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George Smith: A historical vignette

Posted in History on 2nd Dec 2021


Nikhil Agarwal, Bsc (Hons), is a 5th year Medical Student at the University of Aberdeen with a first-class honours’ degree in Anatomy. He is passionate about research particularly in the fields of Neurosurgery and Orthopaedic surgery, having been accepted to present at numerous national conferences.

Pragnesh Bhatt, MBBS, MS, MCh, FRCS, FRCS, EANS, PCME, FHEA, FEBNS, is a Consultant Neurosurgeon at the Aberdeen Royal Infirmary. He qualified in 1987 after training in India and the UK. His work is in general Neurosurgery in both adults and children. He has a particular interest in complex spinal surgery.

Correspondence to: Mr Nikhil Agarwal, University of Aberdeen College of Life Sciences and Medicine, MBChB Office, Foresterhill Rd, Aberdeen AB25 2ZD, UK. E. nikagarwal@live.co.uk
T. +447715310566
Conflict of interest statement: None declared.
Provenance and peer review: Submitted and internally reviewed.
Date first submitted: 22/4/2021
Acceptance date: 3/5/2021
Published online: 2/12/2021
Creative Commons Attribution
https://doi.org/10.47795/AFST2742


Dr George W Smith was an American Neurosurgeon who pioneered the famous Smith-Robinson procedure of anterior cervical discectomy and fusion. Furthermore, he has been credited with developing the vessel encircling aneurysm clip, the automatic drill and a treatment for trigeminal neuralgia with Stilbamidine. This brief article looks back at his great achievements.

Dr Smith was born on December 4th 1916 in Deer Creek, Minnesota. He gained his Bachelor of Science degree from the University of Indiana in 1939, after which he proceeded to gain a Doctor of Medicine from the School of Medicine in Indianapolis in 1942 [1].

Dr Smith completed his internship years at Gorgas Hospital, which was an army installation in Panama. He was a Physician for the United States Army during World War 2 from 1944-1946. During his time in the war, Smith gained significant experience in spinal injuries. He took this knowledge with him and continued his medical training as a resident in the University of Maryland. He later became an instructor at the University of Maryland in 1950, for two years.

Smith was subsequently appointed as an instructor at John Hopkins University. Thereafter he became Assistant Professor in 1953. Later in the same year, he become a Professor and the Chief of Orthopaedic Surgery at John Hopkins University.

During his time at John Hopkins, Dr Smith found that the administration of IV Stilbamidine was an effective treatment for trigeminal neuralgia. This was far safer and cheaper than other potential treatments offered at the time. He noted that the pathology was still unknown and that there were very few successful treatments for trigeminal neuralgia. He conducted a small trial with 14 outpatients, who were given IV Stilbamidine. The patients noticed that the severity of their pain and the number of attacks decreased over time. It was found that complete freedom from pain occurred two to four months after the initiation of treatment. However, during his trial, he discovered that the use of Stilbamidine resulted in a side effect of blunting of corneal reflexes [2]. His treatment, despite its success, was eventually dropped due to the risk of significant toxicity.

While at John Hopkins, Smith met with an Orthopaedic Surgeon, Dr Robert Robinson, and in 1955 Smith and Robinson first described their idea of cervical discectomy and fusion [3]. They continued this work and published their method in 1958 in The Journal of Bone and Joint Surgery. In this paper Smith and Robinson described their experiences with the anterior removal of the intervertebral disc and interbody fusion, with a report of 14 patients [4]. However, in the same year there were two other independent publications of versions of anterior approaches to the cervical spine. One was proposed by Dereymaeker & Mulier, with the other being proposed by Cloward.

Smith & Robinson’s method was an incredible improvement on previous techniques as it did not require any manipulation of the spinal cord. Their method involved removing one or more cervical discs and allowing for the fusion of the intervertebral bodies. However, what made this technique different from the other two which were published in 1958, is that there was no need for direct decompression of the neural elements. In comparison, Cloward visualised and decompressed the spinal cord and removed any osteophytes there. Smith and Robinson assumed that by removing the disc, and fusing the bodies, the osteophytes would be resorbed, and decompression of the skeletal structures was achieved. They then placed iliac bone grafts in the disc spaces and the incision created was then closed [5].

Following their original paper in 1958, a follow-up was conducted and published in 1962. A more comprehensive study and follow-up was conducted which included the results of their first 55 patients [6]. It was found that the fusion rate was around 88%. They concluded that “when other treatment seems impractical, anterior interbody fusion appears to be good surgical treatment for degenerative joint and disc disease of the cervical spine” [6]. This was then followed by another review in February 1969, in which a report on 93 consecutive cases was published in the Journal of Neurosurgery. This included patients who were treated between 1960 and 1964. They found their treatment to be successful, eliminating pain for most patients who were operated on [7].

In June 1956, Dr Smith left John Hopkins to assume his new role at the Medical College of Georgia as Chief of Neurosurgery and Associate Professor. A month later he was promoted to Professor. During his time at the Medical College of Georgia, Dr Smith started working on building a residency programme for the university. Following on from this, he continued his medical research and innovation. In 1960, Dr Smith created the vessel encircling clip for brain aneurysms. This was a very important advancement as it allowed the surgeon to tackle aneurysms on the arterial wall opposite the surgeon, which was previously far more challenging [8].

Dr Smith then moved on to develop the automatic drill. Smith wanted a device which could drill through the skull but stop as soon as it penetrated the last layer of bone. He published his ideas in the Journal of Neurosurgery in 1950 [9]. However, it was much later, on 8th July 1958, that Dr Smith was awarded a patent for his idea of an automatic drill. The simple idea was that once the drill had passed the outer and inner parts of the skull, there is a pressure change. Smith found a way for the drill to detect this change and disengage the drill automatically. He commented that this new drill offered a whole host of advantages to neurosurgery. Smith found that his new drill markedly reduced operating times, with a far more efficient way to open the cranium. The safety of operations was far greater, as there was a much smaller chance of hitting brain matter. Before this invention, surgeons had to take into consideration the thickness of the skull, which differed from patient to patient. However, this became redundant with the automatic drill. It was also found that the drill produced sizeable chips of bone which could be used to fill in the defect created by the drill [10]. These points illustrate how this invention of Smith’s may have been his greatest contribution to neurosurgery.

Dr Smith was a man who travelled very frequently and so this led him to obtain his own private flying license, which allowed him to fly his own aircraft. However, unfortunately it was this which led to his untimely demise. In April 1964, on his way to a routine meeting to the Harvey Cushing Society, Dr Smith’s plane crashed in North Texas, killing him as well as his wife and mother-in-law [11].

Dr George W Smith has been regarded as one of the key surgeons in the innovation of spinal surgery. His inventions in anterior cervical decompression and fusion, as well as the creation of the automatic drill, are achievements which benefit thousands to this day.


References

1. Viers A. (2012). Historical Vignette: George W. Smith, George Health Sciences University http://www.ganeurosurgical.org/files/Spring_2012/Angela%20Viers,%20MD%20-%20George%20Smith%20Historical%20Vignette.pdf

2. Smith G, Miller J. STILBAMIDINE FOR TIC DOULOUREUX. Lancet [Internet]. 1955;266(6892):723. Available from: http://www.sciencedirect.com/science/article/pii/S0140673655922856

3. Robinson RA, Smith GW. Anterolateral cervical disc removal and interbody fusion for cervical disc syndrome. Vol. 96, Bull. Johns Hopkins Hosp. 1955. p. 223–4.

4. Smith GW, Robinson RA. The treatment of certain cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion. Vols. 40-A, J. Bone Jt Surg. 1958. p. 607–24.

5. Bohlman HH. The Cervical Spine Surgery Atlas. 2nd ed. JBJS [Internet]. 2004;86(10). Available from: https://journals.lww.com/jbjsjournal/Fulltext/2004/10000/The_Cervical_Spine_Surgery_Atlas__2nd_ed_.35.aspx

6. Robinson RA, Walker AE, Ferlic DC, Wiecking DK. The Results of Anterior Interbody Fusion of the Cervical Spine. JBJS [Internet]. 1962;44(8). Available from: https://journals.lww.com/jbjsjournal/Fulltext/1962/44080/The_Results_of_Anterior_Interbody_Fusion_of_the.7.aspx

7. Riley LH, Robinson RA, Johnson KA, Walker AE. The Results of Anterior Interbody Fusion of the Cervical Spine. J Neurosurg [Internet]. 1969;30(2):127–33. Available from: https://thejns.org/view/journals/j-neurosurg/30/2/article-p127.xml

8. Louw DF, Asfora WT, Sutherland GR. A brief history of aneurysm clips. Neurosurg Focus. 2008;11(2):1–4.

9. Smith GW. An Automatic Drill for Craniotomy. J Neurosurg [Internet]. 1950;7(3):285–6. Available from: https://thejns.org/view/journals/j-neurosurg/7/3/article-p285.xml

10. Smith GW. An Automatic Drill for Graniotomy. Hosp Top [Internet]. 1951 Apr 1;29(4):47. Available from: https://doi.org/10.1080/00185868.1951.9951539

11. Viers A, Smith J, Alleyne Jr CH, Allen Jr MB. Neurosurgery at Medical College of Georgia, Georgia Regents University in Augusta (1956–2013). Neurosurgery [Internet]. 2014 May 9;75(3):295–305. Available from: https://doi.org/10.1227/NEU.0000000000000421