Intolerant Bodies: A Short History of Autoimmunity by Warwick Anderson and Ian R. Mackay (review)

Chronic diseases characterized by varying symptoms and signs and unpredictable exacerbations and remissions have long plagued us and resisted easy explanation, classification, and treatment. In the twentieth century, those protean ailments not linked to infection, cell pathology, or organ dysfunctions have migrated in and out of different provisional schemes, such as the once prominent “psychosomatic disease” framework. In Intolerant Bodies, physician historian Warwick Anderson and clinical immunologist Ian Mackay explore the history and science of the most prominent framework in the past half century for a large fraction of previously unexplained and often unnamed chronic illness—autoimmunity. Like the halting diagnostic experience of many patients and the belated biomedical recognition of autoimmunity, this important work of historical scholarship comes late in the game, after many other diseases and etiological schemes have already gathered a significant historiography. My guess is that autoimmunity as a historical subject had to wait for the complementary expertise of Anderson and Mackay, who deftly explicate the evolving science of immunology while finding social, political, and philosophical meaning in its metaphor-laden categories (e.g., “killer” T cells) and concepts (e.g., tolerance, rejection, self, and nonself).

Intolerant Bodies is the latest addition to Hopkins’s “biographies of disease” series. What makes Intolerant Bodies a biography of disease? Autoimmunity after all refers to many different biological processes, resulting in a diverse set of diseases whose clinical manifestations and histories follow many different plot lines. What Anderson and Mackay underscore is that autoimmune diseases, sharing a common cause in the individual’s antibody and/or cellular “attack” on his or her own tissues, are at their core highly idiosyncratic—and thus biographical. “To a remarkable degree,” the authors emphasize (p. 140), “the notion of autoimmune disease, with its emphasis on idiosyncrasy and individual variation, represents the survival of older, Hippocratic beliefs in disease as a biological process.” But despite its highly individual nature, autoimmune disease has been defined and explained by putatively universal and ever more molecular biological mechanisms. Anderson and Mackay trace the resulting tensions, not only in the history of immunology as a science, but in the lived experience of patients (e.g., Flannery O’Connor’s lifelong battle with lupus erythematosus) who try to control and make sense of their unique disease trajectories.

Anderson and Mackay situate their history of autoimmunity within the larger clinical and epistemological problem of distinguishing the abnormal from the normal. The book focuses on autoimmune disease, but it is necessarily also about autoimmunity as a normal physiological process. The immune system does not simply regulate the boundary between self and nonself, occasionally missing the mark, leading to disease. It is also the name we give to those processes that constitute the biological self in the face of ever-changing internal (pregnancy, cell death, cancer) and external challenges (infection, environment, transplants). Autoimmunity is thus a chapter in the longer history of the ways evolutionarily adaptive and individually homeostatic bodily responses lead to physiological effects that might—or might not—be understood by sufferers and clinicians as illness. The authors begin the book with what at first seems like a detour, an exploration of how fever was understood by many nineteenth-century clinicians. Autoimmunity, they argue, “has the ambivalent status possessed by fever in the nineteenth century, as it represents—in fact, quite vividly—a destructive aspect of the body’s regulatory mechanism” (p. 16).

Intolerant Bodies is a few books in one. Anderson and Mackay confidently explicate the many changing scientific beliefs about autoimmunity while exploring clinical and patient narratives, as well as anthropological, philosophical, and literary appropriations of autoimmune ideas, nomenclature, and findings. The result is untidy, but the better for it, as the boundaries between the body, society, lab, and clinic are highly permeable, permitting autoimmune-inspired ideas and terms to migrate and take on hybrid identities and meanings.

A few of Anderson’s and Mackay...