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Foreword

The second reprinting of The Shoulder is sponsored by the American Shoulder and Elbow Surgeons. By so doing, this group acknowledges its deep gratitude to Ernest Amory Codman, M.D., and makes this classic available to the medical practitioners of the world. The book describes in detail the many lesions affecting the shoulder. It lays down the foundation for all the pathological processes capable of causing shoulder disability and is the point of reference from which all future research must begin.
In addition, the reader will be introduced to a marvelous personality with many facets. Dr. Codman has many interests and a unique but admirable philosophy of life that is frequently tinged with pleasant humor.

This is the second time I have been asked to sketch briefly the life of Ernest Amory Codman, but I have studied his life and works many times. With each reading of this great pioneer's struggles to hold on to ideals which he believed to be right, his ups and downs in the world of medicine and in his social world, I am awed by his keen intellectual powers, his astute powers of observation, his tenacity of purpose in the face of all opposition, his integrity and his many contributions which have stood the test of time. Yes, he was egotistical but also humble. Although he rode roughshod over all those who opposed him, he had great compassion for the men affected. His career was indeed a stormy one. His ideas were often not accepted by his colleagues in spite of the fact that many of them knew he was right. He was often scorned, ridiculed and avoided both in the medical and social world. Although these many deterrents often caused much discouragement and frustration, never did they change his course of action to achieve his goals. As it has been true with scores of great intellects in all fields of life, so it was with Codman. Few in his lifetime realized the value of his many contributions. Many years passed before some of his most important works were fully appreciated by his profession, and before the seeds he planted in the field of medical reform took hold and bore fruit.
Codman was of pure English Puritan stock, born December 30, 1869, in Boston. The Boston area provided his preliminary education in private schools and he entered Harvard Medical School in 1891. He spent the third year of his medical education abroad and was awarded the degree of Doctor of Medicine in 1895. It was while traveling abroad and visiting the many clinics which were the centers of medical education of that time, especially London, Paris, Berlin, Vienna and Cairo, that he first came across a little book written by Dr. E. Albert which described the subdeltoid bursa. This small area of the human anatomy was to become the theme of his life's work and although there were many other interests throughout his life which from time to time took precedent over the subdeltoid bursa, he pursued the study of the shoulder joint throughout his entire life, the culmination being a book entitled The Shoulder which he published privately in 1934.
He was endowed with great powers of observation and being a perfectionist he recorded many of his original observations, some of which he pursued with great tenacity leaving no stone unturned. Because of this personal trait he became an authority in many new fields. The same year that he was awarded the degree of Doctor of Medicine, he was appointed Assistant in Anatomy at the Harvard Medical School. During the next several years he studied in minute detail the subdeltoid bursa and its pathology in the dissecting room and on postmortem specimens. It was this background which provided the groundwork for the many clinical observations on the shoulder joint which Codman made in subsequent years. He pursued his studies on the shoulder in the Massachusetts General Hospital when he was appointed Surgeon to the Outpatients in 1899. However it was not until 1904 that his first paper appeared on the subject of the subdeltoid bursa. At this time he was to learn that he was not the first to describe this region of the shoulder joint; it had been described by Kuster in 1902 who called it the subacromial bursa, which designation Codman promptly adopted because he considered it to be more appropriate than subdeltoid bursa.
By this time Codman had accumulated extensive knowledge of the anatomy of the shoulder region and the clinical entities which affected it. However this store of information which he tried to disseminate among his colleagues made little if any impression upon them, a fact which caused considerable frustration and often gave Codman a sense of failure. But these moods never prevailed for long. A mind such as Codman's seeks new outlets and new interests.
In 1895 he became interested in Roentgen's discovery and immediately became aware of the clinical significance that such a modality would have in the diagnostic and therapeutic fields of medicine. He spent five years studying intensively and experimenting with x-ray apparatus. In the laboratory of the Harvard Medical School there was an apparatus, a Crookes tube, which was identical to the one with which Roentgen worked. Working together with Professor Trowbridge of Harvard and Professor Elihu Thomson of the General Electric Company at Lynn, Massachusetts, he soon learned all the intricacies of the Crookes tube and in 1896 was ready to apply his knowledge to clinical studies. Within the next five years he devoted all his time to the study of x-ray interpretation of pathologic states. The result was that he published several articles on x-ray subjects; an outstanding one dealt with x-ray burns. He became interested in the study of joints and bursa and compiled an anatomic study of each joint in the body in different positions as they were portrayed by x-ray after being injected with a nonradiable material. This work was done on cadavers. This study was completed in 1898 and presented to the Warren Museum. A byproduct of this study was a monograph on the wrist dealing with the normal motion of this joint.
Another byproduct of his interest in x-ray dianosis was a monograph entitled, "The Use of X-ray in Diagnosis of Bone Diseases," which he submitted for the Gross Prize given every five years in Philadelphia. At that time the committee awarding the prize comprised prominent Philadelphia surgeons, among whom were W. W. Keen and J. W. White. To his dismay Codman did not receive the prize which was awarded to the author of an essay dealing with the benefits of ligation of the carotid arteries in cases of malignant disease of the face. Although failure to receive the prize was a great blow to Codman, the incident did crystallize in his mind the fact that the busy surgeons of his day had as yet not grasped the practical significance of x-ray in the diagnosis of disease and that the material which he had presented was unintelligible to them. It was a great satisfaction to him when five years later, Dr. W. W. Keen requested that he write a chapter on the use of x-ray in surgery. Codman submitted to Keen the unpublished paper in toto which had been previously submitted for the Gross Prize. To his astonishment the paper appeared in Keen's Surgery without any change.
From what has already been written one would believe Codman's time and interests were only in the field of research. This by far is not true. He was a practicing general surgeon and was deeply interested in all surgical problems. His astuteness again bore fruit when he made a pre-operative diagnosis of a perforated duodenal ulcer and operated successfully on the patient. This was the first case diagnosed and operated on at the Massachusetts General Hospital This interest stimulated him to pursue a study of chronic duodenal ulcers and surgery of the duodenum which culminated in a paper on this subject in 1909. The fact that the lesion was seldom diagnosed was evident when he was able to collect only fifty proven cases from the histories of the medical and surgical departments; eleven of these were cases of his own. Throughout this period, in spite of his keen interest in surgical lesions of the upper abdomen, he never lost interest in the shoulder and at this time demonstrated that rupture of the supraspinatus tendon could be repaired. He operated successfully in two cases.
At the turn of the century, Codman conceived the End Result Idea "which was merely the common-sense notion that every hospital should follow every patient it treats long enough to determine whether the treatment was successful and to inquire 'if not, why not' with a view to preventing similar failures in the future." This idea was to be the source of much controversy, yet it is the one thing which really portrays Codman as a great figure, for in spite of all opposition, the seeds that he planted at this time finally came to fruition. Through his efforts this plan was instituted on the service of his chief, Dr. F. B. Harrington of the Massachusetts General Hospital; but it was not until a visit of the Society of Clinical Surgery to the British Surgeons that he was able to convice Dr. E. Martin of Philadelphia of the merits of this plan. Martin immediately saw the value of such an idea and apphed the plan to enhancing his own views on hospital standardization. At this time the two Martins, Dr. E. Martin of Philadelphia and Dr. Franklin Martin of Chicago laid the basis for the formulation of the American College of Surgeons. Others keenly interested in such an organization were J. G. Mumford, Cushing and Ochsner. The End Result Idea became the instrument for standardizing hospitals "primarily on the basis of service to patients as demonstrated by available records". Therefore, in 1912, Dr. E. Martin acting under the auspices of the informal Clinical Congress of Surgeons of North America appointed a Committee on Standardization of Hospitals. Codman was appointed chairman of this committee. Martin also appointed another committee which was to organize the American College of Surgeons. Within a period of four years the Committee on Standardization of Hospitals became a committee on the American College of Surgeons and it was still headed by Codman.
Needless to say Codman took his work very seriously and approached the many tasks before him with great zeal and enthusiasm, always preaching the doctrine of End Result studies. In spite of all his efforts it is very doubtful if many surgeons throughout the country really appreciated the full significance of the Idea and what influence it would have on American medicine and surgery of the future. On the other hand so convinced was Codman that he was on the right path and that the End Result Idea had great merit that he opened a small hospital of his own where he could work out his ideas and make it an example of the Idea. This decision was really forced upon him by the existing seniority system at the Massachusetts General Hospital, tradition making it impossible for him ever to attain the status of Chief of Service. His zeal in seeking supporters for his idea and exposing his opposition brought on a head-on collision with his colleagues on May 14, 1913, when he spoke on "The Product of a Hospital" in the Philadelphia Academy of Medicine. There he posed such questions as "For whose primary interest is it to have the hospital efficient: the patient who seeks relief; the public who supports the hospital and in turn expects a high standard of knowledge on the part of their own private physician or surgeon, or the hospital which as an institution has an individuality of its own?" "Who represents or acts for these interests?" "For whose interests is it to insist on the resignation of incompetent old Doctor So and So who is one of the best fellows that ever lived?" "Who will warn the largest contributor that his agreeable classmate, Dr. So and So is totally unfit to remove his stomach?"
The following year, in May of 1914 he presented a paper entitled, "A Study on Hospital Efficiency" before the American Gyne-coligical Society. In this presentation he brought to light many defective practices in the medical profession which were bound to react on prominent persons concerned with hospital practices. Some of these were members of boards of trustees of hospitals; others, superintendents of hospitals. But the greatest number was made up of prominent physicians and surgeons. In order to impress his colleagues with the importance of his mission he used every means available to him. The End Result Idea as Codman saw it had no place for the seniority system which operated in all major hospitals of the country. In protest over the system and to impress the board of trustees, he resigned from the staff of the Massachusetts General Hospital in 1914. His resignation was of course accepted. He then applied for the position of Surgeon-in-Chief on the grounds that his results in the past ten years had been better than those of other surgeons. He was able to support his claim with documentary evidence. His application was ignored.
His next move in enhancing the End Result Idea was to enlist the support of the community, his reasoning being that by exposing the existing evils of hospital practice and organization, and by ridiculing those concerned he could achieve his goal. At that time he was chairman of the local medical society and with this authority he organized a panel to discuss hospital efficiency. This was indeed a very difficult and delicate situation, so much so that it was a hard task to obtain the speakers of his choice. He did however succeed in assembling a heterogeneous panel that comprised a hospital efficiency expert, a surgeon from out of town, a hospital superintendent, a member of the board of trustees of the Peter Bent Brigham Hospital, and the mayor of Boston, James M. Curley. Not wishing to have any stone unturned, he assigned himself the last topic on the program, "General Discussion". Using every trick of advertising that could be conceived, the meeting insofar as its attendance was concerned, was a success; the hall was packed; there was hardly standing room. Many of the questions in the minds of the audience and many of Codman's own ideas and answers to these questions were portrayed through the medium of the cartoon that had not been mentioned or shown before the meeting. Only the artist and Codman were aware of its existence. It was entitled, "The Back Bay Golden Goose Ostrich". This cartoon is found in this book of Codman's, The Shoulder. It depicts President Lowell sitting on Cambridge Bridge wondering whether it would be possible for the professors of the medical school to support themselves on their salaries if they had no opportunity to practice among the rich people of the Back Bay. The Back Bay is represented as an ostrich with its head in a pile of sand, devouring humbugs and kicking out her golden eggs blindly to the professors who show more interest in the golden eggs than they do in the medical science. On the right is the Massachusetts General Hospital with its board of trustees deliberating as to whether, if they really used the End Result System and let the Back Bay know how many mistakes they made on the hospital patients, it would still be willing to give its golden eggs to support the hospital and would still employ the members of their staff and thus save the expense of their salaries. Armies of medical students on their way to Harvard were seen crossing the river having heard that the End Result System would be installed in her affiliated hospitals. Varied reaction was noted throughout the audience. Many administrators who were intimately associated with hospital administration got up and left. Many of these were colleagues for whom Codman had great respect. A few vehemently voiced their anger; a few congratulated him, but the majority were just amused. In this volcanic eruption many were burned, but Codman also was singed. Some members of the profession depicted him as a ruthless, radical personality lacking respect for tradition and the medical profession. The eruption was followed by a request for his resignation as chairman of the local medical society. He lost his position as Instructor of Surgery in the Harvard Medical School, and for many months many of his closest friends refused to speak to him. At all social gatherings he was avoided.
Codman had anticipated this reaction and was prepared to meet it head on. In 1916 he published a third report on "Study on Hospital Efficiency" based on a five-year study of all those who had died after operation in fifteen years at the Massachusetts General Hospital. It brought to light the value of efficiency analysis. So convinced was he of the value of the material that he had brought to light, he sent at his own expense (three thousand dollars) a copy to every member of the Massachusetts Medical Society and of the American College of Surgeons.
This last effort brought much gratification to Codman. He received many requests for copies of the report from physicians, surgeons, and hospital trustees. The Woman's Hospital in New York City instituted almost in toto the End Result System. Other New York hospitals followed suit, accepting certain features of the Idea. The situation in Boston became less tense and Harvard Medical School gave him a room for five years in which to conduct his Registry of Bone Sarcoma. He was honored by the Massachusetts General Hospital with an appointment as Consultant Surgeon in 1929. But more important than all of these acknowledgements was the acceptance of the cartoon by the Boston Medical Library; it was mounted on cloth and arranged like a folding map. It was just a matter of time for more and more hospitals to adopt some features at least of the End Result Study and it was a great comfort to Codman and the members of the Society of Clinical Surgery who had stood solidly behind him that the idea was finally gaining ground. He was given much encouragement by many of his friends at the Massachusetts General Hospital to continue his work and the End Result System was finally established and maintained in the Massachusetts General Hospital. In this hospital, the policy of special assignments to certain physicians in order to investigate new and old methods relative to their value to the patient was progressing satisfactorily. In 1917 Codman relinquished his chairmanship of the Committee on Hospital Standardization. By this time the College of Surgeons had become a powerful organization in America and the work of the Committee on Hospital Standardization had become an important function of the College.
The next few years were interrupted by World War I. Before the United States entered the war, Codman had served with the Canadian forces in England. Here together with Dr. H. V. Andrews, of Boston, he participated in the organization of an emergency hospital in Halifax and set up an End Result System in the hospital. He was in England only a short time and returned to the United States in September of 1917, whereupon he was appointed Senior Surgeon of the Coast Defences of the Delaware. In November he became Regimental Surgeon in the Artillery and set up the System in his new post. In January of 1919 he became Surgeon-in-Chief at the Base Hospital in Camp Taylor where he again instituted an elaborate and efficient End Result System. As a result of his efforts in the service, the System was established in many units, and he never failed to exalt its merits and values. He returned to Boston in June, 1919.
Upon his return it soon became apparent to him that his economic status was deplorable and he was forced to pay attention to the "art of a money maker, at least until I pay off my debts." In spite of this resolution, he soon found himself involved in the organization of a Registry of Bone Sarcoma, a study which occupied his attention for the next thirteen years. He gained much satisfaction from this work but little financial return. This material again gave him an opportunity to demonstrate the value and merit of the End Result System in hospital organization and also made him an authority on the subject of bone tumors. He magnanimously offered his services as consultant free to his colleagues. Many limbs were sacrificed at this time because of lack of knowledge of the varieties and behavior of bone tumors. Many erroneous diagnoses were made leading to either overtreatment or undertreatment of the patient. At this time in 1920 there were four eminent authorities on bone tumors, Blood-good, Coley, Ewing and Mallory. These men all supported Codman in his study. By his attitude, his knowledge of the subject and his action Codman decried surgeons who assumed the responsibility of treatment without consulting those more versed in the subject of bone sarcomas. These facts he brought vigorously before trustees of hospitals in order to emphasize the point that surgeons were not appointed to hospital positions because of their knowledge. As before, the enthusiasm and zeal he exhibited in conducting his campaign did not enhance hs popularity. Many took offense to his attitude and his methods, particularly the most successful surgeons of the day who as Codman stated, "spent their lives in the practice of the art of medicine rather than in that of the science, and, being financially successful, are able to influence the trustees of hospitals against analysis of the results; (and) comparison of achievements would be, to them, as odious as a comparison of incomes." The tenacity, force-fulness and enthusiasm that Codman demonstrated in the End Result Idea were part of him until his death in Boston on November 23, 1940.
Let us review some of the contributions that he has made to his beloved profession and which have been accepted, tried and tested by the profession; his contributions in the field of x-ray, gastrointestinal diseases, the shoulder and bone tumors have stood the test of time and attest to his powers of clinical observation. Needless to say the End Result Idea is the very backbone of hospital standardization today. It provides material for clinical research thereby making it possible to adequately evaluate method of treatment in the most critical fashion. Much of the pertinent knowledge that has been accepted as fact today has evolved from such studies. It was Codman who first instituted the policy of assigning young men to special areas, and these special assignments undoubtedly laid the groundwork for specialization such as we see it today. The End Result Idea and its byproducts have been adopted by the American College of Surgeons and are the very backbone of the policy designed to standardize hospitals in the United States.
Insofar as the shoulder is concerned, the detailed anatomic description of the shoulder and the many clinical entities which affect it has undoubtedly been the greatest gift Codman has made to the surgeons of this world. He stressed chiefly the importance of making an early diagnosis of rupture of the supraspinatus tendon. He pointed out in his own way that only 100 neglected cases of this lesion might cost more than the gross income of the average doctor in a lifetime. In this book, The Shoulder, there is very little that can affect this region that has not been thoroughly studied, evaluated and discussed by Codman. Although there have been many volumes on the shoulder since Codman's, we all must admit that this monumental piece of work has been the basis and the groundwork from which all other works have evolved. Codman undoubtedly is one of the greatest figures that has ever walked across the stage of American medicine, and it is a sad commentary that so few physicians and surgeons are familiar with this man's uphill struggle, his life, his goals, and the achievements. But in his latter years Codman was much aware of the reaction of men at large towards their colleagues of the same period and stated, "honors, except those I have thrust on myself, are conspicuously absent from my chart, but I am able to enjoy the hypothesis that I may receive some from a more receptive generation."

Anthony F. DePalma, M.D.
 

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