Ernest Amory Codman, MD, 1869–1940
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- Brand, R.A. Clin Orthop Relat Res (2009) 467: 2763. doi:10.1007/s11999-009-1047-8
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This biographical sketch on Ernest Amory Codman corresponds to the historic text, The Classic: The Registry of Bone Sarcomas as an Example of the End-Result Idea in Hospital Organization, available at DOI 10.1007/s11999-009-1048-7 and The Classic: Registry of Bone Sarcoma: Part I.—Twenty-Five Criteria for Establishing the Diagnosis of Osteogenic Sarcoma. Part II.—Thirteen Registered Cases of “Five Year Cures” Analyzed According to These Criteria, available at DOI 10.1007/s11999-009-1049-6.
God bless you! I suppose I should hate you if I lived in the same town, but my feeling, being remote, is quite other. Indeed the very enemies who lurk in second story windows with muffled rifles are waiting your passing, are the ones who take off their hats in deepest respect as your cold, but beautiful, corpse is carried away” .
Codman published over 100 papers and books. Perhaps in addition to his works on tumors the best known are his contributions to the shoulder. He also has considerable eponymic fame : “Codman’s tumor,” “Codman’s triangle,” “Codman’s exercises,” “Codman’s sign,” “Codman’s paradox,” “Codman’s bursa.”
Mallon carefully documented a meeting at the Boston Medical Library in 1915 : “But if one single night can effectively ruin a surgeon’s career, it is likely that this happened to Codman on a Boston winter’s eve in 1915.” The issue was hospital efficiency. Codman apparently spoke only briefly at that several hour meeting, but “nobody remembers a word said that day other than those brief few spoken by Codman.” Stories appear in the Boston Post and the Boston Daily Globe: “Cartoon Raises Surgeon’s Ire: Dr. Codman Stirs Up Medical Society” read a headline in response to a controversial cartoon Codman showed of an ostrich burying his head in the sand and with derogatory remarks. The Suffolk Medical Society requested his resignation, and he complied, resigning from the Surgical Section of the Society.
Codman’s idea of the End Result developed between 1902, when he published his first attempt to analyze end results in the literature, and 1910, when he wrote, “From the day in the summer of 1910 on which Dr. Edward Martin of Philadelphia and I drove back to London in a hansom cab from the Tuberculosis Sanitarium at Friml[e]y this End Result Idea has taken the major share of my intellectual efforts.”
Closely related to his idea of an End Result System, Codman developed the first registry. In two papers we republish here [1, 2], Codman described a way to follow patients nationally. His registry on bone sarcoma became practical in 1920 with a gift of $1000 from the family of a patient. Subsequently he was sufficiently persuasive as to obtain over $8000 from the American College of Surgeons. He was not altogether as successful in encouraging his colleagues to contribute to the registry. In 1924 he commented, “I want to see the American College of Surgeons as a pack of hounds on Bone Sarcoma, each baying when he finds a case and bringing it to the attention of the pathologists of the country” . But, “In three years the Registry has only found five five-year cures of true osteogenic sarcoma by amputation.” By 1926 he had solicited only 17 cases from an organization of over 7000 members  despite multiple solicitations. But, in addition to the chief purpose of the registry (to answer key questions about the treatment), he noted a number of “by-products,” one of which was a “more or less acceptable standard classification.” (Diagnostic criteria for osteogenic sarcoma were far from clear and in citing an earlier study  Codman noted that of 148 cases referred for bone sarcoma, only 68 could be confirmed as “malignant newgrowth of bony origin.”) Codman himself then proposed 25 clinical, radiographic, and histologic diagnostic criteria.
The concept of a registry is now well developed in a number of industrialized countries (mostly but not entirely related to joint arthroplasty), although never successful in the United States for mostly political and economic reasons. It is fair to say, however, that Codman was far ahead of his time. His concept of the End Result is certainly the forerunner of today’s “evidence-based medicine.” His reasoning for establishing registries is as cogent today as then, and if the philosophical and emotional objections to his ideas are less 100 years later, we still lack the political will to institute such registries in the United States. The importance of his ideas cannot be overemphasized.