6.12.1913  -  12.12.2002

Books of N.M.Amosov

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The First Day. Tamara

The morgue. Such an inoffensive little building standing in the depth of our Institute garden. It is pleasant here. The bright green of the trees. Flowers. It seems that Red Riding Hood should be using this path. No. Here they carry corpses.

I am a doctor. I am going to an autopsy. Yesterday a little girl died during an operation. She had a complicated congenital heart condition, and we operated, disconnecting her heart and using our artificial blood circulation machine. This is a new technique. Newspapermen describe it rhap-sodically: a dying child... the heart is switched off... the machine takes over... some ten, twenty, thirty minutes... a heroic struggle... sweat on the surgeon's brow... All is well! The surgeon, exhausted but happy, tells the waiting parents that their child is saved. In two weeks the boy is playing football.

Let them all go to hell.

I am going to perform an autopsy. No doctor likes this procedure, to finish his work in the morgue. I don't like it either. When there are simple cases, I send my interns to do it. Later on they report to me during our usual morning conferences. A few terse words, some complicated medical terms (young interns like to sound scientific), and a human being is written off. At least, that is how it would sound to anyone listening to their words: '... the autopsy has produced the following conclusive findings'. Simple? No, not simple at all. All those cut-up corpses live in my memory, there is hardly any room left there for more. I am choking on them.

Stop, professor! Don't start feeling sorry for yourself again. Go and do your work. Your day is just beginning. Our morgue is like all morgues; sort of grey. The windows are wide enough, but somehow only a little light niters through. And not only because they are covered half way up with thin white paint. I don't know why.

A zinc-covered table. Poverty. It should have been marble. However to a corpse it makes no difference. It is funny, I have seen so many of them, but I still can't get used to them. There she lies, such a tiny thin body upon such a big cold table. Two pigtails. Her mother probably braided them for the last time yesterday morning. The pink ribbons are crumpled. It is best not to look. But no, I must. This is my handiwork.

'Let's start.'

The dissecting room people are probably used to this. They don't treat people, just cut them up. But perhaps they also have some feelings. I must give them this credit.

Our doctors are here. Some of them were helping me yesterday. They seem to be depressed enough. I get so angry when they laugh in the dissecting room. Here is death, take off your hats! But, of course, all that is comparative.

I must determine now whether in this case the operation was correctly performed. And learn how to do it better next rime so that others won't die. Or, at least, not so often.

'Gloves. Instruments. I shall examine the heart myself. Thank you.'

This was a complicated case, a so-called ventricular septal defect, commonly known as a hole in the heart. This occurs when there is an opening in the partition between the lower chambers of the heart, the ventricles. The dark venous blood mingles with the arterial, the heart becomes overstrained, children gasp and turn blue at the slightest exertion. Few of these blue babies live to adolescence.

And in this case there was an additional complication, the constriction of the lung artery so that sufficient blood could never reach the lungs to become reinvigorated. Those two things often happen together, and this was an especially difficult case.

Well, doctor, perhaps you should feel better? This little girl, Tamara, would have died anyway, she was born doomed. Her mother told me that she used to sit by the window all day long and watch other children play. She loved her dolls and had a vivid imagination. Perhaps she could have become a poetess. Or an artist. Perhaps.

There are two kinds of surgery used in cases like this. One is to enlarge the opening into the pulmonary artery with a special instrument, working by touch on the pumping heart, leaving the hole in the septum, or ventricle wall, well alone. No recovery, but several years could be added to the child's life, and children become active. The operative mortality rate is about fifteen per cent. The second method: the heart is stopped with the help of the heart-lung machine and the ventricle wall is cut wide open. The hole between the ventricles is then either stitched up or closed with the help of a porous plastic patch. The pulmonary artery entrance is enlarged and a part of the ventricle muscle is removed.

This is new and very difficult surgery. The heart remains open for almost an hour. The blood, despite the machine, seeps through and makes the surgeon's work difficult. It is easy to damage small vessels and the valves. After it is all over, heart spasms are weak, and there is a grave danger of post-operative complications. Some thirty per cent of patients die on the table, or shortly thereafter.

There she lies, this percentage. Anyway, life and death are statistics. Rather like the rate of defective manufactured goods. But what to do? Still, seventy children out of a hundred survive, go to school and marry. After the second operation, marriage is permissible.

But this little one didn't make it.

I can see it all now. I have put in the stitches sloppily. Some of the sutures are placed too close to the edge of the patch. But the opening into the pulmonary artery I had enlarged well: I can push my finger into it. However, this is no consolation. With the hole between the ventricles this is even worse. Lungs fill with blood. Oedema, Death.

Everything is quite clear, professor. Newspapermen can continue to sing dithyrambs to you. Young doctors can look upon you with awe and admiration. But, in fact, you had murdered this little girl, to be frank about it. Or butchered her, as they often say about surgeons.

There is no escape. All that I can do now is drop the lancet and at least tell all those present what I think of myself and my operation. It helps. A little.

No, that is not enough. Perhaps I'd better stop doing this sort of surgery altogether. I've had enough of these little girls with pigtails. Up to here. I've had enough of this stupid thing called life with its heartache and constant irritation. But no, this is not that easy. I must study this case and try to figure out a better way of putting in those damned sutures. It is so easy to do this now. No rush, no hysteria. The heart no longer quivers, no longer tries to pump blood which is no longer there. And the nylon bows in the pigtails which I saw yesterday protruding from under the sheet are also dead now, and no longer frighten me.

So, let's see. Probably this is the way I should have done it. Then I would have missed the heart nerve and the sutures would have held better. Yes, that's it. Better luck next time.

Now I must thank our dissecting room manager, Seraphima Petrovna1, and leave.

'Please look out for those ribbons, don't let them get smeared with blood.'

I lift the latch and find myself in the garden among the young lindens. (The latch on the door is a precaution against relatives who sometimes burst into the morgue during autopsies. One must be humane. Still, autopsies, unpleasant as they are, are extremely useful, they help to determine mistakes, and teach us how not to repeat them.)

The green lindens in the brilliant sun. The fragrance of last night's rain. What a joke!

So this difficult ordeal is over. One always tries to push unpleasant things out of one's memory, to get over them quickly. Then they seem to be easier to bear.

I should not have been in such a hurry yesterday. The machine could have worked a little longer. I should have stopped, pinched off the aorta, removed the blood with a sucker, and checked on the patch and the sutures again. One should never be so sure.

Yes, but on the other hand it was already forty minutes since we had disconnected the heart. The machine ruins the red corpuscles, the erythrocytes. With each minute toxic circulatory residues build up in the tissues. Then the heart is given an impossible task to clear them out. One often sees perfect patches during autopsies, so what did they help?

And then that pale little face protruding from under the sheet. And that fear which slowly fills me during surgery, and grows with each twist of the knife. She will not come to... The heart will not start up... And her father and mother walking in the street outside the clinic, up and down, up and down... I saw them when I was washing my hands. So, 'let's stitch it up! It looks pretty good.'

Of course I should have stopped and made sure, checked on the patch and on every suture.

What's the use of thinking about it, now?

* * *

I walk into our experimental laboratory. In my day's programme there is still a little time before my next operation. Anyway, I'm hardly in a mood for any surgery at the moment. I must cool off.

The laboratory is my love. My latest love. In my life I have had many emotional involvements, poetry, women, surgery, automobiles, my little grand-daughter. Now, when my life is drawing to its inevitable conclusion, I have but one passionate desire, to learn the meaning of human life, of humanity. And what we must all do, the young and the old, in this frightening age when time has got out of hand, and everything is rushing on so madly. To me the human race appears like a giant surging aloft, but with fetters on his feet. At any moment it can be pulled back, crash down, burn to cinders and disappear. It is like a nightmare where one knows that one must shout, must warn someone. But who? And how?

However, our laboratory has more modest aims. All that we are trying to do is lower the mortality rate among our patients. That's all. For the moment.

The Director of the Institute has given us a small building and appointed the staff. We have started working. There is a workshop, several engineers and technicians, physiologists and laboratory assistants. This is not yet an organized working collective, but their youth gives me hope.

At this point the apparatus for artificial blood circulation, our heart-lung machine which we call AIK after the Russian words, apparat iskusstvennogo krovoobraschenia, interests me more than anything else. It is necessary to improve it to the point where the surgeon would have more time to operate, when the machine would not ruin the blood. Our problem number one is haemolysis. As the erythrocytes are destroyed, the haemoglobin enters the plasma and colours it red. And, strange as it may seem, it then becomes toxic to the heart and the kidneys.

Petya, Misha2 and Oleg built our machine some two years ago, one of the very first machines of this kind ever constructed. Petya and Misha are factory lads, the enthusiasts3. They started out as lathe-hands, but now they are engineers. Oleg is a physician. Together they made a fine team. As long as we had used our AIK for simple operations, we had been very happy with it. We thought it was the best in the world because it used a mere seven hundred and fifty cubic centimetres of blood instead of the three or four litres used abroad. We had bragged shamelessly about it.

But then came disappointments. Haemolysis! The heart could not remain disconnected for longer than thirty or forty minutes. For us this time is insufficient for any really advanced surgery. So I am pressing our physiologists, engineers and technicians to find the reason for haemolysis and to eradicate it, but without enlarging the amount of blood used in the machine. Everyone is breaking his head over it, but so far without success.

A new engineer has joined our laboratory, Volodya 4 Tamasoff. Actually he is not yet full-fledged, and still a student, but he has been accepted here as an engineer. I have high hopes for this boy. He has left the Institute of Automatics, a currently glamorous speciality, to accept a lower position in medicine. Has taken a step into the unknown, so to say. I very much like young people like that, intent, alert, independent.

I am now sitting with him in our artificial blood circulation laboratory.

'Volodya, I'd like to hear your report about your first reconnaissance into the haemolysis problem.'

'You are in too much of a hurry, Professor. I can't tell you anything definite. Not yet.'

'Tell me what you can. We haven't much time.'

'I think that haemolysis occurs when there is an excessive turbulence in the pump and connective tubes. We must study carefully the conditions of fluid movement. Also it is quite possible that erythrocytes are crushed in the pump by the rollers. It may be necessary to leave a layer of blood between all moving parts.'

'But there are American works, I have read them myself, which maintain that pressure does not produce haemolysis.'

'So what? There are all kinds of works. We must check on everything ourselves, and check well. Frankly the entire system of experimental work in our laboratory is inefficient. Measurements are not precise enough, the uniformity of conditions is not maintained, some assistants don't know how to work with precision instruments.'


'Absolutely. If you want to do really serious work, let me bring some order into the experimental methods here, so that we could produce data we can trust and work with.'

This statement surprises me. Our physiologists have been conducting experiments, our biochemists have been studying haemolysis and carrying out all sorts of analyses, and up to now there has never been any question of sloppiness or inefficiency.

I am thinking. The laboratory director, Victor Petrovich, even though young, is already a science candidate. Our girls, Alia, Nadya, Mila, Sveta,5 have been working with us for several years, have shared with us all the joys and despairs creating the machine, and are servicing it now. So what shall I tell them? 'To one side, kids. This new engineer, and not even an engineer, but a student, will now teach you how to do your work, to conduct experiments and analyses.'

Suddenly I hear a wail:

'Ah - ah - ah!'

Everything turns dark all round me, everything dies. Even the trees seem to be bending. Something snaps inside.

To hell with medicine, to hell with the haemolysis problem! I can't stand all this any longer! I must go away. Run. Hide in my office. Close all the windows. Disappear. Cease to exist. Dissolve.

'I must go, Volodya. Tell Victor Petrovich that I want him to listen to your suggestions, to study them. If he has any queries, let him speak to me.'

I am walking through two laboratory rooms. Everyone avoids looking at me. Quite rightly!

Now, across the garden. From the morgue, more heartbreaking wailing. It is surprising how the sound carries. The patients who have been walking in the garden slowly drift inside. They are probably ashamed to look at me. How will they feel now going into the operating theatre with me waiting inside when their turn comes? Dreadful.

Near the entrance to the clinic there sit mothers of the children who have been admitted. Of course, they also hear everything. And probably know the woman who is screaming. They all know one another, companions in misery. I am running the gauntlet of their disturbed eyes. And in my soul I want to shout: 'Take your children away! Can't you see that I am at the end of my tether?'

The wailing grows more desperate, more animal-like. I steal a quick glance in the direction of the morgue. A small lorry-like car stands near it, with a little coffin on it and wreaths. They must have ordered it last night. A woman is lying across the coffin, hugging it. Her mother. Damn.

Finally I reach my office. But even from here I can hear that poor woman. Now I must sit down and quietly think everything out. Quietly, if possible...

But no, this does not work. A quick knock at the door and a woman bursts in. Her eyes are insane.

'Professor! Please tell me what to do? I'm' afraid of surgery. It's the second operation! She won't live through it!'

Again... What can I tell her? I'm not God. Yes, quite possibly she won't live through it. But why should I live through all this?

I know this woman. She is young, and probably even pretty. But now she's a fright to look at. Her husband is a middle-aged man with a shy, soft face. The only child, Maya, is twelve, a tall, gawky, pleasant girl. Three months ago, my assistant, Maria Vassilievna6, performed a routine operation on her, tied off the opening between the aorta and the pulmonary artery. This is a congenital heart disorder. This opening, normal in the foetus, should close after birth, but sometimes it doesn't, and then it should be closed surgically. It is the simplest of all heart operations. In our clinic we have done over a hundred of them, and lost just one patient. In Maya's case, some friends and acquaintances had called me before the operation and begged me to perform it personally rather than letting some of my younger colleagues do it. Such requests always irritate me. How would young surgeons acquire their experience?

The operation had gone off well. The connection was closed with the help of a special apparatus recently developed in Moscow using tantalum wire stitches.

However, almost immediately there were some mildly unpleasant after-effects to which I had paid scant attention, I had many more serious cases on hand.

At first we thought that the complications were more or less routine, the darkening of one pulmonary lobe due to the accumulation of bronchial phlegm and seeping in of air from the alveoli. The phlegm was drained through a tube inserted into the respiratory canals. The darkening remained, and a cavity appeared, a lung abscess. The pus was drained through a puncture. Maya's condition did not appear particularly alarming. The punctures were repeated, some medications were administered and in about three weeks the cavity disappeared. The darkening in the lobe had all but dissolved, and the girl was sent home.

But the very next day her mother ran to us with terror-filled eyes: Maya was spitting blood. Haemoptisis. We took several X-rays, several analyses, and again discovered nothing alarming. Not that we could quite explain it, but we felt that there was little to worry about. We reassured the mother, apparently a breach in some small vessel; it often happens after pulmonary abscesses. It would pass.

But it didn't pass.

Three days ago the girl was brought back to the clinic with severe lung haemorrhage. It had happened twice during last night. The haemoglobin count had fallen off fifty per cent. I personally conducted a thorough fluoroscopic examination, a rather large darkening in the upper part of the left lung connected with a shadow of the heart and the aorta.

We think that the source of haemorrhaging is in the lung: it is possible that the abscess had not fully healed and the secondary inflammatory process then damaged the wall of some important artery. Perhaps even the aorta? Judging by the rate and severity of haemorrhaging it is quite obvious that quick death is indicated. There is just one alternative, surgical interference, and the quicker the better.

We proposed emergency surgery the day before yesterday, but the parents refused permission. Yesterday also.

And now Maya's mother is in my room. Her father, I know, sits on a bench outside, under the windows of the children's ward.

It is difficult for me to look at this woman.

'Your Mayachka7 needs an operation. Otherwise she will be gone, and gone very soon. You must give your permission. Dangerous? Yes, very. But otherwise, it's hopeless.'

She is sobbing.

'Why, oh why has this happened to us? Why didn't you operate yourself?'

'That wouldn't have altered anything. It's routine surgery and it's been done correctly. We cannot foresee and avoid all the complications after any major surgery.'

The dry official words. And my face is also dry and official. I would have liked to calm her down, to dry off her tears with a handkerchief. Or cry with her a little. But I can't permit myself this luxury. I represent science. I feel terrible.

'Professor, dear professor, please save my daughter, save our Mayachka! We trust only you, your golden hands. I beg you.'

She needn't beg me. I was planning to operate myself in any event. So I promise. She thanks me. Finally she walks to the door, dragging her feet. She stops there, turns, looks at me like a dying animal:

'Please, forgive me for saying it. But try to do it well, all right? Please.'

'Please.' Oh my God! What must I do to survive it all, to carry with me all this human pain? The operation will be extremely dangerous, Maya may well die on the table. What would I tell her mother then? Inevitably I should be at fault, it is impossible for a surgeon not to make some slight mistake which can prove fatal to a patient in this condition. So I should shrug my shoulders, mutter some miserable words of self-justification uttered in a usual self-righteous tone. 'Science is not omnipotent, it's fate, you must bear it.' Bear it? How?

And the most ridiculous part of it is that I don't need it all. I don't need operations like this, neither for money, nor for glory, not even for my own vanity and self-gratification. I've had more than enough of all that. But what to do? Let Maria Vassilievna do it again? She is an excellent surgeon and performs routine surgery better than I. But this is not a routine case, it is very complicated and uncertain. And then if the girl dies while I'm operating it's one thing, if someone else, it's another. For the mother at least. She would always think: 'If only the Professor had operated himself, perhaps Maya would have still been alive.'

Besides, my dear friend, you are in charge of the clinic. You must perform all the most dangerous things. Until you become convinced that your assistants know how to do it better than you.

There is no escape.

And what if we don't operate? She will die. Yes, but she would die a natural death, not from my hands. This is quite simple to arrange. All I have to do is to express the slightest uncertainty, and the parents will immediately back out. Everything would be in order, as the Germans say. 'Unfortunately we have been unable to secure the parents' permission.'

Simple? Not to them. They would suffer. They would suffer in any event. If they refuse and she dies, 'why did we refuse?' If they agree and she dies, 'why did we allow him to do it? Perhaps she would have got well by herself!'

Of course I know that she won't get well, not one chance in a hundred. Her only hope is surgery. The risk? I think, about fifty per cent. Percentages again. Just like in bookkeeping. No, there is no escape. I must order the girl to be prepared for surgery.

I ring up, give all the instructions.

I have some time now. So I will visit the wards, the third floor, there are fine kids there. They are already out of danger, and they don't really need me at all. But I need them. Especially today, right now, before facing the terrible task ahead.

A long corridor. Not very wide, not very light, not too clean. Several tables for nurses along the walls. A large recess with windows and an enclosed balcony, here we have the children's dining room. Now children are playing here. Some have already had their operations and will be sent home soon. Others are undergoing observation. No really difficult cases here. Just normal-looking kids.

Two boys are playing with a toy automobile. It is shot to pieces, there are no wheels, no steering wheel, no top; obviously it has passed through many small hands. In another corner three little girls are playing hospital. I stop near the vacant nurse's desk, pick up some reports, feign business. The girls are sitting on the floor, dolls in hands. The conversation:

'You need probing. This is not painful, don't cry, don't be scared. When you first feel the needle, shut your eyes and repeat "no pain, no pain". That's all. Masha, pass me the probe!'

Masha is five. Her medical education is limited: she does not know what a probe is. Nadya is very upset:

'How can you be a doctor this way? Even a ward nanny knows what a probe is! Where have you been all your life? All right, just hold the patient and watch. Sonya, switch on the X-ray!'

It is remarkable how children use their imagination. With a few rags and wooden sticks they can create complicated plays. With years this faculty disappears. Unfortunately.

Misha approaches the girls. He is seven, and they have told me that he is impersonating me. Misha is an experienced man; he has undergone all sorts of tests, an operation with the AIK machine, and multiple post-operative complications. He is walking now, but still carries one shoulder lower than the other. His manner is rather gruff.

'Nadia, what a stupid woman, you don't do it right! The probing is always done in the dark. Get your patient under the bed. I'll do it myself, give her to me, stupid!'

'Don't touch her! This is our patient! Go and do your own operations! You've already cut up two dolls and both of them died! Manya is still crying. Her mother is poor and can't buy her another one that opens her eyes! Get out of here, you butcher!'

Nadya is firing away like a machine-gun. Misha is ready to grab her hair. He already reaches for it, but stops in time. He is still in slight pain and therefore vulnerable.

Women!' He almost spits at them.

Let them fight. It is good when children begin to rough-house after surgery. True, some of them can take the clinic apart, and one must restrain them.

Another little boy. He is not playing. He is sitting in the corner watching others. Another blue baby. He is down for complicated, perhaps dangerous surgery. It's best not to look at him. It is better not to become too friendly with children before they are operated on. During my morning rounds, I look at their chests, check their hearts. I try not to look at their faces. After surgery, well, that's another matter. Then you can love them all you want, without danger.

I walk on. At the end of the corridor there is a large room separated from the others by a glass partition. This is our post-operative ward.

Maria Dimitrievna is in charge here8. She is still only a nurse, but she runs the place with an iron hand. She is perhaps forty, thin, reserved, severe, even tough. No nonsense with children, no molly-coddling, but a great deal of real love.

This is a difficult place. Some six to eight children are always recovering here from post-operative shock. The moment they are out of it, they are taken to other wards. There are no easy cases here. Two nurses and a hospital nanny run the place. In the course of the day they carry out a number of complicated tasks, injections, transfusions, enemas, stomach pumps, massaging, moving, feeding, wound dressing, etc., etc. And, after all, these are children. They cry, they play up, one must have great patience with them.

Today it is comparatively quiet here. I walk around, greet the children, talk to them. And, of course, check temperature and analysis charts. This is a pleasant task for me today, all the patients are doing fairly well.

Somewhere, deep in my subconscious, there is a nagging thought about Maya, about the coming operation. I am trying to drive it away. There will be time for this, for this ever-mounting fear. But meanwhile, let's look at these children.

Volodya is four. When I approach his bed, he shuts his eyes, he pretends to be asleep, but his eyelids are quivering. This is his protective reaction: he knows that doctors don't like to disturb sleeping children. He hopes to avoid injections by feigning sleep.

'Volodineka, open your eyes. You are not asleep.'

No reaction.

'Open your eyes. There won't be any injections now. Anyway, I hope to discontinue them.'

The eyelids quiver, then move. He sees there is no danger. I don't even have a stethoscope. And Maria Dimitrievna is not around. He wakes up, smiles. Moves his hand to shake mine.

'It's true that you'll call off shots?'

'True, but not today. Perhaps tomorrow.'

Now he's upset.

All children are pleasant. This has a purely biological foundation. When you take a child into your arms, you experience a feeling which can't be expressed in words. For some reason no one has invented the right word for it.

And the children who have been 'suffered through' are especially dear. Not only to parents, but to surgeons as well. They become precious, they carry in them a part of your soul.

This Volodya was operated on four days ago using the artificial blood circulation machine. He had a hole in the ventrical partition wall with some important secondary pulmonary changes.

We opened his chest and cut through the pericardium, the heart bag. Even then the heart beats became irregular. We began to hurry. The machine was not yet connected when fibrillation occurred, the disorganized fluttering instead of regular spasms. My own heart went into the pit of my stomach. Such a fine boy. I tried heart massage, he didn't respond. Then, in desperation, we inserted a tube into his right auricle and a metallic cannelure into the femoral or thigh artery. The machine took over. Just in time.

The operation itself was fairly easy. The hole was stitched up without a patch. The ventricle wall was closed. The machine was stopped. The heart took over strong and clear. The question which started to torture us was whether the brain had been damaged. In our panic no one could tell definitely how much time had gone between the heart massage and the time the machine was connected in. If over five minutes, the cerebral cortex, the higher brain, would be destroyed, then a person becomes incapable of thought, a sort of human vegetable. For a time the boy's pupils were enlarged, a bad sign. True, they became normal after a while, but still... We finished the operation in dead silence.

Dimitri Alexeyvich, our chief anaesthetist, and his girl assistants did everything possible to normalize the blood indices, and finally they succeeded. But the boy would not wake up. For three hours we all sat round him. The heart worked well, the breathing was normal, the lips rosy, but he would not open his eyes. We started to lose hope. I went out to smoke, to be alone with my misgivings. Suddenly Tatiana, the anaesthetist's assistant, burst wildly into the room:

'He has opened his eyes!'

I ran all the way to the post-anaesthesia room. Yes, indeed, the eyes were open. True, they were still senseless and sleepy, but open!

'Volodya, Volodineka, my darling!'

He turned his head. Whew! I could go. There, downstairs, his mother was probably going through agony. But all was well, quite well. So far. He had opened his eyes!

Today Volodya's mother is sitting beside his bed. The operation was a success, her little son smiles, eats, sleeps; it seems that all fears are now over. She is happy. Her eyes sparkle.

Poor mothers, how often this post-operative bliss is misleading. In the depths of the little body the enemy forces might be slowly assembling, to deliver a crushing blow during one of the nights. In the course of a few hours, no, minutes, everything could be utterly destroyed. Perhaps phlegm is accumulating in one of the lungs, the nest of future pneumonia, or a blood clot is forming at the point of some inner suture, ready to break away and cause thrombosis in one of the brain arteries. There are many dangers hanging over little patients. To detect them in time, Maria Dimitrievna is constantly watching the blood pressure and taking blood for analysis, and Nina Nikolaevna, the physician, checks hearts several times each day and takes daily X rays.

'Professor, everything is all right now? There's no further danger? I'm so grateful to you!'

'The danger is still there, but it diminishes every hour. And you'd better save your thanks for the day when you will be taking Volodya home with you.'

Another little boy, also Vova9. He was operated on yesterday. His condition is still serious, and he lies inertly, with half-closed eyes and a rusty smear in the corner of his mouth, apparently he has been vomiting. He has constant transfusions, physiological saline solution, plasma, whole blood. There is a tube inserted into each nostril, oxygen feeding. The urine drops through a catheter. A blood-pressure band encircles his arm. He is given injections every two or three hours. His mother, a collective farm worker10, looks at him with terror in her eyes. She feels every injection in her own body and instinctively attempts to grip the nurse's arm. She is constantly weeping, paralyzed with fear and depressed by the unusual surroundings. She does more harm than good by remaining here. Maria Dimitrievna wants her taken out of the ward.

But today I can't do it. The vision of Tamara on the dissecting table, and Maya and her mother stand before my eyes. Let this mother look at her Vova. I think that tomorrow, or the day after, she will calm down. There is nothing basically wrong with the boy, and I hope there won't be any complications. The operation was well done and was radical. All will be well with Vova.

I must now visit Lenochka11. She has been moved to another ward, sharing it with two women. She has lived seven years since birth, and seven days after her operation. Perhaps this was her second birth because death stood right behind her. I don't want to remember this struggle, all those nightmarish complications. Terror and utter despair seized me several times and I violently, inexcusably swore at my assistants, even though they were not to blame for what was happening, or at least, very little. But all this is past. Almost all. I don't think anything really dramatic can happen now if, only eight days after the operation, things go so well.

I sit near her bed. I want to caress her, to touch her, to hear her voice.

'How are you doing, Lenochka? Slept well?'

She lifts her long lashes and under them I see her sky-blue eyes.

'Quite well,' she drawls, a little coquettishly. (My darling!) 'They don't give me any shots any more, and I'm moving into the sixth ward. Only my daddy had to leave...'

She is well scrubbed and well groomed. Two thick pigtails are beautifully plaited and tied with satin ribbons. (Who is braiding the hair of that girl before she is put into her little coffin? Her mother probably can't do it. All right. Enough!)

Our laboratory girls are probably responsible for Lenochka's elegance. We have a flock of young girls working downstairs who like to come up here and take care of their favourites. I don't think her father could have done it quite so well, and the nurses are too busy to give beauty treatments to the patients, they have their hands full watching over their health.

Lena's father is some sort of mechanic. Her mother has a small child at home and could come here for two days only. They live some fifty kilometres away. So the father had to take over. However, our nurses like fathers. They say that men are more sensible and don't panic so easily. And this particular father has repaired all sorts of equipment around the ward during the last seven days. He is very handy with tools.

Parents are a difficult problem. We don't allow anyone into post-operative wards for adults, 'to prevent infection' as we explain. But here, parents stay with their children though the danger of infection is even more serious. This is our concession to pity. It is difficult, no, impossible to drive parents away when their children are hovering between life and death. Your tongue just wouldn't move to order them out. Some of them actually help the nurses and nannies with simple tasks; we are somewhat understaffed and extra hands can always be used. But most of them get in the way. It takes special training to be useful in a hospital ward. One must have strong nerves, or at least be accustomed to the sight of suffering. There are a few nasty parents too, they become hysterical, or are just mean. They think that all doctors are heartless, and all nurses lazy and cruel. They think that we actually want to murder their children. Parents like these must be kept out, despite their loud threats to complain. The actual complaints however are extremely rare. Perhaps later, after considering quietly and soberly, they realize the shamefulness of their behaviour. It is impossible not to see the sacrificial hard work going on within these walls day and night.

There are also impudent types. They filter into the wards through the back entrance, and some even bring their own hospital robes. We suspect that one old woman in the admission ward is helping them, taking presents for it.

'Professor, you are wanted in the theatre!'

'In a minute. Just as soon as I complete the rounds.'

Listen, my dear fellow, enough of wasting time on small nonsense. Enough of procrastination. Go and do your most important work. Lenochka and Volodya don't need you here, they are well on the way to recovery. Vova will live also. So there is some justification for your work, before God, or before yourself. And that's the main thing.

   1Note the use of patronymic again: Seraphima daughter of Peter.
   2Diminutive of Peter and Michael.
   3The official title given in the U.S.S.R. to workers volunteering their time and effort to acquiring higher skills.
   4Diminutive of Vladimir.
   5Diminutive of Nadejda, Ludmilla, Svetlana. This usage establishes a warm and informal relationship.
   6Maria daughter of Basil. This indicates certain respect while the use of a family name is considered to be rude among people knowing each other well.
   7Endearment of Maya. Little Maya.
   8Since the revolution the medical profession in the U.S.S.R. has been taken over by women. Some seventy per cent of practising physicians are women.
   9Vova like Volodya is diminutive of Vladimir. Volodenika, Vovochka are endearing forms.
   10The Soviet euphemism for peasant woman.
   11Endearment of Lena which in turn is the diminutive of Helen.

Translated from the Russian by George St.George
© George St.George, 1966