6.12.1913  -  12.12.2002

Books of N.M.Amosov

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The Second Day... My Team

I am dressing up. Cleaning my glasses.

I am operating today in the small theatre. It is especially geared for the AIK machine. Besides, it has a glass ceiling through which the operation can be observed. There are circular rows of seats there. It's a good thing that spectators are thus isolated, but it is unpleasant that the whole thing is so public. Surgery is not a circus.

I peek into the theatre. He is already lying on his side covered with a sheet. No longer Sasha, but an abstract patient, or case as we call them. I don't recognize anything familiar about him. I am not going to look as his face under the sheet, it is probably the face of a stranger.

Everything seems to be in order. The anaesthetist, Dima, and his assistant Lenya, are in their places. Lenya is rhythmically working the respirator bag. The blood falls from the drip and into the vein in infrequent drops. Peaceful blood. Maria Vassilievna is arranging the operation field. Now she is simply Masha, or Marya1, depending on the circumstances. We are very informal here. The assistant surgeons are standing by. The mechanics are sitting near their machine. All is peace and quiet. Only Marina, my theatre nurse, is a little red in the face. Probably there have been slight altercations, she has a quick temper. Never mind, that's none of my business for the moment. Let them settle their own arguments.

Everything is so orderly and clean. The basins are still spotless. The only blood is in the glass drip suspended from an iron stand. Such a serene picture. If it could only stay like this to the end.

As always I wash my hands silently and without thoughts, mechanically scrubbing with a brush. Everything has been thought out. Nothing new can be added. This is a special kind of calm which always comes to me just before the operation.

Finally I enter the theatre. The incision has already been made and the breastbone split. The oozing blood vessels are being methodically closed by diathermic burns.

They put the robe on me, and the mask. I take my place beside Maria Vassilievna. There is not much room to work here with four surgeons and the nurse, all crowding around one open chest.

'The valves?'

Just an affirmative nod. The words are unnecessary. I see them lying on Marina's table, three of them, of different sizes for proper fitting.

I cut through the muscles and open the pleural area. Of course! Surprises begin. The lung appears to be stuck fast to the chest cavity wall. This irritates me: it takes time to separate connective tissues accurately, and our time is in short supply today, the patient's general condition warrants all possible speed. But there is nothing I can do but try to preserve my equanimity.

The pericardium is finally cut through. The heart comes into view. It shakes me momentarily. The X-rays have shown that it was enlarged, but this! The left auricle is like a bag, the ventricle is enormous and pulsating strongly. When it contracts probably only half the blood is forced into the aorta, the rest flows back into the auricular area through a defective valve.

Revision: It means that the finger is inserted through the opening in the auricle and into the heart. I can feel the folds of the valve, they are rough and stiff and I feel large granules of lime. The strong flow of blood hits the finger tip at every contraction of the ventricle.

Actually all this has been expected.

For a moment I am thinking. Shall I just put in a new valve or try to mend the old one first? To put the artificial valve in is quicker, and the patient would not die on the table. At least he shouldn't. But then? Would the valve grow in? The heart is so badly deformed that the conditions for a successful in-growth are not good. And how long would it serve in this case, even if it takes? Of course, if the plastic work proves to be impossible then the artificial valve will become necessary, but shouldn't I try plastic correction first? This would mean an extra hour for the heart-lung machine, which would bring on the danger of excess haemolysis, of liver and kidney complications. In Sasha's condition all these are very real dangers.

Like every surgeon I don't want my patient to die here, right now, on the table, or immediately afterwards. That's the cardinal point. What happens later, weeks, months or years after today, would not be so acute.

But this is not right, not in this case. I must consider carefully and objectively, putting my own interests aside.

Again I insert my finger into the heart. For a split second a thought: how easy it has all become, a finger in the heart! I remember how I was bathed in sweat the first time I attempted it. Eight years ago I was younger. Today I would not start the career of a heart surgeon.

I am feeling, probing, considering. I should decide now because when the heart is open it will no longer contract, and I won't be able to see the actual working of the valve.

I am not thinking about Sasha. I don't see his smile, don't hear his voice. I don't even feel that this is a living human being, all that has sunk into the subconscious. I am a craftsman examining a piece of material I have to work on. The conscious thoughts are all about the immediate problems, how best to tackle them.

The valve then. All right, we will postpone the final decision pending visual examination.

For a moment I glance at the glass ceiling. Over me, behind the glass, sit our doctors and nurses. Even some strangers. Just like a circus with gladiators. Death versus my little team. I needn't worry, this is a good team. They have met death before, and have beaten it many times. If only no one makes a mistake today.

'Let's connect.'

This means to connect up the AIK machine. One tube is inserted into the right ventricle, it conducts the blood into the oxygenerator, the artificial lung. There it is collected by the pump, the artificial heart, and is sent through a second tube into the femoral artery. On the way it passes through a heat exchange apparatus which first cools the blood to produce hypothermia, and then, at the end of the operation, heats it back to normal.

The connection itself is a well worked-out procedure, but it takes time. Everything is going on quite well. The tube is inserted into the heart without a drop of blood. This is excellent. I know my job. But let's not count our goddamned chickens. Shsh, professor, no vulgarity! Sasha has probably never used such language in his life, his speech, like his thought, is elegant. I turn to the mechanics.

'Ready, girls?'


'Let's go.'

The motor starts up. It still makes a little noise, but nothing compared with the earlier models.

A quick check-up: venous pressure, oxygenerator, tubes, the pump action. The report: all systems are working normally.

'Start cooling.'

I must now insert a tube into the left ventricle, to pump out blood seeping in from the aorta, and especially all the air that might get in there before the re-start of the heart. This is something I overlooked with Shura: a bubble of air must have got into the blood and caused embolism, an arterial obstruction in the brain.

For a moment a scene appears before my mental eyes. A ward at night. The rhythmic movements of the artificial breathing apparatus. She is lying almost dead, cold and with no pulse. Only on the cardiograph monitoring screen there are infrequent electric jumps, showing rare and already unnecessary heart spasms. The brain has been destroyed by embolism, and the body is dying. All one has to do is to order the machine to be stopped, and in thirty seconds the heart would stop as well. Actually there is absolutely no point in continuing all this, but it is so difficult to say these two words: 'stop it'. I shiver even now when I think about it.

This is what this tube in the ventricle means: it is there to prevent the repetition of that scene. It must be inserted well. Actually this is not very difficult, we are forever doing it here. One must put in four sutures around the point of the insertion and then when the tube is taken out, the stitches simply tighten, and there is no hole.

All is done. Now we can take a little break.

We have about ten minutes before the patient's temperature is lowered to the necessary twenty-two degrees. We are all washing our hands with sublimate.

Marina is fumbling on her instrument table getting ready for the next and most important stage of the operation. The mechanics are taking samples for analysis. Dima is checking his battery of medications and ordering some additional ones. It's a pleasure to watch the team at work.

But actually we have nothing to do at the moment. A temporary lull before the battle. No thoughts at all in my head. I stand there and just look at the heart. I see that it is contracting slower and slower as the temperature falls. It is working now without any useful purpose, the blood circulation has been taken over by the machine.

'Marina, have you checked your needles and threads? Where are the valves?'

'Here, under the napkin.'

'Show me one.'

Here it is, the artificial heart valve. A little structure of non-corrosive wire to which some plastic material has been carefully sewn in such a way that there are folds just like those in the real valve. Not a bad piece of work done by Misha Savchenko. 'The Moor' as one of the engineers has christened him. A good fellow, really, though not without some minor faults. The main thing, a thinker.

There is nothing else to do. We are waiting. Twenty-five degrees. The tissues are cold like those of a corpse, they are unpleasant to touch. The heart contracts forty times per minute. What we need is fibrillation, a spasmodic disorderly quivering of heart muscle which must replace the regular concentric contractions. Under these temperature conditions, this is tantamount to heart stoppage. It would give me an opportunity to work calmly and methodically without a time pressure; to cut, to sew.

Twenty-three degrees. Fibrillation.

'Here we go.'

The auricle is cut wide open. A strong vacuum sucker clears the area of blood in a few seconds. Here it is, the valve, the holy of holies. Sanctum sanctorum of the human body. The key to its life. The heart is dry and motionless. Dead? No, not quite, there are still some hardly visible quivers. This is still life.

Everything is instantly confirmed. Our worst suspicions. The folds are shortened, stiff. Lime is deposited in large granules, and also in solid concentrations up to a centimetre in diameter. Along one of the folds, a wide crack. There it is, the 'insufficiency'. Corrective plastic surgery is out of the question, or rather, much too dangerous to even attempt.


I seize the folds with a clamp and cut the valve out at its circular base. This is a little frightening, I'm still not quite used to this. It reminds me of my first amputations: a leg is gone and it won't be there ever again. Instead of the valve there is now a formless opening. A new valve must be fitted in and sewed on along the edges of the hole.

Now starts the real torture. It is very difficult to put in sutures, there is no room to work. The damned needle-holders don't hold needles firmly enough, they turn around like dervishes. It is impossible to calculate how much bile I have wasted cursing them, probably litres. Abroad they make special needle-holders with holding surfaces treated with diamond dust. They hold a needle in a dead grip. I have seen them myself. But our ministry still will not budge. They don't give a damn. They don't have to work with them.

I am boiling with rage. If only one of those damned bureaucrats ever got on my table, I would show him a thing or two.

But somehow none of them ever get here.

I am sewing for a long time, swearing all the while. I swear into the space, and at Marina who has misplaced the holder which I have specially selected for this operation, and at Maria Vassilievna who is not catching the ends of sutures fast enough. I swear at the whole goddamned world. I confess, in my mind I use obscenity. In my younger days I used to move in the circles where such expressions were quite accepted. Then the war, of course. I had learned some choice bits there. The 'maternity language' as one of my friends used to call it because of the frequent allusions to somebody's less than chaste 'mother' in these oaths. Strong and colourful, but hardly a fit language for a distinguished professor. However, even if I had said it all aloud, no one would have paid any attention; they are used to my swearing.

But there is an end to everything. The valve is in its place, firmly anchored by thirty fairly good sutures. Even, very good. I feel an enormous relief. I can at last look around and appraise the general picture.

'What is the haemolysis level?'

'It was twenty at the thirtieth minute.'

'How long has the machine been working?'

'Fifty-five minutes.'

'How is it you don't have a later analysis?'

'Their centrifuge does not work very well.'

('They' are our biochemical laboratory.)

'Damn them! They never know how to handle their equipment, sons-of-bitches.'

This is a totally unjust accusation, just a momentum of my irritation over the needle-holders. Actually our laboratories work very well and perform a great deal of highly valuable precision work.

The haemolysis is still fairly low. All that is left to be done now is to stitch up the heart. Not too bad. Given good instruments, heart surgery need not be too troublesome. And patients needn't die. Undoubtedly in time we shall solve all our problems. We shall catch up and outstrip everybody, even the Americans. I'd better start working on a paper straight away and then show the patient to the Society.

Whoa! What are you talking about? What paper, what Society? The patient is lying here with a wide-open heart, you have already scored one unnecessary fatality. And anyway, how can you think about anything like that at a moment like this?

I am ashamed of myself. There exists this little worm of vanity in everyone. You think you have smothered him with noble words and noble thoughts, but he is still very much alive. Could it be that it is this vanity worm who makes me tackle all these surgical impossibilities? I don't know. Sometimes I'm beginning to doubt myself. The most dangerous things to any man are fame and power.

Whatever it is, we are now sewing up the heart. This is also a delicate procedure because the auricular walls are thin. We have started on the blood warming process. The warm blood moves along the coronary vessels and the heart is becoming warm. Now it is very much alive, the quiverings are strong even though still disorderly. Technically this is known as large fibrillation.

When one is sewing up one needn't be in a hurry. There is no point in rushing. The warming-up process takes twenty to thirty minutes. In the operating theatre all is quiet now. The only sound is the clattering of basins coming from the adjoining sterilization room, nurses are washing up there. There is nothing holy to them, they treat the operating theatre as though it were a kitchen, little tramps. Fine girls, all of them.

The heart is now securely closed.

'The temperature?'

'Thirty-four. The rate of heating has slowed down a bit.'

This is normal. The fibrillation is very energetic now; the heart is beating like a frightened bird trying to break out of a cage. One good electric kick would organize these disorderly quiverings into concentrated contractions.

'Get the defibrillator ready!'

This is an electric apparatus producing a shock of several thousand volts in a fraction of a second. It shocks the heart into resuming its normal rhythm, breaking off fibrillation. A very useful gadget.

And suddenly, oh joy! The heart begins to work rhythmically by itself. Something has happened, and out of chaos there has been born order.

'Normal rhythm!'

This is the voice of our doctor, Oxana, who is watching the electro-cardiagraph monitoring screen.

'You're late, beautiful! We can see it ourselves!'

We are all overcome with joy. The defibrillator is a fine thing, but there have been instances when it failed to start up the heart. This has happened to us in the past. For hours we would take turns massaging the heart, squeezing it between our palms, pushing some of the blood through the lungs and body. Time and time again we would connect the defibrillator, but the heart would continue to fibrillate even though there was a smell of burnt flesh in the room coming from the electrodes. Then we would stop, exhausted, look at each other and say: 'death'.

But this heart is working! What's more, it is working well! Fine, clean contractions. We must just warm it up with the machine for a while, and stop. Success! I am ready to scream with joy.

This lifeless cut-up body will again be Sasha, our dear clever Sasha!

'All right, kids. Let's extract the drainage tube from the ventricle.'

Yes, it is about time. No danger of embolism. For the last twenty minutes not a single air bubble has slipped along the tube. We have been watching it like hawks. We won't be caught like idiots for the second time.

'Very well, Masha, my dear. You take out the tube and I'll tighten the circular suture. One, two, three - now!'

Just a routine, really. No point in dramatizing it. Suddenly:

'My God! Hold it! Vacuum sucker, you slobs, may the devil take you all! Get off your behinds!'

I still don't know exactly what has happened. Either the thread has snapped, or the muscle wall has broken through, but the moment the tube was extracted there appeared an open hole and, out of it, a spurt of blood a metre high! Of course just for one contraction: the next second I close it with my finger. The crisis is momentarily over.

Now I must stitch up the hole. This is not at all easy because the heart is pumping strongly and is quivering in my hand. Also the damned hole must be kept closed. It is difficult, but it is possible. This is not the first time, but somehow everything has gone so well that I didn't expect it today. Fortunately the machine is still working so there is no danger of occlusion and death.

But this proves to be more difficult than I thought. Without releasing my finger from the hole I attempt to put on new sutures. But the moment I begin to tighten them, the muscle comes apart and there is a hole again. Damn it all! It is even larger than before, much larger! The blood spurts from it like a geyser. I press two fingers over it, but the blood continues to flow all around them.

Instantly peace and quiet have flown away. Everything becomes grim, dangerous, evil.

A calm winter day. A man is walking peacefully across the frozen river. Suddenly the ice breaks, he goes through and the black water is all round him. He fights, shouts in terror, grabs at the edges of the ice, but they keep breaking away under his fingers. The black water is overwhelming him.

It is the same here. Only the blood is bright red. A lot of it.

What to do? What to do?

'Patch! Marina, a plastic patch! Quicker, you cow! Get ready good strong sutures and a big needle! Sucker! Give me that sucker! Damn it, it doesn't work properly, you idiots -!'


I must put in a patch, like a patch which ships' carpenters put over a breach in a hull. But this is terribly difficult to do when the heart is pumping full blast and the damned needles are twirling in the holder like crazy ballerinas.

I don't know how long all this takes. First, a small patch. It doesn't hold, blood spurts from under it on all sides. Then, over that, another patch, a large one the size of a palm. Many sutures all round the edges. The blood is sucked off by a vacuum sucker and is sent back into the machine. The sucker can't cope with the volume of blood and some of it spills on my stomach and on the floor. For a moment I think about cooling the patient again and stopping the heart, but that would mean almost certain death.

Somehow, finally, I succeed. The flow of blood is arrested, just a few drops here and there keep squeezing from under the patch. A few more sutures, and the field is dry.

Yes, dry. The sucker is switched off. The heart is working evenly even though not as strongly as before: we haven't been able as yet to replace fully the loss of blood. He is having a transfusion, and it is getting better.

I glance around. Everyone looks exhausted and unhappy. Miserable. No more elation, no more joy. They are still under the spell of the disaster, they are in slight shock, and they can't believe that this is all over. Correctly, too. Nothing is really over. We can now expect all sorts of mishaps.

A little superstitious thought: perhaps this has been sent to me because of my treatment of Stepan? Perhaps I should have handled that affair differently? One can't insult people like that with impunity. But what could I do? I wasn't defending myself, but our clinic, our reputation, our patients. But still I could have handled it differently. With more humanity.

'Oxana, how are things with you?'

'Not very good, but tolerable. The myocardium appears to be weak.'

Of course, it is weak. That's exactly why the sutures did not hold. Well, we must now wrap things up.

'How long has the machine been going?'

'A hundred and sixty minutes.'

'That long? Haemolysis?'

'We haven't the last analysis, but just before the last complication it was eighty.'

It means that now it is much higher. Pumping blood out of the wound and reprocessing it through the machine ruins epythrocytes, and we have repumped at least twenty litres.

'Stop the machine.'

I look up. Behind the glass everyone is watching tensely. I become annoyed. Just like a circus, watching with bated breath, will he miss the net or not? Frightened and excited at the same time. But no, this is not true. Most of them have been honestly suffering this along with me. I must not think I'm an exception, an angel among villains. People are good. Very good. One must constantly repeat this to oneself. Otherwise life would not be worth living.

Dima is very busy with the patient. This is a difficult phase for him, the most responsible one. I deliver a corpse to him, and he must bring it back to life. He must restore proper breathing, he must regulate the function of the vessels and the heart. This is his department. He must quickly calculate everything, evaluate, make decisions. To match the heart action to the capacity of the circulatory system. To watch for a possible oedema in the lungs as a result of weakening of the left ventricle. To build up the general tone of the system with hormones. To spur the heart action with special medications. To re-establish quickly coagulation of the blood which has been removed by heparin during the artificial circulation. One must know a great deal, and know how to apply this knowledge quickly and efficiently. Unfortunately in our work controls are limited. Electro-cardiagram, the venous and arterial pressure, eye pupils, the colour of the skin. Biochemical analysis, but each takes half an hour, at least.

The machine is working slower and slower. Then it stops altogether. We watch the heart intensely. Dima is constantly checking the pupils and trying to take the blood pressure at the same time. Finally he succeeds, and reports:

'Pressure, seventy. The pupils are contracted and constant'.

This is the test for embolism. I am quite sure that there is no danger here. But then how can one be sure of anything in medicine, the most unsure of all sciences? We are working with probabilities and approximations.

Through the hole in the auricle, closed by a clamp at the moment, I insert my finger to check on my new valve. It feels dry.

'No back flow of blood.'

I measure the auricular pressure. Ten. It was thirty before.

'Let's pump a little blood into the artery.'

The pump in the machine is turned manually several times. The blood pressure rises to eighty-five. This is sufficient for the moment. Now we can extract the tube from the heart, disconnecting it altogether from the machine. It seems to be working well.

So, actually, this is all. We must now put in a few sutures on the pericardium, insert a drainage tube into the pleural area and sew up the outer wound. But before this is done we must make absolutely sure that the flow of blood from the smallest vessels even has been fully arrested. The coagulation level is now low, and post-operative haemorrhaging is the most common and bothersome complication.

This takes almost an hour. Here one must not hurry. We are all slightly groggy after our tribulations, and only slowly coming back to our normal senses. But the heart is working well! Now, if he wakes up all right, we should be really happy. For the moment. Later on there might be other worries, other anguished hours, but up to now this operation has gone better than I expected.

We are putting the last stitches in the skin, when suddenly we hear the quiet voice of Dima:

'He has opened his eyes.'

The way he says it one would think that nothing else could possibly have happened!

We knock our heads together leaning over Sasha's face. Yes, here he is, alive. His eyes are open. The look is still senseless, but a man with embolism does not open his eyes. One more burden rolls off my shoulders, off my soul. True, there is still a danger of bleeding or a kidney failure. The haemolysis after disconnecting the machine was a hundred and fifty. This is high. In olden days patients in such a condition died. But now we have learnt to cope with it. If heart weakness does not develop, then the kidneys will evacuate this entire haemolysis out of the system with the urine in six to eight hours.

The second, or rather first danger is haemorrhaging. Unfortunately it often occurs after operations with the prolonged use of the heart-lung machine. Some factors in the blood become damaged. This too will be corrected, I hope, in later models, but at this moment we must still contend with it.

'Dima, make sure that you have enough whole blood on hand, to avoid a night rush. You need at least two litres.'

'I have already ordered it.'

The operation is really over. The wound is taped up and they carefully turn Sasha over on his back. His eyes are closed again, but this is a normal post-operative sleep. If you pinch him he moves his arms and legs. No paralysis anywhere.

It has taken us five and a half hours from the moment of the first incision to the taping up. And if you count immediate preparations, over six hours.

'Professor, shall we start disassembling the machine?'

'No. Wrap the tubes up in sterilized napkins and stand by. Marina, leave some sterilized material on your table.'

'All this stuff has been exposed to contamination. I'll set up my table again.'

'Good girl.'

Very good. And so are all the members of my team. I'm proud of all of them.

All this is simple precaution. Everything should go well from now on. But one must be ready for anything. How many times in the past have I been forced to open the pleural area again to look for a single small bleeding vessel because blood kept appearing in the drainage tubes?

We leave the post-operative team in the theatre and depart. People upstairs begin to disperse as well. The show is over.

* * *

We are blissfully relaxing now in the nurses' room. I collapse like a sack into an armchair and can't move a finger, complete exhaustion, physical and nervous. How many both anguished and happy hours have I spent in this very chair! I yawn constantly. Oxygen hunger, as though I have been operated on myself.

As always there are not enough chairs in the room and people are sitting on window sills, on the table, even on pulled-out desk drawers. Our clinic personnel who had been watching the operation from behind the glass are all here, but no strangers; I don't permit them to disturb us after operations with their questions and comments. Here we are a family. We are all smoking. The windows are open. It is a beautiful May day outside, drawing towards evening.

How rewarding it is when the work is done and everything has gone well! When you know that Sasha is lying there, alive. With a brand-new valve in his heart. With his life given back to him, and his letter in my pocket which I need not read now.

However this is not only because it is Sasha, the man we all know and love. Had it been a perfect stranger we should have felt just the same. After successful surgery every patient is a joy. You have put your work into them, your soul. I don't know exactly how to describe this feeling, it is a special one, unlike any other.

'I never doubted you could handle that hole, professor,' comments Vasya.

We are all still under the spell of what we have gone through, and our conversation revolves around the operation.

'You didn't, but I did,' I answer, blowing out the cigarette smoke. 'For a moment I was quite lost. Of course, sooner or later we should have plugged it, the machine was still working and we could have pinched off the aorta. But the risk! As it was, the haemolysis figure jumped to hundred and fifty.'

'Still, I wasn't afraid.'

'It's because you're young, Vasya, and cocky. You still don't appreciate the full scope of danger. I was the same way at your age.'

'What happened, anyway? The thread must have broken. All four stitches couldn't have come apart at once.'

This is Maria Vassilievna. She sits there exhausted, like myself unable to move. She is an excellent dedicated doctor, and a fine surgeon. My best, my closest assistant.

'I don't know really, Masha. All of a sudden the thread was in my hand, and I threw it away. I had to plug that hole in a hurry. There was no time to look at anything.'

Vasya is drinking water from a container in the corner. I am also very thirsty because my shirt and trousers are drenched with sweat. During some of these complicated operations I lose as much as two kilograms. I checked that once. But I don't care, at this moment I am swelling with happiness.

'Well, comrades, we can put in valves, after all, can't we?'

'Yes, professor, but the method of putting in sutures should be changed.'

'Yes? How?'

Genya begins to explain. One must first run the sutures through the edges of the valve hole, without setting in the valve, and then run them through the edges of the valve itself. Only then should the valve be set in place and the sutures around it gradually and simply tied up one after another.

Very practical and clever. A very promising suggestion. I must investigate this thoroughly.

Now I must go up to my office and write the report of the operation. I hate it, and there is no avoiding it. It is a tedious task, but it is a part of a surgeon's work. And it is impossible to do it here, too much noise. Send them away? No, that wouldn't be right. These are precious moments for all of them, they are enjoying this relaxed communion, and they have deserved it. If they disperse now this quiet sense of great common happiness would be broken: each would find something to do. The wonderful atmosphere would be gone, and it would be impossible to recreate it.

'Genya, shall we go to my office and write up the operation?'

Genya is obviously unhappy about this suggestion: I can see it in his face. It is so peaceful here. It isn't often that the professor and the interns become so completely equal. But Genya must go. This is a question, but it is also an order, no matter how delicately it is given. I have selected Genya because of his excellent memory and his sense of detail.

He chucks away his cigarette, picks up the surgery journal and the case history. He is ready.

I also hate to leave, but I must. Besides, I have to change, I am wet right through. It is easy to catch cold, May or no May. I don't want to fall ill now. I want to do more operations like today's, to schedule a few of them as quickly as possible. All I need now is experience.

On my way up I look into the theatre. All is quiet. The mess has been cleaned up. Sasha is asleep. Lenya is squeezing the oxygen bag. Dima is speaking softly to Oxana. I remember, someone has told me that those two are in love. Just gossip perhaps, but maybe true? Well, love has never hurt anyone, and people in love work well together. Fine kids, both of them. I need not worry, they should be happy together. Everything looks so tranquil, but this may be a misleading impression: who knows what processes are going on within that inert body? But by all outward appearances, all goes well.

In the dressing room things are piled pell-mell. Even my corner is not inviolate, somebody has dropped my undershirt on the floor. Never mind, I can pick it up. I'm too tired and too happy to be annoyed.

It is a relief to put on dry things. And it is pleasant to look at Genya. So lean, graceful, muscular, young, as he stands there in his athletic briefs.

'Interested in any sport, Genya?'

'I was once, yes, but where would I get the time? I have different interests now. My study, my work.'

'Well, work is work, but physical culture is important. Not competitive sport, that's nonsense, but physical culture.'

This is one of my favourite subjects. I understood it when I turned forty and began to put on weight and my heart started to complain a little. I had lost every ounce of fat, and now I can engage in propaganda.

   1Masha is an endearment of Maria, Marya a disparaging form.


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