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Presidential Address
September 21, 2009

Influence of Endocrine Surgery on General Surgery and Surgical Science

Author Affiliations

Author Affiliation: Department of Surgery, University of California at San Francisco/Mount Zion Medical Center.

Arch Surg. 2009;144(9):800-805. doi:10.1001/archsurg.2009.159

As the 2009 president of the PCSA [Pacific Coast Surgical Association], I am honored to welcome you here today. In 1974, when I was a junior faculty member at UCSF [University of California at San Francisco], I was fortunate enough to attend my first meeting of this society on the island of Maui, Hawaii. Because of the enthusiastic friendship evident among its members and the outstanding quality of the scientific meeting, I knew immediately that this was a group to which I would want to belong. Today, the PCSA continues to represent an exemplary society of community and academic surgeons.

Orlo H. Clark, MD

Orlo H. Clark, MD

From a trade to a profession

As members of the PCSA, we have the honor to be respected as scientific surgeons, but in the history of Western medicine, the role of the surgeon was not always so highly valued. The question I would like to address is this: How did we progress from being barber surgeons to the scientific surgeons of today? Because of limited time, I will discuss the contributions of only 4 surgeons: Ambroise Paré (1510-1590), John Hunter (1728-1793), Emil Theodor Kocher (1841-1917), and William Stewart Halsted (1852-1922). These surgeons, and others, were responsible for the transition of surgery from a poorly respected trade to a highly valued profession. Paré, Hunter, Kocher, and Halsted were all anatomists as well as general surgeons who were particularly fascinated by surgical endocrinology even though the function of endocrine glands and internal secretions was unknown until the late 19th century. The work of these 4 surgeons contributed significantly to the development of endocrine surgery and the integration of surgical science and general surgery.

During the Middle Ages and early Renaissance in Western Europe, surgeons were criticized for what were considered crude technical skills and the occurrence of frequent mortality after surgical procedures. There was more faith in miraculous healing and in the power of the saints than in secular medicine.1(p145) The anatomy that was taught during this period was that of Galen from 200 AD and was generally not informed by human dissection.2(p103) In 1231, Emperor Frederic II of the Kingdom of Sicily established regulations for licensing the practice of medicine for both medical doctors and surgeons, including 5 years of study. Thus, in southern Europe, few differences existed in status between medical physicians and surgeons.3(p119)

In northern Europe, however, there was a hierarchy among medical physicians and even among surgeons. Medical physicians received a formal education and studied the classical languages, including Latin and Greek. They were taught medicine from the classical philosophy of Aristotle.4(p2,3) Even though they did not work with their hands, they directed the surgeons who performed the anatomical dissections. According to medical historian Victor Cornelius Medvei,2(p90) the first postmortem dissection performed to determine the cause of the plague was conducted by a medical physician from Cremona, Italy, in 1288, and the first public dissection occurred in 1300 in Bologna, Italy.

Although surgeons generally learned their trade through an apprentice system, in 1210 the College of St Cosmas was established in Paris for the purpose of surgical education.3(p119) Those surgeons who received some formal education wore long coats to distinguish themselves from the barber surgeons who wore the more practical short coats. Generally excluded from a university education, barber surgeons could not read Latin or Greek and were considered ignorant by both the medical physicians and the surgeons of St Cosmas.3(p119) In fact, during the early 16th century, the surgeons of St Cosmas agreed to concede preference in status to the medical physicians and helped to unify forces against the barber surgeons. The barber surgeons learned their trade by observing the living body rather than reviewing ancient documents and provided more services to the people than their more prestigious colleagues since they drained abscesses, stabilized fractures, and performed venesections and other useful procedures. One can only imagine the difficult situations these barber surgeons had, having primitive instruments and no knowledge of bacteriology or infections.

Ambroise paré

The famous Renaissance surgeon Ambroise Paré was the first to significantly improve surgical science and surgical care. Born to a working class family in a village in France in 1510, Paré was a contemporary of the theologians Erasmus, Luther, Knox, and Calvin; the artists Raphael and Titian; and the medical reformers Paracelsus and Vesalius.5(px) Paré is recognized by many as having done more than any surgeon of his time to elevate the status of the surgical profession to one of dignity and esteem.5(pix) After receiving little formal education, Paré began an apprenticeship as a barber surgeon with his older brother, who was a master surgeon in Vitre, France.5(px) At age 22, Paré left the provinces for Paris and studied at the Hôtel-Dieu, the only public hospital in Paris at the time. He worked in Paris until 1536, when he joined the military service, probably for economic reasons.6

During the 16th century, military surgeons were usually unavailable to members of the infantry, but some officers hired barber surgeons for their personal care. These barber surgeons, however, were free to treat other wounded soldiers if their employer did not need their services.6 As the barber surgeon for Marshal Montejan, colonel-general of the French infantry, during an invasion into northern Italy against Charles V, Paré cared for many wounded infantry men and learned about the treatment of fractures, gunshot wounds, amputations, and other related injuries.5(pxii) At this time, gunshot wounds were traditionally treated by pouring boiling oil on the wound to counteract the suspected “venomous nature” of the wound in a procedure advocated at least 500 years earlier by Avicenna (980-1037), “the Prince of Physicians” from Egypt who had “advanced the doctrine that cautery should be used instead of the knife.”2(p97) During one battle, Paré had to treat so many wounded infantry men that he did not have enough heated oil and, therefore, began applying “a digestive of yokes [sic] of eggs, oil of roses and turpentine.”1(p225) Surprised when he subsequently observed a more favorable outcome in the wounded infantry men who had not received the traditional therapy of heated oil, Paré reported these results in clear defiance of customary practice. His observations and conclusions illustrate the importance of evidence-based rather than a priori practices in surgical science.

In 1541, after returning to Paris, he resumed his anatomical studies. Paré passed his examinations for admission to the community of barber surgeons and became a surgeon to the French court. As a military surgeon, Paré would most likely have relied on texts such as those by Guy de Chauliac (1300-1368), an authority on surgery in the 14th and 15th centuries, who was keenly aware of the importance of anatomy, and Jean de Vigo (1460-1520), physician to Pope Julius II, who, like Avicenna, wrote that gunshot wounds were poisoned and needed to be treated with boiling oil.1(p225) Although Paré knew no Latin, as a keen observer, he challenged such beliefs. In 1552, Paré accompanied the Vicomte de Rohan (Rene I Rowland Morgan) to Germany, where he “gained new fame as ‘the charitable surgeon’ by taking the trouble to save lives of common soldiers who would ordinarily have their throats cut by their comrades to save them from a worse fate.”1(p225) It has often been stated that “Paré was worth the equivalent of 10,000 soldiers on the battlefield as the men knew their chances of survival were greatest if he was present.”6

Because of his stellar reputation, Paré became a member of the College of St Cosmas in 1554 and was later appointed surgeon by 4 kings of France.5(p23,24) He was criticized, however, by the jealous members of the Faculty of Paris both because of his lack of a formal education and because of the barber surgeon's encroachment on their “medical territory” that represented a threat to the organized structure of the medical profession at that time. Ironically, in many ways, his position as a barber surgeon enabled Paré and other barber surgeons to perform more useful tasks and help more patients. Noticeably confident, he criticized the “strolling surgeons” who frequently had to leave town quickly after a failed operation and advised them that it was unnecessary to castrate a patient to perform a successful hernia operation.7

In the yet undiscovered field of endocrinology, Paré was interested in endocrine abnormalities and “monsters” such as children born with ambiguous genitalia.2(p112) According to Aristotle, monsters were persons who differed remarkably in appearance from their parents, and many recommended that they should be eliminated.3(p189) Paré was more tolerant, however, and wrote that “in essence that which is not harmful to others is not subject to harsh moral judgment.”8(p42) In his essays, Paré reported several instances of apparent sexual ambiguity and was fascinated by virilism and amenorrhea. He writes that “‘some women, having lost their monthly flow, or having never had them degenerate into a male type and are called masculine women, because they are robust, aggressive and arrogant and have a man's voice and become hairy and develop beards; because the blood they (normally) lose every month is retained.’”4(p46) Paré's astute observations of such endocrine abnormalities helped establish the importance of empirical science over traditional learning and were prescient for his time. He demonstrated that observation and original thinking are necessary for effective surgical science.

Although Paré was a superb observer, he incorrectly thought a patient with exophthalmic goiter had an aneurysm of the neck, probably because of the associated bruit and thrill.9 In the second edition of his anatomy text titled Anatomie Universelle de Corps Humain, published in 1561, Paré considered the pancreas and adrenal glands as tissue cushions that were present to protect the adjacent structures and vessels from injury.2(p112) This erroneous idea continued through the mid–17th century, when Sir Thomas Wharton (1614-1673) first used the word thyroid for the thyroid gland and stated that the thyroid “contributes much to the rotundity and beauty of the neck, filling up the vacant space around the larynx and making its protuberant parts almost to subside and become smooth, particularly in females, to whom for this reason a large gland has been assigned, which renders their necks more even and beautiful.”2(p113)

Paré published more than 20 articles on anatomy and wrote several books, including a translation of the 1543 publication of Vesalius' De Fabrica. This made it available to other surgeons in the vernacular, thus enabling surgery to evolve beyond the dependence on earlier authorities, such as Aristotle and Galen. He suggested that the “5 duties” of a surgeon were “to remove the superfluous, to restore what has been dislocated, to separate what has grown together, to reunite what has been divided, [and] to redress the defects of nature.”2(p130) Paré had a profound impact on both medicine and surgery throughout Europe. His most important contributions to the field of general surgery were the demonstration of the detrimental effects of treating gunshot wounds with boiling oil, the value of ligating arteries and veins during amputation, and podalic version, that is, turning a baby in the womb to facilitate a feet-first delivery, first described more than 10 centuries earlier by Soranus of Ephesus (98-138 AD).2(p112) His strong personality, independent thinking, and keen observations led to the emancipation of surgery from centuries of theory and dogma. His commonsense approach to surgery and his clinical practices continued until the time of John Hunter 200 years later.

John hunter

John Hunter (1728-1793) was born in Scotland, the youngest of 10 children. Although he was known to lack seriousness as a student and, according to his sister Dorothy, he “‘would do nothing but what he liked and neither liked to be taught reading nor writing nor any kind of learning,’ he was ‘by no means considered . . . a stupid boy.’”3(p188) He made such little progress with his lessons, however, that at age 13 he abandoned his formal education, an act that resulted in considerable family disappointment. Rather than reading the reviews of others, Hunter preferred to examine situations and information with his own eyes.3 Like Paré, Hunter was fortunate to have an older brother who was a barber surgeon. William Hunter, who was better educated and a superior anatomist and surgeon, founded the Covent Garden Anatomy School in London. In 1746, John joined his brother as his student and eventual associate at the school. John Hunter's strong will and predilection for independent decisions proved valuable in his study of anatomy. Although human dissection had become permissible in Europe after the death of Emperor Fredrick II in 1240,10(p74) it was still difficult to obtain bodies for anatomical dissection, and, thus, grave robbing was a common practice in Hunter's time. Hunter helped his brother in this endeavor. Hunter's most famous grave robbery was that of the body of the Irish Giant Charles Byrne, who was 8 ft 2 in tall. Byrne's skeleton can be seen in the Hunterian Museum at the Royal College of Surgeons.

In 1749, Hunter began his anatomy and surgical training in London with William Cheselden (1688-1752) at the Royal Hospital, Chelsea, subsequently trained with Sir Percival Pott (1714-1788) at St Bartholomew's in London, and in 1754 became a student at St George's Hospital, also in London. In 1761, he served as an army surgeon in the Belle Île campaign south of Brittany and in 1762 in Portugal with the British Army.10(pp16,17) At the time of these military campaigns, Hunter's contemporaries considered infection an unavoidable stage of healing. Hunter, however, proposed that “suppuration may be considered a resolution but it is a mode of resolution which we mainly wish to avoid.”2(p93) During this period, Hunter wrote his first article on the descent of the testicle and on congenital hernias.2(p758) In 1767, he was elected to Britain's most prestigious scientific body, The Royal Society, and began his experiments on venereal diseases. One year later, he received his diploma from the Company of Surgeons and became a surgeon at St George’s. Publishing his first major work, The Natural History of the Human Teeth, in 1771, Hunter began giving lectures in surgery, anatomy, and physiology in 1773. In 1786, he wrote Treatise on the Venereal Disease, Observations on Certain Parts of the Animal Economy, and, subsequently, A Treatise on Blood, Inflammation, and Gunshot Wounds. Hunter established the principle of high ligation of aneurysms that saved numerous limbs and lives.1(p346) His students included Edward Jenner, who introduced smallpox vaccinations; Astley Cooper, a pioneer in the surgical treatment of vascular aneurysms; and John Abernethy (1764-1831), Hunter's immediate successor in London.1(p348)

Among Hunter's discoveries in endocrinology was the problem of the freemartin that occurs when a cow delivers twin male and female calves, a phenomenon documented in his 1779 publication “Account of the Free Martin” in Philosophical Transactions of the Royal Society.10(pp282-330) The word freemartin comes from the word ferry, a cow that is not in milk, and from the word martin, a barren animal that is killed for food on Martinmas.2 Because of his interest in this phenomenon, Hunter dissected 3 such animals and was the first to report that in the case of a freemartin, the male calf is normal but the female calf is a hermaphrodite with both male and female reproductive organs.10(p204)

At this time, the generally accepted doctrine was that all species were created with a fixed and never-changing sexual state. Hunter's experiments suggested to the contrary that “every animal and every part of every animal possessed an innate propensity to malformation” and that “each part of each species seems to have its monstrous form originally impressed upon it.”10(p204) It was not until 1911, however, that Julius Tandler and Karl Keller explained that freemartins occur only when the female twin shares a common placental circulation with her male sibling.11 The changes that occur are due to the exposure of the female twin to testosterone despite the absence of a Y chromosome.2(p201) Nevertheless, Hunter's defiance of accepted views on sexual identity paved the way for more advanced discoveries, including those made by Charles Darwin in the 19th century.

Hunter's curiosity about hermaphroditism may have derived from his interest in the transplantation of human testes documented in his book The Natural History of Human Teeth (London, 1771).10(p201) He was “especially interested in the power of the union of the transplant and tissue into which it was grafted.”10(p201) Reporting that a cock's testicle could be transplanted into the abdomen of a hen, he considered the effects of such transplantation on secondary sex characteristics and provided the first accounts of the importance of the testes for maintaining the seminal vesicles, the prostate, and Cowper's gland.12 In related experiments, he demonstrated that only 1 testicle was necessary to maintain normal sexual function and that castration prevented the regrowth of antlers in a stag. Although theories on the effects of castration on animals and man were generally accepted since the time of Aristotle, the mechanism for the changed appearance was unknown. Hunter performed his experiments to determine the “properties of the vital principle.”10(p201) The original preparation of a tooth transplanted into the cock's comb and the cock's testis transplanted to the abdomen of a hen can be seen today at the Hunterian Museum.

Many surgeons and historians were and still are surprised that Hunter was successful with his transplantation experiments because he had no knowledge of bacteriology or immunologic rejection.2(p204) Hunter's testicular experiments and his curiosity about transplantation lend support to the claim that he was an important early experimental endocrinologist. Arnold A. Berthold (1803-1861), who autotransplanted a testis in a rooster, however, was the first to suggest that the testis maintained secondary sex characteristics by acting through the blood.12 Hunter may not have suspected a circulating factor because he was aware of hermaphrodites having both male and female sexual organs in the same animal. He knew that in rare cases, birds had male plumage on one side and female on the other.2(p204) These observations would be hard to explain by a circulation factor or internal secretion.

Medical historian Fielding H. Garrison states, “It is no exaggeration to repeat that Hunter found surgery a mechanical art and left it an experimental science.”1(p347) What he did for the social status of the surgeon is indicated by the remark of one of his colleagues: “He alone made us gentlemen.”2(p204) When his former student Jenner asked him a question about an experiment on a hedgehog, Hunter replied, “But why do you ask me a question by the way of solving it? I think your solution is just; but why think? Why not try the experiment?”1(p347) Because of his numerous original experiments and anatomical dissections, Hunter is considered “the founder of experimental and surgical pathology as well as a pioneer in comparative physiology, dentistry, endocrinology, and experimental morphology.”1(p346) His experiments in the still-unidentified fields of endocrinology and endocrine surgery were an essential aspect of his contributions to general surgery and surgical science.

At the end of the 18th century, despite the dramatic advances made by Paré, Hunter, and many others, surgery remained a relatively primitive and certainly a dangerous specialty within medicine. Only with the advent of general anesthesia, including nitrous oxide, ether, and chloroform, during the mid–19th century did surgery become acceptable for patients and surgeons. The discovery and subsequent acceptance of antisepsis by Joseph Lister in 1867 significantly decreased the mortality caused by infections after operations. Improved hemostatic forceps, lighting, and other equipment, as well as increased knowledge and experience, also led to more positive operative results. Prior to 1850, about 70 thyroid operations had been performed, with a mortality rate of 41%.13 The famous Swiss surgeon Theodore Billroth (1829-1849) reported the same mortality rate in the mid–19th century and, therefore, discontinued thyroid operations for a 10-year period.14 Numerous other prominent surgeons at this time, including Robert Liston (1794-1843) from London, Johann Dieffenbach (1792-1847) from Berlin, and Samuel Gross (1805-1884) from Philadelphia, strongly recommended against thyroidectomy. In 1850, the French Academy of Medicine condemned thyroid operations.15(p28) Despite these recommendations, the use of general anesthesia and antiseptic techniques made thyroid and other operative procedures safer. Nevertheless the function of the thyroid gland remained unknown until the discoveries made by Emil Theodor Kocher.

Emil theodor kocher

Emil Theodor Kocher (1841-1917) was born in Bern, Switzerland, about 100 years after John Hunter. In contrast to Paré and Hunter, Kocher excelled in his studies and received his medical degree summa cum laude from the University of Bern. On graduation, he spent a year visiting clinics in England with Sir Robert Hutchinson, Sir James Paget, and Sir Thomas Spencer Wells after he was apparently refused a position as a surgical assistant by the leader of German surgery Bernhard von Langenbeck (1810-1887) and by the founder of cellular pathology Rudolf Virchow (1821-1902) because their academic positions were restricted to Germans.15(p27) In 1872, at the age of 31, Kocher became professor of surgery at the University of Bern.15(p27)

During his first 10 years at Bern, Kocher did 101 thyroid operations with a mortality rate of 12.8%.13 By 1889, his operative mortality for thyroid operations decreased to 2.4% and for benign goiters to about 1%. In 1895, he described more than 1000 patients who had thyroid operations. Only one of those patients, who had a thyroid carcinoma removed, developed tetany.16 Kocher recommended exposing the recurrent laryngeal nerves during thyroid operations and reported rare postoperative hoarseness, in contrast to the 14% recurrent laryngeal nerve injury reported by others at this time.16(pp2-11) Certainly, Kocher's low complication rate attests to his superior technical skills and would be difficult to repeat today.

In 1883, at the German Surgical Congress, Kocher reported the postoperative course of his patient Marie Bichsel, an 11-year-old girl who had had a total thyroidectomy for Graves disease. Following her operation, Kocher reported that the referring physician wrote that “‘the girl had undergone a marked change in personality. Indeed, he finally informed me that she had become quite cretinoid.’”13 Aware that the surgeon Jacques-Louis Reverdin (1842-1929) of Geneva, Switzerland, had previously noted that 2 of his patients also suffered from decreased mental capacity after thyroidectomy, Kocher examined 18 of his patients who had been treated by total thyroidectomy. Sixteen of 18 had adverse mental and physical changes comparable to those found in cretins. The 2 patients who did not manifest such changes had remnant thyroid tissue in the pyramidal lobe. He also noted that younger patients developed more noticeable changes after total thyroidectomy and that patients treated by subtotal or partial thyroidectomy did not become cretinoid.

Because of his findings, Kocher recommended against total thyroidectomy for benign thyroid disease. Further experiments by Kocher's contemporaries confirmed that the thyroid is essential for life. For example, Moritz Schiff (1823-1896) subsequently reported in 1884 that total thyroidectomy was fatal in dogs and could be prevented by previous autotransplantation of thyroid tissue.17 In 1891, these experiments and similar experiments on monkeys by Sir Victor Horsley (1857-1916) encouraged George Murray (1865-1939) from Newcastle upon Tyne, a previous student of Horsley, to inject sheep thyroid in a 46-year-old woman with myxedema. This treatment resulted in her dramatic improvement, and she remained well for 28 years. The following year, Edward Fox (1859-1938) of Plymouth, England, demonstrated that similar good results could be obtained by eating “‘half a sheep's thyroid, lightly fried and taken with current jelly once a week.’”1(p695) This was the first demonstration of successful organotherapy.

Kocher was a general surgeon with a special interest in thyroid surgery. He described operations for inguinal hernias and carcinoma of the rectum, for mobilizing the duodenum (Kocher maneuver), and for reducing shoulder dislocations.17 His textbook Chirurgische Operations-lehre (Operative Surgery), published in 1892, not only included methods that he had used successfully but also served as a standard reference for a generation of surgeons.15(p27) He helped establish that surgery should be based on sound pathophysiology. He improved the technique of thyroidectomy and other operations and documented that gentle and meticulous technique without appreciable blood loss was both indicated and possible. He demonstrated the importance of ligation of the thyroid arteries prior to thyroid lobectomy. He invented many new surgical instruments and helped educate many visiting surgeons from around the world. In 1909, Kocher received the Nobel Prize in medicine and physiology in recognition of “his work in physiology, pathology and surgery of the thyroid gland.”14(p495) He was the first and only surgeon to receive the Nobel Prize for clinical discovery and technical excellence.13 Perhaps his most important contribution to the discipline of surgery, however, was his ability to draw conclusions from the adverse effects of total thyroidectomy because it established a model for inductive thinking in surgical science. This ability was especially evident when he documented that cachexia myxedema develops after total thyroidectomy and that the thyroid gland is, therefore, necessary for life. Kocher's influence continued to reverberate after his death and is especially evident in the achievements of the American surgeon William Halsted.

William stewart halsted

William Stewart Halsted (1852-1922) was born to a middle class family in Long Island, New York. Despite his reputation as a talented athlete but mediocre student, he studied at Yale and entered Columbia University College of Physicians and Surgeons in 1874.15(p33) He subsequently spent 18 months at Bellevue and New York hospitals, followed by 2 years in Austria, Switzerland, and Germany, where he attended lectures and became aware of the European systems of graduate medical education.15(p33) After Halsted returned to New York City, he joined the faculty at Columbia University's College of Physicians and Surgeons as an instructor of anatomy and later joined the faculty of The Johns Hopkins Medical Center in Baltimore, Maryland. At Johns Hopkins, he worked in the research laboratory of Dr William H. Welch, chair of pathology. During this period, Halsted investigated the treatment of aortic aneurysms, perfected the procedure of radical mastectomy for breast cancer, developed the Halsted operation for hernia repair, and performed important physiologic studies on the thyroid and parathyroid glands.

As a general surgeon with a strong interest in the thyroid gland, Halsted adopted his friend and mentor Kocher's technique for thyroid operations and stated,“‘The extirpation of the thyroid gland for goiter typifies, perhaps better than any other operation, the supreme triumph of the surgeon's art.’”14(p493) Halsted was also interested in the autotransplantation of parathyroid and thyroid glands. In 1909, before the function of these glands was known, Halsted and Herbert Evans studied the blood supply to the parathyroid glands using a variety of dyes.3(p531) Their description of the anatomy of the blood supply to the human parathyroid glands remains accurate today. In 1909, Halsted demonstrated that tetany would occur when an autotransplanted parathyroid was removed, helping to establish the function of these glands.18 In addition to making these significant discoveries, Halsted is remembered for his book The Operative Story of Goiter and for his mentorship of numerous outstanding surgeons, including Harvey Cushing, the father of neurosurgery and neuroendocrinology.

As chairs of the departments of medicine and surgery at Johns Hopkins, William Osler and William Halsted were responsible for introducing a training program with gradual increasing responsibility for resident education. Halsted initially modeled his residency program after the European systems. Osler, Halsted, and Welch received grants from the John D. Rockefeller Foundation. It seems that after reading Osler's textbook The Principles and Practice of Medicine, Rockefeller's advisor, the Baptist minister Frederick Bates, “was shocked to learn how few medical diseases could be treated”3(p531) and, therefore, encouraged the Rockefeller Foundation to award grants to Osler, Halsted, and Welch for research. This funding helped established full-time academic chairs that freed these academic leaders from their previous demanding clinical responsibilities. This academic model proved to be successful and coincided with a seminal change in attitude toward surgical science as a valid discipline and as an institutional mechanism for linking research and surgical practice. The 20th century saw a continued sloughing off of the crude image of the barber surgeon by wedding academic research to clinical practice, a marriage we still uphold today in our academic medical centers.

Like Paré, Hunter, and Kocher, Halsted will also be remembered for his creative thinking in the field of general surgery and his contribution to scientific research and clinical training. As endocrinology and general surgery with an endocrine focus became established fields at major American medical centers, other prominent surgeons in the United States built their reputations and their institutions' success on their expertise in thyroid and, subsequently, parathyroid surgery. The list includes Charles Mayo at the Mayo Clinic, George Crile at the Cleveland Clinic, Frank Lahey at the Lahey Clinic, Oliver Cope at Massachusetts General Hospital, and Leon Goldman at UCSF.

Surgery today

As surgeons, we have the opportunity to help our patients according to the most up-to-date surgical techniques and the most advanced discoveries in the laboratory. We and, therefore, our patients benefit significantly from the integration of research and surgery, from respect for and pursuit of surgical science. We owe much to our mentors, who were not afraid to take risks and challenge accepted beliefs even in the face of jealousy and skepticism from their peers. These surgeons laid the foundation for the scientific knowledge we have in the discipline of surgery today. These 4 surgeons whose contributions to surgical science I have discussed all expressed an interest in endocrinology even before the function of the traditional endocrine glands was fully understood. Their astute observations and early practice of evidence-based medicine led to discoveries that were essential for the knowledge we have today that most organs in the body, such as the heart, kidney, liver, gastrointestinal tract, and bone, also secrete hormones.

Crucial decisions must be made before, during, and after surgical operations. Thus, we must continue to ask how we can improve the care we are providing. Questioning established practices and applying new technology and solving clinical problems are essential for further advances in surgery and medicine. Like Paré, Hunter, Kocher, and Halsted, we must ask critical questions and try to establish informed answers. Our current market-driven economy that demands fiscal efficiency threatens to undermine the delicate balance between basic science research and clinical practice. As leaders in surgery, we must, nevertheless, persevere in our efforts to think beyond the boundaries of the clinic, the operating room, and the billing office so that surgical science continues to advance and inform the procedures of the future.

Correspondence: Orlo H. Clark, MD, Department of Surgery, University of California at San Francisco/Mount Zion Medical Center, 1600 Divisadero St, Hellman Bldg, Room 347, San Francisco, CA 94115 (orlo.clark@ucsfmedctr.org).

Accepted for Publication: May 12, 2009.

Financial Disclosure: None reported.

Previous Presentation: This address was presented at the 80th Annual Meeting of the Pacific Coast Surgical Association; February 14, 2009; San Francisco, California.

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