A ‘300 per cent mortality rate’ for one surgery – Fact or fiction?

Any physician with a rudimentary knowledge of medical history has probably heard of Mr Robert Liston (1794-1847).

Liston was a surgeon who became well known for his speed and precision, but also for a couple of startling stories. Over time, he became so renowned that some of the feats and quotes attributed to him have become the stuff of legend, opening up the question as to what really happened, and what was apocryphal.

For those who need a refresher, Liston was born in Scotland and studied at Edinburgh Medical School from 1808 and eventually ended up as Operating Surgeon in the Royal Infirmary of Edinburgh. This was after a controversy which saw him fired due to a disagreement with his superior Dr George Bell. He went on to become the first Professor of Clinical Surgery at University College Hospital in London in 1835.

Liston gained a reputation as the fastest surgeon of his time. This was practically important, as many of his surgeries were conducted in the pre-anaesthesia era. Speed was of the essence to lessen the duration of pain as much as possible, as well as the time spent vulnerable to infection. Historical accounts report how he would instruct his medical students to “time me, gentlemen” before each surgery and it is also written that he once took just 30 seconds to perform an above-the-knee amputation.

He was also known for his stature. Well-fed modern populations have generally grown taller, but at the time the average height of the adult British male was around 5’7’’, whilst Liston stood at the then-towering 6’2’’.

His surgeries must have been a sight to behold. In the interests of speed, he often clenched the knife between his teeth while his hands were busy removing the appendage. Curved amputation blades were commonly used at the time for circular procedures, but Liston used straight blades.

Liston briefly described his technique thus: “The incisions from within outwards, be it remembered, are always performed more quickly, and with much less pain, than those in the opposite direction.” This method was exploited a little by Liston for dramatic purposes and he became known for this flamboyant gesture with the arm as the incision was made.

His colleague Dr F William Cock noted: “… a thrust of the long, straight knife, two or three rapid sawing movements, and the upper flap is made… the flap is held back; another thrust, and the knife comes out in the angle of the upper flap; two or three more lightning-like movements, and the lower flap is cut…”. Liston used bone forceps to remove bone fragments and the spicule after amputation.

But did Liston’s extraordinary speed ever have unintended consequences? This is where the line between history and legend begins to blur and brings us to the story of the so-called “300 per cent mortality rate”. Well, according to the tale, Liston worked so quickly that he sliced through the fingers of his young assistant and accidentally nicked the coat of a spectator. Reputedly, the assistant later died of hospital-acquired gangrene, the patient succumbed to the same infection, and the shocked bystander is said to have died shortly afterwards.

However, there are no primary sources to indicate all this ever took place. What is beyond doubt is that Liston was an innovator. He embraced the use of anaesthesia only two months after Dr William Morton performed the first public surgical procedure demonstrating its effectiveness. Liston is also responsible for the ‘Liston splint’, an innovative way to immobilise fractures of the femur, and which was designed to overcome the problem of limb shortening caused by overriding bone fragments.

He developed an extensive knowledge of anatomy, which made him confident enough to take on patients whom other surgeons had considered a lost cause.

He performed the first operation in Europe using ether in 1846 and was influential in promoting the widespread use of anaesthesia. His surgical tools were integrated into surgical kits in the US Army, and his flap technique was taught to military surgeons in the American Civil War.

Last word to one of his contemporaries, who said at the time: “It is told that when he amputated, the gleam of his knife was followed so instantaneously by the sound of the bone being sawn as to make the two actions appear almost simultaneous.”