Candid, insightful, unexpectedly funny, a timeless collection that will compel anyone fascinated by the miracles of the human body, life, and death.
About the Author
Richard Selzer (1928–2016) was for many years a surgeon practicing in New Haven, Connecticut, where he was also on the faculty of the Yale School of Medicine. He was born in Troy, New York, was graduated from Union College and Albany Medical College, and from the Surgical Training Program of Yale University. In 1975 he won the National Magazine Award for his essays on medicine. Dr. Selzer’s books include Letters to a Young Doctor, Mortal Lessons, Down from Troy, Imagine a Woman and Other Tales, and Raising the Dead.
Read an Excerpt
I send as your graduation present my father's old textbook of physical diagnosis. It was published in 1918. Lifted yesterday from a trunk in the attic it is still faintly redolent of formaldehyde, and stained with Heaven only knows what ancient liquid. I love my old books — Longfellow, Virgil, Romeo and Juliet and Moby Dick — but I love this Textbook of Physical Diagnosis more. I can think of no better thing to give you as a reminder that all of Medicine is a continuum of which you are now a part. Within you is the gesture of the prehistoric surgeon who trephined his neighbor's skull on the floor of a cave. Within you, the poultice of cool mud applied to a burn by an old African woman. The work of all doctors before you is in your blood. Yours will enter the veins of whosoever comes after you.
The patients shown on the pages of this book are long since dead; so, too, the doctors and nurses who tended them; so, too, the photographer who peered at them from beneath the black curtain of his camera. Gone, the brilliant pink chancre that gave to one man all of his distinction; gone, too, the great goiter that made of the most ordinary woman a grinning queen; and the boyish bravado that rose above a huge scrotum infested with microfilaria. To read this book is to understand that disease raises the sufferer, granting him from out of his fever and his fret an intimate vision of life, a more direct route to his soul. Now he has the body of a poet.
You cannot separate passion from pathology any more than you can separate a person's spirit from his body. Think of a particular person's spirit and, Presto! it is immediately incorporated. It has the size and shape of his body. The flesh is the spirit thickened. Gaze long enough at your patients, and from even the driest husk there will fly upward a shower of sparks that, to him who gazes, will coalesce into a little flame. Look at the pictures in this book and learn that the sick are refugees who must be treated kindly and gravely, without condescension. In the beginning you will love their wounds because they give you the occasion for virtue; later you will love the sick for their own sake. Rendered helpless by their afflictions, they cherish the memory of fertile lands and cool green glades and the company of love — all the stuff of their former selves. These people know something you and I do not yet know — what it is to live with the painful evidence of your mortality.
Notice that in each picture the eyes of the subjects have been covered by a black band to conceal identities. But the eyes are not the only windows to the soul. I have seen sorrow more fully expressed in a buttocks eaten away by bedsores; fear, in the arching of a neck; supplication, in a wrist. Only last week I was informed by a man's kneecaps that he was going to die. Flashing blue lights, they teletyped that he was running out of oxygen and blood. As soon as I got their cyanotic message, I summoned his family for a last vigil. A doctor's eyes must not be blindfolded against the light.
My hat is off to the photographer of this book, who chose misery for his subject in order to endear it. If I were you, I would not show these pictures to the squeamish who will be threatened by the echoes of their own mortality. Nor to vulgar people who decree that what they think ugly or gross ought not to be photographed. It would offend them. But what some think of as ugliness can become beauty to others — an ulcer, a dwarf, blood spreading on a pillow. An amputated leg retains something of the character of the one from whom it has been severed. Much as does the broken-off handle of a Greek amphora. It could have been part of nothing else. Retrieved and held up to fit, the handle sings again its old amphoric song. Personally, I suspect that truth is more accessible in "ugliness" than it is in beauty. The man who photographed the people in this book knew that in October, when the leaves fall from the trees, you can see farther into the forest.
Let us look through the book together. A quick glance might lead you to think these folk impoverished. My God! you say, a squirrel in his packed nuttery has more than they. Well, perhaps. But to me they seem the freest humans on earth. For while they stand on the narrow ledge of physical torment, no one would try to jostle them from their perch to take their place. Soon, you know, they will leap from that ledge to the plain where the bones of their ancestors lie strewn. The rest of us must still contend for a place in the sun, must face as best we can the dreadful future tense.
On one page there are two photographs of the same woman. She is naked save for her high-button shoes. In the first picture, she stands sideways to show her huge, pendulous umbilical hernia. It hangs to within six inches of her knees like an apron. In the second, she lifts the flap with her two hands as though to begin a dance. On the next page a man with a detachable collar and sleeve garters holds out a hand whose fingers are mummified from lack of circulation.
And here is a black man shown from the rear. His back is so wasted that he resembles a hanging bat — lax webs slung from the shoulder blades and cinched at the hips. His scapulae have scrambled to the top of the wreck, and crouch there in fright.
A young woman throws her head back to show her credential here, a thyroglossal duct cyst seen as a lump at the front of her neck. Her mouth falls open to reveal her small upper front teeth, each one separated by a cunning space. The interior of her mouth is dark, a receptacle. Her face is oddly corrupt. Perhaps she is kneeling ... and those babyish sharp teeth.
Next, the reckless stare of a hyperthyroid, her eye showing too much white. She lives in a frenzy. Her pulse, respirations, appetite, everything is furious. Her gaze, too. Here, at last, is countenance befitting the mood of the body. Even the page trembles finely in my hand.
Now a congenital syphilitic intent that you should see his perforated palate. A triangular hole in that palate leads to an upper vault that is hidden from view, all but a bit of glistening membrane at one corner. It is a secret room at the very base of his brain. Of the man's face, you see only the nostrils and a Ubangi mouth stretched to accommodate the mirror inserted for the photography.
Here, the kyphotic, the scoliotic, the severely lordotic. Their faces are older by far than their S-shaped bodies, as though the curvature of a spine is associated with a compensatory prolongation of childhood. Childhood, it is said, ought to be prolonged by whatever means possible. But not at the cost of such crookedness.
And on this page, a youngish woman with cross-eyed breasts. A pouch of fatigue hangs beneath one nipple. The other breast is shrunken, turned inward in bewilderment. You cannot see her face or arms, which might allow you to draw some conclusions. But at her throat — a string of brave dark beads.
An old woman lies back in whorish recumbency, her knees flexed and having drifted apart. She wears white cotton stockings rolled below the knees and knotted there. Her hands reach down to open her vulva to show something beefy and red growing just inside. It has always been her role to be helpful.
All this famished flesh. Pale as a family of fatherless little boys. Saint Hildegard was right; God does not inhabit healthy bodies. Now, shut the book, close your eyes and hear the crimson thump of your heart.
If, in a darkened room, a doctor holds a bright light against a hollow part of the body, he can see through the outer tissues to the structures within — arteries, veins, projecting shelves of bone. In such a ruby gloom, he can distinguish between a hernia and a hydrocele of the testicle, or he can light up a sinus behind the brow to find the tumor there. Unlike surgery, which opens the body to direct examination, this transillumination gives an indirect vision, calling into play only the simplest perceptions of the doctor. The pictures in this book are a kind of transillumination. They hold a camera before the human body and capture through the covering layers the truth within.
Dear to me as it is, the Textbook of Physical Diagnosis is only a book, and cannot make of you a doctor.
In the matter of Physical Diagnosis greed is not a sin; it is a virtue. There can never be enough hearts and lungs to teach a Doctor his business. Do not rely upon the X-ray machine, the electrocardiograph or the laboratory to tell you what your hands, eyes and ears can find out, lest your senses atrophy from disuse. The machine does not exist that can take the place of the divining physician. The physical examination affords the opportunity to touch your patient. It gives the patient the opportunity to be touched by you. In this exchange, messages are sent from one to the other that, if your examination is performed with honesty and humility, will cause the divining powers of the Augurs to be passed on to you — their last heir.
Before long, you will lay your palm upon the back of a patient's chest, first on one side, then the other, and you will detect any diminution in the transmitted vibration of his voice. You will know, then, that in that place beneath your hand, the drawn breath does not fill a part of the lung that has become collapsed or carnified. Now listen there with your stethoscope. It is your cocked ear. Are there wheezes? bubbles? Do they occur as the breath is drawn or expelled? Are the bubbles coarse or fine? They will be fine only in the air sacs of the lung, coarse only in the large tubes — bronchi or trachea.
Again lay your palm upon the patient's chest such that your fingers contact him everywhere. Now tap your middle finger with the middle finger of your other hand. Listen ... no, feel, it is something between listening and feeling that you do here — for the note that is struck. It ought to have a certain echo, a timbre. If it is not resonant, but instead the sound is flat and dead, something — fluid, a mass — is interposed between the lung and your hand. Tap out the area of dullness. Does it shift as he changes position? Why, then, like all fluid, it seeks its own level. Tap your way up the patient's back. At what place does the dullness change to resonance? The ninth rib? The eighth? Now you know how much fluid is present. You know, too, between which ribs your needle must pass in order to draw it out so that the compressed lung may expand. Even as you diagnose, you have begun your therapy.
Place your hand over the patient's heart. Let your fingers receive its beat. Find the exact place where the thrust is strongest. If this impulse is beyond the anterior fold of the armpit, the heart is enlarged. Should there be no single clean beat but a "thrill," as though a wren is stirring beneath your hand, the heart is damaged by disease or made wrong from the beginning. Now listen with the stethoscope. What you felt as a thrill is heard as a murmur. The wren sings. Touch and hearing blend, confirm. If the murmur be no soft whisper, but a harsh grate, or a rumble up and down the scale, a valve of the heart is damaged. Do you hear the slap of its calcified leaflets? Soon you will know which valve is tight, which leaky. Listening to the heart is like learning the songs of birds. A song once heard and identified is your own from then on. It will never be confused with the songs of other birds.
Is the rhythm crazy, coming willy-nilly, irregularly irregular? Then you have heard "fibrillation." Are the beats too close together to count? Perhaps this is "flutter." A bruit is a thrill that is heard. Here blood eddies around a narrows. Learn the language of this craft. Bruit, murmur, thrill, flutter, fibrillation — these are simple nouns that will soon become infused with knowledge and implication. Rejoice in these words that are used only in the highest purpose and that bind you to the others who do this work.
The abdomen is perhaps the deepest of mysteries. The very word abdomen has no known origin. It comes down to us from ancient times. Perhaps, they say, it means a secret place where things are stowed. You must approach such a mystery with tact. It is more threatening for a patient to uncover his abdomen than his chest. It is a kind of surrender. The abdomen, unprotected by a cage of ribs or a thick hide, presents itself equally to the surgeon's knife and the assassin's dagger. The slightest roughness on your part is a breach of the Articles of Medicine. In palpating the abdomen, the pressure of your hand must be neither too heavy nor too light. Too heavy a touch produces a guarding — a defense of the musculature. You will feel nothing through such a barricade. Too light, and you will tickle. This yields only discomfort and embarrassment. It goes without saying that your hands must be warm and dry. The belly is sensitive to every shock. Once intimidated, it can be reassured only at some effort, and then never fully. If the abdomen be divided into four quadrants, it is best to begin in the left upper quadrant, which is the least likely to be the site of disease, although by no means immune. Request that the patient roll himself a bit toward you. Guide him until he is at an angle of forty-five degrees. This allows the spleen to fall forward. Press just below the rib cage while asking him to take a deep breath. Such a full inspiration will depress the diaphragm and with it, the spleen. If the spleen is enlarged beyond normal size, its lower pole will bump against your fingers. How far below the ribs do you feel it? Two fingerbreadths? Three? From this, you may estimate its degree of enlargement. Beware! Many the spleen, outsized and therefore delicate, that has been ruptured by the undue pressure of the examining hand.
The most cerebral of all examinations is that of the brain. Encased as it is in a bony box, the brain cannot be approached directly, but its condition must be deduced from signals given at the most distant outposts. The navel, say, or the knee. Stroke the sole of a patient's foot. Stroke it firmly with a hard instrument, and see the toes of that foot rise and spread. This is the sign of Babinski. It tells, perhaps, of a blood clot or tumor in the motor cortex of the opposite side of the brain. Ask your patient to stand and close his eyes. "I won't let you fall," you assure him. Almost at once he sways to one side and would surely fall if you did not catch him. So! the cerebellum too is involved. You are closing in on the lesion. Soon you will know its exact location. Now you are happy in the way that a hunter is happy when, following the spoor of an animal, he comes upon fresh evidence.
Just so, in the name of Asklepios, do I invite you to begin the sacred process of divination called Physical Diagnosis. There is no more beautiful sight in the world than that of a kindly, efficient doctor engaged in the examination of the body of a fellow human being.
I heard the other day that Hugh Franciscus had died. I knew him once. He was the Chief of Plastic Surgery when I was a medical student at Albany Medical College. Dr. Franciscus was the archetype of the professor of surgery — tall, vigorous, muscular, as precise in his technique as he was impeccable in his dress. Each day a clean lab coat monkishly starched, that sort of thing. I doubt that he ever read books. One book only, that of the human body, took the place of all others. He never raised his eyes from it. He read it like a printed page as though he knew that in the calligraphy there just beneath the skin were all the secrets of the world. Long before it became visible to anyone else, he could detect the first sign of granulation at the base of a wound, the first blue line of new epithelium at the periphery that would tell him that a wound would heal, or the barest hint of necrosis that presaged failure. This gave him the appearance of a prophet. "This skin graft will take," he would say, and you must believe beyond all cyanosis, exudation and inflammation that it would.
He had enemies, of course, who said he was arrogant, that he exalted activity for its own sake. Perhaps. But perhaps it was no more than the honesty of one who knows his own worth. Just look at a scalpel, after all. What a feeling of sovereignty, megalomania even, when you know that it is you and you alone who will make certain use of it. It was said, too, that he was a ladies' man. I don't know about that. It was all rumor. Besides, I think he had other things in mind than mere living. Hugh Franciscus was a zealous hunter. Every fall during the season he drove upstate to hunt deer. There was a glass-front case in his office where he showed his guns. How could he shoot a deer? we asked. But he knew better. To us medical students he was someone heroic, someone made up of several gods, beheld at a distance, and always from a lesser height. If he had grown accustomed to his miracles, we had not. He had no close friends on the staff. There was something a little sad in that. As though once long ago he had been flayed by
friendship and now the slightest breeze would hurt. Confidences resulted in dishonor. Perhaps the person in whom one confided would scorn him, betray. Even though he spent his days among those less fortunate, weaker than he — the sick, after all — Franciscus seemed aware of an air of personal harshness in his environment to which he reacted by keeping his own counsel, by a certain remoteness. It was what gave him the appearance of being haughty. With the patients he was forthright. All the facts laid out, every question anticipated and answered with specific information. He delivered good news and bad with the same dispassion.
Excerpted from "Letters to a Young Doctor"
Copyright © 1982 David Goldman and Janet Selzer, Trustees.
Excerpted by permission of Houghton Mifflin Harcourt Publishing Company.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
Table of Contents,
Letter to a Young Surgeon I,
Letter to a Young Surgeon II,
Letter to a Young Surgeon III,
A Pint of Blood,
Letter to a Young Surgeon IV,
Letter to a Young Surgeon V,
The Virgin and the Petri Dish,
The Grand Urinal of the Elks,
About the Author,
Most Helpful Customer Reviews
I enjoyed this book greatly. Books like 'Complications' are a waste of literary space, everybody should read this book and all the other books in Mr. Selzer's collection.