered with dust, hen-grass, sand, and grit.” The Amiss brothers also declared that there was no hope. Andrews angrily answered that he had been hearing that was the case, but if “you damned doctors would do something for me I’d get well.” Andrews noted that he once had a hound that “ran a mile with its guts out and caught a fox, and I know I am as good as any damned dog that ever lived and can stand as much.” The doctor replied with a pun, “This man is full of all kinds of grit.”

Finally, Andrews was taken from the battlefield and carried in great agony to a field hospital. Near midnight, the surgeons began to operate on Andrews and his seven hour old wound on the dining room table at the Garnett House. When the blood and gore was cleared, it was found that Andrews had a second severe wound near the hip that ran across his upper thigh.  (Such a wound could itself easily be mortal).  Nevertheless, the doctors carefully cleaned the wounds and then replaced the intestines, sewing the wound shut with cotton and a “common calico needle” as that was all that was available.

The medical prognosis continued to be characterized as beyond grim.  Dr. Harvey Black, a good surgeon and friend of Andrews, when asked replied that there was almost certainly no hope for Andrews.

Andrews came out of the surgery cool and composed, repeatedly asking the question of what his chances were. When he asked if it was at least one in ten or one in twenty, the doctor said “not more than that.” Andrews cheerfully declared his intention “to hold on to that one chance.”

Andrews wife had been staying in Baltimore with her three children. From the morning newspaper, she learned her husband had been mortally wounded. (She had already suffered one scare where her husband had been reported dead.) Mrs. Andrews left for Culpeper and arrived near 6 PM on August 16 with the couple’s seven month old baby. It was the first time that Andrews had seen the child.

Despite having survived this long, all the doctors were convinced that peritonitis must set in and Andrews would die. Within five weeks, however, the wound had healed enough that Andrews could sit up. A few weeks more and he was limping around on crutches. He was able to return to limited ordnance duty by October. Astonishingly, Andrews  actually eventually returned to FIELD SERVICE with the Army of Northern Virginia in the spring of 1863, wearing a silver plate over his wound. Once back, he quickly managed to get wounded again, this time at  the minor battle of Stephenson’s Depot on June 15, 1863. At this point, someone decided that it would be in Andrews best interest to serve the Confederate cause on ordnance duty in Europe. Andrews did not object.  Sent to Germany, Andrews proudly showed off his scar of the “most desperate wound ever received by a man from which he recovered.”

After the War, Andrews was a renowned architect in Baltimore. He grew to an “enormous size” and won at least a few bets with surgeons for bottles of wine over his wound.  Andrews died a natural death on January 6, 1903 at the age of 73.  The bloody and torn jacket he wore at Cedar Mountain is on display at the Maryland Historical Society.

In a war where a Union general died of a scraped shin, recoveries like Andrews’ — although exceedingly rare — are absolutely remarkable.  If you ever feel like giving up hope because no one says there is any, remember the story of Major Andrews and the terrible wound he took at the battle of Cedar Mountain.

6 versus 8

My oncologist originally slated me for 8 cycles of ABVD.

Since I have been having so many lung problems, I have been researching whether it would be foolhardy to cut from 8 cycles to 6 cycles. Especially since I was “clean” at 3 cycles. (That lung warm spot I am convinced was just active inflammation.)

As yet, I haven’t found a clinical trial or anything that states that 8 cycles has been shown to have a better cure rate than 6 cycles. I do know 6 cycles seems to be the “standard” of care and 8 cycles isn’t done as commonly in the United States as 6 cycles.

Since I know a lot of folks read my blog and the search engines also seem to bring in a number of people :) I am going to put out an appeal. Has anyone ever found or know of a clinical trial that compares 6 cycles to 8 cycles of ABVD chemo?

Its a balancing act, obviously — chemo is very toxic (not just miserable in the short term), yet if you don’t kill the Hodge on the first try, your chances of success go down considerably and you’re in a whole new ballpark.

(The main reason I am so concerned is these lung problems … where at first I wanted to NUKE THE STINKING HODGE, now I wonder if we’re not nuking Jenny in the process.)

8 down, 8 (perhaps less) to go

Eight treatments down and, if we remain on my oncologist’ original schedule, 8 to go. The halfway mark. Finally.

The Hodgkin’s is in remission, but it hasn’t been without cost. I’ve lost several pounds. While my blood counts remain stable (even excellent as far as WBCs — the infection fighters — go) , I’m still anemic with hemoglobin of 11.0.

Much more onimous is my significant loss of lung function and my loss of some heart function. My heart function dropped from an excellent, athlete’s heart rate of 75% to a more average 62%. That’s quite a significant drop, but anything above 50% is considered normal and “ok” according to my oncologist. As far as the lungs go, I have a significant dry cough. While most of my PFT stayed normal, my ability to exchange carbon monoxide is well below normal. It hurts when I take a deep breath. My doctor decided that he was dropping the bleomycin because of it.

Dr. S says he is otherwise pushing forward without the bleo — I’m completely done with bleo for any further treatments. Having done some research, I am hoping because I was in remission at 3 cycles, my doctor can actually stop the chemo at 6 cycles (12 treatments) rather than doing 8 cycles (16 treatments). The lung damage should correct since we caught it early, but I am now worried about my heart. Its still doing well, but that drop was significant and I am concerned.

I have my usual side effects: a not insigificant headache, some nausea, lack of appetite, generally lethargy, and hiccups. I always get hiccups. Otherwise, the only “new” symptom is this shortness of breath and cough. Hopefully without the bleomycin, it will correct.

I’m radioactive

Apparently I am radioactive until May 28, 2007.  They even gave me a card to carry.

 Not only do my drugs come in a biohazard bag, but now I have to carry around a little card with me that suggests that small animals and little children should probably stay away.

(I checked.  I don’t glow in the dark and I don’t seem to have gained any super powers beyond my normal, above average charm.)

could Hill have had the Hodge?

Paging TV’s Doctor House.  Could A.P. Hill have had Hodgkin’s Disease?  Would it have been within the possible differential diagnosis?

I’ve been wondering since I was diagnosed with Hodgkin’s Disease whether perhaps Confederate General A.P. Hill also possibly had the Hodge.  Of course there is no way to know for sure.  But I wonder.  For those who don’t know by now, I have a pretty big website on A.P. Hill entitled <em><a href=”http://www.aphillcsa.com/”>And Then A.P. Hill Came Up</a></em>.  That’s why the particular interest in Powell Hill.

Most knowledgable Civil War buffs know that Powell had an interesting medical history.  His mother was something of a hypochondriac, it’s thought, and Hill seems to have inherited many of her tendencies as well as her delicate build.  But as far as we know, Hill’s real health problems didn’t seem to begin until he was a junior at West Point.  Again, as most everyone knows, Hill caught gonorrhea while on furlough in the summer of 1844.  While in most people gonorrhea runs its course (even without the use of antibiotics like we have to treat it today), Hill wasn’t so lucky; he ended up hospitalized at West Point for a time, then he had to be sent home.  His illness was so severe that he was left back a year and didn’t graduate West Point until 1847.

Hill also had several significant illnesses while in the pre-War US Army after his graduation.  He was sick with typhoid fever, yellow fever, and another severe but unidentified illness (it was thought to be yellow fever again, but we know now that yellow fever only tends to strike a person once since one case gives immunitity).  These sorts of severe illnesses were quite common in the antebellum period.  A perusal of medicial histories prior to the Civil War of many future generals shows many of them survived close scrapes with malaria, yellow fever, and other diseases that we would clearly dread.

During the early part of the Civil War, we find that Hill was relatively healthy.  He was ill in December 1860 through January 1861, then again in August and September 1861.  Each time the complaint seems to have been relatively non-specific.  Of course, many men went through periods of illnesses; this was not something strange or peculiar to Powell.  In November 1862, Hill did have a very interesting symptom — his arm swelled up and was rendered useless.  This was almost certainly a form of lymphedema.  In a letter to Stuart, Hill self-described this symptom:

<blockquote>Many thanks in sending me the letter. It found me with only one arm useful — the other swollen as big as old Sacketts leg. I suppose I am to vegetate here all winter under that crazy old Presbyterian fool — I am like the porcupine all bristles, and all sticking out too, so I know we will have a smash up before long. I don’t like the complexion here.</blockquote>

Interestingly, during his very best period of time as a general (roughly June 1862 until the end of September 1862), Hill didn’t have any documented cases of illnesses despite the stress of being on almost constant campaign.  Perhaps the stress of constant campaign, however, is what ultimately led to an illness or perhaps it broke down his immune system enough to allow a cancer or other problem to begin …

Hill was wounded at Chancellorsville (a relatively minor wound in the back of the calves of his legs), then he was sick again at Gettysburg.  From Gettysburg on, Hill was often ill until his death on April 2, 1865 at the hands of a Union soldier who shot him at almost point blank range through the heart.  His illnesses followed an off and on pattern.  Sometimes he was well enough to command, other times he was not.

Hill’s most recent biographer, James Robertson, suggests that Hill’s chronic illnesses during the Civil War were a result of the STD he caught at West Point.  Robertson hypothosized that Hill’s severe case of gonorrhea resulted in severe prostatits and formation of a stricture which ultimately resulted in impaired renal function and chronic infection.  This theory has been mainly been accepted by mainstream Civil War authors and historians.  However, I have always thought that this theory was questionable due to the fact that Hill was able to sire four children in a relatively brief amount of time — that doesn’t sound like a man with impaired prostate function, but hey I am not a doctor, I don’t play one on TV, and I didn’t even stay at a Hollywood Inn Express last night.  Also, in his bio of Hill (admittedly all I have access to), Robertson never directly quotes anyone saying more on what Hill’s symptoms were other than things that are vague like he looked sick or delicate.  So while not dismissing Robertson’s theory out of hand, I have to admit to some skepticism.

Hill’s other biographers, interestingly, varied in what they considered Hill’s problem to be.  The theories ranged from everything from manic depression (what we’d term “bipolar” disorder) to hypochondria (trying to escape from duty as a corps commander), to a liver problem (”biliousness”) to perhaps tuberculosis or chronic malaria.  A gastrointestinal ailment has also been suggested, like an ulcer.  It is interesting that none of them came up with the same theory as Robertson did — I guess that shows how tough it is to diagnose a medical condition of someone who has been dead for 140 years and for whom no blood tests, scans, etc exist.

Any one of those disorders — other than manic depression or hypochondria, two considerations I do not consider very valid in light of the fact of Hill’s very visible and real physical decline and the fact that, as stated, he performed wonderfully under extremely heavy stress from June 1862 to September 1862! — could explain Hill’s chronic symptoms.

I consider myself an A.P. Hill biographer too.  And so I feel like I should have my own theory.  And drum roll, my theory is … remembering that case of lymphedema … A.P. Hill had a form of Hodgkin’s or Non-Hodgkin’s lymphoma.  Just like me.

The type of physical decline and weight loss seen in pictures of Hill and mentioned by letter writers suggests he was being eaten away inside out by cancer.  An aggressive form of Non-Hodgkin’s lymphoma would have quickly killed Hill in a matter of months, but an indolent form of the disease could, for example, cause a slow decline that could take years to reach the level of causing death.  Hodgkin’s Disease can also follow an indolent course, particularly the nodular sclerosing type like I have.  Also, Hill was about the right age for Hodgkin’s Disease (which usually strikes between ages 15 and 35).  As I know from first hand experience in my own case, Hodgkin’s can wax and wane over time — you can have periods of good health followed by periods where you don’t feel very well and have strange, flu-like symptoms.  It can cause strange pains, swellings, and a fever that comes and goes along with night sweats (this is called a Pel Ebstein fever).  Pressure from masses in his body could have accounted for back pain upon riding his horse, difficulty moving or sleeping, restlessness, even impaired ability to think on the battlefield.  It could have also caused the otherwise mysterious arm lymphedema.

I think Hill became ill with lymphoma between September 1862 and December 1862.  It would explain his long, slow decline.  The heavy stress of near constant campaigning and fighting may have been enough to weaken his immune system and leave him prone to an immune system cancer.

Hodgkin’s Disease was known to medicine in the 1860s, but if Hill’s case was like mine and he didn’t present with classical symptoms (i.e. a lymph node popping out of the neck or arm pit or groin), I doubt in the age before x-rays and CT scans whether he could have been diagnosed.

Of course, this is all conjecture on my part.  Its just an interesting theory to think on for what may have been wrong with the “Mystery Man of the Confederacy,” as historian Clifford Dowdey termed him.

Lessening the possibility of my theory being true, of course, is the fact that Hodgkin’s Disease is relatively rare — there are currently only about 7,500 cases a year.  And as I have stated there is no way to know just what the heck Hill had — be it cancer or a prostate problem or something totally different like a form of lupus or other auto immune disorder.

(If any medical folks are out there and would like to comment, I’d appreciate hearing your thoughts — whether they support my uneducated medical theory or not.  Thanks!)