Wilfred Trotter: surgeon, philosopher

Abstract

There is no significant biography that records the accomplishments of Sir Wilfred Trotter, who was a general surgeon in its pure sense at a time when surgical specialization was in its infancy. Trotter was born in the 1870s in England. Despite being bedridden during his childhood with a musculoskeletal condition he was able to study medicine at London University, and eventually became Professor and Chair of Surgery at the University College Hospital, a position he held until his death in November 1939. He made many contributions to surgical care, particularly in the field of oncology. He attended to many famous people, including King George V and Sigmund Freud and was greatly honoured in his own milieu. He was named honorary surgeon and Sargent Surgeon to the king. In addition, he was a thoughtful individual who addressed problems in human behaviour, contradicting the stereotype of the contemporary surgeon.

University of Toronto President David Naylor, when he was dean of the Faculty of Medicine, communicated with academic staff on the exciting future for investigative medicine.¹ To accentuate the need for progressive thinking, Dr. Naylor cited a relevant quotation by the “famous surgeon Wilfred Trotter”who wrote “a new idea is the most quickly acting antigen known to science.” Although Trotter was indeed a famous surgeon he came from an older era with a different culture, such that despite Naylor's citation and description, Sir Wilfred's fame has diminished, and his name is unlikely to be recognized by most surgeons today.

Early days

Wilfred Louis Batten Trotter (Fig. 1) was born in Coleford, Gloucestershire, England,² on Nov. 3, 1872. His father was a businessman. His early years were unremarkable except for the fact that he was bedridden with some form of musculoskeletal disease during childhood. He nevertheless bore his illness well, survived and entered the University of London's University College Hospital (UCH) in 1891 where he obtained a Bachelor of Medicine with distinction followed by a Bachelor of Science degree, a gold medal and scholarship. He completed his surgical training and applied for a staff appointment to the UCH only to be rejected in favour of a contemporary. This forced him to work as a demonstrator of anatomy until 1906, when Sir Victor Horsley, the pioneer neurosurgeon, resigned from the UCH surgical staff, allowing Trotter to gain a staff appointment there.

FIG. 1. Wilfrid Trotter, 1872–1939.

Even though Trotter's career proved to be stellar in all of its varied aspects — practice, teaching and academia — there is no signal biographical work extant to record his achievements. Even when one resorts to the omniscient Internet for information, there is scant referral to Sir Wilfred.

His surgical career

At a time when surgical specialization was in its infancy,^3–7 Trotter was the ultimate general surgeon. He made outstanding contributions to standard textbooks of surgery, describing his particular interest, namely subdural hemorrhage. He was a pioneer in the use of thyroidectomy for the management of Graves' disease at a time when neither radioactive iodine nor antithyroid drugs were available. He was particularly interested and skilled in the surgical treatment of malignant tumours in the head and neck, and he developed various surgical approaches. One was the median labiomandibular glossotomy, which provided access to pharyngeal cancers. He had also devised a quadrilateral flap for a surgical approach to the viscera of the head and neck, called the Trotter flap. This flap was used by Dr. Harold Wookey of the University of Toronto to create a neopharynx, a pioneer refinement after laryngopharyngectomy that permitted significant patient rehabilitation. Trotter also lent his name to a syndrome of nasopharyngeal cancer that caused deafness and weakness of the palate.

By 1920 he had become esteemed among his peers, assuming the position as prime consultant in surgical oncology, particularly as it affected cancer of the upper respiratory tract. In 1928 he was asked to consult on King George V who lay gravely ill. Trotter (perhaps with others) recognized that the king's illness was due to a misdiagnosed pulmonary empyema, which Trotter treated successfully by a rib resection, resulting in the king's full recovery. Initially he refused any reward, but eventually he was knighted and named honorary surgeon and Sargent Surgeon to the king as a direct result of his work. Trotter received many other honours. He became an executive participant of the Royal College of Surgeons of England, the Royal Society, the Association of Surgeons and the Royal Society of Medicine. Numerous honorary degrees were bestowed upon him. He was called upon frequently to deliver named lectureships to students, faculty and colleagues. The most august lecture that he delivered was the Hunterian Oration in 1932 for which he took as his subject “the commemoration of great men.”

His abilities were considered almost mythical by contemporaries,^3,4 who noted that he would do “his personal very best for patients” and “no gentler hands were ever given to a surgeon.” He was said to show “technical skill in operating” and “an uncanny feel for diagnosis.” Although he was not known as an ingratiating or ideal teacher — perhaps because of an acerbic wit and aloof demeanour — he surprised many when during the mid-1930s he gave up private practice and dedicated himself to the direction of the hospital's surgical teaching unit. Here, he became a patient mentor and supervisor of surgeons in the making, and “spent his day stimulating their brains and teaching them from his experience.”³ In 1935, following the retirement of Professor Choyce, Trotter was appointed to the Chair of Surgery at UCH. He continued there, although he had poor health in his later years, until he died on Nov. 25, 1939, shortly after the outbreak of World War II.

Trotter's relationship with Ernest Jones

From the viewpoint of Trotter's accomplishments in practice, teaching, consultancy, invited lecturerships and executive participation in various medical associations, one can easily appreciate his reputation as an eminent surgeon. However, there was more to the charisma Trotter exhibited so effortlessly. His thoughtfulness and introspectiveness despite his aloofness impressed his colleagues that he had special character. He seemed to exemplify the ideal surgeon of a modest English prototype of that time.

Early on in his student days, Trotter befriended a school chum,⁸ Ernest Jones, a man who became the first British psychoanalyst and classical biographer of Freud. Trotter and Jones shared consulting rooms in the early years of their practices in Harley Street. Trotter had written a book entitled The Instinct of the Herd in Peace and War in which he discussed the phenomenon of group pressure in determining individual behaviour in an attempt to stimulate man's self-awareness. The book has been considered a significant sociologic treatise.

In the early 1900s Trotter drew Jones's attention to the review of a new book called Studies in Hysteria by a man named Freud. Thus, Jones became for the first time in his life aware of Freud, recognizing quickly a similarity not only of interests but even techniques in approaching patients whose hysterical illness presented as physical derangements.

Trotter and Jones then attended the very first psychoanalytic congress together, which was held in 1908 in Salzburg, Austria. However, about this time, Jones was accused of sexual impropriety by a young female patient. He withdrew from medical life and left England to work in Toronto under Professor C.K. Clarke, a Canadian pioneer in psychiatric education and practice.

Along with his long-time mistress, Loe Kan, and younger sister Elizabeth, Jones set up his home in the Bloor and Bathurst area in what was then considered Toronto suburbia. In his autobiography entitled Free Associations, Trotter emerges as the most important person after Freud, and was venerated by Jones. In 1913, after another episode of a similar risqué accusation by a female patient, Jones returned from Toronto to England to establish a psychoanalytic practice as well as a psychoanalytic institute. Trotter took pains to make it clear that he was intent on distancing himself from Jones in order to pursue his surgical career, which he did most successfully. The two, however, must have had an ongoing relationship. About 1912, Jones's sister Elizabeth, who had been operated on by Trotter, decided to return home from Canada in response to correspondence by an eligible suitor. Trotter became aware of her intentions and dramatically appeared on the railway platform on her arrival in London. He proposed marriage to her, a proposal she immediately accepted. Jones has stated, “I doubt if they had ever been alone together. They had certainly never written to each other and the only intimate passage between them had been an operation he had performed on her thyroid gland. Theirs was as successful a marriage as I have known.”⁸ Jones and Trotter were brothers-in-law, and while the closeness of their early years together had now evaporated, Jones nevertheless persisted in appealing to Trotter for his assistance regarding problems affecting the health of his immediate family and acquaintances. Freud was an acquaintance who had been permitted to leave Austria by the Nazis in 1939 largely because of intercession by Jones who brought him out physically to London. Freud had undergone treatment for oral cancer by mandibulectomy and en bloc maxillectomy 16 years previously as well as various radiation treatments, reoperation and local fulgurations. Freud brought with him not only his immediate family and housekeeper but his own personal physician, a Dr. Schur, who lived in Freud's home.^7–9 Following their arrival in London and additional treatments Schur became convinced that Freud had a further recurrence of his cancer. Trotter was brought in by his brother-in-law to see Freud as the consultant who was the acknowledged superior force in British surgical oncology. The diagnosis was elusive, but eventually the cancer became obvious and Freud underwent further futile radiation therapy. Trotter was consulted regarding Freud subsequently and recognized that the tumour was inoperable. He counselled against any further intervention.

Trotter's legacy

In 1946,¹⁰ Trotter's papers were published, with an introduction by his son (Dr. W.R. Trotter), consisting of various addresses he had made on such matters as “art and science in medicine” and “has the intellect a function?” How different these addresses are from the lectures given by contemporary academic visitors, which exemplify the efficiency of the electronic age in describing such things as quality control, molecular biology and robotic surgery. There does not seem a place these days for such patrician matters as “has the intellect a function?” Trotter's essays if read characterize the man he was — thoughtful, analytic, deliberative over ideas and aspects of human behaviour. He was recognized as a surgeon philosopher in an age and culture that admired such an exemplar. If one thinks of the varied directions that Trotter's talents and mind took him, one may regret a passing age, where the leisurely rumination of the nature of man, science, the value and making of good doctors were so well presented and appreciated. In an address to students undertaking their hospital training in 1932, Trotter stated “the uniformity of thought is an increasingly apparent goal and demand of civilization. Still there burns on in most of us a small wild spark. I advise you to nourish it as a precious possession. Really to think for oneself is as strange, difficult and dangerous as any adventure. As the wise ones say, it will do you no good, but like virtue which it does not otherwise greatly resemble, it will be its own reward.” The philosopher surgeon had indeed spoken well.¹⁰

Competing interests: None declared.

Correspondence to: Dr. Irving B. Rosen, 600 University Ave., Ste. 1521, Toronto ON M5G 1X5; fax 416 586-4654; irosen@mtsinai.on.ca