RICHARD   SELZER
Riebard Seher (1928- ) grew up in Troy, New York, and studied medicine. He described bis coming-of-age in an affecting memoir, Down from Troy. A practicing surgeon, Selzer is one of the new wave of literary scientists-clinicians (Stephen ]ay Gould, Lewis Thomas, F. Gonzalez-Crussi, Oliver Sacks) who have brought a wealth of knowledge about the natural world to the essay form. What sets Selzer apart from these others is his willingness to write much more personally, even confessionally, about his feelings, reactions, and motives, in the tradition of the idiosyncratic first-person essay. He is also steeped in the sound of old English prose and relishes antiquarian diction and syntax; in Selzer one hears echoes of Sir Thomas Browne's Urn Burial, Burton's Anatomy of Melancholy, Montaigne, Lamb, and Hazlitt.
Mortal Lessons: Notes on the Art of Surgery was Selzer's first essay collection, and it contains astonishing arias to the body and disease. One of these, "The Knife," proceeds by proposing a series of metaphors (religious, sexual, equine, and so on) for the surgeon's tool, until the object is surrounded by multiple, contradictory meanings. The author makes a synec-dochic identification with his scalpel (a later collection was called Confessions of a Knife). Selzer's capacity for giddy wonderment, even in such sobering confines as the operating theater, may strike some readers as self-indulgent or a kind of tasteless black humor, but he keeps tight control over his prose, and his compassion never falters, ultimately, his descriptions have the tonic effect of making us look realistically at the impermanence and sturdiness of flesh.
The Knife
ONE HOLDS THE KNIFE as one holds the bow of a cello or a tulip—by the stem. Not palmed nor gripped nor grasped, but lightly, with the tips of the fingers. The knife is not for pressing. It is for drawing across the field of skin. Like a slender fish, it waits, at the ready, then, go! It darts, followed by a fine wake of red. The flesh parts, falling away to yellow globules of fat. Even now, after so many times, I still marvel at its power—cold, gleaming, silent. More, I am still struck with a kind of dread that it is I in whose hand the blade travels, that my hand is its vehicle, that yet again this terrible steel-bellied thing and I have conspired for a most unnatural purpose, the laying open of the body of a human being.
A stillness settles in my heart and is carried to my hand. It is the quietude of resolve layered over fear. And it is this resolve that lowers us, my knife and me, deeper and deeper into the person beneath. It is an entry into the body that is nothing like a caress; still, it is among the gendest of acts. Then stroke and stroke again, and we are joined by other instruments, hemostats and forceps, until the wound blooms with strange flowers whose looped handles fall to the sides in steely array.
There is sound, the tight click of clamps fixing teeth into severed blood vessels, the snuffle and gargle of the suction machine clearing the field of blood for the next stroke, the litany of monosyllables with which one prays his way down and in: clamp, sponge, suture, tie, cut. And there is color. The green of the cloth, the white of the sponges, the red and yellow of the body. Beneath the fat lies the fascia, the tough fibrous sheet encasing the muscles. It must be sliced and the red beef of the muscles separated. Now there are retractors to hold apart the wound. Hands move together, pa«, weave. We are fully engaged, like children absorbed in a game or the craftsmen of some place like Damascus.
Deeper still. The peritoneum, pink and gleaming and membranous, bulges into the wound. It is grasped with forceps, and opened. For the first time we can see into the cavity of the abdomen. Such a primitive place. One expects to find drawings of buffalo on the walls. The sense of trespassing is keener now, heightened by the world's light illuminating the organs, their secret colors revealed—maroon and salmon and yellow. The vista is sweetly vulnerable at this moment, a kind of welcoming. An arc of
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the Hver shines high and on the right, like a dark sun. It laps over the pink sweep of the stomach, from whose lower border the gauzy omentum is draped, and through which veil one sees, sinuous, slow as just-fed snakes, the indolent coils of the intestine.
You turn aside to wash your gloves. It is a ritual cleansing. One enters this temple doubly washed. Here is man as microcosm, representing in all his parts the earth, perhaps the universe.
I must confess that the priestliness of my profession has ever been impressed on me. In the beginning there are vows, taken with all solemnity. Then there is the endless harsh novitiate of training, much fatigue, much sacrifice. At last one emerges as celebrant, standing close to the truth lying curtained in the Ark of the body. Not surplice and cassock but mask and gown are your regalia. You hold no chalice, but a knife. There is no wine, no wafer. There are only the facts of blood and flesh.
And if the surgeon is like a poet, then the scars you have made on countless bodies are like verses into the fashioning of which you have poured your soul. I think that if years later I were to see the trace from an old incision of míne, I should know it at once, as one recognizes his pet expressions.
But mostly you are a traveler in a dangerous country, advancing into the moist and jungly cleft your hands have made. Eyes and ears are shuttered from the land you left behind; mind empties itself of all other thought. You are the root of groping fingers. It is a fine hour for the fingers, their sense of touch so enhanced. The blind must know this feeling. Oh, there is risk everywhere. One goes lightly. The spleen. No! No! Do not touch the spleen that lurks below the left leaf of the diaphragm, a manta ray in a coral cave, its bloody tongue protruding. One poke and it might rupture, exploding with sudden hemorrhage. The filmy omentum must not be torn, the intestine scraped or denuded. The hand finds the liver, palms it, fingers running along its sharp lower edge, admiring. Here are the twin mounds of the kidneys, the apron of the omentum hanging in front of the intestinal coils. One lifts it aside and the fingers dip among the loops, searching, mapping territory, establishing boundaries. Deeper still, and the womb is touched, then held like a small muscular botde—the womb and its earlike appendages, the ovaries. How they do nestle in the cup of a man's hand, their power all dormant. They are frailty itself.
There is a hush in the room. Speech stops. The hands of the others, assistants and nurses, are still. Only the voice of the patient's respiration remains. It is the rhythm of a quiet sea, the sound of waiting. Then you speak, slowly, the terse entries of a Himalayan climber reporting back.
"The stomach is okay. Greater curvature clean. No sign of ulcer. Pylorus, duodenum fine. Now comes the gall-bladder. No stones. Right kidney, left, all right. Liver . . . uh-oh."
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Your speech lowers to a whisper, falters, stops for a long, long moment, then picks up again at the end of a sigh that comes through your mask like a last exhalation.
"Three big hard ones in the left lobe, one on the right. Metastatic deposits. Bad, bad. Where's the primary? Got to be coming from somewhere."
The arm shifts direction and the fingers drop lower and lower into the pelvis—the body impaled now upon the arm of the surgeon to the hilt of the elbow.
"Here it is."
The voice goes flat, all business now.
"Tumor in the sigmoid colon, wrapped all around it, pretty tight. We'll take out a sleeve of the bowel. No colostomy. Not that, anyway. But, God, there's a lot of it down there. Here, you take a feel."
You step back from the table, and lean into a sterile basin of water, resting on stiff arms, while the others locate the cancer.
When I was a small boy, I was taken by my father, a general practitioner in Troy, New York, to St. Mary's Hospital, to wait while he made his rounds. The solarium where I sat was all sunlight and large plants. It smelled of soap and starch and clean linen. In the spring, clouds of lilac billowed from the vases; and in the fall, chrysanthemums crowded the magazine tables. At one end of the great high-ceilinged, glass-walled room was a huge cage where colored finches streaked and sang. Even from the first, I sensed the nearness of that other place, the Operating Room, knew that somewhere on these premises was that secret dreadful enclosure where surgery was at that moment happening. I sat among the cut flowers, half drunk on the scent, listening to the robes of the nuns brush the walls of the corridor, and felt the awful presence of surgery.
Oh, the pageantry! I longed to go there. I feared to go there. I imagined surgeons bent like storks over the body of the patient, a circle of red painted across the abdomen. Silence and dignity and awe enveloped them, these surgeons; it was the bubble in which they bent and straightened. Ah, it was a place I would never see, a place from whose walls the hung and suffering Christ turned his affliction to highest purpose. It is thirty years since I yearned for that old Surgery. And now I merely break the beam of an electric eye, and double doors swing open to let me enter, and as I enter, always, I feel the surging of a force that I feel in no other place. It is as though I am suddenly stronger and larger, heroic. Yes, that's it!
The operating room is called a theatre. One walks onto a set where the cupboards hold tanks of oxygen and other gases. The cabinets store steel cutlery of unimagined versatility, and the refrigerators are filled with bags of blood. Bodies are stroked and penetrated here, but no love is made.
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Nor is it ever allowed to grow dark, but must always gleam with a grotesque brightness. For the special congress into which patient and surgeon enter, the one must have his senses deadened, the other his sensibilities restrained. One lies naked, blind, offering; the other stands masked and gloved. One yields; the other does his will.
I said no love is made here, but love happens. I have stood aside with lowered gaze while a priest, wearing the purple scarf of office, administers Last Rites to the man I shall operate upon. I try not to listen to those terrible last questions, the answers, but hear, with scorching clarity, the words that formalize the expectation of death. For a moment my resolve falters before the resignation, the attentiveness, of the other two. I am like an executioner who hears the cleric comforting the prisoner. For the moment I am excluded from the centrality of the event, a mere technician standing by. But it is only for the moment.
The priest leaves, and we are ready. Let it begin,
Later, I am repairing the strangulated hernia of an old man. Because of his age and frailty, I am using local anesthesia. He is awake. His name is Abe Kaufman, and he is a Russian Jew. A nurse sits by his head, murmuring to him. She wipes his forehead. I know her very well. Her name is Alexandria, and she is the daughter of Ukrainian peasants. She has a flat steppe of a face and slanting eyes. Nurse and patient are speaking of blintzes, borscht, piroshki—Russian food that they both love. I listen, and think that it may have been her grandfather who raided the shted where the old man lived long ago, and in his high boots and his blouse and his fury this grandfather pulled Abe by his side curls to the ground and stomped his face and kicked his groin. Perhaps it was that ancient kick that caused the hernia I am fixing. I listen to them whispering behind the screen at the head of the table. I listen with breath held before the prism of history.
"Tovarich," she says, her head bent close to his.
He smiles up at her, and forgets that his body is being laid open.
"You are an angel," the old man says.
One can count on absurdity. There, in the midst of our solemnities, appears, small and black and crawling, an insect: The Ant of the Absurd. The belly is open; one has seen and felt the catastrophe within. It seems the patient is already vaporizing into angelhood in the heat escaping therefrom. One could warm one's hands in that fever. All at once that ant is there, emerging from beneath one of the sterile towels that border the operating field. For a moment one does not really see it, or else denies the sight, so impossible it is, marching precisely, heading briskly toward the open wound.
Drawn from its linen lair, where it snuggled in the steam of the great
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sterilizer, and survived, it comes. Closer and closer, it hurries toward the incision. Ant, art thou in the grip of some fatal ivresse? Wouldst hurtle over these scarlet cliffs into the very boil of the guts? Art mad for the reek we handle? Or in some secret act of formication engaged?
The alarm is sounded. An ant! An ant! And we are unnerved. Our fear of defilement is near to frenzy. It is not the mere physical contamination that we loathe. It is the evil of the interloper, that he scurries across our holy place, and filthies our altar. He is disease—that for whose destruction we have gathered. Powerless to destroy the sickness before us, we turn to its incarnation with a vengeance, and pluck it from the lip of the incision in the nick of time. Who would have thought an ant could move so fast?
Between thumb and forefinger, the intruder is crushed. It dies as quietly as it lived. Ah, but now there is death in the room. It is a perversion of our purpose. Albert Schweitzer would have spared it, scooped it tenderly into his hand, and lowered it to the ground.
The corpselet is flicked into the specimen basin. The gloves are changed. New towels and sheets are placed where it walked. We are pleased to have done something, if only a small killing. The operation resumes, and we draw upon ourselves once more the sleeves of office and rank. Is our reverence for life in question?
In the room the instruments lie on trays and tables. They are arranged precisely by the scrub nurse, in an order that never changes, so that you can reach blindly for a forceps or hemostat without looking away from the operating field. The instruments lie thus! Even at the beginning, when all is clean and tidy and no blood has been spilled, it is the scalpel that dominates. It has a figure the others do not have, the retractors and the scissors. The scalpel is all grace and line, a fierceness. It grins. It is like a cat—to be respected, deferred to, but which returns no amiability. To hold it above a belly is to know the knife's force—as though were you to give it slightest rein, it would pursue an intent of its own, driving into the flesh, a wild energy.
In a story by Borges, a deadly knife fight between two rivals is depicted. It is not, however, the men who are fighting. It is the knives themselves that are settling their own old score. The men who hold the knives are mere adjuncts to the weapons. The unguarded knife is like the unbridled war-horse that not only carries its helpless rider to his death, but tramples all beneath its hooves. The hand of the surgeon must tame this savage thing. He is a rider reining to capture a pace.
So close is the joining of knife and surgeon that they are like the Centaur—the knife, below, all equine energy, the surgeon, above, with his delicate art. One holds the knife back as much as advances it to purpose. One is master of the scissors. One is partner, sometimes rival, to the knife.
The   Knife
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In a moment it is like the long red fingernail of the Dragon Lady. Thus does the surgeon curb in order to create, restraining the scalpel, governing it shrewdly, setting the action of the operation into a pattern, giving it form and purpose.
It is the nature of creatures to live within a tight cuirass that is both their constriction and their protection. The carapace of the turtle is his fortress and retreat, yet keeps him writhing on his back in the sand. So is the surgeon rendered impotent by his own empathy and compassion. The surgeon cannot weep. When he cuts the flesh, his own must not bleed. Here it is all work. Like an asthmatic hungering for air, longing to take just one deep breath, the surgeon struggles not to feel. It is suffocating to press the feeling out. It would be easier to weep or mourn—for you know that the lovely precise world of proportion contains, just beneath, there, all disaster, all disorder. In a surgical operation, a risk may flash into reality: the patient dies ... of complication. The patient knows this too, in a more direct and personal way, and he is afraid.
And what of that other, the patient, you, who are brought to the operating room on a stretcher, having been washed and purged and dressed in a white gown? Fluid drips from a bottle into your arm, diluting you, leaching your body of its personal brine. As you wait in the corridor, you hear from behind the closed door the angry clang of steel upon steel, as though a battle were being waged. There is the odor of antiseptic and ether, and masked women hurry up and down the halls, in and out of rooms. There is the watery sound of strange machinery, the tinny beeping that is the transmitted heartbeat of yet another human being. And all the while the dreadful knowledge that soon you will be taken, laid beneath great lamps that will reveal the secret linings of your body. In the very act of lying down, you have made a declaration of surrender. One lies down gladly for sleep or for love. But to give over one's body and will for surgery, to lie down for it, is a yielding of more than we can bear.
Soon a man will stand over you, gowned and hooded. In time the man will take up a knife and crack open your flesh like a ripe melon. Fingers will rummage among your viscera. Parts of you will be cut out. Blood will run free. Your blood. All the night before you have turned with the presentiment of death upon you. You have attended your funeral, wept with your mourners. You think, "I should never have had surgery in the springtime." It is too cruel. Or on a Thursday. It is an unlucky day.
Now it is time. You are wheeled in and moved to the table. An injection is given. "Let yourself go," I say. "It's a pleasant sensation," I say. "Give in," I say.
Let go? Give in? When you know that you are being tricked into the hereafter, that you will end when consciousness ends? As the monstrous
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silence of anesthesia falls discourteously across your brain, you watch your soul drift off.
Later, in the recovery room, you awaken and gaze through the thickness of drugs at the world returning, and you guess, at first dimly, then surely, that you have not died. In pain and nausea you will know the exultation of death averted, of life restored.
What is it, then, this thing, the knife, whose shape is virtually the same as it was three thousand years ago, but now with its head grown detachable? Before steel, it was bronze. Before bronze, stone—then back into un-remembered time. Did man invent it or did the knife precede him here, hidden under ages of vegetation and hoofprints, lying in wait to be discovered, picked up, used?
The scalpel is in two parts, the handle and the blade. Joined, it is six inches from tip to tip. At one end of the handle is a narrow notched prong upon which the blade is slid, then snapped into place. Without the blade, the handle has a blind, decapitated look. It is helpless as a trussed maniac. But slide on the blade, click it home, and the knife springs instantly to life. It is headed now, edgy, leaping to mount the fingers for the gallop to its feast.
Now is the moment from which you have turned aside, from which you have averted your gaze, yet toward which you have been hastened. Now the scalpel sings along the flesh again, its brute run unimpeded by germs or other frictions. It is a slick slide home, a barracuda spurt, a rip of embedded talon. One listens, and almost hears the whine—nasal, high, delivered through that gleaming metallic snout. The flesh splits with its own kind of moan. It is like the penetration of rape.
The breasts of women are cut off, arms and legs sliced to the bone to make ready for the saw, eyes freed from sockets, intestines lopped. The hand of the surgeon rebels. Tension boils through his pores, like sweat. The flesh of the patient retaliates with hemorrhage, and the blood chases the knife wherever it is withdrawn.
Within the belly a tumor squats, toadish, fungoid. A gray mother and her brood. The only thing it does not do is croak. It too is hacked from its bed as the carnivore knife lips the blood, turning in it in a kind of ecstasy of plenty, a gluttony after the long fast. It is just for this that the knife was created, tempered, heated, its violence beaten into paper-thin force.
At last a little thread is passed into the wound and tied. The monstrous booming fury is stilled by a tiny thread. The tempest is silenced. The operation is over. On the table, the knife lies spent, on its side, the bloody meal smear-dried upon its flanks. The knife rests.
And waits.
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