Reflections on gastrointestinal surgery

Reflections on gastrointestinal surgery

PRESIDENTIAL ADDRESS R. Scott Jones, MD, Charlottesville, Virginia Serving as president of the Society for Surgery of the Alimentary Tract is witho...

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PRESIDENTIAL ADDRESS

R. Scott Jones, MD, Charlottesville,

Virginia

Serving as president of the Society for Surgery of the Alimentary Tract is without doubt the greatest honor of my professional life, and I shall always remain grateful to the membership for this uniquely distinctive honor and privilege. Many subjects are suitable for this presentation today; issues such as advancing technology, challenges in surgical education, the fragmentation of general surgery, the cost of health care, and the crisis in funding of biomedical research are crucial to our Society. Because these important subjects have been and will be discussed herein and elsewhere, I set them aside for a topic that for me is more pleasant. Instead, I prefer to use this opportunity to honor and express my respect and gratitude to several of my former teachers and mentors. Each of these individuals made important contributions to research, patient care, and education relevant to patients with digestive diseases. In addition, they contributed significantly to the programs or to the leadership of the Society for Surgery of the Alimentary Tract, the American Gastroenterological Association, or both. Edgar J. Poth, MD, PhD: Edgar Poth is currently the Ashbel Smith Professor of Surgery at the University of Texas Medical Branch. He was born on February 1,1899, in Seguin, Texas. At the University of Texas in Austin, he earned a BS degree in chemistry and physics during a 3 year period with election into Phi Beta Kappa. After receiving an MS degree in organic chemistry and bacteriology, he moved to the West Coast to obtain a PhD degree in physical chemistry and physics from the University of California at Berkeley. After serving 1 year as instructor in chemistry at Berkeley, he entered the Johns Hopkins University From the Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia. Requests f& reprints should be addressed to R. Scott Jones, MD, BOX 161. Department of Surgery. University of Virginia Medical Center, Charlottesvllle, Virginia 22906. Presented at the 26th Annual Meeting of the Society for Surgery of the Alimentary Tract. New York, New York, May 14-15. 1965.

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School of Medicine to obtain his MD degree. Following his undergraduate medical education, he moved to Stanford University for surgical training. During his residency, he developed research interests that he pursued for the next 40 years. After serving 1 year as chairman of the department of surgery at the University of Arkansas, he returned to Johns Hopkins to pursue his research interests. In 1942, Dr. Poth was appointed associate professor of surgery at the University of Texas Medical Branch, and the following year, he was promoted to the rank of professor. He has worked at the Medical Branch from that time up until this day. Dr. Poth made several contributions to surgery, including studies on the pathophysiologic characteristics and treatment of peptic ulcer; he improved the techniques of total gastrectomy and devised a substitute gastric pouch, and he also made original contributions to the understanding of control of pancreatic and gastric secretion. Dr. Poth is best recognized for his work in intestinal antisepsis. While on the faculty at Hopkins, he pioneered investigations that culminated in the application of sulfa drugs for intestinal antisepsis. After early work proved several agents to be unsuitable for bowel preparation, Dr. Poth began studies on succinylsulfathiazole. Animal studies revealed that this agent reduced colonic flora and was poorly absorbed. His subsequent rigorous clinical investigations, that confirmed in human subjects the previous experimental findings, led to the introduction of the agent, succinylsulfathiazole, and the concept of antimicrobial bowel preparation into clinical practice. A few years later, after the isolation of neomycin, Dr. Poth investigated that agent for its utility in intestinal antisepsis. He found it to be effective in reducing bowel flora, relatively poorly absorbed after oral administration, safe, and ideally suited for antimicrobial bowel preparation. We now know from careful scientific studies that the practice of antimicrobial bowel preparation clearly reduces the morbidity and mortality of colon surgery. Dr. Poth was a pioneer of this concept and of its practice.

The Amertcan Journal of Surgery

Presidential Address

It was my privilege to study under Dr. Poth as a student and subsequently to serve as his intern for 5 months. Dr. Poth is a scholar possessing independence of thought, steadfast dedication to scientific principles, and an inquiring, critical mind. His clinical practice was characterized by careful planning, strict attention to detail, and a sense of discipline. Jonathan Evans Rhoads, MD: In 1962, I was accepted into the surgical residency at the Hospital of the University of Pennsylvania. Jonathan Evans Rhoads was then John Rhea Barton Professor and chairman of the department of surgery. Jonathan Rhoads, a Philadelphia Quaker, was born on May 9,1967. He graduated Phi Beta Kappa from Haverford College and went on to attend the Johns Hopkins University School of Medicine, where he was elected to Alpha Omega Alpha. Upon graduation from medical school, he returned to his home city of Philadelphia to the Hospital of the University of Pennsylvania, where he began and completed his surgical training. He was chief resident in surgery in 1939. Dr. Rhoads began his academic career with the appointment of associate in surgery but steadily rose through the ranks in the department of surgery at the University of Pennsylvania to earn the title of professor of surgery in 1949. During his entire career on the faculty at the University of Pennsylvania, Dr. Rhoads made important contributions to the programs of the Graduate Hospital, the Children’s Hospital, and in the Harrison Department of Surgical Research. From 1956 through 1959, Dr. Rhoads served as the provost of the University of Pennsylvania. In 1959, he was appointed John Rhea Barton Professor of Surgery and chairman of the department of surgery, a post he held for the next 13 years. Subsequent to that, he was director of the department of surgery at the Pennsylvania Hospital from 1972 through 1974. Dr. Rhoads’s contributions to his profession, to his community, and to his country are too numerous to describe in detail, so we shall have to emphasize the highlights. Dr. Rhoads has occupied many editorial positions, probably the most significant of which was his chairmanship of the editorial board of the Annals of Surgery. He has supported numerous societies with his membership, his time, and his talents. I will relate to you those societies that he has served as president or executive officer. They include the American College of Surgeons, the American Philosophical Society, the American Surgical Association, the Association of American Medical Colleges, the College of Physicians of Philadelphia, the Council of Medical Specialty Societies, the International Federation of Surgical Colleges, the International Surgical Group, the Philadelphia Academy of Surgery, the Society of Clinical Surgery, and the Society of Surgical Chairmen. You will see that he was not only one of the earliest members of the Society

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for Surgery of the Alimentary Tract, but he served as our president in 1968. He continues to make important contributions to the society, including his Founder’s Lecture at last year’s meeting. Another of Dr. Rhoads’s very significant contributions is Rhoads Textbook of Surgery, which is presently in its fifth edition. Many residents and students, including myself, have used this book as the standard text during surgical education and training. Dr. Rhoads’s trainees must be a source of pride and satisfaction to him. He has trained more than 65 surgeons, the majority of whom currently hold academic positions and themselves are contributing to surgical education and training. He has made many important observations, innovations, and discoveries in his scientific and clinical life. His very early bibliography reflects an interest in nutrition. In addition to his scientific interests in nutrition, his active clinical work stimulated many technical innovations. He pioneered the development of the abdominal perineal approach to the treatment of imperforate anus, and he perfected the two-team approach to the Miles operation. Parenthetically, it is interesting that he pioneered the development of peritoneal dialysis. His early bibliography reflects a record of original contributions that continued throughout his career, and it is his work and influence that are responsible for the current interest in and attention to nutrition in surgery and all other clinical disciplines. The significance of nutrition or malnutrition to clinical care was not only a part of Dr. Rhoads’s research, but it received day-to-day emphasis in the care of his patients. In 1962, he expressed his novel idea of providing intravenous nutrition by infusing 5 liters of dextrose and amino acid solution daily, while eliminating the infused fluid with diuretics. This “5 liter program,” as it was called, was promptly supplanted, however, by the use of the central venous catheter to allow infusion of hypertonic nutrient solution into a central vein. The animal experiments conducted by Stanley Dudrick and colleagues proved that this concept was both methodologically and physiologically sound, and that animals would grow and thrive when they received nutrients only through the vein. Subsequent work by Dudrick, Rhoads, and coworkers proved the practical clinical application of intravenous hyperalimentation. Thus, Dr. Dudrick and his mentor, Dr. Rhoads, established a clinical tool that is as important and significant for patient care as any advanced in the last three decades. The profession, of course, now recognizes Dr. Rhoads’s role in the development of intravenous nutrition, which he and his younger colleagues and students, particularly Stanley Dudrick, conceived and implemented for the first time at the Hospital of the University of Pennsylvania.

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As a professor Dr. Rhoads is noted for his tireless energy and enthusiasm for surgical practice. He possesses an uncompromising commitment to excellence in every endeavor. From Dr. Rhoads, we all learned the lessons of attention to detail, dedication to hard work, and the real meaning of surgical discipline. He is a man of profound and reflective intellect. His record of community service and service to education is unequalled. In addition to his intellect and analytical mind, Dr. Rhoads possesses a remarkable wit and sense of humor. Frank P. Brooks, MD: While in training at the Hospital of the University of Pennsylvania in Philadelphia, I worked in the laboratory of Dr. Frank Brooks. During that time, Dr. Brooks was the chief of the gastroenterology section of the department of internal medicine, although his laboratory was in the department of physiology. Although Dr. Brooks is not a surgeon and is not a member of the Society for Surgery of the Alimentary Tract, he has made so many contributions to the understanding of gastrointestinal physiology and gastrointestinal disease that I must tell you about his accomplishments. Dr. Brooks was born on January 2,192O in Portsmouth, New Hampshire. He graduated from Dartmouth College and entered Dartmouth Medical School, which was then a 2 year school, and then received his MD degree from the University of Pennsylvania. He subsequently received the degree of Doctor of Medical Sciences from the University of Pennsylvania. After graduating from medical school, he interned at the University of Pennsylvania, and then completed training in radiology to become a board-certified radiologist. He did a gastrointestinal fellowship and an internal medicine fellowship at the Lahey Clinic in Boston, Massachusetts, then returned as a fellow in medicine at the Hospital of the University of Pennsylvania. Dr. Brooks then obtained a postdoctoral fellowship in physiology under Dr. J. Earl Thomas at the Thomas Jefferson Medical College in Philadelphia. He then returned to the full-time academic faculty of the Hospital of the University of Pennsylvania and proceeded to rise through the academic ranks to be appointed professor of medicine and professor of physiology in 1970. Dr. Brooks served as chief of the gastrointestinal section at the University of Pennsylvania from 1962 to 1974. He has held a leadership role in most of the national societies of internal medicine. He has also served on study sections, National Institutes of Health advisory councils, and panels for the National Academy of Sciences. He has served on the editorial boards of the American Journal of Physiology, the Proceedings in Experimental Biology and Medicine, and the American Journal of Digestive Diseases and is currently the editor of Digestive Diseases and Sciences. He was president of the

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American Gastroenterological Association from 1980 to 1981. Dr. Brooks has enjoyed a highly productive research career, and his most important work has involved first, the regulation of pancreatic secretion and second, the regulation of gastric secretion. Dr. Brooks’s work has contributed to increased understanding of the fundamental processes of pancreatic secretion of water and electrolytes, as well as pancreatic secretion of enzymes. Dr. Brooks and his associates performed several classic experiments that delineated the role of the central nervous system in the regulation of gastric secretion and correlated control of feeding behavior with control of acid secretion. In addition to his important original scientific work, Dr. Brooks has written 7 books and 35 book chapters. Dedication to teaching characterizes his career. He taught in the department of medicine while maintaining a heavy teaching commitment in physiology. Dr. Brooks’s fellows in the laboratory and clinic have always appreciated his enthusiasm for talking with them about their work and for advising them about their projects. He has maintained an active clinical practice and is an excellent clinician as well. Dr. Brooks is an outstanding teacher, scientist, and clinician. He has provided 30 years of dedicated leadership to gastroenterology and gastrointestinal physiology. It was a great privilege to work with Dr. Brooks in the department of physiology at the University of Pennsylvania. It provided a fine introduction to experimental work. I found Dr. Brooks to be an excellent example and an excellent teacher. He is truly a tireless worker not only in his scientific and clinical endeavors, but also in his service to professional organizations and the government. Morton I. Grossman, MD, PhD: Upon completion of my surgical residency at Penn in 1967, I obtained, largely because of the assistance and support of Dr. Frank Brooks, a fellowship to work in the laboratory of Morton I. Grossman at the Wadsworth Veterans Administration Hospital in Los Angeles. Morton I. Grossman was born to Russian immigrants in Massilon, Ohio in 1919 and was the youngest of three children. Because of his intellectual gifts and diligent work, he negotiated secondary school rapidly, entered the Ohio State University at age 16, and graduated in 1939. He then enrolled in the Ohio State University Medical School, where he stayed for 2 years, transferring to Northwestern University in Chicago in his third year. During that time, he decided to pursue a scientific career, and, in addition to a medical doctorate, he was awarded a PhD degree. At Northwestern, he worked with Professor A. C. Ivy, who was the leading gastrointestinal physiologist of that day. Two years after Dr. Grossman’s

The American Journal of Surgery

Presidential Address

graduation, the Ivy group moved to the University of Illinois, and in a short time, Dr. Grossman was appointed professor at the age of 32. Dr. Grossman served two assignments in the U.S. Army, one from 1944 to 1946, during which time he primarily performed induction examinations, and the other from 1951 to 1955, when he served largely in a research capacity. Although in the army he investigated nutrition and conditioning to cold weather, he also worked on the glucostatic theory of hunger and appetite and did extensive studies to determine the caloric content of various foods. He left the army in 1955 and went to the Wadsworth Veterans Administration Hospital, where he spent the remainder of his professional life. From 1955 to 1962, he served as chief of gastroenterology. Very clearly, however, his true love was research, and in 1962, he was appointed senior medical investigator, which permitted him to devote the remainder of his professional life to research. He did experience one period of administrative work in 1965. He briefly held the position of chairman of the department of physiology, but he resigned when he realized that it interfered with his research. In 1973, he became director of the Center for Ulcer Research and Education and embarked on what was probably the most productive period of his life. It is impossible to enumerate in a presentation such as this the significant contributions of Dr. Grossman. I will mention only a few. He was the driving and sustaining force of Gastroenterology for 35 years. His involvement with the journal began in 1943, when he served as assistant to the editor, who was A.C. Ivy. In 1957, he was appointed to the editorial board. In 1959, he was associate editor and for 5 years (1960 through 1965) served as editor in chief. From 1973 to 1978, he served as chairman of the editorial board. No other individual has contributed more to the standards of excellence and critical scientific and editorial policy than Dr. Grossman. Under his leadership and influence, Gastroenterology grew from its modest beginnings to become the recognized forum for excellent work in the field that it is today. Dr. Grossman served as the president of the American Gastroenterological Association in 1968. It is interesting that one of his wishes was that it become an open society, which it basically is today. In 1978, Dr. Grossman received the Friedenwald Medal of the American Gastroenterological Association. This of course is the highest honor that association can bestow upon any person. The award was presented to Dr. Grossman by his longstanding friend, collaborator, and colleague, R.A. Gregory. Also in 1978, Dr. Grossman presented the SSAT Distinguished Guest Lecture and was elected to honorary membership in the Society. Dr. Grossman left many legacies to gastroenterology, not the least of which being his 90 fellows. It is

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interesting that at least 14 of them became surgeons. Thirty of his fellows currently hold substantial academic positions. A review of Dr. Grossman’s publications is absolutely astonishing. He published 400 scientific articles, 134 editorials or letters, and 71 books or book chapters. Even those numbers do little to express the enormity of his work. His bibliography reveals clear scientific insight, clear writing, and unequalled precision of thought. He was a master of experimental design and the scientific method. His work on pancreatic secretion is classic. His first paper on gastrointestinal physiology described the adaptation of pancreatic enzyme secretion to the composition of the diet. He provided physiologic proof of gastrin’s regulation of gastric secretion and cholecystokinin’s regulation of pancreatic secretion. His work proved that gastrin was the agent responsible for the Zollinger-Ellison syndrome. His classic experiments proved the existence of local and long reflexes in regulating gastric acid secretion. He introduced and elaborated the concept of neurohumoral regulation of gastrointestinal secretion. He emphasized quantitative accuracy in gastrointestinal research and clarified the concept of potentiation in the regulation of gastrointestinal secretion. During the biochemical phase of the study of gastrointestinal hormones, he and his fellows extensively investigated the interactions of gastrointestinal hormones, which permitted the formulation of a receptor hypothesis that is currently of great value in gastrointestinal research. When I reflect upon Dr. Grossman, the things that come to my mind are his vast knowledge of physiology, his keen intellect, and his remarkable interpersonal sensitivity. He was an early-morning person; he was in the lab before anyone else in the morning and was readily available to his fellows each and every day. He communicated not only through speech, but also through notes and handwritten annotations in the margins of manuscripts and elsewhere. He would not tolerate fuzzy thinking or fuzzy expression. The scientific method was his code of existence and revealing the truth was his life’s work. Dr. Grossman’s unit was clearly the hub of scientific thought concerning regulation of gastrointestinal secretion during the time from 1960 to 1980. His death from carcinoma of the esophagus on May 26,198l was an irreplaceable loss to science, to the medical profession, and to humanity. J. Englebert Dunphy, MD: Upon completion of the gastrointestinal fellowship with Morton Grossman, it was my good fortune that the chief of surgery, Dr. Al Hall, offered me a position at the San Francisco Veterans Administration Hospital. At that time, Dr. Marvin Sleisinger had just become chief of medicine at the San Francisco Veterans Administration Hospital. Research and clinical programs in gastrointestinal diseases were developing

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rapidly, and there was great enthusiasm in the surgical and medical faculties. As a result of this, my first academic appointment was at the University of California, San Francisco, to the Department of Surgery, which was then chaired by Dr. J. Englebert Dunphy. Dr. Dunphy was born on March 31,1908 in Northampton, Massachusetts. He graduated from the College of the Holy Cross in 1929 and from Harvard Medical School in 1933. After serving as surgical intern and assistant resident surgeon at the Peter Bent Brigham Hospital, he spent a year as an intern in pathology, then returned to the department of surgery to continue his training. He spent a year as a fellow in surgery at the Lahey Clinic and as a Cabot Fellow in Surgery at the Harvard Medical School. He completed his residency in 1940. From 1940 to 1946, he served in the U.S. Army Medical Corps, where he was chief of the surgical services of the Fifth General Hospital in Europe. He rose to the rank of Lieutenant Colonel. After the war, he returned to the Peter Bent Brigham Hospital and rose through the academic ranks to clinical professor in 1953. In 1955, he was named professor and chief of the fifth surgical service of the Boston City Hospital, and in 1959, he was recruited to Portland, Oregon, where he served as the McKenzie Professor and chairman of the department of surgery of the University of Oregon Medical School. After 5 years of unqualified success in Oregon, Dr. Dunphy accepted the position of professor and chairman of the department of surgery at the University of California School of Medicine at San Francisco. In 1975, he became professor emeritus and associate chief of staff for education at the Veterans Administration Hospital. Dr. Dunphy’s accomplishments are extremely difficult to summarize. He served on the editorial boards of several prestigious journals, including The New England Journal of Medicine, the Annals of Surgery, The American Journal of Surgery, the Journal of Surgical Research, Surgery, Gynecology and Obstetrics, Cancer, and the Western Journal of Medicine.

Dr. Dunphy must have been a member of virtually every medical society in the world. Enumerating only those of which he was president requires mentioning the American College of Surgeons, the American Surgical Association, the Society for Surgery of the Alimentary Tract, the Society of University Surgeons, and the San Francisco Regional Cancer Foundation. He served as president of this society in 1969, and his presidential address, “The Cut Gut,” reflected his long interest in wound healing as well as in gastrointestinal surgery. Dr. Dunphy is the author of several textbooks. The ones with which you are probably most familiar are Repair and Regeneration: The Scientific Basis for Surgical Practice, by Dunphy, Wells, and Kyle,

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and Dunphy’s The Scientific Foundation to Surgery, Hunt and Dunphy’s Fundamentals of Wound Management, and Physical Examination of Surgical Patients by Dunphy and Botsford. His book, Current Surgical Diagnosis and Treatment, prepared in collaboration with Dr. Lawrence Way, may be the most widely read surgical text in the world. Dr. Dunphy’s first article, “Mesenteric Vascular Occlusion,” coauthored by Dr. Robert Zollinger, is recognized as a classic in which they outlined the syndrome of gut infarction. The fundamentals of wound healing fascinated Dr. Dunphy, and he and his colleagues were very productive investigators in that discipline. Dr. Dunphy was quite interested and expert in the care of bleeding peptic ulcer and published several articles on that important topic. In addition to his interest in bleeding duodenal and gastric ulcer, he was also particularly interested in perforation. He had great insight into the management of perforation, obstruction, and other complications of duodenal disease. His paper with Drs. Way and Goldman on Zollinger-Ellison syndrome represented one of the largest experiences at that time and remains a classic reference on the topic. His publications on biliary problems, including the management of common duct stones, are likewise classic references. We all recognize that Dr. Dunphy was a compassionate and sensitive person, but he was also greatly concerned about ethics in surgery and in the care of patients. Although I was not a resident in Dr. Dunphy’s program, I did begin my academic career under his leadership and came under his influence at a formative time of my own professional life. All surgeons are deeply indebted to him for the example that he set, particularly for his qualities of thoughtfulness, compassion, and humanity. He was clearly an exemplary surgeon of outstanding surgical skill and judgement, and he was clearly a leader of men. I don’t think I know of another person as beloved by his students and colleagues as Professor J. Englebert Dunphy. He nominated me for membership in this Society, and for his support and encouragement, I shall remain eternally grateful. David C. Sabiston, Jr., MD: David Sabiston, Jr., was born in Onslow County, North Carolina on October 24, 1924. He received a BS degree from the University of North Carolina in 1943 and was elected to membership in Phi Beta Kappa. He then graduated from Johns Hopkins University School of Medicine as a member of Alpha Omega Alpha in 1947. Dr. Sabiston served as intern and resident in surgery at the Johns Hopkins Hospital, becoming chief resident surgeon in 1952, under Professor Alfred Blalock. He then served 2 years in the U.S. Army Medical Corps, at which time he participated in cardiovascular research under D. E. Gregg. He was appointed assistant professor of surgery at the

The American Journal of Surgery

Presidential Address

Johns Hopkins University School of Medicine in July 1955 and rose through the ranks to professor of surgery in 1964. During that time, he served as a Fulbright Research Scholar at Oxford University and Great Ormond Street, London. In 1964, he was appointed professor and chairman of the department of surgery at Duke University Medical Center and in 1971 was awarded the prestigious James Buchanan Duke Professorship of Surgery at Duke. Dr. Sabiston provided an excellent environment in which young people could maximally develop their clinical and investigative skills. This leadership provided me the privilege of working and collaborating with several outstanding young people, including George Austin, Bill Meyers, John Hanks, Dana Andersen, Bruce Schirmer, and Warren Kortz. In addition, the excellent climate of cooperation and collegiality at Duke permitted very productive interaction with Dr. Malcolm Tyor and all members of the outstanding gastroenterology division there. In reviewing Professor Sabiston’s accomplishments, it is important to recognize that he established an outstanding department and an outstanding surgical residency at Duke University. The facilities, the quality of the faculty, and the quality of the residents at that institution are simply unequalled. He has played a key leadership role in national and international surgery. He either is or has been president of the American College of Surgeons, the American Surgical Association, the American Association for Thoracic Surgery, the Society of University Surgeons, the Southern Surgical Association, the Society of Surgical Chairmen, and the Whipple Society. He serves on the editorial boards of the Annals of Surgery (of which he is the chairman), the Journal of Thoracic and Cardiovascular Surgery, Circulation, the Annals of Clinical Research, the Archives of Surgery, the World Journal of Surgery, and Surgery, Gynecology and Obstetrics. We must also recognize Professor Sabiston’s leadership role in surgical education. His work in providing the Davis-Christopher Textbook of Surgery and his role as co-editor on Gibbon’s Surgery of the Chest are outstanding and monumental contribu-

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tions to surgical education. Although certainly Dr. Sabiston is above all a skilled cardiac and thoracic surgeon and has received acclaim for his work in cardiac and vascular surgery, thoracic surgery, and surgical education, I would like to point out that he has been a supporting member of the Society for Surgery of the Alimentary Tract since its earliest days, and he has made several important contributions to gastrointestinal surgery. He has published on diseases of the esophagus, on diaphragmatic hernia, and the surgical treatment of portal hypertension. During the last several years, the operation of total abdominal colectomy, mucosal proctectomy, and ileoanal anastomosis has been employed increasingly for the treatment of inflammatory bowel disease and multiple polyposis. The procedure was first developed in animals by Dr. Sabiston and Dr. Mark Ravitch, and their paper describing the procedure was published in 1947. It is interesting that even though this procedure was reported in 1947 and subsequently by a follow-up report a few years later from Duke Medical Center, the operation did not gain wide acceptance in clinical practice until recently. David C. Sabiston is a man who demonstrates total single-minded dedication to his profession, to his patients, and to his students. He is the hardest working, most effective teacher, leader, and administrator it has been my pleasure to observe. Concluding remarks: The problems confronting the surgical profession today are formidable and complex. Medicine is being deprofessionalized and buffeted by economic pressures, government, and organizational conflicts. I am convinced that a successful solution to these problems will depend on our adherence to sound, basic, professional principles. The professional lives of the men just discussed provide guidelines for us if we will recognize them, and the lives of these men reflect several common denominators: a continuing quest for the truth through the scientific method, dedication to service to society and to the profession, dedication to service to patients, sensitivity to human pain, and diligent hard work. If we can recognize and follow these principles, our problems may be more solvable than we realize.

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