Sir James Young Simpson and Chloroform (1811-1870) Part 7

CHAPTER X

PERSONAL--PROFESSORIAL--PROFESSIONAL

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 distinguis.h.i.+ng 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 fas.h.i.+on 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 on to 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 pract.i.tioners 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 a.s.sociated 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 fa.r.s.eeing 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 att.i.tude was characteristically conscientious.

We are told that he habitually put the following question to himself when contemplating a serious operation: "Am I conscientiously ent.i.tled 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, ill.u.s.trative 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 failed 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 cla.s.s in a confiding spirit--not as the superior person delivering _ex cathedra_ 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 subst.i.tute. On one occasion he re-appeared pale, weak, and lame, after such an enforced holiday, and was greeted enthusiastically by a crowded cla.s.s. He told them that his servant had said to him that a rumour was 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 a.s.sure 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 pract.i.tioners 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 condition 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 ma.s.ses 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 of the tissues until liberty was obtained. This process was practically incompatible with the ideal form of healing, known as healing by _first intention_, _i.e._, union without appreciable loss of substance or the formation of _pus_ 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 subst.i.tutes 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 pract.i.tioners. 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 antic.i.p.ated 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 read 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 cla.s.s-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 h.o.m.oeopathy, 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 of 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 blessings to humanity made manifest by him. He himself recognised that he had failed to gain for acupressure a place in practice such as he had gained for chloroform, but he looked forward to a time, perhaps a quarter of a 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-five 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 accomplis.h.i.+ng 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 subst.i.tuted 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-fas.h.i.+oned 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 had 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 fact 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 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 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 far and wide amongst country pract.i.tioners. 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 cla.s.sified and summarised. The operations selected were amputations, and the result briefly was this:--

Total number of cases 2,098 } Mortality, " " deaths 226 } 10.8 per cent.

The relative mortality of the different amputations was also shown:--

669 Thigh cases; deaths, 123; mortality, 18.3 per cent.

618 Leg " ; " 82; " 13.2 "

433 Arm " ; " 19; " 4.3 "

378 Forearm " ; " 2; " 0.5 "

The table on the next page compared the results of operations for injury with those performed for disease.

FOR INJURY.

Cases. Deaths. Mortality.

per cent.

Thigh 313 80 25.5 Leg 409 57 13.4 Arm 344 14 4.0 Forearm 313 2 0.6

FOR DISEASE.

Cases. Deaths. Mortality.

per cent.

Thigh 356 43 12.0 Leg 209 25 12.0 Arm 89 5 5.6 Forearm 60 0 --

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 p.r.o.nounced than even he himself had antic.i.p.ated. "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?" 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; 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.

Column Headings-- C: Cases.

D: Deaths.

_______________________________________________________________________ HOSPITAL. FOR INJURY. _______________________ _______________________________________________ Thigh. Leg. Arm. Forearm. ___________ ___________ ___________ ___________ [C] [D] [C] [D] [C] [D] [C] [D] _______________________ _____ _____ _____ _____ _____ _____ _____ _____ Edinburgh Infirmary 134 48 28 9 7 3 19 7 Glasgow " 100 60 93 50 101 38 66 9 Nine London Hospitals 320 123 173 53 48 13 37 7 _______________________ _____ _____ _____ _____ _____ _____ _____ _____ Total 631 239 283 89 78 22 75 15 _______________________ _____ _____ _____ _____ _____ _____ _____ _____ Mortality per cent. 64.4 54.8 40.1 14.8 _______________________ ___________ ___________ ___________ ___________

_______________________________________________________________________ HOSPITAL. FOR DISEASE. _______________________ _______________________________________________ Thigh. Leg. Arm. Forearm. ___________ ___________ ___________ ___________ [C] [D] [C] [D] [C] [D] [C] [D] _______________________ _____ _____ _____ _____ _____ _____ _____ _____ Edinburgh Infirmary 65 48 58 29 21 12 39 5 Glasgow " 177 68 82 27 23 6 19 1 Nine London Hospitals 139 88 179 102 97 33 64 11 _______________________ _____ _____ _____ _____ _____ _____ _____ _____ Total 304 196 330 181 219 88 169 25 _______________________ _____ _____ _____ _____ _____ _____ _____ _____ Mortality per cent. 37.8 31.4 28.2 2.0 _______________________ ___________ ___________ ___________ ___________

The total number of cases 2,089 } mortality 41 per cent.

The total number of deaths 855 } Placed side by side the Town (hospital only) and Country (private practice only) figures compared as follows:-- _Hospital_ cases 2,089; deaths 855; mortality 41 per cent. or 1 in 2.4 _Country_ " 2,098; " 226; " 10.8 " 1 in 9.2

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 vanis.h.i.+ng point. In his review of the progress of wound treatment during the Victorian Era published in the Diamond Jubilee number of _The Pract.i.tioner_, 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 faint 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 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 fatal 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 faces encrusted with active smallpox into the very faces of pa.s.sers-by in the streets of Edinburgh; 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.