Letters to the Editor - Europe PMC

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London: Sampson Low, Marston, Searle and. Rivington, 1888. 7 Pahor AL. What killed Kaiser Frederick III. First Meeting ofthe British Section ofEuropean Society ...

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Journal of the Royal Society of Medicine Volume 86 May 1993

Letters to the Editor Preference is given to the letters commenting on contributions published recently in the JRSML They should not exceed 300 words and should be typed double-spaced.

Tracheostomy I was most interested in Dr Conacher's article on Brodie's tracheostomy (September 1992 JRSM, pp 570-2). Tracheostomy is a time honoured operation which was even performed at the time of the Ancient Egyptians'. Not only did the article refer to Brodie's tracheostomy, but to another famous patient who had a tracheostomy, Kaiser Frederick III. In January 1887 Crown Prince Frederick (who was married to Vicky, eldest daughter of Queen Victoria, and whose eldest son William was to become Emperor of Germany following his death) suffered from a change of voice which was diagnosed as a cold. He initially received the remedies for colds which were prescribed at that time. However, his hoarseness did not improve and he was then seen by the leading laryngologists in Berlin. A swelling on his left vocal cord was noticed and he received repeated galvanocautery for that. The lesion still persisted in spite of this treatment and thus a laryngofissure was arranged for 21 May 18872. Morell MacKenzie (the most famous laryngologist at the time) was hastily called from London to visit the Crown Prince in Berlin who gave his opinion on his condition. Morell MacKenzie arrived in Berlin 20 May 1887 and he advised against the operation. Morell MacKenzie carried out different treatments on the Crown Prince which also included galvanocautery. The Crown Prince initially began to improve (Morell MacKenzie was rewarded with a knighthood by Queen Victoria), only to regress later on. Eventually it became evident that he was suffering from carcinoma of the larynx. He required a tracheostomy which was carried out 8 February 1888. When his father, William I, died in March 1888, Frederick became Frederick III, Emperor of Germany. He was to last for only 3 months to succumb to his cancerous condition3-5. This was followed by acrimonious charges and accusations and insults between Morell MacKenzie and other doctors involved in the case of the unfortunate Kaiser. Apart from that it is interesting to note the different devices which were invented to help the Kaiser to breathe better6. Studying the course of Frederick III illness and the pathology reports, I suggest that his case should be considered verrucous carcinoma of the larynx, the first such case known in history7. AHMES L PAHOR

ENT Department Dudley Road Hospital Dudley Road, Birmingham B18 7QH

References 1 Pahor AL. Ear, nose and throat in Ancient Egypt: Part II. J Laryng 1992;106:773-9 2 Pack GT, Campbell R. Historical case records of cancer: the laryngeal cancer of Frederick III in Germany. Ann Med Hist 1940;2:151-70

3 Chalet NI. Sir Morell MacKenzie revisited. Laryngoscope 1984;94:1307-10 4 Minnigerode B. The disease of Emperor Frederick III. Laryngoscope 1986;96:200-3 5 Pahor AL. What killed Kaiser Frederick III? XXXIIIrd International Congress on The History of Medicine, Granada, September, 1992 (in press) 6 Sir Morell MacKenzie. The Fatal Illness ofFrederick the Noble. London: Sampson Low, Marston, Searle and Rivington, 1888 7 Pahor AL. What killed Kaiser Frederick III. First Meeting of the British Section ofEuropean Society for the History of Otorhinolaryngology, Birmingham, 1981

Cyanocobalamin - a case for withdrawal In his recent paper Dr Freeman (November 1992 JRSM, p 686) makes the following statement': Evidence has been presented that oral treatment with vitamin B12 cannot replace body stores in patients with Addisonian pernicious anaemia where there is a lack of gastric intrinsic factor due to an autoimmune gastritis causing malabsorption of vitamin B12 or in those who have undergone total gastrectomy or ileal resection. Such patients will require life-long parenteral vitamin B12 therapy.

Because this statement is unreferenced and follows a description of my recent commentary2, it could be misinterpreted as having been derived from evidence presented in that commentary. This is not the case, however, as these are precisely the patients in whom oral therapy has been shown to replace body stores of B123. Based on a thorough review of the literature, I am aware of no evidence presented anywhere involving adequate doses of oral B12 (1 mg per day) that support Dr Freeman's statement. Oral B12 remains a useful therapeutic option for the treatment of B12 deficiency. FRANK A LEDERLE

Department of Medicine (111-0) VA Medical Center One Veterans Drive Minneapolis, MN 55417, USA

References 1 Freeman AG. Cyanocobalamin - a case for withdrawal: discussion paper. J Roy Soc Med 1992;85:686-7 2 Lederle FA. Oral cobalamin for pernicious anemia: medicine's best kept secret? JAMA 1991;265:94-5 3 Berlin H, Berlin R, Brante G. Oral treatment of pernicious anemia with high doses of vitamin B12 without intrinsic factor. Acta Med Scand 1968;184:247-58

The author replies below: As I see it, there is no basis for Dr Lederle's concern that my statement, as quoted by him, might be misinterpreted as being derived from evidence presented in his commentary. My statement did not follow his assertion that oral vitamin B12 remains a useful therapeutic option for the treatment of B12 deficiency, but followed my review on the various forms of vitamin B12 (cobalamins) isolated. Dr Lederle further states that my statement is unreferenced. This is not the case for it was followed by my pointing out that in the UK intramuscular hydroxocobalamin has replaced cyanocobalamin as it is retained in the body longer. Thus for maintenance therapy, it need only be given at intervals of 3

months'4. My thesis is that the retention and continued use of oral or systemic cyanocobalamin places patients