This latest installment in Charles Rosenberg’s venerable series for the Johns Hopkins University Press is less “biography of disease” than biography in disease. This neat, tacit pun yields distinctive insights into twentieth-century biomedicine. Anderson and Mackay anchor their argument in Owsei Temkin’s classic 1963 distinction between ontological and physiological disease concepts. The former treat disease as a specific entity; the latter as a process, a part of someone’s life. For Temkin, then, physiological disease concepts could also be considered “biographical.” Autoimmunity, argue Anderson and Mackay, is a model of biographical disease—a prime example of individuality in medicine.
Therefore, they note, the history of autoimmunity supplies a counter-melody to the primary tune of twentieth-century medicine, in which the germ theory and specific disease overpower older notions of illness as unique to each patient. In Anderson and Mackay’s descant, four themes—lupus erythmatosus, type 1 diabetes, multiple sclerosis, and rheumatoid arthritis—illustrate how the medical individual persists through the twentieth century. A standard approach would be to begin with a historiographical overview, then devote a chapter to “biographies” of each disorder, and finally sum up with a synthetic conclusion. Instead, Anderson and Mackay interweave each disease into a roughly chronological composition tracing the strange career of the self in immunology.
Individuality preceded the self. Serologists recognized the uniqueness of the individual well before Macfarlane Burnet proclaimed that the essence of the immune system was distinguishing self from non-self. In the 1940s, pathbreaking studies described allergy and anaphylaxis as rogue attacks of self on often-beneficent non-self. The idea of autoimmunity waits until the 1950s—about the middle of the book—to take center stage. As it developed, the authors show, it became heavily inflected with Cold War themes of surveillance, recognition, conformity, and regulation. Then, as immunology went molecular, Anderson and Mackay insist (in contrast to authors such as Alfred I. Tauber) that the self didn’t vanish so much as change its clothes. But is network theory really a “reframing” of the self—or is it a new conception of individuality? To blur the distinction is to conflate the biomedical and the social. Indeed, the authors next make the delicious observation that when scientists at last rejected romantic philosophical notions of the self for explaining immunology, philosophers, and historians embraced immunology as a metaphor for understanding the self. This twist prompts the clever authorial decision to move the requisite chapter on historiography to the end. It works as recapitulation, while turning the cited scholars into historical actors.
One wishes the composition were longer. A chapter on patients’ voices was necessary given the authors’ passion for the individual, yet the smattering of published patient memoirs they offer seems thin and under-analyzed. These pages cry for the tough work of conducting interviews, obtaining patient records, and closely analyzing the texts. More serious and puzzling, the book stops just short of the revival of individualized medicine driven by genomics and the simultaneous rise in diagnoses of autoimmune disorders—a cliff-hanger that leaves me anxiously awaiting some industrious graduate student’s dissertation.
But brevity is the soul of Rosenberg’s series. A few deleterious mutations notwithstanding, Intolerant Bodies is an essential contribution to the history of individuality in medicine, a book as idiosyncratic and original as its subject.
Nathaniel Comfort is a professor in the Department of the History of Medicine at The Johns Hopkins University. He is the author, most recently, of The Science of Human Perfection: How Genes Became the Heart of American Medicine (Yale, 2012). He is a regular reviewer for Nature and has published with Natural History, the New York Times Book Review, National Public Radio, Science, New Scientist, The Believer, The Point, and elsewhere. He blogs at http://genotopia.scienceblog.com and tweets from @nccomfort.