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ADOLF LORENZ ON HIMSELF
1482
ANNOTATIONS CLINICAL RESEARCH AT CAMBRIDGE
ADOLF LORENZ ON HIMSELF
towards the
AN important step A PIONEER in orthopaedics born in poverty, Adolf development of research at and clinical teaching Cambridge has been Lorenzwas always regarded by his mother as taken by the general board of the University. The destined to become " ein grosser Herr " through board has recommended the establishment, under the the promise of her brother, the future Abbot Gregory, faculty of medicine, of a department of medicine, to have him educated as a choir boy in the great Benedictine monastery of St. Paul, Carinthia. When whose head shall be the regius professor of physic ; the and the appointment of an assistant director, at boy, at the age of four, clad only in fustian breeches and shirt, found in his father’s saddler’s a salary of E700 a year, to organise and conduct clinical research at Addenbrooke’s Hospital and shop a single funeral glove, he rushed to his mother in the university laboratories. In making these saying : "Am I not a real grand gentleman now" recommendations the board refer to the oft-expressed He received the discouraging answer : " But you desire to make better use of the opportunities pro- must have two gloves for that " and spent the rest vided by the hospital for the investigation of disease. of his life, he says, in the search for this qualification. Plans for such development have hitherto been Forty-five years later, during one of his numerous frustrated by lack of funds, but an income of not visits to the States, he quoted this story; he felt less than ;E1200 will shortly become available under he had found the glove, for he had won the esteem the Elmore bequest, and full provision can now be of medical colleagues. In his boyhood, in spite of made for the stipends of three or four qualified bare feet, except in mid winter, and a restricted diet, graduates who will undertake research under the his only ailments were bow-legs and an attack direction of the regius professor. "The Elmore of conjunctivitis ; while the cover shows a man looking bequest," the report continues, "is one reason for less than his eighty years, hale and hearty. The the immediate establishment of a laboratory for choir boy would have become a Benedictine monk research in clinical medicine, but another and very and not a doctor, if it had not happened that the important reason is the appointment of Dr. Ryle Obergymnasium was some distance from his home, as regius professor of physic. His two immediate and he had to find his own lodgings and earn his held their chairs for comparatively keep by tutoring and so tasted the sweets ofliberty predecessors and of feminine society. short periods and, with only a short prospective tenure This work is the record of an egoist, but an interestat the time of his appointment, neither of them could be expected to develop a school of clinical research ing and versatile one. Lorenz writes in simple in Cambridge. Professor Ryle has many years before language with a sense of dramatic values and a sure him, which he hopes to devote to research, and it is instinct for the effective word. His book gives the incumbent on the University to provide him with impression that orthopaedics as a specialty started in Vienna about 1890 and there is not the slightest proper facilities. The new arrangements with Addenbrooke’s Hospital... have enabled Professor Ryle reference to the Italian pioneers or to the Boston to arrange for clinical research to be conducted in workers, while of early visits to Berlin, London, and the wards and in the out-patients’ department of Paris, the author says : "There was nothing to see or learn." He must have missed Liverpool altogether. Addenbrooke’s Hospital, without additional expense He laments the neglect of apparatus by the younger or the on the These university hospital. falling of orthopaedic surgeons, who are beguiled have the of the generation approval honorary arrangements staff of the hospital, who are willing to put at the by the attractions of operative work, a swing of disposal of the staff of the proposed department of the pendulum back to the day when Lister made open medicine all the clinical material that is available." surgery safe. Lorenz recognises the need for scalpel Accommodation for laboratory work will be provided and chisel, but would like them to be the last resort, by the allocation of certain rooms in the pathologicalnot the first. He asks to be remembered as a " condepartment. Besides the professor the staff will consist Iservative " surgeon, though he actually achieved fame as a bloodless one. He explains that his manipuof the assistant director and three or four graduates (the ; lative J were forced upon him in early Listerian methods Elmore students) who will devote their whole time 4days because a chronic to clinical observation and research. Members of eczema, induced by the the visiting staff of the hospital and of its laboratory 4carbolic spray, drove him from operative work, till staff will also join the unit. The establishment ofaseptic technique again put the knife in his hand. r this new department should provide excellent oppor-The disaster ofhis youthful career thus benefited tunities for collaboration between those engaged uponfthousands of patients. The book is largely written for that American public clinical problems and workers in the other scientific "which gave the author marvellous welcomes during of the Addenbrooke’s Hosdepartments University. pital is situated in convenient proximity to the1his extraordinary tours of healing across the States. departments of pathology, biochemistry, physiology,9rhe first of these resulted from the offer of a twormillion dollar fee for the reduction of a congenital and pharmacology. 1aip dislocation in the child of a multi-millionaireIt is estimated that in addition to the income from the s fee which did not include the prolonged after-care, Elmore bequest, n400 a year will be needed for the 1]nvolving a second visit of the professor to the States the assistant director and the maintenance of payment of the laboratory. Towards this sum the faculty aend later of the little girl to Vienna. The other board of medicine have allocated 1450 a year from vTisits to America were equally extraordinary because, the Sheild Fund, leaving :E950 to be provided from t-;hough the author cooperated with general practithe University Education Fund. Although the t:;ioners, physicians, and lay boards of well-known iospitals, he appears to have ignored entirely the report of the general board has yet to be applications for the assistant directorship may be 1 My Life and Work. By Dr. Adolf Lorenz, Hofrat and of Orthopædic Surgery, University of Vienna. P Professor addressed to the regius professor at any time before "
"
approved, h
August
1st.
New York and London: Chas. Scribner’s Sons. 1936. Pp. 362. 12s. 6d.
N 11
THE SI7.E AND SHAPE OF THE HEART
band of skilled orthopaedic experts who have made
information
famous their centres in Boston, New York, Baltimore, to mention only a few. There is a brief reference to his helpful colleague Albee, and a note that an invitation to the New York Ruptured and Crippled Hospital, given by a physician, was afterwards withdrawn on the representations of other colleagues. It is clear from the author’s account of his professional activities that in addition to his technical skill and original ideas it was his personality as a whole which made him so acceptable alike to the poorest parents of cripples and to business magnates in U.S.A., as well as to crowned heads in Europe and to presidents of the United States.
crude
THE SIZE AND SHAPE OF THE HEART
IN his Lumleian lectures, published in the last two issues of THE LANCET, Dr. John Parkinson gave a masterly account of the variations in shape and size of the heart as revealed by radiography. He described the different forms of silhouette of the normal heart associated with different types of body-build, the abnormal appearances produced by such common deformities as scoliosis, and the deviations from the normal attributable to pathological enlargement of the different chambers of the heart. Incidentally he made it abundantly clear that the information given by the senses of touch and hearing, skilfully combined, on which our fathers in medicine chiefly relied, had been proved to be depressingly unreliable. Seeing is believing, and while the exact significance of shadows thrown by gastric ulcers or duodenal deformity may still be in doubt, the cardiac silhouettes visible under the X rays carry conviction interpreted by the experienced cardiologist with a comparatively small margin of error. Not that radiology can tell the whole truth. A radiogram with the patient facing the screen gives us a nearly perfect picture of what we used to try to map out roughly by percussion. But it is still only a diagram in two dimensions; further information can be obtained by rotating the patient, but even so there is no reliable formula for calculating heart volume, -and what we would really like to know is the threedimensional volume of the heart. As Dr. Parkinson has shown, the greatest contribution which radiology has made to our knowledge of the pathological anatomy of the heart is that the shape of the cardiac silhouette in the different positions enables us to say which chambers of the heart are enlarged. The more conservative members of the profession may be disturbed by Dr. Parkinson’s wholesale condemnation of percussion as a means of estimating the size or shape of the heart, and there is something to be said from this point of view. Admitting that the doctor’s coarse thumb and finger often fail to plumb the exact depth and width of the heart, and that radiology can tell us everything which we can learn from percussion with a much greater degree of accuracy, they will contend that it is not, and in the immediate future is not likely to be, available as a routine method for use by the general practitioner. It is certainly incumbent on the clinical teacher to show his students not merely what can be achieved under ideal conditions, but also what they themselves may hope to achieve under the limitations imposed by family practice, where they still have to rely chiefly on their unaided senses. Can we afford entirely to dispense with palpation and percussion ?’? If not we can at least, and this is common ground, teach students the limitations of these methods, and show them, as Dr. Parkinson has done, that the
1483
they are capable of giving is only a very approximation to the truth. There is another anomaly that has yet to be completely resolved-the fact that both in health and in disease the anatomy of the living heart as revealed by radiography differs considerably from that seen in the post-mortem room. One reason for these differences may well be that the heart of the cadaver is not generally examined in situ. In this respect the investigations of Dr. T. Skene Keith reported on p. 1466 of this issue provide an important connecting link between the clinical and post-mortem findings. Dr. Keith is concerned here chiefly with the four normal types of heart silhouette he has been able to make out from a study of some 50 cases. It is rather disappointing that he makes no reference to any cardiac radiograms that may have been taken during the life of this group of cadavers, but he states that in’a subsequent paper on the diseased heart it will appear that there is a fair degree of agreement between the outline of the heart as seen at autopsy and that obtained in orthodiagrams or teleradiograms. This is likely to be a study valuable to cardiologists, who will join Dr. Keith in gratitude to Dr. Parkinson who put the idea of this investigation into his head and by encouragement kept it there. DOUBTS ABOUT DRUGS ALL plants which have been cultivated by man have been profoundly modified from their wild condition. Of late years this has been carried out deliberately and the difference between a Cox’s orange pippin and the crab apple or between an exhibition rose and a dog rose of the hedgerows would fill us with astonishment if we were not accustomed to it. These thoughts prompted Mr. Harold Deane’s address last Monday afternoon at Bournemouth as chairman of the British Pharmaceutical Conference. Mr. Deane has drugs in his blood, if one may put it that way ; his grandfather was the first president of the conference 70 years ago and practised his calling in those ruder ages when the legislature had not as yet been persuaded that the sale of poisons should be allowed only by those who could read and write. In the case of the apple, as in that of the rose, there are easily applied tests of quality ; thus the orange pippin tastes better than the crab, and the standard rose is more beautiful to look at, more pleasing to the nose, and more enduring than the dog rose. There are no such simple tests for the properties of cultivated drugs ; their medicinal value cannot be judged by their flavour, their appearance, or their colour. Mr. Deane took as an example the cultivated English henbane : " It has," he said, " an altogether different appearance from, and a stronger aroma than, the imported herb. The ordinary pharmaceutist will say it is a much superior drug, and a tincture made direct from the English drug hardly seems the same preparation as the one made by diluting a liquid extract of the foreign drug. Is there any difference in the medicinal activity’? No one really knows." Coming from an eminent pharmacist these observations are a little disquieting. The compilers of the British Pharmacopoeia have assumed that the alkaloids are the only thing that matter and have also assumed that these alkaloids are the same after an extract has been evaporated down as they were before ; while admitting that these assumptions are " quite likely true," the chairman of the conference says " there is no proof of them." Here, it will be seen, is a twofold doubt : are the medicinal virtues of plants due solely to the
ANNOTATIONS CLINICAL RESEARCH AT CAMBRIDGE
ADOLF LORENZ ON HIMSELF
towards the
AN important step A PIONEER in orthopaedics born in poverty, Adolf development of research at and clinical teaching Cambridge has been Lorenzwas always regarded by his mother as taken by the general board of the University. The destined to become " ein grosser Herr " through board has recommended the establishment, under the the promise of her brother, the future Abbot Gregory, faculty of medicine, of a department of medicine, to have him educated as a choir boy in the great Benedictine monastery of St. Paul, Carinthia. When whose head shall be the regius professor of physic ; the and the appointment of an assistant director, at boy, at the age of four, clad only in fustian breeches and shirt, found in his father’s saddler’s a salary of E700 a year, to organise and conduct clinical research at Addenbrooke’s Hospital and shop a single funeral glove, he rushed to his mother in the university laboratories. In making these saying : "Am I not a real grand gentleman now" recommendations the board refer to the oft-expressed He received the discouraging answer : " But you desire to make better use of the opportunities pro- must have two gloves for that " and spent the rest vided by the hospital for the investigation of disease. of his life, he says, in the search for this qualification. Plans for such development have hitherto been Forty-five years later, during one of his numerous frustrated by lack of funds, but an income of not visits to the States, he quoted this story; he felt less than ;E1200 will shortly become available under he had found the glove, for he had won the esteem the Elmore bequest, and full provision can now be of medical colleagues. In his boyhood, in spite of made for the stipends of three or four qualified bare feet, except in mid winter, and a restricted diet, graduates who will undertake research under the his only ailments were bow-legs and an attack direction of the regius professor. "The Elmore of conjunctivitis ; while the cover shows a man looking bequest," the report continues, "is one reason for less than his eighty years, hale and hearty. The the immediate establishment of a laboratory for choir boy would have become a Benedictine monk research in clinical medicine, but another and very and not a doctor, if it had not happened that the important reason is the appointment of Dr. Ryle Obergymnasium was some distance from his home, as regius professor of physic. His two immediate and he had to find his own lodgings and earn his held their chairs for comparatively keep by tutoring and so tasted the sweets ofliberty predecessors and of feminine society. short periods and, with only a short prospective tenure This work is the record of an egoist, but an interestat the time of his appointment, neither of them could be expected to develop a school of clinical research ing and versatile one. Lorenz writes in simple in Cambridge. Professor Ryle has many years before language with a sense of dramatic values and a sure him, which he hopes to devote to research, and it is instinct for the effective word. His book gives the incumbent on the University to provide him with impression that orthopaedics as a specialty started in Vienna about 1890 and there is not the slightest proper facilities. The new arrangements with Addenbrooke’s Hospital... have enabled Professor Ryle reference to the Italian pioneers or to the Boston to arrange for clinical research to be conducted in workers, while of early visits to Berlin, London, and the wards and in the out-patients’ department of Paris, the author says : "There was nothing to see or learn." He must have missed Liverpool altogether. Addenbrooke’s Hospital, without additional expense He laments the neglect of apparatus by the younger or the on the These university hospital. falling of orthopaedic surgeons, who are beguiled have the of the generation approval honorary arrangements staff of the hospital, who are willing to put at the by the attractions of operative work, a swing of disposal of the staff of the proposed department of the pendulum back to the day when Lister made open medicine all the clinical material that is available." surgery safe. Lorenz recognises the need for scalpel Accommodation for laboratory work will be provided and chisel, but would like them to be the last resort, by the allocation of certain rooms in the pathologicalnot the first. He asks to be remembered as a " condepartment. Besides the professor the staff will consist Iservative " surgeon, though he actually achieved fame as a bloodless one. He explains that his manipuof the assistant director and three or four graduates (the ; lative J were forced upon him in early Listerian methods Elmore students) who will devote their whole time 4days because a chronic to clinical observation and research. Members of eczema, induced by the the visiting staff of the hospital and of its laboratory 4carbolic spray, drove him from operative work, till staff will also join the unit. The establishment ofaseptic technique again put the knife in his hand. r this new department should provide excellent oppor-The disaster ofhis youthful career thus benefited tunities for collaboration between those engaged uponfthousands of patients. The book is largely written for that American public clinical problems and workers in the other scientific "which gave the author marvellous welcomes during of the Addenbrooke’s Hosdepartments University. pital is situated in convenient proximity to the1his extraordinary tours of healing across the States. departments of pathology, biochemistry, physiology,9rhe first of these resulted from the offer of a twormillion dollar fee for the reduction of a congenital and pharmacology. 1aip dislocation in the child of a multi-millionaireIt is estimated that in addition to the income from the s fee which did not include the prolonged after-care, Elmore bequest, n400 a year will be needed for the 1]nvolving a second visit of the professor to the States the assistant director and the maintenance of payment of the laboratory. Towards this sum the faculty aend later of the little girl to Vienna. The other board of medicine have allocated 1450 a year from vTisits to America were equally extraordinary because, the Sheild Fund, leaving :E950 to be provided from t-;hough the author cooperated with general practithe University Education Fund. Although the t:;ioners, physicians, and lay boards of well-known iospitals, he appears to have ignored entirely the report of the general board has yet to be applications for the assistant directorship may be 1 My Life and Work. By Dr. Adolf Lorenz, Hofrat and of Orthopædic Surgery, University of Vienna. P Professor addressed to the regius professor at any time before "
"
approved, h
August
1st.
New York and London: Chas. Scribner’s Sons. 1936. Pp. 362. 12s. 6d.
N 11
THE SI7.E AND SHAPE OF THE HEART
band of skilled orthopaedic experts who have made
information
famous their centres in Boston, New York, Baltimore, to mention only a few. There is a brief reference to his helpful colleague Albee, and a note that an invitation to the New York Ruptured and Crippled Hospital, given by a physician, was afterwards withdrawn on the representations of other colleagues. It is clear from the author’s account of his professional activities that in addition to his technical skill and original ideas it was his personality as a whole which made him so acceptable alike to the poorest parents of cripples and to business magnates in U.S.A., as well as to crowned heads in Europe and to presidents of the United States.
crude
THE SIZE AND SHAPE OF THE HEART
IN his Lumleian lectures, published in the last two issues of THE LANCET, Dr. John Parkinson gave a masterly account of the variations in shape and size of the heart as revealed by radiography. He described the different forms of silhouette of the normal heart associated with different types of body-build, the abnormal appearances produced by such common deformities as scoliosis, and the deviations from the normal attributable to pathological enlargement of the different chambers of the heart. Incidentally he made it abundantly clear that the information given by the senses of touch and hearing, skilfully combined, on which our fathers in medicine chiefly relied, had been proved to be depressingly unreliable. Seeing is believing, and while the exact significance of shadows thrown by gastric ulcers or duodenal deformity may still be in doubt, the cardiac silhouettes visible under the X rays carry conviction interpreted by the experienced cardiologist with a comparatively small margin of error. Not that radiology can tell the whole truth. A radiogram with the patient facing the screen gives us a nearly perfect picture of what we used to try to map out roughly by percussion. But it is still only a diagram in two dimensions; further information can be obtained by rotating the patient, but even so there is no reliable formula for calculating heart volume, -and what we would really like to know is the threedimensional volume of the heart. As Dr. Parkinson has shown, the greatest contribution which radiology has made to our knowledge of the pathological anatomy of the heart is that the shape of the cardiac silhouette in the different positions enables us to say which chambers of the heart are enlarged. The more conservative members of the profession may be disturbed by Dr. Parkinson’s wholesale condemnation of percussion as a means of estimating the size or shape of the heart, and there is something to be said from this point of view. Admitting that the doctor’s coarse thumb and finger often fail to plumb the exact depth and width of the heart, and that radiology can tell us everything which we can learn from percussion with a much greater degree of accuracy, they will contend that it is not, and in the immediate future is not likely to be, available as a routine method for use by the general practitioner. It is certainly incumbent on the clinical teacher to show his students not merely what can be achieved under ideal conditions, but also what they themselves may hope to achieve under the limitations imposed by family practice, where they still have to rely chiefly on their unaided senses. Can we afford entirely to dispense with palpation and percussion ?’? If not we can at least, and this is common ground, teach students the limitations of these methods, and show them, as Dr. Parkinson has done, that the
1483
they are capable of giving is only a very approximation to the truth. There is another anomaly that has yet to be completely resolved-the fact that both in health and in disease the anatomy of the living heart as revealed by radiography differs considerably from that seen in the post-mortem room. One reason for these differences may well be that the heart of the cadaver is not generally examined in situ. In this respect the investigations of Dr. T. Skene Keith reported on p. 1466 of this issue provide an important connecting link between the clinical and post-mortem findings. Dr. Keith is concerned here chiefly with the four normal types of heart silhouette he has been able to make out from a study of some 50 cases. It is rather disappointing that he makes no reference to any cardiac radiograms that may have been taken during the life of this group of cadavers, but he states that in’a subsequent paper on the diseased heart it will appear that there is a fair degree of agreement between the outline of the heart as seen at autopsy and that obtained in orthodiagrams or teleradiograms. This is likely to be a study valuable to cardiologists, who will join Dr. Keith in gratitude to Dr. Parkinson who put the idea of this investigation into his head and by encouragement kept it there. DOUBTS ABOUT DRUGS ALL plants which have been cultivated by man have been profoundly modified from their wild condition. Of late years this has been carried out deliberately and the difference between a Cox’s orange pippin and the crab apple or between an exhibition rose and a dog rose of the hedgerows would fill us with astonishment if we were not accustomed to it. These thoughts prompted Mr. Harold Deane’s address last Monday afternoon at Bournemouth as chairman of the British Pharmaceutical Conference. Mr. Deane has drugs in his blood, if one may put it that way ; his grandfather was the first president of the conference 70 years ago and practised his calling in those ruder ages when the legislature had not as yet been persuaded that the sale of poisons should be allowed only by those who could read and write. In the case of the apple, as in that of the rose, there are easily applied tests of quality ; thus the orange pippin tastes better than the crab, and the standard rose is more beautiful to look at, more pleasing to the nose, and more enduring than the dog rose. There are no such simple tests for the properties of cultivated drugs ; their medicinal value cannot be judged by their flavour, their appearance, or their colour. Mr. Deane took as an example the cultivated English henbane : " It has," he said, " an altogether different appearance from, and a stronger aroma than, the imported herb. The ordinary pharmaceutist will say it is a much superior drug, and a tincture made direct from the English drug hardly seems the same preparation as the one made by diluting a liquid extract of the foreign drug. Is there any difference in the medicinal activity’? No one really knows." Coming from an eminent pharmacist these observations are a little disquieting. The compilers of the British Pharmacopoeia have assumed that the alkaloids are the only thing that matter and have also assumed that these alkaloids are the same after an extract has been evaporated down as they were before ; while admitting that these assumptions are " quite likely true," the chairman of the conference says " there is no proof of them." Here, it will be seen, is a twofold doubt : are the medicinal virtues of plants due solely to the