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As Horsley’s workload increased at the National Hospital, it became necessary to make new surgical appointments to support him. Charles Ballance (1856–1936) came on staff in 1891 but was somewhat overshadowed by Horsley – whom he had assisted in the famous operation on Captain Gilbey (discussed in Chapter 5) – and resigned in 1908. He became a celebrated aural and general surgeon in his own right. Donald Armour (1869–1933) and the technically brilliant Percy (“Pretty Percy”) Sargent (1873–1933) both assisted Horsley in the early years of the twentieth century, became assistant surgeons at the hospital in 1906, and full surgeons three years later, after Ballance had resigned. All three made their mark in the field of surgical neurology, helping to establish the tradition of neurosurgical excellence at the hospital. But it was Horsley more than anyone who was responsible for advancing the emerging specialty of neurosurgery and who developed a school of followers that included Wilfred Trotter (p. 00), Armour, and Sargent in Britain, Ernest Sachs (p. 00) in the United States, Edward Archibald in Canada, Thierry de Martel in France, and Vilhelm Magnus in Norway.
During and after the late 1890s, Horsley turned increasingly from diseases of the individual to the ills of society, as discussed in earlier chapters. Prominent among his concerns were attempts to limit the extent and spread of venereal diseases (defined then as syphilis, gonorrhea, and soft chancre or chancroid) and to improve the certification system for disease.
Founded in 1871, the Brown Animal Sanatory Institution of the University of London survived legal challenges to its birth and spawned legal proceedings at its closure. It thrived initially despite chronic underfunding, but it was shut down in 1939 at the onset of war, was damaged by bombs during the hostilities, and was subject to a compulsory purchase order by the local authorities once peace was declared. Nevertheless, it was for a time the premier research institution for the medical sciences in Britain, and to work there was in itself both an achievement and a privilege. Its staff was among the most distinguished in the land.
Horsley was not one to win friends with an easy smile, gentle asides, and whispered confidences, and he certainly did not always bother with subtleties or even genteel niceties in expressing his views. Some have wondered what drove an outspoken and confrontational man like Horsley into the “muddy pool of politics.”1 He became involved early in a number of social issues in which he had a personal stake, such as opposing the clamor and charges of the antivivisectionists and speaking in support of the temperance movement, as discussed in other chapters. The challenges, verbal sparring, and camaraderie were to his liking and he gained increasing national prominence by his stands. This led him to become more engaged in the cut and thrust of medical and then national politics, enjoying the support of many of his contemporaries in doing so. It was as if he needed something with which to challenge himself, something to fight about. The experience of having to deal with his son’s epilepsy and his own failure to cure it by surgery may well have caused Horsley to turn further from clinical work and become even more immersed in social and political activities.2
In addition to the leading role he played in various professional organizations that served to protect doctors and the general public, each from the other, Horsley attempted unsuccessfully to reform certain aspects of the Royal College of Surgeons and then assumed an important role in reforming and leading the British Medical Association, ensuring that it became more representative of the profession and more concerned with the welfare of its members. He enjoyed being in the public eye, having his views heard, and influencing the course of events in accord with his liberal principles. He used his position in the association to support legislation to improve the health and welfare of children and then became an ardent advocate of the National Insurance Bill, which caused him to be cast aside by many of his friends. An idealistic man of strong opinions who was always ready to help those less fortunate than himself, his support of social legislation was not for personal gain. Indeed, it cost him dear, for his private practice withered as colleagues stopped referring patients to him, either in anger or in the belief that he was turning from a clinical to a political career.
James B. was a Scottish lad of twenty-two with focal epilepsy when he entered into the medical history books. He had been run over by a cab when seven years old, sustaining a depressed, compound skull fracture to the left of the vertex that led to a loss of brain substance and local infection. He developed seizures at the age of fifteen, and these became increasingly frequent and sometimes occurred in flurries such that he experienced as many as three thousand fits over a two-week period. They most commonly started in the right leg:
The right lower limb was tonically extended, and the seat of clonic spasm. The right upper limb was then slowly extended at right angles, to the body, the wrist and fingers being flexed; the fingers next became extended, and clonic spasms of flexion and extension affected the whole limb, the elbow being gradually flexed. By this time, spasms in the lower limb having ceased, but those in the upper limb continuing vigorously, spasm gradually affected the right angle of the mouth, spreading over the right side of the face, and followed by turning of the head and eyes to the right.
To sum up, the parts affected were so in the order of lower limb, upper limb, face, and neck; the character of the movements was, first, extension, then confusion, finally, flexion, showing clearly that the focus of discharge was situated around the posterior end of the superior frontal sulcus [italics added].1
The epileptic focus was thus localized based on principles derived from experiments in animals, and its site coincided with that of a scar on the scalp and an associated bony defect in the skull.
Horsley’s first brain operation for the treatment of posttraumatic epilepsy in May 1886 was followed rapidly by others: by the end of the year he had operated on the brain in ten cases, and by the end of the decade in forty-four.1 His technical facility in handling the brain had been developed through his experimental studies in animals and by his experience as a pathologist. His skill, self-confidence, anatomical knowledge, and ambidexterity allowed him to operate with enormous speed, thereby lessening the very real risks of anesthesia, and his adherence to the new principles of antisepsis, which many of his surgical contemporaries initially rejected, reduced the complication rate from infection. Working primarily at the National Hospital assured him of a plentiful supply of patients requiring neurosurgical intervention. Localization of the pathological abnormality was by clinical methods alone.
Although many women did not work outside the home in late Victorian and Edwardian Britain, more options than domestic service, factory work, or nursing were becoming available for those seeking a job. Shop assistants and clerical workers were in demand, and new opportunities had arisen in teaching and a few other professions. By 1901, for example, there were more than two hundred female doctors, almost a tenfold increase over the number twenty years earlier. Nevertheless, women continued to face disadvantages and prejudices. They therefore agitated for greater involvement in public affairs, the right to vote in parliamentary elections, and to receive the same pay as men for equal work. Both Eldred and Victor Horsley shared these wishes, although Eldred may well have influenced the extent and intensity of her husband’s views.1 Victor became involved in supporting the suffragists to an extent that involved him in controversy with professional colleagues and the government, and contributed to his failed attempt to be elected to parliament (Chapter 10). It was thought – wrongly as it happened – that he supported the lawless methods adopted by some of the more activist suffragists.
When University College, with its medical department, was built on Gower Street as the original University of London, a small dispensary was opened close by as a teaching facility. It soon became evident, however, that the medical school would need an affiliated hospital to provide clinical training. The college opened a public fund and provided a site on the other side of Gower Street to erect its own hospital, and in 1834 the hospital (originally the North London Hospital but later renamed University College Hospital) was opened. It contained one hundred and thirty beds, but when completed was intended to house another one hundred patients. Over the following years, the hospital was enlarged until it became evident that complete rebuilding was necessary. Between 1897 and 1906 a new hospital was built, largely with funds donated by Sir John Blundell Maple, the owner of a large furniture and furnishings store close to the college.
It was a year of contrasts, culture, and crises. In 1857, James Buchanan presided over a United States in which African Americans were not regarded as citizens and slaves could not sue for their freedom. Queen Victoria sat comfortably on the British throne with Palmerston as her prime minister, while India mutinied. Charlotte Brontë, Charles Baudelaire, Charles Dickens, Gustave Flaubert, William Makepeace Thackeray, and Anthony Trollope were among the many writers with new books published during the year, and new musical offerings by Franz Liszt and Giuseppe Verdi were to be heard in the concert halls. In America an economic crisis led to recession, the collapse of a New York financial institution, and a run on the banks.
Unlike the conventional image of a successful doctor, Horsley was thin, pale, and restless, with piercing blue-gray eyes and a daunting manner.1 He had a small lock of white hair just above his forehead (as did his brother Gerald), heavy eyebrows, and a rather bushy moustache. His clothing was comfortable – he preferred shirts with soft, loose collars – rather than fashionable, and he spurned the frock-coat, then the uniform of the medical establishment. He had a tremendous presence and an infectious laugh, attracting attention as soon as he entered a room, the impact of his personality immediately evident.
In 1911, when the Daily Mail announced that Horsley had won the international Lallelongue Prize for surgery, it added a personal anecdote. At his club, a friend had asked him whether he could say what whisky was. “Certainly,” remarked Sir Victor, “it is the most popular poison in the world.”1 Horsley is remembered for his strong views on alcohol and for his monumental row about its effects with Karl Pearson, a man who was as fond of controversy and as outspoken as Horsley. Pearson, professor of applied mathematics (and later the first Galton professor of eugenics) at University College, had established there a biometrics laboratory and the Francis Galton Laboratory for National Eugenics and was interested in the relative importance of heredity and environmental factors in evolution.
Horsley’s work over the years had involved much experimentation in animals, and this inevitably brought him the opprobrium of a certain segment of the general public. He took on with seeming relish those crusading against such experimentation, becoming the bête noire of the antivivisectionists as he responded to their jibes and insults, always concerned to have the last word.
In the latter half of the nineteenth century, there was growing interest in the operation of the nervous system in health and disease. University professors studied different aspects of neurological form and function. On the clinical side, several new hospitals devoted to the nervous system were established in the British capital (see ), and an insane asylum in the north of England became a leading center for research into mental and neurological disorders. In Paris, the large Salpêtrière Hospital was converted from a hospice for destitute, chronically ill, or supposedly immoral women to a hospital with a primary focus on neurological disease. Patients were examined, symptoms and signs were analyzed, distinct diseases were identified, and treatable disorders were managed appropriately. Patients were also photographed, and some were studied by electrical techniques and even by muscle biopsy. Neurology was emerging as a distinct discipline of medicine. Important centers for neurological and psychiatric diseases were established at many other Parisian institutions including the famous Pitié, Bicȇtre, and Sainte Anne hospitals.