Morell Mackenzie


Morell Mackenzie was born in 1837, the eldest child of Dr. Stephen Mackenzie, a general practitioner. At the age of 21, Mackenzie took an examination to qualify from the London Hospital College. He had earned his diploma of membership in the Royal College of Surgeons and the Licentiate of the Society of Apothecaries.

Morell Mackenzie decided to spend the next year studying medicine on the Continent, including stays in Paris, Vienna, Budapest, Berlin, and several cities in Italy. While in Budapest, his interest in laryngoscopy was piqued by Johann Czermak. Czermak showed the young man how to use a new invention, the laryngoscope, which was only five years old at the time.

Morell Mackenzie returned to England and began to study medicine and write about laryngology in earnest. In 1861 he graduated from London University with his Bachelor of Medicine. A year later, he earned his Medicinae Doctor and opened his private practice as a physician laryngologist.

Soon Mackenzie's reputation began to grow, allowing him to open a new office in 1863. This office he called the Metropolitan Free Dispensary for Diseases of the Throat and Loss of Voice. The year 1863 also brought Mackenzie's first brush with fame in physician's circles. He earned the Jacksonian Prize of the Royal College of Surgeons for his three volume essay entitled On the Pathology and Treatment of Diseases of the Larynx: The Diagnostic Indications to include the Appearance as Seen in the Living Person. His presentation to the British Medical Association in the same year coined the terms "abductors" and "adductors" to describe two sets of muscles which open and close the glottis.

The year 1865 was another big one for Dr. Mackenzie. He moved his offices once again, opening a larger and more prominent space at 32 Golden Square, London. This new office was named the Hospital for Diseases of the Throat and was the first laryngological hospital in the world.

By 1873 Dr. Mackenzie was a member of the Royal College of Physicians and was appointed as a Physician at London Hospital. This latter appointment he resigned soon afterward due to his "total devotion to laryngology" and the demands of the Hospital for Diseases of the Throat. Indeed, Dr. Mackenzie's practice was so large that Lady Duff Gordon recalled that "his waiting room was always crowded, and it was impossible to see him without waiting for an hour or two, unless one tipped the butler heavily or — like herself — possessed one of Mackenzie's visiting cards with "Admit at once" written upon it in his own handwriting."

Dr. Mackenzie's reputation was firmly established with his colleagues when he published his text books. The first was The Use of the Laryngoscope in Diseases of the Throat, published in 1865. This text was eventually translated into three languages and ran to three editions. Growths in the Larynx was published next, in 1871. This text documents one hundred cases Dr. Mackenzie treated using the laryngoscope. In it he describes his methods for numbing his patients. In a time before anesthesia he "relied solely on the patient sucking ice immediately before the operation and taking the occasional inhalation of chloroform or bromides."

In 1880 and 1884 Dr. Mackenzie published his most celebrated works, Diseases of the Nose and Throat, volumes 1 and 2. These two books were so important that thirty-seven years later, they were still referred to as the "laryngologist's Bible" by Sir St. Clair Thomson. In 1887 Dr. Mackenzie also helped found the Journal of Laryngology and Rhinology with R. Norric Wolfenden and was a founding member of the British Rhino-Laryngological Association.

By 1887, at the age of 50, Morell Mackenzie had been practicing laryngology for twenty-five years. His reputation as a throat specialist was firmly established in England and abroad. It was at this time that Dr. Mackenzie was called to treat his most controversial patient, Crown Prince Frederick of Prussia and Germany. Sir D'Arcy Power was moved to write of Dr. Mackenzie: "[e]ndowed by nature with great manipulative skill, constant practice had rendered him a master in the use of the laryngoscope and of the laryngeal forceps; but he was also by nature somewhat indiscreet, and his mind was essentially polemical...If it had not been for this episode in his career (the illness of Crown Prince Frederick), Mackenzie would have been remembered as an able practitioner in a special department of medicine, endowed with great mechanical skill and power of invention."

The story of Crown Prince Frederick begins several months before Dr. Mackenzie had been called from London. In 1887 Dr. Gerhardt, Professor of Clinical Medicine at the University of Berlin, attempted to remove what he diagnosed as a polyp from the throat of the 56 year old Prince. Dr. Gerhardt first employed a snare and finally used galvano-electric cautery to remove the "polyp". After thirteen of these procedures, Crown Prince Frederick felt better but his symptoms of hoarseness and vocal cord sluggishness soon returned.

Frederick's physicians suspected that he was suffering from laryngeal cancer and were preparing to perform a thyrotomy when the powerful Chancellor Otto von Bismark and Frederick's father, Emperor William I, discovered their plans. Both men asked that a specialist in throat medicine be sought. Meanwhile, Crown Princess Victoria, wife to Frederick, was increasingly alarmed at his condition. Victoria, the daughter of Queen Victoria of England, wrote to her mother regarding Frederick's illness. While it is not clear which party actually sought him out, Mackenzie was requested to examine Crown Prince Frederick's throat. Morell Mackenzie, therefore, went to Berlin and performed two biopsies on the Prince. Both were examined by Dr. Rudolph Virchow, who proclaimed them to be cancer free. Mackenzie therefore counseled all those involved against surgery.

In the summer of 1887, Queen Victoria held her Jubilee in London to celebrate her ascendancy to the throne of England. Her daughter and son-in-law, the Crown Prince and Princess, were there. Dr. Mackenzie took this opportunity to perform a third biopsy which was again examined by Dr. Virchow and, again, revealed no cancer. Dr. Mackenzie noted a swelling of the mucous membrane in the back of the larynx which he diagnosed as a chronditis of the artyenoid. Dr. Mackenzie applied galvano cautery to remove the growth. Crown Prince Frederick seemed to recover well from the operation and even regained much of his voice. The Crown Prince and his family returned to the Continent with high hopes for the Prince's full recovery.

In November of 1887, Mackenzie was called to San Remo, Italy, where Crown Prince Frederick was spending his winter. Upon arrival Dr. Mackenzie discovered that Frederick's condition had worsened. In particular he found a new growth in the Prince's throat: "its appearance was altogether unlike that of the one which I had destroyed...it had in fact a distinctly malignant look." Mackenzie informed his patient that the diagnosis was most likely laryngeal cancer and told Crown Prince Frederick that he must decide how he wished his illness to be treated.

The Crown Prince was presented with two treatment options: excision of the larynx or tracheotomy. Frederick decided that when it became necessary, a tracheotomy would be performed. Mackenzie and the other consulting physicians issued an official report to Chancellor Bismark and Emperor William I on the Crown Prince's condition. The German press got ahold of the letter and broke the story of the Crown Prince's illness in all the national newspapers. Mackenzie was the leading physician treating Frederick at this time, but he was able to offer the ailing prince little more than constant checking of his condition and attempts to make him more comfortable. As the news of the Prince's condition spread, the press began to criticize Dr. Mackenzie's treatment of the patient and accused him of mismanaging the case.

In January of 1888 Frederick's condition worsened still and he required the palliative tracheotomy which he had approved as treatment for himself. The procedure was performed by a German physician, Dr. Bramann. Morell Mackenzie was retained as a member of the team of physicians monitoring the Crown Prince's health, but was no longer the leading physician in the case. Dr. Bramann and a colleague, Professor Geheimrath von Bergmann, were now in charge, monitoring the Prince's health and managing the tracheotomy tube. Of these two Dr. Mackenzie wrote: "[i]t certainly appeared to me that neither Professor von Bergmann nor Dr. Bramann, well-informed surgeons though they doubtless are in many matters, had had much experience in the sort of work they had now taken upon themselves to do."

Interestingly, in February of 1888 Morell Mackenzie published a report in the Lancet in which he stated that cancer had still not been officially diagnosed. Due to the lack of pathological evidence, which he felt crucial to such a diagnosis, he instead referred to the disease as a "chronic interstitial inflammation of the larynx combined with perichondritis." This public acknowledgment of his patient's condition is even more unusual if one considers his later reproach of German physicians in making the health of their patient so public. Although he would later lament the lack of patient confidentiality afforded to the Prince, Dr. Mackenzie apparently felt the need in early 1888 to try to clear his name which was being so tarnished in the press at the time.

It would be nearly a year before Mackenzie would publish his private feelings about the case in his book, The Fatal Illness of Frederick the Noble. Complaints regarding the suitableness of his fellow physicians was just one aspect of the book. Dr. Mackenzie further made a much more serious charge of malpractice. It was Mackenzie's belief that the incision made by Dr. Bramann when performing the tracheotomy was not centered properly. Combined with his accusation that the trachea tube inserted by Dr. Bramann was too large, Dr. Mackenzie states that the Crown Prince suffered irritation of the trachea and eventual complications in his condition that lead to his death.

Between January and March of 1888 the physicians surrounding the Crown Prince bickered regarding the Bramman tachea tube. The result was that Frederick was constantly being fitted with new trachea tubes and canulae. Seven trachea tubes and canulae of five different designs were used in all. One was designed by Dr. Mackenzie himself and named the San Remo canula after the city it was manufactured in. The results of these tubes were universal discomfort for the Crown Prince, coughing, and bleeding. Dr. Mackenzie noted that because the tracheotomy had been off-center, "a moderate-sized tube would have been likely to have wounded the walls of the trachea under the circumstances, but an enormous tube such as that (first) used by Bramann, would have been sure to have done so."

Two months after the operation, in March, Crown Prince Frederick's father, William I, died. This prompted Frederick to return from San Remo to Berlin. While he felt too ill to be present at the funeral he was crowned Emperor Frederick III of Prussia and Germany soon after. Emperor Frederick III was ill during his entire reign and Morell Mackenzie never left his side. On March 6th the Emperor restored Mackenzie as leading physician in the case, but as Mackenzie himself noted, "[the Emperor] was now a complete invalid."

On March 12th Morell Mackenzie felt that the tracheotomy tube needed, once again, to be replaced. As a matter of courtesy, Mackenzie agreed to allow Professor von Bergmann to replace the tube. Bergmann's attempt, however, was unsuccessful. Bergmann missed the tracheotomy hole and plunged the tube, instead, into the front of the Prince's neck creating what Mackenzie named "a false opening". This injury to the Emperor caused him much pain and quickly became infected. According to Mackenzie the infection drained the last of the Emperor's strength.

On June 15, 1888, Emperor Frederick III died, he had reigned only 99 days. Prior to his death, the 57 year old monarch felt so indebted to the care of Morell Mackenzie that he honored him with the Cross and Star of the Hollenzollern Order. An honor that Frederick's son, Wilhelm II, implied was coerced in his memoirs written in 1926. He wrote, "[it is questionable] whether the Englishman really pronounced his diagnosis in good faith. I am convinced that this was not the case....he was out not only after the money, but also after the English aristocracy."

After Emperor Frederick III's death, the German press denounced Morell Mackenzie and the Empress Victoria for their parts in the management of the Emperor's disease. Empress Victoria was blamed by German press for asking a British physician to attend her husband. Emil Ludwig wrote, "She stands indicted for serious indiscretion. She summoned from her native land an undistinguished physician, simply because she attributed a shortcoming of Nature to the physicians of the land she had adopted." Mackenzie felt the added scrutiny of world press and fellow physicians who criticized Mackenzie's handling of the case. Lady Duff Gordon recalled that "it was impossible to imagine the furor created by the case of the German Crown Prince; nothing else was talked of for months, and Mackenzie's name was on everybody's lips every hour of the day". She had even "known people to stand on chairs in a hotel restaurant to watch Mackenzie at dinner."

As noted earlier, Dr. Mackenzie sought to protect himself by publishing an angry book, The Fatal Illness of Frederick the Noble, which discusses his diagnosis and treatment of the Emperor as well as his feelings toward the German doctors he worked with. The book was received with unfavorable criticism and led to his censure by the Royal College of Surgeons and the British Medical Association. Mackenzie resigned from the Royal College of Physicians. During this period Mackenzie also sued The Times of London for reporting that his treatment of the Emperor was inadequate. The court awarded him substantial damages and costs, but the criticism did not abate. Morell Mackenzie's return to London was also marked by a decline in his practice which, in his absence from England, appears to have been usurped by the physician he left in charge. Morell Mackenzie died four years after Emperor Frederick from influenzal pneumonia.

It has been felt by many that had Emperor Frederick III lived, his son Wilhelm II, aka Kaiser Wilhelm, would not have come to power so young. Wilhelm II led Germany into World War I and many felt that the tragic deaths associated with the Great War could have been averted by the marked diplomacy of Frederick III. It seems unlikely, however, that the Crown Prince Frederick could have survived removal of his larynx had the correct diagnosis been made early enough. Deaths on the operating table or shortly after surgery were common and it is doubtful that Frederick could have averted his death longer than his delayed diagnosis had already afforded him. Irwin Morre wrote in 1926, "Sir Morell Mackenzie's greatness was demonstrated, and may be estimated, in the case of the Crown Prince, by his superior knowledge and experience of contemporary surgery, for whatever can be said for or against his diagnosis and treatment the fact remains that, by his opposition to operation, he saved for the German nation the Crown Prince's life for a considerable time."

Bibliography:

Otolaryngology: An Illustrated History Neil Weir, Butterworths, 1990.

Biographical History of Medicine John H. Talbott, 1970.

"Sir Morell Mackenzie Revisited" Ned I. Chalat Laryngoscope, Vol. 94 no. 10, 1984.

Morell Mackenzie R. Scott Stevenson, William Heinmann Medical Books, Ltd., London, 1946.

The Fatal Illness of Frederick the Noble Morell Mackenzie, Sampson Low, Martson, Searle, and Rivington, Ltd., London, 1888.