House Call

You cannot open this book without contemplating the author, since the publishers have covered the jacket with his face, large. They have good reason, since he is a remarkable and well-known man. He appeared full grown in public in the early Sixties as writer and actor in the revue Beyond the Fringe, that slaughter house of sacred cows. Everyone of its young cast of four went on to become successful, none more so than Miller. Late at night on television now, his face intrudes into the rooms of those who are not watching the wrestling or the cowboy movie. He is urbane, witty, original, and in control of an encyclopedic stretch of subjects. From how Alcibiades perverted the young to what it was Zarathustra spake, he has his views.

Author, doctor of medicine, critic, conversationalist, producer, director, he is all these, and with penetration, confidence, and panache. He edited and presented the arts program “Monitor” for the BBC, reviewed films for The New Yorker, made the film of Alice in Wonderland for television, has directed plays for major British theatrical companies including a controversial Merchant of Venice. Recently, he has turned to opera in Germany and in England, where his latest offering is The Marriage of Figaro.

While most people observe these activities with astonishment and admiration, there are, needless to say, those who are querulous and suspicious. If you hear “Just can’t stand the fellow” emerging from padded armchairs at the Athenaeum, the members are probably rubbing out Jonathan Miller. Of all the abnormal forms of social behavior, none is less acceptable than brilliance on display. I stand to one side in astonishment because I went through an identical education to Miller’s ten years earlier. In my day, we were carefully taught to loathe Shakespeare, to suspect the motifs and motives of grand opera, and to keep our heads low. A gentleman did not intrude on another with original thoughts.

So how can we put young Miller in his place? One way is to call in an expert who has spent a lifetime specializing in some topic on which Miller has ventured an opinion. “Could it be that he does not know that Ziegelganzberger would have been familiar to Mozart as the inventor of the pretzel and not, as he implies, the baker of croissants?” Now Miller has written a book on the human body and I could qualify as one of those experts. I could nitpick my way through this book locating errors and omissions and showing where he has failed to do his homework since leaving medical school twenty years ago. I will not do so because it would miss the point of a highly original book which is written with grace and elegance.

This book must have two origins in Miller’s background and way of thinking. He is soaked in medicine. His father was a distinguished psychiatrist. He married a fellow medical student who is now in that most taxing of specialties, the general practice of family medicine. He did his preclinical training at Cambridge, probably the best medical school in Britain at the time, and his clinical training at University College Hospital in London. Both at Cambridge and at UCH, some of the most prominent teachers and problems were concerned with the nervous system, and it is not surprising that his particular interests turned to neurology. The second influence must have come from his concern for the theater, which began by the time he was an undergraduate in Cambridge and took a major part in a revue from which Beyond the Fringe evolved.

In view of these two features of his background, it is not surprising that Dr. Miller should have become concerned with problems of communication between people and between a person and himself. What else is acting about? A particular interest was in expression and gesture. His own performances on television are a source of irritation to those who are habituated to the poker-faced pedant who drones on while trying to find a suitable place to hide his hands. Miller’s face, hands, and body are a pantomime which accompanies his voice like the chorus and orchestra in one of the operas he has directed. It is also therefore not surprising that his most serious writing up to now has been a biography of Marshall McLuhan.^* In a sweeping survey of the ways history, culture, and technology have affected communication, Miller produced a more important book than anything McLuhan himself ever wrote. Although he does not say so explicitly, I believe that The Body in Question takes up this subject again.

What is the question? Whether we are dualists and live in our bodies or whether we are monists and are our bodies, we are at least closely associated with some seventy kilograms of matter about which we are personally totally ignorant. This ignorance is not a question of lack of education. A doctor trained in a series of specialties knows inordinate detail about the structure and workings of the deepest recesses of the human body. In spite of this, he feels nothing of the normal ongoing working of his own body and therefore knows nothing directly about himself. Superb sense organs allow us to appreciate events in the outside world. We are in touch with the surface of our bodies. Once inside, we are in sensory limbo. A doctor may declare that he has an open bile duct inside himself but that fact is not knowledge, it is an assumption based on analogy. He does know that patients with blocked bile ducts have yellow skins and pale feces. Since he has neither of these, he may reasonably assume that his bile is freely flowing. This is a peculiarly roundabout form of knowledge about such a close personal possession. When our insides begin to deviate from their normal range of activities, we may experience certain types of feelings which indicate that something is wrong.

Hunger is an example of such a feeling but what exactly do we know when we feel hungry? Some scientists would claim that we then detect the presence of some abnormal chemical concentration such as a low level of blood sugar. This would place the feeling of hunger in the same general class of sensory experiences as smelling roses, seeing the sun, hearing a whistle, or tasting tabasco. Aristotle’s five senses were smelling, seeing, hearing, tasting, and something vaguely called the body sense. This last is a confused mixture and only to be included with the other four with care. The first four deal with events in the outside world which have an impact on our body surface. Touch and pressure on the skin can safely be classed with our sensory experiences concerned with our relations with the outside world.

But once inside our skins and we begin to experience hunger, thirst, nausea, or asphyxia, we are dealing not just with a change of venue but with a totally different class of experiences. We no longer locate the spatial origin of the experience. We have no vocabulary to discuss details. Unlike external events which can be completely neutral, the perception of these internal events is inevitably associated with attention, strong feelings, learning, and, above all, with impending action. There are some scientists who, like myself, maintain that we are not consciously aware of the events which set off these states but we are aware only of their consequences. We feel the existence of a state of need which signals the paramount importance to the organism of seeking food or water or whatever may be the biologically relevant action.

If this approach is correct, then we remain consciously ignorant of the particular events within us which led to the development of the feeling. The outer world in which we live is full of objects, events, and phenomena which we may explore, dissect, and contemplate. From the inner world of our own bodies, feelings of hunger, thirst, anxiety, and sleepiness come over us as a result of processes that are not available for personal dissection and contemplation.

I take the explanation of this problem to be Miller’s first aim but he goes on to two other sorts of body questioning. He asks: what sort of questions does a person ask himself when deciding that he is now sick and needs to visit the doctor? And he asks: what sort of questions does the doctor ask of the patient and the patient’s body? He shows how the doctors and patients may clash in conflicting semantics. If his book has a purpose, it is to help patients and doctors understand the meaning and aim of their different questions. The book was written at the same time as a thirteen-episode television series on the same topic which will be seen in the US in the fall of 1979. Television allows Miller to guide the viewer on a tour of the body. He uses himself as a model in a series of demonstrations from the gentle and amusing to the horrific in the British tradition of being one’s own guinea pig.

I prefer the book to the television series because it is more concise. It has left out some episodes, but these are not essential. On television, Miller has mutual fun with some highly verbal Cockneys on the streets of London, asking them where their heart, liver, and spleen are located—a useful illustration of our ignorance of our insides. A patient with appendicitis is asked where his pain started. He answers that it began on the train going home. The doctor dismisses this silly answer since he wants to know where in the abdomen the pain started. The book, magnificently illustrated, allows the reader to consider how he questions his body and how others in other cultures and times have done so. The book cannot include the episode when Miller did a post-mortem on television, which earned him the title of “Dissector-General of the BBC.” Still, the reader will learn a lot about his own body and his attitudes will be changed. Even though I am obviously familiar with the subject matter, I found many ideas and attitudes which were new to me and very provocative.

The book starts on a deceptively simple level describing the “natural shocks that flesh is heir to.” A patient finds a lump in his abdomen, feels awful, fails to defecate, and vomits. Four types of warning—findings, feelings, failings, and actions—tell him there is something wrong. The patient then orders these signs and symptoms according to the nastiness, alarm, disability, and social embarrassment that they produce and, on that basis, decides if medical help is needed. All this may sound at first simple and obvious but I know of no other place where this process is described so clearly.

Once in the hands of the doctor and especially if he is admitted to a hospital, the patient undergoes a change of role not unlike the rite of passage described by social anthropologists. As in initiation ceremonies, the patient undergoes a ritual separation from the old version of himself through a stage of washing, stripping, and isolation to emerge as a fully ordained member of the patient class. We are excluded as I have said from an intimate knowledge of what is actually going on inside us, yet each of our cultures has nevertheless produced explanations of the mechanism of our suffering. A Frenchman suffering from a headache points knowingly to his liver, the British hint ever so delicately that it’s due to their constipation, while Germans know it’s their circulation. I recently saw a sad example of this in a very sick German lady visiting a third specialist who confirmed that she had an inoperable brain tumor. She complained, “But he didn’t take my blood pressure.” A German doctor would have known better and would have matched his actions to the patient’s expectations.

Once sick, we turn for help and healing to an oracle or wise man. Miller tells how we form hypotheses on the origin of our sickness, comparing Western medical practice to that of the African Zande tribe he visited. When we believe that our illness comes from evil people—witches, sorcerers, or those who poison our food with chemical additives—we turn to those skilled in elimination. If it is an evil world that threatens us with its spirits, devils, and pollution, we consult the relevant specialists. They confirm our suspicions, pinpoint the details, and mobilize the forces of good against the forces of evil.

The Zande magician, Miller points out,

differs from the faith-healer and resembles the scientist in basing his practices on observation. He examines the world around him, recognizes similarities and acknowledges distinctions. But that is as far as the connection between magic and science goes. For the magician, similarity is an unquestionable sign of underlying identity and automatically implies that the manipulation of one thing will inevitably cause changes in anything which resembles it. The difficulty is that there is always a respect in which something could be said to resemble anything else.

Up to this point, Miller has discussed the process of crossing the threshold to a personal recognition of sickness. Now he turns to the remarkable self-help mechanisms within us which silently work away to maintain a stable healthy internal environment. Temperature, blood circulation, body chemistry are not given to us at birth; they are maintained within normal limits by the continuous active intervention of spectacularly tuned and intermeshed control mechanisms. Miller goes on to show in detail how our ideas developed about the functioning of three crucial elements of this internal control system—breathing, the blood, and the heart. Just as the jets of a fountain have a recognizable and steady state dependent on the continued supply of energy to the water, so our bodies maintain their steady state only by virtue of using a continuous supply of energy. But the statues around the fountain had their structure impressed on them once and for all by the sculptor, and their stability does not depend on a continuous energy supply.

We too have stable structures, self-sculptured by the process of embryonic growth, and Miller devotes a chapter to this astonishing growth of structure within which the dynamic energy-consuming conditions of life may proceed. Life depends on this maintained stability of structure and function but life itself is full of action and motion. Therefore in the last section of his book Miller discusses the springs of action and how it is we can move our bodies to explore, to perceive, to achieve goals.

Throughout the three major sections on the healthy body which deal with the internal milieu, growth, and movement, Miller shows how we have moved our method of explanation from mysticism to mechanism. In following the historical development of the understanding of various parts of us, he describes how a growing awareness of the possibilities of mechanical contrivances suggested powerful analogies with structures found within the body. The society within which Harvey studied the heart had developed pumps for mines and knew about the theory and practice of inlets, outlets, pistons, and valves. With this background, Harvey could move from thinking that the heart was like a pump to showing that it was a pump. The sixteenth- and seventeenth-century theorists who were still following the ancient approach of Galen intuitively felt that the body, like the world, was made of earth, air, fire, and water. The metallurgists and chemists beavering away with their retorts and probing inorganic chemistry led step by step to the recognition that the body did not act as though it contained fire. Rather, it really does contain a fire fed by oxygen and producing carbon dioxide.

This Miller’s tale has a clear moral. There have been periods in history when we probed the world around us, dissected phenomena, and then, to test our understanding, built up gadgets to imitate and control the world. Miller proposes that exploration and control of the physical world during these periods influenced not only the physicists and engineers but also the way in which artists painted and the way in which we understand our own bodies. He likes to emphasize the progress from analogy to hypothesis to experiment, where the proposal can fall or survive on testing. He has made a good case for this sequence having been followed in our understanding of the heart and circulation and muscle and kidney.

However, I find the case weak when we come to the understanding of our brains, where analogies have usually been grossly misleading. I think we will learn more about how to build interesting machines from studying the brain than the other way around. Similarly, Miller well describes how we know how we grow and maintain ourselves from embryo to adult, but I doubt our acquiring this knowledge owed much to the simultaneous development of computers, as he seems to suggest when he cites, in connection with our understanding of genetic codes, the linear program of instruction J.M. Jacquard used for his loom or a “numerically controlled milling machine.” Any cell that proposed something as trivial as a computer-operated milling machine for self-reproduction would have been dismissed instantly from the production line of biological evolution.

In spite of these caveats, I agree with Miller in the curious paradox that considering the body of man as a machine has liberated man to consider his own humanity. We are surely the result of the interaction of forces, some of which we do not yet understand. That is very different from being subject to mystical forces which we are forbidden to understand.