Published with permission from Elsevier.

Neurosurgical Giants: Feet of Clay and Iron by Paul Bucy – 1985
ISBN: 9780444009396

By Eugene Stern

Howard Christian Naffziger

1884-1961

An erect, commanding figure with a twinkle in his eye (some of the time), white-haired, every inch a fine physician, Howard Naffziger was the West’s neurosurgical giant and had been for many years when he turned over his academic reins as Professor and Chief at the University of California, San

Francisco, in 1952. His beginnings were molded by an intelligent mother in the fascinating, rough-hewn environment of Nevada City in the western goldmine ridden slopes of the California Sierra Nevada. Following graduation in Medicine from the University of California, he was strongly motivated by Dr. Camillus Bush, surgeon, to improve his surgical education at the Johns Hopkins Hospital and, although initially rebuffed by Harvey Cushing’s un-cordial reception, Naffziger convinced the “chief” of his strong motivation by hard work, and his neurosurgical career was launched. Although invited by Cushing to move with him to Harvard, Naffziger returned to the far west, carrying the seeds of surgical education, neurosurgical specialization, and the superior standards of Halsted and of that great man’s colleagues back to the “coast.” These standards he never deserted, and the seeds rooted and flourished.

The years it took for them to blossom encompassed the first World War. Albeit a member of the American Expeditionary Force in France, his primary neurosurgical contribution at that time came from his efforts in

behalf of the excellent military manual of neurosurgery published by the Surgeon General’s office.

It is of interest to review his writings in the early years of his career as he acquainted the medical community with the value of surgical expertise in managing neurological problems. While culturing neurosurgery, he retained a catholic interest in all facets of surgery as a broad discipline, and to his death was a doctor, a surgeon, and a neurosurgical specialist, depending upon the need of the occasion and eschewing a chauvinistic attitude.

As neurological surgery grew from fledgling to eagle status in those great years of the 1920s, Naffziger’s writings reflected his active mind and spanned the entire field of the new specialty. Before the Great War and immediately afterwards, he published works on head and peripheral nerve injuries, intracranial pressure problems, tic douloureux, and spinal cord tumors.

Three major contributions appeared in the mid-1920s. In 1924 he described traumatically induced collections of subdural fluid that acted as mass lesions and emphasized the importance of surgical evacuation of the watery or bloody fluid from the nonabsorbing subdural space. The major work by Putnam on subdural hematoma in 1925 referred to this important paper; and Naffziger’s interest in the general topic was sustained, as evidenced by the 1934 paper with Brown on chronic subdural hematoma in infants.

In that same year (1924), he joined Locke in a splendid anatomical paper defining, by injection and corrosion techniques, the cerebral subarachnoid system, thereby filling in part a void that had existed from the landmark paper of Key and Retzius in the previous century.

The following year, referring to the calcified pineal image in plain roentgenograms, he stated, “It occurred to us that the position of this structure might be of diagnostic value …. ” Naffziger clearly enunciated the value of the “pineal shift” in the anterioposterior projection in diagnosing lateral displacements of the cerebral hemispheres, and who, today, does not look for this valuable sign?

By 1928, his excellent reputation was broad and in that year, the paper, so well illustrated by Ralph Sweet, on surgical exposures was published and continues to receive and deserve study. In it, he described the valuable occipital flap for combined supra- and infratentorial exposure; he contributed a midline cerebellar exposure and noted the importance of a fascial fringe for proper closure along the superior nuchal line. This paper reflected a master surgeon’s work and was echoed in a technical sense when he later described the “California flap” for pituitary tumors, a simplified and more acceptable modification of the Cushing flap then in vogue.

Called from his clinical faculty status to the Professorship and Chairmanship of the Department of Surgery of his University in 1929, he launched the first formal surgical residency training program in the western United States and firmly established his role as a surgical educator. Although neurosurgery was a favored subspecialty in that program through the merits of Naffziger’s leadership and forceful personality, yet it was not until 1947 that he relinquished the reins of the Department of Surgery as a whole to assume those of the first head of a separate department of Neurological Surgery, a prototype the successor of which exists today.

In the two years after his call to the chairmanship, he published two papers of value. The first of these was the fundamental experimental paper on depressed fractures of the skull, work done in conjunction with Glaser. The paper made clear that changes in the brain are caused by the force producing the injury to the skull rather than by the depression of the bone; it dispelled the myth, still abroad, that untreated depressions cause progressive brain damage. The second contribution ( 1931) was the first of a sequence of papers defining the entity of infiltrative endocrinopathic exophthalmos and its vision- saving surgical treatment. The dramatic case report of the first orbital decompression revealed the trail-blazing and innovative nature of the man whose world-renowned work on this problem culminated in his Hunterian Lecture on the subject in 1954 for the Royal College of Surgeons of England of which he was an Honorary Fellow.

Naffziger trained relatively few neurosurgical specialists in the early years; (the tempo was to increase after the second World War), but he had profound influence upon surgical education in the West and upon standards of excellence in the general field of surgery nationally. His influence was appreciated through the American Board of Surgery ( of which he was a founding member), through the American College of Surgeons, of which he was an officer and Regent for so many years, and through the American Board of Neurological Surgery as Chairman for numerous terms. He gave of his energies and canny wisdom and expertise in furthering the standards of surgical care in hospitals; he was instrumental in founding the Northern California Chapter of the College of Surgeons and he strived, diligently,

against a stifling tide to correct deficiencies in nursing education. • Intermingled with his service roles he presented first-rate papers, which continue to command review. His paper with Brown on hour-glass tumors of the spine added a significant chapter to our understanding of neoplasms that are contiguous within and without the spinal canal. His papers on the scalenus anticus syndrome (the Naffziger syndrome) may have been partially discredited, but they placed the structures of the thoracic outlet under scrutiny as important in explaining neurovascular compression problems not accounted for by cervical ribs. With Aird, he presented needed experimental data on the effects of ethyl alcohol on the contents of the subarachnoid space, and with that same esteemed colleague, he established the value of bilateral jugular vein compression in eliciting symptomatology and signs of disease, especially within the spinal canal (Naffziger’s test). An excellent paper on the role of structures other than the intervertebral disk in explaining root-compression findings (with Inman and Saunders) and fine papers on spine injuries, nerve injuries, and on unusual surgical and neurological problems documented a fertile and vigorous scholar. An example of his tenacious ingenuity was the pursuit of a logical solution to the challenge of the syndrome of the jugular foramen for which he, with Davis and Bell, offered a successfully applied procedure in correcting the paralysis of deglutition following a careful functional anatomical analysis of swallowing based on some of the earliest medical radiological cinematography.

Neurosurgeons of the future, as Naffziger generically observed in his 1939 Presidential Address to the American College of Surgeons, will appraise their forebears only as creators. And so with him. They will barely recall his many international honors, his numerous presidencies of senior surgical societies (e.g., The Pacific Coast, The American, The Society of Neurosurgical Surgeons). They are likely to be unaware of his service to the Office of Scientific Research and Development during World War II or to the National Research Council as a member, nor are they likely to have heard of his participation in the medical mission to post-War Poland and the Philippine Republic or of his aid as surgical consultant in the Korean conflict. Nor will they be able, easily, to measure his contribution as Regent of the University of California from his retirement in 1952 to his death in 1961 during which time he gave of his broad knowledge to the master-planning of medical educational expansion in that great institution.

It would be only through his students, family, and friends that so many qualities of a great surgeon and teacher could be communicated; his incisive thinking, his devotion to excellence, his insistence on dedication, hard work, and unimpeachable integrity. Lost to but a few would be his humor, his courtliness, his graciousness, his dignity. A warm physician, he gained much of his own inspiration from those before him and those who taught him. May his honor of medicine be communicated to those who follow him and be

implemented in as many good works.

Editor’s Comments

Of all the neurological surgeons in the United States, Howard Naffziger was certainly the most debonair. A fine figure always immaculately dressed and as one might well expect from such a man, always with a keen eye for the ladies. He was a close personal friend. We worked together closely in the

formation of the American Board of Neurological Surgery and in its operation over a period of several years. Although I was 20 years his junior, he never made me feel my lack of years and experience as compared with his. Two things stand out in Howard Naffziger’s career-his development of neurological surgery on the West Coast of the United States and his position as a statesman in medicine and neurological surgery. His well considered judgement was always highly appreciated and respected by his associates. He was responsible for few innovations. Among those few were the orbital decompression for malignant exophthalmos and the shift of the pineal body resulting from unilateral cerebral expanding lesions. One of Naffziger’s greatest accomplishments was his selection of his wife. She is one of the most remarkable women ( other than my own wife) that I have ever met. She impresses me as a typical daughter of our Far West. She is lovely in appearance; she is vigorous. As of recent dates she still frequently rode horseback in spite of her years. She is a delightful hostess.