“Did you know: Robert Liston performed the highest mortality procedure in history – 300%!! He was performing a leg amputation but in his haste he sliced off his assistant’s finger and slashed an observer’s coat. The patient and the assistant died of wound sepsis and the observer collapsed on the spot from shock.”
This Fact of the Day was written on the noticeboard of the Emergency Department doctors’ office in the hospital where I work. It stayed there for months, as Facts of the Day are wont to do. It’s a mildly amusing story, until you stop and consider the consequences of it being true: the fate of the poor victims and, you would think, the end of a fellow doctor’s career.
I really wanted this story to be false, so I thought I would do some digging – a bit of Mythbusting, if you will. I started with a quick Google search (other search engines are available). On typing in “Robert Liston”, the second highest Autocomplete suggestion was “300 percent mortality rate.” I clicked on that, and let me tell you dear reader, What Happened Next Will Shock You…
…only kidding, we don’t do that here.
But honestly, it was link after link to websites proclaiming the same thing: Robert Liston had conducted a single operation which resulted in the deaths of three people. He was characterised as a showman, a butcher, and a careless killer. The stories abounded: Liston striding dramatically across the boards of the operating theatre, crying ‘Time me, gentlemen’ to the watching medical students; Liston misdiagnosing an aneurysm in the neck by the unfortunate method of sticking-a-knife-in-and-seeing; Liston whose nickname summed him up perfectly – the Fastest Knife in the West End.
Most of these articles were on trivia-factoid Today-I-Learned-style pages such as The Atlantic, Medium, Gizmodo, QI, and so on. Some, however, belonged to institutions such as the Association of American Medical Colleges, Surgeons’ Hall Museum in Edinburgh, and the BBC. YouTube videos on the subject have been viewed hundreds of thousands of times, and the 300% story has even been told by a published historian, Lindsey Fitzharris, on the Joe Rogan Experience podcast (from 5:01 to 6:40). Now to be fair, Rogan is actually pretty sceptical of the story. His reaction is to say “Maybe that wasn’t real…that seems like horse****, doesn’t it, a little bit?” But the response was, “No of course, these stories, you know…they get blown out of proportion…[but] you know it’s a stressful situation,” and everyone moved swiftly on.
Where’s the smoking gun?
At this stage it felt like I was chasing a lost cause – maybe the story was true after all. My defence of Liston would have to be flimsy and patronising, something like ‘well, he had to operate quickly because they didn’t have anaesthesia in those days.’ But I kept faith because I hadn’t yet found a primary source, for example an eyewitness account, a surgeon’s case log, or a newspaper article. None of the articles mentioned any concrete details either, such as a date, a place, or a name for the patient. Given that the event supposedly happened in the nineteenth century, and not the Dark Ages, I thought stronger evidence in the form of primary sources and tangible facts felt like a reasonable expectation.
I was, to be fair, able to find articles and books that didn’t mention the 300% story at all. These included profiles of Liston at the Oxford Dictionary of National Biography, the Royal Colleges of Surgeons of England and of Edinburgh. Turning to my trusty copy of The Greatest Benefit to Mankind, which is practically encyclopaedic in its scope, I found that Roy Porter doesn’t mention the 300% operation either.
Finally though, I found what I was looking for: articles to confirm my scepticism. One was a blogpost by Michael Brown, part of his larger project with the Wellcome Trust investigating emotion and its place in nineteenth century surgery. The second was everyone’s favourite source of reliable information: Wikipedia.
Wikipedia? I already know exactly what you’re thinking. But Liston’s Wikipedia entry was the first place I read these beautiful words: “Doubts have been raised as to the veracity of these cases… ‘Liston’s most famous case’ may be apocryphal.”
The heroic editors of this page were so unconvinced by the provenance of the story that there is an entire section of the Talk Page titled “Liston’s most famous case – did it really happen?” User ‘Vilhelm.s’ complained, “I couldn’t find anyone who cites any historical sources, and more sober academic papers about Liston do not mention it.”
Great Medical Myth-making
Michael Brown confirms that the majority of these stories originate with Richard Gordon’s 1983 book Great Medical Disasters. Gordon was a British doctor-turned-author, perhaps most famous for writing the Doctor in the House series of books and films. Great Medical Disasters is less an authoritative history textbook and more a gossipy Adam Kay-esque romp though some anecdotes from the past (I should point out that I have nothing against Richard Gordon or Adam Kay’s style of writing. I just think Gordon’s work shouldn’t be referred to as a serious piece of historical evidence.). Gordon describes Liston’s ‘four most famous cases’ in somewhat irreverent fashion. Here are the top two:
“Liston’s second most famous case
Amputated the leg in 2 ½ minutes, but in his enthusiasm the patient’s testicles as well
Liston’s most famous case
Amputated the leg in under 2 ½ minutes (the patient died afterward in the ward from hospital gangrene, they usually did in those pre-Listerian days*). He amputated in addition, the fingers of his young assistant (who died afterward in the ward from hospital gangrene, they usually did in those pre-Listerian days). He also slashed through the coattails of a distinguished surgical spectator, who was so terrified that the knife had pierced his vitals he dropped dead from fright.
That was the only operation in history with a 300 percent mortality.”
* [“Pre-Listerian” refers to Joseph Lister (1827 – 1912), the celebrated pioneer of antisepsis]
Richard Gordon, Great Medical Disasters, 1983
Gordon only provided two sources for his stories about Liston, and Dr Brown dismisses them in short order. One is an article by F.W. Cock for the University College Hospital Magazine, which is an account of the first operation done under ether in the United Kingdom, which Liston carried out in 1846. The catch is that Cock was not present at the time, and his account is published in 1911. His story of events contradicts those published by William Squire, who was one of Liston’s assistants for the operation in question.
Cock also lists among his sources, “10. Tradition,” which had apparently been handed down to him from his father and uncle, who both trained at University College Hospital. To me this seems like a fantastic get-out clause for doing any actual research. Seriously, under that heading he explains:
“I remember [my father and uncle] and several other old friends and fellow students, including Dr William Squire, meeting at my father’s house. Among other reminiscences, the first operation under ether was described at considerable length, each man taking part in it. This made a great impression on me, and it is from the recollection of this talk that I drew this account, modifying it only from the authorities already quoted.”
F.W. Cock, The First Operation under Ether in Europe: The Story of Three Days, 1911
I don’t want to go down that particular rabbit-hole, but suffice it to say that Cock’s article doesn’t mention the 300% mortality operation at all – we can rule it out as a viable piece of evidence for the story.
Unfortunately, despite my best efforts I couldn’t find anywhere on the internet a copy of Gordon’s other source: an article by Percy Flemming. It was published in the same place, the University College Hospital Magazine, but in 1926, a full 15 years after Cock’s article. Brown notes that it is a “general biographical account,” which relies heavily on many of Cock’s elaborations and exaggerations.
Not being able to read Flemming’s account means that I can’t take my search up to the very end, at least until the day that I can track the magazine down. For now, I’m going to take Dr Brown’s word for it: he describes the 300% story as “apocryphal” even after his reading of Flemming’s article. Therefore, at the very least, there is no evidence to support the occurrence of the famous and disastrous operation, but it seems pretty safe to say that it probably didn’t happen at all.
“Falsehood flies, and the Truth comes limping after it”
Having made this conclusion, it’s time to pause and wonder how the 300% story caught fire like this. I don’t simply mean the ease with which misinformation spreads around; plenty have written on that subject, from Jonathan Swift to Terry Pratchett. But for a story to fly around the world without anyone seriously checking the facts suggests that those people who are telling it want it to be true, and most of those who are hearing it assume it’s true.
The narrative underlying many of the accounts of the 300% story is that it was just one more sorry episode in a dark age of larger-than-life, incompetent surgeons inflicting horrific pain in imaginative and gruesome ways on their patients, who would mostly go on to die anyway from infective complications of their surgery. What would save the people from this horror? Antisepsis and anaesthesia, of course, the foundation stones of modern surgery.
It’s interesting that clinicians of the brave new post-anaesthesia, post-germ-theory world are portrayed in a very different light. They are scientific and considered in their approach, more successful with their treatments – in other words we see them as more like us. The doctors who came just before this time stand in the darkest shadow of that success, and so have the misfortune of seeming more primitive than they were.
The reality was different. Doctors of the first half of the nineteenth century were every bit as thinking and as feeling as we see ourselves to be. As Michael Brown writes elsewhere, during this time period surgeons were looking to elevate their status to that of physicians, and they did that by creating the image of a skilled, scientific, and actually fairly cautious group of professionals.
Not such a heartless bunch
This caution arose partly from the realistic view that many procedures were unlikely to be helpful to patients, and partly from a heightened emotional sensibility, which was philosophically and culturally in vogue at the time. This sensibility went beyond simply encouraging a feeling of compassion; it was seen by many surgeons of the time, including Benjamin Brodie, to be integral to the good practice of surgery:
“I do not hesitate to say that he who can look with indifference on the agonies of a fellow creature is not the person to practise surgery.”
Address by Benjamin Brodie, published in The Lancet, 1824
A strong sense of empathy was attributed by John Bell, an Edinburgh surgeon, to the particular strain that surgery placed on the emotions of the operator. Here he is arguing with James Gregory, the Professor of the Practice of Physic at Edinburgh University, on this very point:
“He [Gregory] never passed a sleepless night, reflecting what was to be done on the morrow; never witnessed the severities of the surgeon; never strained hard his breath, nor involuntarily clenched his hands at the sight of another’s agony; nor blanched with fear, nor felt the palpitations of anxiety, in the midst of an eventful operation?”
John Bell, Answer for the Junior Members of the Royal College of Surgeons of Edinburgh to the Memorial of Dr James Gregory, 1800
All this is to say that the portrait of Robert Liston we paint today is as untrue as it is unkind. Early nineteenth century doctors weren’t as a rule heartless, reckless or malicious, any more than we are today. They were mostly just doing their best in the face of limited technology and scientific knowledge: the last two years have taught us how that feels.
The responsibility to tell a balanced history of medicine lies with all of society, since the history of medicine is the history of the care of patients, and we are all among that number at some time in our lives. A more balanced view of medical practice in the past might help to understand the difficulties faced by modern medicine today. And doctors, including in my hospital’s A&E, would do well to think of Robert Liston as a colleague – separated by time and space, but equally deserving of empathy and a fair hearing.
Further reading and references
If you got this far, then fair play to you. If you would like read even more, or follow up on some of the sources mentioned above, then please see here:
Dr Michael Brown, historian of medicine at Roehampton University, has done a lot of work in the field of nineteenth century surgery, and I wouldn’t have got anywhere without being able to read his work. Here is the website of his Surgery and Emotion project, and here is the specific blogpost about Robert Liston. Here is his chapter from the The Palgrave Handbook of the History of Surgery, which is entitled Surgery and Emotion: The Era Before Anaesthesia. It inspired much of the second half of my blog.
The Oxford Dictionary of National Biography could be free for you to access if you have a UK public library card! It depends on whether your local library is subscribed to it: I’ve used my Coventry and my Birmingham memberships successfully. Here is a link to it.
F.W. Cock, The First Operation under Ether in Europe : The Story of Three Days. Reprinted from the University College Hospital Magazine, February, 1911. Available to view at the Wellcome Collection website, here.
John Bell, Answer for the Junior Members of the Royal College of Surgeons of Edinburgh to the Memorial of Dr James Gregory , Edinburgh, 1800. Available to view at the Wellcome Collection website, here.