DOWN FROM TROY: A Doctor Comes of Age by Richard Selzer, William Morrow and Company, Inc., 1992, $20.

Review by Del Meyer, MD

Dr. Richard Selzer, a surgeon from Yale, recounts his childhood memories of Troy, NY, as the son of one of the town's doctor. His mother, an artist, wanted him become a writer. His father, however, continually reminded his mother of the boys fine surgical hands. Every evening at bedtime, his mother, a self taught soprano, sang an ecumenical litany to her sons, Dickie, as Richard was called, and his brother Billie. She would sing "Shema Yisroel" alternated with "Ave Maria" and "Keep Me, O Keep Me, King of Kings, Beneath Thine Own Almighty Wings," which was Dickie's favorite. His father accused his mother of religious inconsistency. She defended herself: "With prayers, there is no harm in being especially sure." Mother said she was glad she had an untrained voice and had never learned to read music. This way she wasn't a slave to the rules. It was all done by ear and by instinct. If she heard a song once, it belonged to her ever afterward. Dickie never missed her performances at the Troy Music Hall which had the most perfect acoustics in North America. It still does. No one knows how this accident happened.

Mother was also the "doctor's wife" a position of no small importance in those days. Not a day went by that she wasn't stopped on the street and asked for medical advice, which she ladled out as if it were bounty. She didn't always get it right and a portion of Father's time had to be spent countermanding her suggestions.

Dickie's father was a general practitioner, one of a dozen or so who presided over the physical breakdown of the Trojans. In addition to the usual degenerative diseases, there were rampant alcoholism, VD, malnutrition, and TB. The phlegm on the cobblestones was apt to be red. Father occasionally took the boys on house calls. After the conclusion of each school year, the house calls remained a favorite part of the summer vacation. The office was in their brownstone on Fifth street. Father took care of the prostitutes on Brothel row which was Sixth street. These ladies enjoyed great notoriety due primarily to the reputations of their famous clients. He generally had one or more of the women in his waiting room on most days. Despite Father's repeated assurances that neither syphilis nor gonorrhea could be transmitted by sitting, Mother persisted in washing down the oak chairs with creosote every morning, all the while breathing deep sighs of damnation.

Once Father received two tickets to Havana, Cuba, from a Mame Faye. The prostitute was unable to take a vacation and so gave them to Father "for services rendered." Billie, being an infant at the time, was left behind with friends. On his twenty-first birthday, mother not only explained to Dickie that Havana was the site of his conception, but she took him there.

Father & Mother frequently argued. Mother did not share Father's love for Troy. Born and raised in Montreal, albeit in the ghetto of St. Urbain Street, she considered Troy a geographical come-down. Dickie learned from his parents marriage that there is no need to clear up misunderstandings. It is mainly by them that one day advances into the next and that people continue to relate to one another. The "discussion" between Dickie's parents concerning his becoming a writer versus a surgeon continued.

"When I was 12, and it appeared to Father that he might be losing, he committed the supreme act of seduction," Dr. Selzer writes. "He died. . . Since I could not find him in the flesh, I would find him through the work he did." He became a surgeon. When he turned 40, however, his mother's wish was fulfilled. He also became a writer.

Dr. Selzer returns to his native Troy after 50 years in this is his seventh book. A town with an extraordinary assortment of hookers, (Dr. Selzer did not find out until he was 50, that many of the prostitutes his father treated in his surgery had had him as a client as well as a physician) merciful nuns, spinster schoolteachers, hard-drinking working men, retired professors, and voraciously hungry fat ladies. His insights, humor, humanity, all come to life in this narrative, an art he states he learned from the Bard of Troy, a one-eyed veteran of World War I, named Duffy.

The book was sent as a promotion to our society library. It's nostalgia is worth experiencing.

Dr. Selzer's previous book, Letters to a Young Doctor published by Simon & Schuster in 1982 and in paper back by Touchstone in 1983 was also made available. His twenty or so letters on various subjects would be refreshing reading for many of us.

The initial letter accompanied the graduation gift of his father's textbook of physical diagnosis, 1918 edition, he had found in his attic. "I love all my old books--Longfellow, Virgil, etc., but I love this Textbook of Physical Diagnosis more. There is no better reminder that all of Medicine is a continuum of which you are now a part. The patients shown, the doctors and nurses who tended them, the photographer who peered at them, the chancre that gave one man his distinction, the goiter that made an ordinary woman a grinning queen, are all now dead. To read this book, with figures wearing a black band where the eyes should be to conceal identities, gives these patients identities, a more direct route to their souls, for now they have the body of a poet. I have seen sorrow more fully expressed in buttocks eaten away by bedsores; fear, by the arching of a neck; supplication, in a wrist; a knee cap that informed me that the patient was going to die. Don't show these pictures to the squeamish who will be threatened by the echoes of their own mortality, nor to vulgar people who decree that their perceptions of the ugly or gross ought not to be photographed. For their ugliness may become beauty to others. For in fact truth is more accessible in 'ugliness' than it is in beauty." He then invites us look through the book together--which he then proceeds to do. If you pick up this book and do that with him, you will have a richly rewarding remembrance.

The letter "Imelda" is a tribute to his mentor, Hugh Franciscus, Chief of Plastic Surgery at Albany when he was a medical student. While on his third year clerkship on Surgery, Dr. Franciscus invited Selzer to accompany him on his trip to Honduras, to operate on the natives down there. He states, "I do that every year somewhere." He told Selzer that he would arrange his time away, and Selzer would act as his personal interpreter, use the clinical camera, and "what you'd see would make it worthwhile."

Dr. Franciscus would see patients in the afternoon that he would operate on the next morning. His team presented a fourteen year old girl with a complete, unilateral left-sided cleft lip and cleft palate with no other congenital defects. He asked the girl to take the rag away from her face and the girl shrank back. "Tell her to take the rag away or send her away." Selzer tried to persuade the girl gently when Franciscus jerked the rag and the girl's head jerked with it and then revealed an utterly hideous defect, with an insect fastened within a split that went all the way to the nose. "Open your mouth," Franciscus said, which Selzer translated. "Tomorrow, I will fix your lip."

In the operating room the next day, everything went smoothly until he was ready to lower the scalpel when the anesthesiologist interrupted by announcing hyperthermia to 108 degrees, arrhythmia, and cardiac standstill. When he told the family in broken Spanish their daughter died, they said, "The doctor must not be sad." They thanked him for fixing their daughter's hairlip so she might go to Heaven without it. The mother announce that her sons would pick up their sister ma~ana. When the sons picked up the girl's body wrapped in a straw mat onto a wooden cart, the mother said, "Si si, the doctor is one of the angels, He has finished the work of God. My daughter is beautiful." What could she mean! The lip had not been fixed. The girl had died before he would have done it. "Only a fine line that God will erase in time," she said. Dr. Selzer reached into the cart and lifted a corner of the mat. Where the cleft had been was now a fresh line of tiny sutures. Now that Dr. Franciscus has died, he can safely tell the story of ten o'clock the night before, how one of the lanterns from a patient room had mysteriously gone down into the morgue; how Dr. Franciscus had located the child's body; how he had repaired the cleft in the morgue that night; and the references in his lectures that followed in which Selzer was the only one that new. Now we all know. This kind of rich experience can probably never be experienced again in our day and age.

The letter entitled "The Virgin and the Petri Dish" is very relevant to our current sexual awareness emphasis. "Conception is something closed to men. A woman becomes a vessel, a harbor, an enclosure for a jot of yolk and protein--an egg she lays each month, at just the right time, when the hormone runs highest, which is extruded from the ovary, caught up in the fallopian tube, undulated and propelled the whole length of its canal to the horn of the uterus, where the little pearl of great price is relinquished into an enclosed garden in which the rarest of plants is to be grown, the womb, raked clean of all weeds and debris, made ready to receive the egg."

"The sperm carrier waits, biding his time, dreaming of the day when he will let out the equipment on which he dotes, in which all of his pride is invested, waiting for the signal, the glance, the word, or certain touch which indicates to him that the hunger of her womb has become voracious. With pounding heart, the sperm carrier positions himself as his body grows hard and his heart is softened by love, as the sluice is opened spurting a hundred million sperm of which only one will claim the egg. Orgasm is not unlike the pain of childbirth."

I once had a woman tell me the last labor pain as the child is born was like a humongous orgasm. I had never seen it recorded in textbook or mentioned in discourse elsewhere. The rest of his descriptions continue to reveal a sensitivity and awareness which is difficult but necessary to impart to physicians in their formative years. This book will be an asset to every physician whether in training or just reflecting on his practice or his life.