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Epilogue

AN EPILOGUE
THE ETHICS OF ADVERTISING BY THE MEDICAL
PROFESSION

Advertise.
(1) To give notice, advice, or intelligence to; to inform or apprise; — followed by of before the object of information, as, to advertise a man of his loss.
(2) To give public notice of, or to describe with a view to sale or recovery and the like; as, to advertise goods; to advertise a runaway.
Synonyms: To apprise; inform; make known; announce; proclaim; promulgate; publish.

Webster's Dictionary.

THIS EPILOGUE is addressed particularly to those members of the American College of Surgeons who originally subscribed for this book. It is, therefore, like the preface, somewhat intimate, although quite as scientific as the meat layer of this literary sandwich, for it is also an effort to trace truth as it dodges about among appearances or hides in plain sight behind respectable customs.
Our profession is being more or less justly criticized in our own journals and in the lay press because we have provided no satisfactory method whereby the layman may be promptly and economically attended by the particular specialist best qualified to treat each of his ills. One who practices any specialty will readily admit the truth of this charge against our methods, for he daily sees patients who have suffered greatly, both physically and financially, because they did not have appropriate treatment as soon as the diagnosis could have been made, perhaps months or even years before. The lesion which is the subject of this book offers a striking example. Every specialist feels as I do, that his cases should have been recognized sooner, and yet every one of us will admit that while he is treating his special organ, he may be overlooking some other ailment of greater importance in some other organ. Knowing this, he insists on a general examination by the patient's own doctor or he calls in a diagnostician to make one. Few true specialists will receive, for more than a short time, the responsibility of the whole patient. They insist that the general practitioner should be his major adviser and friend. As a matter of fact, this is not as altruistic as it sounds, for many of us would have to admit that we do not even know how to make a good modern general examination. And what would we do in case some dangerous or disagreeable condition appeared, such as a contagious disease,  delirium tremens, insanity,  an incurable condition  or the complication of financial irresponsibility? The specialist for these things is apt to be the family doctor. Constantly under fire from the specialists for not having a consultation sooner, the practitioner is, at the same time, censured by the patients for his tendency to call in a specialist. The specialist charges more than he does, but the prac-titioner backs him in so doing for the following reasons among others. He knows that the specialist, to achieve his position, has had to spend most of his time and energy in unpaid hospital work and perhaps in expensive travel to observe the work at other clinics, and very likely, also, he may have written a book! The doctor also wants the specialist to charge significantly more than he does, so that his own patients will not all run away from him. Not infrequently he knows what the patient ought to have done, and that the specialist's glamour can make the patient have it done, although he cannot, himself, make the patient submit to it. This problem has become an economic one, and the modern "pay-clinic" is one very reasonable attempt at its solution. The question which I want to discuss is whether any amount or any manner of advertising could help to better our present methods. Far be it from me to suggest more advertising, for my waste basket daily receives material, which, if converted into cash at cost price, would easily support one person.
First let us consider what ways we have at present by which to apprise, inform or otherwise advertise a patient with a rare disease so that he may receive appropriate treatment, and vice versa, how may a doctor, who has given intensive study to some one condition, obtain the patients who need his help?
Our present Tel-U-Where System is made up of units scattered over our country and designated by Dr. or M.D. on conventional doorplates. Possibly his special field is also indicated on the doctor's sign, but this is not in general considered to be in good taste. We urge every person to attach himself or herself to one of these units as a permanent patient, so long as mutual trust is maintained. Every one should have a yearly physical examination by his physician, and if found to be sound, be instructed as to how to keep sound, and warned of the consequences of any bad habits or physical weaknesses which his physician may discover. Should the physician, at any time, find a minor condition requiring treatment which he can give effectively, he may treat the patient and charge a fee, limited in a general way by the local fee table of the County or State Medical Society. If a specialist's service be required, the physician should either refer the patient directly to a specialist competent to treat the condition, or call the consultant to make or confirm the diagnosis, and to instruct him, the physician, as to how to give the appropriate treatment. The consultant's fee is not so much limited by the local fee table as by general custom, and especially by the statement of the physician to the consulting specialist of the patient's circumstances, while to the patient is explained the reputed standing of the consultant among his confreres and in the public eye.
Thus, we, the profession, appoint the physician an arbiter between patient and consultant, for he should have, on the one hand, an intimate knowledge of his patient's financial condition, and of the consultant's standing and attainments on the other. Consultants are expected never to attempt collection of fees of which the practitioner has expressed his disapproval. Since a consultant often responds to the call of a practitioner for a patient who can pay little or nothing, the practitioner usually urges his well-to-do patients to pay a handsome fee to the same consultant. Some consultants habitually refuse to accept any fee until the practitioner has been paid his moderate charge.
The patient, having once chosen his practitioner, is supposed to remain the patient of that practitioner and to consult no other physicians or specialists without his consent, as indicated in a letter to the new doctor. This point of "etiquette" has grown up to safeguard the patient, for there may be facts about him such as previous diseases, nervous or mental history, or social complications—financial responsibility, etc.—which the new physician should know. Moreover, it is merely ordinary courtesy for the patient to be frank with the doctor he trusts, although it is human nature to try to avoid hurting his friend's feelings by showing a lack of confidence in his professional knowledge. The patient may, at any time, leave one physician and go to another, but he should notify the first physician before so doing. The second physician necessarily receives him in a different spirit, with less feeling of responsibility for the trust imposed, if he does not do this.
Now this system has grown up more by custom than by the plans of the leaders of the profession. The fact that it exists is because our ethics in general are simply the dictates of the Golden Rule. The system is a good one, if not an entirely practicable one. It works, in fact, almost in proportion to the tendency of mankind, laymen and physicians, to abide by the Golden Rule in their daily lives. It probably works more nearly perfectly than other forms of etiquette or ethics in other classes of people for two main reasons. First, because the physician usually chooses his calling from high-minded motives and secondly, because a patient's moral resolutions are usually highest when he is sick. The devotion of doctors and nurses to a sick man or woman is seldom unappreciated at the time it is given, though it may soon be forgotten, especially if the bill has not been paid. "When the Devil was sick, the Devil a Monk would be."
However, the burden of these customs lies on the conscience of the general practitioner. In addition to the obligation to know and recognize the early symptoms of hundreds of different diseases and injuries, which may need a specialist's attention, he is expected to know the reputations of the individual specialists themselves, whose more or less superficially concealed advertisements he has little time to read in our journals. It is perhaps even more difficult for him to choose a specialist than it is for the layman to choose his doctor. In both choices, reputation for honesty and for training are of more importance than for personal attainments. The practitioner, in making his choice, has much help from knowledge of the hospital positions held by the consultants, as well as from the general standing of the hospitals themselves in the community at large. Hence, all of us wish to stand well on the staff of a renowned hospital. Just as a layman in choosing a doctor may pick his medical school, and then select the nearest graduate of that school, so a doctor may pick his hospital before choosing his consultant.
Theoretically this system is a good one, and thinking men among physicians, statesmen, educators and philanthropists are constantly and patiently endeavoring to strengthen it rather than to plan a new one. Naturally the unit of the system where the sign M.D. hangs, is the chief point to strengthen. This may be done in several ways. The efforts of many of the best minds in the profession are given to teaching medical students the impossible task of caring for these unit stations. They still (I think futilely) hope that men can hold such superhuman jobs. Some of us have aimed to raise the standards of the hospitals, so that incapable or dishonest consultants will not be given places on their staffs, hoping that in time the public will not be satisfied with consultants who do not have, and take, full advantage of hospital opportunity. A much smaller, but still an active group of minds, aim by legislation to raise the standards of education required for a license to become a unit of the system.
The great majority of those of us who are consultants or specialists, occupy ourselves with post-graduate education in the form of advertisements addressed to the existing units, in order to keep them informed of the advances in our specialties and of our own hospital positions and professional standing. These, sometimes altruistic, advertisements are delivered in person at great national meetings or at small local clubs; in print in countless medical journals and as reprints of such articles. Occasionally our time hangs so heavily that we write a book. In all this flood of literature directed to these units of our system, there is but a small modicum which the recipient doctor can assimilate. Too much of it is to tell him how much we know. Moreover, much of this material, especially when it is as exact as we can make it, proves to be very ineffective as an advertisement of ourselves. Judging by my own experience my papers represent time and energy wasted, so far as bringing patients to my door is concerned, because most of my papers have been on unsolved problems. However, these meetings and articles do help us to educate ourselves and to stimulate our colleagues, even if only a hazy amount reaches the units of our advertising system. Quantity probably counts with them as much as quality, for few busy practitioners can have time for much more than a glance at the titles of our papers.
Of late, there is a tendency to advertise our clinics as a whole, rather than our individual attainments. This is probably an improvement in effectiveness and perhaps in ethics. In our community the Medical School of Harvard University gives a series of Sunday afternoon public lectures at which the university presents its good and faithful medical servants directly to the public and to the newspapers. I certainly approve of this. The Massachusetts General Hospital has repeatedly told the public of the advantages of the Baker Memorial, even mentioning the prices of the professional service. I approve, although this seems to be a challenge to the individual local surgeon to put under his sign "Clearance Sale; prices less than those of the Baker Memorial." He certainly cannot hope to compete with either of these organizations in newspaper publicity. Nevertheless, notwithstanding the prestige of these renowned institutions, the majority of patients still go to the ordinary Tel-U-Where System described above.
Both the public and the profession are so in the habit of reliance on the conscience and common sense of the family doctor, that the advertising of great institutions, or even the purely advisory one of Dr. Evans, cannot change the custom. I, for one, believe that the conscience of the medical profession as a whole is a little better than that of the average man, but we are human and must earn our livings. In matters of life and death our system works tolerably well, because procrastination is apt to recoil on the practitioner; but when it comes to the case of a patient with some small matter like a sore shoulder, each unit feels that he owes it to his family to try his hand at treatment, for he knows that most sore shoulders get well after a time of their own accord, and he needs the patient's money. Moreover, such patients do not take readily to the advice to see a specialist; it costs too much.
To illustrate what I believe happens with our Tel-U-Where System in cases of rupture of the supraspinatus, let us imagine the progress of a patient with this lesion who seeks relief. If the patient came to a doctor who was equipped with an electric baker, the baker would be used. If the doctor had an Alpine lamp, that would be used, and so on, whether the equipment was an infra-red or an ultra-violet lamp, a diathermy set or other form of electric apparatus. If the doctor were an osteopath, cheiropractor or employed as a masseur, some form of manipulative treatment would be given, or, if he had cultivated a reputation for intravenous therapy, colon irrigations, organotherapy, hydrotherapy, heliotherapy, and so on, these methods would be used. If the doctor had faith in drugs, an alarming list of soporifics would be at his command to palliate the pain. Any or all of these methods might help the patient to bear his suffering, but none of them would be at all curative. If the patient went directly to a busy surgeon he would probably be referred to some orthopedist, or to one of the above "specialists," who usually sent his abdominal cases to that surgeon. If he went directly to a busy practitioner, he might be told "There! there! don't worry," given aspirin and forgotten until the next visit, when the drug would be changed. Even if he went to a very painstaking, conscientious practitioner, the latter probably would not recognize the condition, and would not know what specialist to call. Within a few weeks of consulting any of these doctors he would perhaps be referred for an X-ray, and as this would be practically negative, still no diagnosis would be made.
If the patient happened to be an employee, he would lose in these ways the golden opportunity which is present immediately after the accident, and as week after week goes by, gets progressively more unfavorable. In Massachusetts our Compensation laws allow the patient to choose his own physician, and oblige the insurer to pay that physician for at least two weeks—the golden weeks for diagnosis and treatment of most injuries. The insurance examiner seldom sees the patient for some time after this, owing to certain forms of red tape, so that, as a matter of fact, no really early diagnosis can be made by even the examining physicians of insurance companies, to whom the early detection of this injury is most important from the dollar point of view. Those who will have the best chance to detect these injuries and treat them successfully will be the men on duty in great industrial plants and in the accident wards of great hospitals, but these men are often inexperienced. At present the orthopedic surgeon is the most likely practitioner to know that this lesion does occur, and to recognize it, but he seldom sees any kind of case until it has become chronic. Then, too, he usually has a physio-therapy equipment with a large overhead expense, and this might tempt him to procrastinate.
If the doctor who originally sees the patient is puzzled and does recommend a consultant, the chances are that such consultant will be one of his own ilk, or if not, some surgeon who is not interested in shoulders, but who has operated on a member of the practitioner's family, gratis, and for whom, therefore, the latter would like to do a favor. When in doubt, any doctor would prefer a consultant from his own medical school or from the hospital where he himself has been an interne, for his teacher is sure to say a good word to the patient's family in regard to his own abilities and standing. For most patients, a distant consultant is out of the question on account of the expense, and if the disease is rare or new, there is usually no one near-by who has given any particular study to it, so that the doctor calls in a friend, quite likely one of his own religion. I have said nothing about fee-splitting, for I wish to speak only of fairly conscientious practitioners, the units of our Tel-U-Where System, to whom, I insist, that at least the first of my claims should be advertised.

MY CLAIMS IN REGARD TO COMPLETE RUPTURE or THE
SUPRASPINATUS TENDON

1. The lesion exists, is not uncommon, causes prolonged disability, has a clear symptom complex, and may be relieved by a minor surgical operation, if it is promptly done.
2. Since it occurs at a time of life when general mental and physical degeneration readily ensues from enforced idleness, most patients never do heavy labor again, even after their compensation ceases. Thus the economic loss is great.
3. In Massachusetts the cost in compensation for this disability in an individual case is as great as from any major injury. To the man incapacitated it is a major injury. One hundred such neglected cases cost us more than the entire gross income of the average doctor during his lifetime.
4. Since the lesion is important to the employee and to his family, to the physician, to the hospital, to his employer, to the insurer, to the industry and to the consumer, the above facts should be advertised to all, because the relief of the patients, as well as a great saving, largely depend on its prompt recognition. 
5. Hitherto, for twenty-three years the burden of advertising it by the usual professional methods has been assumed chiefly by me, at an expense greater than all my earnings from treating such cases.
6. My advertising has been ineffective, for I have not yet had a patient referred to me immediately after his injury. Moreover, the operation which I recommend is as yet rarely done in any hospital in the world; in fact, the lesion, frequent as it is, is still unknown, much less recognized in many of them.

Evidently there is a dense wall between the employee thus disabled and the writer, who thinks he knows how to relieve him. The patient consults other doctors who have not studied the shoulder; while I earn my living by caring for other conditions to which I have given no more, and perhaps less study, than have other surgeons. Could this wall be penetrated by any form of advertisement consistent with medical ethics? I believe that these patients and their insurers need me; I know that I need their money. How may I advertise to get such cases ? All concerned, from the patient to the consumer, have at least some reason for having the symptoms of the lesion, if not the discoverer, proclaimed. Should the medical profession improve our advertising system or wait for business to do it badly through politics? These are my problems and yours.
Business has now tried the experiment of Workman's Compensation for some years, and is only just beginning to see that a large fraction of the expense is due to carelessness, ignorance or simply lack of being up-to-date, on the part of those doctors who give treatment during the first few weeks after all injuries. The fact that only one hundred neglected or unrecognized cases of any curable lesion may cost as much as the average doctor's earnings in a lifetime may engage attention, and lead business to conclude that our system for the advertisement of our units must be improved. This may be their point of view, although the same facts indicate that doctors should be paid more and expected to accomplish more.
Is it my fault that my advertisements have been ineffective? Look at the list on the chart in the preface. I have usually advertised debatable questions in their early stages, and most of the fields I helped to plow have flourished, although I have reaped little of the harvest. There has been delay on this matter of early operation for shoulder lesions, because the field was rocky and difficult, and in an out-of-the-way region. If I am right, surely I deserve more help, and if I am wrong I should, by this time, have been proved to be so.  There should be some method of "put up or shut up," in such cases. I am quite ready to go to any great clinic for a practical examination. Collect for me fifty patients disabled for six months or more with injured shoulders, X-rays of which are negative, and I will pick you out several instances of complete rupture of the supraspinatus, demonstrate the lesions through tiny incisions, and if the patients wish, make an attempt to cure them, although the operation would be long overdue. And here comes the real difficulty with personal advertising. I cannot guarantee cure; on this fact rests our principle, which is misnamed an ethical one, that the doctor should not advertise in the public press. We would find an excuse quickly enough, if we could deliver our goods with a high degree of certainty. We would even consider such advertisement a duty.
There should be some method by which claims can be tested before they are advertised, even to the general practitioner. Obviously the first checking should be at the hospital where the work is done, the detailed records are filed, and where the patients have been examined also by colleagues. The staff of the hospital, when convinced of the value of the contribution to clinical science, should recommend it for confirmation by the staffs of'all other hospitals. When these have sufficiently agreed to the essential claims, they should be transmitted to all those who practice medicine, by seme authority constituted for that purpose. In England this might be done through the panel system, but in our case it would have to be done through some great professional organization. The idea is present in the Year Books, but the material in them is not checked or corroborated in any way; it is only abstracted at the discretion of a few busy editors. It would be very unreasonable to hold doctors responsible for not reading the Year Books, but if there were an annual number of a great medical journal, which listed all important innovations accepted by the hospitals, all doctors might be expected to inform themselves on the practical details of each certified innovation.
If some such plan had existed twenty years ago, when I published the paper quoted on pages 126-129, by this time there would be thousands of workmen who would have benefited by it, and a vast expenditure would have been saved. To be sure, my contributions would have played an insignificant part among the many advances which have come during this period, such as Graham's dye, the Bucky diaphragm, insulin, liver extract and a hundred other far-reaching innovations of a striking and generally applicable nature. However, a shoulder which is too weak and sore to permit him to work, is just as important to an individual employee and to his insurer, as is a disability from any interesting and spectacular cause. The more trivial the condition and the more study required to understand it, the more need of organized effort to spread the news' about it. There is still much delay in diffusing the benefits of even the great discoveries.
We may now consider the questions of who may be interested in having such advertising done and whether they are doing anything about it.

1. Obviously the patient's interest in any plan is the first consideration, yet his share in diffusing the details can be but a very small one.
2. The practitioner can do somewhat more by telling his fellow practitioners about an individual case or two, but unless the condition is common and readily recognized, his chance of meeting another doctor who has such a patient is small at best. Like the patient, he may readily be deceived or may deceive himself.
3. A hospital does not concern itself with advertising its ability to treat new conditions, until the staff begins to see some profit in so doing. Yet a hospital, once it established an End Result System of organization, would be in the best position to answer any patient's question, "What doctor obtains the best results in conditions like mine?"
4. The employer does not advertise the new lesion; he gets another man and regrets the expense and trouble.
5. The insurer shuts his eyes to most medical aspects and does not even estimate the cost of errors of ignorance, carelessness and of lack of being up-to-date, on the part of the physician giving the first treatment. He concerns himself chiefly with distributing the cost of all errors, whether avoidable or not, between the industry and the consumer. When he once realizes that many disabilities are preventable, he may see his way to helping our profession to advertise new methods which may prevent them.
6. Industry is already writhing with the excessive cost of compensation ; it vaguely thinks the doctors are making too much money; it does not realize that the cost of one hundred neglected cases would engage experts to treat a thousand, for it only thinks of the amount of its premiums.
7. Next to the individual patient, the consumer has the greatest interest, although he is unconscious of it. The patient feels the acute suffering caused by one neglected lesion, but the consumer bears his share of the total loss from avoidable errors in the treatment of all forms of accident. He could well afford to edit a volume to be distributed free to every physician to advertise approved steps in treat-ment. As an example, the cost saved by the prompt treatment of two cases of rupture of the supraspinatus might distribute 1,200 copies of this book.

Actually, our present advertising is not done by any of the above parties for whose interest it would seem important, but by two others —the organized medical profession and the discoverer of the lesion— and our present methods are expensive and ineffective for both.
The medical profession, even against its apparent interest, has assumed a certain duty to present such information to its units, and, as we have previously mentioned, does this in a confused way, through its journals, its societies and its schools, for it is an enormous body, loosely organized at best. It has only recently recognized the duty of advertising to the public at large. The magazine Hygeia, the press articles of Dr. Evans and others, are highly commendable efforts to perform this function. Yet the knowledge which they endeavor to advertise often could not stand the acid test which I recommend, of subjecting claims to corroboration by hospitals, before they are put authoritatively before the units in a way which would compel the attention of every doctor who is in active practice.
To the layman the wranglings of the medical profession are so confusing that legislation can barely be secured to maintain proper boards of health, good standards of medical education and of licensure. Money can barely be obtained to permit health boards to advertise the public concerning serious epidemic and contagious diseases. However, I am confident that if the American Medical Association did publish a single annual number of its journal, with a resume of tested and accepted advances in medicine and surgery, some one would see to it that such a publication was made available without cost to every doctor not a member of the association, and expect from him a certain degree of responsibility in return.
The Federal Government recognizes a duty to advertise the farmer in regard to the diseases which affect his crops and his cattle. It has laboratories for the investigation of these diseases. It is becoming more attentive to the diseases and injuries of man, but it waits for the medical profession to give some tested, authoritative list of accepted improvements in every field of medicine. Slowly it will see the economic importance of injuries and diseases which cause disability, even if they are apparently as trivial as is the one which is the subject of this monograph.
With one exception, we have briefly considered those who are chiefly interested in having new methods of diagnosis and treatment diffused; that exception is the discoverer himself. It is human nature which is to be relied upon in his case, for his Ego usually impels him to seek money or fame. The pathfinders usually thrust the duty of advertising discoveries on themselves, for sometimes their own interests are involved. Even incredulity and opposition whet the ambition of some natures, and the self-imposed duty becomes an obstinate form of egotistic assertion. We enjoy the struggle to be believed. Such may be my own case.

If I could frankly and impersonally analyze my own feelings and ambitions in regard to bringing the lesion which is the main subject of this book to the knowledge of every general practitioner, I might throw a helpful light on the problem stated on the first page of this epilogue.
As a preliminary statement, I assert that I certainly should not have spent five years on this book merely for the philanthropic purpose of instructing the medical profession. It would not have been worth while, had I not felt impelled to use the subject to illustrate the End Result Idea, in order to point to the fact that any hospital which will follow up its cases of shoulder injury, will find instances of this lesion and be able to recognize and to relieve them, and that this would only be one instance among many. As a product of such analyses both the discovery and the discoverer would be automatically and effectively advertised.
I might have written this book twenty years ago, in a more active stage of life. I admit that while engaged with the far more interesting and varied experience of earning a living as a general surgeon, I feared that if I wrote a book on this subj ect, my friends (competitors) would specialize me. It is far more interesting when you get up in the morning to realize that today you may remove a gall bladder, a stomach or a colon, or do a circumcision in a millionaire's family, than it is to know that you will painstakingly do a fussy little shoulder operation just like one which you had done the day before, and the day before that, and the day before that. It is worse still to realize that meantime your reputation as a general surgeon is diminishing and the major surgical cases of absorbing interest are falling to your less studious colleagues.
To some extent my friends have thus specialized me, but I have postponed my decline by shirking writing a book on this subject. This I admit, but not with pride, for I regard my behavior as narrow-minded and due to silly human weakness. There is always a mental wrestle between the general and the particular.   No ambitious man cares to achieve in only one subject. We all want to be broad rather than narrow, and since few have the innate mental capacity to gain success in many or even in several paths, we become "jacks of all trades." However, it seems to me that a man is more likely to be happy if he follows the path he is fitted for, rather than to allow himself to dabble with the things that excite and interest him for the time. We have today thousands of surgeons, each doing hundreds of different operations on the same list, without having time to give thorough study to the anatomy and pathology of all the various regions of the body on which they are called to operate. For instance, most surgeons have paid little attention to the shoulder.
Each dreads that he may be specialized, especially in any minor, non-lucrative field, such as in that of this lesion, which does not occur among the well-to-do. To devote himself to such a thing would mean not only more study, but less pay. It is better to be known as a skillful operator, who may be assumed to be clever at everything, for the public knows little of the relative value of knowledge of anatomy and pathology as compared with dexterity, in determining the success of an operation. Thus it was perhaps worth while for me to write a few articles to draw attention to my ability as an observing young surgeon, but writing a book on the shoulder would have been very poor business, for, so far as my major surgery was concerned, my friends would have said, "He does only shoulder surgery."
Later (1928), when I laid out my plan to use this lesion as an illustration of the End Result Idea, it was at a time of plenty as shown by the chart in the preface. At that time my mind projected my ambitions in somewhat the following order:

1. To hasten better medical service to the public th rough improved hospital organization.
2. To illustrate to all hospitals some of the advantages of the End Result Idea.
3.  To make the life of a doctor count more to himself and to his patients.
4.   To enable great  medical  societies  to  be  of more service.
5.   To render our medical journalism more effective.
6.  To make our medical education more logical.
T.   To contribute to the advance of medical science.
a.  To influence the H. M. S. to seize the E. R. I.
9.  To help people with sore shoulders.
10.  To obtain more such cases to treat.
11. To lay up money for my heirs.
12. Toget some just to spend.
13. Toenjoy my life.
14.   Ego.

Now, 1933, turn to the chart again and behold the curves of income and their trends! I have not changed my investments for I have neither bought nor sold, although I have lent and borrowed, and still owe more than I can pay. The rest of my book is actually in page proof, but I am confronted with a bill of five thousand dollars, for I had planned to have this peculiar book printed for that sum. Neither the printer nor I, both coming from generations of "respectable" people, who have prided themselves on paying their bills, dreamed that a condition would arise such that I might not be able to pay nor he to collect. Yet such is the fact, unless the book "sells." Thus I am compelled by circumstances, which have been largely out of my control, to invert this pyramid of purposes, although still, the satisfac^ tion of the Ego forms the apex.


1.   Ego.
2.Toenjoymylife.
S. Tot'etmoneyjusttospend.
4.  To lay up some for my heirs'.
5.   To obtain more such cases to treat.
6.  To help people with sore shoulders.
T. To influence the H. M. S. to seize the E. R. I.
8.   To contribute to the advance of medical science.
9.   To make our medical education more logical.
10.   To render our medical journalism more effective.
11.   To enable great medical societies  to be of more  service.
19. To make the life of a doctor count more to himself and to his patients.
13. To illustrate to all hospitals some of the advantages of the End Result Idea.
14. To hasten better medical service to thepublic through improved hospital organization.

Then, 1928, the satisfaction of the Ego was to be obtained by the broader purposes for which my effort was made, for I had money to spend and something laid up for my heirs. I was earning a living, and I was slowly teaching others what I could about shoulders. In like manner, my other ambitions were tending to become fruitful. Now, 1933, my Ego sees in large letters chiefly the narrow portion; to enjoy life, I need money, and I have none to spend. My fixed expenses so nearly equal my income that my heirs would receive nothing, should I die. I have even borrowed to the full extent on my War Risk Insurance. Beyond my immediate necessities, the other broader plans are rather hazy. Thus in these five years the subject of the ethics of professional advertising has become a very personal one to me. I must in some way earn my living or be dependent on others. It would seem reasonable that I should do so by treating patients with sore shoulders.
Now, then, my colleagues, I ask you how can I obtain such cases ? You must admit that I have studied disabilities of the shoulder, more than any of you have done. Will you send me your patients? You have not done so in the past, for most of my cases have come through a few personal friends.  Or will you buy my book? I will admit that I rarely buy your books.
I feel that your answers will be negative, if not still stronger. You will say to me, "Leave out your outrageous egotistic preface, your insulting epilogue and your commonplace cartoons, and put your book in the hands of a publisher. He will call it to the attention of every doctor in the country, advertise you as 'the well-known authority,' and in every possible way, however flagrant, his agents will try to get their commissions. Leave it to him; don't soil your hands with advertising. Get your friends to write complimentary reviews for the medical journals, so that your publishers may quote the most florid phrases. Even if nobody buys your book, the salesmen will tell the practitioners throughout the land about you, for they can make no sales without praising your knowledge. Thus you will diffuse your ideas, and operations for your pet lesion will be done everywhere. You will soon have plenty of patients—many of them the failures of other surgeons, who have tried to follow your instructions. Make appointments so that there will always be some one in your waiting room, especially your most successful cases. Have your failures come by themselves, if they can pay; otherwise, don't see them at all. Stick to our regular methods and you will soon be an acknowledged expert, and your patients will expect to pay good fees. No layman appreciates a doctor's advice unless his waiting room is full and his fee is large. Make a success of your own practice, if you want young men to follow you. Efficiency! ,_Nonsense! Don't be so foolish as to say you have spent five years in writing a book recommending immediate suture when you have never done it! Other people will mention your faults and failures enough. Don't write about them! Remember that in our business, as in many others, we must sell what the public demands. You cannot educate it to be End Result-minded in your time. People still believe in gods and fairies, in the serpent of the Garden of Eden, in the patent medicine advertisements, and in a hundred mystic cults. You will get no satisfaction when you are dead, for your memory would never be as cherished as that of Mary Baker G. Eddy or as those of the great spiritual leaders, whose psychic energy would make your helpless patients elevate their arms (unless compensation was being paid) and swear they had no pain! Be reasonable; treat the patient, not the lesion. Lie to him, and to his family if necessary. They expect it from you, just as they do from a political orator. Your own moderate success shows that you can be a humbug, when it is necessary for your personal comfort.   Be moderate in your old age.  Your friends and relatives will be glad to have you retire, and go fishing, and so will your fellow members, if you will stop writing. The shoulder part of your book is all right; why not leave out this End Result Stuff?"
My answer is that to leave it out now would be to me like working for years on preparing a balloon for a long journey of adventure, and at the last moment having the builder insist on having my scientific apparatus removed for fear it would be too heavy, and prevent my return and the payment of the bill. The portion of the book on the shoulder is the balloon, but the really important part of the expedition is in the basket below, containing the preface and epilogue. I designed the balloon to advertise the End Result Idea, and I was planning to pay for the trip as a luxury, provided the whole affair was built on my specifications. It was my balloon, although five hundred members of the American College of Surgeons had promised to be backers to the extent of each agreeing to purchase a report of the trip for five dollars. I did not submit the manuscript to a publisher, for I felt there was little chance of one accepting it with the "sales value" destroyed by two cartoons, a preface and an epilogue, which ridiculed our most sacred medical institutions. This would have been his point of view, even though the central portion of the book might be an excellent and enduring monograph. He would point to that ugly truth displayed in the basket, that few hospitals have any individuals, committees or departments, whose duty it is to persistently investigate the results of medical and surgical treatment, in order to prevent waste products in the forms of unnecessary delay, suffering and failures in achieving relief or cure in each individual case.
There has been a very earnest attempt to make the central portion of this book so good that it would be worth at least five dollars to each of the subscribers, and afterward go about the world for a decade or more as a standard work on the shoulder. I feel sure that it will be at least ten years before any other surgeon would, if he could, take the time and trouble to write a better one. The question is whether the buoyancy of the "sales value" of the shoulder part can carry, what seems to me, its far more important, though unpopular and heavy basket, which flaunts a banner at which presidents of endowed universities cannot afford to look, and even those of state universities would need their smoked political glasses, for the first shock. Even if the balloon floats across the sky, there will be but a small number of surgeons who will notice SHOULDER in large letters and care to study it carefully. However, it is not wholly through surgeons that I hope to plant my ideas in suitable soil where they may flourish. I must somehow reach those who think about hospitals in terms of dollars; those who arrange investments and engage auditors, executive officers who manage and make up budgets, and especially, the directors of insurance companies which pay the bills for our errors in diagnosis, in judgment, in skill, in care and in procrastination. Industry, through the insurance directors, must be made to realize that the cost of avoidable errors is greater than the cost of good medical care.
I must harp on the fact that only one hundred neglected cases of any lesion may cost them more than the gross income of the average doctor in a lifetime. When they realize this, the captains of industry, the bankers, the statesmen, the philanthropists, the politicians and the educators, will see to it that the hospitals take inventories of their products. My old slogan of the hospital standardization campaign: "Hospitals which do not take inventories of their product do not audit their accounts," will have meaning to these business men, once they overcome their mystic awe of our profession. They will ask questions of our trustees, superintendents and chiefs of staffs, and, after a time, will not be misled into thinking that new wards or new operating rooms are needed more than follow-up systems and efficiency analyses, as the successful physicians and surgeons would have them believe. These men, and they are good men, became successful under old ideas; of course they would advise spending a legacy on a new ward or operating room, rather than on a system to search out their personal errors. They want their new operating rooms and wards for more individual experimentation and publicity, and as training grounds to turn out more students "to take their responsibility as the physicians of the future." In other words, as soon as they are given their degrees, to begin to aim for the goal of increasing their reputations among the well-to-do classes, by the success with which they can evade responsibility for their errors, and give social publicity to their achievements. These are ugly things to put in the basket of my balloon for the enemies' guns to bring down amid the applause of the multitude, who have justly worshiped the old-fashioned, and now no longer possible, family physician.
Suppose that I could persuade some rich old lady to leave her millions to a certain hospital to be devoted to a constant efficiency analysis of the results of treatment—would the trustees accept the gift? Would she not be dissuaded by her lawyer and influenced instead to endow a new ward in her own memory ?
Shame on me for thinking that doctors are as human as business men, bankers, insurance directors and politicians, and need periodic investigation! Shoot away at the balloon, down with the author, down with the End Result Idea; if the stuff he has written on the shoulder disappears in the sea, it is no great loss!



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As a matter of fact, I think I have a higher ideal of the character of the doctor than has the general public. If I did not believe that most doctors choose their profession in order to be of service, I would not appeal to the members of the American College of Surgeons. I believe we are much more interested in keeping our profession clean than is the public. The rich old lady wants to have her dear doctor at her bedside to inquire about the condition of her bowels, rather than to have him operating on a difficult emergency at the hospital, especially if the interne, who is taking his place, is her nephew, who is learning how to be a prominent surgeon. Under present conditions one cannot blame her and can only praise her nephew, if he seizes the opportunity.
It is because I do believe that there is a chance that the American College of Surgeons may adopt some of my ideas that I have continued to appeal to its members, and have, as a last effort, addressed them in this volume. The first printing of a thousand copies will be exclusively for them, but if my claims in regard to the supraspinatus are confirmed, I may eliminate the objectionable portions, and perhaps be able to sell the rest of the book to a publisher. However, at least for a time, a thousand copies of the balloon will float about our private sky to try the marksmanship of my friends. Let them think before they aim at either the balloon or the basket, for the balloon is, for a time, invulnerable. There is no use shooting at it with mere abuse. Ignore it, do not point to it, distract every one's attention from the banner it flaunts, but don't shoot at the basket—it might fall on you before you are ready to receive it. And besides shooting at it will only call attention to it. A few holes in the banner will do no harm, for the material is simple homespun truth. As for the balloon itself, the only missile which can bring it down will be a better book on the shoulder, and to write that will take some time. So long as it is the best book on the subject, it will carry its unpopular load, for doctors themselves sometimes have sore shoulders and will consult it in spite of the cartoons. Now and then some layman will find that although the shoulder part must be studied, the rest need only be read.
Who knows but that some day a copy may be dusted off in a library and shown to some lonely old hospital trustee, who has money which he may bequeath in order that an annual inventory may be taken of the products of his hospital. I am convinced that if a single great general hospital once did this thoroughly, the others would have to follow. Perhaps I might have made more use of my own life, if I had devoted my energies to exploiting some patent medicine or breakfast food, in order to leave a fortune for this purpose!
 
To make my suggestions more concrete, I submit the following plan to the American College of Surgeons:
(1) An annual letter to every approved hospital, asking for a list of the original contributions of the staff, which they consider should be known to every general practitioner.
(2) A Committee of the College to receive the answers to this letter, and to select from them a limited number of subjects for study and confirmation by other hospitals.
(8) A report from the Committee to all hospitals giving its selected list for confirmatory study, and also the entire list stating that confirmatory studies of the unselected innovations would also be welcome.
(4) On receiving these lists, each hospital would assign one or more members of its staff to give particular study to each of the selected subjects, and call for volunteers in the others. At the same time the staff would give authority to members who accepted these assignments to treat all such cases coming to the hospital, irrespective of what wards or on which services the patients might be admitted.
(5) At the end of a year or more these chosen members of the staffs would make critical reports to the Committee, confirmatory or otherwise of the originator's observations and claims.
(6) The Committee would then, in cooperation with the Committee on Scientific Meetings, arrange for discussion of the selected subjects at the annual meetings of the College, giving the originator in each case the opportunity to read the central paper, which would, of course, appear in Surgery, Gynecology and Obstetrics, together with the discussion it provoked.
(7) A single annual issue of Surgery, Gynecology and Obstetrics to be edited for the general practitioner, giving statements of those advances of which he should have knowledge, and the names of those in all hospitals who have confirmed these advances, and have thus fitted themselves to treat such cases.
(8) An announcement in this special Journal to the members of the profession not affiliated with hospitals, that original ideas which they individually may have, will be listed for investigation, if, in the opinion of the Committee, the ideas are important and the originator's claims are endorsed by other responsible individuals.

Among the advantages of such a plan would be the following: (1)   The effect on individual hospitals.   In many hospitals at present there is little or no effort made to contribute to medical science. Usually this inertia is due to modesty, but even in a most remote place, there may happen to be individuals who have unusual capacity to do original work, or, at any rate, a willingness to do their bit in helping to verify original work. Such men would be stimulated to make efforts which they do not now make at all. Their confirmatory work might be oi great value, and would be sure to be of some value. Patients in their communities would benefit by their study, as would also their colleagues.
Hospitals which already have reputations would be eager to justify them. Such hospitals are usually manned by young men who desire to contribute to medical science; this plan would relieve these men of the often distasteful and expensive work of making their contributions known to the practitioner, who, in the end, will be the one to use them. Moreover, there is a self-depreciating type of man who must have his publicity done for him, and his hospital will want the credit for his work and make him present it properly. Another effect would, in my opinion, be still more important although less obvious. I think this plan would increase the spirit of cooperation in a hospital staff. The spirit of cooperation among the staff members of small hospitals is often high. If one of their number were willing to take part in such a research, either in presenting an original communication or in cooperating to verify one, I believe that others would give him all the help they could, not only at the hospital, but by asking him to see their private cases, for it is obvious that most men cannot devote much time to such studies without some thought of sooner or later profiting by them.
It is not unlikely that some of the best material would come from hospitals with no academic affiliations or time-honored traditions, for the cases treated at such hospitals are just as varied and interesting, and offer as much to the original mind, as do those at the most famous clinics. Some geniuses who are hidden might be thus revealed. The main objection would be more work, but this would be voluntary, and, in my opinion, would be welcomed by a few members of each staff. Of course there would be men who would shirk doing their bit, and this might create some hard feeling, but I do not believe that the total amount of hard feeling would be greater than at present, for this depends on the friction of characters rather than on facts.
(2) The effect on the general practitioner. One can hardly doubt that if next year the College asked every approved hospital to make an investigation of all shoulder injuries, that, at the end of the year most of the practitioners in the country would know at least that such a lesion as is the main subject of this book does occur, a fact which certainly many do not know now, even in this community, where I have talked about it for years.
In the first place, in each hospital, the responsibility of studying the question would be assigned to one man, and he would soon teach the salient points to the other members of the staff. If he examined the bursae at all autopsies, he would soon be able to demonstrate the lesion. When he had learned the local anatomy, it would not be long before a clinical case could be found; he would operate, and his colleagues would have a chance to see the lesion and observe his technique. At a meeting of the local medical society, he would show the case, explain the diagnosis and findings, and review the subject in general. He would accentuate the importance of prompt diagnosis and operation, and urge every one to be on the lookout for an early case, explaining that the College was asking for a general research, and he was doing his bit for a year. Practitioners generally take a certain pride in bringing to the hospital "interesting cases." Even this searching method would still not reach a considerable fraction of those who practice medicine. In most cities, and perhaps in many towns, our professional meetings, although open to the medical public, are not well attended. One reason is that the multiplicity of unauthoritative and often impracticable papers has worn down the enthusiasm of the local doctors, and what little desire they may have retained to keep up-to-date. I believe that sparks of interest would be fanned into flame, if they realized that we were making a national effort to study for a time a particular class of case. Then, too, they would know who to consult if a case turned up in their practices.
(3) The effect on the patient. The College was organized for service to ourselves and to the community at large, and it has had a remarkably successful record in so doing, particularly in the latter object. Service in advancing surgical science and in giving the community the benefit of .that science efficiently, honorably and reasonably, has naturally been our chief field of endeavor. Service to the patient is the central idea, and insisting that hospitals ascertain the degree of service rendered, in order to constantly improve the value of service to be given future patients, should be almost as sacred a principle. The plan I have suggested is merely another phase in the campaign in which these two banners are carried. The present activities of the College have the same general purposes. The Committees on Fractures, Malignant Disease, Registry of Bone Sarcoma, Industrial Surgery, Scientific Meetings, Publications, etc., all aim to put at the service of the public, through the general practitioner, the best which surgical science can give.  These efforts are expensive, our dues are already a burden to many of us—why add another item to our budget in these hard times ?  Certainly there should be good reasons.
(4) The effect on the College. Apart from the satisfaction of performing a great human service, there would be certain points by which our present activities would be increased in value. For instance, the general meetings of the College at which the subjects of joint research would be eventually discussed, would be vastly more instructive and entertaining than under present methods, by which we listen to constituted authorities. To hear an authority on a subject of which one knows nothing, can never be so interesting as to hear him speak about something on which one has had some opportunity to form one's own opinion. If one's hospital has been doing its bit, each member of its staff will inevitably have some opinion, even if he himself has not done the work. Indeed, at the end of a year or two, when the subject is no longer an assigned one, every member of the staff would have to care for his own share of the cases in question.
The quality of the papers eventually presented in print would be better, because under the encouragement of their own hospitals, and in the limelight, the readers would take greater pains. Not only would the quality of the papers improve, but those of poor quality, read for purely personal advertising purposes, would tend to diminish in quantity, because discouraged by lack of recommendation from their own hospital staffs. Pointless papers read by local authorities would be less apt to be committed to print. Then, too, opportunity counts. For instance, I have no doubt that a surgeon for some great mining plant would see as many instances of rupture of the supraspinatus in one year as I do in ten, and could make a more informing study on that account.

Finally, the annual publication of one number of Surgery, Gynecology and Obstetrics, edited with the idea that it is to go to a vast number of general practitioners and contain only the salient points of new surgical discoveries, would be an interesting volume to all of us, as well as to the practitioner. It would chiefly concern itself with the diagnosis rather than with the treatment of the lesions in question. Results, supported by the reputations of the hospitals concerned, would be dwelt upon, for the practitioner needs to know what his patients may expect, rather than long descriptions of pathologic appearances, technical procedures and erudite theories such as most journals now contain. It would also give the practitioner a list of those who had taken part in confirming investigations, and this would serve as a directory to the nearest local consultant, who would be up-to-date in regard to that particular question.  The authoritative and relatively impersonal character of such a volume would intrigue, if not demand, their interest. It would contain also those portions of the reports of the special Committees of the College, which would be of interest to general practitioners. It would attract notice in the daily press.
Perhaps our example would be followed by the American Medical Association, which might issue a similar number regarding accepted medical advances. Such a volume might take some share of the attention which practitioners now give to the commercial druggists' advertisements, the volume of which proves that they are now read. In fact, some of these advertisements are perhaps more truthful and scientific than some of those which we publish as "papers." Our Tel-U-Where units need help. How can they function as advertising stations and individually select what is worth advertising? For instance, what does the general practitioner know of the early symptoms of poisoning due to the modern, complex chemicals which are of ever-increasing use in industry? The unexpurgated deluge of medical articles through medical journals and the bulletins of commercial druggists, to the abyss of proprietary advertisements, is constantly increasing. The most acute practitioner cannot distinguish the wheat from the chaff, and little organized effort is made to help him. He cannot even afford all the Year Books, or understand them if he reads them. In his confusion he finds it better to adhere to the old methods he was taught, years before, in the medical school. I need say nothing more of the evident importance to our national economics and to industrial insurance, which might result from some such plan as I have outlined.
Arguments have been presented to show the need and the possibility of a form of advertisement consistent with reason and with our ethics. What of the counter arguments ? I have been unable to think of any of consequence, except the financial one and the difficulty which might be experienced in getting cooperation from hospital staffs. The former is clearly not a serious one, for a cost price could be charged for the single annual copy of the Journal, but I fear the latter may be. Surgeons are loath to make changes in their habits of work. We all like to try our hand at each new operation, and the idea of dividing up newly-discovered and interesting cases among our colleagues for purposes of intensive study, is not welcome to us. Those of us who have the gift of being successful, seldom have the time for intensive research and like "to try anything once" with a minimum of study and record of results, so that we may be somewhat prepared to use the experience for a private patient.  To choose one of our colleagues to study a series of cases for us and for the College, even though only for a year or two, would require a certain magnanimity. Yet surgeons have done this. The staff of the M. G. H. has now done this for many years, as I have explained in the preface. I can think of no other valid objections, except the question of an initial power sufficient to overcome the existing inertia in order to give momentum to this plan.
You may not approve of my suggestions. You may not even take the trouble to test the statements made, after our usual professional manner, in the central portion of the book, in which there is scarcely a chapter without one or more original observations which need confirmation by other students, before they should go to the practitioner. Yet, sooner or later, according to our usual customs, you will try by haphazard human experiments the operations which I recommend. You will do these experiments individually, without careful record or publicity of the failures, merely to satisfy yourselves that you each can make the diagnosis and accomplish the technical procedure. Why not try an experiment now, with this one relatively unknown form of injury to see whether by an organized effort you can test my claims and then diffuse those ideas which prove to be important? Would this not be more sensible than to permit me to write a book for a publisher to broadcast as authoritative, or to allow one of our colleagues to say in a respectable medical journal, that the intravenous injection of a certain drug is 100% effective in bursitis? Your present ethics encourage us to have such advertisements.
You may object to my personal form of presenting this problem and tell me to try the drug which my colleague recommends so highly, for my own analysis shows that my results are far less satisfactory than those which he describes, except in the milder forms of bursitis, which get well soon with no treatment but rest. Well, then, use his claims to test, and afterward to proclaim. Perhaps the makers of the drug will contribute the expenses for the experiment. Let them have your authority, as well as that of the prominent surgeon, whom they are now at liberty to quote in their publications to the practitioner, without any infringement of our ethics. If the fact is confirmed, it should have as wide a publicity as possible. Dr. Richards tells us that he made the discovery of this remarkable cure by accidental observation in a case where the drug had been given for other reasons, but promptly relieved a coincident bursitis, from which the patient was suffering. The surgeon repeated the experiment in seventy other cases with the same success; then he felt that he should let others know of this simple procedure so that they might relieve their cases. He can no more be blamed if the makers of the drug advertise him to the ends of the earth, than I may be, if a publisher advertises me.
I might give you many other instances of innovations which, if true, should be broadcasted and which you may substitute for what I have to offer. It is safe to say there would be a hundred such in the journals which appear every month. You will say that you cannot investigate all these. I do not ask you to—only those on which the writers have the endorsements of the staffs of their own hospitals, and of these, only those selected by your committee as especially worthy of transmission to the general practitioner. You may rely on the combined staff of a hospital not to recommend the work of one of their number unless they are proud to do so. They are in the best position to know whether his work is sincere and accurate. One's colleagues are very critical; indeed, I think the danger would be that the annual reports from many hospitals would be negative as to new discoveries, for their reputations would be safer, if they kept the lid on boiling enthusiasm. The pressure of a real discovery, however, would soon be too strong for the combined efforts of jealous colleagues to resist. A young man could afford to take time to convince his fellow members, for after that was once done, he need not concern himself about convincing the rest of the world, piecemeal, as he must now. It is partly because I have had uphill work in fighting for my pet lesion that I desire to make a path for other more able and less obstinate young men, who are willing to work, but are too modest (or too poor) to battle for their discoveries. My circumstances have been such that I could afford to fight. If I had had children I could not have devoted so much of my life to such luxuries.
You may say, if you please, that I have written this book for my personal gain. I have. You may say that I want all hospitals to investigate shoulder lesions, so that I can sell a copy of this book to each hospital. I do. You may say that I want more consultations and operations on cases of shoulder disability. I do. You may say that I would be glad to have more surgery of any kind among well-to-do patients. I would. Does not your "shingle," like mine, tell the world much the same things? Such accusations I will not resent unless you allege that I have written this book wholly for my personal gain. I insist that you credit me with at least the ambitions listed in the order of my pyramid with the apex up, no matter how hazy the base may be in these hard times. Write down your own motives and compare them with mine; are they in a very different order, especially toward the apex?
Your signs of Dr. or M.D. tell the world that you are units of our advertising system, which should enable patients to reach appropriate doctors. Are they?
If you are a great statesman or scientist, the base of your pyramid may be so large and well-proportioned that it would form a sphere about your ego, while mine is not symmetrical, for it extends only in the portion limited to the surgical field. I feel no call, as must the president of a university, to study deeply into politics, law, finance, journalism, philanthropy, or into the many other worthy fields of human endeavor. My limited brain is fully employed in my relatively small field. You may be more conservative, and, avoiding all detailed study, feel that you do your bit by being a good-natured deadweight on all enthusiasts. You may feel that you are leading a more rounded life, but your ego will still be the center, and the circumference of your sphere perhaps be smaller than that of my unsightly pyramid, if I can extend it sufficiently in one section. On the other hand, your sphere may be large and still symmetrical, if you are always ready to give an ear to those who are devoted to special forms of service, and to champion them, if the evidence they have accumulated appeals to }rour intellect apart from your prejudices and emotions. If you are such a person, I crave your help, for it is mainly by convincing such as you, that such as I may succeed.
Thus for the present my ideas about the shoulder, as well as about advertising, are in the hands of those of my colleagues who have subscribed, or may subscribe, for this book. A thousand copies will not travel far without a publisher. You may prefer to let well enough alone, and continue to try your individual experiments for yourselves, to see whether you can make the diagnosis of complete rupture of the supraspinat'us tendon and think out better methods for operating; my suggestion is merely that each hospital should appoint a young man to study the subject thoroughly so that he can do these experiments on a Tational basis. If you each experiment to see whether you can do them, it will take much longer to establish routine and effective procedures. The subject is too complex, and there are not enough cases for you all to experiment upon, even if you each took the pains to read this book. Besides your errors are expensive for us all. Let the man who does this work make some reputation among your local practitioners and insurers, so that your communities may be saved an expense that will be greater than all the money he will earn in a lifetime. If he does this well, give him some other problem to solve, and if he does that well, credit it to him when there is a question of promotion on your staff.   Remember that the years he devotes investigation of this subject for you, may set him backward in his ambition to be a general surgeon unless he makes some contribution to our knowledge of the subject. His capacity for original work and sincerity are on trial and he might fail.
What difference does it make to you if he buys my book? I believe I have something to sell him, although what I have for sale is too crude to sell to every practitioner. After all, I have never yet sutured a supraspinatus tendon immediately after the accident which ruptured it.   I may not be right in spite of my evidence and my convictions.
My work may stimulate some one to write a better book, and that may be detrimental to the prospects of my heirs. However, if my work or my writings succeed in bringing about the establishment of an End Result System of Organization in our hospitals, even a few years earlier than it would otherwise have arrived, I shall have left to the children of my great nieces and nephews, more than a money value, although they will share it with all the other heirs of the world.
Most people desire to leave money to their heirs chiefly to protect them against sickness and injury. If our children's children have health, and are assured of the maximum benefits of medical science when sickness or injury does overtake them, they should enjoy looking out for themselves, and providing better conditions still, for their own third and fourth generations.

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