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His genius—Fertility of resource — Personal
influence — Work in obstetrics and gynaecology and surgery—His lecturing and
teaching —The healing of wounds—Acupressure—Hospitalism—Proposal to stamp
out infectious diseases.
PROFESSOR A. R. SIMPSON has said that his uncle
Sir James Simpson's genius showed itself in his power of seeing things, in
his power of adapting means to ends, and in his power of making others see
what he had seen and do what he had done. We have seen these characteristics
displayed in his work upon anaesthesia; it is literally true that he left no
stone unturned to gain his end and to make others look upon anaesthesia in
the same light as he regarded it. He declared all the while that if he found
the opposition to the administration of chloroform in midwifery practice too
powerful to conquer alone, he would finally overcome it by bringing about
such a state of public opinion on the subject as would compel the profession
to adopt his methods.
Whether we regard Simpson as a physician or as a
surgeon, as a gynaecologist or as an accoucheur, we find that his success
was always due to the same causes. He possessed no secret remedies such as
an ignorant and imaginative section of the public often credit to successful
medical men. He performed no operations with which other surgeons were not
equally familiar and equally capable of performing; indeed he frequently
sent his surgical cases to operators in whose hands he considered they would
be more skilfully treated than in his. In obstetrics and gynaecology his
skill arose not only from his unrivalled experience, but also from his power
of rapid diagnosis, and his promptness and boldness in treatment.
His readiness in resource was unfailing. On one
occasion, it is related, during an operation the bottle of chloroform was
knocked over and its contents were spilled upon the carpet before the
surgeon had completed his work ; whilst his colleagues were wondering what
was to be done or how a further supply of the anaesthetic could be obtained
with sufficient speed, Simpson was on his knees hacking out with his knife
the portion of carpet on which the chloroform had just fallen ; and by means
of this extemporised inhaler the operation proceeded uninterrupted to the
end.
He carried his distinguishing energy and
thoroughness into every branch of his work; even in extempore speeches made
at meetings of professional societies, he placed facts before his listeners
in so convincing and lucid a manner out of the extensive variety of his
knowledge, and aided by his great memory, that if he did not in reality gain
the point he argued in favour of he generally appeared to do so. On such
occasions too his imperturbable temper was a valuable weapon.
There is no doubt that the genial professor
availed himself fully of the unbounded confidence placed in him by his
patients. Those of us who did not know him cannot appreciate what we have
already said, that the charm of his personality was one of the greatest
factors of his success in practice, and of his social success; there is the
risk of the appearance of exaggeration in any description of this personal
influence. The sympathy of his heart, a real sympathy, not a thin
professional veneer, was made manifest by deed as well as word. It aroused
in his patient, quite unconsciously to both, a feeling that this man, above
all other men, understood his complaint; that he, the sufferer was the
chief, if not the only object of his thought and care. It was said over and
over again of him that his words and look did more good than all his physic,
so able a wielder was he of that healing power which reaches the body
through the mind. Those who knew him not, but falling sick hastened to
Edinburgh to be healed by him, were oftentimes cured simply because they
felt beforehand that he would cure them. They followed unconsciously the
ancient command of the Talmud, where it says, "Honour your physician before
you have need of him," and went to him full of respect and fired by faith.
Wise men have striven through all ages to take advantage of this influence
of the mind over the body, and the necessity of possessing a healthy mind if
the body is also to be healthy. A striking proof of the antiquity of the
thought has been recently furnished in a fashion that would have delighted
Simpson. On a papyrus, dated a.d. 200, brought to light by Egyptian
explorers, it is written that Christ said: "A prophet is not acceptable in
his own country, neither doth a physician work cures upon them that know
him."
The advances which Simpson made in the science
and practice of both midwifery and gynaecology were due to the magnitude of
his experience and the readiness of his genius to profit by experience. His
one thought being the relief of suffering and the prolongation of life, he
approached the bedside as a man with less high aspirations would fail to do.
He considered only the patient's interest, and gave his genius free play. He
took midwifery and gynaecology by storm, and urged them onto great
developments; he believed in observing, helping, or imitating nature rather
than acting, as his predecessors had done, upon preconceived ideas which
oftener than not ran contrary to nature's commands. He avoided
meddlesomeness, and stepped in only as the ally of nature. He took numerous
hints from bygone practitioners and writers, and developed them. To-day we
are profiting by his teaching, and the instruments which he devised or
perfected.
To mention all his suggestions and all his
contributions to the arts which he specially practised would here be
obviously impossible as well as out of place; but to medical readers the
mention of one instrument associated with his name, and known as the sound,
will give a small indication of how much we are in his debt. The principle
of this instrument had been known long before he took it in hand, but it was
left for him to introduce it into practice, perfect it, and preach its value
in diagnosis and treatment. So thorough was his work, so farseeing his
science, that our knowledge of its utility has scarcely been added to since
he first drew attention to it in 1843.
Towards operative work his attitude was
characteristically conscientious. We are told that he habitually put the
following question to himself when contemplating a serious operation : " Am
I conscientiously entitled to inflict deliberately upon my fellow-creature
with my own hands the imminent and immediate chance of death for the
problematic and prospective chance of his future improved health and
prolonged life ?" The fact that he habitually thus questioned himself is an
evidence of the state of surgery at that time. Operations were undertaken
only as a last resource to save life ; the surgeon knew full well that he
placed his patient in further peril merely by cutting through the skin, in a
manner which has now happily become a thing of the past.
His work was so pre-eminently practical that he
never stopped to collect together his experiences into a scientific
treatise. Although he revivified midwifery, and was one of the original
founders of gynaecology, he left to aftercomers the labour of studying what
he had done, and drawing the conclusions on which to strengthen the fabric
of the science. His pamphlets, papers, and reports are very numerous. It
would be wrong to say that modern thought has approved all that he wrote ;
but however much time and increased knowledge may have modified his
teaching, they have not detracted from the value of his researches,
discoveries, and suggestions, or from the stimulating influence of his work
upon contemporary practice and thought.
As a lecturer and teacher Simpson succeeded as
in the other branches of his work. His brilliant exposition of his subjects
and his careful practical manner of teaching his young listeners doubled the
fame which had begun with his predecessor, Professor Hamilton, and has ever
since belonged to the Edinburgh school of obstetricians. But here again his
personal attractiveness and power gained for him the greater part of his
success. In the words of the Lancet, written when reviewing a posthumous
collection of some of his writings, his lectures used to brighten the gloomy
days of the Edinburgh winter; in perusing the publication under review,
Edinburgh men would " almost think they saw the big head and face of the
great obstetrician, as they used to see him beaming with satisfaction or
twinkling with genial humour as he told a good story, or related a happy
case, illustrative of his own bold and original practice." Both as a
lecturer and as a bedside teacher he captured his students by the charm of
his diction, the wide range of his knowledge, and as Professor Gusserow has
pointed out in his masterly memoir, by his peculiar talent of having his
knowledge at his fingers' ends, and that often in very remote details.
Year by year he never foiled to obtain the
affection of his students ; scarcely a man that had been taught by him but
would proudly boast that he was his friend as well as his teacher. He
treated his large class in a confiding spirit—not as the superior person
delivering ex cathedrd utterances, but as the friend rejoicing in his
function of admitting those around him into the knowledge in which he seemed
to revel. He had a happy method of getting on good terms with his audience
before proceeding to the serious business of the lecture. When his health
began to fail he was sometimes unwillingly laid aside, and the lectures were
delivered by a substitute. On one occasion he re-appeared pale, weak, and
lame, after such an enforced holiday, and was greeted enthusiastically by a
crowded class. He told them that his servant had said to him that a rumour
was 170 abroad that he was in Morningside Asylum. He had asked what answer
he had made, and heard that he had replied that so far from being wrong in
his mind his master was writing a book in bed. While he did not say that
this answer was strictly correct, he was happy to assure them, his pupils,
that he was quite right in his mind, although a friend had hinted that
morning that he was rather weak in his understanding!
Old fellow-students meeting each other in after
life as staid practitioners take pleasure in recalling the idiosyncrasies
and peculiarities of their teachers; it is probable that no professor has
ever been talked over with the appreciation which breathes through the
reminiscences of Simpson conjured up by those whom he taught.
Simpson left his mark in other departments
besides those of the subject of his professorial chair and of anaesthesia.
About ten years after the introduction of chloroform he turned his attention
to the process of wound-healing—the repair of necessary wounds inflicted by
surgeons in the course of their work—and although he was promptly told to go
back to his midwifery, he worked persistently at the subject. In those days
the subject was the most burning one in surgery and the methods employed to
bring about successful results varied in different schools. The object of
all methods was the same, viz., to obtain a healthy, clean, and sightly
result after an operation; to leave the part which had been of necessity cut
in a condi-171 tion as nearly as possible approaching that in which it had
been found, without the incidence of any of the too frequent grave
complications. Surgeons did not recognise at first the power of nature to
effect for them what they strove after ; they thought to attain their object
by compelling the tissues to heal as they desired by complicated
applications, and many were the layers of ointments and masses of dressings
heaped on wounds for this purpose. For a long time all efforts were directed
to the discovery of some specific substance, the application of which would
give the necessary impulse towards healing in the desired manner. Before
Simpson's day it had been generally recognised that the cause—but its nature
was quite undreamt of—of the trouble lay in the air surrounding the wound,
and more dressings were piled on to keep out the air. But at the same time
bleeding was arrested by tying the cut arteries with ligatures—chiefly
silken—and these were left with long ends hanging out of the wound to work
their way out by a process of ulceration, or irritation or the tissues until
liberty was obtained. This process was practically incompatible with the
ideal form of healing, known as healing by first intention, union without
appreciable loss of substance or the formation ofpus or matter. So-called
"surgical fever," secondary haemorrhage, and blood-poisoning were the
frequent fatal results of operation wounds treated in this manner. Simpson
and others thought to prevent these alarming diseases by devising other
means of closing the arteries thinking that if some method or material were
used, which nature resented less, the wound would more readily close by
first intention. In 1858 Simpson stated that he had for some time past been
experimenting with substitutes for the ordinary silk and thread ligatures,
and in the course of his experiments had made use of iron, silver, and
platinum wires. In his usual way he hunted up old authorities, and found a
record of both silver and gold threads having been experimentally used by
bygone practitioners. He seems to have been pleased with his results,
stating that he found the tissues much more tolerant of these metallic
ligatures than they were of the ordinary organic ones ; that only "adhesive
inflammation," not ulcerative suppurative inflammation, was excited. This
success, however, was probably due to the superior cleanliness of the metal,
but this he did not recognise; had he done so he might have been led to
strive after surgical cleanliness, and have partly anticipated the great
work done subsequently by others. He went off, however, on a different line,
and searched for some readier method of using metallic means of closing the
blood vessels, being stimulated by the desire to abolish ligatures
altogether. Thus he was led, after ten years' careful research, to the
introduction of a method entirely original—that of Acupressure. This
consisted in the introduction of a fine needle through the tissues across
the course of the artery, so that while the needle pressed upon one side of
the artery the resisting tissues of the body exerted counter-pressure on the
opposite side. He claimed for his method the merits of simplicity, elegance,
and cleanliness, and urged that not only did the tissues tolerate the needle
as they did not tolerate silk or hemp, but that unlike the ligature the
needle could be withdrawn as soon as nature had closed the blood vessel by
the process of coagulation of the blood within it set up by the pressure ;
thus the prolonged irritating presence of a body within the wound which
delayed healing until it had ulcerated its way out was rendered unnecessary,
and a better and more rapid result was attained. He verified his theoretical
considerations by experiments on animals and in one or two operations on the
human subject, and in 1859 reading a communication on the subject to the
Royal Society of Edinburgh.
The paper was written under great pressure of
work, indeed he stated that at that time he was hardly ever able to write
except when himself " confined " ; it was hastily prepared to take the place
of that of another Fellow which had failed to be forthcoming a few days
before the appointed meeting. It was composed at a country house where he
had to sleep for two or three nights watching a case of diphtheria. It was
headed as usual by a Shakspearian quotation, this time briefly in Justice
Shallow's words, thus:—"Tut, a pin!" On the evening of its delivery an
abstract of the paper was forwarded to the leading surgeons in England,
Europe, and America, and diverse were the opinions expressed.
In Scotland the new method met with the greatest
favour and the strongest opposition at one and the same time. Throughout
Europe and America it was everywhere received with applause and support.
Excellent results were obtained when the method was properly applied, but
technical considerations, particularly the difficulty of using it upon blood
vessels far removed from the surface, rendered it unsuitable for universal
application.
Professor Syme met the innovation with vehement
opposition ; possibly he resented this intrusion of the gynaecologist into
the regions of general surgery. He took into his class-room one pamphlet on
the subject by Simpson, which had especially aroused his wrath ; he stormed
at the author before his students for "his vulgar insolence," and then, in a
dramatic scene, expressed the violence of his contempt by savagely tearing
the pamphlet into pieces and casting it away. In a subsequent controversy
between these two old opponents, who had been temporarily united by
Simpson's conduct in consulting Syme professionally, by their joint action
against homoeopathy, and by Simpson's defence of Syme when publicly attacked
by an English surgeon, the feud was renewed.
Simpson persisted for years in collecting
reports or operations in which acupressure was employed, and published them
from time to time in the British Medical Journal and elsewhere. In 1864 his
work on the subject took the form of a volume containing 580 quarto pages.
His friends endeavoured to rank acupressure with chloroform as one of the
blessing to humanity made manifest by him. He himself rccognised that he had
foiled to gain for acupressure a placc in practice such as he had gained for
chloroform, but he looked forward to a time, perhaps a quarter of century
distant, when his method would be beginning to be thought about. In this he
was mistaken for, on the contrary, acupressure was beginning to be forgotten
long before twenty-live years had elapsed. Another worker on more strictly
scientific lines had by that time made healing by first intention, without
complications, the rule instead of the exception, and conferred a benefit on
humanity as great if not greater than that of anaesthesia. In 1867, while
Simpson was still alive, Mr. (now Lord) Lister (then a hospital surgeon in
Glasgow, and subsequently Syme's successor in Edinburgh) enunciated the new
principle of "antiseptic surgery," which recognised the living infective
micro-organisms of the air as the cause of the trouble in wounds. He
directed that as these invisible organisms (known only by means of the
microscope) were present everywhere in the air, found their way into all
sorts of wounds, and set up the decomposition which led to disastrous
results, they were to be destroyed or excluded from wounds; and he suggested
effective means of accomplishing this end. He further abolished the long
ligatures which irritated by their presence, and by the organisms they
conveyed into the wound when imperfectly cleansed as they usually were ; and
substituted non-irritating ligatures which nature herself was able to remove
by the process of absorption. The recognition of this antiseptic principle
effected a much needed revolution in surgery, and in this revolution
acupressure was practically annihilated. Simpson did not live long enough to
see the complete establishment of the Listerian principle; at first he
vigorously opposed what he considered to be an attempt to retain the
old-fashioned ligatures in preference to his new acupressure; but with his
penetrative eye he must have foreseen that should the new practice prevail
and short absorbable ligatures be made possible, acupressure would be
completely superseded.
In the estimation of the writer of the obituary
notice of Professor Simpson in the British Medical Journal, the greatest of
all his works was that undertaken in the subject of Hospitalism. As early as
1847 he been horrified to read in a report of the work done in the Edinburgh
Infirmary, that out of eighteen cases of primary amputation performed during
a period of four years only two survived. He faced this feet with the
courage of the reformer, and sought far and near for other facts to support
the theory which he gradually evolved, that this melancholy failure of
surgeons to save their patients' lives was due not so much to the operation
or the operator 177 n as to the environment of the patient. In later years
he himself often shrank, on account of unfortunate experiences, from
performing capital operations which he had formerly unhesitatingly
undertaken. The unhealthiness of hospitals had long been recognised; and was
especially observed at times when they were overcrowded, as happened during
war time. When the public had thoroughly grasped the utility of anaesthetics,
and recognised that operations could be performed painlessly, there were
fewer refusals to submit to the knife; there was a rush to the hospitals,
and the surgical wards throughout the length and breadth of the land became
crowded with men and women actually longing for operation. Amongst these all
the dreaded sequelae of surgical interference, which no power seemed able to
check, ravaged with alarming severity.
It is to Simpson's credit that he perceived how
the introduction of anaesthesia had taxed the hospitals and bewildered the
operators, who sought diligently but unsuccessfully in every direction for
some means of reducing hospital mortality. He was one of the first to set to
work with method to investigate this question of Hospitalism.
It was towards the end of his career, when the
old Edinburgh Infirmary stood condemned, and various proposals for
rebuilding it on a new site and improved plan were under discussion, that
his voice was most loudly heard. For many years he had thought and i78
taught that the great mortality after operations in hospitals was due to the
impure state of the air therein, derived from the congregation of a large
number of sick persons under one roof. He picturesquely stated that the man
laid on a hospital operating table was exposed to more chances of death than
the English soldier was on the field of Waterloo. His original suggestion
was that hospitals might be changed from being crowded palaces, with a layer
of sick on each floor, into villages or cottages, with one, or at most two,
patients in each room; the building to be of iron, so that it could be
periodically taken down and reconstructed, and presumably thoroughly
renovated. This drastic proposal brings nowadays a smile to the lips, for we
see now how he was groping in the dark ; but the magnitude of it is but the
shadow of the evil it was designed to cure. The change was so great as to be
impracticable in the eyes of most men ; he, on the other hand, contended
that it was to be of incalculable benefit to humanity, and, therefore, no
difficulty, however great, should be allowed to stand in the way. He did not
understand that the evils arose not from the air itself but from what was in
the air, known to us now as the micro-organisms. His remedy was a proposal
to run away from the evils without receiving any guarantee that they could
not and would not successfully pursue. Had Lister not arisen, Simpson's
proposals might have possibly prevailed, for he laboured with all his
persistent energy.
The general belief of the profession—but it was
no more than a belief—was that operations performed in country practice were
not so frightfully fatal as those performed in town hospitals. This was
Simpson's opinion, and he determined to test its truth by appeal to facts.
He drew up a circular with a schedule for the insertion of results in a
statistical form, and sent it for and wide amongst country practitioners. He
awaited the result with anxious expectation; the circular asked for a plain
statement of facts only, and for all he knew the facts might be against his
theory ; but they were not. From all over England and Scotland, particularly
from mining districts, where severe operations after accidents were common,
the filled-up schedules flowed in, to the number of 374. These were
collected, carefully classified and summarised. The operations selected were
amputations, and the result briefly was this:—
The relative mortality of the different
amputations was also shown :—
The table on the next page compared the results
of operations for injury with those performed for disease.
These statistics were accompanied by an
exhaustive detailed examination and explanation; every possible point of
attack was considered and protected. "I doubt not," he said, " that the
segregation of the sick from the sick—every diseased man being a focus of
more or less danger to the diseased around him—is a principle of no small
moment and value." He attributed the comparative brilliancy of these
statistical results to the isolation of the patients only; he endeavoured to
show that the operations were often performed amidst dirty and squalid
surroundings, on dirty and squalid persons. He did not attribute sufficient
importance to the fact urged by many of his correspondents, who supported
his general contentions almost to a man out of their own experience, that
where fresh air, ventilation, and cleanliness prevailed, the results were
always the most satisfactory.
The next step was to take hospital statistics
of similar operations, and the general result appears in the table on page
183.
This testimony to the truth of Simpson's opinion
was more pronounced than even he himself had anticipated. " Shall this
pitiless and deliberate sacrifice of human life to conditions which are more
or less preventable be continued, or arrested ? Do not these terrible
figures plead eloquently and clamantly for a revision and reform of our
existing hospital system r" This was his cry until at length breath failed
him. The opposition was not strong, but the support was weak. Although there
was much criticism, his conclusions were scarcely called in question at all;
trifling holes were picked in his statistics, but his contentions were
universally acknowledged to be correct 5 a few reformers only, persuaded as
he was of the evils of hospitalism and working at the subject, lent him
their advocacy. But he alone stood unperturbed at the extent of the evils
and the magnitude of the change which .he proposed in order to uproot them ;
death laid him low as he stood, but not before he had modified his proposals
by suggesting that existing hospitals might be reconstructed, and new
hospitals built on the now almost universally adopted pavilion system on
which the new Edinburgh Royal Infirmary was one of the first to be built.
The steady advance of aseptic surgery has slowly
but surely brought about the results which Simpson strove to attain by a
radical measure. The enemy which had baffled surgeons for centuries was
revealed by Lister. He sent surgeons smiling into the operating-room
practically certain of success instead of dreading the terrible onslaught
upon their own handiwork of the formerly unseen and unknown destroyer. The
death rate of operations is being daily brought nearer and nearer to
vanishing point. In his review of the progress of wound treatment during the
Victorian Era published in the Diamond, Jubilee number of The Practitioner,
Mr. Watson Cheyne says the mortality of major operations does not now exceed
in hospitals more than three or four per cent., and this is made up
practically entirely by cases admitted almost moribund and operated on in
extremis with feint hope of survival. The field of surgery, too, has been
vastly enlarged, and the term "major operation " includes not merely
operations of necessity, undertaken through ages past as the only possible
means of saving life, but also operations which have become possible only in
recent years—some of them performed merely to make the patient "more
comfortable," or even only "more beautiful." And this glorious result is
due, as Mr. Cheyne truly says, to the immortal genius of Lister.
In 1867 Simpson propounded in the Medical Times
and Gazette a proposal for stamping out smallpox and other infectious
diseases such as scarlet fever and measles. In spite of vaccination, which,
however, was imperfectly carried out, smallpox alone carried off five 184
thousand lives annually in Great Britain. A serious outbreak of rinderpest
in the British Islands amongst cattle had recently been arrested and
exterminated by the slaughter of all affected animals. The disease spread as
smallpox did by contagion, and Simpson fell to wondering why smallpox could
not also be exterminated. His paper was a noteworthy contribution to the
then infant science of Public Health, and his proposal, which was, however,
universally regarded as impracticable, sprang from his courageous enthusiasm
as did that concerning hospitals. He suggested that the place of the
pole-axe in the extermination of rinderpest might in the arrest of smallpox
be taken by complete isolation, and he laid down simple but rigid rules for
its enforcement. An attempt was made to utilise these a few years after when
an epidemic of fetal violence broke out in Edinburgh. He was in no way an
anti-vaccinationist, but his isolation measures were too strong for the
people in those days. We are not surprised that he boldly proposed this
measure, for he related glaring instances of neglect of the simplest
precautions. Beggars held up infants with feces encrusted with active'
smallpox into the very feces ot passers-by in the streets of Edinburgh 5 and
on one occasion a woman was found in Glasgow serving out sweetmeats to the
children of a school with her hands and face covered by the disease. He
cried aloud for legislation to prevent such gross abuses, which he did not
hesitate to stigmatise as little short of criminal. |
