John E Adams, MD
Guggenhime Professor Emeritus and Former Chairman
Department of Neurological Surgery
School of Medicine
University of California, San Francisco, California
Reproduced and adapted with permission from Elsevier Publishers, publishers of Adams JE. The development of neurosurgery in northern California. Surgical Neurology 1993;39:90-93.
Dr. Frank Ingraham, Neurosurgeon-in-Chief at Boston Children's Hospital, was a factor in my decision to pursue a career in neurosurgery. I believe his influence similarly swayed Drs. Eben Alexander and Donald Matson, my classmates at Harvard Medical School and fellow house officers at the Peter Bent Brigham Hospital.
In the spring of 1941, I was called to active duty in the U.S. Navy. Before leaving, I asked Dr. Ingraham for advice about further neurosurgical training and expressed my interest in the Montreal Neurological Institute. Knowing of my origins in northern California, he quickly replied, "Why would you want to go to Montreal when you have Dr. Howard Naffziger in San Francisco?" I was fortunate enough to be able to resume my training under Dr. Naffziger after my tour of duty, on January 1, 1946.
The following brief description of neurosurgery in northern California before, during, and for a short period after World War II derives from my vantage point, first as a resident and then a member of the faculty of the University of California, San Francisco (UCSF) from January 1, 1946 to the present. It is perforce anecdotal and limited primarily to neurosurgeons who were practicing and teaching in the geographical area between the Tehachapi Mountain range in southern California and the Oregon border.
At the UCSF School of Medicine (Figures 1 and 2), Drs. Howard C. Naffziger and Edwin B. Boldrey were full-time members of the faculty. Neurosurgery was a division of the Department of Surgery, Dr. Naffziger being chairman of both. The Neurosurgery Division was allocated 22 beds in the 250-bed University of California Hospital, but it was a service requiring as many as 35-40 beds when they could be borrowed from other services.
The Neurosurgical Service was the repository of patient referrals from northern California, Nevada, and, to some extent, southern Oregon. The waiting list for elective surgery was often as long as 80-100 patients' names, and the waiting period could be as great as 4-6 months. The ratio of staff to private patients was about 40:60. The staff's patients paid for their hospitalization on a sliding scale that ranged from 0% to 100%. A teaching budget appropriated by the California state legislature supplemented the staff's patients' payments. This fund was largely under the control of the neurosurgical resident, and the faculty, of course, received no payment for their services.
Practicing in San Francisco, in addition to Drs. Naffziger and Boldrey at the University Hospital, were Drs. Ottiwell W. Jones, Jr. and Howard A. Brown, who ran a neurosurgical service at the Franklin Hospital (now the Ralph K. Davies Medical Center). Both of them had been trained by Dr. Naffziger (Figure 3). Other neurosurgeons in San Francisco were Dr. Ed Morrissey at St. Mary's Hospital and Dr. Grant Levin at Mt. Zion. Dr. Lester Lawrence practiced in Oakland in the East Bay, and Dr. Frank Lusignan had begun a practice in San Mateo on the peninsula. Between the Bay Area and Los Angeles, a Dr. Hashiba did some neurosurgery in San Jose, and a Dr. Bailey, who had trained at the Los Angeles County Osteopathic Hospital, practiced in Bakersfield.
Dr. Edward Towne became affiliated with Stanford Medical School and Stanford Lane Hospital in 1919. He had graduated from Harvard Medical School and had trained under Cushing at the Peter Bent Brigham Hospital and later at the Mayo Clinic. He served in the U.S. Army Medical Corps in World War I and joined the Stanford faculty upon his discharge from the corps. The other two men on the Stanford faculty were Drs. Fritz Reichert and Ted Fender. Dr. Reichert was appointed Chairman of Neurosurgery in 1926, after completing his residency at Johns Hopkins under Dandy. He served until the early 1950s, when he was replaced by Dr. John Hanbury. Dr. Reichert had the reputation of being difficult to work with, and Dr. Towne resigned his fulltime position shortly after Dr. Reichert's arrival.
Although, at that time, Stanford Medical School was located at what is currently the Pacific Medical Center in San Francisco, there was little contact or dialogue between the neurosurgeons at UCSF and Stanford. I cannot recall Dr. Naffziger ever mentioning Dr. Reichert, and I have been told that Dr. Reichert felt considerable antipathy toward Dr. Naffziger.
At the conclusion of World War II, it was decided to include the Franklin Hospital and the Fort Miley Veterans Hospital in the UCSF neurosurgical training program. Dr. Eugene Stern was the current and only resident at the University Hospital when, as the first post-war returnee, I joined the soon-to-be-enlarged program. Subsequently, two appointments were made each year, and within a few years graduates of the program were establishing practices throughout northern and central California, thus fulfilling the original purpose of the expanded program.
The neurosurgical practice was very similar to that at other major centers. In addition, a large number of patients with severe essential hypertension were treated with a bilateral combined thoracolumbar sympathectomy and splanchnicectomy (Smithwick procedure) done in two stages, 8-10 days apart. The standard general anesthesia for neurosurgical operations at UCSF was rectal avertin followed by nitrous oxide without intratracheal intubation. As might be imagined, if the pleura was torn during the thoracic exposure - which occurred not too infrequently - both the operative procedure and anesthesia became difficult. This often resulted in interesting comments from both the surgeon and anesthetist.
Another interesting sidelight on our neurosurgical practice was a trial of stellate ganglion block to treat early occlusive cerebrovascular accidents. I presented a paper, coauthored by Dr. Naffziger, describing this endeavor at the 1950 meeting of the Pacific Coast Surgical Society. A very much inflated account of this paper was published in the Saturday Evening Post, much to our discomfiture. Dr. Naffziger, in particular, was subjected to mainly light-hearted, but at times rather spiteful, jokes. This occurred before the current careful reporting of scientific news by current science writers.
The rapidly burgeoning postwar population in California led to the erection of the larger Herbert C. Moffitt hospital in 1955 (Figure 4). This development, in combination with the move of Stanford Medical School to Palo Alto, led to further expansion of neurosurgery at UCSF.
By the end of the 1950s, there were neurosurgeons practicing in most communities in northern and central California, which had populations greater than 75,000-100,000. In contrast to the 10 neurosurgeons practicing in the geographic confines of northern California at the close of World War II, there are currently 169 board-certified neurosurgeons with practices between the Tehachapi range and the Oregon border.
Received July 27,1992; revised and accepted August 11,1992.
© 1993 by Elsevier Science Publishing Co., Inc 0090-3019/93/56.00
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