There is an abstract.
Western medicine has always relied on a belief in the power of technology and the value of science. The X-ray machine is one of the most dramatic new tools ever discovered, and I study the history of how technology came to be seen as useful. I use a statistically valid sampling of case records from 1900 to 1925 at the Pennsylvania Hospital to ask why and when physicians at these hospitals came to see X-rays as useful for patient care. After the X-ray ‘s 1895 invention, there was seemingly worldwide agreement that it could be used to diagnose common conditions. X-ray images became part of routine patient care after the underlying structure of the hospital changed due to importation of technologies from business.
This is the introduction.
The widespread introduction of science and technology has been the most consequential change in the United States over the past century. Almost every part of health and health care is dominated by scientific thinking. Of the many dramatic innovations we have seen over the past century, perhaps none has had a more ubiquitous impact than the use of images. The quotidian use of the X-ray, computer assisted tomography scans, magnetic resonance image, and others is what we need to think about. The pictures they produce are usually seen as trustworthy evidence and determinative findings in instances of clinical ambiguity, because they color almost every aspect of patient care. A significant portion of the rapidly increasing money spent on health care in the United States is spent on diagnostic tools, and the tools are used at a much higher rate in the United States than in other industrialized countries.
The introduction of the X-ray machine makes for an especially propitious case study if you want to ask how and why medical technology has come to play such a dominant role in US medicine. The invention of the X-ray machine came at a time when a physicist named William Conrad R was working on it. He used rays that pierced the skin and revealed the shadows of the bone. Rntgen called them X rays because he did n’t know much about them. The image of his wife ‘s hand was sent around the world on Christmas Day 1895.
Reading: EARLY CLINICAL USE OF THE X-RAY
It is difficult to overstate the impact of this event. Almost every segment of society was affected by the sudden ability to see. At a time when there were fewer journals than we have today, the X-ray was the subject of 49 books and more than 1,000 articles within the first year after its invention. X-ray machines were found in many locations because the equipment needed to make them was cheap and easy to use.
X-ray images were initially attempted for many different conditions. The brain was hard to see with the new tool, but it was easy to see foreign bodies with the new machine. Fractures were easy to identify with the new rays. The use of the X-ray machine was seen as essential for clinical care by 1900, especially for making a diagnosis of foreign bodies.
It is not easy to understand the history of the use of the X-ray machine for clinical care. Hospitals are a good place to start analyzing the initial use of the technology. Hospitals at the end of the 19th century and the start of the 20th century were rapidly growing in number and size, increasing in structural complexity, and starting to be seen as clinically relevant not only as a last resort for the worthy poor but also as places where middle-class patients might
A study of early use of the X-ray is not possible if you look at patient care in hospitals. The United States was a mostly rural country. It would be difficult for patients with a broken leg to get an X-ray. They did n’t need to travel to get the test if the hospital had an X-ray machine. Hospitals that saved their patient records from the period allow researchers to track utilization of the new technology using statistically valid, systematic sampling of those records.
There are new tools in old hospitals.
This presentation is based on work done using the case records of the Pennsylvania Hospital, the nation ‘s oldest hospital, and one that takes its history very seriously. Similar to many other institutions, the hospital purchased an X-ray machine in 1897. To study how often and for what purpose the X-ray was used, a systematic sample of 400 case records was obtained for each of the years 1900, 1909, 1920, and 1925. The data obtained from the New York Hospital was not presented in the interests of time.
There is a table 1
|Year||All Patients||Excluding Patients Admitted With Diseases of the Tonsils||Patients With Fractures Only|
|1900||1.31 (0.426-3.02)||1.33 (0.434-3.08)||8.7 (1.01-28.0)|
|1909||6.97 (4.68-9.91)||8.19 (5.51-11.6)||50 (26.0-74.0)|
|1920||16.78 (13.4-20.6)||22.02 (17.7-26.8)||100 (76.8-100)|
|1925||25.25 (21.0-29.8)||32.54 (27.2-38.2)||85.7 (57.1-98.2)|
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In 1900, the X-ray was rarely used for all patients, and for less than 10 % of patients in 1909. A quarter of patients admitted to the hospital by 1925 had an X-ray examination. One can start to refine the analysis by not including patients who are admitted for removal of their adenoids. It was becoming quite popular to have tonsillectomies and adenoidectomies. They were based on the idea that the only way to cure a disease was to remove the offending organisms and the organ that harbored them. The patients who needed removal of their tonsils and/or adenoids were admitted only overnight, and were not seen as having any reason to have an X-ray image taken. The removal of them from the analysis gives a more realistic idea of the use of X-rays in the more seriously ill patients admitted to the Pennsylvania Hospital.
The third column shows patients who were diagnosed with a fractured bone. The most telling column is this one. Fractures were seen as a key diagnosis and a common problem. On the rapidly industrializing Eastern Seaboard, this was especially true. Young men might become injured working on the Philadelphia docks, while others might fall from the apartment buildings. The use of an X-ray for patients suspected of having a broken bone mattered to both the physician and patient. It was a less painful method of diagnosis for the patient than the traditional use of manual manipulation of the broken bone, and possibly a more precise and modern technique for the physician. Fractures were easy to detect with an X-ray, and by 1900 they were best diagnosed with the new tool.
The Pennsylvania Hospital purchased an X-ray machine in 1897 and assigned someone to be in charge of it. Despite the widespread attention paid to this exciting new tool in the medical literature, it was only rarely used to diagnose fractured bones in the Pennsylvania Hospital 1900. The medical literature would have you believe that use was proper in 1909. It might be better to ask what happened that led to the increased use of the X-ray by the first quarter of the 20th century, rather than asking why the X-ray was so little used in 1900 and 1909.
Who was supposed to operate the machine was a big change. The chief medical resident ran the X-ray machine from 1897 to 1909, and his duties included being in charge of a variety of other equipment. The former chief resident ran the X-ray machine for a year. The first insisted on the purchase of new equipment after declaring the old equipment obsolete.
The operation of the X-ray machine changed in 1912. David Bowen would devote his career to using the X-ray machine in that year. He decided to limit his medical practice to use of a new machine because he was an early form of a specialist. He was often referred to as a Rntgenologist in honor of the machine ‘s inventor. He had his own department, he had space assigned to it, and he had an assistant. The percentage of the fees generated from paying patients was kept by Bowen. Over this period, such patients were a small but growing minority of hospitalized patients. Both professional and personal reasons were given by Bowen to encourage use of this new technology.
There was a new way of thinking about the meaning of scientific medicine in general and of a scientific hospital in particular. Hospitals used a systematic approach to record information in patient records. New organizational methods such as the graph and the memo were used. The hospital ‘s annual reports featured scientific record-keeping as significant. Case records between 1900 and 1925 showed all of the record-keeping innovations. The results of laboratory tests, including the X-ray, began to be recorded in a way that included specific data elements. Omitting one part of the data was obvious. A separate department was run by people with specialized knowledge about the use of the test that was recorded on specific forms. The introduction of medical technology into America ‘s oldest hospital was one of the changes.
There is an X-ray examination at the Acculturation Center.
The X-ray machine was looked at by members of the American Clinical and Climatological Association. Francis H gave a talk on the “ Climatology of Nudity ” at the 15th Annual Meeting in 1898. Some of the medical uses of the Rntgen Light were discussed by Williams. The new tool had passed from being a new fad to being a central element of clinical care according to Williams. He thought that there was no need for fear when using the X-ray. The summit of Mt. was climbed by 22 members of the Association. They enjoyed dinner in Washington.
Williams was wrong, along with most other early adopters. The X-ray tube could be dangerous for both patients and physicians who were early users. Early X-ray users would test to see if the tube was putting out an adequate amount of X-ray by looking for a glow in their hand when put in front of the beam, a method of testing that would soon reveal itself to have deleterious consequences. Recent historical work suggests that the early radiologists knew more about the dangers than they let on. They pushed ahead even though they saw a brave new world, and did so in a way that made them feel better about their suffering.
Lessons from the past.
To understand the medical use of a machine, even one that seems to have obvious utility, one must study more than just the medical applications of the device. It is necessary to study how that machine is used. The system within which a machine is used is also considered. The organizational structure of the institution would be included in the case of the X-ray machine. The case for using X-rays to diagnose fractured bones was firmly established by 1900, but it was not a regular part of patient care for decades to come. Changes in the type of person who was running the machine, changes in the payment mechanism, and changes in the way that data were visualized were required for it to become a part of routine patient care.
Diagnostic capabilities came at a cost. The machine ‘s use had consequences for early users. The consequences were a direct result of early radiographers trying to accommodate a new world.
The world we live in is filled with technology. The most profound technologies are those that disappear. They are indistinguishable from everyday life until they are woven into it. It is easy to forget that it has a history. As we introduce even more technology into the practice of clinical medicine, history may give us insight.
More detail on the sampling methodologies as well as the findings from the New York Hospital can be found in the work originally published in Technology in the Hospital.
There are potential conflicts of interest.
There is a discussion.
Schreiner, Los Altos : That was fascinating. There was an independent push towards the use of X-rays based on the institutionalization of both the technology and the people administering that technology. In the 19th century and earlier America, broken bones were a common consequence of a vigorous and challenging outdoor life. If you are correct that the use of X-rays was not solely driven by medical need, the implication would be that the effectiveness of the treatment was not proportional to the increase in patients. Is there a sense that outcomes improved ? Is there any evidence that taking an X-ray image impacted outcomes to the same extent that it was taken ?
I have both a sense and data, which is even better. You ask good questions. People already knew how to diagnose fractured bones before the X-ray was invented. The diagnostic procedure was painful for the patient. If you grasp one piece of the bone here and one piece of the bone there, and you can move the two pieces independently, then there is a break in the bone. The procedure is not very pleasant for the patient. The need for such a procedure could be reduced by the X-ray. To be able to use the X-ray, you had to use transportation. Everyone in the hospital was already there, including physicians, patients, and diagnostic technology. Most people who broke their bones were n’t in hospitals and were n’t near hospitals. The early X-ray machine was not portable. Many physicians had to use manual diagnostic techniques. Hospitals became central for medical care as the X-ray was being invented. There was an industrial age on the Eastern Seaboard. Railroads were expanding, workers were unloading ships on the docks, and a lot of people were breaking their bones and being taken to the hospital. I looked at the lag time between admission to the hospital and taking an X-ray to answer your question. After the invention of the X-ray, there was a lag between admission to the hospital and the X-ray being taken. We can assume that the diagnosis and treatment decision was made on admission, not on the basis of the X-ray image, which was taken later not to make a diagnosis or to guide therapy. The physicians wanted to see what the fracture looked like after getting a new tool. The median lag time was under a day by 1925. The X-ray was being used to make a diagnosis. Is it possible that it made a difference in terms of treatment ?
Markovitz : That was very interesting. I was fascinated by the fact that diagnostic radiology was once a macho field. It has changed. I wanted to know how patients reacted to X-rays. The name sounds very imposing. How did they deal with the effects ?
You bet they were worried. They were worried about something. They were worried about the new electricity in hospitals. People were still trying to agree on whether to use DC or AC current. There was a lot of electricity, there were a lot of loose wires, and sometimes patients and physicians were killed in hospitals. They were very worried. I can show you a painting that shows a man getting an X-ray who is very scared. John Sloan had X-rays in the 1920s.
I really liked your talk. I wondered if the use of radiology and cathode ray tubes outside of medicine was affected by medicine.
That is a great question. I mentioned in the talk that it was easy to make cathode ray tubes. If you had a little money, you could make a tube and take pictures. X-rays became medical in one of the most interesting aspects of the history. They were not always medical. Lay entrepreneurs used to set up X-rays stands at the opera house. There were people on the street. People gave their X-ray pictures to their loved ones as if it was the most beautiful picture they had ever had. In Magic Mountain, Hans Castorp holds up his beloved ‘s X-ray image of her chest and says “ How often did I hold it, how often pressed it to my lips. ” Many people who bought X-rays did not buy a medical X-ray. It was being taken by photographers. The field of taking an X-ray picture has changed. The claim that the radiologist is not a photographer, taking the picture for the patient to take home or give to someone else is associated with that change. The radiologist claims to be a consultant. The example of physicians who do a blood count is used when making this claim. They wo n’t give you the smear if you come to me with a blood count. In a similar way, what you are buying from me as a radiologist is my expert opinion about what the X-ray shows, not the actual physical image itself. The X-ray works its way into the medical world. Outside of medicine, the X-ray machine is used.
Goodenberger is in St. Something you said made me remember. When I was a kid, you could walk into a shoe store and put on your shoes and see your toes wiggle under a fluoroscope. Did you know of other uses of this in the general public ?
The non-medical use of the X-ray machine is at the tail end of what I was talking about. I did the same thing. It was a lot of fun.