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JAMES Gardner (18981987) is best rememberedfor his skull tongs and his theories on congenitalhindbrain abnormalities and hydromyelia. Few of

todays practitioners, however, know about the breadth anddepth of the accomplishments of this great teacher and pio-neer neurosurgeon. Gardners career straddled the transitionof neurosurgery from an art practiced by few individuals toa science that has evolved into the current complex arrayof subspecialities. Through his diverse activities in the aca-demic neurosurgical arenas of patient care, education, andclinically relevant research, Gardner helped to strength-en the fledgling discipline. During his three decades at theCleveland Clinic, he served actively in many important ca-pacities and strongly believed in and enjoyed the concept ofgroup practice. In addition, the tradition of clinical research

and academic excellence established by Gardner laid thefoundation for the accomplishments of the neurosurgery de-partment at his institution and continues to be an importantpart 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 Gardners parents,his two sisters, and their housekeeper died of tuberculosisbefore he finished high school. He received a B.A. degreefrom Washington and Jefferson College in 1920 and ongraduating from medical school in 1924 was appointed toa 2-year rotating internship at the University of Pennsylva-nia. Gardners father, Gardner, and his son (William JamesGardner III) all graduated from the University of Pennsyl-vania in (1894, 1924, and 1954, respectively), thereby keep-ing intact the family tradition of graduating a James Gard-ner every 30 years from the University of Pennsylvania. Hemarried 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 andice skating, whereas his skiing career was cut short when hebroke his tibia in an accident. He was an excellent dancer,even inventing shoes for dancing on carpet, was a memberof a barbershop quartet of colleagues from the Clinic, andthoroughly enjoyed giving and attending a good party.

Gardner and Frazier: The University of

Pennsylvania (19261929)

Two key events were to occur in Gardners life that led to

J. Neurosurg. / Volume 100 / May, 2004

J Neurosurg 100:965973, 2004

Historical vignette

W. James Gardner: pioneer neurosurgeon and inventor

NARENDRA NATHOO, M.D., PH.D., MARC R. MAYBERG, M.D., AND GENE H. 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 movedto 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 ofhypotension and air embolism when the patient is in the sitting position, Gardner invented the clinical G suit. He wasthe first to advocate and use induced arterial hypotension for intracranial surgery and the first neurosurgeon in the USto publish his experiences performing lumbar discography. He converted an operating table so that he could inducehypothermia during aneurysm surgery and then applied pneumatic cuffs to occlude the major arterial supply to thebrain. 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 contributions to the discipline of neurosurgery are now takenfor granted.

KEY WORDS W. James Gardner hydromyelia trigeminal neuralgia

skull tongs neurological history

W

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Abbreviations used in this paper: CSF = cerebrospinal fluid;LP = lumbar puncture; TN = trigeminal neuralgia.


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his interest in neurosurgery and his subsequent move to theCleveland Clinic. In a sense, both were related to his as-sociation with Professor Charles H. Frazier, who was thechairman of the surgical department at the University ofPennsylvania. 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 anunexpected vacancy on Fraziers service that coincidedwith the beginning of Gardners mandatory 3-month ro-tation in neurosurgery in April 1926. This was created bythe decision of Fraziers assistant, Temple Fay, to spend 2years on William G. Spillers neurology service. Rotationon Fraziers service had become unpopular among the in-terns because of its demanding nature and the Chiefs sterndemeanor. Gardners plan was to practice general surgeryas his father had done, and he believed that he could weath-er this experience. To Gardners dismay, however, he foundhimself, a neophyte, alone in an extremely busy clinicalsevice. He worked very hard, day and night, to keep upwith the workload, and gradually found himself becomingimpressed with Fraziers personality, dedication, and surgi-cal skilland with neurosurgery. When Frazier still had notfound a new assistant at the end of his initial rotation, Gard-ner volunteered for another 3 months. At the end of thatsecond 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 Fraziers assistant for thenext 3 years at a salary of $125 a month.16 One of Gardnershighlights during his residency was to attend clinical con-sultations between Frazier and Spiller, at which, despitetheir respect for each other, there was almost certain to bean argumentespecially 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 extendedfamily from Pennsylvania whose members had hereditarybilateral 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, showingclearly 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.73 This wasthe first report of hereditary deafness resulting from bilater-al acoustic neuromas.

The Cleveland Clinic Years

The Interview

The second happenstance to alter Gardners life was theCleveland Clinic disaster. On May 15, 1929, an explosionof smoldering x-ray films occurred in the basement of theoutpatient department of the Clinic. The poisonous gas thatwas released took the lives of 123 people, including theclinics first neurosurgeon, Charles E. Locke, who hadtrained with Harvey Cushing. This accident led to the de-velopment of a new composition for x-ray films and to newregulatory processes regarding their storage.

The clinic, as the result of this catastrophe, found itselfbadly in need of a neurosurgeon to assume the leadership of

the now busy service. Clinic records show that George CrileSr. (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 ChubbyGrant. Frazier, though, who had approximately 5 years leftuntil his retirement, wanted Grant to take over the unit at theUniversity 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 inSeptember 1929. Dr. Lower, a urologist and another of theClinics founders, was in attendance specifically to inviteGardner for a visit to the Clinic. Gardner accepted and wasentertained 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 tothe bed of a patient who 2 weeks previously had been sur-gically treated by a general surgeon for an unlocalized braintumor. 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 aleft temporal tumor. Lower then suggested that Gardner re-move the tumor; however, Gardner declined because he hadcommitments in Philadelphia the next day. Lower then ledGardner to the surgical pavilion where an operating roomwas prepared for a craniotomy. Unable to resist the oppor-tunity to demonstrate his surgical skills, Gardner performeda large left-sided osteoplastic flap, removed a large globu-lar meningioma, and finished the surgery in 2 hours and 20minutes. 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 Gardners side; the stock market crashed 30days later and the Great Depression began in the US. Sobegan his career as Chief of Neurological Surgery at theCleveland Clinic, an association that was to last for 33years. After he stepped down as chief in 1962, he was a se-nior consultant with the department until his first retirementin 1964.

Postretirement Years (19641974)

After mandatory retirement from the Cleveland Clinic in1964 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 (19641967), andwas on the staff at the Huron Road Hospital from 1964 to1974. With the establishment of an emeritus program at theCleveland Clinic, he rejoined the Department of Neurosur-gery staff after his second retirement in 1974.

Gardners Contributions to Neurological Surgery

Gardners busy and diverse practice at the Clinic placedhim 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

In 1946, while he was operating with Albert LaLonde (a

N. Nathoo, M. R. Mayberg, and G. H. Barnett

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resident) on a brain tumor, a nurse from the ward mentionedto them that a patient who had undergone evacuation of achronic subdural hematoma the previous day was dying.Gardner sent LaLonde to assess the patient and to performan LP to rule out recurrent bleeding. The resident found thepatient in a CheyneStokes respiratory pattern and the LPrevealed a very low pressure. Gardner then requested that

LaLonde repeat the LP and inject saline until the pressurewas restored. The resident reported that after he had inject-ed 60 ml of normal saline into the lumbar subarachnoidspace, the previously comatose patient awoke, looked overhis shoulder, and said, What the hell is going on backthere? From then on the compressed hemisphere was reex-panded during surgery in each patient with a chronic subdu-ral hematoma.62 Gardner also described the latency periodof these lesions by performing animal experiments.30,49

Spinal Surgery

Lumbar Discography

After Lindbloms initial description in 1948, the firstlumbar discography in the US was performed at the Cleve-land Clinic by Wise and Weiford in 1951, with Gardner, etal.,42 following shortly thereafter in March 1952 with thesecond paper. The next 89 cases in which this modality wasused were reported by Wise, et al.,72 in June 1952; an ad-ditional 165 lumbar discographies were later reported in1957.71 In 1962, Collis and Gardnes2 described their expe-rience examining 1014 cases, the largest series reported atthat time. Four hundred ninety-three of 1014 patients whounderwent lumbar discography subsequently underwentsurgery 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 theirtechnique of lumbar discography at the American MedicalAssociation 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,67 Gardner, Sehgal, and Dohn15 published in a nonpeerreviewed journal their experience with subarachnoid in-

jections of methylprednisone acetate for patients sufferingfrom Pantopaque arachnoiditis. In 60 of 100 patients theymanaged 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 morethan 3 decades and having witnessed the increasing special-ization of surgery for spinal degenerative diseases, Gardnersent out a questionnaire to all neurosurgical chiefs to evalu-ate current trends in disc surgery in their units. In an invit-ed editorial published in Surgery Gynecology and Obstet-rics in 1965, Gardner12 wrote, The surgeon who operateswithin the spinal canal should be prepared by training andexperience 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 discouragedfrom expanding into this essentially neurosurgical fieldwhich is fraught with pitfalls for the inexperienced.

Hydrodynamic Theory for Congenital Hindbrain

AnomaliesGardners hydrodynamic theory on the pathophysiolo-

gy of syringomyelia and other dysraphic states was basedon his clinical experiences.16 In brief, Gardner believed thateach systolic pulse generated a pressure gradient through-out the CSF (Bering effect) that tended to force the CSF outof the ventricles. He suggested that this hydrodynamic ef-fect was responsible for the formation of the subarachnoidpathways when the rhombic membrane ruptured, but that italso played a role in shaping the developing brain. If failureor inadequate rupture of the rhombic membrane occurred(fourth ventricular outlet obstruction), the pulsatile CSFwould 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.7,8,12,21,27,33,35,36,41,43 Therefore, depending on the delicate balance betweenlateral ventricle and fourth ventricular choroid plexus pul-satility, he believed that the DandyWalker and Chiari mal-formations were part of the same spectrum of disease, andthat both were caused by embryonal hydrocephalus.

Gardner was a steadfast believer in and defender of thehydromyelic theory of Morgagni, which was proposed in1769. In his 1960 paper on myelomeningocele Gardner22

starts off with a quote from Roger Bacon (ca. 12141294)about the four stumbling blocks of truth, and goes on to crit-icize Von Recklinghausen, who in 1886 discredited Mor-gagnis hydromyelic theory. Furthermore, Gardner believed

that solely on the basis of appearance, Von Reckling-hausen assumed that myeloschisis represented a failure ofneural tube closure rather than rupture, as Gardner believed.He goes on to state that Therefore to this day, becauseof custom and influence of the great Von Recklinghausensauthority, the araphic theory has gone unchallenged eventhough embryological, pathological, clinical, and experi-mental evidence favors Morgagnis less fragile hypothesis.

In 1973, using a combination of his clinical experience aswell as expertise in physics, physiology, embryology, anat-omy, and ultrastructure, Gardner published his monographcalled The Dysraphic States: From Syringomyelia to An-encephaly. Recently, Gardners hydrodynamic theory hasbeen partially corroborated with magnetic resonance imag-ing findings.66

Functional Neurosurgery

Hemifacial Spasm and TN

Gardners lifelong interest in TN began during his resi-dency in 1926. As early as 1915, Frazier began to practicesubtotal sectioning of the sensory root and in 1918 he pro-posed sparing the motor root. This latter technique was putto the test when a distinguished lady from Lima, Peru, whohad been surgically treated by Frazier in 1917, returnedwith pain on the contralateral side. During the previous sur-



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gery, Frazier had not attempted to spare the motor root.Gardner described the atmosphere in the operating room onthe morning of surgery as tense and electric, and despiteFraziers flawless surgery with positive faradic stimulationof the motor root prior to closure, the patients chin wasseen to be resting on her sternum postoperatively. Much toeveryones relief, voluntary contractions began to appear in

the masseter 10 days later.16

Based on clinical experience, Gardner believed that TNis a symptom rather than a disease, which may present inconditions such as multiple sclerosis, basilar impression, orin relation to tumor or vascular compression, either in theposterior fossa or the middle cranial fossa.9,20,37,45 Expand-ing on the hypothesis supported by Olivecrona,65 Lee,63 andTaarnhj,69 Gardner initially believed that the pain of TNwas caused by the development of an artificial synapse inthe sensory root fibers where the nerve crossed the apexof the petrous bone.11 This artificial synapse was caused bydemyelination secondary to the development of a saggingtentorium, which was accompanied by advancing age andhumans upright posture. This sagging tentorium, whichmay be further influenced by the mild platybasia second-ary to osteoporosis, transformed the normally oval-shapeddural foramen that transmits the nerve into a relatively flatslit.31,44,53 This change in shape led to neural distortion thatresulted in focal demyelination, leading to short circuitingof sensory action potentials, thereby forming, in effect, anartificial synapse. Although Dandy in 1934 had made theobservation that the trigeminal nerve was often cross-com-pressed by a neighboring elongated artery or sometimes avein, the first reported vascular decompression of the nervewas performed by Gardner. In 1959, Gardner and his Fel-low, Miklos,25 published their results of decompression ofthe sensory root in a series of 200 patients with TN whowere followed up for as long as 6 years. One hundred of thepatients made up the Cleveland series, in which the ap-

proach was primarily extradural, whereas the other 100patients (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, and26.5% had severe recurrences. Sensory loss was present in26% of the patients with complete response and in 28% ofthose in whom treatment failed. This led Gardner to believethat neither surgical trauma to the nerve root nor incision ofits 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 refractoryperiod typical of a reflex, and that these motor paroxysmscould 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.15 Gardneralso showed that paroxysms of hemifacial spasm, like TN,may be stopped immediately and with no impairment offunction 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 cranialnerve. His work preceded the use of the intraoperative mi-croscope, however, and therefore he was unable to inspectthe 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, andcausalgia of the upper limbs, and for trauma to the brain.In 1946, Karnosh (a neuropsychiatrist at the ClevelandClinic), Gardner, and Stowell62 reported the effects of tem-porary cerebral sympathectomy accomplished by bilateralstellate ganglion blocks on organic brain diseases and psy-choses.60,61 This discovery occurred incidentally in January

1946 when a 38-year-old woman received bilateral stellateblocks for cerebral embolus accompanied by hemiplegiaand DejerineRoussy 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 thatthey claimed the procedure produced, although motion pic-ture analysis revealed no improvement in motor functionand 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 sufferingfrom depression and anxiety and in patients with knownschizophrenia. 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 observedin psychotic patients.59

Gardner: As Inventor

Gardner believed that his research had to have a directclinical application, otherwise he would pay the issue scantattention. Despite his immense clinical workload, he stillhad the energy to explain clinical phenomena and help sickpatients, and never went without some project to occupy histime. Each problem was followed through with doggeddetermination even though the initial results were oftenenough to discourage the most enthusiastic researcher. His

inventiveness, combined with hard work and determiation,was among his greatest attributes. We briefly review someof his inventions.

The Gardner Neurosurgical Chair (1938)

During his residency, Gardner learned that Frazier hadrecognized the tremendous advantage of placing a patient inthe sitting position while performing surgery for TN.16,19

Frazier commented that this position prevented a puddle ofblood from covering the nerve filaments, placed the opera-tive field comfortably at the level of the surgeons eyes, andthat smaller amounts of anesthetic agents could be used. Inaddition, de Martel started using the sitting position in 1911and 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 earlyrecognition of syncope could be corrected by lowering thepatients head. Gardner mentions one occasion when Fra-zier, on returning from a visit to de Martels 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-oldgirl whom he made straddle a wooden chair, cross her armson its back, and rest her head on her forearms. Frazier de-scribed this as a horrible exhibition.16




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Gardner started using the sitting position in 1930 andsoon came to realize its benefits, especially when he per-formed surgery on the posterior fossa or the posterior neckregion. Gardner reviewed his series of 56 suboccipital cra-niectomies and 78 supratentorial craniotomies performedwith patients in the sitting position.19 From this experiencehe recognized the dangers of hypotension and air embolism

when using this position; as a result, Gardner developed aneurosurgical chair equipped with a head clamp for rigidfixation that could be used to position the patients headfirmly in any position during surgery. He built the first mod-el of the Gardner chair in 1938 and then a later version in1955.22 A modified version of the Gardner chair (Fig. 1) isstill used today by the senior author (G.H.B.) for selectedcases.

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,29,70 even in the presence of intracranial infection.32

Constant Traction Dressing (1945)

Gardners war experience fueled his interest in crani-al wounds.14,25,29 Together with Seitz, a research engineer atthe Cleveland Clinic, he developed the constant tractiondressing which was more comfortable than the usual gauzedressing.45 More importantly, however, the skin edges un-derwent progressive approximation resulting in a narrowerscar, in some cases averting the need for secondary suturingand/or skin grafting.13 The dressing consisted of two metalmembers (0.004 in thick) connected by a sheet of latex. Themetal spurs were short so that they only penetrated the stra-tum corneum and did not cause pain. As approximation ofthe wound occurred, shorter dressings were applied.48

Induced Hypotension for Hemostasis (1946)

Gardner was the first to apply the method of controlledhypotension during surgery as an aid to hemostasis.10,39 Hebelieved that intravenous transfusions given to a patient insevere shock must pump the intravenous injected bloodthrough the pulmonary circulation and then out into theaorta, before the heart itself can benefit. Believing that theprimary function of the heart was to maintain a normal levelof pressure in the elastic aorta and that patients in severeshock who were given intravenous fluids would experiencean 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 arethrown onto the weakened heart (Page procedure). This,according to Gardner, appeared to be a more physiologicalthan intravenous infusion of the blood in severe hemorrhag-ic shock. He reported the beneficial effects of controlledhypotension in 161 patients during a 6-year period (19461953). Forty-six of 161 patients with difficult intracranialmeningiomas who were treated using the Page procedurewere compared with another group of 44 patients in whomintracranial 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 ratherthan the Page technique. In his paper on meningioma andhypotension, Gardner mentions that surgeons with theirnatural repugnance to blood loss have been slow to adopt aprocedure which entails deliberate removal of blood fromthe circulation. Illustrative of this reluctance, Gardnernotes that one advocate of the total spinal method had re-ferred shudderingly to the Page procedure as the oligemicshock 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 100consecutive patients in whom the mattress was used andfound the value of the pressure pad to be so obvious that allpatients who required the pad were given this form of care,so that he was unable to perform a subsequent randomizedstudy. Gardner calculated that he saved 1 hour of a nursestime per patient per day with the pressure pad.23,43

The Clinical G Suit (1956)

Following his service in World War II, Gardner realizedthe potential of the antigravity suit that prevented blackoutsin fighter pilots. He modified the G suit to consist of twosheets of vinyl plastic sealed at the edges to form a largeinflatable bladder that was placed beneath the patient. Theedges were folded over so that the patient was enclosedfrom the rib cage to the ankles, and the entire contraption



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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 tilted backward like

a rocking chair so that the patients feet could be higher than thehead. It still provides more favorable positioning for cranial surgerywith the patient sitting than most modern surgical tables. A slot inthe back allowed the surgeon to perform an LP during surgery, ifrequired. By adding a table top to the backward-tilted chair and athree-point head fixation device, the supine patient could be readiedfor craniotomies. The chair was also accompanied by a lifter thatcould lower the patient into an adjacent bed.


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was drawn snug by lacing. The system had a manometerand was inflated by a gas tank (Fig. 3). If a patient experi-enced hypotension while in the sitting position or if Gardneranticipated hypotension in any position, the clinical G suitcould be inflated in a matter of seconds.17,50 The clinical Gsuit helped save the life of a staff members wife after shedeveloped postpartum hemorrhaging which, after 11 hoursof futile surgical efforts to control intraabdominal bleed-ing, had resulted in 56 blood transfusions administered overa period of 18 hours. She was placed in the G suit at apressure of 20 mm Hg and this raised her blood pressure,

stopped the bleeding, and saved her life.52In their 1956 paper, Gardner and Dohn wrote that while

doing a literature search, they discovered that one of theearliest descriptions of the antigravity suit had been madeby George Crile Sr.3 in 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 hypotensionhas been documented in many publications.4,6,17,50

Hypothermia With Temporary Occlusion of Major BrainArteries 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 couldligate or clip the aneurysm while the patient was in a stateof hypothermia.46 One 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 intowhich a 16-gauge syringe had been previously inserted onthe opposite end. The other end of the cellophane tubingwas 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 tubing with the syringe on its oppo-site end. Air from the syringe introduced into the catheter

expanded the cellophane tube, thus occluding the artery. Inapplying the device, the cellophane tubing was passed twicearound the common carotid artery with the distal end tied tothe proximal end, where it was fastened to the catheter. Toocclude the vertebral artery, it was only necessary to exposea cervical vertebral foramen and draw the cellophane cuffpartly through it. The four catheters were then connected bya series ofT-tubes to an ordinary blood pressure apparatusso that all four arterial cuffs could be simultaneously acti-vated.46 To induce hypothermia, Gardner, Wasmuth (an an-

esthesiologist), and Hale35 converted an operating table intoa refrigerating trough by enclosing the patient in a water-tight plastic sheet draped over a rectangular frame and thensubmerging only the body in ice water.

GardnerWells Cervical Traction Tongs (1959)

In 1959 Gardner developed his cervical skull tractiontongs 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 theupward-directed tapering pins to engage in the outer ta-ble of the temporal bones at points between the ears and theskulls equator (Fig. 4). The principal advantage over the

Crutchfield tongs was that no shaving was necessary, andafter application of a local anesthetic agent, advancing thetapered points through the scalp caused the stretched skin tofit snugly about the pins, thereby sealing their point of entry,which prevented bleeding. One of the points was renderedretractable by an enclosed spring that was calibrated to in-dicate the pressure. On encountering bone, the stiff springyielded 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 developedsafeguards against perforations of the inner table.1,24 TheGardner 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 waterproofplastic material. The apparatus consists of a pneumatic mattresswith air cells 3 cm in diameter that run transversely the width of themattress, with alternate cells connected to a manifold that consti-tutes the edge of each side of the mattress. Alternating inflation anddeflation of the transverse cells occurs at intervals of 2 to 3 minutesso that the patients 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 consistedof two sheets of vinyl plastic sealed at the edges to form a largeinflatable bladder, so that the patient was enclosed from the ribcage to the ankles; the entire contraption was drawn snug by lacing.

The system included a manometer and the suit was inflated by agas tank.


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Waterbed and Hammock (1961)

Gardner developed a waterbed for children who wereprone to pressure sores due to hydrocephalus. The infantwas floated on a bag of water, which was made redundantand relaxed by placing it in a box or crib. An alarm systemwas 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, therebypreventing an increase in the deformity.40

The G Splint (1962)

The G splint (Immobil-Air), developed in 1962, was aspinoff from the clinical G suit. This pneumatic splint, in-flated by mouth in a matter of seconds, was designed as afirst-aid device to be used in an emergency to stabilize thepatient 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 wasforced between the two layers, resulting in compression ofthe limb by the inner layer, whereas the outer layer tendedto 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 experienceda sudden pain in his knee. Raising his trouser leg, a rapidswelling in the knee due to spontaneous hemorrhage wasdiagnosed; this occurred in an old knee injury sustainedwhen a torpedo in World War I struck Penfields destroyer.An orthopedist present in the cafeteria ordered immediatebed rest and a compression bandage. Gardner, however, hada sample of the G splint with him, and he quickly applied itdirectly over the trouser on Penfields leg, thus stopping thebleeding. Penfield subsequently wrote to Gardner request-ing another splint and in his letter of thanks he mentionedthat he never subsequently left home without it.16

Other Gardner Inventions and Contributions

His pioneering contributions to neurosurgery occurred inseveral other areas such as cerebral hemispherectomy26 inthe treatment of glioma, and treatment of carotidcavernousfistula by muscle embolization.58 Among Gardners other

lesser known inventions was his adaptation of the Sout-tar craniotome (1929) soon after arriving at the ClevelandClinic (this was used until power tools for opening the skullwere introduced in the 1960s);16 the development of a neu-rosurgical suction irrigator;64 modification of the respiratorwith D. E. Hale (1948);57 recording time on roentgenograms(1954);51 and a ventriculomastoid shunt in which a Holtervalve 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 contributionsto the field are now taken for granted. His theories on the

pathogenesis of several neurological disorders have stoodthe test of time or have served as the foundation on whichcontemporary 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 residentswho passed through his service.

His genius has not gone unrecognized by neurosurgicalorganizations and the Cleveland Clinic. During his neu-rosurgical career, Gardner was active in many national andregional organizations. He was President of the Society ofNeurological Surgeons, Vice President of the Cushing Soci-ety, on the Board of Governors of the American College of



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FIG. 4. Photograph showing the GardnerWells cervical tractiontongs. The main structural element is a rigidC-shaped metal bar thatroughly conforms to the coronal suture of the skull. Sharp taperedpins positioned at an upward angle at the ends of the C-shapedmetal structure are screwed into the skull.

FIG. 5. Photographic portrait of W. James Gardner.


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Surgeons, and a member of the American Board of Neu-rological Surgery for 6 years. He was an honorary guest ofthe Congress of Neurological Surgeons in 1987 and in 1982received the Cushing Medal from the American Associa-tion of Neurological Surgeons for his contributions to neu-rosurgery. The Cleveland Clinic and the Department ofNeurological 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 ClinicArchives Department for providing access to the archival material(Dr. Gardners personal notes and original reprints), for providingassistance with the figures, and for verifying historical accuracy. Wealso thank Dr. Donald Dohn (former resident and colleague of Dr.Gardner) for verification of historical accuracy.

References

1. Barnett GH, Hardy RW: Gardner tongs and cervical traction. Med

Instrum 16:291292, 19822. Collis JS Jr, Gardner WJ: Lumbar discography. An analysis of onethousand cases. J Neurosurg 19:452461, 1962

3. Crile G Sr: Blood Pressure in Surgery: an Experimental andClinical Research. Philadelphia: Lippincott, 1903, pp 288289

4. Dohn DF, Gardner WJ: The antigravity suit (G suit) in surgery;control of blood pressure in the sitting position and in hypotensiveanesthesia. JAMA 162:274276, 1956

5. Dohn DF, Gardner WJ: The treatment of hydrocephalus by ven-triculo-mastoid shunt utilizing the Holter valve. Surg Forum 13:440441, 1962

6. Ferrario CM, Nadzam G, Fernandez LA, et al: Effects of pneumat-ic compression on the cardiovascular dynamics in the dog afterhemorrhage. Aerosp Med 41:411415, 1970

7. Gardner WJ: Anatomic anomalies common to myelomeningoceleof infancy and syringomyelia of adulthood suggest a common ori-

gin.Cleve Clin Q 26:

118133, 19598. Gardner WJ: Anatomic features common to the Arnold-Chiariand the Dandy-Walker malformations suggest a common origin.Cleve Clin Q 26:206222, 1959

9. Gardner WJ: Concerning the mechanism of trigeminal neuralgiaand hemifacial spasm. J Neurosurg 19:947958, 1962

10. Gardner WJ: The control of bleeding during operation by inducedhypotension. JAMA 132:572574, 1946

11. Gardner WJ: Cross-talkthe paradoxical transmission of a nerveimpulse. Arch Neurol 14:149156, 1966

12. Gardner WJ: Diastematomyelia and the Klippel-Feil syndrome.Relationship to hydrocephalus, syringomyelia, meningocoele, me-ningomyelocele, and iniencephalus. Cleve Clin Q 31:1944, 1964

13. Gardner WJ: Electrical burn of the brain. J Neurosurg 5:9094,1948

14. Gardner WJ: Experiences of a US Naval Mobile Hospital Unit no.4 in the Southwest Pacific. Ohio State Med J 39:570573, 1943

15. Gardner WJ: Five-year cure of hemifacial spasm. Report of a case.Cleve Clin Q 27:219221, 1960

16. Gardner WJ: Half century of neurosurgery. Surg Clin North Am58:945956, 1978

17. Gardner WJ: Hemostasis by pneumatic compression. Am Surg35:635637, 1969

18. Gardner WJ: An inflatable emergency splint. Clevel Clin Q 29:5456, 1962

19. Gardner WJ: Intracranial operations in the sitting position, in Rav-din IS, Adson AW, Grant FC (eds): Surgery in two Parts. PartII. General Surgery and Allied Subjects. Comprising Contri-butions in Surgery in Honor of C.H. Frazier. Philadelphia: Lip-pincott, 1935, pp 138145

20. Gardner WJ: The mechanism of tic doloureux. Trans Am NeurolAssoc 3:168173, 1953

21. Gardner WJ: Myelomeningocele, the result of rupture of the em-bryonal neural tube. Cleve Clin Q 27:88100, 1960

22. Gardner WJ: A neurosurgical chair. J Neurosurg 12:8186, 195523. Gardner WJ: Prevention and treatment of bedsores. An air mat-

tress accomplishing alternation of pressure points. JAMA 138:583, 1948

24. Gardner WJ: The principle of spring-loaded points for cervicaltraction. Technical note. J Neurosurg 39:543544, 1973

25. Gardner WJ: Progress in neurosurgical treatment of war wounds.Ohio State Med J 43:936938, 1944

26. Gardner WJ: Removal of the right cerebral hemisphere for infil-trating glioma. Report of a case. JAMA 101:823826, 1933

27. Gardner WJ: Rupture of the neural tube.Arch Neurol 4:17, 196128. Gardner WJ: Specialization in intraspinal surgery. Surg Gynecol

Obstet 121:838839, 196529. Gardner WJ: Tantalum in the immediate repair of traumatic skull

defects: method of immobilizing the wounded brain. US Nav MBull 43:11001106, 1944

30. Gardner WJ: Traumatic subdural hematoma. With particularreference to the latent interval. Arch Neurol Psychiatry 27:847858, 1932

31. Gardner WJ: Trigeminal neuralgia in elderly women. Geriatrics

18:731739, 196332. Gardner WJ: The use of tantalum for repair of cranial defects in in-fected cases. Cleve Clin Q 13:7287, 1946

33. Gardner WJ, Abdullah AF, McCormack LJ: The varying ex-pressions of embryonal atresia of the fourth ventricle in adults.Arnold-Chiari malformation, Dandy-Walker syndrome, arach-noid cyst of the cerebellum, and syringomyelia. J Neurosurg 14:591605, 1957

34. Gardner WJ, Anderson RM, Lyden M: The alternating pressurepad: an aid to the proper handling of decubitus ulcers. Arch PhysMed Rehabil 35:578580, 1954

35. Gardner WJ, Angel J: The mechanism of syringomyelia and itssurgical correction. Clin Neurosurg 6:131140, 1958

36. Gardner WJ, Collis JS: Klippel-Feil syndrome. Syringomyelia,disastematomyelia and myelomeningoceleone disease? ArchSurg 83:638644, 1961

37. Gardner WJ, Dohn DF: Trigeminal neuralgiahemifacial spasmPagets disease: significance of this association. Brain 89:555562, 1966

38. Gardner WJ, Frazier CH: Bilateral acoustic neurofibromas. A clin-ical study and field survey of a family of five generations with bi-lateral deafness in thirty-eight members. Arch Neurol Psychiatry23:266300, 1930

39. Gardner WJ, Hale DE: Arterial bloodletting during operation asaid in hemostasis. Am J Surg 79:635644, 1950

40. Gardner WJ, Holmok DE: The water-bed and the hammock. Usein hydrocephalus and scaphocephaly. Am J Dis Child 102:237238, 1961

41. Gardner WJ, Karnosh LJ, Angel J: Syringomyelia; a result of em-bryonal atresia of the foramen of the Magendie. Trans Am Neu-rol Assoc 82:144145, 1957

42. Gardner WJ, Ling A: Controlled hypotension by the bleedingmethod in operations for intracranial meningiomas. Surg Gyne-col Obstet 98:343346, 1954

43. Gardner WJ, McCormick LJ, Dohn DF: Embryonal atresia of thefourth ventricle. The cause of arachnoid cyst of the cerebello-pontine angle. J Neurosurg 17:226237, 1960

44. Gardner WJ, Miklos MV: Response of trigeminal neuralgia to de-compression of sensory root; discussion of cause of trigeminalneuralgia. JAMA 170:17731776, 1959

45. Gardner WJ, Pinto JP: Taarnhj operation: relief of trigeminalneuralgia without numbness. Cleve Clin Q 20:364367, 1953

46. Gardner WJ, Salmoiraghi GC: Pneumatic cuff for temporary oc-clusion of arteries. JAMA 160:1224, 1956

47. Gardner WJ, Sava GA: Hemifacial spasma reversible patho-physiological state. J Neurosurg 19:240270, 1962




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48. Gardner WJ, Seitz VB: Constant traction dressing. Am J Surg 70:232323, 1945

49. Gardner WJ, Shannon EW: A study of 27 cases of chronic subdu-ral hematomas. Ohio State Med J 39:835, 1943

50. Gardner WJ, Storer J: The use of the G suit in control of intraab-dominal bleeding. Surg Gynecol Obstet 123:792798, 1966

51. Gardner WJ, Takiguchi R: A method of recording time on a roent-genogram. AJR 71:1060, 1954

52. Gardner WJ, Taylor HP, Dohn DF: Acute blood loss requiring fif-ty-eight transfusions: use of antigravity suit as aid in postpartumintra-abdominal hemorrhage. JAMA 167:985986, 1958

53. Gardner WJ, Todd EM, Pinto JP: Roentogenographic findings intrigeminal neuralgia. AJR 76:346350, 1956

54. Gardner WJ, Turner OA: Bilateral acoustic neurofibromas. Fur-ther clinical and pathological data on hereditary deafness andRecklinghausens disease. Arch Neurol Psychiatry 44:7699,1940

55. Gardner WJ, Wasmuth CE, Hale DE: A method of convertingan operating table into a refrigerating trough. J Neurosurg 13:122123, 1956

56. Gardner WJ, Wise ER, Hughs CR, et al: X-ray visualization of theintervertebral disk. With a consideration of the morbidity of diskpuncture. Arch Surg 64:355364, 1952

57. Hale DE, Gardner WJ: A modification of the respirator. JAMA

136:984985, 194858. Hamby WB, Gardner WJ: Treatment of pulsating exophthalmos.With report of two cases. Arch Surg 27:676685, 1933

59. Karnosh LJ, Gardner WJ: The effects of bilateral stellate ganglionblock on mental depression; report of 3 cases. Cleve Clin Q 14:133138, 1947

60. Karnosh LJ, Gardner WJ: Observations on mood after stellate gan-glionectomy. South Med J 41:631636, 1948

61. Karnosh LJ, Gardner WJ, Stowell A: The effect of cerebral sym-pathectomy on organic brain diseases and psychoses. Trans AmNeurol Assoc 72:157160, 1947

62. LaLonde AA, Gardner WJ: Chronic subdural hematoma. Expan-

sion of compressed cerebral hemisphere and relief of hypotensionby spinal injection of physiologic saline solution. N Engl J Med239:493496, 1948

63. Lee FC: Trigeminal neuralgia. J Med Assoc Ga 26:431, 193764. Nosik WA, Gardner WJ: A neurosurgical suction-irrigator. Am J

Surg 44:477478, 193965. Olivecrona H: Cholesteatomas of the cerebello-pontine angle. Ac-

ta Psychiatry Neurol 24:639643, 1949

66. Pillay PK, Awad IA, Hahn JF: Gardners hydrodynamic theory ofsyringomyelia revisited. Cleve Clin J Med 59:373380, 1992

67. Sehgal AD, Gardner WJ: Corticosteroids administered intradural-ly for relief of sciatica. Cleve Clin Q 27:198201, 1960

68. Sehgal AD, Gardner WJ, Dohn DF: Pantopaque arachnoditistreatment with subarachnoid injections of corticosteroids. CleveClin Q 29:177188, 1962

69. Taarnhj P: Decompression of the trigeminal root. J Neurosurg11:299305, 1954

70. Weiford EC, Gardner WJ: Tantalum cranioplasty: review of 106cases in civilian practice. J Neurosurg 6:1332, 1949

71. Wise RE, Gardner WJ, Hosier RB: X-ray visualization of the inter-vertebral disk. N Engl J Med 257:610, 1957

72. Wise RE, Gardner WJ, Hughes CR, et al: X-ray visualization ofthe intervertebral disk. Modern Med 20:104112, 1952

73. Young DF, Eldridge R, Gardner WJ: Bilateral acoustic neuroma in

a large kindred. JAMA 214:347353, 1970

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 16,2004, Orlando, Florida.

Address reprint requests to: Gene H. Barnett, M.D., Brain TumorInstitute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleve-land, Ohio 44195. email: [email protected].



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Documents

Gardner Manuscript