Authors: Richard Hollingham
University College Hospital, London,May 1842
The operating theatre was positioned at the centre of the hospital,
next to the mortuary. It was separated from the public areas by thick
walls and a long corridor. This arrangement had two significant
advantages: it helped shield passers-by from the screams; and its
proximity to the mortuary meant that surgeons could move easily
from operation to post-mortem, often with the same patient.
As it was, most people did their best to avoid the precincts of the
hospital on operating days, and the staff did their utmost to distract
anyone within screaming distance. It was not good for morale,
particularly for those in the surgical wards who would soon go
under the knife.
The steeply raked semicircular wooden galleries of the operating
theatre had been swept that morning. The dust hung in the air,
dancing in the few shafts of sunlight that managed to penetrate the
grime of the high windows. A smoky coal fire burnt in a grate in the
corner. At the centre of the room, where the surgeon would be
performing, the gas lights hung from the ceiling on a chain above
the operating table.
The table was made of deal – a cheap pine timber – and resembled
a crude workbench. High and narrow, with a wedge-shaped
block for the patient's head, it was bolted to the floor with thick iron
brackets. The grain of the wood was marked with deep grooves and
stained brown by the coagulated blood and soiled blankets of previous
patients. Beneath the table was a box of sawdust, fresh that
morning, although some still remained from previous operations,
stuck to the side of the box like hardened brown putty.
One of the assistant surgeons, known in the hospital as a
'dresser', laid a thick woollen blanket on the operating table while
his colleague carried in a case of surgical instruments. Both the men
were nearing the end of their training and had already assisted in
dozens of operations, although neither of them could say they had
got used to it. The dresser carefully took the instruments from the
deep velvet padding of the case. He laid them out in strict order on
a tray placed on a small cabinet near by. He knew if he got the order
wrong he would be in terrible trouble. He checked his notebook to
make doubly sure.
Operating instruments:
The dresser covered the instruments with a cloth. There was also a
bowl of water so that the surgeon could rinse the blood off his hands
between operations.
Everything was ready. The first operation was scheduled to
begin at noon.
In the male surgical ward the patient, rested and well fed, was as
prepared as he would ever be. His bowels had been emptied that
morning by means of an enema syringe, the resulting discharge
being reported as 'copious and of bad quality at first' (the patient,
the case notes recorded, was well rid of it). Two porters arrived to
take the man to the operating theatre.
As they prepared to lift the patient from his bed on to a canvas
stretcher, they could see that he was in a bad way. The poor man's
lower leg had begun to suppurate: a thick fluid trickled from the
open wound – a mixture of blood and pus seeping between the
jagged ends of broken bone that protruded through the skin of his
calf. The porters tried not to get too close. The smell of decay, like
that of rotting meat, was almost more than they could bear.
Without an operation the patient would die, that much was a
certainty. The only cure for such a compound fracture was amputation,
but with the infection creeping up the man's leg so fast that
you could almost see it, the decision had been taken to remove his
leg at the thigh.
The patient had sustained the injury on the Great Northern
Railway when he had slipped between the platform and a moving
train. Fortunately, the company's terminus at King's Cross was only
a few hundred yards from University College Hospital. This meant
he would be operated on by Britain's finest surgeon, Robert Liston.
Liston had recently been appointed as the hospital's most senior
surgeon, and professor of clinical surgery at the university. Author
of the latest surgical textbook, he was the foremost surgeon of the
age. And he knew it.
The room goes quiet as Liston strides through the door. 'Sharp
features, sharp temper' is how his colleagues describe him. Most of
his students (and many of his staff) are scared of Liston, but he is
good at what he does and his operations are always well attended.
True, there are those who have to attend them, such as the surgery
undergraduates, but there are usually also rival surgeons and even
visiting dignitaries in the audience. This is, after all, the very latest
surgical practice, the best the British Empire has to offer.
Liston – six feet two inches tall, domineering and self-assured –
hangs up his frock coat, takes an apron from the peg and rolls up
his sleeves. 'Good afternoon, gentlemen,' he says to the now packed
theatre. 'Today I shall be performing an amputation of the thigh in
the usual manner.'
The two porters take this as their cue to carry in the patient.
They lift him as gently as possible on to the operating table. The
patient winces. This, he thinks, must be how condemned prisoners
feel as they are led to the scaffold. His eyes dart around the room,
his heart pounds, his utter terror mitigated only by the excruciating
pain from his leg whenever he moves – a pain overlaid by a duller,
steady, nauseating ache. He wants to vomit but can only gag
.
Liston had made surgery his life's work and knew it had the
power to save lives, but even he – described by his enemies as arrogant
and aloof – operated only as a last resort. He also made every
effort to instil in his students some sense of the feelings and fears of
the patient. 'These operations must be set about with determination
and completed rapidly, in order that dangerous effusion of blood
may be prevented,' he told them. 'They are not to be undertaken
without great consideration.' In short, it was all about speed.
The porters shut the doors and stand guard, arms folded, defying
anyone to pass them. It has been known for patients to try to make
a run for it, but this one only groans and mumbles indistinctly. It
is probably a prayer. Most patients pray – it's amazing how many
people find religion in the operating theatre. Many also beg or
plead to be taken back to the ward even though they know that
without surgery they will die. Others lie on the table calmly, as if
possessed by some inner strength. Women, Liston finds, are often
the most composed.
A dresser slips the strap of 'Petit's improved tourniquet' around
the patient's upper thigh and pulls it through a small clamp. A
wedge-shaped ridge on the strap is placed against the artery but not
yet tightened, its purpose being to prevent blood loss during the
operation. Without the tourniquet the patient's entire body would
bleed dry in less than five minutes. Applying it properly was a matter
of some skill. Tighten it too early and the upper leg would swell with
blood. Too late and the patient could bleed to death.
Liston has himself witnessed the disastrous effects of a poorly
applied tourniquet and is fond of telling the story in his lectures.
'A scene of indescribable and, under other circumstances, most
laughable confusion ensued,' he says. 'Two assistant surgeons got
on the table and pressed with all their might and main on the
groin to stop the bleeding.' Liston is, in this instance, good
enough not to reveal the surgeon responsible, but the story serves
to remind people of his intolerance of error. The fate of the
patient is not recorded.
With Liston in charge, there will be no such mistake today. One
of the dressers takes a handkerchief from his pocket and ties the
patient's good leg to the table to keep it as far away as possible from
the knife. Two other assistants firmly hold the patient's shoulders
and arms to stop him struggling. They try to keep their hands away
from his mouth. He can squirm but cannot move; scream but not
bite. The patient glances at the instruments, then at the ceiling.
Finally at the audience – witnesses to his fate.
Liston motions for a young student to come forward from the
gallery to support the limb that is going to be removed. The nervous
pupil knows that if his grip slips or the leg bends, causing
the bone to snap rather than be sawn through cleanly, he will suffer
Liston's anger and abuse. He also hopes that Liston himself keeps
a steady hand.
The surgeon clamps his left hand across the patient's thigh.
His right hand reaches for his favourite knife, marked with a series
of notches – one for each operation. The knife glitters in the flickering
gaslight. Liston turns to the galleries; everyone is leaning
over the railings to witness the action. 'Time me gentlemen!'
Those familiar with a Liston operation already have their pocket
watches ready.
In one rapid movement, he slices into the flesh, and a dresser
immediately screws down the tourniquet to stem the rhythmically
spurting fountain of blood. Drawing the blade under the skin
with the grain of the muscles, Liston pulls it towards the hip, down
to the bone, then sweeps it around the leg and back towards the
knee to leave two U-shaped incisions on the top and bottom of
the thigh. There is nothing theatrical about the patient's cry. It is a
chilling, horrible scream of terror. He is weeping now, struggling,
mewling, whimpering.
Liston flings the knife into a tray and grabs the saw. His assistant
puts his hand into the cut, fingers reaching right the way down to
the bone. He pulls back the mass of skin, muscle, nerves and fat
towards the hip to expose as much bone as possible. Liston places
his left hand on the exposed bone and, with his right, begins to saw
through it with rapid but precise strokes.
The student supporting the leg is concentrating so much that
he barely realizes when he's holding its full weight. He looks down
with a shudder, kicks the box of sawdust towards him and drops
in the severed limb. It lands with a thud, sending up a small cloud
of bloody sawdust.
The saw falls to the floor and, with his assistant still holding back
the flesh of the stump, Liston bends close to tease out the main
artery in the thigh – the femoral artery on the underside of the leg.
The stump begins to ooze as Liston's bloodied hands reach for the
needle and thread. He ties off the blood vessel with a reef knot. A
'good, honest, devilish tight and hard knot,' as he will later tell his
students. He notices other, smaller, blood vessels and knots the ends
together, holding the thread in his mouth at one point to make sure
it is really tight.
Liston shouts at a dresser to loosen the tourniquet. A gently
flowing stream of blood meanders between the ridges of the blanket
to drip into a pool on the floor. But the pool is small, not large
enough to be life threatening. The assistant allows the flesh he has
pulled aside to spring back so that the bone is once again covered
and protected by soft tissue. The two U-shaped flaps of skin are
pulled together over the stump. A thin line of coagulating blood
seeps between them.
The operation is over. From first cut to final stitch, the whole
procedure has taken only thirty seconds. Thirty seconds of remarkable
dexterity, flashing blades, rapid movements and brilliant
showmanship. Thirty seconds of such pain that few patients are ever
able to put it adequately into words. The memory of those thirty
seconds will haunt them for the rest of their lives. If they live.
Fortunately, the mortality rate from Robert Liston's operations
was remarkably good. Between 1835 and 1840 he conducted sixty-six
amputations. Ten of his patients died – a death rate of around one in
six. About a mile away at St Bartholomew's Hospital, surgeons were
sending one in four patients to the mortuary, or 'dead house', where
the all too frequent post-mortems took place.
Given that many surgeons were appointed through patronage
or, more usually, nepotism, there was a large degree of surgical
incompetence even in the most renowned hospitals. Surgeon
William Lucas at Guy's Hospital in south London was generally kept
away from the operating theatre for everyone's safety. In one thigh
amputation he cut the U-shaped flaps of skin the wrong way round
leaving a raw stump and a dismembered limb with two excess
flaps of skin. His botched operations (the word 'botched' became
synonymous with failed surgery) were notorious. They were thought
to be the main reason that a young dresser at Guy's, John Keats,
abandoned the surgical profession to become a poet.
In rural areas the local physician was expected to carry out his
own operations. The medical literature of the day is littered with
accounts of attempted surgical procedures and their consequences.
Martin A. Evans, a physician in Galway, recorded a typical example
from his casebook in the
Lancet
medical journal of 1834. His patient
was forty-five-year-old Martin Conolly, whose leg was crushed by
falling timber. Having persuaded the man that amputation offered
the only chance of survival, Evans conducted the surgery, but his
account gives little detail about the procedure itself, except that it
was 'done by circular incision without assistance'. It is unlikely to
have been as quick and efficient as Liston's operation, but was
performed 'in the usual manner'.
As soon as the limb was removed Conolly reported feeling
better and stronger, but in a few moments became faint and gradually
weaker. 'He died,' reported Dr Evans, 'without having lost
four ounces of blood during the entire process.' Evans attributes
this not to any surgical failure resulting in massive internal
bleeding, but to the patient. 'He had been a strong man, but was
fearful of consequences, the only cause to which I can attribute
his sudden dissolution.'