Biomédical platforms

Configurations

Volumn 8, Issue 3, 2000, Pages 337-387

  Keating, Peter ^a   Cambrosio, Alberto ^b  

^a UNIVERSITÉ DU QUÉBEC À MONTRÉAL   (Canada)

^b MCGILL UNIVERSITY   (Canada)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 0008856304     PISSN: 10631801     EISSN: 10806520     Source Type: Journal    
DOI: 10.1353/con.2000.0021     Document Type: Article

References (227)

1. Gilles Deleuze, quoted in lan Pindar, "A Very Long Scream with the Odd Couple," TLS, January 2, 1998, pp. 7-8.
2. Although this message as well as the following ones have been posted to a public discussion forum, we have decided to keep them anonymous by simply indicating the date at which the message was posted as well as the institution from which it was sent. In the present case: January 3, 1997-Lenox Hill Hospital, New York City.
3. The excerpt displays some of the properties of a typical medical case report: see Paul Atkinson, Medical Talk and Medical Work (London: Sage, 1995);
4. Kathryn Montgomery Hunter, Doctors'Stories: The Narrative Structure of Medical Knowledge (Princeton: Princeton University Press, 1991).
5. The term "CD" means "cluster of differentiation" and refers to the statistical procedure used to categorize the reagents produced by various laboratories and companies; see Alberto Cambrosio and Peter Keating, "A Matter of FACS: Constituting Novel Entities in Immunology," Medical Anthropology Quarterly 6 (1992): 362-384.
6. Alberto Cambrosio and Peter Keating, "Of Lymphocytes and Pixels: The Techno-Visual Production of Cell Populations," Studies in History and Philosophy of Biological cmd Biomédical Sciences 31(2000): 233-270.
7. January 6, 1997-City of Hope, Calif.
8. January 7, 1997-British Columbia Cancer Agency.
9. January 8, 1997-Maine Medical Center.
10. January 9, 1997-Laboratory of Pathology, National Cancer Institute, NIH.
11. The question of whether disease entities should be considered as "real" has been explicitly raised by the team of leading pathologists who have produced the latest classification of lymphomas, the so-called REAL classification (the acronym for "Revised European-American Lymphoma" classification, but also an obvious pun on the suggested ontological status of disease entities). On this episode, see Peter Keating and Alberto Cambrosio, "Real Compared to What? Diagnosing Leukemias and Lymphomas," in Living and Working with Ke\v Biomédical Technologies: Intersections of Inquiry, ed. Margaret Lock, Allan Young, and Alberto Cambrosio (Cambridge: Cambridge University Press, 2000), pp. 103-134.
12. Susan Leigh Star, "Triangulating Clinical and Basic Research: British Localizationists, 1870-1906," History of Science 24 (1986): 29-48.
13. January 8, 1997-Maine Medical Center.
14. January 13, 1997-City of Hope, Calif.
15. January 9, 1997-Pathology, Mayo Clinic Scottsdale.
16. Rue Bucher and Anselm Strauss, "Professions in Process," American Journal of Sociology 66 (1961): 325-334;
17. Rue Bûcher, "Pathology: A Study of Social Movements Within a Profession," Social Problems 10 (1962): 40-51.
18. Anselm Strauss, "A Social World Perspective," Studies in Symbolic Interaction 1 (1978): 119-128;
19. Anselm Strauss, idem, "Social Worlds and Their Segmentation Processes," ibid., S (1984): 123-139.
20. Adele E. Clarke, "A Social Worlds Research Adventure: The Case of Reproductive Science," in Theories of Science in Society, ed. Susan E. Cozzens and Thomas F. Gieryn (Bloomington: Indiana University Press, 1990), pp. 15-42;
21. Adele E. Clarke and Monica J. Casper, "From Simple Technology to Complex Arena: Classification of Pap Smears, 1917-90," Medical Anthropology Quarterly 10 (1996): 601-623.
22. Fujimura's work, at first firmly embedded in a social world perspective, has progressively integrated insights from different approaches, namely actor-network theory. For an example of her early work, see Joan H. Fujimura, "The Molecular Biological Cancer Research Bandwagon: Where Social Worlds Meet," Social Problems 35 (1988): 261-283;
23. for an example of more recent work, see Joan H. Fujimura, "Grafting Science: Standardized Packages, Boundary Objects, and Translation,'" in Science as Practice and Culture, ed. Andrew Pickering (Chicago: University of Chicago Press, 1992), pp. 169-211.
24. Many thanks to Armand Hatchuel (École des Mines, Paris) for taking the time to discuss with one of us (AC) the issues raised in the next paragraph; see Armand Hatchuel and Benoît Weil, Experts in Organizations: A Knowledge-Based Perspective on Organizational Change (Berlin/New York: Walter de Gruyter, 1995). For a pioneering study of "task interdependencies" among physicians (i.e., physicians' interactions "across departmental boundaries for sharing knowledge, information, resources and clientele" following advances in medical technologies), see
25. Roger Gosselin, "Probing into Task Interdependencies: The Case of Physicians in a Teaching Hospital," Journal of Management Studies 22 (1985): 466-497, quotation on p. 466.
26. Atkinson, MedicalTalk (above, n. 3), p. 61.
27. On the "synecdochal aspect" of the relation between samples and patients, see Charis Cussins, "Ontological Choreography: Agency Through Objectification in Infertility Clinics," Social Studies of Science 26 (1996): 575-610.
28. On the role of medical records, see Marc Berg, "Practices of Reading and Writing: The Constitutive Role of the Patient Record in Medical Work," Sociology of Health and Illness 18 (1996): 499-524.
29. For a discussion of the relation between representations of the body in anatomical textbooks and (surgical) interventions on the body, see Stefan Hirschauer, "The Manufacture of Bodies in Surgery," Social Studies of Science 21 (1991): 279-320.
30. For an example of those "early" debates in the field of medical sociology, see M. R. Bury, "Social Constructionism and the Development of Medical Sociology," Sociology of Health ami Illness 8 (1986): 137-169;
31. M. Nicolson and C. McLaughlin, "Social Constructionism and Medical Sociology: A Reply to M. R. Bury," ibid., Sociology of Health Ami Illness 9 (1987): 107-126;
32. M. R. Bury, "Social Constructionism and Medical Sociology: A Rejoinder to Nicolson and McLaughlin," ibid., Sociology of Health Ami Illness pp. 439-441.
33. Steve Woolgar and Dorothy Pawluch, "Ontological Gerrymandering: The Anatomy of Social Problems Explanations," Social Problems 32 (1985): 214-227.
34. For an introduction to this debate see, e.g., H. M. Collins and Steven Yearley, "Epistemological Chicken," in Pickering, Science as Practice and Culture (above, n. 17), pp. 301-325;
35. Michel Gallon and Bruno Latour, "Don't Throw the Baby out with the Bath School! A Reply to Collins and Yearley," ibid., Science As Practice and Culture pp. 343-368.
36. Forceful criticisms of sociological reductionism can be found in Bruno Latour, We Have Never Been Modern (Cambridge, Mass.: Harvard University Press, 1993);
37. Andrew Pickering, The Mangle of Practice: Time, Agenc); and Science (Chicago: University of Chicago Press, 1995).
38. Bernard Conein, Nicolas Dodier, and Laurent Thévenot, cds., Les objets dans l'action: De la maison au laboratoire, Raisons Pratiques 4 (Paris: Éditions de l'École des Hautes Études en Sciences Sociales, 1993).
39. Bruno Latour, Science in Action (Cambridge, Mass.: Harvard University Press, 1987);
40. Pickering, Mangle of Practice (above, n. 23).
41. Hans-Jörg Rheinberger, Toward a History ofEpistetnic Things: Synthesizing Proteins in the Test Tube (Stanford: Stanford University Press, 1997);
42. Peter Galison, Image and Logic: A Material Culture of Microphysics (Chicago: University of Chicago Press, 1997).
43. Galison's proposal is indebted to the notion of "boundary objects" developed within a symbolicinteractionist framework; see Susan Leigh Star and James Griesemer, "Institutional Ecology, Translations' and Boundary Objects: Amateurs and Professionals in Berkeley's Museum of Vertebrate Zoology, 1907-1939," Social Studies of Science 19 (1989): 387-420.
44. Paul Robert, Dictionnaire alphabétique et analogique de la langue française, vol. 5 (Paris: Société du Nouveau Littré, 1962), p. 390;
45. Centre National de la Recherche Scientifique, Trésor de la langue française, vol. 13 (Paris: Gallimard, 1988), pp. 538-539;
46. Alan Rey, éd., Dictionnaire historique de la langue française, vol. 2 (Paris: Dictionnaires Le Robert, 1992), p. 1545;
47. The Oxford English Dictionary, vol. 7 (Oxford: Clarendon Press, 19 70), pp. 966-967;
48. Webster's Third New International Dictionary of the English Language, vol. 2 (Chicago: Encyclopaedia Britannica, 1971), p. 1735;
49. William A. Craigie, A Dictionary of American English on Historical Principles (Chicago: University of Chicago Press, 1940), p. 1764.
50. CD4 cells are a particular kind of white blood cells directly affected by the AIDS virus; their decline correlates with disease progression. The measurement of CD4 cells was made possible by the adoption of the immunophenotyping platform.
51. M. Bergeron et al., "Comparison of Single versus Double Platform Absolute Count Determination of T-cell Subsets by Flow Cytometry," International Conference on AIDS 11:2 (1996): 255 (abstract no. Th.A.4008);
52. G. Tillemans, "The Netherlands AIDS Platforms: From National Policy-Making to Local and Regional Implementation," ibid., International Conference on AIDS 6:2 (1990): 303 (abstract no. F.D.885).
53. For a verbatim transcription of an extremely adversarial meeting on the implications of the changing definition of AIDS, see CDC/HIV/AIDS Prevention, Meeting on the Expansion of the AIDS Sun'dllance Case Definition, September 2,1992 (Atlanta, Ga.: Center for Disease Control, 1992-HIV/OAD/9-92/027).
54. See also Dennis H. Osmond, "Classification and Staging of HIV Disease," in The AIDS Knowledge Base, éd. P. T. Cohen, Merle A. Sande, and Paul. A. Volberding (Boston: Little, Brown, 1994), section 1.1,.pp. 1-15;
55. Sophie W. Chang, Mitchell H. Katz, and Sandra R. Hernandez, "The New AIDS Case Definition: Implications for San Francisco," JAMA 267 (1992): 973-975;
56. Robert W. Ryder and Roy D. Mugerwa, "The Clinical Definition and Diagnosis of AIDS in African Adults," in AIDS in Africa, ed. Max Essex et al. (New York: Raven Press, 1994), pp. 269-281.
57. This and similar meetings were characterized by the presence and intervention of lay activist groups such as Act-Up. Epstein has chronicled and analyzed the role and activities of these groups: Steven Epstein, Impure Science: AIDS, Activism, anil the Politics of Knowledge (Berkeley: University of California Press, 1996);
58. Steven Epstein, idem, "Activism, Drug Regulation, and the Politics of Therapeutic Evaluation in the AIDS Era: A Case Study of ddC and the 'Surrogate Markers' Debate," Social Studies of Science 27 (1997): 691-726.
59. One could ask whether and how patient groups have had any input into the development of a given biomédical platform; in the case of AIDS, for instance, the answer is none, since patient groups worked on the platform, taking CD4 for granted.
60. To say that something-for example, a nosological system-is a basis, but not a foundation, for a given activity (say: cancer diagnosis), means that a comparison between two cancer classifications will not be based on a criterion of truth, but on pragmatic criteria (which one is better for a given purpose). For a similar discussion of objectivism and foundationalism in legal practice, see Barbara Herrnstein Smith, Belief andRcsistance: Dynamics of Contemporary Intellectual Controversy (Cambridge, Mass.: Harvard University Press, 1997), pp. 1-22.
61. In the case of pathology, while pragmatic reasons are often advanced to promote a given nosological entity, (biological) truth is also sometimes invoked as a (controversial) reason for favoring a given entity over another-namely, when the existence of the favored entity can be grounded in a new, emerging platform (such as immunophenotyping). On this dynamics, see Keating and Cambrosio, "Real Compared to What?" (above, n. 10).
62. McGraw-HillDictionaryo\'Scientificand'Technical Terms, 5th ed. (New York: McGraw-Hill, 1994), p. 1525.
63. T. F. Bresnahan and S. Greenstein, Technological Competition and the Structure of the Computer Industry, Center for Economic Policy Research Publication no. 315 (Stanford: Stanford University, 1992). Thanks to Abdel-Karim Ousman for this reference.
64. Claudio U. Ciborra, "The Platform Organization: Recombining Strategies, Structures and Surprises," Organizational Science 7 (1996): 103-118, quotation on p. 113;
65. Marc S. Gerstein, "From Machine Bureaucracies to Networked Organizations: An Architectural Journey," in Organizational Architecture: Designs for Changing Organizations, ed. David A. Nadler, Marc S. Gerstein, and Rober B. Shaw (San Francisco: Jossey-Bass, 1992), pp. 11-38.
66. Thanks to Pascale Bourret for thé Ciborra reference.
67. Both Ciborra, "Platform Organization" (above, n. 34), and
68. Gerstein, "From Machine Bureaucracies" (above, n. 34), explicitly contrast the notions of platform organization and network organization. A similar contrast can be drawn between platforms and networks as described by actor-network theorists.
69. Thomas S. Kühn, "Second Thoughts on Paradigms," in idem. The Essential Tension (Chicago: University of Chicago Press, 1977), pp. 293-319.
70. We feel warranted in translating "plateau" as "platform," since not only are the two terms used as synonyms in other expressions (e.g., continental plateau or platform), but also this is how our French informants tended to translate the term.
71. Christian Maillard, Histoire île l'hôpital de 19-40 ànos jours: Comment la santé est devenue une affaire d'État (Paris: Dunod, 1986), pp. 63-74.
72. Jean-Charles Sournia, Histoire du diasnostic en médecine (Paris: Éditions de Santé, 1995), p. 173
73. also notes that during the last two decades the introduction of new diagnostic equipment has gone hand in hand with a profound transformation of hospital architecture, of the daily functioning of hospitals, and of the medical pathways that patients are required to follow. As pointed out in Architecture et conception hospitalière (Paris: Institut Français d'Architecture, 1985), p. 8
74. starting with the mid-1970s, "the center of gravity of the hospital has moved from hospitalization, i.e., accommodating and nursing in-patients, to a greater range of more and more sophisticated means of diagnosis and treatment, grouped together within a 'medico-technical' department." According to Sournia, this trend has resulted in an estimated 237% increase in the number of diagnostic tests performed in France between 1970 and 1980;
75. see Jean-Charles Sournia, "La place actuelle de la biologie dans la pratique médicale et dans les dépenses de santé," Bulletin de l'Académie Nationale de Médecine 165 (1981): 213-219
76. Similar increases have generated calls for limiting the use of diagnostic technologies, a recurring theme being that they are often used in no medically justifiable way; for the U.K., see, e.g., F. G. R. Fowkes, "Containing the Use of Diagnostic Tests," British Medical Journal 290 (1985): 488-490.
77. They have also led to the establishment of complex regulatory mechanisms-such as the French Nomenclature des actes de biologie médicale, a periodically revised, expanding list of the diagnostic tests that will be reimbursed by Medicare, in which each test is assigned a monetary value.
78. Jacques-Louis Binet, Les architectes de la médecine (Besançon: Les Éditions de l'Imprimeur, 1996), pp. 13, 138.
79. For a detailed sociological analysis of the 1957 health-care reform, see Haroun Jamous and B. Peloille, "Professions or Self-Perpetuating Systems? Changes in the French University-Hospital System," in Professions and Professionalization, ed. J. A. Jackson (London: Cambridge University Press, 1970), pp. 109-152;
80. Haroun Jamous, Sociologie de la decision: La réforme des études médicales et des structures hospitalières (Paris: Éditions du Centre National de la Recherche Scientifique, 1969).
81. See also Jean-François Picard, "Poussée scientifique ou demande des médecins? La recherche médicale en France de l'Institut national d'hygiène ài'INSERM," Sciences sociales et santé 10:4 (1992): 47-106.
82. On the Caen Hospital, see the 20th anniversary issue of the hospital's journal Transversal (October-November 1995).
83. L'architecture hospitalière au XIXe siècle: L'exemple parisien, Les Dossiers du Musée d'Orsay 27 (Paris: Éditions de la Réunion des Musées Nationaux, 1988).
84. Pavilion medicine is now retrospectively presented as the antithesis to the project of a modern "synthetic" medicine, one that would replace isolated specialists with multidisciplinary teams; see Binet, Les architectes de la médecine (above, n. 39), p. 132.
85. Following Foucault's groundbreaking analysis of hospital architecture, several authors have discussed this topic from the point of view of the history and sociology of medicine: see Michel Foucault et al.. Les machines àguérir: Aux origines de l'hôpital moderne (Brüssels/Liege: Pierre Mardaga, 1979);
86. Lindsay Prior, "The Architecture of the Hospital: A Study of Spatial Organization and Medical Knowledge," British Journal of Sociology 39 (1988): 86-113;
87. Lindsay Prior, idem, "The Local Space of Medical Discourse: Disease, Illness and Hospital Architecture," in TlieSocial Construction of'Illness: Illness andMedical Knowledge in Past and Present, ed. Jens Lachmund and Gunnar Stollberg (Stuttgart: Franz Steiner Verlag, 1992), pp. 67-84;
88. Allan M. Brandt and David Charles Sloane, "Of Beds and Benches: Building the Modern American Hospital," in TheArcliitecture ofScience, ed. Peter Galison and Emily Thompson (Cambridge, Mass.: MIT Press, 1999), pp. 281-305.
89. For an intriguing look at (domestic) architecture and medical knowledge, see Annmarie Adams, Architecture in the Family Way: Doctors, Houses, and Women, 1870-1900 (Montreal: McGill-Queen's, 1996).
90. Prior traces the development of hospital architecture from pavilion hospitals, linked to a miasmatic understanding of disease, to the installation of isolation cubicles following the rise of the germ theory of disease, to the modern development of the dispensary as the embodiment of social medicine; he thus overlooks the development of platform hospitals. The debate initiated by Foucault turns on the question of whether architectural artifacts should be viewed as merely "reflecting" or "embodying" developments in medical knowledge, or whether they should be seen as prescribing medical practices; see, for instance, the criticism of Prior's argument in Nicholas J. Fox, The Social Meaning of Surgery (Milton Keynes: Open University Press, 1992), p. 15.
91. To a large extent, this amounts to a false problem, insofar as its basic presupposition-namely, that the issue can be described as one of a discrete entity ("Architecture") standing in some sort of relation to another ("Medical Knowledge")-is highly questionable. It is more fruitful to replace questions about the correspondence (or lack thereof) between two distant entities with the detailed analysis of the sequence of small steps performed by long chains of intermediaries; see Bruno Latour, "The 'Pedofil' of Boa Vista: A Photo-Philosophical Montage," Common Knowledge 4 (1995): 142-187.
92. On architectural practices as shaping and confining spaces, and thus establishing frameworks for action, see Steen Eiler Rasmussen, Experiencing Architecture (Cambridge, Mass.: MIT Press, 1991).
93. For a similar preoccupation in German publications with juxtaposing architectural and organizational diagrams, see Axel Hinrich Murken, Vom Annenhospital zum Grossklinikum: Die Geschichte des Krankenhauses vom 18. Jahrliundert bis zur Gegenwart (Cologne: DuMont Buchverlag, 1988), p. 235.
94. Huguette Michel, "L'informatique dans les laboratoires centraux d'hématologie de l'Assistance Publique" (Mémoire de maîtrise de sciences et techniques de gestion des organisations sanitaires et sociales: Gestion Hospitalière, Université de Paris-Dauphine, 1983).
95. Y. Madec, "La biologie hospitalière: Regards sur une fabuleuse et irrésistible ascension," Techniques hospitalières 613 (1997): 23-30.
96. On recent German hospitals, see Murken, Vom Armenhospital zum Grossklinikum (above, n. 43), pp. 234-267.
97. On the "tower on podium" form, see Paul James and Tony Noakes, Hospital Architecture (Essex: Longman, 1994), pp. 11-14.
98. Thanks to Annmarie Adams and David Theodore of McGill University for providing us with initial information about hospital architecture.
99. See A. Landsborough Thomson, Haifa Century of Medical Research, vol. 2, The Programmes of the Medical Research Council (London: HMSO, 1975).
100. Funding for medical research in the form of grants-in-aid (as opposed to public health projects) rose from 500,000 pounds to 23 million pounds in the period 1946-1971:
101. A. Landsborough Thomson, Half a Century of Medical Research, vol. 1, Origins and Pol icy of the Medical Research Council (London: HMSO, 1973), p. 197.
102. Robert L. Geiger, "Science and the University," in Science in the Twentieth Century, ed. John Krige and Dominique Pestre (Amsterdam: Harwood Academic, 1997), pp. 159-174.
103. The NIH was preceded by the National Institute (singular) of Health: see Victoria A. Harden, Inventing the NIH: Federal Biomédical Research Policy; 1887-1937 (Baltimore: Johns Hopkins University Press, 1986).
104. For an overview of American medical research prior to World War II, see Richard H. Shryock, American Medical Research: Past and Present (London: Oxford University Press, 1947).
105. William G. Rothstein, American Medical Schools and the Practice of Medicine: A History (New York: Oxford University Press, 1987), p. 238.
106. Between 1970 and 1984, funding rose to over $6 billion a year: ibid.
107. For an overview of the history of clinical research, see Christopher C. Booth, "Clinical Research," in Companion Encyclopedia of the History of Medicine, vol. l, ed. W. F. Bynum and Roy Porter (London: Routledge, 1993), pp. 205-229;
108. Christopher Lawrence, "Clinical Research," in Krige and Pestre, Science in the Twentieth Century (above, n. 48), pp. 439-459.
109. Rothstein, American Medical Scliools (above, n. 49), p. 251.
110. Cited in Jean-François Picard, "De la médecine expérimentale (1865) àl'INSERM (1964)," in Les scicnces biologiques et médicales en France, 1920-1950, éd. Claude Debru, Jean Gayon, and Jean-François Picard (Paris: CNRS, 1994), pp. 329-344, on p. 342.
111. Stedman's Medical Dictionary, 21st éd. (Baltimore: Williams and Wilkins, 1966).
112. The word "biomédical" has had a career independently of "biomedicine." French dictionaries, such as the Larousse, have the adjective but not the noun. Moreover, in the 1960s the neologism "bio-medical" (with the hyphen) existed in English independently of the noun. One of the earliest journals to use the word in its title was the British journal "Bio-medical Engineering," which first appeared in 1965. The journal intended to review "engineering techniques applied to Medicine. In other words, everything involved in analysis, measurement, computing and control applied to diagnosis and therapy" ("Bridging the Gap," Bio-Medical Engineering 1 [1965]: 3). The first (French-British) journal bearing the title Biomedicine appeared in 1973 as a continuation of the European Journal of Clinical and Biological Research.
113. Hugh L. Dryden to Roy W. Johnson, November 17, 1958, NASA Archives, Washington, D.C. We would like to thank Mark Kahn and Roger Launius at the NASA history office for having uncovered this early use of the word for us.
114. Richard G. Hewlitt and Francis Duncan, A History of the United States Atomic Energy Commission, vol. 2, Atomic Shield, 1947-19S2 (University Park: Pennsylvania State University Press, 1969), chap. 8.
115. M. Cazaubiel, "Une nécessité: Le plateau technique de biologie," Techniques hospitalières 566 (1992): 39-44;
116. R. Devilder, "Une nouvelle logistique pour les laboratoires hospitaliers," ibid., 613 (1997): 31-42.
117. Interview with Jean-Jacques Prat, Hôpital Lariboisière, Paris, March 13, 1997.
118. See also Sournia, "La place actuelle" (above, n. 38), p. 214.
119. Hôpitaux de Toulouse, Programme général, vol. 1, Institut Fédérât!fde Biologie: Hôpital Purpan (Toulouse: unpublished document, 1996). The platform of the new Pompidou hospital (also known as "the hospital of the 21st century") has a planned surface of almost 20,000 m2, corresponding to more than 35% of the hospital: see L'Hôpital du XV, box D-1493, Archives of the "Assistance Publique-Hôpitaux de Paris" (AP-HP), Paris.
120. Interview with R. Devilder, C.H.U. Nantes, July 4, 1997.
121. On automation as leading to the performance of different activities, see Peter Keating, Camille Limoges, and Alberto Cambrosio, "The Automated Laboratory: The Generation and Replication of Work in Molecular Genetics," in The Practices of Human Genetics, ed. Michael Fortun and Everett Mendelsohn (Dordrecht: Kluwer, 1999), pp. 125-142.
122. Devilder's claim, far from being the expression of an exaggerated faith in the capabilities of the Nantes platform (of which he is the technical director), does correspond to the kind of interrogations that key French clinicians have raised following the spread of automation. For instance, two eminent hematologists noted back in 1980 that automated equipment was
123. producing "a perception of the state of health or illness of the patient very different from that which we derived and still derive by our eyes, hands, ears, in association with our memories, emotions, and our clinical intuition" (Jean Bernard and Marcel Bessis, "The Impact of Automation on the Future of Hematology," Blood Cells 6 [1980]: 115-117, quotation on p. 116).
124. Devilder interview (above, n. 60). See also Bernard Gouget et al., "La dynamique de la biologie au sein du plateau technique hospitalier," Gestions hospitalières 337 (1994): 453-458.
125. . September 11, 1998-Pathology, Karolinska Hospital, Stockholm.
126. . September 11, 1998-Pathology, National Cancer Institute, NIH.
127. September IS, 1998-Pathology, Karolinska Hospital, Stockholm.
128. September 16, 1998-Mount Sinai School of Medicine, New York.
129. September 17, 1998-FDA/NIH.
130. Devilder interview (above, n. 60).
131. J. D. Minna and A. F. Gazdar, "Translational Research Cornes of Age," Nature Medicine 2 (1996): 974-975.
132. Maurice Le Mandat, Prévoir l'espace hospitalier (Paris: Berger-Levrault, 1989).
133. Gouget et al., "La dynamique de la biologie" (above, n. 61).
134. Sournia, Histoire du diagnostic (above, n. 38), pp. 155-200.
135. The French epistemologist Dagognet similarly spoke of the "contamination" of medical semiology by the basic sciences. Arguing that a diagnostic sign made sense only as part of a set of signs and symptoms, he rejected any understanding of diseases as collections of individual signs and as fully formed, a priori defined entities; clinical investigations should thus follow a strategy of differential diagnosis rather than obeying a logic of screening ("dépistage"): see "La nature de la pensée médicale (II): Point de vue de F. Dagognet," Le concours medical, October 22, 1966, pp. 6281-6285.
136. Of course, Dagognet was fighting a losing battle, as shown by the present-day development of screening procedures. For a discussion of periodic screening in asymptomatic (note the term: "asymptomatic," rather than "healthy") adults, a notion backed by major institutional groups, including the Canadian Task Force on the Periodic Health Ex-amination, and key medical organizations, such as the American Cancer Society, the American College of Physicians, and the American Medical Association, see Silvya K. Oboler and F. Marc LaForce, "The Periodic Physical Examination in Asymptomatic Adults," Annals of Internal Medicine 110 (1989): 214-226.
137. For a discussion of the pros and cons of mass screening, see David Mant and Godfrey Fowler, "Mass Screening: Theory and Ethics," British Medical Journal 300 (1990): 916-918.
138. Peter Keating and Alberto Cambrosio, "Interlaboratory Life: Regulating Flow Cytometry," in The Invisible Industrialist: Manufacturers and the Construction of Scientific Knowledge, éd. Jean-Paul Gaudillière and liana Löwy (London: Macmillan; New York: St. Martin's Press, 1998), pp. 250-295.
139. Michael Lynch, "The Discursive Production of Uncertainty: The OJ Simpson 'Dream Team' and the Sociology of Knowledge Machine," Social Studies of Science 28 (1998): 829-868, on p. 867 n. 88.
140. Michael Lynch, personal communication. In a different tradition, Hatchuel has spoken of "axiomatic notions," i.e., a language that can work simultaneously for an observer as a language for description, and for the actors as a language for action: see Armand Hatchuel, "Les axiomatiques de la production: Éléments pour comprendre les mutations industrielles," in La performance économique m entreprise, éd. Jacques-Henri Jacot and Jean-Pierre Micaelli (Paris: Hermes, 1996), pp. 35-53.
141. Susan Leigh Star and Karen Ruhlcder, "Steps toward an Ecology of Infrastructure: Design and Access for Large Information Space," Information Systems Research 7 (1996): 111-134.
142. For his description of experimental systems, see Rheinberger, Toward a History (above, n. 26).
143. For the quotation, see Hans-Jörg Rheinberger, "Experiment, Difference, and Writing: I. Tracing Protein Synthesis," Studies in History and Philosophy of Science 23 (1992): 305-331, 309.
144. Rheinberger (ibid., pp. 133-142) has proposed that the notion of "experimental cultures" can perform this task. We believe the idea is a nonstarter because it signals a return to the kind of culturalist, humanist assumptions that the notion of experimental systems was designed to avoid.
145. What both holds together and separates science and technology is not how they are produced. More precisely, rather than an economy of the production of epistemic things, we suggest that the regulation of those things determines which unprecedented differences produced within an experimental system attain significance or acquire the status of epistemic thing. Without an economy of regulation, it is impossible to tell which differences are significant and which are trivial.
146. Rheinberger, Toward a History (above, n. 26), pp. 176-186.
147. One could, of course, trace the roots of biomedicine back to Koch, Pasteur, or even the scientific revolution. When we speak of biomedicine, however, we refer not solely to an epistemic content but also to an institutional process. The word "biomedicine" itself is a neologism that came into usage in the postwar period.
148. Michel Gallon and Bruno Latour, "Unscrewing the Big Leviathan: How Actors Macro-Structure Reality and How Sociologists Help Them To Do So," in Advances in Social Theory and Methodolog}': Toward an Intégration of Micro- and Macro-Sociologies, ed. Karin Knorr-Cetina and Aaron V. Cicourel (Boston: Routledge and Kegan Paul, 1981), pp. 277-303.
149. In Foucault's sense of "a decidedly heterogeneous set of discourses, institutions, architectural arrangements, regulatory decisions, laws, administrative decisions" (Michel Foucault, Dits et écrits, vol. 3 [Paris: Gallimard, 1994], p. 299; our translation).
150. This is far from surprising if one considers not only that the very distinction between lymphoma and leukemia has not always been self-evident, but also that it has once again been called into question with the present-day recasting of the diagnostic categories within an immunological frame.
151. Karl M. Vogel, "The Leukemias," in Nelson Loose-Leaf Medicine (New York: Thomas Nelson and Sons, 1920), pp. 66-90.
152. Frederick W. Gunz, "The Dread Leukemias and the Lymphomas: Their Nature and Their Prospects," in Blood, Pure and Eloquent: A Story of Discovery, of People, and of Ideas, ed. Maxwell M. VVintrobe (New York: McGraw-Hill, 1980), pp. 511-546.
153. Vogel, "Leukemias" (above, n. 85), p. 68;
154. Russell L. Cecil, A Text-Book of Medicine (Philadelphia: Saunders, 1930), p. 977.
155. Harvey R. Gralnick et al., "Classification of Acute Leukemia (NIH Conference)," Annals of'Internal Medicine 87 (1977): 740-753, quotation on p. 741.
156. In spite of the official-sounding name, the formulation of the FAB classification was not the result of a high-level meeting between representatives of the three countries but, rather, a spontaneous initiative of a small group of medical researchers from those countries. The acronym itself (FAB) was apparently chosen during a taxi ride when one of the researchers, in a moment of unrestricted enthusiasm at the end of the working day, exclaimed "It's fab!" (interview with Dr. Georges Flandrin, Hôpital Necker, Paris, November 7, 1996).
157. We mention this anecdote to point out that, far from there being a unique, bureaucratic path to the establishment of biomédical classifications, there can be several, ranging from the informal to the formal. For the FAB proposal, seej. M.
158. Bennet et al., "Proposais for thé Classification of the Acute Leukaemias (French-American-British [FAB] Co-operative Group)," British Journal of Haeniatolog)' 33 (1976): 451-458.
159. And not only in the strictly scientific literature: since the 1980s, one can commonly read in the daily newspapers about T4 cells and the decline in their number in AIDS patients.
160. Interview with Melvyn F. Greaves, London, July 2, 1996.
161. They were able to achieve an 85% degree of uniformity in a final exchange of slides. This rate of agreement was not always to be reached by other users of the FAB Classification: as with other morphological classifications, its application continued to be characterized by "observer subjectivity" and "interobserver variability." See, e.g.. Fred R. Dick, J. O. Armitage, and C. P. Burns, "Diagnostic Concurrence in the Subclassification of ALL using FAB Criteria," Cancer 49 (1982): 916-920;
162. David R. Head et al., "Reproducibility of the FAB Classification of Acute Leukemia: The Southwest Oncology Group Experience," American Journal of Hematology 18 (1985): 47-57.
163. The proposed classification was based on the classical characteristics. The two large groups ("lymphoblastic" and "myeloid") were respectively divided into three and six further subgroups, based on morphological and staining characteristics. Whether or not the lymphoblastic leukemias were indeed lymphoblasts was the subject of subsequent discussion. As the formulators of the classification admitted, it was more a matter of tradition than a matter of visibility: "Thus three broad divisions of undifferentiated nonmyeloid blast-cell leukemias emerged. Because the majority fell into the first group of childhood leukemia, traditionally called lymphoblastic, this term was retained for the whole group, although in nearly three quarters of all patients specific evidence of lymphocytic characteristics was lacking" (Gralnick et al., "Classification of Acute Leukemia" [above, n. 88], p. 741).
164. Bennet et al., "Proposals for the Classification" (above, n. 89).
165. Melvyn F. Greaves, "Biological Effects of Anti-Immunoglobulins: Evidence for Immunoglobulin Receptors on T and 'B' Lymphocytes," Transplantation Reviews 5 (1970): 45-75.
166. The idea that the classification of pathological entities should be based on their relationship to normal entities struck some as slightly paradoxical. For instance, the hematologist Jean Bernard remarked at a conference held on unclassifiable leukemias: "By définition, then, the leukemic cells are abnormal cells and their metabolism and
167. functions are presumed to be abnormal.... it is clearly illogical to classify abnormal cells by their resemblance to normal cells, since their very abnormality consists in their being not normal" (Jean Bernard, "Introduction," in Unclassifiable Leukeinias, ed. Marcel Bessis and George Brecher [New York: Springer-Verlag, 1975], pp. 3-5, quotation on p. 3).
168. Early adherents of the immunological approach to the naming of diseased cells came up with the symmetrical complaint that "the conventional concepts of normal hematopoiesis, which were used by them ['the great hematologists'] as the scientific basis of leukemia and hematosarcoma nomenclature and classification, was itself almost entirely based on the aspects of neoplastic cells, which constitutes a vicious circle" (G. Mathé and D. Belpomme, "T and B Lymphocytic Nature of Leukemias and Lymphosarcomas: A New but Still Uncertain Parameter for Their Classification," Biomedicine20 [1974]: 81-85, quotation on p. 81).
169. G. Brown et al., "Expression of Human T and B Lymphocyte Cell-Surface Markers on Leukaemic Cells," Lancet, September 28, 1974, pp. 753-755, quotation on p. 755.
170. Melvyn F. Greaves, "Clinical Applications of Cell Surface Markers," Progress inHeinatology 9 (1975): 255-303, quotation on p. 258.
171. There is clearly a rhetoric of objectivity at work here. But the point remains that researchers at the time felt that there was a gain, and not necessarily an absolute difference. Notice also that the gain is in terms of classification. Nobody suggested that leukemias somehow become more real through quantification; it is, rather, the consensus on their classification that becomes more real. As Brouet et al. put it: "These immunological studies allow an objective approach to the classification of acute leukemias" (Jean-Claude Brouet et al., "Classifications immunologiques des leucémies aiguës lymphoblastiques: Corrélations cliniques et morphologiques," ;Actualités hcmatologiqiies 10 [1976]: 148-155, quotation on p. 154, our translation).
172. The FACS remained a "new" technology for about five years. As late as 1979 it was still described as "relatively recent," although, by then, it had been assimilated under the more generic term "flow system" (Melvyn F. Greaves et al., "Analysis of Leukaemic Cells with Monoclonal Antibodies," in Monoclonal Antibodies in Clinical Medicine, ed. A. J. McMichael and J. W. Fabre (London: Academic Press, 1982), pp. 129-165, quotation on p. 130).
173. For example: "There are a number of ways to combine immunological membrane analysis with the morphological analysis of normal and malignant haemopoietic cells. Each of these techniques has certain disadvantages. Conventional immunofluorescence is compatible only with phase contrast of cells, while techniques using peroxidase-, ferritin- and radio-labelled antisera can give good morphology but are fairly time-consuming" because it separated the cells, the FACS enabled researchers to combine morphology and cell-surface antigen structure (G. Janossy et al., "Use of the Flu-orescence Activated Cell Sorter in Human Leukaemia," in Iitummofluorescence and Related Staining Techniques, ed. W. Knapp, K. Holubar, and G. Wick [Amsterdam/New York: Elsevier/North-Holland Biomédical Press, 1978], pp. 111-122, quotation on p. 111).
174. Joan Austoker, A History of tiie Imperial Cancer Research fund, 1902-1986 (Oxford: Oxford University Press, 1988), pp. 303-304.
175. Alberto Cambrosio and Peter Keating, Exquisite Specificity: The Monoclonal Antibody Revolution (New York: Oxford University Press, 1995).
176. Scientific Report of "Unité 108" (Prof. Maxime Seligmann), INSERM Archives, box 9203-186, 1974-1976 (Le Vésinet, France), our translation. Many thanks to the archivist, Hélène Chambefort, for her invaluable help in guiding us through the archival documents.
177. Abul K. Abbas, Andrew H. Lichtman, and Jordan S. Pober, Cellular and Molecular Immunology (Philadelphia: Saunders, 1991), p. 19.
178. Cambrosio and Keating, "Matter of FACS" (above, n. 4).
179. H. Rappaport, Tumors of the tleniatopoietic System, Atlas of Tumor Pathology (Washington, D.C.: U.S. Armed Forces Institute of Pathology, 1966).
180. Juan Rosai to William Hartmann, May 31, 1977, "Fascicles Editorial Advisory Committee," Correspondence 1977, Archives of the Army Institute of Pathology, Washington, D.C.
181. V. T. DeVita, H. Rappaport, and E. Frei, "Announcement of Formation of the Lymphoma Task Force and Pathology Reference Center," Cancer 22 (1968): 1087-1088.
182. Jane Marjorie Tang, "Hal Downey and the Development of Hematology in America" (Ph.D. thesis, University of Minnesota, 1988), p. 149.
183. Downey to Henry C. Nachtrieb, cited in ibid., Hal Downey and the Development of Hematology in America p. 96.
184. Armed Forces Institute of Pathology, Annual Report (Washington, D.C.: U.S. Armed Forces Institute of Pathology, 1954), p. 19.
185. Karl Lennert, "Classification of Malignant Lymphomas (European Concept)," in Progress in Lynipliology, ed. A. Ruttimann (Stuttgart: Georg Thieme Verlag, 1967), pp. 103-109, quotation on p. 103.
186. Karl Lennert, "Preface," in Yoshitaka Mori and Karl Lennert, Electron Microscopic Atlas of Lymph Node Cytology and Pathology (Berlin: Springer Verlag, 1969), p. v.
187. Lennert, "Classification of Malignant Lymphomas" (above, n. 112), p. 104.
188. Clive R. Taylor, "Changing Concepts in the Classification of Lymphoma," in Malignant Lymphoproliferative Diseases, ed. J. G. Van Den Tweel, C. R. Taylor, and F. T. Bosnian (The Hague: Leiden University Press, 1980), pp. 175-184.
189. Steven E. Come and George P. Canellos, "The Clinical Relevance of Histopathologic Classification in Non-Hodgkin's Lymphomas," in Controversies in Cancer: Design of Trials anil Treatment, ed. Henri J. Tagnon and Maurice J. Staquet (New York: Masson, 1978), pp. 161-173, quotation on p. 162.
190. Ibid., Controversies in Cancer: Design of Trials Anil Treatment p. 163.
191. Thomas M. Grogan et al., "Immunologie Approaches to the Classification of NonHodgkin's Lymphomas," in Immunologie Approaches to the Classification and Management of Lymplioinas and Leukeniias, ed. John M. Bennet and Kenneth A. Foon (Boston: Kluwer, 1988), pp. 31-148, quotation on p. 31
192. Clive R. Taylor, Hodgkin's Disease and the Lymphomas, vol. 4 (Montreal: Eden Press, 1980), from the foreword, n.p.
193. Centers for Disease Control, "Guidelines for the Performance of CD4+ T-Cell Determinations in Persons with Human Immunodeficiency Virus Infection," Mortality and Morbidity Weekly Report 41 (1992) (RR-8), p. 2.
194. "Presently... most of our products... are directed both towards the clinical and the research market and so the same product can be used by both markets, so that's why we're called the research platform but we're really focussed in cytometry" (interview with the senior product manager of a flow cytometry company, May 7, 1996).
195. Ibid.
196. Ibid. That the relation between manufacturers and users is particularly close in the biomédical field has long been noticed;
197. see, e.g., F. Narin and E. Noma, "Is Technology Becoming Science?" Scicntomctrics 7 (1985): 369-381.
198. On breaking down the inside/outside dichotomy, see Bruno Latour, "Give Me a Laboratory and I Will Raise the World," in Science Observed, ed. Karin D. Knorr-Cetina and Michael Mulkay (Beverly Hills: Sage, 1983), pp. 141-170.
199. Louis A. Kamentsky, "Future Directions for Flow Cytometry," Journal of'Histochemistry and Cytochemistry 27 (1979): 1649-1651, quotation on p. 1650.
200. We use here Howard Shapiro's designation and, in part, his periodization: see Howard M. Shapiro, Practical Flow Cytometry, 2nd ed. (New York: Alan R. Liss, 1988), p. 199. The various editions of Shapiro's book are highly respected in the flow cytometry community. The first edition, privately printed in 1984, went under the name Building and Using Flow Cytomctcrs.
201. This led to a confrontation between manufacturers, the FDA, and the College of American Pathologists when the FDA discovered that reagents designated for research use were in fact being used for diagnostic purposes. On this episode see Keating and Cambrosio, "Interlaboratory Life" (above, n. 73).
202. The considerable confusion of the early 1980s as to where the market for flow cytometers actually lay implied difficult design choices. As a biological research device, emphasis on sorting capacity and flexibility was clearly necessary. As a clinical diagnostic device, computer-controlled simplicity was the key. A partial solution to this fundamental design problem emerged in the mid-1980s when Ortho went modular with its Cytofluorograf 30/50 System: rather than design an instrument that either sorted (research) or did not sort (clinic), Ortho decided to manufacture a "system" where the sorter could be treated as a "module" that could be added to or subtracted from the system as a whole. Modularity has become a characteristic of recent instruments such as B-D's FACSCalibur.
203. Shapiro, Practical Flow Cytometry (above, n. 125), quotation on p. 204.
204. S. B. Leif, R. C. Leif, and R. Auer, "The EPICS C Analyzer: An Economically Designed Flow Cytometer Computer System," Analytical and Quantitative Cytology and Histology 7 (1985): 187-191.
205. Becton Dickinson, Normal Values: Definition of 'a Reference Range for Lympliocytc Subsets of'HealthyAdults, Clinical Monograph no. 1 (San José, Calif.: Becton Dickinson Immunocytometry Systems, 1991).
206. Interview with Hans J. Tanke, Leiden, May 14, 1997. See Hans J. Tanke, "Cytochemical Staining of DNA and RNA for Analytical Cytology: Development of Methods for Image and Flow Cytometry and Their Diagnostic Application" (Ph.D. thesis. University of Leiden, 1982);
207. Adrian van Es, "Immunological and Clinical Factors Influencing Rejection of Human Renal Allografts: A Single Center Study" (Ph.D. thesis, University of Leiden, 1984);
208. Jan Willem Gratama, "Immunological Studies in Allogeneic Marrow Grafting" (Ph.D. thesis. University of Leiden, 1986). Asked (in our interview) to characterize the status of that kind of thesis, Dr. Tanke replied: "It is fundamental research of biological applications. Human molecular genetics is very important for us or oncological applications, but at the end of the thesis it may indicate diagnostic applications and in that situation we have a good relationship with pathology and genetics. There is a minimum amount of instrument development, but not zero. Sometimes it starts with buying some equipment, putting the equipment together, changing somewhat in the hardware and developing software, then investigating certain applications. doing cytochemistry, developing tests, making probes, investigating certain things in cells and then applying it to patients. That would be the entire line, from developing the cytometry instrumentation, developing cytochemistry, the probes and the immunocytochemical stain, doing a pilot study and then going through a clinical study."
209. For a pathologist's view of the "mechanics of operating an immunophenotyping laboratory," see K. Foucar, I. M. Chen, and S. Crago, "Organization and Operation of a Flow Cytometric Immunophenotyping Laboratory," Seminars in Diagnostic Pathology 6 (1989): 13-36.
210. For a technician's description of a "clinical" flow laboratory, see Thérèse Oakley, "Bravely Entering the New World of Flow Cytometry," Medical Laboratory Observer 24:1 (1992): 4214. Generated mainly within clinical settings, standards are fed back into the research system, where they serve as guidelines for acceptable diagnostic practices. We have termed this process "interlaboratory" regulation: see Keating and Cambrosio, "Interlaboratory Life" (above, n. 73).
211. As noted by Shapiro, Practical Flow Cytometry (above, n. 125), p. 292, the sale of flow cytometers, based on the belief that T-cell subset ratios were an appropriate screening test for AIDS, took off just prior to the discovery of the HIV virus in 1985 and the related development of an antibody test for diagnosing HIV infection. Access to therapy as covered by national health systems is based on the absolute number of CD4 cells; Belgium, for example, requires patients to have <100 CD4+ per mm3 of blood in ' order to be eligible for tri-therapy:
212. Jean-Luc D'Hautcourt, "Contrôle de qualité: Revue de l'offre et des résultats," in Immunologie de l'infection àVIH (Paris: Biotem, 1997), pp. 87-95, on p. 87.
213. For example, a 1995 interlaboratory study out of Brigham and Women's Hospital in Boston found that "of the 24 patients in this survey, 14 had CD4-count results with enough variation to have led to conflicting treatment recommendations; three of the 24 patients fulfilled the revised Centers for Disease Control and Prevention case definition of AIDS on the basis of results from some but not all laboratories" (P. E. Sax et al., "Potential Clinical Implications of Interlaboratory Variability in CD4+ T-Lymphocyte Counts of Patients Infected with Human Immunodeficiency Virus," Clinical Infectious Diseases 21 ([1995]: 1121-1125, quotation on p. 1121).
214. An early Centers for Disease Control study implicating forty-one laboratories using paired sample sets found that 25% of the laboratories could not identify two abnormal samples as abnormal: see Hélène Paxton et al., "Results of the Flow Cytometry ACTG Quality Control Program: Analysis and Findings," Clinical Immunology and Imnninopatliology 52 (1989): 68-84. The chairman of an early NIH standardization committee who sent out his own blood as a control discovered that the results were "all over the place" (interview with Alan Landay, Chicago, 21 November 1991). The variability of CD4 counts was also no secret to patients, who engaged in "CD4 shopping" to find results that would allow them to be entered into clinical trials for new anti-HIV drugs. Given the novelty of the immunophenotyping platform, the problem for regulators was not simply the lack of reproducibility of data: nobody knew what degree of reproducibility one could reasonably expect.
215. See J. Philip McCoy, John L. Carey, and John R. Krause, "Quality Control in Flow Cytometry for Diagnostic Pathology. 1. Cell Surface Phenotyping and General Laboratory Procedures," American Journal of Clinical Pathology 93, suppl. 1 (1990): 27-37, on p. 37.
216. See, e.g., NCCLS, Clinical Applications of Flow Cytometry: Immunophenotyping of Leukeinic Cells; Proposed Guideline, Document H43-P (Villanova, Pa.: National Committee for Clinical Laboratory Standards, 1993).
217. B. H. Mayall, "Editorial," Cytometry 1 (1980): 1. ISAC itself is not an exclusively clinical.organization. A recent survey conducted by ISAC suggests that the Society successfully spans the pure/applied spectrum: a breakdown of the 1,365 respondents gives their disciplinary affiliations as natural sciences (439), research medicine (469), and clinical medicine (370);
218. see Philip N. Dean, "Membership Profile of the International Society for Analytical Cytology," Cytometry 15 (1994): 185-188.
219. "As these [immunophenotyping] and other flow cytometric assays leave the research laboratory and become integrated into the mainstream of diagnostic pathology, the performance of proper quality control for these assays becomes crucial not only for optimal patient care, but also to fulfill the requirements for reimbursement by third-party carriers" (McCoy, Carey, and Krause, "Quality Control" [above, n. 134], p. 27).
220. J. K. A. Nicholson, "Quality Control in Immunophenotyping: U.S. Efforts to Establish Common Methodology and Their Impact," European Journal ofHistoclicinistry 38, suppl. 1 (1994): 7-12, on p. 7.
221. For a review of the problems associated with CD4+ counts and clinical trials, see David T. W. Fei, Hélène Paxton, and Anthony B. Chen, "Difficulties in Precise Quantitation of CD4+ T Lymphocytes for Clinical Trials: A Review," Biologicals 21 (1993): 221-231.
222. This quotation, as well as others in this and the following two paragraphs, are extraded from our field notes taken during the previously mentioned-November 1995 NIH consensus conference on the immunophenotyping of leukemias and lymphomas (Bethesda, Maryland). Many thanks to Dr. Raul C. Braylan for inviting us to that conference.
223. M2, M3, etc. are subcategories of the myeloid leukemias as defined in the FAB Classification. It was generally recognized that this was not the case with all FAB cate-godes. There were some categories that only immunophenotyping could apparently display, leading to yet another problem: "So far, flow is confirmatory; what should be done when it is at odds with morphology? Won't an increased use of flow make new diseases? M7 used to be rare. With flow it is common. Flow is the only way to get MO or M7" (field notes, above, n. 140).
224. L'automatisme m hématologie, special issue of Nouvelle revue française d'hématologie 20:2.(1978);
225. Automation: What to Measure and Why, special double issue of Blood Cells 6:2-3 (1980).
226. Jean Bernard, "Summing Up I," Blood Cells 6 (1980): 499-500.
227. Thanks to Hans-Jörg Rheinberger for suggesting this example.