_SIR WILLIAM FERGUSSON AND CONSERVATIVE SURGERY._
The association of the word “conservative” with operative surgery, so
strongly identified in the popular mind with the removal of portions
of the body, needs some explanation to the non-professional reader.
In former times inflammation with denudation of bone was commonly
believed to necessitate amputation; and diseased joints, especially
the elbow, knee and ankle, with ulceration of cartilages, were
generally considered incurable, except by removal of the limb. As
Fergusson said, the ways of surgery get grooved; they are hallowed in
the estimation of some. The man who steps from the groove is held to
be rash and is called to account. How much this was the case will be
seen by the reception accorded to conservative surgery, which aspired
to do away with many of the radical proceedings of the past.
The term “conservative surgery,” as first used by Sir W. Fergusson
in 1852, meant operations for the preservation of some part of the
body, which would otherwise have been unnecessarily sacrificed. A
smaller and more limited operation was undertaken to remove simply
the incurably disorganised portion of the body, such as a diseased
joint, and not an entire limb. Thus Fergusson said, “a compromise
may be made, whereby the original constitution and frame, as from
the Maker’s hand, may be kept as nearly as possible in its normal
state of integrity.” “No one can more thoroughly appreciate a
well-performed amputation than I do, but I certainly appreciate
more highly the operation which sets aside the necessity for that
mutilation.”
* * * * *
Two great surgeons thus bear testimony to Fergusson: “The
improvements which he introduced in lithotrity and in the cure of
cleft-palate may almost be considered typical,” says Sir Spencer
Wells,[3] “of the school of modern conservative surgery, and will
long be acknowledged as triumphs of British surgery in the reign of
Victoria.” He was, in the words of Sir James Paget, “the greatest
master of the art, the greatest practical surgeon of our time.”
WILLIAM FERGUSSON was born on March 20th, 1808, at Prestonpans,
East Lothian, and was educated first at Lochmaben in Dumfriesshire
and afterwards at the High School of Edinburgh. At fifteen he
entered a lawyer’s office, by his own desire, but soon found that
law did not suit him, and at seventeen exchanged law for medicine,
which profession his father had wished him to adopt. He was
early attracted by the teaching of Robert Knox, the celebrated
anatomist, who quickly discerned the stuff his pupil was made of.
Fergusson would often spend from twelve to sixteen hours a day in
the dissecting-room. One of his dissections of the nerves of the
face, preserved in the museum of the Edinburgh College of Surgeons,
remains an admirable example of manipulative skill and dexterity, and
the stand on which it is placed is also a specimen of his work. At
twenty Knox made him demonstrator to his class, which then numbered
four hundred. He had previously assisted John Turner, Professor of
Surgery at the College of Surgeons. At the early age of twenty-one
Fergusson became Fellow of the College of Surgeons by examination.
Knox then promoted him to a share in his lectures on general anatomy,
and the young lecturer also gave demonstrations on surgical anatomy,
which proved highly valuable. He soon began to manifest his skill
in operative surgery, and in 1831 he was elected surgeon to the
Edinburgh Royal Dispensary, and showed his boldness by performing
the important operation of tying the subclavian artery, which as
yet had only been twice done in Scotland. In 1833 he married Miss
Ranken, heiress of the estate of Spittlehaugh in Peeblesshire. This
marriage, while it placed him beyond pecuniary difficulty, had no
effect in diminishing his industry. In 1839 he became surgeon to the
Royal Infirmary, and Fellow of the Royal Society of Edinburgh, and
already shared the highest surgical practice with Syme. In fact there
was hardly room for two such men in Edinburgh. Liston had betaken
himself to London. In 1840 Fergusson followed his example, accepting
an invitation to King’s College, which was now establishing its
hospital. At a farewell presentation, Lizars said that he had seen no
one, not even Liston himself, surpass Fergusson in the most trying
and critical operations. The man of whom this could be said at the
age of thirty-two had every chance of success in London, even though
he came thither with scarcely any personal friends to back him.
Professor Partridge, his old friend, gave him a cordial introduction,
and he established himself in Dover Street, Piccadilly, only to find
that his first year’s private practice did not exceed £100. Yet
it cannot be denied that Fergusson came to London at a fortunate
period. Within a few years death or retirement withdrew from practice
many of the most capable operators, such as Liston, Aston Key, and
Astley Cooper. Thus his success was really rapid, for his third year
brought him £1000, and in 1847 he removed to a large house in George
Street, Hanover Square. His style of operating soon attracted general
attention both among students and practitioners, and King’s College
operating theatre became the resort of all the medical students and
practitioners who could cram into it.
As an operator Fergusson was most peculiarly skilled, and he appears
to have had a natural manipulative dexterity, which he assiduously
cultivated. Like Sir Charles Bell and other eminent surgeons, he was
a splendid fly-fisher; and his manipulation served him in good stead
in acquiring skill on that most difficult of instruments, the violin.
Carpentering and metal-working came easily to him, and gave him
great readiness in improvising splints or other apparatus desirable
for his patients’ special circumstances. Yet having such power and
dexterity, he did not choose to display it on all possible occasions,
but rather was conspicuous for his frequent abstinence from operative
interference, counting it a greater glory to save a limb than to
cut one off, and taking endless trouble to preserve a portion when
amputation would have been much easier.
Although the rivalry between Fergusson and Syme frequently led to
open dissensions, yet no man more freely, fully, and repeatedly
acknowledged Syme’s great services than Fergusson. Thus he always
ascribed the chief merit of the revival of the “conservative”
operation of excision of the elbow-joint to Syme. Originally
suggested by Park, and first performed by Moreau, it was not until
the operation was taken up by Syme that it attracted serious
attention. Fergusson followed in his wake, and extended the same
principles till there was scarcely a part which could be conserved
which he had not laid hands on with that object. To take an
instance from parts of small size. A gentleman of active habits, in
charge of a large establishment, to whom the use of a pen was of
vast importance, had a bad whitlow at the end of his right thumb.
An abscess was opened in due time, and the bone was found bare.
Amputation was urged, but the patient objected, and on consulting
Fergusson, he was advised to wait, and then a few weeks afterwards
the portion of bone that died was removed through the original
opening for the abscess. Before long, the thumb, apparently entire,
was as useful as ever. “Opinions may differ,” says Fergusson, “but
for my own part, I deem it a grand thing when by prescience even the
tip of a thumb can be saved.”
To Liston’s boldness and rapidity Fergusson added greater caution
and self-control. In lithotomy both were equally distinguished,
and attained their end with the simplest instruments. An anecdote
recorded in the _Medical Times and Gazette_ (Feb. 17, 1877)
illustrates this. Some practitioners were discussing the relative
merits of some leading hospital surgeons, and introduced the subject
of lithotomy. “I saw Mr. —— perform lithotomy to-day in half a
minute.” “Oh,” replied B, “I saw —— once extract the stone in twenty
seconds.” “Have you ever seen Fergusson perform lithotomy?” “No.”
“Well then, go; and, look out sharp, for if you only even wink,
you’ll miss the operation altogether.”
In 1845 Fergusson revived the plan of excising the head of the femur
for incurable disease of the hip-joint, and it became established
as a valuable operation, in spite of Syme’s violent opposition. In
1847 Mr. Fergusson excised the entire scapula, where the whole
arm would otherwise have been sacrificed. In 1850 his attention
became concentrated on diseases of the knee-joint, and before
long he excised the joint for severe disease. Although the result
was unfavourable, Fergusson, undismayed, repeated the operation
successfully, and in spite of strong criticism and opposition,
continued for at least fifteen years, it has become established.
The strength of the feeling aroused on this subject was so great
that once when Fergusson was about to excise a knee-joint at King’s
College Hospital, a surgeon, once a colleague, publicly protested
against the performance of the operation. Fergusson’s earlier
cases were not always well selected for the operation, and he had
many disheartening failures. But he persevered and improved in his
selection of cases, and achieved what he regarded as the greatest
triumph of conservative surgery.
Some of Fergusson’s greatest triumphs were in connection with
hare-lip and cleft-palate. His first formal operation in surgery
was for hare-lip in 1828. Up to 1864 he had operated on nearly four
hundred cases with only three deaths. The adoption in 1850 of a
spring or truss to push the sides of the lips forwards, invented
by Jem Hainsby (the old dissecting-room attendant at Guy’s), and
the father of a child-patient, was of great value in preserving the
mobile parts of children from undesirable movements. In regard to
cleft-palate Fergusson’s labours were of even greater value, for
he discovered by careful dissection the reason why the edges of
the wound were so often prevented from uniting, and by dividing the
muscles concerned, in addition to other valuable improvements in
practice, he enabled many patients to gain an excellent undivided
palate. Up to 1864 he had operated on 134 cases, of which 129 were
successful, and only two failed entirely. It is unnecessary to go
through the long list of successes won by Fergusson; but it is well
to mention that when he found the existing instruments unsuitable for
his purpose, he never rested till he had invented better ones. The
bull-dog forceps, the mouth-gag for operations on the palate, various
bent knives, and many other instruments and apparatus bear the stamp
of his inventive skill.
With all his operative brilliancy, that did not constitute
Fergusson’s chief claim to admiration, nor was it the principal cause
of his success. The perfect planning of the operation beforehand
from beginning to end, down to the smallest detail, and being ready
for every possible emergency with the precise method for meeting it,
distinguished him most. Consequently he neither hurried, wearied,
nor hesitated when he began. Things were so perfectly planned, his
assistants so well drilled, that not a word needed to be spoken, and
this produced a curious appearance at times, so that it was often
remarked that he must be on bad terms with his assistants. He left no
detail unsupervised, and completed the operation entirely himself,
even applying bandages and plasters. His coolness under difficulty
was probably connected with his forethought; he could often cover
his own or others’ mistakes in the coolest manner, and this put him
in the best position for remedying them. It was his pride never
to be late. He hated unnecessary waste of time, and once when a
friend intending to tie a large artery had laid it bare by a fine
dissection, and was showing it with natural gratification, Fergusson
called him to the point by remarking, “Jist put a thread round it.”
So when a large artery had been wounded, and an assistant eagerly
tried to stop the bleeding with his finger, Fergusson said: “Jist
get your finger out of the way, mon, and let’s see what it is,” and
satisfactorily tied the vessel.[4] He was remarkably neat too in his
completion of an operation, and could not bear to leave any traces
behind, either in hospital or private house.
In the subjects which he had thoroughly studied and on which he had
practical experience Fergusson was a master. This is seen in his
“Practical Surgery,” which reached a fifth edition in 1870, and
in his lectures on the Progress of Anatomy and Surgery delivered
at the College of Surgeons in 1864 and 1865. But as a systematic
lecturer he did not achieve great success, nor was he conspicuous as
a bedside teacher owing to his reticent manner. It was in operating
that he shone most, and in his remarks on operations; to see him
operate was for the student or practitioner already instructed what
to observe a lesson full of practical value. On some important
questions he was imperfectly informed, and this was proved when he
opposed the movement for securing a pure water supply to large towns,
and favoured the anti-vivisectionists in some remarks and evidence
which showed considerable ignorance of physiological discovery and
progress. Again, his attitude towards homœopathic practitioners
largely compromised his influence at one time.
Fergusson’s social instincts as well as his personal sympathies won
him favour from all classes, and his male as well as his female
patients felt deeply his kindly attentions, while children simply
worshipped him. His practice was always to treat a hospital patient
with exactly the same consideration as one in private. Mr. Henry
Smith records the profound impression made upon him as a young
student by his remarkable kindness and gentleness towards a little
lame boy. It is not to be wondered at that he inspired his patients
with the utmost confidence, an art that many equally clever have
lacked. A gentleman who came to London to have an enormous tumour
of the lower jaw removed, saw several eminent surgeons, but chose
Fergusson as the operator without hesitation. “Directly he put
his hands upon me,” said this gentleman, “to examine my jaw, I
felt that he was the man who should do the operation for me; the
contrast between his examination and that of others was so great.”
As Mr. Henry Smith says, “Fergusson not only shone pre-eminently
as an operator, but he possessed a profound knowledge of his art,
and wielded all its resources with consummate skill. His powers of
observation were remarkable; his memory was most tenacious; his
shrewdness, sound common-sense, tact and knowledge of men, and how
to deal with them, were acknowledged by all; and conspicuous amongst
them was that facility of resource in all trying emergencies, which,
added to his extraordinary mechanical skill, made him what he was,
and brought about a success which has seldom been vouchsafed to any
surgeon.”
Fergusson became M.R.C.S., Eng., in 1840, and Fellow in 1844.
He was appointed Surgeon to the Prince-Consort in 1849, and
Surgeon-Extraordinary to the Queen in 1855, and Sergeant-Surgeon
in 1867. In 1861 and again in 1868 he was elected to the Council
of the College of Surgeons, notwithstanding the strong opposition
of the existing council on the first occasion. In 1867 he became
an examiner in surgery, and in 1870 President of the College. His
lectures as Professor have already been mentioned. We may add that he
was President of the Pathological Society in 1859 and ’60, and of the
British Medical Association at its brilliant London meeting in 1873.
His many other appointments and distinctions must be passed over,
with the exception of the baronetcy, which he received in 1866.
Fergusson never tired of work. His fine energies kept him ever
fresh. He could sing, or dance a Highland reel, with energy long
after middle age, and when just returned from a prolonged and tiring
journey. He was a munificent patron of literature and the drama;
attended many an author without fee, and would not unfrequently pay
for their lodging near him in cases where that was desirable. His
spirit of hospitality was lavish, whether in London or at his seat
at Spittlehaugh in Peeblesshire. He was ever ready to show kindly
feeling towards even those who censured him most severely, and his
forgiving nature was many times most conspicuously evident. Whenever
he had any consciousness of having done or said anything calculated
to wound another’s feelings, old or young, he never rested until he
had made reparation in some way. He held a truly modest estimate
of himself, was unspoiled by popularity, and never became at all
overbearing. He was a staunch friend, to old pupils especially,
and a liberal helper of members of the profession generally. Many
a surgeon who has risen has owed to him essential help. Indeed, he
displayed the best Christian characteristics, and was, in Mr. Henry
Smith’s words, “the true type of a Christian gentleman.” He died in
London, after an exhausting illness, of Bright’s disease, on February
10th, 1877, and was buried at West Linton, Peeblesshire, where his
wife had already, in 1860, been buried. A portrait of him by Lehmann
was presented by subscription to the London College of Surgeons in
1874, and a replica is in the Edinburgh College of Surgeons. His best
monument is in the life and work of the multitude of his pupils, whom
he influenced and stimulated as few have ever done.
FOOTNOTES:
[3] Surgery, Past, Present and Future, 1877.
[4] Henry Smith, Biographical Sketch of Sir W. Fergusson.