Frederick Treve's first surgical operation for appendicitis

Sir Frederick Treves, baronet (1853–1923), surgeon and author, was born at 108 Cornhill, Dorchester, Dorset, on 15 February 1853, the youngest son of William Treves, an upholsterer, and his wife, Jane (1814–1892). He attended Dorchester Grammar School and then Merchant Taylors' School in the City of London. He read medicine at the London Hospital, where, among others, John Hughlings Jackson and Jonathan Hutchinson taught him. In 1875 he qualified as a Member of the Royal College of Surgeons, having in the previous year become a Licentiate of the Society of Apothecaries. After a job as House Surgeon at the London Hospital, he became Resident Medical Officer at the Royal National Hospital for Scrofula (later the Royal Sea Bathing Hospital) at Margate in 1876, to which his brother William (Frederick's senior by 10 years) was Honorary Surgeon. His research on scrofula, the origin of which puzzled him, would be published as a book entitled Scrofula and its Gland Diseases in 1882, the very same year that Robert Koch demonstrated that it was due to a bacillus.

Treves went into practice in Wirksworth, Derbyshire, having married Anne Elizabeth Mason in 1877, with whom he had two daughters. He passed the Fellowship of the Royal College of Surgeons in 1878 and in the following year gave up practice in Derbyshire to return to the London Hospital as Surgical Registrar. He was appointed Assistant Surgeon in September 1879 and became Full Surgeon in 1884, at 31 years of age. He became a Demonstrator of Anatomy in the medical school attached to the London Hospital and built up a reputation as a teacher and writer and a leading surgeon. His consulting room at 6 Wimpole Street became one of the most popular in England.

In 1883 the Royal College of Surgeons, of which he was one of the Hunterian professors of anatomy in 1885 and Erasmus Wilson Lecturer in Pathology in 1881, awarded him the Jacksonian prize for a dissertation on ‘The pathology, diagnosis and treatment of obstruction of the intestine’ (1884). Treves had a particular interest in the condition known as perityphlitis. He operated on his first case on 16 February 1887, and later read a report to the Society, as reproduced here. He advocated the operative treatment of appendicitis, although he advocated delaying surgery until a quiescent interval had been reached. Note that in this first operation, Treves did not in fact remove the appendix; he merely straightened out a kink and then closed the abdomen,¹ though his practice soon changed to the removal of appendices. After The Philadelphia Medical News published a report by Thomas George Morton, who had excised a partially perforated appendix on 27 April 1887, Treves wrote the following letter to the journal, published on 5 November 1892²:

“I have just read with interest a leading article in the Medical News for August 6 on the matter of operative treatment of the vermiform appendix. The fact that I live in a remote island, and further that a holiday of 2 months has taken me away from the haunts of books, must explain this tardy allusion to that paper.

“The article discusses the origin of the operation for removing the vermiform appendix, and it is stated that to Dr Thomas G. Morton belongs the credit of first devising this procedure; the suggestion is also made that the operation should be called ‘Morton's operation,’ and it is asserted that Morton's operation embodies one of the most important and radical advances of modern surgery. Dr Morton thus becomes the founder of what will, I suppose, be known as ‘Appendiceal Surgery,’ should the present love for ridiculous terms survive.

“I gather that Dr Morton's first operation was performed in 1888, and was reported in the Philadelphia County Society's Transactions for that year. The nature of the transaction is not stated. Who first excised the appendix some musty and forgotten tome will no doubt reveal in the course of time … In 1886 a patient with relapsing typhlitis came under my care at the London Hospital, and after due consideration, I proposed to ‘deliberately seek for and remove his appendix.’ I operated on him during a period of apparent health, on February 16, 1887, and was able to correct the distortion of the appendix without removing it. He made a perfect recovery. On September 19, 1887, I brought the matter before the Royal Medical and Surgical Society. The paper was read in February, 1888. I advised the treatment of selected cases of relapsing typhlitis by the deliberate removal of the offending appendix during a quiescent period. The proposal was not well received. In due course, however, an exuberant reaction took place, and of late appendices have been removed with a needless and illogical recklessness which has brought this little branch of surgery into well-merited disrepute.

“Discussions on questions of priority constitute the most pitiable and petty items in the literature of medicine. The object of [this] letter is merely to bring up from oblivion an unpretending paper which lies buried in the annals of an ancient society.

Believe me to remain, yours faithfully,

FREDERICK TREVES”

In his account of a case of relapsing typhlitis treated by operation, Treves wrote that the terms ‘typhlitis’, ‘perityphlitis’, and ‘paratyphlitis’ meant much the same, namely “an inflammation in the vicinity of the caecum”. However, he pointed out that the term ‘typhlitis’, implying inflammation of the caecum, was usually a misnomer, since it was inflammation of the vermiform appendix that was important. He had presumably not read a paper by the American pathologist R.H. (Reginald Heber) Fitz that had been published in 1886 in the American Journal of Medical Sciences, in which he wrote that “As a circumscribed peritonitis is simply one event … in the history of inflammation of the appendix, it seems preferable to use the term appendicitis to express the primary condition.”³ It has been said that when James Murray proposed including the word ‘appendicitis’ in the New English Dictionary (later to be called the Oxford English Dictionary) he was dissuaded from doing so by the Regius Professor of Medicine at Oxford, William Osler, who said that the word was medical jargon and would not last. However, the word would have appeared in the second fascicle, Ant–Batten, which was published in November 1885, so this story seems doubtful. The word was included in the first supplement to the dictionary, which was published in 1933. Treves himself inveighed against the term: “One knows that the academical-minded have a great objection to this uncouth term ‘appendicitis’; it lacks precision, but it has found its place in the clumsy nomenclature of medicine, and has been accepted by the public with an extraordinary amount of generosity”.⁴

Treves retired from the active staff of the London Hospital in 1898 at the age of 45, primarily as a result of his extensive private practice. In 1899, on the outbreak of war in South Africa, he volunteered to serve as Consulting Surgeon in the Boer War, and on his return to England was appointed Surgeon-Extraordinary to Queen Victoria in 1900. In 1900 Treves published an account of his experiences of the South African War, under the title The Tale of a Field Hospital. He was made Companion of the Most Honourable Order of the Bath and Knight Commander of the Royal Victorian Order in 1901. Many further honours were conferred upon him in his lifetime; for example, he was appointed Sergeant-Surgeon to Edward VII (1902) and to George V (1910), and created Knight Grand Cross of the Royal Victorian Order (1905).

On 24 June 1902, 2 days before the date fixed for his coronation, Edward VII became acutely ill with perityphlitis. His physicians in attendance called for Treves and, after consultation with Lord Lister and Thomas Smith, he operated to drain the abscess. The king protested, “I must go the Abbey,” but Treves was adamant: “Then Sire, you will go as a corpse.” The king made a good recovery and was crowned on 9 August. Treves became known worldwide and was created a baronet in the same year. By 1901, Treves had removed a thousand appendices. Yet appendicitis that progressed to peritonitis claimed Treves' daughter Hetty in 1900, despite his belated surgical intervention.

Treves has also found fame for the case of Joseph Carey Merrick (1862–90), better known as the Elephant Man. Merrick was disfigured by a congenital condition that until recently was thought to have been due to neurofibromatosis, but was probably Proteus syndrome.⁵ He had been exhibited as a freak in an empty shop opposite the London Hospital in Whitechapel Road by Tom Norman, an entrepreneur acting as his agent. Treves was appalled by Merrick's treatment, and after meeting him presented Merrick to the London Pathological Society at 53 Berners Street, Bloomsbury, on 2 December 1884. When Merrick returned penniless in 1886 after touring Europe, Treves took him into a vacant room in the London Hospital in Bedstead Square and treated him for exhaustion, malnutrition, and bronchitis, overseeing his treatment and spending time getting to know him. When Merrick died in 1890, his remains were cast in plaster, specimens were taken, and Treves dissected the body. The remains are on display at the Royal London Hospital Museum. Treves' account of the case of Joseph Merrick, The Elephant Man and Other Reminiscences, was published in 1923.

After the First World War, during which he served at the War Office as President of the headquarters' medical board, Treves moved to Lake Geneva in Switzerland with his family. He died at the Clinique de Rosemont in Lausanne on 7 December 1923, most probably from peritonitis. His ashes were buried on 2 January 1924 in the cemetery of St Peter's Church, Dorchester. His friend, Thomas Hardy, who chose the hymns, attended the ceremony and later wrote a poem for the occasion published in The Times, titled In the Evening. In Memoriam Frederici Treves, 1853–1923 (Dorchester Cemetery, 2 January 1924):

In the evening, when the world knew he was dead,
He lay amid the dust and hoar
Of ages; and to a spirit attending said:
“This chalky bed? –
I surely seem to have been here before?”

“O yes. You have been here. You knew the place,
Substanced as you, long ere your call;
And if you cared to do so you might trace
In this gray space
Your being, and the being of men all.”

Thereto said he: “Then why was I called away?
I knew no trouble or discontent:
Why did I not prolong my ancient stay
Herein for aye?”
The spirit shook its head. “None knows: you went.

“And though, perhaps, Time did not sign to you
The need to go, dream-vision sees
How Aesculapius' phantom hither flew,
With Galen's, too,
And his of Cos – plague-proof Hippocrates,

“And beckoned you forth, whose skill had read as theirs,
Maybe, had Science chanced to spell
In their day, modern modes to stem despairs
That mankind bears! …
Enough. You have returned. And all is well.”

Eponyms associated with Frederick Treves

Treves' folds: two inconstant folds of peritoneum

Treves' ileocaecal fold: an ileocaecal fold of peritoneum associated with the appendix

Selected bibliography by Frederick Treves

Scrofula and its Gland Diseases (1882)

Surgical Applied Anatomy (1883; 7th edition, 1918)

Intestinal Obstructions (1884)

A Manual of Surgery (1886)

A German–English Dictionary of Medical Terms, with H. Lang (1890)

A Manual of Operative Surgery (2 volumes, 1891)

The Student's Handbook of Surgical Operations (1892; 5th edition, 1930)

A System of Surgery (2 volumes, 1895)

The Tale of a Field Hospital (1900)

The Other Side of the Lantern (1905)

Highways and Byways of Dorset (1906)

The Cradle of the Deep (1908)

Uganda for a Holiday (1910)

The Land that is Desolate (1912)

The Country of ‘The Ring and the Book’ (1913)

Riviera of the Corniche Road (1921)

The Lake of Geneva (1922)

The Elephant Man and Other Reminiscences (1923)

DECLARATIONS

Competing interests

None declared

Funding

None

Ethical approval

Not applicable

Guarantor

MR

Contributorship

Both authors contributed equally

Acknowledgements

This paper was originally published as Chapter 21 of Doctoring History by Manoj Ramachandran and Jeffrey K Aronson, published by the Royal Society of Medicine Press in 2010