by Peter Ford
Treves was now able to live up to the aspiration of owning a home in Bloomsbury, where he occupied 18 Gordon Square with his wife and two baby daughters. Other honours and publications followed, and he found he could only get through all his commitments by observing a stringent self-discipline, rising as early as five or six each morning to write, study or catch up on correspondence before proceeding to his main duties of lecturing and operating throughout the day in the Medical School. The surgeon’s task was heavy and exacting. One house governor of the London Hospital recalled how Treves’s operating coat became so stiff with congealed blood that it stood upright without visible means of support when placed on the floor.
Already Treves had developed the combination of brusque directness and glimpsed moments of bluff yet genuine kindness the public mind associates with eminent physicians. He became immensely popular with many of his students, to whom he preached a message of self-reliance: that they should rely on their judgement, make a firm decision and unhesitatingly act on it. The student who said to him one day about a case, ‘It might be a fracture, sir, or it might be only sprained,’ was sharply rebuked: ‘The patient is not interested to know it might be measles or it might be toothache. The patient wants to know what is the matter, and it is your business to tell him or he will go to a quack who will tell him at once.’
Despite his many professional duties, he still found time to speak for the Temperance Society on ‘Alcohol: a Poison’; and to become chairman of the medical section of the Mission to Seamen. Then, with the year 1884, he was elected to the position of full consulting surgeon to the London Hospital.
Another change of life-style became necessary. He now had to build up a private consulting practice to bring him fees to make up for the fact that this was no salaried post, though he would continue to receive fees for his teaching and he had, of course, royalties from his published writings. Promptly he moved his family from Bloomsbury to 6 Wimpole Street, where he was able to set up consulting rooms in the heart of the Harley Street area.
It was a period of industrial depression, when few working-class families had as much to live on as £1 10s. (£1.50) a week. Yet, as Treves knew, at least one of his colleagues at the hospital, Sir Andrew Clark, was earning over £12,000 a year. ‘Considering the number of patients who can comfortably be seen between nine and two o’clock and the number of visits that can be managed between two and seven,’ Sir Andrew once wistfully remarked, ‘I see no hope of improving that figure.’ On the other hand, income tax had just been reduced from 8d. to 7d. in the pound.
The world, in a very real sense, was on the verge of opening out at Treves’s feet. And this was precisely the stage his life had reached on the day when Dr Tuckett told him about the very odd Elephant Man to be seen in a freakshow across the road from the London Hospital, and was persuasive enough to make him decide to go and take a look.
CHAPTER 3
A Living Specimen
Eventually they stood facing each other in Treves’s room in the Anatomical Department of the Medical School of the London Hospital.
We cannot begin to guess at what the freak from the exhibition shop made of Frederick Treves, this tall young surgeon, broad-shouldered and athletic in build, intensely observant and self-assured, possessing indeed a master’s sailing certificate for his recreational yachting activities on the Dorset coast; a man who had already witnessed in his professional life most of the varieties of disease and physical distortion induced by environment, behaviour or genetic misfortune in the slums of the world’s greatest metropolis, but who had never come across anything quite like the Elephant Man before.
By contrast, we know what Frederick Treves made of Joseph Merrick as he measured him up and stripped him finally naked to the point where he was fully revealed as the most bizarre spectacle imaginable. Yet, of the man himself, he says little. ‘He was shy, confused, not a little frightened and evidently much cowed. Moreover, his speech was unintelligible … I supposed that Merrick was imbecile and had been imbecile from birth.’ The emphasis of the examination was on the physical aspects: to pass a tape measure round the head and limbs, finger the skin, assess the movement of the joints, hold back the shapeless blubber of the lips with a spatula to examine the inside of the mouth. There were massive abnormalities of the skin and flesh as well as some obvious and extraordinary distortions in bone structure. Meticulously Treves charted every feature, recorded each peculiarity that he could discover on the appalling map of Merrick’s body, but seemed to have hardly begun to approach any closer to an explanation in this chaotic anatomical wilderness.
The proportions were grotesque: a measurement of 36 inches was recorded for the head’s circumference, another of 12 inches for that of the right wrist and one of 5 inches for the most swollen finger of the right hand. Yet Merrick was a short man, scarcely more than 5 feet 2 inches in height. In the skin Treves felt he could recognize two distinct abnormalities. First, there was an abnormality of the soft, subcutaneous tissue that lay immediately beneath the skin. It seemed in places to have greatly increased in quantity so that in these regions the skin was raised up above the surrounding tissue. Where this happened, the skin was so loose on the body that it could be slipped about quite easily, or grasped and drawn away from the deeper tissue in folds.
In three areas these changes were so marked that the weight of the skin drew the tissues down into pendulous folds that hung almost like curtains of flesh from the body. One of these folds, about six inches square, hung in front of the right armpit, taking its root from the surface of the right breast and shoulder. A similar but less conspicuous fold hung down behind the armpit. It was in the buttocks, however, that the process was most marked. Here the skin flap was so thick and extensive that at first sight it looked as though the buttocks themselves descended in a great fold reaching almost to the level of the mid-thigh. So heavy and awkward was this fold of flesh that it tended to interfere with the functioning of the bowel and the action of defecation.
The second abnormality Treves recognized in the skin was the presence of numerous warty growths or papillomata. These varied in size from small pimple-like roughenings of the skin to huge cauliflower-textured masses. Their size and number varied between different areas of the body. In fact, the skin of the left arm was free from blemish, and parts of the face, and the eyelids and ears, seemed unaffected; the penis and scrotum were perfectly normal. Over the chest and abdomen the warts were small and sparse, but over the back of the head, and from between the shoulder blades down to the lower back and buttocks, they spread out as exuberant growths of dusky purplish skin, deeply cleft and fissured. From the largest of these warty growths there rose the exceedingly foul odour that Treves first noticed in the exhibition shop.
If the skin changes made Joseph hideous, however, it was the skeletal changes which made him misshapen; but again, not all of the body was affected. Metamorphoses in the bones seemed to be confined to the skull, the bones of the right arm and hand and those of each leg below the knee.
The skull was enormous. It was completely irregular in shape, its surface being covered by huge rounded bosses of bone, some of them larger than tangerines. The most conspicuous bony lump stood out on the brow, but there were others to the side and back of the head. The whole left side of the head actually seemed to bulge out immediately above the ear, so that the ear was itself folded downwards almost at a right angle. It was extremely difficult to trace the complete surface of the skull with any precision, for over most of the scalp the skin had produced cauliflower-like masses and folds of loose skin in abundance.
The bones of the face were similarly distorted. The forehead was unduly large, uneven and rather protuberant, making the eyes appear small and set back deeply in the head. The bones of the right cheek were also much enlarged, so that the cheek was hard and prominent. The swelling here had pushed the hard palate forward and down and forced the nose and mouth somewhat to the left. When the mouth was open it was possible to see a s
car where a piece of tissue had evidently been removed at some time by an operation; the lower jaw seemed quite normal.
The right arm was greatly inflated, being two or three times the size of its fellow. Treves gained the impression that every bone in the limb, apart from the shoulder blade and collar bone, was uniformly enlarged, but there were none of the knobbly swellings upon the bones that were so prominent in the skull. The fantastic distortions of the bones had almost crippled the arm, for when Treves tried to manipulate it he found that, while it could be moved fairly freely at the shoulder and elbow, the wrist and fingers were so stiff as to make the hand almost useless. Merrick could not, for example, turn this particular hand over and back again. The hand meanwhile was weirdly deformed, its huge misshapen fingers crowding one another into deformity and even partial dislocation of the joints. Strangely enough, though, the finger nails on the hand were perfect. As if in mocking contrast, the left arm was completely unaffected, having a delicacy and neatness of proportion that made Treves think of the arm of a young girl.
Both feet were distorted in a manner similar to the right arm, the bones being uniformly enlarged and the toes malformed and enormous. Merrick’s posture illustrated the presence of the old disease of his left hip that Treves had already diagnosed, for he stood with his left leg held stiffly forward and away from the body. Apart from the tell-tale sign of a former hip disease and the various changes to the skin and bones, however, Treves could find little else amiss. The irony was that the Elephant Man apparently enjoyed good health in all other respects, suffering from no serious illness apart from his mysterious condition and even possessing an appreciable muscular strength.
As the examination and interview proceeded, so Treves became more accustomed to the Elephant Man’s distorted fluting voice and was able to add a little to his background knowledge of the man. The operation to the upper jaw, he gathered, had been carried out a year or two earlier in Leicester Infirmary. A developing tumour of the connective tissue in this area had apparently grown to the extent where it projected so far beyond the mouth that Merrick could no longer close his lips or masticate or move his jaw effectively. The surgeons at Leicester therefore advised him that it should be cut away.
Treves tried to discover whether there was any evidence for similar deformities occurring in Merrick’s family. Apparently there were none. Merrick stated that he had neither brother nor sister. His head, right arm and feet had been badly deformed for as long as he could remember, but when he was a child his skin was no more than roughened, loose and rather thick. The story of the profound shock suffered by his mother when bowled over by a circus elephant was once more offered as a helpful clue.
In writing ‘The Elephant Man’ Treves conveys the impression that once he had completed his examination he returned Merrick to the care of the showman at the end of the day and that was the last he saw of him during the present stage of the story. Again this is a simplification of events for he certainly remained in touch with Joseph Merrick and Tom Norman over several days. Some time during this period, if not during the initial clinical interview, he arranged for the first photographs to be taken. He also persuaded Mr Norman to allow his charge to be brought as a case for discussion and diagnosis before the eminent members of a learned medical society, the Pathological Society of London.
It seems reasonable to speculate that there would at this point have awakened in poor Joseph Merrick’s heart, if not the wild hope of a cure, at least the chance of a wise, informed explanation or an assurance that something might be done to halt the encroachments of his disease.
Meetings of the Pathological Society of London were held on alternate Tuesday evenings at 8.30, at the headquarters of the society at 53 Berners Street, in Bloomsbury. Advance notice of meetings was always given in the British Medical Journal, together with a list of cases to be presented; it was also usual for a summary of any meeting to appear in the journal’s following issue.
The British Medical Journal for 29 November 1884 was already in the press with its notice of the next meeting on Tuesday, 2 December, and the seven items listed for exhibition. Mr Frederick Treves was down simply to display two cases of tumour of the palate. He must have moved quickly, uncertain about how long he could remain effectively in touch with a case as peripatetic as a travelling freakshow exhibit. He sought and gained permission to display Joseph as an additional item at the 2 December meeting.
The Pathological Society of London was a highly respected institution. It had been in existence for thirty-eight years and was to flourish through to 1932, when it voluntarily disbanded so that it might be reconstituted as the Pathological Section of the present Royal Society of Medicine. It drew members not only from among London pathologists, surgeons and physicians, but also from doctors who worked in many of the leading provincial medical centres. A number of the society’s members were not only eminent in the field of medicine but were also associated with the realms of biology and the related sciences.
On 2 December Joseph Merrick was duly conveyed during the evening from Whitechapel to Bloomsbury. It must have surprised him to find himself the only living exhibit presented, or, for that matter, the only complete exhibit in the lecture room. All the other displays consisted merely of organs or sections of tissue removed from patients during an operation or at a post mortem.
Joseph’s appearance as he entered certainly caused a stir among the society’s members. The most astonished of them was John Bland-Sutton, the assistant surgeon from the Middlesex Hospital who had chanced on the Elephant Man’s freakshow before Treves.
My surprise was great [he wrote] a fortnight later to find this man exhibited by Treves at the Pathological Society of London. He not only submitted Merrick for examination by members of the Society, but published a detailed and illustrated account of this unfortunate man in the Transactions for 1885.
Could there be just a hint in this comment that Bland-Sutton felt Treves was being a little theatrical in his choice of a case; that it lay perhaps on the borderline of medical discretion to have put it forward; that there was maybe even a touch of the showman’s instincts in the action?
Yet while the Elephant Man may have been seen in his freakshow by other gifted medical personalities, the fact remains that it was Treves who took the initiative in deciding that here was a case which demanded an explanation. In fact, apart from the first murmurs of surprise, there seems to have been little response from the members. No one came forward with any constructive suggestion, and the problem of diagnosis was carried no further. The digest of the meeting that appeared in the British Medical Journal for the following week simply stated:
Congenital Deformity – MR TREVES showed a man who presented an extraordinary appearance, owing to a series of deformities: some congenital exostoses of the skull; extensive papillomatous growths and large pendulous masses in connection with the skin; great enlargement of the right upper limb, involving all the bones. From the massive distortion of the head, and the extensive areas covered by papillomatous growth, the patient had been called ‘the elephant-man’.
The correspondent for the Lancet evidently shared Bland-Sutton’s reservations over the propriety of demonstrating such a sensational case before the society. A lengthy account of the meeting that the journal published contains no mention whatsoever of Joseph’s presence.
It seemed as if Treves was fated to be left with his original vague diagnosis of a congenital deformity, and that Joseph, none the wiser for his brief sojourn among higher medical authorities, must return to the care of Mr Tom Norman and the relentless round of earning his living on the freakshow circuits. For most doctors that would have been the end of their attempts to solve such a puzzle; but Frederick Treves lacked nothing in determination. Four months later he tried again. It seemed to him just possible that, by putting the case forward one more time, having given adequate notice in the medical journals, some doctor or specialist with knowledge of such a strange condition might be encouraged to at
tend the meeting; or, alternatively, that the lapse of time might have allowed some of those who saw Joseph Merrick previously to consider the problem at leisure.
By now Treves knew nothing of the whereabouts of Merrick, but he had the photographs and he had the data and clinical findings from his first examination. These he was able to present to the meeting of the Pathological Society of London which was held on Tuesday, 17 March 1885. On this occasion his endeavours attracted a response. Among those gathered for the meeting was Dr Henry Radcliffe Crocker.
Radcliffe Crocker was then just forty years old, a physician from University College Hospital, London, who had specialized in diseases of the skin. As a student he had come under the influence of the late Dr Tilbury Fox, a dermatologist who attempted to reduce the then chaotic problems of dermatology to some semblance of scientific order. Tilbury Fox soon infected the younger doctor with an enthusiasm for his speciality, and within a few years Radcliffe Crocker was emerging as one of the world’s leading authorities on skin diseases.
Having listened to Treves’s presentation of the Elephant Man’s case in silence, Radcliffe Crocker rose to make his own observations. His dissertation was quietly brilliant. Surely, he suggested, this was no new or undescribed disease. It seemed a case that must surely be classified as belonging to a rare group of disorders termed as dermatolysis (a loosened or pendulous condition of the skin) and pachydermatocoele (a condition where tumours arise from an overgrowth of skin). Both these skin disorders, though excessively rare, had been known for some years.
It was Radcliffe Crocker’s opinion that these two forms of skin disorder were in some way related, that an association was already recognized between them by the medical profession; for, on one or two other occasions, as in Treves’s case, they had been found to coexist in the same patient. He felt that the particular interest in the example of the Elephant Man lay in the fact that he presented a third feature: a deformity of the bones. The combination of the skin conditions with bone changes was, so far as he knew, something never before described.