Elliot Weisenberg, MD

Introduction

Very early in medical or graduate school, we learn that Rudolf Virchow described the abnormal protein amyloid, and learn of Virchow’s node, Virchow’s triad, and Virchow’s angle. They learn he was responsible for the acceptance of the cell theory. Yet these major discoveries and efforts barely scratch the surface of his accomplishments. In his lifetime he gave innumerable lectures and speeches, helped the careers of many notable clinicians and pathologists, and published over 2000 books and papers. He played an important role in changing medicine in Germany. Though best known for his work in pathology, medicine, and public health; Virchow was also a noted statesman, historian, humanitarian, and anthropologist.

The early years

Rudolf VerchowRudolf Ludwig Karl Virchow was born on October 13, 1821 in Schievelbein in Eastern Pomerania, now Swidwin in Poland, a rural and poor region. He was an only child. His father Carl Christian Siegfried Virchow (1785-1865) was a farmer and worked as the city treasurer as well as what is variably described as merchant, business man, and butcher, considered the “family business.”. Very little is known about his mother Johanna Maria Nee Hesse (1785-1857) except that she had a penchant for worrying and complaining. A paternal uncle had modest success as a military engineer as did a maternal uncle as an architect, and one of his sons, Hans, had some success as an anatomist.

Virchow was a brilliant student. He became fluent in German, Latin, Greek, Hebrew, English, Arabic, French, Italian, and Dutch. He was something of a “class clown” in school but always first in his class in any academic endeavor. He entered gymnasium in Koslin in 1835 and graduated in 1839. His thesis was entitled “A Life Full of Work and Toil is not a Burden but a Benediction.” He chose to pursue medicine over theology as a career because he did not believe his voice could handle the burden of giving sermons; interestingly, later in life he became strongly anti-clerical. In 1839 he received a military fellowship to study medicine at Friedrich-Wilhelms Institute in Berlin, known as the Pepiniere. This was a program that allowed gifted children from poorer families to study medicine; after graduation they were to become military surgeons. His professors included Johann Peter Mueller and Johann Schonlein. He graduated in 1843 and wrote his thesis on the corneal manifestations of rheumatic disease. He became a subordinate physician on graduation and in 1844 was appointed company surgeon (roughly a rotating internship) at Charity Hospital in Berlin. There he was known as the “little doctor” and was loved by his patients. In 1845, at the age of 23, he published a treatise on thrombosis and hemostasis, which identified the risk factors for the formation of blood clots, now known as Virchow’s triad. That year he also described leukemia, and pulmonary and cerebral emboli, rejecting the dogma that they formed in situ, as opposed to originating elsewhere and migrating to the lung or brain.

In 1845, in two famous speeches to the Friedrich-Wilhems Institute, Virchow vigorously espoused a model of medical practice based on clinical observation, chemical analysis, animal experimentation, and necropsy, including microscopic examination. He explicitly rejected medical theories founded on postulated but unproven theories based on “vital forces” and the humoral imbalances of disease that dated to Hippocrates and were generally accepted by leading physicians at the time. In 1846 he passed his licensure examination and succeeded Siegfried Froriep as hospital prosector at the Charity Hospital. This provided him with a respectable salary and rent free accommodation, a very important benefit as at the time, a living wage was not a given for practicing physicians. In 1847 he published papers on uric acid secretion in the fetus and newborn. He described the pulmonary fungal infection aspergillosis. He differentiated between what he described as splenic and lymphatic types of leukemia, that we now call lymphoid and myeloid leukemias. He also described osteocytes in bony lacunae. In 1847 some of Virchow’s papers on thrombosis and hemostasis were rejected by a prominent medical journal. In response, he established his own journal. This journal, Archives for Pathologic Anatomy and Physiology and Clinical Medicine, was co-edited by Virchow and Reinhardt until Reinhardt’s death in 1852, and then edited by Virchow until his death in 1902. It is now known as Virchow’s Archive and remains to this day published and respected.

The doctor

In 1847-1848 a typhus epidemic ravaged Upper Silesia, a desperately poor, predominantly Polish part of Prussia. The epidemic was very prevalent among weavers and was affecting the overall Prussian economy. Virchow was sent by the Prussian government to study the epidemic. One of the observations he made was of patients who likely had kwashiorkor, a form of protein-calorie malnutrition. The epidemic and the poverty of the inhabitants had a profound effect on Virchow. He came to conclusions about poverty and its role in the causation of disease and epidemics.

Virchow’s report to the Prussian government caused a stir. Among its conclusions was that the epidemic was due to poor living conditions, including poor diet and hygiene. He condemned the economic system where hereditary, often absentee landlords, known as Junkers, controlled the land and means of production, and were often exempt from paying taxes. He condemned the educational system, where most of the population spoke only Polish, and most of the teachers spoke only German. He concluded that “the government had done nothing for Upper Silesia.” His recommendations included a separation of Church and State, as a Lutheran church linked to the Prussian state was of little benefit to a Polish, Catholic population; full democracy; shifting taxes from poor workers and farmers to rich Junkers; the adoption of Polish as an official language; the improvement of agriculture and roads; the forming of agricultural cooperatives; the reopening of orphanages to care for children orphaned from the epidemic; and the local administration of relief funds. It would be an understatement to write that his report was poorly received by the Prussian government. Eight days after it was submitted, however, Virchow was on the barricades in Berlin, fighting against that government.

Virchow’s most productive period as a pathologist was in Wuerzburg, when he essentially was in internal exile from 1849 to 1856. Part of this work was a repudiation of Hippocrates’s humoral theory of disease and of a theory of Rokitansky who had performed approximately 60,000 autopsies and believed that when an anatomic cause could not be identified, death could be explained by blood dyscrasias causing blastema (acellular material) to spawn abnormal cells that led to disease.

In Wuerzburg, Virchow’s efforts led to widespread acceptance of the cell theory: omnis cellula e cellula, each cell stems from another cell. However, in a series of lectures in 1858 later published as a book Cellular Pathology as Based on Physiological and Pathologic Histology, the cell theory was advanced and gained acceptance. In tribute, the first volume was dedicated to Goodsir, who in 1825 had first coined the term “cell theory.”

In Wuerzburg Virchow also defined hypertrophy and hyperplasia, distinguished between fatty infiltration and degeneration; described amyloid; and postulated a relationship between chronic inflammation and malignancy. In Cellular Pathology, he wrote: “There is no life but through direct succession, thus every cell is derived from a preexisting one…. The body is cell state in which each cell is a citizen…. Disease is a conflict between the citizens of the state caused by outside forces…. Disease is not something personal or special, but only a manifestation of life under modified conditions, operating according to the same laws that apply to the living body at all times.” In short, Virchow insisted on direct observation as a basis for medical conclusions and denied imbalances (dyscrasias) and lack of special vital or healing forces as a basis for disease.

In Virchow’s time, direct observation had its limits, which likely led to most of Virchow’s major errors. Thus, Virchow denied bacteria’s role in the causation of tuberculosis and believed, at least until near his death, that pulmonary tuberculosis was a non-specific form of chronic pneumonia. He also resisted the theory that a single bacterium could lead to disease, however, he did postulate that bacterial toxins could cause illness. He opposed many valid theories about bacterial origins of disease and had misconceptions about diphtheria, typhus, cholera, yellow fever, plague, leprosy, influenza, and the benefit of anti-toxin therapy. He did, however, reverse himself on almost all of his errors by 1901. Sadly, while Virchow adopted methods recommended Ignatz Semmleweis, a Hungarian physician working in Vienna who discovered that cleanliness and handwashing by obstetricians greatly reduced puerperal fever, he, like most prominent physicians, only belatedly and reluctantly acknowledged Semmleweis’ contribution.

A notable example of Virchow using his influence to improve public health is his role in the construction of the Berlin sewers. In 1859 he was elected a member of the Berlin city council. He believed that citizens had a constitutional right to a healthful existence, that disease was often related to poor living conditions, and that epidemics were man made. In 1868 typhus reappeared in Berlin and East Prussia, and there was a very high rate of infant mortality. At that time waste disposal consisted of cesspools and outdoor privies and was often transported and used as fertilizer. Only one quarter of houses had water closets. Deep gutters carried domestic and industrial waste to city canals and the Spree River. Waste gathered in city streets after a heavy rain. Virchow thought that water did not have to smell to be unhealthy and that waste was contaminating the water supply leading to disease.

In the late 1860s Virchow prepared a new sewerage system for Berlin. He studied sewers in Paris and other cities and concluded that cesspools and wells needed to be eliminated; in 1868 he published an article “Canalization or the Night Cart System?” which concluded that a sewer drainage system for rainwater, liquid offal, and excrement was necessary. Virchow consulted experts, set up committees, and examined financial, scientific, and technical problems in order to get the sewers built. He was confident that adaptation of sewerage farms as used in England would reduce disease. Construction of the sewers was started in 1874 and Virchow’s prediction of a dramatic reduction in disease was born out.

Among other contributions, Virchow advocated the use of hospitals for patient care, instruction, and research. He established schools of nursing. He described the pathologic changes of rickets, characterized echinococcal cysts, described fungal nails, discovered the amino acids leucine and tyrosine, published a standard autopsy protocol, advocated an internationalist approach to medicine, and participated in numerous international conferences. He described the lifecycle of Trichinella and instituted meat inspection in Germany and essentially eliminated it by 1900 (as opposed to around 1960 in the United States). Aware of the link between human and animal diseases he invented the term “zoonosis,” advocated cooperation between physicians and veterinarians, and lectured veterinary students. He described ochronosis, disproved the hereditary nature of leprosy, equipped hospital trains, and worked to improve conditions in schools, military barracks, and prisons, and eliminate child labor.

The statesman

On March 18, 1848, eight days after returning from Silesia, a revolution against the government erupted in Berlin, as elsewhere in Europe, and Virchow was fighting on the barricades. Temporarily, at least, liberals and democrats forced monarchs to accept outside influence. But their victory was short lived. By 1849, reactionaries (upper bureaucrats, royalists, Junkers) were restored to power and an obedient parliament was put in place. The government suspended Virchow for his political activities. He was reinstated, but with reduced privileges, prior to accepting a position in Wuerzburg. In 1856, Virchow became professor at Berlin University. In 1861, William I was appointed regent and then became king. William was originally believed to be a liberal and a brief “political spring” occurred in the late 1850s during which Virchow’s interest in politics was reawakened. This view of William proved to be premature; he was a professional soldier who believed he ruled by divine right. By 1861 Virchow had co-founded the German Progressive party and was elected to the Prussian parliament. In the 1861 elections, led by Virchow, it became its largest party. In February 1862 William dissolved parliament when his army reforms were refused. In the 1862 elections the Progressives and their allies achieved a majority in parliament. A compromise between parliament and the army was almost reached, but was rejected by William. Then William nominated the ambassador to France, Otto von Bismarck, to be prime minister and minister of foreign affairs.

Bismarck was brilliant and cynical. He sent deputies home without mandated budget laws and ruled unconstitutionally by decree until 1866. Virchow resisted Bismarck’s efforts. In 1865 Bismarck, an experienced dueler, challenged Virchow. Legend has it that as the one challenged, Virchow, could choose the weapons and decided on pork sausages, cooked for him, and raw and filled with trichinella for Bismarck. Although Bismarck was successful in his subsequent plans, Virchow did not give up political work. He remained on the Berlin city council until his death, and was elected to the Reichstag in 1880.

The anthropologist

Anthropology and the related area of archeology were Virchow’s main interests after 1870, but his work in this field began earlier. In 1865 he discovered pile dwellings in Northern Germany. In 1869 he co-founded the German Anthropological Association and in 1870 he founded the Berlin Society of Anthropology, Ethnology, and Prehistory and edited its journal until his death. Also in 1870 he excavated hill forts in Pomerania. Interestingly, he excavated wall mounds in Wollstein with Robert Koch in 1875 and edited Koch’s paper on the subject. His work in this area would eventually lead him to Bulgaria, New Guinea, the Andaman Islands, Egypt, the Caucasus, and Turkey.

In 1871 an error during the Franco-Prussian war greatly affected Virchow’s work in anthropology. The Musée des Jardins des Plantes in Paris was accidentally shelled by German artillery. In response, Armand de Quatrefage, a French naturalist, published La Race Prussienne in which he contended that German unity was due to anthropological accidents, that Prussians were racially Finns of Mongolian descent, and that the “Finnoprussians” were a barbaric destructive race. Virchow initially responded with a “rant” in 1872, but then set about to refute de Quatrefage with three scientific studies. A study of the Finnish race identified three racial types among modern Finns. A craniologic study of Germans, especially the Frisians, and an enormous survey of German school children. Teachers administered a survey to 6,760,000 students. It studied color, not measurements, and Jewish children were studied separately. Many rumors circulated about this study, perhaps the most amusing is that the King of Prussia lost a card game to the Sultan of Turkey and lost 40,000 fair-haired children in the bet.

The conclusions of the study were a disappointment to those who believed in a superior Germanic race. Virchow stated that nowhere were Germans, or any other nationality, racially uniform; less than one third of Germans were fair skinned, blue eyed, and blond (although he determined that Prussians were blonder than other Germans). He noted that a significant number of Prussians were dark and a significant number of Jews were blond. He concluded that the concept of a master or Aryan race was “Nordic mysticism” and that there was no evidence for the superiority of any race or nation. Throughout his life Virchow worked closely with Jews and fought anti-semitism. He was involved in the abolitionist movement, and regarded anti-semites as crude and ignorant. He also believed that the European colonization of Africa was folly and he unsuccessfully worked against Germany acquiring colonies. One of Virchow’s most famous quotes, is “If different races would recognize one another as independent co-laborers in the great field of humanity, if all possessed a modesty which would allow them to see merits in neighboring people, much of the strife now agitating the world would disappear.”

In 1901 there were many celebrations of Virchow’s 80th birthday. On January 4, 1902 he fractured his femur jumping from a moving streetcar. He predicted the bone would heal, but the forced inactivity would lead to his rapid decline and death. He died of heart failure on September 5, 1902.

Conclusion

It is amazing how much one man was able to accomplish. Virchow was curious and intellectually honest. He worked very hard, but by most accounts was pleasant company and never seemed rushed. He was an excellent teacher devoted to his students. He enjoyed music and an occasional beer, but had no time for sports or hobbies. In 1850, at the age of 28, he married Rose Mayer, 17 years his junior, daughter of Carl Mayer, a pioneer in the modern practice of obstetrics and gynecology. They had six children. He enjoyed hiking during his vacations, and often made formal observations of various phenomena during his walks. He advocated vivisection, but showed compassion for experimental animals. His offices were always cluttered, and he had a terrible handwriting. He wrote most of his papers in one sitting. He was extremely self-confident, yet he refused the honorary title “von Virchow”. Despite his problems with Bismarck, he was very patriotic. He was very forgiving, writing laudatory articles and making speeches praising former adversaries such as de Quadrafage, Behring, Rokitansky, and others. He was utilitarian, once remarking on research: “if it doesn’t cure patients, what good is it?” He was in good health nearly all his life despite working as a pathologist without gloves or a mask. He only slept two or three hours a night. His career coincided with great technical improvements in the quality of microscopes and the use of dyes to stain tissue. Most importantly, Virchow believed that physicians should be “attorneys for the poor” and have an obligation to society, and especially, society’s least fortunate.

 


Elliot Weisenberg, M.D., Departments of Pathology, Advocate Illinois Masonic Medical Center, The University of Illinois at Chicago, and Rosalyn Franklin University of Medicine and Science.