JAMESGardner (1898–1987) is best remembered for his skull tongs and his theories on congenital hindbrain abnormalities and hydromyelia. Few of today’s practitioners, however, know about the breadth and depth of the accomplishments of this great teacher and pio-neer neurosurgeon. Gardner’s career straddled the transition of neurosurgery from an art practiced by few individuals to a science that has evolved into the current complex array of subspecialities. Through his diverse activities in the aca-demic neurosurgical arenas of patient care, education, and clinically relevant research, Gardner helped to strength-en the fledgling discipline. During his three decades at the Cleveland Clinic, he served actively in many important ca-pacities and strongly believed in and enjoyed the concept of group practice. In addition, the tradition of clinical research and academic excellence established by Gardner laid the foundation for the accomplishments of the neurosurgery de-partment at his institution and continues to be an important part of its mission.
Biographical Sketch
W. James Gardner was born in McKeesport, Pennsyl-vania on June 12, 1898, and attended McKeesport High
School. He spent his boyhood summers hunting and fish-ing in the Allegheny forest and maintained this love of out-door activity throughout his life. Both of Gardner’s parents, his two sisters, and their housekeeper died of tuberculosis before he finished high school. He received a B.A. degree from Washington and Jefferson College in 1920 and on graduating from medical school in 1924 was appointed to a 2-year rotating internship at the University of Pennsylva-nia. Gardner’s father, Gardner, and his son (William James Gardner III) all graduated from the University of Pennsyl-vania in (1894, 1924, and 1954, respectively), thereby keep-ing intact the family tradition of graduatkeep-ing a James Gard-ner every 30 years from the University of Pennsylvania. He married a clinical psychologist, Ann Ray Kieffer, in 1928. He participated in sports with the same zeal and energy that he gave to his scientific pursuits. He took up tennis and ice skating, whereas his skiing career was cut short when he broke his tibia in an accident. He was an excellent dancer, even inventing shoes for dancing on carpet, was a member of a barbershop quartet of colleagues from the Clinic, and thoroughly enjoyed giving and attending a good party.
Gardner and Frazier: The University of Pennsylvania (1926–1929)
Two key events were to occur in Gardner’s life that led to
Historical vignette
W. James Gardner: pioneer neurosurgeon and inventor
NARENDRANATHOO, M.D., PH.D., MARCR. MAYBERG, M.D., ANDGENEH. BARNETT, M.D. Brain Tumor Institute and Department of Neurosurgery, Cleveland Clinic Foundation,Cleveland, Ohio
¥ W. James Gardner, a skillful neurosurgeon and inventor, is best remembered for his cervical tongs and hydrodynam-ic theory of syringomyelia.
A pioneer of modern neurosurgery, Gardner trained under Charles Frazier in Philadelphia, and in 1929 he moved to Ohio where he became chief of neurosurgery at the Cleveland Clinic, a position he was to hold for the next 33 years. A large surgical practice made it imperative for Gardner to develop surgical methods that were quick, effective, and advantageous for patient and surgeon. He was an early proponent of the sitting position for patients undergoing cra-nial surgery, which led to the development of a neurosurgical chair with a head fixation device. To reduce the risks of hypotension and air embolism when the patient is in the sitting position, Gardner invented the clinical G suit. He was the first to advocate and use induced arterial hypotension for intracranial surgery and the first neurosurgeon in the US to publish his experiences performing lumbar discography. He converted an operating table so that he could induce hypothermia during aneurysm surgery and then applied pneumatic cuffs to occlude the major arterial supply to the brain. His pioneering work has been documented in many other areas such as hemifacial spasm and trigeminal neural-gia, for which he performed the first vascular decompression, in cervical sympathectomy for treatment of various ail-ments, and in the use of intrathecally delivered steroid drugs for sciatica. During his career, he authored 256 publica-tions and one book on the dysraphic states. Many of his contribupublica-tions to the discipline of neurosurgery are now taken for granted.
KEYWORDS • W. James Gardner • hydromyelia • trigeminal neuralgia •
skull tongs • neurological history
W
Abbreviations used in this paper: CSF = cerebrospinal fluid;
his interest in neurosurgery and his subsequent move to the Cleveland Clinic. In a sense, both were related to his as-sociation with Professor Charles H. Frazier, who was the chairman of the surgical department at the University of Pennsylvania. Frazier was a pioneer neurosurgeon, who al-so maintained a busy general surgical practice, with a spe-cial interest in thyroid problems.
The first event that impacted his life and career was an unexpected vacancy on Frazier’s service that coincided with the beginning of Gardner’s mandatory 3-month ro-tation in neurosurgery in April 1926. This was created by the decision of Frazier’s assistant, Temple Fay, to spend 2 years on William G. Spiller’s neurology service. Rotation on Frazier’s service had become unpopular among the in-terns because of its demanding nature and the Chief’s stern demeanor. Gardner’s plan was to practice general surgery as his father had done, and he believed that he could weath-er this expweath-erience. To Gardnweath-er’s dismay, howevweath-er, he found himself, a neophyte, alone in an extremely busy clinical sevice. He worked very hard, day and night, to keep up with the workload, and gradually found himself becoming impressed with Frazier’s personality, dedication, and surgi-cal skill—and with neurosurgery. When Frazier still had not found a new assistant at the end of his initial rotation, Gard-ner volunteered for another 3 months. At the end of that second rotation Frazier still had not found a new assistant, so Gardner, having enjoyed his stint in neurosurgery, vol-unteered for a third 3-month rotation. After this, he wrote, “the die was cast,” as he became Frazier’s assistant for the next 3 years at a salary of $125 a month.16One of Gardner’s
highlights during his residency was to attend clinical con-sultations between Frazier and Spiller, at which, despite their respect for each other, there was almost certain to be an argument—especially on where to turn the bone flap.
As a resident, Gardner conducted considerable research, such as studying the effect of various substances on intra-cranial pressure and a comprehensive review of an extended family from Pennsylvania whose members had hereditary bilateral acoustic neuromas. In 1930, with Frazier as coau-thor, he reported a field survey of five generations of a fam-ily in which central neurofibromatosis was found, showing clearly mendelian dominant-type inheritance.38 They
per-formed surgery on a seventh-generation family member54
and finally managed to convince Dr. Eldridge of the Na-tional Institutes of Health to study this family.73This was
the first report of hereditary deafness resulting from bilater-al acoustic neuromas.
The Cleveland Clinic Years The Interview
The second happenstance to alter Gardner’s life was the Cleveland Clinic disaster. On May 15, 1929, an explosion of smoldering x-ray films occurred in the basement of the outpatient department of the Clinic. The poisonous gas that was released took the lives of 123 people, including the clinic’s first neurosurgeon, Charles E. Locke, who had trained with Harvey Cushing. This accident led to the de-velopment of a new composition for x-ray films and to new regulatory processes regarding their storage.
The clinic, as the result of this catastrophe, found itself badly in need of a neurosurgeon to assume the leadership of
the now busy service. Clinic records show that George Crile Sr. (one of the four Cleveland Clinic founders and a co-founder of the American College of Surgeons) had writ-ten to Frazier, expressing interest in Francis “Chubby” Grant. Frazier, though, who had approximately 5 years left until his retirement, wanted Grant to take over the unit at the University of Pennsylvania. Frazier instead recommended Gardner for the position.
By coincidence, Gardner was scheduled to present a pa-per on the therapeutic effects of encephalography at a meet-ing of the Pennsylvania State Medical Society in Erie in September 1929. Dr. Lower, a urologist and another of the Clinic’s founders, was in attendance specifically to invite Gardner for a visit to the Clinic. Gardner accepted and was entertained that evening by the Criles and Lowers. The fol-lowing morning he was escorted to the Clinic by Dr. Lower, purportedly to meet the staff. Instead Gardner was taken to the bed of a patient who 2 weeks previously had been sur-gically treated by a general surgeon for an unlocalized brain tumor. A right subtemporal decompression had been per-formed but no tumor had been disclosed. On clinical ex-amination, Gardner found that the patient exhibited papil-ledema with a Broca aphasia and made a diagnosis of a left temporal tumor. Lower then suggested that Gardner re-move the tumor; however, Gardner declined because he had commitments in Philadelphia the next day. Lower then led Gardner to the surgical pavilion where an operating room was prepared for a craniotomy. Unable to resist the oppor-tunity to demonstrate his surgical skills, Gardner performed a large left-sided osteoplastic flap, removed a large globu-lar meningioma, and finished the surgery in 2 hours and 20 minutes. With this display of his clinical acumen and surgi-cal skill, the job was his with a salary of $6000 per year.16
Luck was on Gardner’s side; the stock market crashed 30 days later and the Great Depression began in the US. So began his career as Chief of Neurological Surgery at the Cleveland Clinic, an association that was to last for 33 years. After he stepped down as chief in 1962, he was a se-nior consultant with the department until his first retirement in 1964.
Postretirement Years (1964–1974)
After mandatory retirement from the Cleveland Clinic in 1964 at the age of 65 years, Gardner opened a private prac-tice in the Greater Cleveland area, was the head of neuro-surgery at the Fairview General Hospital (1964–1967), and was on the staff at the Huron Road Hospital from 1964 to 1974. With the establishment of an emeritus program at the Cleveland Clinic, he rejoined the Department of Neurosur-gery staff after his second retirement in 1974.
Gardner’s Contributions to Neurological Surgery Gardner’s busy and diverse practice at the Clinic placed him in a unique position to make contributions in many as-pects of neurosurgery. A brief review of some of his impor-tant contributions follows.
Neurotrauma Chronic Subdural Hematomas
resident) on a brain tumor, a nurse from the ward mentioned to them that a patient who had undergone evacuation of a chronic subdural hematoma the previous day was dying. Gardner sent LaLonde to assess the patient and to perform an LP to rule out recurrent bleeding. The resident found the patient in a Cheyne–Stokes respiratory pattern and the LP revealed a very low pressure. Gardner then requested that LaLonde repeat the LP and inject saline until the pressure was restored. The resident reported that after he had inject-ed 60 ml of normal saline into the lumbar subarachnoid space, the previously comatose patient awoke, looked over his shoulder, and said, “What the hell is going on back there?” From then on the compressed hemisphere was reex-panded during surgery in each patient with a chronic subdu-ral hematoma.62Gardner also described the latency period
of these lesions by performing animal experiments.30,49
Spinal Surgery Lumbar Discography
After Lindblom’s initial description in 1948, the first lumbar discography in the US was performed at the Cleve-land Clinic by Wise and Weiford in 1951, with Gardner, et al.,42following shortly thereafter in March 1952 with the
second paper. The next 89 cases in which this modality was used were reported by Wise, et al.,72in June 1952; an
ad-ditional 165 lumbar discographies were later reported in 1957.71In 1962, Collis and Gardnes2described their
expe-rience examining 1014 cases, the largest series reported at that time. Four hundred ninety-three of 1014 patients who underwent lumbar discography subsequently underwent surgery in which fewer interspaces were explored surgi-cally, resulting in less trauma to nerve roots, while the inci-dence of multiple herniations was 1.5% (410 surgically ver-ified herniated discs in 404 patients). In the discussions that followed its publication, the paper received mixed reviews, with Ralph Cloward strongly endorsing the results. In 1951, both Gardner and Cloward independently exhibited their technique of lumbar discography at the American Medical Association convention in Atlantic City.
Epidural Steroid Delivery/Pantopaque Arachnoiditis Based on his previous work with Seghal on corticoste-roid agents administered intradurally for relief of sciati-ca,67Gardner, Sehgal, and Dohn15published in a non–peer
reviewed journal their experience with subarachnoid in-jections of methylprednisone acetate for patients suffering from Pantopaque “arachnoiditis.” In 60 of 100 patients they managed to reduce the radicular pain with no adverse ef-fects for a period of up to 2 years.
Spinal Specialization
By the 1960s, after a neurosurgical career spanning more than 3 decades and having witnessed the increasing special-ization of surgery for spinal degenerative diseases, Gardner sent out a questionnaire to all neurosurgical chiefs to evalu-ate current trends in disc surgery in their units. In an invit-ed invit-editorial publishinvit-ed in Surgery Gynecology and Obstet-rics in 1965, Gardner12wrote, “The surgeon who operates
within the spinal canal should be prepared by training and experience to handle any type of surgical lesion that he may
encounter.” He therefore made an impassioned plea “. . . that less qualified surgeons in spine must be discouraged from expanding into this essentially neurosurgical field which is fraught with pitfalls for the inexperienced.”
Hydrodynamic Theory for Congenital Hindbrain Anomalies
Gardner’s hydrodynamic theory on the pathophysiolo-gy of syringomyelia and other dysraphic states was based on his clinical experiences.16In brief, Gardner believed that
each systolic pulse generated a pressure gradient through-out the CSF (Bering effect) that tended to force the CSF through-out of the ventricles. He suggested that this hydrodynamic ef-fect was responsible for the formation of the subarachnoid pathways when the rhombic membrane ruptured, but that it also played a role in shaping the developing brain. If failure or inadequate rupture of the rhombic membrane occurred (fourth ventricular outlet obstruction), the pulsatile CSF would then flow through the patent obex and enter the cen-tral canal with the resultant “water-hammer” pulse effect causing dilation of the central canal, leading to syringo-myelia, whereas an open neural tube was due to overdis-tension and rupture rather than failure to close.7,8,12,21,27,33,35,36, 41,43Therefore, depending on the delicate balance between
lateral ventricle and fourth ventricular choroid plexus pul-satility, he believed that the Dandy–Walker and Chiari mal-formations were part of the same spectrum of disease, and that both were caused by embryonal hydrocephalus.
Gardner was a steadfast believer in and defender of the hydromyelic theory of Morgagni, which was proposed in 1769. In his 1960 paper on myelomeningocele Gardner22
starts off with a quote from Roger Bacon (ca. 1214–1294) about the four stumbling blocks of truth, and goes on to crit-icize Von Recklinghausen, who in 1886 discredited Mor-gagni’s hydromyelic theory. Furthermore, Gardner believed that “solely on the basis of appearance,” Von Reckling-hausen assumed that myeloschisis represented a failure of neural tube closure rather than rupture, as Gardner believed. He goes on to state that “Therefore to this day, because of custom and influence of the great Von Recklinghausen’s authority, the araphic theory has gone unchallenged even though embryological, pathological, clinical, and experi-mental evidence favors Morgagni’s less fragile hypothesis.” In 1973, using a combination of his clinical experience as well as expertise in physics, physiology, embryology, anat-omy, and ultrastructure, Gardner published his monograph called “The Dysraphic States: From Syringomyelia to An-encephaly.” Recently, Gardner’s hydrodynamic theory has been partially corroborated with magnetic resonance imag-ing findimag-ings.66
Functional Neurosurgery Hemifacial Spasm and TN
Gardner’s lifelong interest in TN began during his resi-dency in 1926. As early as 1915, Frazier began to practice subtotal sectioning of the sensory root and in 1918 he pro-posed sparing the motor root. This latter technique was put to the test when a distinguished lady from Lima, Peru, who had been surgically treated by Frazier in 1917, returned with pain on the contralateral side. During the previous
sur-gery, Frazier had not attempted to spare the motor root. Gardner described the atmosphere in the operating room on the morning of surgery as “tense and electric,” and despite Frazier’s flawless surgery with positive faradic stimulation of the motor root prior to closure, the patient’s chin was seen to be resting on her sternum postoperatively. Much to everyone’s relief, voluntary contractions began to appear in the masseter 10 days later.16
Based on clinical experience, Gardner believed that TN is a symptom rather than a disease, which may present in conditions such as multiple sclerosis, basilar impression, or in relation to tumor or vascular compression, either in the posterior fossa or the middle cranial fossa.9,20,37,45
Expand-ing on the hypothesis supported by Olivecrona,65Lee,63and
Taarnhøj,69Gardner initially believed that the pain of TN
was caused by the development of an artificial synapse in the sensory root fibers where the nerve crossed the apex of the petrous bone.11This artificial synapse was caused by
demyelination secondary to the development of a sagging tentorium, which was accompanied by advancing age and humans’ upright posture. This sagging tentorium, which may be further influenced by the mild platybasia second-ary to osteoporosis, transformed the normally oval-shaped dural foramen that transmits the nerve into a relatively flat slit.31,44,53This change in shape led to neural distortion that
resulted in focal demyelination, leading to short circuiting of sensory action potentials, thereby forming, in effect, an artificial synapse. Although Dandy in 1934 had made the observation that the trigeminal nerve was often cross-com-pressed by a neighboring elongated artery or sometimes a vein, the first reported vascular decompression of the nerve was performed by Gardner. In 1959, Gardner and his Fel-low, Miklos,25published their results of “decompression” of
the sensory root in a series of 200 patients with TN who were followed up for as long as 6 years. One hundred of the patients made up the Cleveland series, in which the ap-proach was primarily extradural, whereas the other 100 patients (Copenhagen series) underwent an intradural ap-proach. In the combined series, 62% of the patients report-ed a complete response, 11.5% had a mild recurrence, and 26.5% had severe recurrences. Sensory loss was present in 26% of the patients with complete response and in 28% of those in whom treatment failed. This led Gardner to believe that neither surgical trauma to the nerve root nor incision of its dural sleeve was essential to the success of the surgery. He believed that hemifacial spasm, on the other hand, lacked the characteristics of self limitation and a refractory period typical of a reflex, and that these motor paroxysms could best be explained on the basis of a peripheral rever-berating circuit set up between the afferent (proprioceptive) and efferent fibers at the point of compression.15Gardner
also showed that paroxysms of hemifacial spasm, like TN, may be stopped immediately and with no impairment of function by a nontraumatic manipulation of the nerve root.47
Gardner found that in 19 patients with hemifacial spasm, eight had vascular compression of the seventh cranial nerve. His work preceded the use of the intraoperative mi-croscope, however, and therefore he was unable to inspect the dorsal root entry zone adequately.15,47
Surgery for the Autonomic Nervous System
Gardner routinely practiced cervical and stellate ganglion
sympathetic blocks for cerebral embolus, thrombosis, and causalgia of the upper limbs, and for trauma to the brain. In 1946, Karnosh (a neuropsychiatrist at the Cleveland Clinic), Gardner, and Stowell62reported the effects of
tem-porary cerebral sympathectomy accomplished by bilateral stellate ganglion blocks on organic brain diseases and psy-choses.60,61This discovery occurred incidentally in January
1946 when a 38-year-old woman received bilateral stellate blocks for cerebral embolus accompanied by hemiplegia and Dejerine–Roussy syndrome. This led to the implemen-tation of this procedure in a series of patients with cere-bral vascular disease, brain atrophy, and Parkinson disease. Most patients were enthusiastic about the improvement that they claimed the procedure produced, although motion pic-ture analysis revealed no improvement in motor function and it was believed that this apparently impressive improve-ment in mood was caused by the sympatholytic effects. Karnosh and Gardner decided to try bilateral stellate gan-glion procaine blocks in a small group of patients suffering from depression and anxiety and in patients with known schizophrenia. In three patients with depression, the tempo-rary sympathetic block resulted in an improvement of af-fect, a relative euphoria, transient relief from suicidal idea-tion, and psychomotor retardation. No effect was observed in psychotic patients.59
Gardner: As Inventor
Gardner believed that his research had to have a direct clinical application, otherwise he would pay the issue scant attention. Despite his immense clinical workload, he still had the energy to explain clinical phenomena and help sick patients, and never went without some project to occupy his time. Each problem was followed through with dogged determination even though the initial results were often enough to discourage the most enthusiastic researcher. His inventiveness, combined with hard work and determiation, was among his greatest attributes. We briefly review some of his inventions.
The Gardner Neurosurgical Chair (1938)
During his residency, Gardner learned that Frazier had recognized the tremendous advantage of placing a patient in the sitting position while performing surgery for TN.16,19
Frazier commented that this position prevented a puddle of blood from covering the nerve filaments, placed the opera-tive field comfortably at the level of the surgeon’s eyes, and that smaller amounts of anesthetic agents could be used. In addition, de Martel started using the sitting position in 1911 and found that it decreased hemorrhage and aided respira-tion. De Martel favored operating with the patient in the sit-ting position after induction of local anesthesia so that early recognition of syncope could be corrected by lowering the patient’s head. Gardner mentions one occasion when Fra-zier, on returning from a visit to de Martel’s clinic in Paris, recounted what he saw when the famous French neurosur-geon performed surgery while the patient received local an-esthesia. De Martel had apparently performed a suboccip-ital craniectomy for a cerebellar tumor in an 11-year-old girl whom he made straddle a wooden chair, cross her arms on its back, and rest her head on her forearms. Frazier de-scribed this as a “horrible exhibition.”16
Gardner started using the sitting position in 1930 and soon came to realize its benefits, especially when he per-formed surgery on the posterior fossa or the posterior neck region. Gardner reviewed his series of 56 suboccipital cra-niectomies and 78 supratentorial craniotomies performed with patients in the sitting position.19From this experience
he recognized the dangers of hypotension and air embolism when using this position; as a result, Gardner developed a neurosurgical chair equipped with a head clamp for rigid fixation that could be used to position the patient’s head firmly in any position during surgery. He built the first mod-el of the Gardner chair in 1938 and then a later version in 1955.22A modified version of the Gardner chair (Fig. 1) is
still used today by the senior author (G.H.B.) for selected cases.
Tantalum Cranioplasty (1944)
Although Fulcher was the first to report the use of tanta-lum in repairing a cranial defect, it was Gardner who pop-ularized this material (pure metal: 73rd element in the Pe-riodic Table). Using a thinner sheet (to reduce the degree of radiopacity) cut by conventional scissors and molded, Gardner advocated its use in primary repair of cranial de-fects,29,70even in the presence of intracranial infection.32 Constant Traction Dressing (1945)
Gardner’s war experience fueled his interest in crani-al wounds.14,25,29Together with Seitz, a research engineer at
the Cleveland Clinic, he developed the constant traction dressing which was more comfortable than the usual gauze dressing.45More importantly, however, the skin edges
un-derwent progressive approximation resulting in a narrower scar, in some cases averting the need for secondary suturing and/or skin grafting.13The dressing consisted of two metal
members (0.004 in thick) connected by a sheet of latex. The metal spurs were short so that they only penetrated the stra-tum corneum and did not cause pain. As approximation of the wound occurred, shorter dressings were applied.48 Induced Hypotension for Hemostasis (1946)
Gardner was the first to apply the method of controlled hypotension during surgery as an aid to hemostasis.10,39He
believed that intravenous transfusions given to a patient in severe shock must pump the intravenous injected blood through the pulmonary circulation and then out into the aorta, before the heart itself can benefit. Believing that the primary function of the heart was to maintain a normal level of pressure in the elastic aorta and that patients in severe shock who were given intravenous fluids would experience an additional strain on an already ischemic heart, he thought that intraarterial infusion of fluids would restore the cere-bral and coronary blood flow more rapidly before the bur-den of an increase in venous pressure and blood volume are “thrown onto the weakened heart” (Page procedure). This, according to Gardner, appeared to be a more physiological than intravenous infusion of the blood in severe hemorrhag-ic shock. He reported the benefhemorrhag-icial effects of controlled hypotension in 161 patients during a 6-year period (1946– 1953). Forty-six of 161 patients with difficult intracranial meningiomas who were treated using the Page procedure were compared with another group of 44 patients in whom intracranial meningiomas were surgically treated during
the same period. A mortality rate of 8.7% (Page procedure) compared with 13.6% (without the technique) was record-ed. For cerebral aneurysms, Gardner preferred to induce hy-potension with one of the ganglion blocking drugs rather than the Page technique. In his paper on meningioma and hypotension, Gardner mentions that “surgeons with their natural repugnance to blood loss have been slow to adopt a procedure which entails deliberate removal of blood from the circulation.” Illustrative of this reluctance, Gardner notes that one advocate of the “total spinal method” had re-ferred shudderingly to the Page procedure as the “oligemic shock method.”42
Alternating Pressure Pad (1948)
Gardner developed the alternating pressure pad (Fig. 2) and used it first at the Clinic in July 1947. He analyzed 100 consecutive patients in whom the mattress was used and found the value of the pressure pad to be so obvious that all patients who required the pad were given this form of care, so that he was unable to perform a subsequent randomized study. Gardner calculated that he saved 1 hour of a nurse’s time per patient per day with the pressure pad.23,43
The Clinical G Suit (1956)
Following his service in World War II, Gardner realized the potential of the antigravity suit that prevented blackouts in fighter pilots. He modified the G suit to consist of two sheets of vinyl plastic sealed at the edges to form a large inflatable bladder that was placed beneath the patient. The edges were folded over so that the patient was enclosed from the rib cage to the ankles, and the entire contraption
FIG. 1. Photograph showing the Gardner neurosurgical chair. The chair could be raised or lowered by a foot pump and also rotat-ed around a vertical axis. Using a crank, it was tiltrotat-ed backward like a rocking chair so that the patient’s feet could be higher than the head. It still provides more favorable positioning for cranial surgery with the patient sitting than most modern surgical tables. A slot in the back allowed the surgeon to perform an LP during surgery, if required. By adding a table top to the backward-tilted chair and a three-point head fixation device, the supine patient could be readied for craniotomies. The chair was also accompanied by a lifter that could lower the patient into an adjacent bed.
was drawn snug by lacing. The system had a manometer and was inflated by a gas tank (Fig. 3). If a patient experi-enced hypotension while in the sitting position or if Gardner anticipated hypotension in any position, the clinical G suit could be inflated in a matter of seconds.17,50The clinical G
suit helped save the life of a staff member’s wife after she developed postpartum hemorrhaging which, after 11 hours of futile surgical efforts to control intraabdominal bleed-ing, had resulted in 56 blood transfusions administered over a period of 18 hours. She was placed in the G suit at a pressure of 20 mm Hg and this raised her blood pressure, stopped the bleeding, and saved her life.52
In their 1956 paper, Gardner and Dohn wrote that while doing a literature search, they discovered that one of the earliest descriptions of the antigravity suit had been made by George Crile Sr.3in 1903. He abandoned this work,
how-ever, because of technical difficulties with his suit (con-structed from India rubber), while at the same time improv-ing methods that had been developed for blood transfusion. The principle of applying the G suit to combat hypotension has been documented in many publications.4,6,17,50
Hypothermia With Temporary Occlusion of Major Brain Arteries by Pneumatic Cuffs (1956)
Gardner developed pneumatic cuffs that were used to oc-clude the four major arterial vessels to the brain simultane-ously during aneurysmal rupture so that the surgeon could ligate or clip the aneurysm while the patient was in a state of hypothermia.46One end of moistened cellophane tubing
(1 cm in flat width and 8 cm in length) was tied to the ampu-tated end of a No. 8 French gauge soft rubber catheter into which a 16-gauge syringe had been previously inserted on the opposite end. The other end of the cellophane tubing was ligated and both proximal and distal ends were tied, thus forming a loop with the No. 8 French catheter protrud-ing from one end of the tubprotrud-ing with the syrprotrud-inge on its oppo-site end. Air from the syringe introduced into the catheter
expanded the cellophane tube, thus occluding the artery. In applying the device, the cellophane tubing was passed twice around the common carotid artery with the distal end tied to the proximal end, where it was fastened to the catheter. To occlude the vertebral artery, it was only necessary to expose a cervical vertebral foramen and draw the cellophane cuff partly through it. The four catheters were then connected by a series of T-tubes to an ordinary blood pressure apparatus so that all four arterial cuffs could be simultaneously acti-vated.46To induce hypothermia, Gardner, Wasmuth (an
an-esthesiologist), and Hale35converted an operating table into
a refrigerating trough by enclosing the patient in a water-tight plastic sheet draped over a rectangular frame and then submerging only the body in ice water.
Gardner–Wells Cervical Traction Tongs (1959)
In 1959 Gardner developed his cervical skull traction tongs and later, with Wells, improved the design for emer-gency bedside application under antiseptic rather than asep-tic conditions. His design maximized the mechanical effi-ciency of the tong for cervical traction by repositioning the upward-directed tapering pins to engage in the outer ta-ble of the temporal bones at points between the ears and the skull’s equator (Fig. 4). The principal advantage over the Crutchfield tongs was that no shaving was necessary, and after application of a local anesthetic agent, advancing the tapered points through the scalp caused the stretched skin to fit snugly about the pins, thereby sealing their point of entry, which prevented bleeding. One of the points was rendered retractable by an enclosed spring that was calibrated to in-dicate the pressure. On encountering bone, the stiff spring yielded until the outer end of the spring-loaded point bare-ly protruded beyond the flat surface of the knurled end. Gardner later simplified the construction and developed safeguards against perforations of the inner table.1,24 The
Gardner tongs are now widely used in many institutions.
FIG. 2. Photograph showing alternating pressure pad. The
alter-nating pressure pad mattress is constructed of a flexible waterproof plastic material. The apparatus consists of a pneumatic mattress with air cells 3 cm in diameter that run transversely the width of the mattress, with alternate cells connected to a manifold that consti-tutes the edge of each side of the mattress. Alternating inflation and deflation of the transverse cells occurs at intervals of 2 to 3 minutes so that the patient’s body is alternately resting on the odd-numbered cells and then on the even-numbered cells. The inflation and defla-tion of the two air systems is driven by a small air pump.
FIG. 3. Photograph showing the clinical G suit, which consisted of two sheets of vinyl plastic sealed at the edges to form a large inflatable bladder, so that the patient was enclosed from the rib cage to the ankles; the entire contraption was drawn snug by lacing. The system included a manometer and the suit was inflated by a gas tank.
Waterbed and Hammock (1961)
Gardner developed a waterbed for children who were prone to pressure sores due to hydrocephalus. The infant was floated on a bag of water, which was made redundant and relaxed by placing it in a box or crib. An alarm system was incorporated to detect leakage and the water tempera-ture could be thermostatically controlled. Gardner also de-veloped a hammock that prevented an infant with scapho-cephaly from resting on the flat side of its head, thereby preventing an increase in the deformity.40
The G Splint (1962)
The G splint (Immobil-Air), developed in 1962, was a spinoff from the clinical G suit. This pneumatic splint, in-flated by mouth in a matter of seconds, was designed as a first-aid device to be used in an emergency to stabilize the patient from hemorrhaging in the extremity and to immobi-lize the broken limb. This pneumatic splint was a double-walled sleeve of transparent plastic film in which air was forced between the two layers, resulting in compression of the limb by the inner layer, whereas the outer layer tended to elongate, exerting a splinting effect and traction.18
After delivering a lecture on syringomyelia to the neuro-surgery staff at McGill University in Canada, Gardner no-ticed Wilder Penfield walking with a slight limp in the cafe-teria. While picking up his food tray, Penfield experienced a sudden pain in his knee. Raising his trouser leg, a rapid swelling in the knee due to spontaneous hemorrhage was diagnosed; this occurred in an old knee injury sustained when a torpedo in World War I struck Penfield’s destroyer. An orthopedist present in the cafeteria ordered immediate bed rest and a compression bandage. Gardner, however, had a sample of the G splint with him, and he quickly applied it directly over the trouser on Penfield’s leg, thus stopping the bleeding. Penfield subsequently wrote to Gardner request-ing another splint and in his letter of thanks he mentioned that he never subsequently left home without it.16
Other Gardner Inventions and Contributions
His pioneering contributions to neurosurgery occurred in several other areas such as cerebral hemispherectomy26in
the treatment of glioma, and treatment of carotid–cavernous fistula by muscle embolization.58Among Gardner’s other
lesser known inventions was his adaptation of the Sout-tar craniotome (1929) soon after arriving at the Cleveland Clinic (this was used until power tools for opening the skull were introduced in the 1960s);16the development of a
neu-rosurgical suction irrigator;64modification of the respirator
with D. E. Hale (1948);57recording time on roentgenograms
(1954);51and a ventriculomastoid shunt in which a Holter
valve was used for the treatment of hydrocephalus (1962).5
Conclusions
W. James Gardner was a pioneer neurosurgeon, scientist, inventor, and educator (Fig. 5). Many of his contributions to the field are now taken for granted. His theories on the pathogenesis of several neurological disorders have stood the test of time or have served as the foundation on which contemporary theories rest. In total, Gardner trained 28 neu-rosurgeons and 14 others served their fellowships with him; this was in addition to the many general surgical residents who passed through his service.
His genius has not gone unrecognized by neurosurgical organizations and the Cleveland Clinic. During his neu-rosurgical career, Gardner was active in many national and regional organizations. He was President of the Society of Neurological Surgeons, Vice President of the Cushing Soci-ety, on the Board of Governors of the American College of
FIG. 4. Photograph showing the Gardner–Wells cervical traction
tongs. The main structural element is a rigid C-shaped metal bar that roughly conforms to the coronal suture of the skull. Sharp tapered pins positioned at an upward angle at the ends of the C-shaped metal structure are screwed into the skull.
Surgeons, and a member of the American Board of Neu-rological Surgery for 6 years. He was an honorary guest of the Congress of Neurological Surgeons in 1987 and in 1982 received the Cushing Medal from the American Associa-tion of Neurological Surgeons for his contribuAssocia-tions to neu-rosurgery. The Cleveland Clinic and the Department of Neurological Surgery established the annual Gardner lec-tureship in his honor in June 1978.
Acknowledgments
We thank Ms. Martha Tobin (Department of Neurosurgery, Cleveland Clinic Foundation) for helping to edit the manuscript, Fred K. Lautzenheiser and Carol Tomer from the Cleveland Clinic Archives Department for providing access to the archival material (Dr. Gardner’s personal notes and original reprints), for providing assistance with the figures, and for verifying historical accuracy. We also thank Dr. Donald Dohn (former resident and colleague of Dr. Gardner) for verification of historical accuracy.
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Manuscript received September 24, 2003. Accepted in final form January 12, 2004.
This paper will be presented in part at the 72nd Annual Meeting of the American Association of Neurological Surgeons May 1–6, 2004, Orlando, Florida.
Address reprint requests to: Gene H. Barnett, M.D., Brain Tumor
Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleve-land, Ohio 44195. email: [email protected].
