Surgery, Science and Industry: A Revolution in Fracture Care, 1950s-1990s (review)

This clearly written book describes the development of a remarkable and somewhat mysterious organization. Anyone who has crashed to the ground while running for a bus, or found himself trapped at the bottom of a rugby scrum, will know something about "osteosynthesis": the process whereby a surgeon opens up a fractured limb and, using metal implants and plates, performs an operation that allows freedom of movement to the injured area during the healing process. This approach was invented by the Arbeitsgemeinschaft für Osteosynthesefragen (the Association for the Study of Internal Fixation and Fractures), located—eerie analogies with Thomas Mann's Magic Mountain—in the elite Swiss ski resort of Davos. Fully to appreciate Schlich's narrative, readers need to be equipped with a working knowledge of the Kafkaesque complexities of AO's interacting "familial," academic, industrial, and international structures. The organization comprises a center in Switzerland, complete with lavish research facilities; an international wing, currently claiming a membership of more than two thousand; manufacturing tie-ins to produce AO instruments and implants, with a turnover of approximately $600 million; and a section publishing textbooks in every major language.

In tracing and interpreting the development of this uniquely integrated medical "family," Schlich has drawn on archives at Davos, oral evidence, and a voluminous secondary literature. His background chapter on the "Cinderella of modern surgery" depends heavily on Roger Cooter's research into British orthopedics in the late nineteenth and early twentieth centuries. Thereafter, Schlich enters into the fine detail of the establishment of AO in the late 1950s. Moving on to an account of the "symbiosis of surgery, science and industry," the author evaluates power relations in the period in which the new organization set about developing its own instruments and implants. Chapters on the face-to-face character of education and training, science and research, and the beginnings of acceptance on the part of the medical mainstream prepare the way for an in-depth survey of the transmission of the technique to the former German Democratic Republic, where "even small district hospitals in the countryside made every effort to be able to work according to AO principles" (p. 178).

Schlich also interrogates the fate of the new approach in the United States. Whereas in Switzerland the "cultural pattern of fraternity" constituted an ideal seedbed, "in the GDR, the policy of tight centralized state control over health care providers accomplished the same objective with even more efficiency" (p. 194). In America, however, free market conditions that had long dominated and shaped the health-care sector worked against the intimate, guildlike principles of Davos. Schlich's final task is to engage with issues of adaptation and change. In what may be an overly sanguine conclusion, he asserts that the decision to build a new center in Switzerland, rather than in a location closer to an American or European university research department, reaffirmed AO's Swiss family virtues, and confirmed the organization's leading position in a field that it had controlled for nearly fifty years.

Taken as a whole, this study emphasizes continuity. Eschewing a Whiggish approach to the history of medicine, Schlich is convinced that "even a successful medical technology is the result of specific choices made by human beings" (p. 258). He also claims that contemporary medicine builds on the "consequences of past decisions and not of a quasi-natural tendency toward progress and improvement" (p. 259). Nevertheless, it would be erroneous to underestimate the role played by exceptional individuals. Hans Willenegger, president of AO International—pictured here with his foot on a lectern, earnestly probing an imaginary bone fragment in his ankle—had by 1992 made "32 circumnavigations of the planet" in order to spread the sacred word of Davos (p. 225...