Selzer's Mortal Lessons

SHARP COMPASSION

The French wit Chamfort has an epigram to the effect that one must swallow a toad before breakfast to be sure of running across nothing nastier before bedtime. Sound advice, no doubt, in his revolutionary and insanitary century when the appearance of moral disease, accidental or deliberate disfigurement, and the sports of nature in her more freakish moments were commonplace in the streets. In our time and our part of the world, however, Chamfort's epigram sounds like a typically Gallic exaggeration. Unless we stumble across or are involved in a gory car accident it is quite possible to live a life well insulated from scenes of real stomach-churning vileness. A surprising number of people have never seen a corpse. Hardly any lay people have seen major operation, especially one that fails and ends with the patient's death, or a massive congenital deformity. We have got things so arranged that, in pathological metaphor, society has grown a cyst around the morbid and the painful and thereby isolated it from the rest of the body politic. The contents of the cyst are revealed only to medical and paramedical workers. It is only they, and not the rest of us, who need that prescriptive toad with the toast and orange juice.

In proportion as we have hidden away life's unpleasantness, the public appetite for medical detail has grown stronger. A whole sector of the entertainment industry caters to it, from the blandest doctor-nurse soaps to those TV documentaries -- the moral equivalent of a public execution, and practically a genre in their own right -- set in big casualty departments where the cameras home in hungrily on the stretchers has they come through the swing doors with their freight of maimed bodies. But here too we are protected from the worst.

Curiously enough, though, doctors have not shown themselves too eager to assuage this appetite. Quite a number of good, even great writers have been recruited from the medical ranks: Sir Thomas Browne, Chekhov, the raconteur Oliver Gogarty, the American poet William Carlos Williams and essayist Oliver Wendell Holmes. But with how many of these was their experience as healers really central to their art? Practically none. Browne's Religio Medici (1643) is about the difficulties of faith, not the problems of a Caroline GP. The cheerfully obscene medical student in Ulysses, Buck Mulligan, is Joyce's version of his friend Gogarty; impossible to imagine him as Dr Gogarty's self-portrait.

No, most doctors who have aspired to literature have been the souls of discretion, discreet about their patients and cases and even more so about their own motives. John Mortimer, a barrister, gives us his Rumpole with its heartless, dry little professional jokes and its glimpses of lawyers in unbuttoned mood. The effect isn't very reassuring, but it rings very true. The fictional self-image of doctors, on the other hand, has rarely deviated from the comic, sentimental vein: the knockabout farce of Richard Gordon's Doctor books or the saccharine pieties of Dr Finlay's Casebook.

A surgeon, in particular, one cannot readily see blowing the gaff on his trade with anything like John Mortimer's gusto. Surgeons are very well aware that they are the nearest thing we have to a secular priesthood, schooled in dreadful mysteries. For the surgeon's is the last of the medical arts to retain a direct connection with the bloody history of killing-or-curing. Everywhere else has triumphed crisp sheets, high electronics, disposable plastic and laboratory glassware. It is only the skill of the surgeon that still has the whiff of the shambles about it. He's the one with the bloody hands. He alone still cures in the primeval way, in the only way in which we believe, in our heart of hearts, that we can be cured: by having the bad cut out of us. Even now we sense a link between the modern suave practitioner and those heroes of pre-anaesthetic days like Robert Liston, half butcher and half artist, who could take off a leg in thirty seconds with no equipment but a curved knife and a broad thumb pressed squarely on the patient's femoral artery. Yes, if doctors are discreet, surgeons are positively secretive about their trade, especially its less creditable side. And this is a pity, because the surgeon-writer must necessarily have to hand a wealth of material far from the common run, rich in drama, pathos, horror, heroism. Which brings us to Richard Selzer.*

We recall that it was the opinion of some of the early Fathers of the Church that Man at bottom is a saccus stercoris, a sack of shit. Some such vision of Man as an excrementitious vessel informs these twenty-four essays of Selzer's on the "art of surgery". I intend no disparagement when I say that the themes of many are nasty and a few disgusting. No doubt it is hard for the surgeon to see much grandeur in the human condition. Selzer has indeed a sardonic view of our pretensions. Of our reluctance to accept aging he says: "many a brittle hip's been fractured in pursuit of the phantasm that if you can fornicate at 85, you are not yet old." Yeats the poet, we learn, was persuaded by a quack, Steinach, to have his testicles tied off. For him the operation was a success: blocking the spermatic ducts unleashed a flood of renewed creativity. But the popularity of vasectomy has not generally induced a literary Renaissance. From which we conclude that the effect in Yeats' case was psychosomatic. Such self-deception Selzer sees as typical of man the arrogant vertebrate, determined to thrust himself erect no matter what the muscular and skeletal cost. "Swollen, bunched, sacculent, hung down, gibbous, hummocky, knobbed, sagging, adroop, warped, tipped and tilted" we pay a high cost for being able to stare at the stars.

As this mass of adjectives perhaps suggests, Selzer's prose knows little restraint. Indeed, it is so often inflated, so bombastic, so mannered, that one feels an impulse to prescribe an appointment at the surgery of Dr Swift, who also regarded human frailties with a clinician's eye but chose a cold lithe prose to describe them. When he is not trying too hard, Selzer can manage a simple and moving effect. To remove a tumour from a woman's cheek he has had to sever a facial nerve. Her husband is present:

"Will my mouth always be like this," she asks.

"Yes," I say, 'it will. It is because the nerve was cut."

She nods and is silent. But the young man smiles.

"I like it," he says. "It is kind of cute."

Such a scene has been set down, one feels, with a minimum of editing, just as it happened. The temptation to dress it up has been resisted. Selzer does not long forget to be 'literary'. When he does remember, he tends to write like this, of pregnancy nausea:

You, sulky Stomach, turn violet morn to greenest midnight. Despised alike are sight of food and the horrid goat-footed Impregnator. Stomach, stomach, wherefore this spite, this discompassion, this fury to discommode?

Emetic all right, this Wardour Street English, but not, presumably, in quite the way intended. His very floridity sometimes leads him into inaccuracy. The liver is not "turned to fatty globules" by a single drink (though the effect of a small dose of alcohol is temporarily just discernible through a microscope). Some of the anecdotes are hard to swallow, too: "in one village in northwest Thailand there is a street that is paved with the bladder stones of its children." Paved? Well, maybe; but we would still like to know which village exactly.

Selzer's gift, then, is not for popular scientific exposition. He is most remarkable when he is able to give free rein to his Jacobean imagination. Take the essay "The Corpse", which is a meditation on the physical facts of death. It is subtitled, "a homage to Sir Thomas Browne," and it is indeed an Urn Burial for our time. The treatment, however, like the style, lacks the grave memento mori of the original. The modern way of death hardly permits that. It's hard, for example, to be elegiac over the suction trocar. Selzer gives us a rhapsody on its use instead. The trocar is a hollow pointed rod a metre long connected by hose to a powerful pump. Its purpose is to pierce the body and to empty it of fluids preparatory to embalming, just as you might suck out the contents of an over-ripe plum through its skin. First, into the stomach and intestines; then, into the heart. Belly and chest cavity greedily ravaged, it's down into the scrotum: "the testicles mashed, ablaze with their billion whiptail jots. All, all into the sink -- and thence to the sewer. This is the ultimate suck." Once empty, the body is pumped full of phenol. The effect being aimed for is akin to those horribly life-like simulacra of food displayed outside restaurants in Japan. The phenol combines with the natural urea in the corpse and it is literally turned to plastic. Selzer relishes uncovering details that even the author of The Loved One flinched from.

"Horror, like bacteria, is everywhere." It's certainly present in Selzer's grisly anecdote of how, one sunny morning, pedestrians found themselves treading on tiny sprawled human bodies in the street. "You look up to see if all the unbaptized sinless are falling from Limbo"; but no, it's just that aborted foetuses from his hospital had fallen out of a sack on the way to the city incinerator. Perhaps this gruesome incident never really happened, or perhaps it has been touched up. But actually it matters little whether it did happen or not. For what Selzer is trying to show us are some of the medical realities of abortion; realities which are still there, decisions which have to be made every day, even after we have exhausted ourselves moralising on the subject. It is a medical fact that occasionally an aborted foetus cries and breathes after being passed, so that "there is nothing to do but let it live." In Selzer's hospital, he tells us, policy dictates that foetuses under a pound must be burnt in the city incinerator, while those over a pound are buried in the city cemetery. We shudder at the absurdity: but those inconvenient scraps of flesh are still there, to be disposed of. If we can't decide, how can we expect doctors to tell us if abortions are garbage or dead babies?

It is the virtue of Mortal Lessons, then, that it breaches every rule of medical etiquette. Selzer confronts head-on every taboo of his profession. Outsiders like psychiatrists have speculated cautiously, hesitantly, on the dark sexual and sadistic urges that impel some people into a position where they can, with social and legal impunity, cut open their fellow beings. Where they whispered, Selzer garrulous, embarrassingly candid about the feel of "the slow slide of intestines against the back of his hand" or how, under his slicing scalpel, "the flesh splits with its own kind of moan. It is like the penetration of rape." It is an exercise in bad manners. It loudly avows the unavowable.

* Richard Selzer, Mortal Lessons: Notes on the Art of Surgery (Chatto & Windus, 1981).