disease; and when, to his own delight and that of his friends, he was allowed back to work, his activities were severely restricted for a long time, and all heavy physical effort had to be avoided.
He knew that he would not live for many years, but in spite of this, perhaps because of it, he returned to his work with an infectious gaiety and unquenchable enthusiasm.
It may be that Lambrinudi’s name is not widely known outside Britain. Here there was no ant-like industry to leave a dusty monument of publica- tions; his life was too short and too chequered by reverses. In any case humdrum work was dis- tasteful to him; he had hardly any use for col- lected data, for statistics, or for the well-worn methods of pathological investigation. Once when he was asked to look at a section he said,
“It’s no use expecting me to see anything there, I’m color blind.” Perhaps he was, yet the truth was that he cared little about the material struc- ture of the body, but everything about its mecha- nism, about form in relation to function.
Lambrinudi spent endless time studying the workings of the foot. Out of this labor came his conception of a stabilizing operation for drop- foot, and the first rational procedure for the cor- rection of clawing of the toes in pes cavus—so well thought out that he predicted and proved that in the milder cases correction of the action of the toes would reduce the deformity of the arch itself—and his description of the condition, which he called metatarsus elevatus. It was the same in his work on adolescent kyphosis and congenital dislocation of the hip. His recent advocacy of the teaching of orthopedic surgery in the first clinical years sprang from a conviction that no knowledge of the body, in health or disease, could be com- plete without some understanding of the machin- ery of the limbs, the spine, and the body as a whole; and he undoubtedly put his finger on a weak point in medical teaching.
In the last year of his life, Lambrinudi made plans to write a book on orthopedic surgery. It is lamentable that now it can never be written, for it might well have brought out his emphasis upon function and vital mechanics from beneath the shapeless mass of pathological data, carpenters’
tricks, and shaky generalizations that we find in most textbooks on orthopedic surgery and that obscure the fact that whatever else it may be, the greater part of the body is, in a literal sense, a machine.
There is, however, no need to fear that Lambrinudi will be forgotten. His many friends
will always remember the refreshing vigor of his conversation, his boyish delight in discovery—
whether the work was his own or another’s—and his outspoken but good-humored contempt for humbug and hypocrisy. Very occasionally the chain of his physical weakness produced signs of chafing; but there was no bitterness in him only regret, that he could not do all that his eager spirit desired. While yet a medical student he had served the country of his birth in the Balkan wars.
Just before the Second World War he played with the idea of going there again, to set up a national orthopedic scheme. As he said, “I’d have a shot at being the Robert Jones of Greece.” Lam- brinudi succeeded Trethowan as orthopedic surgeon at Guy’s; he was president of the Ortho- pedic Section of the Royal Society of Medicine;
and he served two terms as a member of the Executive Committee of the British Orthopaedic Association. He held other offices, too. Yet these are only the professional trappings, and it is the man and his character that stand out in the remembrance of his colleagues who mourn his early death.
Sir William Arbuthnot LANE
1856–1943
Sir William Arbuthnot Lane was a surgeon of sur- passing operative dexterity and by his pioneer work has exerted great influence on bone surgery.
He was born on July 4, 1856, at Fort George, Inverness, being the eldest child of Benjamin Lane, a brigade surgeon who saw service in the Indian Mutiny. The boy’s grandfather was William Lane, MD, of Limavady, County Derry, Ireland. His mother, Caroline Arbuthnot Ewing, was the daughter of an inspector general of hos- pitals, whose ancestors also derived from County Derry.1At the age of 12 years, after much wan- dering abroad with his parents from one military station to another, William was sent to school at Stanley House, Bridge of Allan, a modest estab- lishment but where he received an education for which he was always immensely grateful. His father feared his love of athletics but this did not prevent the boy from winning several school prizes and matriculating at Edinburgh University.
On leaving school Lane decided to follow his forebears in the study of medicine, and his father, being posted to Woolwich, entered him as a student at Guy’s Hospital in October 1872 because it was near London Bridge station, to which traveling from home was easy and inex- pensive. He was only 16 years old and looked even younger; his bearded and frock-coated fellow students began by tolerating his youthful appearance with an air of condescension; but they were soon to learn of his exceptional ability.
Among his teachers were Addison, Gull, Samuel Wilkes and Pavy, men who left a permanent influ- ence on medicine.9
He qualified as a member of the Royal College of Surgeons in 1877 but was advised to take a London degree. This meant retracing his steps, beginning with matriculation; he did so with grat- ifying results, being awarded the gold medal in anatomy at the intermediate examination and the gold medal in medicine at the final examination in 1881. The following year he became a Fellow of the Royal College of Surgeons and in 1883 pro- ceeded to the degree of Master of Surgery. His first intention was to become a physician, for he had no particular taste for surgery, but at the time the prospect of election to the staff was much more promising on the surgical than the medical side; thereupon he decided for surgery. In those days teaching hospitals recruited their staff from the dissecting room; to Lane it was a good omen when he was appointed a demonstrator of anatomy in 1882, having Hale White, elected the previous year, as a colleague and with whom he lived in St. Thomas’ Street. In 1883 he was appointed assistant surgeon to the Hospital for Sick Children, Great Ormond Street, and in 1888,
at the age of 32 years, he was elected assistant surgeon to Guy’s Hospital.
During his 6 years’ demonstrating in the dis- secting room, Lane conducted researches upon the function of the skeleton and its adaptation to stress and strain. He made an intense study of changes in bones, cartilages and joints due to occupational posture, pressure and strain of manual laborers.3He stated: “ To those who are unfamiliar with these changes, the variation from the normal is most striking and interesting, for the skeletons of many of the laborers differ from the usual type in a most remarkable manner. In other words, the form of the skeleton depends upon and varies with the mechanical relation of the individual to his surroundings.” Among others he examined the skeletons of brewers’ draymen, shoemakers, coal heavers and deal porters. He noted that in each of these occupations there was a peculiar bodily disposition during activity, with many tendencies to skeletal change; the habitual assumption of this attitude eventually induced structural change. In the case of the brewers’
drayman who carried a heavy barrel on his right shoulder, the spine had become adapted to meet its burden. The upper thoracic vertebrae were deflected to the left side so there had been greater strain imposed on the intervertebral joints of the left than on those of the right side. This unequal stress was plainly manifest by well marked beak-like upping of some of the vertebrae on their left side. Lane considered these osseous changes to be an adaptive reaction designed to broaden the surfaces of the vertebrae to meet the unusual occupational stress. This was certainly an origi- nal interpretation of the pathological changes occurring in the vertebrae; the fact that only a few vertebrae were affected and those at the site of greatest strain, lent some support for this view—what Lane called “crystallisation of the lines of force.” Most observers would probably say that the changes were those of a localized spondylitis of traumatic origin. That view, however, seems less illuminating than Lane’s interpretation of the change as an adaptation to function.
In 1889 he began writing a series of papers on middle ear disease.4 He described the antrum and its functions, at the same time pointing out how inadequate, in suppurative otitis media, was the drainage provided by the prevailing method of perforating the mastoid process with a small trephine. Lane was the first surgeon in this country to open and explore the mastoid antrum,
employing specially devised gouges and chisels for the purpose.
Soon after his appointment to the Hospital for Sick Children, he introduced the startling innova- tion of rib resection for empyema drainage.2 Ambroise Paré had performed the same operation but it was forgotten. Lane, reporting the proce- dure, wrote:
I found many cases of empyema which had been treated in the usual way by aspiration, followed if nec- essary by intercostal incision and drainage, both of which are not infrequently totally inadequate. To meet this difficulty, after determining the lower limit of the pus-containing cavity, I removed a sufficient length of a rib to permit of free access and perfect drainage. In the aperture so made, a tube of considerable calibre could be fastened so that its internal opening was flush with the pleura. Through such an opening it was readily possible to open and drain a pericardium filled with pus. By such active and efficient means these cases of empyema recovered rapidly and thoroughly.
In 1905 Lane published a book on cleft palate and hare lip, which went to three editions.7 He advocated repair of hare lip soon after birth so that a cleft palate might be closed earlier than was customary, in order to enable the face and jaw to develop normally and the nasopharynx to func- tion properly. He closed the palatal cleft with a flap of mucous membrane and periosteum. This provided a complete partition between nose and mouth, but the new soft palate was often too rigid to play an efficient part in speech. The operation has long since been superseded by the procedures of plastic surgery, whereby there is secured a mobile lip, by the use of skin grafts, and a long freely movable soft palate. Early closure of hare lip is still preferred.
In 1909 Lane excised a carcinoma of the cer- vical esophagus; the gap was repaired by skin flaps from the neck. This operation was some- thing of a landmark in surgery. It was said to have inspired Wilfred Trotter in his planning of similar operations for excision of carcinomata of the pharynx.
In the later period of his hospital career, Lane devoted much attention to the consideration of alimentary toxemia. He maintained that the assumption of the erect attitude favored down- ward displacement of the viscera, to prevent which peritoneal bands were developed. These bands produced kinks of the bowel at various points and so led to chronic intestinal stasis, thereby facilitating infection of the upper alimen-
tary tract. This toxemia was said to be responsi- ble for a large number of ailments such as duodenal ulcer, pancreatitis, cholangitis, goiter, cardiac and renal degeneration; furthermore, patients with intestinal stasis readily developed tuberculosis and rheumatoid arthritis. Holding the view that the toxemia causing these diseases was due to the obstructive action of the colon, he embarked on extensive colectomy for their cure.
Intestinal stasis and Lane’s remedy for it aroused a good deal of controversy. A discussion at the Royal Society of Medicine, extending over six meetings, took place in 1913. Lane was quite def- inite in his affirmations as to the fact of intestinal stasis and its cure by colectomy. The evidence, however, was not sufficiently convincing; there were no follow-up reports submitted to prove the permanent value of so drastic a procedure. The operation never got a foothold; it gradually faded out.
Internal Splinting of Fractures
Lane’s early researches on skeletal function led him on to study restoration of function in skele- tal injury and disease. He declared that a fracture that had healed with its fragments displaced induced an alteration in the mode of pressure transmission to other bones, accompanied by potential articular changes. He was profoundly dissatisfied with the poor level of attainment reached in fracture treatment generally. He attrib- uted much of this unsatisfactory state to the lack of intelligent interest in fractures, particularly in adhering to traditional splints that failed of their purpose. It was in 1883 that Lane began writing on fractures and, after the experience of a decade in their handling, he had reached the conclusion that for the intractable fracture open reduction with rigid fixation was necessary. This decision started an epoch, for the rigid internal splint has had an application in orthopedic surgery beyond the dream of its originator. It is well, therefore, to give the ipisissima verba of its introduction to the Clinical Society of London on April 13, 1894.6
On January 8, 1894, Lane operated upon a man aged 34 years with oblique fractures of tibia and fibula, inserting binding screws.
Lister, in 1877, with antiseptic precautions, wired a fractured patella, obtaining osseous union, a result rarely obtained by external splint- ing. Notwithstanding the success of the operation, he was submitted to some unfavorable criticism
for this “unjustifiable procedure.” Lane persisted with the operative treatment of fractures; in an ununited fracture of the neck of the femur he obtained osseous union by passing two long screws from the greater trochanter, through the neck into the femoral head, thereby anticipating the later nailing operation.5It was some time after 1905 that he introduced his well-known steel plates and screws; with these he extended the range of fracture operations.8But his operating on simple fractures raised a storm of criticism and even abuse. In his hands the operation was per- formed under strict asepsis, but some other sur- geons less meticulous in their technique failed to obtain union of the fracture because of sepsis.
This led to a tendency to blame the operation rather than the manner in which it was performed.
No-touch Technique
Lane soon realized that if the operative treatment of fractures was to be safe, a rigorous aseptic technique was essential. The skin over a wide area was prepared several hours before the operation;
on the table the part was painted with a solution of iodine. The operation area was surrounded by a generous supply of sterile mackintoshes clipped to the skin. All instruments after sterilizing were kept dry. The knife used for incising the skin was discarded and a fresh knife employed in the wound. Towels covering the skin were clipped over the edges of the wound because the exposed raw edge was considered a greater danger than the prepared skin. The theater sister held an instru- ment with forceps when handing it to the opera- tor and she threaded needles with the aid of two pairs of forceps. To facilitate reduction and control of the fracture, Lane devised pairs of pow- erful bone forceps with long handles, which kept the hands well away from the wound. No part of an instrument that entered the wound was allowed to touch the surgeon’s hand. All ligaturing and sewing were done with the aid of needle holder and forceps. This scrupulous no-touch technique was a byproduct of Lane’s fracture work, but it has had a transforming effect on operative ortho- pedic surgery.
Lane retired from the active staff of Guy’s in 1920 but continued to practice from his house at 21 Cavendish Square. He turned his attention to educating the public in healthy living, for he maintained that disease was due to defective diet and bad habits. In 1926 he founded the New
Health Society to teach the public the simple laws of health; to aim at rendering fruit and vegetables more accessible to the housewife and at reason- able cost; to relieve overcrowding by promoting a return of the people to the land. The campaign involved press and platform propaganda, which brought him into conflict with established author- ity, although several members of the profession supported the movement. The society was largely responsible for founding a chair of dietetics at London University.
In 1908 Lane was elected to the council of the Royal College of Surgeons; he served for 8 years.
He was invited to deliver the Murphy oration and when he arrived in America to do so he was given a tumultuous welcome. He was elected a Fellow of the American College of Surgeons. In 1913 Lane was made a baronet; some years later he became a Companion of the Bath and a Chevalier de la Légion d’Honneur. He died on January 16, 1943, in his 87th year.
In appearance he was tall and slim with a dis- tinguished bearing; his face pale, strong and handsome with the head slightly inclined to the right. He spoke with a soft, quiet voice. He was twice married, first in 1884 to Charlotte, daugh- ter of John Briscoe, with whom he celebrated his golden wedding, and in 1935 to Jane, daughter of N. Mutch. He had a son and three daughters, two of whom married members of the staff of Guy’s Hospital and the other achieved distinction as an educationist.
Arbuthnot Lane was a man of great originality of ideas and a superb surgical craftsman. He took a leading part in the advance of surgery soon after the antiseptic system was established. He was one of the first to proceed from the antiseptic method of operating to that of asepsis. And he actually pioneered the perfection of aseptic surgery by introducing the no-touch technique. This last way of operating and his metallic internal splint have had a profound influence upon bone and joint surgery.
He fascinated his assistants by his extraordi- nary dexterity and imbued them with enthusiasm for surgery.
References
1. British Journal of Surgery (1943) In Memoriam. Sir W. Arbuthnot Lane 31:1
2. Lane WA (1883) Cases of Empyema in Children Treated by Removal of a Portion of Rib. Guy’s Hospital Reports 41:45
3. Lane WA (1887) A Remarkable Example of the Manner in which Pressure-Changes in the Skeleton may Reveal the Labour History of the Individual.
Journal of Anatomy and Physiology 21:385 4. Lane WA (1890) Two Cases of Subdural Abscess
Resulting from Disease of the Antrum and Middle Ear. British Medical Journal i:1301
5. Lane WA (1893) On the Advantage of the Steel Screw in the Treatment of Ununited Fractures.
Lancet ii:1500
6. Lane WA (1894) A Method of Treating Simple Oblique Fractures of the Tibia and Fibula more Effi- cient than those in Common Use. Transactions of the Clinical Society of London 27:167
7. Lane WA (1908) The Modern Treatment of Cleft Palate. Lancet i:6
8. Lane Sir WA (1914) The Operative Treatment of Fractures, 2nd end. London, The Medical Publish- ing Co. Ltd
9. Tanner WE (1946) Sir W. Arbuthnot Lane, Bart. His Life and Work. London, Bailliere, Tindall and Cox He died on July 8, 2000 at the age of 84 years.
pathologist Erwin Uehlinger, professor of pathol- ogy at the University of Zurich, were significant.
His intention was to continue his career in phys- iology, but work in field hospitals during Finland’s war against the Soviet Union from 1941 to 1944 made him a surgeon. He had his training in surgery and orthopedics at the Helsinki Uni- versity Hospital and at the Orthopedic Hospital of the Invalid Foundation, but worked as a general surgeon until 1956, although his interest was in the study and treatment of diseases of the muscu- loskeletal system.
Anders Langenskiöld was the medical director and chief surgeon of the Orthopedic Hospital of the Invalid Foundation in Helsinki from 1956 to 1968. During this time, he made many important contributions to orthopedic science. His work on experimental scoliosis, reconstructive surgery in poliomyelitis, coxa plana and coxa vara infantum, bone transplantation, tibia vara, and many other conditions dealing with the age of growth and adolescence is well known all over the world.
In 1968, he became professor of orthopedics and traumatology at the University of Helsinki, and was the head of the Department of Orthope- dics and Traumatology, Helsinki University Central Hospital, from 1969 to 1979, and simul- taneously a consulting surgeon at the Orthopedic Hospital of the Invalid Foundation. This was a very busy time in his life because of teaching activities, research work, invited lectureships all over the world, and many national and inter- national activities associated with orthopedic surgery and traumatology. He became an hon- orary member of the American Academy of Orthopedic Surgeons, of the Scandinavian Ortho- pedic Association, of the Scandinavian Society for Rehabilitation, and an Honorary Fellow of the British Orthopedic Association and of the Royal College of Surgeons of England.
The main subjects of his research have been pediatric orthopedics and normal and pathologic bone growth. Internationally, he is well known for his finding that partial closure of a growth plate can be eliminated by bone bridge resection and implantation of an interposition material, and for his studies on tibia vara.
In 1991, he closed his private practice. Lan- genskiöld has played an important role in the development of orthopedic surgery and trauma- tology in Finland, and today most orthopedic centers in this country are headed by his disciples.
Thus, the knowledge and experience of the Langenskiöld school have spread all over the
Anders LANGENSKIÖLD
1916–2000
Anders Langenskiöld, son of the famous ortho- pedic surgeon Fabian Langenskiöld, was born in Helsinki, Finland, in 1916, and graduated with a degree in medicine from the University of Helsinki in 1943. In 1941, Langenskiöld wrote his doctoral thesis on electrophysiology under the guidance of the Nobel Prize winner Ragnar Granit. Studies of histopathology in Switzerland in 1949 were of importance for his future work.
Many years of cooperation with the famous bone
