It's a pleasure to introduce the Facilius Award to Kurt Lehner. He'll be talking about American views of Sir Victor Horsley and the Cushing era. And the discussant will be Dr. Jim Goodrich. Congratulations. Thank you. Good afternoon. I'd like to thank today, begin today by thanking the AANS for inviting me to give this talk. It's truly an honor to have received the Facilius Award. So today I'm going to be talking a little bit about some research I conducted with Dr. Michael Scholder regarding how the early British neurosurgeon, Victor Horsley, was viewed in his lifetime in America. So there's little doubt that Horsley was a neurosurgical pioneer. He's today best known perhaps for his development of bone wax. However, he also contributed greatly to the principles of cerebral localization. He was one of the first surgeons to utilize large decompressions for increased intracranial pressure. He helped develop the concept of stereotaxis and the stereotactic frame with his colleague Richard Clark. He was the first surgeon to perform a laminectomy for intradural tumors. Perhaps less known are his contributions to biology. He conducted seminal studies on myxedema in the thyroid gland and was partially responsible for the eradication of rabies in Great Britain. He was also a vocal proponent of animal experimentation in Britain at a time when it was fairly unpopular. So following his death while serving as a military neurosurgeon in World War I, this passage from Fulton's biography of Harvey Cushing has done much to influence American neurosurgery's view of Horsley. In it, Fulton recounts Cushing's experience, stating that he saw that Horsley dashed upstairs, had a patient under ether in five minutes, was operating 15 minutes after he entered the house. He made a great hole in the woman's skull, pushed up the temporal lobe with blood everywhere, gauze packed into the middle fossa, the ganglion cut, wound closed, and was out of the house less than an hour after he entered it. The Horsley biographer and medical historian J.B. Lyons stated in 2001 that it is likely that this passage, violent in style and exaggerated in content from a much publicized biography, has harmed Horsley's reputation irremediably. So we ask, did he actually deserve the reputation he had? What exactly was this man's reputation in America during his lifetime? So we utilized numerous approaches to answer this question, including searches of classical neurosurgical texts and Victor Horsley biographies. Today I'm going to focus on namely his relationship with Americans that he knew during his lifetime and I'm going to focus on three listed here, Sir William Osler, Harvey Cushing, and Ernest Sachs. Osler first met Horsley in 1878 while Horsley was a student at University College London. Afterwards he followed Horsley's surgical and scientific work closely. Horsley actually supported Osler's appointment at Oxford University and Osler's final published writing was a kind review of Paget's biography of Horsley. So Osler had many opportunities to comment on Horsley's surgical and scientific achievements. On Horsley's research on myxedema, he stated it was a most important contribution to the physiology of the thyroid gland and its relation to the remarkable cretinoid condition. And he called epilepsy surgery one of the most interesting aspects of surgery. Osler actually penned a large portion of the British medical journal's obituary of Horsley and in it he wrote that better than any man of his generation, Victor Horsley upheld a great British tradition for he combined the experimental physiologist and the practical surgeon to a degree unequaled since John Hunter. He called Horsley's mind resolute, keen, and fertile. He had the true scientific spirit. And he also took a moment to comment on Horsley's forays into politics in which he called him a born reformer who could not resist. He was fearless, dogmatic, and assertive, always with a fanatical conviction of the justice of his cause. So there's little doubt that Osler considered Horsley one of the great physicians of his generation and that he had a great respect for the man. Cushing first met Horsley while traveling in Europe in 1900 and as far as we can tell only saw Horsley operate the single time I described earlier. From the same day in Fulton's biography, he stated that he found Horsley living in seemingly a great confusion, dictating letters during breakfast to a male secretary, patting dogs between letters, and operating like a wild man. Nonetheless, the two maintained a professional relationship which evolved over time and I'm going to comment a little bit more about that later. Ernest Sachs was for a short time a student of Cushing's at Johns Hopkins University. Sachs traveled to London in 1907 to learn neurological surgery from Horsley and then returned to the U.S. to become the first professor of neurosurgery at Washington University in St. Louis. At first, seeing Horsley operate it, he was a little put off by the technique. It was not at all in line with what he had observed in America that was mainly influenced by Halstead. However, with time he came to see that Horsley's handling of the tissue was exquisite and very delicate and that he had a superb understanding of the neuroanatomy and physiology. Looking back on the relationship between Horsley and Sachs, Sachs commented, of the many privileges that I've had in my life working with various big men, that year and a quarter I spent with them I prize as the most valuable and delightful I ever had. We actually obtained a never-before-published communication between Ernest Sachs and Jeffrey Jefferson regarding a conference held in the honor of the 100-year anniversary of Horsley's death. And in Sachs' comments on Horsley, he talks about his politics, saying he wasn't elected to parliament because he was too progressive. As you know, he and Lady Horsley were strong for women's suffrage. And on Horsley's legacy, he says, as for contributions to science, I am inclined to think that Horsley's were more important than Harvey Cushing's. So it's clear that Sachs, one of the pioneers of neurosurgery in the U.S., held a great respect for the man. And it's also clear that Horsley was well respected by the American medical community. But we also wanted to know how he was perceived by the American public in that time. And it's easy in searching databases of American newspapers from the early 1900s to find positive reviews of Horsley's work. Here are three articles commenting on Horsley's achievements in surgery. Here are three articles commenting on Horsley's achievements in science. Here are two articles commenting on Horsley's anti-vivisection stance. And here are three articles commenting on Horsley's stance on alcohol. He was actually a staunch prohibitionist and a teetotaler. So how exactly did Horsley come to be seen as described in Fulton's biography? For one, he could be considered something of an eccentric and an instigator. On the right, you can see him with his pet dog, Scamp, and his bird, Noah. A classmate described him as keen and energetic with a strong hatred of humbug of all kinds. He protested words and phrases like special idiosyncrasy, which he called a mere cloak for ignorance. He also held strong views on subjects such as food and alcohol. He denounced mustard and such-like compliments with vigor. It's not exactly a portrait of a man easy to get along with. He also held controversial social stances. His stance against alcohol was unflinching. He was a staunch supporter of women's suffrage. While running for parliament, his political opponents actually considered him to have a weak stance against the suffragettes' violence. And this was in line with his controversial politics. He was an early proponent of nationalized health care in Britain, which led the British Medical Association to decry him as a democrat turned socialist, and they actually severed ties over this view. So those aspects of Horsley certainly did little for him winning favor with the establishment. But what about his relationship with Cushing? For one, the men had very different personalities. Horsley was vocal in his opinions with a distaste for brash, self-confident Americans. He had an abundant energy with research which could be called unfocused. It was mostly whatever interested him. He detested cigarettes. He had no airs about him. He was an aristocrat turned socialist. Cushing, on the other hand, was self-confident and reserved in opinions. He was a practical, focused clinical scientist and a heavy cigarette smoker. He was more conservative in his political views, and he met Horsley early in his career while he was trying to make a name for himself. But perhaps the biggest difference between the two men is the eras in which they operated. Here are two photos demonstrating that. On the left is Horsley preparing to operate in a room full of unmasked men, and on the right is Horsley operating in a theater where sterility is observed. That really highlights the biggest difference. Horsley practiced antiseptic surgery where speed was considered an ideal. This was at the very beginning of neurological localization. Horsley always used craniectomies, and it was during a time when Americans traveled to Europe to learn surgery. Cushing, on the other hand, practiced aseptic surgery and trained in a slow methodical technique under Halstead. He actually wrote at one point, there should be a legal penalty imposed for speeding in brain surgery. He had x-rays to aid in his diagnosis, he utilized craniotomies, and this was during a time when Europeans traveled to America. As Cushing matured, he grew to respect Horsley more as a man. He actually commented that Horsley was a daisy after seeing one of his lectures, and this was a positive comment at the time. They corresponded periodically. Cushing's diary entry from World War I actually contains an entry upon hearing of Horsley's death. It's really a fascinating look into the complex relationship between the two men. Here's a selection. It says, what an unbelievable creature Horsley was, an absolute believer in himself and no other until the end. Much that was amazing. His extraordinary energy starting at 5 in the morning and dashing about until one's head reeled. A remarkable person. So in conclusion, Victor Horsley had gained a great recognition and respect in Britain and Europe starting in his late 20s and increasing throughout his career. He was similarly admired in the U.S. and Canada, and our research indicates that he could be viewed as something of a celebrity by the American public. The passage from Cushing's biography doesn't really tell the entire story of Horsley's operative skills. It really tells more of a story of a clash of two eras of surgery. With that, I'd like to thank Dr. Scholder for his mentorship and guidance, and the neurosurgery department at North Shore University Hospital for all their support. Thank you. Jim Goodrich will comment on this paper. Well thank you very much for the opportunity to speak on this remarkable contribution of which I have a couple of thoughts to share. It's an important historical assessment. It reviews both contemporary literature and public media, which we don't uncommonly see today. And the interesting thing is the whole concept of how Horsley became to the American public and to American neurosurgeons was based on a single line in Fulton's biography, which I find pretty remarkable, and I'm also a victim of the same concept. I see why speakers are having trouble with this thing. But as the previous team revealed, enormous contributions to the field, epilepsy, laminectomy, transplants on the pituitary, craniopharyngioma, a concept of developing a stereotactic frame, and then of course a new form of bone wax. And again, all started from this statement which really describes somebody running around a kitchen pretty much out of control. But when you think about it, anesthesia was very limited, your bleeding was not, you did not have the ability to transfuse, so the concept of what he did in that kitchen is what anybody would have done. So to me, and then adding in Paul Busey's comment, where he collaborated Fulton's writings, but the interesting thing, he comments that Horsley was not a good technical surgeon, but he'd never seen him operate. So this was a comment based upon an observation that didn't exist. So the contributions, I think this is an extremely important historical reassessment because many of us have been misled over the years. I love the review of both the contemporary literature and the addition of the public media, and in the end, I think he really does deserve the appropriate respect as being one of the fathers of neurosurgery, certainly that special field of neurosurgery. Thank you very much. Thank you.

Sir Victor Horsley

neurosurgery

bone wax

cerebral localization

animal experimentation