MORTAL LESSONS NOTES ON THE ART OF SURGERY With a New Preface ~ RICHARD SELZER .~ , A Harvest Book • Harcourt, Inc. San Diego New York London ,:JW. ,~hng ~l Co. £amuy 241 !\,JJ..£a:wt & ,:AiL~, 9('n 40151 039lt44 To Jon, Larry, and Gretchen PREFACE It is a quarter of a century since this book was written. Looking Preface copyright © 1996 by Richard Selzer Copyright © 1974, 1975, 1976, 1987 by Richard Selzer at it now, I am inclined to use an editorial pencil to spare myself a number ofembarrassments this time around. Why do All rights reserved. No part of this publication may be I have the feeling that these pieces were first written in a for­ reproduced or transmitted in any form or by any means, eign language and that this volume is a translation for which I electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, alone am responsible? Still, I am surprised that the author without permission in writing from the publisher. (perhaps it is best to consider that he and I are not the same person) has come so close to expressing precisely what I think Requests fur permission to make copies of any part of now. In a way, that writer of twenty-five years ago is the older of the work should be mailed to the following address: Permissions Department, Harcourt, Inc., the two, as I don't seem to think of myself as anything but a 6277 Sea Harbor Drive, Orlando, Florida 32887-6777. mere pickle of a boy. (Even in my dreams I am a youngster making love for the first time. It is both ridiculous and Library of Congress Cataloging-in-Publication Data exhausting! ) Selzer, Richard, 1928­ Mortal lessons: notes on the art of surgery/Richard Selzer­ 1st Harvest ed. There is no one way to write. The minimalists have shown p. cm.-(A Harvest book) that plain, unadorned prose in words of one syllable can reach "WIth a new preface." the heights of beauty and power. Myself, I have always been Originally published: New York: Simon & Schuster, cl976. ISBN 0-15-600400-3 intoxicated by words, grabbed up great armsful of them and 1. Surgery. I. Title. run across the page letting fall what may, and only then paus­ RD39.S44 1996 ing to select, sort, rearrange. I deplore that so many thousands 617-dc20 95-53778 of our best words have fallen into obsolescence or are deemed Printed in the United States ofAmerica First Harvest Edition archaic. In this volume I have rescued not a few of those long­ FHJLMKIGE unused words and disinterred a number of buried phrases. If I could find no word to express what I intended, I made one 7 THE KNIFE THE KNIFE One holds the knife as one holds the bow of a cello or a rulip-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, fol­ lowed 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 severed blood vessels, the snuffle and gargle of the suction still struck with a kind of dread that it is I in whose hand machine clearing the field of blood for the next stroke, the the blade travels, that my hand is its vehicle, that yet again litany of monosyllables with which one prays his way this terrible steel-bellied thing and I have conspired for a down and in: clamp, sponge, suture, tie, cut. And there is most unnarural purpose, the laying open of the body of a color. The green of the cloth, the white of the sponges, the human being. red and yellow of the body. Beneath the fat lies the fascia, A stillness settles in my heart and is carried to my hand. the tough fibrous sheet encasing the muscles. It must be It is the quietude of resolve layered over fear. And it is this sliced and the red beef of the muscles separated. Now there resolve that lowers us, my knife and me, deeper and deeper are retractors to hold apart the wound. Hands move to­ into the person beneath. It is an entry into the body that is gether, part, weave. We are fully engaged, like children nothing like a caress; still, it is among the gentlest of acts. absorbed in a game or the craftsmen of some place like Then stroke and stroke again, and we are joined by other Damascus. instruments, hemostats and forceps, until the wound blooms Deeper still. The peritoneum, pink and gleaming and with strange flowers whose looped handles fall to the sides membranolls, bulges into the wound. It is grasped with for­ in steely array. ceps, and opened. For the first rime we can see into the There is sound, the tight click of clamps fixing teeth into cavity of the abdomen. Such a primitive place. One expects 92 93 THE BODY THE KNIFE to find drawings of buffalo on the walls. The sense of tres­ spleen. No! No! Do not touch the spleen that lurks below passing is keener now, heightened by the world's light the left leaf of the diaphragm, a manta ray in a coral cave, illuminating the organs, their secret colors revealed its bloody tongue protruding. One poke and it might rup­ maroon and salmon and yellow. The vista is sweetly vul­ ture, exploding with sudden hemorrhage. The filmy omen­ nerable at this moment, a kind of welcoming. An arc of the tum must not be torn, the intestine scraped or denuded. liver shines high and on the right, like a dark sun. It laps The hand finds the liver, palms it, fingers running along its over the pink sweep of the stomach, from whose lower sharp lower edge, admiring. Here are the twin mounds of border the gauzy omentum is draped, and through which the kidneys, the apron of the omentum hanging in front of veil one sees, sinuous, slow as just-fed snakes, the indolent the intestinal coils. One lifts it aside and the fingers dip coils of the intestine. among the loops, searching, mapping territory, establishing You turn aside to wash your gloves. It is a ritual cleans­ boundaries. Deeper still, and the womb is touched, then ing. One enters this temple doubly washed. Here is man as held like a small muscular bottle-the womb and its earlike microcosm, representing in all his parts the earth, perhaps appendages, the ovaries. How they do nestle in the cup of a the universe. man's hand, their power all dormant. They are frailty I must confess that the priestliness of my profession has itself. ever been impressed on me. In the beginning there are There is a hush in the room. Speech stops. The hands of vows, taken with all solemnity. Then there is the endless the others, assistants and nurses, are still. Only the voice of harsh novitiate of training, much fatigue, much sacrifice. the patient'S respiration remains. It is the rhythm of a quiet At last one emerges as celebrant, standing close to the truth sea, the sound of waiting. Then you speak, slowly, the terse lying curtained in the Ark of the body. Not surplice and entries of a Himalayan climber reporting back. cassock but mask and gown are your regalia. You hold no "The stomach is okay. Greater curvature clean. No sign chalice, but a knife. There is no wine, no wafer. There are of ulcer. Pylorus, duodenum fine. Now comes the gall­ only the facts of blood and flesh. bladder. No stones. Right kidney, left, all right. Liver ... And if the surgeon is like a poet, then the scars you have " made on countless bodies are like verses into the fashioning Your speech lowers to a whisper, falters, stops for a long, of which you have poured your soul. I think that if years long moment, then picks up again at the end of a sigh that later I were to see the trace from an old incision of mine, I comes through your mask like a last exhalation. should know it at once, as one recognizes his pet expres­ "Three big hard ones in the left lobe, one on the right. sions. Metastatic deposits. Bad, bad. Where's the primary? Got to But mostly you are a traveler in a dangerous country, be coming from somewhere." advancing into the moist and jungly cleft your hands have The arm shifts direction and the fingers drop lower and made. Eyes and ears are shuttered from the land you left lower into the pelvis-the body impaled now upon the arm behind; mind empties itself of all other thought. You are of the surgeon to the hilt of the elbow. the root of groping fingers. It is a fine hour for the fingers, "Here it is." their sense of touch so enhanced. The blind must know this The voice goes flat, all business now. feeling. Oh, there is risk everywhere. One goes lightly. The "Tumor in the sigmoid colon, wrapped all around it, 94 95 THE KNIFE pretty tight. We'll take Out a sleeve of the bowel. No co­ lostomy. 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.