The physician as writer* By Richard Alan Selzer, M.D. 6 St. Ronan Terrace New Haven, Connecticut 06511

A surgeon, turned writer, discusses his experiences and the perils of changing professions. He reminisces about his early formative years, growing up in Troy, New York, and investigates the beauty of language and the pitfalls of misuse.

Good writing can be found almost anywhere: take this from Cecil and Loeb's Textbook of Medicine in the chapter on infectious diseases: "Tapeworms may be harbored for years and, except for the inconvenience of the gravid segments crawling out of the anus, the host continues in robust health enjoying both food and drink" [1]. Now, show me the writer who wouldn't die to have written that! The operating room is not your basic nest of nightingales, but somehow or other I have learned to sing there-arias of terror and bravado such as befit the work of a surgeon. I began to write at the age of forty: the psychic energy for it appeared rather abruptly in the middle of my life, and I suddenly found myself with a pencil and a blank sheet of paper. The first story that I wrote was a retelling of the biblical tale of Jonah and the whale. Since I knew what the gastric mucosa looked like better than those biblical authors, I could describe Jonah's new home with a great deal more flair. From that day on, I decided to dedicate myself to learning this new craft in much the same way that I had, earlier on, dedicated myself to learning the craft of surgery, and so I began to write every day. It had to be done between one and three in the morning because I was otherwise, as you might imagine, occupied. But between one and three in the morning I was in the kitchen, with the rest of the world asleep, and all the light in the universe directed down onto a blank sheet of paper. That is how I wrote my first three books. Anyone can tell that they are nocturnal creatures, rather like bats or owls. I decided to write stories. I chose the horror genre because surgeons love horror, don't you know, and also they are quite easy to write. You don't need a whole lot of character development or philosophical profundity. No, all you need to do is to make your reader shiver once, and you've done it. And so, in the dead of night, I wrote dozens and dozens of these horror stories, and before you know it, they began to * The Joseph Leiter NLM/MLA Lecture presented May 23, 1989, at the Eighty-Ninth Annual Meeting of the Medical Library Association, Boston, Massachusetts.

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appear in such eminent journals as Ellery Queen's Mystery Magazine. I was quite full of myself over that, and after a while a publisher from New York City called me up and said, "Do you have enough of those to make a book?" "Do I!" I said and backed up a truck next to his office. Out of that mass of horror he selected twenty stories, and he called it Rituals of Surgery [2]. It didn't have a darn thing to do with surgery, but he thought that would sell books. He was wrong! But in due course, there it was, a book with my name on it-Rituals of Surgery. Or as my nextdoor neighbor called it, rich wolves of surgery. She is not a nice woman! I was completely dazzled and I was of no use to anyone.

The operating room is not your basic nest of nightingales, but somehow or other I have learned to sing there-arias of terror and bravado such as befit the work of a surgeon. About two weeks after it was published, I was in the New Haven, Connecticut public library returning a book. The librarian, an old friend of mine as I go there so often, was at the desk, and just ahead of me, returning (be still my heart) Rituals of Surgery, was one of those vestiges of Yankeehood which are still seen on the streets of New England towns and villages. Picket-thin she was without an ounce more soft tissue than absolutely necessary to hook ligament to bone, and with an iron gray bun impacted at her nape, and a nail through that. Thinking to garner for me within earshot the most wonderful compliment, my friend the librarian said to this woman, "What did you think of that book?" Holding it between thumb and forefinger as though it were moist and disgusting, she said, dropping it to the table with a terrible thud, "I would never let that man operate on me." It was my first encounter with book reviewing. I remember that it was three o'clock in the afternoon, and I went straight home and got into bed and pulled 1

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the covers over my head. I didn't get up until my wife came and fed me oatmeal with a long, wooden spoon. I have since become a bit more thick-skinned about that sort of thing, preferring to follow the suggestion of the immortal Tallulah Bankhead, who said, "To hell with criticism! Praise is good enough for me." Writing a story or an essay or a memoir is rather like the embryology of poultry. First, there is the ecstatic discharge of vision and next, the fusion of this vision with the nourishing mind. Then comes the incubation and hatching of the creation, and here is where the fetus changes shape, size, characterreliving antiquity, prehistory even. "Ontogeny recapitulates phylogeny"-remember that? At times the fetus assumes the look of the most ancient writings, taking words, phrases, and sentences from Homer and Dante, only to peel them off at a later time. Little bits of Shakespeare and Melville are pressed in, allowed to harden, and then are chipped away. Through all these borrowings and influences, the thumb of the writer is busy imprinting the soggy, malleable mass with its own mark, until at last what is born is something unique, a story among a race of stories, identifiable as such, but never to be confused with another of its species. I should like to talk a little bit about language, the language of medicine, if you will. I do so because I see that the once rich, alliterative, resonant language of medicine has become reduced to a kind of shorthand that is most compatible with computers, rather than human beings. Every term is abbreviated or given an acronym in the interest of efficiency and speed. This language has an ugly, staccato sound that is not unlike the very noises made by the machinery with which we measure and otherwise investigate our patients. Blip, blip, blip, it goes with a stultifying monotony. What is being lost is nothing short of our heritage. Becoming a writer at the age of forty brought me once again face-to-face with the magical power of medical language. It was very important since the subject of my writing was to be my work as a doctor. I grew up in Troy, New York during the great depression. The whole town was, as Lyndon Johnson might have put it, stone-sucking poor. Father's office was on the first floor of an old house, and we lived upstairs. In the front windows of the first floor were plates of milk glass announcing the office hours: one to three, six to eight-which was absurd because father would have been happy to see anybody anytime, and nobody had any money to go to a doctor. During the hours of one to three in the afternoon, and six to eight in the evening, my brother Billy and I were forbidden to speak out loud, lest we disturb the sacred rites that were going on downstairs. I still have a little difficulty speaking out loud during those periods of time. After eight o'clock, when father came 2

up from his darkened office for his dinner, Billy and I (he was ten and I was nine) would sneak downstairs to the consultation room and go up to the medical textbooks on the shelf. There, by the shamefaced light of a candle stub, we would look at the pictures and read the words. Our favorite was the textbook of obstetrics and gynecology. It was then and there that I first became aware of the rich, alliterative language of medicine. I remember that some of the best words began with the letter "C." "Cerebellum"-I said it out loud-"cerebellum"-and let the word drip off the end of my tongue like melted chocolate. "Carcinoma"-it sounded rather like that aria from Rigoletto that my mother used to sing. And then I learned the word that made a surgeon of me-choledochojejunostomy. All those syllables, marching across the page, ending in that terminal "y." I thought, if that's the way surgeons talk, I'm going to be one of them.

I see that the once rich, alliterative, resonant language of medicine has become reduced to a kind of shorthand that is most compatible with computers, rather than human beings. Shortly after my retirement four years ago, I was asked to teach a seminar in creative writing to the medical students at Yale. Every Monday night in one of the conference rooms, sixteen or seventeen students and I met for three hours, and we wrote our little hearts out. I must say that a medical education ill prepares one for the rigors of writing. I will tell you precisely what we learned in the thirteen-week period: we learned the difference between "prostate" and "prostrate." "It is no easy thing," I told them, "to lie prostate on the ground-even for those of us who have one." We learned that the word "disembosom" has nothing to do with breast surgery. It is to be used figuratively, as in, "Permit me to disembosom myself of a secret." Entirely unlike "disembowel," which has every right to be taken literally. We learned the difference between "prone" and "supine." Now I do accept that this is a fairly knotty problem, in so much as so distinguished a doctor-writer as Robin Cook, in one of his immortal novels, has an obstetrician instruct his nurse to place a woman in the prone position, that he might perform a pelvic examination. I would suggest that any woman so positioned ought to get a second opinion. Finally, we learned the importance of punctuation. "Good heavens, he ejaculated!" is not the same as "Good heavens!" he ejaculated. I was more than amply rewarded, however, for my efforts when a student told me at the end of this course that the philtrum, that sweet groove that runs from the nasal septum to the midportion of the Bull Med Libr Assoc 78(1) January 1990

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upper lip, is formed by the shushing finger of the angel who warns the newborn baby not to reveal the secrets of life before birth. I shall never see a philtrum in the same way again.

We learned the difference between "prostate" and "prostrate." 'It is no easy thing," I told them, "to lie prostate on the ground-even for those of us who have one." To acquire a love of language, it is necessary to know precisely what each word means, of course. To know also its origin and derivation lends a word infinitely more significance. Let me give you an example: the word "patient" comes from the Latin verb, patior, meaning to suffer. Implicit in the word "patient" is suffering. A doctor has patients, lawyers have clients. The word "client" descends from the Latin cliens, which was the word given to the vassals of a feudal lord for whom services, such as protection, were rendered in return for payment. Such knowledge thoroughly distinguishes the members of these professions in a way that nothing else can. Similarly, one can trace the origins of the commonly used words "sarcoma" and "phagocyte." Sarcos is Greek for flesh, Iisarcoma" is a fleshy tumor. Phagos is the Greek "to eat," as in "phagocyte"-that cell of the body that devours cellular debris and bacteria. The ancients believed that the stone crypt in which a body was placed after death ate up the flesh, leaving behind the indigestible bones, and so they called that stone box, a sarco phagus, a sarcophagus. The origin of some words is admittedly lost in antiquity-the word "abdomen," for one; no one really knows where that comes from. "Belly," on the other hand, is a good, old Anglo-Saxon word meaning "sack," and thus Shakespeare could describe Falstaff as a "sack of guts" [3]. Of all the blessings for which I am thankful, foremost is that thirty years of surgery have not slain my illusions about the human body. I still approach it with a kind of awe, the same kind of awe that Marianne Moore, the poet, expressed when she wrote: What sap went through that little thread to make the cherry red! [4]

I think that becoming familiar with the beautiful language of medicine has helped to retain that kind of wonder at the human body. In act 5, scene 1 of Hamlet, as you remember, he has returned from abroad and happens upon a funeral procession that includes the King, Gertrude, and Laertes. Remember that Bull Med Libr Assoc

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Hamlet had inadvertently slain Polonius, the father of Laertes and Ophelia. Now Hamlet conceals himself, and to his horror discovers that it is Ophelia whose funeral is taking place. From his hiding place, he beholds Laertes leaping into the open grave to embrace his sister one more time. Hamlet listens as Laertes expresses his grief in rather high-blown terms, replete with references to the sacred mountains of Greece, Olympus, and so forth. Hamlet steps forth to reveal himself and says in a tone of contempt, What is he whose grief Bears such an emphasis? Whose phrase of sorrow Conjures the wandering stars and makes them stand Like wonder-wounded hearers? [5]

It is the phrase "wonder-wounded hearers" that struck me with amazement when I read the play again last week, for it is exactly what I have tried for these twenty years to do to my readers.

I think that of all the specialists in medicine, perhaps the pathologist is at greatest risk of losing his sense of mystery about the body. There are some human qualities for which medicine offers no solution. I think that of all the specialists in medicine, perhaps the pathologist is at greatest risk of losing his sense of mystery about the body. There are some human qualities for which medicine offers no solution. In a monograph reprinted by the American Philosophical Society in 1907, E. A. Spitzka, professor of anatomy at the Jefferson Medical College, told of an experiment in which the brains of 130 famous men were examined post mortem. Gross and microscopic measurements of these specimens were taken in order to discover the source of genius in anatomical terms. The prize in the collection was labeled "Walt Whitman, American poet, six feet tall, weight 200 pounds." The weight of the brain was given variously as 45.2 and 43.3 ounces. Unless the gift of arithmetic has deserted me, the difference is 1.9 ounces. Now this might not seem like much to a genius, but to those of us who are just trying to do the best we can, such a give-or-take-an-ounce-or-two attitude toward the human brain is reprehensible; the liver, the kidney, maybe-but the brain! Now it happened that just before Walt Whitman's brain was to be dismantled, some careless attendant in the laboratory let the jar in which it was kept fall to the ground. This led E. A. Spitzka to remark to the philosophers, "It is not stated whether the brain was totally destroyed by the fall, but it is a great pity that not even the fragments of the brain were rescued" [6]. A great pity indeed! I can under3

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stand preserving the brains of our notables as objects of veneration, if such be the romantic predilections of a fanatic few, or even as relics perhaps. But it is an affront, not only to him who cried out, "I loafe and invite my soul" [7], but to the whole of creative mankind as well, to count the number of brain cells per square inch of cerebral lobe, or measure the circumference of the medulla oblongata in search of the secrets of poetry. In any case, I suspect, it was not the carelessness of that laboratory attendant that ruined the experiment: it was the ghost of Walt Whitman himself who jogged the man's elbow. I would hope that my own ghost would serve me as well, should the dreadful occasion arise. A writing doctor who withdraws from medicine to sit behind a quiet and unmolested door, and remains in the town in which he has worked, takes a number of risks. I remember, not long ago, giving a benefit reading for the local library. When I arrived at the hall, I was astonished to find that it was filled with 200 of my former patients. It seemed to me that they had grouped themselves anatomically, with the gall bladders up front, the hernias in the middle, and the hemorrhoids at the rear, where they belonged. I had a moment of panic when I thought that, at a given signal, they would all rise and display their incisions.

I used to be a doctor who wrote: now I am a professional, one who is held to account rather than indulged for his eccentricity. Amateurity gives one a certain leeway-one can cavort, misbehave. There are other risks. Since my subject as a writer was my work as a doctor, would I be punished for defecting? Would I have anything else to say? The hospital, the operating room, was my native land. A writer turns his back on his native land at his own risk, and all of that. I need not have worried-there is always the sharp and aching tooth of memory, and for those who care, my nightly dreams are still filled with patients and operations. An even greater risk in giving up surgery was that I had surrendered my amateur status as a writer. I used to be a doctor who wrote: now I am a professional, one who is held to account rather than indulged for his eccentricity. Amateurity gives one a certain leeway-one can cavort, misbehave. The mind of the amateur is frisky: he makes free with every bit of the language. As an amateur, I used archaic words, and when no word existed, I made one up. That sort of thing, all very heady, was done in the secure knowledge that I would not be held responsible. I was not a real writer, I was a surgeon. But now that 4

is all over. Still I can't quite break the habits of a lifetime, and I must tell you that I am, even now, trying to invent a new word. I'll tell you about it. Every person has seen a path of moonlight on the water. It is a sight that each time it is beheld nudges the mind along the loftier paths of romance or melancholy. But this phenomenon, path of moonlight on the water, has no name-not in English, nor in French, nor in Italian for that matter. What is wrong with "path of moonlight on the water," you want to know? Well nothing, really, but such a thing of beauty deserves its own word, and I mean to give it one, so that all writers who come after me will know and use it. After months of hithering and thithering, I have narrowed the possibilities down to two: "lunaqua" and "aqualune." I am presently leaning more to "lunaqua" simply because of the dearth of words in English that end in "-qua." I gave up trying to do "path of sunlight on the water" when all I could come up with was "aquasol," which is the name of a nasal decongestant. Making up words is hardly unique: doctors do it all the time. Think of that ancient Greek physician who did just that when he sought to describe someone who was short of breath and fighting for air. From across the room he heard the wheeze that marked each difficult exhalation. It seemed to be lodged deep within the chest of the sufferer, and he called what he heard "asthma" (a word that sounds like what it is, and that has carried with it ever since the added power of onomatopoeia). From "asthma" has descended the even more forceful word, "gasp." "Hiccup," too, is what it sounds like, and "cough." Just so has our language grown and enriched itself, out of the need to describe. Many is the nonmedical writer who has yielded to the urge to invent. At the age of twenty-four, Samuel Taylor Coleridge wrote one of his chums, "Will you try to look out for a fit servant for us . . . scientific in vaccimulgence?" [8]. "Vaccimulgence"? Don't bother looking it up in the dictionary-Coleridge made it up. Nor has it, to my knowledge, ever been used since. It comes from the Latin words vacca, meaning "cow" (as in "vaccination"), and the verb mulgere, "to milk" (as in "emulsify"), ergo, "vaccimulgence," the milking of cows. It is one of my fondest hopes to become the second person ever to use that word. For those of you who would race to your desks to try to beat me to it, I offer that it is no easy thing to use "vaccimulgence" in a sentence: I know because I have been trying for six months. I am referring, of course, to its artful use, not the mere plunking down of the word as in "I came upon a pretty girl drowsy at her vaccimulgence," or "He decided to become a veterinarian when first he experienced the joy of relieving cattle through vaccimulgence." They simply won't do. I have even tried to make the word feel at home Bull Med Libr Assoc 78(1) January 1990

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in a tiny, 300-word story titled Vaccimulgence. Here it is: Even before she opened the barn door, Audrey knew from the sound of rhythmic hissing into a zinc pail exactly what she would see: her husband, Roger, sitting on a three-legged stool, his forehead pressed into the flank of a cow, absorbed in the tactile mysteries of vaccimulgence. It occurred to her that it had been years since he had touched her with anything near that tenderness. Either he had not heard her footsteps behind him, or he had and chose to ignore. Whatever, Roger remained as he was, and gave no sign. From where she stood, Audrey could see his elbows working, working-the metallic whine of the milk hitting the side of the pail was the most hateful sound of her life. At that moment, she could not have drifted from her purpose, even had reason returned. No, she had come to the barn to kill, and kill she would. She was no more than twenty feet from where Roger sat when she raised the barrel of the shotgun and fired. At the blast, the body of the man was flung from the stool, then lifted into a crouching position. The sudden movement overturned the pail. In a moment the floor of the barn at his feet was running with blood and milk. And slowly, as in a dream, he turned to gaze down at the lifeless body of his beloved cow. "Elsie," he sobbed, "why? Why?" "She had it coming," said Audrey, "but I could never expect you to understand that." The end.

When I turned sixty, I naturally decided to write my memoirs. The only trouble is that my memory is shot-to-hell. I discovered it the minute I sat down at my desk and picked up a pen. I'm writing them anyway. When I turned sixty, I naturally decided to write my memoirs. The only trouble is that my memory is shot-to-hell. I discovered it the minute I sat down at my desk and picked up a pen. I'm writing them anyway, as I have found that I can remember a good deal that might or should have happened, and I have never been one to place much reliance upon what some people call the truth. I firmly believe that an amusing fantasy has more reality than a boring fact. Already in my memoirs I am up to the age of fifteen, and you would be surprised at the number of things I might, or might not, have done. Here's one: For a good part of my life, I spent as much time in a hospital as in a house, and that is bound to have an effect on the way one sees the world or the condition of society. My earliest recollections of the hospital were of St. Mary's in Troy, New York. Actually, that was its nickname, short for St. Mary, Consoler of the Afflicted. Or as father liked to say, and made me say it too, Maria Consolatrix Afflictorum. He was of the conservative branch of atheism and insisted upon the Latin. The year was 1935; father was a general practitioner Bull Med Libr Assoc 78(1) January 1990

there, and now and then he would take me on his rounds to St. Mary's Hospital. It was a five-story, redbrick building, built in 1914-a long rectangle with two pavillions or wings extending from either side. Since it was operated and staffed by an order of nuns called the Daughters of Charity, that building was winged in more ways than one. The hospital was situated halfway up the slope of a steep hill, from which you could look down over the town. Ever since, I have always thought that halfway up a hillside is just where a hospital belongs, midway between a cathedral on the top and a jailhouse at the foot-in touch with both the sacred and the profane. Whether it was prophetic or simply a matter of logistics, the cemetery was right up the street. From the solarium on the second floor, you could watch the smoke from the crematorium chimney rise and diffuse over the city, as the dead insisted upon mixing with the living. In summer, with the windows open, you could even catch a whiff of it, a compelling early lesson in death, resurrection, and ecology. I can still close my eyes and smell that blend of starch, candlewax, ashes, and roses that permeated St. Mary's Hospital. It is an odor that I have not smelled since in any of a lifetime of hospitals. It was the odor of sanctity, I think.

I can still close my eyes and smell that blend of starch, candlewax, ashes, and roses that permeated St. Mary's Hospital. It is an odor that I have not smelled since in any of a lifetime of hospitals. It was the odor of sanctity, I think. The nuns ran the place as though it were the flagship of a fleet on the eve of a naval battle-with military precision. Here, if nowhere else, cleanliness was next to godliness. The polished floors wore a perpetual fanatic gleam: dirt was rooted out as though it were sin. It would take more than mere senility to make me forget Sister Michael's evening inspection of the long, marble corridor. Behind her limped a wretched porter who had spent the entire day washing and waxing the floor. I remember the stiff, white wings of her cornet slicing the gloom, the crusader's curve of her nostrils. Her eyes that reconnoitered every corner, then turned upon the miscreant, with the glare of black olives, as she pointed to a bit of smudge that was invisible to me. I remember how the Nun of Wrath pointed one bony finger at the spot for the poor devil to see: how he stood there with the good-for-nothing look of a dog that has just made a mess on the carpet. With the student nurses, she was equally exacting. Like that precise princess in the fairy tale, the one who was put out-of-sorts by a rose leaf out of place in the garden, just so did Sister Mi5

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chael appear in the doorway of a ward, sniff once or twice, and go directly to the very bed where one corner of a sheet had not been tucked to ferocity. The habit of the Daughters of Charity was black, full, and fell to within an inch and a half of the floor. From a cord about the waist, a black rosary hung. The wimple was topped by a starched white cornet with a broad lateral flap on either side of the head. One alone was a sailboat: two, side-by-side, a regatta: three, a whole armada. These sisters did not walk; they skimmed, they hovered. Free of the drag of gravity by which the rest of us are rooted to the earth, they floated quickly and noiselessly, save for the soft click of wooden beads tossing among the folds of their habits. With each step, the black nose of a shoe would peek from beneath the hem, then dart back inside the flaring recesses, as though each of them were sheltering a family of mice. More than once in the springtime, I sat in the many windowed solarium that was filled with vases of lilac and peony, and gazed down the long hall in full expectation that the very next thing I would see coming toward me would be Maria Consolatrix Afflictorum Herself, to whom I would-oh, yes, I would-hold out my own wounded heart. One evening father came to collect me there. "What were you doing?" I asked him. "I was bringing a baby boy into the world," he replied. (That's the way they used to talk in those days.) "Where did you bring it from?" "A sealed garden." "How did you get in if it was sealed?" "The gate was opened just long enough for me to reach in and take him out. Next subject." I opened a new line of questioning: "What is the Holy Trinity?" "It's just an expression." "No, what is it really?" "It means the three who are one." "I don't get it," I told him. Father thought for a long moment. "Well, look," he said. "Here we are walking down this corridor. Do you see those three wall lamps along the way? The first one is the Father, the next one is the Son, and the third is the Holy Ghost. Each lamp gives out its own light, but as we walk down the hall passing from one light to the next, we still get some of the light from each one, no matter where we are. Now do you get it?" "You made that up." "Then shut up!" he explained. It is fifty years later, and as for the Holy Trinity, I still don't quite get it; but of all the explanations I have been given over the years, father's makes the most sense. At St. Mary's, the beds were lined up along the walls of large ward rooms. In time of need, a moveable curtain screen could be placed so as to conceal the newly dead, or to afford, if not privacy, at least the implication of it. To this day, I am of the opinion that private rooms are a wrongheaded idea. Once encaged in a private room, the patient is out-of-sight, as well as alone. This cannot be as safe, or as functional, as a great ward with fifteen beds lined up on 6

either side, over which one sharp-eyed nurse could keep constant surveillance. To say nothing of the lovely commiseration that prevails in a ward, and the hustle bustle that is the antidote to the boredom of the bedridden. What architects and doctors have lost sight of is the pleasure the sick take in just plain gossiping. It is on a ward, not in a private room, where the craving for gossip is more likely to be satisfied. Besides, unless the gift of prophecy also has deserted me, a ward is not one inch farther away from heaven than a private room. When the time comes for me to be put to bed in a hospital, let it be in a ward where my sighs and groans can mingle with the sighs and groans of my fellow human beings in the consolation of fraternity. And where it might be given to each of us in turn to utter the most beautiful sentence in the English language: There, but for the grace of God, go I.

When the time comes for me to be put to bed in a hospital, let it be in a ward where my sighs and groans can mingle with the sighs and groans of my fellow human beings in the consolation of fraternity. As severe as Sister Michael was with the porter and the students, just so kindly did she move among the sick. Mercy, just before leaving the world of medicine forever, lingered awhile among those nuns. How different those sisters were from the doctors who stepped importantly among the puddles of patients-especially the surgeons, each of whom was quite convinced that, having left the ward, his disembodied radiance lingered on. Father was the Sisters' favorite. Their affection was based on his good-humored teasing, to which they responded with a commotion of cornets and a rolling up of the eyes. With what wit and gallantry he returned to those laborious virgins a glimmer of their long forsworn sexuality. Temperamentally unable to surrender to faith myself, I have remained in a condition of awe at the faith of others. It is what constitutes, for me, a belief in God-only once removed, like a cousin. When I was twelve, father lay dying in St. Mary's Hospital, long before my eyes had had their fill of him. I remember the vigilant nuns grouped like lamps in the darkened room, his face graying away, theirs glowing with an imperturbable golden light. Years later, during summer vacations from college, I worked as a night orderly at St. Mary's. It was on my first night of duty that I was told to wheel a stretcher from the emergency room to the operating room, and to go as quickly as I could, for the cargo in my charge was a young woman who, I was told, Bull Med Libr Assoc 78(1) January 1990

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was hemorrhaging briskly. With one hand holding aloft a bottle of saline solution, and the other pushing, I set off at a speed just short of reckless endangerment, only to find that the single working elevator was in use. When minutes went by (or hours, what does it matter how long?) and still the elevator didn't come, I began to despair for the life of my patient. From the head of the stretcher rose moan after moan, to break the heart of Caligula. Was the red stain on the sheet spreading? A Daughter of Charity arrived also, to wait for the elevator. At last, I heard, from the upper regions of the shaft, the door slide shut, the gears engage, and the car set in motion. Like a sentry on the qui vive, I prepared to storm and capture that elevator, and rescue my very first patient from certain death, only to watch as the empty car passed sluggishly by without stopping. Its slow disappearance from view remains one of the most sickening events of my life. Again and again, I kicked that door and pounded it with my fist, and I cursed it, much as Jesus cursed the fig tree that bore no fruit. "Goddamn elevator!" I cried aloud, "may your cables rust, your gears be stripped, your door go unhinged, so that never again shall you know the bliss of ascension or descent." To all of which the Daughter of Charity responded with one of those sad little smiles those people keep in their repertoire. Then she reached for her beads and began to offer it up. That nun hadn't got past bead one, when the elevator appeared out of nowhere, and we all rose up to a happy ending. That was the trouble with working at St. Mary's. You were always at risk of having Her called in on consultation, which kept a permanent sheepish expression on the faces of the heathen. Once I lived for the importance of surgery. Now I live for the triviality of writing? Hardly. Do not imagine that laboring in prose is a lighter-hearted pursuit. Nor should you think that the stories, essays, and memoirs of a doctor are insignificant in the grand scheme of things. Trifling though they may sometimes be, they are tenacious trifles that may far outlast the collected colectomies of my life. Nor are they easier to perform than an appendectomy, say, or a choledochojejunostomy. But they are harder, by far, to make come out right. The technique is more intricate, the process more painstaking, and, to me, just as much a matter of life and death. In surgery, it is the body of the patient that is opened up and put back together. In writing, it is the whole world that is taken in for repairs, put back in running order piece by piece [9].

Bull Med Libr Assoc 78(1) January 1990

Once I lived for the importance of surgery. Now I live for the triviality of writing? Hardly. Do not imagine that laboring in prose is a lighter-hearted pursuit. All of which brings me to the end of this talk. The place where I must utter the last word. Should it be "Amen" or "so-be-it"? Despite what the dictionary says, they do not mean the same thing. "So-be-it" carries with it an air of acceptance, of resignation. It is a quiet term murmured with the head bowed. "Sobe-it." "Amen," more often than not, is a word shouted in jubilation. Especially when the first syllable is held and the second cut short, as in "Aay-men." Totting up my endings, I see that I have many more "sobe-its" to my credit than "Amens," which is not the way I had hoped things would go. So just to help even the score, I hereby cry out "Aay-men!" So speaketh the bastard son of surgery and literature who signs himself Richard Selzer.

REFERENCES 1. BROWN HW. Cestode or tapeworm infections. Section on Metazoan diseases. In: Cecil RL, Loeb RF. Textbook of medicine, 10th ed. Philadelphia: Saunders, 1959:385. 2. SELZER RA. Rituals of surgery; short stories. 1st Touchstone ed. New York: Simon and Schuster, 1980, c1974. 3. SHAKESPEARE W. King Henry IV, part I. Act 2, scene 4, line 444. 4. MOORE M. Nevertheless. In: The Oxford book of American verse. New York: Oxford University Press, 1950:771. 5. SHAKESPEARE W. Hamlet. Act 5, scene 1, lines 250-3. 6. MORLEY C. The Whitman centennial. In: Essays by Christopher Morley. Garden City, NY: Doubleday, Doran, 1928: 441. 7. WHrrMAN W. Song of myself. In: The Oxford book of American verse. New York: Oxford University Press, 1950: 279. 8. COLERIDGE ST. To Thomas Poole, November 5, 1796. In: Griggs EL, ed. Collected letters of Samuel Taylor Coleridge. Vol. 1, 1785-1800. Oxford: Clarendon Press, 1956:249-51. 9. SELZER RA. Taking the world in for repairs. New York: Penguin Books, 1987.

Received May 1989; accepted July 1989

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The physician as writer.

A surgeon, turned writer, discusses his experiences and the perils of changing professions. He reminisces about his early formative years, growing up ...
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