Morrell Mackenzie – Otolaryngological cause for World War 1 …!!!

FAMILY HISTORY

His family History goes back quite a long way.  Early in the 17th century G. Grandfather Rev. Bernard Mackenzie was the Minister of Cromarty from the Northeast corner of Scotland, County of Ross, end of 17th century.  Morell’s father gravitated to England to become a medical practitioner at Leytonston, Essex County England.  However his father died young in 1855 in a fall from his carriage leaving seven children, Morell the oldest.  Morell’s early life was shaped by sharing the cares and anxieties of helping his mother raise the children.  The early assumption of responsibility probably explains the solemn, in not somewhat taciturn manner and the lack of a sense of humor in this great man.  His younger brother, Stephen Mackenzie became dermatologist to the London Hospital.  He introduced the Finsen Lamp from Sweden for treating skin disorders, especially Lupus.

 EDUCATION

In 1851 after his Father’s death, Morell was employed by Union Insurance Company Office.  He didn’t like it and worked less than a year.  He told his mother he would like to study medicine.  In 1852 he began to study Medicine at London Hospital.  In those days they didn’t have schools but used hospital with facilities to train doctors.  He studied from 1852 to 1858.  In 1858 he became a member of the Royal College of Surgeons of England.  From 1858 to 1860 he spent one year in both Paris and Vienna.  In 1860 he was on the continent, helped by his mother’s sister, a lady of means who was able to finance his journey.  In 1859 he visited Czermak of Budapest, leading laryngologist on the continent and learned the use of the laryngoscope who had swiped the idea from Manuel Garcia who trained singers on the continent and had devised the idea of using a mirror reflecting sunlight to examine singers vocal cords, used as guide to see if it was progressing.  It was called “laryngo mirror”.  This inspired Mackenzie because he had difficulty examining his patients’ throats at the hospital.   Back to England in 1861 he received his Bachelor of Medicine at London University and in 1862, his Doctor of Medicine.  In 1863 in the span of one year, he developed a tremendous practice treating diseases of the throat.

 PUBLICATIONS

1863 – Treatment of Hoarseness & Loss of Voice (after 1 year in practice) 3 editions.

1863 – “On Pathology & Treatment of Diseases of the Larynx” (Jacksonian Prize Essay)

1865 – Use of the Laryngoscope* 3 editions

1874 – Essays on Growths in the Larynx

1879 – Diphtheria, its Nature and Treatment

1884 – Hay Fever & Paroxysmal Sneezing

1886 – Hygiene of the Vocal Cords (about care of his tubercular patients)

1888 – The Fatal Illness of Frederick the Noble

*One passage from this book reads, “Complete loss of voice after two years standing cured by one application of galvanism.”  At that time they would put a copper collar on the patient with a copper collar right over the thyroid cartilage and Mackenzie had devised a long forceps with a wad of cotton on the end of it which was connected to one wire, and the electrode on the throat was connected to the other one.  He says, “Miss T., age 26 years, was sent to me March 1864, by Dr. C.J.B. Williams.  For the last two years her voice had been entirely suppressed and she had only been able to speak in a feeble whisper.  When I saw her she was rather delicate, had a bad appetite, and was easily fatigued.  Her local physician in the country had prescribed various treatments as well as various tonics prescribed by Dr. Williams, but all without effect.  Upon examining this patient with the laryngoscope, I found the vocal cords perfectly healthy but relaxed.  I passed the electric current through them.  The voice was immediately restored.

 EARLY PRACTICE

As to his early practice, from 1860 on his return from Budapest, he became registrar at London Hospital.  His appointment allowed him to engage in private practice in which he soon began to use laryngeal mirrors, and to build up quite a reputation as a physician interested in diseases of the throat.  He tried to persuade the authorities at the London Hospital to allow him to set up a clinic for diseases of the throat, but due to the prevailing opposition to specialization in medical practice, he was refused.  No other hospital in London would permit this either.  As it was obvious that there were a great number of patients who were in need of examination and treatment for serious diseases of the throat, he decided to found his own clinic.

In 1862 he founded his own clinic around Regent Street, occupied the first floor and rented out the upper part to help pay expenses.  This was hardly necessary as the Metropolitan Free Clinic for Diseases of the Larynx and Loss of Voice was an instant success.  By 1865 he had moved to more commodious quarters at the corner of Golden Square and Upper John Street opposite a house that was for many years the home of John Hunter.  Here was founded the Hospital for Diseases of the Throat, with clinics, dispensary, and wards with 16 beds.  The place was immediately inundated with patients who came from all over London.  The Hospital was continually enlarged by taking over adjoining property as it became available until early in the present century the site reached its current size.

When the hospital was founded there was no public transportation in London and Mackenzie realized that his patients, many of them seriously ill had to walk many miles to the hospital, and then after examination had to walk back again.  He therefore established two satellite clinics one on the west and another in the southeast.  These were of great help but aroused indignant opposition from the local residents who thought dreadful epidemics would result.  He abandoned these clinics soon after with the opening of the first underground railway and the institution of horse drawn busses.

While still a young man, Mackenzie was accumulating an immense experience in diagnosis by inspection with indirect laryngoscopy, of morbid conditions of the throat.  He had great dexterity in the use of biopsy forceps and cautery.  He had become a great teacher and attracted physicians from all over the world; some stayed as assistants and others went home to establish their own clinics.

Clinton Wagner – founded Metropolitan Throat Hospital in N.Y.

James Nolan Mackenzie – First clinic in Baltimore

Chevalier Jackson – in 1886 traveled over by steerage and nursed a patient with smallpox on the way.  Owing to lack of funds he could only remain a few weeks, but never forgot the experience.  Jackson saw an “unpractical device designed for inspection, perorally, the esophagus.”  On his return, Jackson worked on this problem, and by 1890 he had developed a usable esophagoscope with which he was able to remove coins and tooth plates from the gullet.

 TROUBLES

The medical profession of the 19th century was very jealous of priority of their prestige, and their patients, and when they thought that any of these had been infringed by their colleagues they indulged in the most violent quarrels, not always in private.  Mackenzie was not immune from these troubles.  He had been adopted by Queen Victoria and the court and by many of the highest in the government and the aristocracy not only as throat specialist but also as adviser in so many matters that he was not often involved as an active protagonist.  On two occasions, however, a group of his colleagues walked out on his hospital for diseases of the throat in Golden Square and founded their own hospital.  Reasons given were that Mackenzie was too autocratic in his management of the hospital.

 THE LARYNOGOLOGICAL CAUSE OF THE 1ST WORLD WAR

The central figure in this great drama in Mackenzie’s life was Crown Prince Frederick of Germany, heir apparent to the throne of the most dynamic country on the continent.  He was a liberal with an admiration for England, married to the eldest daughter of Queen Victoria.  The Crown Princess, an attractive, intelligent woman, also named Victoria, was unhappy with the cold atmosphere of the Prussian court and lacked her husband’s popularity with the German people.

In January of 1887, at the age of 55 years, the Crown Prince developed a persistent hoarseness supposedly due to a cold contracted the previous fall.  Dr. Gerhardt, Professor of Clinical Medicine at the University of Berlin, was called into consultation.  Indirect laryngoscopy disclosed “a long, low, somewhat uneven pale little nodule about 4mm in length and 2mm in height.”  He attempted to remove the growth by a wire snare and circular knife but without success.   He finally succeeded after 13 applications of the galvanocautery, the diagnosis was a polypoid thickening of the vocal cord.

Two months later the area had failed to heal, the hoarseness was more pronounced, and Professor Gerhardt found the movement of the left vocal cord sluggish.  He requested consultation with Professor von Bergmann, the leading surgeon in Germany, who had had experience with laryngeal operations.  Both men were in agreement that a diagnosis of cancer of the larynx was quite likely and recommended a laryngo-fissure for removal of the tumor.  Another German laryngologist, professor Tobold, was called and made a firm diagnosis of cancer.

Final arrangements had been made for the operation on May 21st when it was decided to summon Dr. Morell Mackenzie as a final voice in the matter.

Mackenzie arrived in Berlin on March 20, 1887 and proceeded at once with the examination.  He found a pink, slightly rough growth the size of a split pea, attached to the edge and partly underside of the posterior portion of the left vocal cord.  Mackenzie stated that grounds for the operation were insufficient, and that a piece should be excised and studied microscopically by a competent pathologist to determine whether or not cancer was present before embarking on an external operation.  This was done the following morning under cocaine anesthesia and with laryngeal forceps; the fragment was turned over to Professor Rudolph Virchow, the great German pathologist, for study.  He reported the tissue to be superficial and of a benign nature.  Another biopsy on June 8th was done by Mackenzie, and in this specimen, with the deeper tissues described by Virchow, and was benign.  The Royal patient was then handed over to Mackenzie for treatment in England.  Two more biopsies were done in the next few weeks, and all had the same result.  IT MUST BE POINTED OUT HERE THAT VIRCHOW WAS ALWAYS CAREFUL TO POINT OUT THAT HIS DIAGNOSIS CONCERNED ONLY THE TISSUE WHICH WAS GIVEN TO HIM AND NOT THE DISEASE IN THE LARYNX.  In August of 1887, Mackenzie removed a small recurrence of the growth with galvano-cautery and the Prince’s voice returned.  Queen Victoria was so delighted that she invited Mackenzie to lunch and knighted him immediately afterwards.

By November 5th the optimism was gone.  Examination disclosed the left arytenoid to be swollen and bright pink in color with a subglottic tumor present beneath each vocal cord.  Consultations with other German and Austrian laryngologists resulted in a diagnosis of cancer and a recommendation for laryngectomy.  The Crown Prince refused to have this done and continued under the supervision of Mackenzie.

It had previously been decided that should the Crown Prince need tracheotomy, that von Bergmann should do it.  By February of 1888 this need arose by the stridor produced by the encroaching tumor.  On February 9th von Bergmann had his assistant, Dr. Bramann do the surgery in the Prince’s sitting room, over by the window where the light was better: According to Mackenzie, an overly large tube and overly long tube was passed which gave rise to almost constant squabbling among the assorted doctors.  Various lengths and curves of tracheal tubes were tried, hemorrhages resulted, bits of the tracheal rings were expelled but tissue was recovered which undoubtedly was cancerous.  On April 12th, von Bergmann, in attempting to change the tube, introduced a tube without a pilot, made a false passage into the mediastinum, which further hastened the Prince’s demise.  A huge abscess resulted, but which seemed to drain itself for a time.  He rallied for about a month, then slowly deteriorated, dying of aspiration pneumonia on June 15th, 1888.  Autopsy by Professor Virchow confirmed the diagnosis of cancer of the larynx with extension to the glands of the neck, mediastinal abscess and pneumonia.

In the midst of these events the aged Emperor William I died and Crown Prince Frederick succeeded to the thrown where he reigned only 99 days.

The unfortunate King, who had behaved with great courage to the last, had no sooner been laid to rest when a storm broke out in the German medical and lay press.  The German Doctor, who had been proved to be right, issued a lengthy pamphlet, giving their side of the case, attacking Mackenzie and criticizing him for postponing the operation which they had originally recommended.  The lay press was even more violent in its denunciation.  Frederick’s English wife was accused of being responsible for summoning Mackenzie simply because he was British, and even Queen Victoria was stated to have had a hand in the decision.  Neither charge was true, but the attacks had considerable political basis.

Publicly, Frederick’s death proved to be a disaster for Germany and for Europe.  His son, William II, who succeeded him was autocratic and impulsive.  He disliked his mother and came early in life under the influence of the most militaristic and expansionist elements in Germany.  He dismissed Bismarck, who opted for peace, and became his own foreign minister.  He cancelled a treaty of friendship with Russia and announced that he was building a navy capable of challenging Britain on the high seas.  These actions set the course for an inevitable collision of the great powers and resulted in the holocaust of the First World War.

As a final word, some appraisal of the medical aspects of this affair seems justified in view of today’s advanced knowledge.  From the description of the location, appearance and firmness of the initial lesion, it appears highly probable that it corresponded to epithelioma which at first was confined to the cord edge.  Could the King have been saved by the operation which the Germans urged in May of 1887?  Not according to our modern indication.  Since the cord was already infiltrated, as shown by the impaired motility, it was too late for laryngo-fissure and excision of the tumor.  A laryngectomy would have been required and the results of that procedure at the hands of von Bergmann would have been murderous.

As for Mackenzie he was ahead of his time in demanding histologic confirmation for a diagnosis of malignancy, but it is astonishing that a man of his vast experience chose to ignore both the history and the impaired motility of the affected cord which he noted at his second examination.

Mackenzie had never had robust health and had always suffered from asthma.  The strain of playing his part in the tragedy and the bitterness and rancor of its aftermath had such an effect on him that his asthma got steadily worse, and he died in 1892, only four years after the Emperor, at the age of 54, from asthma complicated by an influenzal pneumonia.

 

What is are the interpretations of Rinne’s test?

Rinne’s test compares the air conduction (AC) and bone conduction(BC) in the same ear. The interpretations are:

(a)   Rinne positive- when AC is better than BC found in Normal hearing and SNHL

(b)   Rinne Negative- when BC is better than AC found in Conductive and Mixed hearing loss.

(c)    Rinne reduced positive- where AC is better than BC but with reduced BC seen in SNHL

(d)   Rinne equivocal- when AC and BC are equal seen in mild conductive deafness.

(e)    Rinne false negative-where BC is heard apparently longer in a case severe unilateral SNHL as the sound is transmitted through the skull to the other ear.

(f)    Rinne infinitely positive where the patient hears momentarily a vibrating tuning fork by AC but does not hear by BC. This is seen in profound SNHL of the test ear.

(g)   Rinne infinitely negative – profound conductive deafness