6.12.1913  -  12.12.2002

Books of N.M.Amosov

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The Second Day... Sima and Shura

For two years I haven't touched my book. Two years? Must be - almost to a day. It was also spring then. Late April or early May. I must learn to date my entries. I always miss out dates, even on letters.

* * *

Another spring.

The road leads uphill. I am going to the clinic. Almost every morning I climb this hill. And not only with my legs. With my thoughts, too. These morning walks are good for me. They give me a charge for the day.

The operation. I have a very difficult one to do today. Everything has been calculated and thought out hundreds of times, and I'm just looking at people, trees, cars. Even run through monologues in my mind. But all this is just on the surface of my brain. Deep inside, mentally, I am already in the operating room. The snatches of thoughts. 'I must not forget this. Perhaps I'd better try it this way today. And if I discover this, I must stop. Wait. Discuss it with my assistants.' I even move my fingers a little in response to my thoughts.

Relax, professor. Look around. What a beautiful day. A morning in May. The fragrance of apple blossoms. The first dawn of young leaves on the trees. The fleecy little clouds like gambolling lambs.

Words. Words are destructive - they fetter your thought. However, there must be words. A writer's talent, it seems, is to express feelings with words. No, he must know how to feel also. How simple and pleasant this must be: to dream, feel, describe.

I can't afford feelings today. Perhaps that's why I don't admire this beautiful morning. No, my friend, it's much simpler: you're just blind. And yet, as I remember, I used to like to watch sunrises and sunsets. Yes, long ago, before the war. For me the war has never really ended.

Usually, during my morning walks I don't think about patients. I can control my thought, all the brakes are still holding fast. I think about operations, about the hearts and lungs, not people. About cases, but without faces. Without eyes.

But today I can't control myself too well. This is a very special day, a very risky operation on someone very close to me. Why the devil have I permitted him to become so close? Why have I spoken to him, delved into his soul? No, this is not correct, I have never reached his soul. Only his brain, his intellect. No, perhaps soul was there as well, but a very special soul, cold and dry, like a mathematical formula.

Careful, professor! Don't let yourself go. This is dangerous. Breathe deeper, step livelier. All the sentiments were put to rest last night with a stiff dose of luminal.

But what about him? Has he slept well? It is important for him to have had a good rest. Emotions are mortal enemies of the heart. Even a healthy heart. But how can he approach this without emotion when he knows the truth? Others just trust you, they don't understand the situation, you can often deceive them. But Sasha1 is a mathematician. He has calculated all odds, has taken into consideration all the chance factors.

Unfortunately I'm not too sure about his calculations: I consider them too optimistic. I did not give him all the corrective coefficients; in fact, I don't know them myself any too well. In a number of areas I'm still guessing.

There is still time. I can call the operation off. I will examine him again, and decide then.

What a depressing case. Everything within me revolts against all those idiocies which compose life. Why all these sicknesses, quarrels, wars, oppressions? Again I'm asking stupid question, just like I did two years ago. There are answers to all of them, or rather, they can be had. Sasha knew them all. Sasha again. After our talks, many things have become clear to me. I can't stop admiring his brain. Had he had good health and a little vanity, he could have accomplished great things. The word health sounds ironic today. His very life is hanging by the thinnest of threads.

I wish I could run through in my mind all our meetings, all our talks. I could always get so much strength out of them. I need it today.

My heart is in a painful vice.

No, I had better not. Once the operation is over, there will be time for this. The spring will unwind, the pressure will be off, there will be nothing to alter, nothing to mend. Then one can rummage through one's memories.

But now, step livelier. Walk faster. A surgeon must be alert, durable, lean.

All the preparations were completed yesterday. We even held a special meeting, just as we used to do years before, when we first experimented with our heart-lung AIK machine. The entire clinic is tense: Sasha is everyone's favourite. Probably everyone is thinking: let's hope the professor doesn't fly off the handle today. Not because they are afraid of insults, but they say I am losing my skill when I get excited. It sounds logical, but I haven't noticed it before. Must be my age, I suppose.

I won't swear today. I have no right to take chances.

Here it is, our home, our clinic. It looks handsome against the first pale green of the lindens. It should look good to people walking past it. But I can't see it that way. Suffering has coloured it for me; to me it looks grim.

Two windows of the post-operation room. One of them is open and there is a vase on the sill with the first spring flowers. Behind them my imagination pictures different scenes which, alas, I know only too well. No, I'm going to drive those pictures out of my mind. There is no room for memories today. I must curb my emotion.

Benches. Relatives of our patients are already sitting there. They are always here except on bitterly cold days. Mothers of our children. Some happy, others unhappy. I walk past them with a frozen face. I can't force myself to smile this morning. Generally I don't like talking to relatives. I have enough tact and patience, but not enough human warmth. This, of course, is bad. But I must somehow defend myself from the anguish which seems to permeate this place. I can't live through their emotions. They are worried, but at least they are in good health. I must spare myself for the sick.

Just as I suspected. Sasha's wife is waiting for me, Raissa Sergeyevna, Raya for short. Probably a fine woman, but I didn't want to see her. Everything has been said, discussed, and there's nothing I can add. She doesn't appreciate the desperate state of her husband's health and is panic-stricken at the thought of the operation. Under such circumstances, I wouldn't have operated on any other patient. A patient even if he himself insists on surgery can die on the table, but his relatives remain and you can't explain anything, the surgeon is always a villain to them.

Very well. I'm not worrying about that now. I can't blame myself because he himself demands surgery, and he knows the odds. My only problem is not to make any mistakes today.

'My dear professor, will you operate today?'

'Good morning, Raissa Sergeyevna. Please calm yourself. You will need all your strength later on. Yes, I will operate, unless Sasha has changed his mind.'


'No, he hasn't. I've seen him. He wouldn't listen to me. Please refuse to operate, please!'

'I can't. As a physician I don't see another alternative. Without surgery he won't last a year.'

'But he's not feeling too badly. Just a few days ago, he even went out on the balcony. The newspapers write about new preparations for rheumatism, perhaps they might help? Just suppose he dies today? What then?'

Yes, what then? I can't tell her that she is still young, that she would forget, and marry again. That she is perfectly able to take care of their son. And that the greatest loss would be not for her, but for science, for others. However this is not really so, her loss would be irreplaceable, but science would find other Sashas.

'Raissa Sergeyevna, try to understand.'

Now I deliver a short lecture on the nature of rheumatism, cardiac deficiencies, cirrhosis of the liver. Words which I have repeated at least twenty times. She can't understand me. She looks at me with her watery blue eyes. I am becoming gradually angry.

'Professor, wait at least another week. I beg you!'

'In a week it may be too late to do anything. Please forgive me, I'm in no mood for hysterics this morning. I must go.'

I go. She is still trying to say something. No, I won't listen. That's all I need before a complicated operation! Let her go to hell. Deep inside, I'm sorry for her. She's unhappy, and this is not her fault. Nobody's fault. Or rather, our common fault, for not being able to create life without such dramas, terrible dramas claiming people's lives.

I still have a few minutes before our morning conference. I must go and see him.

The third floor. A small private ward. Flowers. Sasha is sitting up in his bed. A hunched posture, a mournful expression. Pitiful. I'm terribly sorry for him.

'Ah, professor, good morning! Come in, come in!'

He smiles. A beautiful, radiant smile on the thin grey face. I look at him for a moment, both as a doctor and a friend. He seems to be bearing up well.

'Slept well, my boy?'

Usually I am not this familiar with him. I call him Alexander Nikolaevich. After all he is not a boy, but a scientist, a man of refined intelligence and fine manners. He calls all the orderlies by their patronymics. But today this is different. I must get through to him, must give him a boost. His Raya, of course, has already been here and has done her best to unnerve him.

'Stay a minute, professor.'

I force a cheerful smile and sit down facing him.

Suddenly he becomes serious. 'We have but little time. You must attend your morning conference and Dimitri Alexyevich is already waiting for me with his needles. First, about the operation. We shall do what we have decided to do. The only thing that remains to me is to bear it like a man. I will try.'

'Everything will be all right. I am sure.'

I am not sure at all. But I have already said everything I could last night. Once he has decided, he will not change his mind. So I might as well lie.

'No, professor. I like logic, and my logic works well, despite all the emotional pressures. I have detained you not to be comforted. You have done a great deal for me, you are a man who -'.

'Please, Sasha - no big words! I don't like them.' I think this is the first time that I have called him Sasha, and it seems to me that he has liked that.

He reaches under his pillow and brings out a thick school notebook.

'I have a manuscript here. A brief digest of my ideas about which I have spoken to you. There are a few new points, the result of the last few days. Please read this at leisure. I'm not looking for recognition, but it will be - would be pleasant to me if my thoughts should prove to be interesting... to someone. This is number one. The second point, Serezha, my son. You know my wife, Raya. I'm not going to speak about her now. I know that you won't be able to influence my son's upbringing, this is technically impossible, even if you'd wanted to do it. But in a few years he will understand many things he doesn't understand today, and I ask you... speak to him then about life and about myself. And about my work.'

He hands the notebook to me. His hand trembles a little. His eyes are thoughtful and just a little moist. A pause.

'Now, there's still another thing. Here's a letter. In all probability a woman will come to see you, very soon. Read this letter yourself, and then give it to her, under any circumstances. Be sure to read it first, then you will know how to speak to her. And if by any chance I survive - well, we'll simply forget about this and won't mention it again. I suppose that is all.'

He smiles again, his usual wonderful smile. This time, almost a happy smile.

'I could talk to you forever, professor, but there's no time. And your drugs didn't work very well. My head is completely clear.'

'You have a different head, Sasha. When you get well, we shall construct a special machine to regulate advanced brain kitchens. Then the next mathematician will sleep like a baby before his operation and have some fine scientific dreams.'

A rather childish phrase. I try to laugh, and he does the same. Then he glances at his wrist-watch:

'You'd better go, professor. So long, and I wish you all the luck in the world today.'

What he probably means is 'goodbye'. He knows that I feel the same way. We can't fool each other.

I get up. I am relieved that I can leave. People are all the same.

'All right, Sasha, don't worry too much. No use going through long goodbyes, we'll see each other tonight. Keep it up, don't let science down.'

He smiles again, makes a slight parting gesture. I believe he has been cheered up a little, and all of a sudden I also feel better. There is great salutary power in a joke and a smile. Even under such conditions.

It is already five minutes past nine. I'm five minutes late for the conference. Let's hope we all live through this.

Morning conferences in our clinic are an important part of our work. True, they take time, but this is time well spent.

A hall. A single table, large enough for a presidium, but I alone sit at it. Behind me is a large X-ray projection screen. Rows of chairs. In the first row, my senior assistants, the anaesthetist, Maria Vassilievna, Petro, Semyon Ivanovich, Oleg. Behind them, the interns, and still further, nurses. There are many people here; some girls have to stand up at the back. It is not too quiet here either: people like to talk.

We have a certain routine. First, night nurses give their reports: so many patients, so many in good condition, so many dangerously ill, unfortunately there are always enough of those. In about fifteen minutes, the nurses leave for the wards. Then the surgeons who did operations on the previous day describe them to us, what was discovered, what was done, complications, the state of the patients in the morning. All mistakes are discussed openly and honestly. They say that this is a unique procedure we have. 'Criticism and self-criticism, regardless of personalities.' I have long since come to the conclusion that to hide one's mistakes is simply impractical: they will become known anyway and will be blown up by gossip. Of course it is not too pleasant to speak about one's mistakes when there are forty people in the room, the whole town learns about them, but we accept that. This is an extremely useful practice.

Then the physician on night duty makes his report:

'There are one hundred and forty-five patients in the clinic. On the third floor there is a serious case, a woman called Trofimchuk. Asthma, shortness of breath. She's in an oxygen tent. Pulse one hundred and forty, arrhythmia. The general picture is of terminal decompensation. In the postoperative ward the condition of all patients is satisfactory.'

A momentary pause, then:

'The second floor. A serious case, Onipko, one lung removed on account of cancer. Accumulation of air in the remaining lung, I have several times pumped it out from the pleura. There were signs of asphyxiation, but now his condition is more satisfactory. I found his blood pressure rising and have been administering Pentamin.'

I hear Petro whisper under his breath, 'What a liar, what a bastard!' Then, aloud:

'Stepan Stepanovich, what do you mean, "a more satisfactory condition"? He might die at any minute. Better tell us how you have set-up the air-pump.'

Stepan Stepanovich hesitates. I demand a clarification from Petro.

'I don't know what Stepan has been doing with the patient during the night, but this morning I found Onipko blue, gasping for air and with a high blood pressure: a clinical picture of acute oxygen hunger. The pump was not working because it hadn't been set up correctly, and the lung was packed. I re-set the pump, inserted a tube into the trachea and pumped out a great deal of sticky phlegm. He is feeling better now, the blood pressure has gone down to normal, but he has been a long time in a state of oxygen deficiency, and this might affect his heart most dangerously.'

I assume a frozen expression, scenes like this are not unusual with us and they are never treated on a personal basis. In fact, Petro and Stepan Stepanovich are good friends. But with us, our work comes first.

I take over: 'Do you know how to operate the pump, Stepan Stepanovich?'

'Yes, I know.'

'How many times did you check it during the night.'

He answers, many times, but I know he is lying.

'Have you examined the patient?'

'Yes, I have.'

And -?'

Silence. A new question, seemingly a casual one:

'Why did Onipko's blood pressure go up?'

A pause. Then: 'I know now that it was due to oxygen hunger, but I thought it was a simple case of natural hypertension.'

'Too bad you have discovered this only now.'

Another pause. Dead silence in the room. I am thinking: 'What an idiot. What is he doing here?' However, I must be polite. I speak calmly:

'Stepan Stepanovich. The whole thing is clear to me and I don't want any explanations. You will have to leave the clinic because you are not fit to do the kind of work we are doing here. Let me remind you that when you were accepted, we informed you about our conditions. Were we to find you unsuited, I was to tell you so, and you were to start looking for another position and then resign without any black mark against your record. By the same token, were you to find our way of working unsuitable for you, you were free to leave at any moment, even if you were a genius and we needed you desperately. This is no reflection upon your professional ability, our standards are exacting and only a few doctors can meet them. Let me also remind you that you have already had two serious warnings. Also, once before, I suggested that you resign; you promised to do so, but have never come around to doing it. The first time I chose to overlook it, but now I must insist. Human life is irreplaceable, and we can't experiment with it, forgive me for this banal statement.'

A slight pause, then:

Let me repeat again for the benefit of everyone here: this clinic has its own code applicable to the entire personnel. We all work as much and as hard as is required by the situation. No set hours, no overtime computation, no side benefits, we start on time and go home only when our work is done. The second rule: should any worker prove to be unsuited to our standards, he must leave on his own. The question of unsuitability is decided by me, but since it is human to err, I consult my senior assistants. Your case, Stepan Stepanovich, was discussed about six months ago, and it was agreed that you would be asked to leave should you make another error. Therefore, unless you resign now, I'll have no alternative but to ask for your dismissal through official channels. There is no dearth of opportunities for a surgeon in this town, but this clinic needs special kind of people with a special kind of dedication. So?'

Stepan Stepanovich stands there looking miserable.

'Very well, I'll resign. But give me time to find another place... I have a family.'

'How much time?'

Silence. Oppressive silence.

'You have two weeks. Sit down.'

Perhaps this is cruel. I can see that everyone is ill at ease and ashamed. To dismiss a physician like this! But what can one do in such cases? The man is at fault. He pretty nearly killed a patient. This is not the first time he has made this same mistake: six months ago a little boy died during his shift under almost identical circumstances, Stepan failed to pump out phlegm. But I'm still sorry for the young man. Perhaps I should have had another heart-to-heart talk with him? Tried to influence him, to help him? Given him some more time. No, enough. What would I have told Onipko's daughter?

Suddenly Petro gets up:

'Professor, let's keep Stepan on. He will be more careful from now on.'

Petro has himself raised the fuss, and now he wants to be charitable.

'You want to keep him on? Very well, I agree. If you will stand his shifts and care for his patients. Let him just draw his salary.'

How insulting this is! Stepan turns red, rises and leaves the room. I pretend I haven't noticed it. Everyone hates me at this moment, even those who voted for his dismissal six months before. I feel it.

Petro is still standing. 'Please forgive him, professor. We will help him. He's a good doctor. Is that right, comrades?'

There is a hum of supporting voices.

All I can do is keep silent. A very unpleasant episode. But I just can't act otherwise. They all think I'm cruel. But I think just the contrary. I'm helping Stepan to find his proper place in society. Not every doctor can work under our conditions. No, not many even. And still I feel sorry, but I must control my emotion. Let it lie for a while.

'Let's have the report on today's surgery.'

The detailed discussion on all patients booked for surgery each week is held every Saturday. The schedules are set then too. Each morning the surgeons just remind everyone of the operations for the day and discuss the surgical plans. Some of these discussions are quite time-consuming, we welcome all suggestions, all criticism.

Today is a typical day: five operations, one with artificial blood circulation, Sasha. As a rule we begin with lighter cases. Two interns tell us about their stenosis cases. Then, a case of lung cancer. Semyon will again sew up the prenatal channel between the aorta and lung artery in a boy who was first operated on two years ago, just before the tragic case of Maya. I remember too well that dead girl on the table. It is best not to think about that, now.

Since then we have changed our methods. We now close the opening with double sutures and also with a wire clamp. But in four previous cases there were recurrences requiring secondary surgical interference. Fortunately, without aneurisms.

A lot of water has flowed under the bridge since those days. We have advanced greatly. When we say 'we', we mean our clinic. Outwardly this can be noticed by the volume of surgery and a number of previously inoperable cases being operated on. But behind all this lies work and research into the nature of the human body, of ills besetting it.

Our physicians have also advanced. Semyon will today do secondary surgical repair which once only I and Maria Vassilievna could do successfully. Petro is already a doctor of science. He and Maria Vassilievna are now casually performing surgery with the AIK heart-lung machine. Ten candidates are sitting before me right now. True, they don't appear to me more intelligent than they were before, but when I read their papers I know that they have been doing a lot of work in their chosen fields.

Our AIK machine is not the machine we used at first. It is still not absolutely perfect, not to the point of perfection that would completely satisfy us. But we can disconnect the heart now for two or three hours at a stretch and haemolysis stays within tolerable limits. This is good. But it is possible to do this better still, and the engineers are working on new models. We can also use AIK as a supplementary apparatus in lighter cases for many hours without ill effects on patients. There are other new developments as well.

Yes, our renown has grown, too. Our clinic has a widespread reputation. People speak about miracles which we allegedly perform here. Everyone looks at the outward appearances, but only very few know what all this has cost us. When I spoke about our standards, I didn't exaggerate, we are driving ourselves to the very limits. Still, I would have gladly exchanged my fame and all my honorary degrees for just one thing: the lower mortality rate of our patients. Yes - honestly? Yes.

They will now report on Sasha. (We did not discuss his case last Saturday because we did not know then that we would operate on him.) Of course I have discussed it many times with the senior physicians, but the routine must be adhered to, every case must be presented to all the doctors and all suggestions considered. Especially because all of them know and like him. And perhaps they will stop being annoyed with me for my dismissal of Stepan after they hear my plan.

Vasya reports on the case clinically, but before my eyes this story presents itself differently, with all my emotions and painful doubts.

'The patient Popovsky, Alexander Nikolaevich, thirty-two, mathematician, doctor of sciences, was admitted to the clinic four months ago with a diagnosis of insufficiency of the heart valve. In the course of the last two years he has been admitted three times to this clinic, and twice into other hospitals. The general condition is that of a rapid circulatory deterioration. Pulse one hundred and ten with twinkling arrhythmia -'

Now come the findings of various analyses. The X-rays show the enlargement of all sections of the heart. Final diagnosis: chronic insufficiency of the heart valve with large deposits of lime. Impeded blood circulation. Considerable secondary changes in the liver. The indication, immediate radical surgery.

I personally present the surgery plan. Opening of the left pleural area, then the pericardium. Artificial blood circulation. Hypothermia, the artificial cooling of the body. Incision of the left auricular area. The examination of the valve. If the folds are not too badly degenerated, an attempt to perform plastic correction. If that does not appear to be possible, then removal and insertion of an artificial valve. This technique, if successful, would immediately correct insufficiency and facilitate heart action. This has been proved on the test stand.

There are no questions and no suggestions. The junior doctors probably do not feel entitled to question me, and the seniors have been fully briefed by me in advance.

My supporting team: Maria Vassilievna, and two young surgeons, Eugene and Vasia. The anaesthetist, Dima, that is, Dimitri Alexeyevich.

The conference is over. People leave silently. I know that most of them did not like my treatment of Stepan. I don't feel too happy myself about it, but I can't let that bother me. All my thoughts are about the operation. Stepan's hurt pride is insignificant compared with that. He will live through it. Let him work somewhere else and not hurt my patients. This is how I argue with myself. He's erred, he must pay for it. The sense of retribution is deeply ingrained in human nature. All right. I must suppress all this for a while. I can do it and I will. I must concentrate on the operation.

I will go to my office, sit down and think a while. I must pull myself together. Inside.

* * *

My office. Such a cold bare place. Somehow I don't know how to create pleasant surroundings. Well, to hell with them. I am dying for a cigarette, but I don't dare to smoke. Before important operations I am trying to abstain. Nicotine blurs the brain, and makes my hands tremble more than usual.

What shall I do now? They will probably take an hour or so getting everything ready, assembling materials, instruments, nurses and doctors, preparing the patient. I can't bring order into this; I have tried and failed. They say there are clinics working with an absolute precision. If an operation is booked for nine, it starts at nine. I can only envy them.

My desk is covered with papers, but most of them are either unpleasant or uninteresting. Dissertations sent in for criticism. Scientific papers of our kids. Numerous letters from relatives of patients who can't be operated on because their cases have been judged inoperable. How can I answer them? I have no time for protracted explanations. And there are not the right kind of words for this. Ah, here's a pleasant letter! I have read it before, but I want to read it again. From Katya's mother. What was her name? She had sclerosis? Oh yes, the name was Sadovaya! 'Dear professor: yesterday was the first anniversary of the operation. We are celebrating this occasion more than her birthday.' Very warming. We had had some very hard times with her before we succeeded in saving her.

Let me look at Sasha's case history once again. It is a long one, a whole thick folder.

Analysis. X-rays. Entries. And along with them, the real story. Not the one which is written down in this folder, but the one which only I know so well. Everything is intermingled here: Sasha, his work, his sickness, my own emotions, surgery.

Can it be that I have made a radical mistake proposing the valvulotomy and the possible insertion of an artificial heart valve?

I am not thinking with words. I know this story so well that I don't need them. Various pictures race through my mind. Long conversations are condensed into brief sense-digests; they pass by with lightning-like rapidity. When one speaks or writes, one drags along an ever-growing burden of words; many of them heavy, cumbersome, inexpressive, unnecessary. Will there ever come a time when people could communicate without words? Fantasy. They say that mental telepathy occurs between people very close to each other. 'Understanding without words.' Have I ever experienced it? No, probably not. This is something very primitive.

I am not feeling well at all. A feeling of gnawing uneasiness. Probably this sort of thing occurs to war leaders, before some decisive battle.

Our first meeting. Some three years ago. It was in an X-ray laboratory during ambulatory hours. Many patients. A good-looking young man sent in with a mytral stenosis.

'There is no stenosis. The cardiac insufficiency is of the third degree.'

Those therapeutists very often send in patients with wrong diagnoses. Even now. However one must not criticize them, it is the most difficult branch of medicine, working by guess and mental deduction. It calls for extreme intelligence besides experience.

A soft pleasant voice, fine choice of words. Timid questions.

The verdict: 'You must wait. We are still at the exploratory stage in this field.'

Of course, what could I offer him then? Had we made our first bungling surgical attempts in that sphere then? I'm beginning to forget chronology. How is it possible to forget such things?

Yes, there had been some surgical pioneering in the cases of insufficiency even then. I had experimented myself. I can remember it plainly. Bleeding. Fibrillation. Death on the table. The feeling of emptiness and anger. 'A pioneer indeed. Bungler!'

Can the same thing happen today? I can see myself coming home. 'Damn it all to hell! No more valves! I'll stitch up hernias and take out appendices from now on! I'm quitting! I'm through!'

Too bad moments like that become forgotten. You cool off, recover, try again, grow too confident, make mistakes. Anyway, I could offer Sasha nothing then, not even hope. Insufficiency patients just had to wait. Tragically, with death coming nearer every day.

Sasha left, but he came back to us. In six months or so, I think? We were already working on new techniques. The AIK machine was not used on humans then, only dogs. It means that this was more than three years ago. How time flies! Let it fly. I don't want to either stop it, or turn it back, I don't want anything. Of course, this is just a momentary reaction to my present anguish. If the operation is successful, I'll be as cocky as ever. 'Bring them on! I'm just starting!'

I was in one of these expansive moods when Sasha came back. I was sitting in this office, after a successful operation. (Aesophagus, I think. Such a funny old man. He got well.) A feeling of relaxation. A wonderful taste of tobacco smoke in my mouth. (If I could only have one puff now!) I was in no hurry. I examined Sasha at length. Then he still had a thin layer of fat in his stomach; now all this is gone and only the hard liver is pushing its way out. I remember that his personality struck me as even more pleasant than during the first visit. I told him about our work on the new operation. Why? Just to brag, I suppose. But he caught fire, not realizing that all my words were mere wishful thinking. I didn't realize it myself, then. So we went on, further and further. The general conversation about medicine, the nature of it, experimental probing without a firm theory, by touch, by trial and error, by guess and inspiration. Not really a precise science. Then we spoke about a diagnostic machine, there were items in the press about it just then, and we at the clinic had become interested. Sasha was overwhelmed by the idea and offered his services as a mathematician. I remember a thought passing through my mind then: 'Such a pleasant and intelligent young man, and yet his condition will deteriorate, and there is nothing anyone can do about it. Shall I discourage him right now, tell him the truth? Oh, never mind!'

Now this 'never mind' has come home to roost.

Had I told him the truth then, sent him away, I would not have been sitting here now in such a miserable state.

It would have been helpful to have some of those medical machines now. One for the automatic regulation of the heart-lung machine, for instance. Those girl operators make mistakes now and then, and today it will be especially difficult.

Sasha did not go seriously into that work, he had switched to psychology. Too bad. Perhaps we could have had something today which we could have used in his case.

Today our AIK machine will work for at least an hour and a half. Will it be possible to maintain the constancy of all the blood components? The least sign of oxygen hunger would mean the end in his case. He would never survive it.

What an interesting man! I had been completely overwhelmed by him after we had met for a few times. That was our 'honeymoon'. It is a pity our relationship went sour, and had never reverted to its original closeness. The true warmth had been lost. Had he ever felt it towards me? I don't know.

He had opened for me an entirely new world of abstract thinking. What was the essence of his theory? The quantitative co-relation in everything. 'The informative plan of the universe.' I can't explain it in words - not competent enough, and anyway Sasha had invented his own set of terms. It covers everything, biology, arts, social sciences. Everywhere the same law of 'information digestion and assimilation'. I'd better not try to define it accurately. Only he could assort all those things in precise categories and evolve his theories, some precise, some still vague.

And soul? This I don't know. I'm often at a loss to define this word. I often make mistakes in evaluating people on this basis. He had an open smile, gentleness, impeccable tact, courtesy. A complete absence of vanity. Never a censoring word about anyone. Now it seems to me that beneath it all there was a kind of quiet sense of superiority, of detachment. Wisdom or emotional poverty?

Are we good friends? I - yes, but what about him? We used to meet every week. As a doctor I could see his deterioration. He had difficulty in breathing and was always tired. He used to lie down during our discussions, after thousands of excuses which always angered me. He could not be really simple. Was this the result of his genteel upbringing or some innate reserve? I was always a little upset by this. Well, may God help him, one can't judge him today. He is about to mount his Golgotha. (Sounds very stilted.)

Have they taken him up yet? It's ten-thirty, about time. He was smiling so easily today. But what will it be in a few hours? How should I bear his death? (I should have taken Stepan Stepanovich aside and dismissed him privately, not in front of the whole clinic.)

I can remember the operation for which I was preparing when Sasha and I really met. I was sure it would be successful, such stupid confidence. The patient died within a few days from cardiac weakness. My repair job on his heart valve was sloppy. 'This is the last time! Never again! Let them die without me!'

Sasha was also upset over my failure. Soon there appeared signs of decompensation in him, and we had to admit him into the clinic. He used to write all the time, in bed. 'There's so little time left, and I have to solve so many things. I'd like to understand them myself. I know I won't have enough time to convey them to others in any event.'

He was an omnivorous reader, books on Yoga, the Bible, on telepathy, on E.S.P. But he did not become a mystic, and made fun of mysticism. 'There's nothing to it, just an excuse for insufficient knowledge. The whole world is just a machine.'

Machine? Consciously and intellectually I have never believed in God, and yet I feel uneasy when they threaten to reduce all human feelings to computer equations. I want to think that their machine feelings will not be true feelings. Not quite real. But Sasha is absolutely convinced. He says that all emotions can be reduced to mathematics, and that they will be true and real.

I remember the magnificent feeling of elation after our first successful operation with the AIK machine. Could a feeling like this be reproduced mechanically? I don't know. Of course I trust Sasha, I don't question his theories, but perhaps I am too old to start worshipping any new gods. A conventional materialism is enough for me, with its 'qualitative differentiations' between the physical and psychic. And as to cybernetics, I am completely satisfied with the idea of a diagnostic computer and an apparatus regulating the artificial blood circulation. They don't need any feelings.

And what about conscience, for instance? Can a machine have it?

However, I acted childishly quarrelling with him. Friendship is a sacred thing, it can't be toyed with and discarded like a used blood swab. I was insulted if you please, outraged.

Yes, I was wrong, but was our friendship mutual? I should not question this now. Everyone gives just as much as he can. He couldn't give more than he did. With him, everything had gone into intellect. Also, he was a sick man. It was during his second stay with us, if I remember correctly. Yes, the second.

It was a difficult period for me, our first failures. We thought that with the artificial blood circulation, we could correct insufficiency. And then, fatalities. First one, then others. I was in the dumps.

Really, Sasha was not very sensitive. He should not have attacked me when I came to him as a friend seeking help, crushed, destroyed. And instead, he showed me an American magazine with photographs of artificial heart valves. I shrugged them off, a couple of experimental operations, nothing conclusive at all. I was wrong, of course. We had fallen behind and that was our fault. We hadn't worked hard enough, had not tried to overcome all obstacles. 'To overcome obstacles.' Sounds like propaganda.

What exactly had he told me?

'Well, it seems I won't last long enough until you catch up with real science.'

It was the way he said that. Here am I, and there are you. He was then working on something very important for defence, solving some difficult problem, and it was a race against time. And we could not perform an operation which had already been done elsewhere!

What could I tell him?

But why dwell upon it now, why remember? He was a sick man. He was doing important work, and yet he felt that his life was nearing an end. And he saw all the mediocrities around him bungling things away, things which he knew how to do correctly. Enough to make even the most tactful man bitter.

And what about our friendship?

Of course I acted like a spoiled child when I did not go back to him, but he also made no effort to approach me. And how much had I been longing for some little move from his side!

All right, let's forget it. It's all forgotten, almost forgotten. And today I stand in a noble posture. 'You have turned away from me, but I have proved myself. And I don't even expect appreciation.' Yes, somewhere, in the back alleys of my mind, there is a thought like this, 'I have proved myself. What have I proved? Two artificial valves, one fatality. And I did not develop the valve itself, it was Misha Savchenko who had made it. Have I made any mistakes inserting them? Yes, Shura. Our nurses buried her.

But today I shall fight like a demon. I won't let anything slip through my fingers. Or else, I shall really quit, once and for all.

Also, one operation was a success. Sima. Sima, Simochka! This very name is like honey to me. Just like my own daughter.

I remember when I first saw her. A ward inspection. A pretty girl. The look: suffering, hope, fear. It is impossible to describe that look. Insufficiency with acute decompensation. Had been in different hospitals for almost a year. Knows everything. If I refuse, the end.

What could I tell her? If the valve folds are in a good state, something can be done, but what if there are lesions and lime deposits? Then nothing can be done short of removing the valve and replacing it with an artificial one, a wildly speculative attempt. True, Misha had already constructed the valve, a good one. But all the dogs on whom we had experimented died. It seemed that healthy hearts rejected it, we had to hope that hearts in morbid condition would assimilate them; nature works this way sometimes. But we had had no experience, and I did not know how long it would be before we mastered this technique. After that, months of post-operative observation to make sure that the results were lasting. At least a year. Much too long for her.

'Professor, I beg you, don't refuse!'

We will see.'

My office. Her parents, a middle-aged couple. I was completely frank with them. I told them that I was scared to death, that I did not want to accept responsibility.

'Save her! We trust you. You are our only hope.'

Those words cut me like a knife, 'trust, hope'. Well, there was no hope; she was doomed. Surgery was the only answer, perhaps a negative one, but still an answer. And so I agreed. And succeeded.

Sasha says the same thing: 'Please go ahead. I have nothing to lose.' No one wants to understand that I also lose something. (No, Simochka, with you I lost nothing, I found a great deal!)

But what about Shura?

Will it be the same thing with Sasha? God, they are namesakes2. 'There is nothing. Just a machine.'

I remember Sima's operation. I had planned it as a plastic valve correction. The artificial blood circulation. Temperature down to twenty degrees. The heart has stopped. I am opening it up. Terrible! The valve folds are full of lesions. I'm trying a plastic approach, completely hopeless. All I can do is to sew the mess up. I know the heart won't ever start up again. Emotions. I am damning everything and everybody, myself, my assistants, surgery, the patient. 'I know you will surely save me.' I wish everything around me would go to hell. But oaths and emotions help nothing, I must stitch up the wound. Without hope. This is like working on a corpse.

Suddenly someone suggests: 'Let's put in Misha's valve. What do we have to lose?'

A storm of thoughts. Shall I try? If the valve does not take, she will die later on, not now. This is better. And If -? The valve is good, it had been tested on the stand. And if a failure? Whispers: 'They are experimenting on people without sufficient preliminary experience' and - who knows? - perhaps even an official inquiry. If I leave her like this, no one can blame me, 'the case proved to be inoperable'. Oh, to hell with it!

'Bring it in, quickly!'

It had fitted well, and I inserted it cleanly. The operation is over. She wakes up. The heart works beautifully. Everyone is happy. Except me, I feel like a charlatan when I smile. I know that the valve is attached with sutures which will dissolve in a week or two. What then?

What days I had had! Every morning I would run straight to her and listen to the heart. 'Please don't worry, I feel fine.' It was she who would try to calm me down. So funny.

How will I handle all this today? I would have felt so much surer if not for my second case, Shura. I must cut the auricular area wider than I did for her and then I can see the valve better. Of course, the stitching up will be more difficult, but that doesn't matter, the most important thing is to have enough room to work in.

Whatever one may say, there is more hope now: we know definitely that an artificial valve can be successfully inserted. Sima has been alive for three months, and there are no signs of any complications. We don't have to experiment on dogs any longer.

The thing one must guard against is embolism. No, I won't let this happen today. What an idiot I was to let it happen to Shura, I was too excited, too sure of myself. The valve in her case seemed to have fitted even better than Sima's. All right, let's not remember. Let's think about Sasha.

How pitiful he looked when he came to us this time. A pale face, swollen legs, the liver almost up to the navel. The clinical picture of a terminal case. I was so ashamed of myself because of our quarrel. Now all this is gone, we seem to have made peace. I have redeemed my guilt.

'Professor, here I am again. Just try to keep me going for as long as you can.'

'Nonsense, Alexander Nikolaevich. Everything will be all right. You will stay with us for a month or two, then, back to work.'

'Not any longer. My status is that of invalid, and anyway - all I need is a couple of months more. I must finish some work.'

We put him in a private ward. Started to treat him with everything we had. My kids are really remarkable, they can handle difficult cases like seasoned veterans. Especially Maria Vassilievna. Every doctor should be like her. If she could only find time to write her dissertation.

At that time I was still not quite sure about Sima. Only two weeks after the operation. I was waiting for a disaster. I had recurring nightmares, I'm coming into the ward and find her with blue lips, gasping for air. The fear of death in her eyes. Those looks!

But our doctors and nurses were already full of confidence. Our first valve, not a joke! We also knew something and could show those foreigners a thing or two.

Perhaps this atmosphere worked well on Sasha. He started to feel better. Psychology is an important factor.

I wish my own psychology were better today. If it were not for Shura. But no, that case proves nothing. Just a stupid oversight. Today I'll watch every second, all the way. Like a machine.

'Put me in a valve!'

Sasha started to say this a week after admission. 'Put in a valve!' So easy to say! But the idea started to circulate amongst our people, and gradually I have accepted it too. After all, Sima was doing so well, a whole month after the operation. It was a chance for Sasha; without it he had none.

He is probably being taken into surgery now. The second round of medications must now be taking hold. There are certain preparations for suppression of fear and anxiety. They inhibit emotion.

He is fully aware of his condition. He knows me well. He knows that my hands tremble and that I get excited during surgery. He knows that there are many questionable factors which will become apparent only during the operation. (I feel a little ashamed of myself and my medicine.)

We had spoken a great deal of late, after he started to feel better. He even used to come here and sit in that chair. (How comfortable these modern chairs are.)

I tried hard to understand him.

'I have no choice. I have read everything, and I know it all. Also I'm tired. I can't start any serious work because I won't have enough time to finish it. This is like living at an airport, the flight has been delayed, but it will take off without fail. Of course, I'm continuing to think, but this is just a momentum. Actually, I have completed one stage of my work. I understand the basic principles of the laws governing action of cell, individual, society. The next step is to prove it, to fight for it. This is already a job for a whole collective. If I survive, we shall start.'

Then, on another occasion:

'Put me in a valve and I'll describe to you the entire pattern of human behaviour with differential equations.'

But his soul I could not reach. Was it just his outward manner, or the absence of what we call a soul? The Raja-Yoga, 'accomplishment through knowledge'. Or is he just a man obsessed by his own hypotheses?

'Put in a valve. I shall die anyway, so what's the difference? One month sooner, one month later.'

Yes, what's the difference ? If he were a man in love with life, he would have fought for every extra day. Just to live till the spring, to smell the linden buds again. But Sasha lives outside that sort of time.

It is all the same to him, but what about me? If he dies, what would I tell myself? Without surgery he may live perhaps another year. But this would be slow dying. Without sleep, with asthma, with swellings. And there won't be any choice then, nothing to decide. Today he can still decide. Not alone, of course, but with me, only with me. This is not a routine operation where if one surgeon refuses you go to another.

Are you already looking for an alibi, my friend? It won't help. Death is death, and you would be the direct cause of it.

Why do I go through all this, now? It's too late. He is already in the operating room. Dima is injecting Tiopental, and Sasha is going to sleep. What are his last thoughts? No one will ever know. (Why had this stupid thing with Stepan Stepanovich happened this morning? Why not tomorrow?)

I had tried to resist.

'Let's wait a while. Let's make sure that Sima's valve has really taken root. Then let me try once again.'

'No, I want to be next!'

We must try first on an easier case. Your liver is in bad shape, we need time to tune it up.'

I had hoped to do two or three operations before coming to him.

But where would I get such two-three easy cases? Really easy cases don't need artificial valves.

Every serious patient insists on an immediate operation. Regardless of risk. But I know that the risk is much too great, at least eighty per cent, or more. I was simply lucky with Sima. After a few fatalities, it would be impossible even to offer this kind of surgery. Try to prove that the case was really inoperable. Impossible, even to yourself.

Sima has been living for three months and improving. The valve has undoubtedly been integrated. Theoretically I can start on others. I always have suitable cases on hand. All I have to do is to choose one and schedule surgery. That's how it appears from the outside. Why not take a light case with obvious insufficiency, but without decompensation?

In practice this is not so easy. You can't go to a patient and tell him: 'I'm going to insert an artificial valve into your heart, and you will get well.' Everyone of them would grab at this opportunity. And then, if it is a failure, what are you supposed to tell their relatives?

'But, professor, you said, you promised.'

Every patient would know about it. It would undermine all confidence.

Again, and it is the main point, I am ashamed to lie. I haven't learnt to use human lives as experimental material. I've been doing it all my life, but I've never got used to it.

Then there's another terrible thought, and it comes easy to people: 'He likes to do spectacular surgery, looking for glory.' And the devil of it is that there is a grain of truth in it. 'I shall be the first one to insert an artificial valve. I shall make a report to the Society, publish a paper. The newspapermen will clamour to see me.' I am trying to drive these thoughts away, but they are very persistent. And I fear them desperately, superstitiously. I have noticed this many times. Comes an interesting patient. You begin to think about an unusual operation for him, honestly, to save his life. But this terrible thought already stirs in the back of your mind: 'I will write a paper, publish it.' You perform the operation. The patient dies. Anger. Mental flagellation. Despair. Tm a monster! I killed a man to write a paper!'

I am dying for a smoke!

What will happen today? For the hundredth time I'm reviewing the whole thing in my mind. The most dangerous and least known element, the liver. I'm going through all the analyses again. Here, at the admission. Very bad. The next one, a seeming improvement. This one, a marked improvement. Here one can actually consider surgery. (It was during this period that I made my promise to operate.)

And now, this one. An almost catastrophic deterioration. Just one day after Shura's operation!

What terrible days those were.

Shura. I will never forget her. She was a sad case, all alone, incapable of work, living in a communal house. 'I might as well die.' I tried to be scrupulously honest. Perhaps too honest. I explained everything to her, quoted the odds. Told her that she would probably live a few years longer with her own valve, bad as it was. I practically prepared her for death and let her choose.

That was cruel. But I have no strength any longer to decide about human lives. I know that those humane and strong people say, 'A doctor must assume the entire responsibility and has no right to involve the patient in his decision, to give him a psychological trauma.' Some even add: 'This goes for relatives as well.' But where would you get moral strength to decide for everyone?

Shura had no one. Probably I should have assumed full responsibility in her case, and not frighten her. Even lie, if necessary. At least she would have gone onto the table with more confidence. And why did I select her? To get some additional experience before Sasha's operation, or because she had no relatives? No, I truly wanted to save her. She seemed a fairly good risk.

I don't want to remember that day, but I must. So that it won't be repeated today.

Almost certainly in Shura's case the draining tube out of the ventricle had not been properly adjusted after we had checked on the valve function. The machinists claim that everything had been done correctly. It is impossible to determine this now. But the fact remains, air embolism of the brain vessels. She did not wake up.

How I am going to fear this moment today, the awakening. In Shura's case the valve was inserted quite well, everyone could see that during autopsy.

Today I won't permit embolism under any circumstance. We will insert a thick draining tube into the ventricle and pump the blood out for ten, even twenty minutes! We won't allow a single air bubble to get into the blood stream. I can see this tube filled with steady flowing blood. I can almost feel it.

Mistakes. Mistakes. Can one learn to treat people without them? Sasha says this is impossible without machines. The human system is so complicated that the brain can't fully grasp the entire co-relation of elements in it. Only machines can compute and organize all this information for instant use. But I don't think I'll live long enough to see this.

If no embolism, then there might be something else. There is no end to surprises in a difficult case like this one. We just haven't had enough experience. Empty worries. Nothing can be changed any longer.

How a single mistake can ruin everything!

At the time I operated on Shura, Sasha was in a fairly good state. After my fiasco he did not show any emotion at all; he appeared to be calm and as determined as ever. But both his heart and his liver slid back. Apparently he had not taken it so calmly, after all.

For as long as Shura was alive. (Alive, a weird term to apply to a human being without a brain. No, enough of that!)

Her third day was especially difficult. No urine, asthma, she was barely alive. But Sasha repeated the same thing on that day: 'Operate!' How could I operate in my state then, I felt like leaving it all and just running away. This wasn't the first time I had felt like that. But how could I abandon my patients? However, this is probably also a wrong argument: no one is indispensable and my assistants are very able.

Now, if he dies today.

I have done everything I could in this case to eliminate a basic diagnostic error, and to remove from myself the burden of arbitrary decision.

I held a general consultation with my colleagues, the best specialists in town. All the therapeutists agreed that the case was absolutely hopeless. That is, certain death, and a speedy one. Months perhaps, even weeks. At the same time I let them examine Sima. Not to boast, but to justify clinically my plans for surgery. But perhaps also to brag a little? Maybe. It is hard to say now.

The verdict was unanimous: immediate surgery indicated on the basis of previous clinical experience.

This means: go and take your chance. Fine words. Iron logic. If there are only five per cent for possible success, the operation is indicated.

Therapeutists are generous with that sort of advice. I wish they would try to operate on the five per cent margin!

I would like to know who was the bastard who told Sasha about our concilium!

He looked at me with real anger next morning:

'I am master of my own life and you have no right to deprive me of even one per cent of hope!'

How defenceless we all are in the face of life! He demanded from me something which was incredibly difficult for me to do. But he had his point too. When even the slightest deterioration may mean death, one has no right to procrastinate and prepare alibis. But he should have expressed this differently. However, he apologized the next day and I had forgotten all about it.

All right, we shall operate. But we must have a little time to build up your liver.'

'How long?'

'Ten days.'

My heart went into my mouth as I said it, and it has been there ever since. Even if the valve were to take, how long would it last? In Sasha's case, ten years would be a lifetime. Misha tells me that the materials have been thoroughly tested for lasting durability. But why look so far ahead? I must live through today first. Surgical mechanics and techniques develop so rapidly that within the next five years they might have something radically new that would change all today's estimates.

If I could only smoke! Just one draw. But no. I can't. I must be a machine.

Now the ten days have passed. And strange: just as soon as I made a firm promise, his condition began to improve. This means that there are some reserves in him. That is good.

It is interesting to know what he wrote in his notebook, and in the letter. Apparently there is a romance, or rather, was. Will it continue in the future? It's best not to think.

Now, I must bid him a mental goodbye. In the operating theatre there won't be any Sasha, just a body which can become a corpse. Something keeps me from opening his notebook. I can only do this after, whatever the outcome. Then I shall have the right. If he survives, he will become a sort of relative to me, a son. And if he dies, well, I have been appointed his trustee.

How nakedly cruelty enters our life! The man is still alive, but a doctor thinks in legal phrases. Disgusting, but man's death is the end only for him, life goes on and must be lived.

What a fool that Stepan Stepanovich is. Probably had been dreaming about a surgeon's career. They tell me that he has a fine imagination. How little do I know my kids. This is bad.


A knock at the door.

'We are ready, professor.'

Am I ready? I must be. Everything is over, no more emotions. They have been pushed back into the furthest corners of consciousness.

   1Russian diminutive of both Alexander and Alexandra.
   2Shura like Sasha is a diminutive form of Alexander or Alexandra.


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