Rudolf Virchow – Not Just a Triad

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Los Angeles Society of Pathologists George Kypridakis Lecture December 10, 2013 George Kypridakis, M.D.
1929-1990
Secretary-Tresaurer
Los Angeles Society of Pathologists
1977-1990
Rudolf Virchow: more than just a triad… Stephen A. Geller, M.D. Rudolf Virchow (1821-­‐1902) A few famous German pathologists “… at his death Germany would complain of having lost four great men in one: her leading pathologist, her leading anthropologist, her leading sanitarian, and her leading liberal.” Erwin H. Ackernecht Ludwig Aschoff Leopold Auerbach Max Bielschowsky Julius Friedrich Cohnheim Hans Gerhard Creutzfeldt Karl Theodor Fahr Friedrich Theodor v Frerichs Paul Grawitz Friedrich Gustav Jacob Henle Edwin Klebs Peter Kruckenberg Paul Langerhans Theodor Langhans O[o Lubarsch Rudolf Robert Maier Friedrich Sigmund Merkel Albert Ludwig Sigisman Neisser Ludwig Pick Friedrich Daniel v Recklinghausen Curt Schimmelbusch Chris]an Georg Schmorl Karl Weigert Max Wilms Friedrich Wilhelm Zahn Rudolf Virchow – Doctor, Statesman, Anthropologist 1
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Google ‘scores’ … Marilyn Monroe 65,200,000 Abraham Lincoln 48,600,000 Winston Churchill 28,500,000 Greta Garbo 17,400,000 Rudolf Virchow 7,100,000 O[o von Bismarck 6,150,000 Hippocrates 4,530,000 Thomas Hodgkin 3,490,000 Andreas Vesalius 1,060,000 Giovanni Ba]sta Morgagni 1,050,000 William Osler 950,000 Karl von Rokitansky 308,000 Doonesbury – Garry Trudeau
Rudolf Virchow, M.D. 1821-­‐1902 Rudolf Virchow was one of the very greatest physicians and scien]sts of all ]me Revolu]onary Poli]cian Social Scien]st Epidemiologist Anthropologist Archeologist Public health pioneer Scien]st Patriot Liberal An]-­‐militarist Public protector An]-­‐cleric Medical reformist Visionary ‘Father’ of Pathology Linguist Teacher Ethnologist Cellular biologist Philosopher Humanist Hugo Vogel, 1861
Some of Virchow’s most important publica]ons -­‐ 1 Weisses Blut. Neue NoAz Geb Natur-­‐ u Heilk. 1845;36:151-­‐6 necropsy in a case of “leukemia,” published six weeks aier John Hughes Benne[ Thrombose unde Embolie. Gefässentzündung und sep]sche Infek]on, in Gessammelte Abhandlungen zur wissenschFliche Medicine. Frankrut a.M.: Meidinger 1856: 219-­‐732. reprints of papers published between 1846 and 1853 – the concept and principles of thrombosis and embolism Zur Entwicklungsgeschichte des Krebses. Arch path Anat Physiol 1847; 1:194-­‐201. the exci]ng cause of cancer is local irrita]on Some of Virchow’s most important publica]ons -­‐ 2 Ueber die acute Entzündung der Arterien. Arch path Anat Physiol 1847; 1:272-­‐378. exhaus]ve account of the pathology of arteri]s Die pathologischen Pigmente. Arch path Anat Physiol 1847; 1:379-­‐404,407-­‐86. on the origin and chemical composi]on of extra-­‐ and intra-­‐
cellular pigments Ueber eine im Gehirn und Rückenmark des Menschen auggefundene Substanz mit der chemischen Reac]on der Cellulose. Arch path Anat Physiol 1854;6:135-­‐8. amyloid 2
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Some of Virchow’s most important publica]ons -­‐ 3 Die Cellularpathologie in ihre Begründung auf physiologische und pathologiscge Gewebelehre. Berlin: A. Hirschwald, 1858. 440 pp. one of the most important books in the history of medicine Ueber die Natur der consCtuConell-­‐syphiliCschen AffecConen. Arch path Anat Physiol 1858;15:217-­‐336. pathology of syphilis, confirming systemic nature and demonstraCng transfer in blood, recommends mercury therapy Beiträgte zur Lehre von den beim Menschen vorkommenden pflanzlichen Parasiten. Arch path Anat Physiol 1859;9:557-­‐93. first descripCon of pulmonary aspergillosis Die krankha=en Geschwülste. Vol 1-­‐3, HeV 1. Berlin: A Hischwald, 1863-­‐67. collecCon of lectures on tumors Some of Virchow’s most important publica]ons -­‐ 4 Ueber den Hungertyphus und einige verwandte Krankheitsformen. Berlin: A Hirschwald, 1868. 56 pp. report on typhus in Upper Silesia and Berlin, emphasizing the social element in the genera]on of the disease Beiträge sur physischen Anthropologie der Deutschen, mit besondered Berücksich]gen der Friesen. Abh k preuss Akad Wiss Berl 1876. Phys.-­‐math. Klasse, Abt. 1. Berlin: F. Dümmler, 1877, 390 pp. a survey of the physical characteris]cs of German people Crania ethnica Americana. Sammlung auserlesener amerikanischer Schädeltypen. Berlin: A. Asker, 1892, 59 pp., 26 leaves. a monograph on American craniology. Background #1 Born October 18, 1821 – Rudolf Ludwig Carl Virchow – born Schivelbein, Pomerania Carl Chris]an Siegfried Virchow (1785-­‐1857) – farmer, town treasurer, unsuccessful businessman Johanna Maria née Hesse (1785-­‐1857) Approximately same age as Baudelaire, Claude Bernard, Flaubert, Kelvin, Kussmaul, Karl Marx, Herman Melville, Mendel, Pasteur, Schliemann, Semmelweiss, Queen Victoria, Walt Whitman 1835 – entered gymnasium – age 14 – brilliant scholas]cally, but “nonconformist” behavior – ranked last in class, but called “king” by other students – gradua]on thesis: “Ein Leben voller Muehe und Arbeit ist keine Last, sondern eine Wohltat” 1839-­‐43 -­‐ Friedrich-­‐Wilhelm Ins]tut, Berlin “medical science had reached an all ]me low in Germany” Virchow’s birthplace, Schivelbein, Pomerania
Languages in which Virchow was fluent • 
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German La]n Greek French Italian English Dutch Arabic Hebrew Virchow’s teachers at University of
Berlin Friedrich-Wilhelm Institut
Johannes Müller 1801-1858)– anatomist, embryologist,
highly gifted teacher – helped raise German
medicine to a worldwide stature – pioneering work in
the physiology of voice, hearing and sight – chemical
and physical properties of lymph, chyle and blood – key
figure in defining the cell as an entity
Johann Lukas Schönlein (1793-1864) – introduced
Virchow to French methods of clinical examination and
epidemiology – described purpura rheumatica (HenochSchönlein disease) – taught therapeutics and pathology –
physician to Friedrich Wilhelm IV
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Background #2 1843 – “Company surgeon” (rota]ng intern). Charité Hospital, Berlin 1844 – Carl Mayer, leader of Obstetrical Society, geheimrat 1847 – Privatdozent (Lecturer), University of Berlin 1847 – founds, with Reinhardt, Archiv fuer pathologische Anatomy und Phisiologie un fuer klinische Medizin (Virchow’s Archiv) 1847/48 – Typhus epidemic, Upper Silesia 1848 April – Virchow on the Berlin barricades 1849 – government suspends Virchow 1849 April – second dissolu]on of Prussian chamber; reac]onaries triumph 1849 November – forced to leave Berlin for Würzburg engaged to marry Rose Mayer “In the past it was young Virchow and like-­‐
minded men who urged vehemently for a social solu]on of the disease problems ... It is not a mere coincidence that it was the courageous founder of cellular pathology, who regarded the living body as a social organiza]on of cells (“soziale ZellorganisaAon”), who was also the first to have shouted the courageous call for a social therapy.” Alfred Adler Das Eindringen soziales Triebkräie in die Medizin. Virchow’s 1848 report on typhus epidemic in Upper Silesia “one of the … classics of social medicine” -­‐ emphasized economic, social and cultural factors involved in the e]ology of the epidemic -­‐ clearly iden]fied contradictory social forces that prevented simple solu]ons -­‐ outlined revolu]onary program of social reconstruc]on, including full employment, higher wages, establishment of agricultural coopera]ves, universal educa]on and the disestablishment of the Catholic church -­‐ “full and unlimited democracy … educa]on, freedom, and prosperity” March 18-19,1848
Kronenstrasse und
Friedrichstrasse
Aerziliche Standes-­‐zeitung, Vienna 1902;1:1-­‐3. Virchow and colleagues ‘revolu]onary ideas’ -­‐ 1848 Public provision of medical care for the indigent Prohibi]on of child labor Protec]on for pregnant women Reduc]on of working day in dangerous occupa]ons Removal of toxic substances Adequate ven]la]on at work sites Medicine was to be reformed on the basis of: 1.  Health of the people is a ma[er of direct social concern 2.  Social and economic condi]ons have an important effect on health and disease 3.  Measures taken to promote health and combat disease must be social as well as medical 4.  ‘medical sta]s]cs will be our standard of measurement’ 4
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1849-56
Background #3 1850’s were “so hopeless that even Karl Marx withdrew from prac]cal poli]cs …” “Virchow was a Prussian ‘foreigner’ in Catholic Bavaria; and Philis]ne Würzburg, where there were no poor … offered li[le s]mulus to poli]cal ac]on.” Virchow drew hundreds of students to Würzburg; first chair in pathological anatomy in Germany 1851 -­‐ co-­‐editor of Jahresbericht ueber die Leistungen und FortschriUe der Gesamten Medizin 1854 -­‐ 6 volume Handbuch der speciellen Pathologie und Therapie 1855 -­‐ “omnis cellula a cellula” 1856 -­‐ returns to Berlin 1858 – Cellularpathologie Anatomy and Pathology Institute
Julius Hospital Pavilion
School of Medicine
Julius Hospital
Würzburg
University of Würzburg Albert von Kölliker (1817-­‐1905), pathologist fer]liza]on of the ovum, smooth muscle in blood vessels, ZeitschriF fur wissenschaFliche Zoologie Rudolf Virchow (1821-­‐1902), pathologist Archiv fur Pathologische Anatomie, embolism, lympha]c sheaths of cerebral arteries (Virchow-­‐Robin) Ernst von Bergmann (1836-­‐1907), surgeon fat embolism, joint surgery, cranial surgery, an]sepsis, head injury, succeeded Langenbeck in Berlin Wilhelm Röntgen (1845-­‐1923), physicist X-­‐rays (renamed Röntgen rays by Kolliker) 1854
Vesalius à Morgagni à Rokitansky à Virchow
Monumental and revolu]onary contribu]ons to medicine (a 3 century (1543-­‐1858) journey … ) Andreas Vesalius (1514-1564)
De humani corporis fabrica libri septem - 1543
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Vesalius à Morgagni à Rokitansky à Virchow
Vesalius à Morgagni à Rokitansky à Virchow
Giovanni Battista Morgagni (1682-1771)
De Sedibus et causis morborum per anatomem indagatis - 1771
Carl von Rokitansky (1804-1878) – “supervised 70,000 autopsies, and
personally performed over 30,000, averaging two a day, seven days a
week, for 45 years.” – no microscopy
introduced question of ethics in medicine, wrote
on ‘compassion’ – helped to shape era of Austrian high liberalism -
Robert Hooke (1635-1703)
Johannes Peter Müller (1801-1858)
Theodor Schwann (1810-1882)
Assistant to Müller
Micrographia (1665)
Matthias Jakob Schleiden (1804-1881)
Hippocrates (460-­‐370 BCE) Yellow bile Black bile Phlegm Blood blastema cytoblastema Puta]ve material from which all cells were thought to arise 6
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Omnis cellula e cellula 1858
every cell originates from another exisAng cell like it cell theory microscopy Rokitansky letter to Virchow (about corpora amylacea)
Rudolf and Rose, 1859
Virchow is described … early years in Berlin … as dancing with his wife at rare par]es, drinking wine or beer at the end of the gatherings, and joining in the singing. He visited with his assistants, swam, bowled, and climbed mountains … “He respected the rights of others, bore no grudge, lived to correct many of his mistakes, and showed great compassion for the poor, the sick and the lowly.” McManus JFA. Rudolf Virchow in 1858. Laboratory InvesAgaAon 1958;7:549-­‐553. 7
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Virchow’s principal assistants at Charité
Felix Hoppe-Seyler (1825-1895) – founder of
biochemistry, physiological chemistry –early studies of
hemoglobin/oxyhemoglobin – confirmed presence of
iron in hemoglobin – founded Zeitschrift für
Physiologische Chemie in 1877
Friedrich Daniel von Recklinghausen (1833-1910) – monograph on
neurofibromas – coined term ‘hemochromatosis’ – developed
silver stain for cell junctions – described mast cells – students
Included Friedlånder, Zahn, Aschoff, others
Pathology Institute, Charité, Berlin
Some of Virchow’s students Julius Cohnheim Reginald Fitz Nikolaus Friedreich
Paul Grawitz F.G. Jacob Henle Felix Hoppe-­‐Selyer
Edwin Klebs Adolf Kussmaul O[o Lubarsch William Osler Friedrich von Recklinghausen Curt Schimmelbusch Müller
Schönlein
Robert Remak (1815-1865)
“ … the origin of cells is by division of pre-existing cells …” - 1855
Schmiedebach HP. Robert Remak (1815-65). Gustav Fischer, Stuttgart, 1995
Background #4 1859 – elected to City Council Seydel Mayer (brother-­‐in-­‐law), mayor Paul Langerhans, president of city council 1859 – study of leprosy in Norway 1860 – member WissenschaFliche (Council of Scien]fic Advisors to the Prussia government) 1861 – co-­‐founds Deutsche FortschriUspartei (German Progressive Party) -­‐ leader of the cons]tu]onal forces against Bismarck 1861 – elected to Prussian diet, leads “desperate fight of cons]tu]onal forces” against Bismarck 1863 – Die krankhaFen Geschwuelste – 3 volume book on tumors 1864-­‐1870 – Bismarck/Prussia conquer Germany 1865 – Bismarck challenges Virchow to duel; Virchow declines or two pork sausages 1866 – Austro-­‐Prussian war  unifica]on of Northern Germany states (Prussia) building of military hospitals 1868 – co-­‐founds Sammlung gemeinverstaendlicher wissenschaFlicher Vortraege 1869 – founded German Anthropological Society 1869 – founded Berlin Society of Anthropology, Ethnology and Prehistory “I do not think that a living human being can be found that even under torture could actually say what tumors really are.” Die krankhaFen Geschwuelste, vol 1, chapter 1 8
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A 56-­‐year-­‐old man, previously in good health, contracted an upper respiratory infec]on the autumn of 1886. It lingered unduly and was followed by mild hoarseness in January 1887. He was treated with gargles and inhala]ons. Hoarseness persisted and laryngoscopy revealed a sessile 2 x 4 mm nodule on the lei vocal cord. Both vocal cords moved freely. A[empted removed by snare and then by ‘ring-­‐knife,’ failed because the nodule was flat, smooth and hard. Under cocaine local anesthesia galvanocautery was applied 3 ]mes but reexamina]on showed it had increased in size. Galvanocautery was applied daily for 10 days. Following this the pa]ent was sent to a spa for convalescence; inhala]ons and douches were prescribed. It was no]ced that the surface of the lesion did not heal and the suspicion of carcinoma was raised. Reexamina]on by a surgeon (von Bergmann of Würzburg) revealed “a growth that cannot be got at from inside the throat, as it may also exist under the larynx in a fold, where it can not be reached.” Morell Mackenzie, pioneering London otorhinolaryngologist, was summoned. 1886-88
Morrell Mackenzie
Crown Prince/Kaiser Frederick III
Crown Prince Wilhelm and Virchow 1878
Morell Mackenzie’s drawings May 20, 1887
November 6, 1887
Cardesa A et al. The Kaiser’s cancer revisited: was Virchow totally wrong?
Virchows Arch 2011;458:649-657.
Elected to 1859-­‐1901 1862 -­‐1880 1880-­‐1893 Berlin City council Prussian Lower House leader, Progressive Radical Party Reichstag Medicine is a social science, and poli]cs is nothing more than medicine on a grand scale Rudolf Virchow (1821-­‐1902) 9
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“Physicians are the natural a[orneys of the poor … It is their duty to work for improvement of condi]ons … Medicine is a social science, and the health of the people is a ma[er of social concern … If medicine is to fulfill her great task, then she must enter the poli]cal and social life.” Rudolf Virchow I did not push myself into poli]cs. The events pushed me into it. Rudolf Virchow 1875
The great questions of our time will not be decided
through speeches and majority resolutions … that
was the great error of ‘48 and ‘49 …but through
iron and blood.
speech to Parliament, 30 Sept 1862
Otto von Bismarck (1858-1898)
Sword against sausage …
age 75
Rudolf Virchow, 1869
Dropping the Pilot (1890)
Sir John Tenniel
Otto von Bismarck (1815-1898)
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Background #5 1870 – Franco-­‐Prussian war: military hospitals, hospital trains 1870s – increasing emphasis on anthropology 1873 – elected to Prussian Academy of Science 1874 – Die secAons-­‐technik im Leichenhause des Charité-­‐Krankenhauses mit besonderer Rücksicht auf gerichtsäarztliche Praxis 1877 -­‐ Beiträge zur physischen Anthropologie der Deutschen 1878 – excavates with Shliemann in Hissarlik (Troy) [1888 Egypt]
1880 –elected to the Reichstag 1880 – sided with Bismarck in unsuccessful fight against Catholic Church (“kulturkampf”) 1881-­‐1900 – Interna]onal Medical Congresses (London, Copenhagen, Berlin, Rome, Moscow, Paris) La]n, Greek, Hebrew, Arabic, English, French, Italian, Dutch 1881 – excavates in Caucasus 1882 – President, Berlin Medical Society Reichstag, 1894
Virchow was defeated for re-­‐elec]on to Reichstag by Adolf Stoecker (1835-­‐1909), court chaplain to the Kaiser. Stoecker organized 1870 mass mee]ng urging Bismarck to end Jewish immigra]on and exclude Jews from teaching and government posi]ons. Stoecker became a hero for Hitler. Virchow opposed student an]-­‐semi]c league. On basis of anthropologic studies Virchow proclaimed that a pure Germanic race did not exist – data later distorted by Hitler to defend Aryan purity. Autopsy technique
•  Pathologist •  Revolu]onary/poli]cian •  Social Scien]st •  Anthropologist 11
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Neues Museum, Berlin
Virchow
Heinrich Schliemann (1822-1890))
Athens
Background #6 1886 – Berlin Ethnological Museum 1888 – Berlin Folklore Museum 1888 – Emperor Frederick III – first liberal-­‐leaning member of Hohenzollern family succeeded by Wilhelm II – a true reac]onary Hohenzollern 1893 – Rector, University of Berlin 1901 – 80th birthday celebra]ons around the world Hansen, Jacobi, Lister, Osler, many others 1902 January 4 – breaks femur jumping from street car September 5 – dies of heart failure buried in Alter St. Ma[häus Kirchhof, Schöneberg, Berlin Virchow’s triad (thrombosis) •  Altered blood flow •  Altered blood components (hypercoagulability) •  Altered blood vessel endothelium Schliemann
Rudolf Virchow’s contribu]ons (selected) •  Seminal achievements in medicine and science –  Virchow triad –  Discovery of trichinosis –  Die Cellularpathologie •  Excava]ons at Troy with Schliemann •  Edited journal of ethnology •  Disproved existence of predominantly blond, blue-­‐
eyed Aryan (7,000,000 children) •  Manned barricades in 1848 Revolu]on Virchow’s other triad (diseases) •  Poverty •  Ignorance •  Oppression 12
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Selected Virchow eponyms Virchow cell – a macrophage in Hansen disease (leprosy) Virchow cell theory – ‘omnis cellula e cellula’ (every living cell comes from another living cell) Virchow concept of pathology – compara]ve human/animal pathology Virchow disease – leon]asis ossea (now recognized as sign rather than disease) Virchow law – during craniosynostosis, skull growth restricted to plane perpendicular to affected, prematurely fused suture Virchow metamorphosis – lipomatosis in heart, salivary glands Virchow method – autopsy method in which each organ is taken out one by one Virchow node – metasta]c carcinoma in suprclavicular node Virchow psammoma – psammoma bodies in meningioma Virchow-­‐Robin space – perivascular space around cerebral vessels Virchow-­‐Seckel syndrome – “bird-­‐headed dwarfism” Virchow triad – endothelial injury, hemodynamic changes, hypercoaguability Honors by the ]me of Virchow’s 80th birthday Virchow streets – Berlin, Würzburg, Nürnberg Mul]ple celebra]ons, honors, addresses, medals, degrees and celebra]ons from medical socie]es, universi]es and municipali]es in Germany, Austria, Switzerland, England, Scotland, Ireland, France, Italy, Australia, Scandinavia, Holland, Russia, Brazil, Chile, Japan, more Festschrift for 70th birthday
anymore We shall not see him in the flesh … the li[le, slightly bent, lithe man with the parchment-­‐like, somewhat yellowish, much wrinkled face and the slightly grizzled hair … prac]cally unchanged during the thirty years I have known him, with the small, piercing eyes covered by spectacles, which he always pushed up when reading or when about to make one of his caus]c remarks; with his dry, sarcas]c, somewhat monotonous voice; with his rapid gait, with his quiet unostenta]ous demeanor … Sir Felix Semon, Br Med J 1902, II:802 13
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Nature and nature’s laws
Lay hid in night,
God said: Let Virchow be
And all was light.
Sir Samuel Wilks
paraphrasing Pope’s epitath to Newton
Selected references Ackernecht EH. Rudolf Virchow – Doctor, Statesman, Anthropologist. Madison, University of Wisconsin Press, 1953. Harris H. The Birth of the Cell. New Haven, Yale University Press, 1999. Lin JI. Death of a Kaiser. Dayton, Landfall Press, 1985. Rather LJ. A Commentary on the Medical WriAngs of Rudolph Virchow. San Francisco, Norman Publishing, 1990. It is not so great an honor to speak to a
medical audience … but to be listened to by
a medical audience, there’s the honor.
Paul Klemperer
Vielen Dank für irhe Aufmerksamkeit. Haben Sie noch fragen? 14