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Figure 1.
The Elephant Man. BMJ. 1886;2:1189.

The Elephant Man. BMJ. 1886;2:1189.

Figure 2.
Sir Frederick Treves. Vanity Fair. July 19, 1900.

Sir Frederick Treves. Vanity Fair. July 19, 1900.

1.
Tibbles  JARCohen  MM  Jr The Proteus syndrome: the Elephant Man diagnosed. BMJ. 1986;293683- 685
PubMedArticle
2.
Cohen  MM  Jr Understanding Proteus syndrome, unmasking the Elephant Man, and stemmingelephant fever. Neurofibromatosis. 1988;1260- 280
PubMed
3.
Biesecker  LG The multifaceted challenges of Proteus syndrome. JAMA. 2001;2852240- 2243
PubMedArticle
4.
Bouzas  EAKrasnewich  DKaoutroumandis  M  et al.  Ophthalmologic examination in the diagnosis of Proteus syndrome. Ophthalmology. 1993;100334- 338
PubMedArticle
5.
Sheard  RMPope  FMSnead  MP A novel ophthalmic presentation of the Proteus syndrome. Ophthalmology. 2002;1091192- 1195
PubMedArticle
6.
Burke  JPBowell  RO'Doherty  N Proteus syndrome: ocular complications. J Pediatr Ophthalmol Strabismus. 1988;2599- 102
PubMed
7.
Treves  F A case of congenital deformity. Trans Path Soc London. 1885;36494- 498
8.
Treves  F The Elephant Man and Other Reminiscences.  London, England Cassell & Co1923;
9.
Sykes  AH The Doctors in Vanity Fair.  Kendall, England Titus Wilson & Son1995;111
10.
 Sir Frederick Treves [obituary]. Lancet. 1923;21325
11.
Trombley  S Sir Frederick Treves, the Extra-Ordinary Edwardian.  London, England Routledge1989;
12.
Treves  F Surgical Applied Anatomy.  London, England Cassell and Co1883;
13.
 Sir Frederick Treves [obituary]. Br Med J. 1923;21185- 1189Article
14.
 The case of Sir John Millais: passages from the notebooks of Sir FrederickTreves. Br R Coll Surg Ann. 1961;28384- 388
15.
 The case of Sir Henry Irving: passages from the notebooks of Sir FrederickTreves. Br R Coll Surg Ann. 1961;29265- 268
16.
Mackenzie  W A Practical Treatise on the Diseases of the Eye. 3rd London, England Longmans1840;523- 534.
17.
Doyle  AC Round the Red Lamp.  London, England Methuen & Co1894;v
18.
Hayward  WB The royal surgeon talks at ease. New York Times. April6 1924;14
19.
 LM The Elephant Man and other reminiscences. New Republic. 1924;3924
20.
 The Elephant Man. Br Med J. 1923;1335Article
21.
 The Elephant Man and other reminiscences. Lancet. 1923;1547- 548
Special Article
January 2004

Sir Frederick Treves and Sympathetic Ophthalmia

Author Affiliations

From the Section of Ophthalmology, Medical College of Ohio, Toledo.

Arch Ophthalmol. 2004;122(1):99-103. doi:10.1001/archopht.122.1.99

Sir Frederick Treves (1853-1923) is best known as the doctor and protectorof the Elephant Man, Joseph Merrick (1862-1890) (Figure 1). Broadway plays, a movie, and several books have describedTreves' relationship with this horribly deformed man who is now consideredto have had Proteus syndrome rather than the earlier hypothetical diagnosisof neurofibromatosis. Proteus syndrome is a rare disorder characterized bypatchy, irregular overgrowth of multiple tissues. Partial gigantism of thehands and feet, hemihypertrophy, pigmented nevi, soft tissue tumors, and macrocephalyare some of its features.13 Typicalocular findings are strabismus, amblyopia, epibulbar lesions, high myopia,and heterochromia iridis.46 Trevesreported that the Elephant Man's eyes, orbits, and cranial nerves were normal.7

SURGICAL FAME

Treves was the most important surgeon in England a century ago, famousfor having successfully operated on King Edward VII for appendicitis in 1902,just a few days before the King's coronation. He was affiliated with the LondonHospital and the Royal London Ophthalmic Hospital (Moorfields). Treves wroteseveral important medical texts and nonmedical best sellers. The Elephant Man and Other Reminiscences,8 firstpublished the year he died, was the most popular of all his books and is rememberedtoday for the vivid description of Merrick. This book deserves appreciationby ophthalmologists for another story, "A Restless Night," which concernssympathetic ophthalmia.

A caricature of Treves appeared in Vanity Fair magazinein 1900 (Figure 2), 2 years beforehe operated on King Edward VII. The caption comments that when he went offto school,9

no one predicted him an income of so many thousands as he hasmade for years past; when he began to walk the London Hospital no one suggestedhim as Hunterian Professor of Anatomy, or Wilson Professor of Pathology ofthe Royal College of Surgeons: yet he was both these things many years ago.. . he is a bold and skilful [sic] operator, who has written many standardworks on Surgery, and has described some wonderful cases and some remarkableoperations. . . . He is a cheery fellow with an alert manner who can tella story well.

Treves received his medical education at the London Hospital MedicalSchool, where he was strongly influenced by 2 famous faculty members, thesurgeon Sir Jonathan Hutchinson and the neurologist Hughlings Jackson. Aftera brief period in general practice, he returned to the London Hospital asa house staff officer in surgery and quickly climbed the academic ladder.He was a very effective teacher with a charismatic effect on his students.His lectures were clear, precise, and delivered with a touch of dry humor.He could control an audience of unruly medical students or entertain a crowdof street toughs. Students respected Treves for they knew that royalty consultedhim at his private office and that he gave excellent care to the common manat the London Hospital. (This institution, recently renamed the Royal LondonHospital, provided indigent care in a rough district of London and treatedthe largest number of acute surgical cases in England.)

Treves' interests ranged widely. As consultant surgeon to the LondonZoological Garden, he was able to dissect many different species, some asexotic as the Sumatran rhinoceros, and published detailed reports of comparativeanatomy. He was a trim, athletic man with a commanding presence and a sharptongue. His teaching method included "a constant flow of sarcasm" directedat his students and house staff officers.10 Whenan assistant equivocated on a diagnosis, Treves replied,11(p28)

The patient is not interested to know that it might be measles,or it might be a toothache. The patient wants to know what is the matter,and it is your business to tell it to him or he will go to a quack who willinform him at once.

Treves was very efficient in the operating room. He would describe eachcase clearly to all observers, knew exactly what he wanted to do, and didso with excellent results. A crowd of students and visitors from all overthe world regularly followed him on hospital rounds. He worked very hard andwould often return to the hospital on Sundays to examine patients more thoroughlythan he could on teaching rounds. An exhausting bicycle ride of 40 to 50 milesoften followed hospital rounds on Sundays. He was a certified master marinerwho loved to sail across the channel to France, even when challenged by Decemberweather. His students greatly admired him as a teacher and surgeon, and knewhe could better them in nearly any athletic endeavor on land or sea.

His home life was simple and efficient. He would rise at 5 AM every day and write for several hours before breakfasting at 8 AM. The rest of the morning was spent in teaching and hospital rounds.The afternoons were devoted to surgery and private patients. Dinner took placeat home with his wife and 2 daughters. He tried to limit hospital and medicalsociety meetings to one evening per week. His quiet family life included onegreat tragedy, however. Although known as the English master of surgery forappendicitis, Treves was placed in the unenviable position of operating onone of his own daughters when 2 other surgeons demurred. Unfortunately, heoperated too late, and she died shortly afterwards. He was more successfulin the case of Edward VII less than 2 years later. The King then became hisclose personal friend and relied on Treves when making many decisions, bothmedical and social.

In 1907 the King developed a lesion just below the left eye, and Trevesarranged for a physician with the curious name of Bismuth to remove it usingelectrolysis. The King held the leads in each hand, completing an electriccircuit, but unfortunately no one realized that one wire rested on a goldchain he wore around his neck. He screamed out "I am being cut in half," startlingeveryone. Following this fiasco, Treves had the dermatologist who had convincedSir Arthur Conan Doyle to become an ophthalmologist, Malcolm Morris, completethe removal in a pain-free manner. A piece of radium was attached to the King'sspectacles for therapy over several weeks, destroying the lesion.

When Treves was a demonstrator of anatomy at the London Hospital, hewas asked to write an anatomy text for surgeons. SurgicalApplied Anatomy12 was first publishedin 1883 and became a classic used by generations of students, with the lastedition published in 1962. His publisher considered him the ideal author becausehe promised to deliver the manuscript of the text within 4 months, and setthe date and even the time it would be completed, to the great pleasure ofhis editor13:

The promise was literally fulfilled—my first and last experienceof the kind in a long editorial career. The circumstance revealed to me thatone of his chief characteristics was precision—a quality I afterwardsfound him to exemplify in everything he did. His industry was amazing.

Treves published many articles and books on surgical subjects. He wasparticularly interested in unusual cases and presented many to the PathologicalSociety of London. The Elephant Man was his most celebrated case, but he describedmany others, usually publishing the reports in respected journals such as The Lancet and the British Medical Journal.

In 1921, Treves was asked to write an autobiography that would includeanecdotes about many of the famous individuals he had treated. At first Treveshesitated, saying "people don't want to read my muck,"11(p vii) then agreed to write the book. A few months later he deliveredthe manuscript to the publisher, who found it the best autobiography he hadever read. A week later, Treves called the publisher and asked him to meetat a bank and bring along the manuscript. When they met, Treves grabbed themanuscript and locked it in a safety deposit box, telling the publisher thatthe medical director of a rival publishing firm strongly advised him not topublish details about his patients, especially any story dealing with histreatment of royalty and the court. After Treves died his widow destroyedmost of his papers, saying the public would have to remember him for the workhe had done. (Fortunately, at least 2 of the chapters survived the destruction.His descriptions of medical aspects of the lives of the artist Sir John Millais14 and the actor Sir Henry Irving15 havebeen published.) As a consolation prize, Treves offered to write a differenttype of book about his patients who were relatively unimportant figures. Thiswas the origin of The Elephant Man and Other Reminiscences,8 which is a mixture of fact and fiction.

A CASE OF SYMPATHETIC OPHTHALMIA

"A Restless Night" is a fictional story in The ElephantMan and Other Reminiscences.8 It isnarrated by a physician who is passing through an Indian desert and happensto meet a surgeon serving in the Indian Medical Service. They travel togetherfor a day, then stop for the night at a traveler's bungalow in a remote wasteland,the closest village being far across the plain. The small, decrepit rest houseconsisted of a central room and bedrooms on either side. Each bedroom containeda small bed, but no bedding, a solitary chair, a worn table, and a partiallysilvered mirror. One door led to the common room while another opened to adrab bathroom that contained an unpainted tin bathtub. Each man had a servantwho made the bathroom table appear more homelike by emptying the contentsof their dressing bags on it.

After dinner the men sat in the central room, smoked, and shared stories.The Indian Medical Service surgeon described his experiences in the region,including "his conflicts with pessimistic patients and his struggles withfanaticism and ignorance." He said the average Indian "had more confidencein a dried frog suspended from the neck than in the whole British Pharmacopoeia."8(p139)

One of his recollections was unforgettable. It was the tale of a stonemason from a nearby village with an eye that had been penetrated by a stonefragment. Following the injury, the eye became inflamed and the visual acuitywas reduced to just light perception. Aware of the possibility of sympatheticophthalmia after such an injury, the surgeon advised the mason to have hisinjured eye removed promptly, but the man preferred to consult a magician.When the uninjured eye developed inflammation, the mason returned to see thesurgeon, who felt it was probably too late for enucleation of the injuredeye to reduce the involvement of the good eye, but recommended doing so. Hefelt that removing the blind traumatized eye would make the mason feel betterand had little chance of making him worse.

Sympathetic ophthalmia was a well-known complication of penetratingocular trauma. Hippocrates had described the relationship of injury to oneeye giving rise to disease in the other. William Mackenzie gave the entityits name and published a clear description of the process in 1840.16 Early in the 20th century, as now, prompt removalof the traumatized eye was the only known means of preventing the diseasein the uninvolved eye.

Unfortunately, enucleation was too late to help the stone mason. Theuninjured eye was involved by this time and he became totally blind. He blamedall his misfortunes on the surgeon and created a furor at the Indian MedicalService clinic. Shrieking, he8(p141)

cursed the man of healing with a vehemence which should havebrought down fire from heaven. He called upon every deity in the Indian mythologyto pour torments upon this maimer of men, to blast his home and annihilatehis family root and branch. He blackened the sky with curses because the darknesswhich engulfed him prevented him from tearing out with his nails the eyesof this murderous Englishman. Foaming and screaming, and almost voicelessfrom the violence of his speech, he was led away to stumble about his village,where for weeks he rent the air with his awful imprecations. Whether the poorman was now alive or dead the doctor could not say, for he had heard no moreof him.

The Indian Medical Service surgeon had stayed in the bungalow many timesbefore, and always slept in the right-hand bedroom. However, this particularevening the narrator's servant placed the surgeon's belongings in that room.The surgeon did not look forward to spending the night in a room that hadall the discomforts of a prison cell. He locked the door that led to the commonroom and bolted the door that led from the bathroom outdoors. When the onlylamp was blown out, the room became pitch dark, silent, and stifling. A briefperiod of sleep was interrupted by the pattering of animal feet coming towardthe bed and a musky odor. He heard a rat climb onto the bed, another crawlover his clothes, while still one more hit his shoehorn, creating a clatter.Finding this more than he could take, he jumped out of bed, screaming. Therewas a scuttle of small feet toward the drain hole in the outer wall of thebathroom. When silence resumed, he tried to go back to sleep, but the patterof feet and sickening odor returned. Suddenly a sound arose from under thebed "that made every vein in my body tingle." It was a scraping he felt wasdue to a belt buckle rubbing the cement floor, worn by a man crawling on hisstomach. At the same time a small animal with cold paws and hot fur crawledover his bare foot. He jumped out of bed, shouted, and lit a match. The roomappeared empty, but he could not see under the bed. He used another matchto light the lamp which he placed on the floor. A skull-like object came intoview. It was only a dried up piece of bread the rats had been dragging aroundthe room that had made the scraping noise.

Now convinced the room was empty, he moved the bathtub to the outerwall to block the drainhole. He returned to bed and left the lamp lit. Hewas able to sleep again and fell into a dream that continued the evening'sevents. He dreamt that the bathroom door began to open and a hand emerged,followed by the body of a middle-aged Indian man, lean, sinewy, naked, andblind. The eyelids were closed and the sockets were as sunken as a cadaver.The native used his left hand to navigate along the wall and held a stonemason's pick in his right hand. The narrator realized this was the man thatthe surgeon had described earlier that evening. The native had learned ofthe surgeon's arrival, knew which room he usually occupied, and had come tomurder him. Dreaming still, the narrator8(p148)

was so fascinated by the sight of this unhuman creature movingtowards me that I could not stir a muscle. . . . I was so filled with thesense of a final calamity that I felt I had ceased to breathe.

The figure crept along, his teeth glimmering and breath audible.8(p149,150)

In another moment that awful pick would crash into my skull orplunge into my neck. . . . I was mesmerized as would be a rabbit in a cornerwithin a foot of a snake.

The sound of the lamp flame crackling aroused him to roll off the bedquietly onto the floor, between the couch and the wall. While laying on thefloor he could see the sinewy feet of the man and hear "the awful hand movingstealthily over the very pillow."8(p151) From under the bed he seized the man by the ankles and jerked him forward,so that his head crashed on the hard floor. The doctor ran out the bathroomdoor onto the Indian plain where the air was refreshingly cool, the sky fullof stars, and a faint sign of dawn was visible in the distance. The senseof relief was only temporary, replaced by the panic. Had he killed someone?He returned to the bedroom, where the lamp was still lit, but the man wasgone. A patch of blood lay on the floor where the man's head had hit the cementfloor. He awoke, feeling alarmed, cold, and tired. Finding no blood on thefloor, he was relieved to know it was all a nightmare but found it nearlyimpossible to believe the events were not real.

The Elephant Man and Other Reminiscences8 is written in a style typical of turn of the 20thcentury British fiction. It is comparable to Sir Arthur Conan Doyle's Round the Red Lamp,17 acollection of 15 medical stories based on Doyle's experience as a physician.Even though Doyle specialized in ophthalmology before forsaking medicine infavor of fiction, his book does not emphasize eye problems. Doyle's prefacecan serve as an answer to critics who objected to the stark realism of thetales in Treves' The Elephant Man and Other Reminiscences.8 Doyle wrote "if you are anxious tomake your doctors something more than marionettes, it is quite essential thatyou should paint the darker side."17 Doylerealized that doctors do see some beautiful aspects of life, including "fortitudeand heroism, self-sacrifice and love" but felt that these attributes resultfrom bitter sorrow and tribulation. "One cannot write of medical life andbe merry over it," he stated. Doyle felt painful situations are aspects ofreality and appropriate subjects for an author. Doyle thought a shocking storysuch as "A Restless Night" may be bitter, bracing, and more effective thana saccharine tale.

The Elephant Man and Other Reminiscences8 was widely reviewed, nearly always favorably. The New York Times praised Treves for his sympathy, understanding,and ability to look into "the inner consciousness of a strange company ofpeople with emotional experiences of life common alike to the caveman andthe man of the twentieth century."18 The New Republic described Treves as a good raconteur, a surgeonwith a vast supply of haunting tales that were not for those with a queasystomach.19 The British MedicalJournal admired his skill in bringing out "in sharp relief some aspectof human life and character," and Treves' ability to achieve a vivid effect"with economy of language," incorporating humor, tragedy, and even terror.20The Lancet noted,21

Anyone who has worked for years in a great hospital must haveaccumulated a store of facts dealing with various aspects of human naturein which the pathetic and the comic are intimately blended. Few, however,put their recollections into print, and fewer could do so with the blend ofhumour and charity

of Sir Frederick Treves. In the case of the Elephant Man, Treves hada true story that simultaneously repelled and attracted the public, for Merrickwas a spectacularly ugly man with an engaging personality. Capitalizing onthe theme of sympathetic ophthalmia, Treves was able to develop a totallydifferent medical subject into an entertaining horror story.

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Article Information

Corresponding author and reprints: James G. Ravin, MD, 3000 RegencyCt, Toledo, OH 43623 (e-mail: jamesravin@aol.com).

Accepted for publication June 20, 2003.

References
1.
Tibbles  JARCohen  MM  Jr The Proteus syndrome: the Elephant Man diagnosed. BMJ. 1986;293683- 685
PubMedArticle
2.
Cohen  MM  Jr Understanding Proteus syndrome, unmasking the Elephant Man, and stemmingelephant fever. Neurofibromatosis. 1988;1260- 280
PubMed
3.
Biesecker  LG The multifaceted challenges of Proteus syndrome. JAMA. 2001;2852240- 2243
PubMedArticle
4.
Bouzas  EAKrasnewich  DKaoutroumandis  M  et al.  Ophthalmologic examination in the diagnosis of Proteus syndrome. Ophthalmology. 1993;100334- 338
PubMedArticle
5.
Sheard  RMPope  FMSnead  MP A novel ophthalmic presentation of the Proteus syndrome. Ophthalmology. 2002;1091192- 1195
PubMedArticle
6.
Burke  JPBowell  RO'Doherty  N Proteus syndrome: ocular complications. J Pediatr Ophthalmol Strabismus. 1988;2599- 102
PubMed
7.
Treves  F A case of congenital deformity. Trans Path Soc London. 1885;36494- 498
8.
Treves  F The Elephant Man and Other Reminiscences.  London, England Cassell & Co1923;
9.
Sykes  AH The Doctors in Vanity Fair.  Kendall, England Titus Wilson & Son1995;111
10.
 Sir Frederick Treves [obituary]. Lancet. 1923;21325
11.
Trombley  S Sir Frederick Treves, the Extra-Ordinary Edwardian.  London, England Routledge1989;
12.
Treves  F Surgical Applied Anatomy.  London, England Cassell and Co1883;
13.
 Sir Frederick Treves [obituary]. Br Med J. 1923;21185- 1189Article
14.
 The case of Sir John Millais: passages from the notebooks of Sir FrederickTreves. Br R Coll Surg Ann. 1961;28384- 388
15.
 The case of Sir Henry Irving: passages from the notebooks of Sir FrederickTreves. Br R Coll Surg Ann. 1961;29265- 268
16.
Mackenzie  W A Practical Treatise on the Diseases of the Eye. 3rd London, England Longmans1840;523- 534.
17.
Doyle  AC Round the Red Lamp.  London, England Methuen & Co1894;v
18.
Hayward  WB The royal surgeon talks at ease. New York Times. April6 1924;14
19.
 LM The Elephant Man and other reminiscences. New Republic. 1924;3924
20.
 The Elephant Man. Br Med J. 1923;1335Article
21.
 The Elephant Man and other reminiscences. Lancet. 1923;1547- 548
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