ROBERT LISTON Pioneer and visionary

History often reduces pre-anaesthesia surgery to a ‘butchering art’. While the horror of surgery before the discovery of ether and antisepsis can only be imagined, the skill shown by many surgeons operating at this time cannot be understated.

Perhaps the greatest myth from this period is Robert Liston’s 300% mortality rate. Best known for being the first to operate using ether in the UK, Liston (1794–1847) is often reduced to a surgical showman.

It is claimed he walked into the surgical theatre declaring: “Time me, gentlemen”, giving him the accolade ‘the fastest knife in the west end’ – and, of course that he killed three people during one surgery.

Born in Linlithgowshire in 1794, he studied at the University of Edinburgh from the age of 14 covering a range of topics before focusing on medicine. He did not, however, graduate MD and instead took extramural anatomy lessons, becoming an assistant to Dr John Barclay. With a focus on surgery, he became a surgeon’s clerk at the

Edinburgh Royal Infirmary before completing his surgical training in London. He became a Fellow of both the RCSEd and the Royal College of Surgeons of England.

He returned to Edinburgh and started his own anatomical teaching school with his distant cousin, James Syme (1799–1870), although after around four years Liston withdrew from anatomy and focused on a full-time surgical career. In Edinburgh he had a private surgical practice and worked at the Edinburgh Royal Infirmary but, after numerous fallouts, he left for London in 1834, where he spent the remainder of his career, passing away at the age of 53 in 1847.

Dispelling The Myth

The 300% mortality story has become apocryphal and is widely replicated. The tale goes that during an amputation of the leg, in his desire for showmanship and speed, he cut off two of his assistant’s fingers and sliced the coat tail of an audience member. All three are supposed to have succumbed, the patient to blood loss, the assistant to gangrene and the audience member to a heart attack caused by the shock. However, recent research has found the apparent origin of this story lacking in historical fact and accuracy. In my own research, I have found no primary sources relating to this event and it is hard to believe that someone of his stature could have avoided the public scrutiny of such an occurrence.

A rare instance when Liston did fail, resulting in negative publicity, highlights this point. In 1841 a child of 12 was admitted to University College Hospital, London. The house surgeon examined the boy and presented the case to Mr Liston as a suspected aneurysm. However, on seeing the boy and examining his neck, Liston claimed the boy was too young for an aneurysm and diagnosed the swelling as a tumour and proceeded to cut to prove his diagnosis. The incision was followed instantly by excessive bleeding and Liston closed the incision and returned later to operate. Despite tying the artery, the boy unfortunately died from haemorrhage a few days later. Liston published his account of this case and immediately received criticism, particularly from his house surgeon, who published his own account in the Provincial Medical Journal.

He criticised Liston’s write-up and his conduct, arguing he had made a mistake in his assumption and covered it up. Liston received a sustained barrage of criticism about this case for the remainder of his career. This case alone significantly highlights that if Liston had indeed gained a 300% mortality for a single surgery, there would have been ample discussion of that failure in contemporary medical literature

(and no doubt a similar publication of his own defence).

At a time where the mortality rate for surgery was extremely high, Liston had remarkably low mortality statistics. There are numerous reasons for this, including his noted speed. This speed was arguably not a mark of showmanship, but instead a skill that was enabled out of a unique combination of proficiency, precision and dexterity, which qualified Liston as one of the most technically competent of his era. His amputations were measured in seconds and were often performed solo, and his lithotomy procedures were performed in two minutes, which with no anaesthesia most likely reduced the two main causes of operative mortality – blood loss and shock.

His speed can also be attributed to a real concern for the patient’s experience. He advised to always take into consideration the mental state of the patient, only operating on those who believed in a positive outcome. With this attitude it is hardly surprising that he was the first surgeon in the UK to undertake an operation using anaesthesia in 1846, merely a year after it was discovered by dentists in America. It is regrettable that Liston passed away only a year after his most famous surgery – it would have been very interesting to see what developments he could have made with anaesthesia in his arsenal.

Pioneering Surgeon

A case that embodies Robert Liston’s skill and confidence as a surgeon, as well as his patient advocacy, is a tumour removal, the cast of which resides in the museum. In 1834 a Mrs Fraser had a facial tumour removed at the Edinburgh Royal Infirmary by Liston. This tumour obstructed the entire left side of her face and Liston could see numerous veins in the tumour through the skin and feel arteries beating within. With the help of an assistant he removed the tumour while the patient was in a seated position, before lying her down to secure the bleeding vessels after the tumour was removed. This tumour was nine inches long and, of course, this was pre-anaesthesia.

In his write-up, he talks of the patient numerous times: “She had firmly made up her mind to undergo the operation” and had “borne all this with the utmost courage and without a murmur”. After Liston left Edinburgh for London only months after this surgery, Mrs Fraser’s local surgeon wrote to Liston to report on her condition ending: “In a word she is one of the most happy women I am acquainted with.”

Aside from his operating skill, Liston displayed great innovation in his advocacy on cleanliness both pre-surgery and post-surgery. He insisted on a clean apron, clean instruments and clean sponges for each surgical case (bearing in mind this was the era where a bloody washing bowl and apron represented the success of the surgeon). Wounds and limbs would be cleaned before operating and even – and this is quite remarkable – the limb shaved (this was only discovered in the 20th century as a means to eliminate potential bacteria on hairs).

This indicates that Liston linked cleanliness and postoperative inflammation long before most. These innovative procedures most likely assisted in his low mortality rate after amputation between 1835 and 1840, being around 15%, which is remarkable during this time. It would take Joseph Lister’s fascination with inflammation some 20 years later to discover the cause of infection and invent the aseptic surgery we know today (incidentally, Lister was present during Liston’s 1846 ether surgery).

Liston’s contributions to surgical development are endless, including improving amputations by championing the importance of the amputation flap and eliminating the circular cut previously used. He was one of the first to attempt and advocate lithotrity (one of the first minimally invasive surgical procedures) and advanced surgical treatment of aneurysms. He also invented numerous medical instruments, some in collaboration with Edinburgh instrument maker Alexander Young. Liston thought surgical instruments should be simpler and felt that some of these instruments’ complexities seemed “to be chiefly intended to compensate for want of tact and manual dexterity”.

Frequent Fallouts

His flaws seem to centre on his character: confident, argumentative, critical and outspoken. His career is littered with public fallouts with fellow surgeons and medical institutions. Perhaps the most unfortunate of these was with his distant cousin and fellow surgeon, James Syme.

Syme and Liston’s disagreement stemmed from growing competition for surgical posts in Edinburgh during the 1820s. This fallout is

MR. YEARSLEY':::; LET'lEI S TO THE PRESIDENT AND COUNCIL OF THE ROYAL COLLEGE OF SURGEONS IN LONDON, ON THE UNPROFESSIONAL CONDL'CT OF MR. LISTON.

1\fR. PRESIDENT AND GENTLEMEN, MosT reluctantly I come before you in the character of a complainant, more especially as the gentleman whose conduct I must arraign is a member of your honourable Council.

It may still be in your recollection that, in the month of March 1841, I addressed a note to many of the leading members of the profession, inviting them to witness and investigate the effects of extirpation of enlarged tonsils, and also of the uvula, in certain cases of Stammer and defective speech. In the course of my professional practice, I had frequently performed the former of these operations for the cure of deafness. For this I claim no merit. It had frequently been done with the same intention. Neither was the latter operation novel. Both, in short, had long been recognised as minor surgical operations. The only novelty consisted in their application to the treatment of Stammer, and that I freely own was the result of accident.

In some cases in which Deafness and Stammer were associated with enlarged tonsils, and an elongated or thickened uvula, I found that on the removal of these morbid conditions, not only the deafness, but the defective speech was cured or relieved. The observation of this fact led me to direct my attention to Stammer ;and after the treatment of numerous cases, with more or less success; I gave the result of my researches to the profession ; and in selecting the mode of doing this, I consulted the feelings of the profession, my own duty as a member of the College, and altogether waived my personal interest.

Among others whom I invited to be present were Sir Benjamin Brodie and Mr. Robert Liston. I have preserved the replies of these gentlemen. The first, from Sir Benjamin Brodie, is remark.able for its gentlemanly and candid tone. It is as follows:- particularly frustrating as they had assisted each other on some remarkable surgeries in their early careers. Syme actually used one of Liston’s own surgical developments to defend his own risky amputation (amputation at the hip joint), which many said could not be done.

" DEAR Sm, "14, Saville-row, March 8, lll41. " I tbank yon for your invitation, and nm sorry that I cannot avail myself" of it. It will give me grcnt pleasure to learn •that your efforts to cure so great a. calamity prove successful. "Your faithful ~en•ant, "B. C. Bnoon:."

Syme wrote: “When Mr Liston, two years ago, tied the subclavian artery with success for the first time in Great Britain, that operation was looked upon as desperate as amputation at the hip-joint is now. But, since then, instances of its success have become quite common in the records of surgery.”

It would have been interesting to see what else they might have achieved together, but it would seem Edinburgh was not big enough for these two giants. They did nevertheless resolve their differences shortly before Liston’s early death.

One of the more infamous public fallouts was with the Edinburgh Royal Infirmary in 1822, when Liston’s fellow surgeons accused him of poaching hospital patients for his own private practice. The hospital board dismissed and barred Liston from practising on the wards. Liston published letters to the hospital in efforts to clear his name, signing off his last with: “Your much injured, but not yet extinguished humble servant, Robert Liston.”

In his many letters, Liston asked the Infirmary managers, should he really refuse to help a patient just because they happened to have been previously seen at the hospital? He asked the RCSEd to review the matter, but the College declined to become involved.

Critical Voice

Liston was prone to publish surgical cases and new procedures, in which he would criticise previous methods and note failures by other surgeons. In addition, as an ambitious, confident and gifted young surgeon, he willingly attempted surgeries that his peers dared not. Therefore, situations often arose where patients would either have undergone unsuccessful surgeries at the hospital or be told their condition was not operable, only for that patient to be discharged and treated successfully at Liston’s private practice.

This all caused great embarrassment, resentment and perhaps a little jealousy from his fellow surgeons. Nevertheless, six years later, Liston seems to realise that the error of his ways lay in his conduct rather than his actions and apologised to the board of managers for his behaviour towards his fellow surgeons. He was welcomed back on the wards in 1828.

While Liston’s criticism of fellow surgeons or practices was rarely gracious, one might argue that occasionally it assisted in the development of medicine. A great example is represented in a pamphlet, written by a Mr Yearsley in 1842, attacking Liston for his comments on the treatment of stammers. Yearsley had been advertising his surgical work as a cure for patients presenting with deafness and stammers. In one of his published articles on the subject, the editor, clearly in disagreement, used Liston’s review of an alternative therapy to denounce the surgical option offered by Yearsley. The publishers stated: “We refer for confirmation of our opinion to as high an authority as lives” before quoting the following letter from Liston:

“I have … witnessed Mr Hunt’s process for the removal of stammering. It is founded on correct physiological principles … and unattended by pain ... Several young persons have, in my presence, been brought to him … some of them could not utter a sentence … by following Mr Hunt’s instructions, they have been able to speak and to read, continuously … without difficulty. Some of these individuals had previously been subjected to painful and

Above: The face of Mrs Fraser showing a large fibroma, captured by a preoperative wax cast unwarrantable incisions … left with their palates horribly mutilated, hesitating in their speech, and stuttering as before.”

Liston was able to accept that ‘cutting’ was not always the answer. Yearsley took great offence, with the pamphlet designed to publicly ask the English Surgical College to intervene and sanction Liston’s conduct (which they declined). Yearsley called this letter from Liston an ‘attack’ aimed to do him professional injury and a clear indication of Liston’s support of ‘quackery’ and of a treatment that only offered ‘temporary service’. A treatment that, of course, we know now as speech therapy.

It is clear Liston had his flaws – some might even call him arrogant, particularly in his early career – but what is also evident is that his skills made him one of the most innovative surgeons of his day, and he deserves more from history than the apocryphal stories that dominate and perhaps even foil his legacy.