Mikhail Bulgakov
BAPTISM BY ROTATION from A Country Doctor’s Notebook
After graduating from medical school, Mikhail Bulgakov spent the next eighteen months in an isolated, rural area of Russia. This story reflects the new practitioner’s uncertainty and the challenge of moving from book knowledge to practical knowledge. Although he feels isolated and timorous, he has no choice as a doctor but to treat the woman who has been brought to his hospital in the throes of a difficult labor. He takes what is offered by the midwife, then retreats for a hasty consultation with his text. When he completes the procedure (with a positive outcome), he reflects on the need to “engage in lifelong learning.”
MIKHAIL BULGAKOV (1891–1940) graduated from medical school at Kiev University in 1916. After practicing for a decade, Bulgakov became a full-time writer. A Country Doctor’s Notebook, from which this story was taken, was first published in 1925–27. Bulgakov is also the author of the modern masterpiece The Master and Margarita.
As time passed in my country hospital, I gradually got used to the new way of life.
They were braking flax in the villages as they had always done, the roads were still impassable, and no more than five patients came to my daily surgery. My evenings were entirely free, and I spent them sorting out the library, reading surgical manuals and spending long hours drinking tea alone with the gently humming samovar.
For whole days and nights it poured with rain, the drops pounded unceasingly on the roof and the water cascaded past my window, swirling along the gutter and into a tub. Outside was slush, darkness and fog, through which the windows of the feldsher’s house and the kerosene lantern over the gateway were no more than faint, blurred patches of light.
On one such evening I was sitting in my study with an atlas of topographical anatomy. The absolute silence was only disturbed by the occasional gnawing of mice behind the sideboard in the dining room.
I read until my eyelids grew so heavy that they began to stick together. Finally I yawned, put the atlas aside, and decided to go to bed. I stretched in pleasant anticipation of sleeping soundly to the accompaniment of the noisy pounding of the rain, then went across to my bedroom, undressed, and lay down.
No sooner had my head touched the pillow than there swam hazily before me the face of Anna Prokhorova, a girl of seventeen from the village of Toropovo. She had needed a tooth extracting. Demyan Lukich, the feldsher, floated silently past holding a gleaming pair of pincers. Remembering how he always said “suchlike” instead of “such” because he was fond of a highfalutin style, I smiled and fell asleep.
About half an hour later, however, I suddenly woke up as though I had been pinched, sat up, stared fearfully into the darkness and listened.
Someone was drumming loudly and insistently on the outer door and I immediately sensed that those knocks boded no good.
Then came a knock on the door of my quarters.
The noise stopped, there was a grating of bolts, the sound of the cook talking, an indistinct voice in reply, then someone came creaking up the stairs, passed quietly through the study and knocked on my bedroom door.
“Who is it?”
“It’s me,” came the reply in a respectful whisper. “Me, Aksinya, the nurse.”
‘What’s the matter?’
“Anna Nikolaevna has sent for you. They want you to come to the hospital as quickly as possible.”
“What’s happened?” I asked, feeling my heart literally miss a beat.
“A woman has been brought in from Dultsevo. She’s having a difficult labor.”
“Here we go!” I thought to myself, quite unable to get my feet into my slippers. “Hell, the matches won’t light. Ah well, it had to happen sooner or later. You can’t expect to get nothing but cases of laryngitis or abdominal catarrh all your life.”
“All right, go and tell them I’m coming at once!” I shouted as I got out of bed. Aksinya’s footsteps shuffled away from the door and the bolt grated again. Sleep vanished in a moment. Hurriedly, with shaking fingers, I lit the lamp and began dressing. Half past eleven . . . What could be wrong with this woman who was having a difficult birth? Malpresentation? Narrow pelvis? Or perhaps something worse. I might even have to use forceps. Should I send her straight into town? Out of the question! A fine doctor he is, they’ll all say. In any case, I have no right to do that. No, I really must do it myself. But do what? God alone knows. It would be disastrous if I lost my head—I might disgrace myself in front of the midwives. Anyway, I must have a look first; no point in getting worried prematurely . . .
I dressed, threw an overcoat over my shoulders, and hoping that all would be well, ran to the hospital through the rain across the creaking duckboards. At the entrance I could see a cart in the semi-darkness, the horse pawing at the rotten boards under its hooves.
“Did you bring the woman in labor?” I asked the figure lurking by the horse.
“Yes, that’s right . . . we did, sir,” a woman’s voice replied dolefully.
Despite the hour, the hospital was alive and bustling. A flickering pressurelamp was burning in the surgery. In the little passage leading to the delivery room Aksinya slipped past me carrying a basin. A faint moan came through the door and died away again. I opened the door and went into the delivery room. The small, whitewashed room was brightly lit by a lamp in the ceiling. On a bed alongside the operating table, covered with a blanket up to her chin, lay a young woman. Her face was contorted in a grimace of pain and wet strands of hair were sticking to her forehead. Holding a large thermometer, Anna Nikolaevna was preparing a solution in a graduated jug, while Pelagea Ivanovna was getting clean sheets out of the cupboard. The feldsher was leaning against the wall in a Napoleonic pose. Seeing me, they all jerked into life. The pregnant woman opened her eyes, wrung her hands and renewed her pathetic, long drawn-out groaning.
“Well now, what seems to be the trouble?” I asked, sounding confident.
“Transverse lie,” Anna Nikolaevna answered promptly as she went on pouring water into the solution.
“I see-ee,” I drawled, and added, frowning: “Well, let’s have a look . . .”
“Aksinya! Wash the doctor’s hands!” snapped Anna Nikolaevna. Her expression was solemn and serious.
As the water flowed, rinsing away the lather from my hands, reddened from scrubbing, I asked Anna Nikolaevna a few trivial questions, such as when the woman had been brought in, where she was from . . . Pelagea Ivanovna’s hand turned back the blanket, I sat down on the edge of the bed and began gently feeling the swollen belly. The woman groaned, stretched, dug her fingers into her flesh and crumpled the sheet.
“There, there, relax . . . it won’t take long,” I said as I carefully put my hands to the hot, dry, distended skin.
The fact was that once the experienced Anna Nikolaevna had told me what was wrong, this examination was quite pointless. I could examine the woman as much as I liked, but I would not find out any more than Anna Nikolaevna knew already. Her diagnosis was, of course, correct: transverse lie. It was obvious. Well, what next?
Frowning, I continued palpating the belly on all sides and glanced sidelong at the midwives’ faces. Both were watching with intense concentration, and their looks registered approval of what I was doing. But although my movements were confident and correct, I did my best to conceal my unease as thoroughly as possible.
“Very well,” I said with a sigh, standing up from the bed, as there was nothing more to be seen from an external examination. “Let’s examine her internally.”
Another look of approval from Anna Nikolaevna.
“Aksinya!”
More water flowed.
“Oh, if only I could consult Döderlein now!” I thought miserably as I soaped my hands. Alas, this was quite impossible. In any case, how could Döderlein help me at a moment like this? I washed off the thick lather and painted my fingers with iodine. A clean sheet rustled in Pelagea Ivanovna’s hands and, bending down over the expectant mother, I began cautiously and timidly to carry out an internal examination. Into my mind came an involuntary recollection of the operating theater in the maternity hospital. Gleaming electric lights in frosted-glass globes, a shining tiled floor, taps and instruments aglitter everywhere. A junior registrar in a snow-white coat is manipulating the woman, surrounded by three intern assistants, probationers, and a crowd of students doing their practicals. Everything bright, well ordered and safe.
And there was I, all on my own, with a woman in agony on my hands and I was responsible for her. I had no idea, however, what I was supposed to do to help her, because I had seen childbirth at close quarters only twice in my life in a hospital, and both occasions were completely normal. The fact that I was conducting an examination was of no value to me or to the woman; I understood absolutely nothing and could feel nothing of what was inside her.
It was time to make some sort of decision.
“Transverse lie . . . since it’s a transverse lie I must . . . I must . . .”
“Turn it round by the foot,” muttered Anna Nikolaevna as though thinking aloud, unable to restrain herself.
An older, more experienced doctor would have looked askance at her for butting in, but I am not the kind to take offense.
“Yes,” I concurred gravely, “a podalic version.”
The pages of Döderlein flickered before my eyes. Internal method . . . Combined method . . . External method . . . Page after page, covered in illustrations. A pelvis; twisted, crushed babies with enormous heads . . . a little dangling arm with a loop on it.
Indeed I had read it not long ago and had underlined it, soaking up every word, mentally picturing the interrelationship of every part of the whole and every method. And as I read it I imagined that the entire text was being imprinted on my brain forever.
Yet now only one sentence of it floated back into my memory:
“A transverse lie is a wholly unfavorable position.”
Too true. Wholly unfavorable both for the woman and for a doctor who only qualified six months ago.
“Very well, we’ll do it,” I said as I stood up.
Anna Nikolaevna’s expression came to life.
“Demyan Lukich,” she turned to the feldsher, “get the chloroform ready.”
It was a good thing that she had said so, because I was still not certain whether the operation was supposed to be done under anesthesia or not! Of course, under anesthesia—how else?
Still, I must have a look at Döderlein . . .
As I washed my hands I said:
“All right, then . . . prepare her for anesthesia and make her comfortable. I’ll be back in a moment; I must just go to my room and fetch some cigarettes.”
“Very good, doctor, we’ll be ready by the time you come back,” replied Anna Nikolaevna.
I dried my hands, the nurse threw my coat over my shoulders, and without putting my arms into the sleeves, I set off for home at a run.
In my study I lit the lamp and, forgetting to take off my cap, rushed straight to the bookcase.
There it was—Döderlein’s Operative Obstetrics. I began hastily to leaf through the glossy pages.
“. . . version is always a dangerous operation for the mother . . .”
A cold shiver ran down my spine.
“The chief danger lies in the possibility of a spontaneous rupture of the uterus . . .”
Spon-tan-e-ous . . .
“If in introducing his hand into the uterus the obstetrician encounters any hindrances to penetrating to the foot, whether from lack of space or as a result of a contraction of the uterine wall, he should refrain from further attempts to carry out the version . . .”
Good. Provided I am able, by some miracle, to recognize these “hindrances” and I refrain from “further attempts,” what, might I ask, am I then supposed to do with an anesthetized woman from the village of Dultsevo?
Further:
“It is absolutely impermissible to attempt to reach the feet by penetrating behind the back of the fetus . . .”
Noted.
“It must be regarded as erroneous to grasp the upper leg, as doing so may easily result in the fetus being revolved too far; this can cause the fetus to suffer a severe blow, which can have the most deplorable consequences . . .”
“Deplorable consequences.” Rather a vague phrase, but how sinister. What if the husband of the woman from Dultsevo is left a widower? I wiped the sweat from my brow, rallied my strength, and disregarded all the terrible things that could go wrong, trying only to remember the absolute essentials: what I had to do, where and how to put my hands. But as I ran my eye over the lines of black print, I kept encountering new horrors. They leaped out at me from the page.
“. . . in view of the extreme danger of rupture . . .”
“. . . the internal and combined methods must be classified as among the most dangerous obstetric operations to which a mother can be subjected . . .”
And as a grand finale:
“. . . with every hour of delay the danger increases . . .”
That was enough. My reading had borne fruit: my head was in a complete muddle. For a moment I was convinced that I understood nothing, and above all that I had no idea what sort of version I was going to perform: combined, bipolar, internal, external . . .
I abandoned Döderlein and sank into an armchair, struggling to reduce my random thoughts to order. Then I glanced at my watch. Hell! I had already spent twenty minutes in my room, and they were waiting for me.
“. . . with every hour of delay . . .”
Hours are made up of minutes, and at times like this the minutes fly past at insane speed. I threw Döderlein aside and ran back to the hospital.
Everything there was ready. The feldsher was standing over a little table preparing the anesthetic mask and the chloroform bottle. The expectant mother already lay on the operating table. Her ceaseless moans could be heard all over the hospital.
“There now, be brave,” Pelagea Ivanovna muttered consolingly as she bent over the woman, “the doctor will help you in a moment.”
“Oh, no! I haven’t the strength . . . No . . . I can’t stand it!”
“Don’t be afraid,” whispered the midwife. “You’ll stand it. We’ll just give you something to sniff, and then you won’t feel anything.”
Water gushed noisily from the taps as Anna Nikolaevna and I began washing and scrubbing our arms bared to the elbow. Against a background of groans and screams Anna Nikolaevna described to me how my predecessor, an experienced surgeon, had performed versions. I listened avidly to her, trying not to miss a single word. Those ten minutes told me more than everything I had read on obstetrics for my qualifying exams, in which I had actually passed the obstetrics paper “with distinction.” From her brief remarks, unfinished sentences and passing hints I learned the essentials which are not to be found in any textbooks. And by the time I had begun to dry the perfect whiteness and cleanliness of my hands with sterile gauze, I was seized with confidence and a firm and absolutely definite plan had formed in my mind. There was simply no need to bother any longer over whether it was to be a combined or bipolar version.
None of these learned words meant anything at that moment. Only one thing mattered: I had to put one hand inside, assist the version with the other hand from outside and without relying on books but on common sense, without which no doctor is any good, carefully but firmly bring one foot downwards and pull the baby after it.
I had to be calm and cautious yet at the same time utterly decisive and unfaltering.
“Right, off you go,” I instructed the feldsher as I began painting my fingers with iodine.
At once Pelagea Ivanovna folded the woman’s arms and the feldsher clamped the mask over her agonized face. Chloroform slowly began to drip out of the dark yellow glass bottle, and the room started to fill with the sweet, nauseous odour. The expressions of the feldsher and midwives hardened with concentration, as though inspired . . .
“Haaa! Ah!” The woman suddenly shrieked. For a few seconds she writhed convulsively, trying to force away the mask.
“Hold her!”
Pelagea Ivanovna seized her by the arms and lay across her chest. The woman cried out a few more times, jerking her face away from the mask. Her movements slowed down, although she mumbled dully:
“Oh . . . let me go . . . ah . . .”
She grew weaker and weaker. The white room was silent. The translucent drops continued to drip, drip, drip on to the white gauze.
“Pulse, Pelagea Ivanovna?”
“Firm.”
Pelagea Ivanovna raised the woman’s arm and let it drop: as lifeless as a leather thong, it flopped on to the sheet. Removing the mask, the feldsher examined the pupil of her eye.
“She’s asleep.”
A pool of blood. My arms covered in blood up to the elbows. Bloodstains on the sheets. Red clots and lumps of gauze. Pelagea Ivanovna shaking and slapping the baby, Aksinya rattling buckets as she poured water into basins.
The baby was dipped alternately into cold and hot water. He did not make a sound, his head flopping lifelessly from side to side as though on a thread. Then suddenly there came a noise somewhere between a squeak and a sigh, followed by the first weak, hoarse cry.
“He’s alive . . . alive . . . ,” mumbled Pelagea Ivanovna as she laid the baby on a pillow.
And the mother was alive. Fortunately nothing had gone wrong. I felt her pulse. Yes, it was firm and steady; the feldsher gently shook her by the shoulder as he said:
“Wake up now, my dear.”
The bloodstained sheets were thrown aside and the mother hastily covered with a clean one before the feldsher and Aksinya wheeled her away to the ward. The swaddled baby was borne away on his pillow, the brown, wrinkled little face staring out from its white wrapping as he cried ceaselessly in a thin, pathetic whimper.
Water gushing from the taps of the sluice. Anna Nikolaevna coughed as she dragged hungrily at a cigarette.
“You did the version well, doctor. You seemed very confident.”
Scrubbing furiously at my hands, I glanced sidelong at her: was she being sarcastic? But no, her expression was a sincere one of pride and satisfaction. My heart was brimming with joy. I glanced round at the white and bloodstained disorder, at the red water in the basin and felt that I had won. But somewhere deep down there wriggled a worm of doubt.
“Let’s wait and see what happens now,” I said.
Anna Nikolaevna turned to look at me in astonishment.
“What can happen? Everything’s all right.”
I mumbled something vague in reply. What I had meant to say was to wonder whether the mother was really safe and sound, whether I might not have done her some harm during the operation . . . the thought nagged dully at my mind. My knowledge of obstetrics was so vague, so fragmentary and bookish. What about a rupture? How would it show? And when would it show—now or, perhaps, later? Better not talk about that.
“Well, almost anything,” I said. “The possibility of infection cannot be ruled out,” I added, repeating the first sentence from some textbook that came into my mind.
“Oh, th-at,” Anna Nikolaevna drawled complacently. “Well, with luck nothing of that sort will happen. How could it, anyway? Everything here is clean and sterile.”
It was after one o’clock when I went back to my room. In a pool of light on the desk in my study lay Döderlein open at the page headed “Dangers of Version.” For another hour after that, sipping my cooling tea, I sat over it, turning the pages. And an interesting thing happened: all the previously obscure passages became entirely comprehensible, as though they had been flooded with light; and there, at night, under the lamplight in the depth of the countryside I realized what real knowledge was.
“One can gain a lot of experience in a country practice,” I thought as I fell asleep, “but even so one must go on and on reading, reading . . . more and more . . .”
