Sir William Arbuthnot Lane, 1st Baronet

Childhood

William Arbuthnot Lane was born in 1856 in Fort George near Inverness, Scotland, as the eldest of the eight children of Benjamin Lane, a military surgeon enlisted to the British Empire. William attended schools in eight countries on four continents—Ireland, India, Corfu, Malta, Canada, South Africa, and others—while his family followed the army regiment. Amid his mother's bearing seven children in rapid succession after him, William was often left in the care of military personnel. At age 12, he was sent to boarding school at Stanley House School, Bridge of Allan in Scotland.

Education

In 1872, his father arranged for him, age 16, to study medicine at Guy's Hospital. Apparently shy and appearing young even for his age, William initially had some troubles with fellow students, but they rapidly recognized his exceptional abilities. Soon, he was persuaded to switch to surgery, however, a surer career than medicine. Later, he received the degrees bachelor of medicine and master of surgery from the University of London.

Career

In 1877, at age 21, he qualified as a member of the Royal College of Surgeons, and began practice in Chelsea, London, at the Victoria Hospital for Children. In 1883, Lane became a Fellow of Royal College of Surgeons and joined Great Ormond Street Hospital, where he was consultant until 1916. In 1888, at age 32, Lane returned to Guy's Hospital as anatomy demonstrator and assistant surgeon, and remained with Guy's for most of his career.

Lane became especially known for internal fixation of displaced fractures, neonatal repair of cleft palate, and developing colectomy, which, although highly controversial and opposed by most surgical peers, notably advanced abdominal surgery. Lane collaborated with Down Brothers to design a number of surgical instruments, including screw driver, periosteal elevator, tissue forceps, intestinal anastomosis clamp, bone-holding forceps, and osteotome. For his surgery on British royalty, he was awarded baronetcy in 1913.

Lane became an officer in Royal Army Medical Corps, head of army surgery, during World War I (1914–18). For this work as consulting surgeon in Aldershot at the Cambridge Military Hospital and for opening Queen Mary's Hospital in Sidcup—where, overcoming government resistance to fund it, he gave Harold Gillies a ward where Gillies pioneered reconstructive surgery—Lane was made Companion of The Most Honourable Order of the Bath. In 1920, rather soon after returning from wartime service, Lane retired from Guy's Hospital, yet continued private practice out his home office.

Writing

He first published in 1883, seven years after starting his surgery career. He published about 189 articles, including 72 on fractures, 16 on harelip and cleft palate, many others on other subjects, and, after year 1903, 89 articles directly on chronic intestinal stasis—which, like many Victorians, Lane experienced. He wrote several books, including one on cleft palate, one on surgery for chronic intestinal stasis, and one on New Health. Not for print, his autobiography—manuscript dated March 1936, soon before his 80th birthday—was written for family at the urging of his children.

Family

William's first wife, Charlotte Jane Briscoe—daughter of John Briscoe, himself son of Major Briscoe—bore Irene Briscoe in 1890 and Eileen Caroline in 1893, both in St Olave parish. At age 78, Charlotte Jane died in 1935. Sir Lane's daughter Eileen was married to Nathan Mutch, whose sister was Jane Mutch. In 1935, Sir Lane married Jane Mutch (who died in 1966 at age 82).

Image

Lane was tall, rather thin, seemingly aged slowly, his reactions were often difficult to discern, and yet he often exhibited strong opinions. It was often said that Lane was George Bernard Shaw's model for the scurrilous surgeon, Cutler Walpole—obsessed with excising the "nuciform sac", said to be nickname for the colon—in Shaw's play The Doctor's Dilemma. Yet the play was nearly surely about Sir Almroth Wright, whom Lane knew well. After Lane's death, Shaw stated that the play was published long before he had ever heard of Lane, but still regarded Lane's bowel surgeries as "monstrous". And the play well suggests the view of Lane as held by many of Lane's contemporaries.

After 1924, abandoning his private medical practice as well as surgery, Lane's public devotion was social medicine and public education on dietary and lifestyle subversion of constipation and promotion of general wellbeing, his New Health. Of diverse interests, Lane traveled frequently, often visiting America, while gaining friends and colleagues internationally. Among his associates and acquaintances were Alexis Carrel, John Benjamin Murphy, Elie Metchnikoff, Sir James Mackenzie, William Worrall Mayo and sons William James Mayo and Charles Horace Mayo of Mayo Clinic fame.

Quotes of Lane by his Guy's Hospital house surgeon and biographer, William E Tanner:

Death

During a World War II blackout, Sir Lane was struck by a vehicle outside the Athenaeum Club in Pall Mall, London. Thus, he died.

Surgery master

By 1886, Lane had authored a surgery textbook. In 1889 in America at Hopkins, pioneer of abdominal surgery William Halsted had introduced surgical gloves, and then contracted Goodyear Rubber Company to manufacture thin ones preserving hands' tactile sensitivity. In the 1890s, while glove use was still uncommon, Lane introduced long surgical instruments to keep even gloves off tissues. In his open reductions and plating of fractured bones, Lane introduced the "no-touch technique". Thus, Lane pioneered aseptic rather than antiseptic surgery, and thereby made possible new surgeries previously too dangerous.

Lane's surgical skill, widely renowned, exhibited imperturbable calm at difficulties encountered during operations. A contemporary noted "the originality of his procedures and the smoothness, ease, and perfection of technic that proclaimed a real master, a master who dared where others quailed and who succeeded where others would have failed without his skill, his precision, and the confidence with which he planned and executed his operations". Although most of Lane's surgical career was attended by controversy, it could not be denied that—with but the possible exception of Sir Frederick Treves—Lane was London's best surgeon in technique.

Internal fixation

Only anecdotal reports of displaced fractures set by internal fixation predate Joseph Lister's 1865 introduction of antiseptic surgery, whereupon Lister reported silver wire on a displaced petellar fracture. Even before radiography, Lane found that conventional setting by manipulation and splints yielded poor outcomes—bone disunion and joint changes or wear in individuals under much physical activity—and Lane started with wires and screws in 1892. The conservative medical community was vehemently opposed, so revolutionary was Lane's approach that organizations certifying surgeons sometimes automatically dismissed students able to elaborate on such procedures, as nearly 50% of patients whose closed fractures were opened died by ensuing infections. Yet with aseptic surgical techniques previously unheard of, Lane forged ahead.

Other surgeons' poor results of failed fracture union via sepsis were sometimes erroneously associated with Lane. British Medical Association appointed a committee to investigate Lane's practice—and ruled in Lane's favor. Whereas other surgeons would attempt asepsis but lapse, perhaps touching an unsterilized surface, Lane's utterly fastidious protocol was unrelenting. His 1905 book The Operative Treatment of Fractures reported good results. Lane introduced plates, made of steel, in 1907. (Stainless steel, discovered the next decade, was not widely used in medicine or surgery until much later.) Radiography's introduction vindicated Lane's assertion of frequent disunion via nonsurgical intervention. Lane's influence introducing internal fixation rivals and perhaps exceeds that of other, early pioneers like Albin Lambotte and later William O'Neill Sherman.

Backdrop

At 1886, Russian emigrant Elie Metchnikoff—discoverer of phagocytes mediating innate immunity—was welcomed to Paris by Louis Pasteur with an entire floor at the Pasteur Institute. As did Paul Ehrlich—theorist on antibody mediating acquired immunity—and as did Pasteur, Metchnikoff believed nutrition to influence immunity. Sharing Pasteur's vision of science as means to combat humankind's woes, Metchnikoff brought France its first yogurt cultures for probiotic microorganisms to suppress the colon's putrefactive microorganisms allegedly causing toxic seepage, autointoxication. Later the Pasteur Institute's director and 1908 Nobelist, Metchnikoff viewed the colon as a primitive organ that had stored our wild ancestors' waste for long periods, a survival advantage amid abundant predators, but a liability amid civilization's liberating humans to excrete without peril, and predicted the colon's evolutionary shrinkage until, like the appendix, it became vestigial. Metchnikoff's book La Vie Humaine foresaw a courageous surgeon removing the colon. Thus influenced, Lane met Metchnikoff in Lane's home.

The pioneer British psychiatrist Henry Maudsley asserted much "evidence that organic morbid poisons bred in the organism or in the blood itself may act in the most baneful manner upon the supreme nervous centers. The earliest and mildest mental effect by which a perverted state of blood declares itself is not in the production of positive delusion or incoherence of thought, but in a modification of mental tone", then perhaps "a chronic delusion of some kind", though "its more acute action is to produce more or less active delirium and general incoherence of thought". Famed British surgeon William Hunter incriminated oral sepsis in 1900, and lectured to a Canadian medical faculty in Montreal in 1910. Two years later, Chicago physician Frank Billings termed it focal infection. Within the English-speaking world, the lectures of Hunter and of Billings "ignited the fires of focal infection", whose theory converged with the autointoxication principle.

Since 1875, American medical doctor John Harvey Kellogg in Battle Creek, Michigan, at his huge sanitarium—advertised as "University of Health", staffing some 800 to 1 000, yearly receiving several thousand patients, including US Presidents and celebrities—had battled degeneration and disease by fending off bowel sepsis. In the early 20th century, rebuking alleged "health faddists" like Kellogg and Sylvester Graham, American physicians embracing focal infection theory cast themselves in the German tradition of "scientific medicine". German researchers ostensibly repudiated the autointoxication principle, and yet by using different terminology supported it circuitously. Since French pathologist Charles Jacques Bouchard, in Bouchard's 1887 book, became first to use the term autointoxication, French researchers had investigated and openly advocated the principle, already presaged by multiple researchers in Europe and America. Meanwhile, British surgeons still knife-happy, Hunter warned of "intestinal stasis" impairing mental stability, and called for "surgical bacteriology".

Lane

In 1908, Lane reported a syndrome of severe chronic constipation, often with dysfunction of pelvic muscles and obstructed defecation—invariably with psychologic dysfunction, impairing quality of life, but affecting mostly women—and this became called "Lane disease", now otherwise termed slow transit constipation or colonic inertia. That same year, Lane operated. The following year, Lane's book The Operative Treatment of Chronic Constipation was published in London. Lane began with colon bypass, and then, at insufficient improvements, performed total colectomy. Famed for an appendectomy saving England's monarch, Lane warned of "chronic intestinal stasis"—its "flooding of the circulation with filthy material", thus autointoxication—warnings taken seriously by the public.

Such views on the colon, constipation, and autointoxication were standard in the medical profession, yet disagreement raged over explanation and intervention, thus controversy trailing Lane's surgeries. Apparently, Lane had had trouble publishing in British Medical Journal and The Lancet his first articles on chronic intestinal stasis. Some espousing autointoxication found constipation to have a role but one "obscure", the dry fecal matter to diminish putrefaction, whereas stasis of the small bowel, rather, was the especial source of autointoxication. One way or another, most surgeons opposed Lane's operating on constipation.

Royal Society of Medicine called a 1913 meeting, but, despite some 60 synonyms circulating for autointoxication from varying perspectives, suggested neutrality by choosing none and introducing a new term, alimentary toxæmia. Several authors, including Lane, presented papers, whereupon some two dozen responded from April to May. There, "chronic intestinal stasis received its deathblow" when a Fellow's severely antagonistic speech, apparently influencing the course of Lane's career, preempted Lane's opening a surgery school. World War I broke out in 1914, diverting the attention of Lane, newly head of army surgery. Returning from war service, Lane retired from Guy's Hospital in 1920, and continued in private practice. From then onward, Lane wrote almost only on chronic intestinal stasis. Meanwhile, focal infection theory was "coming of age".

In 1916, Henry Cotton in America had embraced focal infection theory with unmatched zeal, became the first to apply it to psychiatry, and rapidly rose to international fame for prescribing removal of dentition, sex glands, and internal organs—most controversially the colon—to treat schizophrenia and manic depression, while claiming up to some 80% cure rate, seemingly worth the 30% death rate. (Soon, independent investigators ventured to Cotton's facility and performed, it seems, psychiatry's first two controlled clinical trials, finding Cotton's clams false.) In 1923, on his European lecture tour, Cotton arrived in Britain, where he learned from Lane an improved surgical technique—as well as a new, far less radical surgical procedure. In autumn 1923, Lane had performed the first 19 "pericolic membranotomies", putatively releasing intestinal adhesions. Wherever apparently possible, Lane replaced colon bypass and colectomy with pericolic membranotomy.

New Health

In the early 1920s, Lane began advocating cancer prevention through diet, thereby drew conflict with British Medical Association, and resigned from it in 1924, renouncing his lucrative private medical and surgical practice, 10 000 pounds a year. In 1925, Lane founded New Health Society, the first organized body for social medicine, which German pathologist and statesman Rudolf Virchow had pioneered in late 19th century to undo disease's sociopolitical causes. The term New Health largely referred to nonsurgical healthcare against constipation. Advertising forbidden of physicians, to avert accusation and disciplining by General Medical Council, Lane had his name deleted from the Medical Register. Lane then promoted his views on healthful diet and lifestyle, including greater intake of whole grains, vegetables, and fruits, return to farm land, ample sunlight exposure and physical exercise, and nutritional yeast for B vitamins—Lane's plan to foster defecation thrice daily, cancer prevention, general health, and longevity. Meanwhile, colectomy for constipation was abandoned amid low success rates but high complication rates.

New Health Society sought to transform the "rapidly degenerating community" into a "nation composed of healthy, vigorous members". Blending utopian vision and progressive gender ideology with social darwinist and eugenic rhetoric—the period's prevailing framework—the Society's view, not hereditarian, however, posed humankind's regeneration as pivoting at health education. Sidestepping issues of poverty and inequality, it took health as a personal responsibility and duty of citizenship, whereby health and happiness were attainable by all who consumed a high-fibre diet, exercised, and got ample sunshine, while using birth control and reforming men's dress. Although embracing modern science, technology, and mass media, New Health Society suggested valorisation of "native" culture, and found the bowels central to health, while constipation anchored many of civilisation's ills. Lane said that his lecture in Oldham, Lancashire, was "packed by three thousand or more people", and "that many people had to be carried out fainting, while outside mounted policemen were kept busy holding back and controlling the crowd who wished to force their way into the hall".

Legacy

Seven years before his 1943 death, Lane's autobiography posed a man "acting upon the repeated request of his children that I should write for them a rough sketch of my life", although "it can be of no interest to others". Rather, two of his former house surgeons at Guy’s Hospital—first W E Tanner and later T B Layton—borrowed it to author biographies. By then, it was generally accepted that Lane's surgeries for constipation had been misguided, and perhaps Lane, too, believed so. By 1982, Lane's introduced colectomy for constipation was declared "clinically futile". And yet for his New Health, including claims that modern society was ruining health, Lane later became viewed as a crank.

Autointoxication

The autointoxication principle became an alleged myth scientifically discredited, while interventions to subvert it were deemed quackery. Lane's rationale and his era's very notion of autointoxication have been depicted as wholly unfounded and irrational or "illogical," due to a pervasive psychological effect of toilet training or a figment of the Victorian era's culture. Yet by the late 1990s, the autointoxication concept and thereby colon cleansing was being renewed in alternative healthcare, allegedly upon a fictitious basis. Combating alleged myths, some gastroenterologists asserted that "no evidence" supports the autointoxication concept that toxins are absorbed from waste in the large intestine.

In basic research, if freed from its simplistic reduction to constipation, the autointoxication principle has now been substantially supported as an independent mechanism whereby gastrointestinal microorganisms contain or produce toxins exhibiting systemic effects—as by transmigration into circulation and driving systemic inflammation—effects that include the psychological. Apparent instances of autointoxication associate not merely with constipation, however, but principally with alternating constipation and diarrhea, as Lane had noted in his 1908 paper that described constipation as but the earlier, underlying etiological factor whereby autointoxication may incite diarrhea, too.

Constipation

There is much disagreement over the meaning of constipation, far overreported by the general public versus conventional medical criteria—under two defecations per week. Despite the general public's remaining prevalence of belief that maintaining good health requires defecation at least daily, many constipated individuals apparently are quite healthy—some even defecating under once a week—whereas others who defecate daily are unhealthy.

Still, constipation remains a "major health problem". Gastroenterologists attribute chronic constipation's associated signs and symptoms to slow colon transit, to irritable bowel syndrome, to pelvic floor dysfunction—apparently a cause of refractory constipation in adolescents, too—or to obstructed defecation, which along with slow colon transit have remained incompletely understood. Individuals have varied complaints and try many remedies for signs and symptoms.

Treating constipation, gastroenterologists' first line of intervention is now dietary—whole foods, principally vegetables, fruits, and grains—or fiber supplements. Meanwhile, roles for lifestyle—exercise, mindset, socioeconomic status—have been recognized, although some gastroenterologists as recently as 2012 have claimed that there is "no evidence" supporting a role for exercise. Some 15% to 30% constipation patients exhibit slow colon transit, which laxatives and medical drugs do not amend. Thus, refractory constipation is sometimes treated surgically reportedly successly, but not always successful, and sometimes even worsening abdominal pain.

Lane disease

The syndrome that Lane reported in 1908, "Lane disease" or "Arbuthnot Lane disease", is now usually termed by gastroenterologists either slow transit constipation or slow colon transit or colonic inertia, exhibited by some 15% to 30% of constipation patients. By 1985, Lane's early article on surgical treatment of chronic constipation had become a classic, while physiologic testing and more accurate patient selection renewed interest in total colectomy with ileorectal anastomosis—that is, removing the entire large intestine and joining the small intestine's outlet to the rectum—to treat colonic inertia, Lane disease. By now, gastroenterology's accepted view is that, although few patients meet the selection criteria, surgery ought to be offered as a treatment option for severe chronic constipation. Selection criteria ought to be extremely stringent, including multiple confirmation of slow colon transit by physiologic testing, and further medical, psychological, and psychosocial evaluations, with patients understanding that colectomy might not improve the condition and might even worsen abdominal pain.

Relevance

Willie Lane was among the last surgeons of an era where one could master three specialties—orthopaedic, abdominal, and ear nose and throat—and some of his designed surgical instruments are still used today. Lane's introduction of the "no-touch technique", which permitted aseptic surgery, is perhaps his greatest contribution to surgery. Even in the 21st century, particular descriptions by Lane "should be required reading by orthopaedic surgeons". Lane's life ought to interest historians of medicine as well as believers in holistic medicine. In his time, some thought Lane a genius, while others disagreed, including Sir Arthur Keith who claimed him not clever but carried by faith. In any event, Lane can be characterised as "a crusader, a perfectionist, and an extraordinarily talented surgeon".