The medical milieu before and during the time of the founding of this society is significant and interesting.

During the last half of the nineteenth century the scientific and ethical standards of medicine were very low in almost all of the country, except along the East Coast. The American Ophthalmological Society had existed since 1864, the American Otological since 1868, the New England Society since 1884, and the Eye Ear Nose and Throat section of the American Medical Society since 1878. Chairs of ophthalmology had been established at Miami Medical College in 1871, and Pennsylvania in 1891. This close contact made scientific interchange and the regulation of ethics possible.

The situation was different in the Middle and Far West. A large majority of specialists were located in small cities with no clinical, hospital, or college facilities. The opportunities for scientific interchange and ethical inspiration were few or non-existent. There was a great need to fill this void.

It was in response to this need that the Western Ophthalmological, Otological, Rhinological, and Laryngological Association was established in 1896 and had its first meeting in Kansas City. In 1903, the name was changed to the American Academy of Ophthalmology and Otolaryngology.

Even though the "Star of Empire" was moving westward, the Pacific Coast was remote from the Midwest and the East. Travel to the East required approximately six days each way. North-south travel through the three Pacific Coast States was much less time-consuming. In addition, the far-western states had much more in common with each other than with the Midwest or East. Our society was created to fill this void. At that time, the principal medical center of the West was San Francisco. It was here that a meeting was called to organize the society by the consolidation of two recently formed groups: The Pacific Coast Ophthalmological Society (President, Adolph Barkan), and the Pacific Coast Otolaryngological Society, (President, Kasper Pischel). At that time almost everyone practiced both eye and ear, nose, and throat.

The meeting was to be held in conjunction with the California State Medical Society and the Rocky Mountain Interstate Society, of which Edward Jackson was president. The papers included "A new giant eye magnet with demonstrations," by Adolph Barkan (1). The first day of this projected three-day meeting was April 17, 1906. The place was San Francisco, then the only great city of the West. Enrico Caruso sang Don Jose in Bizet's Carmen that memorable night. On the morning of April 18, the earth agonized in a great quake and fire destroyed downtown San Francisco (2). Caruso never returned to San Francisco. The giant eye magnet, which was to have been presented to the society on Thursday, April 19, had to be completely rewound, but it is still in service (3). It had been the giant magnet of Cooper Medical College, which became the Stanford University Medical School, succeeded by the Presbyterian Medical Center and then the Pacific Medical Center.

The quake shook the very roots of our society and, after only one day of meeting on April 17, 1906, the next meeting was not held until 1913 in Portland, Oregon. The original plan was that the meeting should coincide with those of the California Medical Society. The latter declined, but it is of interest that the volume of the California Medical Journal, which contained this information, also contained an article on cinematophthalmia, which described the ocular disturbances from this new plaything of the people. We have now progressed to computer terminals. Should we now use the term "Terminal Ophthalmia"?

Our society was founded to improve both the scientific and ethical standards of our specialties. This need for improvement can be understood by a brief discussion of the years before its existence.

In the last half of the nineteenth century, quackery was rampant. The public held the medical profession in low esteem. The fight against quackery was an important part of medical ethics. For example, the Museum of the American Academy contains an advertisement for an "Ideal Sight Restorer," which would eliminate "hideous glasses." Dr. Bates published a book on maneuvers to eliminate spectacles and strengthen the eyes (4, 5). Maps of the iris showed which area had an association with disorders of the liver, heart, and other organs.

Dr. Dayton, the society's president in 1917, noted, "The man who could display the most glaring falsehoods in the daily press regarding his successful treatment of the eye was on the road to success."

Medical schools were a corporation of physicians bent on their own medical improvement. They petitioned the state legislature for the right to establish a school and issue diplomas. They were subject to no regulation. The expenses were met by tuition. The teachers gave their services gratis, but any surplus in the treasury accrued to them as dividends.

Although some improvement had taken place by the time our society was organized, the situation remained bad. Those who tired of general practice could spend six weeks in Vienna and return with a large diploma with which they became specialists in our fields, even though much of the six weeks might have been spent enjoying the Viennese ambiance: its opera, beer halls, waltzes, etc. This intolerable situation begat the American Boards, but the first board, that of Ophthalmology, was not founded until 1916, followed by the ENT Board in 1924.

The PCOOS meetings, which gave relatively easy access to the foremost teachers and medical centers of the time helped lift the clinical scientific standards. The social aspect of the meetings, which was dominated by the more ethical in our fields, helped to elevate the ethical standards.

There have been some who have said that the social functions of this society were too prominent. The dissent from this view was best expressed in 1916 by the fourth president, Dr. Joseph McCool, my professor in the undergraduate years. He stated that the most valuable scientific feature of any meeting is the social. "Most papers presented represent work accomplished successfully, only occasionally do we have one which deals with the writer's failures. It is human nature for us to appear at our best, especially if it be for publication. In the discussion that follows, while much that is said is extemporaneous, the speaker knows full well that he will have ample opportunity to edit his remarks before they appear in the Transactions. But if you want to know what a man really thinks about a subject, get him tête-à-tête either dining or after a meal. It is then that the desire for sympathy or encouragement, inherent in the heart of all men, brings forth an exchange of confidences, and our failures and perplexities are acknowledged.

Proper balance of the social aspects has resulted in the recognition that an erudite and intelligent specialist does and should have broad interest outside science. Nonmedical subjects that have been given include "Goya's Illness," "The Life Story of the First Medical Practitioner of British Columbia," and "Biological Contributions of Leonardo da Vinci."

The relatively small size and friendly nature of the society permitted free discussion of papers. The average number of discussers was five per paper during the 1916 meeting. Two of the fifteen papers were each discussed by nine members. In 1923, a paper entitled, "When is Tympanic Paracentesis Necessary?", eliciting fifteen discussions in addition to the closing remarks. There is little wonder that Dr. Perry said in 1924, "There is one thing we like about this society, the men here do get up and speak...it is not a society, it is a family who, knowing each other intimately, come year after year to these meetings, and I hope this society will always remain a family." In these years, the number of papers that could be presented at any one meeting was limited to fifteen. Unfortunately, the growth of the society, a greater number of papers, and perhaps a change in general temperament altered this. During the Vancouver meeting of 1925, President Cunningham interjected, "We must hurry along...we want discussion but make it brief...as each man rises to discuss we will put his name on the blackboard. Unfortunately, we do not everyone of us know everybody." During the 1928 meeting in Santa Barbara, the meeting was conducted by means of a timer. The old order was changing, and not all change is improvement.

During World War I, it was humiliating to the profession to find that a large percentage were not qualified as the experts they were supposed to be. It was suggested that the members of this organization shape the instruction of future members. Graduate courses should be offered only by institutions having adequate laboratory equipment and competent teachers. Short intensive courses should be given to men already in practice.

Our society considered requiring board certification for membership in 1917 but did not actually require certification for ophthalmologists until 1926, and for ENT specialists until 1927.

The clinical papers and their discussions clearly illustrate the progress from magic to art to science. In the first Transactions of 1916, it was stated that eyestrain was frequently cured by the extraction of a tooth or the removal of a tonsil. The Ophthalmic Record of 1914 relates the following interesting account. "The curious case of the New Jersey boy who sees upside down has been exceeded by a freak of nature in a dachshund puppy owned in San Diego. The dog's sense of distance is reversed. When called, he will back away from his master although obviously desirous of coming to him. A scientist became interested and discovered that the canine was suffering from astigmatic myopia. A special pair of glasses was made for it. After becoming accustomed to the glasses, the dog became normal, although its unusual appearance causes much comment."

Such magic, based on the philosophy, "Post hoc ergo propter hoc," was being supplanted by science. The spice of the business meetings was lost when nonessential verbatim transcript in the Transactions was eliminated in 1935.

Economics were important in the determination of a meeting site during the earlier years of our society. Entertainment expenses were born entirely by the local group of specialists or the president. The president sometimes paid for a dinner at a hotel for the entire society. With the continued growth of the organization, the entertainment expense assessed against local members became considerable. Because of this, the group was no longer welcome in some areas and the choice of meeting places became limited. It was suggested that the society meet in a resort area in order to break the chain of precedent of entertainment by the local men. The Transactions is remarkably frank and complete regarding this problem. In 1924, an invitation was accepted to meet in Vancouver the following year, with the understanding that "the local group would not pay for the entertainment, although they could see that we get what we came to Vancouver for [laughter]." (Remember that prohibition was well established in the United States.) During the 1925 meeting in Vancouver, the society expressed its desire to meet in San Francisco the following year, but had received no invitation from San Francisco. They stated that they might go to Oakland if Dr. Hayward Thomas (past president) would invite them. He answered, "I will not." It was then voted to meet in San Francisco without an invitation. At this time, the meeting place was decided upon during the general business meeting. Not until 1941 did it become the decision of the council.

Some papers at our society have been fundamental breakthroughs in clinical medicine, such as Otto Barkan's "On the Genesis of Glaucoma," which laid the whole basis for the anatomical separations of the narrow and wide angle types.

Good clinical science was exemplified by the address of Lewis Morrison in 1952, in which he pointed out that this country had produced 17 tons of penicillin per month during the previous year, enough to provide 3,000,000 units each for the 130,000,000 people then in this country; that Stanford Hospital Pharmacy (a conservative institution) had dispensed sufficient antibiotics to give each patient 600,000 units of penicillin and every third patient 10 grams of one of the mycins. The resulting unbalanced bacterial flora provided an interesting study.

Such massive administration of antibiotics had profound economic effects. In 1943, the first batches of penicillin were sold to the government below cost at $20 per 100,000 units. By 1945, the cost was 60 cents per 100,000 units and by 1945, four cents. Streptomycin fell from $30 per gram in 1945 to 40 cents in 1952. But the economic effects were felt elsewhere too. By 1950, drugs had practically eliminated infections of the temporal bone. Otolaryngology was confronted with other financial problems, which threatened its very survival: endoscopy was no longer reserved for the laryngologist, and malignancies were being treated by the departments of surgery. Higbee, in 1950, commented sadly that, while other residencies were in great demand, ours are awaiting applications. It is prophetic that the very next paper in this volume of the Transactions was "Remarks on Surgery for Deafness." That which was described as a dying specialty became the most dynamic.

Since those early, but I cannot say peaceful, days of the society, there have been significant changes. The area encompassed has enlarged from three states to thirteen states, two provinces of Canada and Mexico, and the membership has likewise grown. Rapid transportation has made it possible for physicians to travel throughout the continent with little loss in travel time. There is a plethora of meetings, publications, and courses. The need for this society to act as one of the main educational opportunities in the West no longer exists.

Nevertheless, this society affords some opportunities that are difficult to find in our time. The enormous size of many societies, such as the American Academies, makes it difficult to meet with many others. The crowded schedules leave no time for unscheduled discussions and little time to meet in an informal and relaxed setting.

Although our society has grown and the program is more crowded than formerly, it does give ample opportunity for informal discussion and social interchange in addition to solid scientific presentations and courses. Facts that might be biased in a carefully edited presentation can be questioned and one can gain much from knowing "the discusser as a whole person" rather than simply evaluating the formal presentation. An exchange of confidences can occur during a social hour, dinner, or golf game, which can prove to be far more valuable than the paper itself. Our society has always recognized the need that an intelligent specialist has for interests outside of science, as well as the opportunity to meet with our other specialists.

The PCOOS offers something that is almost impossible to find in our too-crowded and pressurized world: the relaxed, informal, but scientific milieu. Millennium? Most vehemently--Yes!

Postscript: Considerably more historical material will be found in: Bettman, J.W.: Wisdom in the Pursuit of Excellence; A history of the PCOOS. Transactions PCOOS, p. 19-45, 1968.

REFERENCES

1) Calif. State J . Med. 4:117-118, 1906.

2) Bronson, W. The Earth Shook, the Sky Burned, Garden City, N.Y., Doubleday & Co., Inc., 1959.

3) Barkan, Hans (deceased Prof. Ophthal., Stanford Univ., son of Adolph Barkan, deceased): personal communication.

4) Bates, W.H. The Bates Method for Better Sight Without Glasses, H. Holt & Co., N.Y., 1943.

5) Bates, W.H. The Cure of Imperfect Sight by Treatment Without Glasses, Central Fixation Publishing Co., N.Y., 1929.