The Department of Surgery, University of California, San Francisco

COMMENTARY The Department of Surgery, University of California, San Francisco

HE DEPARTMENT OF pression of gratitude for the medical arrows with him in Golden Gate Surgery at the Uni- education his daughter had received Park and learning the skills of game versity of California from the “Medical Department” of UC hunting. Pope, who became an ex- (UC), San Francisco, (Figure 2A).2 After the disastrous pert in Yahi culture, later wrote a was shaped by Gold 1906 earthquake damaged or de- book about Ishi’s medical history Rush–eraT adventurers who stayed on stroyed most of the city’s existing hos- and several books about archery. after the gold ran out. In 1852, South pitals, the urgent need for medical fa- During that time, Harold C. Carolina surgeon Hugh H. Toland, cilities necessitated remodeling the Naffziger, MD (Figure 3B), under MD, was lured to California by gold medical school building so that it whose dynamic leadership the de- fever, crossing the 2000-mile over- could serve as a hospital. The first UC partment would gain national land route by wagon train. By then, Hospital opened in 1907 (Figure 2B), prominence, had returned to UC to gold reserves were declining and the under the direction of surgeon Harry teach and develop a first-class sur- number of miners was increasing Mitchell Sherman, MD. Toland con- gical center. Naffziger was born in dramatically. Whereas many other tinued as professor of surgery until his the mining town of Nevada City, forty-niners headed home or turned death in 1880. He was succeeded by Calif—another legacy of the Gold to poker or crime, Toland estab- Robert A. McLean, MD (Figure 2C), Rush. He had served as intern and lished an enormously successful sur- a California native, a graduate of resident surgeon at the UC Hospi- gical practice in the boomtown of Toland Medical College, and profes- tal and obtained the position of as- San Francisco. He founded the sec- sor of anatomy, who introduced for- sistant resident surgeon at the Johns ond medical school, Toland Medi- mal coursework in the new science of Hopkins Hospital in Baltimore, Md, cal College, in the Far West in 1864, bacteriology into the curriculum. working under William Stewart Hal- timing that coincided with a new McLean was succeeded in 1899 by sted, MD, and Harvey Cushing, MD. state law permitting the use of pau- Thomas W. Huntington, MD, who While there, Naffziger recognized pers’ bodies for study by accredited had trained at Harvard University the superiority of Halsted’s system physicians (Figure 1).1 Through (Boston, Mass) and at Massachu- of training surgeons and became the efforts of Richard Beverly Cole, setts General Hospital (Boston) be- aware of the need for experimental MD—another Gold Rush pioneer fore heading west to develop a pri- research programs in medical and an accomplished surgeon who vate surgical practice, treating work schools.4 Although Naffziger had had arrived in San Francisco aboard injuries, hernias, and appendicitis for wide experience in every field of sur- a steamship in 1852—the college be- railroad companies. In the same year, gery, after World War I, he limited came the Medical Department of UC Huntington performed the first total himself to neurological surgery and, in 1873, with Cole as its dean and gastrectomy for carcinoma, after with Cushing, was among the very Toland, the first chair of the Depart- which the patient reportedly sur- first physicians in America to spe- ment of Surgery. The early surgical vived for many years without evi- cialize in this field.4 Naffziger gained curriculum consisted of “lectures on dence of recurrence.2 national renown for his many dis- the principles and practices of sur- Wallace I. Terry, MD, another tinctive contributions to the new gery, demonstrations of surgical California native, became chair in specialty of neurosurgery, includ- technique on the cadaver, and clini- 1912 when the Medical Depart- ing craniotomy decompression for cal lectures at the college building ment was renamed the UC College brain tumor, orbital decompres- and the adjacent county hospital.”2 of Medicine. By 1915, the college was sion for pressure exophthalmos, and Anesthesia was scarce, when it was officially designated the UC Medi- the first partial hypophysection for available at all, and Toland, Cole, and cal School. In a tragic reflection of Cushing disease.5 Naffziger contrib- the other surgeons performed op- that time, the last Yahi Indian was uted perhaps more than anyone to erations on a table in the middle of found starving in Oroville, Calif. He the national reputation that the UC the ward. “Blood and noise were the eventually was brought to live at the Medical School now enjoyed. When principal features observed by the UC Museum of Anthropology at Par- Naffziger succeeded Terry as chair goggle eyed spectators.”3(p39) nassus, where he was named “Ishi,” of the Surgery Department in 1929, In 1898, the school moved to its the Yahi word for “man.” Univer- he developed a residency program present location in Parnassus Heights, sity of California surgeon and modeled after Halsted’s with the help overlooking Golden Gate Park. The outdoorsman Saxton Pope, MD, of H. Glenn Bell, MD, a general sur- land was donated by former city (Figure 3A) became his physician geon who had been chief resident mayor Adolph Sutro, in part as an ex- and close friend, shooting bows and under another Halsted resident,

Figure 1. Hugh H. Toland, MD, and the Toland Medical College, San Francisco, Calif. A, Toland (1806-1880). B, Illustration of Toland Medical College, circa 1866. C, Medical students in the Toland Medical College Dissecting Room, circa 1870. Photograph by Edward Muybridge.

Mont Reid, MD, in Cincinnati, Ohio. fornia (Figure 3C). He was pro- In 1951, UC established a medi- Naffziger wanted residents to expe- foundly interested in the patho- cal school in Los Angeles, the first rience basic science as part of the logic features of the resected surgical of 5 new medical schools in the UC curriculum and established the first specimens, a habit that he in- system. The oldest UC Medical research laboratory on the Parnas- grained in his residents, many of School became distinguished as the sus campus. whom had a rotation in surgical pa- UC, San Francisco (UCSF). During In 1947, Naffziger left the Sur- thology to enhance their skills in this the tenure of Leon Goldman, MD, gery Department to chair UC Medi- very important aspect of surgical as chair of the Surgery Department cal School’s new Department of Neu- training.6 One of those residents was from 1956 to 1963, pioneering con- rological Surgery and Bell became Edwin “Jack” Wylie, MD, a pioneer- tributions to vascular surgery con- the Surgery Department’s new chair. ing giant in vascular surgery, who, tinued to be made, including the first A superb technical surgeon, Bell em- in 1951, was the first in the United axillofemoral artery bypass in 1962. phasized the Halstedian tradition of States to perform thromboendarter- Experimental and clinical gastroin- careful dissection, upgrading the ectomy for atherosclerotic aor- testinal research continued, and standards of general surgery in Cali- toiliac occlusive disease. some of the earliest transplantation

B C

Figure 2. The University of California Medical Department, San Francisco, Parnassus Heights location. A, Photograph of the new Parnassus Heights campus with a streetcar in front. B, The Medical School building at Parnassus, refitted to house a 75-bed teaching hospital in 1907, is shown here in a 1947 drawing by Ralph W. Sweet (1892-1961), professor of Medical Arts and Illustrations at University of California Medical School. C, Robert A. McLean, MD (1858-1918) in an 1874 photo.

Figure 3. Saxton Pope, MD, Howard C. Naffziger, MD, and H. Glenn Bell, MD. A, University of California surgeon Pope, a close companion of the last Yahi Indian, Ishi. B, Naffziger (1884-1961) in his military uniform in 1918. C, Partial scene from a 1937 mural by Bernard Baruch Zakheim depicting the history of medicine. Called the Cole Hall Murals after their original location at the University of California Medical School building lecture hall named for University of California, San Francisco, founder Richard Beverly Cole, MD, this scene shows Bell (1893-1981) performing surgery in the left center foreground. experiments in discordant and con- kidney transplant was performed at other legacy from the Dunphy era cordant species were conducted, UCSF in 1964, and a perfusion ma- has been the major impact his train- which helped set the stage for fur- chine was developed that success- ees have had on surgery ther investigative and clinical ef- fully preserved donor kidneys for 48 forts in xenotransplantation. Endo- hours, an innovation that made throughout the English speaking world. crine surgery was a personal legacy UCSF’s transplantation series one of For a time, it seemed that the imprima- of Goldman. However, additional the most successful in the world.8 tur of the W.W.B.S. (Worked With Bert Society, one of those never organized but changes were in store when J. Engle- The first cardiac transplant at UCSF nevertheless important groups) was re- bert Dunphy, MD, was recruited was performed in 1969. The Dun- quired for elevation to chairmanship.9 from outside the pool of faculty can- phy era also saw the beginning of a didates at UC to become chair in research program in wound heal- When Dunphy retired in 1975, he 1964. Dunphy, who had trained with ing, which continues to receive fund- left behind a well-structured depart- Eliot Cutler, MD, one of Halsted’s ing from the National Institutes of ment with strong division lead- residents, was a gifted surgeon, an Health (NIH), Bethesda, Md, to this ers.10 His successor, Paul A. Ebert, enthusiastic and dedicated teacher, day, and the development of the na- MD, helped establish UCSF as an in- and a scientist with a lifelong inter- tion’s first organized trauma ser- ternational referral center for chil- est in the mechanisms of wound vice at the county hospital, San Fran- dren with cardiac defects and fos- healing. He thought development of cisco General Hospital (SFGH). tered the development of pediatric nascent surgical specialties was being Innovations were taking place in cardiac surgery. Congenital heart held back by a tradition of conser- lower-gastrointestinal surgery, and disease was studied in fetal lambs, vatism7 and brought in faculty from colonoscopy was brought to UCSF myocardial protection with cold is- outside UC. Under his steward- in 1972. Dunphy also integrated resi- chemic potassium cardioplegia was ship, pioneering clinical and re- dency training into one program in- examined, and clinical studies were search activities grew rapidly.8 volving the San Francisco Veterans done on the operative closure of the Vascular surgery became an inde- Administration (VA) Hospital, patent ductus arteriosis in prema- pendent division. Pediatric surgery SFGH, and the University Moffitt ture infants. Exciting work using the began to be defined as a separate spe- Hospital, each of which was devel- fetal lamb model to study the physi- cialty, and research was conducted oped as a strong teaching and re- ologic consequences of a surgically on diaphragmatic hernia, Wilm tu- search unit in its own right, led by created diaphragmatic effect would mor, and neuroblastoma. The first young and creative faculty. Yet an- play a significant role in the devel-

(REPRINTED) ARCH SURG/ VOL 140, DEC 2005 WWW.ARCHSURG.COM 1146 Downloaded from www.archsurg.com at UCSF/Library, on December 20, 2005 ©2005 American Medical Association. All rights reserved. opment of open fetal surgery (vesi- aneurysms. Wound-healing re- many milestones of this group in- cotomy for an infant with urinary search received a 5-year, $3 million cluded the ex utero intrapartum obstruction), first performed in 1981 NIH grant to study collagen synthe- treatment procedure for airway ob- at UCSF. This success was owing to sis and angiogenesis. The newly or- struction in 1995, which has been collaboration among UCSF sur- ganized UCSF Fetal Treatment Cen- performed more than 40 times for geons, obstetricians, and radiolo- ter began an NIH-funded study of infants with various types of air- gists, all of whom were relatively fetal surgery for diaphragmatic her- way obstruction, such as congeni- young junior faculty “who were still nia and controlling preterm labor. A tal cystic adenomatoid malforma- naïve enough to think that we could merger with Mount Zion Hospital tion, cystic hygroma, and tracheal do something that had not yet been (San Francisco), a voluntary, non- obstruction; completion of an NIH- seriously attempted.”11(p518) In the profit hospital in operation since sponsored clinical trial for open re- area of endocrine research, iodine 1887, began a new era in thoracic pair of a fetus with congenital dia- deficiency, hyperparathyroidism, and oncology surgery when UCSF/ phragmatic hernia in 1996; fetal and thyrotropin binding were all Mount Zion became an NIH- endoscopic (fetoscopic) surgery in being investigated. Vascular sur- funded comprehensive cancer cen- 1996; successful resuscitation of a fe- gery research was focused on arte- ter in 1993-1994. The SFGH campus tus during open fetal surgery for sa- rial autografts and visceral arterial of UCSF continued to be a major crococcygeal teratoma in 1996; an atherosclerosis. The role of glyco- force in improving the care of trauma NIH trial of a fetoscopic balloon for lytic intermediates and ramifica- patients. Important clinical ad- congenital diaphragmatic hernia in tions of total parenteral nutrition vances included using computed to- 1998; and percutaneous radiofre- were studied in collaboration with mographic scans to evaluate blunt quency ablation of a sacrococcy- the Lawrence Berkeley National abdominal injury and nonoper- geal teratoma in 1999. Laboratory (Berkeley, Calif) and the ative management of particular types Since Nancy L. Ascher, MD, PhD, UCSF departments of Microbiol- of liver injuries.12 San Francisco Gen- became chair in 1999, solid organ ogy and Immunology. eral Hospital also played a nation- transplantation has taken place in After Ebert departed to assume ally prominent role in the surgical patients with human immunodefi- directorship of the American Col- response to the human immunode- ciency virus, adult live-donor liver lege of Surgeons (Chicago, Ill) in ficiency virus epidemic, leading the transplantation has joined adult-to- 1986, Haile Debas, MD, a leading ex- nation in adopting new infection- child for transplantation proce- pert on the gastrointestinal system control procedures for surgery, in- dures, a new center for patient- who had contributed to understand- cluding double gloving and using directed breast care has been ing the physiologic, biochemical, and waterproof garments and face shields developed, and a multicenter clini- pathophysiologic characteristics of to prevent mucocutaneous expo- cal trial of adjuvant therapy of gastrointestinal peptide hormones, sure to blood. colorectal cancer has been con- was recruited to become the next When Theodore Schrock, MD, ducted. Other important advances chairman. Research dollars to the de- assumed the chairmanship in 1993, over the last 5 years include the department went from 98th place of after Debas was appointed dean of velopment of a novel endovascular 125 in the previous decade to ninth the School of Medicine, major treatment for thoracic and ab- in the nation, reaching second place changes in reimbursements had dominal vascular disease, fetal by the early 1990s. A new Center for tightened their grip on the UCSF endoscopic laser treatment of a the Study of Gastrointestinal Motil- academic medical center, prompt- single arteriovenous communica- ity and Secretion conducted stud- ing a merger between UCSF and tion in twin-twin transfusion syn- ies in patients with esophageal mo- Stanford University (Stanford, Calif) drome, and initiation of a pancreas tility disorders. Transplantation in 1997. Although historically the 2 islet program. An affiliation has been activities accelerated rapidly: the first institutions had shared the staffing established with the East Bay Sur- liver transplant at UCSF was per- of SFGH and the VA Hospital for de- gery Residency Program, centered at formed in 1988, followed by tho- cades, this time the 2 faculties failed Alameda County Medical Center racic organ transplants in 1989, a to come together and the merger was (Oakland, Calif). pancreas transplant in 1989, and a dissolved a year and a half later. The Today, the mission of the UCSF heart-lung transplant in 1991. Lapa- 1990s were also a time of great ex- Department of Surgery is 3-fold: to roscopic surgery also accelerated pansion of the department’s al- develop the next generation of lead- rapidly, beginning with the first lapa- ready strong laparoscopic surgery ers in surgery; to provide outstand- roscopic cholecystectomy, per- efforts. Collaborations with bioen- ing quality clinical care that is both formed in 1990, which was fol- gineers were forged to develop vir- compassionate and cost-effective; lowed just months later by the first tual-reality software and robotic de- and to make significant advances in UCSF laparoscopic cholecystec- vices that would overcome the scientific knowledge and clinical tomy course and expansion of the technical limitations of the instru- practice through both basic and laparoscopic repertoire to Taylor va- mentation in current use. The Cen- clinical research. The “crown jewel” gotomies, appendectomies, and the ter for the Study of Gastrointestinal of our department is our residency excision of liver cysts. Vascular sur- Motility and Secretion also ex- program, consistently ranked among geons began exploring minimally in- panded, and fetal surgery contin- the top 10 programs in the nation. vasive approaches to treating aortic ued full speed ahead. A few of the More than 80% of graduates from the

(REPRINTED) ARCH SURG/ VOL 140, DEC 2005 WWW.ARCHSURG.COM 1147 Downloaded from www.archsurg.com at UCSF/Library, on December 20, 2005 ©2005 American Medical Association. All rights reserved. past 30 years have continued in fel- resident and student education, REFERENCES lowship programs, and almost half clinical activities, and research, are become surgical academicians asso- Adult Cardiothoracic Surgery, 1. A history of the UCSF School of Medicine. Avail- ciated with university departments Pediatric Cardiothoracic Surgery, able at: http://history.library.ucsf.edu. Accessed of surgery. Residents rotate through General Surgery, Fetal Surgery, Pe- June 14, 2005. our flagship hospital, Moffitt/Long diatric Surgery, Plastic and Recon- 2. San Francisco: historical overview. University of Hospital, a quaternary care center structive Surgery, Transplantation, California History Digital Archives Web site. Avail- able at: http://sunsite3.berkeley.edu/uchistory and major university research hos- Trauma (at SFGH), and Vascular /general_history/campuses/ucsf/departments_s pital; SFGH, San Francisco’s mu- Surgery. Recognized nationally and .html. Accessed June 14, 2005. nicipal hospital and its only level I internationally, our division chiefs 3. Blaisdell FW, Grossman M. Catastrophes, Epi- trauma center; the San Francisco VA and faculty have served as officers demics and Neglected Diseases. San Francisco Medical Center, a referral center for of major surgical societies, mem- General Hospital and the Evolution of Public Care. bers of specialty boards, and mem- San Francisco, Calif: The San Francisco General other regional VA hospitals; the Hospital Foundation; 1999:39. UCSF/Mount Zion Hospital, a re- bers of study sections at the NIH. 4. In memoriam: Howard Christian Naffziger. Uni- gional cancer center; the San Fran- Many of the clinical services and in- versity of California History Digital Archives Web cisco Kaiser Permanente Hospital, a dividual faculty are rated as being site. Available at: http://sunsite.berkeley.edu large health maintenance organiza- among the “top 10 in patient care” /uchistory/archives_exhibits/in_memoriam/index3 in the nation. .html. Accessed June 14, 2005. tion; and the California Pacific Medi- 5. Rosegay H. A history of neurological surgery at cal Center (San Francisco), a private- After 101 years, the Department the University of California, San Francisco. practice clinical setting where our of Surgery at UCSF continues to Neurosurgery. 1996;38:794-805. residents train with private commu- value hard work, productivity, and 6. In memoriam: H Glenn Bell. University of Califor- nity-based surgeons. This combina- creativity as we strive to improve sur- nia History Digital Archives Web site. Available at: tion of hospitals gives residents gical techniques, make surgery more http://sunsite.berkeley.edu/uchistory/archives effective while less invasive, and im- _exhibits/in_memoriam/index3.html. Accessed broader exposure to clinical sur- June 14, 2005. gery than any other program in the prove care for patients. In keeping 7. Interviews With J. Englebert Dunphy, MD, UCSF country. with William Osler’s ethos, we con- Oral History Program, Department of Surgery In- Basic and clinical research by fac- tinue to “let each day’s work ab- terview Series 4. UCSF Surgery in the Postwar 13(p10) ulty, fellows, and residents is fun- sorb [our] entire energies.” Years. Building an Exemplary Department of Surgery. San Francisco: The Regents of the Uni- damental to our mission. We pro- versity of California; 2000:11. vide the opportunity for residents to Pamela Derish, MA 8. Way LW. A festschrift for John Englebert Dun- engage in research activities for 2 to Nancy L. Ascher, MD, PhD phy, MD. Am J Surg. 1978;135:273-275. 3 years. Surgical residents can work 9. In memoriam: J Englebert Dunphy. University of in the laboratories of leading basic Correspondence: Dr Ascher, Uni- California History Digital Archives Web site. Avail- able at: http://sunsite.berkeley.edu/uchistory science researchers throughout the versity of California, San Fran- /archives_exhibits/in_memoriam/index3.html. Ac- university. We also offer strong clini- cisco, 513 Parnassus Ave, S-322, San cessed June 14, 2005. cal research opportunities in gastro- Francisco, CA 94143-0104 (aschern 10. Interviews With Paul A. Ebert, UCSF Oral History intestinal surgery, transplantation, @surgery.ucsf.edu). Program, Department of Surgery Interview Se- trauma and sepsis, vascular dis- Acknowledgment: We thank Nancy ries 5. UCSF Surgery in the Postwar Years. Unit- ing Pediatric Cardiology and Congenital Heart ease, cancer, fetal treatment, and Rockafellar, PhD, of the University Surgery. 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