Our next speaker will be our very own Dr. Daghi, who will present the abstract on Sir Victor Horsley and his observations on the surgical management of firearm injuries to the head. Dr. Daghi. Thank you. Congratulations, Dr. Da Silva. That was very, very fine. I'd like to talk about Horsley and firearm injuries to the head. No relevant conflict disclosures. So who was Horsley? We know him as one of the great British neurosurgeons. We know him as the father of neurosurgery, as Dr. Klein said. One of the things that people don't understand is his interest in the military. He was born into an artistic family. He was guided to medicine rather than the cavalry because the family didn't have the money to purchase him a commission. He was knighted in 1902, probably for contributions to rabies rather than anything else. He held his first professorship in pathology, experimental work in bacteriology, and physiology followed. He was a brilliant surgeon, a keen sportsman, and a great shot. He served with the Reserve Artists Rifle as a student in medicine and then joined the Territorial Army in 1910, which was also a reserve division, volunteered for France in 1915, and died in Mesopotamia. And this is one of the famous pictures of Horsley. Why does he matter? He was enormously interesting. He was the first generation of neurosurgeons, studied in England, and very unusually spent the year in Berlin doing research. He wrote in English, French, and German, which he learned at school, and then in Italian, quite fluently. He was a contemporary of McEwen, Godley, Lister, Starr, von Bergman, Kocher, and Krause. He was a very early surgical empiricist. He used animal models to improve and to drive his surgical technique. He was highly innovative. We know about some of his operations and instruments. We certainly know his Horsley-Clark instrumentation. But when you read his thinking, you realize that he always was thinking. He also carried out the first laminectomy that we know of and the first successful removal of a spinal tumor. He was affiliated with the National Hospital at Queen's Square and with the Royal Institution of Great Britain, a picture of which is here on the left is at his time. This is the current time. And if you notice the cars that are parked in front, part of the innovation is these are all electric vehicles. It's one of the best places to charge an electric vehicle in London. This is the famous Horsley-Clark apparatus. Clark did most of the work, but his influence was certainly strong. He was a careful note taker. This is a picture of one of his notebooks. You'll notice that he pasted in to the lab notebook something which today we say we would prefer not to see. But he got really interested in the weaponry of the last 19th century, the new interest in the weaponry for war. And why do you think that was? Remember that England in the 19th century, particularly the last quarter of the 19th century, was a warlike nation. The Raj was the center for England. England Britannia rules the waves. And so what happened in terms of the ability to conquer and to wage war was very important. To the left, you see the bullets that were used up until about the time of the Civil War. This was called muzzle loading. Then you had low power ammunition, and that's in the middle. Many of them were rim fire rather than center fire. And then to the right, you see the bullets that begin to come to the fore. And these are all of the right scale, more or less in the 1870. By World War I, there were many long and short gun patterns, including submachine guns and machine guns. But very importantly, when you look at the wars of the 19th century, starting with the Napoleonic and ending with the Russo-Japanese and the Balkans, in each one, there were advances in weapons technology that were very difficult for surgeons to deal with. One of the most best known American surgeons was Joshua Letterman, who was the Surgeon General of the US Army of the Potomac. And his real contribution was not in the treatment of patients, but in the organization of care. He followed the French idea of having ambulances, but also of having distributed places where surgeons would be able to work. And the evolution of weapons design can actually be traced very carefully. Mid-19th century, you had 10, 15 kilo weapons that were able to shoot probably 200 to 300 rounds, but very rarely. Most rifles shot about 100 yards. If they were very good rifles, perhaps 200, muskets were accurate to about 80 to 90 yards and no more. There was a very slow firing discipline, although it's true that some were able to shoot two to three rounds a minute. That was about it. And the average soldier in the American Civil War was issued 60 rounds for an entire battle. The technical changes in weapon design started with repeating weapons by the 1860. Load once, shoot all day. Sealed cartridges were often reloadable and could be used on the battlefield. And most notably, the British 303, we will come back to that. There was better steel, mostly from Germany, carbon steel and then stainless steel with nickel, breech-loading receivers, which were far more effective than any other kind. And then you had rifled barrels, and then you had a longer range. Higher chamber pressures were possible from about 1884 onwards. Lighter and smaller caliber bullets could be made. You can carry more if they're lighter, and they had superior accuracy and superior energy. The 1860 Spencer could fire 20 rounds a minute, about 10 times more than a muzzleloader. And with more bullets carried and fired per encounter, the battles were very different. France led. They were the first to have a useful battle rifle that was a repeater. The Mauser copied and prevailed. England competed very successfully with the 303 Enfield the U.S. manufactured. So the famous 1903 Springfield, which I was trained on as a sniper rifle, actually copied the Mauser, and there was a patent fight on it. The Mauser of 1893, 1885, and 7mm was particularly useful in the Second Boer War. And the Second Boer War influenced, very, very deeply, strategy for the treatment of bullet wounds in the First World War and Horsley. But Horsley's interest was really the Lee-Enfield rifle. It was the standard British rifle introduced in 1904, and still in use today in Afghanistan and in the Indian Army. Four minutes of angle, quite, quite accurate, unchanged with a bayonet mount, which was terribly important for the time. It could also use modern gunpowder, which is chordite and nitrocellulose. It was introduced in 1895. In about 1906, pointed bullets were introduced to compete with the German and the American, and it was defended by Horsley as humane. Horsley's work in gunshot wounds followed the general work that was done by the surgeon and Nobel laureate Theodor Kocher in Switzerland. He believed in antiseptic, but also aseptic surgery to a lesser extent. He was very interested in hemostasis and experimental study and production of models of gunshot wounds. Kocher, between 1874 and 1895, coined the term the explosive effects of missiles, and he was interested in terminal ballistic events, what happens when a bullet actually strikes. He also thought about humane considerations in bullet designs, and this was very important as well for Horsley. And the question that he dealt with later on in his life was whether the British 303 was a humane weapon, or whether it contravened. At that point, it was the Hague Treaty on the Humane Use of Weapons. The first of Horsley's efforts was based on tissue models and clay. They weren't very good models. One of the problems was they didn't have enough water, so they didn't demonstrate hydrostatic force. But in the end, he was able to relate injury to velocity, to the sectional area and mass of the projectile, to a hydrostatic shock effect, and to the problem of bone or intervening material that was driven ahead of the bullet into the cavity, and the fact that those would act as secondary missions. He carried out a series of animal experiments that are really worth reading, because they formed the basis for much of the work that was done, not only through the Second World War, but into the 1980s, when the FBI decided to change the realm that FBI agents would carry. His particular contribution was the idea of hydrodynamic displacement of the brain en masse in 1897. He operated on 67 dogs, sorry, he experimented on 67 dogs, who were monitored not only for respiration, pulse, and BP, but also for intracranial pressure. That's a separate thing to discuss, but by 1897, he realized the importance of quick changes, first and second derivative changes in the ICP. He also pointed out that the depression at the entry was greater than the size of the bullet, that there was an explosive effect at the moment of impact, well before the bullet, by his abilities to measure, penetrated the skull. And he looked at the effect of the brain remote from the site of impact. He talked about tunneling effects that went to the medulla, and therefore herniation. He also described death to respiratory arrest and vaguely mediated bradycardia. When he went to humans and tried to extrapolate from the dogs to humans, he made a couple of very interesting jumps that turned out to be accurate. The first was that the artificial respiration, even then available, could, in his words, revive, sorry, could revive the respiratory center. That secondary effects, including hemorrhage and ICP, required surgical decompression by what he called ordinary surgical methods. This was not extraordinary, this was ordinary. The tumbling and yaw, which people blamed for many things, did not do much harm. But the things that I mentioned earlier, particularly the sectional area and the velocity, made a huge difference in the spin and in the energy that was deposited in the brain. And finally, recovery due to the absorption of hemorrhage and the reestablishment of partially blocked circulation may be expected to go on for several years if not interrupted by epilepsy and secondary mental change. The Boer War was very important in his thinking. This is a plaque. The Boer War, by the way, has two different interpretations, one from the South African side and one from the English side. This is the South African plaque and it reads, For Freiheit, Volk und Vaterland, for freedom, for the people, and for the fatherland. And if you look at the women, they're coming out of concentration camps into which they were put by the British Army. He came with this overarching principle as a function of what the British did successfully in terms of healing wounds in the Boer War. Eschew, avoid, the fatal and detestable practice of leaving head cases alone. He called that completely ignorant. Do not leave a patient to die steadily. Perform the duty of attempting to save him. Because such a neglected patient got well, he wrote after one case, the non-comprehending surgeon said, let us leave head cases alone as a rule. It is to the credit of the British Army Medical Service that they showed in the observations and work during the Boer War the falsity of this error. So the statement that head injuries should be operated on can be ascribed to Horsley and his aggressive interest in actually pursuing the treatment. Churchill, by the way, he was captured by the Boers and he actually complimented them on the way in which he was treated. His clinical recommendations were based on the premise that patients could survive and ought to be treated aggressively. What did this mean? One, a septic technique. Two, the problem of disinfection, which could take three hours, sorry, 36 hours prior to surgery and the need to operate quickly. He instinctively realized that and spoke about operating as quickly as possible. He was bothered by, his ideas were bolstered by a case operated on by Major Sharon in which a hematoma evacuated at a field dressing station survived and suggested that you don't have to wait to bring patients back. You could actually operate on them where they fell. And he advocated immediate operation, decompression prior to Cushing, evacuation of the hematoma, and again, prior to Cushing, to whom this is very often described, very thorough debridement. In fact, he used a telephone line to get a hum, a signal from a metallic fragment to be able to find the bullet. He was also very sensitive to the use of technology. Well, Horsley was right about ballistics. Wound severity and injury are a function of the impact and of energy transfer. Energy transfer is a function of design. Perforating wounds with high velocity may produce less shock than penetrating wounds, and clay is not a good simulacrum. He was also mostly right about the clinical approach. And he was cited as a standard of care as early as 1915. So what changed in surgery in the late 19th century? Really a number of things. Anesthesia, antiseptics, increasing comfort with complicated surgery, localization of the brain clinically and by technology, and lighting. He was very interested in the humane nature of bullet wounds. And he argued very strongly that both the British revolver and the .303 were humane. And I was very interested to see that the argument of inhumane wounds had been raised by the Palestinians last week at the Gaza fence, and they're following exactly the arguments that were made against the .303 round after the Boer War. Horsley's accomplishments with Kocher were experimental work on animals looking at penetrating head injury, with all the things that we have talked about. Most importantly, and the bottom line, survival should be expected. What Horsley did not do was write a series of cases, develop a training system, adopt asepsis systematically rather than antisepsis, have the advantage of working in the United States, which was wealthy after World War I, as opposed to Britain and the rest of Europe that were terribly impoverished and robbed of humanity. And he did not leave the 19th century behind him. He was always a 19th century surgeon. This is his grave. He died in Mesopotamia. His grave was cleaned up by British forces in Iraq about 15 years ago. And he died of heat stroke. He may have also had an infectious disease which was never diagnosed. But we should remember two things. One, it never hurts to think about being aggressive. And number two, it never hurts to report what you're doing and to try to see in animals what the basis is of the physiology and pathophysiology that you believe affects the patient. So I give you Horsley. He was a very important man, and he's not given sufficient credit.

Sir Victor Horsley

neurosurgery

surgical techniques

gunshot wounds

head injuries