Obituary: Lindsay Symon



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Neurosurgeon who made important contributions to neurosurgical management, technique and training; and who made major advances in cerebrovascular pathophysiology.

Lindsay Symon Professor of Neurosurgery, The National Hospital for Neurology and Neurosurgery/UniversityCollege London b November 4th 1929; q Aberdeen University 1951; CBE TD FRCS FRCS Ed Hon FACS d December 2nd 2019.

When Professor Symon retired from the chair in Neurosurgery at The National Hospital for Neurology and Neurosurgery, Queen Square in 1995 he was honoured with festschrift editions of two major journals; the British Journal of Neurosurgery for his contributions to neurosurgical management, technique and training and Cerebrovascular and Brain Metabolism Reviews for his experimental laboratory research into cerebrovascular pathophysiology, which was always focused on the resolution of clinical problems.

Lindsay Symon was born in Aberdeen and educated at Aberdeen Grammar School. He was awarded a scholarship to Aberdeen University to study medicine at the age of 17 and graduated MB.ChB a month after his 22nd. Birthday. He won the Fife Jamieson Chanock and Lizars Gold Medal in anatomy, the Silberg Prize in anatomy and physiology, the Ogston Prize in surgery, the Anderson Gold Medal in clinical medicine, the Keith Gold Medal in surgery, McQuibban Prizes in medicine and surgery, the Murray Prize in scholarship, and the Fulton Essay Prize in neurology for his dissertation on migraine. He completed the sweep of undergraduate prizes with the Lyon Prize as the Most Distinguished Graduate of the Year in medicine. After appointments as House Physician and then House Surgeon to the Professors of Medicine and Surgery, he joined the RAMC for his National Service which he spent mostly in Graz, Austria where he met and married Pauline Barbara Rowland in 1953, a Liverpool trained Queen Alexandra’s Nursing Corps ward Sister.

He returned to Aberdeen as a research fellow in surgery and then as a surgical registrar. A Medical Research Council Fellowship took him to the MRC Division of Physiology and Pharmacology of the National Institute for Medical Research Laboratories at Mill Hill, where he worked with Professor William Feldberg and pursued his interest in the cerebral circulation, publishing in the Journal of Physiology on the leptomeningeal circulation in dogs. He combined this with an honorary attachment to Professor Valentine Logue’s neurosurgical unit at The Maida Vale Hospital. A Rockefeller Travelling Fellowship (1961-62) took him to the laboratories of John Sterling Meyer at the Wayne State University in Detroit, USA. On his return to the UK he joined Logue’s department at Maida Vale as Registrar and First Assistant until his appointment to the consultant staff of the National Hospitals in 1965. He succeeded Logue as the Professor of Neurosurgery at The Institute of Neurology UCL and Chairman of the Gough Cooper Department of Neurological Surgery at the National Hospitals in 1978.

He held honorary Consultant appointments at St.Thomas’ Hospital, the Postgraduate Medical School at Hammersmith Hospital, the Italian Hospital and the Royal National Ear Nose and Throat Hospital. He was Adjunct Professor in the Department of Surgery at the Southwestern Medical School of Texas in Dallas and Civilian Advisor in neurosurgery to the Royal Navy. He was an Honorary Fellow of the American College of Surgeons, the American Association of Neurological Surgeons and the American Academy of Neurosurgery.

Symon received numerous medals and awards from institutes around the world, including the Jamieson medal of the Australian and New Zealand Neurosurgical Society, the John Hunter and triennial prize of The Royal college of Surgeons of England, the Klaus Joachim Zulch prize of the Max Planck-Gesellschaft in Germany, and the Ottfried Foerster Medal of the German Society of Neurosurgeons. He gave the Olivecrona Memorial lecture at the Karolinska Institute in Stockholm and the Willis lecture to the American Stroke Association. He was an active participant in numerous symposia and conferences around the world and visiting professor or invited lecturer in Canada, Australia, New Zealand, Japan, China, Korea, United States and many European countries. He was made a CBE in 1994. During the 15th WFNS World Congress in Seoul, Korea in 2013 he received the Madjid Samii Medal of Honour. He was an Honorary Fellow of the Royal Society of Medicine.

Symon was particularly interested in the training of neurosurgeons and was a member of the editorial board of Advances and Technical Standards in Neurosurgery from its inception in 1972, becoming its Chief Editor from 1984 to 1994. He was elected President of the World Federation of Neurosurgical Societies and served from 1989 to 1993. During this time, he established a central office and secretariat for the Federation in Geneva and helped to develop educational schemes and courses worldwide. He was Vice President of the European Association of Neurosurgical Societies from 1975 to 1979 and a member of the training Committee from 1979 to 1983. He was President of the Harveian Society of London in 1998.

Symon was well known and much appreciated by his surgical colleagues and referring physicians for his clinical expertise and technical skill. Of around 500 papers publications, about 200 related to clinical aspects of neurosurgery and to technical issues. He was particularly interested in cranial and spinal vascular malformations and aneurysms, and skull base surgery, publishing on acoustic neuroma, trigeminal neuroma, CSF leaks, jugular paraganglioma, craniopharyngioma, haemangioblastoma and meningioma. Technical advances included the development and intraoperative use of somatosensory evoked potentials, central conduction times, intracranial pressure measurements and in acoustic neuroma surgery, electrocochleography and facial nerve stimulation and electromyography. In open aneurysm surgery in the 1970s and 80s he emphasised the need to minimise, within reason, the time taken for the procedure; however, he recognised that a more circumspect approach was needed for the posterior circulation. In the 25 years since his retirement, some of these technical issues have been superseded, but the principles remain.

Around 300 papers came from the Cerebrovascular Research Laboratory which Symon established at the Institute of Neurology with support from the MRC. In collaboration with many academic colleagues, the output from this unit was prodigious, often requiring the development of new techniques, such as the hydrogen clearance method for measurement of local blood flow, ion-selective electrodes and microdialysis to measure electrolyte changes, evoked potentials and intracranial pressure monitoring. There is no doubt that the most important and lasting contribution was the concept of progressive thresholds of ischaemia, first published in 1977. Symon and his colleagues showed that there were two perfusion thresholds with ischaemic injury when blood flow in the cerebral cortex was reduced progressively. Evoked responses were affected at cerebral blood flows below about 20 ml/100g/min with electrical failure at around 16 to 18 ml/100g/min; but potassium efflux, indicating sustained cell membrane failure, did not occur until the local blood flow fell to around 8-11 ml/100g/min. These observations showed that in focal ischaemia there were areas with blood flow below that required for electrical activity, but above that needed to maintain cellular integrity; these areas Symon and his colleagues designated “the ischaemic penumbra”. In these areas there is a precarious balance between blood supply and metabolic demand, and this is time limited, with a tendency to fail, joining the infarct core where the blood flow is inadequate to sustain cell membrane function from the onset of ischaemia. They also noted recurrent, transient, spontaneous increases in extracellular potassium in the penumbra, subsequently referred to as peri-infarct depolarisations and found to be instrumental in the recruitment of penumbra into an expanding core lesion. Much of this pathophysiology has subsequently been confirmed in the injured human brain. Restoration of blood flow to the penumbra has the potential to restore electrical function, but time is short, about four hours or sometimes longer. These important observations are now the basis for the acute treatment of stroke with thrombolysis or catheter extraction of clot.

Apart from medicine, his main sporting interest was golf, which he played regularly from an early age. When working in London he played at South Herts Golf Club and in retirement he was a life member of Tidworth Golf Club. He was also a member of Rye Golf Club and of The Royal and Ancient Golf Club of St. Andrews. For several years he raced dinghies on Graffham Water. He was a Freeman of the City of London and a member of the Caledonian Club. He was a member of the Royal Archaeological Institute and developed interests in mediaeval history, the prehistory of Wiltshire and the naval battles of the 20thcentury.

He was predeceased by Pauline who died in 2018 and he leaves a son and two daughters and five grandchildren.

Michael O’Brien

March 2020
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