Neurosurgery at the University of Minnesota 1937-1985
SHELLEY N. CHOU, M.D., Ph.D.

The Division of Neurosurgery, of the Department of Surgery in the University of Minnesota Medical School, was founded in 1937. Dr. William T. Peyton was appointed Director of the Division. Dr. Peyton, who had been trained as a general surgeon with interest in head and neck surgery, and who had Ph.D. degrees in general surgery and anatomy respectively, was the natural choice. Dr. Peyton’s Ph.D. thesis in anatomy was on the development of the temporal bone, and he had worked very closely with Dr. A. T. Rassmussen, who was a Professor of Neuroanatomy. Dr. Peyton and Dr. Rassmussen were able to continue joint investigations for many years and published a number of papers including one detailed neuroanatomical study of changes in the central nervous system following a mesencephalic tractotomy for the relief of pain in a patient with head and neck cancer.’

Dr. Peyton was certified by the American Board of General Surgery, and when the American Board of Neurological Surgery was founded, he was “grandfathered” in on the basis of his reputation arid position as Professor of Neurosurgery.

 

Dr. Peyton’s office was an 8 x 10 cubicle on Station 22. He had in his office a cabinet for books behind his desk and a small file cabinet. There was only one framed object hanging on the wall and that was a photograph of Dr. A. B. Baker with a gentle smile and a microscope in front of him. Dr. Baker was to shortly succeed Dr. McKinley as Director of the Division of Neurology. Dr. Baker was not only a renowned neurologist, but he also had extensive training in neuropathology. That these two men of extremely different personalities and persuasions could work together and train a large number of neurosurgeons and neurologists has to be considered an amazing feat. Dr. Peyton was a low profile, shy, reticent, man of few words. He was gentle, thoughtful, understanding, but appeared remote. Thus, recognition by his peers came to him rather late. Eventually he was elected into the Society of Neurological Surgeons, the most senior society for neurosurgeons, and the Harvey Cushing Society (now AANS). He was Vice Chairman, and then Chairman, of the American Board of Neurological Surgery. Dr. Baker, on the other hand, was a national person who was later to almost single-handedly lobby for the creation of the National Institute of Neurological Diseases and Blindness, which was to become the NINCDS of today. It is interesting to recall that during the early days of the Joint Neurology, Neurosurgery, Neuroradiology Conference with Drs. Peyton, Baker and Harold Peterson present, there could be a very interesting discussion taking place. Dr. Baker would go on and on for quite some time only to have Dr. Peyton say, “Well, we’ll take a look to find out if you are correct.” Dr. Peterson would then go on in his matter-of-fact way, pointing to the lesion on the Xray and saying, “tumor.”

 
In the early days of Dr. Peyton’s administration he had to work alone because World War II was looming on the horizon, and the young men were being taken into service. The University of Minnesota’s 26th General Hospital soon moved to Europe with the North African campaign. Dr. Harold Buchstein, who was trained as a neurosurgeon at the Mayo Clinic, was able to help Dr. Peyton out for awhile, but he had to go also. Dr. Wallace Ritchie, a well-trained general surgeon in St. Paul, who gradually shifted to neurosurgical practice, was also helpful in the early days. Among the residents, Titrud, French, and Simmons all had to go. Following the war many came back to finish their training. French then stayed on as Dr. Peyton’s associate. Jules Levin and Bob Merrick, who took part of his training at the Neurological Institute in New York City and had a Ph.D. in neuroanatomy with Dr. Rassmussen, followed as neurosurgery residents: then, Kent Olson, Paul Blake, Marty Feferman, Carrel Caudill, Gerry Haines, David Johnson and myself. Bill Ogle stayed for more than a year in the program and returned to Tennessee to practice. Purdue Gould came back from the Korean War to join the training program. In about 1956 Bo Sung Sim came from South Korea to study two years of neurosurgery under Dr. Peyton. He wrote a master’s thesis on the anatomical investigation of the consequences of anterolateral cordotomy.

Following World War II, the Veterans Administration Hospital at Fort Snelling became closely affiliated with the Medical School. Neurosurgery, along with many other medical specialties, used the VA facility as a major training center. Residents regularly rotated through the “Fort”. We had no full-time or seven-eighths staff there. Consultants were regularly scheduled to visit, to assist the resident(s) in patient management including supervising operative procedures. Dr. Buchstein and later Dr. Titrud from the community and Dr. French from the University were regular consultants. Dr. Peyton visited there only occasionally to perform operative procedures which were his “specialties”, as we will further elaborate. Drs. Buchstein and Titrud rendered invaluable service to the teaching of residents and added a special dimension because of their private practice experience and their individual characteristics. We had our own OR at the “Fort” with Ruth Hanson, R.N. in charge. Ruth has since passed away, but her service to our early training program was extremely significant.

To begin with, Ruth was a neurosurgical nurse with the 26th General Hospital in the European Theatre of Operations. Dr. Wallace Ritchie was the C.O. of the neurosurgical unit. As indicated previously, Wally had been a general surgeon of significant stature who eventually became a certified neurosurgeon. He published an excellent textbook in general surgery about which he would later politely decline discussion because he wanted to be recognized as a neurosurgeon. The story went that during the North African Campaign, Wally Ritchie and Ruth Hanson were invited to a formal dinner by the local chieftan. It was an elaborate feast, lasting for some hours: The main course for the evening was a “steamed brain”, sheeps brain from which the arachnoid and subarachnoid vessels had been meticulously removed. It was said to be a delicacy item served only on special occasions. Wally and Ruth had great difficulty eating this dish (their faces may very well have turned green) for, in that same afternoon, the two of them had operated on a huge brain abscess. I am certain the visual and olfactory imprint of that abscess had great impact upon their appetites.

 
Wally continued to support our neurosurgery service at the University until his death in 1969. A Wallace P. Ritchie Lectureship was set up in the Department by his family.

Ruth Hanson knew so much about neurosurgical operative procedures as an operating room nurse that she would tactfully hand the resident the appropriate instrument when it appeared that he

was in a quandry as to what to do next before the consultant arrived to guide him along. I know that to be true because she helped me under these circumstances.

At the University, the Neurosurgery operating room used to be located where Station 51 is currently. Neurosurgery shared a large operating room with the general surgeons. We were able to operate only on Mondays, Wednesdays, and Saturday mornings. Tuesdays and Thursdays were used as clinic days. Dr. Peyton took Tuesdays, and Dr. French took Thursdays. The residents, after the morning ward rounds, would assemble in the outpatient clinic and take note of what was going on. These sessions were informative and relaxed. Once in awhile Dr. Peyton or Dr. French would do an alcohol injection for trigeminal neuralgia, injecting either the mandibular or the maxillary division, right then and there in the outpatient clinic.

In 1954, when the Mayo Tower was completed, we shared the current departmental office space with Orthopedics and started using Room I in the main operating room which we still use today. Our inpatients moved to Station 51. Station 52 was later added. Neurology has remained on Station 50. It was at the location where the Neuro ICU is located today that Dr. Peyton would start his Sunday 9 o’clock morning rounds with all the residents present and several former residents who were then in practice in the Twin Cities.

Dr. Peyton’s favorite operations were retrogasserian trigeminal rhizotomy for tic, cerebellopontine angle tumors, aneurysms, cordotomies, and sympathectomies. He was an excellent surgeon. I recall one posterior communicating artery aneurysm in a patient at the Veterans Administration Hospital on whom I turned a flap. Dr. Peyton came in and used a subtemporal approach taking only 15 minutes to expose the posterior communicating artery and to put a silver clip on the aneurysmal neck. He had excellent judgment. He preferred simplicity in words and in deeds. He used the fewest number of words to make a statement or to ask a question. In the operating room he used the fewest number of instruments. He called the Olivecrona dissector, “The Thing with a Hole in It,” which is what we still call it today.

Dr. Peyton retired in 1960, and I was asked to join Dr. French in the Division. Dr. Peyton stayed on as Professor Emeritus and shared an office with me. He was consulting at the V.A. several times a week and was still active as Chairman of the American Board of Neurological Surgery. Seeing each other often, we were able to talk about personal matters, beliefs, philosophies, etc. One morning, in the spring of 1962, while he was reading in the Biomedical Library, he suffered a heart attack. He was transported quickly from the library through the side door to the third floor of the Mayo Building and up the elevator to the fourth floor, then through the back door into Room I. Resuscitation was carried out successfully, and he was taken to Station 44, the Intensive Care Unit. He had a flail chest because of the resuscitation, and was unconscious for several days. On about the third or fourth day, when he was conscious enough to talk (in those days, tracheal intubation was seldom done for such critical situations), the first question he asked me was, “How is the Service?” He lingered on for many days. He became paraplegic, most probably because of hypoxia of the spinal cord during the period of hypotension. I am not certain to this day as to whether or not he was aware of the paraplegia. He died shortly. I remember distinctly when I was coming back to my office, Joe Galicich asked me how Dr. Peyton was, and when I told him that Dr. Peyton was dead, Joe broke down and cried. I got back in my office in time to cry by myself.

The Peyton Era was characterized by a small staff, close relationships, excellent clinical exposure, and training in judgment as well as in operative techniques.

In research, we had already begun to work on cerebral edema, trauma, brain tumors, peripheral nerves and tumor localization with radioisotopes. Physiological studies using radioisotopes were also carried out. Six of the twenty residents received Ph.D.s and several more, Masters Degrees in neurosurgery from the Graduate School during this period of time. In 1959, just prior to his retirement, all of the former residents gathered together here, along with close associates, Dr. Buchstein and Dr. Ritchie, to pay tribute to Dr. Peyton. It was the birth of the WTP Society which has held regularly scheduled meetings every five years as a homecoming event. This year’s event is the sixth Peyton meeting. It is a special one in that it coincides with Dr. French’s retirement.

With Dr. Peyton’s retirement, s special issue of The Journal Lancet was dedicated to him in 1961. In it, there was brief resume of his life and accomplishments, as well as papers written by the staff at that time, the residents and former residents. This issue of MINNESOTA MEDICINE, dedicated to Dr. French, is to carry on this tradition.

 

The French Era actually began before he became the Director of the Division of Neurosurgery in 1960. Dr. French was rapidly becoming prominent nationally; he was offered the position as Professor and Chairman of the Department of Neurosurgery at the University of Chicago as well as that of the University of Pennsylvania. At least these are the two places, to my knowledge, he went to visit. How many other offers he had, I do not know. Dr. 0. H. Wangensteen, who was Chairman of the Department of Surgery, wanted Dr. French to stay on. In 1957 Dr. Wangensteen made a definite promise that Dr. French would become the Director of the Division in January of 1960.

 
Dr. French’s interest at that time was surgery for intractable seizures. The two specific projects that he had were hemispherectomy and temporal lobectomy with electrocorticography. Dr. Manfred Meier, a clinical psychologist, was recruited to help in the assessment of these patients preoperatively and postoperatively. Dr. Frank Morrell participated as a neurologist and neurophysiologist.

In the mid-50s, Dr. French and I submitted the first research grant application for national funding. That application was submitted to the Atomic Energy Commission to continue the use of radioisotopes in both tumor localization and physiological investigation. In the former, we were trying to use positron scanning with coincidence monitors, and in the latter we were trying to use tagged protein to study CSF flow and turn-over. The site visit was made by one person. On the basis of three or four hours of interviews the project was approved and promised funding right on the spot. The second research grant application was submitted to the U.S. Public Health Service to study the effect of hypothermia on neuronal function as assessed by microelectrode technique. Again, the site visit was made by one person, Dr. Henry Schwartz of St. Louis. On the basis of his visit we were awarded the grant which was continued for three years. Dr. French then put in a training grant in Neurosurgery. A year or so later we submitted a separate training grant for cerebrovascular disease. These training grants brought in significant funding of $60,000-$80,000 a year (in a mid-1960’s dollar value) which was unrestricted. We were able then to increase the training period from a required four years to five years. The laboratory period was increased, and elective neurosurgical training at Hennepin County Medical Center was added. Dr. Ed Seljeskog, who had three years of general surgery training at Hennepin County Medical Center and completed his training in Neurosurgery in 1968, was appointed Chief of Neurosurgery at Hennepin County. Additionally, some of the residents were sent away for further education or on exchanges with other institutions. Thus, Jim Story went to UCLA Brain Research Center; Joe Galicich and Don Long went to Dr. Matson in Boston for additional pediatric neurosurgery training. Ed Katz from Boston spent six months with us. Likewise, Erich Wisiol and Michael Carey went to spend six months with Dr. Collin MacCarty at the Mayo Clinic and in return we got Dave Brown and John Cleary. John stayed on as a staff neurosurgeon at St. Paul Ramsey Medical Center for a number of years until he left us to practice in San Diego. Don Long and Jim Ausman spent two years each at NIH. Jack Wissinger spent a year with Professor John Gillingham at Edinburgh; Ed Seijeskog spent six months with Professor Christianson in Oslo, Norway, and Don Erickson, always adventurous, spent almost six months in Shiraz, Iran. That, of course, was prior to Ayatollah Khomeini.

 
Meanwhile, many of the residents were involved actively in either basic or clinical research. Joe Galicich was the prime mover in using glucosteroids, specifically Decadron, for cerebral edema. The article by Galicich and French in 1961 has been often quoted as the first report on the use of Decadron for the treatment of cerebral edema.2 Long continued his work on the ultrastructure of the CNS and later on added studies of permeability and transport systems in the CNS using specific markers. The latter experiments were done in collaboration with Igo Klatzo at NIH. Ausman used his two years at NIH to work on neuropharmacology and received his Ph.D. from George Washington University in Washington, D.C. Bob Maxwell further elaborated on the cerebral edema project with cold lesions in experimental animals using vital dye as the tracer agent. Strassburger, Galicich, and Story worked on stereotaxis, and Mike Carey and I studied brain abscess. Warren Boop, and later Ed Seijeskog, worked on the hypothalamic pituitary system.

In short, it was a period of greatly increased activity both in the clinical and experimental areas of neurosurgery. We were flexible in retaining a number of residents with funds from the training grants, and the additional year or years in their training definitely had a positive impact on the quality. Clinically, cerebrovascular surgery came into the fore. We were doing increasing numbers of surgical procedures on extracranial vascular problems, intracranial aneurysms, and intracranial AV malformations. The use of hypothermia, sometimes profound hypothermia with cardiac arrest was investigated, as well as induced intraoperative hypotension. Bill Bradley, then a neurology resident, spent some time on neurosurgery and worked with us on an implantable bladder stimulator for emptying of the bladder in paraplegics or quadriplegics. In fact, we implanted the first bladder stimulator in humans in 1962. In spite of initial encouragement, however, this program was eventually shelved because of difficulty in the coupling process in terms of vesical smooth muscle contraction simultaneously with the striated muscle contraction of the pelvic floor. Nevertheless, this experience prompted us to develop methods to assess urodynamics using cystometrogram, EMG of the sphincters, evoked potentials that are now standard practice. Rockswold spent significant time to improve these techniques and worked on innervation of the detrussor as well as the sphincter in primates.

 
Dr. John Moe, Professor and Director of the Division of Orthopedic Surgery at the University, had been one of the few specializing in correcting spinal deformities. As not a few patients with spinal deformities developed neurological complications either consequent to the natural disease process or secondary to surgical/non-surgical interventions, Neurosurgery was often called upon to consult and surgically manage such patients. Drs. Robert Winter and John Lonstein were residents In orthopedics then. We worked closely and performed the first transthoracic vertebrectomy in this country, a modified Hodgson procedure, in a patient with kyphoscoliosis .‘. Continuing Neurosurgery-Orthopedic collaboration resulted in a later publication of a monograph, Spinal Deformities and Neurological Dysfunction.

 
Toward the end of 1960, Dr. French became more and more involved in the planning of the Health Sciences of the University under President Moos. It was a natural move, then, that in 1970 he was appointed Interim Vice President for Health Sciences. He became Vice President in 1971 and remained in this position until 1982. Prior to that, Dr. French had already become a very prominent national figure in neurosurgery. He was President of the American Academy of Neurological Surgery which gave him the Neurosurgeon of the Year Award. He was a member of the American Board of Neurological Surgery. He was on the Editorial Board of the JOURNAL OF NEUROSURGERY and eventually became the Chairman for two years. He had been President of the Neurosurgical Society of America and of the American Association of Neurological Surgeons. He was a consultant to the Surgeon General and consultant to the Central V.A. Office in Washington, D.C.

It should be mentioned that in 1968 the Division of Neurosurgery became a Department in the Medical School along with Orthopedic Surgery and Urology. Dr. 0. H. Wangensteen had retired in 1966. Dr. John S. Najarian became the Head of the Department of Surgery in 1967, but the move to have all the surgical specialties become independent departments had been afoot before Dr. Najarian’s arrival. It was a smooth transition, and I think this worked out well for all concerned.

During the decade of 1960-1970 we had added new faculty members including Story, Long, Seijeskog, Ausman, Maxwell, and John Cleary. Jim Story eventually left to become Head of Neurosurgery at the University of Texas in San Antonio; Long to become Chief of Neurosurgery at Johns Hopkins; Jim Ausman, Head of Neurosurgery at Henry Ford Hospital in Detroit; and George Allen became Professor and Head of the program at Vanderbilt. Don Erickson, after a period of private practice in St. Paul, joined the faculty after Don Long left. John Cleary was at St. Paul Ramsey for several years, and that position was taken over by Willis Brown, Kenneth Murray, Steve Martin, Bee Thienprasit in succession and now by the triumvirate of Castillo, Brix, and Bingham. The St. Paul Ramsey situation has been less than stable because of the fact that we do not use that institution for residency training and, consequently, it has been difficult to keep staff men working there.

At Hennepin County Medical Center the directorship of the Division of Neurosurgery passed on from Ed Seijeskog to Gaylan Rockswold in 1977, and Mahmoud Nagib joined him two years ago. Hennepin County rotation by residents was approved by the Residency Review Committee twelve years ago, and it remains a valuable experience for the residents and medical students alike.
Since 1971 the mode of operation of the Department of Neurosurgery has been undergoing a gradual but definite change. I suspect one reason has to do with personality. I believe in participatory administration. I also believe that the office of the Headship and the person who happens to hold that office should, as far as possible, be distinct. This issue is perhaps to subtle, and the line is too thin. At times I am certain there can be a question of leadership - who is running the Department?

 

In the past ten years there have been major changes in the health delivery system, in the way services are reimbursed, and in the availability of funds for research. Additionally, the competitive market in the form of HMOs, PPOs, etc. have a direct impact on neurosurgery at the University of Minnesota Hospitals. Cost containment and the increasingly important medical ethical issues have become major concerns for us in Neurosurgery.

Briefly, let me enumerate what has taken place in the past decade. First, we have increased the space in the basic science laboratory. Jim Bloedel joined us in 1968 to add a major dimension to the department. Many residents trained with him. Hemrich Bantli joined the department and worked with Bloedel for awhile. Tim Ebner came on to join Bloedel five years ago. In addition to neurosurgery residents we had eight trainees, either post-doctorate fellows or graduate students, trained under them. Last year Bloedel left us to join the Barrow Neurological Institute in Phoenix. It was a great loss to us. But fortunately Tim Ebner stayed, and I believe he will carry on in excellent tradition.
We have significantly improved departmental space. Faculty office space became reasonably adequate, though additional facilities are still needed. We have our own conference room, and for the first time in the history of the institution, a designated, spacious room was renovated for the resident staff, which also houses the departmental library.

Educationally, the traditional conferences continue. Additionally, I have introduced “Professor’s Rounds” on Fridays and management conferences on Tuesdays. The former is designed to have a regular dialogue with the residents in scientific, ethical, and practical matters as they relate to neurosurgery. The latter has to do with developing a total perception of patient care in terms of physician-nursing-hospital-administration-patient
communication and understanding.

The faculty has been stable. We added two very valuable members in Steve Haines and Dennis Turner. Each has his own distinctive strength, Steve in clinical research particularly in statistical analysis and clinical trials, whereas Dennis is interested in basic, single neuron physiology using brain slice techniques. On the clinical side we have set up sub-specialization for the faculty members. Last year we established a Division of Pediatric Neurosurgery with Steve Haines as Director in the hopes that would be able to collaborate better with per and pediatric neurology to enhance research, teaching and service. There has been already some change in external referral patterns in these subspecialty areas. There has always been good internal referral and consultation. Along this line we also have developed collaborative projects with different departments. The Comprehensive Epilepsy Program is an example, with Bob Maxwell participating fully; and the Spinal Center which is a joint effort of the Spinal Cord Society based in Minnesota and the University. The Spinal Center is a collaborative effort of the Departments of Neurosurgery, Orthopedics, Urology, and Physical Medicine and Rehabilitation.

The Department continues to be quite visible nationally. Ed Seljeskog was on the Residency Review Committee for six years and the Secretary of the AANS. Steve Haines is Program Chairman of the Congress of Neurological Surgeons, and both Turner and Ebner are quite active in the Neuroscience Society. I served a term on the American Board of Neurological Surgery and am currently a member of the Residency Review Committee. I also served as President of the Neurosurgical Society of America, the Senior Society, and Vice President of the AANS. It should also be mentioned that a number of Minnesota graduates in neurosurgery served as officers or on executive bodies of national organizations. Augie Geise was the President of NSA as was Luke Hodges, and Jim Story is now its president. Warren Boop and Luke Hodges both were President of the Southern Neurosurgical Society. Many served in other organizations such as the American College of Surgeons, state neurosurgical societies. etc. I am reminded of the journal of SURGICAL NEUROLOGY’s surveys of program directors in neurosurgery,9 of the ten best programs for training neurosurgeons and the ten best programs for turning out neurosurgery academicians. The University of Minnesota was on both lists. I recall there was a great deal of criticism regarding these surveys pointing out that it was only based on the perception of the program directors and that many program directors did not respond. I believe these criticisms were valid, and the result of the survey can only be taken as an indication of the feelings of the Neurosurgical Community. I mention this only to show that in order to keep a training program in a quality position, there needs to be constant vigilance, cooperation of the staff and residents and long range planning. In looking at the graduates of the University of Minnesota Neurosurgery training program almost 50% of the graduates are in academic positions. We have trained a total of 68 residents in 49 years. Among them, nine have been or are program directors and chiefs of the service. Additionally there are five full professors, five associate professors, twelve assistant professors and one instructor. The other half have prestigious positions in the private sector, and many of them are involved in national neurosurgical organizational activities. Resident trainees such as Ruiz, Chu, Choi, Mohandes, and Chanyavanich have returned to lead neurosurgical services in their home countries. All of our trainees are in good health except one who died a few years following training, a tragedy of waste of youth and talent.

Looking at the future, a major concern is funding of graduate medical education. The Federal Government and other third party payers are not willing to foot the bill for training in Neurosurgery or in any other specialty. I am certain this will be a very serious issue over the next five years. The selection of residents through the matching program has lessened our administrative pressures and inequities. I believe that is going to continue. Subspecialization is to continue and be further defined. The explosion of new information in neurosciences, I am sure, will result in new clinical applications. It is not too remote to think that we would be doing brain cell transplants for conditions in which lack of a neurotransmitter could be identified. With high technology on the one hand and cost constraints, as well as the prospective reimbursement plan on the other hand, neurosurgical care and joint decision making with the patient and families will become more and more of a challenge. Whatever the trend may be and wherever neurosurgery may take us in the next decade, I hope that we at the University of Minnesota and our graduates from the training programs will have substantial input. 

 

I have tried to give a historical review of the department and the people that were and are associated with it. In the space available, I cannot provide an account of everything and everybody. I apologize to those whose names did not appear in this paper, and I am entirely responsible for any inaccuracy that may have been inadvertently introduced herein.

In preparing this review, several important items came into focus. First is the recognition that there were and are many hidden heroines in the evolution of the department. Wives of many of us, staff, and residents alike, have contributed a great deal in making us what we are. Clara Peyton, Gene French and Jolene, in their own way, have done their part, as have wives of present and former faculty members and wives of a number of residents, past and present. Second, we have had, over the years, a number of nurses and secretaries working diligently and givingly to further our mission of teaching, research, and service. Third, it seems that perceptions of the more distant events and personalities came into focus far more clearly than those of more recent vintage. I cannot help being curious as to how the present will be viewed some years from now. I guess we will have another day and another story.