Book Review

Technology in the Hospital: Transforming patient care in the early twentieth century

N Engl J Med 1996; 334:128-129January 11, 1996

Article

Technology in the Hospital: Transforming patient care in the early twentieth century
By Joel D. Howell. 341 pp. Baltimore, Johns Hopkins University Press, 1995. $47.50. ISBN: 0-8018-5020-7

For anyone interested in the history of medicine, and the history of hospitals in particular, this is an intriguing and entertaining book. Reflecting on hospital care at the turn of the century, we tend to envision long wards with many beds and nurses in starched uniforms with picturesque caps. Medical technology was sparse and primitive. The hallmarks of a “modern hospital” in the early 1900s were the laundry room, the kitchen, and possibly the telephone system. Diagnostic devices such as x-ray machines were not particularly important in classifying a hospital as modern or advanced. In this book, Howell carefully examines the transformation of medicine into a science-based discipline during the period between 1900 and 1925: how patients were cared for and how hospitals functioned.

Howell describes in some detail the increasing organizational complexity of hospitals during this period. Originally, the patient's room, or more likely the ward, was the place where the patient spent all his or her time, but as hospitals grew in complexity, and technology was introduced, patients were taken during the course of their stay to unfamiliar places such as the x-ray room or the electrocardiography room. Organizational complexity also included the appearance on the hospital staff of persons with specific technical responsibilities.

There were also changes in the social environment and the types of people who were admitted to hospitals. Lower-class patients, many of whom were illiterate or marginally literate, filled the hospitals in the 1900s but were joined by middle-class patients by 1925. This change came about because the public began to view hospitals as the technological and scientific centers of medicine. The admission of middle-class patients meant that increasing numbers of patients who could pay for their health care were sent to hospitals for special care by their physicians. The focus of medical care and medical education moved from the doctor's office (and the home) to the hospital. Hospitals also became the focus of biomedical research and innovation.

The book begins in 1900 with the story of a young laborer who was admitted to the Pennsylvania Hospital with a broken leg. Even though the hospital had an x-ray machine, no x-ray film was obtained. A sample of the patient's urine was examined cursorily on the first day, but no other tests were performed. He was discharged 51 days later; despite the long stay, the record of his hospitalization was only one page long. Twenty-five years later, a cook, also with a broken leg, was admitted to Pennsylvania Hospital, but his stay was quite different; an x-ray film was obtained to confirm the diagnosis, and his urine was tested four times. He was hospitalized for 21 days, and the record of his stay was eight pages long, with one graph. The experience of these two patients dramatizes how hospital care and medicine had changed in 25 years.

The data on which this book is based were derived from a detailed analysis of a random sample of 2500 patient records between 1900 and 1925 at two hospitals, Pennsylvania Hospital in Philadelphia and New York Hospital in New York City, the oldest and second oldest hospitals, respectively, in the United States.

Initially, infectious diseases were the most common diagnoses among patients admitted to both hospitals, followed by traumatic injuries, but by the end of the study period “diseases of the tonsils” were the leading diagnoses at Pennsylvania Hospital and the second most common, after “diseases of the intestines,” at New York Hospital. The resultant increase in tonsillectomies and adenoidectomies reflected the rising popularity of the theory of focal infection.

With the increasingly complex organization of hospitals, cost accounting became a necessity. Written records gave way to calculators, punch cards, and tabulating machines. Gradually, patient records and demographic data became standardized. With the introduction of the x-ray machine, arrangements for paying physicians, especially roentgenologists, were adopted.

Generally, surgeons were considered superior to other physicians for several reasons. Surgery was perceived as “heroic,” surgeons were able to demonstrate measurable results, they developed dramatic operative procedures, and the new hospital structure made surgeons especially prominent. As a consequence of this prominence, the organizational framework of hospitals was modified to foster and accommodate a rapid flow of patients.

It is remarkable that during this innovative and exciting time in medicine, a note of caution and self-examination was expressed by E.A. Codman, a Boston surgeon. He introduced the idea of a careful and systematic accounting of outcomes after surgery, a concept that has been rediscovered in recent years. Codman's efforts prompted the American College of Surgeons to advocate the use of improved and standardized records and to promote formal surgical training.

Medical practice was also affected by efforts to substitute science for unproved theory, especially in diagnostic testing. Among the earliest of these efforts was urine testing. The majority of patients admitted to Pennsylvania Hospital or New York Hospital had at least one routine urine examination (regardless of the diagnosis). Between 1900 and 1925, urinalysis became the first diagnostic test to be repeated frequently during a patient's hospital stay, thus establishing the model for continuous monitoring. Urinalysis was also accorded special attention in medical education: Richard Cabot, the famed Boston physician, “claimed that some Harvard graduates `always knew how to examine urine, even when they knew little else.' ”

The diagnostic use of x-ray films was almost immediately accepted by physicians after the discovery of this technology in 1895, although there were skeptics who denied the advantage of x-ray studies over a good clinical examination. by 1900, most of the major hospitals in the United States had purchased x-ray machines, and by 1925, x-ray films were routinely obtained in cases of suspected fractures.

Although the x-ray machine was adopted with enthusiasm, the introduction of electrocardiography was very slow. New York Hospital did not acquire a machine until 1914, and Pennsylvania Hospital did not purchase one until 1921. By 1925, electrocardiographic studies had become routine, although their clinical value seemed uncertain to many people.

Decades passed before blood counts became commonplace and total white-cell counts and differential counts were incorporated into medical practice. The controversy over their importance soon expanded to debates over the relative roles of clinical judgment and laboratory science, a dispute that not infrequently surfaces today.

Throughout the book, Howell examines medical care and especially the use of medical technology in a social context and “to learn something about how and why medical technology has become such a routine part of U.S. medical practice.” Whether the history of medical technology and its introduction into medical care at the turn of the century is “valuable for those interested in contemporary health policy,” as the author claims, is questionable. Decision making 80 years ago would seem to have little relevance to modern times, given the remarkable differences in the social setting then and now. Even so, the author takes care to identify “contemporary echoes,” such as the current interest in total quality management, which is not too different from efforts to improve efficiency in the early decades of the century, and clinical practice guidelines, which had antecedents in the early 1900s. I recommend this delightful book to anyone interested in the history of medicine.

Seymour Perry, M.D.
Medical Technology and Practice Patterns Institute, Washington, DC 20007-2258