I. HISTORY OF MEDICAL TECHNOLOGY

Medical technologies are objects, directed by procedures, that are applied against the hazards of illness. The object is the tangible dimension of technology. The procedure is the focused and standardized plan that guides the use of the object according to defined purposes.

Some medical technologies are more object-embedded. In them the tangible portion is the principal functional component. The X ray, artificial kidney, and penicillin are examples. Others technologies are more procedure-embedded. Their main function is to organize facts, individuals, and/or other technologies. Examples are the medical record, hospital, and surgical procedures. Indeed, the common synonym for the surgical procedure, the operation, connotes actions that are related as parts in a series.

It is important to distinguish technologies from another medium through which actions are taken in medicine— techniques. Medical techniques are procedures mediated through the human senses rather than through objects. Examples are percussion, pulse-feeling, and psychoanalysis. This perspective on medical technology will be used in this entry.

Technology, Nature, and Ethics

The works of the Hippocratic corpus, a group of essays on medical theory and therapy written between the fifth and third centuries b.c.e., analyze the relation between nature and the agents of the medical art, from the viewpoints of effectiveness and ethics.

The ancient Greek concepts of health and illness were based on a theory postulating four humors or basic elements of the body: blood, phlegm, yellow bile, and black bile. In health, these were in a stable equilibrium. Illness occurred when one or more of these humors increased or decreased and thus changed their proportional relation. This change caused an instability of the equilibrium state synonymous with health, and the breakdown produced illness. Nature— the force that inclined the humors toward remaining in or returning to the proportional relations of the healthful state—was viewed as the most powerful agent of healing. The purpose of the medical art was to assist nature to reestablish the proportional relationship of health among the humors.

Works in the Hippocratic corpus cautioned physicians against misapplying medical means. Such behavior constituted an offense that could harm both the patient and the reputation of medicine. In the essay "The Art," the following observation is made:

For in cases where we may have the mastery through the means afforded by a natural constitution or by an art, there we may be craftsmen, but nowhere else. Whenever therefore a man suffers from an ill which is too strong for the means at the disposal of medicine, he surely must not even expect that it can be overcome by medicine. (Hippocrates, 1923a, p. 203)

To exceed the rational limits of the means of medicine was to commit the sin of hubris.

The technology of Greek doctors was relatively simple. They used ointments, compresses, bandages, surgical instruments, simple and compound drugs, and bloodletting in moderation. They used the techniques of history taking, visual observation, and palpation to learn the circumstances of illness, and prescribed diets, bathing, and exercise to maintain health and combat illness.

The Greeks also recognized that the manner in which physicians dressed, approached the bedside, and discussed illness with a patient could influence their success at healing by producing help and avoiding harm, and thus had an ethical meaning. Accordingly, attention to the effects of the physician as a person on the patient as a person became a significant aspect of Greek medical practice. The physician is told "to have at his command a certain ready wit, as dourness is repulsive both to the healthy and the sick." When coming into the sickroom, doctors should consider their "manner of sitting, reserve, arrangement of dress, decisive utterance, brevity of speech." The doctor was to perform all duties "calmly and adroitly, concealing most things from the patient while you are attending him," lest such revelations cause the patient to take "a turn for the worse" (Hippocrates, 1923b, pp. 291–299).

The Hippocratic Greek physicians recognized that appropriate applications of technology required a searching analysis of its capabilities, of the ethical canons that should guide its use, and of the relation between technology and nature in treating patients. Consideration of these three factors was the significant contribution of Greek civilization to the use of medical technology.

Anatomy and Specialization

The content of the technologies used in medical practice did not change appreciably for two thousand years. Indeed, the Hippocratic works and other Greek texts, in Latin translations, formed the core of medical learning in Europe through the Middle Ages.

As the sixteenth century began, however, a growing interest in firsthand exploration of nature, and learning and questioning the authority of tradition, created what we call the Renaissance, generating a perspective that would eventually exert a profound influence on the development and use of technology in medicine. Although the study of the structural composition of the body through anatomic dissection was thwarted by cultural, social, and religious constraints against dismemberment, Renaissance scientific and artistic interest in the body's physical makeup overcame these restrictions and encouraged its exploration.

The leading figure in this movement was Andreas Vesalius, a physician and professor at Padua, who in 1543 published De humani corporis fabrica. In it the structure of the body was analyzed in detail and portrayed through illustrations that were far in advance of any previous work. Its illustrations, the work of a still unknown Renaissance artist, were startling in their beauty and detail. In contrast, the typical anatomical illustrations of the day were inaccurate and crude outlines, with organs drawn in more as symbols than as representations. Vesalius corrected over two hundred errors in the work that had been the standard, authoritative text in use for almost fifteen hundred years. Written by the Greek doctor Galen in the second century, it reflected typical restrictions on human dissection, for its content was based on animal dissection (mainly pigs and apes) extrapolated to human structure.

Vesalius' book, devoted to the normal anatomy of the body, fostered within medicine an interest in bodily structure, particularly in the changes it underwent when attacked by illness. During the next two hundred years, physicians examined bodies and wrote texts commenting on the pathological transformation of anatomic structure. These efforts were brought together in a 1761 text by the Italian physician Giovanni Battista Morgagni, The Seats and Causes of Diseases Investigated by Anatomy. The work's principal objective was to demonstrate that the symptoms of illness in the living were determined by the structural changes produced within the body by disease. Morgagni demonstrated this relation through a tripartite analysis of cases. Typically, he began by reporting on the clinical course of an illness experienced by a patient who eventually died. This was followed by the autopsy findings. Then came a synthetic commentary in which he connected clinical and autopsy results.

Morgagni asserted that through anatomic examination, particular diseases could be recognized by their telltale footprints on the landscape of the body. As the title of Morgagni's work suggests, the author believed that diseases had "seats" in the body, and that they were expressed through characteristic disruptions of the body's fabric in discernible sites. This perspective ran directly counter to that prevailing under the humoral theory of illness, dominant since Hippocratic times.

Anatomy, beginning in the sixteenth century, when it departed from this whole-body perspective, focused the doctor's vision on the search for sites in the body where a change in structure had occurred. The leading question for anatomists and the physicians who adopted their outlook was Where is the disease? This question and viewpoint paved the way for the modern specialization of medicine, beginning in the nineteenth century and undergirded by a new technology. It justified a retreat by the doctor from patients as individuals to aspects of their anatomy, giving rise to the practice of having different physicians for the eyes, heart, kidneys, and other organs and organ systems.

Technology and the Nineteenth Century

With the anatomic ideology firmly established, the nineteenth century became one of the great centuries for medicine, a time of significant advance and change fueled largely by technologic innovation.

The transformation of diagnosis by technology was one of the century's most important features. The symbol and initiator of this change was a simple instrument used to enhance the conduction of sound, the stethoscope. Its transforming effect was as much caused by the new relationship it generated between physicians and patients as by the new information it provided. Before the stethoscope, the evidence that physicians acquired about illness came mostly from two sources: the visual inspection of the motions and surface of the body, and the story told by the patient of the events, sensations, and feelings that accompanied the illness. It was this encounter with the life of the patient that was at once enlightening, troubling, and engaging for physicians.

The patient's story provided significant diagnostic evidence that often determined the doctor's judgment. But physicians expressed concern about the authenticity of this evidence, which usually could not be confirmed. Who could know if a patient really heard a buzzing in the ears? Diagnosis was prone to the distortions of memory and whim. For all of its evidentiary faults, however, the narrative of the patient's journey through illness connected the doctor with the life of the patient.

The stethoscope challenged the place of the narrative of illness. It was introduced into practice through 1819 treatise (De l'auscultation médiate), written by the inventor of the stethoscope, the French physician René Laennec. Laennec claimed that physicians who placed their ear to one end of the foot-long wooden tube that was the first stethoscope and the other end to the chest of a patient, would hear sounds generated by the heart and lungs indicative of health or disease within them. He demonstrated through autopsy evidence that a particular sound perceived in the chest corresponded to a particular lesion within its anatomic structure. He asserted that his technology enabled physicians to diagnose illness not only precisely but often without the help of other symptoms. Doctors need depend on no one else. They could be scientifically self-reliant. The findings of their own senses, extended by a simple instrument, were adequate to reach diagnostic judgments.

This technological advance reduced the significance of the patient's narrative. Why should physicians painstakingly acquire this story and its subjective and unverifiable verbal evidence, if they could use more objective sonic evidence they gathered themselves? With the stethoscope, physicians stepped back from the lives of patients. They began to engage patients through the anatomic and physiologic signs detected by their instruments.

Other simple technologies to extend the doctor's senses into the body, such as the ophthalmoscope (1850), the clinical thermometer (1867), and the sphygmomanometer(1896), were introduced during the nineteenth century. By the century's end physicians had become skillful diagnosticians, seekers of physical clues they used to deduce the source of their patients' troubles. The doctor's black bag contained the technologies to explore the body physically and to obtain evidence that greatly improved diagnostic accuracy. It was, in fact, through witnessing great skill in the analysis of physical evidence by one of his instructors, Joseph Bell, that a physician-in-training, Arthur Conan Doyle, was led to create the fictional character Sherlock Holmes.

Still, therapy remained limited. In the 1860 address to the Massachusetts Medical Society, Oliver Wendell Holmes, Harvard professor of anatomy, proclaimed: "I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind,—and all the worse for the fishes" (Holmes, p. 203).

The only major bright spot to emerge in the nineteenth century on the therapeutic side of medicine was in surgery. Radical change in the ability of surgeons to perform the dangerous and delicate work of cutting into the body occurred through two separate innovations, one introduced in 1846 and the other in 1867. At the beginning of the nineteenth century, pain had become so inseparably linked with surgical incision that several reports of an anesthetic effect produced by nitrous oxide and ether were disregarded by practitioners. Surgical pain was dealt with by efforts to shorten its presence. Techniques of rapid surgery were developed, with some surgeons capable of detaching a limb in minutes. The conclusive demonstration (in a surgical procedure for a tumor of the neck) at the Massachusetts General Hospital in 1846 of the ability to control operative pain through use of ether, was made by the American Dentist William Morton, who administered the ether. It ameliorated the trauma of surgery for patient and surgeon alike, but cutting into the cavity of the body still was limited by infection.

To control infection, insight was needed into the causal role of bacteria. Joseph Lister, a British surgeon, wrote a paper in 1867 in which he described eleven operations on compound fractures of the limbs in which nine patients recovered without amputation, one required it, and one died. These startling results were made possible by treating the operating space—wound, instruments, surgeon's hands, and air—with the antiseptic carbolic acid. In 1882, the German scientist Robert Koch published a paper that proved through rigorous experiments the causal link between the tubercle bacillus and tuberculosis—a disease that at the time was responsible for about one out of seven deaths in Europe. This essay established the pivotal role played by bacteria in infection. It not only gave further impetus to the practice of antiseptic surgery and liberated surgeons, no longer thwarted by pain or infection, to perform extensive operations within the body cavity. It also produced a new workshop for surgery and all of medicine—the hospital.

The Technologies of Twentieth-Century Medicine

The origins of the hospital reside in military hospitals put up by Roman soldiers on their routes of march, and hospices established early in the history of Christianity to care for the homeless, travelers, orphans, the hungry, and the sick. These multiple activities gradually became divided among separate institutions, one of which was the hospital. It flourished greatly through the medieval period but began a decline afterward, due to diminished church support of its activities.

By the nineteenth century the hospital's medical role was restricted. It was a place for those who could not afford either to call a physician or surgeon to the house for treatment or to employ servants to administer needed bedside care at home. There were two kinds of medicine: home care for the well-to-do and hospital care for the indigent. Hospitals were dangerous places. Infections could rage through them, killing large numbers of patients and making work there dangerous for staff. Hospitals were also feared for the moral dangers said to be posed to women and children by the rough patients they housed.

New technologies transformed the hospital medically and socially. Surgery could no longer be done on kitchen tables at home: it required an antiseptic environment, sterilized instruments, and a staff of skilled nurses for the aftercare of patients undergoing more extensive procedures than were possible in the past.

As the twentieth century dawned, diagnosis and therapy of nonsurgical disease could not be readily done in the home with technology carried in a doctor's bag. diagnostic technology now entered a new phase of development. The simple instruments to extend the senses of the physicians were being replaced by sensing machines too large and expensive to be housed anywhere but in hospitals.

This new technology automatically recorded the data of illness, leaving the reading of its results to the doctor. The X ray, discovered in 1895; the ward laboratory, with its microscopes and chemical tests of the body fluids, which came together as a hospital space in the early 1900s; and the electrocardiograph, introduced in 1906, all converted medical diagnosis from a personal act to a scientific event. The physician leaning over the bedside, at least physically connected to the patient through the stethoscope and similar technologies, became an increasingly anachronistic image as the twentieth century wore on. The physician holding an X ray up to light, studying it, was more in keeping with physicians' growing self-image as scientists. Where was the patient? There was less need for personal medical encounters; the best evidence available to medicine was increasingly not what the patient said, nor what the physician sensed, but what the pictorial or graphic image reported.

As it entered this new technologic phase, medicine required a location within which patients, the increasingly specialized medical staff, and technology could be brought together. The hospital became that place. Its success was dramatic. While there were about four hundred hospitals in the United States in 1875, by 1909 the number grew to over four thousand, and by 1929 surpassed six thousand. No longer shunned but sought by communities, the hospital became the workshop of medicine. By the mid-twentieth century not only patients and technology but also doctors' offices were placed in hospitals. Home care and the house call, no longer adequate as means to apply new medical knowledge, were disappearing as the hospital, perhaps the quintessential technology of the twentieth century to organize medical care, enfolded medicine.

Several other innovations critical to the functions of hospitals and medicine were in place by the mid-twentieth century. One—having integrative influence like the hospital— was the technology of organizing the data of medicine—the medical record. It was fundamentally reformed in the 1920s by the work of the American College of Surgeons (Reiser, 1991). In an era of growing specialization, not only among physicians but also among nurses and the technical experts needed to run the hospital and its machines (there were over two hundred separate healthcare specializations by the mid 1970s), communication was of great importance. How to learn what each had done? Through the record, which was the main agent of synthesis in medicine. In its pages the thoughts and actions of a diverse staff were recorded.

But for all its integrative significance, the medical record remains a problem. It shows the results of the information explosion. These data literally burst the confines of the chart. Hundred-page records abound. They contain the details of medical care, but their order often makes following the course of an illness, or locating a particular bit of information, difficult and frustrating. Innovations such as the unit record (having all hospital encounters of a patient recorded in a single place rather than dispersed through separate charts in each clinic); the problem-oriented record (ordering medical data problems—physical, psychologic, or social—rather than by data source, such as putting laboratory data in one place, X-ray data in another); and the computerized record have yet to solve the problem of what to do with the avalanche of technologic evidence.

Another critical innovation available by mid-century was antibiotics. The mass production of penicillin in 1944 (it had been discovered by Alexander Fleming in 1928) inaugurated the antibiotic era in medicine. Antibiotic drugs flowed from the laboratories of the pharmaceutical industry, finally breaking the hold of bacterial illness. Penicillin was called a wonder drug when it was introduced. Given the drug, a patient gravely ill with meningitis or pneumonia would be up and about and home in a week. Not only was it fast-acting and fully curative, but it was safe and cheap. It was commonly thought that penicillin would be the first innovation of a pharmaceutical revolution to produce not only antibacterial drugs but also drugs to deal as effectively with other human ailments. However, the symbol of medicine in the second half of the twentieth century would not be penicillin but a machine that made its debut in the mid-1950s.

The artificial respirator had a long history, dating back to the mid-nineteenth century, when rudimentary forerunners were fashioned to deal mainly with the respiratory crisis of drowning. A tank respirator introduced by Philip Drinker and Charles McKhann in 1929, which used negative-pressure techniques to secure respiration, became the "iron lung" that sustained victims of poliomyelitis. Its effectiveness was variable, and its use was complicated. But by the mid-1950s, using new machines based on positive-pressure technology, clinicians had a far better means of dealing with diseases and accidents that threatened lives through respiratory failure.

Initially, this machine was intended to assist critically ill persons by temporarily sustaining a vital physiologic function and giving them time to recover. For the first time in medical history, physicians acquired a technology that, allied to other advances in nursing, monitoring, and drug therapy, and all brought together by an integrative technique of care embodied in the intensive care unit (ICU), permitted the long-term sustenance of desperately ill people who had no chance of recovery. Now families and medical staff waited by ICU beds, where the main signs of life were not manifest in the expressions or movements of the patient but in the mechanical sounds, motions, and readouts of the new machinery of rescue.

Ethical Issues in Applying Medical Technologies

As families and medical staff assimilated the consequences of the life-support technology represented by the artificial respirator that could prolong dying or life without cognition, they reached out to the ethical traditions of religion, medicine, and society for help (Pius XII, pp. 501–504). Physicians particularly began to see that the ethical problems to be solved in these crises were as great as or greater than the technical problems of treatment. How to decide whether in a hopeless case to remove the technology that maintained the person's life? On what values should this judgment be based, and who should decide?

Other machines developed in this period posed a similar mix of ethical and technical issues. The artificial kidney was created as a device for acute, intermittent dialysis by Willem Kolff in The Netherlands in 1944. However, it was introduced as a clinically usable machine in the early 1960s in Seattle, Washington, by Belding Schribner. He added an arteriovenous shunt that allowed long-term access to it and made continuing hemodialysis possible. The limited number of machines and personnel to run them led to moral agonizing over developing criteria for selection. Someone had to choose which of the thousands of individuals in the United States having chronic renal failure and able to benefit from dialysis would gain access to a technology that could save their lives. Thirteen years after the machine's introduction, American society decided how to resolve this crisis. In 1973, U.S. congressional legislation provided funds to provide dialysis to all who required it.

Technologies such as the artificial kidney and the respirator have been criticized as offering expensive but partial solutions to fundamental problems of biologic breakdown. The American physician Lewis Thomas calls them "halfway technologies," because they represent only a partial (halfway) understanding of a biologic puzzle that, once solved, will do away with the expense and the disadvantages of such therapies (Thomas, p. 37).

The extraordinary and growing expense of the healthcare system that followed the development of such technologies may be reduced when biomedical research produces comprehensive biologic answers to problems such as organ failure. But in the twentieth century, we have acquired few such complete technologies. One group, already mentioned, is penicillin and other antibiotics, which offer total solutions, that also are inexpensive and rapidly acting, to the problems of bacterial infection. A second generic complete technology is the vaccine. Those invented to prevent smallpox (first introduced in the eighteenth century) and poliomyelitis (developed in the mid-1950s) have in the twentieth century eradicated the first disease and almost wholly contained the second.

The emerging field of genetic research promises fundamental solutions to a host of disorders, with the prospect of their early detection and correction. Finally, the growing ability to visualize the basic structures of the body through endoscopes and computer-driven imaging machines such as the MRI and PET scans provides diagnostic knowledge facilitating the use of therapeutic technologies that promise complete cures. Indeed, genetic and imaging technologies have taken the anatomic concept of illness to its ultimate terminus. To the question "Where is the disease?" the answer now can be "In this particular gene!"

Conclusion

Technologies, history shows, can be imperative: We may be impelled to use the capacities they provide us without adequate reflection on whether they will lead to the humane goals of medical care. The ancient Greeks understood this issue. They recognized that technologic means must be used in consonance with articulated, ethically informed ends. Their example remains worth following.

stanley joel reiser (1995)

bibliography revised

SEE ALSO: Artificial Hearts and Cardiac Assist Devices; Artificial Nutrition and Hydration; Cybernetics; Dialysis, Kidney; Deep Brain Stimulation; DNR; Electroconvulsive Therapy; Enhancement Uses of Medical Technology; Fertility Control: Medical Aspects; Genetic Testing and Screening; Life Sustaining Treatment and Euthanasia; Organ Transplants, Medical Overview; Pediatrics, Intensive Care in;Psychosurgery, Medical and Historical Aspects of; Reproductive Technologies; Tissue Banking and Transplantation, Ethical Issues in; Transhumanism and Posthumanism;Virtue and Character; and other Technology subentries

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