Mortal Lessons: Notes on the Art of Surgery

Mortal Lessons: Notes on the Art of Surgery

by Richard Selzer

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Product Details

ISBN-13: 9780156004008
Publisher: Houghton Mifflin Harcourt
Publication date: 04/15/1996
Series: Harvest Book Series
Edition description: First Edition
Pages: 222
Sales rank: 419,381
Product dimensions: 5.31(w) x 8.00(h) x (d)

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.

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Someone asked me why a surgeon would write. Why, when the shelves are already too full? They sag under the deadweight of books. To add a single adverb is to risk exceeding the strength of the boards. A surgeon should abstain. A surgeon, whose fingers are more at home in the steamy gullies of the body than they are tapping the dry keys of a typewriter. A surgeon, who feels the slow slide of intestines against the back of his hand and is no more alarmed than were a family of snakes taking their comfort from such an indolent rubbing. A surgeon, who palms the human heart as though it were some captured bird.

Why should he write? Is it vanity that urges him? There is glory enough in the knife. Is it for money? One can make too much money. No. It is to search for some meaning in the ritual of surgery, which is at once murderous, painful, healing, and full of love. It is a devilish hard thing to transmit — to find, even. Perhaps if one were to cut out a heart, a lobe of the liver, a single convolution of the brain, and paste it to a page, it would speak with more eloquence than all the words of Balzac. Such a piece would need no literary style, no mass of erudition or history, but in its very shape and feel would tell all the frailty and strength, the despair and nobility of man. What? Publish a heart? A little piece of bone? Preposterous. Still I fear that is what it may require to reveal the truth that lies hidden in the body. Not all the undressings of Rabelais, Chekhov, or even William Carlos Williams have wrested it free, although God knows each one of those doctors made a heroic assault upon it.

I have come to believe that it is the flesh alone that counts. The rest is that with which we distract ourselves when we are not hungry or cold, in pain or ecstasy. In the recesses of the body I search for the philosophers' stone. I know it is there, hidden in the deepest, dampest cul-de-sac. It awaits discovery. To find it would be like the harnessing of fire. It would illuminate the world. Such a quest is not without pain. Who can gaze on so much misery and feel no hurt? Emerson has written that the poet is the only true doctor. I believe him, for the poet, lacking the impediment of speech with which the rest of us are afflicted, gazes, records, diagnoses, and prophesies.

I invited a young diabetic woman to the operating room to amputate her leg. She could not see the great shaggy black ulcer upon her foot and ankle that threatened to encroach upon the rest of her body, for she was blind as well. There upon her foot was a Mississippi Delta brimming with corruption, sending its raw tributaries down between her toes. Gone were all the little web spaces that when fresh and whole are such a delight to loving men. She could not see her wound, but she could feel it. There is no pain like that of the bloodless limb turned rotten and festering. There is neither unguent nor anodyne to kill such a pain yet leave intact the body.

For over a year I trimmed away the putrid flesh, cleansed, anointed, and dressed the foot, staving off, delaying. Three times each week, in her darkness, she sat upon my table, rocking back and forth, holding her extended leg by the thigh, gripping it as though it were a rocket that must be steadied lest it explode and scatter her toes about the room. And I would cut away a bit here, a bit there, of the swollen blue leather that was her tissue.

At last we gave up, she and I. We could no longer run ahead of the gangrene. We had not the legs for it. There must be an amputation in order that she might live — and I as well. It was to heal us both that I must take up knife and saw, and cut the leg off. And when I could feel it drop from her body to the table, see the blessed space appear between her and that leg, I too would be well.

Now it is the day of the operation. I stand by while the anesthetist administers the drugs, watch as the tense familiar body relaxes into narcosis. I turn then to uncover the leg. There, upon her kneecap, she has drawn, blindly, upside down for me to see, a face; just a circle with two ears, two eyes, a nose, and a smiling upturned mouth. Under it she has printed SMILE, DOCTOR. Minutes later I listen to the sound of the saw, until a little crack at the end tells me it is done.

So, I have learned that man is not ugly, but that he is Beauty itself. There is no other his equal. Are we not all dying, none faster or more slowly than any other? I have become receptive to the possibilities of love (for it is love, this thing that happens in the operating room), and each day I wait, trembling in the busy air. Perhaps today it will come. Perhaps today I will find it, take part in it, this love that blooms in the stoniest desert.

All through literature the doctor is portrayed as a figure of fun. Shaw was splenetic about him; Moliere delighted in pricking his pompous medicine men, and well they deserved it. The doctor is ripe for caricature. But I believe that the truly great writing about doctors has not yet been done. I think it must be done by a doctor, one who is through with the love affair with his technique, who recognizes that he has played Narcissus, raining kisses on a mirror, and who now, out of the impacted masses of his guilt, has expanded into self-doubt, and finally into the high state of wonderment. Perhaps he will be a nonbeliever who, after a lifetime of grand gestures and mighty deeds, comes upon the knowledge that he has done no more than meddle in the lives of his fellows, and that he has done at least as much harm as good. Yet he may continue to pretend, at least, that there is nothing to fear, that death will not come, so long as people depend on his authority. Later, after his patients have left, he may closet himself in his darkened office, sweating and afraid.

There is a story by Unamuno in which a priest, living in a small Spanish village, is adored by all the people for his piety, kindness, and the majesty with which he celebrates the Mass each Sunday. To them he is already a saint. It is a foregone conclusion, and they speak of him as Saint Immanuel. He helps them with their plowing and planting, tends them when they are sick, confesses them, comforts them in death, and every Sunday, in his rich, thrilling voice, transports them to paradise with his chanting. The fact is that Don Immanuel is not so much a saint as a martyr. Long ago his own faith left him. He is an atheist, a good man doomed to suffer the life of a hypocrite, pretending to a faith he does not have. As he raises the chalice of wine, his hands tremble, and a cold sweat pours from him. He cannot stop for he knows that the people need this of him, that their need is greater than his sacrifice. Still ... still ... could it be that Don Immanuel's whole life is a kind of prayer, a paean to God?

A writing doctor would treat men and women with equal reverence, for what is the "liberation" of either sex to him who knows the diagrams, the inner geographies of each? I love the solid heft of men as much as I adore the heated capaciousness of women — women in whose penetralia is found the repository of existence. I would have them glory in that. Women are physics and chemistry. They are matter. It is their bodies that tell of the frailty of men. Men have not their cellular, enzymatic wisdom. Man is albuminoid, proteinaceous, laked pearl; woman is yolky, ovoid, rich. Both are exuberant bloody growths. I would use the defects and deformities of each for my sacred purpose of writing, for I know that it is the marred and scarred and faulty that are subject to grace. I would seek the soul in the facts of animal economy and profligacy. Yes, it is the exact location of the soul that I am after. The smell of it is in my nostrils. I have caught glimpses of it in the body diseased. If only I could tell it. Is there no mathematical equation that can guide me? So much pain and pus equals so much truth? It is elusive as the whippoorwill that one hears calling incessantly from out the night window, but which, nesting as it does low in the brush, no one sees. No one but the poet, for he sees what no one else can. He was born with the eye for it.

Once I thought I had it: Ten o'clock one night, the end room off a long corridor in a college infirmary, my last patient of the day, degree of exhaustion suitable for the appearance of a vision, some manifestation. The patient is a young man recently returned from Guatemala, from the excavation of Mayan ruins. His left upper arm wears a gauze dressing which, when removed, reveals a clean punched-out hole the size of a dime. The tissues about the opening are swollen and tense. A thin brownish fluid lips the edge, and now and then a lazy drop of the overflow spills down the arm. An abscess, inadequately drained. I will enlarge the opening to allow better egress of the pus. Nurse, will you get me a scalpel and some ...?

What happens next is enough to lay Francis Drake avomit in his cabin. No explorer ever stared in wilder surmise than I into that crater from which there now emerges a narrow gray head whose sole distinguishing feature is a pair of black pincers. The head sits atop a longish flexible neck arching now this way, now that, testing the air. Alternately it folds back upon itself, then advances in new boldness. And all the while, with dreadful rhythmicity, the unspeakable pincers open and close. Abscess? Pus? Never. Here is the lair of a beast at whose malignant purpose I could but guess. A Mayan devil, I think, that would soon burst free to fly about the room, with horrid blanket-wings and iridescent scales, raking, pinching, injecting God knows what acid juice. And even now the irony does not escape me, the irony of my patient as excavator excavated.

With all the ritual deliberation of a high priest I advance a surgical clamp toward the hole. The surgeon's heart is become a bat hanging upside down from his rib cage. The rim achieved — now thrust — and the ratchets of the clamp close upon the empty air. The devil has retracted. Evil mocking laughter bangs back and forth in the brain. More stealth. Lying in wait. One must skulk. Minutes pass, perhaps an hour. ... A faint disturbance in the lake, and once again the thing upraises, farther and farther, hovering. Acrouch, strung, the surgeon is one with his instrument; there is no longer any boundary between its metal and his flesh. They are joined in a single perfect tool of extirpation. It is just for this that he was born. Now — thrust — and clamp — and yes. Got him!

Transmitted to the fingers comes the wild thrashing of the creature. Pinned and wriggling, he is mine. I hear the dry brittle scream of the dragon, and a hatred seizes me, but such a detestation as would make of Iago a drooling sucktit. It is the demented hatred of the victor for the vanquished, the warden for his prisoner. It is the hatred of fear. Within the jaws of my hemostat is the whole of the evil of the world, the dark concentrate itself, and I shall kill it. For mankind. And, in so doing, will open the way into a thousand years of perfect peace. Here is Surgeon as Savior indeed.

Tight grip now ... steady, relentless pull. How it scrabbles to keep its tentacle-hold. With an abrupt moist plop the extraction is complete. There, writhing in the teeth of the clamp, is a dirty gray body, the size and shape of an English walnut. He is hung everywhere with tiny black hooklets. Quickly ... into the specimen jar of saline ... the lid screwed tight. Crazily he swims round and round, wiping his slimy head against the glass, then slowly sinks to the bottom, the mass of hooks in frantic agonal wave.

"You are going to be all right," I say to my patient. "We are all going to be all right from now on."

The next day I take the jar to the medical school. "That's the larva of the botfly," says a pathologist. "The fly usually bites a cow and deposits its eggs beneath the skin. There, the egg develops into the larval form which, when ready, burrows its way to the outside through the hide and falls to the ground. In time it matures into a full-grown botfly. This one happened to bite a man. It was about to come out on its own, and, of course, it would have died."

The words imposter, sorehead, servant of Satan spring to my lips. But now he has been joined by other scientists. They nod in agreement. I gaze from one gray eminence to another, and know the mallet-blow of glory pulverized. I tried to save the world, but it didn't work out.

No, it is not the surgeon who is God's darling. He is the victim of vanity. It is the poet who heals with his words, stanches the flow of blood, stills the rattling breath, applies poultice to the scalded flesh.

Did you ask me why a surgeon writes? I think it is because I wish to be a doctor.


In the foyer of a great medical school there hangs a painting of Vesalius. Lean, ascetic, possessed, the anatomist stands before a dissecting table upon which lies the naked body of a man. The flesh of the two is silvery. A concentration of moonlight, like a strange rain of virus, washes them. The cadaver has dignity and reserve; it is distanced by its death. Vesalius reaches for his dissecting knife. As he does so, he glances over his shoulder at a crucifix on the wall. His face wears an expression of guilt and melancholy and fear. He knows that there is something wrong, forbidden in what he is about to do, but he cannot help himself, for he is a fanatic. He is driven by a dark desire. To see, to feel, to discover is all. His is a passion, not a romance.

I understand you, Vesalius. Even now, after so many voyages within, so much exploration, I feel the same sense that one must not gaze into the body, the same irrational fear that it is an evil deed for which punishment awaits. Consider. The sight of our internal organs is denied us. To how many men is it given to look upon their own spleens, their hearts, and live? The hidden geography of the body is a Medusa's head one glimpse of which would render blind the presumptuous eye. Still, rigid rules are broken by the smallest inadvertencies: I pause in the midst of an operation being performed under spinal anesthesia to observe the face of my patient, to speak a word or two of reassurance. I peer above the screen separating his head from his abdomen, in which I am most deeply employed. He is not asleep, but rather stares straight upward, his attention riveted, a look of terrible discovery, of wonder upon his face. Watch him. This man is violating a taboo. I follow his gaze upward, and see in the great operating lamp suspended above his belly the reflection of his viscera. There is the liver, dark and turgid above, there the loops of his bowel winding slow, there his blood runs extravagantly. It is that which he sees and studies with so much horror and fascination. Something primordial in him has been aroused — a fright, a longing. I feel it, too, and quickly bend above his open body to shield it from his view. How dare he look within the Ark! Cover his eyes! But it is too late; he has already seen; that which no man should; he has trespassed. And I am no longer a surgeon, but a hierophant who must do magic to ward off the punishment of the angry gods.

I feel some hesitation to invite you to come with me into the body. It seems a reckless, defiant act. Yet there is more than dread reflected from these rosy coasts, these restless estuaries of pearl. And it is time to share it, the way the catbird shares the song which must be a joy to him and is a living truth to those who hear it. So shall I make of my fingers, words; of my scalpel, a sentence; of the body of my patient, a story.

One enters the body in surgery, as in love, as though one were an exile returning at last to his hearth, daring uncharted darkness in order to reach home. Turn sideways, if you will, and slip with me into the cleft I have made. Do not fear the yellow meadows of fat, the red that sweats and trickles where you step. Here, give me your hand. Lower between the beefy cliffs. Now rest a bit upon the peritoneum. All at once, gleaming, the membrane parts ... and you are in.

It is the stillest place that ever was. As though suddenly you are struck deaf. Why, when the blood sluices fierce as Niagara, when the brain teems with electricity, and the numberless cells exchange their goods in ceaseless commerce — why is it so quiet? Has some priest in charge of these rites uttered the command "Silence"? This is no silence of the vacant stratosphere, but the awful quiet of ruins, of rainbows, full of expectation and holy dread. Soon you shall know surgery as a Mass served with Body and Blood, wherein disease is assailed as though it were sin.


Excerpted from "Mortal Lessons"
by .
Copyright © 1987 Richard Selzer.
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.

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