Until the early 1930s, many patients who underwent complex surgery died soon after. But a talented American surgeon made simple but radical changes that completely transformed health care. A skilled Danish anesthesiologist also helped.
American Harvey Cushing was the most brilliant neurosurgeon of his generation. His patients adored him, describing him as a caring specialist and a kind man. However, he kept his staff on a short leash. He was intolerant of mistakes and could seem cold, rude, and even sneering. He was forgiven, however, because the results of his work spoke for themselves.
On April 15, 1931, at the Peter Bent Brigham Hospital in Boston, Cushing performed his 2000th operation to remove a brain tumor. The patient was 31-year-old Ida Gershkovich. She was diagnosed with a tumor that caused the woman to suffer from frequent and terrible headaches. Her vision was getting worse. Throughout the surgery, which lasted several hours, Cushing worked patiently, diligently, and methodically (warning: the video of this surgery may seem too realistic).
At Kushing, up to 27.7% of patients who underwent neurosurgical removal of a brain tumor died. In his clinic, the surgeon reduced the mortality rate to 8%. Gershkovitch also recovered and lived to a ripe old age. “He has been called the father of neurosurgery,” says Dennis Spencer, professor of neurosurgery at Yale School of Medicine. “He was totally devoted to his patients, and he dedicated his life to making brain surgery an independent discipline.”
In the days before antibiotics, when bacterial infection and death hung like a sword of Damocles over all who underwent surgery, Cushing performed operations with the utmost cleanliness. He wore gloves and a mask and did everything he could to ensure complete sterility in the operating room. Most importantly, Cushing continued to work with the patient after surgery, when the risk of complications and death is highest. “Not all surgeons were as attentive to the patient after surgery,” says Spencer. “Cushing applied his meticulous approach to the postoperative period.”
In the days before antibiotics, the risk of bacterial infection and death haunted everyone who went under the knife. He usually treated the surgical wound himself to ensure that no infection was introduced. He introduced a strict system of monitoring and reporting, as well as – for the first time – wide use of X-rays for diagnostics, blood pressure control (and entered the history of medicine as the founder of anesthesia monitoring – note BBC). A specialized team of doctors was responsible for each patient.
“Cushing’s post-op room was more like an intensive care unit than any other surgeon’s,” Spencer says. “Nurses and surgical assistants knew that if the sheets were not tucked in properly, if the dressing was not clean, or if the patient complained about something, they would be in big trouble.”
Of course, the Cushing’s chamber did not resemble modern intensive care units with their sensors and monitors, but the concept was very similar. As surgeries became more complex (during World War II and in the 1950s) and doctors began operating on open hearts, Cushing’s innovative approach to the postoperative period began to spread, saving countless lives.
But the prototype of the modern ICU was for patients scheduled for surgery, not for those who suffered a serious injury or suddenly became critically ill. Another type of intensive therapy has emerged as a result of the epidemic. In the first half of the 20th century, polio infected tens of thousands of people around the world almost every year. Outbreaks usually occurred in the summer, and children were the primary victims. Initial symptoms were similar to the flu. In more severe cases, the virus affected the nervous system, causing paralysis and leaving victims unable to breathe. Those who had the disease were often left with lifelong disabilities or breathing difficulties.
Harvey Cushing had a reputation as a tyrannical chief, but his brilliant mind transformed the hospital. Blegdem Hospital had only one iron lung and six corset ventilators. 316 patients needed them. “The situation was desperate, more than 300 people could have died,” says Fiona Kelly, an intensive care physician at the Royal United Hospital in Bath, UK, and co-author of a scientific study on the response to the epidemic.
The head doctor of the hospital called an emergency meeting to find a solution. Experienced anesthesiologist Bjorn Ibsen, who had previously worked in the United States, proposed blowing air directly into the lungs through a tube rather than using a vacuum to expand the chest. This technique had already been developed, but for use during surgery.
Inserting a tube through the mouth into the windpipe was too painful for patients who needed the procedure for a long time. This could only be done under anesthesia. Then Ibsen suggested a relatively new procedure – tracheostomy: a small hole was made in the neck, and a tube was inserted that led directly to the lungs. This tube was attached to a rubber breathing bag from which air was manually expelled. To save patients, hundreds of doctors and medical students were called to work in the hospital – pumping air into patients’ lungs and monitoring their condition. Up to 70 people worked each shift.
Patients with poliomyelitis had to endure long hours on ventilators – modern mechanical ventilation did not exist at that time. Ibsen’s strategy saved dozens of lives and led to the opening of the world’s first specialized resuscitation and intensive care unit (ORIT) with trained staff in a Copenhagen hospital. However, intensive care is not only a special place in the hospital, but also the principles of how to care for the most critically ill patients.
“Critical care is a medical specialty in its own right,” says Daniel Bryden, associate dean of the UK’s Faculty of Critical Care Medicine, which celebrated its 10th anniversary this year. “It’s not just a place. It’s a whole complex of medical services and a professional ethos of providing those services to people.”
Danish innovations gradually spread around the world. Combined with Cushing’s innovations, they led to the opening of specialized departments in most major hospitals. In 1971, Dennis Spencer helped transform part of the surgical department at Yale-New Haven Hospital in Connecticut, USA, into an ORIT. “At that time, seat belts were not required in cars, and we had a lot of people coming in with severe spinal injuries from accidents,” Spencer recalls. “We needed a specialized unit.”
“On one of the weekends, we got together, painted the walls of the ward, took out the carpet and threw it away, and put in five beds. Then we started training the nurses: teaching them to pay attention to certain things that are important for the condition of spinal cord injured patients. In other hospitals, they followed the same path, forming teams of specialists (nurses, pharmacologists, doctors, anesthesiologists) and using modern technologies – all to treat the most serious patients.
Today, large hospitals may have several different intensive care units – for different types of conditions, from severe cases of Covid-19 to gunshot wounds, strokes or post-operative complications. “I feel like we are the hub of the entire hospital,” says Kelly. “We receive the most critically ill patients at all hours of the day, and it is incredibly gratifying to see those who I initially thought had no chance improve and leave with a big smile on their face.”
Cushing applied his meticulous approach to treatment and the postoperative period, when patients were most likely to suffer complications. Tens of thousands of people owe their lives to intensive care. In the UK, for example, three-quarters of people admitted to intensive care are saved from death. But it is important to remember what happens after the patient is discharged.
“Those who leave the ICU still need special care,” Bryden points out. “It’s not just about staying alive. It’s about the quality of life after you’ve survived.”
There are other problems as well. Harvey Cushing was the first to introduce blood pressure control technology, which is now one of the main elements of ORIT. But as patients are surrounded by more and more devices (ventilators, sensors, cardiac monitors) that provide physicians with data about the patient, from temperature to blood oxygen saturation, it becomes increasingly difficult for specialists to quickly understand all of it.
“There are a lot of analytics and devices out there that give doctors a lot of data, but that data is scattered and they have to organize it somehow in their minds,” Spencer said. In the near future, we will start to develop algorithms with computers – so that it would be possible to input different information and get something meaningful in return. This is the future of intensive care.
What began as the whim of a surgeon obsessed with his work, and continued as he desperately sought a way out of the epidemic, ultimately changed the face of medicine. “The value of what they did cannot be measured,” Kelly emphasizes. “We owe everything to those pioneers.”
Translation: The number of bids should stay the same.
Richard Hollingham is a writer on science and space exploration. He is the author of “Blood and Guts: A History of Surgery. More articles on similar topics can be found on the BBC Future website.