E. Ottolenghi, and Francesco Delitala spread his fame throughout the orthopedic world. Codivilla died in 1912 of chronic gastrointestinal disease, which had plagued him for many years.
In 1902, Codivilla introduced a method of skeletal traction, which he used primarily in the treatment of old deformities of the leg. This involved him in a bitter controversy over priority with Steinmann, whose method of skeletal trac- tion was used primarily in the treatment of fresh fractures.
was a true product of his heritage. He obtained his preliminary education in the private schools of the Boston area and entered Harvard Medical School in 1891. His third year of medical education was spent abroad, and he was awarded the degree of Doctor of Medicine in 1895. While traveling abroad he visited many clinics in the outstanding medical centers of the day—London, Paris, Berlin, Vienna, Cairo and others. While in Vienna he became aware, for the first time, of the sub- deltoid bursa mentioned in a little book by Dr. E.
Albert. This small bursa was to become the theme of his life’s work; and from this theme many side excursions were destined to be taken. Although in subsequent years many other interests took of his time and stamina, nevertheless he pursued the study of the subdeltoid bursa and its environs throughout his entire life, the culmination being a book entitled The Shoulder, which was published in 1934.
Very early in his career he challenged many frontiers in medicine. He pursued these studies with great tenacity; he made and recorded many original observations and became an authority in the new fields. In all his undertakings he worked to capacity; he left no stone unturned, he went deeply into the subject. These traits were first exhibited in 1895 when he was appointed assis- tant in anatomy at the Harvard Medical School.
For the next several years he studied in minute detail the subdeltoid bursa and its pathology in the dissecting room and on postmortem specimens.
This study made him aware of the clinical signi- ficance of this region of the shoulder joint. He applied this knowledge in the outpatient clinics of the Massachusetts General Hospital, when he was appointed surgeon to outpatients in 1899. In 1904 his first paper appeared on this subject. At this time he was to learn that he was not the first to write on subdeltoid bursitis; during the discussion of his paper it was brought to light that Kuster described the bursa in 1902, calling it the sub- acromial bursa, which name Codman adopted promptly because he considered this designation to be more appropriate than subdeltoid bursa.
In spite of his extensive knowledge and famil- iarity with the shoulder region, very few of his colleagues were impressed by his work, so that early in his career he learned that too frequently one is not recognized by one’s own generation.
Although discouraged and frustrated, he main- tained his interest in the shoulder and continued to make new observations and contributions to the field.
Ernest Amory CODMAN
1869–1940
In every generation there are a few outstanding personalities whose luster increases with the years. Such a one was Ernest Amory Codman. His life story is typical of that of many great men whose far-reaching intellectual powers and con- tributions are not recognized and appreciated in their own time; in fact, their efforts may even meet with scorn and ridicule. Often such reaction produces discontent, loss of faith in mankind, frustration and even social and economic hard- ships for these gallant pioneers. As I study the life of Codman, I am awed, stimulated and humbled by his brilliant mind, his integrity, his tenacity of purpose, his keen, original observations, his gal- lantry and his egotism tempered with humility.
Every student of medicine should study his story.
Born in Boston on December 30, 1869, Codman was of pure English Puritan stock. He
Such a mind as Codman’s could not restrict itself to a single area, and in 1895 he became interested in Roentgen’s discovery. Convinced that x-rays were destined to play a major role in surgery, he spent the next 5 years in intensive study and experimentation with them. An appara- tus, the Crookes tube, identical with the one with which Roentgen worked, existed in the laboratory of the Harvard Medical School. Under the guid- ance of Professor Trowbridge, of Harvard, and Professor Elihu Thomson, of the General Electric Company, at Lynn, MA, he learned the essential points of the apparatus and, in 1896, applied his knowledge to clinical studies. During this 5-year period he became an authority in the interpretation of the pathologic states by this medium. He published a number of articles on x- ray subjects; an outstanding one dealt with x-ray burns. Another important contribution of this period was a study of joints and bursas injected with nonradiable material done on cadavers. In 1898 he completed this anatomic study and pre- sented the Warren Museum with an album con- taining standard x-ray anatomic pictures of each joint of the body in different positions. A by- product of this last study was a monograph on the wrist, dealing with the normal motions of this joint.
Although this interest in x-rays brought Codman much satisfaction and made him an expert in x-ray diagnosis, it also brought disap- pointment and frustration. He prepared a monu- mental monograph, The Use of X-ray in the Diagnosis of Bone Diseases, which he submitted for the Gross Prize given every 5 years in Philadelphia. The committee awarding the prize was composed of prominent Philadelphia sur- geons, among whom were W.W. Keen and J.W.
White. The prize 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. Failure to win the prize was a blow to Codman, yet he realized that the busy surgeons of his day had failed to grasp the practical value of x-rays in the diagnosis of disease and that the material that he had presented to the committee was unintelligible to them. It was not until 5 years later that Dr. W.W. Keen requested him to write a chapter on the use of x-rays in surgery. Instead of doing this, Codman submitted to Keen the unpub- lished paper in toto for his book. It was published without change in Keen’s Surgery. Codman had learned another lesson: that conformation of one’s ideas takes time.
While constantly exploring new fields, Codman practiced as a general surgeon. His keen powers of observation in all surgical problems were disclosed again when he made a preopera- tive 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 event led him to pursue a study of chronic duodenal ulcer and surgery of the duodenum. In 1909 he wrote a paper on this subject. The fact that the lesion was seldom diagnosed was evident when he was able to collect only 50 proven cases from the histories of the medical and surgical departments, and 11 of these cases were his own. Nevertheless, during this period his interest in the shoulder con- tinued, and he demonstrated that rupture of the supraspinatus tendon could be repaired; he oper- ated successfully on two cases.
At about this time a seed in the mind of Codman began to take root. It had been planted almost a decade before. It was to make him one of the most controversial figures of his genera- tion. At the turn of the century he 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 or not the treatment was suc- cessful, and to inquire ‘if not, why not,’ with a view to preventing similar failures in the future.”
Through his efforts this plan was instituted on the service of his chief, Dr. F.B. Harrington, at the Massachusetts General Hospital. But it was not until 1910 that he was able to convince Dr. E.
Martin, of Philadelphia, of the merits of his plan.
Dr. Martin then applied the plan to enhancing his own views on hospital standardization. This occurred during a visit of the Society of Clinical Surgery to the British Surgeons, which led to the organization of the American College of Sur- geons, under the leadership of the two Martins, Dr. E. Martin, of Philadelphia, and Dr. Franklin Martin, of Chicago. Among the other prominent surgeons of the time who dreamed of and acted on the crystallization of the College Idea were J.G. Mumford, Cushing and Ochsner. The End Result Idea became the instrument for standard- izing hospitals “primarily on the basis of ser- vice to patients, as demonstrated by available records.” In 1912, a Committee on the Standard- ization of Hospitals was appointed by Dr. E.
Martin under the auspices of the informal Clini- cal Congress of Surgeons of North America;
another committee was also appointed at this
time, its function being to organize the American College of Surgeons. Codman was appointed chairman of the first committee. Four years later the Committee on Standardization of Hospitals became a committee of the American College of Surgeons, and it still was headed by Codman.
With his inherent zeal, enthusiasm and tenac- ity, Codman plunged into the work set for his committee. He labored and preached the doctrine of the End Result Idea. During this period his interest in the shoulder waned but never was lost.
It is doubtful that many surgeons, except for the few who conceived and gave birth to the idea of the American College of Surgeons, recognized the effect that the work of this committee would have on American medicine and surgery. On the other hand, Codman was so convinced of the merits of the End Result Idea that he decided to open 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. It was a volcanic idea, whose rumblings first were heard on May 14, 1913, when Codman spoke on The Product of a Hospital in the Philadelphia Academy of Medicine, when 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 physi- cian or surgeon or the hospital which as an insti- tution has an individuality of its own?” “Who represents or acts for these interests?” “For whose interests is it to insist on the resignation of incom- petent 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, Doctor So and So, is totally unfitted to remove his stomach?” The second rumbling occurred on May, 1914, when he presented a paper entitled A Study on Hospital Efficiency before the American Gynecological Society. Although Codman was sincere and upright in the conduct of his investi- gations and bore malice toward none, of necessity he brought to light many defective practices that were bound to react on prominent persons con- cerned with hospital practice. Some of these were members of the boards of trustees of hospitals;
others, superintendents of hospitals. But the greatest number was made up of prominent physi- cians and surgeons. He used every means to
impress his colleagues with the importance of his mission. The seniority system, which operated in all major hospitals of the country, could not be tolerated in the End Result Idea. In protest over this system and to impress the board of trustees, he resigned from the staff of the Massachusetts General Hospital in 1914. When his resignation was accepted, he applied for the position of Surgeon-in-Chief on the grounds that his results in the past 10 years had been better than those of other surgeons. He supported his claim with documentary evidence. His application was ignored.
Next, he had the idea of enlisting the support of the community. He reasoned that by exposing the existing evils of hospital practice and organi- zation and by ridiculing those concerned, opinion would favor his End Result Idea. He used the authority invested in him as chairman of the local medical society to organize a panel to discuss hospital efficiency. Because of the delicacy of the situation, it was difficult for him to obtain the speakers that he wanted, most of them refusing the invitation. Nevertheless, he did 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. In order to ensure that all phases of the problem were discussed thoroughly, he himself was the last speaker and his topic, General Dis- cussion. The meeting was advertised skillfully;
the response was gratifying; the hall was packed;
there was hardly standing room. Codman pro- pounded his ideas and answered the question in the mind of the audience through the medium of a 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.” It depicts President Lowell standing on Cambridge Bridge wondering whether it would be possible for the professors of the medical school to support them- selves 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 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 were 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 salaries. Across the river and over the hill are seen armies of medical stu- dents on the way to Harvard, having heard that the End Result System would be installed in her affiliated hospitals. Audience reaction was varied, and many who were associated intimately with hospital work got up and left. Many of these were colleagues for whom Codman had great respect:
a few voiced their anger; the majority were amused; a very few congratulated him.
It was like the eruption of a volcano: many were burned, but Codman also was singed. To some he was a radical, ruthless personality with no respect for tradition and the medical profes- sion. He was asked to resign as chairman of the local medical society and was dropped from the position of Instructor in Surgery in the Harvard Medical School. For months, many of his friends refused to speak to him, and he was avoided at social gatherings.
This was a trying period for Codman. However, this reaction had been anticipated, and it did not deflect him from his work. In 1916 appeared the third report on “Study on Hospital Efficiency,”
based on a 5-year study of all those who had died after operation in 15 years at the Massachusetts General Hospital. It brought to light the value of efficiency analysis. At his own expense ($3,000), he sent a copy to every member of the Massa- chusetts Medical Society and of the American College of Surgeons.
Such efforts do not go unrecognized forever.
Codman was gratified to receive many requests for copies of the report from hospital trustees. The Woman’s Hospital in New York City instituted almost in toto the End Result System; other New York hospitals accepted certain features of it.
Even in Boston, relationships became less tense;
Harvard Medical School gave him a room for 5 years from which to conduct the Registry of Bone Sarcoma, and in 1929 the Massachusetts General Hospital honored him with the appointment of Consulting Surgeon. But more important than all these acknowledgments was the acceptance of the cartoon by the Boston Medical Library; it was mounted on cloth and arranged like a folding map. As the years went by, more and more hospitals adopted some features at least of the End Result Study. It was a great comfort to Codman that the members of the Society of
Clinical Surgery stood solidly behind him, although many did not agree with his methods.
Also, many of his friends at the Massachusetts General Hospital endorsed, and even encouraged, his work; and in this outstanding institution the End Result System was established and main- tained. In the Massachusetts General Hospital the policy of special assignments to certain physi- cians in order to investigate new and old methods relative to their value to the patient was pro- gressing satisfactorily. Codman relinquished his chairmanship of the Committee on Hospital Stan- dardization in 1917. By this time the College of Surgeons had become a powerful organization in America, and the work of the Committee on Hos- pital Standardization had become an important function of the College.
For the next several years, Codman’s work at home was interrupted by World War I. Before the United States entered the war, he 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. After a short stay in England, he returned to the United States, and in September, 1917, he was appointed Senior Surgeon of the Coast Defences of the Delaware. In November he became Regimental Surgeon in the Artillery and set up his system in his new post. In January, 1919, he became Surgeon-in-Chief at the Base Hospital in Camp Taylor, where again he insti- tuted an elaborate and efficient End Result System. Through his entire army service, he never relinquished his End Result Idea, setting it up wherever he was located and propounding its merits and values. He returned to Boston and to his closed hospital in June, 1919.
Upon his return to Boston, Codman resolved to abstain from any new projects and determined to become “a money maker, at least until I had paid off my debts.” In spite of this resolution, he soon found himself involved in the organization of the Registry of Bone Sarcoma—a study that occupied him for the next 13 years. This fundamental piece of work gave him much personal satisfaction but little financial return. He used this study to demonstrate again the value of the End Result System in hospital organization. He became an authority on the subject of bone tumors and mag- nanimously offered his services as consultant free to his colleagues. In 1920 there were few workers who had acquired sufficient knowledge of the varieties and the behavior of bone tumors to
warrant their making a diagnosis and recom- mending treatment with reasonable certainty.
Many limbs were sacrificed needlessly; on the other hand, underdiagnosis often resulted in death of the patient. At this time the four eminent authorities were Bloodgood, Coley, Ewing and Mallory. These men supported Codman in his study. By his attitude and his particular knowl- edge of the subject, he decried surgeons who assumed the responsibility of treatment without consulting those more versed in the subject of bone sarcomas. Also, he brought these facts vigorously before trustees of hospitals in order to emphasize the point that surgeons were not appointed to hospital positions because of their knowledge. The zeal with which he conducted his campaign did not enhance his popularity. Offense was taken, particularly by the most successful surgeons of the day who, as Codman stated,
“spent their lives in the practice of the art of med- icine rather than in that of the science, and, being financially successful, are able to influence the trustees of hospitals against an analysis of the results; (and) comparison of achievements would be, to them, as odious as a comparison of incomes.”
From this brief sketch of Codman’s life, one is impressed with his tenacity of purpose. This was true of him until his death in Boston on Novem- ber 23, 1940. Now let us mention some of his ideas and the effect that they have had on medi- cine. Much that he attempted was not achieved in his day, but he set in motion processes that in later decades have gained a momentum of which even he could not have dreamed. His contributions in the field of x-rays, gastrointestinal diseases, the shoulder and bone tumors have stood the test of time and attest to his powers of clinical observa- tions. His End Result Idea has taken root in many disciplines and provides the means for accurate evaluation of methods and practice in medicine and surgery. Essentially it is clinical research. The bulk of the medical literature in all specialties is based on this system of evaluation. It is a method that will gain in depth and breadth, and never will be abandoned by the medical profession.
By establishing the policy of “special assign- ments” to young men in the profession, much good has been achieved. Methods and practices having little value are abandoned, while those of merit are made available quickly to the profession at large. In addition, this feature has laid the groundwork for development of experts in certain fields of medicine and surgery. Although the
trend toward specialization had started before Codman’s time, no one can deny that “special assignments” in hospitals gave it impetus.
The End Result Idea was the first tool used by the American College of Surgeons to standardize hospitals in the United States. Codman’s foremost ambition in life was the establishment of the End Result System in every hospital, and he employed every means at his command to this end. His knowledge of the shoulder joint was molded toward this end. To physicians, surgeons, employees and insurance directors he stressed continually the need of early diagnosis of rupture of the supraspinatus tendon. He pointed out that failure to diagnose resulted in marked disability and loss of money. He calculated that only 100 neglected cases of this lesion might cost more than the gross income of the average doctor in a lifetime. In this way he hoped to acquaint all those involved in medical care with the merits of the End Result System and to interest them in installing it in their particular fields of endeavor.
Codman was a great pioneer. It is a sad com- mentary that so few physicians know of his life and achievements. He grows in stature with each generation. Many of his ideas have already been accepted; many others will yet be. Codman knew the uphill battle that he was fighting when he said,
“Honors, except those I have thrust on myself, are conspicuously absent on my chart, but I am able to enjoy the hypothesis that I may receive some from a more receptive generation.”
