Charles Ballance

Biography

• 1856 – Born August 30 in Clapton, Middlesex, England.
• 1875 – Entered St Thomas’s Hospital Medical School as a member of London University.
• 1881 – Graduated B.S. with gold medal from University of London.
• 1882 – Master of Surgery (M.S.) with gold medal.
• 1887–1891 Examiner in anatomy at the Royal College of Surgeons.
• 1888 – Appointed Aural Surgeon at St Thomas’s Hospital.
• 1891 – Contested assistant surgeon post at St Thomas’s Hospital; following a tie with William Henry Battle (1855-1936), an additional post was created for Ballance. Elected surgeon to the National Hospital for the Paralysed and Epileptic, Queen Square.
• 1895 – First to perform a facial nerve crossover anastomosis (facial to spinal accessory nerve).
• 1900 – Full Surgeon at St Thomas’s Hospital.
• 1906 – Delivered the Lettsonian Lectures on cerebral membranes at the Medical Society of London.
• 1908 – Retired from Queen Square; elected Consulting Surgeon.
• 1908 – Gazetted Captain à la suite, RAMC (Territorial Force).
• 1912–1926 Chief Surgeon to the Metropolitan Police.
• 1915 – Appointed temporary Colonel, Army Medical Services; posted as Consulting Surgeon to Malta during WWI (Gallipoli campaign).
• 1916 – CB (Companion of the Bath), Military Division.
• 1918 – KCMG (Knight Commander of the Order of St Michael and St George).
• 1919 – Retired from St Thomas’s Hospital; became Consulting Surgeon. Delivered Bradshaw Lecture: The Surgery of the Heart.
• 1920 – Vice-President, Royal College of Surgeons.
• 1921 – Delivered Vicary Lecture: A glimpse into the history of surgery of the brain.
• 1922 – Delivered Thomas Vicary Lecture: History of Brain Surgery.
• 1927 – First President of the Society of British Neurological Surgeons.
• 1933 – Delivered Lister Memorial Lecture on nerve surgery; received Lister Memorial Medal.
• 1936 – Died February 8 at his home in St. John’s Wood Court, London, aged 79.

Medical Eponyms

Ballance (triad) sign (1898)

Ballance’s sign, first described in 1898, remains a historically significant eponym in trauma medicine. It refers to the clinical observation of fixed dullness in the left flank (splenic region) and shifting dullness in the right flank on abdominal percussion—suggesting haemoperitoneum from splenic rupture.

This sign was especially valuable before the advent of diagnostic imaging and was used to differentiate splenic injury from other causes of intra-abdominal bleeding. Although now largely replaced by imaging and focused assessment with sonography for trauma (FAST), Ballance’s contribution reflects the ingenuity of late Victorian surgical diagnostics and is still referenced in physical examination literature.

…diagnosis of ruptured spleen is arrived at from:

1. The locality of the injury.
2. The evidence of internal haemorrhage; and
3. The large fixed dulness in the left flank.

The fixed dulness in the left loin and splenic region is not present in intra-abdominal haemorrhage from other organs, and is caused by this region being occupied by large quantities of clot. The dulness, therefore, cannot change with position, and is pathognomonic of this injury. The unusually large proportion of white corpuscles in splenic venous blood offers an explanation of the local coagulation of the effused blood in splenic rupture. Further, the exceptional coagulability of the splenic blood offers an explanation of the fact that these patients do not rapidly bleed to death

Ballance CA, 1898: 357

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Facial Nerve Crossover Anastomosis (1895)

A Landmark in Facial Reanimation Surgery

Ballance was the first to the first to perform a direct intratemporal facial nerve repair (1894) In 1895, Ballance became the first surgeon in history to perform a facial nerve crossover anastomosis, connecting the spinal accessory nerve to the paralyzed facial nerve via an end-to-side suture technique. This innovative approach aimed to restore motor function in patients suffering from facial paralysis due to trauma or middle ear disease.

The procedure is now widely recognized as a historic milestone in facial nerve surgery. Ballance published his operative results in 1903, Remarks on the operative treatment of chronic facial palsy of peripheral origin. His initial case was performed at St Thomas’s Hospital and was later followed by a series of seven cases, including both spinal accessory and hypoglossal crossovers performed by his brother Sir Hamilton Ashley Ballance (1867-1936). His rationale stemmed from prior microscopic studies of nerve healing and regeneration published as the healing of nerves in 1901

This foundational technique established principles that remain relevant over a century later and anticipated modern strategies in facial reanimation and nerve grafting.

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Suppurative Otitis Media and Mastoid Surgery

Ballance and Macewen – Revolutionising Aural Surgery

Sir Charles Ballance and Sir William Macewen (1848–1924) were instrumental in transforming the management of chronic suppurative otitis media (CSOM) and its intracranial complications. At a time when middle ear infections carried high morbidity due to brain abscess and lateral sinus thrombosis, their advocacy of radical surgical intervention marked a paradigm shift.

Ballance was among the first in England to perform complete mastoidectomy with ligation of the jugular vein and drainage of the lateral sinus, following European pioneers such as Hermann Schwartze and Karl Kuster. He later refined this by introducing epithelial grafts (e.g., Thiersch grafts) to line the mastoid cavity, enhancing postoperative healing. His contributions laid foundational standards for otologic surgery and helped establish it as a discrete surgical specialty in Britain.

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Cerebral Localisation and Vascular Mapping

Collaborations in the Golden Age of Experimental Neurology

At the National Hospital, Queen Square, Ballance worked alongside Victor Horsley and David Ferrier in the pioneering field of cerebral localisation. Building on Ferrier’s work in cortical stimulation and experimental brain lesions in primates, Ballance contributed surgical techniques to map cerebral vascular territories—a vital precursor to modern neurosurgical planning.

These efforts led to improved intraoperative navigation and understanding of brain function relative to vasculature. Ballance’s method helped distinguish functional cortical areas by vascular distribution, enhancing safety and efficacy in cranial surgery. His collaborative environment included figures like Charles Sherrington and John Hughlings Jackson, placing Ballance at the heart of neurological innovation in the late 19th century.

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Major Publications

• Ballance CA, Edmunds W. The ligation of the larger arteries in their continuity: an experimental inquiry. Medico-Chirurgical Transactions. 1886; LXIX: 1-30
• Sherrington CS, Ballance CA. On formation of scar tissue. Journal of physiology 1889; 10(6): 550-576
• Ballance CA, Shattock SG. A note on an experimental investigation into the pathology of cancer. Proceedings of the Royal Society. 1890; 48: 393-403
• Ballance CA, Edmunds W. A treatise on the ligation of the great arteries in continuity: with observations on the nature, progress and treatment of aneurism. 1891
• Ballance CA. On splenectomy for rupture without external wound. Practitioner. 1898; 60: 347-358.
• Ballance CA. The conduct of the mastoid operation for the cure of chronic purulent otorrhaea. Medico-Chirurgical transactions. 1900; 83: 1-33
• Ballance CA, Stewart P. The healing of nerves. 1901
• Ballance CA. A case of aneurysm involving the innominate, the right subclavian, and the right common carotid arteries. 1902
• Ballance CA, Ballance HA, Steward P. Remarks on the operative treatment of chronic facial palsy of peripheral origin. Br Med J 1903; 1: 1009-1013
• Ballance CA. Some points in the surgery of the brain and its membranes. 1907
• Ballance CA. The Surgery Of The Brain. Lancet 1920; 195(5027): 1-5
• Ballance CA. A glimpse into the history of surgery of the brain In: Thomas Vicary Lecture. Lancet. 1922; 199(5134): 111-116
• Ballance CA. A glimpse into the history of surgery of the brain (Part II) In: Thomas Vicary Lecture. Lancet. 1922; 199(5135): 165 – 172
• Ballance CA, Duel AB. The operative treatment of facial palsy by the introduction of nerve grafts into the Fallopian canal and by other intratemporal methods. Arch Otolaryngol. 1932; 15(1): 1-70.

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References

Biography

• Sir Charles Ballance, M.S., F.R.C.S. Br Med J 1936;1:339
• Sir Charles Ballance. Lancet 1936; 227(5868): 396
• Obituary: Charles Alfred Ballance, 1856-1936. Bull N Y Acad Med. 1936; 12(3): 146–149.
• Colledge L. Sir Charles Ballance 1856–1936. Annals of Otology, Rhinology & Laryngology. 1936; 45(4): 1186–1188
• Manché A. Sir Charles Ballance: A pioneer surgeon in Malta. Malta Medical Journal 2014; 26(3): 56-59
• Ballance, Sir Charles Alfred (1856-1936). Plarr’s Lives of the Fellows

Eponymous terms

• Waldman EH, Lustig LR. Sir Charles Alfred Ballance: Contributions to Otology and Neurotology. Otol Neurotol. 2005; 26(5): 1073-82.
• Van de Graaf RC, Ljpma FFA, Nicolai J-P A. Sir Charles Alfred Ballance (1856–1936) and the introduction of facial nerve crossover anastomosis in 1895. Journal of Plastic, Reconstructive & Aesthetic Surgery, 2009; 62(1): 43–49
• Rastogi V et al. Abdominal Physical Signs and Medical Eponyms: Part I. Percussion, 1871–1900. Clin Med Res. 2020 Mar;18(1):42-47