Historical Article

Syme and his amputation

N.A. Malcolm-Smith
Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary, Edinburgh

Correspondence to: N.A. Malcolm-Smith, 43 Craiglea Drive, Edinburgh, EH10 5PB Email: nigelms2001@yahoo.co.uk

Introduction Operative technique Sources

Outcome Discussion Summary References

The study examines Syme’s indications for and technique of amputation at the ankle and reviews the outcome of cases operated on by him for the years 1841-1866. Sources are the Ward Journals and the General Registers of Patients of the Royal Infirmary of Edinburgh for the period under review together with abstracts from contemporary medical journals and surgical textbooks. Ninetyeight cases are included in the study, of which 87 survived and 11 died in the post-operative period. The principal indication for this amputation was ‘caries’ and the nature of this disorder is outlined. Syme’s operative technique is described together with variations recommended by other contemporary surgeons. Syme introduced amputation at the ankle joint with the object of reducing mortality and providing a better stump in cases of disease and injury to the foot. The figures from this study conclude that he was justified on both counts

INTRODUCTION
James Syme was born in Edinburgh on 7th November 1799, the son of John Syme of Cartmore, a Writer to the Signet. He was educated at the High School of Edinburgh and entered the University of Edinburgh in 1815, at the age of 16, to study Latin, Botany, Natural History, Mathematics and Philosophy. A year later he joined the Chemistry class under Professor Thomas Carlyle Hope and started his medical career by studying Anatomy in the extramural school under Dr John Barclay. Syme gained his Membership of the Royal College of Surgeons of England in 1821 and was admitted as a Fellow of the Royal College of Surgeons of Edinburgh in 1823. From 1818, he taught in the Robert Liston’s School of Anatomy. After a visit to Paris in 1822 he also lectured on Surgery and entered surgical practice both privately and, from 1829, in his own charity hospital in Minto House in Edinburgh. He was nominated to the Chair of Clinical Surgery at the University of Edinburgh in 1833. Soon after, he was appointed by the Managers of the Royal Infirmary of Edinburgh to the position of Junior Assistant Surgeon with an allocation of 38 beds for teaching surgery on clinical cases. This further cemented the Infirmary’s connection with the University of Edinburgh on the clinical surgical side. He remained in this Chair and practised at the Royal Infirmary, until his death in 1870, except for a short interruption in 1848, when he held the Chair of Surgery at University College Hospital in London.¹

Syme taught and practised as a surgeon for nearly 50 years, during which time understanding of the principles of physiology, pathology and medical statistics was evolving and beginning to have an influence on medical practice. Among Syme’s many interests was the management of diseased joints. In 1831, he published his ‘Treatise on the Excision of Diseased Joints’ which became the definitive work on the subject. Excision of the ankle joint itself for disease of the talus and calcaneum, referred to in contemporary texts as the ‘astragalus’ and the ‘os calcis’ respectively, was described by Syme. He considered it to be of questionable value as support for the body, by the remains of the foot and fibrous ankle joint, was poor. Syme described two other operations for disease or injury of the foot. These were Chopart’s disarticulation of the forefoot, if the disease or injury was restricted to the metatarsal and adjacent areas, and amputation of the leg if the calcaneum and talus were affected and conservative treatment to save the limb had been unsuccessful.^2,3 When, in 1842, the French surgeon J. Baudens published an account of amputation at the ankle, this operation was adopted and refined by Syme who put forward two indications: ‘caries’ where it affected the proximal part of the foot and the ankle joint itself, and compound dislocation of the ankle joint.^3-5

NATURE OF CARIES 
Caries in recent times has become the term used for the cold abscess arising from osteomyelitis of tuberculous origin, however, from descriptions by Syme and his surgical contemporary, John Lizars, cases of ‘caries’ seem more likely to have been chronic pyogenic osteomyelitis rather than of tubercular (‘scrofulous’) origin though Syme notes that ‘suppuration is frequently preceded by scrofulous deposition’.^7-9 In Syme’s day, the different origins of tubercular and pyogenic osteomyelitis were not understood, with the term ‘caries’ being used indiscriminately to denote the condition characterised by the original Latin translation of ‘decay’. Tuberculosis is not recognised nowadays as common in the ankle and is not associated with sequestrum formation.¹⁰ Two of Syme’s cases are described as of ‘scrofulous origin’ and it may be that he recognised a difference between them and the more usual appearances of caries.

The term ‘caries,’ was applied to bones which were the subject of chronic inflammation. Syme considered that local irritants were the source of inflammation and cited as causes of it ‘every source of violence whether chemical or mechanical which alters the structure of the body’ including ‘forcible extension of joints’. He described the outcomes of inflammation as ‘succesful resolution’, or ‘suppuration’ of the exterior or interior of bone leading to ‘excavation’ and enlargement of the external shell described as ‘spina ventosa’. He further describes the process thus: ‘The cavities which are formed in the cancellated substance of bones....frequently contain loose portions of the spongy bone which have been deprived of the vitality by the inflammation’. Recommended treatment included: ‘Free opening to the discharge.......relieves the pain and is followed by either healing or resistance to all means of cure’. He comments; ‘when the ulcer of the bone resists all means of cure it constitutes what is known as ‘caries’ and is characterised by pain, discharge, granulations and ‘effusion of new osseous material in the form of spines and tubercules covered by unhealthy granulation’. At this stage of the illness Syme advised ‘amputation ought to be performed; and if this is impracticable the disease will sooner or later prove inevitably fatal’.6 John Lizars described ‘caries’ as ‘ulceration of the bones’ with a separation of the careous and healthy portions, the former being thrown off like a slough...a sequestrum’ - (Figure 1).⁷

Figure 1: Caries of the ‘Os Calcis and Astragalus’ From: Lizars J. ‘A System of Practical Surgery Part I’ PlateVIII. W.H.Lizars, 1838.

SYME’S OPERATIVE TECHNIQUE
The operation is described by Syme as follows: ‘I cut across the integuments of the instep in a curved direction, with the convexity towards the toes and then across the sole of the foot, so that the incisions were nearly opposite to each other (shown by the firm line in Figure 2). The flaps thus formed were next separated from their subjacent connexions,which was easily effected except at the heel, where the firmness of the texture occasioned a little difficulty. The disarticulation being then readily completed, the malleolar projections were removed with cutting pliers’.¹¹ Syme pointed out that the time from incision to disarticulation was less than a minute confirmed in the clinical notes of J.S. Beveridge, a medical student, of an operation in which he states ‘The operation without any hurry takes 58 seconds’.^12,13

One year later Syme emphasised certain points of technique:

‘The best instrument is a large bistoury or small amputating knife with a blade 4in. long. There is no occasion for a tourniquet, as the assistant has complete command of the vessels by grasping the ankle. The incisions across the instep and the sole should be curved with the convexity forward. Avoid cutting the posterior tibial artery before it divides into the plantar branches (to prevent sloughing of the flap). If the articulating surfaces of tibia and fibula be diseased a thin slice of these bones should be sawn off.’

Figure 2: Line of incisions used by Syme for ankle disarticulation. The firm line indicates the incision in early cases, later modified to that shown by the dotted line. From: Syme J. ‘Amputation at the Ankle Joint’ Monthly Journal of Medical Science 1850; 10: 172.

Four advantages for ankle disarticulation in preference to amputation of the leg are cited:

‘1st. ......less shock from the small extent of the parts removed 2d......the smallness of the arteries divided prevents any risk of serious haemorrhage. 3d.....the cancellated texture of the bone exposed is not likely to exfoliate. 4th. ...from the medullary canal remaining entire, inflammation of its contents and also of the veins is prevented’.¹⁴

In Syme’s original description he also points out that ‘a more comfortable stump will be afforded and that the limb will be more seemly and useful for support and progressive motion’.¹⁵ By August 1844, Syme was able to write that ‘as to the diminution of danger,...... in fourteen cases where the operation has been performed, eight in my own practice and six in that of others, there is not one fatal result’.¹⁶

SURVEY OF SYME’S CASES
This study examines accounts of Syme’s own cases of ankle amputation for which there are records, to note the indications for the procedure and the outcome with particular reference to mortality and morbidity and, where evidence is available, to look at the long-term outlook after amputation.

SOURCES
The material for the study comes from the Ward Journals and the General Registers of Patients of the Royal Infirmary of Edinburgh and contemporary reports in the medical press. The Ward Journals for Syme’s wards in the Royal Infirmary - Wards two, five and six from 1841 to 1853 and wards one to six after 1853 until the end of the period under review.¹⁷ The Ward Journal was the ledger in which the case notes were written and the Managers of the Royal Infirmary required that these Journals be inspected and countersigned (‘docqueted’) by the surgeon in charge. Syme did not hold with this practice of docqueting and this led him into conflict with the Management though eventually he had to concede to their wishes.^18,19 Using the Ward Journals as a source of evidence has two main drawbacks: the chronological record is not complete as the Journals for certain years have been lost and the Surgical Clerks who were the actual writers, varied in their ability to keep detailed up-to-date and legible notes. Some were meticulous, others less so.

In the present study, Syme’s Ward Journals for the following years have been examined, the Journals for the periods in between having been lost: April 1841-July 1841, May 1844-September 1844, April 1850-June 1850, February 1853-December 1853, July 1854-March 1855, March 1860-June 1860, December 1860-April 1861, June 1861-September 1862 and July 1863-May 1864.

The General Register of Patients gives the name, age and dates of admission and discharge of patients, and includes the wards to which patients were admitted. The diagnosis, duration of symptoms and operation are recorded but no details of clinical findings.²⁰

Case reports appeared in the medical literature, and in particular, the London & Edinburgh Monthly Journal of Medical Science and the Edinburgh Medical Journal, to which publications Syme was a regular contributor. These reports are significant in that there is mention of cases which do not appear in the Royal Infirmary archive and must, therefore, be assumed to have been in Syme’s private practice.

The case descriptions in this account are from Ward Journals or the contemporary artcles in the medical press. It is assumed that if admission was to Syme’s ward then they were operated on by Syme himself as in his Ward Journals only Syme is ever named as having undertaken the ‘ankle disarticulation’ operation though other surgeons in the Royal Infirmary of Edinburgh, notably Dr P.D. Handyside and Dr R.J. Mackenzie, were performing a similar operation. The present survey is of Syme’s cases alone; patients of the other surgeons have not been included to obviate distortion of the findings due to differences in case selection criteria or operative technique. The survey is not taken beyond 1866 because after this period mention is being made in the Ward Journals of other surgeons and, in particular, Joseph Lister (Syme’s son-in-law) either operating or advising.

SYME’S AMPUTATION CASES 1841-1866
Patients came from all over Scotland and other parts of Britain for specialist opinion. The majority were referred by surgeons or general practitioners but some came independently. The age ranged from 7 to 70 years. The average age of survivor was 25 years and 45 years for those who died. Most of the fatalities occurred in the older ages and Syme was reluctant to operate on the elderly with disease of the foot.

INDICATIONS FOR ANKLE DISARTICULATION IN THE SURVEY
Records exist of 98 cases on which Syme’s technique for ankle disarticulation was performed by Syme himself or under his close supervision. The indications for operation are shown in Table 2.

Caries: Although 9 out of a total of 74 cases of caries are recorded as having an injury associated with the onset of the disease this proportion may be an underassessment. The 9 cases occurred in a total number of 19 reported in detail either in the Ward Journals or in medical publications. The remainder of the cases are recorded in the General Register of Patients which, whilst giving the diagnosis, operation and outcome, does not include past history.

Open injury: Only two cases of compound fracture/dislocation of the foot were recorded despite Syme making this as one of the prime indications for his procedure.

Gangrene: Two cases are reported with the diagnosis of ‘fever’, the first being specified as typhus.

Tumour: Three patients underwent amputation for tumour.

Other indications for amputation: Strumous disease is mentioned in the General Register of Patients for two patients: this may be a ‘scrofulous’ variant of ‘caries’ or may be a more specific term for what is now recognised as tubercular infection.⁸ Frostbite was a relatively common reason for admission to the Royal Infirmary but usually required only the amputation of digits.

THE INFLUENCE OF ANAESTHESIA
Ether was introduced to Britain in December 1846 and the first patient in the Royal Infirmary of Edinburgh to be operated on under anaesthesia was on 9th January 1847 for a thigh amputation by James Duncan, Senior Surgeon. Syme was noted as having operated on a patient under ether in March 1847 though he was reputed to have had difficulty in producing unconsciousness with this agent.²¹ The anaesthetic properties of Chloroform were recognised by Professor JamesYoung Simpson on 4th November 1847 and chloroform was used within a week for operations on patients of Professor Miller and Dr Duncan. Because it was easier to use, chloroform became popular and ether at that time generally fell out of use.²²

The total number of all major amputations for the years 1842-1849, by all surgeons in the Royal Infirmary of Edinburgh, shows an increase following first the introduction of ether in early 1847 and even more so after chloroform came into use later that year. The rise in the number of amputations (12 in 1842-3 to 32 in 1848-9) appears to be coincident with the introduction of anaesthesia and the records indicate that surgical techniques, such as the more frequent use of primary amputation for compound fractures and the revision of stumps, were being introduced and which would be easier to justify in the anaesthetised patient.

OUTCOME
The outcome of cases is contained in Table 2. Of the 98 cases who underwent Syme’s amputation, 87 (89%) survived and were eventually discharged (‘dismissed’) from hospital.

Mortality: Eleven deaths are recorded of which four were not caused directly by post-operative wound infection. Three cases showed signs of severe infection a week postoperatively and died of septic sequelae within two weeks.

Wound healing: Healing by ‘First Intention’ i.e. without sepsis, was sufficiently unusual that it was specifically mentioned, being recognised as beneficial and leading to earlier recovery. Suppuration of the wound surface, followed by granulation, was considered the normal process of wound healing and it must be presumed that this took place where the healing process is not detailed.²³

Duration of admission to hospital: A consequence of the slow granulating process was that patients sometimes remained in hospital for months until their wounds were healed. (Table 3) Deaths occurred on average two to three weeks post-operatively, the time it took for a fatal wound infection to take its toll if recovery was not to take place. When healing had been by first intention discharge was quicker but even so no admission was for less four weeks.

DISCUSSION
Syme published his indications for ankle disarticulation and claimed advantages over alternative procedures. This survey is an assessment of his recommended technique of amputation in terms of survival and rehabilitation.

THE ALTERNATIVES TO ANKLE DISARTICULATION
Syme’s principal reason for advocating amputation at the ankle joint was to try and avoid leg amputation because of the perceived danger of this latter operation. ²⁴ Certainly, figures for leg amputations for the years 1838 - 1841, before his criteria for the ankle disarticulation procedure had been formulated, showed a mortality rate of 53%, though at a later date, he himself claimed a mortality of only 25% (25) - (Table 4). These figures are not strictly comparable with cases of amputation at the ankle because trauma to the leg is included and the high mortality following leg amputation in trauma to the foot and leg confirm the justifiable fear that surgeons of that time had for this operation. The policy was, understandably, to try and save the limb if at all possible and amputation, if it was be done, was performed within 24 hours of injury, by which time it was considered the patient would have become stable but before the onset of inflammation.²⁶ Syme, however, pointed out that the outcome of compound dislocation of the ankle was even worse without amputation: of 13 of Syme’s patients with compound dislocation of the ankle treated conservatively only two survived and, he claimed, ‘the foot remains in such a state of stiffness, weakness and sensibility of external impressions, as to be rather an encumbrance than a support to the patient.⁵ The gross overall mortality rate of 11% for the 98 cases following Syme’s technique for amputation at the ankle was, on the evidence available, considerably better compared with the 53% mortality reported for leg amputation in the immediate years before the introduction of ankle disarticulation. This figure for mortality after leg amputation is comparable with Simpson’s series from ten hospitals in Europe and America where he quoted a mortality rate of 39% for ‘pathological’ and 52% for ‘traumatic’ indications for amputation.²⁷ Syme, therefore, was correct in supposing that his operation of ankle disarticulation was safer than amputation of the leg. He recognised that, by reducing bleeding and hence haematoma formation and confining the amputation to cortical bone ‘the dangers of inflammation in the medullary veins’ with severe sepsis could in most cases be avoided.²⁸

The outcome of leg amputation for ‘disease’ was better in terms of mortality and at one fatality out of eight (12%) - (Table 4) was nearer to the 7 out of 74 (9.5%) in his subsequent series of ankle disarticulations. The high mortality of leg amputation in traumatic cases indicates that injury itself deleteriously affected the outcome.

REHABILITATION
Syme’s Ward Journals and the General Registers of Patients reveal little of the long-term outcome of patients as, on being ‘dismissed’ from the Royal Infirmary, there were no formal arrangements for follow-up. The need for a good stump was recognised as important for the patient’s subsequent lifestyle but all the accounts of Syme’s patients in the late post-operative period are anecdotal from correspondence and publications in the medical press of the time.

The patients described by Syme (and Handyside) did not necessarily use a prosthesis as such but, as the limb was shortened by about 11/2 ins., a boot was adapted by raising the heel. Both surgeons claimed that as the skin and subcutaneous tissues of the heel were retained a firm foundation was given for the stump. The scar faced anteriorly and as the incisions made by the two surgeons were aligned differently gave either a transverse scar (Syme) - Figure 3 or a horizontal scar (Handyside) - Figure 4.^14,29 Syme in his report on John Wood emphasised that ‘any degree of pressure can be borne by the stump, which as a round form is well suited for the adaptation of a boot or artificial foot, and is strongly protected from external injury by its thick integuments’.²⁴ Further mention of this patient comes from his local surgeon in Dunbar (East Lothian) who wrote: ‘He has become a country tailor and has often ten or fifteen miles to go to his work; still he feels no discomfort’.³⁰ Syme himself exhibited at a meeting of the Medical-Chirurgical Society ‘an apparatus which might be worn after the operation at the ankle...constructed by a bootmaker (Mr Thomas Robson) whose son had undergone the operation’.³¹ Interestingly, a Thomas Robson who had undergone ankle amputation about 1848 (but about whom no clinical details are available) wrote to Syme detailing the long walks of which he was capable and mentioned in conclusion that ‘I still wear the leather case and boot of which you have the pattern.’ It is probable that this was the son of the bootmaker, though no details of the prosthesis are described. A Dr Wilson, on whom Syme had performed ankle amputation in January 1843, wrote over three years later with details of a prosthesis and eleven years later again wrote that he was still active and ‘could walk along the carpeted floor ..... with bare limbs without any stick or support’.^32,33 The success of ankle disarticulation may in fact have been because intricate prostheses were not necessary and a description by Dr Handyside describes how a patient of his, aged eight, who had had an amputation at the ankle ‘walks with perfect ease and freedom with a high heeled and padded boot, and he can rest the weight of the body on the naked stump without the slightest inconvenience’.²⁹

Figure 3: Healed horizontal scar from Syme’s modified incision for ankle disarticulation. From: Syme J. ‘Amputation at the Ankle Joint’ Monthly Journal of Medical Science 1844; 4:648.

PHANTOM PAIN
Baker, in a review of 67 cases of ankle amputation, reported an incidence of 94% with phantom foot and it is likely that Syme’s own cases were aware of phantom pain.³⁴ The aforementioned Dr Wilson in a letter to Syme dated 8th June 1846 states: ‘I have very rarely experienced the feeling of the lost foot being still part of the body and the seat of pain, which is so common a complaint among those who have been deprived of limbs’.³² Of the few accounts that do exist of the late post-operative status none mention phantom pain as being a problem.

Syme’s amputation became the operative procedure of choice for disease and injury of the foot within a relatively short time. Modifications to the operation were made: Syme himself admitted that in his earlier operations he made the heel flap too long and that by reducing it the performance of the operation became easier and there was less chance of sloughing of the flap from damage to the posterior tibial artery. He described in some detail the the incision to be made, shown by the dotted line in Figure 2.^25,35 However, Dr Handyside (Figure 4) and Dr R.J. Mackenzie recommended that the skin incisions should be modified to improve the stump and to make the operation more straightforward to perform.^29,36,37

Figure 4: Handyside’s incision for ankle disarticulation, shown by dotted line, with vertical healed scar. From: Handyside P.D. ‘Caries of the Tarsus and Ankle Joint’ Monthly Journal of Medical Science1845; 5: 575.

Two other surgeons of the same era devised disarticulation operations of the ankle. In 1842 J.B.L. Baudens in France had described a ‘tibio-tarsal amputation’ which was referred to by Syme when he admitted that the operation was not new ‘having been performed on the Continent by different surgeons before I thought of it’.⁴ The main feature of Bauden’s operation was to fashion a flap from the dorsal structures of the foot which would cover the stump. The actual disarticulation and trimming of the malleoli and tibia were similar to Syme’s amputation. However, Syme claimed that ‘doubt was entertained as to the ends of the bones being sufficiently covered to afford the patient a comfortable and useful support for the limb’.³⁸ Nicolai Pirigoff of St Petersburg had performed Syme’s amputation but had experienced difficulties and in 1854 recommended an operation of his own which entailed retaining the posterior part of the os calcis which could fuse with the end of the tibia, giving a longer stump.⁴ Syme was not impressed and in 1856 criticised Pirigoff claiming ‘the modifications...appear objectionable, by complicating the process, displacing the integuments of the heel from their proper position at the extremity of the stump...by retaining a portion of the tarsal bones, and impeding the use of an artificial foot by rendering the limb inconveniently long’.³⁹

The operation was generally acclaimed and an anonymous biographer of Syme in 1851 claimed he ‘introduced a mode of amputation at the ankle joint of his own contrivance which may now be regarded as one of the best established operations in Surgery’.⁴⁰ A leading article summarised the advantages of the operation and concluded ‘the operation instead of frequently proving fatal like amputation of the leg is most entirely free from danger’.⁴¹ The Report of the Associate Members of the Sanitary Commission of the Federal Army of the United States in 1862, who had to edit directives to the Army’s surgeons, including the best and safest amputation of the foot, supported Syme’s procedure. They compared Chopart’s, Syme’s and Pirigoff’s operations for injury of the foot with regard to operative danger and usefulness of the stump and came to the conclusion that ‘preference should be given to Syme’s operation as affording a minimum mortality with a stump best adapted to an artificial limb’.⁴²

SUMMARY AND CONCLUSION
James Syme published an account of his amputation at the ankle in 1843, as an operation to be carried out in preference to amputation of the leg for disease and injury of the proximal foot and ankle, considering that it was both safer and allowed for improved post-operative mobility. His patients for the years 1841-1863 have been reviewed (as far as records permit) and compared with alternative operations and the findings indicate that he was justified in his original reasons for proposing amputation at the ankle joint.

ACKNOWLEDGEMENTS
The author wishes to thank Dr M. Barfoot, Lothian Health Services Archivist, Special Collections, University of Edinburgh Library, for all the help he has given in compiling this article.

REFERENCES
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Copyright: 2 February 2004