The Great-Doctors Approach to Medical History : DOCTORS The Biography of Medicine <i> by Sherwin B. Nuland (Alfred A. Knopf: $24.95; 489 pp.) </i>

Thomas Carlyle decidedly overstated the case when he claimed that “the history of the world is but the biography of great men.” Still, the collective biography approach to history has shown its power to engage the general reader since Plutarch and Suetonius. More than half a century ago, Paul De Kruif’s “Microbe Hunters” applied it with great popular success to the history of medicine. Now the respected surgeon Sherwin Nuland follows suit in “Doctors,” not up to De Kruif’s mark in storytelling verve but with other strengths of its own.

Nuland hangs his history on 13 individuals and two group endeavors, beginning with the quasi-legendary father-figure of medicine, Hippocrates of Cos, in the fifth and fourth centuries BC. The rival school of Cnidus prefigured modern medicine in focusing on specific organs and symptoms, but existing knowledge fell far short of supporting it, whereas the Cos school’s premise of four bodily “humors,” though false, led in practice to a sounder concern with the whole patient and his environment. The writings of Hippocrates, moreover, set ethical and practical guidelines for modern medicine, including the famous Oath.

In the second century AD, the Greek physician Galen emerged as a second giant of the classical canon, emphasizing anatomical precision, through dissection and experiment, as a requisite to understanding disease. Galen made enduring contributions thereby. Yet he relied on animal rather than human cadavers, and on mere speculation to fill gaps. Over the centuries translators and scribes corrupted his writings, commentators misconstrued his insights and precepts, and blind reverence petrified his mutilated legacy.

Not until the 16th Century did the Belgian Andreas Vesalius break the Galenic spell by dissecting human bodies and publishing a brilliantly illustrated analysis of their structure and workings. His contemporary, the French surgeon Ambroise Pare, raised his lowly trade to a respected profession, tempering the savagery and trauma of surgical practice, and building on the best of past authority through reason and his own experience. Though he cared more for the relief of suffering than the advancement of knowledge, his writings created a new and lasting vision of what a surgeon should be and how he should think.

The 17th Century brought the scientific method of hypothesis from hard evidence, tested by reproducible experiments. Exemplifying it, the Englishman William Harvey worked out the nature and function of the circulatory system, correcting Galen on physiology as Vesalius had on structure. With the 18th Century came the Enlightenment, marked in medicine by the Italian Giovanni Morgagni, whose anatomical concept of disease linked specific diseases with malfunctions of specific organs, thus undermining the doctrine of the “four humors.” The Enlightenment also produced the great Scottish surgeon John Hunter, a leader in comparative anatomy, whose zeal and skill made his profession an experimental science as well as an art.

Early in the 19th Century, the Frenchman Rene Laennec’s invention of the stethoscope, now the badge of medical status, brought new precision and objectivity to diagnosis and so further shifted focus from the whole patient to the specific disease. Counterbalancing dehumanization, however, a group of Americans perfected and promoted surgical anesthesia, judged by Nuland to be America’s greatest gift to medicine. In Europe, moreover, the horrendous mortality of postoperative infection spread by doctors themselves in large hospitals came under control. The Hungarian Ignac Semmelweis, neurotically and self-destructively vituperative, failed to convince most fellow surgeons of their own responsibility for the lethal spreading of puerperal fever during childbirth. But the saintly English surgeon Joseph Lister, with the added support of Pasteur’s work on microbes, at last won respect for antisepsis in surgery. This, along with anesthesia, gave scope to more deliberate and meticulous surgery for a wider range of ills.

Nuland brings us into the 20th Century with two Americans: William Stewart Halsted, heroic battler against a 40-year morphine addiction, who made the Johns Hopkins medical school and hospital a beacon of modern medical research, technique, and training; and Helen Taussig, a model of pure science humanized, of Cos and Cnidus in harmony, who with Alfred Blalock designed and promoted the “blue-baby” heart operation and who led the fight to ban Thalidomide as a cause of tragic birth defects.

Finally Nuland turns to a second group achievement: Organ transplantation. Paradoxically, he observes, this culmination of cold-eyed specificity has consequences and implications of quite another sort. What becomes of physical individuality? What are the rights of brain-dead donors? How is death defined? Modern medicine asks other hard questions. How do treatment choices based on cost effectiveness or the use of human subjects in controlled trials square with the Hippocratic Oath? What remains of specificity as multiple disease factors are discerned: Environment, life style, genetics, even mental state? Does the scientific method have limits beyond which one can only resort to art, serendipity and intuition? Is medical policy too important to be left to the doctors? In response to these quandaries Nuland sees a resurgence of holism and humane doctor-patient relationships as both necessary and good.

As the foregoing synopsis hints, Nuland’s book is much more than collective biography. It is a mosaic composed of biography; straight history (scientific, medical, political, social, and intellectual); philosophical homilies; reflections on the surgeon’s work, motivations, ideals, ethics, frailties, joys, and hang-ups; recurrent celebrations of the surgeon’s calling; and a generous sampling of the author’s personal reminiscences.

It is a rich mixture but not always a smooth one. There is abrupt channel-switching, backtracking, and forward-flashing. Points made at length are often restated later at equal length. The editorial scalpel has left some of its work undone here, and so the narrative flags now and then. Nuland’s prose is always fluent, frequently eloquent, sometimes witty, but now and then too florid. As he himself disarmingly admits, he seems occasionally too worshipful of his superdocs, though he does paint their warts.

Nuland’s biographical approach is no substitute for the clarity, balance, and steady forward movement of good history taken straight. His inclusions and omissions are, as he also admits, somewhat idiosyncratic. Nevertheless straight history needs the supplement of books like this.

The personal element in the book, doubtless by design, fascinates the reader with its laying open of a specimen surgeon, cultivated, humane, reflective, in love with his calling. (The layman may and should be disturbed by his relish for the sheer act of vivisection, something common among surgeons in which he himself suspects psychological aberration.) Eloquent, informed, deeply committed, this uncommon book should be a revelation to most general readers.