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Bulletin of the History of Medicine 77.2 (2003) 467-468



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Leslie Klenerman, ed. The Evolution of Orthopaedic Surgery. London: Royal Society of Medicine Press, 2002. x + 246 pp. Ill. £20.00 (paperbound, 1-85315-469-5).

If proof were needed that orthopedics "ain't what it used to be," or that its transformation has been such as to make it largely unrecognizable to its practitioners of scarcely a generation ago, the sixteen essays in this collection go far to provide it. Cast in terms of the "major advances" over the twentieth century—especially since the 1950s—they tell a story of a specialism driven by increasing technical wizardry and multidisciplinary engagements. On the one hand, virtually gone are the diseases and conditions upon which the modern specialism was founded (such as tuberculosis of the bone and joints in children); while, on the other hand, stand revolutionary innovations hardly dreamed of fifty years ago, such as in the surgical reconstruction and replacement of joints and the rapid internal fixation of fractures. [End Page 467]

Laden with medical jargon, this book is intended for orthopedic surgeons who might know some of the "bits of the jigsaw" of their specialism, but lack "a comprehensive perspective" (p. ix). Perhaps because I am not an orthopedic surgeon, it eludes me how the latter is supposed to be obtained. The "bits" are multitudinous, and often fascinating, and they are presented with sometimes surprising verve and wit—but perspectives of any sort are lacking. Chapters focus either on recent areas of subspecialization such as arthroscopy, musculoskeletal tumors, biomechanics, radiology, and product technology (by far the most revealing), or on vast anecdotal panoramas, such as amputation surgery from 1800 to the present, or the evolution of spinal surgery from the nineteenth to the twenty-first century.

From the abundance of references to modern pioneers and daring technical innovators, one might conclude that orthopedics was driven entirely by individual genius—even in the face of equally abundant evidence of its dependence upon collaboration with mechanical engineers, geneticists, biochemists, and drug manufacturers. But through the heroic razzmatazz there also filters a more mundane reality: the routinization of much of the labor of orthopedics, and the promise of its practice becoming even further routinized, as more and more of the joints of increasingly elderly populations in wealthy nations come to need replacement; already, "three hundred thousand total knee replacements and five hundred thousand total hip replacements are implanted annually world wide" (p. 25). A final chapter on "Orthopaedics in 2050" points to a different, nearly contrary, kind of future, one in which the traditional "surgical" component has withered in the face of genetic sampling and manipulation, implants, inhibitors, tissue engineering, xenogenic transplants, advanced chemotherapeutic regimens, lasers, proton beams, immunological agents, and so on.

Unfortunately, none of the contributors stops to reflect either on the politics or political economy of such "advances," or on what becomes (or has already become) of the institutionalized body of the orthopedic specialism during its passage through these "evolutionary" processes. Modern orthopedics as a specialized branch of general surgery was articulated in the early twentieth century in terms of a holistic physiological vision of the structures and functions of the musculoskeletal system—a naturalized division of labor. The Evolution of Orthopaedic Surgery suggests a postmodern medical world where amputated fragments, not wholes, predominate. Significantly, the majority of the book's chapters fall under the subheading "Fragmentation of Orthopaedic Surgery"—the surgery of the hand, the foot, the ankle, the spine, and so on. But the connective tissue is elusive, the master narratives are missing. Orthopedics, as a coherent field of practice, appears to be surviving virtually in name alone, a phantom limb of a history past. "Dismemberment," not "evolution," might have better captured its recent past.

 



Roger Cooter
Wellcome Trust Centre for the History of Medicine
at University College London

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