Getting Under Your Skin: X-rays as Social History

Early in the 1980s, a number of books on the history of the American hospital presented a challenge to social and medical historians. Briefly, the books held that traditional medical history—defined by this group of scholars as the chronicling of the scientific achievements and intellectual development of physicians—was unable to address broader questions regarding the emergence of the hospital as a central institution in American life, the place where most Americans are born and where we expect to die. The younger historians held that to understand the centrality of the institution for the middle class, for example, we had to understand the demographic, spatial, and social forces that pushed the middle class out of their homes during periods of illness; to explain the transformation of the institution as a focus of charity and its development as a capital intensive money-generator, we had to place the institution in the center of the industrial and commercial economies that drove the broader American economy; to explain the emergence of the physician as a central figure in what were once long-term care facilities for the chronically ill, we had to trace the changing economic and social relationship of trustees, physicians, patients, and the government. ¹ As part of a broader effort in this field, hospital history was recentered as historians’ attention moved away from the activities of physicians at the bedside and scientists in their laboratories to the external economic, political, and social relationships that reshaped American health care. In the process, the field of medical history as a whole, once parochial and somewhat iconoclastic, became broadly conceived as a social history enterprise.

While the history of hospitals certainly took on a greater sophistication, the new history tended to avoid the technical and biomedical aspects of change. In part, the resistance to discussing the activities of physicians in the hospital stemmed from a fundamental rejection of certain tenets of the old medical history that saw all change in the institution as deriving from inevitable, positivist “advances” in scientific medicine. In part, the unwillingness to address the practice of medicine derived from a general sense of discomfort with the technical aspects of medicine among PhDs trained in liberal arts doctoral programs. In part, there was undoubtedly a nagging fear that the social historical approach to change in the hospital could be confounded by close attention to the “science” of medicine, whose positivist underpinnings would undoubtedly cloud our developing analysis.

Joel Howell has provided an extremely important service by writing a book that directly addresses the lapse in the recent historiography and provides a model of how to integrate the history of technology in a broader social historical approach. His book looks at some of the defining technologies of the twentieth century hospital—the x-ray, blood counts and analyses, and urinalysis and questions the ways that such technologies transformed patient care and hospital practice. Drawing on a vast array of patient and administrative records of the New York Hospital and the Pennsylvania Hospital, Howell convincingly shows that questions of technological change can be neatly integrated into the social history of the modern institution. Far from being a driving force in shaping the institution, technologies were introduced into hospitals in ways that reflected and were driven by the administrative, cultural, and professional environment.

The book begins with the observation that between 1900 and 1925 virtually every aspect of hospital practice was reorganized and redefined. X-ray departments, blood counts, and urinalysis, along with complex and vastly more detailed medical record keeping, replaced the somewhat haphazard and informal nature of hospital care. Along with the changing medical technologies came an increasingly complex administrative structure that depended upon patient billing, complex accounting practices, and financial arrangements with visiting practitioners and hospital staff alike. Far from finding the new technologies as inevitable and necessarily logical products of an advancing science, universally accepted because of their intrinsic value...