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James Syme (1799–1870)
JAMES SYME (I799-I87O) By JAMES M. GRAHAM, Ch.M., LL.D., F.R.C.S.(Ed.)
Consultant Surgeon, The Royal Infirmary, Edinburgh PRINCIPAL SIR ALEXANDER GRANTin his "History of the University of Edinburgh" referred to Syme as " a man who, under a simple and unpretentious exterior, concealed powers which enabled him to rank amongst the greatest professors of the University," and as one "whose life was characterised by sagacity, decision, and truthfulness." He has also been referred to as the Napoleon of Surgery, a comparison intended to indicate his pre-eminence as a surgeon but not expressing the whole truth, for it could not be said of the great military genius as was said of Syme, that he "never wasted a word, a drop of ink, or a drop of blood" (Fig. I). The
FIc. I Photograph of a letter, bearing the patient's name and address, from Syme to his assistant Thomas Annandale, later Regius Professor of Clinical Surgery at Edinburgh. This letter bears out the statement that Syme never wasted a drop of ink. (The original letter is in the Royal College of Surgeons of Edinburgh.)
Principal, less dramatically but perhaps more accurately, describes him as one who if not infallible was the Wellington of Surgery, almost without a reverse. The description of Syme as a man of war is true only in the sense that when he entered into controversy or went into battle, as he sometimes did, it was IA
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always on a matter of principle and never for his own advantage. He was a man of ability and sterling character, with a special gift for the practical solution of surgical problems. He was in active practice for more than forty years, and during that time by teaching the principles of surgery and by his example he brought his influence to bear upon more future practitioners than any other surgeon of his generation. Not the least of the debt owed by modern surgery to Syme was the link he formed with Lister, who became his devoted adherent while still a young man, and who ultimately succeeded him. Syme performed many original operations, with some of which his name is still associated. It is less well known that he described various plastic operations on the face and jaws, to which some special reference will be made. James Syme was born in 1799 in a house in Princes Street, Edinburgh, opposite where the Scott Monument now stands. He was well connected on both sides of the family. His father was a member of an old legal firm and was also a landed proprietor with estates in the counties of Fife and Kinross. He was educated at the High School of Edinburgh, a famous school with long traditions at which Sir Walter Scott and many other well-known men had been educated. The High School at that time was situated close to the Old Infirmary, and it is a remarkable fact that when in 1829 the present school was opened, not far from Princes Street, the managers of the Royal Infirmary acquired the old High School building and adapted it as the Surgical Hospital to which Syme went in 1833 as Regius Professor of Clinical Surgery and where all his work was done and where Lister, in his turn, had his wards. It is of interest that the old Surgical Hospital, replaced by the present Royal Infirmary many years ago, still continues to serve the purposes of education by housing the Geography Department of the University. The external appearance of the building is the same as when it was the old High School, and later when it was visited in the days of Syme and Lister by surgeons from every part of the world. Syme attended classes in the Faculty of Arts of the University of Edinburgh before commencing his studies as a medical student. He showed his originality while still a student attending the class of chemistry. There were no practical classes or laboratory facilities in these days ; but by carrying out experiments in his lodgings he discovered a new solvent for rubber, distilled from coal-tar, and at the age of 18 published the details of the process in the "Annals of Philosophy." With this process he succeeded in making various textiles completely waterproof. Syme's article was read by a Glasgow business man, a Mr Macintosh, who wasted no time in applying for a patent for the process and made such good use of it that, needless to say, Mr Macintosh's name is now known to many who never heard of Mr Syme. Many years later Syme referred to the matter by stating that the only profit he had gained from his discovery was the confidence he acquired by solving successfully a difficult problem. Syme did not graduate at the University, but received his licence to practise from the Royal College of Surgeons. Monro Tertius, the Professor of Anatomy, was not a popular teacher, and like many other students Syme attended the extramural class of anatomy conducted by Barclay with the assistance of Robert Liston, a distant relation of his own who became his friend and later his rival as a surgeon. This early friendship with Liston, then at the beginning of his great career, had a determining influence on Syme's future, for he not only assisted Liston to
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conduct a class of his own, but succeeded him as lecturer when Liston decided to devote himself to surgery. He was conducting his own class of anatomy at the age of 23, but after three years he followed Liston's example by giving up anatomy for the teaching of surgery. His success as a lecturer was assured from the first, and before he was 30 his systematic class in surgery in the extramural school was attended by over 2 5 o students. His success made him a formidable rival to Liston ; the former friends became estranged and soon there was open enmity between them.
FIG. 2 James Syme. (From "Memorials of the Life of James Syme," by Robert Paterson. Edinburgh: Edmonston & Douglas. I874. )
Syme's early surgical training was obtained in the Royal Infirmary as resident clerk to Sir William Newbigging. When he was 23 he spent some months in Paris attending Lisfranc's course of operative surgery and going the rounds with Dupuytren. Syme and Liston assisted each other at operations as long as they were on friendly terms, and many difficult and dangerous operations were performed in the homes of the patients, most of Whom were poor and humble folk. To show Syme's quality and his courage, it is sufficient to state that at the age of 24 he carried out and recorded the first successful amputation at the hip performed in Scotland. The young surgeon said after this experience : " I have no hesitation in recommending to the serious attention of the operating surgeons amputation at the hip joint although it is the greatest and bloodiest operation in surgery." Although without hospital beds, Syme acquired a steadily increasing private practice. At the age of 29 he had a reputation as a surgeon such as few men of his age have ever had. Liston, his senior by some years, was already on
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the staff of the Royal Infirmary. Unfortunately, the private quarrel between these two men was public property, with the effect that when Syme applied for a vacancy on the staff of the Royal Infirmary the managers refused to appoint him, because they feared the feud between the former friends might lead to disturbing scenes before the students. The closure of the Infirmary to Syme only served to spur him on to obtain in some other way the beds he needed for his poorer patients. As only opportunity was lacking to ensure his career as a surgeon, he took the unprecedented step of providing a hospital for himself. Within a few months he had acquired a lease of Minto House, a mansion not far from the University, and had equipped it as a hospital with twenty-four beds and a suitable operating and lecture theatre. His class in clinical surgery, limited to forty students, although many more applied, was recognised by the Royal College of Surgeons, and the support of the public was obtained by the election of a Board of Directors, including many of the best-known citizens of Edinburgh. During four years spent at Minto House, Syme built up his reputation both at home and abroad. It was during this early period that he revived, after an interval of fifty years, the treatment of diseased joints by excision in preference in many cases to amputation and that he performed the first subcutaneous tenotomy for wry neck in this country. At this time he reintroduced the old operation for the treatment of aneurysm and recorded the first of a series of remarkable operations ; he described his method of treating chronic leg ulcer by blistering the indurated edges. He also published the first edition of his "Principles of Surgery," a textbook which was remarkable in that in the last edition many years later the principles of surgery were more briefly and more simply expressed than in the first. When in 1833 James Russell, the first Regius Professor of Clinical Surgery in Edinburgh, retired at the age of 81, Liston and Syme were candidates for the vacant chair and Syme was elected on his merits as a teacher, but also because he agreed to pay the retiring professor an allowance of £3oo a year, a usual arrangement in these days but one which Liston refused to consider. There can seldom have been such a galaxy of talent associated at one time in a surgical hospital. Lizars and Liston were the surgeons when Syme joined them ; shortly afterwards William Fergusson was elected to the staff, and in 1836 Sir Charles Bell, on his appointment as Professor of Surgery in the University, became a consulting surgeon to the Infirmary. Sir Charles Bell, Liston, Syme, and Sir William Fergusson, all of whom became London surgeons and were outstanding in their generation, had received their early training in the extramural school of anatomy in Edinburgh. Although Liston and Syme had ceased to be on friendly terms, each retained a regard for the other, and a few years after Liston had left Edinburgh for the Chair of Surgery at University College the friendship between them was happily renewed. After Liston's death in 1847 Syme was invited to succeed him, and to the regret of his students and colleagues in Edinburgh he agreed to accept the offer. The surprise caused by Syme's acceptance of Liston's Chair at University College was nothing to the sensation aroused within less than five months by his sudden resignation of the Chair and his return to Edinburgh. It is said that the reason for his resignation was that the Council of University College sought to impose on him the duty of systematic as well as of clinical teaching for which he had been appointed. It is perhaps the greatest tribute to Syme's
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position in Edinburgh and to his popularity that having been f&ed and banqueted on his departure for London, he was welcomed back with the greatest cordiality by his students and colleagues and with relief by the Senatus and the Managers of the Royal Infirmary. He was truly fortunate, for a successor had not been appointed, and Millbank, his residence on the outskirts of the city, had not been sold. Few people know of this strange interlude in Syme's career. A remark made recently by an examiner for the Fellowship bears this out, for he was overheard to say that, when he was asked at the adjudication how a certain candidate had done, he had said that the only mistake made by the candidate was when asked who Syme was, he had replied that he was a London surgeon, a remark which was greeted with loud applause and laughter by the assembled examiners. No one present seemed to realise that the candidate had been right in what he said about Syme, although whether he knew he was right is another matter. As Professor of Clinical Surgery, Syme continued the method of clinical teaching which he had adopted in his Minto House days. In his own words, written near the end of his career, " The plan which I introduced into the Edinburgh Medical School and which I still pursue seems to me worthy of adoption. This is to bring the cases one by one into a room where the students are comfortably seated, and if the patients have not been seen by the surgeon beforehand, so much the better ; then, ascertaining the seat and nature of the complaints, he points out their distinctive characters. Having done this so that everyone present knows the case under consideration, the teacher, either in presence or absence of the patient, according to circumstances, proceeds to explain the principles of treatment, with his reasons for choosing the method preferred; and lastly, does whatever is necessary in the presence of his pupils. The great advantage of the system is that it makes an impression at the same time on the eye and ear, which is known by experience to be more indelible than any other." Before Syme's day clinical instruction took the form mainly of a lecture on a collected series of cases. With certain modifications the system introduced by Syme is still followed in most medical schools. Dr Joseph Bell has left a record of his impressions of his former chief and of his methods of operating. As Dr Joseph Bell's methods of observation and deduction had suggested the character of Sherlock Holmes to Conan Doyle, his description of Syme can be relied on : " His operating was devoid of flourish and dash. He was not very rapid and not very elegant. But on the other hand he was absolutely free from fuss and worry ; all idea of self, his own dexterity, his own appearance was evidently banished when he took the knife into his hand. He thought of nothing but the patient and the best--not the most rapid, nor the showiest, not the easiest--but the best way of relieving him. His imperturbable coolness was contagious and he was generally well assisted. No one could be gentler, less exacting, or more easily satisfied ; and probably no surgeon was ever so simple in his tastes or requirements as to instruments. He always knew beforehand what he meant to do, which is of great assistance in doing anything great. Now and then we have seen him change the whole plan of an operation in the very act of its performance ; but we have hardly ever seen him change his purpose, but only the method of accomplishing that purpose. He was always certain that he could do what he wished and even impressed the onlookers with the certainty of his success." His contributions to the progress of surgery were many and varied ; some
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have already been mentioned. The first original observation which he made was recorded in a dissertation to the Royal Medical Society when he was 22 years of age. In describing the changes in the bones of the leg which may follow the presence of a chronic leg ulcer he said : " When an ulcer happens over a vascular bone I have observed (and to the best of my knowledge the observation is new) that the bone may have its vessels stimulated so that instead of displaying a loss of substance it is much increased in surface and seems everywhere as if shooting out stalactites." This was the first of over two hundred contributions to medical literature, and in this early essay it is apparent that he was already able to express himself in the clear, simple, and incisive style which characterised all his later literary work. His interest in bone was continued and amplified some years later when he carried out a series of experiments on the function of the periosteum which antedated the work of Ollier by twenty years. Many of the operations with which Syme's name is linked were performed for the first time before I846, when ether anaesthesia became available. The operation of external urethrotomy for stricture (I84O) remains a standard procedure although seldom now required. The new method received only tardy recognition and met with such abuse and criticism that the personal issues between the protagonists led to the law courts. Syme recorded a series of Io 9 cases in which the operation had been done with only two deaths. His amputation at the ankle giving a weight-bearing stump was a triumph of conservative surgery with a much lower mortality in the days of sepsis than amputations higher up. Aneurysms were common in Syme's day: he had successfully performed the Hunterian operation for popliteal aneurysm in thirty-four of a series of thirty-five cases. His revival of the old operation for aneurysm near the trunk was his greatest contribution to this branch of surgery. As the essential feature of this operation is the laying open of the sac and the securing of the ends of the main vessel from within the sac, it: is not surprising that Syme referred to such operations as the most arduous in his experience. In this way he operated successfully on cases of carotid, axillary, gluteal, and iliac aneurysm. The most dramatic of the cases he recorded was that of a young man with a traumatic aneurysm of the carotid artery low in the neck following a stab wound, for which his assailant was in prison ; fortunately the operation was successful, for, as Syme recorded, he was only too well aware that the life of the assailant as well as that of the patient was at stake. Certain operations which Syme performed on the jaws, nose, lips, and~tongue may be Of interest to those concerned with modern plastic surgery. In I828, while he was still a young man, he published an account of his famous case of tumour of the mandible. So far as the records go, it appears to be the largest tumour for which the mandible has been excised. It had gradually increased to an enormous size over a period of nine years ; although almost certainly innocent, it was described as an ossifying sarcoma. The tumour completely filled the mouth and occupied all the space below it, extending down close to the sternum and projecting forwards 8 in. in front of the neck; the greatly stretched mouth measured 15 in. in circumference. The patient, Robert Penman, aged 24, was a tall emaciated young man possessed of uncommon fortitude. Not the least intriguing feature of the case was the fact that more than three years previously the patient had been seen by several senior colleagues, including Liston, who had refused to operate. The engraving of the patient (Fig. 3) gives an indication of
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the strain to which both patient and surgeon must have been submitted during the operation, performed without an anaesthetic. 1 The patient was placed sitting in a chair to prevent suffocation, and during the operation " a little respite" was frequently given to prevent exhaustion from continued suffering. The patient bore the operation well and did not lose more than 7 or 8 oz. of blood. All the steps of the operation had been planned and the recommendations which Syme made after the experience differed in no way from the procedure adopted. The chief points he made were that the tumour should be freely exposed and the facial and other
FIG. 3 Robert Penman, aged 24. From a cast made before removal of the mandible by Syme in I828. (From "Memorials of the Life of James Syme.")
arterial branches secured before the mucosa of the mouth was opened, and that the temporo-mandibular joint should be opened from the front. He rejected the advice offered that the carotid artery should be tied partly because of the increased risk of secondary ha:morrhage and partly because, as he stated, the anastomosis after ligation of the carotid was so free that hmmorrhage was not completely controlled even if both carotids were tied ; if bleeding proved excessive the main arteries could be temporarily compressed. It is satisfactory to know that the patient made a rapid recovery and that seventeen years later Syme was stopped in Princes Street by a well-dressed man who introduced himself as his former patient recently returned from America. In referring to this meeting Syme stated: " I was no less surprised than pleased to see how little the operation had injured his appearance or articulation." The dissected specimen (Fig. 4) with The ascending ramus and the molar region on the right side were the only parts not involved, and the jaw was divided at the level of the second bicuspid tooth on that side ; the specimen weighed
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FIG. 4 Specimen after removal of the soft parts. (Photograph of specimen in the Anatomical Museum, University of Edinburgh.)
FIG. Portrait of the patient thirty years after removal of the tumour. (From photograph preserved in the Anatomical Museum, University of Edinburgh.) •
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a large portrait of the patient in oils and a plaster cast taken before the operation and other exhibits in connection with the case of Robert Penman are shown in the Anatomical Museum of the University of Edinburgh. In a signed note in his own handwriting Lister refers to the facts of the case and adds : " T h e importance which he attached to the case, and the confidence with which he looked forward to a successful result, are shown by this accompanying plaster cast and portrait in oils which he had taken before the operation. Nearly thilty years afterwards this patient, still in perfect general health, gave Mr Syme the accompanying photograph of himself (Fig. 5), taken at that time. The case illustrates strikingly Syme's surgical qualities at that early period ; the soundness of his knowledge, his clear judgment, and his boldness and skill as an operator." In 1829 Syme established a plan for complete excision of the maxilla which has been adopted with only minor variations ill the skin incision required for exposure. The surgical treatment previously used for tumour of the maxilla was limited to local and usually incomplete removal of the growth. He regarded lipoma nasi as a form of hypertrophy due to hyperplasia of the elements of the skin, and treated it as in the modern manner by shaving off the redundant masses and remodelling the shape of the nose. He observed that the bleeding surface heals with almost the same rapidity as does the raw area after blistering. The methods of restoring the nose by pedicled flaps from the forehead or forearm were familiar to Syme. He described and illustrated a method by which the nose was rebuilt from flaps from the cheeks. At the same time he observed that while the results of these operations were often creditable to the dexterity of the surgeon and looked well at a distance or in illustrations, owing to disparity in colour and other characters they were often disappointing ; he concluded that such achievements were more curious than useful, especially as by means of enamel or other substitutes reasonably comfortable and seemly imitations of the lost parts can be provided and attached with the aid of spectacles. Although various operations had been proposed for the closure of the gap left after removal of the whole of the lower lip for cancer, the results had been unsatisfactory. The latest method was mentioned only to be condemned, for it consisted in the turning up of a flap of skin from below the chin with the surfaces reversed and the hair-bearing surface left within the cavity of the mouth. In the absence of a satisfactory method Syme, like other surgeons, rarely attempted to restore the lip, but in 1847 he devised an operation with the formation of flaps which proved successful in many cases. Incisions were made from the angle of the mouth to meet at the chin so that the lip with the tumour was removed in a triangular form. Incisions were continued on each side from the front of the chin over the margin of the mandible to the level of the hyoid bone and then curved upwards towards the angle of tlae jaw ; in this way two flaps were raised from the submandibular regions which were sutured together in the midline and to the fixed point of the chin. Syme noted that after the lip had been restored, the patients could articulate and retain fluids perfectly. Fourteen years later he referred to many successful cases treated in this way, and an engraving from one of his cases showed the pleasing result of the operation as performed by Syme. In 1857 Syme devised an operation for removal of the entire tongue and was the first surgeon to do so. Free exposure was obtained by dividing the
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lower lip and soft parts in the middle line down to the hyoid and by splitting the mandible at the symphysis. His object was to ascertain whether this radical operation would give a better result than the partial removal of the tongue which he referred to as an operation regarded by all experienced surgeons as worse than useless in cases of cancer. The first patient on whom this operation was done remained well for five days and then developed septic pneumonia and died. Although the patient had been fed with a tube passed into the ~esophagus, the pneumonia was attributed to inhalations following injudicious efforts of the attendants to test the patient's ability to swallow. Within a year Syme recorded a second case which also ended fatally. From the experience of these two cases he observed that only a complete excision of the tongue would have removed all the disease. He had no doubt that the operation, if not actually fatal, must be one of extreme danger, and as in the event of recovery the permanency of relief would still be doubtful, there should be no hesitation in deciding against the repetition of this procedure. He concluded his reference by observing that, " In promoting the progress of surgery it is hardly of more consequence to determine what is expedient than to ascertain what is not expedient, and I venture to hope that the experience now related may not prove useless by saving others from the disappointment I have myself experienced." Although this pronouncement was meant to be final, it was followed by the publication in the Lancet of 4th February 1865 of a third and on this occasion a successful case. The patient was a man of 52 whose tongue, swollen from tip to base, so filled the mouth that swallowing and articulation were extremely difficult. Mr Syme refused to operate, but later yielded to the patient's repeated appeals to do something to relieve his sufferings. Compelled to make another trial of complete excision of the tongue, he decided to do so without chloroform anaesthesia and with the patient sitting in a chair. With the patient's help and resolution the operation was successfully completed, and on the following day the patient, of his own accord, drank a cup of milk without coughing. The divided mandible was not sutured, but movement was controlled with the help of a dentist who fashioned a shield of guttapercha which embraced the chin and was secured by wire to a metal plate with caps enclosing the teeth on each side. Later Syme reported that his patient had returned to see him nine months after the operation. Before the operation he was bent and feeble, requiring a slate to express his ideas and swallowing even fluids with such difficulty as to feel on the verge of starvation. When he presented himself to Mr Syme he was well and vigorous ; he was able to eat in public and to converse without betraying his defect. Professor Goodsir 'confirmed that no trace of the tongue remained and that the mandible was healed. Ta~ste was impaired, but he could distinguish various flavours in the act of swallowing, possibly due to the taste buds in the palate and on the posterior surface of the epiglottis. Many years later, before the days of intratracheal ana:sthesia, the writer saw F. M. Caird, the third Regius Professor of Clinical Surgery in succession to Syme, perform the same operation successfully with the help of a thoroughly induced local anaesthesia. In addition to his teaching and practice, Syme took a great interest in medical affairs generally and particularly in education. In a letter to Lord Palmerston on medical reform, he advocated the appointment of a medical board for the regulation of medical education. The Bill of 1858 by which the General
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Medical Council was formulated was based on the proposals made by Professor Syme. He became an active member of the General Medical Council and would almost certainly have been elected President had the proposal not been prevented by his last illness. Syme's name will always be linked with that of Joseph Lister. Before settling down in London, Lister intended to make a tour of the Continent, but was advised by Sharpey, the Professor of Physiology at University College, in the first place to see something of Syme's work. With this plan in view he came to Edinburgh in I853 at the age of 26. Syme was then at the height of his powers, and Lister was fascinated by the man and his work. The attraction was mutual, for it is recorded that Syme received the young visitor with open arms, offered him the chance of assisting with private cases and promptly set him to work in the hospital. Lister lingered on, the continental tour abandoned, and in I854 Syme appointed him his House Surgeon in the Royal Infirmary. In a letter to his father Lister wrote: " Syme is, I suppose, the first of British surgeons, and to observe his practice and hear the conversation of such a man is the greatest possible advantage." Lister was a welcome visitor at Millbank, Syme's beautiful and hospitable home on the southern outskirts of Edinburgh, facing the hills ; there he met many distinguished men and Syme's daughter, Agnes, to whom he became engaged and whom he married in I856, the same year in which he was appointed Assistant Surgeon to the Royal Infirmary. Lister continued to assist Syme until he went, in I86O, as Professor of Surgery to Glasgow, where his pioneer work on antisepsis was begun and where he remained until I869, when he returned to Edinburgh as Syme's successor in the Regius Chair of Clinical Surgery. Like most great men Syme was not wholly perfect or above criticism. His occasional fall from grace was due to a combative strain in his nature which led him sometimes beyond differences of opinion into quarrels in which, if not always the aggressor, he was never slow to take up the cudgels. His gift of incisive language sometimes left a sting, and a mere difference of opinion in a surgical matter was apt to develop into a quarrel which sometimes ended in a paper war of recrimination or even in the law courts. Much may be excused, for if human nature does not change it is equally true that manners and the times have changed. The signs of rivalry and even of jealousy, ill-concealed and sometimes maliciously expressed, so evident in medical circles a hundred or more years ago, seldom fortunately in these modern days, if they exist at all, give even a hint of their presence. Syme's battles were always on matters of principle, and if sometimes he aroused the fiercest opposition, equally he inspired devotion and affection on the part of his pupils and assistants. Professor Annandale, Lister's successor, who had been House Surgeon and assistant to Syme, used to say that not once in ten years had there been any serious difference of opinion between them. Lister said of him, " The hostility which he excited in the few was greatly outweighed by the friendship he inspired in the many. This was due to the genuineness of his character, which could not fail to gain respect even from those who differed from him, but also to another quality, as essential as truthfulness to a good surgeon--a most warm heart and a general appreciation of sterling merit in whatever form it might present itself. Mr Syme, in short, besides being a surgical genius of the first order, was a good as well as a great man." Syme's active career came to an end in I869 when he suffered a left-sided
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hemiplegia which left his faculties otherwise unimpaired. In the same year he resigned his Chair and was succeeded by Lister. It was significant of his alert and vigorous mind that he was one of the first to practise and to preach the advantages of the antiseptic system. In his last clinical lecture, delivered in I868, he referred to the new principle of the antiseptic system as destined to revolutionise the practice of surgery. At the same time he was able to record most striking results from the application of Lister's methods, and could report that in the session attended by the students not a single fatal result had followed in all the amputations, excisions of breast, removal of turnouts, and other operations. It was characteristic of his judgment that his last word to his students was an appreciation of a new principle and its significance for the future of surgery. Syme's death in I87 o marks the close of the pre-Listerian era and the beginning of a still more brilliant period in the history of surgery.
Consultant Surgeon, The Royal Infirmary, Edinburgh PRINCIPAL SIR ALEXANDER GRANTin his "History of the University of Edinburgh" referred to Syme as " a man who, under a simple and unpretentious exterior, concealed powers which enabled him to rank amongst the greatest professors of the University," and as one "whose life was characterised by sagacity, decision, and truthfulness." He has also been referred to as the Napoleon of Surgery, a comparison intended to indicate his pre-eminence as a surgeon but not expressing the whole truth, for it could not be said of the great military genius as was said of Syme, that he "never wasted a word, a drop of ink, or a drop of blood" (Fig. I). The
FIc. I Photograph of a letter, bearing the patient's name and address, from Syme to his assistant Thomas Annandale, later Regius Professor of Clinical Surgery at Edinburgh. This letter bears out the statement that Syme never wasted a drop of ink. (The original letter is in the Royal College of Surgeons of Edinburgh.)
Principal, less dramatically but perhaps more accurately, describes him as one who if not infallible was the Wellington of Surgery, almost without a reverse. The description of Syme as a man of war is true only in the sense that when he entered into controversy or went into battle, as he sometimes did, it was IA
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always on a matter of principle and never for his own advantage. He was a man of ability and sterling character, with a special gift for the practical solution of surgical problems. He was in active practice for more than forty years, and during that time by teaching the principles of surgery and by his example he brought his influence to bear upon more future practitioners than any other surgeon of his generation. Not the least of the debt owed by modern surgery to Syme was the link he formed with Lister, who became his devoted adherent while still a young man, and who ultimately succeeded him. Syme performed many original operations, with some of which his name is still associated. It is less well known that he described various plastic operations on the face and jaws, to which some special reference will be made. James Syme was born in 1799 in a house in Princes Street, Edinburgh, opposite where the Scott Monument now stands. He was well connected on both sides of the family. His father was a member of an old legal firm and was also a landed proprietor with estates in the counties of Fife and Kinross. He was educated at the High School of Edinburgh, a famous school with long traditions at which Sir Walter Scott and many other well-known men had been educated. The High School at that time was situated close to the Old Infirmary, and it is a remarkable fact that when in 1829 the present school was opened, not far from Princes Street, the managers of the Royal Infirmary acquired the old High School building and adapted it as the Surgical Hospital to which Syme went in 1833 as Regius Professor of Clinical Surgery and where all his work was done and where Lister, in his turn, had his wards. It is of interest that the old Surgical Hospital, replaced by the present Royal Infirmary many years ago, still continues to serve the purposes of education by housing the Geography Department of the University. The external appearance of the building is the same as when it was the old High School, and later when it was visited in the days of Syme and Lister by surgeons from every part of the world. Syme attended classes in the Faculty of Arts of the University of Edinburgh before commencing his studies as a medical student. He showed his originality while still a student attending the class of chemistry. There were no practical classes or laboratory facilities in these days ; but by carrying out experiments in his lodgings he discovered a new solvent for rubber, distilled from coal-tar, and at the age of 18 published the details of the process in the "Annals of Philosophy." With this process he succeeded in making various textiles completely waterproof. Syme's article was read by a Glasgow business man, a Mr Macintosh, who wasted no time in applying for a patent for the process and made such good use of it that, needless to say, Mr Macintosh's name is now known to many who never heard of Mr Syme. Many years later Syme referred to the matter by stating that the only profit he had gained from his discovery was the confidence he acquired by solving successfully a difficult problem. Syme did not graduate at the University, but received his licence to practise from the Royal College of Surgeons. Monro Tertius, the Professor of Anatomy, was not a popular teacher, and like many other students Syme attended the extramural class of anatomy conducted by Barclay with the assistance of Robert Liston, a distant relation of his own who became his friend and later his rival as a surgeon. This early friendship with Liston, then at the beginning of his great career, had a determining influence on Syme's future, for he not only assisted Liston to
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conduct a class of his own, but succeeded him as lecturer when Liston decided to devote himself to surgery. He was conducting his own class of anatomy at the age of 23, but after three years he followed Liston's example by giving up anatomy for the teaching of surgery. His success as a lecturer was assured from the first, and before he was 30 his systematic class in surgery in the extramural school was attended by over 2 5 o students. His success made him a formidable rival to Liston ; the former friends became estranged and soon there was open enmity between them.
FIG. 2 James Syme. (From "Memorials of the Life of James Syme," by Robert Paterson. Edinburgh: Edmonston & Douglas. I874. )
Syme's early surgical training was obtained in the Royal Infirmary as resident clerk to Sir William Newbigging. When he was 23 he spent some months in Paris attending Lisfranc's course of operative surgery and going the rounds with Dupuytren. Syme and Liston assisted each other at operations as long as they were on friendly terms, and many difficult and dangerous operations were performed in the homes of the patients, most of Whom were poor and humble folk. To show Syme's quality and his courage, it is sufficient to state that at the age of 24 he carried out and recorded the first successful amputation at the hip performed in Scotland. The young surgeon said after this experience : " I have no hesitation in recommending to the serious attention of the operating surgeons amputation at the hip joint although it is the greatest and bloodiest operation in surgery." Although without hospital beds, Syme acquired a steadily increasing private practice. At the age of 29 he had a reputation as a surgeon such as few men of his age have ever had. Liston, his senior by some years, was already on
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the staff of the Royal Infirmary. Unfortunately, the private quarrel between these two men was public property, with the effect that when Syme applied for a vacancy on the staff of the Royal Infirmary the managers refused to appoint him, because they feared the feud between the former friends might lead to disturbing scenes before the students. The closure of the Infirmary to Syme only served to spur him on to obtain in some other way the beds he needed for his poorer patients. As only opportunity was lacking to ensure his career as a surgeon, he took the unprecedented step of providing a hospital for himself. Within a few months he had acquired a lease of Minto House, a mansion not far from the University, and had equipped it as a hospital with twenty-four beds and a suitable operating and lecture theatre. His class in clinical surgery, limited to forty students, although many more applied, was recognised by the Royal College of Surgeons, and the support of the public was obtained by the election of a Board of Directors, including many of the best-known citizens of Edinburgh. During four years spent at Minto House, Syme built up his reputation both at home and abroad. It was during this early period that he revived, after an interval of fifty years, the treatment of diseased joints by excision in preference in many cases to amputation and that he performed the first subcutaneous tenotomy for wry neck in this country. At this time he reintroduced the old operation for the treatment of aneurysm and recorded the first of a series of remarkable operations ; he described his method of treating chronic leg ulcer by blistering the indurated edges. He also published the first edition of his "Principles of Surgery," a textbook which was remarkable in that in the last edition many years later the principles of surgery were more briefly and more simply expressed than in the first. When in 1833 James Russell, the first Regius Professor of Clinical Surgery in Edinburgh, retired at the age of 81, Liston and Syme were candidates for the vacant chair and Syme was elected on his merits as a teacher, but also because he agreed to pay the retiring professor an allowance of £3oo a year, a usual arrangement in these days but one which Liston refused to consider. There can seldom have been such a galaxy of talent associated at one time in a surgical hospital. Lizars and Liston were the surgeons when Syme joined them ; shortly afterwards William Fergusson was elected to the staff, and in 1836 Sir Charles Bell, on his appointment as Professor of Surgery in the University, became a consulting surgeon to the Infirmary. Sir Charles Bell, Liston, Syme, and Sir William Fergusson, all of whom became London surgeons and were outstanding in their generation, had received their early training in the extramural school of anatomy in Edinburgh. Although Liston and Syme had ceased to be on friendly terms, each retained a regard for the other, and a few years after Liston had left Edinburgh for the Chair of Surgery at University College the friendship between them was happily renewed. After Liston's death in 1847 Syme was invited to succeed him, and to the regret of his students and colleagues in Edinburgh he agreed to accept the offer. The surprise caused by Syme's acceptance of Liston's Chair at University College was nothing to the sensation aroused within less than five months by his sudden resignation of the Chair and his return to Edinburgh. It is said that the reason for his resignation was that the Council of University College sought to impose on him the duty of systematic as well as of clinical teaching for which he had been appointed. It is perhaps the greatest tribute to Syme's
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position in Edinburgh and to his popularity that having been f&ed and banqueted on his departure for London, he was welcomed back with the greatest cordiality by his students and colleagues and with relief by the Senatus and the Managers of the Royal Infirmary. He was truly fortunate, for a successor had not been appointed, and Millbank, his residence on the outskirts of the city, had not been sold. Few people know of this strange interlude in Syme's career. A remark made recently by an examiner for the Fellowship bears this out, for he was overheard to say that, when he was asked at the adjudication how a certain candidate had done, he had said that the only mistake made by the candidate was when asked who Syme was, he had replied that he was a London surgeon, a remark which was greeted with loud applause and laughter by the assembled examiners. No one present seemed to realise that the candidate had been right in what he said about Syme, although whether he knew he was right is another matter. As Professor of Clinical Surgery, Syme continued the method of clinical teaching which he had adopted in his Minto House days. In his own words, written near the end of his career, " The plan which I introduced into the Edinburgh Medical School and which I still pursue seems to me worthy of adoption. This is to bring the cases one by one into a room where the students are comfortably seated, and if the patients have not been seen by the surgeon beforehand, so much the better ; then, ascertaining the seat and nature of the complaints, he points out their distinctive characters. Having done this so that everyone present knows the case under consideration, the teacher, either in presence or absence of the patient, according to circumstances, proceeds to explain the principles of treatment, with his reasons for choosing the method preferred; and lastly, does whatever is necessary in the presence of his pupils. The great advantage of the system is that it makes an impression at the same time on the eye and ear, which is known by experience to be more indelible than any other." Before Syme's day clinical instruction took the form mainly of a lecture on a collected series of cases. With certain modifications the system introduced by Syme is still followed in most medical schools. Dr Joseph Bell has left a record of his impressions of his former chief and of his methods of operating. As Dr Joseph Bell's methods of observation and deduction had suggested the character of Sherlock Holmes to Conan Doyle, his description of Syme can be relied on : " His operating was devoid of flourish and dash. He was not very rapid and not very elegant. But on the other hand he was absolutely free from fuss and worry ; all idea of self, his own dexterity, his own appearance was evidently banished when he took the knife into his hand. He thought of nothing but the patient and the best--not the most rapid, nor the showiest, not the easiest--but the best way of relieving him. His imperturbable coolness was contagious and he was generally well assisted. No one could be gentler, less exacting, or more easily satisfied ; and probably no surgeon was ever so simple in his tastes or requirements as to instruments. He always knew beforehand what he meant to do, which is of great assistance in doing anything great. Now and then we have seen him change the whole plan of an operation in the very act of its performance ; but we have hardly ever seen him change his purpose, but only the method of accomplishing that purpose. He was always certain that he could do what he wished and even impressed the onlookers with the certainty of his success." His contributions to the progress of surgery were many and varied ; some
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have already been mentioned. The first original observation which he made was recorded in a dissertation to the Royal Medical Society when he was 22 years of age. In describing the changes in the bones of the leg which may follow the presence of a chronic leg ulcer he said : " When an ulcer happens over a vascular bone I have observed (and to the best of my knowledge the observation is new) that the bone may have its vessels stimulated so that instead of displaying a loss of substance it is much increased in surface and seems everywhere as if shooting out stalactites." This was the first of over two hundred contributions to medical literature, and in this early essay it is apparent that he was already able to express himself in the clear, simple, and incisive style which characterised all his later literary work. His interest in bone was continued and amplified some years later when he carried out a series of experiments on the function of the periosteum which antedated the work of Ollier by twenty years. Many of the operations with which Syme's name is linked were performed for the first time before I846, when ether anaesthesia became available. The operation of external urethrotomy for stricture (I84O) remains a standard procedure although seldom now required. The new method received only tardy recognition and met with such abuse and criticism that the personal issues between the protagonists led to the law courts. Syme recorded a series of Io 9 cases in which the operation had been done with only two deaths. His amputation at the ankle giving a weight-bearing stump was a triumph of conservative surgery with a much lower mortality in the days of sepsis than amputations higher up. Aneurysms were common in Syme's day: he had successfully performed the Hunterian operation for popliteal aneurysm in thirty-four of a series of thirty-five cases. His revival of the old operation for aneurysm near the trunk was his greatest contribution to this branch of surgery. As the essential feature of this operation is the laying open of the sac and the securing of the ends of the main vessel from within the sac, it: is not surprising that Syme referred to such operations as the most arduous in his experience. In this way he operated successfully on cases of carotid, axillary, gluteal, and iliac aneurysm. The most dramatic of the cases he recorded was that of a young man with a traumatic aneurysm of the carotid artery low in the neck following a stab wound, for which his assailant was in prison ; fortunately the operation was successful, for, as Syme recorded, he was only too well aware that the life of the assailant as well as that of the patient was at stake. Certain operations which Syme performed on the jaws, nose, lips, and~tongue may be Of interest to those concerned with modern plastic surgery. In I828, while he was still a young man, he published an account of his famous case of tumour of the mandible. So far as the records go, it appears to be the largest tumour for which the mandible has been excised. It had gradually increased to an enormous size over a period of nine years ; although almost certainly innocent, it was described as an ossifying sarcoma. The tumour completely filled the mouth and occupied all the space below it, extending down close to the sternum and projecting forwards 8 in. in front of the neck; the greatly stretched mouth measured 15 in. in circumference. The patient, Robert Penman, aged 24, was a tall emaciated young man possessed of uncommon fortitude. Not the least intriguing feature of the case was the fact that more than three years previously the patient had been seen by several senior colleagues, including Liston, who had refused to operate. The engraving of the patient (Fig. 3) gives an indication of
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the strain to which both patient and surgeon must have been submitted during the operation, performed without an anaesthetic. 1 The patient was placed sitting in a chair to prevent suffocation, and during the operation " a little respite" was frequently given to prevent exhaustion from continued suffering. The patient bore the operation well and did not lose more than 7 or 8 oz. of blood. All the steps of the operation had been planned and the recommendations which Syme made after the experience differed in no way from the procedure adopted. The chief points he made were that the tumour should be freely exposed and the facial and other
FIG. 3 Robert Penman, aged 24. From a cast made before removal of the mandible by Syme in I828. (From "Memorials of the Life of James Syme.")
arterial branches secured before the mucosa of the mouth was opened, and that the temporo-mandibular joint should be opened from the front. He rejected the advice offered that the carotid artery should be tied partly because of the increased risk of secondary ha:morrhage and partly because, as he stated, the anastomosis after ligation of the carotid was so free that hmmorrhage was not completely controlled even if both carotids were tied ; if bleeding proved excessive the main arteries could be temporarily compressed. It is satisfactory to know that the patient made a rapid recovery and that seventeen years later Syme was stopped in Princes Street by a well-dressed man who introduced himself as his former patient recently returned from America. In referring to this meeting Syme stated: " I was no less surprised than pleased to see how little the operation had injured his appearance or articulation." The dissected specimen (Fig. 4) with The ascending ramus and the molar region on the right side were the only parts not involved, and the jaw was divided at the level of the second bicuspid tooth on that side ; the specimen weighed
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FIG. 4 Specimen after removal of the soft parts. (Photograph of specimen in the Anatomical Museum, University of Edinburgh.)
FIG. Portrait of the patient thirty years after removal of the tumour. (From photograph preserved in the Anatomical Museum, University of Edinburgh.) •
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a large portrait of the patient in oils and a plaster cast taken before the operation and other exhibits in connection with the case of Robert Penman are shown in the Anatomical Museum of the University of Edinburgh. In a signed note in his own handwriting Lister refers to the facts of the case and adds : " T h e importance which he attached to the case, and the confidence with which he looked forward to a successful result, are shown by this accompanying plaster cast and portrait in oils which he had taken before the operation. Nearly thilty years afterwards this patient, still in perfect general health, gave Mr Syme the accompanying photograph of himself (Fig. 5), taken at that time. The case illustrates strikingly Syme's surgical qualities at that early period ; the soundness of his knowledge, his clear judgment, and his boldness and skill as an operator." In 1829 Syme established a plan for complete excision of the maxilla which has been adopted with only minor variations ill the skin incision required for exposure. The surgical treatment previously used for tumour of the maxilla was limited to local and usually incomplete removal of the growth. He regarded lipoma nasi as a form of hypertrophy due to hyperplasia of the elements of the skin, and treated it as in the modern manner by shaving off the redundant masses and remodelling the shape of the nose. He observed that the bleeding surface heals with almost the same rapidity as does the raw area after blistering. The methods of restoring the nose by pedicled flaps from the forehead or forearm were familiar to Syme. He described and illustrated a method by which the nose was rebuilt from flaps from the cheeks. At the same time he observed that while the results of these operations were often creditable to the dexterity of the surgeon and looked well at a distance or in illustrations, owing to disparity in colour and other characters they were often disappointing ; he concluded that such achievements were more curious than useful, especially as by means of enamel or other substitutes reasonably comfortable and seemly imitations of the lost parts can be provided and attached with the aid of spectacles. Although various operations had been proposed for the closure of the gap left after removal of the whole of the lower lip for cancer, the results had been unsatisfactory. The latest method was mentioned only to be condemned, for it consisted in the turning up of a flap of skin from below the chin with the surfaces reversed and the hair-bearing surface left within the cavity of the mouth. In the absence of a satisfactory method Syme, like other surgeons, rarely attempted to restore the lip, but in 1847 he devised an operation with the formation of flaps which proved successful in many cases. Incisions were made from the angle of the mouth to meet at the chin so that the lip with the tumour was removed in a triangular form. Incisions were continued on each side from the front of the chin over the margin of the mandible to the level of the hyoid bone and then curved upwards towards the angle of tlae jaw ; in this way two flaps were raised from the submandibular regions which were sutured together in the midline and to the fixed point of the chin. Syme noted that after the lip had been restored, the patients could articulate and retain fluids perfectly. Fourteen years later he referred to many successful cases treated in this way, and an engraving from one of his cases showed the pleasing result of the operation as performed by Syme. In 1857 Syme devised an operation for removal of the entire tongue and was the first surgeon to do so. Free exposure was obtained by dividing the
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lower lip and soft parts in the middle line down to the hyoid and by splitting the mandible at the symphysis. His object was to ascertain whether this radical operation would give a better result than the partial removal of the tongue which he referred to as an operation regarded by all experienced surgeons as worse than useless in cases of cancer. The first patient on whom this operation was done remained well for five days and then developed septic pneumonia and died. Although the patient had been fed with a tube passed into the ~esophagus, the pneumonia was attributed to inhalations following injudicious efforts of the attendants to test the patient's ability to swallow. Within a year Syme recorded a second case which also ended fatally. From the experience of these two cases he observed that only a complete excision of the tongue would have removed all the disease. He had no doubt that the operation, if not actually fatal, must be one of extreme danger, and as in the event of recovery the permanency of relief would still be doubtful, there should be no hesitation in deciding against the repetition of this procedure. He concluded his reference by observing that, " In promoting the progress of surgery it is hardly of more consequence to determine what is expedient than to ascertain what is not expedient, and I venture to hope that the experience now related may not prove useless by saving others from the disappointment I have myself experienced." Although this pronouncement was meant to be final, it was followed by the publication in the Lancet of 4th February 1865 of a third and on this occasion a successful case. The patient was a man of 52 whose tongue, swollen from tip to base, so filled the mouth that swallowing and articulation were extremely difficult. Mr Syme refused to operate, but later yielded to the patient's repeated appeals to do something to relieve his sufferings. Compelled to make another trial of complete excision of the tongue, he decided to do so without chloroform anaesthesia and with the patient sitting in a chair. With the patient's help and resolution the operation was successfully completed, and on the following day the patient, of his own accord, drank a cup of milk without coughing. The divided mandible was not sutured, but movement was controlled with the help of a dentist who fashioned a shield of guttapercha which embraced the chin and was secured by wire to a metal plate with caps enclosing the teeth on each side. Later Syme reported that his patient had returned to see him nine months after the operation. Before the operation he was bent and feeble, requiring a slate to express his ideas and swallowing even fluids with such difficulty as to feel on the verge of starvation. When he presented himself to Mr Syme he was well and vigorous ; he was able to eat in public and to converse without betraying his defect. Professor Goodsir 'confirmed that no trace of the tongue remained and that the mandible was healed. Ta~ste was impaired, but he could distinguish various flavours in the act of swallowing, possibly due to the taste buds in the palate and on the posterior surface of the epiglottis. Many years later, before the days of intratracheal ana:sthesia, the writer saw F. M. Caird, the third Regius Professor of Clinical Surgery in succession to Syme, perform the same operation successfully with the help of a thoroughly induced local anaesthesia. In addition to his teaching and practice, Syme took a great interest in medical affairs generally and particularly in education. In a letter to Lord Palmerston on medical reform, he advocated the appointment of a medical board for the regulation of medical education. The Bill of 1858 by which the General
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Medical Council was formulated was based on the proposals made by Professor Syme. He became an active member of the General Medical Council and would almost certainly have been elected President had the proposal not been prevented by his last illness. Syme's name will always be linked with that of Joseph Lister. Before settling down in London, Lister intended to make a tour of the Continent, but was advised by Sharpey, the Professor of Physiology at University College, in the first place to see something of Syme's work. With this plan in view he came to Edinburgh in I853 at the age of 26. Syme was then at the height of his powers, and Lister was fascinated by the man and his work. The attraction was mutual, for it is recorded that Syme received the young visitor with open arms, offered him the chance of assisting with private cases and promptly set him to work in the hospital. Lister lingered on, the continental tour abandoned, and in I854 Syme appointed him his House Surgeon in the Royal Infirmary. In a letter to his father Lister wrote: " Syme is, I suppose, the first of British surgeons, and to observe his practice and hear the conversation of such a man is the greatest possible advantage." Lister was a welcome visitor at Millbank, Syme's beautiful and hospitable home on the southern outskirts of Edinburgh, facing the hills ; there he met many distinguished men and Syme's daughter, Agnes, to whom he became engaged and whom he married in I856, the same year in which he was appointed Assistant Surgeon to the Royal Infirmary. Lister continued to assist Syme until he went, in I86O, as Professor of Surgery to Glasgow, where his pioneer work on antisepsis was begun and where he remained until I869, when he returned to Edinburgh as Syme's successor in the Regius Chair of Clinical Surgery. Like most great men Syme was not wholly perfect or above criticism. His occasional fall from grace was due to a combative strain in his nature which led him sometimes beyond differences of opinion into quarrels in which, if not always the aggressor, he was never slow to take up the cudgels. His gift of incisive language sometimes left a sting, and a mere difference of opinion in a surgical matter was apt to develop into a quarrel which sometimes ended in a paper war of recrimination or even in the law courts. Much may be excused, for if human nature does not change it is equally true that manners and the times have changed. The signs of rivalry and even of jealousy, ill-concealed and sometimes maliciously expressed, so evident in medical circles a hundred or more years ago, seldom fortunately in these modern days, if they exist at all, give even a hint of their presence. Syme's battles were always on matters of principle, and if sometimes he aroused the fiercest opposition, equally he inspired devotion and affection on the part of his pupils and assistants. Professor Annandale, Lister's successor, who had been House Surgeon and assistant to Syme, used to say that not once in ten years had there been any serious difference of opinion between them. Lister said of him, " The hostility which he excited in the few was greatly outweighed by the friendship he inspired in the many. This was due to the genuineness of his character, which could not fail to gain respect even from those who differed from him, but also to another quality, as essential as truthfulness to a good surgeon--a most warm heart and a general appreciation of sterling merit in whatever form it might present itself. Mr Syme, in short, besides being a surgical genius of the first order, was a good as well as a great man." Syme's active career came to an end in I869 when he suffered a left-sided
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hemiplegia which left his faculties otherwise unimpaired. In the same year he resigned his Chair and was succeeded by Lister. It was significant of his alert and vigorous mind that he was one of the first to practise and to preach the advantages of the antiseptic system. In his last clinical lecture, delivered in I868, he referred to the new principle of the antiseptic system as destined to revolutionise the practice of surgery. At the same time he was able to record most striking results from the application of Lister's methods, and could report that in the session attended by the students not a single fatal result had followed in all the amputations, excisions of breast, removal of turnouts, and other operations. It was characteristic of his judgment that his last word to his students was an appreciation of a new principle and its significance for the future of surgery. Syme's death in I87 o marks the close of the pre-Listerian era and the beginning of a still more brilliant period in the history of surgery.