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The Massachusetts General Hospital

Early history and neurosurgery to 1939

Fred G. Barker

✓ The early history of the Massachusetts General Hospital (MGH) is reviewed with emphasis on the development of neurological surgery. The hospital opened in 1823. Early trephinations were performed by Dr. John Collins Warren and others for treatment of trauma and epilepsy. In the 1880's, interest in brain surgery increased, and Dr. John Elliot performed several trephinations for brain tumors, three of which were witnessed by Dr. Harvey Cushing during his years at the MGH as medical student and intern. In 1911, all brain surgery was placed in the hands of Dr. S. J. Mixter. He later shared the assignment with his son, Dr. W. J. Mixter, who described herniation of the intervertebral disc with Dr. J. S. Barr and became the first Chief of the Neurosurgical Service at MGH in 1939.

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Fred G. Barker II

✓ In 1848, Mr. Phineas Gage suffered destruction of his left frontal lobe in a unique fashion: passage of a metal rod through his head after a freak explosion. His change in character after the accident is the index case for personality change due to frontal lobe damage. Yet, from 1848 to 1868, it was widely believed among American physicians that he was mentally intact. The case was used as evidence against phrenology, a crude precursor of modern cerebral localization theories.

The two original reports of the case by Drs. John Harlow (Gage's physician) and Henry J. Bigelow show subtle differences in attitude toward Gage's posttraumatic character change. In his 1848 report, Harlow promised a further communication that would address Gage's “mental manifestations.” Bigelow's article portrayed Gage as fully recovered. Although delayed by 20 years, Harlow's second report rapidly changed the perception of the case in the medical community, as reflected by contemporary citations.

The educational backgrounds of Harlow and Bigelow are examined to explain their differing attitudes toward the case. Harlow's interest in phrenology prepared him to accept the change in character as a significant clue to cerebral function which merited publication. Bigelow had learned that damage to the cerebral hemispheres had no intellectual effect, and he was unwilling to consider Gage's deficit significant. Although Bigelow's paradigm was initially more influential, Harlow's more closely matched emerging theories of cerebral localization. His version of the case was used by David Ferrier as the keystone in the first modern theory of frontal lobe function, and this is how the case is remembered today.

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Fred G. Barker II and Bob S. Carter

Systematic reviews and metaanalyses have become increasingly popular ways of summarizing, and sometimes extending, existing medical knowledge. In this review the authors summarize current methods of performing meta-analyses, including the following: formulating a research question; performing a structured literature search and a search for trials not published in the formal medical literature; summarizing and, where appropriate, combining results from several trials; and reporting and presenting results. Topics such as cumulative and Bayesian metaanalysis and metaregression are also addressed. References to textbooks, articles, and Internet resources are also provided. The goal is to assist readers who wish to perform their own metaanalysis or to interpret critically a published example.

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Edward R. Smith, William E. Butler, and Fred G. Barker II

Object. Death after ventriculoperitoneal (VP) shunt surgery is uncommon, and therefore it has been difficult to study. The authors used a population-based national hospital discharge database to examine the relationship between annual hospital and surgeon volume of VP shunt surgery in pediatric patients and in-hospital mortality rates.

Methods. All children in the Nationwide Inpatient Sample (1998–2000, age 90 days—18 years) who underwent VP shunt placement or shunt revision as the principal procedure were included. Main outcome measures were in-hospital mortality rates, length of stay (LOS), and total hospital charges.

Overall, 5955 admissions were analyzed (253 hospitals, 411 surgeons). Mortality rates were lower at high-volume centers and for high-volume surgeons. In terms of hospital volume, the mortality rate was 0.8% at lowest-quartile-volume centers (< 28 admissions/year) and 0.3% at highest-quartile-volume centers (> 121 admissions/year). In terms of surgeon volume, the mortality rate was 0.8% for lowest-quartile-volume providers (< nine admissions/year) and 0.1% for highest-quartile-volume providers (> 65 admissions/year). After multivariate adjustment for demographic variables, emergency admission and presence of infection, hospital volume of care remained a significant predictor of death (odds ratio [OR] for a 10-fold increase in caseload 0.38; 95% confidence interval [CI] 0.18–0.81). Surgeon volume of care was statistically significant in a similar multivariate model (OR for a 10-fold increase in caseload 0.3; 95% CI 0.13–0.69). Length of stay was slightly shorter and total hospital charges were slightly higher at higher-volume centers, but the differences were not statistically significant.

Conclusions. Pediatric shunt procedures performed at high-volume hospitals or by high-volume surgeons were associated with lower in-hospital mortality rates, with no significant difference in LOS or hospital charges.

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Fred G. Barker II and Christopher S. Ogilvy

✓ The authors report findings from a metaanalysis of all published randomized trials of prophylactic nimodipine used in patients who have experienced subarachnoid hemorrhage (SAH). Seven trials were included with a total of 1202 patients suitable for evaluation. Eight outcome measures were examined, including good versus other outcome, good or fair outcome versus other outcome, overall mortality, deficit and/or death attributed to vasospasm, infarction rate as judged by computerized tomography (CT), and deficit and/or death from rebleeding.

Nimodipine improved outcome according to all measures examined. The odds of good and of good plus fair outcomes were improved by ratios of 1.86:1 and 1.67:1, respectively, for nimodipine versus control (p < 0.005 for both measures). The odds of deficit and/or mortality attributed to vasospasm and CT-assessed infarction rate were reduced by ratios of 0.46:1 to 0.58:1 in the nimodipine group (p < 0.008 for all measures). Overall mortality was slightly reduced in the nimodipine group, but the trend was not statistically significant. The rebleeding rate was not increased by nimodipine. A metaregression yielded findings indicating that the treatment effect of nimodipine in individual trials was positively correlated with the severity of SAH in enrolled patients.

Although the majority of individual trials examined did not have statistically significant results at the p < 0.01 level according to most outcome measures, the metaanalyses confirmed the significant efficacy of prophylactic nimodipine in improving outcome after SAH under the conditions used in these trials.

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Mitchell J. Ramsey, Michael J. McKenna, and Fred G. Barker II

✓ The authors present the case of a man who had superior semicircular canal dehiscence syndrome in addition to chronic otitis media. This case is atypical because the patient coincidentally had middle ear and mastoid disease, which previously had been treated surgically. The prior ear surgery delayed the diagnosis of superior semicircular canal dehiscence syndrome and increased the complexity of the repair of the superior semicircular canal dehiscence.

Superior semicircular canal dehiscence syndrome is a recently recognized syndrome resulting in acute or chronic vestibular symptoms. The diagnosis is made using history, vestibular examination, and computerized tomography studies. Neurosurgeons should be aware that patients with superior semicircular canal dehiscence syndrome who experience disabling chronic or acute vestibular symptoms can be treated using a joint neurosurgical—otological procedure through the middle cranial fossa.

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Fred G. Barker II

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Fred G. Barker II and Michael W. McDermott

An important goal of the Section on Tumors of the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) since its founding in 1985 has been to foster both education and research in the field of brain tumor treatment. As one means of achieving this, the Section awards a number of prizes, research grants, and named lectures at the annual meetings of the AANS and CNS. After a brief examination of similar honors that were given in recognition of pioneering work by Knapp, Cushing, and other early brain tumor researchers, the authors describe the various awards given by the AANS/CNS Section on Tumors since its founding, their philanthropic donors, and the recipients of the awards. The subsequent career of the recipients is briefly examined, in terms of the rate of full publication of award-winning abstracts and achievement of grant funding by awardees.

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Fred G. Barker II