HOW EDWARD VII NEARLY WASN'T

William Boyd investigates how the prejudices

of the most famous surgeon in Britain almost cost the life of a future sovereign

ON 13 JUNE 1902 Edward VII had under a fortnight to wait until his coronation. On that day the King travelled from Bucking- ham Palace to Aldershot to review a parade of troops. He did not feel well and it was observed that his normally florid complexion was blanched and drawn. By the 14th he was complaining of pains in the abdomen and nausea.

Edward was a prodigious eater and drinker and his personal physician, Sir Francis Laking, suspected that these symp- toms were the familiar ones brought on by His Majesty's compulsive overindulgence. He prescribed a laxative and confidently expected matters to resolve themselves naturally. It was not to be. On the night of the 14th the King suffered violent spasms of abdominal pain and repeated vomiting. Laking called in an eminent surgeon for consultation, Sir Thomas Barlow. The two men feared the worst: King Edward VII was afflicted with perityphlitis.

Perityphlitis is one of the forgotten names in the medical lexicon. It was used to refer to the mysterious and inevitably fatal 'abdominal affections of the right side' that had been killing people for thou- sands of years. The cause was obscure but the symptoms were remorseless: abdomi- nal pain, followed by vomiting, fever, intestinal inflammation and ultimately death from general peritonitis — the inflammation and corruption of the serous membrane which lines the abdominal cavity.

The disease was a potent killer: in 1856 one study showed that out of 47 cases of perityphlitis only one survived. Over the years countless victims' corpses had been dissected and their innards poked about and pored over, but it wasn't until 1812 that a surgeon suggested that this fatal inflammation of the abdomen might be caused by an initial inflammation of the vermiform appendix, a small worm-shaped attachment of the blind gut.

`Appendicitis', as the disease came to be known towards the end of the 19th centu- ry, was very much an American appella- tion. American surgeons, in particular McBurney and Fitz, were in the vanguard of the treatment of the disease. Unlike sur- geons in Europe, they advocated the earli- est possible removal of the appendix as soon as the symptoms appeared. In Europe this was regarded as modish, not to say perverse, nonsense.

If, in the 19th century, as a European, you were afflicted with appendicitis you would be dosed with opium and purgatives and it would be hoped the problem would disappear of its own accord. If not, and if an abscess appeared around the appendix and grew as it filled with pus, it would be hoped that a natural process of capsula- tion would then occur that would seal off the abscess from the abdominal cavity. The argument ran that the American method of early intervention created greater risks of general infection: it was too precipitate, better to wait until capsu- lation had occurred and then drain off the offensive matter. There was no greater advocate of this procedure, and no one more sceptical of the American way, than Britain's most eminent surgeon, Frederick Treves, and it was he who was now called to the King's bedside.

Frederick Treves (1853-1923) was a self- made man, the son of a cabinet-maker who had risen to the heights of the medical pro- fession. In 1902 he was internationally recognised as a brilliant surgeon and the authority on diseases of the abdomen and gut. He was a prolific writer and his medi- cal textbooks were in standard use. More than this, he was a friend and confidant of King Edward and Queen Alexandra and was sergeant-surgeon to the monarch from 1901.

Additional renown had accrued in the 1880s after his care and handling of Joseph Merrick, the so-called 'Elephant Man'. It was Treves who formulated the adage that a good surgeon needs 'a lacemaker's fin' gers and a seaman's grip'. He might have added that, in what we now recognise as the dawn of modern surgery, a good sur- geon also required an adamantine ego and unswerving ambition. Treves possessed all these attributes and in the small world of Edwardian medicine he guarded his pre- eminence jealously.

Treves was called to Windsor on the 18th where he confirmed the earlier diagnosis of perityphlitis. True to his own methods, he proposed waiting a while before operating to ensure that the capsulation should be completed. Treves visited the King daily, and then, on the 21st, an improvement was observed. The King's temperature dropped and the abdominal swelling appeared to go down, and he felt well enough to travel to London.

The coronation, set for the 26th, seemed likely to take place as planned, the abdomi- nal pains apparently cured by the tradition al doses of opium. But on the afternoon of the 23rd the pain returned and with it fever and repeated vomiting. The remission had been short and it was decided that an open' ation should take place on the morning of the 24th. Treves was to act as surgeon; also present were Laking, Lord Lister and the surgeons Barlow and Smith. Edward VII was grossly corpulent — Idsd waist measurement was 48 inches — an Treves had to cut to a depth of almost five inches before he found the abscess, forte' nately still encapsulated, surrounding die, remains of an almost completely destroyeu appendix. Treves then cut into the abscess and the pus was discharged. The resulting cavity was cleaned and two rubber drainage tubes were inserted. The wound was dressed with iodoform gauze. As Treves s biographer Stephen Trombley* comments' `Contrary to contemporary reports and cur; rent misinformation, Treves did 0, remove the King's appendix. The belie; that Treves and the King combined make appendicitis "fashionable" is founded.' Treves deliberately did not remove the appendix, and he would have been appalled to think that he had done afe thing to popularise 'appendicitis'. But t fact is that he took a massive risk in Pro,

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ceeding the way he did and in not removing

the appendix. It was now vital that the wound cavity close of its own accord, but from the bottom up, as it were. Any other form of healing might give rise to a sinus which could provoke other complications. The few days or so after the operation were anxious ones, as the surgeons and doctors waited apprehensively for any sign of the symptoms of general peritonitis. Luckily for them, King Edward made a good recovery, and by mid-July was fit enough to convalesce for three weeks on the royal yacht. The coronation eventually took place on 9 August.

Treves was credited with saving the King's life (and was duly made a baronet), yet there is a school of thought which would allege that in fact he needlessly endangered it. His insistence on waiting for some days before operating, his surgi- cal intervention occurring finally when the King was in extremis, and then his decision not to remove the appendix and only to d. rain the abscess were in line with prevail- ing medical orthodoxies. But they were far from being unchallenged orthodoxies, even in 1902.

Indeed, there was a consensus of well- informed medical opinion and overwhelm- ing evidence that indicated that the swift removal of the appendix was the only truly successful method of treating these abdominal inflammations. Each of Treves's decisions could have resulted in King Edward's death: the delay and the reliance on opium could have caused the abscess to rupture; the tendency to operate Only at the last minute often provoked peritonitis rather than relieved it, or was so late as to be redundant; and to leave the remains of the ulcerated appendix in the wound and to rely on chance that it would little properly can be argued, with even a

ittle hindsight, to be instances of malprac- tice, Why was Treves, who throughout his Career was such an innovator, such an advancer of surgical practice, so remiss when it came to the saving of his sovereign's life? The answer lies, I would suggest, in a curious blend of xenophobia, vanity and shameful remorse.

In 1888 Frederick Treves removed a vermiform appendix, and laid claim to be the first man in Britain to do so. However, there is no doubt that the honour in dis- covering that the appendix was the root of so many abdominal inflammations went to American surgeons. Treves, for all his pio- neering work, was an also-ran and his sub- stantial ego was unhappy with this state of affairs. He sought repeatedly to denigrate all the American advances in this field, using every resource of patronising mock- ery and pompous cynicism at his disposal. His disappointed vanity led him uncharac- teristically to adopt the most conservative of approaches in this area of his expertise. Most surprisingly for a surgeon, as Tromb- ley observes, Treves did not advocate surgery. His preferred method of treating 'perityphlitis' was by medical means bed rest and opiates. His wilfulness was to have tragic consequences.

In 1900, Treves's daughter Hetty, aged 18, fell ill with abdominal pain. Treves did not diagnose appendicitis. Hetty became iller and iller, feverish and vomiting. For some reason, Treves refused to see what was happening. Eventually, inexorably, other symptoms appeared that indicated that, as a result of her father's delay, Hetty had contracted peritonitis. Treves decided to operate but two colleagues persuaded him that it was pointless. Hetty died in great physical distress. It is almost impossible to imagine Treves's feelings at this time, and he never

spoke of the enormous grief and guilt he must have felt. Yet he did write about it, obliquely. In 1923, the year he died, Treves published a curious story called The Idol with Hands of Clay. It tells the story of a young surgeon who, convinced of his own mastery of his craft, decides to operate on his own wife when she falls ill with appen- dicitis. During the operation he makes a fatal mistake and his wife falls into a coma, the surgeon struggles to save her, and yet he is unable to do so and she dies in his arms.

Some glimpse of Treves's response to his own tragedy is made available here:

[The surgeon] caught a sight of himself in the glass. His face was smeared with blood. He looked inhuman and unrecognisable. It was not himself he saw: it was a murderer with the mark of Cain upon his brow. He looked again at her handkerchief on the ground. It was the last thing her hand had closed upon. It was a piece of her lying amidst this scene of unspeakable horror. It was like some ghastly item of evidence in a murder story. He could not touch it. He could not look at it. He covered it with a towel.

And yet this terrifying object lesson made him an even stauncher opponent of the new advances occurring in America. By ironic happenstance, a few days before he operated on Edward VII Treves gave a lec- ture on appendicitis in Hammersmith Town Hall, a talk which was a sneering exemplar of his contempt for the American surgeons as well as being both patently wrong and purblind about medical matters. He stated with arrogant confidence, 'The very great majority of all cases of appen- dicitis get well spontaneously .. . [another 'Is there a non-vocal model?' fact] which I think should be emphasised as strongly as the last one, is this: opera- tion during an acute attack of appendicitis is attended with great risk to life.'

Four days later, the man who held these opinions had to operate on his king.

Treves was very lucky. Edward VII was even luckier, and no thanks to his sergeant-surgeon. Treves's hubris, negli- gence or wilful obstinacy had caused the death of his daughter. That same wilful obstinacy could easily have caused the death of Edward VII. It is intriguing to speculate what the course of the nation's history, and perhaps Europe's, might have been if George V had come to the throne in 1902 instead of 1910.

In Treves's case, however, the analysis is not so speculative. The death of his daugh- ter, as the story demonstrates, shocked him terribly. In such a situation, what could he have done? To admit all his thinking and public statements about appendicitis were wrong would be to com- pound the guilt unbearably. The only way I can understand this aberrant behaviour in an otherwise innovatory and brilliant sur- geon is that for Treves so doggedly to per- sist with his old discredited theories, to continue to think he was right and the Americans were wrong, allowed him to live with himself more easily; the more he scoffed and sneered, the more it allowed him to see his daughter's death as a tragedy and not as something of which he was directly culpable.

More relevantly, when the same set of symptoms recurred in his monarch, for Treves then to advocate the swift removal of the royal appendix would also have been a tacit admission of the fatal misdiag- nosis of his daughter, just two years earli- er. Because of his personal grief, the barely admitted guilt he felt, Treves had to recommend bed rest and opiates to his dangerously ill king.

He nearly got away with it. The remis- sion of the 21st, 22nd and 23rd June seemed to bear out everything he had said in the Hammersmith lecture. But when the pain and the vomiting returned, Treves had to contradict his own best medical advice and undertake an operation during an acute attack of appendicitis. But even then he could not go all the way and remove Edward's appendix. The ruined vestigial organ was left in the King's body, almost, one might say, as a small symbolic gesture of medical defiance — the final act of a man who could not admit he had been wrong.

© William Boyd 1994 *Sir Frederick Treves by Stephen Trombley (1989). Treves's wife destroyed all her hus- band's private papers and this is the only biography of Treves. I am indebted to Trombley's fine book for many of the facts recorded here. All suppositions, however, are my own.