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ON MR. LISTON'S METHOD OF HOLDING THE KNIFE IN LITHOTOMY.
nion of this excito-motor power; no part of the vascular system upon to state, that I am pefectly convinced that Mr. Liston which ie not linked with the excito-secretory sub-system. held the knife, during that stage of the operation, as I have But here I close this brief communication. My present obin the illustration of that operation, in my work represented ject is only to draw the merest sketch of this vast subject, on the " Principles and Practice of Surgery," and the following a extensive and series of most cautious which demands experiments and observations. The efforts of many labourers, through are the grounds of my conviction :-
lst. During the years I had the privilege of being a pupil of many years, will be required fully to develope the two subthat great surgeon, he invariably held the knife as here delisystems of t7ie Diastaltic Nervous System. I propose, shortly, to treat this important subject at greater neated, in demonstrating the operation on the dead subject, length and with more details. and in the operations which I saw him perform on the living December 25th, 1856. body. No one ever watched the surgical proceedings of another with greater admiration and attention than I did those of Mr. ON ________________
Liston ; and since the first year I listened to his lectures, and MR. LISTON’S METHOD OF HOLDING THE heard him describe, and saw him demonstrate to his class his KNIFE IN LITHOTOMY. method of holding the knife in lithotomy, my impression as to BY WILLIAM
PIRRIE, F.R.S.E.,
REGIUS PROFESSOR OF SURGERY IN MARISCHAL COLLEGE
PROFESSOR FERGUSSON
AND
UNIVERSITY.
having stated that Professors Miller,
Erichsen, and myself, have given
erroneous delineations of the in which Mr. Liston held the knife in cutting into the Madder, in the operation of lithotomy, I think myself called
manner
2nd. Before my first
body, sence
operation of lithotomy on the living I performed the operation on the dead subject, in preof Mr. Liston, and was directed by him to hold the knife
delineated. 3rd. In every edition of Mr. Listen’s "Practical Surgery," in illustrating his own operation, the hand is delineated in the attitude which I maintain was practised by Mr. Liston. It has been said, that an error was committed by the artist. It is difficult, however, to conceive that an artist could have made an error in delineatiing the attitude of the hand, and still more difficult to believe that Mr. Liston would haveadmitted an error of illustration into the first edition of his work, and repeated it in the three following editions. 4th. When I was appointed Professor of Surgery in this - university, Mr. Liston, well knowing my admiration of his method of performing lithotomy, had the kindness to send me .some admirable illustrations of his own operation ; and, amongst others, an oil painting which he got prepared for the express purpose of enabling me to demonstrate to my students his method of performing this operation. Mr. Liston stated, that he held the knife while the artist made the drawing, and no one who ever saw the remarkable hands of that wonderful man would, for one moment, hesitate to admit that they are admirably and faithfully delineated. In that painting the hand is delineated in the attitude I have represented, and ever since it has been my duty to teach the mode of performing this operation, I havebeen in the habit, both during Mr. Liston’s lifetime and since his lamented death, of calling the particular attention of students to his method of holding the knife while cutting into the bladder. as
his method has been perfectly distinct and decided ; and it is, that, in the first step of the operation, he held the knife with his finger on the back of the instrument, as Professor Fergusson describes ; but, while cutting into the bladder, he held it as represented in the accompanying illustration of his operation in his " Practical Surgery."
5th. Through the kindness of Professor Miller, I had an op portunity, some weeks ago, of seeing, in the anatomical rooms of the University of Edinburgh, a painting which belonged
to Dr. Monro and I have in my possession authority for stating, " that it is a copy of Liston’s class illustration, made
expressly during Liston’s lifetime, and under his superintendence, for Dr. Monro." In that painting, the attitude of Mr. Liston’s hand is precisely that which, I maintain, he practised while cutting into the bladder ; and it is exactly the same as that which is delineated in the oil painting which Mr. Liston got prepared for myself, and the same as represented in all the editions of his own "Practical Surgery." 6th. The late Dr. Ewing, while teacher of Surgery in this university, had an illustration of Mr. Liston’s operation. That illustration became the property of Dr. Laing, the immediate successor of Dr. Ewing, as teacher of Surgery, and it came into my possession when I became Professor of Surgery ; but it was unfortunately destroyed by a fire in the College, along with my former collection of preparations. I called on Dr. Laing to re’’
quest him to inform me if he had a distinct recollection of the attitude of the hand in that illustration, and he instantly took up an instrument, and at once demonstrated the attitude, and it was that which is delineated in all the illustrations of Mr. Liston’s lithotomy. Dr. Laing was not aware of the difference of opinion as to how -Alr. Liston held the knife, and, in consequence, was not aware of my object in making the inquiry, His distinct recollection, therefore, cannot but be regarded as rather a striking piece of corroborativeevidence, as the drawing was one that had the approval of Mr. Liston. It is fortunate that there are so many delineations of Mr. 5
" The result of amputation at the hip-joint has been investiListon’s method of holding the knife in lithotomy. The cirattitude to cumstance of all the artists giving the same the gated by Dr. Stephen Smith, of the United States; he has colhand can be explained only on the hypothesis that each gavea a lected 98 cases in which this operation has been done, of which faithful representation. 56 died, and 42 were cured. With reference to the cause of I trust that the facts mentioned above may clearly convince amputation, it is stated that in 30 cases it was for injury; of others that Professors Miller, Erichsen, and myself, have not these 18 died, and 12 were cured; whilst in 32 cases in which been guilty of giving, in our works on Surgery, erroneous de-’it was done for chronic disease, 16 died, and 16 were cured. lineations of Mr. Liston’s method of holding the knife in litho- It is a remarkable fact, according to Dr. Smith, that the mortality from this operation has been greatly less of late years tomy. I regret that there should exist any want of unanimity of than formerly ; this he attributes to the cases having been opinion amongst the admirers of Mr. Liston’s method of opera- better selected, the operation more skilfully performed, and,, ting in lithotomy; and, for my own part, I am particularly above all, to the employment of anaesthetics; indeed the emgrieved to differ on this point from one so highly distinguished ployment of chloroform must necessarily greatly diminish the risks of an operation such as this, in which the effect of a shock as Professor Fergusson, for whom I entertain sentiments of the is much to be dreaded."-p. 76. greatest admiration and esteem. In previous "Mirrors" we have placed upon record three inAberdeen, December, 1856. stances of amputation at the hip-joint, to which we would especially beg to refer the reader; the first by Mr. Charles Guthrie, at the Westminster Hospital, for malignant disease of the femur, (THE LANCET, vol. i. 1853, p. 405;) the second by Mr. Adams, at the London Hospital, for a very extensive OF THE PRACTICE OF fibro-cystic tumour of the leg and thigh, (THE LANCET, vol. i. 1854, p. 442;) and the third by Mr. Erichsen, at University for a severe injury to the thigh from the passage of College, MEDICINE AND SURGERY two loaded railway trucks over it, (THE LANCET, vol. i. 1855, IN THE p. 363.) In all these the result was fatal, Mr. Guthrie’s on the second day, Mr. Adams’ on the twelfth day, and Mr. HOSPITALS OF LONDON. Erichsen’s the same evening. A successful case of this operation by Mr. Wigstrom, of the 14th Dragoons, at Lahore, appears Nulla est alia pro certo noseendi via, nisi quam plurimas et morborum in THE LANCET, vol. i. 1850, p. 411. In some remarks which et dissecttomim historias, tam aliorum proprias, collectas habere et inter we ventured to offer upon Mr. Guthrie’s case, we took occasion se comparare.—MoRGAGNI. De Sed. et Caus. Morb.lib. 14. Procemium. to glance at the history of the operation from the time of Morand in 1739 down to Mr. Sands Cox in 1845. We at the same time went over the principal facts bearing on this importLONDON HOSPITAL. ant operation, which some of our readers will perhaps take the DISARTICULATION OF THE HIP-JOINT IN A FEMALE, AGED FORTY, trouble of referring to, as on the present occasion we are preFOR MEDULLARY CANCER OF THE THIGH, COMMENCING EIGHT vented from dilating on the subject owing to the length of the MONTHS BEFORE; PUNCTURE BY A TROCAR FIVE DAYS PREcases. VIOUS TO THE OPERATION, GIVING EXIT TO THIRTY OUNCES In Mr. Curling’s case, like that of his colleague Mr. Adams, OF BLOODY FLUID ; RECOVERY. the disease was manifested in the presence of a tumour of the thigh, of considerable size, which proved to be medullary.(Under the care of Mr. CURLING. ) It was punctured two days after admission, and about cancer. WITHIN the past nine months we have had the opportunity thirty ounces of fluid were evacuated, being principally blood, of witnessing on two occasions the operation of amputation at the first twenty ounces possessing a dark colour. Subsequently the hip-joint-the first by Mr. Curling, at the London Hos- to this, the growth of the tumour rapidly increased, so that measures of an urgent character were demanded, and an pital, in March last ; the second by Mr. Hancock, at the anxious consultation with Mr. Luke, Mr. Adams, and other of Charing-cross Hospital, in October. Both have been perfectly his colleagues, resulted in the performance of disarticulation at successful in their results. Our readers are aware that this the hip-joint. It will be observed that the anterior flap was operation is seldom had recourse to in civil practice, as a glance I not made first in the present instance, as the tumour would at our " Mirror" for some years past will show. It is more ’, necessarily have been transfixed, and the operation thus complicated and somewhat hazardous. The posterior frequently the task of the military surgeon to perform this rendered was therefore first made, and then the anterior, whilst the flap operation in the field, and generally under great disadvantages. femoral artery was carefully compressed in the groin, and very Those surgeons who have studied this subject will probably re- little blood was lost. The patient looked rather pale -ancl collect that during the eventful days of June, 1S48, in the delicate for a few days afterwards, but owing to an otherwise French capital, amputation at the hip-joint was performed good constitution, conjoined with extreme quiet and care in a four times; three with quickly fatal results; but the fourth I small ward, the stump rapidly healed by first intention, and not a single untoward symptom showed itself. We had An was successful; the patient-an insurgent at the Hopital St. ’I, several times of seeing Mr. Curling dress the Antoine under the care of M. Nelaton-lived four months; the , opportunity stump, and were struck with the healthy condition of the stump had perfectly healed, but death occurred from pneu- patient, notwithstanding the loss of such an extensive part of monia of the left lung, with ulcerations of the large bowel. ’, her body. Her progress since leaving the hospital has been This patient, from being an insurgent, was subject to visits ’, satisfactory, and no return of the disease has taken place, from the police, which to some extent must have influenced although there was an œdematous swelling of the other foot and leg, which has to some extent subsided. The evidence the result.* With the very large field of civil practice afforded afforded by the naked eye, as well as the microscope, clearly by the London hospitals, the opportunities for witnessing this pointed out the nature of the disease, but as there is no herediimportant procedure are comparatively limited; few surgeons tary tendency, we will hope that its reappearance, should it therefore have the chance of performing it more than once occur, m; y be remote. Mary Ann G--, aged forty, married, residing at Speen, during their active career, although it has been twice done by near Newbury, Berks; admitted March 4th, 1856. She states in also twice cases Mr. Liston, and by Mr. Syme. In the that her father and mother died from old age, being of the which it has been resorted to, it has been justified only under ages of eighty-five and eighty-four; she has been married many the most urgent circumstances; very few indeed would hazard years, and has had five children. Her occnpation is that of a it unless as a last resort; and when it is considered how exten- schoolmistress, and she has always had good health during the sive is the mutilation, it is gratifying to know that in its re- last twenty-four years; before that, she was rather delicate. .sults there is not so great an amount of fatality as was believed She has only one sister, who is of sound constitution. About but a short time back. The following extract from Erichsen’s twenty-six years ago, the patient suffered from a contusion over " Science and Art of Surgery" will, we think, satisfactorily show the knee, and was cupped. She has had no illness since then this :until last August, when she first noticed a small lump upon the which she thought to depend upon rheumatism, * See British American Journal of Medical and Physical Science, vol. iv., for right thigh, 123 cases of Gun-shot Wounds, reported by Dr. Gibb, occurring in Paris in and various applications were made to it, but without any effect. The swelling continued steadily to enlarge, without June,1848.
A Mirror
li
6
lst. During the years I had the privilege of being a pupil of many years, will be required fully to develope the two subthat great surgeon, he invariably held the knife as here delisystems of t7ie Diastaltic Nervous System. I propose, shortly, to treat this important subject at greater neated, in demonstrating the operation on the dead subject, length and with more details. and in the operations which I saw him perform on the living December 25th, 1856. body. No one ever watched the surgical proceedings of another with greater admiration and attention than I did those of Mr. ON ________________
Liston ; and since the first year I listened to his lectures, and MR. LISTON’S METHOD OF HOLDING THE heard him describe, and saw him demonstrate to his class his KNIFE IN LITHOTOMY. method of holding the knife in lithotomy, my impression as to BY WILLIAM
PIRRIE, F.R.S.E.,
REGIUS PROFESSOR OF SURGERY IN MARISCHAL COLLEGE
PROFESSOR FERGUSSON
AND
UNIVERSITY.
having stated that Professors Miller,
Erichsen, and myself, have given
erroneous delineations of the in which Mr. Liston held the knife in cutting into the Madder, in the operation of lithotomy, I think myself called
manner
2nd. Before my first
body, sence
operation of lithotomy on the living I performed the operation on the dead subject, in preof Mr. Liston, and was directed by him to hold the knife
delineated. 3rd. In every edition of Mr. Listen’s "Practical Surgery," in illustrating his own operation, the hand is delineated in the attitude which I maintain was practised by Mr. Liston. It has been said, that an error was committed by the artist. It is difficult, however, to conceive that an artist could have made an error in delineatiing the attitude of the hand, and still more difficult to believe that Mr. Liston would haveadmitted an error of illustration into the first edition of his work, and repeated it in the three following editions. 4th. When I was appointed Professor of Surgery in this - university, Mr. Liston, well knowing my admiration of his method of performing lithotomy, had the kindness to send me .some admirable illustrations of his own operation ; and, amongst others, an oil painting which he got prepared for the express purpose of enabling me to demonstrate to my students his method of performing this operation. Mr. Liston stated, that he held the knife while the artist made the drawing, and no one who ever saw the remarkable hands of that wonderful man would, for one moment, hesitate to admit that they are admirably and faithfully delineated. In that painting the hand is delineated in the attitude I have represented, and ever since it has been my duty to teach the mode of performing this operation, I havebeen in the habit, both during Mr. Liston’s lifetime and since his lamented death, of calling the particular attention of students to his method of holding the knife while cutting into the bladder. as
his method has been perfectly distinct and decided ; and it is, that, in the first step of the operation, he held the knife with his finger on the back of the instrument, as Professor Fergusson describes ; but, while cutting into the bladder, he held it as represented in the accompanying illustration of his operation in his " Practical Surgery."
5th. Through the kindness of Professor Miller, I had an op portunity, some weeks ago, of seeing, in the anatomical rooms of the University of Edinburgh, a painting which belonged
to Dr. Monro and I have in my possession authority for stating, " that it is a copy of Liston’s class illustration, made
expressly during Liston’s lifetime, and under his superintendence, for Dr. Monro." In that painting, the attitude of Mr. Liston’s hand is precisely that which, I maintain, he practised while cutting into the bladder ; and it is exactly the same as that which is delineated in the oil painting which Mr. Liston got prepared for myself, and the same as represented in all the editions of his own "Practical Surgery." 6th. The late Dr. Ewing, while teacher of Surgery in this university, had an illustration of Mr. Liston’s operation. That illustration became the property of Dr. Laing, the immediate successor of Dr. Ewing, as teacher of Surgery, and it came into my possession when I became Professor of Surgery ; but it was unfortunately destroyed by a fire in the College, along with my former collection of preparations. I called on Dr. Laing to re’’
quest him to inform me if he had a distinct recollection of the attitude of the hand in that illustration, and he instantly took up an instrument, and at once demonstrated the attitude, and it was that which is delineated in all the illustrations of Mr. Liston’s lithotomy. Dr. Laing was not aware of the difference of opinion as to how -Alr. Liston held the knife, and, in consequence, was not aware of my object in making the inquiry, His distinct recollection, therefore, cannot but be regarded as rather a striking piece of corroborativeevidence, as the drawing was one that had the approval of Mr. Liston. It is fortunate that there are so many delineations of Mr. 5
" The result of amputation at the hip-joint has been investiListon’s method of holding the knife in lithotomy. The cirattitude to cumstance of all the artists giving the same the gated by Dr. Stephen Smith, of the United States; he has colhand can be explained only on the hypothesis that each gavea a lected 98 cases in which this operation has been done, of which faithful representation. 56 died, and 42 were cured. With reference to the cause of I trust that the facts mentioned above may clearly convince amputation, it is stated that in 30 cases it was for injury; of others that Professors Miller, Erichsen, and myself, have not these 18 died, and 12 were cured; whilst in 32 cases in which been guilty of giving, in our works on Surgery, erroneous de-’it was done for chronic disease, 16 died, and 16 were cured. lineations of Mr. Liston’s method of holding the knife in litho- It is a remarkable fact, according to Dr. Smith, that the mortality from this operation has been greatly less of late years tomy. I regret that there should exist any want of unanimity of than formerly ; this he attributes to the cases having been opinion amongst the admirers of Mr. Liston’s method of opera- better selected, the operation more skilfully performed, and,, ting in lithotomy; and, for my own part, I am particularly above all, to the employment of anaesthetics; indeed the emgrieved to differ on this point from one so highly distinguished ployment of chloroform must necessarily greatly diminish the risks of an operation such as this, in which the effect of a shock as Professor Fergusson, for whom I entertain sentiments of the is much to be dreaded."-p. 76. greatest admiration and esteem. In previous "Mirrors" we have placed upon record three inAberdeen, December, 1856. stances of amputation at the hip-joint, to which we would especially beg to refer the reader; the first by Mr. Charles Guthrie, at the Westminster Hospital, for malignant disease of the femur, (THE LANCET, vol. i. 1853, p. 405;) the second by Mr. Adams, at the London Hospital, for a very extensive OF THE PRACTICE OF fibro-cystic tumour of the leg and thigh, (THE LANCET, vol. i. 1854, p. 442;) and the third by Mr. Erichsen, at University for a severe injury to the thigh from the passage of College, MEDICINE AND SURGERY two loaded railway trucks over it, (THE LANCET, vol. i. 1855, IN THE p. 363.) In all these the result was fatal, Mr. Guthrie’s on the second day, Mr. Adams’ on the twelfth day, and Mr. HOSPITALS OF LONDON. Erichsen’s the same evening. A successful case of this operation by Mr. Wigstrom, of the 14th Dragoons, at Lahore, appears Nulla est alia pro certo noseendi via, nisi quam plurimas et morborum in THE LANCET, vol. i. 1850, p. 411. In some remarks which et dissecttomim historias, tam aliorum proprias, collectas habere et inter we ventured to offer upon Mr. Guthrie’s case, we took occasion se comparare.—MoRGAGNI. De Sed. et Caus. Morb.lib. 14. Procemium. to glance at the history of the operation from the time of Morand in 1739 down to Mr. Sands Cox in 1845. We at the same time went over the principal facts bearing on this importLONDON HOSPITAL. ant operation, which some of our readers will perhaps take the DISARTICULATION OF THE HIP-JOINT IN A FEMALE, AGED FORTY, trouble of referring to, as on the present occasion we are preFOR MEDULLARY CANCER OF THE THIGH, COMMENCING EIGHT vented from dilating on the subject owing to the length of the MONTHS BEFORE; PUNCTURE BY A TROCAR FIVE DAYS PREcases. VIOUS TO THE OPERATION, GIVING EXIT TO THIRTY OUNCES In Mr. Curling’s case, like that of his colleague Mr. Adams, OF BLOODY FLUID ; RECOVERY. the disease was manifested in the presence of a tumour of the thigh, of considerable size, which proved to be medullary.(Under the care of Mr. CURLING. ) It was punctured two days after admission, and about cancer. WITHIN the past nine months we have had the opportunity thirty ounces of fluid were evacuated, being principally blood, of witnessing on two occasions the operation of amputation at the first twenty ounces possessing a dark colour. Subsequently the hip-joint-the first by Mr. Curling, at the London Hos- to this, the growth of the tumour rapidly increased, so that measures of an urgent character were demanded, and an pital, in March last ; the second by Mr. Hancock, at the anxious consultation with Mr. Luke, Mr. Adams, and other of Charing-cross Hospital, in October. Both have been perfectly his colleagues, resulted in the performance of disarticulation at successful in their results. Our readers are aware that this the hip-joint. It will be observed that the anterior flap was operation is seldom had recourse to in civil practice, as a glance I not made first in the present instance, as the tumour would at our " Mirror" for some years past will show. It is more ’, necessarily have been transfixed, and the operation thus complicated and somewhat hazardous. The posterior frequently the task of the military surgeon to perform this rendered was therefore first made, and then the anterior, whilst the flap operation in the field, and generally under great disadvantages. femoral artery was carefully compressed in the groin, and very Those surgeons who have studied this subject will probably re- little blood was lost. The patient looked rather pale -ancl collect that during the eventful days of June, 1S48, in the delicate for a few days afterwards, but owing to an otherwise French capital, amputation at the hip-joint was performed good constitution, conjoined with extreme quiet and care in a four times; three with quickly fatal results; but the fourth I small ward, the stump rapidly healed by first intention, and not a single untoward symptom showed itself. We had An was successful; the patient-an insurgent at the Hopital St. ’I, several times of seeing Mr. Curling dress the Antoine under the care of M. Nelaton-lived four months; the , opportunity stump, and were struck with the healthy condition of the stump had perfectly healed, but death occurred from pneu- patient, notwithstanding the loss of such an extensive part of monia of the left lung, with ulcerations of the large bowel. ’, her body. Her progress since leaving the hospital has been This patient, from being an insurgent, was subject to visits ’, satisfactory, and no return of the disease has taken place, from the police, which to some extent must have influenced although there was an œdematous swelling of the other foot and leg, which has to some extent subsided. The evidence the result.* With the very large field of civil practice afforded afforded by the naked eye, as well as the microscope, clearly by the London hospitals, the opportunities for witnessing this pointed out the nature of the disease, but as there is no herediimportant procedure are comparatively limited; few surgeons tary tendency, we will hope that its reappearance, should it therefore have the chance of performing it more than once occur, m; y be remote. Mary Ann G--, aged forty, married, residing at Speen, during their active career, although it has been twice done by near Newbury, Berks; admitted March 4th, 1856. She states in also twice cases Mr. Liston, and by Mr. Syme. In the that her father and mother died from old age, being of the which it has been resorted to, it has been justified only under ages of eighty-five and eighty-four; she has been married many the most urgent circumstances; very few indeed would hazard years, and has had five children. Her occnpation is that of a it unless as a last resort; and when it is considered how exten- schoolmistress, and she has always had good health during the sive is the mutilation, it is gratifying to know that in its re- last twenty-four years; before that, she was rather delicate. .sults there is not so great an amount of fatality as was believed She has only one sister, who is of sound constitution. About but a short time back. The following extract from Erichsen’s twenty-six years ago, the patient suffered from a contusion over " Science and Art of Surgery" will, we think, satisfactorily show the knee, and was cupped. She has had no illness since then this :until last August, when she first noticed a small lump upon the which she thought to depend upon rheumatism, * See British American Journal of Medical and Physical Science, vol. iv., for right thigh, 123 cases of Gun-shot Wounds, reported by Dr. Gibb, occurring in Paris in and various applications were made to it, but without any effect. The swelling continued steadily to enlarge, without June,1848.
A Mirror
li
6