A Brief History of Sir Hugh Cairns and His Helmet Creation Study of Prognostic Factors for Duration of Sick Leave After Endoscopic V, Et Al

207 Original Original

8. Hansen TB, Dalsgaard J, Meldgaard A, Larsen K. A prospective 21. Katz JN, Amick BC 3rd, Keller R, Fossel AH, Ossman J, Soucie A Brief History of Sir Hugh Cairns and His Helmet Creation study of prognostic factors for duration of sick leave after endoscopic V, et al. Determinants of work absence following surgery for carpal Breve História sobre Sir Hugh Cairns e Sua Criação do Capacete carpal tunnel release. BMC Musculoskelet Disord. 2009 Nov tunnel syndrome. Am J Ind Med. 2005 Feb;47(2):120-30. doi: 22;10:144. doi: 10.1186/1471-2474-10-144. 10.1002/ajim.20127. Lara Mariana Rosa1 9. Acharya AD, Auchincloss JM. Return to functional hand use 22. Amick BC 3rd, Habeck RV, Ossmann J, Fossel AH, Keller R, Carlos Umberto Pereira2 and work following open carpal tunnel surgery. J Hand Surg Br. Katz JN. Predictors of successful work role functioning after carpal 1,3 2005;30(6):607-10. doi: 10.1016/j.jhsb.2005.06.018. tunnel release surgery. J Occup Environ Med. 2004;46(5):490-500. Nicollas Nunes Rabelo doi: 10.1097/01.jom.0000126029.07223.a0. 10. Acioly MA, Maior PS, Telles C, de Aguiar GB. Bilateral mini- open decompression in the treatment of carpal tunnel syndrome 23. de Moraes VY, Godin K, Dos Santos JB, Faloppa F, Bhandari ABSTRACT caused by persistent median artery: case report. J Neurol Surg A M, Belloti JC. Influence of compensation status on time off work Introduction: Sir Hugh Cairns was an Austrian physician who contributed much to neurology and neurosurgical practices. He created Cent Eur Neurosurg. 2013 Dec;74 Suppl 1:e124-7. doi: 10.1055/s- after carpal tunnel release and rotator cuff surgery: a meta-analysis. the anti-impact helmet for motorcyclists, which led to a significant reduction in mortality due to head injury. Besides, he performed 0032-1328959. Patient Saf Surg. 2013 Jan 2;7(1):1. doi: 10.1186/1754-9493-7-1. tests and antibiotic treatments on neurological infections. He has made many publications on neurosurgical techniques that are used to 11. Bowen GA. Naturalistic inquiry and the saturation 24. Parot-Schinkel E, Roquelaure Y, Ha C, Leclerc A, Chastang this day. Method: This article discusses his biography and its several discoveries and contribution to medicine and society.Conclusion: concept: A research note. Qual Res 2008;8(1):137–52. doi: JF, Raimbeau G, et al. Factors affecting return to work after carpal Hugh Cairns was the inventor of the anti-impact helmet responsible for reducing head injuries from motorcycle accidents. He was a 10.1177/1468794107085301. tunnel syndrome surgery in a large French cohort. Arch Phys Med founder of the neurosurgery specialty at Oxford University. His surgical techniques and studies are widely used in surgical and student Rehabil. 2011;92(11):1863-9. doi: 10.1016/j.apmr.2011.06.001. practices nowadays. 12. Smith JA, Osborn M. Interpretative phenomenological analysis as a useful methodology for research on the lived experience of pain. 25. Peters S, Page M, Coppieters M, Ross M, Johnston V. Br J Pain. 2015;9(1):41-2. doi: 10.1177/2049463714541642. Rehabilitation following carpal tunnel release (Review). Cochrane Keywords: Hugh Cairns; Helmet; Biography; Neurosurgery; Historical review; British Neurosurgery Database Syst Rev 2016;(2):1-183. doi: 10.1002/14651858. 13. Brislin RW. Back-Translation for Cross-Cultural CD004158.pub3. Disponível em: https://research-repository.griffith. RESUMO Research. J cross cultural psychol. 1970;1:185–216. doi: edu.au/bitstream/handle/10072/339730/PetersPUB2682. Sir Hugh Cairns foi um médico austríaco que contribuiu muito para a neurologia e práticas neurocirúrgicas. Foi responsável 10.1177/135910457000100301. Introdução: pela criação do capacete anti-impacto para motociclistas, o que levou à significativa redução da mortalidade por traumatismo 14. Martin H. Patients’ health beliefs and adaptation to carpal tunnel craniano. Além disso, executou testes e tratamentos antibióticos em infecções neurológicas. Realizou muitas publicações sobre técnicas syndrome based on duration of symptomatic presentation. J Hand neurocirúrgicas que são utilizadas até os dias atuais. Método: Este artigo discorre sobre sua biografia e suas respectivas descobertas Ther. 2007;20(1):29-35; quiz 36. doi: 10.1197/j.jht.2006.10.002. CORRESPONDING AUTHOR e contribuição à medicina e sociedade. Conclusão: Hugh Cairns foi o inventor do capacete anti-impacto responsável pela redução de ferimentos craniais em acidentes motociclísticos. Além disso, foi fundador da especialidade de neurocirurgia da Universidade 15. Jerosch-Herold C, Mason R, Chojnowski AJ. A qualitative study of the experiences and expectations of surgery in patients de Oxford. Suas técnicas cirúrgicas e seus estudos, atualmente, são amplamente utilizados nas práticas cirúrgicas e estudantis. with carpal tunnel syndrome. J Hand Ther. 2008;21(1):54-61. doi: Raissa Mansilla Cabrera Rodrigues, MD 10.1197/j.jht.2007.09.001. Palavras-chave: Hugh Cairns; Capacete; Biografia; Neurocirurgia; Revisão histórica; Neurocirurgião britânico Serviço de Neurocirurgia 16. Katz JN, Keller RB, Fossel AH, Punnett L, Bessette L, Simmons Hospital Universitário Antônio Pedro BP, et al. Predictors of return to work following carpal tunnel release. Am J Ind Med. 1997;31(1):85-91. doi: 10.1002/(sici)1097- Niterói-RJ, Brasil 0274(199701)31:1<85::aid-ajim13>3.0.co;2-3. E-mail: [email protected] 17. Chaise F, Bellemère P, Fril JP, Gaisne E, Poirier P, Menadi A. Return-to-work interval and surgery for carpal tunnel syndrome. Conflict of interest: The authors have no conflict of interest to Results of a prospective series of 233 patients. J Hand Surg Br. declare. 2004;29(6):568-70. doi: 10.1016/j.jhsb.2004.05.005. 18. Carmona L, Faucett J, Blanc PD, Yelin E. Predictors of rate of Ethics: The study was approved by the local Research Ethics return to work after surgery for carpal tunnel syndrome. Arthritis Care Res. 1998;11(4):298-305. doi: 10.1002/art.1790110411. Committee (CAAE 63075016.6.0000.5243/2016). 19. De Kesel R, Donceel P, De Smet L. Factors influencing return to work after surgical treatment for carpal tunnel syndrome. Occup Med (Lond). 2008;58(3):187-90. doi: 10.1093/occmed/kqn034.

20. Butterfield PG, Spencer PS, Redmond N, Rosenbaum R, Zirkle 1 Neurosurgery Department, UniAtenas University Center Medical School; Paracatu, MG, Brazil DF. Clinical and employment outcomes of carpal tunnel syndrome 2 Department of Neurosurgery of FBHC and Neurosurgery Service, Aracaju, Sergipe, Brazil in oregon workers’ compensation recipients. J Occup Rehabil 3 Neurosurgeon and Professor, UniAtenas University Center Medical School, Paracatu, MG, Brazil 1997;7(2):61–73. Doi: 10.1007/BF02765877.

Received: Jul 10, 2019 Accepted: Jan 14, 2020

Mansilla R, Acioly MA, Romão TT, AMangolin A, Silva JSS, Landeiro JA - Patient’s Perceptions of J Bras Neurocirur 30 (3): 197-206, 2019 Rosa LM, Pereira CU, Rabelo NN - A Brief History of Sir Hugh Cairns and His Helmet Creation J Bras Neurocirur 30 (3): 105-111, 2019 Carpal Tunnel Surgery 208 Original

In London, neurology professionals were interested in BRIEF HISTORY knowing and addressing Cushing’s principles on their patients, and Cairns already had a great deal of interest in neurology and was nominated by Lady Osler to Cushing on one of his visits Hugh William Bell Cairns (Figure 1) was born in South to England. With that, Cairns won the Rockefeller Traveling Australia on July 26, 1896, and died on July 18, 1952. He Fellowship for a year as an assistant to Dr. Harvey Cushing at was the only son of a couple, an Australian mother and a the Peter Bent Brigham Hospital, Boston, in 19263. Scottish father. At the University of Adelaide, he began his medical studies at the age of fifteen, which were discontinued In 1927, Cairns returned to London as one of the city’s first one year before his graduation to join the Australian Army neurosurgeons to master modern techniques. He learned how Medical Corps (AAMC) during World War I. In 1916, he to examine the neurological system in detail, to evaluate visual returned to conclude his studies and received the South fields, to interpret radiographs and ventriculograms of the Australian Rhodes Scholarship to study medicine at the skull, and to perform operations for intracranial tumors, as Oxford University. In 1917, he was declared captain of the well as principles of Cushing’s surgical practice, which Cairns AAMC and sent to the Middle East and France until the end has adopted and has always used. In that same year, Cairns of World War I. In 1919, he entered Balliol College, Oxford, was recognized as associate member of the Society of British where he studied physiology and was taught by Sir Charles Neurological Surgeons3. Sherrington. Hugh Cairns conquered a position at the Radcliffe Infirmary, where he remained for one year, working In February 1928, he performed 15 operations on the brain as an anatomy demonstrator, and it was there that he met Sir and spinal cord, and only one-third of the patients died, William Osler (1849-1919). Osler introduced Cairns to the this fact earned him financial support from the Rockefeller renowned American neurosurgeon Harvey Cushing in 1922. Foundation to invest in surgical equipment and to subsidize Later, in June 1926, he took over the position of First Assistant assistants and trainees in Neurosurgery 2,3. in the surgical unit of the London Hospital and worked with Sir Henry Souttar1-4. At first, the ideas and techniques of Cairns were not accepted and adhered to by London professionals. It was only in 1933 that the London Medical Society became convinced of his principles, and he became the first full-time British neurosurgeon to be responsible for the Department of Neurosurgery at the London Hospital. This event marked the beginning of the specialty of neurosurgery in England. Later, in 1935, when the Rockefeller Foundation agreed to fund a new neurosurgery unit at Queen Square, Cairns was appointed to work at the two major neurological centers in London, as Honorary Neurological Surgeon at the Maida Vale Hospital (1931-1934) and the Queen Square National Hospital (1934-1937). Besides, in 1937, he became Professor of Surgery at Oxford, after Lord Nuffield, a philanthropist, financed Oxford’s Medical College to make it a research center, and also was the founder of the neurosurgical unit at the Radcliffe Ward, following the Cushing lines3,4,5.

Figure 1. Picture of Hugh Cairns 1 In London, neurology professionals were interested in knowing and addressing Cushing's principles on their patients, and Cairns already had a great deal of interest Rosa LM, Pereirain CU, neurology Rabelo NN -and A Briefwas Historynominated of Sir Hugh by Cairns Lady and Osler His Helmet to CushingCreation on one of his visits to J Bras Neurocirur 30 (3): 207-210, 2019 England. With that, Cairns won the Rockefeller Traveling Fellowship for a year as an assistant to Dr. Harvey Cushing at the Peter Bent Brigham Hospital, Boston, in 19263.

In 1927, Cairns returned to London as one of the city's first neurosurgeons to master modern techniques. He learned how to examine the neurological system in detail, to evaluate visual fields, to interpret radiographs and ventriculograms of the skull, and to perform operations for intracranial tumors, as well as principles of Cushing's surgical practice, which Cairns has adopted and has always used. In that same year, Cairns was recognized as associate member of the Society of British Neurological Surgeons3.

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In London, neurology professionals were interested in In 1938, Cairns was appointed advisor to the War Office for of the pathophysiology, mechanisms involved in the injuries BRIEF HISTORY knowing and addressing Cushing’s principles on their patients, the treatment of skull wounds in the military population. and investigations of the designs and models of materials and Cairns already had a great deal of interest in neurology and Along with Sir Charles Symonds (consultant neurologist of the used in the manufacture of helmets were performed1,3,7. The was nominated by Lady Osler to Cushing on one of his visits Royal Air Force – RAF), George Riddoch (Army neurologist helmet consisted of a durable shell, an inner band and a hat Hugh William Bell Cairns (Figure 1) was born in South to England. With that, Cairns won the Rockefeller Traveling who participated in World War I in the treatment of spinal band, a component that acted as the shock absorber7. The Australia on July 26, 1896, and died on July 18, 1952. He Fellowship for a year as an assistant to Dr. Harvey Cushing at and brain injuries) and Sir Farquhar Buzzard, who founded outer part of the helmet was smooth and had internal alloys was the only son of a couple, an Australian mother and a the Peter Bent Brigham Hospital, Boston, in 19263. the Combined Services for the Head Injury Hospital, to attend and was capable of changing the local and general effects Scottish father. At the University of Adelaide, he began his the army and air forces at St Hugh’s College in Oxford. It was of head trauma, preventing the fracture of the skull and its medical studies at the age of fifteen, which were discontinued In 1927, Cairns returned to London as one of the city’s first chosen because of its proximity to London and the Radcliffe complications. In 1940, the army already had some helmets, one year before his graduation to join the Australian Army neurosurgeons to master modern techniques. He learned how ward. In this place were established several specialized units in which were replaced by only a few motorcyclists. There were Medical Corps (AAMC) during World War I. In 1916, he to examine the neurological system in detail, to evaluate visual the different medical areas, such as orthopedics, and treatment canvas helmets and another model that was used in armored returned to conclude his studies and received the South fields, to interpret radiographs and ventriculograms of the base for head trauma. The St Hugh’s Hospital was opened vehicles. The largest decline in mortality occurred after Australian Rhodes Scholarship to study medicine at the skull, and to perform operations for intracranial tumors, as in 1940 with 50 beds and even housed 430 beds. The main November 1941, when emergency helmets became mandatory Oxford University. In 1917, he was declared captain of the well as principles of Cushing’s surgical practice, which Cairns objective was to take care of the military and reintegrate them for the entire army of on-duty motorcyclists 3,4,8. AAMC and sent to the Middle East and France until the end has adopted and has always used. In that same year, Cairns into service. It was the first hospital to provide occupational of World War I. In 1919, he entered Balliol College, Oxford, was recognized as associate member of the Society of British therapy and rehabilitation to Red Cross recovery centers 2,3,5. Cairns, before experiencing the occurrence of several deaths where he studied physiology and was taught by Sir Charles Neurological Surgeons3. of motorcycle patients who did not wear helmets, had already Sherrington. Hugh Cairns conquered a position at the Cairns initially persuaded the War Ministry to obtain all the witnessed the care of an illustrious man who was a soldier of Radcliffe Infirmary, where he remained for one year, working In February 1928, he performed 15 operations on the brain surgical devices necessary for the use of the neurosurgeons of World War I, Colonel Thomas Edward Lawrence. In 1935, as an anatomy demonstrator, and it was there that he met Sir and spinal cord, and only one-third of the patients died, the army, because he feared that there would be a shortage of Laurence was injured in the countryside after a motorcycle William Osler (1849-1919). Osler introduced Cairns to the this fact earned him financial support from the Rockefeller steel for the making of these instruments due to the war. St crash and had a skull fracture and was taken, in a coma, to the renowned American neurosurgeon Harvey Cushing in 1922. Foundation to invest in surgical equipment and to subsidize Hugh’s Hospital cared for approximately 13,000 patients with Bovington Camp Military Hospital where the neurosurgeon Later, in June 1926, he took over the position of First Assistant assistants and trainees in Neurosurgery 2,3. head injuries during World War II, and several neurosurgeons, Cairns was. Lawrence died five days later. This accident was in the surgical unit of the London Hospital and worked with neurologists, and specialist nurses took internships there 2,3. added to Cairns’ experiences in the war, which were decisive Sir Henry Souttar1-4. At first, the ideas and techniques of Cairns were not accepted in the creation of motorcycle helmets for the prevention of and adhered to by London professionals. It was only in The beginning of the war has caused a major increase in head trauma 4. 1933 that the London Medical Society became convinced motorcycle crash rates in England. Cairns described that in of his principles, and he became the first full-time British the first 21 months of the war, the number of motorcyclists and Also during World War II, Cairns created mobile neurosurgery neurosurgeon to be responsible for the Department of passengers killed on roads was 2,279, 21% more than in the units (MNSU) where he worked as a neurosurgical advisor1,5. Neurosurgery at the London Hospital. This event marked corresponding months in peacetime, an approximated value These units allowed neurosurgeries to be performed within 24 the beginning of the specialty of neurosurgery in England. of three deaths per day, and most of the victims were members hours of the injury, and his team consisted of a neurosurgeon, Later, in 1935, when the Rockefeller Foundation agreed to of the army. It was at this time, in November 1941, that Cairns a chief assistant, two local surgeons, an anesthesiologist, a fund a new neurosurgery unit at Queen Square, Cairns was introduced the mandatory use of helmets for all motorcyclists, general pathologist, and an electroencephalograph. These appointed to work at the two major neurological centers in as impact helmets were used only by racing motorcyclists, a centers operated until 19442,5,6. London, as Honorary Neurological Surgeon at the Maida Vale measure that reduced the rate mortality by more than 50%. Hospital (1931-1934) and the Queen Square National Hospital Thus, throughout England was introduced the use of impact Also, during his medical career, Cairns, in addition to adjusting (1934-1937). Besides, in 1937, he became Professor of Surgery helmets, which has spread by countries around the world 2,3,6-8. the use of anti-impact helmets, contributed to advances in at Oxford, after Lord Nuffield, a philanthropist, financed the treatment of infectious processes in the nervous system. Oxford’s Medical College to make it a research center, and The helmet was developed by Cairns and an Oxford physicist, He underwent penicillin and sulphonamide therapy for also was the founder of the neurosurgical unit at the Radcliffe the motorcycle enthusiast Holborn, after accidents studies meningitis cases, which were successfully reported, including Ward, following the Cushing lines3,4,5. and radiological and clinical findings in post-traumatic 16 patients, of whom 12 survived. In addition to all these patients, many of whom had cranial lesions. Also, analysis contributions and scientific publications on techniques Figure 1. Picture of Hugh Cairns 1 In London, neurology professionals were interested in knowing and addressing Cushing's principles on their patients, and Cairns already had a great deal of interest Rosa LM, Pereirain CU, neurology Rabelo NN -and A Briefwas Historynominated of Sir Hugh by Cairns Lady and Osler His Helmet to CushingCreation on one of his visits to J Bras Neurocirur 30 (3): 207-210, 2019 Rosa LM, Pereira CU, Rabelo NN - A Brief History of Sir Hugh Cairns and His Helmet Creation J Bras Neurocirur 30 (3): 105-111, 2019 England. With that, Cairns won the Rockefeller Traveling Fellowship for a year as an assistant to Dr. Harvey Cushing at the Peter Bent Brigham Hospital, Boston, in 19263.

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and discoveries in Neurosurgery, it is noteworthy that, the 7. Cairns H. Head Injuries in Motor-cyclists. The Importance of the Crash Helmet. Br Med J. 1941;2(4213):465-71. doi: 10.1136/ neurosurgical principles of Cairns are used to the present day bmj.2.4213.465. 3,5,6. 8. Cairns H. Crash Helmets. Br Med J.1946; 2: 322. Doi: 10.1136/ bmj.2.4470.322. CONCLUSION

CORRESPONDING AUTHOR Hugh Cairns was the inventor of the anti-impact helmet responsible for reducing head injuries from motorcycle accidents. He participated in World War I, in which he Nícollas Nunes Rabelo, MD can carry out many studies on the neurological impact of Av. Antônio Diederichsen, nº 190, Ap. 193 accidents, as well as the use of antibiotics in the treatment of Jardim América, Ribeirão Preto, São Paulo neurological disorders and surgical practices. In addition to E-mail: [email protected] all this contribution, he was also one of the founders of the neurosurgical specialty at Oxford. His surgical techniques and studies are widely used in surgical and student practices nowadays.

REFERENCES

1. Smith S. Hugh William Bell Cairns [Figure]. 194?. Figure, color, 918 × 1,515. Available in: https://en.wikipedia.org/wiki/File:Hugh_ William_Bell_Cairns.jpg. 2. Stone JL, Patel V, Bailes JE. Sir Hugh Cairns and World War II British advances in head injury management, diffuse brain injury, and concussion: an Oxford tale. J Neurosurg. 2016;125(5):1301- 1314. doi: 10.3171/2015.8.JNS142613. 3. Tailor J, Handa A. Hugh Cairns and the origin of British neurosurgery. Br J Neurosurg. 2007 Apr;21(2):190-6. doi: 10.1080/02688690701317193. 4. Maartens NF, Wills AD, Adams CB. Lawrence of Arabia, Sir Hugh Cairns, and the origin of motorcycle helmets. Neurosurgery. 2002 Jan;50(1):176-9. doi: 10.1097/00006123-200201000-00026. 5. Weiner MF, Silver J. St Hugh’s Military Hospital (Head Injuries), Oxford 1940-1945. J R Coll Physicians Edinb. 2017;47(2):183-189. doi: 10.4997/JRCPE.2017.219. 6. Sundaravadhanan CS. Sir Hugh Cairns: The Neurosurgeon Who Introduced Crash Helmets. J Neurosci Rural Pract. 2017;8(4):647- 648. doi: 10.4103/jnrp.jnrp_167_17.

Rosa LM, Pereira CU, Rabelo NN - A Brief History of Sir Hugh Cairns and His Helmet Creation J Bras Neurocirur 30 (3): 207-210, 2019