,rMedicine in American History Refer to: Mandell P, Raih T, Taylor LW: A history of orthopedics in San Francisco and the West (Mledicine in American History). West J Med 125:502-508, Dec 1976
A History of Orthopedics in San Francisco and the West PETER MANDELL, MD; THOMAS RAIH, MD, and LLOYD W. TAYLOR, MD, San Francisco
The unique development of early medical specialization in the West can be traced to California's geography and economic development. Such early specialization produced men with orthopedic inclinations. Early orthopedists founded the first medical school and the first modern teaching hospital, helped to found Stanford's Lane Medical Library and made the first use of x-rays in the West. In addition many of these orthopedists were prominent in the political and social activities of the time.
EARLY MEDICINE in California centered about the system of missions set up from San Diego to San Francisco by the first Spanish settlers. These missions were not only spiritual but also medical centers for the surrounding agricultural communities. Early in its history California medicine developed a tradition of referring cases from the sparsely populated farmlands to a central area. This tradition was to be important in later years for the development of medical specialization including orthopedics in the West.' Before the gold rush California was isolated. Few people could muster the time and money necessary to make the arduous journey over the deserts, mountains or vast ocean stretches. But those who did arrive in California were very much interested in medicine and their health, and they wasted little time in telling the world of their newly discovered land. The great selling point of California was its healthful climate which the scientists of the day had computed to be one of This paper is based on material presented as an exhibit at the 1975 meeting of the American Academy of Orthopaedic Surgeons and on material presented in 1975 at a University of California, San Francisco, Orthopedic Grand Rounds. Reprint requests to: Peter Mandell, MD, 2233 Post Street, Suite 103, San Francisco, CA 94115.
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the finest in the world. A year before the gold rush a San Francisco physician wrote:2 Nor is sickness that scourge of humanity here to harass and hinder us in our pursuits. The general salubrity of California has justly become a proverb. The surgeons of San Francisco have remarked that wounds heal here with astounding rapidity owing, it is supposed in great measure, to the extreme purity of the
atmosphere. Despite its great health claims San Francisco was able to attract less than 5,000 people by 1848. Yet within the next four years the Bay Area became one of the great commercial centers of the world following the discovery of gold in the Sierra Nevada foothills. With this discovery a major revolution in San Francisco medicine occurred. Hundreds, perhaps even thousands of doctors poured into California seeking riches first in the gold fields and then in medicine, healing those who had struck it rich. A month after the discovery of gold there were about 30 physicians set up in tents within 100 yards of Sutter's mill. And it is easy to understand why when one recalls that the charge for cholecystectomies was $1,500
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Figure 1.-Elias Samuel Cooper, founder of the first medical school in the West and one of the West's first joint surgeons.
apiece, with other surgical procedures similarly priced. Many of the "doctors" who came to town were poorly trained and most were persons who had been driven from their eastern or European cities to San Francisco. The ratio of physicians to patients quickly grew to five times the national average and has remained elevated to this day.3 This influx of doctors naturally sparked competition and violent literary attacks by one group of physicians upon another. In 1850 one doctor wrote "We physicians are at the most ruinous discount . . . held in so low repute that many a worthy physician studiously conceals his title." Another doctor of the period observed, "We live in continual war with each other-an internecine war, murderous and suicidal."4 Amid this surfeit of doctors, San Francisco's earliest orthopedic ancestor, Elias Samuel Cooper, felt compelled to open the first medical school in the West. Dr. Cooper (see Figure 1) was an aggressive man who, according to Emmet Rixford, "could not be accused of hiding his light under a bushel, for he advertised widely his ophthalmic and orthopaedic dispensory in the sev-
eral score of newspapers of the mining districts."5 Dr. Cooper's efforts to increase the number of physicians in San Francisco were not met with great enthusiasm. One member of San Francisco's medical community greeted the introduction of Cooper's school with these words: A medical college is not needed here. There is no fund for the endowment of the college, and there are no students to attend the lectures, and there are no capable physicians who have the leisure and philanthropy to deliver lectures gratis.... We hope our Atlantic brethren will not be deceived. The Pacific Medical College is now a legitimized sham-a legal humbuga chartered advertising medium for the man (who founded it).6
Cooper's orthopedic credentials include contributions on knee joint surgical procedures. He apparently researched this subject in some detail and was said to have originated a totally new theory for such operations. Cooper was also the first San Francisco surgeon to publish on an orthopedic topic when he wrote "A New Method of Treating Long Standing Dislocations of the Scapulo-Clavicular Articulation" in 1861.7 Dr. Cooper's orthopedic contemporaries include Augustus Jesse Bowie who was known throughout the city for his conversational powers. It was said that so legend were Dr. Bowie's talents that "sometimes men took to bed in order to have the pleasure of the doctor's visit."8 Bowie's formal training ceased when he was 13. Thereafter he apprenticed himself to a surgeon in Baltimore and arrived in San Francisco in 1849 aboard one of the first United States Navy steam powered ships to join east and west coasts. In addition he became the first surgeon at St. Mary's Hospital when it opened in 1861. Indeed, according to an article by E. S. Cooper, Dr. Bowie's fame as a bone surgeon was won at St. Mary's Hospital. Cooper9 noted that Bowie: had a number of cases of operations for Pseudoarthrosis, and, with one exception, had entire success. This is more than can be said of the Hospital Surgeons of London and Paris, who not only fail in removing the deformity, but frequently lose their patients. The latter circumstance seldom or never occurs in this
city. It cannot be denied that San Francisco leads the surgical world in the success of operations THE WESTERN JOURNAL OF MEDICINE
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Figure 2.-Harry Mitchell Sherman orthopedist in the West.
upon the bones. So much is this the case, that
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born in Rhode Island
rush. He trained
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New England as did many of his distinguished successors in the West. Only a year after his arrival Sherman developed an interest in crippled children. He became the surgeon at Children's Hospital and before he died in 1921 he had made Children's Hospital the orthopedic center of the West. One of Sherman's students recalled that Sherman's manner was that of a grande seignior -formal, courteous and punctilious. But Sherman seems to have had his less formal moments as well. One of his favorite pastimes at lunch was taking target practice with his .44 caliber pistol in his downtown office. By 1900 Sherman was such a respected member of the orthopedic community that he was elected president of the American Orthopaedic Association. That same year his future partner, James T. Watkins, while touring the orthopedic centers of Europe was amazed to learn that whenever he told his hosts that he intended to practice in San Francisco they would reply "Oh yes, Sherman is in San Francisco."'1 Sherman was interested in hospital construction and experimented with different colored tiles and drapes in the operating room. He finally hit upon green, a color still used today. Sherman was one of the first men in San Francisco to recognize the importance of a university teaching hospital after the model of Johns Hopkins. His opportunity for this endeavor came when the 1906 earthquake and fire devastated the city and most of its hospitals. Sherman and others converted part of the University of California Medical School to a teaching hospital and Sherman supplied not only the first patient to the new hospital but also the first bed. Not only was Sherman the first internationally recognized orthopedist in the Bay Area but he was a man great enough to admit his mistakes in public. He once published an article detailing the reexploration of a patient in whom he had left a sponge seven years before.12 Even in his time such written candor was rare. Sherman's longtime partner was James T. Watkins, who was born in Baltimore but passed much of his years in California. His grandfather, Commodore James T. Watkins, had carried the news of California's admission to the Union around the Horn. While growing up Watkins had the pleasure of meeting many of his father's famous friends, including Mark Twain and Bret Harte. After moving back east to attend the University of Virginia young Watkins obtained a medical
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Figure 3.-The first medical use of x-rays in the West at the University of California, Berkeley, Physics Laboratory.
degree from Columbia in 1894 and then spent three years in New York. For an additional three years he studied orthopedics at various European centers with Hoffa, Lorenz and Lange. In 1902 James T. Watkins, now a bright young physician, returned to San Francisco and became the first on record to openly challenge Harry Mitchell Sherman's medical judgment. After two months of stony silence Dr. Sherman quietly asked young Watkins to join him in practice. Dr. Watkins became an outstanding community and national figure. Immediately after the 1906 earthquake he became the city's health officer. He was a charter member of the American College of Surgeons and helped organize the San Francisco Orthopaedic Club in 1920 and the Western Orthopaedic Association. As 41st President of the American Orthopaedic Association in 1927 Watkins courted the orthopedic world by hosting the annual meeting at Yosemite Valley. In his presidential address he stressed the compatibility between science and religion. When Watkins died in 1934 the orthopedists of the West had lost their leader and San Francisco had lost a great citizen.
During the period when Sherman and Watkins were working and studying in San Francisco other innovative men were also beginning a grand tradition of orthopedic research in California. A. W. Morton was one such man. In 1903 he reported his successful results in treating a long-standing, infected, tibial nonunion by implanting a dog bone still attached by a pedicle to the dog. Dog and man were then encased in plaster for five weeks, and according to Morton the patient suffered very little pain except for the first two or three postoperative days when the dog attempted to move.13 A far more important experiment for orthopedics was conducted at Berkeley in February 1896 (see Figure 3). A 13-year-old boy had received a gunshot wound to his hand and his surgeon had been unable to locate the bullet by probing. The boy was then taken to the University of California physics laboratory where his hand was strapped to a photographic plate and held there for 90 minutes of x-ray exposure. The resulting picture was of poor quality and the boy was then reexposed for two and a half hours before a good picture was obtained. This experiment was the first medical use of x-rays in the West."' Around the turn of the century several men who made contributions to Bay Area orthopedics were coming to the front. Emmet Rixford for example was a surgeon with orthopedic leanings who had graduated from Cooper's medical college. He had a strong interest in engineering and his early publications dealt with green stick fractures, torsion fractures and other afflictions of bones and joints. Rixford was instrumental in setting up Stanford's Lane Medical Library. His love of books was so great that during the fire and earthquake of 1906 Rixford buried some of his books to prevent their destruction. Some of these books are still housed in the Lane Library. Sam Hunkin came to California as a sailor from Cornwall. He worked his way through college firing a steamboat on Lake Tahoe. He enrolled at Toland Medical School and upon graduation in 1890 he became an assistant to Harry Sherman at Children's Hospital. Hunkin was a swift and skillful surgeon, who spent about 30 minutes doing a laminectomy. He was a prolific writer, and as early as 1912 he reported 12 successes in 12 attempts at treating femoral neck fractures with a large silver plated
nail. THE WESTERN JOURNAL OF MEDICINE
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Figure 4.-Leonard Wheeler Ely, orthopedics at Stanford University.
Hunkin was a colorful figure who could be seen making his rounds from hospital to hospital in a chauffeur-driven limousine. He had what might be termed a keen eye for the ladies-aided, of course, by his smooth style and impeccable dress. In his later years it appears that Hunkin dropped into obscurity as if shunned by the medical society of the day. His personal life apparently did not meet the standards expected of a physician. Except for his obituary and his numerous publications, there is little evidence that this man practiced orthopedic surgery in San Francisco for nearly 40 years. Leonard Wheeler Ely (see Figure 4) was born and educated in New York. He began his practice in the East and then started his trek west, settling for a time in Denver where he developed interest in joint tuberculosis. In 1913 he met and married the daughter of Ray Lyman Wilbur, the president of Stanford University, and in 1914 he became the first professor of orthopedics at Stanford. From that time until he retired in 1934 he published more than 100 articles and three textbooks. Throughout his writings and teachings Dr. Ely worked to place the knowledge of bones and joints on a firm scientific basis. Although Ely had served in World War I he felt compelled to contribute to the war effort in 506
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World War II at the age of 74. When he was not accepted into the military service as a physician he went to work in a shipyard. However, the task proved too much for him and he died quietly in his sleep. Bay Area orthopedics took a turn for the better in 1923 when Shriners Hospital was established. Its first chief was Walter I. Baldwin who was succeeded at Shriners by Edward (Ned) Bull in 1927. Bull was so compulsive about his lectures that he often stayed up until three in the morning preparing one, only to sleep right through it. While he was chief at Shriners (19271931) he loved to teach but he loved to talk even more and many a physician avoided being cornered by Dr. Bull unless they had an hour or so to spare. Sylvan Haas was the next Shriners chief. He did his internship at Lane Hospital and then spent one year in Europe studying pathology. During World War I he was instrumental in organizing what later became the Armed Forces Institute of Pathology. His early interest in pathology primarily dealt with bone physiology and disease and set the ground work for his research. He wrote a great deal, was a tireless researcher and published more than 50 articles during his lifetime. Dr. Haas was one of the first American authors to study the epiphysis in detail. He was an early pioneer in the treatment of leg length discrepancy by epiphysiodesis. Several of Haas' contemporaries also contributed to Bay Area orthopedics. These men include George McChesney, Lionel Prince, J. Judson Sale, John Loutzenheiser and General Norman T. Kirk, who became Surgeon General of the Army. Yet it remained for LeRoy Abbott to make the Bay Area a major center for orthopedic training. Abbott was born in Minnesota but graduated from the University of California Medical School in 1914. He then trained in Boston where he had a chance to observe firsthand how the finest orthopedic training in the country was then carried out. During World War I Abbott was fortunate enough to meet some of the great British orthopedists, including Sir. Robert Jones and Sir Harold Stiles. In fact, after the war Abbott became Stiles' first American resident. His training completed, Abbott launched his academic career in Michigan and then Missouri before returning to the University of California in 1930. There he found his work cut out for him as he assumed the chairmanship of a division with
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no recent leader, practically no funds and a clinical staff of only 12. There were no salaries paid to him or his staff and precious few beds at the university and county hospitals. From this shaky beginning Abbott was to fashion a formidable orthopedic department. He did it by his own great teaching ability and by his knack for keeping people busy and productive enough so that they had little time to squabble among themselves. Some of Abbott's Bay Area colleagues such as Ralph Soto-Hall, Donald King, Keene Haldeman and Merrill Mensor are still contributing to orthopedics today. Abbott had the sagacity and luck to surround himself with brilliant men. In 1931 he coaxed Dr. Frederick Bost to join him after the completion of his training at Harvard. Bost became chief of San Francisco [General] Hospital where he was recognized by his students as a great, if somewhat hard-driving, teacher. A man of short stature, Bost used to back up, stand on his toes and rest his heels against a wall when lecturing on rounds. He became chief at Shriners Hospital and is the only Bay Area orthopedist to have been president of the American Academy of Orthopaedic
Surgeons. About the same time that Bost joined his department, Abbott was able to get J. B. de C. M. Saunders to work in orthopedics. Saunders was apparently hired in Scotland by the chief of the University of California anatomy department as a half-time anatomist and half-time surgeon, but when Dr. Saunders arrived in San Francisco the surgery salary was not available and Abbott seized the opportunity to give Saunders an appointment in orthopedics.15 Dr. Abbott was never one to let a good opportunity go to waste or to use time foolishly. In 1947, he had need of an orthopedist for the Ft. Miley Veterans Administration Hospital. One day he was administering the anatomy portion of the Orthopaedic Board Examination to Dr. Floyd Jergesen, a man whom Abbott had met and talked with before. Abbott offered him the job at Ft. Miley on the spot, and while they were discussing the details, the bell rang without a single anatomical question having been asked.16 Abbott also called upon some of his promising residents to fill teaching and research duties in his department-men such as Verne Inman and Gerald Gill. Inman combined his strong interests in engineering with those in medicine. He taught anatomy for a time before beginning his ortho-
pedic training. In 1940 Inman received a grant from The National Foundation for Infantile Paralysis to study the anatomy and physiology of skeletal movements. Along with Abbott and Saunders he produced a classic study on shoulder movements. The experiences gained in this initial prewar study were to prove invaluable to Dr. Inman, as World War II brought an increased need for prosthetic devices. When the manufacturers of these devices found that they did not understand what they were trying to replace, Drs. Inman, Saunders and Abbott produced papers on the major determinants of gait, the action of the ankle joint, referred pain from skeletal structures and the biomechanics of hip joint motion. These studies have become part of the foundation of modem orthopedics and are a far cry from the early Bay Area experiments of Morton and his dog bone graft. In addition to surrounding himself with great men at the University of California, Abbott also expanded his residency program to include hospitals throughout the east and west bay areas. With the incorporation of the East Bay hospitals Abbott had a chance to expose his residents to the teaching talents of such men as Harold Hitchcock, Leonard Barnard and Douglas Toffelmier. By 1957 when Abbott retired, his goal of achieving a great orthopedic service in the Bay Area had been achieved. From a department with no leader, no funds and few teachers Abbott had fashioned a department of national prominence.
Conclusion The orthopedic history of the Bay Area has been remarkably colorful and varied. Its early Spanish heritage began with the mission referral system which led to medical specialization. The gold rush brought in medical entrepreneurs from all over the world whose wisdom helped to found the orthopedics of today. Some of the great social and scientific institutions of the West were founded by, or with the help of, men interested in bone and joint surgery. We have mentioned E. S. Cooper and his medical school-which was to become the medical school of Stanford University. Emmet Rixford helped to establish one of the great medical libraries of the West. Harry Sherman established Children's Hospital as the. orthopedic center of the West in its day and put San Francisco on the orthopedic map. In addition, orthopedists were in the forefront THE WESTERN JOURNAL OF MEDICINE
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of much important scientific research in the Bay Area. We have noted that the first x-ray films taken in the West were of a boy with an extremity injury. The first J.physicians to clearly define how men walk were Bay Area orthopedists, as well.
6. Trask JB, 310 1, p Wooster D: Pacific MSJ 2:495-499, 1859, Cited in 7. Cooper ES: A new method of treating long standing disloca-
tions of the scapulo-clavicular articulation. Am J Med Sciences
41:389-392, 1861 of the early 8. Three figures Bulletin, famous society The San Francisco 15 Mar 1913 set of San Fran~~~~~~~~~~~~~~~cisco. 9. Cooper ES: San Francisco Medical Press, Jan 1861, p 48
10. Saunders JBdeCM: Reference 1, pp 322-323 11. Watkins JT: Doctor Harry Sherman dean of orthopaedic surgeons on the west coast of America (Unpublished papers of 1. Saunders JBdeCM: Geography and geopolitics in California the Watson family, undated) 12. Sherman HM: A gauze sponge left in the skull for over six medicine. Bull Hist Med 41:293-324, Jul-Aug 1967 Cal St J Med 9:174, Apr 1911 2. California Star, 1 April 1848 2. Califomia Star, 1 April 1848 ~and13. one-half Morton years. AW: Bone transplanting, and report of a case. Cal 3. Saunders JBdeCM: Reference 1, p 310 St J Med 1:213, Jun 1903 4. Gibbons AH: Annual address of the retiring president. Trans 14. The Examiner, 25 Feb 1896, p 48 M Soc Calif, 1858, p 23 15. Inman V: Personal communication 5. Rixford E: Presidential address. Ann Surg 88:321, 1928 16. Jergesen F: Personal communication
Important Medical-Legal Aspects of Immunization There have been some recent medical-legal developments that I think may cause you grave concern . . . and I would urge you to spend a little more time talking to parents on a child's first visit for immunizing agents. In 1963, in the case of Davis vs. Wyeth, wherein an adult who had participated in a mass Sabin vaccine program in Idaho contracted poliomyelitis, and in which case it was shown that his paralytic disease was vaccine-associated: The first court of jurisdiction found for Wyeth, the defendant, saying that it was well-known that Sabin oral polio vaccine did carry a small risk (1 case in 3 million, or 1 in 5 million, depending on the type of vaccine strain) and that, therefore, this was to be expected . . . The 9th Federal Circuit Court, however, reversed the decision and said that there was an "implied warranty" any time a manufacturer put a product on the market. And even though that manufacturer had fulfilled all the standards of safety testing as required by the government at that time, the manufacturer himself (or his representative) must warn the patients who are receiving these products of the risk. Seven years later, in 1970, there was an outbreak of natural poliomyelitis in South Texas due to polio type 1. Because of this there was a mass program in the community, and in a public health clinic an 8-month-old child . . . received a feeding of vaccine strain and paralytic poliomyelitis later developed. It was shown conclusively by expert witnesses who studied the virus recovered from the child that the child suffered from natural poliomyelitis and not from the vaccine strain. Yet, the courts found against the manufacturer, Wyeth. They disregarded the expert testimony that the vaccine had nothing to do with the child's paralytic disease, which was naturally acquired, and again brought up this business of the implied warranty. Now . . . this may sound like it's a long way from your individual practice . . . but to protect ourselves and to be defensive I would suggest to you very strongly that you give the parents a handout on immunizing agents that you're going to use rather routinely . . . You better make sure that your chart reflects that you have talked to the parents about the immunizing agent; and you should also record the child's temperature. And my advice to you is that although there is no contraindication, in my opinion, to use the trivalent oral polio vaccine in a febrile child, I wouldn't use even that in a febrile child now because of some of the medical-legal implications I've seen. -HENRY G. CRAMBLETT, MD, Columbus, OH Extracted from Audio-Digest Pediatrics, Vol. 21, No. 14, in the Audio-Digest Foundation's subscription series of tape-recorded programs. For subscription information: 1930 Wilshire Blvd., Suite 700, Los Angeles, CA 90057.