The Knife (Richard Selzer)

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 gentlest 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, part, 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 a maroon
and salmon and yellow. The vista is sweetly vulnerable at this moment,
a kind of welcoming. An arc of the liver 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 tum 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 mine, 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 tom, 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 bottle, 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 gallbladder. No stones.
Right kidney, left, all right. Liver … uh-oh.”

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 highceilinged,
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 theater. 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. 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 faltds 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 Alexandra, and she is the daughter of Ukrainian
peasants. She has a flat steppe of a face and slanting eyes. Nurse
and patient are speaking ofblintzes, borscht, piroshki-Russianfood
that they both love. I listen, and think that it may have been her
grandfather who raided the shtetl 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 arid
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 stream of the
great 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 fornication
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 diseasethat
for whose destruction we have gathered. Powerless to destroy
the sickness before us, we tum 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 warhorse 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. 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 bl~od. 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 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 unremembered 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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