University Times

X-ray machines appeared on the medical scene in 1895. By the turn of the century, they could be found in every hospital of consequence in the world. But they had a serious problem, one that had nothing to do with radiation. Nobody was using them.

Rather than ordering X-rays as part of the treatment for broken bones and other injuries, doctors and hospital administrators spent their time arguing over the costs of X-rays and whether they were worth the price.

What happened to a patient in Philadelphia's Pennsylvania Hospital in 1902 was typical. The man was admitted to the hospital with a broken leg on Jan. 7. After 18 days of casually charted ups and downs in his condition, an X-ray finally was ordered on Jan. 25.

It would take almost two more decades before X-rays would become part of the routine treatment for injuries, said University of Michigan medical historian Joel Howell at the recent C. F. Reynolds Medical History Society lecture. And the big reason for that change had little to do with the practice of medicine. It was because of Henry Ford.

"In this period, factories were really where it was at," Howell explained. "They were efficient. They were accumulating large amounts of capital and they were a model for much of what was going on in the hospital, not just in terms of the assembly line, but also in terms of management." Following the industrial model, hospital superintendents who once had simply handed down orders were by the 1920s consulting with departments before making decisions, Howell said. They also had come to rely on the cost accounting methods used by industry to determine how much money each department was bringing in and how much it was costing. Before Ford, hospitals used accounting methods that assigned funds to large categories. During his lecture, Howell showed a copy of the 1902 budget for the University of Michigan Hospital. It fit on a single sheet of paper. Such accounting methods caused debates like that over the cost of X-rays and delays in the treatment of patients, according to Howell.

When coupled with scientific advances, such administrative changes also brought with them the glorification of the surgeon. Although anesthesia was available in the 1850s, Howell noted, operations were relatively uncommon until the 1920s because it was difficult to gauge their cost effectiveness. The typical hospital of the 1890s performed about 240 operations annually. By 1925, that figure had climbed to almost 2,500 operations annually.

As HMOs are hotly debated topics in medicine today, so was the rise of factory-style hospitals around World War I. One publication from the period showed the concern about cost and health care with a drawing of a line of nurses forced to punch a time clock before they can care for a critically ill patient.

"The concern that money is going to damage health care is very old," Howell pointed out.

Howell's lecture, "Technology and the Making of Modern Medicine," was full of such insights into the American hospital going back all the way to the 1840s, when hospitals were places to be avoided at all cost.

A typical hospital of 150 years ago would be unrecognizable today. To begin with, Howell said, it would have had nothing to do with a medical school. In fact, most medical students, most physicians, would have spent their entire careers without seeing a hospital. Patients were treated in their homes.

Only the poor went to hospitals in the mid 19th century, but not all the poor. The poor in hospitals were the "worthy poor," hard working citizens who could not make ends meet. The "disreputable poor," alcoholics, prostitutes, the insane, were placed somewhere else.

Such disparity in treatment between the rich and the poor was seen by society as inevitable, according to Howell. Hospitals themselves were not supported by patient fees, but by the voluntary donations of the rich who saw such support as their duty.

Within the mid 19th century hospital, the superintendent would have lived with his wife, who probably was in charge of nursing and meals. Physically, hospitals of the period looked like houses and many of them at one time had been homes, Howell said, which is the source of the hospital terms "house officers" and "spending the night in the house." Once admitted to a hospital, a patient usually stayed for months. Nurses were mainly former patients who had no- where else to go after they were released. Attending physicians were paid in prestige and praise for doing their duty to the poor.

Technology in a hospital of the 1850s was almost nonexistent. Even if a hospital owned a thermometer or stethoscope, chances were good that nobody on duty knew how to use it. The idea that science and technology should play a role in health care, in fact, was totally foreign. Benjamin Rush summed up the situation when he said: "Medicine is my wife, but science is my mistress." "What he meant by that was that medicine was what he did for a living and science really had nothing to do with the core essence of a professional institute," Howell explained.

How bad hospitals were a century and a half ago is evident by a request from one superintendent to purchase a bathtub so that patients scheduled for surgery could be washed. He was told there was no money available, according to Howell. An 1856 report from another hospital urged nurses to change the straw on the beds of patients once a month.

"It was a disgrace to even let your servant wind up in one of these hospitals," Howell said.

The transition in hospitals began with the shifting of population from rural settings to port cities like Boston, New York, Philadelphia and New Orleans.

"These were urban settings in which, when you became ill, if you were a single young man who had moved to the city to make your living, there was nobody who could stay at home to take care of you, unlike living in a rural, family oriented situation," Howell explained. "So, if you got sick, if you broke your leg, you needed to go into the hospital in part simply to get basic kinds of care." The first hospital census conducted in 1873 found 120 hospitals with about 35,000 beds in the nation. By 1909, urbanization had pushed that figure to 4,359 hospitals with approximately 421,000 beds. While the nation's population also grew substantially during that period, the increase in hospitals was far greater than the population increase, according to Howell.

During the 1920s, hospitals became such important institutions that their physical structure dominated the environments in which they stood. Patients also were no longer poor, but members of the middle class. Advertisements from the period encouraged people to go to the hospital for treatment.

On the down side, mass treatment in hospitals and advances in medical technology brought with them a distancing of the patient and physician, according to Howell. Instead of handwritten reports on each patient, physicians began using standardized forms that turned the patient into a collection of organs. Such forms could be directly traced back to business, Howell said.

Even though hospitals became the places to be treated for illness and injuries around World War I, they were not always available to everybody. In 1923, according to Howell, 23 percent of hospitals nationwide and 30 percent of hospitals in the South would not accept African Americans as patients. Many hospitals that did had only a few beds in their basements reserved for African Americans.

In response, the African American community founded its own hospitals. By 1920, there were over 100 African American hospitals in the country.

Although the medical establishment of today has placed its trust in technology, Howell said that culture, not technology, will determine in which direction medicine will go in the future, just as it has in the past.

"We can never lose sight of the fact that medicine and technology, we [physicians] and our patients, all exist in the larger fabric of American society and American culture," Howell said. "Although there are many paths to go, whatever direction we go is not going to be determined by pure science and pure objective technology, but rather by a cultural milieu and a cultural decision.

–Mike Sajna