The mysterious illness of Emma Lazarus, Lady Liberty’s poet

28 The Pharos/Summer 2014 The mysterious illness of Emma Lazarus, Lady Liberty’s poet

Robert S. Pinals, MD The author (AΩA, University of Rochester, 1955) is Clinical Professor of Medicine in the Department of Medicine at the Robert Wood Johnson Medical School of Rutgers University in New Brunswick, New Jersey.

The New Colossus Not like the brazen giant of Greek fame, With conquering limbs astride from land to land; Here at our sea-washed, sunset gates shall stand A mighty woman with a torch, whose flame Is the imprisoned lightning, and her name Mother of Exiles. From her beacon-hand Glows world-wide welcome; her mild eyes command The air-bridged harbor that twin cities frame. “Keep, ancient lands, your storied pomp!” cries she With silent lips. “Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!”

mma Lazarus is remembered today mainly for her iconic sonnet, written hastily to include in a booklet used in fundraising for the pedestal of the Statue of Liberty.1–3 The statue was a gift from the French to the American people to celebrate liberty and other values shared by the two nations.1–3 The poem attracted little attention in 1883 and, in

Left,E Illustration of a group of immigrants on the steerage deck of a steamship viewing the Statue of Liberty as they arrive in New York Harbor, circa 1887 (© FPG/Getty Images) Above, Emma Lazarus. Engraving by T. Johnson (© Bettman/CORBIS)

The Pharos/Summer 2014 29 The mysterious illness of Emma Lazarus, Lady Liberty’s poet

Manuscript of The New Colossus by Emma Lazarus. © Bettmann/CORBIS

fact, seemed to have little connection with the intent of the Life and career gift. When Lazarus died four years later, at age thirty-eight, Emma Lazarus was born in New York City in 1849, the her obituary did not mention Lady Liberty’s sonnet, but re- second of five children of a wealthy sugar refiner. She was edu- viewed her poetry and other published works in complimen- cated at home by tutors, who emphasized cultural and literary tary terms.4 Lazarus never saw the statue after it was erected interests and fluency in languages. Summers were spent at the on its pedestal in 1886; she was travelling in Europe at the seashore in Newport. At age eleven she began writing poetry time and already ill. At the ceremonial unveiling of the Statue and her first collection was published privately when she was there were speeches by many dignitaries, but no mention of seventeen. Her poems also appeared in periodicals and she de- the poem or of immigrants. Not until several years later, when veloped many connections within the New York literary com- great hordes of destitute refugees arrived in New York Harbor munity. Her Sephardic Jewish family was fully assimilated and from Eastern and Southern Europe, was it recognized that did not practice their religion; virtually all of her friends were with her prescient words Lazarus had envisioned the essence Christian. She never married and was never known to have had of America’s future. a romantic relationship with a man. Lazarus’s life was transformed by violent anti-Semitic outbreaks in Russia in the early 1880s. She took part in relief

30 The Pharos/Summer 2014 efforts for immigrants and incorporated their distress into her November 19, 1887. The death certificate was signed by E. L. poetry and essays. Lazarus was the first American to propose Partridge, MD, a prominent New York physician whose special a Jewish state in Palestine, more than a decade before the first interest was in obstetrics. The names of other attending phy- Zionist Congress in Europe. Her passionate identification with sicians are unknown. The diagnosis, one rarely made at that the newly arriving Russian Jewish refugees emerged when she time, was Hodgkin’s disease. was invited to submit a poem for the Statue of Liberty pedes- tal fundraising campaign in 1883. Later, Lazarus realized that Discussion immigrants with other religious and national backgrounds Our limited knowledge of the clinical details of the illness had similar problems. Lazarus had returned from her first that led to Emma Lazarus’s death at age thirty-eight is derived European trip three months earlier; she was thrilled to have almost entirely from her letters. It is difficult to reconcile the met many famous writers and artists and looked forward to group of symptoms described with the diagnosis of Hodgkin’s another visit. Unfortunately, however, this was delayed by what disease on her death certificate. The observations of the team may have been the first symptoms of her illness in 1884 and by of attending physicians in New York City are unavailable and her father’s death the following year. In April 1885 she felt well it is highly unlikely that an autopsy was performed, given her enough to sail. high social class, her death and funeral service at home, and her burial, which followed directly. Illness and death What was known about Hodgkin’s disease in 1887 and how Almost all of the information about Lazarus’s illness is was that diagnosis made? In 1832, Thomas Hodgkin, a London derived from her letters, particularly those to a close friend, physician, described the clinical and gross pathologic findings Helena DeKay Gilder.1,2 The illness may have presented as early that included lymph node and spleen enlargement.5,6 By 1887 as September 1884 when she developed a “severe and danger- Pieter Klaases Pel and Wilhelm Ebstein had described the in- ous malady from which she slowly recovered.” 1p209 After arriv- termittent fever associated with Hodgkin’s disease in a minority ing in England she complained of severe fatigue and “mental of cases.6 Late nineteenth-century reports of the histopathol- incapacity,” 1pp217–18 but did not allow this to interfere with her ogy featured a distinctive association of mononuclear cells and ambitious tour, which also included France, Holland, and Italy. giant cells, which would eventually replace the gross pathology At some point, probably in December 1885, she developed as the basis for diagnosis. Hodgkin’s disease was considered a fever that reappeared intermittently during the remainder to be a variant form of tuberculosis by W. S. Greenfield (1878) of her life. She found it necessary to spend more days in bed, and Carl Sternberg (1898) although the characteristic giant but refused to abandon sightseeing and meetings with inter- cells were atypical.6 In 1902, after Robert Koch’s discovery of esting people. During the summer of 1886 she was staying in the tubercle bacillus, Dorothy Reed, then a recent graduate and Herefordshire, near the home of Elizabeth Barrett Browning’s research fellow in Pathology at Johns Hopkins Medical School, father, when a “mysterious disease” struck suddenly.3 She pointed out the organism’s absence in Hodgkin’s disease.7 She had severe pain. Swallowing was difficult and digestion was concluded that it was “a histopathological disease entity.” 6 Not impaired.3 These symptoms were accompanied by extreme until the mid-twentieth century would it be recognized with fatigue and cognitive dysfunction. certainty as a neoplastic condition.6 By January, 1887 she was too weak to write and dictated a At the time of Lazarus’s death in 1887 surgical pathology, letter transcribed by her sister Annie.2 She was bedridden and which had started in Germany, was in an embryonic stage in very discouraged. Annie wrote the next letter three weeks later, America.8 Contemporary case reports included some with describing night sweats and fever, and also noting that Emma confirmation by autopsy,9 but diagnosis by biopsy lay several was groaning with pain. In April Annie wrote: “Her face is very years in the future. We must presume that the physicians car- much paralyzed now—one ear is quite deaf & her eyes are both ing for Lazarus made a bedside diagnosis of Hodgkin’s disease going very fast. . . . she can’t bear a ray of light.” 2p165 Somehow based her lymphadenopathy, splenomegaly, and history of in- Emma was able to rally and dictate a letter in July, saying that termittent fever. Various neurologic signs and symptoms had she had regained enough strength to undertake the voyage been reported previously10 and would not have been surprising home but “I have no use of my eyes . . . and fear I shall be crip- in an advanced case with obvious cachexia. Hodgkin’s disease pled for many months to come.” 2pp166–67 Although we presume was considered to be an atypical form of tuberculosis; central she sought medical care in Europe, we have no information on nervous system (CNS) involvement by tuberculosis was well that subject, nor about any treatment she may have received. recognized. She returned to New York on July 31 and was put to bed Lazarus’s neurologic deficits included motor loss, facial in the family home, closely attended by doctors and nurses. weakness, loss of vision and hearing, dysphagia, photophobia, Her pain required opiates and her downhill course continued. and cognitive dysfunction. Several paraneoplastic syndromes On August 6, her sister Josephine wrote that “Emma is decid- associated with Hodgkin’s disease and other lymphomas have edly worse and the doctors say she is failing.” 2p169 She died on some of these manifestations, including motor neuron disease,

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Guillain-Barré syndrome, inclusion body myositis, Sweet syn- celebrated Lazarus’s role in transforming the statue into the drome, and primary CNS vasculitis.11 In addition, the immu- Mother of Exiles. During World War II Hollywood’s patriotic nodeficiency associated with Hodgkin’s disease may increase fervor gave rise to recitations of the sonnet’s last few lines in susceptibility to rare viral infections, particularly JC virus, several movies. In Saboteur, a 1942 film directed by Alfred which causes progressive multifocal leukoencephalopathy Hitchcock, the dramatic climax takes place on the Statue of (PML). The cardinal clinical features of PML are visual deficits, Liberty’s torch hand, from which a Nazi saboteur falls to his motor weakness, and cognitive impairment.12 With the very death. After the war, lines from the sonnet were included in the limited information available on Lazarus’s illness we can only Broadway musical Miss Liberty by Irving Berlin, an immigrant speculate about the nature of her neurologic condition; PML from Russia. Today, Emma Lazarus is acclaimed as a champion may be the best guess. of immigrants, a warrior against anti-Semitism and a proto- The cause of Lazarus’s severe intermittent pain is also Zionist visionary.1 Almost single-handedly she reinvented the mysterious, as we have no knowledge of its location, duration, message of the colossal woman occupying New York harbor’s or character. Bone or visceral involvement or inflammatory entrance, a statue which she had only imagined but never arthritis are possible and, especially in relationship to its epi- seen. Lady Liberty, in Lazarus’s own words, would become the sodic nature, one might mention the pain induced by alcohol Mother of Exiles, lifting her lamp beside the golden door. ingestion in some patients with Hodgkin’s disease.13 Lazarus drank wine but probably not regularly. However, many popular References liquid medications of that era contained alcohol. In one series, 1. Schor E. Emma Lazarus. New York: Schocken; 2006. seven percent of Hodgkin’s disease patients had this pain and 2. Young BR. Emma Lazarus in Her World: Life and Letters. its frequency was disproportionately higher in women. The Philadelphia: The Jewish Publication Society; 1995. pain appears very soon after alcohol is ingested, even in small 3. Jacob HE. The World of Emma Lazarus. New York: Schocken; amounts and subsides within thirty minutes to several hours. 1949. Almost all patients have objective evidence of disease near 4. Emma Lazarus. Death of an American poet of uncommon the site of the pain. Painful lymph nodes become swollen and talent. New York Times 1887 Nov 20: 16. warm, suggesting that vasodilatation may be the mechanism, 5. Hodgkin T. On some morbid appearances of the absorbent but other vasodilators fail to reproduce the pain. glands and spleen. Med Chir Trans 1832; 17: 69–97. During her short life Lazarus’s main goal was to have her 6. Bonadonna G. Historical review of Hodgkin’s disease. Br J work recognized and approved by the literary establishment.1,2 Haematol 2000; 110: 504–11. Unfortunately, during her lifetime the barriers to the accep- 7. Reed DM. On the pathological changes in Hodgkin’s disease, tance of creative work by women were enormous. Even Emily with especial reference to its relation to tuberculosis. John Hopkins Dickinson, now one of America’s most revered poets, died in Hosp Rep 1901–2; 10: 133–96. 1886 virtually unrecognized and unpublished. Lazarus had cor- 8. Hazard JB. An introduction to the history of surgical pathol- responded with Ralph Waldo Emerson, the leading American ogy. Am J Clin Pathol 1981; 75 (3 Suppl): 444–46. poet, and even travelled to Massachusetts to spend some 9. Satterthwaite TE. Hodgkin’s disease: five cases with two post- time with him. He was very encouraging and supportive, but mortem examinations. Post-Graduate MY 1887–8; 3: 85–91. when Parnassus, an anthology of special poems he selected, 10. Hutchinson JH. Case of adenoid (Hodgkin’s); enlargement of was published none of Lazarus’s work was included. She was the cervical glands with multiple lymph-adenomatous tumors of the heartbroken and protested vigorously in a letter to him, but he brain, spinal column, lungs, sternum, subcutaneous tissue, etc.; with did not respond. remarks, an analysis of fifty-eight recorded cases, and a bibliography. At the time of her death there was little public awareness of Trans Coll Phys Phila 1874–5; 3: 47–67. Emma Lazarus and her work outside of the New York literary 11. Briani C, Vitaliani R, Grisold W, et al. Spectrum of para- community and those who had shared in her immigrant relief neoplastic disease associated with lymphoma. Neurology 2011; 76: efforts. Her sonnet had not been mentioned during the cer- 705–10. emonies at the Statue of Liberty’s public opening in 1886. Her 12. Berger JR. The clinical features of PML. Cleveland Clin J Med sisters destroyed her papers and diaries, and in 1889 published 2011; 78 Suppl 2: 8–12. some of her poems, but not “The New Colossus.” 13. Atkinson K, Austin DE, McElwain TJ, et al. Alcohol pain in However Lazarus had influential friends who had not for- Hodgkin’s disease. Cancer 1976; 37: 895–99. gotten her; one of them, Georgina Schuyler, successfully pro- moted the mounting of a memorial plaque upon which “The The author’s address is: New Colossus” was engraved on the pedestal of the Statue of 18 Pickman Drive Liberty in 1903. Bedford, Massachusetts 01730 On the fiftieth anniversary of the statue’s dedication a Email: [email protected] Slovenian immigrant writer, Louis Adamic, and many others

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