Julie Anderson

What is Past is Present

Writing this book has been an adventure in many ways, from the initial proposal conceived with David Cantor on the basis of his research on arthritis, to the work with Francis and the extension into museum projects at the Royal College of Surgeons, London, and at Wrightington Hospital. We did not expect to include as much as we have on patients — that came largely from Julie’s interests in disability and cultural history; nor that we would look so much to America, which came from our shared realisation that the UK story only made sense in a transatlantic context. We have ventured into many new areas, and we have lots of questions still outstanding. But in this conclusion we first quickly survey the histories in the UK and the US, and we then draw together some of the lessons we have learned so far.

The Changing Nature of Patients: Expectations and Information

Throughout the day there were more preliminaries. Sister Holmes came and gave me a knowledgeable, motherly talk about the operation. She was followed by one of the nurses I’d seen in the morning, a nice girl who talked to me animatedly. She said something about the prosthesis — ‘Haven’t you seen one?’ she asked. ‘Haven’t they ever shown you one?’ ‘No,’ I said. I didn’t know that I should have been able to look at it, if they had shown me one. ‘It looks like a pork chop,’ she said…From what I’d imagined, I could see that was what it might well look like. Like a pork chop.1

Hips, Health Services and Quality

So far in this book we have discussed surgeons, engineers and companies, and in the next chapter we will discuss patients. Much of this present chapter will be about governments. We will look at the health services of the UK and the US, and the different ways in which THRs existed in those systems. We then turn to discuss issues of quality regulations, from the industrial standards which applied to the materials of hips, through questions of professional assessments, to national registers of hips inserted, or the lack thereof.

Total Hip Replacement: Introduction, Sources and Outline

On May 9 1933, an article in The Times headed ‘Railway Engineer’s Suicide’, reported that a 57-year old man had shot himself ‘while of unsound mind.’ As the Coroner explained, (He was) Suffering from profound depression caused by physical disability arising from a chronic disease of the hip-joint, which disabled him, which was getting worse, and of which there was no hope of a cure.1

Medical Technology and Industrial Dynamics: The United States and the Global Market

In this chapter we explore the histories of some of the American manufacturers who now dominate the global hip-replacement market. We go on to examine how they have worked with surgeons, not least through technical representatives who visit hospitals and may take a part in the surgical operations. Worldwide, there are 18,000 manufacturers of medical devices, and over 70% of them are small companies with less than 50 employees.1 Some companies only have one or two specialist product lines, or conduct research for the large manufacturers. However, as in many industries, the large multi-nationals have most of the market share.

Change and Stability in Technical Systems: Materials and Environments

In the previous chapters, we have followed the initial development of THRs, especially in Britain, and the development of the hip-joint industry, predominantly in the US. In this chapter we return to the technologies, to examine in more detail how they evolved, and what constrained them. In the next chapter we will relate the technology to its use in health services and to questions of regulation.

The Industrial Development of British Hip Replacements and the Charnley/Thackray Relationship

In the last chapter we focussed on surgeons and engineers, but we also mentioned the companies with which they worked. Deloro Stellite, the metal company, sold the McKee-Farrar and initially made some of the Stanmore models; Zimmer UK, a major orthopaedic supplier, was mainly responsible for the Stanmore; and the London Splint Company worked with the Exeter team, and was taken over by their long-time American associate, Howmedica. We introduce the present chapter by briefly exploring the histories of these British companies, before we go on to detail the relationship of Thackray with Charnley. This introduction will also show how the THR business built on the single-component hip prostheses which had been invented in the US but were also manufactured and sold in the UK.

Surgeons and Engineers in Postwar Britain: Medical Technology in Local Contexts

Before WWII, operations on arthritic joints were a last resort. Most involved cutting away part of the joint and fixing it (arthrodesis) so as to prevent motion and so reduce pain.1 In some cases, the operated joint was manipulated to allow a certain amount of motion.2 But the limitations of fixing joints were clear, especially to American patients, and it could not be done on both hips.3

Introduction: Devices, Designs and the History of Technology in Medicine

Medicine has been transformed in the last two centuries, and these transformations were intimately linked to technological developments. If we follow the US Office of Technology Assessment and define medical technologies as ‘the drugs, devices, and medical and surgical procedures used in medical care, and the organizational and supportive systems within which such care is provided’,1 then medical technology makes up much of modern medicine. Medical technologies changed diagnostic procedures and treatment regimes, and technical innovations were closely associated with new approaches in medical science and with the rise of what we call biomedicine, the marriage between laboratory science and medical practice.2 They spawned industries and led to new organizations. This volume seeks to understand and explain a number of the devices and designs that transformed medicine, the politics they embodied, the people who devised and used them, the spaces in which the transformations took place, their impact on medical knowledge and practice, and the consequences for practitioners, patients and society.