160 tanning methods in desert war burns (90% infected), for the proflavine will continue to diffuse from the diep6t- dressing and yield a concentration of about 0.2—0.25% during the 2-4 days period of evacuation. Wakefaeld. R. M. HEGGIE. E. M. ABBOTT. Obituary WILLIAM ARBUTHNOT LANE BT, cs, MS LOND, F R C 8 Sir Wm. Arbuthnot Lane, consulting surgeon to Guy’s . Hospital and the Hospital for Sick Children, Great Ormond Street, died at his London home on Jan. 16 j in his 87th year. C. H. Fagge, presenting Lane’s portrait to Guy’s on behalf of his old house-surgeons, hailed him i as a man of great originality ) as a man or grealJ originality of ideas, of unusual mechanical sense and of remarkable tech- nical dexterity. Indeed he was a great surgeon because of his superb craftsmanship ; he had been as a student an admirer of Arthur Durham, and this was the aspect of surgery that appealed to him. It also appealed to his fellows, for we are told of a private medical dinner, at which nearly all the guests were surgeons, and they all agreed that Lane was the man they would choose to operate on them. " No-one zuiott & Fry who saw him operate," writes H. M. M. W., " can ever forget the superlative magic of his technique, and when the Mayo brothers came from America they described that technique as the finest in Europe. Everything with him seemed so easy, he was never at a loss. I remember saying to him once ’ When a surgeon does a difficult operation one says how wonderfully he did it, but when you operate one says how easy it looks.’ " Lane was born at Fort George, Inverness, in 1856, the son of Brigade-Surgeon Benjamin Lane, LRCSI, and was educated at Stanley House, Bridge of Allan. He quali- fied from Guy’s when he was only 21 and less than ten years later was appointed surgeon to Great Ormond Street and a few years later to the staff of Guy’s. When he first qualified he was demonstrator of anatomy with his life-long friend Hale-White, and together they published observations of their work in the dissecting- room, especially how occupations influenced the skeleton. His first surgical innovation was to excise a piece of rib when treating an empyema, his next was to operate for cleft palate early in life, but he soon became known for his practice of screwing or plating every fracture of a long bone when accurate, apposition of the fragments could not be obtained byother means. He was satisfied only with perfection-his skill and patience in dealing with a comminuted fracture of the femur were amazing-and his Operative Treatment of Fractures (2nd ed. 1914) is a matchless record of 22 years experience of this method. And these results, be it remembered, were achieved without mechanical table or apparatus, only a relay of powerful dressers to overcome muscular spasm. In all his operative work he practised strict asepsis with a rigorous no-touch technique. In the early years of this century he began to put forward the view that most of the ills of the flesh were due to faulty emptying of the colon and consequent absorption of toxins. For this chronic stasis he found an explanation in the mechanics of the large bowel where it crosses the brim of the pelvis on the left side. Here in early life the bowel was apt to develop a kink, accentuated by the erect attitude and by the overloading of the colon above with unsuitable food and over-frequent meals. But this was only the last of a series of kinks in the alimentary canal for the relief of which he devised measures set out with missionary fervour in his Operative Treatment of Chronic Constipation (1909). The retort that the kink was in his own mind was always met with perfect good humour and the witness of lives saved or brightened ; later he founded the New Health Society to support his hygienic gospel. During the last war he was inevitably attracted to the new science of plastic surgery. He served as a colonel in the AMS and founded at Sidcup a special hospital for the treatment of facial injuries. Lane was interested in his craft rather than his profession. He was for instance a teacher but not an examiner, and he attended societies only to address them. He inspired his students with enthusiasm and devotion, but he gave them dogmatic statements rather than reasoned expositions. He gave his patients meti- culous care and exacted-with courtesy-punctuality and attention to detail from his assistants. His loyalty was unswerving and he remained true to his friends- and to his own ideas. Speaking at his memorial service in Guy’s chapel on Jan. 21, Mr. E. G. Slesinger said: " Lane would follow the line he had laid down for himself, utterly uninfluenced by opposition or criticism. Indeed, he thrived on opposition, and I have often heard him say what a blessing it was to have enemies, because their opposition was so.stimulating. He himself was a hard hitting and vigorous opponent on any matter of profes- sional controversy, but personally he was the most kind-hearted and gentle of men, loyal to a degree to those who had gained his affection." Lane married in 1884 Miss Charlotte Briscoe and they had three daughters and a son who succeeds to the baronetcy awarded to his father in 1913. On her decease he married in 1935 Miss Jane Mutch. JAMES LANGFORD .BROWNRIGG MACFARLANE M R C S ; SURGEON LIEUTENANT R N V R James MacFarlane, who was killed in action during December while serving in HMS Achates, went to school at Dean -Close, Cheltenham, and began his medical career as a student at St. Mary’s Hospital, Paddington, where he qualified during .1941. He started his clinical work as ENT house-surgeon at Park Prewett Hospital, where he proved as efficient in his duties as he had been popular among his fellow students. His colleagues there remember his successful efforts to make the Christmas of 1941 as cheerful as possible for everyone-he was a keen musician and played the cello-and one of them writes : " When Macfarlane went to join the Navy in tollowing February he left a gap among the residents which was never completely filled, and we were always glad to see him again whenever he visited us while on leave. He came down to Park Prewett only a few weeks before he met his death, and appeared as cheerful and as keen on his new life as ever." Shortly after joining the Navy he became engaged to Miss Mollie Sargeant of Skegness. He was 28 years of age.. DAVID WALTON FELL - M B LOND ; LIEUTENANT R A M C Lieutenant David Fell, who has died in North Africa- at the age of 27, was the third son of Dr. A. Nolan Fell of Colchester. He was educated at Haileybury and, joining ms eicier prother an oTi. Mary’s Hospital, qualified in 1938, taking his London MB the same year. After holding a house e appointment at St. Mary’s he en- tered the EMS and spent over two years as surgical registrar at St. Bernard’s Hospital, Southall. He joined the RAMC in February of last year. He married Miss Peggy White of Chiswick and leaves her with a young son. G. H. C. 0. writes : "]David was as delightful was reliable and efficient at his work. His zest and enthusiasm stimulated all with whom he came in contact and his joie de vivre, combined with the personal interest he felt for those under his care, reflected itself in the
Transcript
160
tanning methods in desert war burns (90% infected), forthe proflavine will continue to diffuse from the diep6t-dressing and yield a concentration of about 0.2—0.25%during the 2-4 days period of evacuation.
Wakefaeld.
R. M. HEGGIE.E. M. ABBOTT.
ObituaryWILLIAM ARBUTHNOT LANE
BT, cs, MS LOND, F R C 8
Sir Wm. Arbuthnot Lane, consulting surgeon to Guy’s .
Hospital and the Hospital for Sick Children, GreatOrmond Street, died at his London home on Jan. 16 jin his 87th year. C. H. Fagge, presenting Lane’s portraitto Guy’s on behalf of his old house-surgeons, hailed him i
as a man of great originality )as a man or grealJ originalityof ideas, of unusual mechanicalsense and of remarkable tech-nical dexterity. Indeed hewas a great surgeon becauseof his superb craftsmanship ;he had been as a student anadmirer of Arthur Durham,and this was the aspect ofsurgery that appealed to him.It also appealed to his fellows,for we are told of a privatemedical dinner, at which nearlyall the guests were surgeons,and they all agreed that Lanewas the man they would chooseto operate on them. " No-one
zuiott & Fry who saw him operate," writesH. M. M. W., " can ever forget the superlative magic ofhis technique, and when the Mayo brothers came fromAmerica they described that technique as the finest inEurope. Everything with him seemed so easy, he wasnever at a loss. I remember saying to him once ’ Whena surgeon does a difficult operation one says howwonderfully he did it, but when you operate one sayshow easy it looks.’
"
. Lane was born at Fort George, Inverness, in 1856, the
son of Brigade-Surgeon Benjamin Lane, LRCSI, and waseducated at Stanley House, Bridge of Allan. He quali-fied from Guy’s when he was only 21 and less than tenyears later was appointed surgeon to Great OrmondStreet and a few years later to the staff of Guy’s. Whenhe first qualified he was demonstrator of anatomy withhis life-long friend Hale-White, and together theypublished observations of their work in the dissecting-room, especially how occupations influenced theskeleton. His first surgical innovation was to excise apiece of rib when treating an empyema, his next was tooperate for cleft palate early in life, but he soon becameknown for his practice of screwing or plating everyfracture of a long bone when accurate, apposition of thefragments could not be obtained byother means. Hewas satisfied only with perfection-his skill and patiencein dealing with a comminuted fracture of the femur wereamazing-and his Operative Treatment of Fractures (2nded. 1914) is a matchless record of 22 years experience ofthis method. And these results, be it remembered, wereachieved without mechanical table or apparatus, only arelay of powerful dressers to overcome muscular spasm.In all his operative work he practised strict asepsis with arigorous no-touch technique. In the early years of thiscentury he began to put forward the view that most of theills of the flesh were due to faulty emptying of the colonand consequent absorption of toxins. For this chronicstasis he found an explanation in the mechanics of thelarge bowel where it crosses the brim of the pelvis on theleft side. Here in early life the bowel was apt to developa kink, accentuated by the erect attitude and by theoverloading of the colon above with unsuitable food andover-frequent meals. But this was only the last of aseries of kinks in the alimentary canal for the relief ofwhich he devised measures set out with missionaryfervour in his Operative Treatment of Chronic Constipation(1909). The retort that the kink was in his own mindwas always met with perfect good humour and thewitness of lives saved or brightened ; later he founded
the New Health Society to support his hygienic gospel.During the last war he was inevitably attracted to thenew science of plastic surgery. He served as a colonel inthe AMS and founded at Sidcup a special hospital for thetreatment of facial injuries.Lane was interested in his craft rather than his
profession. He was for instance a teacher but not anexaminer, and he attended societies only to addressthem. He inspired his students with enthusiasm anddevotion, but he gave them dogmatic statements ratherthan reasoned expositions. He gave his patients meti-culous care and exacted-with courtesy-punctualityand attention to detail from his assistants. His loyaltywas unswerving and he remained true to his friends-and to his own ideas. Speaking at his memorial servicein Guy’s chapel on Jan. 21, Mr. E. G. Slesinger said:" Lane would follow the line he had laid down for himself,utterly uninfluenced by opposition or criticism. Indeed,he thrived on opposition, and I have often heard himsay what a blessing it was to have enemies, because theiropposition was so.stimulating. He himself was a hardhitting and vigorous opponent on any matter of profes-sional controversy, but personally he was the mostkind-hearted and gentle of men, loyal to a degree tothose who had gained his affection."Lane married in 1884 Miss Charlotte Briscoe and they
had three daughters and a son who succeeds to thebaronetcy awarded to his father in 1913. On her deceasehe married in 1935 Miss Jane Mutch.
JAMES LANGFORD .BROWNRIGG MACFARLANEM R C S ; SURGEON LIEUTENANT R N V R
James MacFarlane, who was killed in action duringDecember while serving in HMS Achates, went to schoolat Dean -Close, Cheltenham, and began his medicalcareer as a student at St. Mary’s Hospital, Paddington,where he qualified during .1941.He started his clinical work asENT house-surgeon at ParkPrewett Hospital, where heproved as efficient in his duties ashe had been popular among hisfellow students. His colleaguesthere remember his successfulefforts to make the Christmasof 1941 as cheerful as possible foreveryone-he was a keen musicianand played the cello-and one ofthem writes : " When Macfarlanewent to join the Navy in tollowingFebruary he left a gap among the residents which wasnever completely filled, and we were always glad to seehim again whenever he visited us while on leave. Hecame down to Park Prewett only a few weeks before hemet his death, and appeared as cheerful and as keen onhis new life as ever." Shortly after joining the Navy hebecame engaged to Miss Mollie Sargeant of Skegness.He was 28 years of age..
DAVID WALTON FELL -
M B LOND ; LIEUTENANT R A M C
Lieutenant David Fell, who has died in North Africa-at the age of 27, was the third son of Dr. A. Nolan Fellof Colchester. He was educated at Haileybury and,
joining ms eicier prother an oTi.
Mary’s Hospital, qualified in 1938,taking his London MB the sameyear. After holding a house eappointment at St. Mary’s he en-tered the EMS and spent over twoyears as surgical registrar at St.Bernard’s Hospital, Southall. Hejoined the RAMC in February oflast year. He married Miss PeggyWhite of Chiswick and leavesher with a young son. G. H. C. 0.writes : "]David was as delightful
was reliable and efficient at his work. His zest andenthusiasm stimulated all with whom he came in contactand his joie de vivre, combined with the personal interesthe felt for those under his care, reflected itself in the
161
confidenee he inspired. Surgery was always his mainlove, but he had many other interests. He had a wideknowledge of the arts, more especially music and litera-ture ; he represented his hospital at rugger and swim-ming, and he was never happier than when spending ayachting holiday on the East Coast."
CLINICAL INSTINCT IN DIAGNOSIS
S. WATSON SMITH, M D EDIN, F R C PCONSULTING PHYSICIAN, ROYAL VICTORIA AND WEST HANTS
HOSPITAL, BOURNEMOUTH
"What act proves all its thought had been?"IN those engaged in the practice of clinical medicinethere is an attribute possessed and applied subconsciouslyby the few rather than by the many which has beentermed clinical instinct-a quality characterised by aretentive, responsive memory with an unusual mobilityof intellect, being the fruit of unapparent painstaking.The words " tact," " instinct," " intuition " do notdefine the quality ; in fact, the definition does not comeready to hand ; but it is embraced by Xenophon’stranslated description of the almost indefinable kind ofquickness and rightness of perception possessed bySocrates, an amazing quality he termed, " tact," shownby this wisest of men in all circumstances and situations,believed by Socrates himself to be the result of divineinspiration and guidance. Here it is : " a quick exerciseof judgment, informed by knowledge of the subject,trained by experience, and inferring from cause to effectwithout consciousness of the process."
This faculty of clinical instinct is looked upon amongclinicians as a right and valuable possession, beingutilised in diagnosis, though made use of too in the artof prognosis. Those who have acquired skill in its useare usually old to the ways of clinical medicine, who haveprofited by experience and by previous error : it is notfound except in the thinker, being rare as the practiceof thinking itself ; the fortunate possessor is the physicianwho can see with the seeing, understanding eye. How-ever; it is a talent which, unless exercised, can becomestunted and withered. He who would acquire it musthave a something more than experience. WalterBagehot wrote : " to a great experience one thing isessential, an experiencing nature.... Some occasionscome to all men ; but to many they are of little use, andto some they are none." And this is true : one comes
acros,s those who profit more by experience in a few yearsthan others do in a professional life-time.
’
’
Seldom is the faculty to be found in other than the dailybedside worker among doctors. The merely clever may,mistakenly, seem to have it, being apt and ready at theguess diagnosis ; but, failing to see the wood for thetrees, will achieve a due medical humility and skill onlyif profiting by past misinterpretations.The practitioner gifted with this accomplishment is
alive and quick-thinking, has a wide knowledge of. hissubject,. laboriously acquired and sifted, and a goodmemory for individual, similar cases seen : he has thehappy knack of bringing an unprejudiced mind fresh toany new problem, refusing to approach it in any narrowsense or to countenance irrelevancy ; but addressinghimself to the problem in hand with a logical mind,riveted upon the subject, working with speed and con-centration, keeping a proper sense of mental perspective.To quote from William Hazlitt’s Table Talk: " reasonand knowledge, when at their height, return into a kindof instinct."
.
-
It has been said that first impressions are often right ;they are certainly the clearest and most lasting ; inclinical practice, they seem to linger round some one orother symptom or physical sign, not necessarily aprominent or leading one, enabling a provisional diagnosisto be made, more often than not to be confirmed bysubsequent findings. Perhaps the sense most made useof here is that of sight : a knowledge of appearances thataccompany disease is indispensable to it ; in fact,clinical instinct can be acquired and cultivated by theexercise of intellect and memory stimulated by thepictorial art, of which more use ought to be made inmedical literature and practice than it presently is. Themind’s eye is daily of help at the bedside as well as in theonsulting-room, offering suggestion or information in a
flash to be utilised in reasoning by logical induction fromone or other presenting symptom or sign, then bydeduction, so to lay the foundation of a correct diagnosis.It is the rule that, other things being equal, the goodlogician is the better diagnostician.
Although a presenting sign may mean more to oneclinician than to another, there are several which cometo mind as signalising particular diseases, such as : thepetechiae of acute infective endocarditis, and the Osler’snodes that characterise the subacute form of the disease ;the characteristic, periodic temperature of the Pel-Ebstein type of lymphadenoma ; the few rose-pinkpapules which, when present, constitute the distinctiveeruption of typhoid fever; the collapsed eyeball ofdiabetic coma ; the telangiectasia of the face in coarsehepatic cirrhosis ; the rigid, expressionless, greasy faceof parkinsonism-these to mention only a few examplesof picked signs that speak volumes.
But, of course, the possession of clinical instinct isnot enough : method and order in examination that is atthe same time speedy and complete is of the very essenceof success in diagnosis.
Notes and News
TRAFFIC IN BABIESIT seems that babies are being bandied about rather
freely just now, and the National Children AdoptionAssociation has for some time taken a serious view ofpractices which are gaining currency. In the Times ofAug. 10 last year, Lady Caldecote, chairman of theassociation, drew attention to the mushroom adoptionagencies springing up since the outbreak of war, manyof which were promoting indiscriminate and hastyadoptions ; an article appearing in the next day’s issuequoted evidence justifying this uneasiness. A case wasmentioned in which an adoption society appealed forfunds in a letter inviting people to attend the annualmeeting without giving any place or date, or enclosinga financial statement. The president and founders,whose names appeared on the letter head, were all dead;and recipients were asked to send a donation if they couldnot attend the meeting. Cases have also been knownwhere advertisements offering babies for adoption haveappeared, and when replies have come in the advertiserhas set about finding the babies. It is perhaps significantthat women with young children, whether their own oradopted, escape the call-up. Many babies offered foradoption are illegitimate, and the mother after the firstimpulsive action may wish to have her child back. Shemay fancy that because she has filled in a form for anadoption society she has no right to it ; whereas, in fact,no-one has a legal right to take a child from its motheruntil a court order has been made. Lately the NationalCouncil for the Unmarried Mother and her Child has alsoexpressed concern about casual adoptions, and hasprotested against adoptions arranged by private peoplesuch as doctors, midwives, nurses, health visitors andworkers in citizens’ advice bureaus. The council feelthat though these people may be full of goodwill theyhave not had enough experience in choosing appropriatehomes. This seems a less serious menace, however, thanthe possibility of traffic in unwanted children for gain,which the Adoption Association fears. Under the Adop-tion of Children (Regulation) Act 1939, which shouldhave been put into force in 1940, it would have beenan offence for any body of people to arrange adoptionsunless it had been registered ; and notices advertisingadoptions would have been prohibited. The act nowin force prohibits money being given or received by theparties to the adoption, but there is nothing to prevent athird party, who has arranged the adoption, from gettingpayment. An obvious safeguard seems to be to put thenew act into force as soon as possible. In the House ofLords last week Lord Davies asked that this should bedone, but the Earl of Munster pleaded the need to econo-mise administrative staff at the present time.
The fact that goods made of raw materials in shortsupply owing to war conditions are advertised in thispaper should not be taken as an indication that they arenecessarily available for export.
