Authors: Aleksandr Solzhenitsyn
There were some nurses in the room too, some of them no better than these doctors. Again, it was Nizamutdin Bahramovich who had taken them on and protected them.
There were times when the pressure of it all got Lev Leonidovich down and he felt he couldn't carry on another day. All he wanted was to break with the clinic and go somewhere else. But where could he go? Any new place would have its own senior doctor who might be even worse than the one here, its own puffed-up fools and its own drones filling the place of workers. It would be different if he could take over the clinic on his own, and, just for a change, organize things on an efficient basis. He would make everyone who had the capacity do a proper job of work and employ only as many as were needed. But Lev Leonidovich wasn't in a position to be entrusted with a senior doctorship, unless it was in some place miles from anywhere. Out here was close enough to Moscow for someone to be sent.
Anyway, he didn't really want to be in charge. He knew that administrators were seldom efficient in their actual profession. At one period in his life he had seen some great men who were down and out, and he had recognized what a futile thing power is. He had seen former divisional commanders whose dream it was to get work as kitchen orderlies. His first practical teacher had been the surgeon Koryakov, whom he had once literally had to pull out of a rubbish heap.
At other times things calmed down, smoothed themselves out, and Lev Leonidovich reckoned he could put up with it all and wouldn't have to leave. His fears would then go to the opposite extreme. He was frightened lest they might get rid of Dontsova, Gangart, and himself. This was the way things seemed to be going; every year the situation became not simpler but more complicated. It was no longer easy for him to tolerate abrupt breaks in his life. He was nearly forty and his body now craved a degree of comfort and security.
His own life was a source of great puzzlement to him. He didn't know whether to make a heroic charge forward or to swim quietly with the current. It wasn't here that his serious work had begun. In the beginning, his career had been full of scope. One year he'd fallen only a few yards short of a Stalin Prize. Then suddenly their whole establishment had burst like a bubble. Certain areas of research had been stretched too far, there had been too much haste. After the collapse, he never actually submitted his thesis. It was partly Koryakov who had put him into this frame of mind. “You just keep working,” he had said to him. “There'll always be time to write it down.” But when would there be time?
And what was the use of writing it all down?
Lev Leonidovich's face showed no disapproval of the senior doctor, He screwed up his eyes, pretending to listen, particularly as they were suggesting that he carry out the first-ever operation on the thorax next month.
Everything comes to an end, and so did the five-minute conference. The surgeons filed slowly out of the room and gathered on the upper landing. His paws still tucked into the narrow belt round his belly. Lev Leonidovich set off like a grim, absentminded colonel, leading his team on the main rounds: Yevgenia Ustinovna, gray-haired and simple-looking, Halmuhamedov with his luxuriant curls, fat Pantyokhina, red-haired Angelica, and two nurses.
Some rounds were like flying visits, everyone in a hurry to get the job done. They should have hurried today as well, only the timetable decreed that there should be a slow, general round, taking in every single surgical case. They walked into the wards one after the other, all seven of them, diving into an atmosphere stale from the stifling medical smells, the reluctant use of ventilation and the patients' bodies. They squeezed in, making way for each other in the narrow passage between the beds and looking over each other's shoulders. Gathered in a little circle round each bed, they were supposed to spend either one, three or five minutes penetrating each patient, just as they had already penetrated the heavy air of the ward. They had to penetrate his pains, his emotions, his anamnesis, his case history, the progress of his treatment, his present conditionâin fact, everything theoretically and practically possible for them to do.
If there had been fewer of them, if each had been the best specialist available and not merely a man who drew a doctor's salary, if there hadn't been thirty patients to every staff member, if they hadn't had to bother about the most tactful thing to put in a case history (a document which might one day find itself on the desk of a state prosecutor), if they hadn't been human beings, that is to say firmly attached to their skin and bones, their memories and intentions, and if they hadn't derived a vast relief from the knowledge that they weren't the ones in painâthen very probably such a system of doctors' rounds would have been the best conceivable solution.
But as Lev Leonidovich very well knew, things were as they were. Still, the rounds could neither be cancelled nor replaced. He therefore led his team round the wards, as he always did, narrowing his eyes (one eye more than the other) and tamely listening as his staff recited (not speaking off the cuff but reading out of files) the facts about each patient: where he was from, when admitted (he already knew this about the senior patients), reason for admittance, type of treatment being administered and in what intensity, blood count, whether he was already down for an operation or wasn't to be operated on, and if so why, or whether the question hadn't yet been decided. He heard some of the patients out and sat down on their beds. Some of them he asked to show him the diseased place. He examined it, felt it, and covered the patient up himself with a blanket or else invited the other doctors to feel it.
The really difficult cases couldn't be resolved on rounds like these, you had to call the patient in and examine him on his own. You couldn't be too outspoken during rounds either, you couldn't call a spade a spade and come to an agreement with each other. You couldn't even say that a patient's condition had worsened, all you could say was “The process seems somewhat more acute.” Everything was discussed in euphemisms and half-allusions (sometimes even in substitutes for substitutes), or else in a way that was in direct antithesis to the truth. No one ever said “cancer” or “sarcoma,” nor could they use terms that patients half understood, like “carcinoma,” “CR” or “SR.” Instead they had to use harmless words like “ulcer,” “gastritis,” “inflammation,” or “polyps.” What these terms actually meant could be explained in full only after the rounds. Sometimes, for the sake of better understanding, they were allowed to use expressions like “The shadow in the mediastinum has widened,” or “The case is not respectable,” “We cannot exclude a lethal outcome” (which meant the man might die on the operating table). When in spite of everything he ran out of expressions, Lev Leonidovich used to say, “Put that case history to one side,” and then they would move on.
During the rounds they would reach very little understanding of the disease or of each other, but the less agreement reached, the more important Lev Leonidovich attached to improving the patient's morale. He began to see the improvement of morale as the main aim of the rounds.
“
Status idem,
” someone might say to him. (“No change.”)
“Is that so?” he would reply happily. At once he would check the remark with the patient herself. “You feel a bit better, do you?”
“Yes, perhaps,” the patient would agree, slightly surprised. She hadn't noticed it herself, but if the doctors had noticed it, it must be true.
“There, you see! Little by little, you'll soon get better.”
But another patient sounded the alarm.
“Tell me,” she said “why do I have these pains in the spine? Perhaps I've got a tumor there as well?”
“O-oh, no-o.” Lev Leonidovich smiled as he drawled out the words. “That's a subsidiary development.” (He was telling the truth: a secondary tumor
was
a subsidiary development.)
He stood over an old man with a terrible, sharpened face and the gray complexion of a corpse, who could hardly move his lips. “Patient is receiving general tonics and sedatives,” they told him.
It meant the end. It was too late to treat him. There was nothing to treat him with; the only aim was to reduce his suffering.
Then Lev Leonidovich would knit his heavy eyebrows, as if making up his mind to lift the curtain and explain what had to be explained: “All right, Grandpa, let's be quite frank and open about this. What you're feeling now is a reaction to your earlier treatment. Don't push us too hard, just lie there quietly and we'll see you get better. Just lie there. You may think we're not doing very much, but we're helping your organism to defend itself.”
The doomed man would nod his head. The doctor's frankness had turned out to be less lethal than expected. It kindled his hope.
“You can observe a tumorous formation of such-and-such a type in the iliac region,” someone might report, showing Lev Leonidovich an X ray.
He would hold the murky, black transparent X-ray film up to the light and nod encouragingly. “That's a very good photo! Very good!”
And so the patient would be encouraged. As far as she was concerned, it wasn't merely good, it was very good. The photograph was very good, but only because there was now no need to take another. It clearly showed the size and boundaries of the tumor.
Throughout the ninety-minute general round, the senior surgeon would make a point of never saying what he really thought. He took care to prevent his tone expressing his feelings. At the same time, the staff doctors had to make accurate notes for the case histories, those files of reference cards, filled out in longhand with pen and ink, which might later provide the basis for one of them being put on trial. Never once did Leonidovich turn his head abruptly, never once did he look alarmed, his benevolent, bored expression indicating to patients how simple their diseases were. They were all well-known disorders, and not a single one was serious.
An hour and a half of acting combined with scientific analysis was enough to exhaust Lev Leonidovich. He frowned, straining the skin on his forehead.
Then an old woman complained she hadn't had her chest tapped for some time, so he tapped it.
An old man announced, “Look, there's something I want to tell you.”
He started a confused story about his interpretation of the origin and development of his pains. Lev Leonidovich listened patiently, even nodding occasionally.
“There was something you were going to say, wasn't there?” said the old man, allowing him to speak.
The surgeon smiled. “What is there for me to say? Our interests are exactly the same. You want to be cured, we want you to be cured too. Let's carry on in agreement.”
He knew a few words of Uzbek, enough to say simple things to them. There was one very sophisticated-looking lady who wore glasses. Even seeing her on a hospital bed in a dressing gown was somehow embarrassing, so he decided not to examine her in front of the others. He gravely offered his hand to a little boy who had his mother with him. Then he gave a seven-year-old a flick on the tummy, and they both had a laugh together.
There was only one patient he treated with a certain lack of politeness, a schoolmistress who demanded the right to consult a neurologist.
By now he was in the last ward. He came out as exhausted as if he'd done a full operation. “Smoke break, five minutes,” he said.
He and Yevgenia Ustinovna puffed out two big clouds of smoke after throwing themselves on the cigarettes as if they were the climax of the round. (Yet they told the patients that tobacco was carcinogenic and strictly contraindicated!)
Then they all went into a small room and sat down round a table, The names mentioned during the rounds now came up for discussion once again, but the general impression of improvement and recovery that an outside listener might have gathered during the rounds was now completely exploded and disintegrated. The man with
status idem
was an inoperable case being given symptomatic X-ray treatment to suppress the immediate pain, but without any hope of a cure. The little boy Lev Leonidovich had offered his hand to was incurable too, suffering from a widely dispersed tumor, and it was only because his parents insisted on it that he had to stay in hospital a while longer. As for the old woman who'd demanded to have her chest tapped, Lev Leonidovich said, “She's sixty-eight. If we give her X-ray treatment, we may put it off till she's seventy. If we operate, she won't live a year. What do you think, Yevgenia Ustinovna?”
If even such a staunch supporter of the knife as Lev Leonidovich was giving the case up, Yevgenia Ustinovna would certainly be in agreement.
In fact he wasn't a supporter of the knife, but he was a skeptic. He knew that there was no instrument as good as the naked eye for letting you see a clear picture, and that nothing could remove what had to go more radically than the knife.
There was one patient who, not wanting to decide on an operation himself, asked if he could consult with his family. Lev Leonidovich said, “His family live in the depths of the wilds. In the time it takes to get in touch and for them to come here and give their opinion, the man will die. We must persuade him and get him on the operating table, not tomorrow but the next time round. Of course it is a risk. We'll give him a lookover, then maybe we'll just sew him up without doing anything.”
“What if he dies on the table?” asked Halmuhamedov with an air of importance, as though he were the one taking the risk.
Lev Leonidovich moved his long, intricately shaped eyebrows, which had grown together in the middle. “An if is an if, but if we do nothing he'll die for sure.” He paused to think. “We've got a good death rate so far, we can take the risk.”
After every discussion he would ask, “Does anyone disagree?”
However, the only opinion that interested him was Yevgenia Ustinovna's. Their experience, age and approach were quite different, but their views almost always coincided, which showed it was easy enough for sensible people to understand one another.