Making Sense of Illness By Robert A. Aronowitz (review)

BOOK REVIEWS Making Sense of Illness. By Robert A. Aronowitz. Cambridge: Cambridge UP, 1998. Pp. 256. $29.95. In Making Sense ofIllness, Robert Aronowitz thoroughly reviews the circumstances and what he calls "the social process of negotiation" involved in the changing understandings offive diseases, each with a background ofvarying, often controversial, etiologic concepts. The illnesses are 20th-century chronic fatigue syndromes, ulcerative colitis, Lyme disease, angina pectoris, risk factors for coronary heart disease, and the "Type A hypothesis," designating individuals vulnerable to coronary artery disease. Aronowitz recognizes the achievements ofscientific research in establishing the conventional biomedical model of disease, but he seeks to expand the understanding of human illness in terms of the role of the individual and the associated societal circumstances. In this effort he characterizes his concept as "the social construction of disease," namely that human illness is more than a series of molecular events but also involves "individual idiosyncracy"—the individual's contributions (personality, emotions) to the expression of disease. Aronowitz begins by briefly presenting six clinical situations. The first, the case of patient Harold, introduces the problem of two 20th-century chronic fatigue syndromes . Like many other so-called functional disorders, the illness is not fully explained by the specific pathology and therefore, is subject to widely ranging theories as to the nature of functional illness. Elizabeth's problem leads into a review of the psychosomatic origin of ulcerative colitis, the enthusiastic support of "psychosomatic diseases" in this country during the period 1920 to 1950, and the circumstances encouraging replacement of psychogenic with "scientific" viewpoints. Patient Margaret provides the opportunity to review the biomedical history of Lyme disease and the differing evaluations of this condition between U.S. investigators and the earlier European experience with a disease resembling Lyme disease, erythema chronicum migrans. Patient Marty prompts an historical account of the changing classification of angina pectoris and coronary heart disease, the impact of new biological knowledge, technological developments, and the subsequent epidemiological perceptions. In the fifth case, Louis, the author focuses on the social consequences of coronary artery disease, including other contributory factors (e.g., hypercholesterolemia) , the consequent economic and social costs, and the changing clinical practice and public health measures motivated by the risk factor concept . In Louis he traces the 50-year history of the Type A hypothesis in coronary heart disease. In the conclusion, Aronowitz summarizes the various issues as to the definition, diagnosis, treatment, and prevention of disease, and endeavors to make sense of illness through the prism of specific disease or individual sickness. The case descriptions are followed by a series ofchapters: From Myalgie Encephalitis to Yuppie Flu—A History of Chronic Fatigue Syndromes; The Rise and Fall Perspectives in Biology and Medicine, 42, 2 ¦ Winter 1999 291 of the Psychosomatic Hypothesis in Ulcerative Colitis; Lyme Disease—The Social Construction of a New Disease and of Social Consequences; From the Patient's Angina Pectoris to the Cardiologist—Coronary Heart Disease; The Social Construction of Coronary Heart Disease Risk Factors; and The Rise and Fall of the Type A Hypothesis. The final chapter, Conclusions, is an overall summation ofAronowitz's expanding concept of human illness. The final section of the book is a series of detailed notes supporting each chapter. Aronowitz has been thorough in his research . Each set of notes is appropriate and informative. I was particularly interested in Chapter 2, on the psychosomatic hypothesis of ulcerative colitis, and in the accompanying citations. As a student ofulcerative colitis since the 1930s, I am familiar with this literature and I approve ofAronowitz's selections . He correctly points out that the psychosomatic hypothesis ofulcerative colitis, already advanced for other diseases, was triggered by the flawed but nevertheless provocative clinical observations of initially four and later 12 patients by medical student CD. Murray in 1930. Murray previously had worked in the constitutional clinic ofGeorge Draper, himselfinterested in psychosomatic origins ofdisease, [1], and he was involved in recording the physical features of individuals allegedly vulnerable to particular illnesses (nephritis, tuberculosis, gallbladder disease and gastric ulcer), an experience that undoubtedly stimulated Murray's interest in psychosomatic illness. These observations soon were confirmed by AJ. Sullivan of Yale, then quickly adopted by leading psychiatrists of the day...