ON MR. LISTON'S METHOD OF HOLDING THE KNIFE IN LITHOTOMY.

gradual manner. be the respect in which we hold our predecessors, are mainly of sight or hearing, and guided by living authorities, or by those immediately preceding headache, either their nourishment and stimulus should be in- who have recently passed from the scene. I believe I but recreased, or suckling should be at once discontinued. Where peat the sentiments of every one when I say that, though eight there is any predisposition to insanity, mothers should not, if years have passed away since the death of Robert Liston, his possible, be allowed to suckle their children. In all cases of presence is still felt amongst us as a living authority. What this kind, the dependence of the mania upon exhaustion is that was eight years ago can scarcely be deemed less at the abundantly evident. It is especially likely to happen when present day, and amongst most of those who had the benefit pregnancy and lactation are allowed to proceed simultaneously. of his personal instructions I feel confident that what he said There is in the subjects of this form of disease the same and did in his capacity as a teacher of surgery must ever resuicidal and homicidal tendencies as in puerperal insanity. I main bright in the memory. Time generally brings about and evinces the correct hue of every feature and transaction in life ; once met with a case in which a mother delivered of twins became affected in her mind from suckling, and a wet-nurse and at this date, when Mr. Liston’s professional character is a. matter of surgical history, I trust that it will not be deemed was procured in the person of a young girl who had given birth to an illegitimate child. She had nursed her own infant for irrelevant to the profession that I should bring forward the some time, and then, while being drained by the twins, again besubject of this paper, even though, in the estimation ofsome, came pregnant. Signs of insanity manifested themselves, and it may seem one of trivial importance. she was one day found dead, hanging behind the door of her room. No surgeon in modern times has achieved so great a reputaThis form of insanity sometimes comes on weeks or months after tion in lithotomy as the late Mr. Liston. Some may have the close of lactation. I have no doubt that the woman Brough, operated on a greater number of cases, others may have, by who killed, two or three years since, several of her children chance, met with more extraordinary instances, but no one had at Esher, and who is now a confirmed lunatic in Bethlehem, greater opportunities or greater influence as a teacher than fell had suffered from over-lactation. She had weaned a child not to his lot. He was surgeon to the Royal Infirmary of Edinlong before the dreadful tragedy, had complained of loss burgh, at a time when the medical school of that city was of sight and severe nervous disorder, and had suffered in her larger in numbers than at any other period; and how he filled head in previous lactations. The preventive treatment of this the professional eye in London, at University College, needs no form of insanity consists, of course, in weaning as soon as any comment from me. In my study and estimation of surgical In the teachers, few, if any, have come up to the standard of Mr. marked signs of nervous disorder are perceived. management of such cases, great care in guarding the Liston; but it is apart from the intentions of this paper ta patient is necessary, and the treatment of this disease must be dwell on such a topic. Suffice it to say, that it is my conviction that the operation of lithotomy, as at present performed a supporting and stimulating one, combined with perfect rest, and the avoidance, as far as possible, of all moral and physical in Great Britain and the colonies, is in a great measure founded on the example and doctrines of this distinguished surgeon. excitement. Many of his pupils, now settled in all parts of the world, operate on the example of their master, and some of the most eminent teachers and authors of surgery of the present day ON take him as their model, chiefly from the circumstance that MR. LISTON’S METHOD OF HOLDING THE they have had the advantage of his instructions. For myself, I have ever felt grateful for the instruction I KNIFE IN LITHOTOMY.* received from his example, and, after an experience of nearly BY WILLIAM FERGUSSON, ESQ., F.R.S., thirty years, I say without hesitation, that I have never seen PROFESSOR OF SURGERY IN KING’S COLLEGE, ETC. lithotomy performed in a superior style to that which characterized his master hand. The success of his practice was equal to its brilliancy of execution; and I am within the mark when PERHAPS no single operation in surgery has attracted so much I say that thousands have wished that they might be lithoattention as lithotomy, and, notwithstanding all that has been tomists like Liston. In my own humble capacity, I have written on the subject, any allusion to it, on such an occasion founded the principal features of the operation for stone which I perform on his example; and with large experience, though as this, is likely to excite some expectations, which may I be at no distant date to lay somewhat less than that of the master, and a conviction that probably disappointed. hope before the profession the results of a tolerably large personal the proceeding is worthy of example, I feel impelled to do that justice to the subject which I think it deserves. experience in this interesting operation, but my present object Within the last twenty years, five works on Surgery, more is chiefly to perform a duty to which I have long felt impelled. or less original, have been published in this country by wellI have no novelty to propound-no fancy or theory of my own ; known professors. One of them has been the production of but I mean simply to draw attention to a remarkable error, as Mr. Liston himself; the others of immediate pupils, or of those I consider it, which has gradually crept on the illustration of who have had the opportunity of seeing his practice. In my own work, in that of Professor Miller, of Edinburgh, Professor this operation, as portrayed in most of the modern works on Pirrie, of Aberdeen, or of Professor Erichsen, of University surgery which have appeared in this country within the last College, the operation of lithotomy has, I believe, been de. scribed chiefly from the 1JI1odel of Mr. Liston. The terse twenty years. Every step, attitude, movement, or anything having the description by Mr. Liston of the operation in which he so resemblance to novelty, regarding this operation-perhaps the greatly excelled, needs no special comment on the present occasion. Of the description which I myself give, it is indelicate most interesting and exciting in surgery-may be said to posto offer my opinion; nor have I a fault to find with that given sess historical interest. Nothing concerning it has been over- in print by my three distinguished contemporaries, whom I intellects connected with surgery have have also the pleasure of calling friends; yet, strange to say, the and looked, highest been associated with it. It is known, however, that contro- an error of illustration prevails in all these works, with the exversies have arisen on points which to many have seemed ception of my own, which, if allowed to remain longer without rise in after years to discussions and disputes, without a shade of doubt. Witness the discussions regarding notice, might give which never be decided on positive proof. The intention the incisions in the so-called Celsian operation, and those that of this paper is to fix that positive proof, and my wish is to have prevailed regarding the method of lithotomy practised by challenge during living authority the correctness of the views Raw and Cheselden. Even in England, it may be said to be which it is now my object to establish. Here are displayed before the present company five sketches still matter of doubt how the last-named lithotomist performed the principal part of his operation. At any rate, we all know of a principal step in the operation of lithotomy-that of cutting into the neck of the bladder. Nos. 1, 2, 3, and 4, are taken the discussions that have arisen on the subject, and it is now respectively from the works of Liston, Miller, Pirrie, and my intention to lay before the profession a question of a similar Erichsen.* The sketch No. 5 is from my own. At a first glance kind, which I presume can only be settled by the living gene- all these will appear nearly, if not altogether, alike; yet I reration. quest particular attention to the difference in the position and My experience in life leads me to say that in all worldly attitude of the hand in No. 6 from all the others. I take Mr. transactions, and in all professional points, we, whatever may * The sketches from Miller, Pirric, and Erichsen, are here omitted. They * are similar to Liston’s. Read before the Medico-Chirurgical Society, March 25th, 1856 that their symptoms When nursing women

come

on

in

a

more

complain of loss

could

425

Liston’s

sketch, No. 1,

as

the first and chief of the others.

In

any of the professors alluded to. I witnessed all his public in Edinburgh, and during that time I have the best reason for knowing that he performed lithotomy on forty patients in the Royal Infirmary. I was a close and zealous observer, and few, if any of his movements, escaped my notice. I am, therefore, very confident that he did not cut into the neck of the bladder with his hand in this attitude, but that he held the hand and knife much in the style represented in No. 5, and that he cut with the knife underhand, and not overhand as has been erroneously depicted by himself and the other professors to whose works I have alluded. I have communicated with all these gentlemen on the subject, and Professor Miller admits the correctness of my views. I have the additional negative proof, if I may so call it, that none of them, in so far as I can understand, hold the knife in the way represented in their works. But irrespective of any admission from these gentlemen, I feel confident that the view which I take is the correct one, and for further proof I appeal to the many thousands who have seen Mr. Liston perform this operation. Besides remarkable dexterity there were other features about Mr. Liston’s hand which could not fail to attract attention. This member may be truly said to have been a remarkable feature in his well-built manly frame. Although of stature and bulk beyond the average proportions, the hand was even larger than might have been expected on such a form, and to a. stranger, at a first glance, and when viewed in a state ofquietude, it must have appeared a heavy, and, so to speak, inanimate organ. The wrist was thick, the metacarpal portion massy, heavy, and devoid of other striking characteristics. The fingers were plump and round, of due proportions to the rest of the member, and the nails, which were good, were perhaps the handsomest features on the organ. The skin was soft, and seemed to have a layer of adipose tissue under it,, which probably contributed in no small degree to hide those prominent points which are usually observed on a hand which possesses much physical energy. When once in action, however, a greater contrast could scarcely be imagined. The previously-supposed deficiency of animation would be at once forgotten, and the organ, so questionable in its appearance and proportions, would speedily excite feelings of wonder in the looker-on. The movements could not be called quick; there was a slowness which might be said to be in accordance with its massiveness, but this slowness was amply compensated by the precision and effectiveness of each step. Whether the movement was slight and trivial, or called for the utmost vigour, there was the same calm energy of purpose displayed. was no halting or hesitating; no repetition for what should have been done at first. The hand seemed endowed with an intellect of its own, irrespective of the mind of its master, and there was a quiet gravity in all which the organ did which was very remarkable; the facility with which the phalanges, particularly the distal ones, could be bent on special occasions, was peculiar. Whether for light or vigorous movements ; for producing the tinkle of a tiny stone in the bladder, or snapping the femur with a single squeeze of the cutting forceps, the hand seemed perfect in its energy and mechanism, and whatever was required was accomplished almost before the spectator was aware of the movements having been made. Astonishment and admiration were usually the result, and the of a well-performed operation by sucha hand, couldrecollection fade, in most minds, only with life. knife which Mr. Liston used for lithotomy was shaped in the blade, with a slight modification at the heel, like an scalpel; it was about two inches and three-quarters. beyond the handle, and its cutting edge was an inch and a half in extent. The length, including handle and blade, was about inches. Themanner of holding it was peculiar: the seven ebony handle, which was thick, broad, and strong, compared that of a scalpel, was almost concealed in the palm of the as it was held betwixt the point of the thumb and distal phalanx of the middle finger; the front of the forefinger rested the back of the instrument at the junction of the handle and the blade, and when the principal incisions in lithotomy made, the flat or side of the instrument, from the back to the cutting edge, was parallel with the descending ramus of pubis. The palm of the hand and the cutting edge of the knife were directed downwards and outwards, and almost invariably the back end of the handle rested in the centre of the palm of the operator’s hand. Occasionally I have seen some slight modifications in these features. Thus, when the upper part of the wound in the skin-that nearest the scrotumseemed not high enough, then the palm of the hand, with the knife still held as described, might be turned upwards, as the edge of the blade was placed against the skin, to the extent of

practice

No. 1. LiSTON.

this it will be

of the cutting instrureference to the incision in question, the hand is in an attitude unusual in surgery, and in particular in such an attitude as I maintain was never practised by Mr. Liston himself, nor even by those who consider that they describe his operation. It will be observed that this attitude is one which is rare in handling a knife, and to those familiar with the subject, who will give it consideration, it will soon be seen that it it is not compatible with the precision and firmness which are at the same time required in this stage of lithotomy. The contrast between these figures and that of No. 5 will be immediately seen. Here the hand is represented ment is

seen

that whilst the

appropriately placed with

point

No. 5. FERGUSSON.

There

I The with the

fingers and palm downwards, and in that attitude denoting more vigour and decision than in the others. On this point possibly there may be a difference of opinion; but what I chiefly wish to draw attention to is this, that neither Mr. Liston, nor any of his distinguished pupils referred to, have illustrated the operation in the correct manner. Mr. Liston actually misrepresented his own operation; and his pupils, whilst professing to describe it, have taken his representation as the model, and so perpetuated an error, which in time may possibly lead to much misapprehension, if not evil consequences. It may be said that surely Mr. Liston’s own sketch should be taken as the correct representation; but on this point I know that he was conscious of an error. The error I have little doubt was committed by the artist, who, whilst paying attention to the anatomy, and to the position of the point of the knife, had considered the attitude of the hand of minor importance.

But it may be asked on what ground do I question this subas so many first-rate authorities seem to agree with the original. Now my answer here is, that I havemyself seen Mr. Liston perform the operation perhaps more frequently than

ject,

426

ordinary with

hand

on were the

half

inch or so. And again, when the perineum was very piece of zinc plate, merely laid upon it; the other extremity and the point of the knife was in the prostate, the tips of the cylinder was closed by a disc of the same metal, and of all the fingers, and that of the thumb, would be in a manner soldered. At the same time, another thermometer was susconcentrated round the posterior part of the handle, the only pended, nearly over the cylinder, at the height of about ten part which was external to the wound. Even here, however, inches from the ground, and in the free air. The state of the the downward aspect of the palm gave that firmness and pre- sky was carefully noted during all the experiments. cision of movement which characterized all that Mr. Liston’s By the annexed Table, in which the results of several of the experiments are recorded, it will be seen that, not only the right hand did in this operation. It may be thought by many that I have raised a point of same general fluctuations of temperature occurred, as have very trivial importance, but such is not my view. Experience been observed, within certain limits, by Mr. Wilson,* Mr. has taught me, in a variety of ways, that to those interested Six, Dr. Wells, Melloni, and others, but that, on intensely in the subject of lithotomy, there is not a single feature regard- cloudy nights, the quantity of heat reflected back by the clouds ing it that does not demand the most careful consideration, and was sufficient to raise the temperature of the exposed thermomethod of holding the knife and the hand seem to me meter to a higher degree than that indicated by the thermoalmost of vital importance. Were a great painter represented meter which was in the cylinder within the ground, and paron canvass holding his brush over-hand, the attitude would taking directly of the earth’s warmth. These experiments were excite ridicule, but could do no special harm; but when a great made in one of the gardens at the back of Connaught-place surgeon has his hand and knife erroneously represented, the West, Hyde-park. mischief may be serious. Supposing that in thirty years all Mr. Liston’s pupils may have ceased to teach; supposing, as is Compurutive Temperatures during the Night, of T7termognetei,.9 Sheltereclfrom the Sky, and of others Exposed to it:possible, that in the same lapse of time there is no living witness of Mr. Liston’s operation; and supposing, too, that the majority of the works of our present authors should still lead the practice of surgery at that time, the hand and knife might come to be held by future practitioners as if in imitation of one of theI most dexterous and successful of lithotomists. It is the beauty and in some respects the claim to superiority of our modern surgical publications that the embellishments and illustrations by means of woodcuts are superior to the productions of our predecessors. The works of Scultetus, Pare, and others, may raise a doubt on this subject, but as to the value of illustrations there can be none. The modern practice of inserting woodcuts in conjunction with the type is truly admirable, and it were a pity that from oversight or otherwise an improper impression should thus be given on a point so important as that to which this paper pertains. Even in so old a work as that of Tolet, published at Paris in 1581, on Lithotomy, the hand is represented holding the knife, with palm and edge directed downwards. I confess myself an admirer, I may say an imitator, of Mr. Liston in regard to this operation. I believe that it was in some respects unique, and believing, too, that it is largely folThe mean temperature of the air in the garden was 44° at the times of lowed in the present day, and likely to be a standard proceedmaking the observations. I have to on the in it views ing, subject thought right put my Thus it is satisfactorily shown that on the rraoderately cloudy such a way as best to meet the notice of the profession. Trusting that this very important and delicate surgical ques- nights, when compared with those of the three fine nights, tion may not be deemed unworthy the notice of this Society, I (namely, the 27th, 28th, and 29th of November,) the thermorespectfully take this method of giving it that publicity which meters indicated the presence of reflected heat in a degree not in my opinion it deserves. differing from what might have occurred in the open country; but that on the densely cloudy nights they indicated a degree of George-street, Hanover-square, 1856. heat, sensibly above what they could have derived from the earth’s surface. Other thermometers were suspended at the same time in ON THE pairs. One of each pair was placed in a situation where it was more or less sheltered from the the other was placed INFLUENCE OF ARTIFICIAL HEAT ON THE about two feet from it, and at sky; the same height from the ATMOSPHERE OF LONDON. ground, but fully exposed to the sky. The result was, that on the intensely dark and cloudy nights the temperature of the BY WILLIAM D. CHOWNE, M.D., exposed thermometers attained a higher degree than that PHYSICIAN TO CHARING-CROSS HOSPITAL. attained by those that were sheltered. This occurred on the nights when it was found that the exposed thermometer already THE well-known effects of clouds, in reflecting back the heat spoken of, as being suspended near the ground, attained a than that in the cylinder within the ground. radiated to them from the earthand terrestrial objects, induced higher temperature in Hence, ordinary circumstances the air under a although me to make some experiments on the subject, the details of which shed is during the night warmer than the unsheltered air, yet might, I considered, prove interesting to the profession. These on extremely overcast nights, the relative temperatures are rewhich exist on experiments were made at a time when the agents for pro- versed, and are rendered analogous to those sunny days, when thermometers exposed to the sun’s rays ducing artificial heat are most generally in operation-namely, indicate a higher temperature than those sheltered from in winter months. It might be easily imagined that the vast them. amount of heat generated in the metropolis, and in all large Dr. Wells, when he had changed the place of conducting his exmanufacturing towns, by the use of furnaces, by domestic periments on dew from the open country to Lincoln’s-inn-fields, fires, by gas-light, &c., must exercise a considerable effect on considered that the surrounding houses had an influence on his thermometers. He says-"In situations where large masses of the temperature of the atmosphere of these localities. bare solid matter exist.........agreater heat will be received by the the in to ascertain order During year 1850, temperature the exposed body than what is radiated by itself. For example, ofthe London atmosphere on fine clear nights when compared it seemed certain to me that the houses surrounding Lincoln’swith that on moderately cloudy nights, as well as on intensely inn-fields had an influence upon my thermometers during my dark and clouded nights, when radiation would be most ob- experiments there at night, beyond what arose from their structed, a cylinder of zinc-plate, three inches in diameter and * Edinburgh Philosophical Transactions, vol. i., p. 170. twelve inches long, was inserted vertically in the earth, and &dag er; Philosophical Transactions, vol. lxxiv., part ii., p. 430. 1784. And Six’s a thermometer was placed within it. The upper orifice of the Posthumous Works. Canterbury, 1794. &Dag er; On the Nocturnal Cooling of Bodies exposed to a Free Atmosphere. cylinder, being just level with the ground, was covered by a Scientific Memoirs, selected, vol. v., p. 543. 1847. an

deep,

the

.

427 427