ICU and You · ICU Book Club · Number 1
Jonathan Miller, 1978 — and the argument that the metaphor is the instrument
A new column, for books that have made a difference to how we teach, train or practise in intensive care. Not textbooks, or not only textbooks — anything that changed how somebody thinks about the work. Some will be old. Some will not be medicine at all.
I am starting with mine, but the point of the series is what other people have to offer, and there is an invitation at the foot of the page. Send me the book that did it for you.
Jonathan Miller. The Body in Question. Jonathan Cape, London, 1978. Written alongside the thirteen-part BBC television series of the same name.
For me, this book and the accompanying thirteen-part BBC series were hugely influential. I was young enough when I read it that I cannot honestly claim it made me do medicine. Something was already forming. What it did was tell me the thing I was forming into was more interesting than I had understood.
Miller's premise is that we have almost no useful access to our own interiors. We do not feel our kidneys working. The sensations we do get are vague, poorly localised and frequently lying to us. So every culture has had to build the inside of the body from the outside, out of whatever was lying around.
What was lying around, mostly, was machinery. The body has been a furnace, an alembic, a clockwork, a set of pipes. Harvey could not demonstrate the circulation until somebody had built a decent pump for him to think with. Miller's argument is that the metaphor is not decoration laid over the physiology afterwards. The metaphor is the instrument. It is what makes the fact thinkable in the first place, and it also decides what you will fail to see. He saw that the computer was the metaphor that would help us imagine and reimagine our own brains — with our own brains.
This was the idea that spoke to me, and it has been quietly useful for these past decades. It says the discipline advances by importing from outside itself. Which means the reading you do that is not medicine is not completely time off from medicine.
Intensive care makes this concrete in a way most specialties do not. We are the ones still watching physiology happen in real time — compliance, oxygen delivery, filling pressures, the whole system visible and moving on a screen at three in the morning. We intervene at the level of the mechanism. And every one of our mental models is borrowed from somewhere else. Circuits. Reservoirs. Waterfalls. Even ships with sails. Miller would have recognised all of it.
He is also the argument in person. Physician, then Beyond the Fringe, then thirty years of opera. The man who wrote the best book about how doctors think left the profession and directed Rigoletto. Draw from that what you like.
It has dated in places. Read it anyway. It is short, and the prose is most of the pleasure.
Is there a book that made a difference to you, in medicine or well outside it?
Tell me what it was and what it did. If you like, I will read it and post a review here. Better still, send me your own review and I will publish the best of them, with your name on them.
The button opens a reply straight to me. If your device blocks it, write to icuandyou@icloud.com instead.