The bicentenary of James Young Simpson (1811–1870)

The 200th anniversary of the birth of James Young Simpson is 7 June 2011. There will be three days of multidisciplinary symposia in Edinburgh to celebrate the bicentenary [1]. James Simpson was born as the eighth child of a poor baker in Bathgate, about 18 miles from Edinburgh. It soon became apparent that the boy had great intellect and his mother rallied the family to dedicate themselves to his education. Fortunately, in 1815, through a benefactor, the local school became one of the best funded and staffed parish schools in Scotland [2]. James Simpson’s mother instilled him with ambition before she died when he was aged nine. He entered Edinburgh University at the age of fourteen, initially reading classics before changing to medicine – and qualified LRCSEd in 1830. During this time, he acquired the middle name ‘Young’– he was too young for admission to pursue an MD. So he had a sojourn into general practice, of which midwifery was a major part. He returned to Edinburgh University in 1831 and wisely chose the topical subject, inflammation, for his thesis. Entitled De Causa Mortis In Duibusdam Inflammationibus Proxima (‘of the immediate cause of death in certain inflammations’, this was accepted in 1832 [2]. It led to a post in pathology as assistant to Professor John Thomson, who inspired Simpson to specialise in midwifery. In 1840 at the age of 28 years, Simpson became Professor of Midwifery at the University of Edinburgh. In 1997, the European Academy of Anaesthesiology celebrated the Chloroform Sesquicentenary in Edinburgh. However, besides introducing chloroform in 1847, Simpson made many other contributions to anaesthesia, obstetrics, gynaecology, infection control and archaeology, as well being a loyal member of the Free Church of Scotland. Like every human being he had his faults, and it is salutary to reflect on his performance. Simpson’s greatest contribution was, probably, to champion analgesia during childbirth at a time when the desirability of this was disputed on medical, moral and religious grounds. Thus, he was the first to use ether in obstetrics (January 1847) [3]. Although many obstetricians accepted its use for difficult or instrumental deliveries, objections were raised in offering analgesia for the pains of ‘normal’ labour. Simpson continued to promote this. Finding that ether was not ideal for obstetrics (slow induction, flammable and explosive), he searched for a better agent – experimenting with numerous potential chemicals. On the suggestion of David Waldie he tried chloroform in November 1847. In two weeks, he published on its clinical use [4]. Simpson clung to his belief that chloroform was superior to ether, despite reports, from 1848 onwards, of deaths of apparently healthy patients under chloroform induction. In the last year of his life, Simpson himself reported a death. In his report, he stated that until then he had not seen the employment of chloroform terminate in death [5]. However, he was in fact very much aware of a death under chloroform administered by a dentist, Dr Roberts, in 1855. The dentist lived close to Simpson, who was called and went to attempt resuscitation [6]. Part of Simpson’s legacy was that chloroform continued to be the favoured anaesthetic agent in Scotland for well over a century after its introduction. This was despite the definitive work of Goodman Levy (1911) showed that light chloroform anaesthesia can produce ventricular fibrillation [7]. It is a sad fact that if legislation had existed to force the earlier demise of chloroform, many deaths may have been avoided [8]. Simpson explored the concept of local anaesthesia in 1848. He experimented with the application of chloroform and other substances in earthworms, fish, frogs, rabbits and guinea pigs [9]. If cocaine had been available to him, he might have become ‘the father of local anaesthesia’, but purification of this alkaloid by Niemann took place twelve years later. It was Simpson who pointed out the high level of albumin in the urine of patients with puerperal convulsions (eclampsia) in 1843 [10]. In 1845, he described a method of delivery in placenta praevia, when conventional methods failed: turn the baby, grasp its feet and forcibly deliver it past the placenta. He pointed out that this could reduce the high maternal mortality from haemorrhage in this condition at the time (1:3 with 2:3 of the babies dying) [11]. On the introduction of ether, Simpson did consider possible effects on the fetus. In a paper published in March, 1847 he wrote: ‘it will be necessary to ascertain anaesthesia’s precise effects, both upon the action of the uterus and on the assistant abdominal muscles; its influence, if any, upon the child; whether it has a tendency to haemorrhage or other complications’ [3]. This was amazingly astute, and these are the same questions we must still ask ourselves about any new technique in obstetric anaesthesia. Unfortunately, Simpson and his early followers did not follow this; it was nearly a century before obstetricians began to tailor this practice to limit the effects of anaesthesia on labour and the neonate. He invented the ‘air tractor’ in 1848, a suction cup and pump for extracting babies instead of forceps, which could be difficult and injurious [12]. This was the forerunner of the Ventouse vacuum extractor. In 1841, Simpson reported his successful treatment of a tumour by amputation of the cervix (the first in Britain) [13]. In 1843, he designed his own version of the uterine sound [14]. When Britain was threatened with a cholera epidemic in 1838, Simpson published his study of the 1832 epidemic, in which he opposed the miasma theory [15]. From 1840, being aware of Alexander Gordon’s work on preventing puerperal fever (Aberdeen, 1795), Simpson claimed that the infection could be transmitted through the hands of midwives [16] and taught his students so; he used a solution of potassium cyanide to wash his hands before operating [17]. This preceded the 1847 publication by Semmelweis on the efficacy of washing hands with chlorine water. In 1858, partly to avoid suppuration of wounds closed by silk/linen sutures, Simpson proposed a new method of haemostasis – by metallic sutures or pins – that he called ‘acupressure’. [18]. (Nowadays the term acupressure usually means stimulation of acupuncture points without needles). Finally, he expounded on ‘hospitalism’ (overcrowding) as a factor that increased infection rates [19], but this was eclipsed by Lister’s introduction of antiseptic surgery. For anaesthetists, perhaps the most notable of Simpson’s many works on archaeology was his paper on ancient Greek medical vases used for containing lykion (an extract of berberis), which was applied locally to treat ophthalmic inflammation [20]. It is interesting to muse how Simpson would fare with his various projects today. He ensured that he kept up to date with all medical developments, but in 1840, there were only around 50 medical journals in existence whereas today there are hundreds. However, during his time, distribution of the paper journals took days to months, but we can get instant access to most journals electronically now. He would not be allowed to experiment with any potential anaesthetic agent he liked, without rigorous scrutiny and approval by research ethics committees and drug regulatory bodies. There is little doubt whether he would have critically reviewed every new innovation and tried to improve it. Noting that he played an important political role at the start of medical regulation by the Medical Act of 1858 [2], it seems certain that he would have risen to the current training and ethical challenges, and would probably be President of a Medical Association or Royal College. Today’s anaesthetists would do well to heed the lessons of history to emulate Simpson’s drive and to avoid his shortcomings. AGM is Honorary Archivist, Association of Anaesthetists of Great Britain & Ireland. No external funding and no other competing interests declared.