What do Arnold Schwarzenegger, the late Audrey Hepburn and a snow leopard at Calgary Zoo have in common? Like millions of non-celebrities, each enjoyed the benefit of a total hip replacement (THR). Whether judged in terms of clinical outcome, patient satisfaction or social accessibility, this now mundane species of cyborgism was perhaps the most successful medical engineering endeavour of the second half of the twentieth century. Yet, as Julie Anderson, Francis Neary and John Pickstone document in their excellent new interdisciplinary history, THR's spectacular success evidently owed very little to academic science. For that very reason, this book – the first monograph on its topic – makes salutary reading for historians of science. Apart from further confirming the inadequacy of crude ‘applied-science’ models of technology and medicine, the authors show by example how to avoid the solipsism of science-centred historiography. Not once as they guide us through the complexities of often highly unfamiliar territory do they make recourse to that staple narrative simplifier, the much-mythologized power of the ‘laboratory’ to supply essential technical knowledge and expertise.
A key strength of this artfully structured book is its consistently transatlantic comparative focus, with no single actor, location or institution allowed to dominate the narrative. Nor is there any easy reduction of the story to a simple competition between the principal locations, Wigan (Lancashire) and Warsaw (Indiana). The second chapter outlines the origins of THR in the UK in the 1930s, showing how a variety of approaches were cultivated across the country after the Second World War in somewhat idiosyncratic collaborations between surgeons and engineers, seeking primarily to restore mobility to the elderly infirm. Only some of these collaborations survived to the point that their prosthetic hardware was taken up by large American medical companies and transformed by the century's end into diversified, mass-production, consumer-friendly products for broader age groups. While the fourth chapter demonstrates that the US corporation has now largely displaced the UK surgeon in directing the course of THR development, the national origins of the enterprise were still manifest as late as 1995, and again three years later when the elderly British Queen Mother (born in 1900) received her THR from patriotically sourced technology.
The third chapter features a particularly memorable cameo of the surgeon–technician–THR nexus, concerning the (unusually) well-documented collaboration between the irascible Mancunian professor John Charnley (1911–1982) and the Thackray instrument-making company in Leeds. This transpennine alliance enabled Charnley to develop his low-friction, plastic-and-stainless-steel, ball-and-socket prosthesis into clinical and commercial viability, overcoming the audible squeak of its plastic precursor. As a relative latecomer to the field, starting at Wrightington Hospital in Wigan in the late 1950s, Charnley aimed for an inexpensive, patient-friendly and low-maintenance THR – fully in line with the goals of the UK's youthful National Health Service. While he succeeded in this respect, his more traditional surgeon's ethos of eschewing personal profit and allowing open publication of this innovation (albeit restricting sales only to those who had learned the operating-theatre techniques directly from him) had rather less happy consequences. Once news had circulated internationally about the relatively high success rate of the Charnley-type THR, his gentlemanly sharing of his models was soon exploited by European and US rivals who began to market unattributed copies. Thus by 1969 Charnley reluctantly felt obliged to take out patents for subsequent developments to maintain the quality and eponymous identity of the device. Although he secured a US distributor he did not, however, achieve any increase in market share. Issues of patent royalties, propriety and overseas sales indeed vexed Charnley for the rest of his career, even as rival THRs multiplied to enhance surgeon and patient choice beyond Charnley's famed candidate solution.
Subsequent chapters offer a similarly sophisticated if at times dense account of the many tricky and underdetermined decisions about the choice of plastic and material construction, government regulation (for safety), surgical skill and disinfection regimes for THR. For example, the fifth chapter addresses the recurrent problem of deep infection suffered by a small minority of THR patients, showing how Charnley rejected antibiotic solutions typically adopted in the USA. He instead produced a sterile-air operating theatre with the collaboration first of his Wrightington assistant Harry Craven, and then with the local company Howorth Air Systems, which more typically supplied breweries and textile mills with this essential industrial technology of anti-bacterial hygiene. The authors thus nicely elucidate the striking absence of closure in design and management, carefully avoiding reification of this heterogeneity into a monolithic ‘THR’.
Similarly, the THR patient – or perhaps better THR user? – is not black-boxed as a passive recipient. Showing due sensitivity to the sometimes tense dynamics of the three-way relationship signalled in the book's title, the whole of the seventh chapter is dedicated to ‘the changing nature of patients’. Specifically it documents the ever greater diversity of THR recipients, the greater level of information latterly supplied to them in pre-operative choices, and their growing expectation that it was they rather than surgeons who adjudicated what constituted operative success. We have thus clearly come a long way from the melancholy story, told on the book's first page, of the suicide of an unnamed railway engineer in 1933, depressed by the crippling effects of his chronic hip disease. Even though the millions of happier THR recipients over the last seventy years might have played less football than they wished, and needed in some instances a second replacement THR, this is one case of a patient-centred medical technology that has all but eliminated what was once an incurable disability.
The reflexive concluding chapter, ‘What is past is present’, indicates that this book – just like the THR enterprise – could have emerged so successfully only from a collaboration between contributors with both complementary expertise and a capacity to readjust historiographical horizons. Although not destined for the popular-historical market, Surgeons, Manufacturers and Patients sets new academic standards for how to write about the complex interactions between medicine and technology – unmediated by science.
