6.12.1913  -  12.12.2002

Books of N.M.Amosov

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The First Day. Maya

I go to the theatre. Any further delays are impossible. Everything inside me is taut. All feelings have contracted into a little clot and hidden in the far corner of my subconscious. The whole world is clear. Black and white.

I am dressing. The glasses. The surgical mask. There are small disorders near the entrance, but I must remain calm. I can't afford to fritter my nerves away. There will be more ample reasons for that.

Maya is already in the operating theatre. The tube has been inserted into the trachea, the anaesthesis apparatus has been connected. She is asleep. My assistants, Maria Vassilievna, Pyotr Alexandrovich and Volodya are dressing the operating field with sterilized sheets.

Now that I'm here they will start. The theatre nurse, Marina, a serious, lithe, beautiful woman, is standing near the instrument table. She is quite ready, and so are the others. We have a fine team here.

I wash my hands in the theatre ante-chamber. Without words, and almost without thoughts. In the subconscious everything has been thought out, yesterday, today, a few minutes ago in the children's wards. I scrub my hands with one brush. Another. A sterilized towel. I am ready.

I enter the theatre. They hand me a napkin and some alcohol. I put on my robe.

'Fix the light. Why can't you ever put it on properly for an operation?'

Stop! I must not get wound up. Anyway they won't do it properly next time no matter what I say. Let them be.

Maya is lying on her right side. The scar has been cut away and the clamps are being put on small blood vessels. Maria Vassilievna's movements are precise and economical, she seems to be an embodiment of quiet efficiency. But this is misleading. She is a highly nervous woman and when she operates on her own she often grumbles. A good surgeon with steel-like nerves is fiction, just like an actor who does not get nervous before his entrance. One must get nervous, otherwise he is in the wrong profession. I make all these notes with a small part of my brain. Marina is handing instruments over to Maria Vassilievna in response to her finger snaps, without words, knowing what is needed. She is very experienced and has been working with me for years. An excellent nurse. No, a trusted assistant.

The gloves. Alcohol again. I take my place, take over. I cut through intercostal muscles and get into the pleural cavity. It is filled with commissures. The lung has become connected to the chest cavity wall, a normal picture after surgery. The commissures are hard, I can't separate them with my fingers; I must use the lancet or scissors. There is a good deal of bleeding; it must be coagulized or simply checked by electric diathermy. Puffs of smoke and the smell of burnt flesh.

Everything is done practically without thinking, by reflex. I can see the operating field, the lung. In my head there is a definite plan, with variations; it is carried out step by step with simple mechanical movements. The hand movements replace thought. A move, one look, an instant evaluation of the situation, a new move. The whole world is temporarily disconnected from me; one can work like this for six hours without feeling fatigue. Of course, only when the operation is challenging. Otherwise it is like any other repair work; one becomes almost a mechanic. But this case is challenging and difficult, or rather, will be difficult.

Just as soon as the upper lobe of the lung is separated from the pectoral wall, it becomes obvious that a tissue density, resembling a tumour, is located along the vessels leading away from the heart, on the aortal curve, on the pulmonary artery. The lung is just attached to it and even though the tissue has thickened, the source of the haemorrhaging must be there, in the large vessels. When I press on the tumour with my finger I can feel it pulsate.

Aneurism! Aneurism of the aorta!

The clinical picture becomes instantly clear. After the first operation an abscess occurred in the lung, and the inflammation has ruined the aortal wall. A cavity has formed attached to the aorta - the aneurism - a widening of the artery caused by the changes in its wall. It has broken through into a bronchial tube with resulting haemhorrhaging. Any further haemorrhage may prove to be fatal.

Everything is very clear, and very bad, much worse than I had expected. There is an abscess in the lung, and an opening in the aorta. The area of the aneurism covers a part of the aortal curve. All this is covered with commissures, hard as gristle. Besides all this, inflammation of the lung tissue.

My hands continue to work automatically, separating commissures and coming closer to the aneurism. There is just one thought in my mind, what to do next? While working, one feels calmer, and it seems to me that I don't quite appreciate the gravity of the situation.

I must stop, wash my hands. This is a pause for thought and a cool appraisal of the situation.

So, there are two alternatives.

First, to stitch up the wound and abandon the operation. Retreat is still possible. The case may be written down as inoperable.

The picture: outside the mother runs to me. 'All is well? Maya will live?' Alas, no. She will die, and die very soon. There was nothing we could do. Or, rather, it was too dangerous, she could easily have died on the table. And this way? Silence. Were there any chances at all? Yes, but not many. I had no right to take them. Then why did you try? I did not know the exact situation before the operation. What shall we do now, take her to Moscow? No, impossible. She would die in the plane.

A pause. A look.

The picture continues. The girl is brought into the ward. Pale little face. Eyes full of hope. Then, a little later, a coughing spell. Blood. A lot of blood. Another look, full of bewilderment. What has happened ? What about the operation? Of course, a professor is not obliged to be in the ward. The interns can do everything, especially because there is not much that can be done, except futile blood transfusions. So I knew what would happen? Yes. And was afraid to be blamed for butchering the girl? No. What was I afraid of then? The morgue, the funeral, the mother's tears? Yes. Then you shouldn't be a doctor.

Another alternative, to try to separate the aorta above and below the aneurism, as close to it as possible. And the pulmonary artery. And the lobe of the lung. Then pinch off the aorta and quickly cut away the aneurism along with part of the lung. Then stitch up the aortal wall. All right, but one can pinch off the aorta for the maximum of ten minutes and only if the vessels leading to the brain are above the clamp. Any longer period would destroy the spinal cord. To do all that in ten minutes? Impossible. But then it is possible to plug the opening with the finger, remove the clamps, let the brain be washed out by the arterial blood, and then apply the clamp again. This can be repeated several times. We have had some experience of this and it has been successful. But in Maya's case we also have commissures and the inflammation. And then it is by no means certain that the hole in the aorta can be stitched up at all, and if not, well - that's the end.

Her mother again. No words this time. Just terror in her eyes. 'Dead?' Yes. I couldn't do a thing. Aneurism, Commissures. Degeneration of inflamed tissues. They were much too brittle. Haemorrhage... 'She's dead - dead' Ah-a-a-a!'

But just suppose I succeed? Then in a few days I can go to the ward as I did today. 'Well, Maya, my darling, how are you? Slept well?'

There is no third choice. To tie off the bronchial tube and let it go at that? The inflammation of the lung would progress and kill her just the same.

Only two alternatives. Just two choices.

It is hard to choose. Let's work a bit longer, the final decision can still be postponed a little. If the separation of the aorta and the preservation of the brain arteries prove to be impossible, the question would settle itself.

I go back to work.

The plan proves feasible. Not only possible, but almost successful. I widen part of the pericardium, separate the rising aorta, and moving down along it, reach the important vessels. I make a canal under it and run a thread through. This has been the hardest part of all. I free the aorta below the aneurism. I do the same with the pulmonary artery. This has been a time-consuming work, the operation has already lasted for three hours, but I don't notice it. The anaesthetist is silent, it means that everything is going well. I can see this myself, the pumping heart is right before my eyes. I must save every bit of my nervous energy for the future even though there are many things which irritate me. Peyotr Alexandrovich is assisting carelessly, he hasn't had enough experience of working with me. But the other two are tense, alert, efficient.

A constant blood transfusion. Every drop of blood lost on the swabs and napkins is immediately replaced.

I speak to the anaesthetist: 'Dimitri Alexandrovich, ask them to send us some more blood from the station. If I decide to go ahead, we shall need a great deal.'

I continue. Everything goes very slowly, the separation of blood vessels from the commissures requires infinite skill. The progress is measured by split millimetres. My hands work by themselves. Thoughts are infrequent and fitful. What if we use the heart-lung machine? Then we can pinch off the aorta more easily, and there would be no pressure of time.

Unfortunately, the setting-up of the machine takes two hours. Besides, we have no whole blood on hand. I must continue the way I have begun.

The operation goes on surprisingly well, my every move is precise and measured. I am beginning to think that I am God. That there is nothing I can't do. Just look at those separated vessels, and the lung! So clean, so dry. It is not an easy task in view of all those commissures to work so close to an aneurism, it's no joke at all. Few surgeons would even risk it.

Really, after all, I'm not a bad surgeon. Perhaps one of the very best.

Stop bragging, professor! Look at your trembling hands, they have been trembling all your life. And then remember the scene near the morgue this morning, the coffin, the wailing. Big hero, indeed!

All the preliminary operations have been completed. Even more than that, I have tied off the bronchial tube. It is still possible to retreat, but now is the time to make the final decision.

But making any decision proves to be unnecessary. Suddenly there is a geyser of blood which hits me straight in the face. Instantly the hole is found by touch and plugged by my finger.

'Clean my glasses!'

For a second I'm blind. But no matter. My finger knows what to do.

'Keep mopping up the blood in the wound!'

The aneurism wall has burst. In one place I have cut too deep through a commissure and... well, I should have expected that. But it has all happened so suddenly, so dramatically.

Why didn't I stop in time?

Now, it's too late. No retreat any more. However, things are still under control. The heart works well. Quite well.

No. Not any more. Not really. Should I remove my ringer, the pleural cavity would flood with blood, the blood pressure would go down to zero, and the heart would start quivering barely perceptibly, instead of beating. I must press the hole down. Like that boy in Holland who held his finger in the hole in the dyke. But there they came to relieve him. No one here is going to relieve me.

'Start transfusion direct into the artery! As quickly as you can! Hurry!'

I draw in air like a diver before taking a plunge. As though this is my last breath.

'Petya, clamp off the aorta! Maria, pinch off the pulmonary artery!'

Now I remove my finger. A weak spurt of blood, then it slackens off. No pressure.

'The vacuum sucker! Goddam it, it doesn't work! Give me another one, quickly!'

I have ten minutes at my disposal. So very little. I tear open the wall of the burst aneurism, clean out the blood clots. I must cut away a section of the lung to reach the aorta. But this is difficult to do, there are many still un-separated commissures. Whoever has built the human body has done it seemingly with just one idea in mind - to impede surgeons.

The power shears! Quick, you cow!'

A split-second thought: why swear? Oh, what's the difference ! The section of the lung is cut away, almost torn off.


In the aorta wall there is a hole about a centimetre long. The edges are uneven, the tissues are weakened by inflammation, they would never hold the thread. Impossible.

'What have I done, what have I done, idiot!'

This, about myself. I am a complete nonentity, a miserable quack. Let everyone know it. I don't care. All I want is to drop dead, this very second, while that other heart is still beating. But I have no right to drop dead.

I must do something. Must try. What if the sutures will hold after all? God - grant me a miracle!

'Marina, the sutures. Check them for strength, each one.'

I sew desperately, trying to put the stitches as far away from the edges as I can. But it is hopeless - the tissues are coming apart like butter, nothing holds at all. Just as I thought.

'Give me more! More! Marina!'

These hopeless, bumbling attempts take about five precious minutes. From some small vessels the blood continues to seep into the aneurism, flooding the field. We have to tighten the pulmonary artery clamp - or else.

'Professor, the pressure is falling off.'

'Keep pouring the blood in! Open the femoral artery on the other thigh, you slobs!'

'There is no pulse.'

My God, my God, what now? I can see and feel how the heart spasms grow weaker and weaker. We must remove the clamps from the aorta.

'Petya, Maria, Volodya! I'll close the hole with my finger, and you remove the clamps. All at the same time. One, two, three - now!'

The clamps are loosened. The pressure in the aorta is low, but blood keeps seeping in from somewhere. The heart all but stops.

'Keep pouring blood in! Clean the wound with a sucker! Get adrenalin ready, three cubes!'

No, we must pinch off the aorta again, the blood floods the entire field. And I must massage the heart. It is hopeless, of course, quite useless, but it is still trying to beat. And just supposing there's a miracle? No, stupid, there are no miracles. No God.

'Petya, clamp the aorta. Maria, cut the pericardium wider for a massage. What? You pulled out the clamp altogether, you idiot? Where were your eyes, you bastard? We shall never get it under again - never! How can I work with such cretins?'

Various insulting epithets. I shout because I'm in despair. Petya has made a mistake of course, he should not have pulled out the clamp. But does that change anything? I remove my finger from the hole, there are sluggish little spurts; exactly like those from a barrel when the liquid is at the very bottom.

I am almost crying. I don't want to live in this horrible world where little girls die like this.

I am massaging the heart. With each squeeze a bit of blood oozes out of the aorta. I still can't attach the clamp. I am hysterical. I am swearing at Petya, and at Maria blaming her for the first operation, even though there are no reasons to suspect that anything had been done incorrectly. I am going to pieces.

Adrenalin. Massage. New transfusions. All this is painfully slow. The heart gives infrequent lazy spasms as though slowly going to sleep. But I must do something, I must, I must!

'Professor, the pupils have already been enlarged ten minutes.'

The meaning of these terrible words slowly sinks in. So, this is it. Death. One must accept the fact, even though the heart continues to quiver convulsively now and then, quite unnecessarily. It is clinically dead.

'Very well, that's all. Stop the transfusion. Save the blood for those who will need it.'

All of a sudden, an utter apathy comes over me. Almost a relief. But not quite. It is impossible to describe this.

'Stitch up the wound.'

I stagger out into the ante-chamber. Towards an armchair. No, I must change first. I'm covered with blood like a butcher.

However, I sit down. My head is empty. My hands are numb. My feet throb with pain. Nothing matters any longer. Everything is over.

But no, not quite. There are Maya's mother and father. (Strange, when one thinks of a dead child's parents, mother always comes first.) Of course, they must have sensed already that things are not going well. It's been five hours since we took Maya up to surgery. But they still hope, parents never cease hoping. There is not much hope left by this time, just a little hope hanging on a slender thread of utter impossibility to accept the death of one's only child, but still it's hope, and now someone must go and sever this thread. There is no use in waiting, in putting this off. All is over. The wound is covered, the blood washed away. Maya lies covered with a sheet. No, not Maya. A corpse. I can't utter this word aloud.

Several tired doctors assemble in the room. Someone must go and speak to the mother. Actually, I should do it, but I procrastinate, keep silent, hoping that someone will come to my rescue. Finally, Peyotr Alexandrovich turns to Volodya:

'Go and tell her mother.'

Volodya can't disobey an order, we have a certain discipline, and he's a junior amongst us. He hates to do this, but he rises slowly and walks to the door.

Too late. We have procrastinated too long. The door bursts open and Maya's mother runs in. She looks insane, at this moment she probably is. She runs straight to the operating table and throws herself onto her daughter's corpse, just as they do in bad novels. She is sobbing some tender words. Kisses the dead blue lips.

'Wake up, Mayachka, wake up, my dearest, my darling, wake up, wake up!'

She does not utter the words I am waiting for: 'What have they done to you!' She does not blame anyone - not yet. She doesn't yet realize, does not want to understand that her daughter, her precious Mayachka, is no longer here, that she is speaking to an already slowly decomposing corpse.

The room is almost empty now. It is difficult to watch this scene. Nurses are crying.

I get up, approach the woman, try to speak to her. I say some stupid dead words which I am ashamed to repeat, words I have said so many times before and been ashamed every time I spoke them. Finally, with some effort, they lead her away into the post-operative room, a little room where patients spend some time after an operation before being taken into the wards. There she is sick. I don't see it because I remain in the ante-chamber and again sit down. Someone tells me that she is lying on the floor. On the floor? Why? Oh yes, there are no beds and no couches there, just some round white metal stools.

Then she and her husband are taken home in a hospital car. What they will do there, I don't know.

Maria Vassilievna is weeping in the corner.

Now I must write a report, a detailed one. 'All attempts to close the defect in the aortal wall proved to be unsuccessful. The haemorrhage continued, and life was slowly ebbing away -'.

Ebbing. The day is ebbing, too. I've done my work, I can go home. The darkness is gathering outside. This is a relief. At least no one will see me. Shall I ever forget this day?

* * *

I am walking through the park under some large trees. The evening sky is clear and pale. It is very quiet here. The faint hum of the city comes from the far distance, first lights begin to appear here and there. Everything is calm and pretty. Poets write poems about this. What poems? All this is a fraud! Behind those twinkling windows people are suffering. They drink, they fight, They count money. They hate, they long for something which they will never get, they become sick. They grow old. With every second they draw closer to death. And further, behind the horizon, they die of hunger. Or make atom bombs, getting ready to send upon humanity an avalanche of death and pain.

The pale sky and the smell of flowers do not affect me now. I am depressed. I must think, must search. Must find some way of living with that pale sky. Only an insensitive man can just admire it, without thinking

The door of my home. I hear a tender, ringing little voice like a silver bell:

'Who is there?'

This is my grand-daughter. Lenochka. She is four. She calls me daddy because her real father left when she was a mere baby. I love her very much. Yes, very, very much.

'Why are you so late? You had an operation?'

I lift her in my arms, kiss her. And before my eyes there stands that other little girl, the same pigtails, the same nylon ribbons. Only that other one was so thin.

'Is everything all right, daddy? Did the patient die?'

She asks this lightly. The word dead still means nothing to her. It doesn't mean anything to anybody, not to the living; we all know that there is death, but we don't believe it. But in time we learn to pretend. Lenochka has had no time to learn this yet.

'Yes, my darling. She died.'

My wife comes into the room. She is also a doctor, a good one, and during the many years of our marriage we have learnt to read each other's faces. We never ask questions.

Everything is as usual. I change, put on my slippers. A silent dinner, if this can be called a dinner. Let us not dramatize things, let's pretend that nothing has happened. But I need a drink. This is essential after a day like this. I am resorting to this medicine quite often now. And why not? What do I have to lose, what to preserve?

At this point the programme calls for sleep. Using this as a pretext, I can escape into my study and stretch out on my sofa. I sleep here now. My wife is a light sleeper and once awakened, she can't go back to sleep, and she needs her rest. Here I can put a bottle of cognac and a little glass on a chair next to my bed. Just like the stories of Remarque or Hemingway. Funny. Even at moments like this one succumbs to theatrical effects and compares oneself to fictional heroes. Or is this something special to me?

Tonight, there won't be any sleep, not for a long while. Through my slightly befuddled brain there pass the images of the day. The wailing of the woman over the coffin. The first woman. Then the second one. 'Please, try to do it well, all right?' I tried, but I didn't do it well. I failed.

The door is closed and there is no one in the next room. So I can grab my head and moan: oh, my God, my God.

Murders. Every day in hospitals throughout the world people are dying. Often because of doctors' mistakes. Especially surgeons'. It is easier for therapeutists: the patient did not respond to the medicine and died. By himself. He couldn't be saved. Too bad, science is still very limited. Of course, doctor, we understand, this wasn't your fault. But what when your lancet slips and an aneurism bursts into your face?

There are different murders. A bandit kills for money or just for blood lust. This is disgusting, and they punish him with death.

A jealous man kills because he cannot endure his anguish. He gets a lighter punishment; in some cases they even let him go. Love is still respected. However, for a murderer to remain alive is often the worst punishment. Still, most of them get over it in time.

An automobile driver kills accidentally. He himself is a victim. The murder jumps at him like a wild beast and ruins his life. But what can one do? One cannot permit drivers to run people down. Let them watch out more carefully.

There is also war. Many murders, for an ideal. Or someone's profit. Or because of the mad designs of some rabid politicians. The war murder is noble. They give medals and titles for it, the more the better. People, soldiers, get used to killing quite easily. Especially now when it is done by long distance without smearing one's hands with blood. This is an abstract murder. Besides, for a soldier it is honest. They might as well kill him. He has no choice. He must kill, or be killed.

Then, at the bottom of the list, are surgeons. No one calls us murderers, except hysterical relatives. We have noble aims. A man is in danger, the surgeon fights for his life, and now and then he loses the battle. But what of it? One can't always win.

This is not the first time that I lie like this on this very sofa. There have been many deaths in my career. Murders? Yes, also murders. Unpremeditated murders, to use the legal jargon, but murders just the same. One must call things by their proper names. I have thought a great deal about my life, and I am thinking now. Hundreds of the most complicated operations, and a fair percentage of failures. Some deaths have been caused directly by me. But no, those were not murders! Everything within me protests against this word. I had taken calculated risks to save lives.

How sad and unpleasant I feel today. What was my mistake with Maya? I should have stopped in time. Just as soon as I saw the aneurism, I should have stopped. Sewn up the wound. She would have lasted until tomorrow with transfusions. Tomorrow we could have set up our AIK machine, got some fresh blood. Then I could have disconnected the heart and carefully patched up the hole in the aorta, cutting away a part of the lung, without pressure, without hysteria.

Nonsense. It's not that easy at all to operate on an aneurism, even with the heart-lung machine. It is almost hopeless, taking into consideration the patient's condition. And then she would have to be kept alive until tomorrow, a very questionable proposition.

Still my chances would have been much better. Mistakes : I'm making mistakes like a small boy.

There are different operations. You operate on a mortally wounded soldier. Death is inevitable in any event. There are other hopeless cases where the surgeon's work is almost symbolic, he is supposed to do something, he tries, he makes mistakes, but that does not really matter. But Tamara and Maya? Did they have to die?

Tamara's case was especially painful. It was not even an emergency one. The girl walked into the clinic on her own feet, and she would have lived for three to four years at least, even without surgery. Then something went wrong during the operation, I still don't know what exactly, and now she is laid out on a table, in the front corner1.

Let's have a drink.

Surgery is supposed to be a corrective science, then why do patients die so often?

There are cases when everything is done correctly, and the patient is dead. Perhaps there was a faulty calculation, the doctor was not clever enough appraising the case. But in some cases proper calculation is impossible. The science itself is at fault.

Then often the operation is not performed skilfully enough, somewhere the surgeon has erred, or he has not used the proper technique in this particular case. A good craftsman would have done it, but the less skilled one fails. Death! One can perform ten operations brilliantly, and slip on the eleventh, and there's another fatality. A surgeon is not only a physician, he is a craftsman, like a jeweller or toolmaker. There are good craftsmen, and bad. And if you are not first-rate, you had better quit.

A surgeon must be intelligent, he must know his craft and he must keep on learning it his whole life through.

But even that is not enough. My friend, a mathematician, does not recognize medicine as a science. No exact computation, no science. He says that everything in life must be done with computers, that the human brain is much too limited. Perhaps. I don't know. I haven't absorbed this yet. But one thing is certain, as a precision machine the human brain is imperfect; it forgets things, it mixes them up, it misplaces facts and figures fed into it. It can be put out of focus with a few small glasses of cognac. This cannot happen to a machine.

To be a good surgeon, one must not only be good with instruments, but have extensive experience to cope with unusual conditions which he may encounter. He must perform a great deal of actual surgery. And he must have a special psychological make-up for it. You see how beautifully it all sorts out into neat compartments, with a few glasses of cognac.

It means that deaths are unavoidable no matter how skilful the surgeon is. One can't wait until medicine becomes exact and faultless. This would take scores of years, perhaps centuries, and millions of patients would die waiting. One can't avoid mistakes in any work. In our work mistakes are paid for by lives. To become a craftsman one must practice, must ruin the material he is working with. Our material is people.

This is terrible, but you can't change it.

Therefore, there is no point in going to pieces because two little girls died who would have died anyway. No one can possibly blame you for it. The important thing is honest intention. And no pecuniary considerations, no money - an honest man can't do this kind of work for money. Then you can come home from your work, have a drink and go to bed. And if your nerves are weak, well, you're in the wrong profession, that's all.

Lenochka comes into the room to bid me goodnight. After her bath, she is so clean, so pink. She is glowing with health and joy of living.

'Goodnight, daddy. You're drinking cognac? Walk with me to bed.'

'Goodnight, my darling. No. Go alone tonight. I'm very tired. I must rest.'

She kisses me and runs away stumbling in her long nightie, chirping like a bird.

Most likely I'm not fit to be a surgeon. I'm too sentimental, too soft. I shouldn't be in work which kills people.

They say there is a proper percentage of fatalities after different kinds of surgery. The world's statistics of mistakes and failures. In our country? The level is about normal, a little more here, a little less there. Figures don't lie. But one doesn't see the dead behind the figures. Their photographs are not printed in medical journals.

That first girl, Tamara, had such serious eyes.

And Maya was so gay, so full of life.

The past tense. Had. Was.

Let's have another little glass.

Cognac tastes particularly bitter tonight. No, I won't become an alcoholic.

Feeling sorry for yourself again? Don't. After all, not everyone dies. Those children you saw in the convalescent ward today, they were wonderful. And all those former patients who come for a check-up every Monday. Grown-up, smiling, handsome. You look at them and all the bitterness inside melts away. And you go back to surgery and do more work.

I have been in surgery for thirty years. That's a long time. I started out as a young dreamer, transplantation of organs, rejuvenation. The lancet the crowning glory of medicine. Home practitioners, the lower form of life. 'I will accomplish miracles!' When I think about myself, as I was then, I feel a little contempt and a tinge of sadness. Regrets? No. Generally speaking I have lived a good life. Nothing spectacular, but good and honest. Aspirant, assistant, reader, professor. Almost like those doctors portrayed in plays and novels, limited, slightly comical pedants?

No. 'I've seen diamonds in the sky!'2 Surgery has given me such passions, like nothing else could have done. I am a creator, I am a doer. My conscience is my only judge. And what else can impose upon one a more severe judgment?

Words, beautiful words. It has been such hard labour, all the way.

Tonight I am lying on my sofa, crushed, a little drunk, all my dreams of accomplishment just as remote as they were thirty years ago.

No, that's not true. It's sorrow and disappointment which speak in me tonight. And fatigue. Much has been accomplished.

Back in the 'thirties simple stomach operations and kidney removals were regarded as almost miraculous achievements. Only our master-surgeons very rarely and timidly attempted to touch the pectoral cavity, with almost uniformly unsuccessful results. Then, for a while, they discontinued it altogether. And now my assistants perform routine heart surgery every day, and the patients recover.

All this has cost us many lives and a great deal of suffering, but today we can show profits for our labours.

How little we knew at that time, how unsure were we of our methods! But gradually there had been progress. Blood transfusion, local anaesthesia, various accomplishments in prophylactics and diagnosis. Fewer and fewer deaths. You grow bold, you start on the more difficult cases with supreme confidence, and - bang, bang! - you fall flat on your face. 'Why did I try this? Why didn't I stop in time?' But then you cool off, evaluate your mistakes, and start out again, like all other surgeons throughout the world.

After the war we really started on the chest, lungs, oesophagus. I was already a professor then. That, however, is not an important point. Surgery makes everyone equal, a young doctor and an academician: just show us your skill, what you can do. And as to the degrees and titles, they are merely for the pay-rate3. That is what rank-and-file doctors think; in reality professors and academicians consider themselves superior beings. They are the initiated. Many of them have forgotten their fears and misgivings when they were defending their miserable dissertations, and naively believe that they have made a lasting contribution to science.

Many? And how about yourself and your 'Variations of diaphragmal nerve behaviour?'

But let's not be super-critical. I have worked hard and honestly. I have never put too much stress on my degrees and titles. They are good to have, one can get a better clinic, better conditions for experimental surgery.

1949. The first pneumonactomy. Six and a half hours. The patient in deep shock, and I collapse on a divan. True, it was a difficult case. He got over it. That was very exciting. Where is he now, my Semyon, my Senia, as I used to call him fondly? I haven't seen him for five years. The last time I saw him he was a rural postman. 'I walk at least twenty kilometres every day.' A pleasant memory! And he was once doomed.

There have been many such Semyons in my career; how could I have survived otherwise? But somehow these happy memories don't come to me tonight. After Semyon there was Pavlik, Paul, with a chronic lung abscess. The haemorrhage and artery damage. He died. I was lying on this very sofa then, just like tonight.

But none the less we have conquered the lung, today we can operate almost with a guarantee. I have also made some contribution here. No, let's forget that. I thought I had developed a new technique of bronchial tube surgery only to learn that it had been discovered before. So much for my contribution.

No, let's be honest. I had assembled some fine experience material and developed a good method. Have been teaching it to surgeons. Many of them are now using my findings, and using them well. Patients recover, thank their doctors. This is a definite credit to a craftsman working with the most precious material of all - people.

How difficult self-criticism is! Had I not had tragic days like today, I would have probably thought myself a rare talent, like some of my colleagues. This is also not true. I'm no more conscientious than others.

Then we started heart surgery. Again the whole procession of faces and dates. My first patient, a woman with an advanced stenosis and heavy decompensation. An intelligent woman, she well knew that she was doomed. A widow. 'I want to live just a few years longer, I must raise my son.' Why didn't she go to Moscow? They were performing those operations there. I don't know. But I will be forever grateful to her for the trust she put in me. She was very lucky not to die on the table, I grow red in the face when I think of that operation. I was so awkward, so frightened. But she is alive today. And her son has grown up. I'm so thankful to her.

Yet the heart is the most difficult area. It will probably prove to be my undoing. Why do I do it then? For the love of my fellow men? Keep quiet, doctor. You're doing it for yourself.

There has been joy, but also many disappointments. The results were often unsatisfactory. We must learn to open the heart and replace all its component parts.

Then, the epic story of the construction of the AIK. Yes, it had been a high adventure, a true epic, with all the human passions. Had I been a writer I could have written a book about it. Honestly, I had been partly instrumental here. Of course without Oleg, Pyotr, Maria, Dima, and many others, the whole thing would not have been possible. It was a real collective effort.

Do they like me?

They used to, but now I don't know. I'm becoming more and more detached from them. I'm drying up inside, I'm becoming irritable, intolerant, dour. They probably ascribe this to my sense of self-importance.

I remember our first operation with the AIK. It was a failure. For a whole year afterwards we had worked with dogs, improving the machine. Then, the first success! A little boy Kolya, another blue baby with a hole in the heart, the ventricular septal defect. The operation was not really radical, but he survived and improved. That was a great achievement. In the entire Soviet Union there were only a few clinics then with records of successful cases. I remember our pride, all the emotional turmoil. Our confidence as we tackled other cases. After each operation several doctors were in constant attendance on every case, day and night.

Only the first operations were good. Then, a whole series of failures. We began to take on more and more difficult cases. But what else could we do? Who needs help more than those previously inoperable cases?

However that was a dismal stretch.

The entire history of the so-called Big Surgery stands before my eyes. I have taken part in it, often in the front ranks. I can't say that I have achieved anything really brilliant. I'm no inventor, just a good practitioner. In time my name will be forgotten.

I don't care about that, now. But later?

Is it cognac or my depression which makes my thoughts so formless? It is some mixture of sentimentality and bitterness.

Let's have another drink, just to clear the head.

Enough! My whole life I have striven for clarity of thought. Now I must bring some logic into my own mind.

Does humanity need surgery? Undoubtedly, yes. Not all patients die. The majority survive and enjoy life. For as long as science permits them. True, there have been many unnecessary deaths, but that is unavoidable. Unfortunately. From the dawn of time people sacrificed to various gods hoping to earn their favour.

How did the ancient priests feel butchering children upon their altars?

Are we such priests?

One should not over-glamourize surgeons. They risk other people's lives, not their own. In this respect they are not soldiers, but generals. Yet, we don't remain unscathed. We are performing hard and difficult work for the benefit of humanity. Why do we do it? Not for money. A surgeon lives no better than a family doctor, or an engineer. Vanity? Of course, while you are young it flatters your ego to be regarded as a sort of superman. But for me this no longer exists. No? Yes, it is still pleasant, but not pleasant enough to risk spectacular even though hopeless operations for the sake of this pleasure. What else then? Well, perhaps the sense of challenge, of contest, of struggle which makes the final victory so rewarding. And, finally, the duty. Perhaps you are being coy? The explanation is much too primitive. Psychologists must study the stimuli which govern all human behaviour. Stimulus is a Greek word, it describes a prod with which the Greeks used to drive on their animals. Isn't it the same thing with us?

The nature of man. What is man? This question has been posed many, many times, and the answers are just as numerous, and often completely contradictory.

Man is kind by nature.

Man is the cruellest animal in existence.

Has he a multiple image? What is good and evil? Progress? Future?

It would be good to learn the answer before death. Is it so impossible to keep all those little boys and girls happy, just as happy as they are when they have love, good health, and all the material necessities of a good life? And what is happiness?

Once again I have strayed from my original line of thought.

I'm not feeling well. I'm particularly depressed tonight. This has happened to me before, but not like tonight. I've reached some sort of saturation point. Victories no longer bring the joys which they used to bring. The suffering of the unfortunate has poisoned my soul, has deprived it of peace. Old banal phrases. Cliches. Disgusting.

I am very familiar with physical suffering. But there are many other forms of suffering of which I know nothing. Humiliation, poverty, injustice, inability to communicate with others.

Then what do I want to do?


How many times this thought has come to me at moments like this. In the struggle which surgeons wage, only patients die. But when the heart stops in your hands, when you feel the quivering life ebb away, how many times have I felt like dying myself to prevent this disaster. But there is no exchange, the patient dies, and I live on. Then time passes, and I am no longer ready for this exchange. I have changed my mind. But each such bitter moment gradually ruins one's life.

The history of medicine knows the cases of surgeons' suicides. Kolomnin, the pupil of Pirogoff, inserted a massive dose of cocaine into a patient's colon. It was a well-calculated, well-thought-out action, but the patient died. Kolomnin went to his study and shot himself.

Dr Block, a German, attempted a double lung operation at the turn of the century in the case of advanced tuberculosis. The patient died on the table. The doctor poisoned himself the same day. It was a double funeral.

Of course, reasonable people would consider these cases as temporary insanity. If this practice were accepted, all surgeons should have been dead long ago. There would be no one left to perform a simple appendectomy.

These are extreme cases and can't be considered seriously. But I, for one, take off my hat before their sense of humanity.

Perhaps you are just moralizing? You are afraid of responsibility and looking for an escape? Using humanity as a shield? I don't know. Tonight life has little meaning to me. Of course I love my granddaughter very much. I have never loved my daughter this way. I was young then perhaps, had other interests. But, in fact, Lenochka can grow up without me. Eugenie and Lisa would certainly know how to bring her up.

It seems to me now that I'm saying something very stupid.

No, I will not poison myself. Even though nowadays there exist such wonderful poisons. You go to sleep with beautiful dreams and never awaken. Marvellous. No more operations and mothers' tears.

All right, enough of sentiment. Such a noble hero indeed! 'He could not bear it, he felt it was the best solution for everyone.' They used to write this in old novels which, frankly, I can no longer read.

I'm quite drunk. Another little glass? No. Enough for tonight.

There is still another escape. I can go into pure science. Laboratory work is so pleasant. You sit, think, experiment. You feel sorry for dogs, of course, but still they are not people. Physiology is a fascinating subject. There are so many things to discover, to learn - how to control blood pressure, the effects of oxygen hunger upon tissues, shock... One can teach doctors: 'On the basis of our experiment on animals, we feel that such-and-such techniques are indicated in such-and-such cases.' Let them experiment then on human beings. And if your techniques don't work, you can always explain this away. 'You should have approached this on the basis of accumulative experience, Comrades. One can t blindly transpose laboratory indications into clinical practice.' Mothers would no longer be coming to me with their tears. I'm a scientist! What do they understand about theory? All they want is the knife.

Of course, theory is an important field. Without those scientists, we could not cut into the lungs and patch up ventricle walls. Also without them we would not be living in dread of the atom bomb which can tomorrow bury all our little Lenochkas. However, that is not the scientists' fault. But why not? They should have handled those matters with more thought, more care, instead of rushing blindly after beautiful mirages. They should not have been so overwhelmed by the seeming omnipotence of human genius.

I think I'm delving into a sphere which is foreign to me. Would I be able to restrain myself? They say mirages are fascinating. I don't know. I've never seen any.

No, pure science is not for me - medical science, I mean. I'm probably wrong, but I don't like it. Physiology is a fine thing, and experiments on animals are necessary. But the real satisfaction comes from watching results, from facing direct responsibility, from sharing joys and sorrows of all those mothers.

Again, high-sounding phrases.

And so I have gone far afield, and have returned to my starting point. There is just one course open to me - work. More surgery. I must learn more and teach other surgeons to work well and honestly.

No, that's not all. One must search. Science is very important. Real science, for people.

Now I'm going to bed. Officially going to bed. I'll take some luminal on top of the cognac.

Yes, I am going to bed. My Lenochka is already fast asleep. My wife and my daughter, Lisa, will go to bed just as soon as I turn off my light. I should go and say goodnight to them, let them think that I'm back to normal. But I'm not back to normal at all. In my subconscious I'm with those two families, in those two houses. What are they doing? Have they gone to bed, or are they still crying - two of them over the little coffin ready for tomorrow's funeral, and two in an empty house where their poor Mayachka seems still to be living? What can one say about that? Nothing.


The End of the First Day

   1An allusion to a Russian custom of laying out the dead upon a table in the so called icon corner.
   2An allusion to Actor in Gorky's 'The Lower Depths'.
   3All medical workers in the U.S.S.R. are government employees and are paid in accordance with an approved pay scale.


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