Doctor Nuland's case book

Why should we care how the body works? Leaving aside those of us whose job requires this knowledge, do right-minded adults concern themselves with the workings of the body, except when it goes wrong? And more to the point, would they read a book running to nearly 400 pages on the subject?

Well, that depends. A technical manual, of the sort you can get about your car, with cut-away diagrams and an emphasis on the naming of parts, would probably be as dull as many lectures I sat through as a medical student, and would have little general appeal. This book is not dull, but nor is it merely a description of human anatomy and physiology.

Sherwin Nuland, an American surgeon who teaches surgery and the history of medicine at Yale University, has written a work that also has large elements of autobiography and personal philosophy rooted in the normal functions and ailments of the organism that has occupied his professional life.

The book opens with the story of a woman who against the odds survived severe internal bleeding. The explanation of how she escaped death touches on every aspect of human physiology, and the chapters that follow cover the biology of the cell, the organs of the body and their integrated function, at a level close to that of the first year at medical school. The effects of disease provide insights into the "wisdom of the body" - "wisdom" here referring to the coordinated function of millions of cells that underpins the organism's struggle for survival - and most of the dozen chapters deal with illness as well as normal function. But diseases appear not as they might in a textbook, but rather in lengthy case histories.

The case history dates from the era of Hippocrates in the fifth century bc, and its form has changed remarkably little since. In essence, it is a story told by a doctor to teach the origins of disease and the course of illness. What is often missing from the case history is the perspective of the patient. But Nuland emphasises the emotional experiences of the patients in his narratives, and includes detailed and often verbatim descriptions of what the illness meant to them.

The accounts are well crafted, with a richness of detail and a flair for bringing out the drama often to be found in catastrophic illness. Nuland himself features in many as the doctor, although in the longest, about a patient who had a heart transplant, he is an observer. This one is particularly interesting, because of the revealing comments he makes about the medical staff involved; the surgeons of the transplant team are praised for their technical excellence, yet are implicitly criticised for keeping emotionally distant from the patient.

But most of the doctors and patients to be found in these case histories have a wholesomeness that is perhaps too sweet for the non-American palate; even the crack addict ultimately renounces drugs and declares he wants to become a doctor. And although Nuland sometimes remarks on the problems which may arise between doctors and patients - for example, when things go wrong, such difficult but interesting issues are not explored.

The power of scientific medicine in the late 20th century, as exemplified by organ transplantation, has given it a status which approaches that of a religion. But this status creates tensions between doctor and patient. The doctor understands so much more about the patient's body and illness than does the patient, and this superior knowledge makes it perhaps inevitable that there will be elements of paternalism and domination in their relationship.

Nuland writes in a friendly style, although sometimes strains too hard to add interest to what he has to say: "In the gradual process of concocting the ingredients that are biology into the cassoulet that is man, the sauces of instinct have simmered into the motivations and yearnings that give flavour to human life". His tone is generally serious, with occasional flashes of humour. He works in a few too many quotations from nonmedical writers, but the historical detail is mostly apt and memorable. The facts are accurate (but no references are given) and typographical errors virtually absent, although national pride was hurt to see an English physician, Richard Asher (who described Munchausen syndrome, the syndrome of feigned illness), misnamed in the text and index as Alter.

Through his roles in the case histories, and his candid remarks at other points, Nuland is revealing about himself as a person. We learn of his unhappy first but successful second marriage; his love of his children; his high-minded devotion to his work (which includes making evening rounds at the hospital, even if it means leaving dinner guests); and his Webster's dictionary (this perhaps puts in too many appearances). Such self-revelation is rare in the writings of doctors, even American ones. The book concludes with a chapter that summarises his philosophy of life. Nuland emerges as an agnostic humanist who believes that the "human spirit" arises from the harmonious workings of the organs of the body. He tries - and in my view fails - to establish a link between the functions of the body and the moral and spiritual dimensions of life. If good and evil have meaning, it cannot be deduced from an account of cell biology. Nevertheless, the work stands as a testament to a doctor with an individual and memorable voice, different from that of many in contemporary medicine.

David Sprigings is consultant physician, Northampton General Hospital.