• variations in the belief: through science anything might be possible
• how medicine shifted from care-based to science/technology based
• it isn't just about getting the best treatment--it is about what patients expect and and a wide range of factors that go into doctors and organizations decisions about how to treat patients
• the direction medicine goes in is as much a result of social choices as of scientific progress
  

• doctors didn't want the focus off them (ego)
  
• share the respect and money with other people
• patient might lose trust in the doctor, trust the machine instead
• doctors who have learned one way don't want to take the time to learn a new way
• to be more certain
• science/technology gives the doctor prestige/authority
  
• at least once you have learned to use it well
• more knowledge doesn't necessarily do the patient any good
• knowledge and successful treatment aren't very well linked
  
• machines don't fit smoothly into existing medical practice, you need new specialists to use the machines
• waiting for tests will slow down treatment
• what if the doctor is quite sure, and the test says something else--will the doctor be required to defer to the test?
  

• you might expect quantitative techniques replaced qualitative techniques, but it is more complex
  
• recording of color and specific gravity increased even though the techniques did not change
• measurement of sugar increased both because of new techniques and because of new understanding of diabetes
• textbooks discuss the importance of measuring urea and techniques existed, but it was not widely done and not done only in the cases where it might be most relevant
  
• the centrifuge allowed more "efficient" microscopic examination of urine
• doing routine laboratory analysis of urine helped educate young doctors to be science-minded
• urine testing became a monitoring device, not just a means of arriving at a diagnosis
• the patient's condition is being evaluated in a lab away from the patient, not by a doctor observing the patient

• as other ways of diagnosing disease became more available, urine analysis was used more narrowly

X-rays got quick public attention, but why were they less used in patient care?

• x-rays were discovered in 1895, by 1900 their medical use was well documented
  
• doctors didn't want their expertise replaced by machines
• the closest x-ray machine was far from many patients
• hospitals wanted x-ray machines to attract patients
  
• even in hospitals that had machines, x-rays were at first used rarely
• even in 1910 no more than half of patients with broken bones had x-rays taken
• that changed by 1920/25, perhaps partly because of the experience of WWI but also because a new specialty had developed to operate the machine and interpret the results
• in the 1920s the hospital began to be a place you went for tests your doctor could not do

The public reaction to x-rays was intense

• it might be interpreted as the deeper self or as a warning of death or a threat to privacy
• women's bodies might be examined more scientifically by men
• statistics show women were less often examined by x-ray in Pennsylvania but more often in New York
• machines were used to increase the prestige of doctors by association with science and technology
• particularly if the patient paid for the interpretation, not the photograph
• as medicine shifted from care-based to technology based, the number of women doctors dropped
• machines were part of the efficiency movement

Blood counts

• counting white and red blood cells began as early as the 1880s
• the meaning of blood counts was not clear and they weren't necessarily quick to do
  
• note p. 181--the important doctors who saw machines as less than clinical experience and skill
• were the techniques of scientific research relevant to clinical care?

Detecting diseases in blood

• anemia was a fairly easy case, though the older practice was to diagnose from clinical signs
• malaria was one of the first diseases where the disease organism could be seen in the blood
• white cell count helped predict whether the person was likely to survive pneumonia
• typhoid was particularly difficult to diagnose
• appendicitis was similar and one of the triumphs of surgery (if the diagnosis was correct)
• surgeons didn't like the idea of other doctors deciding by blood count whether the patient had appendicitis
• doing a blood count could be more scientific, or it could be helpful to doctors without advanced clinical skills

Medical advances are full of social choices as well as scientific ones
Is that what we saw in the civil war as well?

• before the civil war, hospitals were mostly for poor people, during the war hospitals had to be developed to provide standardized care for soldiers, in the early 20th century hospitals are still standardizing but they are also trying to grow by offering cutting edge treatment
• at that point care was more central to medicine and science was just beginning to be influential.  Already you can tension between science and individualized medicine
  
• care = concern the doctor shows for the patient but also individual treatment for the patient's situation
• patients had to get used to new experiences in how they got health care
• over time doctors are getting more detailed information and they need to learn how to use it
• only when you to get to the early 20th century are hospitals becoming a place you might go by choice in many cases
• hospitals allow better training of doctors
• in the civil war, spread techniques from the best doctors
• in the early 20th century medical education is being reformed to teach more science and to give students more hands on experience--hospitals needed to grow to get young doctors better hands on training
• sanitation and cleanliness was pioneered in the civil war and with further development it made possible moving medical care to the hospital
• standardization/Taylorism (techniques for organizing work efficiently)/data collection are necessary conditions to the move to a more scientific medicine
  

How to make choices about technology (another set of questions to ask to look at the social side of medical progress)

• how much does it benefit the patient compared to other alternatives
• how does it change the status of the doctor
• what if the laboratory results contradict what the doctor thinks s/he knows from experience and skill?
  
• does it make money for the hospital
• does it aid in training young doctors
• how does it affect the doctor-patient relationship?
• what are the causes of lags between theory and practice?
• how do local cultures vary?
• are medical decisions individual to the patient or universal based on science?
  

Anyone interested in a summer course on Historic and Contemporary Healthcare Architecture of northern Italy, May 18-May 31?  An architecture course with no prerequisite.  For further information contact Prof. David Allison at adavid@clemson.edu