Brit J Obs Gyn 1957 V-64

OBSTETRICAL-GYNAECOLOGICAL EPONYMS : JAMES YOUNG SIMPSON AND. HIS OBSTETRIC FORCEPS BY HAROLDSPEERT From the Department of Obstetrics and Gynecology, Columbia University, New York

THEobstetric forceps has been modified and re- the same as Dr. F. Ramsbotham’s, but scarcely designed in new form probably more times than so much curved. The lock is Smellie’s, but with any of the other countless number of instruments knees or projections above it of such size as to and devices that man’s mind has conjured up for prevent the blades readily unlocking in the the diagnosis and treatment of his ills. The intervals between the pains, these giving it the Chamberlen family is often credited with inven- fixed character of the locks of Levret and tion of the first safe and effective forceps, in the Bunninghausen’s instruments, without their late sixteenth or early seventeenth century ; but complexity. The joints are made so loose as to archaeological evidence (Fig. 1) shows the allow of their lateral motion and overlapping to forceps to have been in use for the delivery of a very considerable degree, thus facilitating their living infants much earlier, probably the second introduction and application. And, lastly, the or third century, in the days of the Roman handle is that used by Naegele and other German Empire (Baglioni, 1937). During the latter part accoucheurs, viz., with transverse knees or rests of the nineteenth century almost every obstetri- below the lock for one or two of the first fingers cian of renown seems to have felt the need to of the right hand to drag by, the long forceps add his own modification to the forceps; and being only properly used as an instrument of even now scarcely a year passes without the traction, not of compression. In addition, the addition of at least one new instrument to our handles are grooved and marked 011 the anterior forceps arsenal. For fully a century now, how- side, to distinguish that from the other side ever, year in and year out, the vast majority of when the blades are within the pelvis . . .” forceps deliveries has been carried out by means The forceps were used in the management of of an instrument popularized by Sir James uterine inertia, haemorrhage during labour, Young Simpson and usually known as the and other complications, “but the common Simpson forceps, although models embodying reason for employment of the long forceps,” in minor changes continue to bear the names of Simpson’s words, “is morbid contraction of the their new inventors. brim of the pelvis in its most general form, and Simpson demonstrated his forceps for the from its most general cause, viz., in the conjugate first time on 10th May, 1848 at a meeting of the or antero-posterior diameter, from projecting Obstetrical Society (Simpson, 1848). forward of the promontory of the sacrum. How “They differ from the short forceps in some points are the long forceps applied when used in this, of construction,” he explained, “but more the case in which they are most generally had particularly in regard to their mode of appli- recourse to in practice? It is first requisite to cation and working. They differ for example in state, that under this complication the child’s their length; in the shanks being parallel for head is found situated in the brim, with its long some distance beyond the lock, an indispensable or fronto-occipital diameter lying in the trans- point in order to prevent them injuring the verse diameter of the brim, or with the forehead outlet; in their blades being curved; and in the looking to one ilium, and the occiput looking part intended to embrace the head being to the other. In other words, the long diameter sufficiently long and large . . . The blades are of the head is not placed, as usual, in the right 2 PI. 744

history-of-obgyn.com JAMES YOUNG SIMPSON AND HIS OBSTETRIC FORCEPS 745 diagonal diameter of the brim, but more in its sacrum; the lumbar portion of the spine was transverse; for where the promontory of the distorted; and she walked very lamely. The sacrum forms a morbid projection, the trans- present was her second confinement. Her first verse forms the longest diameter of the brim, labour had been long and difficult . . . delivered and, consequently, the one in which the child’s by craniotomy . . . Even after the cranium had head comes to be placed by the uterine efforts been fully broken down, a considerable time and . . . the lateral surfaces of the child’s head come much traction had been required to drag the to be compressed between the protruding sacral diminished and mutilated head of the infant promontory and the interior of the symphysis through the contracted brim of the pelvis; and pubis . . .” she was long in recovering. Contrary to the Modern obstetrical teaching emphasizes the urgent advice of her medical attendant, Mr. importance of symmetric, or cephalic, appli- Figg, he was not made aware of her present or cation of the forceps to the sides of the foetal second pregnancy till she had arrived at nearly head. Simpson, by contrast, advised asymmetric, the end of the ninth month. It was thus too late or pelvic, application of the blades. “The blades to have recourse to the induction of premature of the long forceps,’’ he wrote, “should be placed labour, which had been strongly pressed upon obliquely upon the child’s head-one, the her as the only means of saving her child, posterior, over the side of the occiput; and the should she again fall in the family way. The pains other, or anterior, over the side of the brow or of her second labour commenced in the forenoon temple, and consequently should be situated of the 19th. I saw her with Mr. Figg at five in the oblique diameter of the brim. (See o’clock in the afternoon, and again at seven. Woodcut, Fig. 3.)-The markings on the child’s The 0s uteri was pretty well dilated, the liquor head after birth always show this mode of amnii not evacuated, the presenting head very application of the instrument: when properly high, mobile, and difficult to touch; and a applied upon the mother, and when their pulsating loop of the umbilical cord was felt situation relative to the pelvis is examined, they floating below it in the unruptured bag of are found to have assumed this position; and membranes. From five to nine o’clock the pains in experiments with the instrument (when the seemed only to push the circle of the 0s uteri head of a dead child is fixed in a pelvis with a further downwards, without increasing its contracted brim), this is the position and dilatation, or making the head in any degree relation which the instrument will be seen to enter into the pelvic brim. Assisted by Dr. assume with relation to the infantile head and Ziegler, Dr. Keith, and Mr. Figg, I shortly after maternal pelvis. Besides, in thus placing the nine o’clock made the patient inhale the ether instrument, while we incur less danger of vapour. As she afterwards informed us, she injuring the urethra and other important parts, almost immediately came under the anodyne we place the blades of the instrument in exactly influence of the ether. But in consequence of those parts of the pelvic circle where there is doubts upon this point, its use was continued least pressure and consequently most room for for nearly twenty minutes before I proceeded to them . . .” turn the infant (as I had previously pre- Simpson is remembered eponymically for his determined to do). A knee was easily seized, forceps, but far greater to his credit was his and the child’s extremities and trunk readily introduction of anaesthesia into obstetrical drawn down; but extreme exertion was required practice. On 19th January, 1847, for the first in order to extract the head. At length it passed time, he administered ether to a patient in the contracted brim with the anterior part of its labour, reporting the case in the March issue right parietal bone deeply indented by pressure of the Monthly Journal of Medical Science against the projecting promontory of the (Simpson, 1847a). “The pelvis of the mother”, sacrum, and the whole cranium flattened and Simpson wrote, “was greatly contracted in its compressed laterally. The infant gasped several conjugate diameter from the projection forwards times, but full respiration could not be and downwards of the promontory of the established . . .

48 4

history-of-obgyn.com 746 JOURNAL OF OBSTETRICS AND GYNAECOLOGY “On questioning the patient after her delivery, to be joyfully and gratefully welcomed by she declared that she was quite unconscious of medical science, as one of the most inestimable pain during the whole period of the turning and boons which man could confer upon his suffering extracting of the infant, or indeed from the first fellow-mortals.” minute or two after she first commenced to Arguing for the extension of anaesthesia to breathe the ether. The inhalation was dis- obstetrics, Simpson (1847a) made the forceful, continued towards the latter part of the process, impassioned plea : “NOW,if experience betimes and her first recollections on awaking were goes fully to prove to us the safety with which ‘hearing’, but not ‘feeling’, the head of the ether may, under proper precautions and infant ‘jerk‘ from her (to use her own expres- management, be employed in the course of sions), and subsequently she became more parturition, then . . . instead of determining , . . roused by the noise caused by the preparation whether we shall be ‘justified’ in using this of a bath for the child. She quickly regained full agent . . . it will become, on the other hand, consciousness, and talked with gratitude and necessary to determine whether on any grounds, wonderment of her delivery, and her insensibility moral or medical, a professional man could to the pains of it . . .” deem himself ‘justified’ in withholding, and not The ensuing controversy over the use of using any such safe means (as we at present pre- anaesthesia in obstetrics has had few equals in suppose this to be), provided he had the power the annals of medicine. Simpson’s practices by it of assuaging the agonies of the last stage were violently opposed by many of the clergy of natural labour, and thus counteracting what as well as his medical peers, but to each attack Velpeau describes as ‘those piercing cries, that the articulate Simpson replied with devastating agitation so lively, those excessive efforts, those logic, impeccable taste, albeit liberally salted at inexpressible agonies, and those pains appar- times with incisive sarcasm, and extensive ently intolerable’, which accompany the ter- biblical quotations in rebuttal of his critics’ mination of natural parturition in the human protestations against man’s alleviation of the mother.” travail of childbirth (Simpson, 1856). The Simpson’s entreaties were met at first by the distinguished Meigs of Philadelphia referred to reticence characteristic of his conservative the pain of parturition as a “physiological colleagues, as evidenced by his address to the pain”, and the equally renowned Ashwell of Medico-Chirurgical Society of Edinburgh on 1st London wrote in the Lancet (Ashwell, 1848). December, 1847. “Probably at the date at which that to use anaesthesia in obstetrics constitutes I write,” he lamented, “there is not one in “unnecessary interference with the providenti- twenty-perhaps not one in a hundred-of the ally arranged process of healthy labour . . . physicians and surgeons of Great Britain who sooner or later, to be followed by injurious have, as yet, thought seriously upon the propriety and fatal consequences”. of alleviating and annulling the tortures atten- Recalling the words of Galen: dolor dozentibus dant on human parturition; orwho have acknow- inutilis est (pain is useless to the pained), ledged to their own minds the propriety of Simpson went further, demonstrating the mortal bestirring themselves so as to be able, in the potentialities of pain. By widespread question- exercise of their profession, to secure for their naire study of the results of thigh amputation patients an immunity from the throes and he showed that ether anaesthesia had reduced agonies of childbirth.” the mortality from the operation by almost It soon became apparent to Simpson that half. “Bodily pain,” he wrote (Simpson, 1847b), ether suffered from certain shortcomings as an “with all its concomitant fears and sickening obstetrical anaesthetic, and in the autumn of horrors . . . is, with very few, if indeed any 1847 he began his search for a better agent, in exceptions, morally and physically a mighty and collaboration with Drs. and unqualified evil. And, surely, any means by J. Matthews Duncan. Their experiments were which its abolition could possibly be accom- carried out at the conclusion of the day’s work, plished, with perfect security and safety, deserves in Simpson’s dining room. A small quantity of

history-of-obgyn.com FIG. 1 Ancient marble bas-relief depicting a birth scene. The accoucheur, in the centre, holds a pair of obstetric forceps aloft in his right hand. This marble tablet, measuring 74 i55 cm., was discovered in the early twentieth century in the vicinity of Rome. The attire and furnishings in the scene date it in the second or third century A.D. (From Baglioni).

H.S. [746j

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FIG. 2 FIG. 3 James Young Simpson (181 1-1870). Illustration from Simpson’s paper, showing application of his forceps. JAMES YOUNG SIMPSON AND HIS OBSTETRIC FORCEPS 747 the test liquid was placed in a cup or drinking Three weeks later, at its meeting on 1st glass, which was immersed in hot water, if December, 1847, Simpson employed his most necessary, to increase the volatility. The experi- impassioned oratory in an address to the same menters then proceeded with their hazardous Society. Singing again the praises of anaesthesia task of inhaling the vapours and noting the for childbirth, and especially of the newly- effects. It was in this manner that Simpson and discovered merits of , he stated : his assistants came upon the anaesthetic pro- “I do not remember a single patient to have perties of chloroform on 4th November, 1847. taken it who has not afterwards declared her Exhilarated by his new discovery, Simpson sincere gratitude for its employment, and her employed chloroform in the confinement of the indubitable determination to have recourse again wife of Dr. Carstairs of Edinburgh 4 days later, to similar means under similar circumstances. the child being named “Anaesthesia”. Simpson All who happened to have formerly entertained reported the event to the Medico-Chirurgical any dread respecting the inhalation, or its effects, Society of Edinburgh on 10th November, 1847 have afterwards looked back, both amazed at, in the following words (Simpson, 1847~):“The and amused with, their previous absurd fears lady to whom it was first exhibited during and groundless terrors. Most, indeed, have parturition had been previously delivered in the subsequently set out, like zealous missionaries, country by perforation of the head of the infant, to persuade other friends to avail themselves of after a labour of three days’ duration. In this, the same measure of relief, in their hour of trial her second confinement, pains supervened a and travail . . . All of us, I most sincerely fortnight before the full time. Three hours and a believe, are called upon to employ it by every half after they commenced, and ere the first stage principle of true humanity, as well as by every of the labour was completed, I placed her under principle of true religion. Medical men may the influence of the chloroform, by moistening, oppose for a time the super-induction of with half a teaspoonful of the liquid, a pocket anaesthesia in parturition, but they will oppose handkerchief, rolled up into a funnel shape, and it in vain; for certainly our patients themselves with the broad or open end of the funnel placed will force the use of it upon the profession. The over her mouth and nostrils. In consequence of whole question is, even now, one merely of time. the evaporation of the fluid, it was once more It is not-ShalI the practice come to be generally renewed in about ten or twelve minutes. The adopted? but, When shall it come to be generally child was expelled in about twenty-five minutes adopted? Of course, it will meet from various after the inhalation was begun. The mother quarters with all due and determinate opposition. subsequently remained longer soporose than Medical men will, no doubt, earnestly argue that commonly happens after ether. The squalling of their established medical opinions and medical the child did not, as usual, rouse her; and some practices should not be harshly interfered with minutes elapsed after the placenta was expelled, by any violent innovations of doctrine regarding and after the child was removed by the nurse the non-necessity and non-propriety of maternal into another room, before the patient awoke. suffering. They will insist on mothers continuing She then turned round and observed to me that to endure, in all their primitive intensity, all the she had ‘enjoyed a very comfortable sleep, and agonies of childbirth, as a proper sacrifice to the indeed required it, as she was so tired but would conservatism of the doctrine of the desirability now be more able for the work before her.’ of pain. They will perhaps attempt to frighten . . . In a little time she again remarked that she their patients into the medical propriety of this was afraid her ‘sleep had stopped the pains’. sacrifice of their feelings; and some may be Shortly afterwards, her infant was brought in by found who will unscrupulously ascribe to the the nurse from the adjoining room, and it was a new agency any misadventures, from any causes matter of no small difficulty to convince the whatever, that may happen to occur in practice. astonished mother that the labour was entirely But husbands will scarcely permit the sufferings over, and that the child presented to her was of their wives to be perpetuated, merely in order really her ‘own living baby’.’’ that the tranquillity of this or that medical 488

history-of-obgyn.com 748 JOURNAL OF OBSTETRICS AND GYNAECOLOGY dogma be not rudely disturbed. Women them- further studies in midwifery, alternately assisted selves will betimes rebel against enduring the the professor of pathology at the university and usual tortures and miseries of childbirth, merely Mr. Dawson, the family doctor in Bathgate, and to subserve the caprice of their medical atten- visited the clinics of France and England. dants. And I more than doubt if any physician is Simpson then returned to Edinburgh and entered justified, on any grounds, medical or moral, in general practice, but devoted his principal deliberately desiring and asking his patients to attention to midwifery. He soon obtained an shriek and writhe on in their agonies for a few appointment at the Lying-in Hospital and in months or a few years longer-in order that, 1838 began giving courses of lectures in mid- by doing so, they may defer to his professional wifery on his own. When he was only 28 years apathy, or pander to his professional prejudices.” old he became a candidate for the recently In 1853 , the first full-time physician vacated chair of midwifery at the university, anaesthetist, administered chloroform to Queen waging his campaign for this coveted position in Victoria during the birth of Prince Leopold, her a manner reminiscent of today’s political con- eighth child; and Her Majesty was lavish in her tests. When his state of bachelorhood was appreciation of the new agent and the pain relief mentioned in argument against his appointment, it provided. This, probably more than any other Simpson promptly took unto himself a wife. single event, bowled over most of the remaining The Town Council finally elected him to the opposition to anaesthesia in labour and led to chair by a single vote’s margin over his chief the rapid and widespread acceptance of chloro- rival, Evory Kennedy, Master of the Rotunda form in obstetrical practice. Not long thereafter in Dublin. Simpson’s wife is said to have Simpson was made a baronet, the inscription on subsequently “poured out more tea than any his coat of arms reading “VICTODOLORE” (pain woman in Scotland”. conquered). The lectures of the newly-elected professor With his characteristic vision Simpson (1 847b), attained a new high in popularity, surpassing after he introduced ether into obstetrics, foresaw in attendance all the other medical courses in the advantages of a special anaesthesia room for the university. In addition to his forceps and his surgical patients, for in September, 1847 he introduction of anaesthesia, Simpson made a wrote: “In our surgical hospitals, if a ward number of other important contributions to immediately adjoining the operating theatre were obstetrics and gynaecology. He invented a set aside for operation cases, it would in this way cranioclast for fracturing the base of the foetal facilitate the process of etherization, and ensure skull, and contrived the uterine sound and the more certain and perfect results from it.” sponge tent for dilating the cervix, thereby James Young Simpson was born 7th June, providing access to the uterine cavity for the 1811 in Bathgate, Scotland, the youngest of removal of endometrial polyps. Almost at the seven sons of the village baker (Anderson, 1911 ; same time as Semmelweis he called attention to Ballantyne, 1911 ; Barbour, 191 1; Croom, 1911; the contagiousness of puerperal fever, giving the Findley, 1939; Hart, 191 1 ; Robinson, 1946; most convincing exposition until then of the Simpson, A..R., 1911; Simpson, E. B., 1911; similarity between this scourge and surgical Watson, 1936, 1948). At age 14 he enrolled in fever; but he failed to encourage Lister, working the , with the help of contemporarily at the University of Edinburgh, his family’s combined resources, but withdrew in the latter’s experiments on antisepsis, and from the arts course two years later to pursue the never accepted Lister’s concept of the bacterial medical curriculum. After three years of medical origin of infection. He wrote on hermaphrodit- study, when Simpson had completed all the ism and on the freemartin, and dispelled the required courses, he passed his final examination widely held but erroneous belief that among and received the diploma of the Royal College of human twins the female was sterile if her co-twin Surgeons. Being only 18 years old, however, he was a male. Simpson was probably the first to had to wait two more years for his licence to stress the importance of bimanual examination practise. During the interim he undertook of gynaecological patients. “In making this

history-of-obgyn.com JAMES YOUNG SIMPSON AND HIS OBSTETRIC FORCEPS 749 examination,” he wrote in 1850, “as in making hear the sound of ss ss ss running through the most other examinations of the uterus, a rule room as there passed from mouth to mouth the requires to be followed which is too often forgot, exclamation ‘C’est Simpson, C’est Simpson’ ” namely to use both hands for the purpose. For (Simpson, A. R., 1911). if we are examining the uterus internally with Simpson died of coronary disease on 6th hlay, the forefinger, or fingers of the right hand, the 1870, at age 58, and was buried in Warriston facility and precision of this examination will be Cemetery in Edinburgh, alongside the five of found to be immensely promoted by placing the his nine children who had predeceased him. left hand externally over the hypogastric region, A day of public mourning was declared in so as to enable us by it to steady, or depress, or Edinburgh, its shops and the University were otherwise operate upon the fundus uteri. The closed, and it is said that thirty thousand external hand greatly assists the operations of bereaved citizens attended the funeral. A bust of that which is introduced internally; and farther Simpson, erected in Westminster, bears the we can generally measure, between them, the inscription, “To whose Genius and Benevolence size, relation, &c., of the included uterus.” the world owes the blessings derived from the Simpson’s interests ranged wide beyond the use of Chloroform for the relief of suffering,” limits of his profession. He published extensively a fitting but modest tribute to one of nature’s on archaeological subjects, became an ardent true noblemen. and authoritative antiquarian, and remained constantly engrossed in literature, philan- REFERENCFS thropical enterprises, medical reforms, and civil Anderson, J. (1911): Edinb. med. J., ns. 6, 516. and university politics. He served as President Ashwell, A. (1848): Luncet, 1, 291. of the Edinburgh Obstetrical Society from 1841 Baglioni, S. (1937): Fisiof. c Med., 8, 169. to 1858. His nephew and successor to the chair Ballantyne, J. W. (1911): Edinb. med. J., n.s. 6, 554. Barbour, A. H. F. (1911): Edinb. med. J., n.s. 6, 534. of midwifery in the university, Sir Alexander Croom, H. (1911): Edinb. med. J., n.s. 6, 523. Simpson, later spoke of Simpson’s house as “a Findley, P. (1939): Priests of Lucinu. The story of rendezvous for all sorts and conditions of men. obstetrics. Little, Brown & Co., Boston. p. 234. The strangest streams of life were constantly Hart, D. B. (1911): Edinb. med. J., n.s. 6, 543. flowing through it. Candidates for seats in Robinson. V. (1946): Victory over pain. %human, New York, p. 191. Parliament or in the Council Chamber of the Simmon.-I A. R. (1911): Edinb. rned. J.. n.s. 6.491 city, for vacant chairs in the University, for posts Simpson, E. B. (1911): Edinb. rned. J.; n.s. 6; 482. in the Infirmary, for lectureships in many Simpson, J. Y. (1847a): Month. J. med. Sci., 7, 721. schools of medicine, and for pulpits in town or Simpson, J. Y. (1847b): Month. J. med. Sci., 8, 144. Simpson, J. Y. (1847~):Account of a new anaesthetic country-all came to seek his advice and agent, as a substitute for sulphuric ether in bespeak his influence. Antiquaries came with and midwifey. Communicated to the Medico- their latest finds; artists and architects sought Chirurgical Society of Edinburgh at their meeting on his opinion of their designs; poets brought him 10th November, 1847. Edinburgh. (Reprinted in their new poems, and novelists their stories; the New York, 1848.) Simpson, J. Y. (1848): Month. J. med. Sci., 9, 193. Arctic voyager, the African explorer, the . Simpson, J. Y. (1850): Month. J. med. Sci., 10, 3. traveller from Mecca, missionaries from all Simpson, J. Y. (1856): The obstetric memoirs and con- parts of heathendom, came with news and gifts tributions of James Y. Simpson, M.D., F.R.S.E. of every kind.” A companion who accompanied Edited by W. 0. Priestley and H. R. Storer. Lippincott, Philadelphia. Vol. 2, p. 463. him to a reception in Madame Victor Hugo’s Watson, B. P. (1936): Amer. J. Obstet. Gynec., 32, 547. salon in Paris reported that “the excitement was Watson, B. P. (1948): Amer. J. Obster. Gynec., 56, something tremendous, and for a time you could 205.

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