The American Journal of Surgery (2014) 207, 670-672
North Pacific Surgical Association: Historian’s Lecture
The way we were: surgical practice at the dawn of the North Pacific Surgical Association Preston L. Carter, M.D., F.A.C.S.* Historian, North Pacific Surgical Association, General Surgery Service, Madigan Army Medical Center, Tacoma, WA 98431, USA
KEYWORDS: Surgical history; Surgery early 20th century; Surgical ethics; Stab wound heart; Prostatectomy; Pyloric stenosis
Abstract The North Pacific Surgical Association Historian’s centennial lecture, with review of the geographic challenges for members of this society at the time of its founding and selected insights into surgical practices and philosophies of a century ago. Ó 2014 Elsevier Inc. All rights reserved.
A century ago, a small group of geographically isolated but forward-thinking American surgeons in Washington and Oregon and their Canadian colleagues in British Columbia formed a regional surgical society to share their experiences and ideas and to advance surgical practice in northwestern North America. The North Pacific Surgical Association (NPSA) held its inaugural meeting in Vancouver, British Columbia, in November 1912. Except for 1943 and 1944 when the exigencies of World War II took precedence, the NPSA has met annually since then, rotating between the host cities of Victoria and Vancouver in Canada and Portland, Seattle, Spokane, and Tacoma in the United States. In recent years, Alberta has been added as a partner to the Victoria caucus, with active participation from the members in Calgary and Edmonton. This year’s meeting at the historic Empress Hotel marks the centenary
This article was researched and prepared with no connections or sponsorship from the medical industry. * Corresponding author. Tel.: 11-253-968-2200; fax: 11-253-9680232. E-mail address: [email protected] Manuscript received November 29, 2013; revised manuscript December 22, 2013 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2013.12.026
of the society. For this occasion’s Historian’s presentation, I offer glimpses of the surgical world as it was for our founders in 1913. For perspective, it is important to realize just how remote the Pacific Northwest was at that time. In contrast to today, when we take nationwide and global travel as a given, travel to and from this region in the early 20th century was slow and arduous. By land, the only reliable connections between Northwest cities were by rail. Passenger air travel was nonexistent. Access to Victoria was by ferry steamer. Surgeons of the region attending a meeting ‘‘back east’’ faced a Pullman trip of several days each way. There were few surgical journals. Long-distance communication was by postal mail or telegram. Telephone service was available within cities, but transcontinental long-distance calling was not yet a reality. Our founders would be amazed by the ease of today’s communications. In 1913, medical academia in the northwest was sparse. In the NPSA region, the sole medical school was at the University of Oregon in Portland, with a total enrollment of 57 students. Annual tuition was $150. In Canada, the nearest medical school was in Winnipeg, Manitoba. Reflecting the fact that the NPSA organizers were also local medical leaders, the Oregon dean was the founder, K.A. Mackenzie, who was also the first President of the Association.1
P.L. Carter
NPSA Historian’s lecture
With some effort, it is still possible to access original hardbound or online content from 1913 editions of JAMA, the Annals of Surgery, Surgery, Gynecology, and Obstetrics, and the Canadian Medical Association Journal. A review of these sources provides a fascinating look back in surgical time. Obviously, surgery a century ago differed greatly from today. A detailed review of the differences and similarities would require far more time and space than is possible here. I hope that a few snippets will be enlightening. Although it is easy for us to be smug about discarded practices, we must be mindful that many present-day ‘‘gold standards’’ will also soon be outdated. For every quaint journal entry from that era, one finds another that shows how much could be surgically accomplished with such limited resources. The year 1913 was an age of steady surgical progress. Half a century before, the advent of general anesthesia and, subsequently, regional anesthesia opened the door to previously unthinkable surgical possibilities. Development of surgical antisepsis and improved surgical lighting led to further progress, as did the discovery of X-rays, whose images were poor by modern standards but a quantum advance at the time. Despite these milestones, much of today’s surgical armamentarium was unknown to our founders. Commonplace tools of today, such as electrocautery, computed tomography imaging, and vital signs monitoring systems lay in the future. Antibiotics were unknown. Postoperative fluid resuscitation was often given in the form of saline enemas, a practice known as proctoclysis, sometimes with the addition of coffee! Blood transfusions were rare and accomplished by direct donor-to-recipient exchange via venovenous or arteriovenous cannulation. Medicine then, especially surgery, was emphatically a man’s world. Articles from this era are written with an assumed gender reference of ‘‘medical men.’’ Women comprised fewer than 4% of medical students. Fewer still were in surgery. In the entire 1913 Annals of Surgery, there is but 1 article authored by a woman. In 1913, prerequisite requirements for medical school entry were far more lax than at present. Many medical schools required but a single year of preliminary college study before matriculation. After graduation, the process of residency training in surgery was also much less structured. The methods of residency training at leading centers of the daydsuch as Johns Hopkins under Halsteddwould be recognizable to today’s trainees, except for work-hour limitations. But in many other places, residency arrangements were much looser, little more than semistructured apprenticeships with established community surgeons. After entering practice, there was little oversight over surgical outcomes. Mortality rates varied greatly between hospitals. Even at reputable facilities, fatal outcomes were not uncommon from procedures that we would today consider to have exceedingly low risk. In the pages of JAMA, physician obituary pages were a regular feature, usually including cause of death. One finds numerous examples of physicians who died ‘‘a week after an operation for appendicitis,’’ ‘‘four days after an operation for gallstones,’’ and the like. The
671 principle that there are no ‘‘routine’’ operations was emphatically valid in 1913. Surgical articles of 1913 were lengthy and predominantly single authored. Sages of the era, such as Crile, Halsted, Mayo, and Meyer, were frequent contributors. Disease processes almost unknown today but then common such as locally advanced breast cancer, exophthalmic goiter, and obstructing or bleeding peptic ulcer were common topics. Even more foreign to contemporary readers are articles on surgical treatments for tuberculosis, ptosis of various abdominal organs, or accounts of complex, pedicled reconstructive flaps. Descriptions of operative technique were colorful and vivid. Although surgical outcomes from that time are devoid of statistical calculations, this is, perhaps, a refreshing change from today’s articles of heavily massaged data and subset analysis. What these old articles lack in scientific rigor, they make up for with lucid prose and striking candor in reporting both good and bad outcomes. To a degree unimaginable today, our predecessors openly shared fatal outcomes with their readership. Halsted reported a woman with an aortic aneurysm, which he buttressed with an aluminum band. She improved for several weeks, only to exsanguinate from band erosion on the planned day of discharge.2 Today, such a spectacular final outcome would in all probability be buried deep in a surgical department’s nondiscoverable ‘‘Quality Assurance’’ minutes. My review rediscovered the first published NPSA articles. The first was by Dr Robert McKechnie of Vancouver, who reported his experience with 6 cases of pyloric stenosis, 2 with fatal outcome.3 Dr McKechnie, the subject of my historian’s review 2 years ago, was an NPSA founder and a charter member of the Board of Governors of the American College of Surgeons. In his article, it becomes apparent that the thenpreferred surgical treatment for pyloric stenosis was not pyloromyotomy but posterior gastrojejunostomy for bypass of the obstructed pylorus. Because ultrasound was not yet available, diagnosis was often much delayed compared with the present era, and the child was often far more nutritionally compromised. Dr McKechnie’s article has a classic description of the advanced clinical picture of the disorder and of detecting the elusive ‘‘olive.’’ The second NPSA author whom I encountered was Dr A. E. Rockey of Portland, another founder and leading community surgeon. (His wife, incidentally, was a leading member of a group opposed to women’s suffrage in Oregon.) Dr Rockey reported a series of more than 300 suprapubic prostatectomies. These were described as ‘‘short operations,’’ for which the steps of opening the bladder, detaching the hypertrophied prostate from its bed, and retrieving the specimen should take not more than about 5 minutes! His described technique involved having the operator elevate the prostate with 2 fingers of his gloved left hand inserted per rectum, after which the ungloved right hand was ‘‘boldly thrust into the bladder,’’ so that the fingernail of that index finger could better begin enucleation of the hypertrophied gland. Spinal anesthesia was preferred. The operation when performed in that way was described as ‘‘so little disturbing
672
The American Journal of Surgery, Vol 207, No 5, May 2014
that one of the patients smoked a cigar during the procedure and called for his lunch immediately on return to his room.’’4 Ironically, in a separate article (and ambiguous as to whether it was one of his own patients), Dr Rockey also reported an instance of death from spinal anesthesia.5 By description, this case appears to have been a ‘‘high spinal’’ leading to fatal respiratory embarrassment. Although surgical practices such as these are certainly outdated, it is also well to recognize the tremendous bold operations of the era that paved the way for further surgical progress. Space permits but a few examples. They show both the impressive courage of the surgeons and the ability of the human body to recover from what was most certainly ‘‘maximally invasive’’ surgery. Torek reported the first successful resection of the intrathoracic esophagus for cancer in 1913. Via a left thoracic approach, he mobilized and resected a mid-esophageal cancer, mobilizing the arch of the aorta in the process to improve exposure. To avoid the hazards of intrathoracic anastomosis after resection, he left the patient with a cervical esophagostomy and gastrostomy. To permit the patient a semblance of normal eating, external rubber tubing was used to connect the 2 stomas at mealtime. Food was chewed to a fluid state and swallowed via the ‘‘rubber esophagus.’’ The patient was described as being ‘‘quite happy’’ with the arrangement.6 Another example of century-old heroic surgery is a published report of emergency thoracotomies for stab wounds to the heart. As an example of the vivid clinical writing of the era, and the spectacular events surrounding one of the cases cited, I cannot do better than these abridged quotes from the original article7: T.E., age 20, a cook, was stabbed in the chest with a long, rusty penknife. The stab caused severe pain, but neither felled him, nor caused him to feel faint. He set out at once for the hospital without assistance, a distance of about 2 blocks. He began to feel weak, and was found crawling up the steps of the hospital entrance. After being disrobed, a small wound, bleeding continuously, was found to the left of the sternum at the third rib. The patient was sweating and very pale. The heartbeats could be heard indistinctly. There was no bruit. Operation with ether was begun about 45 minutes after infliction of the injury. A thoracotomy was made at the level of the 4th ribs and a flap was raised, fracturing the costal cartilages near the sternum. Blood was spurting from the pericardium with each pulsation. A penetrating wound of the left ventricle was found. Bleeding was free and continuous, whether greater during diastole we were unable to say, as the heart was now beating very rapidly and resembled a quivering mass of muscle. The wound was closed with six continuous silk sutures. During the suturing, the descending branch of the left coronary artery was struck, with profuse hemorrhage which required an additional suture. During the operation, 24 ounces of salt solution were given, as well as subcutaneous strychnine. At the end of the operation, the pulse was 150, the respirations 32. Recovery was stormy. The patient was allowed out of
bed on the 35th day, and discharged on the 56th day. He returned to work, and remained well for four years, but then died of tuberculosis.
In addition to these amusing and amazing cases, the literature of 1913 contains numerous examples of enduring surgical wisdom. In an address before the American Medical Association entitled, ‘‘The Qualifications of the Surgeon,’’ the author, Dr William Haggard, wrote, paraphrased slightly: The first great requirement of a surgeon is a conscience. It should be a constant mentor and great arbiter of the momentous decisions which come daily. Surgeons should recall their misgivings with which, on the strength of a fallible opinion they advise and perform operations; their thankfulness when a grave complication is averted; their forebodings when disasters become realities, sometimes leading to a distressing death; and their self-criticism and the regret which can ensue. And yet, are not such surgeons, who can appreciate their own limitations in spite of years of devotion, more to be respected than those who take up surgery lightly and with inadequate conscience.
Further sage advice comes from our founder, Dr McKechnie. In reflecting on the 2 fatal outcomes in his pyloric stenosis series, he noted that ‘‘these failures, as failures often do, can teach us a lesson.’’ Clearly, Dr McKechnie was following the principles set forth by Dr Haggard that surgeons of conscience should always be as mindful of their failures as they are of their successes. For all surgeons who want to truly appreciate their present-day craft, it is worthwhile to occasionally take time to peruse a truly old journal, such as those reviewed here. The writings of these long-dead authors give insight into their world, their challenges, and their contributions to surgical progress. It is clear that the NPSA founders were men of conscience and vision, who sought, as I hope we still seek today, to approach surgery more as a calling than a business and to strive for ever-better results by sharing their experiencesdboth good and baddwith each other, and through publication, with the medical world at large. This is their legacy and their lasting challenge to us, the present and future leaders of the NPSA. For a century, our organization has, I think, met that challenge well. I am confident that the founders’ vision will be sustained in the years ahead.
References 1. Medical colleges of the United States and Canada. JAMA 1913;67: 569–603. 2. Halsted WS. Partial occlusion of the thoracic and abdominal aortas. Ann Surg 1913;58:183–7. 3. McKechnie RE. Congenital hypertrophic pyloric stenosis. Can Med Assoc J 1913;3:566–71. 4. Rockey AE. Prostatectomy by a composite method. SGO 1913;16: 424–9. 5. Rockey A. Death from spinal anesthesia. JAMA 1913;67:422. 6. Torek W. First successful resection of the thoracic part of the esophagus for carcinoma. SGO 1913;16:614–7. 7. Stewart FT. 5 cases of suture of the heart. Ann Surg 1913;58:67–85.
North Pacific Surgical Association: Historian’s Lecture
The way we were: surgical practice at the dawn of the North Pacific Surgical Association Preston L. Carter, M.D., F.A.C.S.* Historian, North Pacific Surgical Association, General Surgery Service, Madigan Army Medical Center, Tacoma, WA 98431, USA
KEYWORDS: Surgical history; Surgery early 20th century; Surgical ethics; Stab wound heart; Prostatectomy; Pyloric stenosis
Abstract The North Pacific Surgical Association Historian’s centennial lecture, with review of the geographic challenges for members of this society at the time of its founding and selected insights into surgical practices and philosophies of a century ago. Ó 2014 Elsevier Inc. All rights reserved.
A century ago, a small group of geographically isolated but forward-thinking American surgeons in Washington and Oregon and their Canadian colleagues in British Columbia formed a regional surgical society to share their experiences and ideas and to advance surgical practice in northwestern North America. The North Pacific Surgical Association (NPSA) held its inaugural meeting in Vancouver, British Columbia, in November 1912. Except for 1943 and 1944 when the exigencies of World War II took precedence, the NPSA has met annually since then, rotating between the host cities of Victoria and Vancouver in Canada and Portland, Seattle, Spokane, and Tacoma in the United States. In recent years, Alberta has been added as a partner to the Victoria caucus, with active participation from the members in Calgary and Edmonton. This year’s meeting at the historic Empress Hotel marks the centenary
This article was researched and prepared with no connections or sponsorship from the medical industry. * Corresponding author. Tel.: 11-253-968-2200; fax: 11-253-9680232. E-mail address: [email protected] Manuscript received November 29, 2013; revised manuscript December 22, 2013 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2013.12.026
of the society. For this occasion’s Historian’s presentation, I offer glimpses of the surgical world as it was for our founders in 1913. For perspective, it is important to realize just how remote the Pacific Northwest was at that time. In contrast to today, when we take nationwide and global travel as a given, travel to and from this region in the early 20th century was slow and arduous. By land, the only reliable connections between Northwest cities were by rail. Passenger air travel was nonexistent. Access to Victoria was by ferry steamer. Surgeons of the region attending a meeting ‘‘back east’’ faced a Pullman trip of several days each way. There were few surgical journals. Long-distance communication was by postal mail or telegram. Telephone service was available within cities, but transcontinental long-distance calling was not yet a reality. Our founders would be amazed by the ease of today’s communications. In 1913, medical academia in the northwest was sparse. In the NPSA region, the sole medical school was at the University of Oregon in Portland, with a total enrollment of 57 students. Annual tuition was $150. In Canada, the nearest medical school was in Winnipeg, Manitoba. Reflecting the fact that the NPSA organizers were also local medical leaders, the Oregon dean was the founder, K.A. Mackenzie, who was also the first President of the Association.1
P.L. Carter
NPSA Historian’s lecture
With some effort, it is still possible to access original hardbound or online content from 1913 editions of JAMA, the Annals of Surgery, Surgery, Gynecology, and Obstetrics, and the Canadian Medical Association Journal. A review of these sources provides a fascinating look back in surgical time. Obviously, surgery a century ago differed greatly from today. A detailed review of the differences and similarities would require far more time and space than is possible here. I hope that a few snippets will be enlightening. Although it is easy for us to be smug about discarded practices, we must be mindful that many present-day ‘‘gold standards’’ will also soon be outdated. For every quaint journal entry from that era, one finds another that shows how much could be surgically accomplished with such limited resources. The year 1913 was an age of steady surgical progress. Half a century before, the advent of general anesthesia and, subsequently, regional anesthesia opened the door to previously unthinkable surgical possibilities. Development of surgical antisepsis and improved surgical lighting led to further progress, as did the discovery of X-rays, whose images were poor by modern standards but a quantum advance at the time. Despite these milestones, much of today’s surgical armamentarium was unknown to our founders. Commonplace tools of today, such as electrocautery, computed tomography imaging, and vital signs monitoring systems lay in the future. Antibiotics were unknown. Postoperative fluid resuscitation was often given in the form of saline enemas, a practice known as proctoclysis, sometimes with the addition of coffee! Blood transfusions were rare and accomplished by direct donor-to-recipient exchange via venovenous or arteriovenous cannulation. Medicine then, especially surgery, was emphatically a man’s world. Articles from this era are written with an assumed gender reference of ‘‘medical men.’’ Women comprised fewer than 4% of medical students. Fewer still were in surgery. In the entire 1913 Annals of Surgery, there is but 1 article authored by a woman. In 1913, prerequisite requirements for medical school entry were far more lax than at present. Many medical schools required but a single year of preliminary college study before matriculation. After graduation, the process of residency training in surgery was also much less structured. The methods of residency training at leading centers of the daydsuch as Johns Hopkins under Halsteddwould be recognizable to today’s trainees, except for work-hour limitations. But in many other places, residency arrangements were much looser, little more than semistructured apprenticeships with established community surgeons. After entering practice, there was little oversight over surgical outcomes. Mortality rates varied greatly between hospitals. Even at reputable facilities, fatal outcomes were not uncommon from procedures that we would today consider to have exceedingly low risk. In the pages of JAMA, physician obituary pages were a regular feature, usually including cause of death. One finds numerous examples of physicians who died ‘‘a week after an operation for appendicitis,’’ ‘‘four days after an operation for gallstones,’’ and the like. The
671 principle that there are no ‘‘routine’’ operations was emphatically valid in 1913. Surgical articles of 1913 were lengthy and predominantly single authored. Sages of the era, such as Crile, Halsted, Mayo, and Meyer, were frequent contributors. Disease processes almost unknown today but then common such as locally advanced breast cancer, exophthalmic goiter, and obstructing or bleeding peptic ulcer were common topics. Even more foreign to contemporary readers are articles on surgical treatments for tuberculosis, ptosis of various abdominal organs, or accounts of complex, pedicled reconstructive flaps. Descriptions of operative technique were colorful and vivid. Although surgical outcomes from that time are devoid of statistical calculations, this is, perhaps, a refreshing change from today’s articles of heavily massaged data and subset analysis. What these old articles lack in scientific rigor, they make up for with lucid prose and striking candor in reporting both good and bad outcomes. To a degree unimaginable today, our predecessors openly shared fatal outcomes with their readership. Halsted reported a woman with an aortic aneurysm, which he buttressed with an aluminum band. She improved for several weeks, only to exsanguinate from band erosion on the planned day of discharge.2 Today, such a spectacular final outcome would in all probability be buried deep in a surgical department’s nondiscoverable ‘‘Quality Assurance’’ minutes. My review rediscovered the first published NPSA articles. The first was by Dr Robert McKechnie of Vancouver, who reported his experience with 6 cases of pyloric stenosis, 2 with fatal outcome.3 Dr McKechnie, the subject of my historian’s review 2 years ago, was an NPSA founder and a charter member of the Board of Governors of the American College of Surgeons. In his article, it becomes apparent that the thenpreferred surgical treatment for pyloric stenosis was not pyloromyotomy but posterior gastrojejunostomy for bypass of the obstructed pylorus. Because ultrasound was not yet available, diagnosis was often much delayed compared with the present era, and the child was often far more nutritionally compromised. Dr McKechnie’s article has a classic description of the advanced clinical picture of the disorder and of detecting the elusive ‘‘olive.’’ The second NPSA author whom I encountered was Dr A. E. Rockey of Portland, another founder and leading community surgeon. (His wife, incidentally, was a leading member of a group opposed to women’s suffrage in Oregon.) Dr Rockey reported a series of more than 300 suprapubic prostatectomies. These were described as ‘‘short operations,’’ for which the steps of opening the bladder, detaching the hypertrophied prostate from its bed, and retrieving the specimen should take not more than about 5 minutes! His described technique involved having the operator elevate the prostate with 2 fingers of his gloved left hand inserted per rectum, after which the ungloved right hand was ‘‘boldly thrust into the bladder,’’ so that the fingernail of that index finger could better begin enucleation of the hypertrophied gland. Spinal anesthesia was preferred. The operation when performed in that way was described as ‘‘so little disturbing
672
The American Journal of Surgery, Vol 207, No 5, May 2014
that one of the patients smoked a cigar during the procedure and called for his lunch immediately on return to his room.’’4 Ironically, in a separate article (and ambiguous as to whether it was one of his own patients), Dr Rockey also reported an instance of death from spinal anesthesia.5 By description, this case appears to have been a ‘‘high spinal’’ leading to fatal respiratory embarrassment. Although surgical practices such as these are certainly outdated, it is also well to recognize the tremendous bold operations of the era that paved the way for further surgical progress. Space permits but a few examples. They show both the impressive courage of the surgeons and the ability of the human body to recover from what was most certainly ‘‘maximally invasive’’ surgery. Torek reported the first successful resection of the intrathoracic esophagus for cancer in 1913. Via a left thoracic approach, he mobilized and resected a mid-esophageal cancer, mobilizing the arch of the aorta in the process to improve exposure. To avoid the hazards of intrathoracic anastomosis after resection, he left the patient with a cervical esophagostomy and gastrostomy. To permit the patient a semblance of normal eating, external rubber tubing was used to connect the 2 stomas at mealtime. Food was chewed to a fluid state and swallowed via the ‘‘rubber esophagus.’’ The patient was described as being ‘‘quite happy’’ with the arrangement.6 Another example of century-old heroic surgery is a published report of emergency thoracotomies for stab wounds to the heart. As an example of the vivid clinical writing of the era, and the spectacular events surrounding one of the cases cited, I cannot do better than these abridged quotes from the original article7: T.E., age 20, a cook, was stabbed in the chest with a long, rusty penknife. The stab caused severe pain, but neither felled him, nor caused him to feel faint. He set out at once for the hospital without assistance, a distance of about 2 blocks. He began to feel weak, and was found crawling up the steps of the hospital entrance. After being disrobed, a small wound, bleeding continuously, was found to the left of the sternum at the third rib. The patient was sweating and very pale. The heartbeats could be heard indistinctly. There was no bruit. Operation with ether was begun about 45 minutes after infliction of the injury. A thoracotomy was made at the level of the 4th ribs and a flap was raised, fracturing the costal cartilages near the sternum. Blood was spurting from the pericardium with each pulsation. A penetrating wound of the left ventricle was found. Bleeding was free and continuous, whether greater during diastole we were unable to say, as the heart was now beating very rapidly and resembled a quivering mass of muscle. The wound was closed with six continuous silk sutures. During the suturing, the descending branch of the left coronary artery was struck, with profuse hemorrhage which required an additional suture. During the operation, 24 ounces of salt solution were given, as well as subcutaneous strychnine. At the end of the operation, the pulse was 150, the respirations 32. Recovery was stormy. The patient was allowed out of
bed on the 35th day, and discharged on the 56th day. He returned to work, and remained well for four years, but then died of tuberculosis.
In addition to these amusing and amazing cases, the literature of 1913 contains numerous examples of enduring surgical wisdom. In an address before the American Medical Association entitled, ‘‘The Qualifications of the Surgeon,’’ the author, Dr William Haggard, wrote, paraphrased slightly: The first great requirement of a surgeon is a conscience. It should be a constant mentor and great arbiter of the momentous decisions which come daily. Surgeons should recall their misgivings with which, on the strength of a fallible opinion they advise and perform operations; their thankfulness when a grave complication is averted; their forebodings when disasters become realities, sometimes leading to a distressing death; and their self-criticism and the regret which can ensue. And yet, are not such surgeons, who can appreciate their own limitations in spite of years of devotion, more to be respected than those who take up surgery lightly and with inadequate conscience.
Further sage advice comes from our founder, Dr McKechnie. In reflecting on the 2 fatal outcomes in his pyloric stenosis series, he noted that ‘‘these failures, as failures often do, can teach us a lesson.’’ Clearly, Dr McKechnie was following the principles set forth by Dr Haggard that surgeons of conscience should always be as mindful of their failures as they are of their successes. For all surgeons who want to truly appreciate their present-day craft, it is worthwhile to occasionally take time to peruse a truly old journal, such as those reviewed here. The writings of these long-dead authors give insight into their world, their challenges, and their contributions to surgical progress. It is clear that the NPSA founders were men of conscience and vision, who sought, as I hope we still seek today, to approach surgery more as a calling than a business and to strive for ever-better results by sharing their experiencesdboth good and baddwith each other, and through publication, with the medical world at large. This is their legacy and their lasting challenge to us, the present and future leaders of the NPSA. For a century, our organization has, I think, met that challenge well. I am confident that the founders’ vision will be sustained in the years ahead.
References 1. Medical colleges of the United States and Canada. JAMA 1913;67: 569–603. 2. Halsted WS. Partial occlusion of the thoracic and abdominal aortas. Ann Surg 1913;58:183–7. 3. McKechnie RE. Congenital hypertrophic pyloric stenosis. Can Med Assoc J 1913;3:566–71. 4. Rockey AE. Prostatectomy by a composite method. SGO 1913;16: 424–9. 5. Rockey A. Death from spinal anesthesia. JAMA 1913;67:422. 6. Torek W. First successful resection of the thoracic part of the esophagus for carcinoma. SGO 1913;16:614–7. 7. Stewart FT. 5 cases of suture of the heart. Ann Surg 1913;58:67–85.
