Medicine: Those Expensive New Toys

When the X-ray machine was introduced in 1896, it was as if Hamlet's desire that "this too too solid flesh would melt" had become eerie reality. Public and physicians alike went wild. Gentlemen bought X-ray photographs of objects concealed in boxes, and fashionable ladies had X-ray portraits taken of themselves as gifts for friends and lovers. But it was physicians who were most intoxicated with the new device's possibilities. Without manual probing, they could now evaluate the extent of bone fractures and precisely locate where foreign bodies were lodged in tissues.

Seventy-six years later, the computerized axial tomography, or CAT, scanner, hailed as the greatest advance in radiology since the discovery of X rays, appeared on the medical scene. Combining X-ray equipment with a computer and a television cathode-ray tube, this revolutionary diagnostic device can visualize cross sections of the human body to detect, among other disorders, tumors, blood vessel damage and bile duct obstructions. But whereas an X-ray machine cost $50 in 1896, today's CAT scanner may run to $700,000 or more.

The CAT has become something of a whipping boy in the current cost-containment controversy, a symbol of the insanely soaring expenses of the U.S. medical care system. Government officials and consumers are questioning whether the benefits derived from the flood of innovative techniques of the past 20 years justify the high cost. Even physicians who traditionally have taken to the new technology with the enthusiasm of small boys trying out new toys, are voicing doubts.

In the case of the CAT scanner, for instance, most doctors would agree with the Boston physician who observes: "It has all but relieved us of doing angiograms or putting air into people's brains. Both of those had an element of risk and were not nearly so accurate as the CAT." But when it comes to the usefulness of whole body scanning there is considerably more disagreement, even though evidence is mounting in the machine's favor. Another important question is how many of the devices the country needs, and can afford.

The questions raised by the CAT apply to practically every other procedure and piece of equipment in use today. Items:

> Electronic fetal monitoring is used in many hospital maternity units during labor and delivery. A sonar-like ultrasound system keeps track of the baby's heart rate, and an electrically wired belt across the mother's abdomen notes uterine contractions. Electrodes are attached to the baby's head to get an electrocardiogram. Blood samples for analysis may be drawn from the baby's scalp. The object: to detect fetal problems early enough for physicians to intervene. The U.S. spends some $80 million a year on this effort, and the fetal death rate in the U.S. has in fact declined since electronic monitoring was introduced in the mid-1960s, but there is little evidence linking the two. Moreover, critics say that the benefits are uncertain and that there is risk to the baby of laceration and infection of the scalp and respiratory problems, and to the mother of uterine perforation, pelvic infections and an unnecessary Caesarean section should the monitoring mistakenly indicate the baby is in distress.