From The New England Journal of Medicine
In the introduction to this history of 20th-century hematologic diseases, Keith Wailoo asks, "What is the relationship between technology, especially diagnostic technology, and disease?" If nothing else, Drawing Blood shows that this relation is extremely complex, shaped not only by the biologic characteristics of specific diseases and the mechanics of various forms of technology, but also by the larger culture in which disease and technology acquire meaning. Wailoo examines the appearance, disappearance, and reclassification of five 20th-century "blood diseases": chlorosis, splenic anemia, aplastic anemia, pernicious anemia, and sickle cell disease. He does not tell heroic stories of discovery and technological innovation. Instead, he describes how hematology as a specialty and as a set of practices, tools, and diseases changed in tandem with changing cultural practices and beliefs, especially changes in the economic and professional organization of medicine and in different groups' ideas about sex, race, heredity, and responsibility for disease. The book's first chapter, on the now-forgotten disease chlorosis, illustrates Wailoo's approach and goals. Chlorosis was frequently used as a diagnosis in the 19th and early 20th centuries but is difficult to define or even discuss today. Family doctors working in their patients' homes used chlorosis to name and treat tiredness and weakness in young women and girls whom they thought were anemic. A standard medical view of the history of chlorosis is that this vague syndrome was jettisoned as medical innovators, armed with blood-measuring techniques, learned to classify hematologic disorders, especially anemias, on a more scientific basis. But Wailoo shows that chlorosis had no such simple relation with technological innovation. As much as technological change played a part, chlorosis was gradually abandoned when family doctors yielded their prominent position in medicine to hospital-based practitioners and when the social views -- and social realities -- of women changed. Wailoo's analysis breaks new ground when he examines how the rise and especially the fall of chlorosis have been "remembered" by different groups. In addition to the important role ascribed to new blood-measuring techniques, early clinical observers attributed the decline of chlorosis to improved social conditions (e.g., better housing, working conditions, and nutrition), despite the fact that doctors had never confined the diagnosis of chlorosis to the lower social classes and that earlier clinical wisdom had attributed chlorosis to the ill effects of women's emancipation. In another telling of the decline of chlorosis, some feminists have stressed that women themselves rejected the invalid role. Given this deft demonstration of the ways in which the history of disease has been used to reinforce different groups' values and interests, Wailoo is understandably cautious about drawing any simple lessons from either the history or the metahistory of chlorosis. Instead, he focuses on broader historical statements, such as that the definition, diagnosis, and memory of chlorosis have continuously reflected anxieties about sex roles and that technology "by itself is not a reliable guide to understanding what diseases are and how diseases move through time." Like chlorosis, "splenic anemia" makes little sense today but was commonly diagnosed and treated by abdominal surgeons in the early decades of this century. These surgeons used a simple, if somewhat circular, definition: splenic anemia was caused by the spleen and was cured by splenectomy. In Wailoo's view, the rise and fall of splenic anemia is largely the story of the changing professional organization of medicine. Abdominal surgeons were dominant in the early 20th-century hospital and were therefore able to define diseases that fit their world view and interests. When their status was diminished, as internists, hospital administrators, and others took on positions of responsibility in the hospital, this tenuous diagnosis was abandoned. The chapter on aplastic anemia stresses the role of laboratory specialists who wanted to identify people who might be susceptible to industrial toxins. Interest in aplastic anemia was part of a larger program to find medical-technological solutions to the problem of industrial safety. The chapter on pernicious anemia focuses on how this disease changed from a protean clinical syndrome with no single defining characteristic to a seemingly more specific and mechanistically defined entity -- a macrocytic anemia that responded to mass-produced liver extract. Wailoo emphasizes the parts played by academic medicine, intraprofessional conflict (whether the hematologist's tools can or should define the disease), and pharmaceutical companies in this transformation. The chapter on sickle cell anemia is perhaps the strongest. Wailoo shows how race relations and racial ideas influenced early ideas and practices. He emphasizes the way that the latent potential for sickling "seen" in the blood of asymptomatic persons, which was the immediate byproduct of early diagnostic techniques, was used by clinicians and others as evidence of inherent, biologic limitations of blacks. Wailoo recreates the rich historical context, which included such practices as not using "Negro blood" for transfusions and using sickling tests to decide whether persons belonged to the white or black race. Wailoo does not simply blame doctors or technology for stigmatizing women and blacks or for reducing rich, patient-centered concepts of clinical syndromes to misleading, if seemingly more objective, diseases. His discussion of the evolution and use of electrophoresis shows, for example, that technology can sometimes help emancipate and clarify. Electrophoresis catalyzed a new molecular understanding of the hemoglobinopathies, which inevitably led to skepticism about any simplistic racial views of these diseases. Wailoo is so enthusiastic about making theoretical points and generalizations that the narrative thread is sometimes difficult to follow. An inevitable but unfair criticism of Wailoo's rich contextual approach is to ask why he did not cast his net even farther -- by considering other developments in hematology (e.g., AIDS, blood typing, and hemophilia) or by placing more emphasis on factors touched on only briefly, such as the role of disease-specific advocacy groups. Wailoo necessarily had to limit the scope of this study and separate important from minor influences on change. On the whole, he uses a wide array of sources and types of data to carry out an insightful analysis of a diverse sample of 20th-century hematologic diseases. It is worth commenting that although scholars of the history of medicine will consider Drawing Blood a well-done but hardly atypical example of the "social construction of disease," Wailoo explicitly uses this phrase only once. My guess is that he wants to steer clear of its more extreme relativistic connotations, as in "chlorosis was a mere social construct" (i.e., chlorosis had no basis in biologic "reality"). However one categorizes Wailoo's historical approach, his detailed analysis of the complex web of social factors that have influenced the names and meanings of disease does not easily yield simple lessons for resolving current controversies. In the book's conclusion, Wailoo nevertheless offers a few cautionary lessons for current controversies, such as that over prostate-specific-antigen screening for prostate cancer. Wailoo argues that such controversies cannot be adequately understood or resolved if they are framed solely as issues about technology assessment and clinical efficacy. Like the other diagnostic techniques Wailoo analyzed, prostate-specific-antigen testing has engendered a debate fueled by conflicting values and interests (e.g., between the professional aspirations of urologists and those of generalists), as well as by fears of cancer and medical interventions. Wailoo makes a general plea for a new language, other than that used by economists and epidemiologists, to "assess the meaning of technology in modern medicine." Although he does not offer a detailed view of this new language, Wailoo convincingly uses the history of hematologic diseases and technology to demonstrate why we need one. Reviewed by Robert A. Aronowitz, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
"Wailoo's [Drawing Blood] breaks new ground." -- The New England Journal of Medicine
"This book is a marvelous example of how many threads can be spun together to create a compelling narrative. It interweaves histories of disease over the past century, of technology, of hematology, and of medicine in the broadest sense....This book [is] a fine history of the practice of medicine... Drawing Blood is first-class history at many levels and can be read with profit and pleasure by the clinician, historian, non-medical scientist, and interested layperson." -- Science
"A major contribution to the social history of medicine and to the growing literature on professionalization." -- American Historical Review