Table Of ContentSurgery, Science and
Industry
A Revolution in Fracture Care, 1950s–1990s
Thomas Schlich
Surgery, Science and Industry
Science, Technology and Medicine inModern History
General Editor:John V. Pickstone, Centre for the History of Science, Technology and
Medicine, University of Manchester, England (www.man.ac.uk/CHSTM)
One purpose of historical writing is to illuminate the present. At the start of the third
millennium, science, technology and medicine are enormously important, yet their
development is little studied.
The reasons for this failure are as obvious as they are regrettable. Education in many
countries, not least in Britain, draws deep divisions between the sciences and the
humanities. Men and women who have been trained in science have too often been
trained away from history, or from any sustained reflection on how societies work.
Those educated in historical or social studies have usually learned so little of science
that they remain thereafter suspicious, overawed, or both.
Such a diagnosis is by no means novel, nor is it particularly original to suggest that good
historical studies of science may be peculiarly important for understanding our present.
Indeed this series could be seen as extending research undertaken over the last half-
century. But much of that work has treated science, technology and medicine
separately; this series aims to draw them together, partly because the three activities
have become ever more intertwined. This breadth of focus and the stress on the rela-
tionships of knowledge and practice are particularly appropriate in a series which will
concentrate on modern history and on industrial societies. Furthermore, while much
of the existing historical scholarship is on American topics, this series aims to be inter-
national, encouraging studies on European material. The intention is to present science,
technology and medicine as aspects of modern culture, analysing their economic,
social and political aspects, but not neglecting the expert content which tends to
distance them from other aspects of history. The books will investigate the uses and
consequences of technical knowledge, and how it was shaped within particular
economic, social and political structures.
Such analyses should contribute to discussions of present dilemmas and to assessments
of policy. ‘Science’ no longer appears to us as a triumphant agent of Enlightenment,
breaking the shackles of tradition, enabling command over nature. But neither is it to
be seen as merely oppressive and dangerous. Judgement requires information and
careful analysis, just as intelligent policy-making requires a community of discourse
between men and women trained in technical specialities and those who are not.
This series is intended to supply analysis and to stimulate debate. Opinions will vary
between authors; we claim only that the books are based on searching historical study
of topics which are important, not least because they cut across conventional academic
boundaries. They should appeal not just to historians, nor just to scientists, engineers
and doctors, but to all who share the view that science, technology and medicine are
far too important to be left out of history.
Titles include:
Roberta E. Bivins
ACUPUNCTURE, EXPERTISE AND CROSS-CULTURAL MEDICINE
Roger Cooter
SURGERY AND SOCIETY IN PEACE AND WAR
Orthopaedics and the Organization of Modern Medicine, 1880–1948
David Edgerton
ENGLAND AND THE AEROPLANE
An Essay on a Militant and Technological Nation
Jean-Paul Gaudillière and Ilana Löwy (editors)
THE INVISIBLE INDUSTRIALIST
Manufacture and the Construction of Scientific Knowledge
Thomas Schlich
SURGERY, SCIENCE AND INDUSTRY
A Revolution in Fracture Care, 1950s–1990s
Crosbie Smith and Jon Agar (editors)
MAKING SPACE FOR SCIENCE
Territorial Themes in the Shaping of Knowledge
Science, Technology and Medicine in Modern History
Series Standing Order ISBN 0–333–71492–X hardcover
Series Standing Order ISBN 0–333–80340–X paperback
(outside North America only)
You can receive future titles in this series as they are published by placing a standing order. Please
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and address, the title of the series and one of the ISBNs quoted above.
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Surgery, Science and Industry
A Revolution in Fracture Care, 1950s–1990s
Thomas Schlich
© Thomas Schlich 2002
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10 9 8 7 6 5 4 3 2 1
11 10 09 08 07 06 05 04 03 02
Contents
List of Figures vi
Foreword by Ulrich Tröhler viii
Acknowledgements x
Introduction: The AO 1
Part I Setting Up a Network, 1950s–1970s
1 Dealing with Broken Bones 9
2 Starting the Network 28
3 A Symbiosis of Surgery, Science and Industry 46
4 ‘Tacit Knowledge’: Education and Training on a Face-to-Face Basis 65
5 Science and Surgery: Bones in the Laboratory 86
6 The Science of Surgery: Clinical Research 110
Part II Coping with Success, 1970s–1990s
7 Acceptance: The AO becomes Mainstream 141
8 Optimised Control: The AO’s Success in East Germany 169
9 The Long Road to Success: The AO in the US 180
10 Redefining Osteosynthesis: Another Revolution in Fracture Care 196
11 Control and Cooperation on a Global Scale: AO International
and AO Foundation 218
Part III Conclusion
Conclusion: Surgery, Science and Industry in Modern Medicine 239
Notes 260
Bibliography 310
Index 337
List of Figures
1. Systematic conservative treatment. 18
Lorenz Böhler, Technik der Knochenbruchbehandlung im Frieden
und im Kriege(9th to 11th revised and augmented edition),
Maudrich, Wien, 1943, vol. 1, p. 193. Reproduced courtesy
of Wilhelm Maudrich Verlag, Vienna.
2. Nailing of the hip. 22
Lorenz Böhler and Wilhelm Jeschke, Operative Behandlung der
Schenkelhalsbrüche und Schenkelhalspseudarthrosen und ihre
Ergebnisse, Maudrich, Wien, 1938, pp. 124–5.
Reproduced courtesy of Wilhelm Maudrich Verlag, Vienna.
3. Compression device. 50
M.E. Müller, M. Allgöwer and H. Willenegger, Manual der
Osteosynthese.AO-Technik, Springer, Berlin, 1969, p. 31.
Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin.
4. X-rays, osteosynthesis. 51
M.E. Müller, M. Allgöwer and H. Willenegger, Technik der
operativen Frakturenbehandlung, Springer, Berlin, 1963, p. 91.
Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin.
5. Instruments box. 52
M.E. Müller, M. Allgöwer and H. Willenegger, Technik der
operativen Frakturenbehandlung, Springer, Berlin, 1963, p. 80.
Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin.
6. Corroded hip nails. 59
Lorenz Böhler, Technik der Knochenbruchbehandlung im Frieden
und im Kriege(9th to 11th revised and augmented edition),
Maudrich, Wien, 1943, vol. 2, p. 940. Reproduced courtesy of
Wilhelm Maudrich Verlag, Vienna.
7. Faculty of the first AO course. 69
Reproduced courtesy of the AO Foundation, Davos.
8. Operating Room Personnel course. 75
Reproduced courtesy of the AO Foundation, Davos.
9. Hans Willenegger presents the AO Manual to Lorenz Böhler. 78
Photograph reproduced courtesy of the AO Foundation, Davos.
10. AO fellowships. 80
The statical data were kindly provided by Isabella Badrutt,
AO-International, Davos. The chart was produced by
Tobias Katzer, Institute for the History of Medicine, Freiburg.
vi
List of Figures vii
11. Perren’s experiment. 92
M.E. Müller, M. Allgöwer and H. Willenegger, Manual der
Osteosynthese. AO-Technik, Springer, Berlin, 1969, p. 9.
Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin.
12. Primary bone healing. 103
M.E. Müller, M. Allgöwer and H. Willenegger, Manual der
Osteosynthese. AO-Technik, Springer, Berlin 1969, p. 8.
Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin.
13. AO classification. 117
M.E. Müller, S. Nazarian, P. Koch and J. Schatzker,
The Comprehensive Classification of Fractures of Long Bones,
Springer, Berlin, Heidelberg, etc., 1990, p. 13. Reproduced
courtesy of M.E. Müller and Springer Verlag, Berlin.
14. The diaphyseal fracture types. 118
M.E. Müller, S. Nazarian, P. Koch and J. Schatzker,
The Comprehensive Classification of Fractures of Long Bones,
Springer, Berlin, Heidelberg, etc., 1990, p. 15.
Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin.
15. AO documentation card. 126
M.E. Müller, M. Allgöwer and H. Willenegger, Technik der
operativen Frakturenbehandlung, Springer, Berlin, 1963, p. 27.
Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin.
16. Conservative fracture treatment. 145
Cartoon by Otto Soglow, The New Yorker, 1939.
Reproduced courtesy of Condé Last Rights and Permissions.
17. AO cooperation. 147
Reproduced courtesy of Urs Heim.
18. Tension band principle. 197
M.E. Müller, M. Allgöwer and H. Willenegger, Manual der
Osteosynthese. AO-Technik, Springer, Berlin, 1969, p. 33.
Reproduced courtesy of M.E. Müller and Springer Verlag, Berlin.
19. DCP. 202
M. Allgöwer, L. Kinzl, P. Matter, S.M. Perren and T. Rüedi,
Die Dynamische Kompressionsplatte DCP, Springer, Berlin, 1973,
pp. 26–7. Reproduced courtesy of Springer Verlag, Berlin.
20. Hans Willenegger. 226
Photograph reproduced courtesy of the AO Foundation, Davos.
21. AO Foundation 1984. 230
Diagram reproduced courtesy of the AO Foundation, Davos.
22. AO Foundation expenditures. 233
Chart reproduced courtesy of the AO Foundation, Davos.
23. AO Alumni Association members. 234
The statistical data were kindly provided by Esther Stoop,
AO International, Davos. The chart was produced by
Tobias Katzer, Institute for the History of Medicine, Freiburg.
Foreword
Interdependent collaboration between clinical medicine, laboratory science
and industry is an increasingly prominent feature of post-World War II health
care. The AO, an abbreviation originally standing for the Swiss
Arbeitsgemeinschaft für Osteosynthesefragen founded in 1958, that is, the
Association for the Study of Internal Fixation of Fractures (ASIF) as this
worldwide organisation is now termed, seems to fit this development. From
around 1960, the AO promoted the systematically organised treatment of a
great variety of fractures with its own industrially produced and marketed
plates, screws and instruments. Today, the AO system represents a sort of
international gold standard. Albeit not new in the 1950s, many variants of
such treatments before the AO had more often than not been considered as
being a haphazard ‘injury superaddit to an injury’. Thus, the obvious
questions are: How, where and why did this true revolution in fracture care
come about? Was it ubiquitous and simultaneous? How is it to be explained
in personal biographical, sociocultural and even political perspectives? How
were unavoidable errors and opposition dealt with? Deeply rooted in their
cultural soil, the less than half a dozen founders certainly had far-reaching
visions; they also had complementary capabilities which made them strong
as an association, and they were altruistically generous in financial matters.
Yet, is this sufficient to explain the AO as a mutual win–win merger for
surgical practitioners, laboratory scientists and producers alike for the benefit
of patients? Are there similarities with developments in other (medical) fields?
What are, in brief, the general and specific reasons for the AO’s incontestable
success? These historical questions and answers have a bearing for our current
and future practices.
Thus, reading the AO’s history, chapter after chapter, as written by a young
historian, is an exciting privilege for one who has known, as I have, the AO’s
first 25 years fairly well from personal experiences as a student, scientist –
and patient. When the truly engaging author opens new vistas, describes and
analyses entire pictures, and solves some of the riddles involving the past 15
years of AO history, he is constantly leading one to understand its benevolent
founders, their successors, and indeed parts of one’s own life, in an often
unexpected context. At last, the changes that have transpired in medical
culture over the past 40 years become tangible.
A core issue is the evidence deemed sufficient to warrant changes: What
criteria were needed for an innovation to be considered ‘better’ than a time-
honoured treatment – and by whom? The answers are at times surprising.
What makes for fascinating reading immediately raises further questions as
viii
Foreword ix
to whether or in what respect our contemporary criteria are different, and, if
(not) so, why.
Two examples: the highly lauded physiological and pathophysiological
concepts of bone formation and repair emerge to have played the role of
satisfying the academic need for scientifically explaining the empirical success
of osteosynthesis ex post rather than as a basis for specific techniques. And
with all the clinical, statistical and laboratory evidence at hand to show and
explain the excellent chance-to-risk ratio of operative fracture treatment, its
success in daily practice has depended on human factors: the personal contact
with colleagues, motivating and to some extent even controlling them within
‘the AO family’, and, above all, the trustworthiness of its protagonists have
been essential.
Suchpersonalqualitiesandseeminglyold-fashionedvirtuesare,thosewith
surgery, science and industry careers should bear in mind, indispensable
complementstothequestfornaked,quantified,objectivestandards;apursuit
thatisrightlystressedinourtimes.Indeed,thebookmakesitscaseonhow
theAOusedbothfactsandvirtuestocopewithitsownsuccessandthepartly
self-induceddevelopmentsinthisemergingtrilateralfield.Itiscertainlyworth
reflectinguponwhetherthismodelmightworkinthefutureandelsewhere.
Well founded standards are to be strived for, certainly, in surgery as well
as in history, but they are not enough to make patients – or readers – happy.
Thanks to both his professional skills as a historian and his empathy when
treating the apparently hitherto unique AO phenomenon, Thomas Schlich
will succeed in making many readers and, perhaps, via the surgeons amongst
them, many a patient happy.
Ulrich Tröhler, MD, PhD, FRCP(Edin.)
Professor of Medical History
University of Freiburg/Germany
March 2002
