VIRCHOW’S MISTAKE

By Charles T. Lucas

     The story I’m about to tell involves a family and professional feud.  The protagonists were locked in ideological conflict, creating an extraordinary maelstrom at the very center of national and medical life at the time.  It begins with the Hohenzollerens at the pinnacle of their power on the European continent. They ruled a unified Germany under Prussian dominance and they elevated Berlin to the most powerful, if not most beautiful city in Europe, but in spite of their success, they are best remembered for their particular knack for making war and their besetting sin, vain pomposity.

     William the First, a mildly popular, simple-minded patriarch was carried on the shoulders of his prime minister to occupy the Imperial throne of the German Empire as Bismarck himself proclaimed.  While the empire was a constitutional monarchy in theory, if was not one in practice.  The divine right of kings was more to the tastes of both Wilhelm and his Chancellor.  Ignoring parliament, they built a strong industrial base and a large, well-organized army equipped with the latest weapons.  The powerful Prussian Army enabled Bismarck to use his political skill and cunning to unite Germany under Prussian leadership between 1864 and 1871.

     Bismarck was a tough, massive, unscrupulous minister with a clarity of vision and a precise idea of where he wanted to go.  He was an outspoken enemy of liberalism and a strong defender of the powers of the Prussian kings.  In perhaps his most remembered speech to the Prussian National Assembly in 1862, he said “Germany doesn’t look to Prussia’s liberalism, but to its power; not by means of speeches and majority verdicts will the great decisions of the time be made, that was the great mistake of 1848 and 1849, but by iron and blood.

     Wilhelm’s consort, the Empress Augusta, was a complex woman; high-strung, intelligent and artistic.  Her views were liberal and diametrically opposed to her husband’s.  Their oldest son Frederick Wilhelm the Third, who was to be heir to the throne, was caught in the middle of his parents’ unhappy marriage and ideological conflict.  He became a successful military officer, but he was a sensitive and open-minded man who shared his mother’s liberal views and politics.

     England compared with Germany had demonstrated a genius and extra-ordinarily versatile talent for self-government.  Their Queen, Victoria, descended from the undistinguished House of Hanover, was the greatest British sovereign after Elizabeth I.  If not personally brilliant, she was a woman of much sense and considerable sensibility.  She is famous for the way she managed to get on with dynamic, shrewd and competitive prime ministers, to balance her prestige about the changeable whims of politics and to lead a dignified, plain life.  She established herself as the Matriarch of Royal Europe.  Eventually, her descendants or their close relatives were connected with almost every important ruling house in the continent.  Britain was the sole constitutional monarchy of major importance and Victoria did not herself lay down the law, but she became the symbol of royal grandeur and stability.  He adored consort, Prince Albert, a transplanted German prince, was more cultivated and liberal than the Prussian Hohenzollerens.  He dreamed of a united Germany based on popularity-backed parliamentary government similar to Britain.

     When young Frederick Wilhelm III, or “Fritz” as he was called, visited the British Royal Family at Balmoral in Aberdeen, Scotland, Victoria and Albert were quick to plan for a liaison between him and their eldest daughter Vicky.  Vicky, not yet fifteen, was a lively, intelligent and pretty girl.  Fritz was 24 at the time, tall and handsome.  The young couple immediately fell in love and they were later wed at the Royal Chapel in England.  It was a regal affair at which Mendelssohn’s Wedding March was played for the first time.  When Vicky, a true British liberal of her time, moved to Germany to become a member of the Royal Court, she was disliked and distrusted immediately by Bismarck, as she was the anathema of his reactionary chauvinism.  He referred to her as “the English woman.”  She called him “that clever madman.”  Their hostility for one another was total, bleak and undisguised.

     Fritz, while probably not as intelligent as Vicky, was open-minded and compassionate.  He was loved by the German people who called him “Unser Fritz”.

     Fritz and Vicky’s firstborn, William I, or “Willy” as he was called by his family, suffered a dislocated left shoulder during birth, permanently damaging his brachial plexus.  His withered arm may have contributed to his later psychological imbalance and saber rattling over-compensation.  Bismarck, fearing loss of his power when Fritz ascended the throne, was quick to turn Willy against his parents as soon as possible.  He also packed the Reichstag with members under his influence to weaken Fritz’ future power.

     In autumn of 1886, while visiting the King and Queen of Italy in Northern Italy, Fritz took a cold.  After his recovery, hoarseness persisted.  He was treated with gargles by Dr. Hans Wegner, his Physician in Ordinary.  After the hoarseness persisted for two months, Dr. Wegner sought consultation from Professor Ernst Gerhardt, Professor at the Royal University in Berlin.

     Gerhardt stout, bald and in his early 50’s was not a trained laryngologist, but he had an interest in diseases of the throat.  On March 6, 1887, he came to the New Palace where he examined the Crown Prince.  He found “a 4mm x 2mm elongated, low, pale, red nodule on the edge of the left vocal chord between the vocal process and the middle third”.  He tried unsuccessfully to remove the growth using a wire snare and a circular saw.  He, therefore, decided to use galvano-cautery to destroy the growth.  It had almost completely disappeared after thirteen treatments with the cautery.  Fritz’ voice was still hoarse, but more resonant than before.  Gerhardt was concerned that the growth may be cancerous.  Two weeks later, his voice was much worse and the growth had enlarged.  Now convinced that the growth was malignant, Professor Gerhardt requested a consultation from Professor Ernst von Bergmann, Professor of Surgery at the University of Berlin and an eminent military surgeon.  Von Bergmann was a tall, imposing figure known to be pompous and an extremely adept politician.  He was reputed to have looked more like a military general than a physician.  He examined Fritz, but as he was not trained to use a laryngoscope, he deferred to Dr. Gerhardt’s diagnosis, saying, “Gerhardt makes the diagnosis, I am only the operator”.

     Von Bergmann proposed that an exploratory laryngo-fissure of thyrotomy operation be performed with total extirpation of the growth progressing to total larynectomy if that should be necessary.  The operation was planned for 7 o’clock on May 21^st at the New Palace.  An operating table was brought in from the Charity Hospital in Berlin and two nurses were in residence in preparation for the operation.

     Gerhardt’s findings to support his diagnosis were:

1.     The rapid recurrence of the growth.

2.     Its hardness and uneven surface.

3.     The absence of the repair process.

4.     Impaired mobility of the vocal cords.

5.     No evidence of infection.

6.     The patient’s age (56 years)

The German physicians decided to inform Vicky but they would wait to tell Fritz on the morning of the operation.

Vicky was undecided about whether to consent to the operation, but she thought it was her duty to inform the Emperor Bismarck.  When Bismarck heard the plan, he was infuriated.  He thought it unethical for the physicians to propose operating on a patient without first obtaining his consent, particularly the heir to the German throne.  He demanded that a laryngologist whose reputation was internationally acclaimed be consulted before any further treatment was given.

Dr. Wegner presented his colleagues with a list of noted laryngologists from which a consultant could be chosen.  The list included Dr. Moure of Paris, Professor von Schrotter of Vienna and Dr. Morrell Mackenzie of London. 

They decided on Dr, Mackenzie because his textbook Diseases of the Throat and Nose was widely used in Germany, and Mackenzie was well regarded in the German medical community. Also, as France and Austria had been recently defeated militarily by Prussia, Mackenzie was politically a better choice. Vicky was pleased to have a British consultant for Fritz as she had very little confidence in German medicine after Willy's birth Injury.

The German physicians were so confident in their diagnosis of cancer they expected Mackenzie merely to confirm it and concur with the proposed surgery by von Bergmann. It should be pointed out that in the late 19th century laryngology was a specialty looked upon as associated with medicine and not surgery. The extent of surgical treatment by laryngologists was limited to opening abscesses, removal of tonsils and endolaryngeal removal of polyps and other small tumors of the larynx.

Morell Mackenzie was an eminent laryngologist in London. When Mackenzie was a student medical education in London at the time consisted of only anatomic dissections and "walking the hospitals" with little systematic teaching in medicine.

He, therefore, traveled to Paris and Vienna to visit the clinics there, which were considered the best training for higher qualification. While in Paris he studied under Charcot, the neurologist, and Trousseau (the first in Paris to practice tracheostomy). In Vienna, he studied under Rokitamsky, the great pathologist, who impressed upon him the great importance of anatomical pathology as the basis upon which all clinical knowledge must be founded. Rokitamsky insisted, "A careful diagnosis must always be established before treatment is given."

After completing his medical training, he established The Hospital for Diseases of the Throat (the first of its kind in the world) In London. He was a handsome man with dark, quick eyes, reputed to be arrogant and mercenary by some critics. Even his trusted and loyal assistant Dr. Mark Hovell said or Mackenzie, "he was always somewhat of a humbug". Although his political views were liberal, his medical views were conservative.  A Liverpool laryngologist is quoted as saying "Mackenzie was always in favor of the mild rather than drastic action."

On Wednesday evening, May 18, 1887, Mackenzie was about to retire after a long day of seeing patient’s in his office, when he received a telegram from Dr. Wegner requesting him to come to Berlin Immediately to see the Crown Prince in consultation. As he pondered the telegram there was a knock on his door. It was Dr. Reid, Queen Victoria's personal physician. He brought a message from Her Majesty requesting Mackenzie to go to Berlin at once to examine her son-in-law.  He was not informed as to the nature of the Crown Prince's illness. He left the next morning, arriving in Berlin on the afternoon of May 20th. He was met at the train station by Dr. Wegner who informed him that his German colleagues had diagnosed Fritz' illness as cancer of the larynx and that they intended to operate as soon as possible, but as a precaution, given the importance of the patient, they were seeking a second opinion from him.

At the palace, Dr. Mackenzie was shown to his room. But before he could change from his traveling clothes, the Crown Prince's personal secretary knocked on his door. He informed him that the Crown Prince wished to see him at once. Mackenzie followed him into the drawing room where Fritz was waiting. Fritz apologized and thanked him for coming a11 the way from London at such short notice. Mackenzie was favorably impressed by Fritz's humbleness and intimacy. After consulting with the German physicians, he returned to Fritz’s dimly lit room for his first examination. He describes his findings as follows: "I saw a growth about the size of a split pea at the posterior part of the left vocal cord; it was a pale pink color, slightly rough on the surface, but not lobulated. The litt1e tumor lay over the processus vocalis, but extended also a little way behind and below that point. On phonation a portion of the growth disappeared from view; a fact which showed that it was partly attached to the undersurface as well as the side of the cord, in other words, the neoplasm was partly subglottic in situation."

After completing his exam, he returned to the Conference Room where he somewhat casually remarked to his colleagues "the growth seems to me like a wart or papilloma." The stunned German physicians expressed that in their opinion the growth was clearly cancer. Mackenzie recalls "there was nothing characteristic in the appearance of the growth; and it was quite impossible to give a definite opinion as to its nature, without a more searching examination." "I pointed out that the opinion expressed by colleagues had come to on what seemed to me insufficient grounds and that they omitted the most essential, and at the same time, most obvious means of arriving at a correct diagnosis. The first thing to be done was to pick off a piece of the growth through the natural passage and have it examined microscopically by an expert." It is not hard to imagine how this opinion was received by the German physicians. Gerhardt complained that, because of its location, biopsy of the growth would be difficult. The others felt that the delay was unnecessary, but they agreed to allow Mackenzie to biopsy the growth and send it to Professor Rudolph Virchow.

It must be remembered that at the time surgical pathology was in its infancy and the biopsy of tumors for diagnosis prior to surgery was an uncommon practice.

The next morning on his second attempt, using unfamiliar biopsy forceps, he was able to obtain a tiny fragment of tissue. This was placed in absolute alcohol and taken to Professor Virchow.

Virchow was a small, wiry, vigorous and versatile man. At age 66, he was a medical giant in Germany.. Of Interest he was also an outspoken political liberal, one of the few who could stand up to Bismarck in the Prussian Parliament. Once he so irritated Bismarck, that the Iron Chancellor challenged him to a duel, which Berliners found a great joke, but Virchow declined the honor.

It was Saturday, so Virchow told Wegner the report would not be available until Monday morning. While they awaited the report, the royal couple entertained Mackenzie with gala dinners and walks through the beautiful palace gardens. That evening Vicky wrote to her mother, "Oh how relieved I am! I shall be able to sleep tonight and look at my darling Fritz without the agonizing that tomorrow may be the last we spend together. I bless Dr. Mackenzie."

About 11 o'clock a.m. Monday morning, Dr. Wegner returned to the Institute where he waited until Virchow finished an autopsy demonstration for medical students. Virchow said the tissue sample was too small for definitive diagnosis, but it was not malignant. He issued only an oral report and requested a larger tissue specimen.

At his second operation Mackenzie could not obtain a specimen. He notes "In this kind of work the operator knows when he has seized what he is aiming at, just as an angler feels when he has a bite." Because the larynx was congested he elected to wait before attempting another biopsy.

On his return to Potsdam, he brought his biopsy forceps. The following morning he successfully removed larger fragments of the growth. As before, they were sent to Virchow. Virchow reported that the tissue represented an epithelial growth combined with papillary offshoots, representing pachydermia verrucosa, a reactive process to inflammation. He added, "Yet the healthy condition of the tissue on the cut sample allows a very favorable opinion to be formed as to prognosis. Whether such an opinion would be justified in respect to the whole disease cannot be ascertained with certainty from the two portions removed. However, there is nothing present in them which would be likely to excite suspicion of a wider and graver disease."

Mackenzie now planned to totally remove the growth. He requested that the operation be performed at his London office where he was more accustomed to operating. Fortunately for Mackenzie, as there was official resistance to the Crown Prince' leaving Germany, Queen Victoria's Golden Jubilee celebration was planned which allowed the Crown Prince to travel to London. On June 28th Mackenzie removed all the remaining tumor. The tissue was again sent to Virchow who again reported no evidence of malignancy.

Toward the end of July the tumor had recurred. This time Mackenzie applied cautery to burn out the growth.

That Autumn while the Crown Prince and his wife vacationed in the Austrian Alps Dr. Mark Hovell, Mackenzie's assistant who was traveling with the royal couple 1n Mackenzie’s' absence, discovered an oblong swelling, about 5 mm in length and 3 mm in width below the vocal cord. Mackenzie was summoned and he confirmed Hovell’s finding.

It was decided that Fritz should spend the winter in the milder climate of Italy, so on November 3rd he proceeded to San Remo to reside in the beautiful V111a Zirio. The tumor continued to enlarge and Mackenzie was now suspicious of malignancy. He informed Fritz, "a very unfavorable change has taken place in your throat." To which Fritz asks, "Is it cancer?" Mackenzie replied, "I am sorry to say sir, it looks very much like it, but it is impossible to be certain." Fritz grasped his hand warmly and smiled saying "I have lately been fearing something of this sort. I thank you Sir Morell for being so frank with me."

Mackenzie requested a consultation from Dr. Hermann Krause, a respected Berlin laryngologist and Dr. von Schrotter. After examining Fritz they concluded that the growth was in fact cancer. The physicians prepared a report stating their conclusion that the growth was cancerous and they outlined the advantages and disadvantages of laryngectomy, both partial and complete. Professor von Schrotter had the dubious honor of reading the report to the Crown Prince. It was felt best to address him in his native language. Von Schrotter did not, however, use the word cancer in his statement.

After a few minutes the Crown Prince sent the physicians a message, written in his own hand, declining to have his larynx excised, but agreeing to submit to tracheostomy should it be necessary. Dr. Bramann, a young assistant to von Bergmann, was sent to San Remo to be ready to perform a tracheostomy should it be necessary.

Fritz began to experience violent coughing episodes as the necrotic tumor fragments sloughed and fell into his trachea. His respiratory function was deteriorating so that he could not climb a flight of stairs. On February 11, 1888 Fritz' respiratory difficulty was extreme. Mackenzie decided that an im­mediate tracheostomy was indicated, but Dr. Dr. Bramann wanted to wait for Dr. von Bergmann to perform the operation. Mackenzie, however, proclaimed that if the operation was postponed he would decline a11 responsibility and those who opposed it would be answerable for the Crown Prince's death. Bramann was in a tight spot. He was nervous about accepting such responsibility without the approval of his chief but if a delay resulted in the death of the Crown Prince, he would be held re­sponsible. He, therefore, agreed to proceed. When he made his incision Mackenzie and Hovell thought it was too far to the right of the midline. They also felt that the tube he used was too long and may injure the posterior wall of the trachea. They made an experiment to confirm their suspicions, using a surgical probe bent at the end they measured the incision as illustrated in the slide.

Later when Fritz expectorated some of the sloughed material von Bergmann had it sent to Professor Waldeyer, Virchow’s assistant, who examined it microscopically since Virchow was in Egypt on an archeological expedition. Waldeyer reported that the slough contained malignant cells. That Waldeyer may have been able to diagnose cancer when Virchow had not probably can be attributed to the fact that Waldeyer disputed Virchow's theory that cancer arises from the connective tissue. He had proposed instead that cancer arises from the epidermal tissues.

March 9, 1888, Emperor Wilhelm I died at age 90. Fritz prepared to return to Berlin. After preparing a statement announcing his ascension, he presented Mackenzie with the Cross and Star of the Hohenzolleren Order, the highest honor that could be bestowed on a foreigner. Mackenzie advised him not to attend his father's funeral. Fritz heeded Mackenzie’s' advice.

Near midnight on April 14th Fritz' illness changed dramatically. He experienced violent coughing episodes which were unabated by adjusting his cannula. Mackenzie decided to change the tube but first summoned von Bergmann as he had previously agreed. Von Bergmann arrived at the palace about 5 o'clock in the afternoon and the events which transpired thereafter caused Mackenzie to refer to this as the "fatal day." Von Bergmann excitedly rushed into the room past Mackenzie, not listening to his report. He placed a chair opposite the window and asked the Emperor to sit down on it. He quickly undid the tape holding the tube in place and pulled out the tube. He then attempted unsuccessfully to push a tube he held in his hand into the wound. Fritz was seized by violent coughing and hemorrhage. When his second attempt failed he placed his finger into the wound to enlarge it, but he still was unable to insert the tube. He called for his assistant Bramann who was waiting outside in the carriage. Bramann easily inserted the tube. Mackenzie alleges that von Bergmann forced the tube into the soft tissue of the neck in front of the trachea thus creating a false passage. Two days later Fritz was febrile and purulent material could be expressed from the wound, indicating an abscess.

As it was becoming apparent to Fritz that he was dying he wished to return to his birthplace in Potsdam, the New Palace. After his return to Potsdam, Mackenzie could see that he was sinking day by day. He informed him, "I am sorry to inform you sir, that you are making no progress." Fritz, in spite of his skeleton-appearing body replied "I feel pretty well today." Some hours later he handed Mackenzie a strip of paper on which he had written, "I am very sorry that I made no progress."

On June l3th Mackenzie was remaining at Fritz' bedside all night. He heard rates 1n his lungs signaling bronchopneumonia and the end was close at hand. During the afternoon, having heard of Fritz' grave condition Bismarck came to visit. Fritz greeted him with a fleeting smile; too weak to grasp a pen he motioned Vicky to stand beside Bismarck. He placed her hand in the Chancellor's with an imploring look. Understanding immediately, Bismarck leaned over the dying monarch and whispered, "I will take care of her." Early June 15th Fritz' color became cyanotic, his breathing shallow and rapid. Sensing the end was at hand, his daughters gathered into the room and wept. Vicky had stayed at his bedside except for a few minutes at a time for several days. His servants kneeled around his bed. At 11 o'clock a.m. his sons Willy and Henry and their wives arrived. Dr. Bramann led all his physicians, heads bowed, past their patient's bed. At 11:05 a.m. Dr. Mackenzie announced, "The Emperor has passed away."

The next day, von Bergmann said to Mackenzie, "A post-mortem examination is going to be performed. Do you wish to come? "Mackenzie, irritated by von Bergmann's casual manner replied, "Do I care to come? How can you ask such a question?"

The post-mortem examination was hurriedly performed as the lying-in-state had been arranged to begin within an hour. Virchow later stated that he regretted that more time had not been spent on drawing up the protocol. The permission was granted by Willy, without his mother's knowledge, and was limited to the examination of the lungs and neck only. It was performed by Virchow, assisted by Waldeyer, who prepared the specimens for micro­scopic examination and by Dr. Langerhans who took notes of the findings. They found that nearly the whole of the larynx was destroyed by a large gangrenous ulcer save for the epiglottis and aryepiglottic folds. The mucous membranes of the trachea below the tracheostomy were free from ulceration. On the left side of the neck, close to the jugular vein there was a lymph node about the size of a pigeon's egg containing metastatic cancer. The lungs demonstrated aspiration bronchopneumonia. The examination of the neck was vague, but the abscess described by Mackenzie was not described. Their microscopic examination confirmed their gross findings of epidermal carcinoma.

One-half an hour after his father's death Willy's Hussar regimen surrounded the palace. The soldiers were tramping through the palace entering bedrooms and emptying drawers and cupboards. One of the officers led Vicky from her garden into the palace where he proceeded to go through Fritz^’ desk throwing the contents all over the floor. Willy appeared in full dress uniform refusing to give his mother an explanation for his conduct. He was full of himself, very much the Emperor, playing bu11y right and left. When Queen Victoria heard of his conduct she wondered if he was right in the head. He wanted to arrest Dr. Mackenzie, but was dissuaded by his father's lawyer. Vicky feeling imprisoned in her own home, took her three daughters and they escaped into the night to their farm in Bornstadt where they would be safe. She was, therefore, unable to attend her beloved Fritz' funeral. Bismarck did not attend either. So much for the Iron Chancellor's deathbed promise to Fritz.

The disagreements between the physicians were played out openly in the press during the Emperor's illness and after his death. Mackenzie had cultivated newspaper correspondents and editors, supplying them freely with infor­mation from his point of view. Von Bergmann used the controlled govern­ment press to issue his opinion. After the Emperor's death, the press was vehement in their criticisms of Mackenzie. They bombasted him with the most outlandish claims. For his part, Mackenzie was a man of complex and contradictory character; He greatly enjoyed seeing his name in the newspapers. His self-esteem was titillated from being a friend and confidante of the German Emperor and Empress and his intimate position in the innermost circle of the Imperial Court. Amid the German Court intrigues, Mackenzie dramatized himself as the champion of the Empress. He told Queen Victoria that the Empress was betrayed and had no one to consult

except, of course, himself.

Von Bergmann was arrogant and pompous. He considered Berlin the surgical center of the world and himself the dominant figure in it. He was a general surgeon with the whole human body as his empire and he despised with utmost contempt all specialists and particularly the new specialists of laryngology, in which more physicians were pretending to possess surgical skill. He resented Mackenzie, an Englishman, for having cared for the Emperor of Germany. It is not, therefore, surprising, that these two men should generate such antagonism and acrimony toward one another.

On July 11th the Imperial Press, in Berlin, issued a publication; a black bordered pamphlet 62 pages in length, entitled "The Medical Report of Kaiser Frederick III" written by the German physicians under the general editor ship of Professor von Bergmann. In addition to Mackenzie, Virchow and Krause were noticeably absent from contributors. In the pamphlet the physicians mercilessly criticized Mackenzie's management of the Emperor's illness. They boasted of their early diagnosis and played down the serious­ness of their proposed operation. Mackenzie threatened legal action and blocked publication of the English translation of the pamphlet. The Empress described the report as "wicked" and urged Mackenzie to respond to it. At her counsel he published his defense entitled "The Fatal Illness of Frederick The Noble". It was equally vindictive His assistant, James Donelan, urged him to put it up for ten years as "it will do you no good, for you are only playing into hands of your enemies." Unfortunately Mackenzie ignored this prophetic advice.

The medical community harshly criticized Mackenzie for his book. They had not had the opportunity to read the German treatise. He resigned from the Royal College of Physicians when it was hinted that his resignation would be welcomed. He was censured by the Royal College of Surgeons with the comment "No provocation such as Dr. Morell Mackenzie alleges, can justify the publication or the language employed in it."

Mackenzie died broken-hearted in 1892 at age 54 He was buried in the churchyard at St. Mary's Church in Wargrave near his beloved summer cottage. Among the numerous wreaths which covered his coffin was a magnificent one from Empress Frederick (Vicky) of Germany.

As medical historians the case of the Kaiser's cancer provides us with many questions on which to focus our retrospect scope. How could the great Virchow have failed to diagnose the Kaiser's cancer for he had five chances? Did it matter that he was unable to do so? If the liberal Emperor had been saved would Germany have been spared the disastrous events leading to World War 1?

The medical questions are the easiest to answer with any certainty. If as Ling proposes, Fritz's cancer was a verrucous carcinoma, an indolent type of squamous carcinoma, Virchow can be absolved of the responsibility for not making that diagnosis, as verrucous carcinoma was not described until 1948 by an American pathologist, Dr. Lauren Ackerman. Verrucous carcinoma so closely resembles the benign response of the mucosa to inflammation that even today pathologists often struggle with the diagnosis.

Virchow's diagnosis of pachydermia verrucosa was considered a form of carcinoma In situ by Ewing in the third edition of his famous textbook of 1926. The concept of carcinoma in situ or the pre-invasive stage of car­cinoma did not gain general acceptance until the mld-20th century. The biopsies which Virchow examined did not demonstrate invasion, the necessary criterion for the diagnosis of cancer at that time.

As the neoplasm was subglottic it was almost certainly too extensive to be resected by thyrotomy as proposed by von Bergmann. Laryngectomy was almost universally fatal at that time and had a laryngectomy been performed by von Bergmann it would have almost certainly have killed Frederick the III and prevented his ascension and brief rule (99 days).

If the failure of the biopsy to diagnose the Kaiser's cancer delayed acceptance of this procedure in surgical practice, it was certainly short-lived and of no consequence.

Argument that Virchow was too old and only a part-time pathologist has very little support

The importance of Frederick's death on the course of European history is more difficult to evaluate. Many historians have expressed the view that because of Fritz' more enlightened philosophy and his admiration of the British system of government, he would have established a true parlia­mentary government in Germany. His ability to lead the German people in a more representative government would have prevented the disaster created by the reactionary and repressive activities of his psychopathic son.

This concept has been rebuked by Ober and others who derisively regard such thinking as "If Wilkes Booth had missed" school of historiography. They contend that Fritz was only liberal when compared with the other Hohenzollerens, hardly an honor! Ober's opinion relies on a quote by Bismarck from his Recollections that when he stated his conditions for continuing as Prime Minister to Frederick III; they were no parliamentary government and no foreign influence to which Fritz responded "Not a thought of that." It must be pointed out that Fritz was a dying man at the time of the remark and that there were no witnesses save Bismarck. Bismarck's Recollections contain many inaccuracies, most of which portray the Iron Chancellor in a favorable light. Fritz had openly opposed Bismarck in the past and Vicky's contentious relationship with the elderly minister would have certainly made a request for his retirement likely.

It can be stated without hesitation, that Unser Fritz would have ruled the German people more compassionately than his Neanderthal father or his saber-rattling son.

In conclusion, the only heroes in this historic episode were the brave patient, his adoring wife and the reticent Virchow.

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