Reviewed by Victoria A. Harden

Historian, National Institutes of Health, Director, DeWitt Stetten, Jr., Museum of Medical Research, Bethesda, Maryland 20892-2092

A person entering a hospital today routinely undergoes laboratory tests that the attending physician uses in making a diagnosis. The patient, family members and consulting physicians all rely on the results of such technological inquiry — often presented as numbers or graphs or pictures produced by a machine. The purpose of this book is to explain how medical technology became so pervasive in the hospital and also so convincing a tool that we rarely question its findings. Indeed, we sometimes question the very existence of diseases that depend solely on clinical judgment for diagnosis. Joel D. Howell approaches the subject of technology in the hospital both from the vantage point of a practicing physician, who can speak with authority on the subject as a user, and from that of a holder of a doctorate in history. By melding his two specialties, Howell has produced a study that should intrigue physicians and historians alike. His book is the first of a planned two-volume comparative study of technology and patient care in the United States and England. Based on quantitative data obtained from patient records from the New York Hospital in New York City and the Pennsylvania Hospital in Philadelphia, Technology in the Hospital presents more than 30 figures and 11 tables as well as extensive notes and an appendix explaining sampling techniques and coding forms.

Howell begins by examining the changing organizational structure of hospitals at the turn of the twentieth century, because they provided the institutional loci in which new technologies were introduced. During the so-called Progressive Era, roughly 1875–1925, faith in a better life through science soared and became allied with the efficiency movement that sought to integrate sound business practices into all aspects of social organization. The adoption of business methods — especially cost accounting based on careful record-keeping — by hospitals helped transform them from institutions designed for long-term care of the sick into facilities designed to treat and release patients as soon as possible. This change was also characterized by a growing faith in tables and graphs as symbols of science, and the replacement of handwritten clinical comments with standardized forms in patient records.

The medical specialty that benefited the most from the new hospital organization was surgery. Data from patient records at the two hospitals Howell studied reveal that the percentage of patients operated on doubled between 1900 and 1925. Since anesthesia, antisepsis and asepsis had been incorporated into surgery by 1900, some other explanation must be given for this dramatic increase. Howell argues that two factors contributed significantly. First was the emergence of the theory of focal infection, which, in turn, led to an extensive increase in the numbers of tonsillectomies and adenoidectomies. Second was the new organizational scheme itself. Its efficiency in moving patients into and out of modern operating rooms contributed to the surgeon's view of himself as a bold medical activist in the crusade against disease.

At the heart of Howell’s book are five chapters that examine in detail the medical and social meanings of three modern technologies: urinalysis, the X ray and blood tests. Between 1900 and 1925, urinalysis changed dramatically. From a routine admissions procedure done on virtually all patients admitted to the hospital in 1900, urinalysis was transformed into the premier test of the new, scientific approach to medicine. It proved to be an effective transition test, because it did not require elaborate new machines to make it useful. Examination of the color of the urine had been used to assist diagnosis of certain conditions for centuries; a hygrometer provided information about specific gravity that also guided diagnosis or at least helped to rule out particular diseases. Techniques for determining sugar and urea content had been described in the literature, and the relatively simple manual centrifuge made it possible to examine the content of urinary sediment in a short time. By 1925, urinalysis was employed with discrimination. It was repeated often and used not only to diagnose particular diseases but to monitor their changing clinical course as well.

In contrast to urinalysis, the X-ray machine represented a totally new technology when it was introduced just before the turn of the century. Physicians immediately apprehended its medical possibilities, and Howell emphasizes that it is “difficult to overestimate the profound impact the invention of the X ray had on the broadest possible scope of humankind.” Howell argues that it was not clear at the beginning how the X ray would be used in medicine. Making an X-ray picture required costly and dangerous equipment, a facility wired for electric power and the use of expensive materials. Early in the century, taking an X ray was not done without serious consideration. The new technique proved valuable in the Spanish American War for identifying the location of bullets and other foreign objects in soldiers’ bodies and for diagnosing suspected fractures. On the other hand, in 1901, when President McKinley was shot, his surgeons elected not to use this new tool to locate the bullet, and they were praised for restrained medical judgment.

Howell’s case studies reveal how the numbers of X rays steadily increased in both the hospitals he studied between 1900 and 1925. For patients with suspected fractures, the percentage X-rayed in 1900 ranged between 4 and 8 percent; by 1920, nearly 100 percent of such patients were X-rayed upon admission. By 1925, X rays had become as routine for fractures as they are today. More interesting is which person in the hospital was charged with performing X rays. Between 1897 and 1909 at the Pennsylvania Hospital, the chief resident was assigned responsibility for operating the X-ray machine. By 1912, however, this responsibility had shifted to a physician who specialized in making and reading X rays. Furthermore, he received a salary for this work and split the fees with the hospital, retaining three-fourths of the money for himself. This transition also resolved a debate about what a patient was purchasing when an X ray was taken, the picture itself or its interpretation. By 1912, the medical community firmly believed that a patient was buying the expert opinion of a physician. To emphasize this, the X-ray pictures themselves were no longer released to patients. This brought to an end the practice of lay people cherishing X-ray art as intimate portraits of themselves and their loved ones.

Howell also explores the impact of the X ray on society. In one example, he describes public fears that the X ray would strip away feminine modesty. Male physicians who took care of respectable women were instructed how to examine them by touch alone, without looking directly at the female genitalia. When it was demonstrated that X rays did not stop at the skin after passing through clothing and thus did not jeopardize feminine privacy, the new technique came to offer quite the opposite meaning to physicians and their patients. It was embraced as a means by which male physicians could examine women more carefully without offending their sense of delicacy.

Blood examination is the last laboratory tool that Howell discusses. He details various instruments and techniques used to count red cells and white cells, to measure hemoglobin and to obtain a differential count of the percentage of different types of white cells in the peripheral circulation. Like the urinalysis, these tests helped to fix the notion of a special room, the laboratory, as a critical component of modern medicine and to render unnecessary the patient’s presence as a criterion for arriving at a diagnosis. Malaria was the first important disease for which a blood test was routinely the means of diagnosis, and demonstrating the malarial parasite in red blood cells hastened the adoption of blood tests for other diseases. Most other diseases, however, were not so definitively diagnosed by blood tests. Howell discusses three common diseases — pneumonia, typhoid fever and appendicitis — in which the role of the blood count was intensely debated. He shows how counting white cells in patients with pneumonia came to be valued for its prognostic value but not as a guide for therapeutic decisions. For typhoid fever, in contrast, a diagnostic blood test based on the agglutination reaction was developed by Fernand Widal and widely employed. The utility of leukocytosis and a differential count for patients with possible appendicitis remained a contentious issue for physicians. Clinical experience in this situation often proved more reliable than scientific data. Debate about this, Howell argues, symbolized the tension between an older generation of physicians who venerated the trained clinical eye and the new generation that put its faith in bacteriology and the results of laboratory tests.

In his final chapter, Howell speculates about what his historical study might contribute to discussion of health care reform today, especially to concerns about the appropriate use of medical technology. In contrast to scholars who have concluded that technology’s effect in the twentieth century has been essentially to distance patients from their physicians, Howell argues that technology per se “does not arrive at the bedside with its meanings already determined” and that “some of the most important medical technologies are organizational systems rather than mechanical artifacts.” He draws parallels between the adoption of business techniques by hospitals in the Progressive Era and the philosophy of managed care articulated by health maintenance organizations that seek to control the costs of medical care by businesslike methods. Although Howell occasionally repeats himself in an effort to ensure that the reader understands his aims in each chapter, this flaw does not detract significantly from the value of the book. Howell concludes that the history of technology in the hospital is rich with nuances of human social interaction and cannot be reduced to a simplistic, linear story of scientific progress any more than our medical care and technological dilemmas today will yield easily to simplistic solutions. By providing such a perspective, he enriches our understanding and stimulates careful thought about the problems we face.