Bulletin of the History of Medicine

Medical historians have long known that a disease is not just a disease. Whatever its underlying biological and/or genetic roots, a disease must be understood as operating in an ever-evolving social and cultural context. In Occupation and Disease, Allard Dembe displays particular sensitivity to this issue. In this fine book, he sets out “to identify the key social factors that affect the initial emergence and recognition of occupational disorders” (p. 5). By definition, such disorders “occur among workers, or former workers, who come into contact with various causes or components of causal complexes while on the job” (p. 12). “The determination that a disorder is caused by a patient’s job,” Dembe explains, “occurs in a rich social context colored by the unequal power relationships that generally prevail between employees and management and the work environment and between patients and physicians in the health care setting” (p. xi). It is Dembe’s task to investigate that context.

He does so by providing three richly documented case studies. The first examines cumulative trauma disorders (CTDs) of the hands and wrists (particularly carpal tunnel syndrome); the second, back pain; and the third, noise-induced hearing loss (NIHL). Each study follows a similar trajectory, beginning with a comprehensive historical analysis, then moving on to consider a host of contemporary concerns, and concluding with a summary that highlights the main points. Hasty readers would do themselves a disservice, however, if they relied on the summaries alone, for this would blind them to the wealth of arresting details that Dembe provides. Consider my favorite: In the discussion of carpal tunnel syndrome, readers learn of the extraordinary influence of the distinguished Cleveland hand-surgeon George Smith Phalen, who, according to Dembe, was “absolutely convinced that the cause of carpal tunnel syndrome was not occupational” (p. 70). Largely as a result of Phalen’s professional eminence and influence, from 1950 to 1980 “carpal tunnel syndrome was most often viewed as a disease of middle-aged women which was probably associated with hormonal changes” (p. 76). “Phalen’s social views and his stereotyping of what constitutes ‘women’s work,’” Dembe thus argues, “shaped the history of occupational hand disorders for thirty years” (p. 76)—but this situation “changed dramatically in the 1980s with the emergence of hand and wrist disorders as a major concern for trade unions, politicians, government safety officials and the media” (p. 82).

Dembe’s analyses of back pain and noise-induced hearing loss are likewise full of fascinating anecdotes. That back pain and hearing loss are as old history itself Dembe does not deny. What is a relatively recent phenomenon, however, is the idea that such injuries might be occupationally induced—and, perhaps more importantly, worthy of financial compensation. The two do not necessarily go hand-in-hand, however. Whereas nineteenth-century physicians recognized the existence of so-called writer’s cramp and telegraphist’s cramp long before the existence of any institutionalized scheme for workers’ compensation, it was social [End Page 562] insurance systems in Europe and later in the United States that, Dembe argues, were largely responsible for the “emergence of the recognition of back pain as an occupational disorder” (pp. 127, 156). Of course, other factors were also at play. Particularly significant was the “corresponding expansion that took place in orthopedic surgery as a field of professional specialization” (pp. 150–51) during the middle third of the twentieth century—a period during which more than a million disc excisions were performed (p. 153).

Space does not permit me to give this original and absorbing work the full attention that it deserves. In brief, Occupation and Disease provides a compelling refutation to previous studies that explain the origins and evolution of occupational illness in terms of some linear medical model. Even more impressive, it offers a methodologically rigorous, historically nuanced account of how ideas and interests are continually colliding to form new categories of sickness and disease.