American Surgical Instruments: The History of Their Manufacture and a Directory of Instrument Makers to 1990 (Norman Surgery Series, No. 9)

This is the first comprehensive history and directory of the American surgical instrument trade prior to 1900 and provides a wealth of information never before available. Though a great deal is known about the practice of surgery and the men who performed it in colonial and nineteenth-century America, very little is known about the makers and dealers who provided the tools for these great figures. Dr. Edmonson has created a much-needed resource for historians, curators, and instrument collectors alike.

From the foreword by John Kirkup, M.D., F.R.C.S.:
"In essence, this book provides a meticulous analysis of the medical, surgical, and dental instrument trades in America from the later years of the eighteenth century to the earliest years of our own . . .[T]he detailed Directory fills a notable hiatus with its exhaustive listing of companies . . . Here museum conservators, instrument collectors, and others will find answers to many questions of name, place, and time.

This is complemented by an absorbing introductory essay which emphasizes the former close cooperation of instrument makers with leading doctors and medical schools and how this determined the location and commercial success of businesses . . . In an extensive appendix, Dr. Edmonson reviews instrument manufacture in the nineteenth century . . . It is a great pleasure to write this foreword to Jim Edmonson's pioneering analysis of a craft industry that illuminates so positively a unique period in both American and surgical history."

Sushruta said more than 2000 years ago that to be a fit physician, one must have multiple virtues and be "fully equipped with supplies of medicine, surgical instruments and appliances." The two books reviewed here describe surgical instruments and will attract readers with various interests. One of the books contains reproductions of two surgical-instrument catalogues from the time of the Civil War and will be of special interest to Civil War buffs and medical historians. Edmonson has written a beautiful introduction to the two catalogues, and we learn much about the two families who made the instruments and prepared the catalogues.

The most common operation performed during the Civil War was amputation -- the Union Army performed 29,990 such procedures. It is thus not surprising that most of the instruments in the two catalogues are related to what was then standard practice. The technique of amputation is well described in The Principles of Surgery, written by Dr. James Syme in 1856 (London: J. Murray). As soon as the patient was given an anesthetic, the skin was incised with a large amputating knife. If a fish-mouth incision was used or a flap was created, then a catlin knife was the instrument of choice. The skin was retracted, and the muscle incised with large knives. The bone was exposed, and a bone scraper or raspatory was used to elevate the periosteum. The bone was cut with a surgical saw. Attention was then turned to the major blood vessels, which were grasped with a tenaculum or an artery forceps. To eliminate future sequestra of bone and to make the healing process optimal, a gnawing forceps or bone file was used to smooth the stump of bone. The total operative time was usually under 15 minutes. All the instruments in the catalogues are well described and illustrated. Furthermore, the Snowden catalogue gives the prices of the instruments. They were not cheap, especially when one considers that the gross annual income for a pre-Civil War physician was $500 to $1,000, often paid in kind rather than money. Fortunately, for Union surgeons, instruments were purchased by the War Department. For Confederate surgeons, the situation was more difficult, and they relied on instruments captured from the Union Army or purchased from England, which are depicted in the Weiss catalogue.

For a comprehensive historical treatise on American surgical instruments, we must turn to Edmonson's book, American Surgical Instruments. The history is fascinating. We learn that three major events markedly changed surgical instrumentation: the introduction of anesthesia, the development of surgical specialties, and the advent of surgical antisepsis. Anesthesia made nontraumatic surgery possible, and there was a burgeoning of new techniques, including those used in thyroid diseases and peptic ulcer disease, and even appendectomy, which was not performed until after 1870. By the 1900s, surgeons were already developing neurosurgical procedures and special instruments for urology. Antisepsis had a profound effect on instruments, since manufacturers could no longer use tortoise shell and ebony for the handles. Stainless steel became the standard.

In addition to the changes in surgical instruments, Edmonson describes the manufacturing and marketing of such instruments. For example, he states that in 1781, there was a lottery in conjunction with an advertised sale of instruments. The winner of the lottery acquired instruments at a fraction of their cost, and thus more people were attracted to the sale.

Edmonson does not confine his treatise to instruments for physicians and surgeons. Dental instruments, cupping sets, and steam atomizers are also well illustrated. The real attraction of Edmonson's book is the well-written text and historical vignettes. Historians will be particularly attracted to the two reproduced catalogues, but the real gem is American Surgical Instruments, a history book that can be appreciated by students and residents and by surgeons who want to know about their professional heritage.

Reviewed by Donald Trunkey, M.D.
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