■;.^
 
 THE FATAL ILLNESS 
 
 OF 
 
 REDERICK THE NOBLE 
 
 BY 
 
 SIR MORELL MACKENZIE 
 
 Mark now liow a plain tale shall put you down." 
 
 Henry IV., Part /., Act ii., Scow h 
 
 LONDON : 
 vSAMPSON LOW, MARSTON, SEARLE & RIVlNGTOxX, 
 
 LIMITED, 
 
 %\.. guitstaji's ^ouse, 
 
 Fetter Lane, Fleet Street, E.C. 
 
 1888. 
 
 \All rights rescwcd,'\
 
 LONDON : 
 
 PRINTED BY WILLIAM CLOWES AND SONS, LIMITED, 
 
 STAMFORD STREET AND CHARING CROSS.
 
 Spec' 
 
 owflicdica 
 library 
 
 PREFACE. 
 
 It has been a painful task to me to write the following 
 pages, not because there is anything in the charges 
 recently brought against me by some of my German 
 colleagues, which I have the slightest difficulty in 
 meeting, but because I feel most keenly the unseem- 
 liness of a controversy which must necessarily cause 
 additional suffering to hearts which have already 
 been tried beyond the common lot. Although the 
 pamphlet issued from the Imperial Press at Berlin 
 embodies accusations which amount to a charge of 
 malpraxis, I should have been content, so far as I am 
 personally concerned, to leave my professional reputa- 
 tion to the judgment of impartial men. Under the 
 special circumstances of the case, however, I feel it to 
 be a duty which I owe to those exalted persons who 
 honoured me with their fullest confidence through 
 thirteen months of terrible anxiety, to justify the trust 
 which they placed in me. My position, as will easily 
 be understood, was one of the greatest difficulty, 
 owing not only to the overwhelming responsibility of 
 the 'case itself, but to what I may call its external 
 complications. I know of no instance in history in 
 
 812,^06
 
 4 Preface. 
 
 which a physician, who simply tried to do his duty 
 to his patient to the best of his abihty, has had to 
 endure so much calumny and misrepresentation. ] 
 I say nothing of the abuse and even threats which 
 were liberally showered on me, for to these things 
 I was utterly indifferent, and I can, therefore, claim 
 no credit for despising them. But one must be 
 more — or less — than man to bear deliberate and 
 persistent distortion of his words and acts and 
 motives with equanimity. It is true that the accusa- 
 tions were in many instances absurd, and ev^en self- 
 contradictory, but my assailants evidently acted on 
 the cynical maxim attributed to Voltaire, "Throw 
 mud enough and some of it is sure to stick ; " and 
 from the nature of the case there were few, even 
 among professional men, who could form a correct 
 judgment on the facts as presented to them. Two 
 things supported me in what would otherwise have 
 been an intolerable position. First, my own con- 
 sciousness of perfect integrity of purpose ; secondly, 
 the absolute trust and delicate consideration with 
 which from first to last I was trusted by my noble- 
 hearted patient. No physician could wish for a 
 patient more obedient to his injunctions, more 
 full of "sweet reasonableness," than the ruler of 
 the mighty Empire of Germany. 
 
 As there is a good deal of plain speaking in the 
 following pages, and as the conduct of some of my 
 German colleagues is discussed with a freedom which 
 may seem unprofessional to those who have not read
 
 Preface. 
 
 the attack which these gentlemen have made on me, 
 I take this opportunity of saying that I have 
 advanced nothing here with respect to my hostile 
 colleagues which has not been publicly stated already, 
 nor have I made any allegations except in self- 
 defence in reply to charges against myself. I regret 
 extremely that the controversy should have assumed 
 such a tone, but I may remind my readers that I am 
 in no way responsible for it. 
 
 In conclusion I may be allowed to refer to some of 
 the difficulties under which I have laboured in 
 drawing up this vindication of my professional 
 character. I have been unable for obvious reasons to 
 allude to several points, which, though not bearing on 
 the purely medical aspect of the case, were yet most 
 important factors in determining the course which 
 was pursued. I think I have also some grounds of 
 complaint against the Prussian Government, which, 
 whilst allowing my adversaries free access to the 
 State Archives, refused me the same privilege. As I 
 have shown in the body of this little work (p. 207), 
 these " official sources " are of a very miscellaneous 
 character ; but among them there are important docu- 
 ments relating to the case of the late Emperor which, 
 in justice to me, should not have been kept from the 
 public. Amongst others may be mentioned the 
 protocols of Professor von Schrotter, Dr. Krause, and 
 myself, drawn up in November 1887, and more espe- 
 cially the written refusal of the Emperor (then Crown 
 Prince) to submit to any other external operation
 
 6 Preface. 
 
 than tracheotomy. The protocols which it is proved 
 that Professors Gerhardt and von Bergmann sent in 
 to the Haus-Ministerium would also furnish inter- 
 esting reading, and would show what really were 
 the views of these gentlemen before I was summoned 
 to Berlin. The first Report of Professor Virchow 
 would also be highly instructive. I can only hope 
 that these documents and other matters bearing on 
 this historical case will some day be made public. 
 I at least have no reason to fear the full light of 
 day. 4 
 
 M. M. 
 
 19, Harley Street^ IV., 
 Octobtr, 1888.
 
 CONTENTS. 
 
 Preface 
 
 Section L— HISTORICAL. 
 
 Chap. 
 
 I. My First Visit to Berlin and Potsdam 
 
 II. My Second Visit to Potsdam 
 
 III. The Crown Prince in England . 
 
 IV. ToBLACH — Venice— Baveno 
 
 V. San Remo— The Worst Fears Confirmed 
 
 VI. San Remo— Suspense .... 
 
 VII. San Remo — The Tracheotomy . 
 
 VIII. Charlottenburg 
 
 IX. The Emperor's last stay at Potsdam 
 
 X. The Epilogue 
 
 Section IL— CONTROVERSIAL. 
 XI. The Truth about the Proposed Operations 
 XII. The Indictment 
 
 Section IIL— STATISTICAL. 
 XIII. Results of Recorded Operations 
 
 PAGE 
 
 3 
 
 9 
 31 
 
 45 
 60 
 
 65 
 
 78 
 
 86 
 
 124 
 
 169 
 
 179 
 
 iSS 
 206 
 
 229
 
 ILLUSTRATIONS. 
 
 FIGS 
 I. 
 
 2. 
 3. 
 
 4- 
 
 5. 
 6. 
 
 7. 
 8. 
 
 9. 
 10. 
 
 12. 
 
 13- 
 14. 
 
 15. 
 
 16. 
 
 17- 
 18. 
 
 19. 
 
 20. 
 
 21. 
 22. 
 
 Sketch of the growth as first seen .... 
 
 Sketch of growth after first operation 
 
 Sketch of growth after the third operation 
 
 Sketch made June 28th, showing the Larynx after complete 
 removal of the growth ..... 
 
 Sketch showing Mr. Hovell's observations on September 9th 
 
 Sketch made Nov. 6th, showing new growth 
 
 Bramann's Canula ....... 
 
 An ordinary full-sized Canula ..... 
 
 Bramann's Canula (half-size) in situ .... 
 
 Diagram showing Durham's Tube used too late . 
 
 The San Remo Canula shown in position . . . , 
 
 A Surgical Probe bent at right angles near its distal .exlre 
 mity ......... 
 
 The Probe foreshortened ...... 
 
 Diagram showing how the Probe would have appeared on each 
 side, if Dr. Bramann had opened the Trachea in the median 
 line .......... 
 
 Diagram with half the Trachea removed, showing measure- 
 ments inside ........ 
 
 Durham's Tube acting well ...... 
 
 Durham's Tube (full size) twisted to left side 
 
 Diagram showing the part into which von Bergmann plunged 
 the Canula ......... 
 
 Diagram showing von Bergmann's false passage . 
 
 The extremities of von Bergmann's unprotected, and Durham's 
 guarded, Canula ........ 
 
 Diagram showing abscess resulting from the false passage . 
 
 The last Canula used ....... 
 
 PAGE 
 
 13 
 18 
 
 31 
 
 47 
 60 
 
 65 
 93 
 94 
 95 
 106 
 
 115 
 
 116 
 118 
 
 119 
 
 128 
 
 147 
 148 
 
 151 
 155 
 157
 
 THE FATAL ILLNESS 
 
 OF 
 
 FREDERICK THE NOBLE. 
 
 SECTION I.— HISTORICAL. 
 
 CHAPTER I. 
 
 MY FIRST VISIT TO BERLIN AND POTSDAM. 
 
 Reception by the Crown Prince. — On the evening of 
 Wednesday, May i8, 1887, as I was about to retire to 
 rest after a day of hard professional work I received 
 a message requesting me to proceed to Berlin to 
 see His Imperial Highness, the Crown Prince of 
 Germany. No hint was given as to the nature of the 
 case, about which I had only heard vague rumours to 
 which I had paid no particular attention. There was 
 no train that night, but I started the next morning, 
 and reached the German Capital on the afternoon 
 of Friday, May 20th, being met by Dr. Wegner, 
 Physician-in-Ordinary to His Imperial Highness, and 
 Deputy Medical Director-General in the German 
 Army. We drove at once to the Kronprinz Palais, 
 where I found rooms prepared for me. I had 
 scarcely time to change my travelling clothes before 
 the Hof-Marschall, Count Radolinsky, came to con- 
 duct me to the Crown Prince, His Imperial High- 
 ness received me most graciously, apologising with
 
 10 The Fatal Illness of Frederick the Noble. 
 
 the charming bonhomie which endeared him to all 
 who knew him, for all the trouble which his throat 
 was causing to other people, and in particular for the 
 long and fatiguing journey which it had entailed on 
 me. He spoke in English with scarcely a trace of 
 foreign accent, but his voice, though perfectly intelli- 
 gible, was little better than a gruff whisper. His 
 Imperial Highness offered to submit himself to 
 examination there and then, but on my venturing to 
 suggest that it would be better that I should first 
 confer with the doctors already in attendance, he 
 at once acceded to my request. 
 
 Introduction to viy Colleagues. — Thereupon I was 
 taken to another room, \v'here I found the following 
 physicians and surgeons assembled : Professors 
 Gerhardt, von Bergmann and Tobold, Dr. von Lauer, 
 Physician-in-Ordinary to the aged Emperor, and 
 Medical Director-General in the German army, Dr. 
 Wegner, whom I have already mentioned, and Dr. 
 Schrader, another military surgeon, who occasionally 
 acted as Dr. Wegner's deputy in attending the 
 Imperial family. With Professor Gerhardt I was 
 already personally acquainted, and he was known to 
 me professionally as a physician who, in the midst of 
 his labours in other departments of medical science, 
 had found time to give some attention to diseases of 
 the throat. Professor von Bergmann I had heard of 
 in connection with the Servian and Russo-Turkish 
 wars, and I knew that he had been called from 
 St. Petersburg to take the Chair of Surgery at Berlin 
 after it had been declined by Professor Billroth, of 
 Vienna, and Professor Volkmann, of Halle, to whom 
 it had previously been offered. I had never, how- 
 ever, seen him mentioned in laryngological literature, 
 save as a somewhat unfortunate operator in a few 
 cases of extirpation of the larynx. Professor 
 Tobold's name had at one time been familiar to me 
 as that of one of the earliest throat physicians in 
 Germany : but in the development of the speciality
 
 Introduction to my Colleagues. 1 1 
 
 he had dropped almost entirely out of notice, and 
 had ^grown to be little more than a nominis umbra 
 to the present generation of practitioners. I confess 
 that I felt some surprise that among those with whom 
 I was invited to take counsel in a case of such import- 
 ance there was not at least one of the leading German 
 specialists in throat diseases. Every laryngologist 
 could, without any difficulty, name several men in 
 Germany whose reputation is not confined to their own 
 country ; their absence here seemed to me so signifi- 
 cant that I rather hastily concluded that the Crown 
 Prince must be suffering from some obscure disease 
 of which the laiyngeal affection was only an acci- 
 dental complication. 
 
 Tlu first Constiltation. — After I had been intro- 
 duced to my colleagues, the consultation began. 
 Dr. Wegner read a report of the case from the 
 beginning up to the time that Professor Gerhardt was 
 called in. It appeared that the Crown Prince had suf- 
 fered from what was supposed to be catarrhal inflam- 
 mation of the larynx, with great hoarseness, in the 
 previous January, and that he had been treated with 
 the ordinary remedies without result. I may here 
 mention that, as I afterwards learned, the Crown Prince 
 himself always attributed the origin of his illness to a 
 severe cold which he caught in the autumn of 1886. 
 Whilst in the north of Italy, the Crown Princess and 
 he had taken a drive one evening with the King and 
 Queen of Italy. The coachman lost his way ; it 
 became dark and chilly, and the Crown Prince, 
 who had no great-coat with him, felt as if he had 
 taken cold. He told me that his throat had never 
 been quite well since that evening. When Dr. 
 Wegner had concluded his report, Professor Gerhardt 
 described the condition of the Prince's throat 
 wheii he first saw it, and gave a general sketch 
 of the treatment which he had adopted, without 
 entering into details. I merely gathered that there 
 was a small growth on the left vocal cord, which
 
 1 2 TJie Fatal Illness of Frederick tJie Noble. 
 
 Dr. Gerhardt had tried to destroy with the galvano- 
 cautery, and that the Crown Prince had then been 
 sent to Ems, where he had spent some weeks without 
 deriving any benefit. 
 
 My first Examination. -^A.i\.Q.x hearing these state- 
 ments, I proceeded to examine the case for my- 
 self. For this purpose we went into a darkened 
 room, where I made a careful inspection of the 
 Crown Prince's throat with the laryngoscopic mirror. 
 I saw a growth about the size of a split pea at 
 the posterior part of the left vocal cord ; it was of 
 a pale pink colour, slightly rough on the surface, but 
 not lobulated. The little tumour lay over the pro- 
 cessus vocalis, but extended also a little way behind 
 and below that point. In deep inspiration, the sharp 
 receding angle formed by the junction of the mem- 
 branous with the cartilaginous part of the cord was 
 seen to be obliterated, its place being taken by a 
 rounded prominence. On phonation a portion of the 
 growth disappeared from view — a fact which showed 
 that it was partly attached to the under surface as 
 well as the side of the cord ; in other words, the 
 neoplasm was partly subglottic in situation. The 
 mucous membrane covering the vocal cord was red 
 in the neighbourhood of the growth, but at the front 
 part, for about one-fourth of its length, the cord was 
 perfectly natural in appearance. There was no trace 
 of ulceration on the growth, which, to the naked eye, 
 bore the look of a simple wart or papilloma (as seen 
 in Fig. i). The affected cord did not move with the 
 same freedom as its fellow on the right side, the play 
 of its fibres being hindered by the excrescence at- 
 tached to it, which also prevented the two cords from 
 coming together in the way required to produce clear 
 vocal sound. The mucous membrane in other parts 
 of the lar^-nx was slightly congested and relaxed. 
 Except for the loss of his voice, however, the throat 
 gave His Imperial Highness no trouble ; there was no 
 pain, no difficulty of breathing, no hindrance to swal-
 
 My first Examination. 13 
 
 lowing. The Crown Prince was in every other respect a 
 model of stalwart health, far stronger to all appearance 
 than the average even of strong men. He came of a 
 healthy stock, and had not impaired his fine consti- 
 tution by excesses of any kind. He had, however, 
 been subject to occasional attacks of relaxed throat, 
 and he had necessarily led a life of considerable 
 exposure. He had had to use his voice a good deal 
 
 Fi^. I. — Sketch of the p;rowth as first seen. Of course the drawing 
 does not show the lower, or rather under, part of the growth, which 
 was the portion that was specially difficult to seize and take away. 
 
 The following explanations may, perhaps, be useful to those unaccus- 
 tomed to examine the larynx : — 
 
 In speaking of "right" and "left," it must not be forgotten that a 
 laryngoscopic sketch represents the throat of a person placed opposite 
 the observer. In the case of an ordinary famihar view, the relation 
 of the two sides is at once apparent ; besides which, certain features 
 at once make it clear which side of the body is on view ; but, in 
 looking at a laryngoscopic picture, the two sides being actually 
 identical, confusion arises. It should therefore be borne in mind 
 that the right side of the larynx is opposite the left side of the 
 observer, just as the right hand of a person would be opposite the 
 left hand of a person standing in front of him, and the same remarks, 
 of course, apply to the left side of the larynx. To get a proper idea 
 of the laryngoscopic pictures in this book, it should be held hi front 
 of, and rather above, the reader, the upper part of the book being 
 inclined forwards at an angle of 45°. 
 
 both in the open air and indoors. This was the case 
 as it presented itself to me. 
 
 TJie Question of Diagnosis. — When I had made 
 my examination the other doctors and I withdrew in 
 the ordinary way to discuss the matter. Professors 
 Gerhardt and Tobold gave a positive opinion that 
 the disease was cancerous, and Professor von Berg-
 
 14 The Fatal Illness of Frederick the Noble. 
 
 mann, though expressing himself more guardedly, 
 substantially agreed with them.* All three were 
 unanimous in thinking that a cutting operation from 
 the outside would be necessary for the removal of 
 the growth ; the precise nature of the surgical pro- 
 cedure that would be required was never, however, 
 discussed in my presence. In fact our consultations 
 never reached the stage at which that question would 
 have come up for consideration. When it came to 
 my turn to speak, I said that " there was nothing 
 characteristic in the appearance of the growth ; and 
 that it was quite impossible to give a definite opinion 
 as to its nature, without a more searching examina- 
 tion." I pointed out that the opinion expressed by 
 my colleagues had been come to on what seemed to 
 me to be insufficient grounds, and that they had 
 omitted the most essential, and at the same time, 
 the 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. 
 Professor Gerhardt said it would be difficult, if not im- 
 possible to do this on account of the awkward situa- 
 tion of the growth ; and Professor Tobold expressed 
 a similar opinion. Whilst freely admitting that the 
 operation in this case presented exceptional difficulties, 
 I said that I thought it could be done, and that at 
 any rate it should be attempted. I then turned to 
 Professor Gerhardt and said to him, " Will you try ? " 
 He replied " I cannot operate with forceps." I next 
 asked Professor Tobold if he would make the attempt, 
 but he also declined, saying, " I no longer operate." 
 These replies increased the surprise which I already 
 felt at a case of such a nature having been entrusted 
 to the hands of these gentlemen, for a throat-specialist 
 
 * I was afterwards informed by Dr. Wegner that until I 
 arrived Professor von Bergmann had declined to take any 
 responsibility with regard to the diagnosis. He had always 
 snid, " Gerhardt makes the diagnosis, I am only^the operator,"
 
 The Question of Diagnosis, 15 
 
 who cannot use the forceps is like a physician who 
 cannot use the stethoscope, or a carpenter who cannot 
 handle a saw. I then expressed my readiness to 
 attempt the operation, and it was unanimously agreed 
 that, if I succeeded, the fragment removed should 
 be sent to Professor Virchow, who is universally 
 admitted to be the greatest living authority on all 
 matters pertaining to morbid anatomy. Although 
 anxious to keep clear of controversial topics in this 
 place, I must here interrupt my narrative for a 
 moment to call attention to the eminently disin- 
 genuous manner in which this subject is dealt with 
 by Professor Gerhardt. He makes no allusion to the 
 conversation given above, but contents himself with 
 saying, " Mackenzie was entrusted (!) with the removal 
 of portions of the tumour," * as if my colleagues had 
 graciously waived their rights in my favour, or as if I 
 were the handicraftsman to carry out the behests of 
 my scientific superiors. The insinuation thus subtly 
 conveyed has absolutely no foundation in fact. My 
 colleagues had not taken the very first step towards 
 establishing their diagnosis on a scientific basis, nor 
 apparently had they even thought of so doing.f The 
 proposal came from me, and it was only after they 
 had acknowledged their inability to carry it out, that 
 I undertook to make the attempt. I must be excused 
 for dwelling a little on this point, for it was from 
 this circumstance that the jealousy of my German 
 colleagues, which subsequently led to so much 
 unpleasantness, first took origin. 
 
 My First Operation. — Having, as I have already 
 said, no knowledge of the nature of the case before I 
 
 * Die Kraiikheit Kaiser Friedrich des Drittcn, p. 9. 
 
 t It was only on reading the German pamphlet that I 
 learned that Dr. Gerhardt had, as a matter of fact, made 
 several ineffectual attempts to remove a portion of the growth 
 with -snares and sharp spoons. This is admitted in the docu- 
 ment in question (p. 2), but Professor Gerhardt carefully 
 refrained from mentioning it to me £it the time.
 
 1 6 The Fatal Illness of Frederick the Noble. 
 
 arrived in Berlin, I had left home unprovided with 
 . any instruments beyond those required for a simple 
 laryngoscopic examination. After the consultation, 
 therefore, I visited the shop of the principal surgical 
 instrument maker in Berlin ; but, although he had sold 
 many of my own laryngeal forceps, he did not happen 
 to have any in stock. This was a great disappoint- 
 ment to me, for every surgeon knows what a difference 
 there is between operating with an instrument familiar 
 to his hand and one to which he is unaccustomed. 
 I found a forceps, however, of a French pattern with 
 which I determined to make the attempt. Mean- 
 while the Prince and Princess had returned to Pots- 
 dam, and I was left alone in the Kronprinz Palais 
 with leisure to think over the whole situation, and in 
 particular of the operation which I was to perform the 
 next morning. It was trifling enough in itself, and I 
 had done it with success on several hundred patients, 
 but never in a case so fraught with momentous issues. 
 I had an instrument the blades of which were only 
 half the size of mine ; besides, only the front blade 
 moved, whereas I was accustomed to a forceps in 
 which both blades opened. If I failed — and failure 
 was not unlikely — my colleagues, whose jealousy was 
 already alarmed, would be sure to make the most of 
 it, and what was far worse, the illustrious patient 
 would be subjected to a grave operation, which was 
 possibly unnecessary. If, on the other hand, I suc- 
 ceeded, what would Professor Virchow's report be as 
 to the nature of the growth removed } 
 
 It must be borne in mind that the extraction of a 
 growth from the larynx with forceps is an altogether 
 different matter from attempting to burn it away with 
 the cautery. In the former case the operator either 
 succeeds or he fails, and his success or failure is at 
 once evident not only to the bystanders but to the 
 patient. The manipulation is one which requires no 
 ordinary degree of skill, and the operator's movements 
 are guided, not by direct vision, but by an image of
 
 My first Operation. 17 
 
 the parts he is attacking reflected on a little mirror 
 which he has to hold in the throat with one hand 
 whilst he wields the forceps with the other. With the 
 cautery a great moral impression may be produced 
 without any corresponding physical execution, or the 
 burning may be effected in the wrong place without 
 the patient being aware of the fact. I was, therefore, 
 about to attempt an operation of extreme delicacy 
 under circumstances calculated to tax my nerve to 
 the utmost ; and there would be no possibility of 
 concealing or explaining away a failure. 
 
 Early on the following morning (May 21st) all the 
 doctors assembled again in the palace. As the room 
 in which the operation was to take place was rather 
 small. Dr. Wegner suggested that, besides himself, 
 only the two physicians (Gerhardt and Tobold) who 
 could use the laryngoscope, should be present. Co- 
 caine was then applied to the Crown Prince and 
 everything was got ready. Whilst we were waiting 
 till the local anaesthetic had produced its effect, some 
 one knocked at the door. Dr. Wegner left the room 
 and almost immediately returned, bringing Professor 
 von Bergmann with him. He observed that he was 
 not previously aware that the Professor was a laryngo- 
 scopist, but as he now claimed to be so he was 
 admitted into the somewhat crowded room. When 
 the cocaine had taken effect, I introduced the forceps 
 into the larynx, but failed to seize the growth. As a 
 rule I do not introduce the forceps more than once at 
 the same sitting, but in this instance, as I was work- 
 ing at some disadvantage with an unfamiliar instru- 
 ment, I determined to try again. I did so, and this 
 time was more successful. On withdrawing the 
 forceps and opening the blades (which are hollow on 
 the inside like spoons), there was a fragment of 
 growth in one of them, which I showed to those look- 
 ing on. I saw a look of amazement, quickly followed 
 by one of annoyance and disappointment, come over 
 the faces of Professors Gerhardt and Tobold ; Dr. 
 
 C
 
 1 8 TJte Fatal Illness of Frederick the Noble. 
 
 Wegner, on the other hand, seemed delighted, and 
 warmly congratulated me. After the operation, Pro- 
 fessor Gerhardt made a laryngoscopic exarnination, 
 and said he could see that the fragment which I had 
 removed had been taken from the posterior and under 
 part of the growth.* It was at once placed in spirit 
 by Dr. Wegner, and given by him into the hands of 
 Professor Virchow. The appearance of the growth 
 after my operation is shown in Fig. 2. 
 
 Fig. 2. — Sketch of growth after first operation. Sketch made 
 May 22nd. (See Explanations, Fig. i, p. 13.) 
 
 At Potsdam with my Imperial Host. — After the 
 operation the Prince returned to Potsdam, where he 
 graciously invited me to stay with him, adding " You 
 can go into Berlin every day for some hours if you 
 find it dull." In the afternoon I went to Potsdam, 
 where I had the honour of driving out with their 
 Imperial Highnesses and the three Princesses in a 
 wagonette. On the following day I accompanied 
 the Imperial family to Bornstadt, where I was shown 
 the model farm which supplied them with milk, 
 
 * In his recent report Professor Gerhardt gives a different 
 account of the matter. He says {Op. cit.^ p. 9), " I saw a small 
 loss of substance in the mucous membrane on the upper surface 
 of the left vocal cord near the external border of the tumour." 
 Although Dr. Gerhardt has for some reason modified his opinion 
 as to the exact spot from which the fragment was taken, there 
 can be no doubt that wherever it came from it was diseased, not 
 healthy, tissue. This was acknowledged by Gerhardt at the 
 time.
 
 At Potsdam with my Imperial Host. 19 
 
 butter and eggs. Whilst staying at the Neue Palais 
 (now Friedrichskron) I visited the picturesque church 
 and churchyard, both of which gave ample evidence, 
 by their condition, of the interest taken in them 
 by their Imperial Highnesses. I was particularly 
 charmed with the creche, or children's nursery, estab- 
 lished in the village by the Crown Princess ; the 
 children, between twenty and thirty in number and 
 ranging from a few months to five or six years in age, 
 looked healthy and happy, and the whole appearance 
 of the place and its inmates bore eloquent testimony 
 to the fostering care of the Princess. 
 
 The Prince and Dr. Gerhardt. — The Princesses drove 
 home, but I had the privilege of walking back to 
 Potsdam with the Crown Prince, who took the oppor- 
 tunity to speak to me very seriously as to his condition. 
 He told me that a friend (he did not mention whether 
 it was a lady or a gentleman) met him at Ems and 
 said to him, " I was going to call on you, for I am 
 grieved to hear that Gerhardt says you have cancer." 
 His Imperial Highness asked me if I did not think 
 Professor Gerhardt had done wrong in sending him 
 to Ems if he believed him to be suffering from cancer 
 I replied that I had assuredly never heard of the 
 Ems waters doing good in a case of cancer, but I 
 ventured to suggest that possibly the physician had 
 been misrepresented. The Prince then asked me if 
 it was usual for medical men to mention that a 
 patient was suffering from cancer to outsiders, or, as 
 he expressed it, to " other people," " when the patient's 
 own wife" was not told of it. I again took the 
 liberty of pointing out that Professor Gerhardt might 
 be able to give a satisfactory explanation of the 
 matter if it were brought under his notice. His 
 Imperial Highness seemed extremely dissatisfied 
 with Gerhardt, not only for his indiscretion in talking 
 about the case, but for having sent him to Ems 
 though believing him to be suffering from malignant 
 disease. He then changed the subject, and among 
 
 C 2
 
 20 The Fatal Illness of Frederick the Noble. 
 
 other things we talked of the scenery. I expressed 
 great admiration of the landscape at Wildpark, whichj 
 I said reminded me of an English park. The Crown 
 Prince thereupon said that next to Germany he pre- 
 ferred England, and especially Scotland for scenery. 
 He spoke with the keenest delight of the beauties 
 of nature, for which he evidently had a most appre- 
 ciative eye. More than once, however, during our 
 walk, the Crown Prince reverted to the Ems 
 incident, and though naturally reserved about him- 
 self, he could not help showing that Professor 
 Gerhardt's indiscretion, even more than his want of 
 medical judgment, rankled in his mind. In the 
 course of our conversation, I asked the Prince if it 
 was true as commonly reported that he had been a 
 great smoker. He told me that like many other 
 reports it was quite untrue, and that for many years 
 he had hardly smoked at all. He said that when 
 campaigning he had sometimes solaced himself on a 
 fatiguing march, or after a hard-fought battle with a 
 pipe, and he had been seen doing this by a great 
 number of his troops, who probably afterwards talked 
 about it. In this way the Prince said he supposed 
 that his perfectly undeserved reputation as a devotee 
 of tobacco had become established. 
 
 The Crown Prince, though hardly ever out of uni- 
 form in Berlin, was often in plain clothes whilst staying 
 at his palace at Wildpark. I was greatly struck by 
 the genial courtesy of his bearing to the peasants whom 
 he met ; instead of a perfunctory nod or a careless 
 wave of the hand, he returned their salute by taking 
 off his hat, as an ordinary Englishman does in saluting 
 a lady. It was easy to see that the stately Kron- 
 prinz was " Unser Fritz " in the hearts of the lowliest 
 among his future subjects. 
 
 What I had prevejited. — In the course of a walk, in 
 which the Crown Princess was good enough to invite 
 me to accompany her, she informed me that before 
 my arrival it had been determined to perform an
 
 IVhat I had pi'evented. 2 1 
 
 external operation on the Crown Prince. This was 
 fixed to take place at 7 A.M. on Saturday, May 21st. 
 An operating table had been brought from the 
 Charite hospital, and two nurses were already in the 
 palace. Her Imperial Highness said that it had 
 been Bergmann's intention to open the larynx in 
 the middle line in front,* so as to see the extent 
 and connections of the growth with a view to its 
 complete removal if feasible. In fact, as Her Imperial 
 Highness observed, " It was to be an exploratory 
 operation ; but when once begun, it was quite uncer- 
 tain where it would end." These statements are 
 confirmed by Professor von Bergmann himself,t who 
 affirms, moreover, that he had all the risks of the 
 proposed operation and its probable results clearly 
 laid before the Prince. From what he says, how- 
 ever, t it is easy to gather that he gave the Prince a 
 highly optimistic view of his prospects, especially in 
 the matter of voice. I have the best reason for be- 
 lieving that it was not till several months later, when 
 the Crown Prince was at Braemar, that he learned 
 quite accidentally from one of his gentlemen-in- 
 waiting the formidable nature of the operation which 
 had been almost forced on him in May. 
 
 It has often been privately insinuated, if not openly 
 stated, that the illustrious patient was never informed 
 as to the true nature of his disease — that, in fact, 
 he was buoyed up with false hopes. The truth, how- 
 ever, is that Gerhardt's gossip about the case brought 
 a knowledge of its serious nature to the Prince's 
 cognizance at a very early period. Although, for 
 the sake of his family, he manfully assumed a cheer- 
 ful demeanour, the horrible idea that he was the 
 subject of cancer must have frequently occurred 
 to him. 
 
 Virchoiv's First Report. — Professor Virchow's report 
 
 * An operation called by the Germans Laryngofissur^ and in 
 this country, generally, thyrotojuy. 
 t Op. cit. X Ibid.
 
 The Fatal Illness of Frederick tlie Noble, 
 
 
 was of course awaited with the keenest anxiety, for on 
 it depended the course to be pursued. Two days after ^ 
 the removal of the fragment, Dr. Wegner informed 5^ 
 me that the great pathologist had failed to find any 
 evidence of malignancy, but would like to have a 
 further piece for examination. Dr. Wegner after- 
 wards told me, however, that Professor Virchow was 
 perfectly satisfied with the result of his examination, 
 and did not require any more of the growth. Subse- 
 quently a report was received from Professor Virchow 
 in which he pronounced the portion of growth which 
 had been submitted to him to be of benign nature. 
 He stated that the epithelial cells were increased in 
 number and size, and added, that as the section had 
 penetrated through the whole thickness of the growth 
 down to the tissue of the vocal cord (as shown by the 
 presence of longitudinal elastic fibres), there was no 
 reason to suppose that the remainder of the growth 
 was different in structure from the portion which he 
 had examined. This report is unfortunately not 
 published in the German pamphlet, though it is 
 deposited among the " official sources " on which that 
 document professes to be based. I may here mention 
 that I applied to the Haus-I\Iinisterium, through 
 Count Radolinsky, in December, 1887, for copies of 
 the various documents relating to the Crown Prince's 
 illness which had been deposited in the State 
 Archives, but my request was positively refused — for 
 what reason I am at a loss to conjecture. According 
 to Professor Gerhardt, however, who has had access to 
 all the papers, Virchow's examination showed only 
 '' an irritative process ; but there was an isolated nest 
 of concentric epithelial cells (a cell-nest in fact) in the 
 midst of proliferating epithelium." * Virchow declared 
 verbally at the time that the affection might be a 
 pachydermia laryftgis t — a thickened warty condition 
 of the lar}*nx resulting from chronic inflammation. 
 
 ♦ Op. cit, p. 9. t I^id,
 
 Virchow's first Report. 23 
 
 This report conclusively proves that whatever the 
 affection from which the Crown Prince was suffering 
 might be, the tissue which I removed was not healthy- 
 tissue (as has been suggested), but one presenting a 
 warty character. It is simply inconceivable that the 
 first pathologist in the world should mistake healthy 
 for diseased tissue, and it is incredible that such a 
 man should, under any circumstances whatever, have 
 lent himself to any wilful deception. 
 
 My Second Operation. — On May 22nd I found the 
 left ary-epiglottic fold and the left vocal cord, together 
 with the whole of the right one, a good deal con- 
 gested. The voice was slightly hoarse. During the 
 day it became clear, but towards night it was husky. 
 In the evening I observed that though the anterior half 
 of the right vocal cord had become almost normal in 
 colour, the middle third was bright red ; there was 
 also still some slight congestion of the left ary- 
 epiglottic fold. The congestion appeared to me to be 
 of a catarrhal nature, and as the Crown Prince at 
 that time did not take much care of himself, it was 
 supposed that he had caught cold. I should mention 
 that this tendency to the sudden development of 
 localised congestion in the larynx was subsequently 
 noticed by Dr. Wolfenden, Mr. Mark Hovell, and 
 Professor Krause, as well as myself, as a peculiar 
 feature* in the Crown Prince's case. On May 
 23rd, in the presence of Professor Gerhardt and Dr. 
 Wegner, I made a second attempt to remove a piece 
 of the growth from the larynx. Before introducing 
 the forceps I examined the throat, and found the 
 larynx in much the same state as on the previous 
 evening. 
 
 This time I did not succeed in bringing anything 
 away with the forceps. I did not pass the instru- 
 ment far enough down, and the blades closed before 
 
 * There is every reason to believe that this abnormal irrita- 
 bility was due to the extraordinary mode in which Gerhardt had 
 burnt the larynx. {See page 40.)
 
 24 The Fatal Illness of Frederick tJie Noble. 
 
 they were in contact with the growth. 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." There was no resistance, and I was sure 
 before I withdrew the forceps that the blades would 
 come up empty. In view, however, of the congestion 
 to which I have alluded, I thought it well not to run 
 the risk of irritating the larynx by any further 
 manipulation on that day. 
 
 Gerhard fs False Accusation. — An occasional fail- 
 ure of this kind, as every laryngologist of any 
 experience knows, is so common that I attached 
 no importance whatever to the incident, and should 
 certainly not have thought it worth mentioning 
 had it not been for some remarkable events which 
 followed. When I had laid aside the forceps, say- 
 ing I would not again use them at that sitting, 
 Professor Gerhardt asked to be allowed to examine 
 the lar}-nx. He had scarcely put the mirror in posi- 
 tion when he withdrew it with a highly artistic expres 
 sion of horror and alarm. He asked me to look 
 which I did, but without seeing anything more than 
 the congestion of which I have spoken, which was 
 perhaps rather more marked on the right vocal cord. 
 Gerhardt then asked Wegner to look, but that gentle- 
 man did not see anything in particular.* We then 
 retired to my room, when Dr. Gerhardt said that I 
 had wounded the right vocal cord. He was con- 
 siderate enough to add that if symptoms of suffocation 
 should follow this injury, there was a clever surgeon 
 in Potsdam who would be able to perform tracheo- 
 tomy. I assured the Professor that his fears were quite 
 groundless, and showed him that with my f forceps 
 
 * This, though I might claim it as testimony in my favour, 
 I do not attach much importance to, as Dr. Wegner was 
 seldom able to obtain a good view of the interior of the 
 lar)'nx. 
 
 t I had by this time had my own instrument brought over 
 to me.
 
 Gerhardt's false Accusation. 25 
 
 it would be difficult, if not impossible, to wound a 
 healthy cord, even if one tried to do so.* The blades 
 would cut away dinyihrng projecting from the cord, but 
 not a smooth surface like that of a healthy vocal cord. 
 My forceps act very much like the shears used for 
 clipping hedges, supposing them to be blunt-pointed. 
 With such an instrument a man standing sideways at 
 a wall might cut off twigs or weeds projecting from it, 
 but it would be impossible for him to shear off any- 
 thing that did not stick out from the flat surface. As 
 a matter of fact, so incapable is my instrument of 
 seizing anything that does not project, that in the 
 case of very small growths I do not attempt their 
 removal. I never try to remove a growth smaller 
 than a split tare from the vocal cord because my 
 instrument does not act unless there is a certain 
 amount of projection to come between the blades. 
 Had Professor Gerhardt said I had wounded the 
 epiglottis, or one of the capitiila Santorini, which 
 present projections and edges, so placed that they 
 could be seized, the accusation would have been less 
 improbable — that is to say, an exceptionally clumsy 
 person might accomplish the injury attributed to 
 me. A wound of such severity as that described by 
 Professor Gerhardt could hardly have been inflicted 
 without the patient's suffering some inconvenience 
 from it afterwards. After the effect of the cocaine 
 had passed off there would have been smarting at 
 the seat of injury, a very uncomfortable feeling in 
 the throat generally, great irritation in the larynx, 
 leading to coughing, and perhaps even a tendency to 
 spasm of the glottis. Not one of these symptoms 
 
 * Professor Gerhardt states, op. cit., p. 10, that on hi-, men- 
 tioning the matter to me, I expressed myself in the following 
 remarkable terms, " // can bc.^'' I do not pretend to know what 
 these words may mean, but English readers will have no diffi- 
 culty in believing that I never could have used them. The 
 matter is trivial in itself, but affords a useful gauge of my 
 accuser's accuracy in more serious things.
 
 26 The Fatal Illness of Frederick the Noble. 
 
 was present. Above all there would have been the 
 objective symptoms of blood being coughed up. 
 
 The Professor tells us of a large clot of blood 
 sticking out of the wound into the glottis. How was 
 it that none of the fresh blood had been expector- 
 ated ? Perhaps it is as well to remind my readers 
 that I was now operating with my own forceps, and 
 that / did noty because I actually could uot^ wound the 
 right vocal cord. Although, according to Professor 
 Gcrhardt, Dr. Landgraf reported that this supposed 
 wound did not heal until June 29th, the young 
 vStabsarzt was no doubt on the alert for the phantom 
 lesion about which his Chief had given him useful 
 hints {Inforjnatio?ien). * The description of the 
 healing of the imaginary wound gives a touch of local 
 colour, no doubt highly gratifying to the Professor. 
 Dr. Wolfenden reported on June 15th that "the right 
 vocal cord is healthy." Dr. Wolfenden's testimony is 
 all the more valuable, because I had given him no 
 "hints." Indeed, so little thought had I given to this 
 childish complaint of Gerhardt's, that after mentioning 
 it to one or two friends on returning from Potsdam, 
 I had never thought of it again. I had never for a 
 moment dreamt of its being made a serious charge 
 derived from " official sources ! " I have operated 
 many thousands t of times, and many of the leading 
 laryngoscopists of this country and of America have 
 at one time or another seen me operate. Not one 
 of them, I am sure, can say he has ever witnessed 
 any accident of the kind befall me. More than 
 this. When I gave more time to teaching than I 
 
 * These "hints" ceased, it seems, as soon as Landgraf was 
 appointed my " controller," but as they had already been 
 given, there was no occasion for their continuance (see footnote, 
 
 p. 57). 
 
 t I have notes of over 400 cases, and on an average these 
 would be operated on, successfully or otherwise, at least 10 
 times each, so that, at the lowest computation, I must have in- 
 troduced the forceps 4000 times.
 
 Gerhai'dfs false Accusation. 27 
 
 can do now, I used to allow my pupils to operate 
 with my forceps when they had worked with me for a 
 year. Though I have, of course, often seen them fail 
 to get anything away, I have never once heard of any 
 injury being inflicted, even by the rawest hand. I 
 pointed out, moreover, to Professor Gcrhardt that if 
 by some quite exceptional stroke of ill-luck such an 
 out-of-the-way accident had occurred, it was really 
 not a matter of the slightest consequence, as it was 
 well known that wounds of the vocal cords healed in 
 a few days. This is seen after the removal of growths, 
 when in order to extirpate the new - formation 
 thoroughly, it is often necessary to cut into the 
 healthy substance below it. No ill effect of any kind 
 is ever known to follow. 
 
 There can be no difficulty in understanding Pro- 
 fessor Gerhardt's motive in the affair. My success on 
 the first occasion had mortified him, and he was glad 
 of an opportunity to find fault. Operations on small 
 sessile growths, such as I had to deal with in the 
 present case, are often unsuccessful, and I should not 
 have been surprised if I had had to make a dozen 
 attempts before succeeding. As a matter of fact 
 my operations on the Crown Prince were quite ex- 
 ceptionally successful, for in four attempts there 
 was only one failure. This proportion of successes 
 is quite outside the ordinary experience of the 
 deftest operators, and I cannot help feeling that 
 good luck played as important a part as skill on 
 these occasions. But whether I had failed or suc- 
 ceeded, it was hardly professional on the part of a 
 colleague to endeavour to damage me in the eyes of 
 my patient by a carefully prepared coup de theatre 
 such as I have described. Even if I had inflicted the 
 injury imputed to me, I say the conduct of Professor 
 Gerhardt on that occasion would have been unfair 
 both to the patient and to me. Half an hour after 
 Dr. Gerhardt had left, the Crown Prince sent for me, 
 and said, " Did any accident occur during your opera-
 
 28 The Fatal Illness of Frederick the Noble. 
 
 tion, as Professor Gerhardt looked so very much 
 alarmed ? " The Prince added, " My throat feels 
 quite comfortable." I replied that I thought Pro- 
 fessor Gerhardt was under some misapprehension, 
 and that in any case the matter was of no conse- 
 quence. His Imperial Highness said nothing more, 
 and I clearly saw that the plot had failed so far as 
 the patient was concerned. 
 
 Gerhardt keeps up the Farce. — T^^•o days later we 
 had another general consultation at Berlin, and here 
 again Professor Gerhardt's dramatic talent displayed 
 itself Lowering his voice to a tragic whisper, he 
 asked me whether he might be permitted to com- 
 municate " a certain event " to the assembled doctors, 
 adding significantly, " We are among colleagues, and 
 with closed doors." Guessing that his mysterious 
 allusion had reference to my supposed accident, I 
 begged him to be under no restraint, and he then 
 proceeded to explain, in an artless, pitying sort of 
 way, that I had injured the right cord. Professor 
 von Bergmann was then invited to use the lar}^ngeal 
 mirror, and Professor Tobold followed. They both said 
 that they believed the right vocal cord was injured. 
 As Professor von Bergmann had not posed as 
 a laryngoscopist until I arrived in Berlin, and as 
 Tobold showed an obsequious willingness to re-echo 
 every remark made by Gerhardt, I did not attach any 
 importance to their statements. I now made a very 
 careful examination in order to be quite sure as to 
 how the case stood, but could see absolutely nothing 
 beyond the congestion previously described. Pro- 
 fessor Gerhardt looked again, and said he could see 
 a vegetation already sprouting from the wounded 
 spot, adding, with an amiable intention for which 
 I was duly grateful, " It will be interesting to 
 observe whether the new growth (!) will prove to 
 be malignant." I ventured to point out that the 
 development of cancer in a wound supposed to 
 have been made only two days before would in-
 
 Gerhardt keeps tip the Farce. 29 
 
 deed be an event of the greatest interest, as 
 such an occurrence would revolutionize everything 
 that was thought to be known in pathology. Dr. 
 Wegner hereupon interfered with the remark that the 
 discussion was assuming an academic character, and 
 suggesting that we should turn our attention to 
 matters of more practical importance. Before leaving 
 the subject I may remark that, if there had really been 
 any injury, Bergmann and Gerhardt would certainly 
 have insisted on another laryngoscopist being called 
 to bear witness to the mischief ; but they, no doubt, 
 had reasons for not taking this course. I was asked 
 what mode of treatment I proposed to adopt in case I 
 should be unable to remove the growth with forceps. 
 I replied that I should then endeavour to destroy the 
 growth by applying electric cautery from time to 
 time. On the 25th another consultation was held, 
 and it was decided that I should endeavour to 
 remove the growth through the mouth, every portion 
 of tissue thus taken away being immediately sent to 
 Professor Virchow. It had previously been agreed 
 that in the meantime an astringent and sedative 
 powder should be applied by Dr. Wegner, in order 
 to get rid of the congestion and relaxation of the 
 larynx. These conditions, however, proving rather 
 obstinate, I did not consider it advisable to make any 
 further attempt at that time. I accordingly started 
 for England on May 29th. 
 
 Statement of my Position. — Before concluding this 
 chapter, I think it well to define, with the utmost 
 possible clearness, the exact position which I took up 
 with reference to this most difficult case. This is the 
 more necessary inasmuch as my attitude has been 
 misunderstood and misrepresented to an extent 
 almost without precedent in medical practice. I 
 repeat that I gave no opinion one way or the other 
 as to the nature of the disease. I did not say that 
 it was not cancer ; I only said that that opinion was 
 *' not proven ; " and in the absence of positive proof
 
 so The Fatal Illness of Frederick the Noble. 
 
 I refused to sanction surgical procedures which at 
 present are at the best more or less of the nature of 
 experiments, which are always dangerous to life, 
 nearly always destructive to the voice, and which, 
 even when " successful," too often leave the patient 
 unfit for the business of life, or even sometimes in a 
 condition worse than death itself Till the nature of 
 the case should be clearly proved, it seemed to me to 
 be my duty, not merely as a physician, but as a man, 
 to oppose the application of a remedy which the 
 patient might justly think worse than the disease.
 
 My Third Operation, 3 1 
 
 CHAPTER 11. 
 
 MY SECOND VISIT TO POTSDAM. 
 
 My Third Operation. — On June 7th I again arrived 
 at Potsdam, in obedience to a summons from the 
 Crown Prince. On the following morning I ex- 
 amined his throat in the presence of Dr. Wegner, 
 when I found that the congestion formerly present 
 had entirely disappeared. I had not proposed to 
 operate till arrangements could be made for some of 
 my colleagues to be present, but finding the occasion 
 particularly favourable, I did not care to let it slip. I 
 accordingly had my forceps brought to me from my 
 
 Fig. 3. — Sketch of growth after the third operation. (For 
 explanations, see Fig. I, p. 13.) 
 
 room at the top of the palace, and after applying 
 cocaine, succeeded in getting away more than half of 
 the growth. The tissue removed was at once con- 
 veyed by Dr. Wegner to Professor Virchow, and after 
 waiting a day or two for his report, a grand consulta- 
 tion was held, in which all the gentlemen who were 
 present on the previous occasions took part. The 
 following report was read : —
 
 32 The Fatal Illness of Frederick tJie Noble. 
 
 Professor Virchow's Report on the portion 
 
 OF GROWTH removed FROM THE LARYNX OF 
 
 H.I.H. THE Crown Prince of Germany, on 
 June 8th, by Dr. Morell Mackenzie. 
 
 " The two specimens delivered yesterday by 
 Director - General Dr. Wegner, exhibit, on 
 microscopic examination, the appearance of a 
 coarsely granular papillated tumour. Their 
 convex surface had a granular, bluish-white, 
 slightly transparent glistening aspect, in so 
 far as they retained their natural conditions : 
 large portions, indeed, which had been acted 
 upon by catechu showed a dull, brownish, 
 somewhat crumbling character. The cut 
 surfaces were somewhat retracted, and con- 
 cealed by the turning up of the margins : 
 they consisted of a soft, slightly fibrillated 
 tissue, from which projected some shreds of 
 various lengths. The larger of the two por- 
 tions was 3 millimetres in height and had a 
 diameter of 2*5 millimetres ; the smaller was 
 about 2 millimetres in diameter. However, 
 these measurements could not have quite cor- 
 responded to the conditions during life, for by 
 the retraction and infolding of the cut surfaces 
 after extirpation, they must have undergone a 
 diminution. Microscopical examination con- 
 firmed the diagnosis made by the naked eye 
 inspection : — i. The surface everywhere con- 
 sisted of a very firm and thick layer of stratified 
 squamous epithelium. Large colloid granules 
 appeared in many of the cells. Here and there 
 lay a nest of concentrically laminated cells. 
 Internally there occurred a similar stratified 
 layer of cylindrical cells (without cilia), which 
 were seated directly on the connective 
 tissue. 2. The connective tissue layer of the
 
 Professor Vir chow's Report. 33 
 
 mucous membrane was furnished on its surface 
 with long papillary outgrowths, which con- 
 tained large vascular loops besides the connec- 
 tive tissue elements. Each such papilla corre- 
 sponded to a granulation on the surface. 
 Otherwise the mucous membrane showed 
 scarcely any changes ; even proliferation of 
 nuclei and cells was only sparsely detected. 
 The blood-vessels were moderately dilated. 
 Both sections have been made deeply into the 
 mucous membrane and through this into the 
 submucosa. Hence there are found, besides 
 connective tissue with numerous fine elastic 
 fibres, a large number of small nerve trunks 
 (from four to six fibres) and their branches, as 
 well as small arteries and veins ; in some places 
 are seen also collections of lobules of the 
 mucous glands. Although it is thereby proved 
 that the operation had reached the deep parts * 
 underlying the mucous membrane, yet in spite 
 of the most careful examination of these deeper 
 parts, especially at the cut surfaces, no single 
 portion could be found altered in an appreci- 
 able degree. All such changes were confined 
 to the surface. They characterise the lesion 
 as an epithelial growth, combined with papil- 
 lary offshoots (misnamed papilloma), pachy- 
 dermia verrucosa. In no part cotdd an ingrowth 
 of this epithelial formatioji into the mucous 
 membrarie be detected* 
 
 The foregoing statement is an important 
 advance upon the statement of the 21st May. 
 In the specimen then examined changes re- 
 sembling those now present were only very 
 scanty in comparison with irritative changes ; 
 but all such appearances were limited to the 
 periphery of the lesion. Now, on the other 
 
 * None of the italics arc in the original. 
 
 D
 
 34 TJie Fatal Illness of Frederick tJie Noble. 
 
 hand, a vi07'e central portio7i of the growth has 
 apparently been obtained. Although this portion 
 is very mnch diseased* yet the healthy condition 
 of the tissue on the cut surface allows a very 
 favourable opinion to be formed as to prog- 
 nosis.* 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 woicld be likely to excite 
 tJie suspicion of wider and graver diseased \ 
 
 (Signed) Prof. Dr. RUD. ViRCHOW. 
 
 " Berlin Pathological Institute^ 
 Jiine^th, 1887." 
 
 It must be borne in mind that Virchow, know 
 ing that his report would come under the eyes 
 of the patient, was naturally anxious to make it as 
 favourable as he could consistently with truth. It 
 will be observed, moreover, that he was careful to 
 limit his remarks to the portions of tissue actually 
 examined by him. Nevertheless, when discounted 
 to the fullest extent, the report could not fail to b( 
 highly encouraging. The fragment had been takei 
 more from the centre of the growth than the one first 
 removed, and the section had been made quite througl 
 the diseased structure into the healthy parts beneatl 
 it ; it might therefore fairly be accepted as a repre 
 sentative specimen of the whole. The essentia 
 anatomical feature of cancer, viz., the penetration 
 the epithelium into the underlying structures was con 
 
 * None of the italics are in the original. 
 
 t Before leaving Berlin, I suggested to their Imperial High 
 nesses that n order to allay the great anxiety naturally felt b] 
 the pubhc it would be desirable to allow Professor Virchow'*^ 
 report to be published. The Crown Prince accordingly gave 
 orders that it should be communicated to the Berlin medical 
 journals. The translation given above is that which was pub- 
 lished in the Laucel of ]\ine 25th, 1887 (p- 1302), of the German 
 text which appeared in the Berliner Klinische Wochenschrift,
 
 Professor Virchow's Report. 35 
 
 spicuous by its absence. Cancer has been not inaptly 
 defined as an ingrowing wart. However thickened or 
 otherwise diseased the superficial covering may be — 
 however much it may grow outivards — so long as it 
 does not force its way into the deeper parts, there is 
 no cancer. It is true that the evidence here was 
 merely negative, and did not positively disprove 
 the existence of malignancy, but it made it very 
 improbable. As if to emphasise this Professor 
 Virchow went a little beyond his strict province 
 (which was simply to record what he saw), and said 
 that there was nothing in the portion of growth which 
 had been submitted to him that gave grounds for 
 suspicion as to the nature of the remaining part. 
 
 The Case is handed over to Me, — After the reading of 
 Virchow's report, a consultation took place among us, 
 the result of which was that, with the unanimous 
 consent of those present, the case was handed over to 
 me for treatment in the manner I had proposed. 
 My plan, as I have already stated, was to attempt 
 to extirpate or destroy the growth by what is known 
 as the endolaryngeal method ; that is to say, by instru- 
 ments passed into the larynx through the mouth. If 
 after a fair trial this line of treatment was not found 
 to answer, it would have to be considered whether an 
 external operation should be performed, and if so 
 what kind of operation should be done. On May 25th 
 it had been agreed that all portions of growth removed 
 should be submitted to Professor Virchow, and that, 
 in the event of my treatment not proving successful, 
 further deliberations should take place with the 
 view of considering subsequent procedures. The exact 
 agreement arrived at in the consultations of May 25th, 
 and confirmed on June loth, between the German 
 doctors and myself, has been absurdly misrepresented. 
 All that I " agreed to " — I may even go further and 
 say " advocated " — was first, that all portions of 
 growth which I might remove should be sent to 
 Professor Virchow for his report, and secondly, that 
 
 D 2
 
 36 The Fatal tlbiess of Frederick tile Noble. 
 
 in the event of my failing, other measures should be 
 concerted. It was subsequently pretended, though 
 this has not been embodied in the German pamphlet 
 that I had promised to send reports to my colleagues 
 from time to time, and von Bergmann goes so far as 
 to say * that I agreed, if the tumour increased in size, 
 to allow thyrotomy {Laryngofissiir) to be performed. 
 As the exact nature of any proposed future operation 
 was never discussed, it will be seen that there cannot 
 be any grounds for von Bergmann's contention. 
 That there is great confusion in the minds of my 
 German colleagues, as to the arrangements made 
 between us, is shown by the fact that Gerhardt states 
 that the conditions under which I was to take charge 
 of the case were agreed to on the ist of Junef at a 
 consultation held at the residence of Dr. Wegner, at 
 a time when I was not present in Berlin. The con- 
 ditions agreed to were rigidly adhered to by me. 
 The final portion of growth which I removed was 
 submitted to Virchow, and when, in November, my 
 treatment proved unavailing, I invited two eminent 
 laryngoscopists to meet me in consultation to decide 
 what further steps should be taken. 
 
 Under the circumstances no other decision could 
 possibly have been come to than that which was come 
 to on May 25th. In the face of such a report as had 
 been received from the man whose supreme authority 
 on such matters is recognised by the whole medical 
 world, no doctor would have thought for a moment of 
 submitting to a serious operation if the case had been 
 his own. I can certainly answer for myself that, if 
 I had been the patient, I should have had serious 
 doubts as to the sanity of a surgeon who proposed 
 such a thing. 
 
 My Colleagues share my Responsibility. — From what 
 has been stated it will be seen that it is quite untrue 
 that I took the case out of the hands of the German 
 
 * Op. cit.y p. 28. t Ibid., p. 15.
 
 My Colleagues share my Responsibility. 37 
 
 doctors. They had called me in, and I had given my 
 opinion, to which, outwardly at least, they had sub- 
 scribed. They distinctly sanctioned the course of 
 treatment which I had laid before them, and, if I may 
 so express it, I received a mandate from them to 
 carry it out. Had the case turned out well these 
 gentlemen would no doubt have been ready enough 
 to claim their share of the triumph on the ground 
 that they had " entrusted " me with the operation. 
 It is absurd, therefore, to thrust on me the whole 
 responsibility for a decision to which they were all 
 consenting parties, simply because the event belied 
 the hopes that were not unreasonably entertained. 
 If, in spite of Professor Virchow's report, Bergmann 
 and Gerhardt were convinced at that period that the 
 disease was cancer, and at the same time had no 
 confidence in me, either as an observer or an operator, 
 the only Jionottrable course tozvards the patient for these 
 praciitio7iers to have pursued was to have openly 
 withdrawn from me, and to have issued a separate 
 report. Instead of this they endorsed the resolution 
 which was come to with regard to the conduct of the 
 case, /;/ foro externo at least, and thereby contracted 
 a solidarity of responsibility with me. The only 
 possible explanation of their conduct, supposing them 
 to be honourable men, is that they did not feel at all 
 sure about the diagnosis. Further on (p. 202) it will 
 be shown that at the end of September or beginning 
 of October, von Bergmann actually admitted that 
 I had been right in the course I had recommended 
 in the early summer. In showing that the German 
 doctors are equally answerable with me, I am not 
 trying to remove any part of the responsibility from 
 my own shoulders ; I only wish to show the shifty 
 character of the men with whom I had to deal. 
 
 The Crown Prince resolves to come to England. — 
 Another point on which there has been much mis- 
 representation is the choice of London as the place 
 where the treatment should be carried out. When it
 
 38 The Fatal Ilhiess of Frederick tJie Noble. 
 
 was settled that I should try to get rid of the disease 
 by operating through the natural passages, I was 
 asked if I could stay at Potsdam for the purpose, and 
 I pointed out that there were many objections to this. 
 The Crown Prince was extremely anxious to be 
 present at the Queen's Jubilee, and I need hardly say 
 that it was more convenient for me to treat him in 
 London, where I had all the necessary appliances 
 ready to my hand, than in the somewhat haphazard 
 way I had been doing in the Palace. His Imperial 
 Highness's visit to England had been arranged several 
 months before, and, therefore, the suggestion that the 
 treatment should be carried out in London, harmonized 
 with his own plans. I agreed, however, to go to 
 Potsdam if circumstances should (as was not impro- 
 bable) arise which would make it difficult for him to 
 leave Germany. 
 
 More GerJiardtian Amenities, — I have already men- 
 tioned my experience of Professor Gerhardt as a 
 " candid friend " ; I had now to learn his powers as an 
 unscrupulous foe. Before I left Potsdam, the Crown 
 Princess told me that Professor Gerhardt had said to 
 her, that even if I did succeed in cutting away the 
 growth with forceps, the healing or cicatrisation of 
 the wound would so interfere with the working of the 
 vocal cord that, as far as the voice was concerned, the 
 last state of the illustrious patient would be worse 
 than the first. The Professor also gave her to under- 
 stand that the right vocal cord was in a festering 
 condition owing to the injury I had caused ! I assured 
 the Princess that • these alarming statements were 
 absolutely unfounded. With regard to the cicatrix, 
 I said I had cured hundreds of cases without 
 any such ill consequence as Professor Gerhardt 
 professed to fear in the present instance. As for the 
 alleged " suppuration " of the right cord, I was obliged 
 to confess that I had no idea what was meant. After 
 this illustration of Professor Gerhardt's peculiar notions 
 of professional ethics, I was compelled to inform the
 
 Gerhardt appoints a " Controller^ 39 
 
 Crown Princess that I must in future, decline to meet 
 him again in consultation, though I had no wish to in- 
 terfere with his examining the Crown Prince's throat 
 as often as His Imperial Highness might desire. 
 
 Gerhardt appoints a " Controller!' — What finally 
 opened my eyes to the kind of treatment I had to 
 look for from my German colleagues was the under- 
 hand way in which, on pretence of providing the 
 Crown Prince with surgical help in case of emergency, 
 I was to be watched, or as Gerhardt now says, " con- 
 trolled." * The Professor had hoped to accompany 
 His Imperial Highness to England ; but as there 
 seemed to be no necessity for this under the circum- 
 stances, it was arranged that Dr. Wegner should look 
 after the illustrious patient's general health whilst I 
 conducted the special treatment. Had it been openly 
 intimated to me that it would be more satisfactory to 
 the German Court, if the Crown Prince were also 
 accompanied by a competent German laryngoscopist 
 to report from time to time on the progress of the 
 case, I should not have raised any objection. Instead 
 of this, I was informed by Dr. Wegner, that by desire 
 of the Emperor William, a young army surgeon 
 {Stabsarzt) would go to England as his (Dr. Wegner's) 
 assistant. His words were: ''My eyes are not so 
 good as they were, and it would be convenient to have 
 a young surgeon with me in case tracheotomy should 
 become necessary." It was only by accident that I 
 discovered that Dr. Landgraf — the Stabsarzt in ques- 
 tion — was one of Professor Gerhardt's assistants. This 
 fact I learned from a well-known throat-specialist in 
 Berlin, on whom I happened to call before leaving 
 Berlin. This gentleman, moreover, told me that Dr. 
 Landgraf was anything but a skilful laryngoscopist, 
 and had, only a few weeks before, been unable to dis- 
 tinguish the true from the false vocal cords. I after- 
 wards had ample opportunities of seeing for myself 
 
 * Op. cit., p. 15.
 
 40 The Fatal Illness of Frederick the Noble. 
 
 how thoroughly the young Stabsarzt deserved hij 
 reputation in this particular. I shall deal with Dr, 
 Landgrafs so-called " observ^ations " further on. 
 
 The Artificial Prodiictio7i of Cancer. — I must hen 
 make a few remarks on a subject which I should hav( 
 been glad to avoid, viz., the influence of Professoi 
 Gerhardt's treatment on the nature of the malady 
 from which the illustrious patient suffered. The fact 
 however, that Professor Gerhardt has himself raise( 
 the question in his recent publication as to how fai 
 his own treatment was responsible for the unfavour 
 able course of the illness, makes it impossible for me 
 to pass over this subject. 
 
 Before returning to England I learned, on unim- 
 peachable authority, certain facts as to Professoi 
 Gerhardt's previous treatment of the case, which 
 made me feel more anxious about the future than 
 I had up till then seen any reason to be. I havi 
 already said that the Professor himself had touched on 
 the matter very lightly in my presence, and when he 
 mentioned in general terms that he had used the 
 galvano-cautery, I naturally understood him to mean 
 that he had employed this powerful agent according 
 to the recognized rules of surgical practice. When, 
 therefore, I was informed that he had applied the red- 
 hot point to the interior of the larynx every day foi 
 nearly a fortnight I could hardly bring myself to 
 believe it. In all my experience I had never heard of 
 any one applying the cautery to a patient's laryn: 
 oftener than once, or at most twice a week, and I hardly 
 know which to be most astonished at in the present 
 instance, the therapeutic energy of the physician oi 
 the endurance of the patient. Lest any of my readers 
 should suppose that I had been misinformed, or at 
 any rate that the statement just made was exag- 
 gerated, I may say that it is now confirmed by Pro- 
 fessor Gerhardt himself in his recent deliverance.* 
 
 * Die Krankheit Kaiser Friedrich des Dritten^ p. 3.
 
 The Artificial Production of Cancer. 41 
 
 Now no special knowledge is required to under- 
 stand that a delicate organ like the larynx cannot be 
 briitalise in this manner with impunity. The fact 
 that the Crown Prince had been subjected to such 
 barbarous usage at once explained the proneness of 
 the parts to become congested without any apparent 
 causCj which had previously rather puzzled mc. 
 ^very one knows that local inflammation follows an 
 accidental burn, and there is no special sanctity about 
 a similar injury inflicted by a surgeon which prevents 
 its being followed by the natural consequences. It is 
 for this very reason, that a sufficient interval should 
 always be allowed to elapse between the applications 
 of the galvano-cautery. No point in pathology is 
 better established than the connection between local 
 irritation, or chronic structural changes induced 
 thereby, and the development of cancer. Whether 
 this terrible disease be constitutional or not in its 
 origin, there can be no question that the determining 
 cause of its appearance is in very many cases an 
 injury (as a blow), or a condition resulting from an 
 injury (as a scar), or the persistent application to a 
 particular spot of something that keeps the tissue 
 inflamed and " angry " (such as a jagged tooth which 
 chafes the tongue). Workers in paraffin and petroleum 
 are peculiarly liable to cancer of the parts which are 
 habitually exposed to the action of these substances. 
 It is well known that a particular form of cancer, 
 which formerly was common enough in England, is 
 now almost extinct,* simply because, owing to the fact 
 that the cause which produced it has ceased to exist. 
 When soot commanded a good price, it had to be 
 sifted ; this operation necessarily involved a great 
 deal of friction against the skin, whereby irritating 
 particles were, as it were, rubbed into it, and 
 " chimney sweep's cancer " was a frequent result. 
 
 * Erichsen : Sciejice and Art of Surgery^ 9th edition, 
 London, 1888, vol. i., p. 1048.
 
 42 The Fatal Illness of Frederick the Noble. 
 
 Nowadays it does not pay to sift the soot, and th( 
 disease to which it gave rise has disappeared. 
 
 Among causes of local irritation, heat is certainly 
 one of the most active. By far the most common 
 seat of malignant disease in men is the mouth, which 
 is more exposed than any other part of the body 
 to irritation by hot substances. Every surgeon is 
 familiar with this fact. Whether it be a lower lip on 
 which the hot stem of a clay pipe or the smouldering 
 paper of a cigarette has rested day after day ; or 
 tongue exasperated by the frequent contact of acrid 
 tobacco-smoke or the mouthpiece of a foul pipe, or 
 made raw by ardent liquors, or stung and blistered 
 by fiery condiments, the cause is essentially the same, 
 viz., the searing or irritation of the superficial covering 
 by prolonged heat or pungent impressions. In 
 Cashmir, where hot brasiers are often applied to the 
 abdomen and thigh, cancer of these parts is not 
 uncommon,* though all but unknown in either of 
 these situations elsewhere. 
 
 It is highly probable that in addition to the local 
 irritation some particular predisposition must exist iii 
 the patient, though in what this consists we do not 
 know. That in a large number of cases the tendency 
 to cancer is hereditary there can be no question ; an( 
 the truth of this would, I am convinced, be much 
 more evident than it now is if the medical histories ol 
 families, as well as of individuals, were carefuU) 
 inquired into and accurately recorded. Most mei 
 know what their father and mother died of; a large 
 number are acquainted with the cause of the deatl 
 of their grandfathers and grandmothers, but how few 
 have any accurate knowledge as to the nature of th( 
 disease which carried off their great-uncles and great- 
 aunts. This important and interesting subject cannol 
 be pursued here, but it may be remarked that w( 
 
 * Sir James Paget : " Morton Lecture on Cancer am 
 Cancerous Diseases," British Medical Journal^ Nov. 19, 1887 
 p. 1093.
 
 The Artificial Production of Cancer, 43 
 
 know quite enough of the subject to enable us to say- 
 that where there is a history of cancer in a man's 
 family, it would be well for him to avoid all causes of 
 local irritation with especial care. Such a history 
 existed in the case of the Crown Prince on the 
 maternal side, for his mother's sister died of cancer, 
 and his cousin, Prince Frederick Charles, had a 
 malignant tumour removed from his face a year 
 before his death, which did not recur but might very 
 likely have done so had he lived longer. 
 
 Now Professor Gerhardt himself tells us that at a 
 very early period of his connection with the case he sus- 
 pected that the affection was malignant. This makes 
 the manner in which he proceeded to deal with it 
 simply incomprehensible, except on the supposition 
 that his very anxiety made him reckless. It is 
 certain that if the growth was not malignant from the 
 first, Gerhardt, by his unmerciful use of the galvano- 
 cautery, went the surest way to work to make it 
 so. I do not say that he actually caused the cancer ; 
 no one has the right to dogmatise in medicine, which 
 is still an inexact science in which nearly every fact 
 is open to more than one interpretation. I do not 
 hesitate, however, to say that the treatment adopted 
 by Professor Gerhardt was at once unscientific and 
 injudicious. He cannot escape from this dilemma : 
 Either his treatmeiit was too thorough, or it was not 
 thorough enough.Y^If he believed the growth to be 
 benign, the repeated* burning to which he subjected it 
 was barbarous ; if, as he says, he was doubtful as to 
 its nature, that very doubt should have stayed his 
 hand, and have led him to invoke surgical aid much 
 sooner than he did. On twelve consecutive days, 
 according to his own admission, did this physician 
 burn the Crown Prince's larynx with a red-hot wire, 
 and again on four subsequent occasions at short 
 intervals. Finally, as if all this were not enough, he 
 thought it necessary to sear the edge of the vocal 
 cord with a flat burner ! There is no record in
 
 44 TJie Fatal Illness of Frederick the Noble. 
 
 medical literature, so far as I am aware, in which the 
 cautery, a most valuable agent if properly handled, 
 was so terribly misused. 
 
 Some statistics have lately been collected which 
 clearly prove * how rarely a benign growth becomes 
 malignant, either spontaneously or when the ordinary 
 recognized methods of treatment are pursued. What 
 different statistical results would be forthcoming, if 
 the method of treatment pursued by Gerhardt were 
 widely practised ! Whether his ruthless cauterisa- 
 tion actually caused the development of the cancer 
 or not, there can be little doubt that he is largely 
 responsible for the perichondritis which played so 
 important a part in this sad case. Although the 
 inflammation of the cartilage did not show itself till 
 some time afterwards, it is well known that the course 
 of this affection is very slow, and at first extremely 
 insidious. The processus vocalis^ which was the first 
 scat of the perichondritis in this case, is a point where 
 the mucous membrane itself forms almost the sole 
 covering of the cartilage. Hence the spot which was 
 the object of Gerhardt's misdirected energy is one 
 that is peculiarly vulnerable. 
 
 To Slim tip : If the groivth was benign in the first 
 instance^ titer e is, in my opinion, only too mucJi reason 
 to think that Gerhardt s burnings must be held answer- 
 able for its subsequent transformation into cancer ; if 
 it was malignant from the first, the disease was un- 
 doubtedly aggravated by the treatment. 
 
 * Centralblattfur LaryngoIoiie,&>c.,]\i\\. 1888.
 
 The Crozvu Prince in the Jnbilee Procession. 45 
 
 CHAPTER III. 
 
 THE CROWN PRINCE IN ENGLAND. 
 
 The Crowfi Prince in the Jubilee Procession. — On 
 June 14th their Imperial Highnesses arrived in 
 England. With the view of sparing the illustrious 
 patient the fatigue of talking more than was prudent 
 in his condition, it had been arranged that he should 
 stay at some quiet place outside London, and take 
 no part in the Court festivities beyond appearing on 
 a few of the more important ceremonial occasions. 
 Accordingly he took up his residence at Upper 
 Norwood. I need not recall the impression made 
 by his splendid appearance as he rode through the 
 streets of London on June 21st in the Queen's 
 body-guard of Princes ; he was the most striking 
 figure in that historic pageant, and was hailed by the 
 enthusiastic crowd as a King of men by gift of nature 
 as well as by right of birth. Few could have thought, 
 on seeing him then, in the very prime of his magnifi- 
 cent manhood, that behind the hero of Koniggratz, 
 Worth and Sedan, there rode on that day of triumph 
 a grimmer conqueror, who, before another year had 
 passed, would have laid that stately form in the dust. 
 
 On the day of His Imperial Highness's arrival at 
 Norwood I made a careful examination of his throat, 
 and found that only a small portion of the growth, 
 not more than one-third of its original bulk, now 
 remained. The little tumour itself was red, but the 
 mucous membrane immediately surrounding its base 
 was almost natural in colour ; there were, however, 
 scattered patches of hypersemia in different parts of 
 the larynx. This slightly unhealthy condition of the
 
 i 
 
 46 T/ie Fatal Illness of Frederick the Noble, 
 
 lining membrane of the larynx, which, as I have 
 already pointed out, was probably the result of the 
 severe burnings by Gerhardt, caused the Prince to 
 catch cold on the slightest exposure. 
 
 Dr. Norris Wolfenden. — Before the Crown Prince's 
 arrival, I had informed Count Radolinsky that when 
 His Imperial Highness came under my care, all local 
 treatment would have to be carried out either by 
 myself or by some competent specialist thoroughly 
 acquainted with my methods. To this the illustrious 
 patient at once consented, but considerable opposition 
 was raised by Dr. Wegner, who said that Dr. Landgraf 
 had accompanied His Imperial Highness for that 
 very purpose. I reminded Dr. Wegner that he him- 
 self had told me that Landgraf was sent expressly 
 that he might be at hand if tracheotomy became 
 suddenly necessary ; that the young man had been 
 described to me simply as a military surgeon, and 
 that I knew nothing of his ability as a laryngoscopist. 
 Under these circumstances, I said it would be im- 
 possible for me to accept the assistance of Dr. Land- 
 graf in carrying out the details of my proposed line 
 of treatment, and I requested that my colleague, 
 Dr. Norris Wolfenden, one of the Physicians to the 
 Hospital for Diseases of the Throat, should be asso- 
 ciated with me in the capacity of resident medical 
 attendant on the Crown Prince. This was agreed to, 
 and Dr. Wolfenden accordingly took up his residence 
 at Norwood. On June 15th I received from him the 
 following report : — " The larynx is large and well 
 formed, but, owing to the slope of the epiglottis, the 
 view of the interior of the laryngeal cavity is not so 
 easy to obtain as it is in an average case. The under 
 surface of the epiglottis is slightly congested on the 
 right side, and the cushion is rather full. The left 
 ary-epiglottic fold is a little puffy at its lower and 
 posterior part. The left ventricular band is very 
 slightly swollen anteriorly so that the outer border of 
 the left vocal cord in this situation is just covered ;
 
 Dr, Norris Wolfenden. 47 
 
 the right ary-epiglottic fold is normal, and the inter- 
 arytenoid fold towards the left side has lost its sharp 
 definition ; an enlarged vessel is seen on the right 
 ventricular band, which is otherwise healthy. The 
 left vocal cord is of a pale pink colour. At its 
 posterior extremity there is a roundish growth about 
 three millimetres in diameter and two in height. On 
 whispering, both the ab- and the ad- ductive action of 
 the left vocal cord is seen to be feeble, but on loud 
 phonation the latter movement shows no defect. The 
 right vocal cord is healthy. In the subglottic region 
 there is slight congestion, but no thickening is visible." 
 
 Fig. 4. — Sketch made June 28th, showing the larynx after complete 
 removal of the growth. There is a very slight thickening near 
 the posterior extremity of the left vocal cord. (For further explana- 
 tions, see Fig. i, p. 13.) 
 
 It will be seen, both from Dr. Wolfenden's very 
 careful report and from my notes, that His Imperial 
 Highness's throat was still somewhat congested, and I 
 thought it necessary to get rid of this condition before 
 further active measures were employed. With this 
 object sedative and astringent powders were blown 
 into the wind-pipe, and after a few days the parts 
 were brushed with a solution of perchloride of iron. 
 His Imperial Highness came to my house nearly 
 every day for treatment, and in the evening he was 
 seen 'by Dr. Wolfenden. On June 25th the Prince 
 had a rather sharp attack of catarrhal inflammation 
 involving nearly the whole of the throat, causing
 
 48 The Fatal Illness of Frederick the Noble. 
 
 swelling and tenderness of the uvula, and giving rise 
 to slight difficulty in swallowing. 
 
 My FourtJi Operation. — These symptoms, however, 
 speedily subsided, and as nearly three weeks had 
 passed since the previous operation, I thought it time 
 to make another attack on the growth. On June 28th, 
 in the presence of Drs. Wegner and Wolfenden, I 
 succeeded in bringing away with the forceps what 
 appeared to be all that was left of it. Dr. Wegner at 
 once took possession of the substance which had been 
 removed, and packed it up carefully with his own 
 hands, declining even the assistance of my secretary. 
 He then sealed the little packet, which was conveyed 
 by one of the Royal messengers to Berlin, and handed 
 to Professor Virchow for examination. The following 
 is a translation of that gentleman's report : — 
 
 Professor Virchow's Report * on the portion 
 of growth removed from the larynx of 
 H.I.H. THE Crown Prince of Germany, by 
 Dr. Morell Mackenzie, on June 28th. 
 
 "At midday this day I received by special 
 messenger from General-Arzt Dr. Wegner, a 
 sealed flask containing the small portion of 
 the pathological growth just removed from the 
 larynx of H.I. and R.H. the Crown Prince. 
 The object was in absolute alcohol in one 
 piece, and though somewhat shrivelled was 
 well preserved. It had a flat base of longish 
 oval form, 5 millimetres long and 3 millimetres 
 broad, upon which was a small semi-spherical 
 granular surface, about 2 millimetres high. 
 The latter surface had a grey colour, with a 
 faintly ruddy tint ; but the base was almost 
 black. This was evidently from the action of 
 some preparation of iron, for when moistened 
 with hydrochloric acid the dark hue gave place 
 
 ♦ Brit, Med. Journ.^ vol. ii., 18S7, p. 199.
 
 My Fourth Operation. 49 
 
 to a faintly yellowish tint, which changed to 
 an intense blue colour on the addition of a 
 little cyanide of potassium. The paler portions 
 of the growth also showed this reaction in a 
 higher degree. We must assume, therefore, 
 that the iron preparation affected the whole 
 surface, but that only the underlying portions 
 preserved the blue black tint, the superficial 
 parts having become decolorised : further, that 
 the flattish base represented the site of attach- 
 ment of the portion in question, although its 
 black colour might at first give the idea that 
 it had been superficial (in the larynx), and 
 therefore more exposed to the action of external 
 operations. 
 
 Further examination showed that the flat- 
 tened base consisted of club-shaped, rounded 
 papillary outgrowths lying in juxtaposition ; 
 moreover, that a whitish incision-wound, hardly 
 one millimetre wide, ran nearly across the 
 middle of the base, following the long axis 
 pretty closely, and almost wholly concealed by 
 the surrounding papillary outgrowths. 
 
 Microscopical examination showed still more 
 decisively than on the previous occasion that 
 the surface of the excised portion was almost 
 wholly occupied by papillary outgrowths of 
 various size. Only in the immediate neigh- 
 bourhood of the surface of excision was there 
 found a small zone of perfectly smooth super- 
 ficial tissue ; within the papillae the large and 
 hard epithelial cells, in layers and flattened 
 towards the outer parts, represented by far 
 the chief portion of the new formation ; the 
 connective - tissue framework was thin, soft, 
 and vascular. No peculiar cell-formation was 
 observed. 
 
 The incised surface afforded an irregular 
 soft and slightly vascularised tissue. No deep 
 
 E
 
 50 The Fatal Illness of Frederick the Noble. 
 
 layers of tissue^ as after the first, and still more 
 the second, operation, had been removed. The 
 section had been made very near the surface, 
 so that only mucous membrane was removed. 
 Thus only a little tissue, and that difficult to 
 handle, was afforded for the purpose of an 
 opinion on the structure of the underlying 
 parts. 
 
 No alveolar structure, or deposition, or pene- 
 tration of epithelial masses could anywhere be 
 perceived in this tissue. It consisted of young 
 connective tissue, which had increased not to- 
 wards the deeper part, but towards the surface, 
 and contained elements some of which were 
 proliferating. Nowhere did this proliferation 
 reach the character of an independent centre 
 of formation. Th7(s this excised portion, in a 
 still higher degree than was the case with the 
 portions obtained by the previous operations, has 
 shown itself to be a hard, compressed warty 
 growth, that has started, from a moderately 
 irritated and thickened sujface, and the exami- 
 nation of its base has not afforded the least 
 support for the idea of a nezu formation pene- 
 trating inwards!' * 
 
 (Signed) RUDOLF ViRCHOW. 
 
 " Pathological Institute, Berlin. 
 July I, 1887." 
 
 It will be seen that this report, so far as it went, was 
 as satisfactory as those which had preceded it. As 
 only tissue belonging strictly to the growth had been 
 removed this time, no opinion as to the underlying 
 
 * It has already been pointed out (p. 34) that it is the 
 ingrowth of epithelial tissue, here once more expressly stated to 
 have been absent, which is the distinctive feature of cancer as 
 comparable with other new growths. The italics in the above 
 report arc not in the original.
 
 Visit to the Throat Hospital. 5 1 
 
 structures could, of course, be given. On both the 
 former occasions, it will be remembered, Professor 
 Virchow had dwelt with some emphasis on the fact 
 that the forceps had brought away not only a complete 
 section of the tumour, but portions of the structures 
 on which it was seated, which could thus be seen to 
 present no suspicious appearance. I think it right to 
 insist on this, because both Gerhardt and Bergmann 
 speak as if only shreds from the surface of the tumour 
 — the outer husk, as it were — had been submitted to 
 Professor Virchow. The eminent pathologist's own 
 words, in the report just quoted, as well as in the two 
 preceding ones, leave no shadow of doubt on this point. 
 It is impossible to get over his testimony, unless it be 
 supposed that the creator of scientific pathology could 
 not distinguish healthy from diseased tissue in a case 
 where the merest beginner in microscopic work could 
 do so without trouble. The notion is as preposterous 
 as it would be to say that Gounod or Verdi could 
 not distinguish a true note from a false one. 
 
 Visit to the Throat Hospital. — This seems the most 
 appropriate place to mention a pleasant episode 
 belonging to this period, though it has nothing to do 
 with the medical history of the case. On July 15th, 
 the Crown Prince paid a visit to the Hospital for 
 Diseases of the Throat, Golden Square, an institution 
 which, since I founded it in 1863, has relieved more 
 than 105,000 patients. I was unfortunately too ill to 
 be present on the occasion, but I was informed by the 
 members of the Committee who had the honour of 
 receiving the illustrious visitor that His Imperial 
 Highness expressed himself greatly pleased with all 
 he saw. He showed the greatest interest in the 
 patients, to each of whom he spoke a few words of 
 kindly encouragement. A little girl who had under- 
 gone the operation of tracheotomy was sitting up in 
 bed nursing a doll. On being asked by the Crown 
 Prince, "Which is the patient, you or the doll?" the 
 little mite answered, " Sure I don't know which it is, 
 
 E 2
 
 52 The Fatal Illness of Frederick the Noble. 
 
 my dear ! " which delighted His Imperial Highness. 
 There happened to be three German patients in the 
 hospital at the time, and of them naturally the Crown 
 Prince took special notice, asking each of them what 
 part of Germany he belonged to, and a number of 
 other questions. In the crowded out-patient room 
 again he spoke to several of the sufferers waiting their 
 turns to be attended to. 
 
 The Isle of Wight. — Very little reaction followed 
 the removal of the last portion of the growth, and the 
 august patient proceeded to the Isle of Wight, where 
 Norris Castle had been placed at his disposal by the 
 Duke of Bedford. For reasons which will subsequently 
 appear (see p. 21 1), I think it well to mention here that 
 it was the Crown Prince himself who chose the Isle of 
 Wight as a place of residence. He was very fond of 
 the island, and he liked Norris Castle, where he had 
 stayed before, and which had the advantage of being 
 close to Osborne. Dr. Wolfenden continued in at- 
 tendance, and it was arranged that I should go down 
 once a week. 
 
 A Nezo Symptom. — His Imperial Highness much 
 enjoyed his stay in the Isle of Wight, and although 
 I thought the climate seemed to have a relaxing effect, 
 he said he felt well, and was not tired after taking 
 exercise. On the day of the great Naval Review 
 (July 23rd) the Crown Prince talked a good deal, and 
 was very hoarse for a day or two afterwards. On 
 July 2 1st Dr. Wolfenden first noticed a slight 
 swelling on the posterior surface of the arj^tenoid 
 cartilages ; this obser\^ation I confirmed at my next 
 visit. The thickening was in the form of a yellowish 
 ridge ; it projected to the extent of about one milli- 
 metre, and extended across from the outer border of 
 one cartilage to the corresponding part of the other. 
 
 The appearance of this new feature in the case 
 caused me considerable anxiety, for I could not help 
 fearing that it indicated inflammation of the perichon- 
 drium, if not disease of the cartilages themselves. I
 
 GalvanO' Cautery as it should be used. 53 
 
 therefore warned the Crown Princess and other 
 exalted personages that the possibility of the occur- 
 rence of serious perichondritis at some future date 
 must be taken into account. 
 
 Galvano- Cautery as it should be used. — Towards the 
 end of July there was some appearance of recurrence 
 at the seat of the growth which I had removed. It 
 did not project sufficiently for the blades of the forceps 
 to catch it ; I therefore determined to destroy it with 
 electric cautery. This I did in a very careful manner, 
 using an instrument specially constructed for the 
 purpose by my assistant, Dr. Robert C. Myles, now 
 of New York. The electrode, the tip of which was 
 bent at a right angle so as to reach under an over- 
 hanging ledge, was guarded by two ivory plates 
 fastened on with silk-thread covered with hardened 
 gum-arabic, a substance which has been found to be an 
 excellent non-conductor of heat. In this way only the 
 tiny point remained free to touch the part to which 
 it was applied. It was thus impossible to burn any 
 part of the larynx except the spot which it was desired 
 to reach, nor could the heat of the incandescent point 
 be felt by the parts which it did not actually touch, 
 as is often the case with the ordinary instruments. 
 Every provision against all conceivable accidents 
 having thus been made, on August 2nd I applied the 
 cautery, using the utmost gentleness in manipulation 
 and merely touching the site of the growth with 
 the point. The Crown Prince felt hardly any in- 
 convenience from the application, which was not 
 followed by any appreciable reaction. The next day 
 a small flat eschar was visible at the spot which the 
 cautery had touched, but Dr. Wolfenden informed me 
 that there was no appearance of inflammation round 
 it. Six days later I again applied the galvano-cautery 
 with the same precautions as before, in the presence 
 of Drs. Wegner and R. C. Myles. 
 
 Scotland. — On August 9th the Crown Prince 
 started for Scotland, accompanied by Dr. Wegner, Dr.
 
 54 The Fatal Ilbiess of Frederick the Noble. 
 
 Landgraf, and Mr. Mark Hovell, Surgeon to the Hos- 
 pital for Diseases of the Throat, who had succeeded 
 Dr. Norris Wolfenden as Resident Physician, domestic 
 circumstances preventing the latter gentleman from 
 continuing his services. The Crown Prince went on 
 to Braemar, attended by Mr. Hovell ; whilst Drs. 
 Wegner and Landgraf remained at Edinburgh, so as 
 to be within reach in case of emergency. As there 
 has, I believe, been a good deal of comment on this 
 arrangement, I may here take the opportunity of 
 statuig that I had nothing whatever to do with it. 
 My advice on the subject was not asked, and was 
 therefore not given. The Crown Prince simply 
 acquainted me from time to time with the arrange- 
 ments which had been made. Whilst informing me 
 that Wegner and Landgraf were to stay at Edinburgh, 
 he told me that it had been settled that they should 
 both pay him a visit at Braemar. 
 
 On August nth, Mr. Hovell wrote to me that a 
 small slough, caused by the cautery, had come away, 
 and two days later he informed me that the slight 
 wound had healed. The growth thus destroyed never 
 returned. 
 
 During His Imperial Highness's stay at Braemar a 
 marked improvement took place in the condition of 
 the larynx. The lining membrane was much less 
 congested, and his voice became strong and almost 
 natural in tone. The Queen expressed to Mr. Hovell 
 the pleasure she felt at hearing the Crown Prince 
 speak once more in his own voice. I visited the 
 Prince at Braemar on August 20th, and found that 
 the ridge on the posterior surface of the ar>'t^noid 
 cartilages had almost disappeared. I saw him again 
 in London on August 31st, when I noticed that the 
 left cord moved more freely than before, though its 
 action was still imperfect. His general health at this 
 time was excellent. 
 
 Plans for Autumn. — As His Imperial Highness had 
 expressed a wish to go for some weeks to Toblach, in
 
 Gerkardfs Assistant as a Laryngoscopist. 55 
 
 the Tyrol, of which place he had very pleasant 
 reminiscences from a previous visit, and as I saw no 
 objection to his gratifying his wish in that respect, it 
 was arranged that he should go to the Austrian Alps. 
 I advised him, however, if he found the climate of the 
 Tyrol at all cold to go further south. He determined 
 not to pass through Berlin, greatly as he should have 
 liked to see the aged Emperor. As the Crown 
 Prince himself pointed out, however, if he went to 
 Berlin he would have had to receive visits from a 
 very large number of people, and this would have 
 involved an enormous amount of talking, which he 
 feared would hurt his throat. In this decision there 
 can be no doubt that from a medical point of view 
 His Imperial Highness was entirely right ; a visit to 
 Berlin under such circumstances would have been 
 only too likely to do him much harm. The Prince 
 also told me that Dr. Wegner's place would be taken 
 for a time by Dr. Schrader, as the health of the 
 former was not quite satisfactory, and His Imperial 
 Highness said that he himself was now so well that 
 he did not require any other doctor with him but 
 Mr. Hovell, with whom he expressed himself highly 
 satisfied. For this reason, he added. Dr. Landgraf 
 would be relieved of further attendance on reaching 
 Germany. 
 
 Gerkardfs Assistant as a Laryngoscopist. — With 
 the disappearance of the young Stabsarzt from the 
 scene I feel it necessary to say a few words on a 
 subject I would have gladly refrained from touching 
 on. The importance attached by my German critics, 
 however, to what I may call Dr. Landgraf's evidence, 
 leaves me no alternative but to speak quite plainly 
 on this matter. After Dr. Landgraf's first examina- 
 tion, the Crown Prince complained to me of his 
 roughness and want of skill, and on many subsequent 
 occasions His Imperial Highness assured me that 
 after the young German surgeon had used the 
 laryngoscope, his throat felt sore and tired for several
 
 56 The Fatal Illness of Frederick tlie Noble. 
 
 hours. The Crown Prince, whose consideration for 
 the feelings of others was of the most chivalrous 
 description, bore with the infliction as long as he 
 possibly could ; but after a time he asked me if I 
 could not give Landgraf a hint to be more gentle and 
 to take less time in making his examinations. I 
 ventured, however, to represent to His Imperial 
 Highness that this would place me in a very invidious 
 position, and that it would be said in Germany that I 
 did not wish Landgraf to get a proper view of the 
 larynx. I had two or three times the opportunity of 
 seeing him examine the Crown Prince's throat, and 
 his performance was almost as painful for me to 
 witness as it was for the august patient to undergo. 
 Just before his departure for Scotland His Imperial 
 Highness again complained to me about Landgrafs 
 clumsiness, and I felt it necessary to tell Dr. Wegner 
 that if the young surgeon did not mitigate his style 
 of examination, I was sure that the Crown Prince 
 would send to Berlin for some less inexperienced 
 laryngoscopist to replace him. Dr. Wegner begged 
 me to use my influence with His Imperial Highness 
 to prevent a step being taken which would have a 
 most injurious effect on Landgrafs career, while he 
 promised to warn the young surgeon to be more 
 careful in future. 
 
 I confess after seeing how little familiar Dr. Land- 
 graf was with the laryngoscope I did not attach any 
 importance whatever to his observations. And it 
 would seem as if Landgraf was regarded at Berlin 
 very much as he was by me, for though this gentleman 
 every few days sent from the Isle of Wight and else- 
 where most alarming reports to the Prussian capital, 
 no more notice was taken of them than if they had 
 been drawn up by a person who had never used the 
 laryngoscope. I shall refer to this matter again in 
 dealing with Dr. Landgrafs separate report. 
 
 When the Crown Prince was staying in the Isle of 
 Wight, Landgraf, who had then been some weeks in
 
 Gerhardfs Assistant as a Laryiigoscopist. 57 
 
 attendance, seems to have suddenly become distinctly 
 aware that the left vocal cord did not move quite as it 
 should do. This startling discovery he forthwith 
 communicated to some of His Imperial Highness's 
 suite, and it finally came to the ears of the Crown 
 Prince, who was rather alarmed about the matter. 
 When, however, I explained to him that the condition 
 which Landgraf had just noticed for the first time * 
 had existed from the date of my first visit to Berlin, 
 he was perfectly satisfied ! Again Landgraf appears to 
 have mistaken the ridge outside the larynx behind the 
 arytenoid cartilages which I have described (p. 52) 
 for a swelling on the posterior wall, that is to say, 
 inside the larynx below the level of these cartilages. 
 On this, as I afterwards learned, he founded most 
 alarming reports of cancerous infiltration spreading 
 round the orifice of the windpipe, which, as we now 
 see, have been duly deposited in the archives of the 
 Prussian Kingdom ! 
 
 I found that Dr. Wolfenden entirely agreed with me 
 as to Dr. Landgraf 's want of laryngoscopic skill. To 
 him also the Crown Prince repeatedly complained of 
 the German surgeon's examinations, and my colleague 
 expressed to me his surprise that if it was thought 
 
 * At the time I was under the impression that Landgraf had 
 recognized the imperfect action of the left vocal cord for the 
 first time, and I am still unable to account for his extraordinary- 
 excitement on any other ground. I was very much surprised, 
 therefore, on looking over Dr. Landgraf's Report, to find that 
 this condition is mentioned in his first letter to Berlin. The 
 only explanation I am able to ofTer now is that, although he 
 denies it, Dr. Landgraf must have received some useful " hints 
 from Professor Gerhardt." It would appear, therefore, that 
 Landgraf in his earlier reports embodied the hints, whilst on a 
 certain date he actually saw what he had previously described 
 from the " Informationen" of Professor Gerhardt {^Op. cit.) 
 which the Professor evidently gave to his assistant before he 
 heard that the young surgeon had been appointed to " control " 
 me. After that time Gerhardt says, " I ceased to have any 
 correspondence with Dr. Landgraf on this subject " {OP- cit., 
 p. 15). As all the instructions were evidently already given, no 
 further correspondence was required.
 
 58 Tlie Fatal Illness of Frederick the Noble. 
 
 necessary to send any one from Berlin, a more com- 
 petent observ^er was not chosen. 
 
 When, in November, a report based on Landgraf s 
 obser\'ations was drawn up at Berlin, I requested 
 Dr. Wolfenden to give me his views on the subject in 
 writing. The following is his statement : — • 
 
 " I never considered Landgraf a person to be 
 treated seriously. Whatever he may be as a sur- 
 geon, and of this I have no knowledge, he is certainly 
 nothing of a laryngoscopist. His laryngoscopic 
 examinations of the Crown Prince were prolonged, 
 unskilful, and exceedingly tiresome, so much so that 
 the Crown Prince made a complaint after the second 
 examination at Norwood, and asked me whether he 
 should not speak to Landgraf and request him to 
 desist from examining his throat daily. The Crown 
 Prince stated also that Dr. Landgrafs examinations 
 were painful to him, and his manner objectionable. I 
 had not the slightest confidence in the accuracy of 
 Dr. Landgrafs observations, as he constantly imagined 
 he saw things which were not present, and at the 
 same time overlooked the most obvious phenomena. 
 Notv/ithstanding this, I never stood in his way, and 
 whenever he expressed a desire to examine the Crown 
 Prince's throat, I always permitted him to do so before 
 I myself applied any medicament." 
 
 It is with the greatest reluctance I have had to deal 
 thus frankly with Dr. Landgraf, but so much has been 
 made by my opponents of his testimony, that I am 
 compelled in self-defence to show exactly what value 
 should be attached to it. 
 
 Possibilities of the Case. — Shortly before their 
 Imperial Highnesses left England, I thought it my 
 duty to lay before the Crown Princess my views as 
 to the prospects of the Prince. I told the Princess 
 frankly that although at that time the affection 
 did not seem to me to be of a malignant nature, 
 it might nevertheless turn out to be so. I fully ex- 
 plained to her what in my opinion the four possible
 
 Possibilities of the Case. 59 
 
 developments of the case might be : i. The tumour 
 having been destroyed might not grow again, the 
 affection being thus practically cured. 2. The tumour 
 might sprout up again, and require to be removed or 
 destroyed perhaps more than once. 3. A condition 
 known as "multiple papilloma" might result, which 
 was dangerous if not properly treated, but not 
 necessarily fatal. 4. The disease might be cancerous 
 already, or cancer might develop later on. I impressed 
 upon Her Imperial Highness that although at that 
 moment everything looked most promising, the 
 possibility of an eventual unfavourable development 
 must not be ignored. That I laid my views before 
 the Princess in the frankest and most unreserved way 
 I have documentary evidence to prove, and I am quite 
 ready to place this evidence before the President of 
 the College of Physicians and the German Ambassa- 
 dor acting together. With the Crown Prince himself 
 I of course could not discuss the situation with the 
 same freedom ; but whilst encouraging him as to his 
 condition, I was careful not to say anything of a 
 misleading character.
 
 6o The Fatal Illness of Frederick the Noble. 
 
 CHAPTER IV. 
 
 TOBLACH — VENICE — BAVEXO. 
 
 TJie Case enters on a Nezu Phase. — The Crown 
 Prince left London on September 3rd, and travelled 
 by Frankfort and Munich to Toblach, which he 
 reached on the 7th. 
 
 In Mr. Hovell's note-book, under the date of Sep- 
 tember 9th, I find the following note : *' During the 
 journey the Crown Prince's throat has certainly been 
 more relaxed ; on the 6th I noticed that the cushion 
 of the epiglottis was congested and slightly swollen ; 
 on the 7th, on arriving at Toblach, this feature had 
 
 Fig. 5. — Sketch showing Mr. Hovell's observations on September 9th. 
 
 almost entirely disappeared, but the right ary-epl- 
 glottic fold was slightly inflamed, just at the point 
 where it joins the arytenoid cartilage, and the carti- 
 lage of Wrisberg was more prominent on this side ; 
 the inter-ar>'tenoid fold was also slightly puffy, 
 though of normal colour. On the 8th the congestion 
 of the right side had entirely disappeared, but there 
 was a small hyperaemic spot just below the inter- 
 arytenoid fold. There was no swelling whatever,
 
 The Case enters on a New Phase. 6i 
 
 however, in the situation. I observed slight thicken- 
 ing at the hinder part of the left vocal cord, rather 
 farther back than the site of the growth which Sir 
 Morell had destroyed. There was increased hoarse- 
 ness, with some congestion of the larynx, which, 
 however, soon subsided. On the 14th, an oblong 
 swelling, about 5 millimetres in length and 3 in 
 width, was noticed half an inch below the middle of 
 the left cord and parallel with its margin. On the 
 1 8th the tumefaction at the posterior part of the cord 
 had disappeared, but the new subglottic tumour was 
 still visible." 
 
 On the 20th, when I arrived at Toblach, the 
 swelling was nearly round, and measured more than 
 half a centimetre in diameter, but projected very 
 slightly from the side of the larynx. The Crown 
 Prince looked well, and Dr. Schrader gave me a 
 very satisfactory report as to his general health. 
 When out walking, however, he seemed to get tired 
 sooner than the rest of the party. Two days after 
 my arrival he caught cold, and on the following day 
 he was languid, had no appetite, whilst his tempera- 
 ture was lOi^ R, and the left ary-epiglottic fold 
 suddenly became oedematous ; but this condition, 
 together with the feverish symptoms, disappeared in 
 twenty-four hours. Although the oedema was ap- 
 parently due to inflammation from taking cold, the 
 possibility of its being caused by limited perichondritis 
 was discussed at the time. It should be noted that 
 the acute oedematous swelling just referred to seemed 
 to be altogether independent of the little tumour 
 beneath the edge of the vocal cord^ which became 
 gradually smaller but did not entirely disappear. 
 
 A Deceptive Lull. — It had already been arranged 
 that the Crown Prince should spend the winter in 
 Italy, and San Remo was now decided on as the 
 most suitable place for him. As the weather was 
 becoming rather cold at Toblach, I advised His 
 Imperial Highness to spend a week or two previously
 
 62 The Fatal Illness of Frederick the Noble. 
 
 at Venice, of which he was very fond. He accord- 
 ingly went there on September 28th, and stayed till 
 October 6th, the condition of his larynx meanwhile 
 steadily improving. On the 7th he went to Baveno, 
 where Mr. Henfrey had placed his beautiful villa at 
 his disposal. Here I found the Crown Prince's 
 throat in a very satisfactory state, except that the 
 left cord did not move quite freely, and its posterior 
 extremity was on a somewhat higher level than the 
 corresponding portion of the right. I judged that 
 some perichondrial inflammation had taken place 
 about the anterior spur of the left arytenoid cartilage, 
 and that this had pushed the vocal cord a little 
 upwards in that situation. There was no redness, 
 however, at that spot, and I therefore hoped that 
 the morbid process had been arrested. In the larjmx 
 itself there was at this time nothing beyond slight 
 general congestion and the remains of the subglottic 
 swelling which had been discovered on Septem- 
 ber 14th. 
 
 Hopes and Fears. — I then took leave of His Imperial 
 Highness, not expecting to see him again for many 
 months. That I did not, however, even at that time 
 take an entirely optimistic view of the situation is 
 clearly shown in the following passages of a letter 
 which I wrote to Professor Oertel of Munich on 
 Oct. 21 in reply to one which I received from him 
 soon after my return to London : — 
 
 **With regard to your inquiries about the Crown 
 Prince, I am happy to tell you that when I saw him 
 at Baveno he was going on very well. Pfhere has 
 never been anything at all characteristic otmalignant 
 disease as far as (the naked eye) appearance goes, so 
 that my treatment has throughout been based on the 
 observations of your great pathologist. Valuable, 
 however, as Professor Virchow's investigations have 
 been, they of course only furnish negative evidence, 
 and I shall not feel quite safe from anxiety until sij^
 
 Hopes and Fears. 63 
 
 months^ave elapsed since the application of electro- 
 cauteryj I need scarcely assure those who know me 
 that I have never been in the least unwilling to meet 
 my German confreres, and should any unfavourable 
 symptoms unfortunately develop; I should be the first 
 to ask for the co-operation of one of your countrymen. 
 " With regard to the publication of bulletins, I 
 quite agree with you that frequent official communi- 
 cations are desirable, as they often allay anxiety, and 
 prevent the spread of false news. In the case of a 
 private person, however, this question always rests 
 with the patient, and it does not seem right that 
 because the sufferer is of the highest rank his own 
 feelings in the matter should be disregarded. 
 " Yours truly, 
 (Signed) "MoRELL Mackenzie." 
 
 Clouds Gathering. — Things went on well till about 
 the ' middle of October, when Mr. Hovell's reports 
 began to be less favourable. On the 17th the larynx 
 became acutely congested, and ten days later the 
 subglottic swelling was seen to be increasing in size, 
 and the whole of the left side of the larynx was some- 
 what enlarged. On October 28th the surface of the 
 tumour became slightly ulcerated, and the vocal cord 
 above it was slightly swollen along its free edge. In 
 spite of this, the illustrious patient's voice was quite 
 clear, and in the opinion of the Crown Princess per- 
 fectly natural. A mournful interest attaches to this 
 remark of Her Imperial Highness, for this was the 
 last time she was ever to hear the true sound of that 
 beloved voice. The next day the Crown Prince 
 became hoarse again, and on October 30th a new 
 swelling was noticed beneath the right vocal cord, 
 whilst the one on the other side was seen to be 
 throwing out off-shoots. Nevertheless, except the 
 renewed hoarseness, there was little to indicate, either 
 to the illustrious sufferer himself or to others, that a 
 change for the worse had occurred.
 
 64 The Fatal Ilhiess of Frederick tJu Noble. 
 
 On November 3rd the Crown Prince proceeded 
 to San Remo, where a suitable residence, the Villa 
 Zirio, had been prepared for him. On that day 
 Mr. Hovell perceived that the subglottic tumour had 
 grown considerably, being then rather more than one 
 centimetre in diameter, and raised to the extent of 
 about four millimetres. The extension of the growth 
 since it was first observ'ed had always been in an 
 upward direction. On the morning of the 4th some 
 oedema was seen at the base of the left arytenoid 
 cartilage ; this disappeared in the evening, but was 
 again present on the following morning. As the 
 symptoms now presented a decidedly ominous appear- 
 ance, an urgent message was sent to me, on receipt 
 of which I at once started for San Remo, which I 
 reached on the evening of the 5th.
 
 A New Growth appears. 
 
 65 
 
 CHAPTER V. 
 
 SAN REMO— THE WORST FEARS CONFIRMED. 
 
 A new Growth appears. — On the morning of 
 Nov. 6th I examined the Crown Prince's throat, 
 which I found in exactly the condition described in 
 the reports. The mucous membrane over the left 
 arytenoid cartilage was moderately cedematous, and 
 of a bright pink colour. The new growth was bright 
 red in colour, rather more prominent in the centre 
 than elsewhere, and ulcerated on the surface. Its 
 appearance was altogether unlike that of the one 
 
 Y\g. 6. — Sketch made Nov. 6tb, showing a large new growth half an 
 inch bdoro the left vocal cord, and a smaller one hcloiv the right cord. 
 
 which I had destroyed, and the other swellings 
 which had from time to time shown themselves in the 
 larynx ; it had in fact a distinctly malignant look. 
 Without rising from my chair I informed His 
 Imperial Highness that a very unfavourable change 
 had taken place in his throat. He said, " Is it 
 cancer t " to which I replied, " I am sorry to say, Sir, 
 it looks very much like it, but it is impossible to be 
 certain," I felt that evasive answers, which for the 
 
 F
 
 66 TJie Fatal Illness of Frederick the Noble. 
 
 patient's own sake medical men are often compelled 
 to give under similar circumstances, would in the 
 present instance have been out of place. The Crown 
 Prince received the communication with perfect calm- 
 ness. After a moment of silence he grasped my 
 hand and said, with that smile of peculiar sweetness, 
 which so well expressed the mingled gentleness and 
 strength of his character, " I have lately been fearing 
 something of this sort. I thank you, Sir Morell, for 
 being so frank with me." In all my long experience 
 I have never seen a man bear himself under similar 
 circumstances with such unaffected heroism. He 
 showed not the least sign of depression, but spent 
 the day in his ordinary occupations ; and at dinner 
 time that evening he was cheerful without apparent 
 effort, and chatted freely in his usual manner. A day 
 or two afterwards, in reply to a question as to his 
 general health, the Crown Prince said he had never 
 felt better in his life, adding, with a smile, " Under 
 the circumstances, I really must apologise for feeling 
 so well ! " To appreciate the extraordinary forti- 
 tude displayed by this magnanimous man, it must 
 be remembered that what he had heard was some- 
 thing much worse than a mere sentence of death. 
 He believed at that moment that he was doomed 
 only too surely to a lingering agony worse than 
 death. There is nothing more terrible than the 
 struggle of a powerful constitution with the slow 
 but relentless advance of malignant disease, when 
 the life is as it were eaten out of a man bit by 
 bit, and each day's sufferings are made worse by 
 the anticipation of those that are to come. This 
 was the prospect which the Crown Prince "looked 
 fonvard to without fear, placing his trust in God," to 
 use his own words ; it was one which would have 
 struck dismay into the heart of many a brave man 
 who has never felt fear on the battlefield. 
 
 With the view of having the diagnosis confirmed 
 by the evidence of the microscope, it would have 
 
 ^
 
 A Consultation called. 6^ 
 
 been more satisfactory to have removed a portion of 
 the growth with forceps, and to have submitted it to 
 Professor Virchow. Such a procedure, however, was 
 clearly out of the question whilst the larynx was in so 
 " angry " a condition as it then was ; any additional 
 irritation would have certainly made matters worse. 
 It was fortunate for me that I did not attempt any- 
 thing of the kind, for two days later, acute cedema of^^ 
 the upper opening of the larynx on both sides set in 
 spontaneously ; this condition would inevitably have 
 been attributed to my operation had I ventured to 
 perform one. 
 
 A Consultation called. — In such a serious state of 
 affairs it was of course desirable to have further 
 advice, not that much could be hoped for from 
 medical skill in such a case, but that no opportunity 
 of possible help, however slight, should be neglected. 
 
 The question was : Where should it be sought for ? 
 It was before everything essential to have the assist- 
 ance of men who would bring absolutely unbiassed 
 judgments to the case. At Berlin, to which my 
 thoughts naturally first turned, there was no one 
 (setting aside Gerhardt and Tobold, who had already 
 strongly committed themselves to an opinion on 
 the matter) but Professor Bernhardt Fraenkcl and 
 Dr. Hermann Krause. Professor Lewin, who had 
 formerly been a distinguished laryngologist, had long 
 since given up the speciality, which has for some 
 reason or other never flourished very vigorously in 
 the Prussian capital. The want of official recognition 
 by the University, from which it suffered till com- 
 paratively recent times, has probably been the chief 
 cause of its feeble vitality in that city. At Vienna, on 
 the other hand, which was the cradle of this depart- 
 ment of medical science, the tradition has been kept 
 up, and larjmgology has always been well represented 
 in the professorial body. 
 
 The Counsellors chosen. — I now carefully weighed 
 the respective merits of the three leading throat- 
 
 F 2
 
 68 The Fatal Illness of Frederick the Noble. 
 
 specialists in the Imperial City. If I had been 
 selecting an operator, I probably should have chosen 
 Professor Stoerk ; and if I had been dealing with a 
 disease of such obscurity that the widest experi- 
 ence was required, I should have invited Professor 
 Schnitzler, but at that moment the diagnosis appeared 
 only too clear. In the end I selected Professor von 
 Schrotter, mainly in the hope that his extensive 
 knowledge of respiratory affections would enable him 
 to make some practical suggestions in connection 
 with treatment. Of the two available laryngologists 
 at Berlin I chose Dr. Krause, with whose know- 
 ledge and ability I had been greatly struck at the 
 International Medical Congress held at Copenhagen 
 in 1884. On that occasion I was President of the 
 Section of Laryngology, a dignity which was conferred 
 on me as a special honour, contrary to the almost 
 invariable custom at these gatherings where the presi- 
 dential chairs are filled by local men of ''light and 
 leading." In that position I had an excellent oppor- 
 tunity of forming a judgment as to the abilities and 
 attainments of the principal European and American 
 specialists. Amongst them all no one made his mark 
 more decisively than Krause, who at once took his 
 place as one of the leading laryngologists in Germany. 
 The distinction which he earned at Copenhagen has 
 been more than sustained by his subsequent work, of 
 which I shall speak more in detail further on (see 
 page 225). 
 
 TJie Consultation. — At my request, therefore. Pro- 
 fessor von Schrotter and Dr. Krause were summoned 
 to San Remo. On November 9th a preliminaiy 
 meeting took place in my room at the Hotel Medi- 
 terranee. Professor Von Schrotter, Dr. Schrader, Dr. 
 Krause, Mr. Hovell, and myself being present. I 
 gave an account of the case from the time I first had 
 seen the Crown Prince in I\Iay till the day I took leave 
 of His Imperial Highness at Baveno in October. Mr. 
 Hovell then related the subsequent progress of the
 
 The Consultation. 69 
 
 case from that time up to the date of our meeting. 
 I then described the appearance of the new growth as 
 I had first seen it on November 6th, and concluded 
 by saying, '* This growth looks like cancer." Pro- 
 fessor von Schrotter thereupon said that, after my 
 very clear statement, he had no hesitation in pro- 
 nouncing the disease to be cancer ; he was so sure of 
 it that he felt there was no need for him to see the 
 patient. Whilst thanking the Professor for this 
 flattering testimony to my descriptive powers, I 
 ventured to point out that it was hardly worth his 
 while to have come all the way from Vienna to give 
 it, and I hinted that it would scarcely be treating the 
 illustrious patient with proper consideration to offer 
 him a second-hand diagnosis. Professor von Schrotter 
 then consented to go with us to the Villa Zirio, where 
 the Crown Prince's throat was duly examined. 
 
 Upon returning to the hotel to continue the con- 
 sultation, Professor von Schrotter wished to dictate a 
 report ex cathedrd, but as there was some divergence 
 of opinion between him. Dr. Krause and myself, it 
 was agreed that each should give his opinion sepa- 
 rately in writing. Schrotter affirmed that the disease 
 was cancer, and recommended excision of the entire 
 larynx. Dr. Krause remarked that it appeared to 
 him that it was highly probable that the disease was 
 a " malignant neoplasm," but as the view of the 
 interior of the larynx was almost completely shut out 
 by oedema, he would be glad to know whether iodide of 
 potassium had been administered with the object of 
 clearing up the diagnosis by the exclusion of the 
 presence of any chronic contagious disease.* In my 
 protocol I stated that in my opinion the disease was 
 cancer, pointing out, however, that in the absence of 
 microscopic evidence such a diagnosis could not be 
 made with certainty. I therefore recommended that as 
 soon as the oedema had disappeared, a small piece of 
 
 * On the principle expressed in the old axiom Naturam 
 morbi osteiidit ao'atio.
 
 70 Tlie Fatal Illness of Frederick the Noble. 
 
 the new growth should be removed through the mouth 
 and submitted to Professor Virchow, on whose report 
 as to its nature any future course of action should 
 be based. 
 
 Co7iference luith Prince William. — Whilst we were 
 discussing the case from every side, we learned that 
 Dr. Moritz Schmidt had come to San Remo with 
 instructions from the Emperor to draw up a report on 
 the case of the Crown Prince. We accordingly 
 invited him to be present at the remainder of the 
 consultation. In the evening Prince William, who 
 had by this time arrived, desired that all the physicians 
 and surgeons in attendance should be present at a 
 conference in his room in the hotel. We had only 
 been there a few minutes when the Crown Prince sent 
 for me. I am not therefore in a position to say 
 what passed at this meeting, but I understand that 
 the chief subject of discussion was who should per- 
 form tracheotomy if that operation became necessary. 
 
 Dr. Schmidts Opinion. — The next day a further 
 consultation took place at the Villa Zirio, in which 
 Dr. Schmidt, by permission of His Imperial Highness, 
 took part. On this occasion Professor von Schrotter, 
 without explaining why he did so, receded from his 
 former position and advised against any external 
 operation being undertaken, except tracheotomy, 
 when the necessity for it should arise. Dr. Krause 
 and myself adhered to the views we had already 
 expressed. Dr. Schmidt put forward very strongly 
 the idea that the disease might be the result of an 
 infection which had remained in the system for many 
 years, and urged that large doses of iodide of potas- 
 sium should be given. Professor von Schrotter here 
 interrupted Dr. Schmidt rather warmly, saying, that 
 such a notion was " an old wife's tale " {altes Weiber- 
 geschwdtz). Dr. Krause, whilst allowing that the 
 balance of evidence was altogether against Dr. 
 Schmidt's view, said there could be no harm in try- 
 ing the effect of the drug which had been proposed.
 
 Dr. Schmidt's Opinion. 71 
 
 To this Schrotter and I assented, though neither of 
 us had the least belief in the theory on which the 
 suggestion was based. I may mention here that 
 before Professor von Schrotter left San Remo, I 
 again spoke to him on this subject, and he told me 
 that he had only agreed to iodide of potassium being 
 given, because no external operation was going to be 
 done. Had such a measure been contemplated he 
 assured me that he would not have sanctioned the 
 administration of that remedy. 
 
 At this consultation it was agreed that a statement, 
 setting forth the advantages and disadvantages of 
 excision of the larynx, both partial and complete, 
 should be drawn up and submitted to tac Crown 
 Prince, to whom the decision as to the course to be 
 adopted should be left. I thought it better that the 
 statement should be drawn up by a physician abso- 
 lutely free from bias in the matter than by one who 
 like myself had throughout the case shown himself 
 opposed to severe measures, and at my request 
 Professor von Schrotter was good enough to under- 
 take the preparation of this document. The results 
 of these operations will be found set forth in 
 Section III, Tables II and III in this work. A short 
 bulletin was next drawn up, which it was understood 
 was exclusively for the information of the Emperor. 
 In this we expressed the belief that the disease from 
 which the Crown Prince was suffering was cancer. 
 In signing this document both Mr. Hovell and I 
 considered that we did so subject to the reservation 
 indicated in my special protocol of November 9th. 
 At this meeting it was also agreed that we should 
 formally make the Crown Prince acquainted with our 
 views at a personal interview. I requested Professor 
 von Schrotter to be our spokesman on the occasion, 
 because where a communication of such importance 
 had to be made, and a definite meaning had to be 
 conveyed in carefully chosen words, it seemed best 
 that His Imperial Highness should be addressed in
 
 72 TJie Fatal Illness of Frederick the Noble. 
 
 his native language. I was afraid that if I myself 
 undertook this delicate task it might afterwards be 
 said that I had not made the full gravity of his 
 position clear to the illustrious patient, and had 
 in this way influenced his decision as to future 
 treatment. 
 
 The Diagnosis Communicated to the Crozvn Prince. 
 — Professor von Schrotter discharged his unpleasant 
 duty with great tact and judgment in the presence 
 of the Crown Princess and all the doctors. His 
 Imperial Highness remained standing while the 
 Professor was speaking, and received the terrible 
 communication without any emotion. He was the 
 calmest person in the room. Though Schrotter did 
 not use the word " cancer," he made it perfectly clear 
 to the Crown Prince that that was what we believed 
 him to be suffering from. I am absolutely sure that 
 His Imperial Highness was under no misapprehension 
 on the subject. 
 
 The Crown Princes Decision. — We then withdrew, 
 after placing the statement as to the operations on 
 the larynx in the hands of the Crown Prince. In the 
 course of a few minutes we received a communication 
 from His Imperial Highness, written with a perfectly 
 steady hand, stating that he declined to have his 
 larynx excised, but would submit to tracheotomy 
 should it become necessary. It was then agreed 
 that this operation should, when the time came, be 
 entrusted to Professor von Bergmann, unless difficulty 
 of breathing came on suddenly, when it would have 
 to be done by some one on the spot. Bergmann was 
 selected, not because tracheotomy in a grown-up 
 person suffering from intrinsic disease of the larynx 
 is an operation of any particular difficulty, but 
 because, as he had already been in attendance on the 
 illustrious patient, it seemed right that he should do 
 whatever had to be done in the way of surgery. 
 
 Publication of our Secret Repo7't. — Before separating, 
 we received the most solemn injunctions not to
 
 Publication of Secret Report. 7 3 
 
 divulge our opinions as to the nature of the case 
 or the practical results of our deliberations. The 
 necessity of absolute secrecy on these points was 
 impressed on us both by Dr. Schrader, and by Count 
 Radolinsky. We were given to understand that the 
 German public was to be gradually prepared by a 
 series of cautiously worded bulletins which should 
 make the real state of the case generally known 
 without shocking the feelings of the Crown Prince. 
 This humane intention was, however, frustrated by 
 the immediate publication of our private bulletin to 
 the Emperor in the Official Gazette {Reichsanzeiger). 
 Not only those of the doctors who were still at San 
 Remo, but the officials of the Crown Prince's Court, 
 were amazed on learning this event by telegraph. 
 Whether the occurrence was simply due to a mistake, 
 or whether there was some State reason for publishing 
 the bulletin, I do not profess to know, but it seemed 
 no less strange than unfortunate that so important a 
 statement, made under the seal of the strictest secrecy, 
 should have been at once published with the apparent 
 sanction of the supreme authority, and should thus 
 have been, so to speak, thrust without any disguise 
 or palliation under the eyes of the person chiefly 
 concerned. 
 
 I left San Remo on November i8th, and at my last 
 interview I made a careful examination of the Crown 
 Prince's throat. The following are my notes : — 
 CTThe growth beneath the left vocal cord is smaller 
 and less prominent, and the ulcer on its surface 
 appears also slightly diminished. The oedema on 
 the right side of the larynx has almost disappeared. 
 There is scarcely any movement of the left vocal 
 cord, which is congested and swollen. The right 
 vocal cord is red, and is slightly thickened at its 
 posterior extremity. The small growth below the 
 right vocal cord remains unchanged.^ 
 
 From this date till the middle of December I 
 received a series of reports signed by Dr. Krause and
 
 74 The Fatal Ilbiess of Frederick the Noble. 
 
 Mr. Hovell ; the latter gentleman also sent me 
 private letters containing references to the case, for 
 which of course he is solely responsible. 
 
 Reports from San Remo. — November i8th. — "Congestion 
 of the mucous membrane. It is easy to see the capitiihnn 
 Santorini at the apex of the left arytenoid cartilage ; swelling 
 less, right side free." 
 
 November 20th. — " The ulcerating surface beneath the 
 left vocal cord is less prominent, and the ulcer situated at 
 the posterior part of the left ventricular band is smaller in 
 size. There is slight movement of the left arytenoid cartilage. 
 In other respects the appearance is the same. The voice is 
 still rough, but clearer." 
 
 Mr. Hovell further reported to me that Dr. Bramann, 
 Chief Assistant to Professor von Bergmann, had been 
 sent to San Remo by desire of the Emperor in order 
 to be in readiness to perform tracheotomy, should it 
 be necessary to do it suddenly. 
 
 November 28th. — " There is now no ulceration to be 
 seen. The part of the growth which first appeared is 
 smaller and smoother. There is now a cicatrix on the' 
 portion of the ventricular band formerly occupied by an 
 ulcer. The congestion of the larynx and the swelling of 
 the left side are less. The right vocal cord is less swollen 
 but still congested, especially on the processus vocalis, in 
 which portion it is a little more swollen." 
 
 November 29th. — " During the last week or ten days the 
 enlargement of the submaxillary glands has materially 
 diminished, especially on the left side, and these glands are 
 now hardly to be felt," 
 
 On December ist Mr. Hovell wrote to me as 
 follows : — 
 
 _,J'A11 the local symptoms ameliorated. Dr. Bramann, 
 who was very anxious to make a laryngoscopic examination, 
 was allowed by His Imperial Highness to do so. He has 
 evidently not had any practice in the use of the instrument, 
 and certainly did not see much, if he saw anything at all."
 
 Bramann as a Laryngoscopist. 75 
 
 The joint reports of Krause and Hovell then 
 continue : — 
 
 December 4th. — " During the last week the swelHng of 
 the left side of the larynx has diminished to such a degree 
 that the left ventricular band is seen at times to vibrate. 
 The yellowish prominent ridge on the margin of the left 
 ventricular band has now again diminished, although it was 
 rather more prominent a few days ago. The congestion of 
 the larynx has, on the whole, been less." 
 
 December nth. — ''A few days ago two small nodules 
 appeared on the edge of the left ventricular band, near its 
 anterior part. They have increased in size, and have united 
 to form one growth, which has been increasing rapidly, and 
 now occupies the posterior three-fourths of the left ventri- 
 cular band." 
 
 Bramann as a Laryjigoscopist. — On this subject 
 Mr. Hovell wrote to me as follows : — " Three days 
 ago Bramann again tried to use the laryngoscope, 
 and caused the Crown Prince a good deal of an- 
 noyance. He introduced the mirror into the throat 
 very fairly, but had very great difficulty in focussing 
 the light. The luminous disc was seen to be bobbing 
 about everywhere except on the laryngeal mirror. 
 At last, however, he did get it on, but then he 
 seemed to forget that the mirror was in the patient's 
 throat, and kept it there exactly as he might have 
 done on a papier mdche model. I am sure, however, 
 he did not see much, as, after he had got the light, 
 he slanted the mirror in such a way that it only 
 reflected the back of the tongue. I had taken the 
 precaution beforehand to tell Schrader what really 
 was present, as I knew he would * coach' Bramann 
 on the subject. The latter, however, thought that he 
 would make some discoveries for himself, and I 
 understood from Krause, that he (Bramann) said 
 that the tumour extended above the thyroid carti- 
 lage,! ! After Bramann's attempted investigation I 
 told the Crown Prince that I thought it was not only 
 useless for him to have his throat examined by that
 
 'J 6 The Fatal Illness of Frederick the Noble. 
 
 surgeon, but that it might give rise to erroneous 
 statements being circulated respecting his condition. 
 I reminded His Imperial Highness that Dr. Landgraf 
 had sent most ridiculous statements to Berlin, and I 
 said Bramann might do the same. I finally observed 
 to the Crown Prince, ' I can see that Dr. Bramann is 
 not accustomed to use the laryngoscope.' * Yes,' 
 said His Imperial Highness, * you can see it, and I 
 can feel it ! '" 
 
 The following is the report of Dr. Krause and Mr. 
 Hovell on December 13 : — "The growth has increased 
 during the last two days, especially on its inner sur- 
 face, which now forms an irregular projection towards 
 the mesial line. This morning the left ventricular 
 band is slightly swollen at its anterior part. The 
 general congestion of the larynx has increased." 
 
 About this time I pointed out in England that the 
 treatment which I had carried out had been unani- 
 mously agreed upon by all the physicians and sur- 
 geons in attendance on His Imperial Highness, after 
 Virchow had published his report, and that it was 
 not merely based on my own diagnosis. The cir- 
 cumstances which called forth this definition of my 
 position, was an annotation in the British Medical 
 Joiirnal of December loth, 1887. The following is 
 an extract from a letter which I published in the 
 same journal on December 17th : — 
 
 " When I arrived in Berlin, I gave it as my 
 opinion that the appearances were negative ; that 
 is, that they were compatible with the growth being 
 either malignant or benign. I therefore suggested 
 that a portion should be removed per vias naturales^ 
 for microscopical examination, and the treatment 
 which I finally recommended was based on the 
 clinical aspects of the case,////j- the results of Professor 
 Virchow' s microscopical examination. 
 
 "I may add that, as after Dr. Virchow had made his 
 report, the proposed line of treatment was unanimously
 
 Bramann as a Laryngoscopist. 77 
 
 agreed to by those present at the consultation, all my 
 colleagues were equally responsible for the views 
 entertained at that period. There is no reason, there- 
 fore, why I should be singled out as having formed a 
 * clinical opinion,' or indeed as having arrived at any 
 opinion different from that of my German colleagues. 
 The only difference which existed was the different 
 opinion held by my coiifr-hes before my removal of a 
 portion of the growth, and [that which they enter- 
 tained after] * the reception of Dr. Virchow's report 
 thereon. — I am, etc., 
 
 " MoRELL Mackenzie." 
 
 ^^ December i2thy 
 
 * This sentence, though in the original, was accidentally 
 omitted by the printer.
 
 yS The Fatal Illness of Frederick the Noble. 
 
 
 CHAPTER VI. 
 
 SAN REMO— SUSPENSE. 
 
 / am Recalled to San Remo. — On December 12th 
 further rapid development of the vegetations on th( 
 left ventricular band having taken place in the cours( 
 of a few hours, it was feared that more alarming mani 
 festations might follow, and I was again hurriedly 
 summoned to Italy. I arrived at San Remo 01 
 December 15th, and was pleased to find a markec 
 improvement in the condition of the Crown Prince ai 
 compared with what it had been a month before. Th< 
 swelling of the submaxillary glands had subsided, anc 
 no trace remained of the inflamed and ulcerating 
 tumour below the left vocal cord except a smooth 
 red scar. Covering the posterior half of the left 
 ventricular band, however, were some small white 
 vegetations, which appeared here and there to b< 
 undergoing ulcerations. Mr. Hovell informed me the 
 these vegetations had been much larger on the 13th 
 when they seemed to be hourly increasing in size ; 
 they had, however, begun to slough on the evening of 
 the 14th. The day after my arrival I found that a 
 considerable further diminution had taken place both 
 in their size and number. On that day I had the 
 honour of accompanying the Imperial family to 
 Ospedaletti, and I noticed with some surprise that 
 the Crown Prince was the most vigorous walker in 
 the party. His Imperial Highness complained to 
 me of the conduct of Dr. Moritz Schmidt, who, as 
 he told me, had thought fit to give a lecture on his 
 case at Frankfort after his return from San Remo, 
 in which he had openly stated that the disease from
 
 Recalled to San Reuio. 79 
 
 which the illustrious patient was suffering was of 
 " contagious " origin. The Crown Prince expressed 
 the greatest annoyance at Dr. Schmidt's indiscretion, 
 and begged me to contradict the statement, for which I 
 may here say there was not the shadow of a foundation. 
 
 A Favourable Turn. — As the laryngeal affection 
 seemed to be in a somewhat active state, I deter- 
 mined to remain in the South for a little time, and on 
 December 17th I went for a short trip to Algiers, 
 returning to San Remo on the evening of the 27th. 
 I found that the vegetations on the left ventricular 
 band were now very slight, and limited to its posterior 
 part ; there was, however, a little pufifiness at the 
 upper part of the band where it joined the ary-epi- 
 glottic fold, and the remains of the subglottic growth 
 projected rather more towards the glottis. The 
 larynx was rather congested, and could be felt from 
 the outside of the neck to be somewhat swollen on 
 the left side. On the whole, however, the condition 
 of the august patient was much better than it had 
 been at the time of my first visit to San Remo. 
 
 After my return home I continued to receive 
 reports from Dr. Krause and Mr. Hovell as to the 
 progress of the case from time to time. On January 
 2nd, in addition to the swelling below the right vocal 
 cord, some tumefaction was noticed at the front part 
 of the corresponding ventricular band, whereby the 
 anterior extremity of the underlying cord was hidden 
 from view. The congestion of the larynx and trachea 
 had increased, and there was a copious secretion of 
 mucus. On January 12th all that remained of the 
 growth on the left ventricular band was a little thick- 
 being which was fast diminishing. Since the date of 
 the previous report there had been rather more swell- 
 ing of the left side of the larynx, together with 
 greater congestion, and a more profuse discharge of 
 mucus. All these local symptoms, however, were 
 said to be subsiding, and the illustrious patient's 
 general health was quite satisfactory.
 
 8o The Fatal Illness of Frederick the Noble. 
 
 A Change for the Worse. — Almost immediately 
 after this one of those sudden exacerbations of the 
 symptoms occurred which formed so remarkable a 
 feature of the case. I give below the detailed reports 
 which I received from Dr. Krause and Mr. Hovell, as 
 they supply an accurate picture of the clinical inci- 
 dents from day to day, and show in a very striking 
 manner the suddenness of the change which took 
 place between January 13th and 14th : — 
 
 Januar)' 13th, 1888. — "The thickening on the left 
 ventricular band, which marks the seat of the last 
 growth, has almost disappeared. The swelling of 
 both ventricular bands is decidedly less, and that 
 beneath the right vocal cord has disappeared, except 
 at its anterior part, where it still remains to a shght 
 extent. The congestion of the larynx and trachea is 
 less. There is no glandular enlargement." 
 
 January 14th, 8.30 a.m. — " This morning a whitish- 
 grey prominence has been observed beneath the left 
 vocal cord, narrowing the lumen of the air-passage 
 and producing slight stridor. Temperature, qq'S'' 
 Fahrenheit. Pulse, 94." 
 
 January 14th, 9 p.m. — " During the day there has 
 been a hoarse cough, but unaccompanied with much 
 expectoration. Breath fetid. Temperature, 10 1 '8° 
 Fahrenheit. Pulse, 96." 
 
 January 15th, 10 a.m. — " This morning the whitish 
 prominence is seen to have increased in size since 
 last night, and to now extend two-thirds across the 
 lumen of the air-passage. The glands on the right 
 side, beneath the jaw, are enlarged. Temperature, 
 ioo-8^ Fahrenheit. Pulse, 78." 
 
 January 15th, 9 p.m. — "This evening the whitish- 
 grey substance above referred to is seen to be com- 
 posed of some soft substance, which moves to and 
 fro with forcible inspiration and expiration. Respi- 
 ration less interfered with than in the morning. 
 Glandular enlargement somewhat increased. Cough 
 less frequent, but more expectoration. Temperature, 
 102° Fahrenheit."
 
 A Change for the Worse. 
 
 January i6th, 8.30 a.m. — ''Has passed a quiet 
 night. Respiration free. Membrane still adhering 
 to left side, but projecting less into lumen of air- 
 passage. Less foetor. Temperature, 99*8° Fahren- 
 heit." 
 
 January i6th, 9 p.m. — " Condition much the same. 
 Temperature, 100° Fahrenheit." 
 
 January 17th, 9 p.m. — "About five o'clock this 
 morning, after a violent fit of coughing, a slough, 
 about three and a half centimetres in length and one 
 centimetre wide, came out. Temperature, 99^ Fahren- 
 heit." 
 
 January i8th, 9 p.m. — "The expectoration, since 
 the slough came away, has been tinged with blood. 
 Temperature, 99*4° Fahrenheit." 
 
 The slough was sent to Professor Virchow for 
 examination, and the following is that distinguished 
 pathologist's report thereon. 
 
 Report of the Examination of the Slough 
 FROM THE Larynx of His Imperial Highness 
 The Crown Prince of Germany. By Pro- 
 fessor Rudolf Virchow.* 
 
 "On the morning of January 26th, 1888, Dr. 
 Wegner brought me a sealed box, with a 
 letter dated January 23rd, from Dr. Schrader 
 from San Remo. It was accompanied by a 
 report dated January 17th, from Dr. Krause, 
 respecting a large piece of tissue which had 
 been expectorated on the same day from the 
 larynx of His Imperial Highness the Crown 
 Prince. 
 
 "The portion sent was the whole of the 
 matter expectorated, with the exception of six 
 small particles removed by Dr. Krause for 
 examination [by Dr. Heryng of Warsaw, then 
 
 * The above is taken from the Lancet^ February iSth, 1888. 
 
 G
 
 82 The Fatal Illness of Frederick tJie Noble. 
 
 staying at San Remo] * in the fresh state. 
 The piece of tissue was in a sealed bottle con- 
 taining absolute alcohol. In addition to the 
 large portion referred to, there were also two 
 other separate and somewhat harder pieces — a 
 larger and a smaller. The former, according 
 to Dr. Krause, was originally a part of the 
 principal mass. The examination offered great 
 difficulties, the nature of which could not have 
 been anticipated either from the form or the 
 appearance of the pieces submitted for investi- 
 gation. The large mass greatly resembled 
 certain portions of imperfectly masticated 
 pieces of meat, which are sometimes rejected 
 in vomiting after being swallowed. This view 
 seemed to derive support from the presence 
 here and there of small yellow and brownish 
 particles of fine cellular vegetable structure, 
 and from the existence in the innermost por- 
 tion of the large piece (expectorated) of an 
 abundance of elastic fibres. 
 
 " In consideration, however, of the very pre- 
 cise information conveyed by Dr. Krause to the 
 effect that the substance had been observed 
 before its separation (from the larynx) extend- 
 ing from beneath the left ventricular band from 
 the middle to the anterior angle, and also 
 below the glottis, and even round below the 
 anterior part of the right vocal cord, there 
 could be no doubt, on further examination, that 
 we had to deal with a large slough sponta- 
 neously separated from the inner surface of the 
 larynx, and not with a purely exudative 
 (fibrinous) mass. In the substance, which, 
 according to the report of Dr. Krause, when 
 first expectorated, measured three and a half 
 centimetres in width, whilst at the thinner end 
 
 * The sentence between brackets was not contained in the 
 original report.
 
 Examination of Slough from Larynx. 83 
 
 it was half a centimetre in width (its thickness 
 being four milHmetres), and at the thicker end 
 one centimetre wide, a small smooth semi- 
 circular spot in its long diameter could be seen. 
 All the rest of the surface was occupied by 
 long and very closely arranged fibres. Although 
 there was no epithelium on the smooth spots 
 and no glands beneath it, it cannot be doubted 
 that this was the free surface of the mucous 
 membrane. For beneath it could be seen 
 microscopically a thin layer of almost homo- 
 geneous connective tissue and a great mass of 
 elastic fibres. Beneath this there was deeper 
 down a very thick layer, consisting especially 
 of tubules with granular amorphous contents. 
 From this thick layer originated the long fibres 
 observed with the naked eye. It was not once 
 possible to recognise in these tubular layers 
 and transverse stripes, but they seemed to 
 contain only amorphous matter, in which, on 
 more minute examination, numerous micrococci 
 were found. Here and there numerous, but 
 very small, clear blown bodies or crystal-like 
 deposits were observed. Nevertheless, I have 
 no doubt that these tubular layers and fibres 
 are primitive muscular fasciculi, which through 
 a necrotic process have been destroyed. The 
 slough must therefore be regarded as a necrotic 
 and decomposed part of the larynx, which in 
 parts has been separated from the surface to a 
 depth of four millimetres. The very rich 
 muscular structure could only be attributed to 
 the thyro-arytenoid muscle. 
 
 " I could not determine what kind of morbid 
 process had caused the gangrene, nor what 
 kind of process had produced the demarcation 
 and exfoliation of the substance. Neither 
 ■pus-corpuscles nor granulation-cells could be 
 distinguished, and, in fact, in most places there 
 
 G 2
 
 84 The Fatal Illness of Frederick the Noble. 
 
 was nothing of a heterogeneous nature to be 
 discovered. Only in the larger (of the two 
 smaller pieces), which had been cut off the 
 main mass by Dr. Krause from a somewhat 
 hard spot, and which had the form of a flat 
 wart on section with the naked eye, a central 
 whiter and an external and opaque rather 
 thick covering could be distinguished. In 
 every microscopic section so - called nests 
 {Znnebeln) of epidermoid al cells, for the most 
 part of a homogeneous character, were seen. 
 As a rule, these nest-cells were in the most 
 external layer or in that lying immediately 
 beneath it. The external layer had also most 
 likely consisted of an epidermoidal formation, 
 though these cells could only be here and there 
 partially distinguished. I could not find 
 epidermoidal cells in the deep parts, and dis- 
 tinctly isolated alveoli were nowhere to be dis- 
 covered, in spite of assiduous researches. 
 
 " These examinations will be continued, 
 and if any further result is obtained I will send 
 a report instantly. 
 
 (Signed) " Rudolf Virchow, 
 
 *' Director of the Pathological Institute^ 
 ''January 2()ih, 1888." Berlijl. 
 
 Professor Virchow subsequently sent several private 
 letters, in which, however, he did not add anything 
 to the original report as given above, but he stated 
 that he had not been able to find cartilage in any 
 portion of the slough. The notes of Dr. Krause and 
 Mr. Hovell continue as follows : — 
 
 January 22nd. — '* During the last few days the 
 swelling beneath the right vocal cord has reappeared, 
 but the respiration is not interfered with. There has 
 been but little expectoration during the last twenty- 
 four hours, and no blood is now mixed with the
 
 The Cause of the Trouble. 8 5 
 
 mucus expelled. The glands are still enlarged \ the 
 temperature has been normal since last note." 
 
 January 25 th. — '' Since the last feverish attack some 
 general swelling has remained beneath the vocal 
 cords, and this has caused the voice to be less clear 
 than it was previously. The upper part of the 
 larynx has been only slightly congested for some 
 time past, and a very slight thickening now only 
 remains to show the seat of the last growth." 
 
 The Cause of the Trouble. — This attack was due to 
 the local irritation set up by the presence of the slough 
 which was practically a foreign body in the larynx, 
 and to the systemic disturbance associated with the 
 efforts of the part to get rid of the offending substance. 
 After the extrusion of the fragment of dead tissue 
 the feverish symptoms subsided, and the condition of 
 the larynx became comparatively comfortable. It 
 was obvious, however, that the local disease was 
 entering on a phase of fresh activity, and this naturally 
 made the watchful observers in attendance on the 
 Crown Prince somewhat anxious as to the future. 
 It was therefore decided on January 27th to summon 
 me again.
 
 S6 The Fatal Illness of Frederick the Noble. 
 
 CHAPTER VII. 
 
 SAN REMO — THE TRACHEOTOMY. 
 
 Further Developments. — On arriving at San Remo 
 on the afternoon of January 29th, I found the Crown 
 Prince looking fairly well, but much thinner. I made 
 a lar}'ngoscopic examination in the presence of Dr. 
 Krause and I\Ir. Hovell. The growth at the posterior 
 extremity of the left ventricular band had disap- 
 peared ; but lower down I saw a red, slightly raised 
 scar, extending parallel with but below the left vocal 
 cord along its whole length. Towards the middle of 
 the cord there was a small patch about three milli- 
 metres in length, and one millimetre in depth, which 
 did not appear to be completely healed. Beneath the 
 right vocal cord there was a swelling occupying the 
 middle and anterior portion of the subglottic region. 
 
 After the consultation, Dr. Schrader represented to 
 me that Dr. Bramann was anxious to examine the 
 illustrious patient for himself, and asked me to invite 
 him to take part in our consultation the next day. 
 Whilst pointing out that Dr. Bramann was at San 
 Remo, not as one of the attending physicians, but 
 solely for the purpose of performing tracheotomy, 
 should the necessity for that operation arise too 
 suddenly to allow Professor von Bergmann to be sent 
 for, I said that I was perfectly willing that he should 
 see the Crown Prince if His Imperial Highness did 
 not object. Later in the day, having obtained the 
 consent of the august patient, I called on Dr. Bra- 
 mann and invited him to be present at the consulta- 
 tion on the following morning. He accordingly came, 
 and I watched him make his examination. It was 
 obvious that he had had little or no experience in the
 
 Inexperienced L aryngoscopists. 8 7 
 
 use of the laryngoscope ; but he tried to supplement his 
 imperfect observations with the mirror by percussion 
 of the larynx — a mode of examination which has been 
 abandoned by modern physicians as utterly useless. 
 
 Inexperienced Laryngoscopists. — I may here take the 
 opportunity of saying, that as nothing is more irri- 
 tating, even to a healthy throat, than attempts at 
 laryngoscopic examination made by a 'prentice hand, 
 I consider that I should have been amply justified in 
 declining to allow the Crown Prince to be made the 
 subject of such rudimentary efforts. Dr. Landgraf s 
 examinations, as has been said, were sufficiently 
 trying to the illustrious patient, but the throat at that 
 time was comparatively well. When Dr. Bramann 
 used the laryngoscope on the Crown Prince, matters 
 were very different, and it was essential that every 
 cause of irritation to the swollen and ulcerated 
 parts should be as far as possible avoided. It can 
 easily be imagined that the coughing and retching 
 produced by awkward handling of the mirror would 
 be in the highest degree mischievous to the diseased 
 larynx. This is so true that I myself have been, 
 although quite unjustly, blamed for making too fre- 
 quent examinations. Yet it is now actually made a 
 ground of serious complaint against me, that I tried 
 to prevent the future Emperor of Germany from being 
 made a subject for the experiments of beginners ! It 
 was one of the most distressing features in this case 
 that the patient's very importance, from a political 
 point of view, tended to make regard for his personal 
 feelings an altogether secondary consideration with 
 'many people. Had he been a private gentleman, I 
 should never have allowed him to be subjected to ex- 
 aminations which could be of no earthly use, and which 
 there is too much reason to fear did positive harm. 
 I may add, that no private patient I have ever met 
 with would have submitted to them. 
 
 As according to the reports of Dr. Krause and 
 Mr. Hovell there had not been much change in the
 
 The Fatal Illness of Frederick the Noble. 
 
 1 
 
 local symptoms during the previous two or three 
 days, I took the opportunity of going to Barcelona to 
 see a patient from whom I had received several 
 urgent messages. On my return to San Remo on 
 February 7th I found that the affection had made 
 rapid progress in the interval. The swelling of the 
 left side of the larynx had increased, and there was also 
 marked tumefaction below the right vocal cord. There 
 was now very slight but distinct noise in inspiration, 
 especially when the august patient was talking. In 
 quiet respiration, however, when he was silent, there 
 was no audible sound. On going upstairs to his room 
 in the evening I noticed that he went quite as quickly 
 as formerly, that is to say quicker than most people, 
 but he was slightly out of breath when he reached the 
 top landing, and I advised him to walk up more 
 slowly in future. I should mention that the rooms 
 on the ground floor were very lofty, so that the ascent 
 up the stairs was considerable. On enquiry, I found 
 that the Prince was still sleeping with only one 
 pillow under his head, and I recommended him to 
 use one or two more pillows. This will show how 
 very slight the difficulty of breathing was. The 
 illustrious patient complained of headache, which 
 Dr. Schrader attributed to want of oxygen — com- 
 mencing asphyxia in fact ! I prescribed a ^ nerve 
 sedative which quickly relieved the neuralgia. 
 
 Urgent Symptoms. — On the morning of the 8th 
 we found that His Imperial Highness had not had a 
 very good night ; the breathing was about the same. 
 At the evening visit the illustrious patient said he 
 felt very well. I sent word to Dr. Bramann that I 
 should be glad if he would take part in the consultation 
 the next morning. On the 9th we found that the 
 Crown Prince's rest had been much broken by fits 
 of coughing, but he said he felt very well in spite 
 of having had a bad night. On making a laryngo- 
 scopic examination, I found that the whole of the left 
 side of the larynx down to the level of the left vocal
 
 Tracheotomy decided on. 89 
 
 cord below the epiglottis was very much swollen and 
 inflamed. During deep inspiration the sub-glottic 
 region on the right side was seen to be very red and 
 swollen ; in fact the mucous membrane in this 
 situation formed a distinct broad-based tumour about 
 five-eighths of an inch in diameter, which considerably 
 diminished the lumen of the lower part of the larynx. 
 After we left, the illustrious patient had breakfast, 
 and ordered the carriage for a drive at ten o'clock. 
 He stepped briskly into his carriage, and was much 
 disappointed when he heard that a mistake had been 
 made in bringing it round, and that I had left direc- 
 tions that it would be better for him not to go out. 
 
 Tracheotomy decided on. — After seeing the Crown 
 Prince we proceeded to discuss the situation. The 
 disease had burst into renewed activity so suddenly, 
 and the swelling had encroached on the breath-way 
 to so great an extent in the course of a single night, 
 that I thought there would be the gravest risk in 
 postponing the establishment of an artificial passage 
 even for twenty-four hours. I therefore urged that 
 tracheotomy should be performed at once. In this I 
 was supported by Dr. Krause and Mr. Hovell, who 
 of course were in a position to estimate the pressing 
 nature of the case. Dr. Bramann, who from inexperi- 
 ence in this particular department could not realize 
 the condition, was strongly in favour of postponing 
 the operation till Professor von Bergmann could arrive. 
 Dr. Schrader, who, even before I left for Spain, was 
 anxious that tracheotomy should be done, and who 
 on my return from that country pressed for the per- 
 formance of the operation without delay, now most 
 anxiously pleaded that we should wait till Bergmann 
 arrived. He said, " It would make a very bad im- 
 pression at Berlin if the operation were done by any 
 one else than Bergmann," and seemed to fear that he 
 would get into disgrace if the arrival of that surgeon 
 was not awaited. So strong a sense, however, had I 
 of the danger of delay that I felt compelled to say
 
 90 The Fatal Illness of Frederick the Noble. 
 
 plainly that if the operation were postponed I should 
 decline all further responsibility, and that those who 
 opposed its performance would be answerable for the 
 Crown Prince's life. On this Schrader and Bramann 
 gave way, begging, however, that ice compresses 
 should be applied to the neck for three or four hours 
 in order to see if the inflammation showed any ten- 
 dency to subside. I consented to this, and imme- 
 diately after our consultation I paid a visit to the 
 Crown Prince, and ordered the ice-compresses, but 
 told him that I was afraid that tracheotomy would 
 have to be performed in a few hours. He said, 
 " I feel perfectly well, if it were not for the slight 
 difficulty in breathing ; but if you say the opera- 
 tion must be done, I have no objection." Soon after 
 twelve o'clock, having noticed that the difficulty of 
 breathing was increasing, I informed Dr. Bramann 
 that I thought it would not be safe to put off the 
 operation much longer, and advised him to visit the 
 illustrious patient again. After he had done so he 
 proceeded to make arrangements for the operation, 
 which was fixed for 3 P.M. 
 
 Shortly before that hour we all assembled at the 
 Villa Zirio, and there was some debate as to whether 
 chloroform should be administered. I am myself 
 opposed to the use of this anaesthetic in such cases, as 
 I think it increases the danger of the operation, and 
 the pain of the incision can be almost entirely 
 deadened by freezing the skin. Occasionally, in the 
 case of a very nervous patient, I have found it neces- 
 sary to administer laughing-gas, followed by ether, 
 but I never use chloroform. Dr. Schrader, however, 
 explained to me that as Bramann had never performed 
 tracheotomy without chloroform, it would try his nerve 
 very severely to dispense with it in such a case as the 
 present. I therefore urged the Crown Prince to con- 
 sent to be anaesthetized, and, after discussing the matter 
 at some length, His Imperial Highness said, " If you 
 approve of it, Sir Morell, I will take chloroform."
 
 The Operation, 91 
 
 The Operation. — When everything was ready, the 
 Crown Prince passed through an adjoining room into 
 his ordinaiy sitting room, where it was arranged that 
 the operation should be performed. The bed was 
 placed opposite one of the windows, so that there 
 was an excellent light. Bramann proceeded to give 
 chloroform, but as soon as the Crown Prince had 
 become unconscious, the administration was continued 
 by Dr. Krause, whilst I kept my finger on the pulse 
 at the left wrist. Shortly after Dr. Bramann had 
 made his first incision, I noticed that the pulse had 
 become very weak, and that the face was blanched ; 
 in fact there were evident signs of cardiac weakness. 
 On raising the eyelid the pupil was seen to be widely 
 dilated. The chloroform was suspended for a minute 
 or two, when the pulse became fairly good again, 
 and the operation was proceeded with. After this 
 incident Dr. Bramann seemed to become a little 
 fiiurried, though not to such an extent as to prevent 
 him from operating with skill. In opening the wind- 
 pipe, however, I noticed that he made his incision a 
 little to the right instead of in the middle line. The 
 deviation appeared to me so slight at the time that 
 I attached no importance to it. After opening the 
 trachea, instead of at once plunging in the canula as 
 is usually done by English surgeons, Bramann held 
 aside the two sides of the wound for a minute or two 
 until the bleeding had ceased, and then inserted a 
 very large and long tube. I will frankly own that 
 the delay in introducing the canula seemed to me an 
 improvement on the ordinary plan of plunging the 
 tube into the windpipe as soon as it is opened — a pro- 
 ceeding which usually sets up severe spasm and cough. 
 
 When the operation was completed I congratulated 
 Dr. Bramann on his success. I have already said that 
 in a case like that of the Crown Prince tracheotomy 
 is not, as a rule, a matter of any difficulty, but con- 
 sidering that the young surgeon was operating on his 
 future Sovereign, and that he was not unnaturally
 
 92 The Fatal Illness of Frederick the Noble. 
 
 somewhat unnerved by the catastrophe so nearly 
 caused by the chloroform, I think he did his work 
 very well. On leaving the room, I said to ]\Ir. Hovell, 
 " Did you notice that the trachea was opened a little 
 to the right of the middle line," and that gentleman 
 replied, " I did ; but I should say considerably ^ rather 
 than a little^ * On coming to himself the illustrious 
 patient shook hands warmly with Dr. Bramann, 
 myself, and, I believe, the other doctors. 
 
 As the case here enters on a phase of the highest 
 importance, and as the various episodes must be 
 related in detail in order to make the general situation 
 intelligible, I propose to continue the narrative in the 
 form of a daily record. The facts were all duly re- 
 corded in my note-book at the time, and the following 
 pages are little more than a reproduction of my notes, 
 with a running commentary to make their purport 
 clear to ordinary readers. From the day of operation 
 till the Emperor's death I was never away from him 
 for more than a few hours. 
 
 Dr. Bramann' s Cannla. — February 9th. — I was very 
 anxious when I saw the kind of canula that Dr. 
 Bramann had inserted into the trachea ; it was very 
 large, and also the longest tube I had ever seen 
 
 * I should have been glad to have avoided this subject, 
 had it been possible, but unfortunately soon after the operation 
 took place, the fact that the opening was made to the right 
 of the median hne was mentioned in the British Medical 
 Journal, and is referred to at considerable length by the 
 writers of the pamphlet entitled ' Die Krankheit der Kaiser 
 Friedrich des Dritten.' When I first saw the statement in the 
 British Medical Journal, both I and my colleague, l^Ir. Mark 
 Hovell, were much surprised, and greatly regretted that the facts 
 had got into print. I am permitted by Mr. Hovell to state that, 
 on sifting the matter, he ascertained that the account got inserted 
 in the following way : Mr. Mark Hovell wrote a description of 
 the operation to his lamented father, not intending it to be made 
 use of in the press. Unfortunately IMr. Hovell, sen., described 
 the details to a gentleman connected with the British Medical 
 Journal, but I am quite sure that he had no idea that the facts 
 described by him would be published.
 
 Dr. Bramaniis Caimta. 
 
 93 
 
 inserted, immediately after the performance of tra- 
 cheotomy. It is true that in certain cases where 
 disease creeps down the trachea longer tubes have to 
 be inserted from time to time, but I have never seen 
 a case in which so long a tube was used from the 
 first. Besides its unusual size and length, its upper 
 orifice was considerably larger than the lower, so that 
 
 Fig. 7. — Bramann's canula ; from a tracing of the original instrument. 
 On comparing it with Fig. 8, which is the drawing of an ordinary 
 full-sized canula, the extraordinaiy size and curve of Bramann's tube 
 will be at once evident. 
 
 it had somewhat the shape of a funnel. Any prac- 
 tical surgeon looking at the annexed drawing (Fig. 7), 
 which was actually traced from the tube used, will see 
 that the instrument was exceptional in every respect, 
 and, widely differing from the ordinary full-sized 
 canula (Fig. 8), was eminently calculated to cause 
 irritation of the trachea ; and it will be seen how 
 the lower and back part of the instrument caused a
 
 94 The Fatal Illness of Frederick the Noble. 
 
 wound in the posterior wall of the trachea by pressing 
 on that point. 
 
 February loth. — The Crown Prince had a disturbed 
 night, and there was a small amount of mucus with 
 cough about every two hours, sometimes oftener. The 
 mucus was thin and pink, as is generally the case 
 directly after tracheotomy. This results from a little 
 blood oozing from the wound trickling down into 
 the windpipe, from which it is ultimately coughed 
 up. Considering that the operation had only been 
 
 Fig. 8. — An ordinar}' full-sized canula, from a tracing. 
 
 performed the day before, I thought the illustrious 
 patient's appetite tolerably good. 
 
 There were now six medical attendants to look 
 after the Crown Prince, and for some time after the 
 operation each of us took his turn at the Prince's 
 bedside. I came on duty at six o'clock every evening 
 and remained until ten ; and though I was not now 
 in charge of the case I paid frequent visits to His 
 Imperial Highness during the day. 
 
 My Report on the Case. — On February lOth. — This 
 evening the illustrious patient expressed a wish that I 
 should issue another official report on his case. I at 
 once set about drawing it up, and two days later for-
 
 My Report on the Case. 
 
 95 
 
 warded it to the principal German and English medical 
 papers. It will be seen that it is a precis of much that 
 has been stated in these pages, but it may perhaps be 
 considered to have a certain historic value. From my 
 
 Fig- 9- — Diagram, showing Bramann's canula (half size) m situ, a, the 
 gullet ; b, the larynx with the trachea below. The canula is seen cutting 
 into the back wall of the trachea as occurred in life. 
 
 own point of view, it is of some importance, inasmuch 
 as some months before the fatal issue of the case, it 
 clearly defined my position in the spring and summer 
 of 1887. 
 
 The Case of His Imperial 
 Crown Prince of Germany.* 
 Mackenzie. 
 
 Highness the 
 By Sir Morell 
 
 *' His Imperial Highness the Crown Prince 
 of Germany having expressed his wish that 
 I should now place on record my opinion of 
 his case, the opportunity is afforded of cor- 
 recting some of the statements which from time 
 to time have been inaccurately attributed to me. 
 
 This report is taken from the Lancet, February 18, 1888.
 
 g6 TJie Fatal Illness of Frederick the Nohk. 
 
 The general idea is that I am of opinion 
 that the disease from which His Imperial 
 Highness is suffering is not cancer ;* the view, 
 on the other hand, which I have consistently 
 maintained, is that there nev^er has been any- 
 proof of the existence of cancer. To enter 
 more into detail : When I arrived in Berlin 
 last May I stated to my colleagues that, in 
 my opinion, the appearances seen in the 
 throat were of a negative character — that is 
 to say, that the disease might be either benign 
 or malignant, and that its nature could only 
 be determined by microscopical examination. 
 A portion of the diseased tissue having been 
 taken away by me from the throat of His 
 Imperial Highness, it was submitted to Pro- 
 fessor Virchow, who could not detect in it 
 anything of a malignant nature. Repeated 
 examinations by Professor Virchow of other 
 portions removed by me yielded similar results. 
 
 In the month of July, whilst His Imperial 
 Highness was staying in the Isle of Wight, 
 I pointed out to more than one of his august 
 relatives that the danger that I most dreaded 
 was the occurrence of perichondritis at a future 
 date, and three months later this fear was 
 proved to be well grounded. At the end 
 of October and early part of November 
 entirely fresh symptoms appeared, and at that 
 time the local disease presented an appearance 
 which was consistent with the diagnosis of 
 cancer. It was then impossible to obtain any 
 fresh microscopical evidence in the matter, and 
 I considered it safer accordingly to treat the 
 case as one of a malignant nature. At the 
 same time, however, I drew up and submitted 
 to my colleagues a protocol, in which I stated 
 
 * In this statement the words " cancer, 
 " malignant," are used synonymously.
 
 My Report on the Case, 97 
 
 that although the disease at that moment 
 looked like cancer, I could not agree that the 
 malady was proved to be malignant until a 
 further microscopical examination had been 
 made. The document in which I set forth 
 my views was forwarded to Berlin to be placed 
 in the State Archives. Although the unfavour- 
 able symptoms then present were explicable 
 on the ground of the existence of cancer, yet 
 it was clear to the majority of the physicians 
 at that time in attendance that perichondritis 
 had supervened. 
 
 In the middle of December, however, the 
 unfavourable signs had passed away, and 
 there were no longer any clinical symptoms of 
 cancer. Microscopical evidence on the subject 
 was, however, still wanting. This was fur- 
 nished at the end of January, when a slough 
 was expectorated from the very spot which 
 had presented such a highly suspicious ap- 
 pearance in November. This slough was most 
 carefully and repeatedly examined by Professor 
 Virchow, and the result (which is now pub- 
 lished) again shows that cancer could not be 
 detected. ^ 
 
 To recapitulate. In my opinion, the clinical 
 symptoms have always been entirely com- 
 patible with non-malignant disease, and the 
 microscopical signs have been in harmony with 
 this view/ I need only add that, although in 
 nearly every case of laryngeal disease it is 
 possible at the first inspection to form an 
 accurate opinion as to the nature of the disease 
 presenting itself, yet in a few rare instances 
 the progress of the complaint alone permits its 
 character to be determined. Unfortunately, 
 ,the case of His Imperial Highness is among 
 the latter number, and/at this moment medical 
 science does not permit me to affirm that any 
 
 H
 
 98 Tlie Fatal Illness of Frederick the Noble. 
 
 > 
 
 other disease is present than chronic inter- 
 stitial inflammation of the larynx comT)ined 
 with perichondritis/ 
 'San Remo, February 12th, 1888." 
 
 At the date of that report there was still no con- 
 clusive evidence of cancer, but the microscopic proof, 
 that had hitherto been wanting, was only too soon to be 
 supplied. This, however, will be told in its proper place. 
 
 The Canula gives trouble. — February nth. — The 
 Crown Prince, who had at first been pleased with the 
 results of the operation, now began to show signs of 
 disappointment that he had not derived more benefit 
 from it. He had several very violent fits of coughing, 
 especially whilst trying to drink. I explained to him 
 that this was a common symptom immediately after 
 tracheotomy, which I hoped would disappear in a day 
 or two. There was now a large amount of slimy 
 expectoration streaked with blood. Professor von 
 Bergmann arrived this morning, and immediately 
 presented himself to the Crown Prince. The Pro- 
 fessor joined us in a general consultation in the evening. 
 At this time the illustrious patient's temperature was 
 100° Fahrenheit and the pulse 94, that is to say, there 
 was slight fever, due, no doubt, to the tracheal inflam- 
 mation set up by the canula. ]\Iy German colleagues, 
 however, would not allow that a temperature of 100° 
 Fahrenheit indicated fever. His Imperial Highness 
 sat up for three hours. 
 
 February 12th. — The Crown Prince complained 
 very much of irritation in the windpipe, and asked if 
 a diflerent tube could not be inserted. The fits of 
 coughing were much more frequent and severe, and 
 prolonged paroxysms occurred even when no food or 
 drink had been taken. 
 
 / Explain my Viezus to Braniaim. — During the 
 morning Dr. Bramann paid me a visit at my hotel, 
 and showed me two other tubes, both curved, and 
 more or less resembling the one already in use. I
 
 Suggestions from the Outside World. 99 
 
 told him that I thought neither of these tubes would 
 answer, and I pointed out to him that the large orifice 
 of his canulas would be likely to crush the rings of 
 the trachea with which it would come in contact, and 
 in this way in course of time cause destructive action 
 of a serious nature. Dr. Bramann said that the orifice 
 of the tube was made large in order to facilitate the 
 expulsion of the mucus. To this I replied that as 
 regards coughing, the power of expulsion would be 
 diminished by having the tube much larger at one 
 end than the other, as the draught would thereby be 
 diminished. Finally, I said that I considered his 
 instruments antiquated {uralt), whereupon Dr. Bra- 
 mann left the room, apparently much offended. 
 When I subsequently went to Berlin and visited 
 the instrument makers' shops, I found that the 
 tubes which I had supposed to be antiquated had 
 been specially made for the august patient ; that 
 the large curve, the big instrument, and the large 
 orifice were all specially designed for the benefit of 
 His Imperial Highness. Whilst I regretted very 
 much having regarded Dr. Bramann's instruments as 
 antiquated, I could not help feeling that this was 
 scarcely a case in which it was desirable to try an 
 experiment with a new kind of canula, and it would 
 have been better for Dr. Bramann, though he had, 
 no doubt, acted with the best intentions, to have used 
 a tube which experience had proved to be useful. 
 
 Sziggestions from the Ozitside World. — At this time 
 the immense interest taken in the case throughout the 
 civilised world led to my receiving innumerable letters 
 recommending all sorts of remedies. For weeks after 
 the tracheotomy they continued to pour in from all 
 parts of Europe, and also from America. A kind of 
 compress of live worms in a muslin bag was, according 
 to many of these good people, the sov'ran'st thing on 
 earth in such a case as that of the Crown Prince. 
 A great variety of prepared foods, peptonised pre- 
 parations, essence of beef, and zyminised nutriments, 
 
 H 2
 
 lOO The Fatal Illness of Frederick the Noble. 
 
 were brought under my notice. Cocoa pure and cocoa 
 modified, peptonised and converted into an " elect 
 extract," was enthusiastically recommended. Malt 
 extracts under various names, and in combination 
 with both meat and cocoa, were much vaunted, whilst 
 my friends in Scotland gravely assured me that if 
 Highland whisky and oatmeal did not actually effect 
 a cure, they would at any rate prolong life to its 
 utmost limit. Mineral waters of every kind and from 
 every place were sent in large quantities, and medicines 
 of every description constantly reached me. Medical 
 practitioners in different parts of Europe were also 
 good enough to advise particular remedies. From 
 England calcined oyster-shells had the most con- 
 vincing vouchers ; and, if human testimony is to be 
 accepted, this remedy must have cured several cases 
 of undoubted cancer. From France carbolic acid 
 was the remedy most strongly urged upon me, both 
 as a local injection and as an internal remedy ; whilst 
 Dr. Bergeon's treatment was pressed upon me by 
 several French physicians of eminence, who assured 
 me that they had known cases exactly like that of 
 the Crown Prince which had been cured by this 
 method. The remedy most persistently recom- 
 mended to me, however, was the quack medicine 
 of Count Mattei, whose nostrums many persons in a 
 high position of life most earnestly begged me to try. 
 Dr. Schrader received from Germany large quantities 
 of similar advertisements, which he informed me he 
 forwarded regularly to Berlin, in order that they 
 might be placed in the State Archives of the Haus- 
 Ministerium. I was besought to use massage by 
 dozens of people, and enterprising professors of that 
 art offered to come at once from London, Paris, and 
 even St. Petersburg, to exercise their skill. 
 
 Turkish baths were pressed on my attention by 
 philanthropic proprietors as an infallible means of 
 purifying the body of every species of germs. Miracu- 
 lous waters were sent by devout Catholics ; even
 
 I am Prevented from Giving Relief . lOI 
 
 magic was recommended. A lady earnestly entreated 
 me to set on a table at the foot of the Crown Prince's 
 bed " an oil lamp in which some water and salt had 
 been placed." This lamp was to be lighted when the 
 illustrious patient was asleep, and a small talisman 
 (which was obligingly forwarded to me) was to be 
 placed on His Imperial Highness's breast-bone when 
 he was asleep. I was assured that if this was done 
 the Prince would immediately begin to speak in his 
 sleep, and would not only explain the nature of his 
 malady but indicate the means of curing it. The 
 talisman consisted of two circular pieces of linen 
 stitched together round the edges ; on cutting it open 
 the precious phylactery was found to be nothing more 
 than a piece of common flannel ! On my mentioning 
 this thaumaturgic suggestion to the Crown Prince he 
 smiled and said, " It is very kind of the lady, but I 
 prefer to do without it." I may here say that even 
 strong-minded persons, who know that they are suf- 
 fering from hopeless diseases, often surprise their 
 physicians by seeking help from the most stupid 
 quackery as a drowning man grasps at a straw. The 
 absolute freedom of the Crown Prince from weakness 
 or superstition of this kind was not the least remark- 
 able of his many admirable qualities. 
 
 / am Prevented from Giving Relief. — Feb. 14th. — 
 Though my colleagues thought the discharge from 
 the trachea " moderate," it was more abundant than I 
 liked to see, and it was much streaked with blood. I 
 was now convinced that the lower end of the canula 
 was pressing on the back wall of the windpipe and 
 giving rise to tracheitis, and I asked to be allowed to 
 introduce a short rectangular tube. I pointed out 
 that when the tracheotomy wound healed it would be 
 difficult to use my tube, as owing to the very long 
 ciLrve of the German tube mine zvonld probably not 
 adapt itself to the track made by that instrtiment, and 
 in this way if the insertion of the rectangular tube 
 were delayed too long it would itself cause similar
 
 103 The Fatal Illness of Frederick the Noble. 
 
 irritation in a different part of the windpipe. Pro- 
 fessor von Bergmann would not, however, agree to 
 my proposition. 
 
 Feb. 15 th. — The Crown Prince had a bad night, 
 coughing almost incessantly ; the discharge was more 
 copious, and contained blood, matter and mucus, with 
 here and there small black shreds of tissue under- 
 going decomposition. It appeared as if the violent 
 coughing was beginning to break down the diseased 
 mass within the larynx. I was now getting very 
 anxious, not so much about the progress of the 
 disease, as about the way in which the after-treatment 
 of the operation was being mismanaged, and again 
 begged to be allowed to insert a rectangular tube. 
 
 3'Iy Experience in Similar Cases. — It certainly 
 appeared to me that neither Professor von Bergmann 
 nor Dr. Bramann, w^ell-informed surgeons though they 
 doubtless were in many matters, had had much ex- 
 perience in the sort of work they had now taken 
 upon themselves to do. Dr. Schrader told me that 
 Bramann had performed tracheotomy four hundred 
 times, but all these operations were cases so utterly 
 unlike the present one that it would be simply 
 misleading to class them together. Bramann's pre- 
 vious tracheotomies had nearly all been performed 
 on infants and young children for acute obstruction 
 of the larynx, as in diphtheria. The large majority 
 of these cases die soon after the operation, many 
 indeed under the knife ; whilst in those who survive 
 the tube is dispensed with after a short time. The 
 case is altogether different in an adult, whose larynx 
 is blocked up by new growth, which has a tendency to 
 spread in the direction of greatest irritation. Here the 
 parts require the most careful handling, and it is of the 
 utmost importance to avoid anything that may lead 
 to the larynx being shaken by coughing. Though 
 my own experience of tracheotomy had not been so 
 extensive as that of Dr. Bramann, yet my experience 
 of the particular kind of case with which we were now
 
 My Experience in Similar Cases. 103 
 
 dealing was far larger than his. Up to the year 1880 
 I had performed tracheotomy seventy-three times, 
 sixty-four of these operations having been done on 
 adults, and nine on children. In addition to this 
 personal experience I had also been present at many 
 operations performed on my patients by eminent 
 surgeons, and I had often assisted my colleagues at 
 the Throat Hospital in their operations. Since 1880 
 Mr. Hovell has performed most of my operations in 
 private practice, and has also attended the patients 
 for a week or two after the operation under my 
 general superintendence. At the very lowest compu- 
 tation I have certainly been present at 120 operations. 
 In the bulk of these cases the patients were adults 
 suffering from diseases of a chronic nature. Many of 
 them were cured, and the rest nearly all survived for 
 some months. Thus, with a much smaller total of 
 operations than Dr. Bramann, I had had a far greater 
 number in which careful after-treatment was required. 
 Professor von Bergmann does not, I believe, profess 
 to have any very large experience as regards the 
 operation of tracheotomy in adults. 
 
 The Crown Prince attended to business to-day and 
 walked up and down his room for a considerable time, 
 both in the morning and the afternoon. He com- 
 plained, however, of a neuralgic headache. 
 
 February i6th. — The condition was still most un- 
 satisfactory ; the bloody mucus was more abundant 
 than ever. His Imperial Highness scarcely slept at 
 all, either day or night, being awakened every half 
 hour by fits of coughing. In spite of this, he was 
 gaining strength a little. 
 
 On this day Dr. Krause called on me, and invited 
 me on behalf of Von Bergmann to look at some mi- 
 croscopic preparations of minute sloughs thrown out 
 in the expectoration. Dr. Krause said that he himself 
 had examined them, and was satisfied they were of 
 a cancerous nature, owing to the very large number 
 of nest-cells which they contained. I told Dr. Krause 
 that I did not profess to be a microscopist, and that
 
 104 The Fatal Illness of Frederick the Noble. 
 
 so much depended on the situation of the " nests," 
 and their relation to other tissues, that I did not feel 
 myself competent to judge in the matter. In a case 
 of such vast importance, I thought the decision ought 
 to be left to a pathologist of the first rank. 
 
 My Exajni7iatio7is Objected to. — February 17th. — 
 The Crown Prince again had a disturbed night ; 
 the cough was very harassing, and the bloody secre- 
 tion abundant. I made a laryngoscopic examination, 
 and found that the laryngeal canal was more open, 
 and on closing the tube His Imperial Highness was 
 able to sound his voice very fairly. He did not, 
 however, at all like the tone of it. There was not a 
 trace of blood in the larynx, which proved that the 
 blood in the expectoration came from elsewhere. 
 
 February i8th. — Another very bad night. The 
 headache, however, had yielded to the remedy which 
 usually gave relief I announced to my colleagues 
 that I found the condition of the larynx, relatively 
 speaking, very satisfactory. In the evening, Pro- 
 fessor von Bergmann stated at our consultation that 
 my lar^mgoscopic examination on the previous day 
 had been the subject of serious consideration by 
 himself. Dr. Bram.ann, and Dr. Schrader, and these 
 gentlemen had requested him to say that they con- 
 sidered my having made such an examination in 
 their absence a breach of professional etiquette. I 
 answered that I did not think examining the throat 
 any more of an operation than feeling the pulse or 
 looking at the tongue, both of which I presumed 
 they occasionally did when they were on duty ; 
 and I added that I should not have the slightest 
 objection to either of those gentlemen making a 
 laryngoscopic examination, if he could do so with- 
 out inconvenience to the Crown Prince. As the 
 matter was not worth making a fuss about, however, 
 I promised for the future to give each of my col- 
 leagues formal notice whenever I proposed to make a 
 laryngoscopic examination. 
 
 Bergmann suspects Cancer of the Lungs. — Although
 
 Bergniann suspects Cancer of the Lungs. 1 05 
 
 the illustrious patient's temperature was never 
 much above the normal standard, we frequently- 
 examined the lungs, and on this day (19th) Pro- 
 fessor von Bergmann, after carefully percussing the 
 right side of the back over the lower ribs, said he 
 feared there was a secondary development of cancer 
 in the base of the right lung, and that this was the 
 cause of the haemorrhage. The Professor did not seem 
 to be aware that the dulness on which this diagnosis 
 was founded was caused by the liver which occupied 
 its ordinary situation over which he had been percus- 
 sing. I pointed out to him, moreover, that such a con- 
 dition as he believed to exist was most unlikely to occur 
 under the circumstances without some accompanying 
 pneumonia, of which there was no trace. In thus 
 seeking another cause for the haemorrhage Professor 
 von Bergmann showed that he had abandoned his 
 previous theory that the bloody discharge all came 
 from the larynx. The position which I maintained 
 at this time was as follows : The tracheotomy tube 
 had caused great irritation as shown by muco- 
 purulent and bloody discharge, and by frequent and 
 violent coughing. This coughing after a time caused 
 ulceration and disintegration of the morbid formation 
 in the larynx, and the blood which at first had 
 come solely from the trachea, rasped and wounded by 
 the ill-fitting tube, now came from both trachea and 
 larynx. 
 
 My Ttcbe is Tried Too Late. — February 20th. — On 
 this day Professor von Bergmann permitted me to 
 insert a right-angle tube. Unfortunately, however, 
 owing to the shape of the wound which the other 
 instrument had made, it could not rest in a horizontal 
 position, but was considerably lower at the inner end 
 where it passed into the trachea than at the outer 
 orifice. (See Fig. 10.) Although there was no longer 
 any pressure from the posterior wall, I was sure that 
 my tube would irritate the front part of the windpipe. 
 This is what actually occurred, as indeed I had pre-
 
 io6 The Fatal Illness of Frederick the Noble. 
 
 dieted on the 14th February would be the case, if I 
 was prevented from inserting the tube for some days. 
 February 2ist. — The Crown Prince was exceed- 
 ingly comfortable in the morning. He had slept well 
 during the night, but towards the afternoon the tube 
 was already beginning to chafe the anterior wall, and 
 in the evening I found it causing almost as much irri- 
 tation as the one it had replaced. During the day the 
 Crown Prince had rather a long conversation with the 
 Prince of Wales, who had arrived the day previously. 
 
 Fig. 10. — Diagram showiug Durham's tube introduced too late, and not able 
 to adapt itself to the track of the long German canula. Later on this tube 
 was worn (see Fig. l6) with comfort. It can be seen that the front part of 
 the lower end of the canula is very near the anterior wall of the trachea, and 
 that by the least coughing it would be sure to rub against the delicate 
 lining of that tube. 
 
 In the evening the Crown Prince also had an inter- 
 view with the Grand Duke and Duchess of Baden ; 
 notwithstanding that the Prince had done more talking 
 than usual he did not seem at all tired in the evening. 
 Professor Kussmajtl siunmoned. — February 22nd. — 
 The Crown Princess informed me that Professor von 
 Bergmann had told her that he was quite sure the 
 Crown Prince had cancer of the lungs, and that he 
 should like to have the opinion of Professor Kussmaul
 
 Professor Ktissmatd summoned. 107 
 
 of Strasburg. I said I thought this was quite un- 
 necessary, as I had examined the lungs carefully 
 myself, and I was quite sure that there was no 
 deposit in either of them. Two days later Her 
 Imperial Highness again mentioned the subject to 
 me, and said she thought it would do no harm for 
 Kussmaul to see the Prince. Of course I replied that 
 if Her Imperial Highness wished it, I had nothing 
 further to say. Subsequently, Professor von Bergmann 
 brought the matter forward at a consultation. I then 
 said that I should have no objection to Professor 
 Kussmaul examining the Crown Prince's lungs, but 
 as that gentleman was neither a laryngoscopist nor 
 a microscopist, I could not consent to receive his 
 opinion as to the nature of the laryngeal affection. 
 
 On this day von Bergmann told the Crown Prin- 
 cess and Count Radolinsky that the haemorrhage 
 from which the Prince was suffering would never 
 cease — that it was in fact the beginning of the end. 
 The Crown Princess sent for me to tell me this. I 
 stated my belief that by proper management of the 
 tube, when the case was again placed entirely in my 
 hands, I should be able to stop the bleeding, although 
 it had now become so considerable that I feared that 
 under the most favourable circumstances it would 
 probably take several weeks to bring about the 
 healing of the ulcers which Bramann's canula had 
 caused. Bramann told me this morning in a trium- 
 phant sort of way that he had found a great number of 
 cell-nests in the sputum, which could only come from 
 a cancerous growth. Schrader gave mc the same 
 information in the evening, but without the same 
 scientific enthusiasm. 
 
 Out for the First Time. — February 23rd. — The 
 Crown Prince had had a bad night, but in spite of 
 this he said he felt better, and the day being fine he 
 passed half-an-hour out on the balcony. A large 
 number of people assembled opposite the villa, and 
 greeted the illustrious patient with cheers, salutations,
 
 io8 The Fatal Illness of Frederick the Noble. 
 
 waving of handkerchiefs, etc., which appeared to give 
 him much pleasure. It had been arranged between 
 Professor von Bergmann and myself that I should 
 now resume charge of the case, but Bramann, having 
 requested me to leave the case in his hands a short 
 time, as he felt confident he could stop the haemor- 
 rhage if he were allowed to manage things in his own 
 way for a few days longer, I yielded to his request. 
 The right-angled tube which was irritating the an- 
 terior wall was taken out, and one of Von Bergmann's 
 was substituted for it. It was subsequently proved 
 by measurements made by Mr. Hovell, that one of 
 the reasons, and perhaps the principal one, why the 
 right-angled tube could not be worn, was, that the 
 windpipe, as already said, had been opened to the 
 right of the middle line. (See p. 117.) 
 
 Schrader's Misadventure with the Tube. — During 
 the previous night, Dr. Schrader, who was unfamiliar 
 with the construction of Durham's tracheotomy canula, 
 which was then being tried, loosened the screw by 
 which the tube is fixed to its shield, thereby causing 
 great irritation in the trachea. After he had been 
 vainly tr}'ing for some time to put things right again 
 the Crown Prince wrote on a slip of paper, " Send for 
 Hovell." That gentleman soon made the illustrious 
 patient comfortable.* 
 
 * This incident was mentioned in several of the French and 
 Italian papers a couple of days later, and Dr. Schrader was 
 \Qxy indignant with Mr. Hovell and myself for having, as he 
 thought, made the matter public. The fact was, however, that 
 the whole story was known throughout San Remo the very next 
 morning. A lady confined to her bed in one of the hotels told 
 Dr. Freeman, the popular Enghsh physician at San Remo, all 
 about it a few hours after it happened. She had learned it 
 from a charwoman, who, after doing some rough work at the 
 Villa Zirio early in the morning, used to spend the rest of 
 the day at the Hotel des Anglais. The news which this woman 
 learnt in the morning was all over the town in the afternoon. 
 In such ways many reports, some true and some false, got into 
 the newspapers, and thus the wrong persons were frequently 
 blamed for giving news to the Press,
 
 Hovell Threatened with Imprisonment. 109 
 
 Novell Threatened with Imprisonment. — I may 
 mention here that I constantly received messages 
 from Professor Bergmann through Dr. Schrader as to 
 the necessity of carrying out the treatment antisepti- 
 cally. This meant dipping the inner canula into a 
 weak solution of carbolic acid and water instead of 
 cleaning it with plain water. On one occasion 
 Schrader asked me to tell Hovell (as the latter did 
 not speak German) that surgeons who did not carry 
 out treatment antiseptically were liable to serious 
 punishment in Germany, and that recently a surgeon 
 had been sentenced to three months' imprisonment 
 for neglecting to use antiseptic treatment in a case 
 of compound fracture of the arm. I pointed out to 
 Schrader that in the after-treatment of tracheotomy 
 the use of antiseptics was of little importance, clean- 
 liness being all that was required. I said that of 
 course in the case of a wound from which, by the use 
 of antiseptics, germs could be excluded, that method 
 was of the utmost utility ; but in the case of a canula 
 worn in the throat, and necessarily open to the air of 
 the room, the antiseptic method could not be applied. 
 He answered that it was Professor von Bergmann's 
 wish that Mr. Hovell should have these directions. 
 It appeared to me that the Professor of Surgery, in 
 the matter of antisepticism, attended to the letter 
 rather than to the spirit, and whilst insisting on minute 
 observances connected with the instruments — obser- 
 vances which had been discarded by the inventor of 
 the system himself — he did not always perhaps pay 
 sufficient regard to personal cleanliness. I afterwards 
 told the Crown Prince that I had been requested to 
 inform Hovell that he would run the risk of spending 
 three months in prison if he did not use carbolic acid 
 freely. His Imperial Highness answered with a 
 smile, " If Mr. Hovell is sent to prison, I shall have to 
 go there too." 
 
 February 24th. — The Crown Prince had a fair 
 night, though the first part of it was disturbed by
 
 1 10 The Fatal Illness of Frederick the Noble. 
 
 coughing. The removal of Dr. Bramann's tube for a 
 few days seemed to have reUeved the inflamed part, so 
 that when it was introduced it did not at first cause so 
 much irritation as before. His Imperial Highness 
 was much depressed during the day by the news of 
 the sudden death of his nephew, Prince Ludwig of 
 Baden. On this day I learned from two independent 
 sources in Berlin, that von Bergmann was sending 
 home most alarming letters announcing that the 
 Crown Prince could not live for more than a fortnight, 
 and that on the strength of these messages many 
 noble families connected with the Court were getting 
 mourning prepared. I was considerably surprised 
 that a surgeon of any experience should commit 
 himself to a gratuitous prophecy which there was 
 absolutely nothing in the aspect of the case at that 
 time to suggest. 
 
 TJie Crozvn Prince s dislike of Stimulants. — I now 
 used to have a good deal of conversation with the 
 illustrious patient. I always sat with him at his 
 dinner, or, as it was called, supper, and I generally 
 spent half an hour with him whilst he was eating his 
 mid-day meal. I may here mention that the illus- 
 trious patient's appetite was by no means good, and 
 that he had a great dislike of stimulants. He always 
 mixed his wine with water, and so little did he care' 
 for the flavour of wine, that he always took a sip of 
 plain water after drinking it. In reply to a question 
 which I ventured to put to him on the subject, he 
 said that he preferred being talked to when he was 
 taking his meals, adding that he was sure he eat 
 much more heartily when I was with him than when 
 he was alone. After this I used to have most in- 
 teresting conversations with the Crown Prince, who 
 had travelled a great deal, and as I had done the 
 same, we were able to compare our experiences. He 
 was always pleased, too, when I asked about events 
 in the history of the House of Hohenzollern, and 
 especially about anything connected with Frederick
 
 Different kinds of Canidas suggested. 1 1 1 
 
 the Great. He was also good enough to answer 
 many questions as to his campaigns, and if I did not 
 understand him quickly the Prince never minded 
 taking any trouble in writing what he wished to say. 
 
 Dr. Bramann told me to-night that nest-cells had 
 again been found in the discharge. 
 
 February 25th. — The august patient passed a bad 
 night ; his digestion was also much disturbed. The 
 large long tube had again set up considerable inflam- 
 mation in the windpipe. 
 
 Different kinds of Camilas suggested. — At about 
 this time I received numerous suggestions from sur- 
 geons in England with regard to tracheotomy tubes, 
 and, indeed, both at that time and later on at Char- 
 lottenburg, after the Bergmann catastrophe, many 
 members of the profession in different parts of the 
 world were kind enough to place the result of their 
 experience at my disposal. One of our greatest 
 English surgeons not only wrote to me, but most 
 kindly sent me apparatus to facilitate the after- 
 treatment of tracheotomy. The laity, especially 
 engineers, were fertile in suggestions for warming the 
 air before it passed through the canula. The number 
 of tracheotomy tubes that I received was quite re- 
 markable, many of them being from patients who 
 had been operated on and who were themselves 
 wearing tubes. Here I may mention that while I 
 was at Charlottenburg, a French gentleman took the 
 trouble to travel all the way from Paris to deliver a 
 canula to me personally, and to explain the special 
 advantages which it possessed. 
 
 Bergmami s Reports Again. — On this day I re- 
 ceived a letter from Berlin begging for my "candid 
 opinion" as to the condition of the Crown Prince. 
 Th^' writer gave as his reason for asking the question, 
 that Bergmann had sent word to Berlin that the 
 illustrious patient was not likely to live more than a 
 week, and might die " in four days " ! When I went 
 to Berlin in March I found the statements of my
 
 1 1 2 The Fatal Illness of Frederick the Noble. 
 
 correspondent confirmed from unimpeachable sources. 
 It is quite clear, therefore, that in the last week of 
 February Professor von Bergmann believed the end 
 to be very near. Whether this idea was based on 
 his erroneous supposition that the lungs had been 
 attacked by cancer, and that fatal haemorrhage was 
 likely to take place suddenly, or whether he had any 
 other ground for the prediction, I cannot say. 
 
 / propose a Neiv Ttibe. — February 26th. — The 
 Crown Prince passed a bad night, and Bramann's 
 efforts to stop the bleeding proving quite ineffectual, 
 I asked to be allowed to insert a new tube made 
 in San Remo of the same shape as the one then 
 in use, as far as regards the portion of the canula 
 lying external to the trachea, but so constructed 
 that, instead of passing a long way down the trachea, 
 it would only just enter that tube. My colleagues, 
 however, would not consent to this ; first, because 
 they considered the lumen of my new instrument 
 too small (though it was nine millimetres in diameter), 
 and secondly, because it had not an inner tube. 
 This tube would have relieved the august patient's 
 sufferings at once, as it was too short to chafe the 
 back wall of the windpipe, which was the source of 
 all the trouble with the other. Even if a somewhat 
 smaller quantity of air had been supplied to the lungs, 
 would not the cessation of the coughing and bleed- 
 ing which prevented the Prince from sleeping have 
 been an ample compensation for such a drawback, 
 which after all was more or less theoretical } With 
 regard to the absence of an inner tube, such an objec- 
 tion could have been inspired only by the narrowest 
 surgical pedantry or some less worthy feeling. My 
 improvised tube was of course only intended as a 
 temporary contrivance to be used till a more perfect 
 one could be obtained ; if it had been found to 
 answer, a double tube could then have been made 
 to pattern. I may add, moreover, that as a matter of 
 fact double tubes are a comparatively modern inven-
 
 I propose a New Tube. 113 
 
 tion, and there are at the present moment hundreds 
 of persons wearing single tubes. 
 
 Professor Bergmann, however, went so far as to tell 
 the Crown Princess that with a single tube there 
 would be the greatest danger of the Prince being 
 suffocated when the tube was taken out for a few 
 seconds to be cleaned. With the most docile and 
 intelligent of patients, who had six medical men 
 about him, one or other of whom was always in 
 attendance, it is ridiculous to suppose that there 
 could have been any risk in using a single tube for a 
 few days. Such, however, were the grounds on which 
 I was prevented from affording much-needed relief to 
 the Crown Prince, whose strength was being worn 
 out by constant suffering. 
 
 On this day Professor Kussmaul arrived and took 
 part in the consultation this morning. I was not 
 present, as before meeting him, I wished to have his 
 position in the case clearly defined. I was willing, of 
 course, to receive his opinion on the state of the chest, 
 but not as to the larynx, as I did not know that he had 
 any experience in the affections of that organ. There 
 had, I considered, already been more than enough of 
 such examinations by men whose observations could 
 be of no possible value. After making this protest 
 on the question of principle, I expressed my willing- 
 ness to meet Professor Kussmaul as a matter of 
 courtesy. Later in the day that distinguished phy- 
 sician himself called on me, and whilst acknowledging 
 that he was not very skilful with the laryngoscope, 
 intimated a wish to see what he could of the illustrious 
 patient's throat. 
 
 Kussmaul s Adventures as a Laryngoscopist. — Feb- 
 ruary 27th. — We all met together for the usual con- 
 sultation in the morning, Professor Kussmaul being 
 present as arranged. After making a general ex- 
 amination, Dr. Kussmaul proceeded to inspect the 
 larynx. For this purpose he placed the Crown Prince 
 opposite the window (though far back in the room), a 
 
 I
 
 1 14 The Fatal Illness of Frederick the Noble, 
 
 position in which, when artificial light is used, it is 
 very difficult to obtain a good view. Seeing that the 
 illustrious Professor was quite unaccustomed to make 
 a laryngoscopical examination, I arranged the lamp 
 in a suitable position, placed the chair differently, 
 warmed the laryngeal mirror for him, and assisted 
 him as far as possible. After a long time he managed 
 to throw a feeble ray of light on to the mirror, but 
 evidently did not obtain any view of the interior of 
 the larj-nx. On returning into the next room Pro- 
 fessor Kussmaul observed that what he had seen 
 reminded him, not of any cases he had previously 
 examined, but of a picture of a case of cancer that 
 he had seen in von Burow's Atlas ! As it was quite 
 impossible to see into the interior of the larynx, the 
 swelling of the ary- epiglottic folds completely ob- 
 structing the field of vision lower down, the value 
 of the Professor's souvenirs may be gauged. I see 
 from Professor Kussmaul's report in the German 
 pamphlet that he was sulfsequently instructed, and 
 now acknowledges that he only saw the swelling of 
 the arytenoid cartilages. It seemed to me strange 
 that a man justly distinguished for his great know- 
 ledge and experience as a general physician should 
 condescend to go through the form of making an 
 examination with the technique of which he was clearly 
 quite unfamiliar. Such a proceeding hardly seems to 
 be in keeping with the recognised character of German 
 science, which is nothing if not earnest and thorough. 
 Kussmaul contradicts Bci-gniann. — On his own 
 ground, however, the venerable Strasburg Professor 
 was much more edifying. He absolutely negatived 
 Bergmann's notion declaring himself unable to find 
 the least evidence of cancer in the lungs, or indeed 
 of pulmonary- disease of any kind. Bergmann, in fact, 
 had been entirely mistaken, and Professor Kussmaul's 
 journey to San Remo had been quite useless.* 
 
 * I was always greatly surprised that Professor von Bergmann 
 could have thought that secondary cancer had formed in the
 
 / have another Tube made. 
 
 115 
 
 / have another Tube made. — February 28th. — The 
 Crown Prince passed a fairly good day, but the 
 weather was cold, and he did not go out on the 
 balcony. I spent most of the day in getting another 
 tube made at a silversmith's in San Remo, and 
 Dr. Evans of Paris gave me much valuable assistance. 
 
 -The San Remo Canula shown in position. The letters a and b 
 refer to the gullet and larynx respectively. 
 
 It was made on the same lines as the one previously 
 constructed, that is to say, it had in part the shape 
 of the German tube, but was so short that it would 
 only reach just within the trachea. It was con- 
 structed so as not to pass down the windpipe at all 
 (See Fig. 11), the lower end being cut off in such a way 
 that it was parallel to the upper or outer opening, 
 
 lungs, and I was at a loss to understand why he should be so 
 anxious that Professor Kussmaul should be sent for in order to 
 confirm his extraordinary diagnosis. I was subsequently in- 
 forn^ed, however, that six months previously von Bergmann had 
 seen a case of cancer of the larynx with Professor Kussmaul, 
 in which the lungs became affected as a secondary phenomenon, 
 and he was evidently of opinion that the sequence which he 
 had once observed was invariable. 
 
 I 2
 
 1 16 TJie Fatal Illness of Frederick the Noble. 
 
 k--97w/«> 
 
 instead of being at right angles to it as is the case 
 with most instruments. It was full-sized and was 
 provided zvith an inner tube. 
 
 February 29th. — During the early part of the night 
 the Crown Prince's sleep was much disturbed, but 
 
 ^ from four to eight o'clock he slept fairly 
 
 well. There is abundant discharge, and 
 it contains a good deal of blood. I 
 noticed that the track of the canula, 
 owing to the weight of Bramann's in- 
 strument was lowering itself, so that the 
 San Remo canula had a slightly more 
 horizontal position than we had calcu- 
 lated upon obtaining. I inserted the 
 new tube just described. 
 
 March ist. — The Crown Prince has 
 had a good night, and feels much 
 better. He looks stronger, and says 
 he feels refreshed. The expectoration 
 still contains a good deal of blood. 
 His Imperial Highness spent a consider- 
 able time on the balcony to-day. 
 
 March 2nd. — The Crown Prince had 
 a better night, the cough being much 
 less frequent There was little or no 
 blood in the expectoration, except after 
 a particularly violent fit of coughing. 
 His Imperial Highness spent a good 
 gfcai probe bent part of the day, both morning and 
 at one end at afternoon, on the balcony, where he 
 n5.^^!!?if!:„^2 eat his lunch. At the mornin- con- 
 
 Fiir. 12. — A sur- 
 
 the remaining . 
 
 part, the bent sultation we agreed that it was no 
 portion measur- longer necessary that one of the medical 
 mfilimetres.'''°^ attendants should sit up at night, and 
 as the Crown Prince objected to having 
 a female nurse. Professor von Bergmann was re- 
 quested to get an orderly from Berlin. A day or 
 two later the man arrived, and afterwards took the 
 nursing at night.
 
 BramaniUs Incision. 117 
 
 Brama7tn's Incision^ and HovelVs Measurements. — 
 March 3rd. — The Crown Prince had a fairly good 
 night, and the local condition was better. Professor 
 Waldeyer arrived to-day, in order to make a micro- 
 scopic examination of the material expectorated 
 through the tube. 
 
 Mr. Hovell asked me if he might make some 
 measurements, with the view of ascertaining how far 
 Bramann's incision was to the right of the middle 
 line. To this I saw no objection. Mr. Hovell's in- 
 strument (See Fig. 12) consisted of an ordinary 
 surgical probe, bent at one end at right angles to 
 the remaining part, the bent portion measuring 
 just nine millimetres.* The measurements were 
 made in two ways : first, through a straight silver tube,t 
 which was passed just to the middle of the trachea ; 
 and second, through the naked wound. On introduc- 
 ing the bent probe through the straight canula, and 
 turning it to the (patient's) left side, it entirely disap- 
 peared from view (See Fig. 13), its point barely 
 touching the left wall of the trachea. On turning 
 the probe to the (patient's) right side, it imme- 
 diately struck against the right side of the trachea, 
 leaving two-thirds, that is, six millimetres of its 
 
 * Nine millimetres was chosen as the length of the arm 
 because the first canula used in making these measurements had 
 a diameter of only a centimetre (i.e. ten millimetres), and there- 
 fore a longer arm could not be employed. Though the actual 
 tube finally used was nearly 14 mm. in diameter, the size of the 
 bent portion of the probe was not altered. 
 
 t I had this made for taking tracheoscopic observations. 
 The tube was passed just to the orifice of the trachea, and then 
 a minute mirror was passed through it, and views obtained 
 above and below the tracheal orifice. It need scarcely be 
 pointed out that the rough examinations made by Von Berg- 
 mann, and referred to in the German pamphlet, when he merely 
 reflected a ray of light into the trachea were utterly valueless. 
 The spot that he saw was simply the posterior wall of the 
 trachea opposite the wound ; the bleeding ulcers caused by his 
 long tube (See Fig. 7) were quite below the point of vision 
 without a mirror.
 
 1 1 8 The Fatal Illness of Frederick tJie Noble. 
 
 length visible (See Fig. 13) through the end of the 
 canula. Had Dr. Bramann made the incision in the 
 trachea in the middle line, an equal extent of the bent 
 portion of the probe (three millimetres) would have 
 been visible through the end of the canula (See 
 Fig. 14), whilst six millimetres would have disap- 
 peared at the side of the canula whichever way the 
 
 
 Fig. 13. — The probe foreshortened and introduced on the patient's left 
 side {d)y where it disappears, and on the right side (<:), where a large 
 portion of it remains visible through the canula. The line a b repre- 
 sents the median line of the body, and should bisect the circle formed 
 by the orifice of the tube instead of falling considerably to the left of 
 the middle. 
 
 probe was turned. The diagram (Fig. 15) shows a 
 section of the trachea ; the dark circle representing 
 the canula. It will be seen that the centre is nine- 
 millimetres from the right side of the trachea and 
 fifteen millimetres from the left side, showing that 
 Bramann's incision was three millimetres to the right 
 side of the median line. The canula was in fact nine 
 millimetres from the left side of the trachea and only
 
 Fig. 14. — Diagram showing how the probe would have appeared on 
 each side if the incision in the trachea had been in the median line. 
 
 Fig. 15. — Diagram with half of the trachea supposed to be removed. 
 //' represent the outer walls of the trachea ; the other letters are the 
 same as in Fig. 13. It will be seen that Bramann's incision, instead 
 of being in the median line, was three millimetres to the right of it.
 
 1 20 The Fatal Illness of Frederick the Noble. 
 
 three millimetres from the right side. Measurements 
 made through the open wound yielded exactly the 
 same results. It may be interesting to observe that 
 other measurements showed that the transverse 
 diameter of the trachea was as nearly as possible one 
 inch (25 to 26 mm.). Th'"s slight deviation from the 
 middle line would be a matter of very little import- 
 ance, if a straight canula could be used, but seeing 
 that for the sake of safety it is necessary to have 
 a descending arm, it will easily be understood that 
 this descending portion, if introduced slightly on 
 one side of the trachea, is certain to come into 
 contact with its walls, and set up great irritation. 
 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 used 
 by Bramann, would have been sure to have done so. 
 
 The Microscopic Proof at last. — IMarch 4th. — The 
 Crown Prince had a good night, although there was 
 no decrease in the expectoration, which still contained 
 a good deal of blood. I covered the canula with a 
 piece of very tight-fitting india-rubber tubing, so as 
 to prevent the sharp edge accidentally touching the 
 wall of the trachea. Professor von Bergman n, who 
 attended the consultation in the morning for the first 
 time after several days, subsequently introduced me 
 to Professor Waldeyer, who was good enough to show 
 me several preparations which he had made. In 
 some of the specimens there was a large number of 
 cell-nests, but I did not perceive any alveolar structure. 
 Professor Waldeyer said that although there was 
 no alveolar structure, he considered that from the 
 relation of the nest-cells to one another, he thought 
 it almost certain they had come from an alveolar 
 structure. The nest-cells, moreover, were so abun- 
 dant that he thought they could not have been 
 produced superficially, but were evidently the result 
 of a deep-seated destructive process. As I had 
 always based my diagnosis largely on the micro-
 
 A Treaty of Peace. 12 1 
 
 scopic character of the disease, I no longer had 
 reason to doubt that the morbid process was of a 
 cancerous nature. Subsequently Professor von Berg- 
 mann, who again came to the consultation and signed 
 bulletins, called on me and said that the Emperor was 
 very anxious that the Crown Prince should return as 
 soon as possible to Berlin. I pointed out that for 
 the illustrious patient to return at that season of the 
 year would be likely to be injurious to him, but that 
 when the weather became warm I saw no objection 
 to his return. Professor von Bergmann afterwards 
 asked me to embody my views in a letter, which 
 I accordingly did. 
 
 March 5th. — The Crown Prince had a fairly good 
 night, with much less cough and expectoration than 
 on any night since the operation. His Imperial 
 Highness seemed in very good spirits, and his appetite 
 was excellent. He spent a good deal of time on the 
 balcony. 
 
 A Treaty of Peace. — March 6th. — Professor von 
 Bergmann and Dr. Bramann again attended the con- 
 sultation. Professor von Bergmann brought with him 
 a document which, after undergoing slight modifica- 
 tion, was signed by all present. It ran as follows : — 
 
 " San Remo, March 6tk, 1888. 
 " In view of the rumours circulated in the Press 
 about differences of opinion among the physicians in 
 attendance on His Imperial and Royal Highness the 
 Crown Prince of the German Empire and of Prussia, 
 the undersigned declare that there are no differences 
 of opinion among them regarding the nature of the 
 disease. Just as little have they maintained that the 
 malady is likely soon to take a dangerous turn. The 
 sole responsible treatment is now, as it was before 
 '■ the operation, in the hands of Sir Morell Mackenzie. 
 To the newspapers of Germany, and other countries, 
 the physicians, in the interest of the illustrious patient 
 and of the nations which love and revere him, once 
 more make the request that they will refrain from all
 
 122 TJie Fatal Illness of Frederick the Noble. 
 
 discussion of the disease, or of the methods and 
 instruments used in its treatment. 
 
 " The local affections in and near the larynx of 
 His Imperial and Royal Highness have not under- 
 gone any essential change. The wound has healed, 
 the tube is well placed, the lungs are healthy, the cough 
 and expectoration have diminished. The patient's 
 strength is satisfactory; the appetite is increasing; 
 there is no disturbance of digestion, pain in swallow- 
 ing, or headache. Sleep lasts unbroken for hours. 
 As Geheimrath Von Bergmann's mission is ended, he 
 will shortly leave San Remo. 
 
 (Signed) "Morell Mackenzie. Mark Hovell. 
 ScHRADER. Von Bergmann. 
 
 Krause. Bramann." 
 
 The Case is Restored to me. — March 6th. — The 
 morning being warm and pleasant, the Crown Prince 
 for the first time went into the garden. He came 
 downstairs at half-past eleven, took his lunch at one, 
 and returned to his room at about half-past two. It 
 was as warm out of doors, if not warmer, than in the 
 house, and the illustrious patient greatly enjoyed his 
 stay in the garden, where he nearly all the time 
 remained seated, occasionally, however, taking a short 
 turn up and down. 
 
 The case was now formally restored to me^ but in 
 what a different condition was the illustrious patient 
 from what he had been when I had given him over to 
 the care of the German surgeons ! On the day that he 
 was operated on he felt " perfectly well," except that 
 his breathing was difficult : he was now a confirmed 
 invalid. Besides this the disease in the larynx which 
 had previously been progressing very slowly had, 
 through the coughing caused by ill-fitting trache- 
 otomy tubes, been stirred into extreme activity. 
 Greater destruction was probably occasioned in 
 three weeks in this w^ay than would have occurred 
 in a year had the illustrious patient not been sub- 
 jected to such injudicious treatment.
 
 Death of the Emperor William. 123 
 
 March 7th. — The Crown Prince has had a good 
 night, and the throat feels much more comfortable ; 
 less coughing. 
 
 Serious Nezvs from Berlin. — March 8th. — News 
 reached San Remo that the aged Emperor was in a 
 critical condition, and a despatch was received from 
 Prince Bismarck urging the immediate return of the 
 Crown Prince. His Imperial Highness sent for me, 
 and asked : " Will there be any danger in my returning 
 at once to Berlin ? " I answered, " Yes, Sir ; there 
 would be some danger ; " he then said, " There are 
 some occasions when it is the duty of a man to run 
 risks, and such an occasion is now before me. I shall 
 return the day after to-morrow. I shall be obliged to 
 you to make whatever medical arrangements you 
 think necessary, and to confer with Count Radolinsky 
 on the subject. I look to you to take all steps 
 possible in order to reduce the danger of my journey 
 North to a minimum." 
 
 Death of the Emperor William. — The next day 
 news arrived of the death of the Emperor William. 
 I was not with the august patient at the time, but 
 I was informed by an eye-witness that he was greatly 
 agitated on receiving the intelligence. When I had 
 the honour of seeing His Majesty he was still much 
 upset. He spoke little of the event, though it was 
 evident that he felt the loss of his aged father much 
 more keenly than might have been anticipated con- 
 sidering that the death of a man of such advanced 
 age could hardly have been unexpected. Nothing 
 better shows how far the character of the Crown 
 Prince stood above the ordinary standard of mankind 
 than the fact that the shock of his venerable parent's 
 death left no room for some time for any other 
 feeling. Private sorrow, however, had to give way to 
 public duty ; the responsibilities of his new position 
 had to be faced, and Frederick the Third determined 
 to return at once to his own dominions.
 
 1 24 The Fatal Illness of Frederick the Noble. 
 
 CHAPTER VIII. 
 
 CHARLOTTENBURG. 
 
 T/te New Kaisers Joiirney Home. — On March lOth, 
 after a fair night's rest, Frederick the Third left San 
 Remo at 9 A.M. There was a slight drizzling rain as 
 we drove to the station, but the streets were crowded 
 with people who greeted the new Emperor with 
 enthusiasm. During their stay at the Villa Zirio the 
 Imperial family had made themselves extremely 
 popular in San Remo ; the grand equanimity of the 
 august sufferer had excited universal admiration, 
 whilst the gentillezza of the Empress and the young 
 Princesses had captivated all hearts. At every station 
 we passed there was a vast concourse of people who 
 cheered with a heartiness that evidently gave His 
 Majesty the greatest pleasure. During the journey 
 the Emperor very frequently invited me into his 
 saloon, and I had the opportunity of seeing the keen 
 interest he took in the scenery in the early part of 
 the journey, and the unspeakable delight which he 
 showed the next day when he was once more among 
 his own people. His IMajesty bore the fatigue of 
 travelling very well, and coughed but little ; during 
 the later hours of the day, he occupied himself in 
 writing and in arranging various matters with Count 
 Radolinsky. He finally retired to rest in his private 
 compartment about ten o'clock at night. Mr. Hovell 
 and I slept in His Majesty's saloon. We reached 
 Munich at half-past eight on the morning of the nth, 
 the Queen-Regent of Bavaria meeting His Majesty 
 at the station, and passing some time with the Em- 
 press and him in their saloon. The Queen then
 
 Afi Interview with Prince Bismarck. 125 
 
 graciously expressed a wish that I might be presented 
 to her, and said to me that she was most agreeably- 
 surprised to see the Emperor looking so well after all 
 he had lately gone through. 
 
 In the afternoon Count Radolinsky showed me an 
 autograph note from the Emperor in which His 
 Majesty intimated his wish that I should continue to 
 be the chief physician in attendance on his person as 
 I had been before he came to the throne, and that 
 Drs. Wegner and Krause should see him night and 
 morning, while Professor von Bergmann was to pay 
 him a visit once a week. 
 
 An Intervieiv with Prince Bismarck. — At Leipzig, 
 Prince Bismarck and several of the great State 
 officials paid their respects to the new Emperor. 
 After his audience with His Majesty, the Chancellor 
 expressed a desire to have some conversation with 
 me, and I accordingly travelled in the same carriage 
 with him to the next station. Prince Bismarck said 
 he was most anxious that the Emperor should be 
 spared all unnecessary fatigue, and requested me to 
 lay down rules as to the number of interviews which 
 His Majesty might safely grant each day, the dura- 
 tion of such interviews, &c. I informed the Chan- 
 cellor that I had already drawn up some rules of 
 the kind, which I had given to the Hof-Marschall 
 Prince Bismarck further said he would be glad to 
 assist me in every way to save the august patient all 
 worry and fatigue, adding, that until the foreign 
 Princes arrived to be present at the Emperor William's 
 funeral, His Majesty could remain perfectly quiet. 
 
 Arrival at Charlottenhirg. — We reached Char- 
 lottenburg at eleven o'clock at night in a blinding 
 snowstorm. The Emperor was received by the 
 Crown Prince and other members of the Imperial 
 family, and drove at once to the Schloss. The intense 
 whiteness of the streets and houses, the brilliant 
 illuminations, and the enthusiastic crowds of people, 
 made a very striking picture, and as we drove up to
 
 126 The Fatal Illness of Frederick the Noble. 
 
 the Castle gates, the Garde du Corps, with their eagle- 
 crested helmets, glittering cuirasses and drawn swords, 
 added to the imposing nature of the scene. His 
 Majesty alighted from his carriage with a firm step, 
 and in passing through the hall, spoke to the British 
 Ambassador and several high officials who were there. 
 He very soon retired to his room, where I followed 
 him and found him rather fatigued by the journey. 
 The shaking of the railway carriage had slightly 
 increased the discharge from the canula, but on the 
 whole he had borne the excitement remarkably well. 
 
 His Majesty had a good night, and on the morning 
 of the 1 2th I was pleased to find that the journey had 
 done him little or no harm. He was very slightly 
 feverish, the temperature being 99 • 2, and the pulse "jh^ 
 but otherwise his condition was relatively satisfactory. 
 I should mention here that His Majesty's natural 
 pulse was rather slow, its average number of beats 
 each minute being only 64. There was little or no 
 change during the next two days. 
 
 Threatening Letters. — On March 14th I received 
 several threatening letters. In one of them the writer 
 informed me that he was one of a band of ten who 
 had agreed to sacrifice their own lives in order to take 
 mine. They had drawn lots, and to my correspon- 
 dent it had fallen to make the attempt first, and if he 
 failed, his companions would take his place one after 
 the other, till the deed was done. He added, that if 
 I did not leave Germany by March the 17th, my life 
 would not be worth an hour's purchase. In two of 
 these interesting epistles, it was declared that a 
 German Emperor should be treated by none but 
 German doctors. These threats seemed to be the 
 direct result of the truculent articles which appeared 
 day after day in certain newspapers which made it a 
 point of national honour to support the German 
 doctors through thick and thin. I believe it was 
 the Kolnische Zeitung that said that " IMackenzie 
 dared not let himself be seen in Unter-den-Linden,"
 
 The Windpipe Criimhlmg Away. 127 
 
 the principal street in Berlin, "because if he 
 showed his face there the people would tear him 
 in pieces or stone him to death." This is the 
 paper whose Berlin representative — a certain Dr. 
 Fischer — for many months systematically supported 
 von Bergmann and vilified me. He made me the object 
 of these polite attentions as far back as May, 1887, 
 when he asserted that the operation I had succeeded 
 in doing, was really performed by Tobold, the 
 specialist who "no longer operated!" Some days 
 later (March 17th) I was offered police^ protection, 
 and subsequently I was frequently asked when I was 
 going out, whether I should like to be accompanied 
 by a detective. This I invariably declined. 
 
 The Wi7idpipe CrtLmbling Away. — On March 15th 
 a large slough came away from the upper and 
 deepest part of the wound. It seemed to consist of 
 broken-down tissue — mainly minute pieces of cartilage 
 — from the trachea. This destructive process was no 
 doubt the consequence of the pressure of the large 
 and unsuitable tube which had been the source of so 
 much suffering to the august patient at San Remo, 
 and which he had continued to wear till I was per- 
 mitted to introduce the roughly improvised Italian 
 canula. The effect of the separation of the slough was 
 considerably to enlarge the opening into the wind- 
 pipe, the vertical diameter of which was now rather 
 more than two centimetres (four-fifths of an inch). 
 The upper part of the tracheal orifice was nearly on 
 a level with the wound in the skin, instead of being a 
 good deal below it as before. 
 
 Funeral of the Emperor William, — On the morning 
 of the same day (March 15th) the Emperor had 
 received visits from the Kings and other royal 
 personages who had come to attend his father's 
 funeral. His Majesty asked me if it would be 
 possible for him to take his place at the mournful 
 ceremony, but I was obliged to inform him that in 
 the state of health he was in, the emotional excite-
 
 128 The Fatal Illness of Frederick the Noble. 
 
 ment inseparable from the occasion, to say nothing of 
 exposure to the bitter weather which then prevailed, 
 would make such a step in the highest degree 
 dangerous. For once fhe Imperial sufferer appeared 
 to be unwilling to obey my injunctions ; he begged 
 hard to be allowed to pay the last tribute of respect 
 to the venerable parent by whose deathbed he had 
 not been able to stand, and it required all the firmness 
 I could command to induce him to give way. The 
 funeral took place on the i6th, and His Majesty was 
 
 Fig. i6. — Durham's tube /;/ sitii and acting well. 
 
 more depressed than I had ever seen him. His 
 countenance expressed the deepest sorrow ; he was 
 restless and agitated, and twice he pointed to a 
 window looking toward Berlin, saying, "/ ought to 
 be there !" 
 
 A more comfortable Tube. — On IMarch i6th, finding 
 that the separation of the slough had not been 
 followed by any tendency to haemorrhage, I deter- 
 mined once more to try the effect of a Durham's tube, 
 which now passed easily, and could remain fixed in 
 a horizontal position (See Fig. i6). The canula intro-
 
 A more comfortable Tube. 129 
 
 duced by Bramann having caused such extensive 
 erosion of the mucous membrane of the windpipe with 
 so much local inflammation, I had not ventured before 
 this to use a tube which passed down the trachea. 
 The insertion of the new instrument was borne very 
 well by the Emperor, the temperature remaining 
 normal. 
 
 The next day His Majesty was able to receive a 
 large number of distinguished personages who came 
 to pay their respects to him before leaving Berlin. I 
 found that the new tube had caused some bleeding, 
 which, as my note-book states, was "more this morning 
 than it has been since leaving San Remo." There is 
 no doubt that this was due to the softened and 
 irritable condition in which the lining membrane of 
 the windpipe had been left by the first canula. 
 
 On March i8th I was gratified to find there had 
 been less bleeding. I shortened the horizontal por- 
 tion of the tube (by moving the shield) to the extent 
 of one centimetre, and twisted its lower ejid slightly to 
 the left so as to remove its edge from the right zuall oj 
 the trachea (See Fig. 17). The Emperor attended 
 prayers in Chapel this morning, and it was noticed 
 that he did not cough once during the service. His 
 Majesty received the special Envoys and the whole 
 Diplomatic Body, the audience lasting an hour and a 
 quarter. In the evening the Duke of Cambridge paid 
 a visit to the Emperor. 
 
 The Imperial Invalids daily life. — The weather was 
 still very severe, snow falling almost continuously. 
 At this time the illustrious patient's course of life was 
 as follows : He generally rose soon after eight, after 
 breakfasting in bed, and was dressed by half past 
 nine. He then went down to the Orangery, where 
 the'' Empress accompanied him, whilst I remained 
 near at hand. About ten o'clock His Majesty re- 
 turned to his study, where he gave audiences to his 
 ministers or other officials till noon. Soon afterwards 
 he used to go again to the Orangery, where he re- 
 
 K
 
 1 30 TJie Fatal Illness of Frederick the Noble. 
 
 mained for an hour or so, sitting in the central 
 pavilion, or walking up and down the long corridor. 
 Here also the Emperor often received visitors and 
 officials. Though the Orangery was better than 
 nothing, it was a very depressing place after the 
 bright sunshine and balmy air of San Remo ; the 
 building had not originally been constructed as an 
 Orangery, and the glass-work occupied only one side. 
 The orange trees were old, thick-stemmed, and 
 
 01 
 
 Fig. 17. — Durham's tube (full size). It is twisted slightly to the 
 (patient's) left side, to avoid the right wall of the trachea. Com- 
 pare Figs. 13, 14, and 15. 
 
 covered with leaves, so that the interior was very 
 gloomy. After lunch the Emperor generally saw 
 some members of his family, after which he rested for 
 an hour or two. Before, or after taking his rest, His 
 Majesty often received Prince Bismarck or the Crown 
 Prince. After his siesta the Emperor generally 
 attended to State business, signed papers, and wrote 
 his diary. He dined at eight, and went to bed 
 between half past nine and ten.
 
 The question of Operation in a new aspect. 1 3 1 
 
 The question of Operation in a new aspect. — As the 
 health of the Imperial sufferer had by this time some- 
 what recovered from the effects of the rough handling 
 to which his wounded throat had, in spite of my pro- 
 tests, been subjected at San Remo, the question arose 
 in my mind whether a radical operation should be 
 now proposed to His Majesty. I had resolutely set 
 my face against any such measure when there was 
 still a doubt as to the nature of the disease ; but since 
 Professor VValdeyer had pronounced it to be cancer, 
 the situation was entirely changed. The only hope of 
 cure lay in removal of the disease. It was a very for- 
 lonr^hope, no doubt, and one more than counter- 
 balanced, to my mind, by the immediate risk of the 
 operation and the wretched condition in which those 
 who survive it are almost invariably left owing to the 
 dreadful mutilation they have undergone. Moreover 
 the chances are always enormously in favour of a re- 
 currence of the disease within a very few months. 
 The results of complete extirpation of the larynx have 
 hitherto been so bad (See Table III., p. 244), that 
 some practitioners are doubtful whether so deadly an 
 operation has any place in legitimate surgery. My own 
 opinion, however, is that, fatal as this operation has 
 proved to be, a greater number of patients are cured 
 by it than by what is miscalled " simple thyrotomy." 
 The immediate mortality from the operation is 36 '23 
 per cent, thirty-six patients dying within nine days ! 
 Still 8 cases out of 138 are said to have been cured 
 by this operation ! On the other hand, it is certain 
 that not a few of the fatal or unsuccessful operations 
 carent vate sacro, and are not allowed to appear in 
 published statistics. If the record were complete, the 
 results would probably deter the boldest surgeon from 
 attempting a procedure in which, as Dr. Paul Koch* 
 has said, it is a triumph for the operator if the patient 
 does not actually die under the knife. 
 
 * ' Annales des Maladies de I'Oreille, &c.,' March, 1879. 
 
 K 2
 
 13^ TJie Fatal Illness of Frederick the Noble. 
 
 Nevertheless, as the operation does give the patient 
 a chance — infinitesimal though it be — and the disease 
 is absolutely incurable by any other kind of treatment, 
 I thought it right to discuss with Professor Krause 
 and Mr. Hovell the propriety of mentioning the matter 
 to the Emperor. These gentlemen fully agreed with 
 me that after all the august patient had gone through 
 since tracheotomy had been performed, any severe 
 surgical measure was out of the question. It is certain, 
 however, that even at that time the operation, qua 
 operation, wouldJiaveJieeji perfectly feasible^ecause 
 ^^^ after death the anterior wall of the gullel^was- found 
 I ^ to be intact, and the ulcer could have been dissected 
 away from the posterior wall of the larynx, the 
 cesophageal tube being still left in a state of integrity. 
 Or, if that had not been found feasible, a portion of 
 the CESophagus could have been cut out, as is usually 
 done in these operations. I am far from saying that 
 even if the illustrious patient had been in a state of 
 health to admit of extirpation of the larynx I should 
 have urged him to submit to it, but I maintain that 
 had it not been for the unfortunate mismanagement 
 of the case by Drs. von Bergmann and Bramann in 
 February, the operation might possibly have been 
 undertaken when the nature of the disease had been 
 definitely established by Professor Waldeyer. 
 
 It is beyond all question that the disease made 
 much more rapid progress after the tracheotomy than 
 before. As a rule, that operation has quite the oppo- 
 site effect, for it gives the diseased parts comparative 
 rest, and so far saves them from irritation. Why was 
 the result so woefully different in the present case ? 
 Because the violent shaking of the larynx broke down 
 the tissues, and caused as much destruction in a few 
 weeks as is ordinarily produced by the unassisted 
 action of the disease in many months. What was 
 this shaking of the larynx due to? To the violent 
 and almost continual coughing, set up by the chafing 
 of the delicate inner wall of the windpipe by ill-fitting
 
 The Bleeding Stopped at Last, 133 
 
 tracheotomy tubes. Later on, as will be told in due 
 course, a further source of irritation was supplied by 
 the trickling into the windpipe of matter from an 
 abscess caused by Professor von Bergmann's blun- 
 dering efforts to make force supply the place of skill 
 in introducing a canula. 
 
 The Bleeding Stopped at last. — In the meantime, 
 as I have said, the ill-used trachea had, under more 
 intelligent management, had some chance of recovering 
 to a certain extent. From March 19th to the 22nd 
 there was comparatively little coughing, and hardly 
 any bleeding. His Majesty slept fairly well at night, 
 and the temperature remained almost normal. It was 
 only three weeks since I had been allowed to insert 
 the tube I had had made at San Remo, and the 
 bleeding, which till then had been all but continuous, 
 had now almost ceased ! It must be understood that 
 the loss of blood was much greater than would be 
 gathered from the euphemistic "blood-stained expec- 
 toration " of the bulletins. It was real haemorrhage, 
 slight, it is true, but almost constant, so that a con- 
 siderable amount of blood was lost each day. After 
 March 22nd there was no further bleeding, except 
 once or twice after massage had been performed, and 
 a very slight attack on March 31st. This gratifying 
 result was entirely due to the substitution of a proper 
 tube for the instrument of torture which had wrought 
 all the mischief, and is therefore a significant com- 
 mentary on the assertion repeatedly made by Von 
 Bergmann, in the most emphatic terms, that no matter 
 what tube was used the bleeding would never cease 
 (See p. 107). 
 
 Aiiother " Controller T — About this time I discovered 
 that I had again been placed under " control " — on this 
 occasion by Professor von Bergmann. I learned that 
 the orderly in attendance on the Emperor was in the 
 habit of making daily reports to Bergmann, who had, 
 as a matter of fact, engaged him, of everything that 
 took place whilst he was on duty. This arrangement
 
 134 I^J^e Fatal Illness- of Frederick the Noble. 
 
 was no doubt only an additional proof of the absorb- 
 ing interest which Professor von Bergmann took in 
 the illustrious patient's condition. Although many 
 physicians in my place would no doubt have strongly 
 objected to reports being made behind their backs by 
 a servant to a colleague engaged in the case, I did 
 not think it worth while to take any notice of the 
 matter, especially as the man did his work satisfac- 
 torily in other respects. On the whole I preferred 
 his " control " to Landgraf's ; his " observations " were 
 no doubt just as accurate, and he did not insist on 
 using the laryngoscope. I cannot say, however, that 
 I admire the system of medical police supervision to 
 which I was subjected ; it may be useful for ensuring 
 a copious supply of "■ official sources," but it is insult- 
 ing to the physician, and might easily be injurious to 
 the patient. 
 
 The Wiesbaden Project. — Before the Emperor came 
 to Berlin, there had been some question of his going 
 to stay at Wiesbaden for a time, for the sake of quiet 
 and the comparative mildness of the climate. During 
 the first fortnight of His Majesty's residence at Char- 
 lottenburg this project was often discussed, but as at 
 the time the whole of Germany was deeply covered 
 with snow, there did not seem to be any advantage 
 in his leaving Berlin. Indeed only the sternest 
 necessity would have induced me to consent to the 
 Emperor's undertaking any journey whatever at that 
 time. 
 
 Further Disintegratioji of the Windpipe. — On March 
 23rd fresh evidence was supplied of the havoc which 
 had been wrought by Bramann's tube. During the 
 preceding night the Emperor had had several severe 
 attacks of coughing, which came on at intervals of an 
 hour or two and lasted for a considerable time. On 
 removing the tube in the morning a flat quadrilateral 
 piece of cartilage about twelve millimetres long, and 
 from six to seven millimetres wide, was found loose in 
 the upper part of the tracheal opening. Professor
 
 Massage Tried. 135 
 
 Hartmann, to whom it was sent for microscopic 
 examination, pronounced it to be a piece of hyaline 
 cartilage, which had no doubt come from the wind- 
 pipe. It represented about a sixth part of one of the 
 tracheal rings. 
 
 Massage Tried. — At the general consultation on 
 the same day, it was agreed that as the Emperor was 
 confined to the house by the very severe weather, and 
 was suffering from want of exercise, massage should 
 be tried as the best available substitute. On the 
 recommendation of Professor von Bergmann it was 
 decided that the manipulations should be carried out 
 by Dr. Zebludowsky. As massage has not yet quite 
 found its level among our therapeutic resources, being 
 vaunted as a panacea by some and despised as 
 quackery by others, it may be right for me to point 
 out the precise object for which it was proposed to 
 apply it in the present case. There was of course no 
 idea that it could have any effect on the disease, but 
 it was thought it might be useful as giving passive 
 exercise to the muscles, and stimulating the vital 
 functions which the enforced bodily inactivity was 
 making torpid. Men of stalwart frame who have been 
 accustomed to an outdoor life involving much physical 
 exertion, always suffer greatly from want of exercise, 
 and His Majesty was no exception to this rule. Mas- 
 sage was applied on two or three occasions with great 
 skill by Dr. Zebludowsky, but it was found that it did 
 not suit the illustrious patient, as it over-excited him, 
 and caused some fresh bleeding from the throat. It 
 was therefore decided to discontinue it. 
 
 Honours gracef idly Conferred. — On March 25th the 
 Emperor put into Dr. Krause's hands a document 
 appointing him an Extraordinary Professor in the 
 University of Berlin. The title of Professor has fallen 
 to such " base uses " in this country that, as Matthew 
 Arnold pointed out, learned men are generally rather 
 shy of claiming it. In Germany, however, the use of 
 the title is so strictly regulated that the possession of
 
 1 3 6 The Fatal Illness of Frederick the Noble. 
 
 it is an honour which is greatly coveted ; it also 
 makes an immense practical difference in a profes- 
 sional man's position. At the same time His Majesty 
 handed^ me a slip of paper of which the annexed 
 sketch is a fac-simile reproduction.
 
 Honours gracefully conferred. 137 
 
 This communication is very characteristic of Frederick 
 the Noble, showing as it does his profound respect for 
 the Queen, and his delicate thoughtfulness for humble 
 individuals like myself. I know of no other instance 
 in which a foreign Monarch has, before conferring an 
 honour on an Englishman, not only taken the trouble 
 to ascertain whether the distinction would be pleasing 
 to the recipient's own Sovereign, but obtained leave 
 for him to accept and use it. Honours thus conferred 
 are something immeasurably beyond the mere title or 
 insignia which represent them ; they become precious 
 m^rks of gracious personal interest like the gifts of an 
 attached friend. 
 
 A ttacks by the " Reptile " Press. — From about this 
 time I was made the object of constant attacks in 
 some of the German newspapers which seemed to
 
 138 The Fatal Illness of Frederick the Noble. 
 
 draw their inspiration largely from Professor von Berg- 
 mann; conspicuous among these were the KolniscJie 
 Zeitiing, the Kreuz Zeitung and the Post. A large 
 number of provincial papers took their cue from these 
 journals, and abused me with a virulence of which 
 English people can scarcely form an idea. Threaten- 
 ing letters came to me in shoals, but I am happy to 
 say I also received many messages of sympathy and 
 encouragement ; whilst the former all emanated from 
 one clique, the latter were sent by representatives of 
 all classes, the aristocracy, professional men, merchants, 
 tradespeople and workings men. These kind and en- 
 couraging letters will always be kept by me amongst 
 my most prized possessions, as delightful souvenirs 
 of a most trjnng time. It is amusing, but at the 
 same time somewhat painful, to note, as showing the 
 depths of malignant stupidity to which men may 
 fall when misled by passion, that one of the chief 
 grounds of attack against me was the alleged fact that 
 I was of Jewish origin. When argument and invective 
 were exhausted, the appeal to the anti-Semitic feeling 
 so prevalent among certain classes in Germany was a 
 never-failing resource. My real name was said to be 
 " Moritz Markovicz," of which hypothetical appellation 
 " Morell Mackenzie " was gravely said to be the 
 English equivalent. Quite recently (August 31st) 
 I was favoured with an advertisement taken from an 
 illustrated German paper, in which my portrait was 
 promised for an early number in the following terms : 
 " We shall also lay before our readers an account of 
 the goings-on of that Jewish-English horror Markovicz 
 alias Mackenzie, and as a proof that the so-called 
 Englishman is really a Jew we shall publish his portrait 
 after a cabinet photograph." This interesting work of 
 art has since appeared, and I observe that my " inno- 
 cent nose " has been somewhat cruelly aggravated into 
 a formidable appendage of the caricature Hebraic type. 
 The descriptive letter-press is worthy of the picture. 
 My parentage is thus spoken of : — '* Our readers will
 
 A Hacks by the Reptile Press. 1 39 
 
 remember that it was stated in many quarters that 
 the grandfather of this so-called Englishman was 
 a Polish Jew of the name of Markovicz, who left 
 Posen and settled in England. This man (Morell 
 Mackenzie), who denies everything, has never denied 
 this. The name of Markovicz was afterwards changed 
 to Mackenzie." My respected grandfather, who was 
 extremely proud of his Highland descent, and who 
 never set foot outside the United Kingdom, would 
 doubtless have been surprised to hear that he was a 
 Polish Jew ! A correspondent wrote to me from 
 Dantzig, " It is no good for you to pretend that you 
 are not a Jew. You encouraged a Jewish doctor 
 from this town to settle in London, a thing which 
 nobody but one of the tribe would have thought of 
 doing." Even persons professing to be my friends 
 exhibited a lively curiosity as to my origin. A lady 
 wrote to me from Magdeburg saying that she had 
 defended me on every point, except as to the question 
 of my Jewish faith. If I could only give her some 
 evidence to show that I was not a Jew, she thought 
 things would be more comfortable in that town. She 
 would be glad to know where I was born, and where 
 my ancestors came from. I need not say that if I 
 really did belong to the remarkable race which has 
 produced so many men of the highest distinction in 
 every department of literature, art, and science, so far 
 from being ashamed of such an extraction I should 
 be proud of it. I have only thought it worth while 
 to notice the matter merely as an example of the 
 gross inaccuracy of statement which, not less than sys- 
 tematic scurrility, has been the distinguishing feature 
 of the attacks on me. These absurd attacks are of 
 course utterly unimportant in themselves, but they 
 serve to show the character of the people who sup- 
 ported Professor von Bergmann. That gentleman's 
 journalistic friends not only denied that I did the 
 Emperor any good, but accused me of preventing 
 their protege from using his skill to relieve the 
 illustrious patient.
 
 1 40 The Fatal Illness of Frederick the Noble. 
 
 Out of doors again. — On March 28th the Emperor 
 was able to go out for the first time since his return 
 to Germany. The weather was bright, and His 
 Majesty walked for some time in the open air outside 
 the Orangery. On the 29th (Maundy Thursday) the 
 Emperor, together with the Empress and the rest of 
 the Imperial family, took the Holy Communion, and 
 His Majesty afterwards went for a drive in an open 
 carriage to the Griinewald forest. He wore the ample 
 blue cloak of the Prussian Cavalry, with fur cape and 
 field cap. I followed in a carriage with one of the 
 adjutants. In the afternoon His Majesty walked in 
 the garden and in the park. 
 
 The next day, as the sun was shining brightly, I 
 said to the Emperor, " A fortnight ago, Sir, you asked 
 me if you might drive into Berlin to pay a visit to 
 Her Majesty the Empress Augusta, and I felt obliged 
 to tell you that it would be dangerous for you to 
 leave the house. To-day, I think you may safely go." 
 The Emperor's face beamed with pleasure, and he 
 shook me warmly by the hand, saying, " I am, indeed, 
 delighted." This was the first time he had visited his 
 capital since his return. His appearance there was 
 quite unexpected, and accordingly the police had 
 made no arrangements for the preservation of order. 
 He was received with such enthusiasm that I felt 
 rather alarmed lest the excitement might be too much 
 for him, but he bore it well, and seemed as glad to be 
 among his people as they were to see him. It was 
 sad, however, to think of the stricken Kaiser in the 
 midst of that seething sea of vigorous life. I was 
 agreeably surprised on this occasion to find that, in 
 spite of all the abuse which I had received from a 
 section of the German press, and the threatening 
 letters which had poured in upon me since I had been 
 at Charlottenburg, the Berlin people seemed very well 
 disposed towards me. The men took off their hats, 
 and the ladies bowed to me in a friendly way. On 
 returning to Charlottenburg, His Majesty did not 
 seem at all tired, and was able to walk in the garden
 
 Progress of the Disease. 141 
 
 for some time in the afternoon. Two days later the 
 Emperor paid a second visit to Berhn. 
 
 Progress of the Disease. — On April 3rd His 
 Majesty said he felt better than he had done since 
 the operation. He was able to dress himself almost 
 without help. His temperature, however, was higher 
 that evening than it had been for some time, reaching 
 101° Fahrenheit, whilst his pulse was 86. 
 
 Professor Esmarch, of Kiel, visited the Emperor 
 on this day, and afterwards had some conversation 
 with me. He urged me to give the Chian turpentine 
 treatment a fair trial, saying that in two cases of 
 cancer under his own care it had done a great deal 
 of good. I informed him that it had already been 
 tried in the Emperor's case. 
 
 On April 4th the temperature was still rather high, 
 and the illustrious patient had been much troubled 
 with cough the night before. On the 5th a good 
 deal of disorganised tissue came away from the right 
 side of the opening in the windpipe, and some vege- 
 tations were noticed around the latter. These were 
 touched with nitrate of silver, which, however, only 
 made them look " angry " and inclined to bleed. The 
 next day the upper part of the wound and the channel 
 of the windpipe above the tube was seen to constitute 
 a solid arch of morbid tissue ; whether this was new 
 growth or simple inflammatory swelling it was im- 
 possible to say. There was inflammation of the 
 areolar tissue above and at the sides of the wound, 
 and at the orifice of the trachea. His Majesty also 
 complained of some pain in swallowing ; this appeared 
 to be due solely to the inflamed condition of the 
 trachea, which is, of course, pulled upwards in degluti- 
 tion. The Emperor also suffered from headache, 
 which was, however, relieved by the remedy which 
 generally proved effectual in his case. 
 
 It was only too clear that the whole structure of the 
 windpipe in the neighbourhood of the wound was 
 falling to pieces. On April loth two large fragments
 
 142 The Fatal Illness of Frederick the Noble. 
 
 of cartilage came away, and the trachea began to lose 
 its rigidity. There being hardly any cartilage left in 
 front to support the tube, the latter lay loose in the 
 wound, and the back wall of the trachea tended to 
 fall forwards so as partly to cover the inner end of 
 the tube. 
 
 At this time there was a good deal of excitement 
 in the public mind about the proposed Battenberg 
 marriage, but I cannot say that it produced much 
 effect on the Emperor. 
 
 My visit to Londoti postponed. — It had been arranged 
 some time previously that about this time I should be 
 allowed to return to London for a week or two, and 
 as there were no symptoms indicative of impending 
 danger, I was looking forward to my brief holiday 
 with some pleasure. The Emperor, however, said to 
 me one evening, " I hope you won't mind putting off 
 your return to London for a short time." He con- 
 tinued, " I expect your patients in London must quite 
 hate me for keeping you here." I replied, " No, Sir. 
 All English people take the deepest interest in your 
 health. There is no one who would not make sacri- 
 fices to be of service to you." His Majesty replied, 
 " I cannot understand why it is that people are so 
 kind to me." In the evening the Emperor sent for 
 me and handed me the Cross and Star of the Hohen- 
 zollern Order, together with an autograph letter, of 
 which the following is a copy : — 
 
 " Charlottenburg, April icth, 1888. 
 
 "My dear Sir Morell, 
 
 " You were called to me by the unanimous 
 wish of my German medical attendants. 
 
 ** Not knowing you myself, I had confidence in you 
 in consequence of their recommendation. But I soon 
 learnt to appreciate you from personal experience. 
 
 *' You have rendered me most valuable services, in 
 recognition of which, and in remembrance of my 
 accession to the Throne, I have the pleasure to confer
 
 A Fatal Day. 143 
 
 on you the ' Comthur Cross and Star of my Royal 
 Order of Hohenzollern.' 
 
 " Yours truly, 
 
 " Frederick, I.R. 
 " Sir Morell Mackenzie." 
 
 Mr. Hovell received at the same time a high order 
 from His Majesty — the Second Class of the Kron 
 Order. 
 
 A Fatal Day. — As, owing to the unfortunate series 
 of events which occurred on April 12th, that day 
 proved to be a turning-point in the case, I need make 
 no apology for describing what took place at some 
 length. Before doing so, I may be allowed to say 
 that what I am about to state here is the exact truth 
 to the best of my knowledge and belief There has 
 been so much misrepresentation and downright lying 
 about this matter, and the consequences of what 
 occurred were so serious, that it is necessary to place 
 the whole body of facts before my readers in order 
 that they may be in a position to form a correct 
 judgment. Let it be understood, that if I seem to 
 express myself strongly it is only because I feel 
 strongly ; if I have " nothing extenuated," at least I 
 am not conscious of having " set down aught in 
 malice." 
 
 On the night of April Iith-I2th the Emperor was 
 seized with severe coughing between midnight and 
 I A.M. At 1.30 Mr. Hovell noticed, that although 
 air passed freely through the canula, the breathing 
 was accompanied by a noise as if there were some- 
 thing projecting below the lower end of the tube. On 
 removing the canula the noise ceased — a circumstance 
 wliich caused Mr. Hovell to think (and this view I 
 afterwards confirmed) that the lower edge of the 
 posterior part of the canula must slightly press into 
 the posterior wall of the trachea, owing to its bulging 
 forward at that part. This latter view was supported
 
 144 I^Jt-s Fatal Illness of Frederick the Noble. 
 
 by the fact that the external part of the canula was 
 pushed forward. Mr. Hovell slanted the tube rather 
 more away from the right side, and inserted a pad 
 under the lower edge of the shield so as to tilt the 
 lower and back edge of the canula away from the 
 posterior wall. The noise was somewhat less after 
 this was done, but did not entirely cease. The 
 Emperor also breathed a good deal more quickly than 
 usual. At 2.15 A.M. Mr. Hovell was again called, but 
 found no change. At 2.40 he returned to the illus- 
 trious patient, not having gone to bed in the mean- 
 time, and found him in precisely the same condition. 
 Mr. Hovell was summoned several times afterwards 
 during the night, and on more than one occasion he 
 slightly altered the position of the tube by placing 
 pads under the shield. At 8 A.M. I saw the Emperor, 
 and as the breathing, though quickened and slightly 
 noisy, was quite free, I determined to leave the 
 canula i?t situ till Drs. Krause and Wegner arrived. 
 At the consultation it was agreed to try the effect of 
 a shorter tube. His Majesty appeared to breathe 
 perfectly well as soon as this tube was introduced, but 
 about half-an-hour afterwards the respiration again 
 became rather noisy. I therefore removed the short 
 tube and replaced the former one. As there was no 
 urgency whatever, and as, in anticipation of some 
 trouble of the kind, I had ordered several special 
 tubes in Berlin three days before, I thought it would 
 be better to go and fetch these canulas rather than 
 try any of those I had by me. Finding, however, 
 that the tubes were not quite ready, I directed one 
 of a suitable shape to be quickly made of lead, and 
 asked the instrument-maker to come to Charlotten- 
 burg at once, so that if the first tube did not answer, 
 a second could be made on the spot.* As the tube 
 
 * The advantage of lead is not only that it can be very 
 quickly made, but that the cur\'e of the instrument can also be 
 readily altered. For a short time a tube of this material 
 answers perfectly well.
 
 A Fatal Day. 145 
 
 which I now proposed to try was different in shape 
 from any of those which had been used since the 
 case had been formally given up to me by Professor 
 von Bergmann at San Remo, I thought that pro- 
 fessional courtesy required that I should ask him 
 to be present on the occasion. As I intended to 
 do whatever was necessary with my own hands, 
 there was really no need for the assistance of a 
 surgeon, but it is an elementary rule of civilised 
 medical practice that all those associated together in 
 the management of a case should be made acquainted 
 with the details of the treatment that is carried out. 
 As soon as the new tube was ready, therefore, I de- 
 spatched a messenger to Professor von Bergmann, to 
 request him to come to me as soort as possible, mean- 
 ing of course that I was anxious to proceed to change 
 the tube without delay. 
 
 In sending off that message, little did I think that 
 it would have such fatal consequences. It is no 
 exaggeration to say that these hastily scribbled lines 
 proved to be the death-warrant of the Emperor. 
 Had I had the slightest idea of what was to follow, I 
 should certainly not have allowed any over-punctilious 
 notions of etiquette to mislead me into taking so 
 disastrous a step. At the moment, however, it ap- 
 peared to be the right thing to do. The Emperor on 
 his accession to the throne, had appointed Professor 
 von Bergmann to be one of his medical attendants no 
 doubt in deference to public opinion in Germany, and 
 I had been repeatedly and urgently requested by the 
 chief officer of His Majesty's household, Prince 
 Radolin, to endeavour to work harmoniously with 
 von Bergmann, who, Prince Radolin assured me, was 
 '' greatly trusted by the official classes." Hence my 
 anxiety that there should be no ground for complaint, 
 so far as I was concerned, of any violation of the 
 decencies of professional intercourse. 
 
 It was five o'clock in the afternoon before Professor 
 von Bergmann arrived. As soon as he came into my 
 
 L
 
 1 46 The Fatal Illness of Frederick the Noble. 
 
 room, I noticed that he was in a state of great excite- 
 ment ; whether this agitation was due to exaggerated 
 reports which he rnay have received as to the 
 Emperor's condition, or to causes of a more personal 
 nature, I am unable to say ; but either from over- 
 excitement or from some other cause, Bergmann 
 behaved in a most extraordinary, indeed altogether 
 unaccountable, manner. 
 
 I briefly explained the circumstances, and showed 
 him the tubes which I had got ready, though 
 Bergmann seemed in too great a flurry to be able 
 to listen attentively. We then proceeded to the 
 Emperor's room, accompanied by Mr. Hovell, each of 
 us carrying several tubes. We found the Emperor 
 engaged in writing. The inspiration was distinctly 
 audible, but beyond this there was not the slightest 
 indication of any difficulty in breathing. Professor 
 von Bergmann placed a chair opposite the window, 
 and asked the Emperor to sit down upon it ; and 
 thereupon, without making any remark, he quickly 
 undid the tape which kept the canula in position, 
 pulled the latter out, and, with considerable force, en- 
 deavoured to insert one which he had in his hand, 
 and which was not provided with a pilot. The 
 instrument was forced into the neck, but no air came 
 through it. The Emperor's breathing thereupon 
 became very much embarrassed, and the Professor 
 withdrew the tube. This was followed by a violent fit 
 of coughing, and there was considerable haemorrhage. 
 Professor von Bergmann next seized a tampon-canula 
 covered with sponge, cut the sponge quickly ofl", and 
 then tried to push the tube into the windpipe. Again 
 no air came through the canula, and it was clear that 
 instead of entering the air-passage it had been forced 
 downwards in front of the trachea, ploughing up the 
 soft tissues in that situation, and making what is 
 technically known as a "false passage." Again the 
 Professor had to pull out the tube, and again its with- 
 drawal was followed by violent coughing and streams
 
 A Fatal Day 
 
 ^A7 
 
 of blood. To my consternation, Professor von Berg- 
 mann then pushed his finger deeply into the wound, 
 and on withdrawing it tried to insert another tube ; 
 he again failed, however, and again the attempt was 
 followed as before by most distressing coughing and 
 copious bleeding. The position of the canula as 
 introduced will be understood by examining Fig. i8. 
 Professor von Bergmann then asked that his assis- 
 tant, who was waiting in his carriage outside, might 
 
 Fig. l8. — Diagram (half size) showing the part into which von Bergmann 
 plunged the canula. The instrument, instead of being in the trachea, 
 is seen to be in front of it. 
 
 be sent for. It seemed as if he contemplated doing 
 some further operation, perhaps enlarging the wound ; 
 but the Emperor was saved any further torture by 
 the arrival of Dr. Bramann on the scene. Professor 
 von Bergmann at once yielded the case into the 
 hands of his assistant, and the young surgeon, taking 
 a moderate-sized canula (No. 8 German measure), 
 passed it with the greatest ease into the trachea. 
 There had, indeed, never been any difficulty in intro- 
 
 L 2
 
 1 48 The Fatal Illness of Frederick the Noble. 
 
 ducing the canula. I had inserted a tube in the 
 presence of my colleagues, Drs. Wegner and Krause, 
 at 10 o'clock that morning, and I subsequently took 
 it out and substituted another for it. Although both 
 these tubes had passed quite freely and without 
 causing either coughing or bleeding, neither of them 
 was altogether satisfactory, and other canulae had, 
 therefore, to be procured. The Emperor coughed 
 almost incessantly, and continued to lose much blood 
 for two hours after Bcrgmann's abortive struggles 
 
 Fig. 19. — Diagram showing von Bergmann's " false passage." c is the 
 proper track of the canula ; d, the black part, shows the false passage. 
 
 with the tube ; the severity of the symptoms then 
 began to diminish, but there was still a good deal 
 of coughing with some haemorrhage at intervals, till 
 His Majesty went to bed. 
 
 Half an hour after the Professor's departure, the 
 Emperor sent for me and asked, "Why did Bergmann 
 put his finger into my throat?" I replied, " I do not 
 know, Sir." His Majesty then v/ent on to say, "I 
 hope you will not allow Professor von Bergmann to 
 do any further operations on me." I answered,
 
 A Fatal Day. 149 
 
 "After what I have seen to-day, Sir, I beg most 
 respectfully to say that I can no longer have the 
 honour of continuing in attendance on Your Majesty 
 if Professor von Bergmann is to be permitted to touch 
 your throat again." 
 
 Bergmann's roughness was never forgotten by the 
 Emperor, although the nobility of his nature prevented 
 him from showing any resentment, and even from 
 bearing that awkward operator any ill-will. That 
 von Bergmann should have been under the im- 
 pression that the Emperor felt grateful to him 
 because Bramamt inserted the tube, and that His 
 Majesty should have indicated his satisfaction by " a 
 joyful motion of his hand," and by a " thankful shaking 
 of our [Bergmann's and Bramann's, to wit] hands," * 
 is indeed remarkable, and would tend to show that 
 von Bergmann was not at the time in a condition 
 to observe things accurately. The Emperor often 
 referred afterwards to von Bergmann's roughness, 
 and unimpeachable testimony remains as to the 
 opinion of His Majesty on this subject in his own 
 handwriting three days before his lamented death. 
 I have not been permitted to reproduce this auto- 
 graph, but I shall be happy to show it to anyone 
 who has a legitimate claim to inspect it. The means 
 of testing the truth when von Bergmann and I make 
 opposite statements may not always be present, but 
 here at least is a touchstone of von Bergmann's 
 veracity : von Bergmann says that the Emperor 
 " thankfully shook his hands ;" the illustrious patient's 
 own handwriting, on the contrary, shows that he was 
 by no means satisfied with his treatment by Bergmann. 
 
 I returned to my room and discussed Bergmann's 
 conduct with Mr. Hovell, who, as well as myself, had 
 noticed the strangeness of his manner on his arrival. 
 I could not see anything in the case which could have 
 justified Professor Bergmann introducing his finger 
 
 Op. cit. p. 86.
 
 150 The Fatal Illness of Frederick the Noble. 
 
 into the wound. It is true that there were some 
 granulations round the orifice of the wound, such as 
 are often met with after tracheotomy, but there was 
 really nothing whatever to interfere with the passage 
 of the canula. Mr. Hovell expressed his surprise to 
 me that von Bergmann, who professed to attach such 
 extreme importance to the use of antiseptics, should 
 not have at least washed his hands before introducing 
 his finger into the tracheal wound. It appears, how- 
 ever, according to Bergmann's recent assertion,* that 
 he dexterously managed to dip his hand into some 
 carbolised water, without either of us being able to 
 perceive it. I had never before seen a canula forced 
 into the tissues of the neck, though I had occasionally 
 heard of the accident happening to young operators. 
 One case had also come under my own notice in 
 which the accident, having occurred to a young 
 surgeon, the operation had to be completed by the 
 nurse, who, from her large experience in such cases, 
 was easily able to introduce the canula into the 
 windpipe. This young surgeon, however, was pecu- 
 liarly unfortunate with his tracheotomy cases, two 
 patients having died under his knife shortly after- 
 wards. In all these cases, however, the accident had 
 occurred at the time of the operation, when there 
 is sometimes a little difficulty in getting the tube 
 through the little slit which is made in the windpipe. 
 Under such circumstances the mistake, if not ex- 
 cusable, is at any rate intelligible. But in a case 
 where the operation had been done two months before ; 
 where the wound in the neck and that in the windpipe 
 communicated by what may be called a beaten track, 
 along which the tube, if properly directed, almost 
 found its own way in, it is simply incomprehensible to 
 me that any surgeon should have done such mischief 
 unless his wits were disordered through nervous- 
 ness or some other cause. It was like a man trying 
 
 * Op. cit. pp. 85, 86.
 
 The Reptilia again. 151 
 
 to force a way through the wall of a house when the 
 door stood open before him ! The injury inflicted by 
 von Bergmann was no doubt much more serious than 
 it would have been had he used a right-angled tube, 
 for this instrument is provided with a pilot or rounded 
 knob (Fig. 20, C, r,) which prevents the sharp edge of 
 
 Fig. 20. — The extremities oi von Bergmann's unprotected, and Durham's 
 guarded, canula. B shows the extremity of the canula used by von 
 Bergmann on April 13th, the sharp cutting edge of which is seen at b. 
 C shows the extremity of a Durham's canula with the lobster-jointed 
 pilot, which projects at d, d, c, as a blunt knob, which prevents the 
 edge of the tube ctittifig the tender tissues of the neck. The pilot is of 
 course withdrawn as soon as the canula is introduced. 
 
 the end of the canula from coming in contact with the 
 wall of the trachea, whilst the ordinary canula as used 
 by von Bergmann was, in point of fact, a circular 
 knife (Fig. 20, B, b). It is easy to realize what a 
 dangerous weapon this must be in the hands of a 
 clumsy or excited surgeon. 
 
 The Reptilia Again. — The whole of the incident 
 which I have just related was misrepresented in the 
 grossest way by the K'dlnische Zeitung. Mr. Hovell 
 was accused of having, whilst trying to adjust the 
 canula during the night, injured the trachea and 
 pushed fragments of diseased tissue into the lungs. 
 This (according to the ingenious scribe) brought on 
 repeated attacks of suffocation ; and, after several
 
 1 5 2 The Fatal Illness of Frederick tJie Noble. 
 
 hours' delay, Bergmann had fortunately arrived in 
 time to snatch the Emperor from the jaws of death 
 by introducing a new tube, with much else in the 
 same style. Professor von Bergmann denies that he 
 caused this false and ridiculous statement to appear 
 in the Kdlnische Zeitting. I shall deal more fully 
 with this subject in criticising that gentleman's pub- 
 lished Report (Section II., p. 215). 
 
 Results of Bergmann s Handizvork. — On April 13th 
 the Emperor complained of soreness in the neck. He 
 was able, however, to drive into Berlin in a closed 
 carriage with the Empress and the Princess Victoria. 
 In the evening, as I was going out to dinner I paid 
 a visit to His Majesty at half-past seven. I returned 
 at ten o'clock, and at once went to the illustrious 
 patient. I found him breathing rather quickly, but 
 there was no hindrance to the passage of air through 
 the canula. I left the room to report on His Majesty's 
 condition to the Empress, with whom I remained ten 
 minutes or a quarter of an hour. When I returned 
 to my sitting-room I found that the orderly had 
 called Mr. Hovell to see the Emperor. From Mr. 
 Hovell's description I gathered that there was no 
 change in His Majesty's condition. 
 
 About eleven o'clock, while Mr. Hovell was still 
 with me. Dr. Wegner came to my room and said, *' I 
 have been called by the orderly. I find the Emperor 
 in a very serious condition ; he is breathing very 
 irregularly." I expressed surprise that the orderly 
 should have fetched Dr. Wegner from a distant wing 
 of the palace, when Mr. Hovell and I had both seen 
 His Majesty within the previous half-hour, and I 
 assured Dr. Wegner that there was nothing at all 
 serious in the Emperor's condition. His Majesty was a 
 little feverish, the pulse being 92, and the temperature 
 100 '8° F., and he was breathing rather quickly; but 
 I pointed out to Dr. Wegner that this had nothing to 
 do with any obstruction to the passage of air, and was 
 merely a nervous phenomenon due to febrile irrita-
 
 Results of Bergmann's Handiwoi'k. 153 
 
 tion.* As, however, Dr. Wegner seemed anxious that 
 I should see the Emperor again, I went with him 
 and Mr. Hovell to His Majesty's bedside, and watched 
 the august patient for a few minutes. As Dr. Wegner 
 said he had no suggestion to make either as regards 
 remedies or measures, and did not propose that I 
 should change the tube, I concluded that he was 
 satisfied that the Emperor's condition was not so 
 serious as he had at first supposed. 
 
 Mr. Hovell saw the Emperor several times between 
 eleven and two that night. At the latter hour His 
 Majesty wrote on his tablets, " Why does the orderly 
 ask if my breathing is difficult } I do not notice 
 anything." At half-past four the Emperor told Mr. 
 Hovell that the orderly had again asked him the 
 same question. Towards morning His Majesty's 
 breathing became slower and more tranquil, though 
 several times during sleep it was very hurried. 
 Fearing lest His Majesty should again be worried by 
 the fussiness of the orderly, I took steps in the morn- 
 ing to have him replaced by someone better fitted 
 for the post. This, like almost everything else which 
 I endeavoured to do for the benefit of the illustrious 
 patient, was made a ground of attack on me. It was 
 first stated in the Kdlnische Zeitting that the new 
 attendant was an Englishman. When this was 
 shown to be false, it was said that he was a Jew, on no 
 better ground, as it proved, than that the man had 
 once been a nurse in a Jewish hospital ! I mention 
 these things not as of any interest or importance in 
 themselves, but as showing the incredibly petty spite 
 which animated many of my critics. 
 
 On the 14th the Emperor felt rather poorly in the 
 morning, but was up betimes, and did a great deal of 
 
 * At a later period I came to the conclusion that the quickened 
 respiration which was first noticed on this occasion was due to 
 " shock," or in other words to the injury done by von Bergmann 
 on the afternoon of the previous day. Before that surgeon had 
 dealt his fatal blow hurried respiration had never occurred.
 
 154 T^f^^ Fatal Illness of Frederick the Noble. 
 
 writing. In the afternoon he drove out, and walked 
 about a little in the Thiergarten. At 6 P.M. the 
 Empress sent for me, and said His Majesty had had a 
 slight shivering fit. I was quite prepared for the 
 announcement, for ever since Bergmann's unfortunate 
 performance on the 1 2th, I had been fearing the onset 
 of pneumonia (from the trickling of blood and decom- 
 posing substances into the lungs), or the development 
 of acute suppurative inflammation round the "false 
 passage." In the evening His Majesty's temperature 
 was 103° Fahrenheit ; he had a restless night, and on 
 the following morning there were some rales in the 
 larger bronchial tubes, though there was no sign of 
 congestion in the lungs themselves. Fully realising 
 the gravity of the situation, I requested that Professor 
 Leyden should be summoned. Finding that he was 
 away at Wiesbaden, I obtained permission to call 
 in Professor Senator. That eminent physician, after a 
 most careful examination, could detect no disease in 
 the lungs except slight bronchial catarrh. 
 
 The next day (April i6th) my worst fears were 
 confirmed. The temperature remained at about the 
 same level (.102° to 103^ Fahrenheit), and pus began 
 to be discharged in abundance from the canula and 
 from the lower part of the wound. On pressing over 
 tJie front of the fteck, and caiiying the hand npzvards, 
 matter could be seen to well ont more profusely. 
 This proved that an abscess had already formed in 
 front of the trachea where the canula had been 
 pushed in by Bergmann. The pus was certain to 
 burrow downwards towards the chest, and it was only 
 too likely that nearly the whole of the front of the 
 neck would be converted into a huge abscess, in- 
 volving widespread disorganisation of the structures 
 round about the trachea, gradually undermining the 
 Emperor's strength, and leading only too surely to 
 hectic, and in no long time to death. This fatal 
 complication, be it remembered, was in no way the 
 natural result of the disease ; it was attributable
 
 Results of Berg7nanii s Handiwork. 
 
 155 
 
 solely to the injury done a i^\N days before by " < 
 Bergmann's random stabbing with an unguarded tube. 
 On the 17th we had the advantage of Professor 
 Leyden's counsels ; he also, after an exhaustive 
 examination, failed to find the least evidence of disease 
 in the lungs. These organs were again most carefully 
 examined by Professor Senator and Krause, as well 
 
 Fig. 21. — Diagram showing the abscess resulting from the *' false 
 passage " caused by von Bergmann. a, the gullet ; b, the larynx ; 
 d, the false passage ; <?, the abscess. The diagram is half-size^ and , 
 of course, only shows the side vinv of the abscess ; its depth through 
 the neck, i.e. its lateral extension, is not apparent in this sketch. 
 
 as by myself, and we were unanimous in pronouncing 
 them to be quite unaffected. Professor von Bergmann, 
 however, who had not shown himself a master of the 
 art of physical exploration of the chest at San Remo 
 (see p. 104), insisted, in opposition to us all that there 
 were secondary deposits of cancer in the lungs. He 
 afterwards maintained, in spite of the palpable fact that 
 matter could be literally squeezed out of the neck, that
 
 156 The Fatal Illness of Frederick the Noble. 
 
 the pus came from the lungs ! I need not dwell further 
 on Bergmann's preposterous opinions on this subject 
 than to point out that when two months later, after 
 the illustrious patient's decease, the parts came to be 
 examined, it was clearly proved that no disease of the 
 lungs or bronchial tubes had existed, except what 
 developed a few days before death. 
 
 Our New Colleagues. — Shortly after Professor Ley- 
 den's first visit to the Emperor he was appointed one 
 of the regular attendants of His Majesty. Professor 
 Leyden's great clinical experience, and his careful 
 studies in connection with alimentation, proved of the 
 utmost importance, and I have no hesitation in saying 
 that the extraordinary care and attention with which 
 this distinguished physician regulated the nutrition 
 of the illustrious invalid considerably prolonged his 
 life. 
 
 Professor Senator also proved a most valuable col- 
 league. His wide therapeutical knowledge and prac- 
 tical experience proved of much service in the acute 
 stage of the last attack. In obtaining the co-operation 
 of these two eminent physicians, I felt that the great 
 burden of responsibility, which before that had mainly 
 rested on me, was much lightened. 
 
 Extension of the Abscess. — His Majesty remained in 
 pretty much the same condition for some time. His 
 temperature continued to be somewhat high, rarely 
 falling below lOi^ Fahrenheit, and on one or two 
 occasions rising to 104° Fahrenheit. Remedies were 
 given with the view of reducing the fever, but they 
 had little or no effect. His Majesty suffered a good 
 deal from hiccough, which often prevented him from 
 sleeping. During the day, however, he was still able 
 to receive visitors and officials, and he expressed a 
 hope that the Queen's contemplated visit would not 
 be put off 
 
 On the 1 8th, as there was again some slight noise 
 during respiration, Mr. Hovell removed the small 
 tube which Bramann had introduced after Bergmann's
 
 Extension of the Abscess. 
 
 157 
 
 failure, and put in a larger canula. The substitution 
 was effected without the slightest difficulty, and v/as 
 unaccompanied by either coughing or bleeding. 
 There was no longer any doubt that an abscess had 
 formed in the place where the " false passage " had 
 been made, and that it was extending both down- 
 wards and laterally. On the 20th a large quantity 
 of pus was coughed up during the day. It was not 
 clear whether the abscess had burst into the trachea 
 
 Fig. 22. — The last canula used. Owing to the destruction of the tracheal 
 rings caused by Bramann's tube, the right-angled canula did not get enough 
 support to hold it in position. 
 
 at its lower part, or whether the pus reached the 
 interior of the trachea only through the surgical 
 opening made for the passage of the canula. That 
 a large portion of the pus found an entrance to 
 the air passages in this way was evident, but whether 
 this-Avas the only mode of entrance was not certain. 
 Whether there was one large abscess or a number of 
 smaller ones, von Bergmann having forced the canula 
 in different directions in front of the trachea, could 
 not be positively determined.
 
 1 5 8 The Fatal Illness of Frederick the Noble. 
 
 On this day I changed the tube in the presence 
 of my colleagues for one of the same bore as the 
 Emperor had been wearing before the fatal I2th. 
 
 Some Memorable Words. — In view of the serious 
 aspect which the case was assuming, I thought it 
 right to inform the Emperor that he was in a position 
 of considerable danger, and I ventured to hint to His 
 Majesty that if he had any matters to settle, it would be 
 advisable for him to do so now. The Emperor received 
 this communication with his usual perfect calmness, 
 and shook me warmly but gravely by the hand, say- 
 ing slowly, " I am much obliged to you for telling me. 
 I hope I shall get better — for the sake of my people." 
 I noticed that His Majesty made a slight pause after 
 the word " better," as if he were thinking aloud. At 
 that moment Frederick the Noble was no doubt 
 thinking of the enlightened and far-reaching schemes 
 for the internal development of Germany, which had 
 been maturing in his mind, through all those years of 
 conscientious preparation for his great office. The 
 regret for the uselessness of it all was not for himself 
 but for his people, who were to lose the blessing of 
 his wise and beneficent rule almost before they had 
 learned to appreciate it. 
 
 I believe it was on this day (April 20th), that the 
 Emperor made his touching remark to the Crown 
 Prince : '' Lerne zil leiden ohne zit klageii.'^ (Learn to 
 suffer without complaining). No one was ever better 
 fitted to teach this lesson by his own example than 
 this most patient of sufferers. Another story which 
 was current about the same time, to the effect that the 
 Emperor gave to the Court Chaplain Schrader a slip 
 of paper bearing these words : " Do not pray for my 
 recovery, but for my release," is entirely apocryphal. 
 His Majesty was not aware that the distinguished 
 divine had called at the Schloss till some hours after 
 he had left. 
 
 Increasing Weakness. — No great change occurred 
 in the Emperor's condition for some weeks. My notes
 
 Increasing Weakness. 159 
 
 chronicle slight oscillations of temperature, and 
 trifling differences of appetite, &c., from day to day. 
 Although the august patient was able to transact State 
 business, to give audiences, to receive visitors, and to 
 write his diary, it was impossible not to see that he 
 was steadily, though very gradually, losing ground. 
 The sudden variations in His Majesty's condition 
 seemed to depend largely on whether the discharge 
 of pus was abundant or scanty. As long as the 
 abscess emptied itself freely the Emperor was com- 
 paratively well ; on the other hand, whenever the 
 matter was retained for a few hours the feverishness 
 increased, and the illustrious patient felt languid and 
 ill. But these slight and temporary fluctuations had 
 little effect on the steady decline of health. One re- 
 markable feature in the case was the sudden quicken- 
 ing of the respiration, which often occurred without 
 any visible cause. The Emperor would all at once 
 begin to breathe very rapidly — fifty and even sixty 
 times a minute — and after some time the respiration 
 would become much slower again. It was noticeable 
 that the pulse was not accelerated on these occasions 
 in anything like the same proportion as the breath- 
 ing. This proves, as I have already said, that the 
 quickening of the respiration was a purely nervous 
 phenomenon. The breathing was generally more 
 hurried when the illustrious patient was asleep than 
 at any other time, and the sudden diminution of 
 rapidity on his awakening was sometimes very 
 marked. Thus, on one occasion I find that there 
 is a drop at the time of waking from fifty-three to 
 twenty, and on another from forty-four to eighteen 
 respirations in the minute. The Emperor's sleep was 
 as a rule much broken, lasting only for a couple of 
 hours or so at a time. His appetite, as was to be 
 expected from the temperature, was indifferent at 
 this time ; but when the fever began to decline a 
 little (on April 25th), His Majesty took solid nourish- 
 ment with relish.
 
 i6o The Fatal Illness of Frederick the Noble. 
 
 The Emperor received the Queen, who visited 
 Germany at this time, on several occasions ; he de- 
 clared to me, after Her Majesty's departure, that he 
 was sure her visit had done him much good. 
 
 How the Emperor was Nursed. — This seems to be 
 a convenient place to describe the nursing arrange- 
 ments. His Majesty had a large staff of attendants, 
 but with the exception of the orderly, who was on 
 duty in the sick room at night, there was no trained 
 nurse among them. The Emperor had four personal 
 attendants, two valets, and two jagers, besides his 
 chief personal attendant Wetterling, who had been 
 his soldier-servant almost since the time he joined 
 the army thirty-seven years previously. Wetterling 
 gave a general superintendence, administering the 
 medicines and arranging about the food under my 
 directions. One of His Majesty's valets had also 
 been with him over twenty years, and another for a 
 long period. His two jagers had been with him a 
 shorter time — one only a few months — but whether 
 they had been a longer or a shorter time in his 
 service, and though some were more handy than 
 other-;, they were all equally devoted to their 
 beloved master. The Emperor was indeed a man 
 whose soldiers would have shed their last drop of 
 blood for him, and whose servants rather than neglect 
 their duty would have fainted at their posts. The 
 Empress herself took an active part in the nursing, 
 showing a practical knowledge of the art equal 
 to that of any trained nurse. Her Majesty had 
 several times given excellent proof of her skill and 
 gentleness in dealing with the sick and wounded in 
 the military hospitals during the bloody campaigns 
 of 1866 and 1870; and now, when her own gallant 
 soldier-husband was laid low, she managed the details 
 of the sick room in a way that filled us all with ad- 
 miration. Hitherto the assistance which the Empress 
 had given us, though of the greatest value, was 
 more of a moral than a practical kind. Often, indeed.
 
 The Question of Opening the Abscess, i6i 
 
 when we doctors were losin^^ heart, Her Majesty 
 would cheer us up and stimulate us to fresh efforts 
 by her courage and example ; but now her struggles 
 were really heroic. Often have I seen her wipe away 
 her tears in the Emperor's ante-room, and then go in 
 to him with a smiling face, bringing, as it w^ere, a 
 stream of sunshine into the chamber of suffering, and 
 chasing the look of pain and weariness from the poor 
 patient's countenance. Now Her Majesty took a 
 more active part in the work, and showed herself 
 full of devices for ministering to the Emperor's 
 comfort. 
 
 The Qtcestion of opening the A hscess is considered. — 
 I several times discussed with Mr. Hovell the pro- 
 priety of making a counter-opening in the neck so 
 as to let out the pus, but as I did not know the exact 
 extent of the abscess, or whether there were one or 
 more abscesses, and was not certain as to the mode 
 in which the pus entered the trachea, I decided 
 against any surgical procedure. Several other cir- 
 cumstances also led me to this decision : First, it 
 was not at all clear whether, even if an external dis- 
 charge was established, it would entirely prevent the 
 flow of matter into the trachea, and in the event of 
 non-success we should have had all the inconvenience 
 of an external discharge as well as that which at 
 present existed ; Secondly, the abscess as a rule 
 emptied itself easily, and only occasionally, perhaps 
 once in a week or ten days the orifice became 
 obstructed for a few hours ; Thirdly, as it w^as certain 
 that the illustrious patient was doomed, it seemed to 
 me that it would be a mistake to carry out any 
 operation, however slight. Had the abscess occurred 
 in a case of acute disease I should, of course, have 
 brought the question of an external incision under 
 the notice of my colleagues, but being myself, for the 
 above-stated reasons, averse to interference, I thought 
 it better not to raise the point at a consultation. 
 
 Presents of Floivers. — When the Emperor began to 
 
 M
 
 1 62 TJie Fatal Illness of Frederick the Noble. 
 
 recover, quantities of the most beautiful flowers were 
 sent day after day from all parts of Germany. I have 
 admired the lavish display of beautiful flowers and 
 costly exotics in Paris and New York, but the 
 splendid floral offerings now made to the Emperor 
 exceeded anything I have ever seen. Many of the 
 bouquets were from private individuals, but not a few 
 of the best were sent by the Societies of Old Soldiers 
 which exist in such large numbers in Germany. 
 Some came from school children in Berlin, and on 
 several occasions violets and primroses were forwarded 
 by poor people from England, who expressed their 
 regret that their means did not permit them to 
 send valuable flowers. These humble gifts gave the 
 Emperor very great pleasure. 
 
 Bergmajin Boycotts Me. — On April 26th, on enter- 
 ing my sitting-room to be present at the morning 
 consultation, von Bergmann handed me a note in 
 which he declined all further intercourse with me 
 except such as was rendered necessary by our attend- 
 ance on the illustrious patient. The sequel of his 
 action will be entered into more fully in Section II 
 (p. 214). In the meantime I need only state that a 
 day or t\vo later, after some further amenities which 
 I had no difficulty in tracing to their source, I was 
 obliged to inform the Emperor that Professor von 
 Bergmann had shown fresh signs of hostility to me. 
 I went on to say that, under these circumstances, 
 though I did not wish him to be relieved of his duties, 
 I thought it was necessary that an eminent German 
 surgeon should be called in order to check any mis- 
 representation which Bergmann might make in the 
 future. I suggested the name of Professor Bardeleben, 
 who shares with von Bergmann the direction of the 
 surgical teaching in the University of Berlin. On 
 the following day (April 29th), the Empress informed 
 me that she had received a letter from Professor von 
 Bergmann, asking to be relieved from further attend- 
 ance on the Emperor. In the mean time I bad
 
 Bergmann Boycotts me. 163 
 
 written to Professor Bardeleben, who accordingly took 
 part in the consultation the next morning and re- 
 mained in attendance till the end. Bergmann soon 
 afterwards had the bad taste to attack me in a com- 
 munication which he sent to the Berlin Medical 
 Society, because I had defended myself against the 
 gross charges made against me by his journalistic 
 friends, but he did not attempt to deny that he had 
 failed to introduce the tube or that he had made a 
 false passage. Against these miserable attempts at 
 defamation may be set the following telegram which 
 I had the pleasure of receiving some days later 
 (May loth). " German Liberal workmen from Char- 
 lottenburg and Potsdam, who are making an excursion 
 together to-day in the Griinewald, thank you for the 
 loving devotion and fidelity which you have exhibited 
 at the bedside of our Kaiser. We assure you that 
 your merits will not suffer in the eyes of any good 
 and honest German in consequence of the shameless 
 persecutions {Hetze) directed against you." 
 
 Then follow the names of a number of workmen. 
 
 Further breaking-iip of the Windpipe. — Meanwhile 
 the work of destruction was going on in the trachea 
 and parts around it. Even then there was no 
 thickening — no extension of cancer to the tracheal 
 opening. The breaking down of the tracheal carti- 
 lages could only be accounted for by the injurious 
 pressure on them effected by the large- (14 mm. in 
 diameter) mouthed orifice of Bramann's canula. On 
 the night of 29th-30th April a flapping noise had 
 been audible in expiration as if there were a loose 
 slough at the orifice of the trachea. At seven o'clock 
 in the morning the Emperor had a severe fit of cough- 
 ing and brought up a large piece of necrotic tissue. 
 After this the noise ceased and the breathing became 
 quiet. As the windpipe was in such an utterly un- 
 healthy condition, it had occurred to me that a tube 
 of lighter material than silver would be likely to do 
 
 M 2
 
 1 64 The Fatal Illness of Frederick the Noble. 
 
 less damage. I had therefore ordered a canula to be 
 made of aluminium, and this was worn by His 
 Majesty, except on one or two days now and then, 
 till the end of his life. 
 
 Temporary Improvement. — At the beginning of 
 May a considerable improvement took place in the 
 Emperor's condition. He felt much better and 
 regained strength to a slight extent ; he was more 
 comfortable during the day, slept better at night, and 
 took more interest in what was going on around him. 
 The vegetations around the tracheal orifice, which at 
 the suggestion of Professor Bardeleben had been 
 treated with bismuth, had completely disappeared — a 
 proof that they were not cancerous growths as had been 
 positively stated by von Bergmann. The discharge 
 of pus was still abundant. On May 5th I collected 
 all that escaped between 8 A.M. and 8 P.M., and 
 found that it amounted to three ounces. As the 
 discharge was generally more copious at night than 
 in the day, it follows that an estimate of six ounces 
 would be rather under than above the average 
 secretion during the twenty-four hours. Such a 
 quantity could not come from a cancerous larynx. 
 Besides, the matter was thick and greenish-yellow 
 in colour — in fact, laudable pus — very different from 
 the sanious putrescent fluid, full of miscellaneous 
 debris, that comes away from a cancerous ulcer. 
 In the present instance there could be no ques- 
 tion that the source of the discharge was a large 
 abscess-cavity in the situation of Bergmann's " false 
 passage." A further proof of the abundance of the 
 discharge is supplied by the number of times the 
 canula had to be cleaned in order to prevent its 
 becoming stopped up. Thus I find in my notes of 
 this period such entries as " Canula cleaned eleven 
 times," " seventeen times in the night," and so forth. 
 
 On May 12th His Majesty felt some pain in swal- 
 lowing, which was found to be due to aphthous spots 
 on the uvula and phar^mx. On the 14th fresh vegeta-
 
 A passing Gleam of Sunshine. 165 
 
 tions began to form, and, in spite of all treatment, 
 increased in size, till at the end of a fortnight they 
 had coalesced into a single growth about the size of a 
 large date, which formed a kind of collar round the 
 whole of the tracheal orifice, except at its upper 
 margin. On June 8th these vegetations began to get 
 smaller again, and they gradually shrank, so that at 
 the time of the Emperor's death they were no longer 
 visible. 
 
 A passing Gleam of Sunshine. — On May i6th His 
 Majesty went into the park for the first time for a 
 month. The morning temperature on that day was 
 99*4°, whilst in the evening it was 99°. The difficulty 
 of swallowing had almost disappeared, and the illus- 
 trious patient was making gratifying progress. On 
 the 17th he was in the park again for several hours. 
 He sat on a chair for some time and afterwards drove 
 in his pony-chaise, occasionally walking a few steps. 
 A tent had been erected on the lawn and a rug was 
 placed at its entrance. Late in the afternoon the 
 pony shied at this rug, and reared so much that he 
 almost fell back on the Emperor. Everybody except 
 the illustrious patient himself was greatly alarmed. 
 It was only on my pointing out that violent shaking 
 might injure his throat that His Majesty consented 
 to have the pony taken out of the carriage, which 
 during the rest of the evening was drawn by two of 
 the attendants. 
 
 The Emperor's fondness for Music. — The Emperor 
 spent most of the next day also in the park. He 
 drove to the door of the chapel and listened for a long 
 time to the choir which was practising the music to 
 be sung at Prince Henry's wedding. I had another 
 opportunity not long afterwards of observing the 
 Emperor's fondness for music. At Friedrichskron 
 one day in the early part of June the choir of the 
 Church of the Twelve Apostles sang several hymns. 
 His Majesty sat in the next room but one to the 
 Muschel Hall in which the choir was, but the doors
 
 1 66 The Fatal Illness of Frederick the Noble. 
 
 were open and the beautiful voices of the eighty 
 singers constituting the choir were very distinct. His 
 Majesty was very much affected by the singing ; in 
 fact I noticed that during one of the hymns he could 
 not restrain his tears. I procured him a little wine 
 and water, and with his usual determination he walked 
 to the entrance of the Muschel Hall and bowed his 
 thanks to the singers. 
 
 On May 19th His Majesty drove outside the palace 
 grounds for the first time since his recent attack. 
 The people were more enthusiastic than ever, and 
 when he came home he felt so well that he insisted 
 on remaining in the park for some time. On the 
 2 1 St His Majesty drove into Berlin again, and on the 
 following day he drove out with the Empress. On 
 the 23rd the Princess Irene was expected late in the 
 evening, and His Majesty was anxious to sit up to 
 receive her, but as I knew that the following day 
 would be a fatiguing one for him I persuaded him to 
 retire to rest. 
 
 The Wedding. — On the 24th the Emperor, who had 
 had a good night, rose early in the morning and spent 
 some time with Prince Henry and his bride. His 
 Majesty went to the Blue Gallery, and was much 
 disappointed to find that, thinking he would not be 
 able to be present, the Civil Contract had been signed 
 in his absence. He afterwards attended divine service 
 in the chapel. The brisk way in which the Emperor 
 rose to his feet was noticed by many of those present, 
 but most people thought the illustrious invalid looked 
 much shattered. The great effort which he made to 
 appear as well as possible greatly fatigued him, and 
 he could scarcely take any lunch. Late in the 
 evening, however, he appeared much better, and 
 enjoyed two hours in his pony carriage in the park. 
 His temperature at 5 o'clock was loi •!. It had not 
 been so high as this since May 3rd. In the evening, 
 however, it fell again to 100 '6°. 
 
 The Sky again Overcast. — On the next day the
 
 The Sky again Overcast. 167 
 
 Emperor showed signs of fatigue and depression, 
 though he did not complain. From this day (May 
 25th) I reckoned the commencement of the final 
 decline in His Majesty's health. He was never so 
 well after Prince Henry's wedding. Some days 
 before that event, however, there were signs that the 
 original disease in the larynx was beginning to 
 disseminate itself in adjacent parts. On May 20th, a 
 round nodule about half a centimetre in diameter, 
 was noticed under the skin about an inch above the 
 inner end of the right collar-bone. It was movable and 
 moderately hard, and the skin over it was of natural 
 colour and appearance. This nodule gradually 
 increased in size, and in the early part of June its 
 surface became slightly inflamed. It was judged to 
 be a secondary point of malignant infection, and as a 
 matter of fact it was found on examination after death 
 to contain some cancerous elements. 
 
 On May 26th the Prince of Wales accompanied the 
 Emperor in a drive through the Thiergarten to the 
 Belle Vue, where he too took leave of His Majesty for 
 the last time. On the following day the Emperor 
 showed signs of fatigue and drowsiness, and seemed 
 once more to be gradually losing the energy he had 
 lately regained. On the 29th, however, he was roused 
 by an incident quite outside the ordinary run of his 
 life for a long time past. His Majesty inspected 
 three regiments of Guards, which marched past under 
 the command of the Crown Prince. The Emperor, who 
 was wearing his helmet for the first time since his ac- 
 cession, sat in his victoria. He was greatly moved. 
 Whether from the weight of his helmet or from ex- 
 citement, the Emperor's head was bathed in perspira- 
 tion although the day was not at all hot. Immediately 
 after the inspection I got him some wine, which seemed 
 to revive him. I said to His Majesty, " I am afraid, 
 Sir, it was rather tiring for you seeing the troops march 
 past." He replied, " No, but it is the first time I have 
 seen my soldiers." The Emperor seemed thoughtful
 
 168 The Fatal Illness of Frederick the Noble, 
 
 for the rest of the day, and indeed, under the circum- 
 stances, there was sufficient matter for sad reflections. 
 This inspection certainly seemed to try the Emperor 
 more than anything which had occurred for some 
 time. 
 
 Visit to the Maicsoleinn. — On May 31st the 
 Emperor, who had driven into BerHn the day before, 
 was fairly comfortable. In the evening His Majesty 
 asked me if he might pay a visit the next day, before 
 leaving Charlottenburg, to the mausoleum ; thinking, 
 however, that the day would be a fatiguing one, I 
 suggested his going that evening. We silently wended 
 our way to the little chapel, and the Emperor slowly 
 mounted the steps attended by one of his faithful 
 jagers. I remained outside, and, whilst waiting, my 
 thoughts naturally turned to the Emperor William, 
 and it was a source of satisfaction to me to remember 
 that he had expressed himself as entirely satisfied 
 with my treatment of his beloved son. Of this I had 
 received the assurance both from Prince Radolin and 
 General Loe. The latter gentleman told me in San 
 Remo in the previous autumn that the deceased 
 Monarch, in the presence of several senior officers, 
 had expressed his complete approval of what I had 
 done ; and the Hof-Marschall gave me similar testi- 
 mony — in this case, I believe, by the express desire 
 of the Emperor William. 
 
 In a short time His Majesty descended the steps 
 of the mausoleum, looking sad and weary. Shortly 
 afterwards he said to me, " I shall go to bed early 
 to-night. I feel tired."
 
 The Emperor's Last Joiirjiey. i6g 
 
 CHAPTER IX. 
 
 THE emperor's LAST STAY AT POTSDAM. 
 
 It had been arranged that on June 1st the Emperor 
 should be removed to Potsdam, which from long 
 residence there he looked upon as his natural home. 
 Before starting, however, there was a little diffi- 
 culty with the canula, and as the incident was an 
 almost exact replica of the unfortunate episode of 
 April 1 2th with the part of Bergmann left out, it 
 may be worth while to relate it. I had changed the 
 tube in the morning for a shorter one in the presence 
 of all my colleagues. Half an hour after their 
 departure the Emperor's breathing became slightly 
 tracheal. I at once changed the inner tube, but in 
 five minutes His Majesty sent for me again, when 
 I found that there was a slight noise on inspiration. 
 As we were leaving for Potsdam in a few minutes 
 there was no time to send for Bardeleben, and as 
 I thought it would be unadvisable to allow the illus- 
 trious patient fo travel with the new tube in his 
 throat, I replaced the one he had formerly been 
 wearing. 
 
 Now I might easily have magnified this little in- 
 cident, and represented myself as having rescued the 
 Emperor from impending suffocation. The circum- 
 stances were almost exactly similar to those of the 
 fatal occasion on which Bergmann had done such 
 mischief. In neither case were there any symptoms 
 of the least urgency ; there was only a trifling degree 
 of dyspnoea, and the breathing was accompanied by 
 a slight sound. 
 
 The Emperor's Last Jotirney. — The Emperor drove 
 through the grounds in his pony-chaise to the banks
 
 I/O The Fatal Illness of Frederick the Noble. 
 
 of the Spree, which on one side forms the boundary 
 of the Charlottenburg park, and embarked on board 
 the yacht Alexandra, which was to take him to Pots- 
 dam. Thousands of people had assembled on the 
 opposite side of the ri\er, and when His Majesty 
 appeared their enthusiasm knew no bounds ; a strong 
 body of mounted police had been stationed to prevent 
 the crowd approaching too near the river, but in the 
 excitement of the moment the people pressed forward 
 to the very brink of the stream, and it was very 
 fortunate that some were not precipitated into it. 
 When the little yacht steamed off, a large part of the 
 crowd ran by the side of the river. On reaching 
 Spandau, which was gaily decorated, thousands of 
 school children were seen to be assembled on the 
 banks to greet their Sovereign, and on passing under 
 the bridge, flowers came down in such a deluge that 
 it took two of the sailors half an hour to gather them 
 up. We arrived at Gleinicke bridge at about one 
 o'clock, and found a number of carriages which con- 
 veyed us to Friedrichskron. The Emperor was very 
 little fatigued, eat a good luncheon, slept for a few 
 hours, and then took a drive in his pony-chaise in 
 the park. 
 
 Fresh Complications. — For the next three or four 
 days there was no change in His Majesty's condition. 
 He slept fairly well (for him), and was able to go out 
 a good deal when the weather permitted. He was, how- 
 ever, more easily fatigued than he had hitherto been, 
 and it was only too clear that his life was ebbing away 
 sensim sine sensu. On June 6th the temperature, 
 which for some time previously had averaged from 
 99° to 1 00° F., rose to 102-4° F., and there was 
 a great deal of coughing, owing to the quantity of 
 matter which found its way into the windpipe. That 
 night he hardly slept at all, and the next morning 
 he was xcry weak. He insisted, however, on getting 
 up about 11.30, and giving audience to General 
 Albedyl.
 
 Fresh Complications. 171 
 
 On the evening of the same day (June 7th) it was 
 noticed by the attendant that whilst the Emperor 
 was drinking some milk a small quantity of the liquid 
 came out through the canula. During the night the 
 same thing was repeatedly observed by Professor 
 Krause, who had taken the night duty since the 4th, 
 as Mr. Hovell had been obliged to return to England 
 on account of the sudden death of his father. At 6.30 
 on the morning of the 8th Krause came to my room 
 and said, "What you have so often feared has now 
 happened ; a fistula has formed between the larynx 
 and the oesophagus." He then told me what he had 
 witnessed during the night, adding that once or twice 
 nearly the whole of the milk which the Emperor had 
 taken into his mouth had run out through the tube. 
 At the morning consultation, in which, besides Pro- 
 fessor Krause, Dr. Wegner, and myself, Professors 
 Leyden, Senator, and Bardeleben took part, I remarked 
 that although the symptoms seemed to point to the 
 existence of a laryngeal fistula, I was nevertheless 
 not at all sure that the passage of liquids into the 
 larynx was not merely the result of the imperfect 
 action of the epiglottis. I expressed the same view 
 to my colleagues on several occasions subsequently. 
 The argument in favour of this theory was the ra- 
 pidity with which liquid food escaped from the 
 pharynx into the larynx, and thus through the 
 tracheal opening, whilst on the other hand the idea 
 that there might be a laryngeal fistula was supported 
 by the fact that occasionally His Majesty was able 
 to swallow without any liquid passing into the larynx, 
 a circumstance tending to show that the fistulous 
 passage occasionally became closed. 
 
 The complication in any case was a most serious 
 otie, for in the weak condition of the Emperor any- 
 thing which interfered with his taking a sufficient 
 amount of nourishment would certainly bring his life 
 very speedily to a close. At this time he was still 
 able to take a fair quantity, as the following diet-sheet
 
 1/2 The Fatal Illness of Frederick the Noble. 
 
 (for June 8th) will show : lo A.M., about half a plate- 
 ful of very thick porridge ; I P.M., four eggs beaten 
 up in wine ; dinner, some piirie of chicken, with a 
 little mashed potato ; in the afternoon a large piece 
 of cream ice and three eggs ; no supper, but at lo P.M. 
 a large plateful of shaped boiled rice. In the night 
 some rice, cocoa, and eggs. 
 
 With the view of preventing the fluids which were 
 swallowed from trickling down the windpipe, it was 
 determined to use a tampon-canula. This accordingly 
 I put in on the 9th in the presence of Professors 
 Bardeleben, Leyden, Krause, and Dr. von Wegner. 
 His Majesty slept better the next night than he had 
 done for some little time ; he was able to take eight 
 eggs in the course of it, and said in the morning 
 that he felt better. 
 
 No Progress. — Seeing that the Emperor was 
 sinking day by day, I thought it my duty on the 
 morning of June loth to inform him that he was not 
 doing well. I said to him, " I am sorry to tell you, 
 Sir, that you are not making progress." His Majesty 
 replied, "I feel pretty well to-day." Nothing more 
 was said, but some hours afterwards the Emperor 
 handed me a slip of paper, on which he had written — 
 
 GU/t/i^ (K^/lxM^ ^ifiihMy^ 
 
 h\j\y-^mv^
 
 Dying in Harness. 173 
 
 These pathetic words * showed me that the dying 
 monarch had fully understood the meaning of what 
 I had said to him. 
 
 On the following morning (June nth) as the 
 breathing had become somewhat tracheal I intro- 
 duced a longer tampon-canula. As, however, air did 
 not come quite freely through the tube, I removed 
 it, and then passed it in again with the greatest 
 ease. In doing so, I felt that, about two or two 
 and a half inches below the tracheal opening, there 
 was a slight projection forwards of the posterior wall 
 of the trachea, and by directing the lower end of the 
 canula fonvards, and fixing the instrument in that 
 position, I overcame the slight obstruction and the 
 breathing became quiet. The discharge of pus had 
 now become much less profuse, but the tube still 
 required to be cleaned pretty frequently During the 
 day a good deal of fluid was seen to escape by the 
 side of the canula after swallowing ; the subglottic 
 region was therefore tightly plugged with five small 
 pieces of sponge, which partly checked the leakage 
 through the wound. 
 
 Dying in Harness. — Even at this time the Emperor 
 battled with the prostration which was at last begin- 
 ning to paralyse his hitherto indomitable energy. On 
 this very day (June nth), he was writing his diary 
 and signing documents nearly all the morning, and 
 the amount of work which he got through was 
 wonderful under the circumstances. I always noticed 
 that when His Majesty felt worse than usual, he 
 worked harder than ever ; he had an almost over- 
 whelming sense of the duties of his position, and 
 seemed resolved almost literally to die at his post. I 
 never discouraged the illustrious patient from work- 
 in^g, as I knew that the disappointment he would 
 have felt at being compelled to be idle, would have 
 
 * I am not sure whether the word have is omitted before 
 "made," or whether His Majesty meant to write make instead 
 of made J the former expression would be a literal translation of 
 the German phrase.
 
 1/4 The Fatal Illness of Frederick the Noble. 
 
 more than counterbalanced any good he might other- 
 wise have derived from remaining quiet. More- 
 over the work itself seemed actually to sustain him, 
 and it no doubt was useful in diverting his thoughts 
 from his own condition. 
 
 Artificial Feeding. — On June I2th, Mr. Hovell, who 
 had returned from England the day before, informed 
 me that the Emperor had been able to take very little 
 food during the night, and that a great part of what 
 he did take escaped at the side of the canula. At 
 the consultation afterwards, it was unanimously agreed 
 that artificial feeding had become necessary, and I 
 was requested to undertake it. I pointed out to my 
 colleagues that, owing to the relaxed condition of the 
 posterior wall of the trachea caused by the exfolia- 
 tion of the cartilages in the upper part of the trachea, 
 and to the probably softened state of the oesophageal 
 walls, the passage of a feeding-tube would be attended 
 with considerable danger, but it was decided that the 
 operation was imperatively indicated, whatever the 
 risk might be. Accordingly at about 1 1 o'clock that 
 morning, I passed an oesophageal tube, and intro- 
 duced about a quart of milk through it. His Majesty 
 was again fed in the same way at 2 P.M., half a litre 
 of condensed milk with some cream and whisky 
 being given on this occasion. During the day I took 
 an opportunity of pointing out to His Majesty that 
 he was now almost entirely dependent on the feeding- 
 tube for his supply of nourishment, and that therefore 
 if any difficulty should arise interfering with the 
 passage of the tube, he would be reduced to a con- 
 dition of the most imminent danger. The Emperor 
 merely bowed affirmatively on hearing this state- 
 ment, but asked no questions. In the evening the 
 Emperor wished to go out for a drive, but I thought 
 it better for him to remain on the balcony. At 
 II o'clock he was again fed. In the middle of the 
 day the breathing became tracheal, and the supply of 
 air diminished. This difficulty gradually increased 
 in the evening, and though Professor Bardeleben
 
 A rtificial Feeding. 175 
 
 was expected, the breathing became so bad that I 
 thought it desirable to endeavour to alter the 
 position of the tube. After inserting the pilot, I 
 tilted its point forwards, and in this way succeeded 
 in disengaging the lower end from a fold of the 
 mucous membrane covering the posterior wall of 
 the trachea which partially blocked up the lower 
 orifice. The breathing at once became easy. I re- 
 tired to rest at 3 A.AI., leaving Mr. Hovell on duty. 
 There had been scarcely any discharge of pus for 
 several days ; but on this day (June 12th) some very 
 offensive matter escaped. From this time there was 
 hardly any secretion of pus, but a good deal of mucus 
 continued to come through the canula. 
 
 On the 1 2th the Emperor was fed with the tube 
 three or four times during the day. In the course of 
 the morning I saw the servants making extra pre- 
 parations on the balcony, and was told that this was 
 because the King of Sweden was expected very soon. 
 I had thought that the King's visit had been put off 
 on account of the Emperor's condition ; but it was 
 now too late to intercept the carriages. Besides this, 
 I knew that nothing could now make any difference 
 to the august sufferer. His Majesty was rather 
 breathless, but he was able to receive the King ; the 
 interview lasted only a few minutes. Before he left 
 Friedrichskron I had the honour to be presented to 
 King Oscar, who asked me what I thought of the 
 Emperor. I replied, " It is scarcely necessary to 
 point out to you, Sir, that the Emperor is in a most 
 critical condition, from which I think it is almost im- 
 possible for him to rally ; should he, however, get 
 over this attack, his life might be spared for a few 
 weeks."* 
 
 * I should not have thought it necessary to repeat the sub- 
 ject of this interview had not the " reptile " press recently 
 (September) recommenced on its old system of misrepresenta- 
 tion, and printed a most false and entirely ridiculous account 
 of my interview with the King of Sweden.
 
 176 The Fatal Illness of Frederick the Noble. 
 
 The Beginning of the End. — At 3 A.M. on this day 
 (June 13th) I noticed a change in the Emperor's con- 
 dition, which showed that the end was approaching. 
 There were signs that inflammation of the lungs had 
 evidently set in, and I knew that His Majesty's suffer- 
 ings would soon cease. I had promised to inform 
 the Empress at once if any change occurred, and 
 accordingly at 4 o'clock I knocked gently at her 
 bedroom door. She was not asleep, and answered me 
 immediately. As soon as possible the Empress was 
 by the side of her dying husband, and from that hour 
 she never left his bedside for more than a few minutes 
 at a time. The Emperor remained surrounded by the 
 members of his family throughout the day. As he 
 was very restless, and had not slept during the night, 
 I gave him a mild sedative draught. Soon afterwards 
 he fell asleep and slumbered till 6.30, when he said 
 he felt hungry, and asked me to feed him. I adminis- 
 tered a quart of milk with a little whisky through 
 the tube. He received nourishment in this manner 
 twice again during the day. He showed very little 
 interest in general matters, but was very particular to 
 have his tube changed directly there was the least 
 sound in breathing. 
 
 Thoughtfnl for Others to the Last. — I have said 
 more than once that the Emperor was the most 
 considerate of men, and I cannot forbear relating 
 a striking instance of this quality which occurred 
 within a few hours of his death. My sitting-room was 
 close to His Majesty's room, but in order to reach 
 the latter I had to pass through three rooms. In 
 order to get to his bedside more quickly I generally 
 used to go along an outside balcony so that I had 
 only the ante-room to pass through. Just before day- 
 break on the morning of June 15th it was dull and 
 chilly. In consequence, I suppose, of exposure to 
 the air in going by the balcony I became a little 
 asthmatic. Whilst I was changing his canula on two 
 or three occasions during the night, the Emperor put
 
 L ast Scene of All. ijy 
 
 his hand lightly on my chest and looked up at me 
 with a glance of earnest sympathy, thus mutely ex- 
 pressing his regret that I too was suffering. Those 
 who have much to do with the sick know well how 
 prolonged illness often breaks down the natural frame- 
 work of the character, making even those who in 
 health were utterly unselfish come to be regardless of 
 anything but their own suffering. Frederick the 
 Noble in this, as in everything else, rose above the 
 ordinary standard of humanity ; even in the agony of 
 death he remained true to his own generous nature. 
 
 Last Scene of All. — At 4 o'clock I called Mr. Hovell, 
 and at 5 I tried to snatch a few minutes of rest in 
 an armchair. An hour later, however, the Emperor 
 complained of a feeling of sinking, and signified 
 his wish that I should give him some nourishment. 
 After this he seemed to be somewhat better for an 
 hour or so, and a little later he passed into a deep 
 sleep, which was, however, broken from time to time 
 by the irritation in his throat. 
 
 In order not to intrude on the grief of the sorrowing 
 family, at 10 o'clock I took up my post in the room 
 immediately adjoining the Emperor's bedroom, paying 
 a short visit to the Emperor every few minutes. At 
 II o'clock the eyes of the poor patient, which had 
 languidly followed every movement of the Empress, 
 became fixed, the intervals in drawing breath became 
 greatly lengthened, and soon after 1 1 A.M. I had the 
 sorrowful duty of announcing to the Empress that 
 life was extinct. With his broken-hearted family, 
 and several of his devoted servants kneeling around 
 him, Frederick the Noble breathed his last. 
 
 Thus passed away the noblest specimen of 
 humanity it has ever been my privilege to know. Of 
 his military achievements and his political wisdom it 
 would be presumption for me to speak. During his 
 life his natural reserve and the circumstances in which 
 he was placed led him to efface himself to a great 
 extent, so far as the practical conduct of affairs was 
 
 N
 
 1/8 The Fatal Illness of Frederick the Noble. 
 
 concerned. He could not, however, conceal his kind- 
 ness of heart, which thus came to be the leading 
 feature in the public estimate of him. Only those 
 whose official position brought them into personal 
 contact with him, and a chosen few who were per- 
 mitted to enjoy his confidence, knew that Frederick 
 the Third was a man of commanding intellect. His 
 courage in the field is known to all the world ; his com- 
 passion for suffering and misfortune, and his chivalrous 
 forbearance towards the weak are acknowledged most 
 freely by those whom he conquered in war. It was my 
 lot to know him under very different circumstances ; 
 to see him face disease and suffering with the same 
 unostentatious heroism as he had confronted the 
 enemy in the battle-field ; to see him whilst standing 
 in the very shadow of death, still eager to do what he 
 could for the people over whom he ruled. Only those 
 who had the privilege of constant intercourse with 
 the Emperor Frederick know how much poorer the 
 world is for his death. No one could know him even 
 slightly without loving him ; no one could be more 
 intimately acquainted with him without reverencing 
 him as one of the most large-minded and noble- 
 hearted of men. Though naturally somewhat re- 
 served and dignified, he loved to talk freely with all 
 classes of people. One thing which particularly 
 struck me in him was the absolute genuineness, the 
 transparent honesty of the man. He never affected a 
 knowledge which he did not possess, but was modestly 
 deferential to those whom he thought better informed 
 than himself Though active when the necessity for 
 action arose, his nature was contemplative, and his 
 mind essentially judicial. The manliest of men, he 
 had the gentleness and purity of soul of the purest of 
 women. He has gone down to his grave leaving us 
 the memory and example of a stainless life and a 
 beautiful death.
 
 A Trap is laid for Me. 179 
 
 CHAPTER X. 
 
 T II P: E P I L Q G U E. 
 
 A Trap is laid for Me. — After the Emperor's death, 
 having had no rest for nearly 60 hours, I threw my- 
 self on my bed about 2 P.M. ; but I was shortly 
 afterwards awakened by one of the adjutants, who 
 informed me that the Emperor and Prince von 
 Bismarck desired to see me. I quickly arose and 
 accompanied this gentleman to the young monarch, 
 whom I found sitting with the Chancellor in what had 
 previously been the adjutant's room. His Majesty* 
 received me courteously, and said that Prince Bismarck 
 would like to speak a few minutes in conference with 
 me. The Chancellor thereupon invited me to retire 
 with him into an inner room, where he suggested that 
 I should draw up a brief report on the case of the 
 Emperor Frederick. I at once expressed my readi- 
 ness to do so. The Chancellor then said, " Will you 
 do so before you leave ? " I replied, " Willingly, 
 your Highness. I shall leave on Monday, and I will 
 certainly draw up the document you ask for before 
 then." 
 
 After this conversation I was extremely surprised 
 the next day when an official from the Haus-Minis- 
 terium called on me at one o'clock and asked for my 
 report. I told him I had not had time to draw it up. 
 He said, " If you will dictate it to me I shall be happy 
 to take it down ; " but I pointed out that such an 
 
 * Among the thousand-and-one incorrect statements which 
 appeared in the papers, there was one to the effect that I had 
 asked for an audience of the new Emperor, who had refused to 
 see me. I think it right to state here that I never sought for 
 an interview of any kind with His Majesty. 
 
 N 2
 
 1 80 The Fatal Illness of Frederick the Noble. 
 
 important document could not be dashed off in that 
 way. The official then remarked that it was most 
 important it should be prepared immediately, as the 
 Ministers were waiting for it. I then said, " In that 
 case I will write it for you," and it was arranged 
 that he should wait in the Palace for the document. 
 Within half an hour I drew up a report to the 
 following effect : 
 
 '•'Schloss Friedrichskron, June i6th, 188S. 
 " It is my opinion that the disease from which 
 the Emperor Friedrich III. died was cancer. 
 The morbid process probably commenced in 
 the deeper tissues, and the cartilaginous 
 structure of the larynx became affected at a 
 very early date. A small growth which was 
 present when I first examined the late 
 Emperor was removed by me by several 
 cndolaryngeal operations, and though all the 
 portions taken away were submitted to Pro- 
 fessor Virchow, he was unable to detect in 
 them any evidence of the existence of cancer. 
 Examinations of the sputa made at the begin- 
 ning of IMarch by Professor Waldeyer, however, 
 led that pathologist to believe that cancer 
 was then present. Whether the disease was 
 originally cancerous or assumed a malignant 
 character some months after its first appear- 
 ance, it is impossible to state. The fact that 
 perichondritis and caries of the cartilages 
 played an active part in the development of 
 the disease no doubt largely contributed to 
 make it impossible to form a decided opinion 
 as to its nature till quite recently. 
 
 (Signed) '* MORELL MACKENZIE." 
 
 *' In so far as my observations since last 
 August permit me to form an opinion, I concur 
 entirely with Sir jNIorell Mackenzie's views. 
 (Signed) "T. Mark Hovell."
 
 Miscarriage of the Plot. i8i 
 
 When I proceeded to find the official, I was sur- 
 prised to discover him in earnest conference with 
 Professor von Bergmann. I handed him the report 
 and withdrew. Half an hour later, Dr. von Wegner 
 looked in on me in my sitting-room, and said, ^^Apost- 
 mortem examination is going to be made. Do you 
 care to come ? " I answered, " Do I care to come } 
 How can you ask such a question ? " I immediately 
 called Mr. Hovell and went with him to the room 
 wdiere the autopsy was going to be performed. 
 
 Miscarriage of the Plot. — I now saw why such 
 extraordinary pressure had been brought to bear 
 on me to make me send in my report on the 
 case at once. It was hoped that being under the 
 absolute conviction that there was to be no post- 
 mortem examination, I should be entrapped into 
 making some equivocal statement as to the nature 
 of the disease. After I had thus committed myself, 
 the autopsy would be made and the existence of 
 cancer clearly proved, to my everlasting discomfiture. 
 It was a neat enough little plot in its way, but its 
 authors had left two rather important matters out 
 of account which made their amiable intention fail 
 of its effect. In the first place, since Waldeyer had 
 told me of the result of his microscopic examination 
 I had frankly accepted the cancer diagnosis as defi- 
 nitively established. It was not at all likely there- 
 fore that I would now stultify myself by quibbling 
 about the matter. In the second place, although 
 it appeared to be taken for granted, quite gratui- 
 tously, that I did not wish for an autopsy to be 
 made, I had, in fact, myself proposed it. A few 
 hours before the Emperor's death, I had ventured to 
 ppint out to the Empress that it was desirable that at 
 least a partial post-mortem examination should be 
 made, in order to ascertain the exact situation and 
 extent of the disease. Her Majesty was very un- 
 willing to consent to this ; but at last promised that 
 she would allow whatever I thought necessary to be
 
 1 82 TJie Fatal Illness of Frederick the Noble. 
 
 done. When the Emperor had breathed his last, 
 however, Her Majesty, in the first outburst of her 
 grief, which up to that moment she had heroically 
 kept in check, turned to Dr. von Wegner and begged 
 him to promise that her beloved husband's body 
 should not be touched. The Emperor William II. 
 expressed his concurrence with his mother's wishes 
 as to this matter, and gave orders that they should 
 be respected. On the following morning, however, 
 strong representations were made to His Majesty 
 by General von Winterfeld and others, at the insti- 
 gation of Professor von Bergmann, that as the 
 Prussian law required that the cause of death should 
 be cojistatirty it was necessary that a post-mortem 
 should be made for that purpose. As far as the legal 
 aspects of the case were concerned this was mere 
 sophistr>\ The cause of death had already been 
 certified {constatirt) by myself, and von Bergmann 
 or any of the other doctors could have also given a 
 certificate, if it had been thought desirable. The 
 Emperor William II., however, not perceiving the 
 real motive of the great desire for a post-mortem 
 examination, yielded out of scrupulous regard for the 
 law. I have no doubt that Professor von Bergmann 
 was sorely disappointed at the collapse of his little 
 scheme. 
 
 Report of Post-Mortem Examination. 
 
 The post-mortem examination was made by Pro- 
 fessor Virchow in the presence of Professor Waldeyer, 
 who during the investigation carried out by Virchow 
 cursorily examined some of the parts removed from 
 the body. 
 
 There were also present Drs. von Wegner, Barde- 
 leben, Leuthold, von Bergmann, Bramann, Mr. 
 Hovell, and myself Professors Leyden, Senator, 
 and Krause, who had attended the Emperor up to 
 the day of his death, were not invited, and, as already
 
 Report of Post- Mortem ExaminatioiL i Z}^ 
 
 stated, I was only told of ih^ post-mortem just before 
 it was made. 
 
 Although the autopsy was carried out with care, it 
 was necessarily very incomplete, and unfortunately 
 somewhat hurried by Count Stolberg-Wernigerode, 
 who several times reminded us that it was necessary 
 to finish the examination as soon as possible, as it 
 had been arranged that the lying-in-state should take 
 place within an hour of the commencement of the 
 autopsy. 
 
 The (tracheotomy) wound and an incision over the 
 right carotid artery (made for the purpose of injection) 
 had been stitched up, the cavity in the front of the neck 
 having been previously packed with cotton-wool and 
 bismuth. On removing the stitches " from the stitched- 
 up linear wound 6\ cm. long," after the removal of the 
 large quantity of cotton-wool and bismuth, the report 
 says : " A cavity is left, measuring 5 cm. in depth and 
 almost as much in length, the opening of zvhich, after 
 removal of the stitches, gapes to the extent of 2\ cm!' 
 An incision was made through a nodule situated in 
 the skin, and partly in the subcutaneous tissue on the 
 right side of the neck a little below and external to 
 the tracheotomy wound. The larynx, as well as the 
 upper portion of the trachea and oesophagus, were 
 ligatured and removed. Nearly the whole of the 
 larynx was destroyed, its place being occupied by a 
 large flat gangrenous ulcer ; the epiglottis and ary- 
 epiglottic folds alone remained. At the base of the 
 epiglottis, on the left side, was a nodule as large as a 
 cherry, and near it were several similar nodules of 
 various sizes, but all much smaller than the first one. 
 The mucous membrane of the trachea immediately 
 below the (tracheotomy) wound was free from ulcera- 
 tion and scars. The lower part of the trachea and its 
 bifurcation were not examined. The lungs appeared 
 outwardly quite healthy " and everywhere full of air, 
 down to the lowest edges of the lower lobe," but 
 there was some hypostatic congestion, and there were
 
 1 84 The Fatal Illness of Frederick the Noble. 
 
 a number of minute collapsed patches in the bases 
 containing dilated bronchial tubes, partly surrounding 
 which were layers of extravasated blood. On section, 
 a large number of foci were found in the interior of 
 the lower lobes, some of which contained a material 
 resembling pus, whilst in others the whole mass was 
 still solid. Scattered throughout the upper lobes of 
 both lungs were found similar very ^sXtfoci, in which 
 a large number of yellowish nodules were closely 
 packed together. On opening up the oesophagus 
 behind the cricoid cartilage, there was found a col- 
 lection of greyish-brown secretion, and on removing 
 this there was no trace of perforation. On the left 
 side of the neck, close to the jugular vein, was a 
 lymphatic gland about as large as a pigeon's Qgg, 
 which in its interior showed a medullary-looking 
 yellow spot. On slitting up the bronchial tubes they 
 were found dilated throughout with thickened walls, 
 the mucous membrane lay in thickened folds, and 
 was covered with discoloured debris. 
 
 Owing partly to the fact that the cavity in the 
 tissues in the front of the neck had been filled up with 
 cotton-wool and bismuth, and partly to the circum- 
 stance that the purulent secretion had ceased during 
 the last three or four days of the Emperor's life, 
 there was nothing to call special attention to the 
 existence of the abscess, the general situation of 
 which Mr. Hovell and I were easily able to identify. 
 
 In consequence of the lower part of the trachea 
 not having been examined, the question as to how 
 the pus during life reached the interior of the trachea, 
 viz. whether by merely welling upwards, and entering 
 by the (tracheotomy) wound, or by passing through 
 one or more fistulous tracks between the tracheal 
 rings, was unfortunately not determined. 
 
 Professors Virchow and Waldeyer subsequently 
 made a microscopical examination of particular sec- 
 tions taken from the body of the late Emperor, and 
 the following is an epitome of their report. The
 
 Another Cahuniiy Refuted. 185 
 
 nodule at the base of the epiglottis contained an 
 alveolar structure with epidermoidal contents, among 
 which were nest-cells. The cutaneous nodule re- 
 moved from the neck also contained nest-cells. The 
 lymphatic gland, however, showed the highest degree 
 of change, the normal structure being " replaced by a 
 loose alveolar tissue, the spaces of which are closely 
 filled with epidermoidal cells having large nuclei." 
 In the foci in the htngs were found thick clusters of 
 pus cells, biU no cancer cells. 
 
 Another Calwnny Refuted. — One other point I 
 must touch on before bringing this narrative to a 
 close. Among the many false charges which have 
 been brought against me in connection with this 
 case, there is one which for obvious reasons I could 
 not take any notice of while the Emperor was still 
 alive. It was said that I deliberately deceived him 
 as to his condition, and buoyed him up with false 
 hopes, leading him to believe that he would recover. 
 Now, as to the first point, I will frankly say at once 
 that I did not ever say bluntly to the Emperor, " You 
 are suffering from cancer. Sir ; you are a doomed 
 man." I did not do so in the earlier stages of his 
 malady, because the nature of the case appeared to 
 me to be doubtful, and it is a cardinal rule of 
 medical practice not to communicate suspicions of 
 that kind to the patient, even if they seem well- 
 founded. At a later period, when the case had as- 
 sumed a more serious aspect, my readers will re- 
 collect that I was perfectly open with the illustrious 
 patient, who thanked me for being so frank with him 
 (see p. 66). Professor von Schrotter afterwards made 
 a formal communication to the Crown Prince, as he 
 was then, on behalf of us all, in which he clearly con- 
 veyed what was thought to be the nature of the 
 disease. 
 
 What the Emperor's own inmost thoughts were 
 as to his condition and prospects I am quite unable
 
 I S6 The Fatal Illness of Frederick the Noble. 
 
 to say. For a very long time before his death, 
 he asked no questions except as to what I may call 
 the non-essential features of his case, such as the 
 pulse, the temperature, &c. Though fond of conver- 
 sation, and a most delightful companion, he was 
 always extremely reserved about himself Though 
 I was thrown into such intimate contact with him 
 for so long a time, I know less about the real state 
 of his mind with regard to his own case than I do 
 about almost any other patient whom I have had 
 under my care. It may be that he hoped against 
 hope, but he never spoke either of his hopes or 
 fears to me. 
 
 It must be remembered too that the Emperor 
 had had far greater opportunities of hearing the 
 truth — or what was supposed to be the truth — 
 about his condition than fall to the lot of ordinary 
 patients. Soon after the commencement of his illness 
 Gerhardt's opinion as to its nature had reached his 
 ears. He was a man of heroic fortitude, and not at 
 all likely to brood over fancies, but so terrible a 
 suggestion must necessarily have left a lasting im- 
 pression on his mind. Such an idea cannot be 
 thrown off by any effort of will ; hcej'et lateri fatalis 
 hiriido. The Prince's own question to me when I 
 mentioned the unfavourable change which had taken 
 place (p. 65), shows that the notion of cancer was 
 always present to him. He was in no way misled by 
 me as to the nature of his complaint. I told him 
 honestly exactly what I thought when the occasion 
 arose, and I treated him precisely as I should wish 
 to be treated myself under similar circumstances. 
 
 Consoling Reflections. — In looking back on this sad 
 case there are one or two matters which will always 
 be a source of deep satisfaction to me : one is that 
 through the mild and painless operations performed 
 by myself the dangerous methods recommended by 
 Gerhardt and von Bergmann were prevented, and 
 that I thereby not only prolonged the life of the
 
 Consoling Reflections. 1 87 
 
 Emperor, but also saved him much suffering. The 
 other point which affords me some consolation is that 
 I was able to prevent His Majest)^ suffering any actual 
 pain during the long course of his distressing com- 
 plaint. Even in February, when he was put to so 
 much trouble and inconvenience, when he passed 
 weary days and sleepless nights, whilst von Berg- 
 mann and Bramann were in charge of the case 
 after the performance of tracheotomy, the Emperor 
 experienced no actual pain. Except at the moment 
 when von Bergmann made the "false passage" and 
 forced his finger into the wound, I do not think he 
 ever had a moment of severe pain. Occasional 
 slight neuralgia in the head and mild muscular 
 rheumatism were his worst troubles in this respect.
 
 1 88 The Fatal Illness of Frederick the Noble. 
 
 SECTION II.— CONTROVERSIAL. 
 
 CHAPTER XI. 
 
 THE TRUTH AEOUT THE PROPOSED OPERATION. 
 
 Theses Stated. — I propose to show in the first part 
 of this Section — 
 
 {a) That the operation of thyrotomy {Laryngo- 
 fissur), which it is stated it was proposed to 
 perform on the Crown Prince in May 1887, 
 is not free from risk as is pretended by von 
 Bergmann, but, on the contrary, is a dangerous 
 procedure, soon leading to death. 
 
 {b) That the proposed operation does not afford 
 a fair prospect of eradicating a mahgnant 
 growth, but, on the contrary, is most fre- 
 quently followed by recurrence. 
 
 {c) That the presence of cancer was not ascer- 
 tained even with approximate certainty until 
 November 1887, if indeed it really existed 
 before that date.* 
 
 In the second part I shall briefly consider some of 
 the individual reports contained in the pamphlet 
 entitled, Die Krankheit Kaiser Friedrich des Dritten 
 (' The Illness of the Emperor Frederick III.'). 
 
 * It must not be forgotten that even in November the micro- 
 scopic evidence was still wanting, and that it was not till 
 February, 1888, that the presence of cancer was conclusively 
 proved.
 
 The Danger of the Operation. 1 89 
 
 PART I. 
 
 I shall now proceed to prove my first proposition 
 {a) That the operation of tJiyrotoniy {Laryngofisstir), 
 which it is stated it zvas proposed to perform on the 
 Crown Prince in May, 1887, is not free from risk as is 
 pretended by von Bergmann, but, on the contrary, is a 
 dangerous procedure, soon leading to death. 
 
 The Danger of the Operation. — Professor von Berg- 
 mann maintains that the operation which he was 
 about to perform is free from danger, and he states 
 that he has performed it seven * times successfully. He 
 does not, however, give any details of these opera- 
 tions, nor does he even say that they were done for 
 cancer. Vague statements of this kind are of no 
 value whatever, nor are they accepted by compilers of 
 surgical statistics. 
 
 Professor von Bergmann further states f that there 
 appeared in the Cejitralblatt fiir Laryngologie, since 
 its publication four years ago, reports of fifteen cases 
 of thyrotomy {Laryngofissur^, only one of which had 
 proved fatal, and that in this instance death was due 
 to diphtheria. Such a statement as this is in the 
 highest degree misleading. Anybody not already 
 aware of Professor von Bergmann's reckless method 
 of making statements which have but slight founda- 
 tion in fact, on reading this sentence would suppose 
 that all these fifteen patients had recovered from 
 cancer by means of the operation, except one. It will 
 scarcely be believed that the truth is almost exactly 
 the reverse. Such a number of inaccuracies are con- 
 tained in von Bergmann's statement that they require 
 to be set forth in detail. The operation was actually 
 reported in the Centralblatt no less than thirty times ! 
 The disease, however, was cancer only in ten cases. 
 Of these ten cases only five patients survived the 
 immediate effects of the operation, and only one 
 
 * Op. cit. p. 18. t Ibidem.
 
 1 90 The Fatal Ilbiess of Frederick the Noble. 
 
 patient (Billroth's) remained free from the disease for 
 over two years. In the twenty other cases in which 
 the operation was performed for non-malignant disease, 
 thirteen were papillomata, the large majority of the 
 patients being children from two to eight years old. 
 There was one case of polypus, one of oedema of the 
 larynx, one of membranous occlusion, two of cicatricial 
 stenosis, one of rhinoscleroma, and one of tuberculosis. 
 
 As regards the non-cancerous cases, though only 
 two died shortly after the operation, I have no doubt 
 it would be found on inquiry that repeated subsequent 
 operations had to be performed on many of these 
 patients, and that only a very small percentage can 
 be shown to have made a complete and permanent 
 recovery. It must not be forgotten, also, that in the 
 case of children over three years of age suffering 
 from benign growths, the little patients underwent a 
 dangerous operation, when they might have been 
 cured by one which presented no risk whatever. 
 
 But to return to the subject of the ten malignant 
 cases with which alone a fair comparison can be made, 
 it must be remarked that they are all actually con- 
 tained in my Tables ! (See pp. 234, 236, and 239.) 
 Readers will therefore be in a position to judge of 
 the value of the assertions of von Bergmann, and of 
 his successful cases culled from the pages of the 
 Centralblatt ! 
 
 In Table No. i, p. 234, will be seen a collection of 
 twenty-two cases of thyrotomy, six of which ended in 
 deatJi directly from the operation, on or before the 1 1 th 
 day. Of the remaining seventeen patients, ten had 
 died * when the report was published, three suffered 
 from recurrence of cancerous disease, and must there- 
 fore be looked upon as having died (though not 
 
 * Six patients died within 11 days, one on the 13th day, and 
 two in 7 months. Two patients lived a year, one 15 months, 
 one 19 months, and one 22 months. In the case of one patient 
 who committed suicide in despair at the recurrence of his 
 disease, the date of the fataHty is not given.
 
 The Danger of the Operation. 191 
 
 actually dead when their cases were reported), two 
 cases were published too soon after the operation to 
 be of value for statistical purposes, and two recovered. 
 That is to say, in twenty-two cases there were two 
 cures, or in other words the percentage of recoveries 
 was 9*09, which is equivalent to saying that out 
 of one hundred cases the operation proved fatal 
 in nearly ninety-one ! I have myself never done 
 this operation for cancer, though two patients of mine 
 suffering from that disease (Table I, cases 5 and 7), 
 who were operated on by other surgeons, died in 
 seven months. I performed thyrotomy some years 
 ago in a non-malignant case. The patient had suffered 
 from increasing difficulty in breathing for some time, 
 owing to the vocal cords having become united to 
 each other throughout the anterior three-fourths of 
 the glottis by a tough web. I had twice done an 
 endolaryngeal operation on this patient, but though 
 I had succeeded in dividing the web on each occa- 
 sion, the two cut edges had again become adherent. 
 I therefore determined to slit up the web after 
 dividing the thyroid cartilage, and I performed the 
 operation at the Throat Hospital in the presence of 
 my colleagues. In this case the patient would cer- 
 tainly have died by suffocation if nothing had been 
 done, but I regret to say that the operation was not 
 successful, death having occurred on the eleventh day 
 from pleuro-pneumonia. 
 
 Everyone knows that operations on the air-passages 
 are very liable to be followed by inflammation of the 
 lungs or their serous and mucous membranes, and 
 in adults these complications much more frequently 
 follow thyrotomy (division of the thyroid cartilage) 
 than tracheotomy (opening of the trachea). It is 
 absurd, therefore, to pretend that the operation is 
 free from danger. The actual mortality, shown in 
 Table I, p. 235, does not give an adequate idea 
 of the risks attending it, for there are many hair- 
 breadth escapes among the successful cases. Thus,
 
 192 TJie Fatal Illness of Frederick the Noble. 
 
 in case No. I, according to Dr. Cutter's own words, 
 " the return to complete sensibility was retarded 
 by the accumulation of blood and mucus in the 
 mouth, which ran down the trachea and out of 
 the artificial opening. It was also accompanied by 
 profuse sweating and some flagging of the pulse." 
 After the patient was put to bed "vomiting ensued, 
 and a large amount of blood, mingled with mucus, 
 was evacuated." 
 
 In one of Professor Navratil's cases, * the haemor- 
 rhage was alarming, and the patient nearly died under 
 the knife, owing to the quantity of blood which passed 
 down the trachea. In another of Navratil's cases the 
 patient suffered from high fever after the operation, 
 and expectorated a quantity of blood and pus ; the 
 parts round the wound became cedematous, and the 
 patient was in a very critical state. 
 
 In Professor von Schrotter's casef the operator 
 observed that after dividing the thyroid cartilage, 
 holding open the edges of the wound with blunt 
 hooks " gave rise to such paroxysms of coughing, 
 and caused so much fresh haemorrhage, that the 
 examination could only be carried out for a short 
 time ; " and, further, " that the sputa consisted of 
 pure blood, even well into the night, and on the 
 following day the expectoration was still coloured." 
 
 Mr. Timothy Holmes remarks with regard to his 
 case,t " that the parts over the larynx were found to 
 to be peculiarly vascular." After the haemorrhage 
 caused by the preliminary incision had been checked, 
 the thyroid cartilage was divided. "The bleeding 
 that followed was very considerable." 
 
 Again, the reporter of Mr. Davies-Colley's third 
 operation remarks, § that "the boy at one time ceased 
 to breathe, blood having apparently run down the 
 
 * Berlin. Klin. Wochenschrift, December 7th, 1868, p. 502. 
 t Medicin. Jahrbtcch, Wien, 1869, vol. xvii. zweite Heft, p. 81. 
 X ' Surgical Treatment of Children's Diseases,' 2nd edit., p. 3 H. 
 § British Medical Journal^ September 28th, 1872.
 
 The Danger of the Operation. 193 
 
 trachea into the bronchial tubes, and the chloroform 
 acting powerfully on the lungs. But after artificial 
 respiration had been carried on for several minutes 
 the little patient recovered." 
 
 ' Dr. Fauvel, of Paris, pointed out,* many years ago, 
 that when the thyroid cartilage is divided in the 
 median line, and the two sides of the larynx are held 
 back or pulled outzuardSy the opening is very small, not 
 so large in fact as the (upper) natural opening of the 
 larynx. If in order to obtain a very complete view 
 the sides of the larynx are too forcibly pressed back, 
 great injury is likely to be done to the parts attached 
 to the wings of the thyroid cartilage, and such injury 
 would inevitably give rise to acute and dangerous 
 inflammation. For this reason surgeons do not 
 venture to force back the sides of the larynx (after 
 thyrotomy) to any considerable extent, but are 
 obliged to content themselves with a very imperfect 
 view of the interior. 
 
 Dr. Fauvel's exact words are : " The opening ob- 
 tained by the separation of the two wings of the 
 thyroid cartilage is so narrow that it is with difficulty 
 one can introduce in the adult the blades of a closed 
 forceps. It was impossible for us, in the case of the 
 patient who is the subject of observation, No. 84, 
 to separate the blades of a polypus forceps between 
 the two thyroid wings in spite of the greatest efforts. 
 We should certainly have produced fractures." In 
 this case the operator associated with Dr. Fauvel was 
 not a " rough and ready " surgeon, but the accom- 
 plished Mons. Pean, one of the most brilliant and 
 also the most careful of living operators. 
 
 The operation of thyrotomy is by no means so 
 harmless as it appears, but, like many other surgical 
 procedures so readily undertaken at the present day, is 
 attended with considerable danger. The fashion of 
 reckless operating now in vogue owes its existence to 
 
 ♦ 'Maladies du Larynx.' Paris, 1876, p. 229. 
 
 O
 
 194 T^Ji^ Fatal Illness of Frederick the Noble. 
 
 a combination of circumstances, some of which may- 
 be easily overlooked. One of these is curiously enough 
 the introduction of antiseptic methods. Nearly every 
 great discovery is attended, however, with some 
 drawbacks, and even the life-saving invention of Sir 
 Joseph- Lister, by rendering the conditions under 
 which operations can be performed much more 
 favourable, has resulted in some rash surgery. The 
 conservative traditions of Fergusson, Nelaton, and 
 Langenbeck, have been forgotten, and as ]\I. Verneuil 
 remarks, at present, " if one surgeon cuts something, 
 all his colleagues cut it, but in a different way." Dr. 
 Gottstein, of Breslau, whose practical work on " Dis- 
 eases of the Larynx " is now the best text-book 
 dealing with these diseases which is published in 
 Germany, remarks (page i68) : — 
 
 " The extirpation of malignant neoplasms by thyro- 
 tomy has, according to present experience, given very 
 unsatisfactory results. In twenty cases collected by 
 Paul Bruns, in two instances death occurred soon 
 after the operation, and only in one case no local 
 recurrence took place ; but here the fatal termination 
 was due to cancer of the suprarenal bodies and of the 
 left kidney. In all the other eighteen cases, local 
 recurrence took place after a longer or shorter time, 
 in a few cases indeed after two or three weeks, and 
 only once was it delayed for one and a half years. 
 There was never any mention whatever of a restora- 
 tion of the voice after the operation." 
 
 I repeat, it is only necessary for the reader who 
 wishes to form an idea of the danger of the operation 
 to look at Table I (Section III, page 234). This is 
 the operation which von Bergmann says is no more 
 dangerous than an ordinary tracheotomy ! This is 
 the operation which he assured the Crown Prince in 
 May 1887 was free from danger! This is the opera- 
 tion from which the illustrious patient was saved by 
 my removal of a portion of growth and its subsequent 
 examination by Professor Virchow.
 
 The Inadequacy of the Operation. 195 
 
 The Inadequacy of the, Operation. — I shall now pro- 
 ceed to prove my second proposition, viz. : — (b) That 
 the proposed operation does not afford a fair prospect of 
 eradicatifig a malignant growth, but, on the contrary, is 
 most frequently followed by recurrence. 
 
 The reason why this operation does not afford a 
 fair prospect of success, is because it is nearly impos- 
 sible by means of it to get away the whole of the 
 growth. Hence in these cases recurrence appears to 
 take place very soon after the operation. In speaking 
 of recurrence, it is most important to remember that 
 in cases of cancer recurrence is the equivalent term of 
 death. The patient soon dies when recurrence takes 
 place, or his life may be rendered still more miserable 
 by a second operation. 
 
 In one of Hahn's three cases, rectirrence is said to 
 have taken place five weeks after the operation, but it 
 is much more probable that in this instance the whole 
 of the growth had not been got away. In another 
 case the recurrence which took place was probably 
 very rapid, as the poor patient was so disappointed 
 that he committed suicide. In the last case the 
 patient died on the eleventh day before there had 
 been time for recurrence to take place. 
 
 In the cases contained in Table I, p. 236, recurrence 
 took place twelve times, or in other words, the rate of 
 recurrence was 54 • 54 per cent. This is the percentage 
 in which the disease returned after an operation 
 described by von Bergmann as promising the " best 
 results ! " * It must not be forgotten, also, that in 
 four out of the twenty-two cases operated on death 
 took place so quickly {i.e. in from eighteen hours to 
 eleven days) that there was not time for recur- 
 rence. Had these unfortunate patients lived for a 
 few' "months, and had the recurrence taken place in 
 the same proportion in the four cases as in the others 
 treated in the same way, the actual rate of recurrence 
 would have been almost 90*0 per cent, ! 
 * Op. cit. p. 19. 
 
 O 2
 
 196 TJie Fatal Illness of Prederick the Noble. 
 
 The fifth case in which death occurred as the 
 immediate result of the operation is not included 
 in this calculation, as the disease was found after 
 death to be tuberculosis, and not cancer. As the 
 operation was performed for cancer, however, I have 
 included the case in the Tables. 
 
 There is another point of less importance which 
 may be just touched on here. I do not wish to attach 
 too much weight to it, because life is so incomparably- 
 more important than the preservation of the voice that 
 the latter is in the vast majority of cases an altogether 
 secondary consideration. Special circumstances, 
 however, may modify this general rule. In the case 
 of a parliamentary orator, a clergyman, a barrister, a 
 singer, a military or naval officer — above all, in the 
 case of a future ruler, who has to be not merely an 
 ornamental figure-head, but the real chief and Im- 
 perator of a mighty army — the voice is of the utmost 
 importance. Now what is the effect of thyrotomy 
 (Laryiigofissiir) as regards the voice .'' Fifteen years 
 ago I published in the British Medical Journal 
 (April 26th, 1873) a Table which includes forty- 
 eight cases, seven of which were malignant and the 
 rest benign. Setting aside two cases which proved 
 rapidly fatal, and one (Langenbeck's) in which the 
 voice was not affected either before or after the 
 operation, there remain forty-five patients. Of this 
 number eighteen were completely voiceless after the 
 operation, whilst nine were dysphonic (i.e. hoarse) ; 
 in five the voice was '' modified " ; and in three, 
 though the condition of the voice is not mentioned, 
 there was a strong probability that aphonia or dys- 
 phonia existed. In only tpn cases was a previously 
 defective voice restored by the operation. In fr.ct, 
 the voice was destroyed or "modified" in T]"JJ per 
 cent, of the whole number ! 
 
 As such a large proportion of the cases contained 
 in my Table were benign, the results of the operation, 
 as regards the voice, were no doubt much more
 
 The Inadequacy of the Operatioji. 1 97 
 
 favourable than they would have been had all the 
 cases been malignant, as the removal of a benign 
 growth does not involve the sacrifice of so much of 
 the structure of the vocal cord as is required for the 
 effectual extirpation of a cancerous tumour. 
 
 In dealing with the question of the extent of the 
 growth in May 1877, von Bergmann adopts a method 
 which is no doubt convenient from an argumentative 
 point of view, but which can hardly be called straight- 
 forward. When he refers to himself as the operator, 
 the growth is described * as " limited to the vocal 
 cord." This is said to show the very trivial nature 
 of the operation which would be necessary to effect a 
 cure. When, however, I figure as the operator, and he 
 wishes to show that it was impossible for me to remove 
 the growth through the mouth, he states that it 
 was not circumscribed, but that, on the contrary, it 
 ''affected the under side of the vocal cord d^Vidi prob- 
 ably the side zvallof the lower larynx^ \ In discussing 
 the chances of success in such an operation as he pro- 
 posed to do, I have taken as the basis of my argument 
 von Bergmann's first theory that the disease was 
 strictly localised. If, however, we adopt his improved 
 theory, it is clear, on his own showing, that instead of 
 the operation set forth in Table I, p. 234, he would have 
 found it necessary to perform the one described in 
 Table II, p. 236. In this, although the actual mortality 
 is not quite so great, the results are very discouraging. 
 There are thirty-five of these operations, fifteen of 
 which proved fatal. In these cases death took place 
 in one instance on the fourth day, in one on the 
 eleventh, in another on the twelfth, in one on the 
 fifteenth, in two at the end of five weeks, in two 
 otlxers at the end of six weeks, in one case at the end 
 of seven weeks, and in another after ten weeks. In 
 one case death occurred after thirteen weeks, in one 
 
 * Op. cit. p. 19. 
 
 t Ibidi p. 23. The italics are not in the original.
 
 IqS The Fatal Illness of Frederick the Noble. 
 
 after four months, in one in thirteen months, and in 
 two after sixteen months. 
 
 Uncertainty of the Diagnosis. — Having shown that 
 the operation which von Bergmann proposed in May 
 1887 soon leads to death, because, owing to want of 
 sufficient access to the seat of disease, the growth is 
 not thoroughly removed, and recurrence, therefore, 
 speedily takes place, I pass to the consideration of 
 my third proposition : — 
 
 (c.) That the presence of cancer was not ascertained ift 
 the case of the Crown Prince until November 1887, if^ 
 indeed, cancer really existed at that date. 
 
 The truth of this proposition has been abundantly 
 proved in the first section of this work. Even Gerhardt 
 does not profess to have been certain about the diag- 
 nosis in ^lay, and as for Professor von Bergmann, I 
 have already said that before my first visit to Berlin he 
 did not even pretend to have any opinion at all as to 
 the nature of the disease. He disclaimed all respon- 
 sibility for the diagnosis, his position in the case 
 being, according to himself, simply to act on 
 Gerhardt's instructions.* The true nature of the 
 growth could only be proved by microscopic ex- 
 amination, and, as we have seen, none of the German 
 doctors had been able to extract a piece of it for this 
 purpose. I have myself never attached undue weight 
 to microscopical evidence, but in doubtful cases it 
 affords the only scientific test which we at present 
 possess. I have pointed out in my work on " Growths 
 in the Larynx "f that information afforded by the 
 microscope is fallacious, but in doing so I meant to 
 imply that an isolated examination could not always 
 
 * IMy authority for this statement is Dr. von Wegner, who, on 
 two occasions during my stay at Charlottenburg, told me that 
 before my arrival in Berlin, Bergmann had always said, 
 " Gerhardt makes the diagnosis. I am only the operator." 
 
 t This work was published in the year 1873. I had already 
 then operated on over 100 cases, whilst the remaining cases 
 published in the whole civilized world up to that date only 
 amounted to i8g.
 
 Uncertainty of the Diagnosis. 199 
 
 be relied upon. In the case of the Crown Prince the 
 reports of Professor Virchow afforded only negative 
 evidence ; but it must not be forgotten that several 
 examinations were made in the most careful way by 
 the greatest living pathologist. Great weight must 
 necessarily be attached to them. 
 
 The scientific world is more or less familiar with 
 Virchow's reports, which, however, I have thought it 
 well to publish again in full (See pp. 21, 32, 48 and 81). 
 Not only did the eminent pathologist fail to find any 
 evidence of cancer in the portions submitted to him, 
 but he went further, and said there was " nothing pre- 
 sent in them which would be likely to excite the suspi- 
 cion of wider and graver disease." Professor Virchow 
 not only called attention to the possible non-existence 
 of cancer in any portion of the growth, but he pointed 
 out that " the operation had reached the deep parts," 
 and stated further that the microscopic features 
 " characterise the lesion as an epithelial growth com- 
 bined with papillary offshots (misnamed papilloma)," 
 in fact as pachydermia laryngis, a purely benign kind 
 of growth, or rather hyperplastic thickening. He 
 accentuated his position by giving a lecture before the 
 Berlin Medical Society on June 27th, 1887, on Pachy- 
 dermia Laryngis,* in which he let it be understood 
 that he took the Crown Prince's case for his text. 
 
 It will be seen, therefore, that I had every reason to 
 hope that the disease was not malignant. In a case 
 like that of the Crown Prince, I affirm, without fear of 
 contradiction by any honest physician, that before 
 consenting to an external operation which avowedly 
 would have been more or less of the nature of a leap 
 in the dark, I should have the clearest and most 
 incontrovertible proof that the disease was cancer. 
 
 There are two conditions under which a man may 
 
 form an opinion — one in which that opinion is merely 
 
 an academic one, and the other in which the opinion 
 
 is to be followed by action of the most momentous 
 
 * Berlin. Klin. Wochenschrifl.
 
 200 The Fatal Illness of Frederick the Noble. 
 
 character. Now, though theoretically it may be 
 maintained that the practical results which are to 
 follow an opinion ought not to influence the formation 
 of that opinion, common sense demands a different 
 conclusion. If action is to be taken — and especially 
 if that action brings a human life into immediate 
 danger — much greater certainty ought to be arrived 
 at than if the opinion is not to be followed by any 
 practical consequences. Thus a prudent general 
 may be in doubt as to whether a certain defile is in 
 possession of the enemy. He may believe that it is 
 open, and if it is not necessary to make use of this 
 gorge his opinion may not be weighed with the most 
 minute care. If, however, he has to send a detach- 
 ment through the pass he must be absolutely certain 
 either that it is undefended, or that he can force it 
 before he allows his men to attempt the passage. 
 A jury in giving a verdict ought to be much more 
 certain of the proofs of guilt, if death is to follow 
 their decision, than if the punishment will merely be 
 a few months' imprisonment. In the same manner, 
 if the question of the nature of the Crown Prince's 
 ailment had been merely an academic one, I possibly 
 might have admitted that it was of a sufficiently 
 suspicious character to be placed in the category of 
 cancer ; but when my verdict was to carry with it the 
 performance of an operation sometimes immediately 
 fatal, and even when not immediately fatal, generally 
 followed by a recurrence of the growth, and ultimately 
 leading to more rapid death than if the patient had 
 been left alone, I repeat, I required the most abso- 
 lutely conclusive proofs. To put it in another way : 
 a patient has a small hard lump in the lip which looks 
 a little like cancer, though its nature is not by any 
 means certain. Now we know that such a lump can 
 be cut out without the smallest danger to the patient, 
 and we know also, with almost absolute certainty, that 
 the whole of the disease can be taken away. In such 
 a case we naturally recommend the operation, even
 
 Uncertainty of the Diagnosis. 201 
 
 though it may not be at all certain that the little 
 tumour is malignant. In the case of the breast again, 
 the entire organ can be completely removed with 
 little or no danger ; hence this operation is often per- 
 formed in doubtful cases, and it is well known that 
 many operations of this kind have been performed for 
 perfectly harmless tumours. In the larynx, however, 
 the very opposite conditions exist. There is danger 
 in the operation itself, and the greatest uncertainty as 
 to the complete removal of the disease. When the 
 tongue is the organ affected the same argument 
 applies. In a case of such transcendent importance 
 as that in which I was engaged, I maintain, at the 
 risk of reiteration, that before it would have been 
 justifiable to perform an operation, not only highly 
 dangerous in itself, but extremely uncertain in its 
 results, the most positive evidence of its necessity 
 was required. This, however, was not forthcoming. 
 
 The pathological reports only show that scientific 
 investigation has its limits. The one thing which 
 has been added to our knowledge by this sad case 
 is that, in cancer of the larynx, in very rare cases, 
 a benign groivtk may co-exist with a cancer. These 
 two conditions have been known to co-exist in 
 cancer of other parts ; but the experience of Pro- 
 fessor Virchow, especially directed to that point, is 
 that up to the occurrence of the Crown Prince's 
 case, the two morbid conditions did not occur simul- 
 taneously in the larynx. Had this fact, however, been 
 known before, I very much doubt whether, after the 
 negative results of Professor Virchow's repeated 
 examinations, any surgeon would have ventured 
 to perform an external operation on the illustrious 
 patient. Some people say that Virchow's reports, 
 so far as they were objective, instead of disproving 
 the existence of cancer, actually proved its presence. 
 I may even say for myself that, had I received Pro- 
 fessor Virchow's reports without his comments, I 
 should have come to this conclusion. When, how-
 
 202 The Fatal Illness of Frederick the Noble. 
 
 ever, so eminent a pathologist, a specialist whose 
 position is unique in his own department, expressly 
 declared that no such inference was to be drawn from 
 the appearances he described, would it not have been 
 absurd for me, a mere practical physician, to have set 
 up my opinion against that of Virchow on a question 
 of pathology ? 
 
 Before proceeding to ask what would have been 
 the probable result had von Bergmann operated in 
 May 1887, I may be permitted to call attention to 
 two very important circumstances. These are : First, 
 that when it was known that I had removed a piece 
 of growth, and that it was sent to Virchow for exami- 
 nation, Dr. Hahn (admitted on all sides to be the 
 most experienced and successful operator on the 
 larynx from the outside) remarked to Dr. Wegner 
 that unless Virchow, or some other pathologist, found 
 evidence of cancer in the portion of growth removed, 
 he would not recommend an external operation to be 
 performed. I must remind my readers that had 
 Professor von Bergmann performed the operation on 
 the Crown Prince in May 1S87, Dr. Hahn had been 
 engaged to be present in order to assist, or rather 
 direct von Bergmann. It will be seen, therefore, that 
 in the advice I gave I was supported by the most 
 skilful operator of the day.* 
 
 The second point to which I wish to call attention 
 is that in October 1887, von Bergmann told Count 
 Radolinsky that in preventing the operation in May 
 I had done perfectly right. It is therefore obviously 
 unfair and unscientific for von Bergmann to attack 
 me subsequently, from an ex post facto standpoint, 
 because events did not turn out satisfactorily. t 
 
 * This was told me by Dr. Wegner in IMay 1888, though in 
 July 1887, Dr. Wegner imparted to me a portion of the informa- 
 tion in the Isle of Wight. 
 
 t This information was given to me at San Remo by Count 
 Radohnsky in November 1887. It was mentioned by the 
 British Medical Journal of November 19th, 1887, p. 1127, and 
 has not been denied by von Bergmann.
 
 Uncertainty of the Diagnosis. 203 
 
 It must now be asked, What would have been the 
 probable result if I had sanctioned the proposed 
 operation in May 1887 ? Von Bergmann objects to 
 statistics being made the basis on which a judgment 
 as to the justifiability of operations should be formed, 
 and in view of the terrible results which have followed 
 the various external operations on the larynx, I am 
 not surprised that he should take up this position. 
 He can have no objection, however, to my placing 
 before my readers the results of the experience of so 
 careful an operator as Dr. Eugen Hahn. As already 
 remarked, this gentleman is admitted to be the most 
 successful external operator on the larynx at the 
 present day. He is indeed the only surgeon who can 
 boast of any success whatever, and that success haS; 
 I understand, been obtained in great measure through 
 his care in selecting cases which he thinks suitable 
 for the operation. The public should understand 
 that there are two classes of operating surgeons : 
 viz. those who operate in all cases where there is the 
 smallest chance of success ; and those who refuse 
 to operate unless there is every reason to expect 
 a good result. There is a good deal to be said 
 in favour of both classes. The bold surgeon, who 
 operates in nearly every case that offers itself, no 
 doubt from time to time has achieved some brilliant 
 triumphs. On the other hand, the surgeon who 
 operates only in cases of a very promising character 
 obtains better results in the main than his rasher 
 colleague. Dr. Hahn belongs to the category of 
 careful surgeons. 
 
 Let us consider the results of thyrotomy even in 
 his careful hands. They can be seen at a glance in 
 the subjoined Table. 
 
 Nothing could be more lamentable than this Table. 
 The first case is described as "cured," although the 
 patient had to wear a canula afterwards, or in other 
 words, was no better than if simple tracheotomy had 
 been performed. Case No. 2 is described as " cured,"
 
 204 The Fatal Illness of Frederick tlie Noble. 
 
 although recurrence of the growth took place five 
 weeks after the operation ! Let us follow up the case 
 of this unfortunate patient. 
 
 On May 5th, 1887, less than five months after he 
 had submitted to thyrotomy, total extirpation had to 
 be performed (three weeks before the date on which 
 it was intended to operate on the Crown Prince). The 
 patient survived this procedure only four weeks. Here 
 we have an example of what would in all probability 
 have been the fate of the Crown Prince if von Berg- 
 mann had operated on him in May 1887. His 
 Imperial Highness would have suffered in May all 
 the misery which he went through in the following 
 
 Name of Patient. Result. 
 
 1 Scheidenreicht 
 
 2 Hahn * . 
 
 3 Richter. 
 
 Cured (?) but could not dispense 
 with canula. Recurrence. Death 
 from suicide. 
 
 Cured. Recurrence 5 weeks after 
 operation. 
 
 Death on nth day through heart- 
 failure. Operation only undertaken 
 at urgent request of patient. 
 
 * The patient's name was the same as the operator's. 
 
 February. Instead of this, as the result of Virchow's 
 report, the illustrious patient passed many months 
 of pleasant existence, during which he often told 
 me that he felt as well as ever he had done in 
 his life. If when the time came for tracheotomy 
 to be performed the after-treatment of that operation 
 had been carried out in an intelligent manner, not 
 only would the illustrious patient have been spared 
 much unnecessary suftering, but his life would in all 
 human probability have been prolonged considerably
 
 Uncertainty of the Diagnosis. 205 
 
 beyond what actually was the case. The average 
 duration of life in cases of laryngeal cancer is two 
 years, and there are well authenticated instances of 
 patients undoubtedly suffering from the disease 
 having lived for three and even four years. Taking 
 the average period, however, the Emperor's " expec- 
 tation of Hfe " was till about February 1889. Thus 
 several months of his existence were sacrificed through 
 unskilful treatment and the use of clumsy in- 
 struments. 
 
 Perhaps all the evil results ought not to be laid on 
 the shoulders of Bergmann and Bramann, as the 
 rapid development of the disease was in part pro- 
 bably caused by Gerhardt's extraordinary abuse of 
 electric cautery. The slow progress of laryngeal 
 cancer is universally recognized, the hard encasing 
 cartilage resisting the progress of the disease. In 
 this case, however, Gerhardt's reckless use of the 
 red-hot wire no doubt set up the perichondritis which 
 formed such a prominent feature in the case and 
 hastened the fatal result.
 
 2o6 The Fatal Illness of Fi'ederick the Noble. 
 
 CHAPTER XII. 
 
 THE INDICTMENT. 
 
 The Witnesses. — I propose now to pass briefly in 
 review the various reports contained in the pamphlet 
 in which my adversaries have embodied all their 
 personal and professional grievances against me. 
 Some points have necessarily been touched upon 
 already in one or other of the foregoing chapters ; 
 these I shall not again refer to unless further explana- 
 tion may seem to be desirable for the sake of clear- 
 ness. 
 
 Before dealing with the individual statements, a 
 few w^ords must be said as to the reports collectively, 
 in order that the reader may be in a position to judge 
 between me and my accusers. A Large part of the 
 indictment against me rests on evidence which is 
 utterly worthless, because it is adduced by witnesses 
 who are either too prejudiced to be altogether credible 
 or too ignorant to be in any way competent. I am 
 charged with having failed, or refused, to see certain 
 appearances in the Crown Prince's larynx which 
 should have opened my eyes to the real state of 
 things long before the crisis at the end of autumn. 
 The testimony adduced in support of this is— i, that 
 of Professor Gerhardt, who had the strongest 
 personal reasons for painting the situation in the 
 blackest possible colours ; 2, that of Professor Tobold, 
 who throughout his brief connection with the case 
 was simply \h.Q fidus Achates of Gerhardt; 3, that 
 of Professor von Bergmann, who did not even 
 pretend to see anything in the Crown Prince's 
 throat beyond what he was told to look for ; and 4,
 
 The Witnesses. 207 
 
 that of Dr. Landgraf, whose determination to see 
 something for himself resulted in the highly imagi- 
 native " observations " to which I have more than 
 once alluded. At a later period equally valuable 
 " observations " were made by Dr. Bramann and Pro- 
 fessor Kussmaul, which are now gravely brought 
 forward as independent testimony outweighing that of 
 specialists like Krause, Hovell and myself. I will do 
 Professor Kussmaul the justice to say that I do not 
 think he had any idea of posing as a laryngoscopist at 
 San Remo ; his examination of the Crown Prince's 
 throat was only intended as a sort of medical rite or 
 ceremonial observance appropriate to the occasion. 
 Bergmann, Bramann and Landgraf, however, whose 
 laryngoscopic skill was just as much a qicantite neg- 
 ligeable as that of Kussmaul, were far from being so 
 modest in their pretensions ; they went through the 
 farce with the solemnity of Roman Augurs, and had 
 the results of their pro formd examinations duly 
 added to the "official sources." The whole thing 
 was a melancholy sham. The mere manual art 
 of laryngoscopy can only be acquired by much 
 practice, and when that has been mastered there are 
 still many fallacies of observation which it requires 
 considerable experience to guard against. It is there- 
 fore as preposterous that the "observations" of a 
 novice, who hardly knows how to hold the mirror, 
 should be set against those of an expert, as it would 
 be for me to claim the same importance for astro- 
 nomical observations made by myself as for those of 
 Sir George Airy or Mr. Christie. 
 
 The " Official Sources" — As the authors of the 
 German pamphlet appear to claim some special 
 authority for their production on the ground that it is 
 drawn from " Official Sources," it may be as well to 
 show exactly what that imposing expression means. 
 The " Official Sources," as a matter of fact, largely 
 consist of documents drawn up by those gentlemen 
 themselves in their private capacity. These lucubra-
 
 2o8 The Fatal Illness of Frederick the Noble. 
 
 tions are thereupon incontinently deposited (often, I 
 imagine, without being read) in the State Archives, 
 where they acquire the proper odour of bureaucratic 
 sanctity, and from which they are in due course 
 brought forth as " official " documents of the highest 
 importance. In the present instance, not only were 
 the innumerable protocols and reports of various kinds, 
 which we all had to send in from to time, carefully 
 deposited among the "official sources," but all the 
 quack nostrums, miraculous waters, magical incanta- 
 tions, charms, talismans, phylacteries and relics, with 
 the directions for their use, were solemnly stowed 
 away in the proper pigeon-holes. Even the oatmeal 
 malt extract, the essences and quintessences of beef, 
 and all the infinite variety of patent articles of diet 
 which were showered on the Emperor's doctors by 
 humane persons or enterprising tradesmen, were 
 placed in the same offiicial limbo. It will be seen 
 that the word " official " covers a most heterogeneous 
 collection of " documents," of very different degrees 
 of historical value. 
 
 As regards any opinions or statements attributed 
 to me in " official " documents, I take this opportunity 
 of saying that unless they are signed by me, they 
 have no authority whatever. It is true that rough 
 notes were taken at some of our earlier consultations 
 by Dr. Wegner, but the fair copies embodying our 
 several views were never, I believe, submitted to the 
 individual physicians and surgeons for their perusal 
 and signature. At any rate, I can speak with cer- 
 tainty for myself No document embodying a precis 
 of remarks by me at a consultation was ever placed 
 before me in order that I might say whether it gave 
 an accurate account of my opinion. 
 
 TJie Evidence: Gerhardfs Report. — In dealing with 
 Professor Gerhardt's report, what must strike every 
 impartial reader is, that he thought much more of 
 protecting his own professional reputation than of 
 benefiting the Crown Prince. As he could not himself
 
 TJie Evidence : Gerhardfs Report. 209 
 
 extract a piece of the growth for microscopic examina- 
 tion he should have at once called in some one who 
 could do so. There are at least half-a-dozen men in 
 Germany who could have done the little operation 
 which I subsequently performed. This, however, would 
 not have suited the views of the Professor, who accord- 
 ingly invoked the aid of a general surgeon who could 
 not be his rival in the laryngological field. When the 
 illustrious patient was at Ems, Dr. Wegner already 
 perceived that he had made a mistake in calling in 
 Professor Gerhardt, and expressed an opinion that a 
 competent specialist ought to be summoned.* This, 
 however, was prevented by Professor Gerhardt, who 
 insisted on Bergmann being summoned. At a later 
 period, when for the sake of appearances a throat- 
 specialist had to be called in, instead of sending for 
 one of the leading men in that line, a gentleman was 
 chosen, who, on his own confession, " no longer ope- 
 rated ! " In this way Gerhardt hoped to hide his own 
 incompetence. At a later period I had the honour 
 of being summoned from London, not apparently 
 because my opinion was likely to be of any value, 
 but because " every person who knew how to make a 
 laryngoscopic examination must come to the same 
 conclusion " as Gerhardt had done ! The grounds 
 on which I was called are thus clearly laid down. 
 If the proposed operation had been performed and 
 had proved successful, Bergmann would have said that 
 the nature of the disease was quite clear ; Mackenzie 
 was only called in as a matter of form. If, on the 
 other hand, the operation had proved fatal, Bergmann 
 would have thrown the responsibility of the whole 
 thing on me. 
 
 The first charge brought against me by Professor 
 Gerhardt is that I took the forceps out of my pocket 
 and used them without first disinfecting them. As it 
 happens, the instrument was contained in a silk bag 
 
 * Op. at., p. 5.
 
 2 10 The Fatal Illness of Frederick the Noble. 
 
 lined with carbolised wool, which I have long used for 
 the purpose. He further says that I was not able to 
 throw the light on to the laryngeal mirror, but that it 
 fell on the patient's cheek. Of course in reflecting a 
 ray of light on to a mirror it must pass across the 
 patient's face before it reaches the little glass, and if 
 Professor Gerhardt happened to notice it in its transit, 
 that was certainly no fault of mine. That I could 
 introduce forceps into the larynx at all without the 
 lar>mx being illuminated is too absurd a Xh&ory for 
 further consideration. 
 
 I have already referred to Gerhardt's utterly base- 
 less allegation that I had wounded the right vqcal 
 cord. At the time of the supposed accident, I under- 
 stood that I was charged with nothing worse than 
 clumsiness. In his published statement, however, 
 Gerhardt goes altogether beyond his former amiable 
 insinuation, and accuses me of having been unskilful 
 of malice aforethought. He says,* "This must be 
 the first case in which a laryngeal specialist has 
 endeavoiircd\ by mistake to tear away a piece of a 
 healthy vocal cord." I have only to say that the 
 infamy of so disgraceful a charge recoils on the person 
 who makes it. I am certainly at a loss to understand 
 how a person can endeavotir to do anything by 
 mistake, but the impression which Professor Gerhardt 
 has tried to convey to the public is, I suppose, that, in 
 in order to mislead Virchow, and to get from him 
 a favourable report on the portion removed, I 
 endeavoured to take away a piece of healthy tissue 
 instead of the diseased structure. It would seem that 
 Gerhardt thought the charge which he first made 
 against me was not sufficiently damaging to my 
 reputation, and that he therefore altered it. On this 
 subject I need only say that on every occasion that 
 any tissue was removed by me from the Crown 
 Prince's larynx it was at once submitted to Professor 
 
 * Op. at. p. lo. 
 
 t The italics are not in the original.
 
 The Evidence : Bergmann's Report. 2 1 1 
 
 Virchow. As already remarked, that eminent patho- 
 logist pronounced every fragment examined by him 
 to be unquestionably diseased. 
 
 Several of the other accusations he makes against 
 me are hardly less remarkable for their combined 
 absurdity and malevolence. Thus he actually states 
 that " on the 24th of May it was already generally 
 known that Mackenzie had promised the relatives of 
 the illustrious patient to cure the disease in a fciv 
 weeks!' * Now everybody knows that the length of 
 time required to cure benign growths is most un- 
 certain, and that no laryngoscopist would dream of 
 saying that a patient could with certainty be cured 
 in a few weeks. The most that I ever said on this 
 subject was, that if the disease was not cancer, I 
 believed I should be able to cure it. I never referred 
 to the question of time at all. Another ridiculous 
 statement is, that I said that " the climate of the Isle 
 of Wight would greatly assist in the cure" of the 
 Crown Prince.t Professor Gerhardt appears to be 
 under the impression that the Isle of Wight is a 
 place like Ems or Homburg where patients undergo 
 "cures." I have already explained how the Isle of 
 Wight came to be chosen by the Crown Prince as a 
 place of residence, and I could hardly have imagined 
 that any one could have been so silly as to believe, 
 or even profess to believe, that I recommended the 
 climate as beneficial in cancer. 
 
 The Evidence: Professor von Bergmann s Report. — 
 Professor von Bergmann appears in two different char- 
 acters in the pamphlet : First, as the author of a sepa- 
 rate report ; secondly, as the general editor of the whole 
 publication. How far, in the latter capacity, he acts 
 independently, and how far he is the mouthpiece of the 
 other physicians and surgeons, whose reports appear 
 under the same cover, it is impossible for me to say. 
 But I should imagine that several of his colleagues 
 
 * Op. cit. p. 10. t Op. cit, p. 12. 
 
 P 2
 
 2 1 2 The Fatal Illness of Frederick the Noble. 
 
 would hardly care to be responsible for the statements 
 which appear in that portion of the work which is sup- 
 posed to be under the supervision of von Bergmann. 
 His own report may be conveniently considered under 
 three aspects : First, a narrative of " facts " which 
 does more credit to his imagination than to his 
 memory ; secondly, complaints of the scandalous 
 injustice of newspapers supposed to be inspired by me, 
 and denials of responsibility for the still more out- 
 rageous utterances of papers, supposed to be inspired 
 by him ; thirdly, miscellaneous polemics on more or 
 less irrelevant topics. 
 
 Various portions of von Bergmann's narrative have 
 already been dealt with in the earlier chapters of this 
 book. I need not, therefore, do more than call 
 attention to a few of the grosser mis-statements. 
 In speaking of the period immediately subsequent to 
 the tracheotomy he says, " that [I] admitted that the 
 first tube I had made at San Remo was too narrow in 
 the bore to be used." This is absolutely untrue. I 
 was not allowed to introduce my instrument because 
 it was a trifle smaller than the one already in use. I 
 pointed out that it would be much better to use a 
 smaller tube which would stop the coughing and 
 bleeding, than to wait for a new canula (see Section I, 
 p. 112). But where Bergmann chiefly shows his 
 mastery of the " scientific use of the imagination " is 
 in his account of the events of the fatal day (April 
 1 2th) which may without exaggeration be said to 
 have sealed the doom of the suffering Emperor. The 
 painful story has already been told (see pp. 143-151) 
 and need not be repeated here. It is necessar}', 
 however, to point out the inaccuracies of the 
 German surgeon's version as given in his report. 
 He states that immediately after his arrival at 
 the palace, on seeing the state the illustrious patient 
 was in, he thought ''there was no time to be lost, and 
 with ^Mackenzie's consent [he] sent a servant to fetch 
 Bramann " who was in his carriage outside. As I
 
 The Evidence : Bergmann' s Report. 2 1 % 
 
 have already said (p. 146), so far from the Emperor 
 being on the point of suffocation, we found him quietly- 
 writing when we went to his room. Professor von 
 Bergmann, however, says, " I and my assistant were 
 not the only ones who found the Emperor in a state 
 of suffocation." Now though the Professor certainly 
 did not find His Majesty in such a condition, it is 
 quite true that his assistant did, as something had 
 taken place before he appeared on the scene which 
 had made a terrible change in the state of affairs. 
 Professor von Bergmann did not send for Bramann 
 imtil he had thrice plnnged his sJiarp-edgcd cannla 
 into tJie tissues of the neck in front of the trachea. Dr. 
 Bramann therefore did not witness the unfortunate 
 performance of his chief, though he must have been 
 somewhat puzzled at the latter's failure to do a thing 
 which he himself did without the least difficulty. I 
 observe that Bergmann seeks to corroborate his state- 
 ment as to the Emperor's breathlessness by the testi- 
 mony of General von Albedyll, General Bronsart von 
 Schellendorff, and General von Winterfeldt, who, ac- 
 cording to him, had noticed symptomxs of " suffoca- 
 tion " during the day. These gentlemen are no doubt 
 most distinguished officers, but the question is hardly 
 a military one, and I really cannot accept their opinion 
 on such a matter in preference to the evidence of my 
 own eyes. I am glad to find one sentence of Berg- 
 mann's narrative which I can confirm ; it is quite true 
 that he held apart the edges of the wound, while his 
 assistant introduced the tube. Bergmann seems 
 anxious that he should receive full credit for this 
 achievement, but it is not easy to see on what he 
 grounds such a claim, for the difficulty with the 
 canula had nothing whatever to do with the edges 
 of the wound, and the Professor's help was therefore 
 quite superfluous. 
 
 In connection with this incident an utterly false 
 and calumnious statement appeared in the KolniscJie 
 Zeitujig, from the pen of its Berlin correspondent, a
 
 2 1 4 The Fatal Illness of Frederick the Noble. 
 
 Dr. Fischer, who for some months previously had 
 supported von Bergmann in that journal in a very 
 violent and aggressive manner. The whole occur- 
 rence was grossly misrepresented. Mr. Hovell was 
 accused of having refused to go to the Emperor 
 when summoned by the orderly on the night of the 
 Iith-I2th, and it was asserted that in trying to 
 insert the canula he had forced morbid matter into 
 the windpipe and lungs. Further, that the Emperor 
 was left from lO o'clock on Wednesday morning 
 (nth) till 5 o'clock on Thursday evening (the 1 2th) 
 entirely in the hands of the English doctors, when 
 fortunately von Bergmann arrived in time to save 
 His Majesty's life ! Mr. Hovell was obliged in self- 
 defence to rectify a statement so damaging to his 
 professional character, and in order to do so he had 
 of course to give an accurate account of the facts, 
 including von Bergmann's share in the proceedings. 
 Mr. Hovell's letter was commented on in the ' British 
 Medical Journal,' whereupon Professor von Bergmann 
 took the extraordinary step of sending a communica- 
 tion to the Berlin Medical Society, of which the 
 following is a copy : — 
 
 " On April 28th the ' British Medical Journal ' made 
 these remarks : — 'As Professor von Bergmann has not 
 contradicted this statement (viz. that he had made a 
 false passage) it may be accepted as true ;' that is to say, 
 because I am silent in the face of a statement of facts 
 and of personal attacks, it shows they must be well 
 founded. If the * British Medical Journal ' were not 
 a journal whose scientific value I prize ver>' highly, I 
 might still remain silent in the presence of such an 
 accusation, but under the circumstances I must defend 
 myself. I am not silent because I am in the wrong, 
 but because I, like every honourable British or German 
 physician, do not talk publicly about what goes on at 
 the bedside of .my patients." It was naturally sup- 
 posed when Professor von Bergmann adopted such an 
 unusual course as to make this attack on me at the
 
 The Evidence : BergmaufUs Report. 2 1 5 
 
 Berlin Medical Society, that on a fitting occasion he 
 would give some satisfactory explanation. Two 
 months afterwards he publishes a report, in which, 
 instead of giving an explanation, he suppresses the 
 true facts, and makes a statement which is absolutely 
 false. 
 
 If it was merely a question of credibility between 
 Professor von Bergmann and myself ; if there was 
 nothing more than my word against his respecting 
 this matter, it might be difficult for the public to 
 decide which version to accept. Fortunately for the 
 sake of truth there are objective facts in the case 
 which cannot be explained away by any sophistry. 
 It can be proved that there was no bleeding whatever 
 before Bergmann's arrival. It can also be proved 
 that his forcible attempts to introduce the tube were 
 followed by profuse haemorrhage, the blood running 
 out of the wound in the neck and also down the wind- 
 pipe, and causing violent coughing. Three days after- 
 wards the Emperor had a shivering fit. A day or two 
 later still, an abscess is noticed in the tissues into 
 which von Bergmann thrust his canula. The abscess 
 extends downwards, ounces of pus are secreted 
 daily, the patient is harassed by constant coughing 
 from the pus finding its way into the windpipe, and 
 his strength is reduced by the profuse and continual 
 discharge of matter. At last he sinks and an immense 
 abscess-cavity is found after death just in the place 
 where Bergmann made the false passage ! The logic 
 of these facts is irresistible. 
 
 As to the question of dealings with the press, the 
 disgraceful attack on Mr. Hovell which has just been 
 referred to, though utterly false in almost every detail, 
 yet bore internal evidence of being founded on infor- 
 mation supplied by some one who knew what had 
 taken place. It was a complete breach of the truce in 
 the newspaper warfare raging round the case which 
 had been arranged at San Remo in the early part of 
 March (See p. 121), but which I must admit had
 
 2 1 6 The Fatal Illness of Frederick the Noble. 
 
 never been kept by a certain section of the German 
 press. Although dishonourable to the last degree 
 in itself, it was an adroit manoeuvre from the 
 strategical point of view. A serious injury had been 
 inflicted on the Emperor, the effects of which it 
 would be impossible to hide for any length of time. 
 It was therefore most important to throw the blame 
 on the hated foreign doctors, and as the facts which 
 had occurred in the daytime could not well be dis- 
 torted, Mr. Hovell, who, being on night duty, would 
 have no witnesses to appeal to, was made the object 
 of attack. The Emperor himself, however, knew well 
 who it was that had done him a grievous injury, and 
 neither open slander nor malicious insinuation can 
 deflect the terrible condemnation from the man to 
 whom it was applied by the illustrious suflerer. One 
 proof of the entire disregard for truth which charac- 
 terised the whole article is too striking to omit. It 
 was stated that Mr. Hovell, on being called, told the 
 orderly that it was unnecessary for him to get up, 
 and some further conversation between them was 
 recorded. As Mr. Hovell does not speak a word 
 of German, and the orderly does not know a word 
 of English, it would be interesting to know how the 
 conversation is supposed to have been carried on ! 
 
 Although this impudently mendacious account of 
 the catastrophe appeared at so opportune a moment 
 for Professor von Bergmann's reputation, I am not 
 prepared to assert positively that he himself inspired 
 it. It is possible that the orderly, who had been in 
 the habit of "controlling" me (See p. 133), may have 
 been the " official source " of the lie. A day or two 
 later the Kretiz Zeitiuig referred to the subject, and 
 said that on the fatal 12th I was quite '' rathlos'' 
 " at my wits' end," i.e., quite at a loss to know what to 
 do, and Bergmann was again made to figure as the 
 saviour of the Emperor. These attacks were re- 
 echoed in the provincial press, in still coarser terms. 
 Feeling that definite imputations of so grossly personal
 
 The Evidence : BergmanrH s Report. 2 1 7 
 
 a nature could not be passed over in silence without 
 seeming to admit their truth, I had to insist on the 
 Kreuz Zeitiuig publishing a contradiction of the state- 
 ment. The following is the letter I wrote, which, it 
 will be seen, is very moderate in tone, and contains no 
 allusion to the injury which Bergmann had inflicted 
 on the Emperor : 
 
 *' The remark that I was at my wits' end, and there- 
 fore sent for Professor von Bergmann on Thursday 
 the 1 2th instant, is absolutely false. The truth is that 
 as Professor von Bergmann has charge of the surgical 
 treatment of His Majesty the Emperor conjointly 
 with me, I thought it more courteous to the eminent 
 surgeon to invite him to assist me in inserting a 
 better fitting tube instead of one which no longer 
 served its purpose. As Professor von Bergmann 
 seemed to wish to insert the new tube, I raised no 
 objection. He was, however, unsuccessful, and the 
 tube was finally inserted by Dr. Bramann. As my 
 courtesy led to misrepresentation by you and others, 
 I have since changed the tube when necessary or de- 
 sirable without summoning Professor von Bergmann." 
 
 It would be tedious and not in the least instructive 
 to follow Professor von Bergmann through the various 
 newspaper paragraphs he has collected. He seems 
 to be extremely annoyed at a statement made in 
 the Pall Mall Gazette that he has never had a suc- 
 cessful case of complete or partial extirpation of the 
 larynx. To this he replies that he has had seven 
 cases of thyrotomy i^Laryngofissiir'). It has already 
 been pointed out that these operations were not 
 done for cancer, and besides it may not be super- 
 fluous to emphasise the fact that thyrotomy is not 
 the-' same operation as excision of the larynx. 
 It now also appears that Bergmann has had cne 
 successful case of this latter operation in a patient 
 suffering from cancer. His statement that whilst I 
 was in Berlin he offered * to show me this patient has 
 * Op. cit., p. 20.
 
 2 1 8 The Fatal Illness of Fj-ederick the Noble. 
 
 no more foundation than many others of his so-called 
 facts, I never heard of the case till I read of it in the 
 German pamphlet. Had I had the opportunity of 
 seeing a patient cured by the Professor, I should have 
 examined him with the greatest interest and curiosity. 
 
 Bergmann seems to hold me personally responsible 
 for ever^' paragraph which appeared in the English 
 papers as to the illness of the Crown Prince. I am 
 even taxed with having inspired statements which I 
 knew to be false, about matters of no importance 
 whatever. The Professor's view, so far as I can 
 make out, is that this was done simply from a dis- 
 interested love of lying, for the statements referred 
 to could not by any possibility be of any service to 
 me. He further states that it is proved from "official 
 sources " that I was in the habit of receiving fourteen 
 correspondents. This is absolutely false. I certainly 
 gave some information to the representatives of three 
 German newspapers, but the information was of a 
 most trivial character, viz., as to whether His ]Majesty 
 had had a satisfactory night, or whether his appetite 
 was good. So meagre was the information that I 
 gave, that on the days when the bulletins were 
 published the correspondents did not usually apply 
 to me. So far from encouraging the representativ^es 
 of the press, it is a well-known fact that I subjected 
 myself to systematic misrepresentation by the corre- 
 spondent of a leading English paper, because, after 
 he had "placed his services at my disposal," I 
 declined to receive him. 
 
 Why does not von Bergmann complete the story ? 
 He could easily show, and let me add from " official 
 sources," that this paltry charge against me ivas 
 actually laid before the Eniperor, and further the 
 same unimpeachable " sources " show that His 
 Majesty treated the charge with silejit contempt. I 
 may add that in order to neutralise the absolutely 
 false reports made by the " reptile " press respecting 
 the condition cf the Emperor, if I had been able to
 
 The Evidence : Bergrnann^s Report. 219 
 
 speak the truth, not merely to the representatives of 
 fourteen but of fourteen hundred or even fourteen 
 thousand newspapers, I should have been more than 
 justified in doing so. Sheer physical fatigue caused by 
 my professional duties unfortunately compelled me to 
 limit my interviews with the representatives of the 
 press to the narrowest limits. I may, however, 
 remark in conclusion, that the liberal - minded 
 monarch, whom I had the honour to serve, was not 
 only aware of my relations with some members of 
 the press, but that, in the most important journal- 
 istic episode in which I was concerned, he even con- 
 descended to advise me. 
 
 Dr. von Bergmann's virtuous indignation on the 
 subject of coquetting with the press is edifying even 
 if not altogether convincing. Methinks the Professor 
 doth protest too much when he is not accused, and 
 not enough perhaps when he is. At any rate he has 
 never answered my challenge in the British Medical 
 Journal of May 12th, 1888, p. 1032, where I openly 
 charged him with having been in frequent communi- 
 cation with journalists, and mentioned specific in- 
 stances in which this had taken place. Professor von 
 Bergmann, who was so eager to reply to a remark in 
 the same journal not long before, has never attempted 
 to traverse the statements made by me in that letter. 
 If he held himself as scrupulously aloof from the 
 papers as he would have us believe, the faculty of 
 "thought-reading" \\A\\\ regard to him which seems 
 to have suddenly become developed in several "able 
 editors," is little short of miraculous. Not only did 
 they know by intuition what von Bergmann had 
 said in consultations with his colleagues, but they 
 were able to record measures as having been actually 
 adopted which had been proposed by the Professor 
 without, however, having been carried into effect ! 
 
 Thus on the morning of the 19th of April, Dr. von 
 Bergmann brought with him a piece of elastic tubing 
 which he intended to pass through the canula. He
 
 220 The Fatal Illness of Frederick the Noble. 
 
 then intended to withdraw the canula, and leaving 
 the elastic tube in the throat, afterwards to thread 
 another canula over it, and pass a second one into the 
 trachea. As it happened, there was no occasion for 
 this apparatus, Mr. Hovell having changed the tube 
 without any difficulty during the previous night. The 
 Professor's ingenious device was, however, described 
 in the National Zeitiiiig on the following day, as 
 having been adopted with the greatest advantage. 
 At San Remo Dr. von Bergmann displayed histrionic 
 talent almost equal to that of his brother Professor, 
 Gerhardt. He publicly ejected Dr. Goldberg, a 
 representative of the National Zeitiing, from his room 
 with appropriate Pecksniffian pantomime ; but in 
 spite of this the views which the distinguished sur- 
 geon expressed at our daily consultations were un- 
 failingly reproduced in the columns of that journal. 
 It afterwards turned out that the said Dr. Goldberg 
 was the regular reporter of Bergmann's lectures at 
 Berlin ! When the Emperor was at Charlottenburg, 
 the National Zeitnng published the minutest details 
 concerning His Majesty ; not only was the exact 
 diet given, not only the frequency of the pulse, but 
 even the number of respirations per minute. By a 
 curious coincidence, when von Bergmann retired from 
 the case these details no longer appeared in the 
 National Zeitnng. Details it is true were put in, but 
 they were invented by the ingenious reporter, and 
 were wholly inaccurate. But the power of divination 
 shown by this enterprising journal, with which von 
 Bergmann "had no relations whatever," was even 
 more remarkable in November, 1887. At that time 
 the details of a conference between Professor von 
 Bergmann and Professor Gerhardt, which took place at 
 the Haus-Ministerium, in Berlin, were reported in the 
 National Zeitnng with such amazing accuracy that the 
 '' official " reports of the conference, which now appears 
 in the German pamphlet, is identical in its language ! 
 These facts are, I think, sufficient to show the value
 
 The Evidence : Bergmann's Report. 221 
 
 that should be attached, not only to Professor von 
 Bergmann's own protestations, but to the disclaimers 
 of the various editors who, "of their own accord, 
 declared in the most solemn manner that [Bergmann] 
 had never had any relations direct, or indirect, with 
 them." There is a refreshing simplicity about the 
 dilemma propounded by von Bergmann, viz., that 
 either these honourable gentlemen have " lied inten- 
 tionally," or their solemn statement aforesaid must be 
 received as gospel truth. I at least have no difficulty 
 in deciding which of these alternatives is to be 
 accepted. 
 
 I have not space to follow Professor von Bergmann 
 in his somewhat discursive remarks de omnibus rebus 
 et quibnsdavi aliis. His complaint that I failed to 
 adhere to the arrangement made with my German 
 colleagues has already been answered (pp. 35 and 36). 
 The mystery which he seems to think underlies the 
 fact of Gerhardt not having come to P^ngland in the 
 Crown Prince's suite may of course appear as in- 
 soluble to Bergmann as it does to Gerhardt himself. 
 I cannot profess to be able to dissipate the Cimmerian 
 darkness in which this important matter is involved, 
 but it strikes me as just within the bounds of possi- 
 bility that the Crown Prince may not have cared to 
 be accompanied by a man who had shown himself 
 incompetent, indiscreet, and obstructive. 
 
 Professor von Bergmann's views on the use of the 
 microscope in medicine are of no particular interest 
 to any one but himself. I confess, however, I cannot 
 share the belief which he appears to entertain that his 
 opinion or mine on a question of pathology is as 
 good as that of a specialist in such matters. I may 
 poifit out, however, that Dr. von Bergmann has en- 
 tirely misrepresented the position which I took up 
 at San Remo, as indeed I had maintained from the 
 commencement, viz., that in a case of such im- 
 portance the microscopic examination ought to 
 be made by the leading German pathologist. He
 
 222 The Fatal Illness of Frederick tJie Noble. 
 
 says, ''We could nev^er understand the position of a 
 doctor whose treatment could only be based on the 
 section of an anatomist (microscopist), a position 
 which carried out to its full consequences places the 
 physician behind \hQ post-mortem table!" In other 
 words von Bergmann insinuates that because I ask 
 for a piece of the structure of a doubtful tumour to 
 be examined with the microscope during life^ I am 
 placing myself behind the post-mortem table, Avhich 
 means, if it means anything at all, that I am waiting 
 for the death of the patient in order to discover the 
 nature of his disease. Bergmann's logic appears to 
 be quite as eccentric as his mode of handling trache- 
 otomy tubes. 
 
 The Evidence: Dr. Landgrafs Repoj-t. — I need 
 not waste words on this gentleman's report. The 
 remarks which I have felt obliged to make in the 
 earlier parts of this book as to his mode of making 
 laryngoscopic examinations suffice to show the value 
 which I attach to his "observations." The self- 
 satisfied confidence with which his wonderful state- 
 ments are made would be sublime if it were not 
 ridiculous. Dr. Landgraf may by this time be an 
 excellent laryngoscopist, but it is quite certain that 
 when he was " controlling " me in the summer of 
 1887 he had not learned the rudiments of his art. 
 Hence I am surprised to find that after I had re- 
 moved the growth on June 26th, the young Stabsarzt 
 actually saw that it was no longer there. If he had 
 said that it was twice as large as before, or had moved 
 bodily over to the other side of the lar}-nx, or perched 
 itself on the top of the epiglottis, the discovery 
 would have been more in character. The following 
 extract from Dr. Laridgraf 's diary is a fair specimen 
 of the whole : " I proposed to Dr. Wegner that we 
 should induce His Imperial Highness to give orders 
 that when Dr. Mackenzie made any change in the 
 treatment he should communicate the details and the 
 special reason for it to Dr. Wegner. These details I
 
 The Evidence: Dr. Landgraf's Report. 223 
 
 proposed to take down every time in the form of a 
 protocol. This proposal was declined by the party 
 concerned." * As I was never consulted, I presume 
 " the party concerned " means the Crown Prince. 
 On the 25th June, I find the following interesting 
 entry : " I referred to the importance of repeated 
 examinations for swellings of lymphatic glands, and 
 discussed the chances of thyrotomy {lajyjigofissiir) 
 with one of the highest personages in the august 
 circle." I will not trouble my readers with further 
 extracts from this remarkable document. 
 
 The following little incident, which is related by 
 Dr. Landgraf with the most portentous gravity, is 
 thoroughly characteristic of the man. After he had 
 made an examination of the illustrious patient's 
 throat at Braemar, Mr. Hovell asked him what he 
 saw. I do not know whether Mr. Hovell asked this 
 question merely out of politeness, or whether he 
 wished to ascertain what wonderful discoveries Dr. 
 Landgraf had made. Mr. Hovell has practised 
 laryngoscopy during the last ten or twelve years, and 
 I have never come across a more careful or more 
 accurate obsei*ver. The young Stabsarzt, however, 
 was under the impression that he was a much more 
 skilful laryngoscopist than Mr. Hovell, and expressed 
 his surprise that a gentleman who had had so many 
 opportunities of examining the throat, should ask 
 him for information ! It would indeed be matter for 
 surprise if any one who had ever seen Dr. Landgraf 
 use the laryngoscope should ask him for information. 
 
 The Evidefice : Professor von ScJirotters Report. — 
 There is not much in Professor von Schrotter's report 
 that calls for special notice. There is, however, one 
 important error in his evidence which is very unfair 
 to Professor Krause. The exact words which Krause 
 used in speaking of the diagnosis have already been 
 given (See p. 69) ; instead, however, of quoting these 
 
 * op. at. p. 30.
 
 224 ^/^^ Fatal Illness of Frederick the Noble. 
 
 words, von Schrotter says * that " Krause strongly 
 urged the possibiHty that it might not be a neo- 
 plasm but another disease." This was exactly the 
 position subsequently taken up by Dr. Schmidt 
 (See p. 70), and it cannot be at all satisfac- 
 tory to Professor Krause that language used by 
 Schmidt should be attributed to the wrong person. 
 For some reason not explained, von Schrotter 
 has omitted to explain his change of front as 
 regards the total extirpation of the larynx. He 
 writes, moreover, with a somewhat overwhelming 
 sense of his own importance. The Olympian con- 
 descension with which he speaks of Krause, a 
 laryngologist in every respect his equal except in 
 point of age, as an " industrious young colleague," 
 prepares us for the quasi-celestial wrath with which 
 he seems to have regarded Hovell for daring to 
 express a decided opinion. It does not seem to be 
 admitted as a valid excuse for the English surgeon 
 that his opinion was only 2"iven in reply to a direct 
 question of the Crown Princess. It happened to 
 differ from that enunciated by Professor von Schrotter, 
 and although that oracle himself changed his mind 
 whilst he was at San Remo, Hovell's almost blas- 
 phemous presumption in expressing the opinion 
 ultimately arrived at by von Schrotter has evidently 
 not been forgiven. If I might venture to criticise one 
 of the Viennese Professor's dogmatic utterances, I 
 would ask to be allowed to point out that, if I did 
 not attempt to remove a fragment of the new growth 
 for microscopic examination on this occasion, this was 
 not in the least because he " pronounced categorically 
 against it." The determiiiation not to operate was 
 come to before Professor von Schrotter's arrival, and 
 
 * Op. cit. p. 39. The exact words of our several Reports, 
 deposited in the Archives of the Haus-Ministerium, ought 
 certainly to have been pubHshed in the German pamphlet, the 
 German physicians having had full access to the "sources," 
 though it was absolutely denied to me.
 
 Professor von Schr'otters Report. 225 
 
 was based on the " angry " appearance presented by 
 the larynx, which contra-indicated any manipulation 
 with forceps. 
 
 As Professor von Schrotter's somewhat offensive 
 airs of patronage with regard to Professor Krause 
 might mislead some people as to the relative merits 
 of the two men, I think it right to point out that, 
 although it is true that Professor Krause was at one 
 time a pupil of his, it is no less true the pupil has 
 since shown himself capable of teaching the master. 
 The value of Krause's practical work was publicly 
 testified to by Professor von Schrotter himself at the 
 meeting of German naturalists and physicians in 
 1887, when he declared that whereas he had formerly 
 entirel}^ disbelieved in the possibility of the cure of 
 throat-consumption, he had obtained results which 
 he had never before thought possible, since he had 
 adopted Professor Krause's method of treatment. 
 
 Since the year 188 1 Professor Krause has probably 
 done more for the throat speciality than any living 
 laryngoscopist, and the extent of his investigations 
 has been by no means limited. His articles on 
 Ozaena {Virchows ArcJiiv, 1881) ; his researches on 
 the relation of the cortical substance of the Brain to 
 the Larynx and Pharynx {ArcJiiv filr Physiologie, 
 1883) ; his experimental investigations on the con- 
 traction of the Muscles acting on the Vocal Cords 
 {Virchotu's Archiv, 1884); his work on the use of 
 Lactic Acid in Laryngeal Phthisis {Berlin, klin. 
 Wochenschrift, 1 885) ; his highly suggestive remarks 
 on Functional Disturbances of the Larynx in Diseases 
 of the Central Nervous Sys\:Q^m{Ai'chiv filr Psychiatrie, 
 1886) ; his essays on the Early Symptoms of Lupus 
 and . Tuberculosis of the Pharynx {Berlin, klin. 
 Wochenschrift) ; his philosophical paper on Reflex 
 Nasal Neuroses, and his Experimental Investigations 
 on the Trigeminus {Deutsche vied. Wochenschrift) y 
 have attracted the attention not only of laryngo- 
 scopists, but of all scientific physicians. 
 
 Q
 
 226 The Fatal Illness of Frederick the Noble. 
 
 That in calling in Dr. Krause I had selected the 
 most able representative of the laryngological spe- 
 ciality in Berlin is proved by the fact that the medical 
 advisers of the Emperor William, when they sent 
 another laryngologist to San Remo, did not choose 
 one from Berlin, but summoned a physician from 
 Frankfort. 
 
 I can speak of Professor Krause as a practical 
 physician in the highest terms, having had the 
 advantage of being associated with him for many 
 months. His careful clinical observations, his con- 
 scientious anxiety to do the best for his patient, his 
 gentleness in the sick-room, formed a remarkable 
 contrast to some of his German colleagues, and I 
 shall always feel indebted to him for his valuable 
 co-operation under most trying circumstances. I am 
 happy to be able to say that the Emperor thanked 
 me on more than one occasion for having recom- 
 mended Professor Krause to him. 
 
 Tlie Evidetice : Dr. Moritz Schmidt's Report. — This 
 document is of no scientific value, for it is based 
 on the mythical observations of Landgraf, and has 
 not even the merit of being a truthful report of what 
 took place at San Remo v;hilst Dr. IMoritz Schmidt 
 was there. At the urgent desire of Dr. Schmidt, 
 Professor von Schrotter and I agreed that large 
 doses of iodide of potassium should be administered, 
 the ground for the use of this medicine being 
 Dr. Schmidt's theory that the Crown Prince was 
 suffering from a chronic contagious disease. Never- 
 theless Dr. Moritz Schmidt after his visit to Berlht 
 and his conference with zwn BergniaJin, had the audacity 
 to say that, " considering the gradual development of 
 the disease since the loth March, the age of the patient, 
 and the laryngoscopic appearances, I could only regard 
 the malady as one of perichondritis developed through 
 carcinoma." * The man who at San Remo strongly 
 urged that the disease might be of an enthetic char- 
 * op. cit. p. 45.
 
 Dr. Schmidt's Report. 227 
 
 acter, after his journey to Berlin could only regard it as 
 quite a different complaint ! As if, however, to prove 
 that he knew nothing whatever about cancer of the 
 larynx, Dr. Schmidt has gone out of his way to say that 
 " the course of the disease from the beginning to the 
 end appears to have been a usual and typical one." * 
 Now everyone knows that the disease ran a most 
 exceptional course. Even if the separation of sloughs 
 and the complete healing of the resulting ulcers were 
 not very unusual features, the destruction of the 
 whole of the larynx, with the exception of a portion 
 of the epiglottis, is a thing absolutely unknown in 
 medical literature. I challenge Dr. Moritz Schmidt 
 to produce a single recorded case in which the post 
 mortem appearances were the same as those described 
 by Virchow on the i6th of June, 1888. 
 
 The Evidence : Reports of Professors Kussmaid^ 
 Waldeyer, and Bardeleben. — These call for no com- 
 ment as they contain no controversial matter. Pro- 
 fessor Kussmaul's report confirms my statement that 
 the only use of his visit to San Remo was to disabuse 
 Bergmann's mind of an idee fixe which possessed him 
 that cancer of the larynx is always complicated by 
 cancer of the lungs. Professor Waldeyer's report 
 embodies the results of the careful microscopical 
 examinations which led him to pronounce the disease 
 to be cancer. Professor Bardeleben's notes are little 
 more than a diary of the clinical events whilst he 
 was in attendance. 
 
 The Evidence ; Dr. Bramann's Report. — Dr. 
 Bramann does not seem to have been allowed 
 to write a separate report, but his observations and 
 experiences are apparently contained in communica- 
 tions to Professor von Bergmann. The principal 
 object of his letters appears to be to set himself 
 right with that surgeon, and to show that he was 
 obliged to operate before he arrived. At the time 
 of my visits to San Remo, I was not aware that Dr. 
 * Op. cit. p. 41. 
 
 Q 2
 
 228 The Fatal Illness of Frederick the Noble. 
 
 Bramann was labouring under the misconception that 
 he had come to San Remo to act as a consultant with 
 me. I thought that he knew that he was staying 
 there solely as von Bergmann's assistant to do tra- 
 cheotomy if that surgeon could not arrive in time. 
 When a physician is treating a case of laryngeal 
 disease accompanied by dyspnoea, and when he 
 does not intend to perform tracheotomy himself, 
 he sends for the surgeon when he thinks the time 
 has arrived or is nearly approaching for opening 
 the windpipe. Of course the surgeon has a perfect 
 right to refuse to do the operation if he thinks 
 that it is unnecessary. Thereupon the physician 
 either yields to the views of the surgeon or calls in 
 another operator. The position which von Berg- 
 mann's assistant has taken up, appears to be that 
 when a physician is treating a case a surgeon is to 
 be called every day or every other day to inform 
 the physician when he considers it is necessary to 
 open the windpipe. Such an attitude is entirely 
 novel, and in practice would be attended with diffi- 
 culties which need not be discussed here. According 
 to Dr. Bramann's own statement, he received much 
 of his knowledge regarding the state of the Crown 
 Prince from the equerries in His Imperial Highness's 
 suite. Dr. Bramann had the privilege of meeting 
 these officers at a ''Grog," which was held every 
 evening at nine o'clock in the Reading Room of the 
 Hotel Mediterranee. As the " cHnical observations " 
 of these military gentlemen appear to have been the 
 basis on which Dr. Bramann has founded a large 
 portion of his reports to Berlin, it is unnecessary to 
 refer any further to his statements.
 
 Conclusive Statistics. 229 
 
 SECTION III.— STATISTICAL. 
 
 CHAPTER XIII. 
 
 RESULTS OF RECORDED OPERATIONS. 
 
 Statistics sometimes illusive, but not in this instance. 
 — The paradox that "there is only one thing more 
 misleading than facts, and that is figures," is accepted 
 by many, and no doubt it has a certain amount of 
 truth for its basis. Facts can sometimes be so dis- 
 torted, and figures so manipulated, that very mis- 
 leading conclusions may be obtained. Fallacies are 
 very likely to creep in in dealing with large masses of 
 figures, especially when the problems are compli- 
 cated. Again, statistics are often collected by persons 
 whose competence to make the necessary observations 
 on which those statistics are based is by no means 
 assured. Hence, under certain circumstances, it is 
 obvious that the accumulations of cases, instead of 
 facilitating comparison, may render more obscure the 
 questions which they are intended to elucidate. 
 
 None of these objections, however, is applicable to 
 the Tables which are now brought under notice. 
 The questions at issue are simple : viz. the dura- 
 tion of life after different kinds of operations on 
 the larynx ; the reporters (in most cases the surgeons 
 who have themselves performed the operations) are 
 competent. There are only two sources of fallacy ; 
 one, that whilst surgeons nearly always report their 
 successful cases, they do not invariably record those 
 which terminate in death a few hours after an opera-
 
 230 The Fatal Illness of Frederick the Noble. 
 
 tion. Hence statistics of operations generally show 
 more favourable results than the real facts justify. 
 The other source of fallacy lies in the difficulty of 
 making an absolutely correct diagnosis even with 
 the aid of the microscope. In the recent German 
 pamphlet, Professor von Bergmann (page 22) has 
 attempted to ridicule the microscope as an aid to 
 accurate diagnosis, or, indeed, as furnishing a mode 
 of investigation which can in any way determine the 
 kind of treatment to be adopted. Although this line 
 of argument has been pushed to an absurd extreme, 
 it is possible that the microscope does not always 
 afford an absolute proof of the nature of the disease, 
 even when the entire growth is submitted to examina- 
 tion ; and it is to be feared that in some cases patients 
 have been inadvertently subjected to needless mutila- 
 tion through the removal of a part or the whole of a 
 larynx on account of the presence of growths which 
 were not really malignant. I myself know of two cases 
 in which surgeons removed the entire larynx without 
 even taking the precaution to ascertain the nature of 
 the disease by previously removing a portion endo- 
 laryngeally, and in both these cases the extirpated 
 larynx was found to be free from malignant disease ! 
 
 To make these Tables still more valuable there 
 ought to be a fourth one, showing the duration of life 
 of patients who have been affected with cancer of the 
 larynx, and who have not had any radical operation 
 performed on them. Tracheotomy performed for 
 cancer has not hitherto been considered a sufficiently 
 interesting operation to be placed systematically on 
 record, and the poor patient who gradually declines 
 without any operation is also not considered to 
 possess interest enough to have his case reported. 
 Hence cases of cancer which have merely under- 
 gone tracheotomy, or have died without surgical 
 treatment of any kind, do not generally appear in 
 medical literature. The point at issue is : Does an 
 external operation, and especially thyrotomy {laryjigo-
 
 Conchisive Statistics. 231 
 
 fissiir) afford a reasonable prospect of effecting a cure, 
 or of extending the duration of life for a longer 
 period than leaving the patient alone until tracheo- 
 tomy becomes necessary, if indeed tracheotomy should 
 be required ? And in considering the question of 
 radical operations, it is important to bear in mind, as 
 just remarked, that, in many cases of cancer of the 
 larynx, even tracheotomy can be dispensed with. 
 The patient gradually gets weaker as the disease 
 advances, and a large number of patients die without 
 the necessity for tracheotomy arising. It need 
 scarcely be pointed out that if this operation can be 
 avoided, the euthanasia is greatly promoted. Hence in 
 considering the question of performing the various more 
 or less dangerous radical operations, it must not be 
 considered that the comparison is invariably to be 
 made between one of these operations and a late 
 tracheotomy. The question really is, in many cases, 
 between a radical operation and no operation at all. 
 
 In dealing with the particular case under considera- 
 tion, the main discussion must take place in con- 
 nection with the question of thyrotomy, as that 
 is the operation which von Bergmann alleges he 
 intended to perform. In the published cases (see 
 Table I, p. 234) in which thyrotomy was performed 
 for cancer, the immediate mortality has hitherto 
 been 27*2 per cent. The recurrence has been at 
 the rate of 54*54 per cent, in those cases where 
 the patient survived the operation, but if four of 
 the immediately fatal cases had lived for a few 
 months and the recurrence had been in the same 
 proportion in these cases as in the others, the rate of 
 recurrence would have been nearly 70 per cent. It 
 should be mentioned also that in several of the 
 cases where the patients lived for a few months, 
 they had to wear a tracheotomy tube from the day 
 of the operation to the day of their death ; they 
 were, therefore, in a much worse condition than if 
 tracheotomy had been postponed to a late period of
 
 2^2 The Patal Illness of Prederick the Noble. 
 
 the disease. Only those who have witnessed all the 
 attendant discomforts of tracheotomy can realize what 
 this means. A canula worn on account of a stenotic 
 cicatrix is of comparatively little inconvenience, but 
 a tube worn where there is a broken down malig- 
 nant growth in the larynx is often very distressing. 
 In considering the question of thyrotomy, it must not 
 be forgotten also that if the operation is not successful, 
 and only two cases have ever been reported in which the 
 operation has been successful (viz. cases lo and 17, 
 Table I.), the disease is aggravated by the operation, 
 more rapid development takes place, and the patient 
 dies much sooner than if no operation had been done. 
 It will be seen, therefore, that by thyrotomy, not only 
 are a certain number of patients killed directly by the 
 operation, but in nearly every case life is considerably 
 shortened by that operation, whilst the conditions 
 of existence during that shorter period of remaining 
 life are much less pleasant to the patient than if 
 no operation had been done. Against this we have 
 the chance of a cure. But what a chance I it is said 
 that the prospects of recovery are almost 10 per cent., 
 because out of twenty-two recorded cases two patients 
 recovered, but there is every probability that if the 
 twenty-two cases were made up to one hundred 
 by further operations, no other cures would be 
 found. 
 
 In considering the question of success^ no patient 
 suffering from malignant disease can be considered 
 cicred unless tJie patient lives at least two years * after 
 tJie operation, because that is the length of time a 
 patient may expect to live without an operation. But 
 such is the fell nature of cancer, that it often returns 
 even after two years, and some of the highest living 
 authorities go so far as to say that if the disease does 
 not come back it proves that it was not cancer for 
 which the operation was done. 
 
 * Three years is now the time accepted by surgeons in 
 dealing with cancer of the tongue.
 
 Conclusive Statistics. 233 
 
 The advantages and disadvantages of each method 
 may be put in parallel columns : — 
 
 Palliative Treatment Radical Treatment 
 
 (including tracheotomy). (Thyrotomy). 
 
 Life is preserved under Life is sacrificed at once as 
 
 almost normal conditions for the ^result of the operation in 
 at least one year; and in a 27 "2 per cent, of cases; whilst 
 less favourable state for at in over 54* 54 per cent, death is 
 least one year longer, i.e. alto- hastened owing to the greater 
 gether for two years. activity of the morbid process 
 
 set up by the operation ; and 
 in these cases the condition 
 of existence is rendered less 
 favourable by the premature 
 use of a tracheotomy tube, 
 necessitated by unsuccessful 
 thyrotomy. A complete cure 
 has twice been obtained. These 
 cases are No. 10 and No. 17, 
 Table I. 
 
 A few remarks are necessary in connection with the 
 following Tables, which are based on my own (' Brit. 
 Med. Journal,' April 26th, and May 3rd, 1873), those 
 of Norris Wolfenden ('Journal of Laryngology,' vol. i., 
 December, 1887; vol. ii., January and May, 1888), 
 Hahn (' Berliner Klinische Wochenschrift,' No. 44, 
 p. 919, 1887), and Scheier (' Deutsche Med. Wochen- 
 schrift,' 7th June, 1888). I have included the follow- 
 ing six cases of Billroth which Scheier seems to have 
 overlooked, viz., four cases of thyrotomy, Table I, 
 Nos. 6, 8, 9, and 10, and two cases of total extirpa- 
 tion, Table III, Nos. 21 and 24 (* Archiv. fur Klinische 
 Chirurgie,' vol. xxxi., p. 848). I have also added one 
 case reported by Studenski of Kasan (Russia) (* Cen- 
 tralblatt fiir Laryngologie,' June, 1885, p. 398), two 
 cases reported by Dr. Baratoux {Progrh MMical, 
 1888), and five cases supplied to me by Dr. Pelechin, 
 Professor of Surgery at the Imperial Academy 
 (Petersburg). 
 
 My Table was originally published fifteen years 
 ago to show the results of thyrotomy in cases of
 
 234 TJi^ Fatal Ilbiess of Frederick the Noble. 
 
 growth in the larynx, whether malignant or benign. 
 In the present summary, however, of course the benign 
 cases have been excluded. In the same way from 
 Hahn's and Scheier's Tables, all cases of benign 
 disease, cicatrices, &c., have also been omitted. 
 
 TABLE I.— THYROTOMY {Laryngofissiir). 
 
 The operation Professor Bergmaim says he intended to per- 
 forin, — This Table refers to the operation which von 
 Bergmann says {op. cit., p. 19) he intended to perform, 
 and which he affirms (p. 21) " does not threaten life." 
 
 
 Operator. 
 
 |5. 
 
 
 Disease. 
 
 Subsequent History. 
 
 I Gordon Buck . 
 
 SI 
 
 I85I 
 
 Carcinoma 
 
 Death, in 15 months, a second 
 operation having been necessary. 
 
 2 Sands 
 
 30 
 
 1855 
 
 
 Death from recurrence 22 
 months after operation. 
 
 3 Gibb and Holt- 
 
 29 
 
 1864 
 
 " 
 
 Death in i year, recvurence 
 
 1 basse. 
 
 
 
 
 ha%'ing taken place at 4th month. 
 
 4 Schrtjtter 
 
 1 
 
 63 
 
 1869 
 
 
 Death in 11 days of erisypelas 
 and gangrene, growth not ex- 
 tirpated. 
 
 Death in 7 months, recurrence in 
 
 5 i Mackenzie and 
 
 47 
 
 1869 
 
 " 
 
 
 Wordsworth. 
 
 
 
 
 2 months. 
 
 6 
 
 BiUroth . 
 
 56 
 
 1870 
 
 Epithelioma? 
 
 Death on 7th day ; diagnosis 
 corrected post mortem as laryn- 
 geal tuberculosis. 
 
 7 
 
 Mackenzie and 
 Thornton. 
 
 24 
 
 1872 
 
 Carcinoma 
 
 Death in 7 months, recurrence in 
 
 4 months. 
 
 8 , Billroth . 
 
 36 
 
 1874 
 
 ^, 
 
 Death in 8 months. Recur- 
 
 
 
 
 
 
 rence took place in i month 
 when total extirpation was per- 
 formed. See Table III., No. i. 
 
 9 I Billroth . 
 
 26 
 
 1880 
 
 ,, 
 
 Death from haemorrhage on 13th 
 
 
 
 
 
 
 day, total extirpation having 
 
 
 
 
 
 
 been done on 3rd day for Ee- 
 
 
 
 
 
 
 currence. See Table III., 
 
 ' 
 
 
 
 
 No. 24. 
 
 10 Billroth . 
 
 45 
 
 I88I 
 
 Carcinoma 
 
 CURE. ^^^eU 3 years after. 
 
 u Studenski.Kasan 
 
 56 
 
 1883 
 
 i> 
 
 Death 8 months aftenvards. 
 
 ( Reporter). 
 
 
 
 
 
 12 Solis-Cohen . 
 
 63 
 
 1884 
 
 Epithelioma 
 
 Death in 19 months, recurrence 
 in 3 months. 
 
 13 1 Hahn 
 
 SI 
 
 1884 
 
 Carcinoma 
 
 Death by suicide ; the patient 
 
 
 
 
 
 
 hanged himself in despair when 
 
 
 
 . 
 
 
 
 recurrence took place.
 
 operation Bergmann intended to perforin. 235 
 
 Table I. — continued. 
 
 -»! 
 
 Operator. 
 
 
 si 
 
 *j a, 
 
 Disease. 
 
 Subsequent History. 
 
 12; 
 
 
 .a: 
 
 QC< 
 
 
 
 14 
 
 Billroth . 
 
 66 
 
 1885 
 
 .. 
 
 Death. 18 hours after operation 
 of oedema of the lungs. 
 
 15 
 
 BiUroth . 
 
 40 
 
 1885 
 
 " 
 
 Death 10 days after operation of 
 
 pyaemia. 
 
 16 
 
 Billroth . 
 
 63 
 
 1B85 
 
 " 
 
 *Eecurreiice in 13 months, date 
 of death not given. Total ex- 
 tirpation declined. 
 
 17 
 
 Billroth . 
 
 41 
 
 1885 
 
 Epithelioma 
 
 CURE. No recurrence 2 years 
 and 9 months after operation. 
 
 i8t 
 
 Salzer . 
 
 41 
 
 1885 
 
 Carcinoma 
 
 No recurrence in 3 weeks. 
 
 19 
 
 Hahn . 
 
 S7 
 
 1886 
 
 ,, 
 
 Recurrence in 5 weeks. 
 
 20 
 
 Cohn 
 
 37 
 
 1887 
 
 " 
 
 Recurrence in 3 months in 
 same site. 
 
 2lt 
 
 Stewart . 
 
 4^ 
 
 1887 
 
 Epithelioma 
 
 No recurrence in 4 weeks. 
 
 22 
 
 Hahn . 
 
 64 
 
 1888 
 
 Carcinoma 
 
 Death on nth day after opera- 
 tion, attributed to heart failure. 
 
 * The disease being cancer all cases of rcciirrence might be entered as death 
 (with or without a second operation). 
 
 \ Except as showing that the operation was not immediately fatal, tliese two 
 cases have no statistical value. 
 
 ANALYSIS OF TABLE I. 
 
 Death it will be seen took place in six cases as the 
 immediate * result of the operation, in one instance 
 ia 18 hours, in one in 7 days, in another in 10 days, 
 in two instances in 11 days, and in one in 13 days. 
 The immediate mortality was therefore 6 in 
 22 cases, or 27 '2 per cent. In the remaining 
 cases the operation was successful twice. Five 
 patients died within the year, whilst 3 lived respec- 
 tively 15 months, 19 months, and 22 months. In 
 three cases the patient had to submit to a second 
 operation ! 
 
 * Deaths occurring within six weeks of the operation are con- 
 sidered as due to the operation itself, and are therefore called 
 immediate. Such cases, however, it will be seen, usually termi- 
 nated much more quickly.
 
 236 The Fatal Illness of Frederick tJie Noble. 
 
 Recurrence is known to have taken place in 
 12 cases out of 22, or 54-54 per cent, more than half 
 the cases ; but if we allow for the same rate of recur- 
 rence in the cases which terminated immediately in 
 death as in those which sur\'ived for a short time, the 
 rate of recurrence would be nearly 70 per cent, or if, 
 as is probable, recurrence took place in Studenski's 
 case, the rate would have been almost 74 per cent. 
 
 Success took place in 2 out of 22 cases, or, in 
 other words, in 9*09 per cent These are the only 
 successful cases which are known to have 
 followed the operation of thyrotomy. As 
 already remarked (p. 232), there is every reason to 
 believe that if the 22 cases were made up to 100 by 
 further operations no additional cures would result. 
 The percentage of cures would be only 2, represented 
 
 by the two successful cases which have ever 
 occurred. 
 
 TABLE IL— PARTIAL EXTIRPATION OF 
 THE LARYNX. 
 
 A less tnifav our able operatioiL — This is the operation which, 
 bearing in mind Prof von Bergmann's admission {Op. cit. 
 p. 23), he would probably have found it necessary to 
 perform. 
 
 1 
 
 1 
 
 _j 
 
 Mi\ 
 
 
 ^i 
 
 Operator. 
 
 '^■'z 
 
 ^ 
 
 lU 
 
 Disease. 
 
 Subsequent History. 
 
 -/ 
 
 
 tx.'-' 
 
 < 
 
 a-o 
 
 
 
 I Billroth . 
 
 i 
 
 50 
 
 1878 
 
 Epithelioma 
 
 Death in 16 months, recurrence 
 took place in 6 months. 
 
 2 i Reyher . 
 
 57 1880 Carcinoma 
 
 No relapse in 14 months. 
 
 3 1 Billroth . 
 
 65 ; 1881 
 
 Carcinoma 
 
 Death 5 weeks after operation. 
 
 
 
 
 
 Sepsis. 
 
 4 Schede . 
 
 42 
 
 1882 
 
 Epithelioma 
 
 Still n\ing 17 months after. 
 
 5 1 Skliffkowski . 
 
 47 
 
 1882 Carcinoma? *Recurrenee in 3 months. 
 
 6 1 Wagner . 
 
 53 
 
 1883 ,, 1 Death on 1 2th day after operation. 
 
 * The disease being cancer all cases of reciirrence might be entered as death 
 (with or without a second operation).
 
 A less tuifavoiLrable operation. 
 
 237 
 
 Table II. — continued. 
 
 1 
 
 'o « Operator. 
 
 
 eof 
 
 eration 
 
 Report. 
 
 p 
 
 Subsequent History. 
 
 1"' 
 
 <; 
 
 ^oS 
 
 
 7 j Hahn 
 
 54 
 
 1883 Carcinoma 
 
 Death in 16 months after second 
 operation rendered necessary by 
 recurrence. 
 
 8 Billroth . 
 
 60 
 
 1883 Epithelioma 
 
 Death in 5 weeks after operation. 
 
 9 i Billroth . 
 
 60 
 
 1884 Carcinoma 
 
 Alive 3 months after, but obliged 
 
 ! 
 
 
 
 
 to wear canula. 
 
 10 Billroth . 
 
 58 
 
 1884 
 
 ,, 
 
 Death, recurrence having taken 
 
 
 
 
 
 
 place in 7 weeks afterwards in- 
 
 
 
 
 
 
 vading glands. 
 
 11 
 
 Billroth . 
 
 46 
 
 1884 
 
 ,, * Reported cured in 6 weeks. 
 
 12 
 
 Hahn . 
 
 53 1884 
 
 ,, 
 
 Death in 4 days of pneumonia or 
 
 
 
 
 
 
 mediastinitis. 
 
 13 
 
 Stoerk . 
 
 — 
 
 1885 
 
 Epithelioma 
 
 Alive in Nov. 1887. 
 
 14 1 Bergmann 
 
 46 
 
 1885 
 
 Carcinoma 
 
 Alive in 1886. 
 
 15 Billroth . 
 
 
 1885 ,, 1 Result unkno^\•n, 
 
 16 Salzer 
 
 65 
 
 1885 ,, 1 Death in 5^ weeks of pyaemia. 
 
 17 i Salzer 
 
 60 
 
 1885 ,, 1 Death in 6 weeks of pneumonia. 
 
 18 ; Salzer . 
 
 58 
 
 1885 
 
 ,_ 
 
 Recurrence in 7 weeks. 
 
 19 Salzer . 
 
 41 
 
 — 
 
 EpitheUoma 
 
 Recurrence in 2 months. 
 
 20 Pick 
 
 
 1886 
 
 Carcinoma 
 
 Death in 10 weeks after operation. 
 
 21 1 Socin 
 
 56 
 
 1886 
 
 " 
 
 Death in 13 weeks, a second 
 operation became necessary 3 
 weeks before death. 
 
 22 Hahn . 
 
 68 
 
 1886 
 
 ,, 
 
 Death on nth day. 
 
 23 Hahn 
 
 52 
 
 1886 { Epithelioma 
 
 Cure. 
 
 24 Butlin . 
 
 50 
 
 1886 ; 
 
 Living 5 months afterwards. 
 
 25 Lennox Browne 
 
 61 
 
 1886 
 
 Death in 13 months. 
 
 26 1 Kraske . 
 
 — 
 
 — 1 Carcinoma 
 
 Recurrence in 16 months. 
 
 27 1 Kraske . 
 
 — 
 
 — 1 •• 
 
 Recurrence in 4 months. 
 
 28 1 Mickulicz 
 
 — 
 
 — ! .. 
 
 Living a year after operation. 
 
 29 i Pe'an 
 
 53 
 
 1887 Epithelioma 
 
 JDeath on 15th day of strangulated 
 
 
 
 
 
 hernia. Recurrence had taken 
 
 
 
 
 
 I 
 
 place. 
 
 30 
 
 Hahn . 
 
 43 
 
 1887 
 
 ,, 
 
 Death on 15th day. 
 
 31 
 
 Simanowski 
 
 
 — 
 
 Carcinoma 
 
 Living one year afterwards. 
 
 3-2 
 
 Hahn . 
 
 36 
 
 1887' 
 
 ,, 
 
 N recurrence in 5 weeks. 
 
 33 
 
 Rush ton Parker 
 
 39 
 
 1887 
 
 Epithelioma 
 
 Death 4 months afterwards. 
 
 34 
 
 Multanowski . 
 
 47 
 
 1882 
 
 Carcinoma 
 
 Recurrence in 3 months. 
 
 35 
 
 Hahn . 
 
 42 
 
 Feb. 
 1888 
 
 
 ^Subsequent tracheotomy ; glands 
 much enlarged. 
 
 * " Cured in 6 weeks " has no meaning except that the patient was not killed by the 
 operation. 
 
 t Although this patient died fifteen days after the operation it is not included 
 among the deaths immediately resulting from this procedure. At the same time it 
 is by no means uncertain that the coughing following the operation was not the 
 real cause of the hernia becoming strangulated. 
 
 + Personal information from Berlin correspondent, 28th July, 1888,
 
 238 The Fatal Illness of Frederick tJie Noble, 
 
 ANALYSIS OF TABLE II. 
 
 This Table shows that of thirty-five operations 
 fifteen proved fatal, that is 42*85 per cent. 
 
 Death, it will be seen, took place as the immediate 
 result of the operation in eight cases, in one instance 
 on the fourth day, in one on the eleventh day, in 
 another on the twelfth day, in one on the fifteenth 
 day, twice in five weeks, in one case in five and a 
 half weeks, and in one in six weeks. The imme- 
 diate mortality was therefore 8 in 35 cases, 
 or 22"85 per cent. In the remaining cases, where 
 death had occurred at the time the report was 
 published, the fatal issue took place : once in 7 weeks, 
 once in 10 weeks, once in 13 weeks, once in 4 months, 
 once in 13 months, and twice at the end of 16 months. 
 In the remaining cases no details are given, or the 
 patients were living at the time the report was issued. 
 One patient, as seen below, has lived 2 years. 
 
 Recurrence is only reported to have taken place 
 in nine cases, but there is no information in many of 
 the cases on this point. One case (No. 4) is described 
 as still living ; in another (No. 10) the patient was 
 still "obliged to wear the canula," showing either 
 that there was incomplete removal of the growth at 
 the time of the operation, or that immediate re- 
 currence took place. Another case is reported as 
 cured at the end of 6 weeks, which merely means 
 that the patient did not die from the immediate 
 effects of the operation. In another case (No. 15) 
 the result is " unknown ;" in fact, in this Table the 
 actual rate of recurrence cannot be determined. It is 
 probable, however, that recurrence does not take place 
 nearly so frequently after this operation as in the 
 case of thyrotomy, because partial extirpation affords 
 much more favourable conditions for removing the 
 entire growth than is obtained by simple thyrotomy. 
 
 Respecting Case No. 35, I heard on July 28th, 1888, 
 from a Berlin correspondent, that the patient operated
 
 Total Extirpation of Larynx. 
 
 239 
 
 on by Dr. Hahn in February was readmitted to hospital 
 on April 7th with great dyspnoea. Tracheotomy had 
 to be performed. The glands on both sides of the 
 neck were said to be much swollen. 
 
 Success* occurred in one case (No. 23) out of 
 35 cases, or 2*85 per cent. This operation will pro- 
 bably be found to be much more successful than 
 simple thyrotomy for the reasons just stated in 
 dealing with the subject of recurrence. 
 
 TABLE III.— TOTAL EXTIRPATION OF THE 
 LARYNX. 
 
 An operation which, ivhen not immediately fatal, leaves the 
 patient in a state of abject misery. This is one of the 
 operations brought under the consideration of the Crown 
 Prince in November 1887. 
 
 
 Operator. 
 
 Billroth 
 
 Heine 
 
 Maas 
 
 Schmidt . 
 P. H. Watson 
 Schontorn 
 Von Langen- 
 
 beck. 
 Multanowski . 
 Multanowski . 
 
 Billroth . 
 Maas 
 
 13 Gerdes 
 13 Reyher 
 
 ^1 
 
 c -^ 
 
 Q 
 
 36 
 
 1873 
 
 so 
 
 1874 
 
 57 
 
 1874 
 
 56 
 60 
 
 72 
 57 
 
 1874 
 1874 
 1875 
 1875 
 
 59 
 47 
 
 1875 
 1875 
 
 54 
 50 
 
 1875 
 1876 
 
 76 
 60 
 
 1876 
 1876 
 
 Disease. 
 
 Carcinoma 
 (Recurrent) 
 
 Epithelioma 
 Carcinoma 
 
 Epithelioma 
 Carcinoma 
 
 Subsequent History. 
 
 Death, in 7 months ; recurrence 
 took place in i month. See 
 Table I, No. S. 
 
 Death 6 months after from re- 
 currence. 
 
 Death 13 days after op. pneu- 
 monia. 
 
 Death on 4th day ; collapse. 
 
 Death in 2 weeks ; pneumonia. 
 
 Death on 4th day. 
 
 Death by collapse ; recurrence in 
 4 months. 
 
 Death in 3 months ; pneumonia. 
 
 Death, with recurrence in 2 
 months. 
 
 Death on 4th day ; pneumonia. 
 
 Death in 6 months from recur- 
 rence. 
 
 Death in 4 days ; collapse. 
 
 Death on nth day ; pneumonia. 
 
 * As already remarked (p. 232), by Success is meant the survival for 
 over 2 years.
 
 240 The Fatal Illness of Frederick the Noble. 
 
 Table III— continued. 
 
 •si 
 
 i 
 Operator. 
 
 ^.| SS.-^i Disease. 
 
 Subsequent History. 
 
 6CJ 
 
 
 M3^ rtOS 
 
 
 ;z; 
 
 
 < ' 
 
 « i 1 
 
 
 14 ' Watson . 
 
 60 
 
 1B76 
 
 Epithelioma Death in 7 days. 
 
 15 
 
 Kosinski 
 
 36 
 
 1877 
 
 ,, . Death in 9 months ; pneumonia. 
 
 16 
 
 Wegner . 
 
 52 
 
 1877 
 
 1 No recurrence in 8 months. 
 
 17 
 
 Landerer 
 
 45 
 
 
 Carcinoma j Death 4 months after recurrence 
 1 and secondary deposits. 
 
 18 
 
 Bottini . . ■ 
 
 48 
 
 1877 
 
 Epithelioma Death 3rd day ; pneumonia. 
 
 19 
 
 Von Bruns 
 
 54 
 
 1878 
 
 ,, Death 9 months after recurrence. 
 
 20 
 
 Billroth . . : 
 
 43 
 
 1879 
 
 ,, 
 
 Death 7 weeks after. 
 
 21 
 
 Billroth . 
 
 60 
 
 1879 
 
 Carcinoma 
 
 Death 3rd day ; pneumonia. 
 
 22 
 
 Macewen 
 
 56 
 
 1879 
 
 t 
 
 Death 3 days after ; pneumonia. 
 
 23 
 
 Von Langen- 
 
 beck 
 Billroth . . ' 
 
 78 
 
 1879 
 
 
 Death in 3 days ; collapse. 
 
 24 
 
 26 1880 
 
 ,, 
 
 Death from haemorrhage on 9th 
 
 
 
 i 
 
 (Recurrent) 
 
 day. See Table I, No. 9. 
 
 25 Multanowski . \ 
 
 60 1 1879 
 
 ,, 
 
 Death in 5 days ; pneumonia. 
 
 26 1 Reyher . 
 
 48 
 
 1880 
 
 ,, 
 
 Death on 7th day ; pneumonia. 
 
 27 
 
 Thiersch 
 
 1 
 
 36 
 
 1880 
 
 " 
 
 Death in 18 months, after second 
 operation for recurrence. 
 
 28 
 
 Thiersch 
 
 52 1880 
 
 
 C CJRE. Was living 3^ years after. 
 
 29 j Czerny . 
 
 47 1 1880 1 Epithelioma 
 
 Death in 5 months ; recurrence. 
 
 30 1 Thiersch 
 
 45 1880 1 Carcinoma 
 
 Death 19 weeks after operation. 
 
 31 \ Hahn 
 
 68 
 
 1880 ? Cancroid 
 
 No recurrence 11 months after. 
 
 32 Bohmer . 
 
 — 
 
 — 
 
 Carcinoma 
 
 Death in 12 hours ; oedema of 
 
 lungs. 
 Death in 4 days ; pneumonia 
 
 33 Hahn 
 
 53 
 
 
 
 „ 
 
 
 
 
 
 and mediastinitis from pushing 
 
 
 
 
 
 canula into mediastinum. 
 
 34 Bircher . 
 
 49 
 
 1880 
 
 
 Death in 16 days of pneumonia. 
 
 35 ' Hahn 
 
 68 
 
 1880 
 
 Carcinoma j CURE. No recurrence in 1888. 
 
 36 ; Hahn . 
 
 46 
 
 1881 
 
 ,, Death on 25th day ; gangrene 
 
 1 of lungs. 
 
 37 
 
 Tore 
 
 — 
 
 1881 
 
 Epithelioma Death in 4 days ; pneumonia. 
 
 38 
 
 Pick 
 
 39 
 
 1881 
 
 " 
 
 Death on 5th day ; pleuro-peri- 
 
 carditis. 
 
 39 
 
 Thiersch 
 
 57 
 
 1881 
 
 Carcinoma 
 
 Death 7th day ; pneumonia. 
 
 40 
 
 Winiwarter 
 
 55 
 
 1881 
 
 
 CURE. Patient well in 1884, 
 35 years after. 
 
 41 
 
 Czerny . 
 
 47 
 
 1881 
 
 Epithelioma 
 
 Death 10 months after from 
 recurrence. 
 
 42 
 
 Reyher . 
 
 57 
 
 1881 
 
 1? Carcinoma 
 
 Death Sth day ; pneumonia. 
 
 43 
 
 Kocher . 
 
 59 
 
 i88i 
 
 ? 
 
 Death in 2 years from cancer of 
 abdomen. 
 
 44 
 
 Tilanus . 
 
 51 
 
 i88r 
 
 Epithelioma. 
 
 Death in 36 hours ; collapse. 
 
 45 
 
 Gussenbauer . 
 
 48 
 
 1881 
 
 ,, 
 
 CURE. Living in 1886. 
 
 46 
 
 Voelker . 
 
 44 
 
 1881 
 
 Carcinoma 
 
 Death in 5 months from recur- 
 
 47 
 
 Albert . 
 
 45 
 
 1881 
 
 1 
 
 rence. 
 D eath 8th day ; pneumonia.
 
 Total Extirpation of Larynx. 
 
 241 
 
 
 
 Table \\\— continued. 
 
 ^i 
 
 Operator. 
 
 
 eof 
 
 peration 
 Report. 
 
 Disease. 
 
 Subsequent History. 
 
 dCJ 
 
 
 ^^ 
 
 rtOS 
 
 ^ 
 
 
 < 
 
 » 1 
 
 48 
 
 Hahn . 
 
 46 
 
 1 88 1 Carcinoma 
 
 Death 25th day ; bronchitis. 
 
 49 
 
 Marjary . 
 
 36 
 
 1881 
 
 Recurrence in 3 months. 
 
 SO 
 
 Gussenbauer . 
 
 62 
 
 1881 
 
 Epithelioma 
 
 No recurrence in 14 months. 
 
 51 
 
 Gussenbauer . 
 
 63 
 
 1881 
 
 Carcinoma 
 
 Recurrence in 6 months. 
 
 52 
 
 Reyher . 
 
 73 
 
 1881 
 
 ,, 
 
 Death 9 months after recurrence. 
 
 S3 
 
 Novaro . 
 
 63 
 
 1881 
 
 Epithelioma 
 
 Death 5 months after second 
 operation ; recurrence took place 
 in 4 months. 
 
 54 
 
 Schede . 
 
 54 
 
 1881 
 
 Carcinoma 
 
 Death by suicide at 7th month, 
 recurrence having taken place. 
 
 55 
 
 Chiarella 
 
 41 
 
 i88i 
 
 ,, 
 
 Recurrence in 4 months. 
 
 56 
 
 Maurer . 
 
 47 
 
 1882 
 
 .• 
 
 Death 5 months after from recur- 
 
 57 
 
 Hahn . 
 
 43 
 
 
 
 Epithelioma 
 
 rence. 
 Death 14 months after ; second- 
 
 
 
 
 
 j ary operations for recurrence 
 
 
 
 
 
 1 had to be done. 
 
 58 
 
 Schede . 
 
 54 
 
 1882 
 
 Cancroid 1 Death by suicide in 8| months, 
 
 on recurrence. 
 
 59 
 
 Maurer . 
 
 47 
 
 1882 
 
 Epithelioma Death, from recurrence after i 
 
 60 
 
 Chiarella 
 
 52 
 
 
 
 Carcinoma 
 
 Recurrence in 2^ years (?) 
 
 61 
 
 Sokotowski 
 
 62 
 
 — 
 
 
 Death 8 weeks after operation ; 
 
 
 
 
 
 pneumonia. 
 
 62 
 
 Chiarella 
 
 72 
 
 
 
 Death 8 months after. 
 
 63 
 
 Chiarella 
 
 65 
 
 1 
 
 Death 135 months after opera- 
 tion from asphyxia. 
 
 64 
 
 Reyher . 
 
 65 
 
 1881 1 
 
 Death 7th day from septic pneu- 
 
 
 
 
 
 
 monia. 
 
 65 
 
 Reyher . 
 
 55 
 
 1882 
 
 ,, 
 
 Death 14th day from exhaustion. 
 
 66 
 
 Holmer . 
 
 57 ! 1882 
 
 Epithelioma 
 
 Death 7 months after from re- 
 currence. 
 
 67 
 
 Kocher . 
 
 54 ! 1882 
 
 Carcinoma 
 
 Recurrence in 7 months. 
 
 68 
 
 Whitehead 
 
 46 1 1882 
 
 Epithehoma 
 
 No recurrence in 8 months. 
 
 69 
 
 Von Bergmann 
 
 54 
 
 1882 
 
 Carcinoma 
 
 Death after recurrence in 8 
 months. 
 
 70 
 
 Burow . 
 
 44 
 
 1882 
 
 .. 
 
 Death from asphyxia 4^ months 
 
 after. 
 Death from recurrence 4I months 
 
 71 
 
 Holmer . 
 
 63 
 
 1882 
 
 Epithelioma 
 
 
 
 
 
 
 after. 
 
 72 1 Maydl . 
 
 SO 
 
 1882 
 
 Carcinoma 
 
 No recurrence in 16 months. 
 
 73 
 
 mhn . 
 
 58 
 
 1883 
 
 " 
 
 Death in 4th week ; purulent 
 
 bronchitis. 
 No recurrence in 16 months. 
 
 74 
 
 Kocher . 
 
 59 
 
 1883 
 
 
 75 
 
 Maydl . 
 
 45 
 
 1883 
 
 ,, 
 
 Death 4th day from pneumonia. 
 
 76 
 
 Leisrink , 
 
 72 
 
 1883 
 
 >> 
 
 Death 4. months after from 
 
 77 , Von Bergmann 
 
 1 _ 
 
 1883 
 
 
 pneumonia. 
 Death 4th day from pneumonia.
 
 242 The Fatal Illness of Frederick the Noble, 
 
 Table III — continued. 
 
 Operator. 
 
 c5U 
 
 «0 o 
 
 Q 
 
 Disease. 
 
 Subsequent History. 
 
 Hahn 
 Hahn 
 
 80 I Vogt 
 
 82 
 
 83 
 
 84 
 
 85 
 86 
 
 87 
 
 Hahn . 
 Landerer 
 
 Hahn . 
 
 Novaro . 
 
 Winiwarter 
 Winiwarter 
 Gussenbauer 
 
 88 I Novaro 
 
 189 I Pretorius 
 
 90 \ Novaro . 
 
 91 I Kocher . 
 
 t92 ; Jones, Th. 
 
 93 j Holmes . 
 
 94 , Durante . 
 
 95 Jordan Lloyd 
 Von Bergmann 
 Hahn . 
 Park 
 Hahn . 
 
 t96 
 *97 
 
 t98 
 
 99 
 
 100 
 
 lOlf 
 
 102 
 
 io3t 
 104 
 
 106 
 
 Morris . 
 P6an 
 Labbd . 
 
 Mickulicz 
 
 Hahn . 
 
 Labbd . 
 Mickulicz 
 
 43 
 
 46 
 
 I 56 
 
 60 
 
 I 
 
 ' 59 
 ' 35 
 
 ! 51 
 
 so 
 
 1883 
 1884 
 
 1884 
 
 1884 
 
 1884 
 
 1882 
 
 1882 
 1882 
 1883 
 
 1882 
 1883 
 1883 
 1883 
 
 1884 
 1884 
 1884 
 1884 
 1885 
 1885 
 1885 
 1886 
 
 1885 
 1886 
 1886 
 
 1886 
 
 1886 
 
 1886 
 
 Carcinoma 
 
 Adeno-car- 
 
 cinoma 
 Carcinoma 
 
 Epithelioma 
 
 Carcinoma I 
 Epithelioma 
 
 Carcinoma 
 
 Epithelioma 
 
 Carcinoma 
 
 Epithelioma 
 Carcinoma 
 
 Epithelioma 
 Carcinoma 
 
 Death in 5 weeks from bronchitis. 
 
 Death from recurrence 15 months 
 after. 
 
 Death 4 days after from pneu- 
 monia. 
 
 Death on 4th day of pneumonia. 
 
 Xo recurrence in 18 months. 
 
 Death 3 months after from re- 
 currence. 
 Death i^ years after by feather 
 
 blocking canula, no recurrence. 
 Recurrence 7 months after. 
 Death 9th week from inanition. 
 CURE. Living in 1886, 3^ years 
 
 after. 
 Cure F Lidng in October, 1884. 
 Cure ? Living in 1885. 
 Death in i month ; pneumonia. 
 No local recurrence in 1884, but 
 
 glands invaded. 
 Was well 6 weeks after operation. 
 Death from collapse in 48 hours. 
 Death in two or three days. 
 Death from pneumonia in 6 days. 
 Reported cured in 6 weeks. 
 Death on lolh day ; bronchitis. 
 Reported cured in 6 months. 
 Death on 12th day ; pneumonia 
 
 and erysipelas. 
 Death from collapse in 4 days. 
 Reported cured, no dates given. 
 Death from pneumonia on 14th 
 
 day. 
 Reported cured in few weeks ; no 
 
 dates. 
 Discharged cured ; recurrence 
 
 and death probable. (Operator's 
 
 note). 
 Death from recurrence in 4^ 
 
 months. 
 Death from starx-ation ; power of 
 
 swallowing not restored. 
 
 * Partial resection had been performed (see Table H, No. 7) ; but recurrence 
 ha\ing taken place total extirpation was performed with the above result 
 
 t These cases are without value for statistical purposes, either having been reported 
 too soon after the operation, or being too incomplete.
 
 Total Extirpation of Larynx. 
 
 M3 
 
 Table III — contimied. 
 
 6U 
 
 I07t 
 io8 
 109 
 no 
 
 III 
 112 
 
 "3 
 114 
 
 "5 
 116 
 117 
 
 118 
 
 119 
 120 
 
 I2lt 
 I22t 
 I23t 
 124 
 
 126 
 127 
 
 Operator. 
 
 Axel Iverson 
 Kosinski 
 Axel Iverson 
 Pdan 
 
 Newman 
 Gardner. 
 Hogden . 
 Lange * 
 
 Billroth . 
 Billroth . 
 Reyher . 
 
 Billroth . 
 
 Dupont . 
 Chiarella 
 Stelzner . 
 Novaro . 
 Novaro . 
 Von Bergmann 
 Roswell . 
 
 Schmiegelow 
 Demons . 
 
 128 Gottstein 
 129! Chiarella 
 
 Hahn . 
 
 Five cases com-') 
 municatedinal 
 letter to the I 
 
 131 author, dated] 
 
 132 Sept, 20, \l 
 
 133 \ by Dr. Pele- - 
 
 134 .chin, Professor 
 
 135 ' of Surgery in 
 the Imperial 
 Academy, Pe- 
 
 . tersburg. 
 I36t Gardner . 
 137! Hutley . 
 i38t: W. T. Ball . 
 
 57 
 
 49 
 
 72 
 
 37 
 
 62 
 
 .9 o 
 
 1003 
 1886 
 1884 
 1886 
 
 1886 
 
 1879 
 
 1879 
 1880 
 1882 
 
 1887 
 
 1886 
 1887 
 1887 
 1887 
 1887 
 1887 
 1886 
 
 1888 
 1884 
 
 1887 
 1887 
 1887 
 
 Disease. 
 
 Subsequent History, 
 
 Carcinoma 
 Epithelioma 
 
 Carcinoma 
 
 Epithelioma 
 Carcinoma 
 
 Epithelioma 
 
 Carcinoma 
 Epithelioma 
 
 Carcinoma 
 Epithehoma 
 
 Carcinoma 
 
 Epithelioma 
 
 Death 3 months after. 
 Death in 8 weeks of pneumonia. 
 Reported well 3^ months after. 
 Death from broncho pneumonia, 
 
 date not given. 
 No recurrence in 6 months. 
 Living 4 months after operation. 
 Death in 4 days. 
 Death from septicaemia on 3rd 
 
 day. 
 Death from pneumonia in 3 days. 
 Death from hcemorrhage 8th day. 
 Death from recurrence in 9 
 
 months. 
 Death same night attributed to 
 
 syncope. 
 Alive 5 months afterwards. 
 Death in 4 weeks from pneumonia. 
 Living 5 weeks after. 
 Alive 3 months afterwards. 
 Alive I month afterwards. 
 Death ; no date given. 
 Living 6 months afterwards ; no 
 
 recurrence. 
 No recurrence in 9^ months. 
 No recurrence 10 months after 
 
 operation. 
 CURE. No recun-ence 3^ years 
 
 after. 
 Reported well on 17th day, nothing 
 
 more. 
 Death 4 weeks after operation ; 
 
 cause not stated. 
 
 Death in a few days. 
 Death in a few days. 
 Death in a few days. 
 Death in a few days. 
 Death in five months. 
 
 No recurrence in 6 months. 
 
 t These cases are without value for statistical purposes, either having been reported 
 too soon after the operation, or being too incomplete.
 
 244 l^^^*^ Fatal Illness of Frederick the Noble. 
 
 ANALYSIS OF TABLE IH. 
 
 Death took place in 36 cases in less than 9 days 
 after the operation, and in 14 more within 5 weeks. 
 Death, it will be seen, therefore, occurred as the 
 immediate result of the operation in 50 out 
 of 138 cases, or in 36'23 per cent. 
 
 In the remaining cases, where death had occurred at 
 the time the report was published, the fatal issue took 
 place once within 7 weeks, four times in 8 weeks, 
 once in 9 weeks, three times in 3 months, four times 
 in 4 months, once in 19 weeks, seven times in 5 
 months, twice in 6 months, three times in 7 months, 
 twice in 8 months, five times in 9 months, once in 
 10 months, once in 12 months, once in 13 J months, 
 once in 14 months, once in 15 months, twice in 18 
 months, once in two years, and in three cases the 
 exact date of death is not given. 
 
 Recurrence is only known to have occurred in five 
 cases in contiguous parts, and in one case (No. 91), it 
 is said to have taken place "in the glands." Of 
 course the removal of the entire organ tends to 
 prevent recurrence. In one case (No. 104), the 
 patient was discharged as having recovered from the 
 effects of the operation, but the prognosis was so un- 
 favourable that the operator notes recurrence and 
 death as probable. 
 
 Success occurred in 8 out of 138 cases, or 
 5 '79 per cent- This operation, it will be seen, affords 
 little prospect of success, and the conditions of exist- 
 ence after its performance are so utterly miserable, the 
 patient being almost completely cut off from inter- 
 course with his fellow-beings, and having- to take food 
 in such a distressing way that suffocation is constantly 
 imminent, and that death from star\'ation not unfre- 
 quently takes place.
 
 INDEX. 
 
 Abscess forms in situation of Bergmann's " false 
 passage," 154; extension of, 156; question of 
 opening, 16 r 
 Acknowledgment by the Emperor that the 
 author was summoned by the unanimous 
 wish of his German medical attendants, 142 
 Amenities, Gerhardtian, 158 
 Artificial-feeding. 174 
 Artificial production of cancer, 40, 44 
 Archives of Haus-Ministerium, refused access 
 
 to, 22 
 Bardeleben, Prof., is summoned, 162 ; his 
 
 Report, 227 
 Baveno, stay of Crown Prince at, 62 
 Beginning of the End, the. 176. 
 Bergmann, Prof von, his call to Chair of 
 Surgery at the Berlin University, 10 ; poses 
 for the first time as a laryngoscopist, 17 ; 
 prevents author giving relief, loi ; object-; to 
 author usin^ laryngoscope except in the pre- 
 sence of all the medical attendants, 104 ; 
 mistakes normal liver-dulness for a cancerous 
 lung, 104 ; declares that haemorrhage would 
 never cease 107 ; makes ab-urd reports to 
 Berlin, in; prevents author introducing fir>t 
 extemporised San Remo tube, 112 ; is con- 
 tradicted by Kus-^maul, 114; is requested to 
 visit the Emperor "once a week," 125; 
 makes a "false passage," 146; his " fal e 
 passage " results in an ab>cess, 154, 183 ; his 
 mode of carrying out antiseptic surgery, 109, 
 150; still maintains there is cancer o^ the 
 lungs in opposition to all the medical att n- 
 dants [/to cancer -ivas found in lungs after 
 death), 155 ; retires from the case, 162 ; his 
 final Report, 211 ; repudiates all connection 
 with the German Press ; his joarnalistic 
 friends discover his ideas and private state- 
 ments by thought readins;, 219 ; his views 
 on the application of the microscope to 
 diagnosis, 221 ; his eccentric logic, 222 
 Berlin, author's tirst visit to, 9 ; serious news 
 
 from, 123 
 Bismarck, interviews with Prince, 125, 179 
 Bleeding, the, stopped at last, 133 
 Boycotted by Bergmann, 162 
 Bramann, Dr., his arrival at San Remo, 74 ; 
 his attempts at laryngoscopy, 74, 75 ; per- 
 forms tracheotomy, 91 ; his gigantic and 
 ill-fitting canula, 92 ; has a discussion with 
 the author about canulas, 98 ; his experience 
 compared with author's, 102 ; his Report to 
 Bergmann, 227 ; his eccentric views on the 
 position of surgeons, 228 
 Charlottenburg, arrival of Emperor at, 125 
 Calumny, a refuted, 185 
 
 Cancer, . the artificial production of, 40 ; the 
 causes of, 41 ; the nature of", 35 ; in Cashmir, 
 42 ; in chimney sweeps, 41 
 Canula, Bramann's ill-fittin?, 93 ; curve of 
 Bramann's, 93 ; Durham's rectangular 
 canula proposed by author, 101 ; tried too 
 late, 106; the San Remo, 115; s<iccessfully 
 employed, 128 ; tampon-, first used, 172 
 Canulas, different kinds suggested by various 
 surgeons and patients, jn 
 
 Case, the, handed over to author, 35 ; restored 
 to author (having been in hands of Bergmann 
 and Bramann from Feb. 9), 122 ; possibilities 
 of the case, 58, 59; author's Reports on, 95, 
 180 
 Colleagues, German, share author's responsi- 
 bility, 36 
 Conference with Prince William, 70 
 Congratulations from German workmen, 163 
 Consoling reflections, i85 
 Consultation, the first great, ii ; the second at 
 
 San Remo, 67 
 " Contro'ler," a, secretly appointed, 39 ; another 
 
 acts as private detective, 133 
 Crown Prince, his decision with reference to 
 external operations, 72 ; his dislike of stimu- 
 lants, no 
 Diagnosis, the quest'on of, 13 ; communicated 
 to Crown Prince, 72 ; uncertainty of, before 
 February, 1888, 198. (See also Frederick 
 the Noble) 
 Dying in harness, 173 
 
 Emperor Frederick the Noble, commencement 
 of his illne^-s, n ; his treatment by Gerhardl, 
 II, 12, 40; his visit to Fngland, 45 ; his ap- 
 pearance at the Jubilee procession, 45 ; his 
 visit to the Throat Hospital, 51 ; his stay in 
 the Isli of Wight, 52 ; his residence in Scot- 
 land, 53 ; his visits to Toblach, Venice, and 
 Bave o, 60 et seq. ; his stay at SanRemo, 65- 
 123; residence at Chariofenburg, 124-168; 
 his opinion of Beremann, 149 ; his fondness of 
 music 165 ; his last stay at Potsdam, 169 ; 
 his regrets at making no progress, 172 ; his 
 life shortened by at least eight months, 205 ; 
 his death and character, 177. 178 ; facsimiles 
 of his handwriting, 136, 137, 172 
 Emperor William the First, death of the, 123 ; 
 funeral of the, 127 ; his approval of the 
 author's treatment of Crown Prince, i6i 
 Empress Frederick (then Crown Princess) gives 
 author an account of Bergmann's proposed 
 operation, 21 ; receives statement from author 
 as to his position in the case, 29, 30 ; receives 
 explanation as to the possibilities of the case, 
 58, 59 ; hears the true sound of the Crown 
 Prince's voice for the last time, 62, 63 ; her 
 valuable assistance in nursing, 160, 161 
 Esmarch, Prof., his visit to the Emperor, 141 
 Examination of the throat, author's hrst, 12 
 False passage made by Bergmann, 146 
 Flowers, presents of, 161 
 Feeding, artificial, 174 
 
 Freeman, Dr., curious way in which he gets 
 detaile 1 news of Crown Prince's case through 
 the medium of his patients, 108 footnote 
 Galvano Cautery, dangerous abuse of, by Ger- 
 
 hardt 40, 43 ; as it should be used, 53 
 Gerhardt, Professor, his amenities, 38 ; ap- 
 points a "controller," 39; his statement of 
 his own treannent 11, 12 40; his abuse of 
 clectrocauiery, 41 ; h s false accusation, 24; 
 his probable troJuction of cancer, 40; his 
 infamous charge recoils on himsel', 210; his 
 childish and ignorant complaint that author 
 promised to " cure disease in a few weeks."
 
 246 
 
 Index, 
 
 211 ; his idea that the Isle of Wight is a Bath 
 Establishment, 211 ; his tiistrionic powers, 27 
 
 Hahn, Dr. E., his opinion as to right course 
 of procedure, in May 1887, 202 ; results of 
 his own operations, 203, 204 
 
 Heryng, Dr., fragments of sloughrcserved for,8i 
 
 Hohenzollern, Grand Star of, conferred on 
 author, 142 
 
 Hovell, Mr., goes into residence, 54; his 
 opinion of Bramann as a laryngoscopist, 74, 
 75 ; his reports in conjunction with Krause, 
 74. 75> l^t 80, 81 ; his measurement-; of 
 Bramann s incision, 117-120 ; receives Kron 
 Order, 142 ; sent for by the Emperor, 108 ; 
 threatened with imprisonment, 109 
 
 Indictment of author, 206 
 
 Inexper.enced laryngoscop'sts, 87 
 
 Inspection of troops by P mperor, 167 
 
 Isle of Wight, re idence in the, 52 
 
 Journey home, the new Kaiser's, 124 
 
 Jubilee, the procesii in, 45 
 
 Krause, Prof., bis arrival at San Remo, 68; 
 author's previous knowled e of, 68 ; ex- 
 presses his bdief that disease is a " malignant 
 neoplasm," 69; his reports in conjunction 
 with Mr. Hovell, 7^, 75, 76, 80. 81 ; ciscusses 
 the propriety of an external operation, 132 ; 
 notces passage of liquid food into the 
 larynx; personally appointed professor by 
 the Emperor. 135 ; his valuable works, 225 ; 
 as a practical physician, 226 
 
 Kussm.aul, Prof., arrival at San Remo, 113; 
 his adventures as a laryngoscopist, 113; 
 contradicts Bergmann, 114 ; his Report, 227 
 
 Landgraf, Dr., is appointed by Gerhardt to 
 "control" author, 39; his capacity as a 
 lari'ngoscopist, 55-58 : his report, 222 ; thinks 
 that Hovell asked him for informat'on ! 222 
 
 Larynx, partial extirpation of the, 236; total 
 extirpation of the, 239 
 
 Letters, threatening, 126 
 
 Leyden, Professor, first called in, 154, 155 ; 
 appointed a permanent attendant, 156 ; his 
 services prove most val-.able, 156 
 
 Lungs, Berzmann insists on the presence of 
 cancer in the, 106 ; absence o; cancer in the, 
 proved SL.tpost mortem, 185 
 
 Malice and incompetence of author's opponents, 
 2o€ 
 
 Massage tred, 135 
 
 Mausoleim, visit to, by Emperor, 168 
 
 Memorable words of Frederick the Noble, 158 
 
 Moritz Markovicz said to be the real name of 
 the author, 138 
 
 Myles, Dr. Robert C., prepares larj'ngeal elec- 
 trode, 53 ; assists at operation, 53 
 
 Oertel, Professor, author's letter to, 62 
 Officis.1 sources," their nature and character, 
 207 ; author refused access to, 22 
 
 Operations by the author, his first, 15 ; his 
 second, 23 ; his third, 31 ; his fourth, 48 ; 
 danger of Bergmann's proposed, 189 
 
 Pachydermia laryngis, 22-33 
 
 Peace a treaty of, 121 
 
 Possibilities of the case, statement of, 58 
 
 Post-mortem examinations, 182 ei scq. 
 
 Proof, microscop'c, of cancer, 120 
 
 Publication of our secret Report, 72 
 
 Qut-en, the, her Jubilee, 45 ; expresse; pL-asure 
 at hearing Crown Prince's "own voice," 54; 
 her visit to Berlin, 160 
 
 Reception of the author by the people at Berlin, 
 140 
 
 Refusal of Count Stolberg-Wernige-ode to 
 permit author to examine documents in the 
 Archives of the Haus-Ministerium, 22 
 
 Relief, author is prevented giving, loi 
 
 Report, publication < f the secret, 72 
 
 Repo! ts, by the auth^ r, 95, 180 
 
 Res onsibiii'y shared hyauhor's colleagues, 36 
 
 "Reptile" Press, attacks by the, 138, 151, and 
 footnote 175 
 
 San Remo, Crown Prince's stay at, 65-123; 
 great consultation at, 67 
 
 Schmidt, Dr., his arrival at San Remo, 70 ; 
 thinks disease " a chronic contagious affec- 
 tion," 70 : his conduct comp ained of by 
 Crown Prince, 78; his Report, f26 
 
 Schrader, Dr., his endeavours to postpone tra- 
 cheotomy, 89 ; his erroneous idea as to the 
 cause of neuralgia, 88 ; misadventure with 
 canula, ic8 
 
 Schrotter. Prof., his arrival at San Remo, 68 
 advised total extiri's-t on, 69; subsequently 
 advis d against total extirpation, 70; his 
 Report, 223 ; his offensive patronage of 
 Krause, 225 ; his quasi-ce'eslial wrath wiih 
 Hovell, 224 
 
 Senator, Professor, first summoned ; his co- 
 operation proved most valuable, 156 
 
 Slough, Virchow's Report on the, 81 
 
 Statement cf author's position, 29, 58, 77 
 
 Statistics, 229 
 
 Tai pon-Canula, introduction of, 172 
 
 Telegram from German workmen, 163 
 
 Throat Hospital, visited, 51 
 
 Thyrotomy, dangers of, 190, 194 ; inadequacy 
 of, 195 ; frequent recurrence after, 195 ; des- 
 truction of voice by, 196 ; immeaiate morta ity 
 of, 231, 234, 235; results of. 231, 134 
 
 Toblach, stay of Crown Prince at, 60 
 
 Tracheotomy decided en, 89 
 
 Trap, a, is laid for author, 179; failure of, 181 
 
 Troubles, caused by ill-fitting tubes, 98 
 
 Tube, aut or's i t ied too laie, 106 
 
 Venice, visired by Crown Prince, ' o 
 
 Virchow, Professor, his first Report, 21 ; his 
 second, 32 : his third, 48 ; his Report on the 
 slough, 81 ; his Report on the J>ost-mortcm 
 examination, 182 
 
 Waldeyer, Prof., arrival at San Remo, 120 ; 
 his Report, 217 
 
 Wegner, Dr. von, his statement of the case, 
 II ; called ly orderly to Emperor, 152; is 
 requested by Empress Frederick not to allow 
 post-i7iortetn examination, 182 
 
 Wolfenden, Dr. N orris, enters into residence, 
 46 ; his Report on the Crown Prince's larynx, 
 46 ; his Report from the Isle of Wight, 52 ; 
 his opinion of Landgraf as a laryngoscopist, 
 
 57 
 Words, memorable, of Frederick the Noble, 158 
 World, suggestions from the outside, 99 
 Zebliidowsky, Dr., applies massage, 13s
 
 r
 
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