Defining autoimmunity: an epistemological history

Abstract

The history of most medical specialties spans centuries, even millennia. Surgical procedures are thought to have first been undertaken thousands of years ago, infectious diseases were first rigorously investigated in the early 1700s, and the term psychiatry was coined in 1808. Warwick Anderson and Ian MacKay may have once envisioned that summarising the history of autoimmunity would be straightforward compared with recounting the milestones of other more ancient specialties. But, as their book reveals, although the history of autoimmunity may be fairly short in terms of time, it has been as complex, philosophical, dynamic, and unique as the very concept it has strived to define: the self.Anderson and MacKay write that Intolerant Bodies is “the product of more than thirty years of intellectual engagement between a clinician-historian and a historian-clinician”—a timeframe that has seen arguably some of the most pivotal advances in understanding autoimmunity thus far. Although the concept of immunological self versus non-self was first proposed in the 1940s, it did not gain traction until the 1960s, when researchers began to systematically isolate and characterise immune-cell subsets. It became clear that autoimmune diseases manifest when the ability of the immune system to differentiate self from non-self goes awry. Supported by technical advances, immunological research expanded and the immune system was shown to be a complex, self-regulating network of cells, antibodies, and soluble factors; the concept of autoimmunity needed to be continuously reframed. By the year 2000, the immunological self, “however ambiguous, metaphorical, and suspect”, had gone global.Dozens of autoimmune diseases exist but, to tell their story, Anderson and MacKay focus on just four, one being type 1 diabetes. Diabetes was first reported in the 1880s, and the recognition by a French physician Étienne Lancereaux that there were two forms—the rapidly fatal diabète maigre and the adult-onset, chronic diabète gras—soon followed. By the turn of the century, type 1 diabetes was no longer rare enough to be the subject of case reports. However, even by the time pharmaceutical insulin was introduced as a treatment in 1920, physicians still had next to no insight as to the cause: some proposed diet and predisposition, others blamed viral infections. In the 1960s, researchers observed insulinitis in pancreases from patients who had died from type 1 diabetes, and begun to speculate on an autoimmune cause. In 1974, auto-antibodies were at last discovered, enabling a diagnostic test for type 1 diabetes, but scientists were no closer to finding a cure; once insulinitis is evident, the immunological damage has already occurred.In unravelling autoimmunity's short history, Anderson and MacKay cast the clinical immunologist as something of a James Bond of medical researchers, with “clinical expertise [that] crossed traditional boundaries, permeating pediatrics, adolescent health, internal medicine, and geriatrics”. By advancing knowledge of what were heralded as mysterious autoimmune processes, clinical immunologists “thus altered the illness trajectories of those afflicted with autoimmune diseases, modifying their experiences of body, self, and time”. The authors' ability to populate their epistemological history of autoimmunity with the apposite quotations, landmark discoveries, and philosophical musings of the field's most notable experts truly brings the book to life.What might be the most intriguing chapter of Intolerant Bodies is the understated “Afterword”. Here, Anderson and MacKay delve deeply into examples of the philosophers, social theorists, anthropologists, and others who have borrowed extensively from concepts of autoimmunity, owing to the common quest to define the self. In striving to define the nature of autoimmunity, immunologists have developed an ideal conceptual framework for discussing self, biological individuality, and human identity. Thus, the specialised concepts of autoimmunity are far from limited to the remit of specialists. In their short history, Anderson and MacKay prove that autoimmunity can be presented in various guises for various purposes, from a “personalized pathology” to a “guiding metaphor in understanding the perils of life and identity in the twenty-first century” to a set of concepts that “embody a style of Cold War thinking—especially its emphasis on surveillance, recognition, control, conformity, and regulation”.Considering autoimmunity from a philosophical perspective is unlikely to provide insight into disease pathology. But considering alternative conceptual frameworks might arm physicians with a new way of explaining autoimmune disease to their patients, who the authors note typically display “little interest in philosophical inquiries into self, or even the scientific theories that fasten onto the concept” unless prompted to do so. Moreover, Anderson and MacKay reward any readers who have dedicated decades to researching a cure for type 1 diabetes, and other equally elusive autoimmune diseases, by illustrating just how far into other scholarly realms the concepts of autoimmunity have reached. The history of most medical specialties spans centuries, even millennia. Surgical procedures are thought to have first been undertaken thousands of years ago, infectious diseases were first rigorously investigated in the early 1700s, and the term psychiatry was coined in 1808. Warwick Anderson and Ian MacKay may have once envisioned that summarising the history of autoimmunity would be straightforward compared with recounting the milestones of other more ancient specialties. But, as their book reveals, although the history of autoimmunity may be fairly short in terms of time, it has been as complex, philosophical, dynamic, and unique as the very concept it has strived to define: the self. Anderson and MacKay write that Intolerant Bodies is “the product of more than thirty years of intellectual engagement between a clinician-historian and a historian-clinician”—a timeframe that has seen arguably some of the most pivotal advances in understanding autoimmunity thus far. Although the concept of immunological self versus non-self was first proposed in the 1940s, it did not gain traction until the 1960s, when researchers began to systematically isolate and characterise immune-cell subsets. It became clear that autoimmune diseases manifest when the ability of the immune system to differentiate self from non-self goes awry. Supported by technical advances, immunological research expanded and the immune system was shown to be a complex, self-regulating network of cells, antibodies, and soluble factors; the concept of autoimmunity needed to be continuously reframed. By the year 2000, the immunological self, “however ambiguous, metaphorical, and suspect”, had gone global. Dozens of autoimmune diseases exist but, to tell their story, Anderson and MacKay focus on just four, one being type 1 diabetes. Diabetes was first reported in the 1880s, and the recognition by a French physician Étienne Lancereaux that there were two forms—the rapidly fatal diabète maigre and the adult-onset, chronic diabète gras—soon followed. By the turn of the century, type 1 diabetes was no longer rare enough to be the subject of case reports. However, even by the time pharmaceutical insulin was introduced as a treatment in 1920, physicians still had next to no insight as to the cause: some proposed diet and predisposition, others blamed viral infections. In the 1960s, researchers observed insulinitis in pancreases from patients who had died from type 1 diabetes, and begun to speculate on an autoimmune cause. In 1974, auto-antibodies were at last discovered, enabling a diagnostic test for type 1 diabetes, but scientists were no closer to finding a cure; once insulinitis is evident, the immunological damage has already occurred. In unravelling autoimmunity's short history, Anderson and MacKay cast the clinical immunologist as something of a James Bond of medical researchers, with “clinical expertise [that] crossed traditional boundaries, permeating pediatrics, adolescent health, internal medicine, and geriatrics”. By advancing knowledge of what were heralded as mysterious autoimmune processes, clinical immunologists “thus altered the illness trajectories of those afflicted with autoimmune diseases, modifying their experiences of body, self, and time”. The authors' ability to populate their epistemological history of autoimmunity with the apposite quotations, landmark discoveries, and philosophical musings of the field's most notable experts truly brings the book to life. What might be the most intriguing chapter of Intolerant Bodies is the understated “Afterword”. Here, Anderson and MacKay delve deeply into examples of the philosophers, social theorists, anthropologists, and others who have borrowed extensively from concepts of autoimmunity, owing to the common quest to define the self. In striving to define the nature of autoimmunity, immunologists have developed an ideal conceptual framework for discussing self, biological individuality, and human identity. Thus, the specialised concepts of autoimmunity are far from limited to the remit of specialists. In their short history, Anderson and MacKay prove that autoimmunity can be presented in various guises for various purposes, from a “personalized pathology” to a “guiding metaphor in understanding the perils of life and identity in the twenty-first century” to a set of concepts that “embody a style of Cold War thinking—especially its emphasis on surveillance, recognition, control, conformity, and regulation”. Considering autoimmunity from a philosophical perspective is unlikely to provide insight into disease pathology. But considering alternative conceptual frameworks might arm physicians with a new way of explaining autoimmune disease to their patients, who the authors note typically display “little interest in philosophical inquiries into self, or even the scientific theories that fasten onto the concept” unless prompted to do so. Moreover, Anderson and MacKay reward any readers who have dedicated decades to researching a cure for type 1 diabetes, and other equally elusive autoimmune diseases, by illustrating just how far into other scholarly realms the concepts of autoimmunity have reached.