SEVERE MIALNUTRITION IN A PUBLIC SERVANT OF THE WORLD WAR II ERA: THE MIEDICAL HISTORY OF HARRY HOPI?KNS*
JAMES A. HALSTED, M.D.
Harry Hopkins occupied a unique place in the nation's history as a devoted friend and advisor of President Roosevelt. During World War II he wielded power and influence which, according to testimony by Secretary of War Stimson and General George C. 1\Iarshall amoong many others, was of great benefit to the war effort. Since 1948 I have been interested in his serious illnesses occurring simultaneously with his historic activities. Hopkins had had a gastrectomy for cancer of the stomach in 1937. About a year later he began to have recurrent bouts of devastating malnutrition and finally, he developed liver disease from which he died on January 29, 1946. How could he accomplish the prodigious feats w-hich he did, living wNith three such near lethal diseases? His activities were those for a man of unusually good health plus an indomitable will. He had the latter but rarely the former, except during partial remissions in the malnutrition problem which was never adequately diagnosed. To investigate his illnesses I was able to obtain copies of the Mayo Clinic and i\Iemorial Hospital Records, plus the autopsy report from Memorial xhere he died. Hopkins was born in Iowa in 1890, with a background which was deeply religious. At 22 he graduated from Grinnell College, and later became a social welfare worker in New York. During his years in New York he became Executive Director of the New York Tuberculosis Association, the president of which was James Alexander Miller. (Dr. M\1iller was a member of the Climatological from 1905 to 1948 and its president in 1916). He had demonstrated marked leadership ability and administrative qualities which were unusual but effective. The Association under Hopkins' executive directorship grew enormously in membership with a large increase in both income and expenditure. He believed in positive action when he had the power to take action and worried about finding the money later, a characteristic which shaped his later career as Administrator of Federal Relief and de facto Administrator of Lend-Lease during World War II. He felt that when money was available
* From the Clinical Nutrition Program, Division of Gastroenterology, Department of Medicine, Albany Medical College, Albany, New York. Address for reprints: R.D. #2, Hillsdale, New York, N.Y., 12529. 23
JAMES A. HALSTED
it should be spent wrhen there was compelling need. This philosophy applied not only to his public but to his personal life. He loved a good time and rarely saved. When Roosevelt was Governor of New York from 1928-1932, Hopkins was appointed Director of the Temporary Emergeney Relief Administration. He was very effective in this job and w-hen F.D.R. became I'resident he was made Director of Federal Relief CWA, and later, WPA-in May 1933. President Roosevelt trusted Hopkins and turned to him more and more for advice, ideas and action. Nine billion dollars was spent on Relief and sixty-nine billion on Lend-Lease supplies to the Allies. This great sum was largely under Hopkins' direction. He had become de facto Administrator of Lend-Lease in 1941. Despite outcries to the contrary he was told by F. D.R. to have no truck with politicians and Harry refused to look out for "deserving Democrats". These enormous funds offered juicy patronage plums and Hopkins' refusal to play ball was undoubtedly the source of many of the personal attacks on him such as a lead story in the Chicago Tribune before the 1936 election headlined, "Throw the Rascals Out !" His integrity and honesty, doubtless eoupled with his ill health, probably contributed to the hostility. Hopkins' advisory activities were primarily related to tacties rather than strategy. He was not a man likely to suggest broad topics with philosophical overtones but rather he was extremely effective in summing up a problem or a policy matter which had been proposed and discussed by others. He had a keen analytical mind and was extremely adept at defining the problem at hand and the solution decided upon, then to get things done by succinct action. Churchill facetiously declared that he was going to propose him for the House of Lords with the title of "Lord Root of the M\Iatter". In October 1937 Hopkins' second wife died of cancer. He had had a duodenal ulcer in 1934, confirmed by x-ray, but because his father had died of cancer of the stomach he suspected that he, too, had the same. On December 17, 1937 he entered the Mayo Clinic because of a recurrence of ulcer symptoms plus vomiting. Two months previously x-ray had demonstrated a pre-pyloric ulcer with crater. Upon admission pyloric obstruction was suspected, confirmed by gastric aspiration, and after three days he was operated upon. There was a mass 4 X 2 X 1 cm. in size, with firm omental nodes. The liver was normal. A high, partial gastrectomy of anterior Polya type wN-as carried out with an entero-enterostomy performed ten inches below the anastomosis. The pathologic report was that of a large adenocarcinoma of the greater curvature with involvement of adjacent lymph nodes. The cancer never recurred, surprisingly, because statistically the cure rate of such a large adenocareinoma is in the neighborhood of two or three per cent.
HISTORY OF HARRY HOPKINS
His recovery Nas uneventful with no digestive problems nor other signs of the post-gastrectomy syndrome. About a year after the operation Hopkins was appointed Secretary of Commerce. At that time, early January 1939, he had developed ambitions of being the Democratic nominee for President in 1940. Indeed, it appears that he was first on F.D.R.'s list of possible choices to succeed him in the White House. This career pathway was soon obliterated because in M\Iarch 1939 he had the first of numerous long episodes of great weakness with collapse, diarrhea, edema of the extremities, poor vision and signs attributable to several vitamin deficiencies. He had vomiting on and off for three weeks and lost 18 pounds. With bedrest he improved somewhat but could only work halftime. He spent the summer of 1939, which was tense with the build-up to war, in a country house near Washington. One of his sons had written about his condition as follows: "We were amazed at how sick he was. His letters never indicated this. He went fishing in the morning and took a nap in the afternoon. Then he began having trouble with his legs and soon was too N-eak to step into a boat". Hospitalization became imperative and on August 23rd he re-entered the M\ayo Clinic where he stayed for three weeks, being discharged on September 14, 1939. Hopkins' medical records are of special interest in the multiplicity of detailed and frequent progress notes by many physicians well known to most of us. These notes constituted the best of medical observation and logic expressed in a quality of English rarely seen today. Of course in those days clinical laboratory tests were less sophisticated than at present. The significant features of the second Mayo Clinic admission were as follows: he had lost weight but, importantly, had a good appetite. He had edema of the legs, shiny scaly skin, sore shin bones, and burning of feet and ankles with redness of the toes. There was glossitis, ataxia and weakness of legs. He had poor vision and diarrhea. Examination revealed no abdominal mass, hepatomegaly nor palpable lymph nodes. X-ray studies showed that the anastamoses functioned well. Barium enema did not reveal a gastro-colic fistula. The laboratory findings showed moderate anemia (Hemoglobin 10 gm. per 100 ml.) and macrocytosis on blood smear. (This was reported several times both at this admission and later ones, being emphasized by the laboratory physician). Blood chemistry findings were: Calcium 7.7, cholesterol 105, total protein 2.04 and 3.47. The prothrombin time was 20 seconds. Stool fat was 10.4 gm. in 24 hours. These findings may be interpreted in light of present knowledge of intestinal absorption as showing malabsorption of fat (steatorrhea and low cholesterol), protein, calcium, vitamin K, vitamin A (poor vision), water soluble B vitamins (the neurologic findings and glossitis), and probably folic acid (moderate anemia with macrocytosis).
JAMES A. HALSTED
He was treated with a low residue diet high in vitamins, parenteral vitamins plus crude liver extract intramuscularly three times a week, three blood transfusions and intravenous amigen in 10 % dextrose. He progressed well, the glossitis and edema disappearing with rise in total protein to 5.4 gm/100 ml. He had written his brother Lewis Hopkins, a physician, while in the hospital that his problem was inability to absorb proteins and fat, that he was losing his vision, had lost 30 pounds, that there was no evidence of recurrence of the cancer. He said that weakness and other signs of malnutrition had begun "about a year ago" after a throat infection, with periods of improvement and relapse until July 4, 1939 when he had to take to his bed most of the time. He wrote that he had "a general sense of well-being, excellent appetite, no nausea and no diarrhea. The best I can tell you is that I have a very severe malnutrition". The entire picture was indicative of intestinal malabsorption. Interestingly up to now his physicians had not mentioned sprue, nor the postgastrectomy syndrome including "the dumping syndrome", nor attempted to analyze or clearly define, other than to use the general term of malnutrition. Since the physicians involved included leading authorities on malnutrition secondary to disease it is an indication of the paucity of knovWledge 35 years ago of intestinal function in relation to nutrient absorption and the nutritional effects of gastrectomy. After leaving the Mayo Clinic he continued to improve very slowly but was unable to leave his home for uninterrupted work for another eight months. Eventually, however, he became well enough to have six more years of memorable accomplishment, even though interspersed with remissions and relapses. On May 10, 1940, the day of the German attack on the Low Countries, he went to dinner at the White House. He was feeling miserable and F.D.R. prevailed upon him to spend the night. He remained there for three and a half years, where he was easily available. On August 22, 1940 he resigned as Secretary of Commerce to become a Special Assistant to the President. Although the ups and downs in the effects of his nutrition problem continued, when an emissary was needed to talk to Churchill, Hopkins asked F.D.R. to send him to London. He set off on January 5,1941. This was at a time of partial remission but Churchill wrote later: "There he sat, slim, frail, ill, but absolutely glowing with refined comprehension of the Cause (the defeat of Hitler)-to the exelusion of all other purposes, loyalties, or aims. " The British recognized his ability and relied increasingly on his counsel and intuitive good sense. In July 1941 Hopkins was sent to 1\Ioscow from London where he was on
MEDICAL HISTORY OF HARRY HOPKINS
a second mission. Described as "gaunt and ailing" he made a long dangerous journey by, flying boat north of Norway to Archangel where he had to attend a four hour banquet, have two hours sleep, then fly to M\1oscow for talks with Stalin and others. Returning home he was heavily occupied with lend-lease matters and being instrumental in soluitioIn of many monumental problems. In April 1942 he was in London for a third mission and in August for a fourth. In July 1942 he was remarried. He and his wife, Louise, stayed on at the White House for a year with Diana Hopkins, the daughter of Barbara who had died of breast cancer in 1937, but in August 1943 they moved to their owIn home. In about October 1943 Dr. Rivers of the i\Mayo Clinic saw Hopkins in Washington. This was four years after he had been so desperately ill when malnutrition first manifested itself in 1939. Despite relapse and remission he had carried on the strenuous work involving Lend-Lease matters, with five trips to London and MIoscow for conferences with Churchill and Stalin, and with participation in the Casablanca, Quebec, Cairo and Tehrai. conferences. Dr. Rivers noted that he had edema and ascites, a serum protein of 5.0 gm/100 ml. and red blood count of 3.5 million/cu.mm. He was started on plasma infusions to be given every three weeks. None of the measures was of much benefit because all through the winter of 1943-1944 he was critically ill, unable to work and re-entered the 1\1ayo Clinic on 1\larch 9, 1944 where he stayed until May 7, 1944. The history at this time uncovered the very important fact that he had begun to have attacks of mild diarrhea, often brought on by a large ingestion of fat, in 1931-6 years before his gastrectomy. Other significant findings were as follows: Weight was stationary with a good appetite and fair strength. He had poor vision and impaired dark adaptation. There was absence of body hair. The laboiatory examinations revealed macrocytic anemia (R.B.C. 3.30 million, Hgb. 13.6 and macrocytes on blood smear). The serum protein was 5.4 gm/100 ml. Stool fat showed 14.4 gm. and nitrogen 4.5 gm. per day. Serum carotene was "low". A new observation was that he had noted brief jaundice before admission which subsided. Serum bilirubin on two occasions was 2.5 and 3.75 gm/100 ml. An exploratory operation was done to rule out cancer recurrence and to revise the anastamoses, hoping to obtain better mixing and a larger jejunal absorptive surface. The operation revealed no evidence of recurrence and the liver was reported as being normal. A biopsy was taken but no record of this was available. The pancreas and small bowel appeared normal. Some opinions expressed were as follows: 1. Malnutrition leading to hypopituitarism with adrenal cortical insuffi-
JAMES A. HALSTED
2. A fatty liver from malnutrition "with low-grade cirrhosis". 3. "The fundamental difficulty stems from non-tropical sprue". The post-operative course was uneventful and he recovered to his previous degree of ill health. The therapy, as it had been throughout, was heavily weighted to parenteral vitamins, diet and transfusions both of blood and plasma. After leaving the AMayo Clinic he spent a long convalescence at White Sulphur Springs. Back in Washington July 4, 1944 he was incapable of much work but continued in an advisory capacity to the President, participated very little in the 1944 presidential election but continued as a conduit between London and Washington at highest levels respecting N-ar problems. His astute intellect and negotiating ability, despite the fact that he, was too ill to work more than 2 to 3 hours a day, made him a key person in planning the Yalta Conference which he attended in February 1945. At Yalta he was so sick that he had to spend much of the time in bed but attenided all conferences. On the returni he became wN-orse and left the ship at Algiers whence he flew home to go directly to the M\ayo Clinic for the fourth admission,Februar 27 April 13, 1945.. There were no new findings at this admission, laboratory tests being about as they were a year before. One physician with long experience in nutritional problems, especially steatorrhea, noted in the chart "As far as I am concerned this is non-tropical sprue". Hopkins left the Clinic considerably improved the day after F.D.R. died. He determined to retire from government but negotiations in San Francisco at the Conference to establish the United Nations ran into difficulties essentially over misunderstandings with the Russians. President Truman decided to send Hopkins to M\oscow for talks directly with Stalin. Hopkins was so highly regarded in Russia that the 4 days of meetings probably saved the San Francisco Conference, according to Sherwood.1 He returned exhausted and retired after declining President Truman's request to attend the Potsdam Conference in July 1945. He gave up his Washington house and moved to New York, the city he loved most. He was given an honorary degree from Oxford and planned to go there on October 25, but by that time another episode of collapse with diarrhea and great weakness required hospitalization. He went to 1\Iemorial Hospital on November 1, 1945 where he remained until his death on January 29, 1946. The MI\emorial Hospital admission revealed little new respecting the basic nutritional problem. It Nas emphasized, however, that his attacks of great weakness, with collapse, muscle cramps, parathesias, diarrhea and disturbed vision seemed to be recurrent and intermittent about every three months. Examination revealed cheilosis, papillary atrophy of tongue, blood pressure of 102/70, liver and spleen not palpable. Laboratory findings of
MEDICAL HISTORY OF HARRY HOPKINS
significance were an elevated serum bilirubin which gradually rose to 9.6 shortly before death, serum vitamin A low at 20 units/100 ml., stool fat 35 gm. and stool nitrogen 10 gm. per day. After some initial improvement, increasing jaundice, edema and ascites appeared. Gastro-intestinal bleeding occurred toward the end, then coma and death, three months after admission. The autopsy revealed much blood in stomach and bowel, esophageal varices with rupture, ascites, but no e vidence of recurrent carcinoma. The liver was small, weighed 1350 grams, and had nodules which were irregular in size, some of which were large, with streaks of broN- pigments. The pancreas was diminished in size and yellowish-brown. The autopsy diagnosis was hemochromatosis, pigment cirrhosis, ruptured varices, atrophy, fibrosis and pigmentation of the pancreas. In analyzing Hopkins' medical history three basic problems are involved. The first, a large adenocarcinomna of the stomach, was undoubted and confirmed. This never recurred. One might speculate (perhaps wildly) that his severe malnutrition might have played an inhibitory role in neoplastic
The second problem was the etiology of his mlalnutrition. Two physicians at the M\Jayo Clinic were convinced that the basic cause was non-tropical sprue. The others both at the Mlayo Clinic and M\emorial used the term "malnutrition" without specifying an underlying cause or relating it to the gastrectomy. In view of the onset of diarrheal attacks six years before the gastrectomy, with important signs of piimary malabsorption characterized by recurrences and relapses over a seven year period preceding his death, it seems reasonable to conclude that non-tropical sprue was indeed the best explanation for his malnutrition. There was no evidence for rarer causes of malabsorption such as Whipple's disease, regional enteritis, etc. The third problem was the pathogenesis of the cirrhosis from which he died. Although hemochromatosis was diagnosed it is unlikely that this was in fact correct. Recent examination of the slides show that the iron found was primarily in Kupffer cells, not in the hepatocytes as is characteristic of hemochromatosis, nor was there an excessive amount of iron in other tissues especially the pancreas and spleen. Alcoholic cirrhosis must always be considered but there was nothing to suggest that Hopkins was ever more than a social drinker and during his periods of ill health he often took no alcohol for long periods of time. Because he had had about 35 blood transfusions and innumerable infusions of pooled plasma he was exposed very heavily to hepatitis B virus. Thus it seems more plausible that he had post-necrotic cirrhosis secondary to serum hepatitis. The post-mortem findings were not inconsistent with such a diagnosis. Considering the course of events in Hopkins' health history, beginning
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in 1931, and in light of all the available facts up to his death in 1946, it seems justifiable to speculate that he had non-tropical sprue or adult (eliac disease (gluten enteropathy), and that post-necrotic cirrhosis developed as ail end result of hepatitis B infection, and occurring as a result of the treatment he received for malnutrition. However, since histologic proof is lacking for a diagnosis of sprue, the C.P.C. is incomplete! Had his life span occurred a few years later he might have enjoyed the benefits of the "wheatfree diet" which grew out of the observations of the Dutch pediatricians, Dicke and Wejers, who noted that during the Nazi occupation of Holland with starvation conditions, childhood celiac disease disappeared. Harry Hopkins' place in history may well be judged as more important than many people now recognize. The judgments of Secretary of War Stimson, General George C. Marshall and several historians would bear this out. His role in the war effort which led to the defeat of Hitler, despite his extremely complex and debilitating illnesses, may be regarded as ranking close to the top in importance. Whether, a hundred or more years from now, that event the defeat of Hitler-will be considered one of the great turning points in history, no one yet knows.
ACKNOWLEDGMENTS I am indebted to Mr. Harry L. Hopkins' children, Mr. David Hopkins, Mrs. Diana Baxter, and Mr. Robert Hopkins for making it possible to obtain medical records from the Miayo Clinic and the Memorial Hospital, New York, which provided the basis for the medical history. I am also indebted to those institutions for their cooperation. Dr. Patrick Fitzgerald, Chairman, Department of Pathology, Sloane Kettering Memorial Cancer Center, was enormously helpful in reviewing the pathologic material. The staff of the Franklin D. Roosevelt Library, Hyde Park, New York was most generous in making materials available on 1lIr. Hopkins' life, and providing photographs and slides of the Roosevelt era.
1. SHERWOOD, ROBERT E. ROOSEVELT AND HOPKINS: An intimate history. Harper and Brothers, New York. 1948. 2. BURNS, JAMES MACGREGOR. ROOSEVELT: The soldier of freedom. Harcourt Brace and Jovanovich, Inc., New York. 1970. 3. CHARLES, SEARLE. Minister of Relief. Harry Hopkins and the Depression. Syracuse University Press, Syracuse, N.Y. 1963.
DISCUSSION DR. GEORGE E. SCHREINER (Washington): I find this very interesting. I started medical school at Georgetown in 1943 in the Spring and lived in a house on 34th Street which was just two doors away from an old Georgetown house that had just been purchased by the Hopkins and one hot afternoon there was a knock on my door,
MEDICAL HISTORY OF HARRY HOPKINS
and I presume this was the second Mrs. Hopkins. She asked if she could see how we had fixed up our room and furnished it because they were just in the process of beginning to refurnish the house, and we lived there with several other medical students. The following day she asked if she could bring Mr. Hopkins back to see what we had done on redecorating the room, and he came in and I introduced him to my roommates, and we noticed the sallow skin and slight edema and after he had left specuulated that he might have cirrhosis. I never really did know the outeome of the story. DR. HALSTED: Thank you, Dr. Schreiner, for this interesting observation. I suspect that the sallow skin and slight edema which you noted in 1943 and speculated might be due to cirrhosis was more likely caused by hypoproteinemia and anemia resulting from malabsorption at that time. But since he died three years later from complications of cirrhosis you may have been partly right. However, the exploratory laparotomy a year after you saw him revealed a normal liver grossly. DR. J. EDWIN WOOD, III (Philadelphia): Editorial opinion expressed recently suggests that health records of public officials should become a matter of public record. Do you hold any opinion on this issue? DR. HALSTED: I recently discussed this question, in part, in a letter which I wrote to the New York Times Book Review Section and shall send you a copy. However, that was not really pertinent to this paper although the health record of public servants is certainly a highly important matter. I would say, however, that as we all know even the most sophisticated and educated person who is not a clinician could not accurately interpret such public health records. To answer your question specifically I am not in favor of the suggestion, not that health data of this sort should be hidden-although that of course is another question of ethics-but because they could not be fairly or accurately understood by the public. DR. JOHN STAIGE DAVIS, IV (Charlottesville): I would like to add that one's interpretation of the role Harry Hopkins played depends a lot on one's political point of view. For example, one thing I gather from this is that our country was not only being run by a President in extremely poor health but was advised by a man who was also in extremely poor health. We might characterize the decisions made at these conferences as not reallv so astute, but because of Mr. Hopkin's illness, extremely hasty. DR. HALSTED: As a physician I am merely trying to relate Hopkins' serious health problems to the extraordinary physical and mental effort he was able to exert, perhaps because of an extreme degree of motivation and dedication. Both Secretary of War Stimsoni and General Marshall had the highest regard for Hopkins' ability and positive accomplishments in the war effort, as dicl several respected historians. The same viewpoint respecting the President's ability to function in relation to his health might apply I think. The facts known about his health have been published by Dr. Howard Bruenn.* The rest is conjecture and speculation. As to the results of Conferences these muist be judged by historians. I was interested to read "Witness to History" by Charles Bohlen, who was present at Yalta as the President's interpreter. He believed that Roosevelt was mentally sharp and effective. The interpretation of policy juidgments as possibly affected by health matters is very subjective. 1)R. IRVING S. WRIGHT (New York): I wouild like to ask a question that was not touc('hed UpoIn. I believe I may have some idea of the answer. What was the alcoholic history of Harry Hopkiiis?
* Bruenn, Howard G. Clinical notes oni the illness and death of President lin D. Roosevelt. Annals of Internal Medicine. 72: 579-591, 1970.
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DR. HALSTED: I was skipping a bit to finish on time but did have a note to mention alcohol since this is the commonest cause of cirrhosis. Hopkins drank socially but not excessively according to testimony of people who knew him and with whom I have talked. It is known that he went for long periods of time without any alcohol. I don't think he could have functioned as he did if he drank a great deal. DR. DANIEL N. MOHLER (Charlottesville): What did the autopsy show in the small bowel, in the histology of the small bowel? DR. HALSTED: They took a biopsy of the jejunum at the second operation and I tried to get it but it was lost. The bowel at autopsy was not compatible with sprue but the material was fixed thirty years ago and autopsy material is not likely to give an accurate picture of intestinal epithelium. All one can say is that sprue canniot be ruled in or out. DR. JOHN H. KNOWLES (New York): I have two questions. The first is related to ethics. Even though Hopkins' children gave you permission to inspect his medical records do you think it is ethical to publish them? The second questioni relates to your reaction to another man's view of Roosevelt and to another question asked this morning. These would imply to me that science isn't completely pure and depends on the ideological bias of the observer. One man's illness, in someone he likes, is interpreted by the friendly observer as leading to creativity. In another whom the observer doesn't like, he could conclude that illness is what led him to make so many mistakes! To me the ethics of your work, and the substantial question about the objectivity of observers when it comes to famous people and their medical histories would lead me to wonder how you personally feel about this. DR. HALSTED: Regarding the ethics.-As I stated, this was discussed with Hopkins' heirs-his three children-with their approval. Here is a man, occutpying an uindeniably important place in history, with a disabling health problem who has been dead for 30 years. This to my ethical sense demands as objective studv as possible and with ptublication-for the sake of historical perspective and the work of future historians. A book about Churchill's health and its effect on his judgment, written by his personal physician, Lord Moran, has been widely criticized as an invasion of privacy, unfairly or not, depending on one's viewpoint. The book was published one year after Churchill's lifetime. Would you clarify your other question, John? DR. KNOWLES: The other question is that in this day and age illness doesn't necessarily do anything to a man's judgment and it might even make it more creative. But in Hopkins' case the situation might lead you in certain paths of interpretation. DR. HALSTED: Meaning your political bias? DR. KNOWLES: Yes. DR. HALSTED: Well, it certainly might! I can only say that I leaned over backward in my own mind in trying to be as objective as possible. DR. KNOWLES: Great! Jim, thank you very much. It is of some comfort to me that they lose biopsy reports at the Mayo Clinic as well as other places. DR. HALSTE-D: Not the M.G.H., John?