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Clinical Orthopaedics and Related Research logoLink to Clinical Orthopaedics and Related Research
. 2021 Mar 11;479(4):679–680. doi: 10.1097/CORR.0000000000001712

ArtiFacts: Built for Speed—Robert Liston’s Surgical Technique

Alan J Hawk 1,
PMCID: PMC8083913  PMID: 33704107

Robert Liston (1794-1847) held a (well-earned) reputation as the fastest surgeon of his time. One contemporary recalled of Liston: “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” [7]. Before each of his procedures, he told the observing medical students, “Now gentlemen, time me” [6]. In at least one instance, the amputation took less than 30 seconds.

He is better known, perhaps apocryphally, for accidently amputating a patient’s testicle in addition to his leg [1]. Another time, he allegedly performed a procedure with 300% mortality. Let me explain: A spectator dropped dead at the shock of being slashed with the surgical knife, an assistant succumbed to infection after part of his hand had been cut off as well, and of course, the patient who developed postoperative gangrene [3].

In short, he was remembered as the stereotypical cocky early 19th century surgeon who would not be above proclaiming a procedure a success despite leaving the patient dead on the table. However, Liston’s approach to amputation, and more importantly, to pain management, had a positive motive. His need for speed derived from empathy for his patients rather than from his ego.

In 1844, Liston lectured surgical students at the University College in London: “You must study to perform the operation with as little pain to the patient as possible, for that purpose as quickly as you can, and so leave the truncated part that it shall not be a source of suffering and annoyance to the patient afterwards” [4]. Another method for dealing with surgical pain would not be available for another 2 years when William Morton (1819-1868) performed the first public surgical procedure demonstrating the effectiveness of anesthesia.

Liston was an innovative surgeon who quickly embraced the use of anesthesia and performed Europe’s first surgical operation using anesthesia 2 months after Morton. Additionally, he designed a splint to preserve a fractured lower limb as an alternative to amputation. He revolutionized amputation by cutting flaps to make it more likely for the skin to heal over the residual limb.

Unlike curved amputation knives used in circular procedures [2], his amputation knives had straight blades (Fig. 1). Their use was described by a colleague, Dr. F. William Cock: “… a thrust of the long, straight knife, two or three rapid sawing movements, and the upper flap is made; undergo his fingers and 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 …” [6]. Liston explained the rationale this way: “The incisions from within outwards, be it remembered, are always performed more quickly, and with much less pain, than those in the opposite direction” [5]. These outward cuts provided the dramatic and somewhat alarming flourish for which Liston’s surgical procedures were known.

Fig. 1.

Fig. 1

Two of Liston’s surgical instruments are shown. Liston used the Catlin knife (top) to cut flaps of leg muscle in preparation for limb amputation. Liston used his bone forceps (bottom) to cut away bone fragments and the spicule after the limb had been amputated. The instruments are from a U.S. Army medical surgical kit manufactured by the George Tiemann and Company circa 1865. (M-129.00072) (Disclosure: Photo collage. Image has been manipulated by using dodging and burning techniques and has been cropped to emphasize the subject.) (National Museum of Health and Medicine photo illustration/released.)

However, Liston’s bone-cutting forceps provide even more insight to his character as a surgeon. While the patient’s leg is being amputated, his leg is supported partially by the surgeon, but most of the weight is borne by an assistant. The bone frequently breaks off once the surgeon is almost completely sawn though the bone, leaving a spicule that could cause postoperative irritation within the stump. The forceps were designed to remove that sharp edge. Indeed, the surgeon known for his speed should also be remembered for his attention to detail.

The influence of Liston on American surgery was cemented by the publication of multiple editions of both of his surgical textbooks as well as a compilation of his lectures. His instruments were included in surgical kits issued by the U.S. Army, and his flap technique was taught to military surgeons during the American Civil War (1861-1865). By the turn of the 20th century, surgeons were refining the use of anesthesia to provide more time to operate and aseptic technique to prevent postoperative infection. In 1899, surgical instrument manufacturer Charles Truax observed, “The great majority of operators, however, make use of the Liston knives so long in use and still advised in most standard text books” [8]. Truax recommended that surgeons should have seven instruments for amputations, three of which were developed by Liston: two types of amputation knives and the bone cutting forceps. All three instruments can still be found in today’s surgical instrument catalogs.

Footnotes

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

A note from the Editor-in-Chief: We are pleased to present the next installment of ArtiFacts. In each column, the Collections Manager of the Historical Collections Division of the National Museum of Health and Medicine (NMHM) will present a photograph of a visually or historically interesting artifact from the museum’s collection and provide the story behind the picture. The NMHM, whose collection was recognized as a National Historic Landmark, was originally developed from the Army Medical Museum established during the Civil War to collect “specimens of morbid anatomy together with projectiles and foreign bodies removed.” Its mission today is to preserve and explore the impact of military medicine.

The author certifies that neither he, nor any members of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

The opinions or assertions herein are those of the author and do not represent the views of the Defense Health Agency or of the Department of Defense.

References

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