“The Steel Windpipe” – Mikhail Bulgakov

Then one night I was alone. All around was November blackness, the snow freaking down and shrouding the house, the chimneys howling. I had spent all twenty four years of my life in a sprawling city, and thought that blizzards howl only in novels. Now I knew they howl in real life. The evenings here were interminably long. I would stare at the gleam of the lamp with its dark blue shade reflecting on the window and fantasise. I dreamed of the district centre. It was about 25 miles away. I longed to run off there, and abandon my medical outpost. They had electricity, and four doctors I could ask for advice; it would certainly be less terrifying than here. But there was no chance of running away, and now and then I realised it would be gutless. This was what I had studied medicine for, after all.

But what if they were to bring in a woman with a complicated labour? Or someone with an incarcerated hernia? What would I do then? Advice please. Forty-eight days ago I had graduated cum laude. But cum laude is one thing, and a hernia is another. Once I had watched a professor operate on an incarcerated hernia. He operated and I sat in the amphitheatre. That was the long and short of it…

A cold sweat would run down my spine at the mere thought of a hernia. Every evening I sat in the same posture, drinking one cup of tea after the other. By my left hand were all my practical obstetrics books, with a pocket Doderlein on top. On my right were 10 different volumes on operative surgery, with diagrams. I heched and peched, smoked, and drank cold black tea….

Once I fell asleep. I remember the night quite vividly – it was 29 November. I woke up to someone hammering on the door. Five minutes later I was pulling on my trousers, my eyes fixed imploringly on the holy writ of operative surgery. I could hear a sledge scarpe across the yard: my hearing had become exceptionally acute. It turned out, if anything, to be more terrifying than a hernia or a breech delivery. At 11 o’clock at night someone was bringing a little girl to the Nikolsky medical outpost. The woman with her said tonelessly:

–“The little girl’s weak. She’s dying. Please, doctor, put her in the hospital.”

I recall crossing the yard towards the doorway of the cottage hospital, mesmerised by the flickering of the paraffin lamp. The lights were already on in the surgery and my staff were waiting for me, already dressed and in their gowns. They were Demyan Lukich, my assistant, who was young but very capable, and two experienced midwives: Anna Nikolaevna and Pelageya Ivanovna. And I myself, 24 years old, two months out of university and in charge of the Nikolsky medical outpost.

The assistant solemnly opened the doors and the mother appeared – or rather she flew into the room, slithering in her boots, the snow still beaded and frozen on her headscarf. In her arms she held a bundle that quietly wheezed and whistled. The mother’s face was twisted and she was sobbing noiselessly. When she threw off her coat and scarf and unbound her bundle, I saw a little girl of about three. I looked at her and for the moment forgot about operative surgery, my isolation, my wholly inadequate university training. Everything went out of my mind – the little girl was so beautiful. What could I compare her with? You see children like her only on chocolate boxes – hair in natural rings and curls the colour of ripe barley, huge dark blue eyes, cheeks like a porcelain doll. The way they used to paint angels. But a strange cloudiness was lurking in the depth of her eyes: it was terror – she couldn’t breathe. “She’ll be dead within the hour” I thought with absolute certainty, and felt my heart lurch in alarm.

Tiny recesses appeared in the girl’s throat every time she breathed in. Her veins were distended and her face was turning from pink to a pale lilac. I realised straightaway what her colouring meant. I made my first diagnosis: not only was it correct but, more importantly I voiced it as rapidly as the midwives’ with all their years of experience. “The little girl’s got dyphtherial croup. Her throat’s chockfull of membrane and about to close over…”

“How long has she been ill?” I asked. My staff were tense and silent.

“This is the fifth day. The fifth” the mother said, and searched me with dry eyes.

“Dyphtheria” I said to my assistant under my breath, but then turned to the mother:

“What on earth were you thinking about? Why have you left it so long?”

Then I heard a tremulous voice behind me:

“Five days, sir, five days!”

I turned round and saw a quiet, moon-faced old woman in a headscarf. “I’d like to see the back of you” I thought to myself. With a sickening presentiment of bad news to come, I said:

“Be quiet, woman, you’re only in the way,” and again asked the mother:“Why did you leave it so long? Five days? What were you thinking about?”

Suddenly the mother handed the girl to the old woman with a practised movement and sank to her knees before me.

“Give her some medicine!” she implored and touched the floor with her forehead. “I’ll hang myself if she dies.”

“Get up this minute” I replied “or I won’t even to talk to you.”

The mother stood up quickly, flounced out her wide skirt, took the girl back from the old woman and began rocking her. The old woman turned to the window frame and began praying, and the little girl breathed, still hissing like a snake. My assistant said:

“That’s what they all do. The common folks.” His moustache twisted as he spoke.

“Does that mean she’s going to die then?” the mother asked, staring at me with what I took to be black fury.

“Yes, she’s going to die” I said quietly but firmly.

“Help her! Give her some medicine! Some medicine!”

I could see what was in store for me, but held my ground.

What medicine? Tell me. The girl is suffocating, her throat is already blocked up. For five days you allowed her to die ten miles away. Now what do you want me to do?”

“You know best, sir” the old woman suddenly whined from behind my left shoulder, her mock respectful tone making me loathe her instantly.

“Shut up!” I said to her. I turned to my assistant and instructed him to bring the little girl over. The mother gave the child to the midwife and she started to flail about, evidently wanting to cry but incapable of making a sound. The mother tried to fend us off, but we kept her away and I managed to look at the girl’s throat with the laryngoscope. I had never seen dyphtheria before, except for uncomplicated cases that I’d quickly forgotten. Her throat was full of ragged, white, pulsating membrane. The little girl suddenly got a breath out and spat in my face, but now I was so absorbed in my train of thought that I didn’t blink.

“Listen” I said, surprised at my own composure. “This is the problem: things are far gone and this little girl is going to die. Nothing will save her now – except an operation.”

The word terrified me. Why had I said it? But I couldn’t stop myself. Then the thought crossed my mind: “What if she consents to it?”

“What kind of an operation?”

“I need to cut her throat near the bottom of the neck and put in a silver tube to allow her to breathe” I explained, “and then, maybe, we can save her life.”

The mother looked at me as though I had gone mad and put her arms around the little girl to shield her from me. The old woman started burbling again:

“What? Don’t you let him cut her throat! What? Her throat!”

“Get out, woman!” I said to her with malice. “Give the child a camphor injection!” I told the medical assistant.

The mother refused to hand the girl over when she saw the syringe, but we explained there was nothing to be frightened of.

“Maybe it will cure her?” the mother asked.

“No chance of that.”

Then the mother burst out sobbing.

“Stop crying,” I said. I took out my watch and added:”I’ll give you five minutes to make up your mind. If you don’t agree in five minutes, I won’t do it at all.”

“I refuse” the mother said flatly.

“We both refuse” the old woman added.

“As you like” I added in a dull voice and thought: “Well that’s that. It makes life easier for me. I’ve told them where we stand and offered to try. Look how lost for words the midwives are. They’ve said no, and I am off the hook.” No sooner had I thought this, than a voice piped up that must have been my own:

“Look, are you completely mad? How can you not agree? You’ll kill the child. You have to consent! Have you no pity?”

“No!” the mother shrieked again.

Inwardly I was wondering: “What am I doing? I’m the one who’s going to have to operate on the girl.” But I said:

“Get a move one! Hurry up and consent! You must agree! Look, her nails are turning blue already!”

“No, no!”

“Take them into the ward. Let them sit there.”

They were led out into the gloom of the corridor. I could hear the women weeping and the little girl whistling. The medical assistant came straight back and said:

“They consent!”

Everything inside me went cold, but I said in a loud clear voice:

“Quickly! Sterilise a scalpel, scissors, hooks and probe!”

A minute later I was running across the yard where the snowstorm birled and raged. I rushed into my room. Counting the minutes, I grabbed a book, flicked to the page, and found an illustration of how to perform a tracheotomy. Everything looked straightforward: the throat had been laid open, the scalpel inserted into the windpipe. I started reading the text but couldn’t take the words in – they seemed to be jumping around infront of me. I’d never seen anyone do a tracheotomy. “Well, it’s too late now,” I said to myself, glancing despairingly at the dark blue lamp and the smooth diagram. Feeling that I was about to undergo a terrible and fearsome ordeal, I rushed back to the hospital, oblivious of the storm.

In the surgery a dim figure in bulky skirts fastened itself to me and a voice whined:

“Sir, how can you cut a a little girl’s throat? Surely you can’t be thinking of that? She agreed to it because she’s a stupid old woman. But you don’t have my consent. You don’t. I agree to giving her medicine, but I won’t let you cut her throat.”

”Get this woman out of here” I shouted, and added from sheer spleen: “You are the stupid old woman! You! And she’s the one with brains! Who asked you anyway! Get her out of here!”

A midwife took the woman firmly and led her out of the ward.

“Ready!” announced the assistant abruptly.

We entered the small operating theatre and, as though through a glass darkly, I saw the gleaming instruments, the dazzling light, the oil cloth.… for a last time I went out to the mother. The child had to be wrenched from her arms. All I could hear was a stifled voice saying:” My husband’s gone. He’s in the city. When he comes and finds out what I’ve done, he’ll kill me!”

“He’ll kill her” the old woman echoed, shooting me a petrified look.

“Don’t allow them into the operating room,” I instructed.

We were on our own in the operating theatre: my staff, me, and Lidka the little girl. Naked, she sat on the table and wept without a sound. Then she was laid on the operating table, strapped down, her throat cleaned and swabbed with iodine. I picked up the scalpel and wondered what on earth I was doing. In the theatre it was deathly still. I picked up the scalpel and made a vertical incision down her puffy white throat. Not a drop of blood emerged. Once again I brought the scalpel down the white line that had formed on the slit skin. Again, no blood. Slowly, trying to recall the diagrams in the textbooks, I tried to part the delicate tissue with a blunt dissector. Then from some point at the base of the wound, dark blood welled up, flooded the incision in a trice and ran down the neck. My assistant began to staunch it with swabs, but the flow didn’t let up. Calling to mind everything but everything I had seen at university, I began to clamp the edges of the wound with small forceps, but this didn’t help either.

I turned cold and sweat broke out on my forehead. I bitterly regretted studying medicine at all, and ending up in this godforsaken place. In recklessness brought on by desperation, I jabbed the forceps into the area of the incision, snapped it shut and the flow of blood ceased immediately stopped flowing. We swabbed the wound with pieces of gauze; and the incision lay there before me. Clean and absolutely incomprehensible. There was no sign of a windpipe anywhere. The incision I had made resembled no illustration I had ever seen. I spent the next few minutes poking about in the wound blindly and inconsequentially, first with a scalpel, then with the probe, trying to locate the windpipe. After a couple of minutes I began to despair of ever finding it. “This is the end” I thought. “Why did I volunteer to do this? I could have kept my mouth shut about the operation and Lidka would have died quietly on the ward. Now she’s going to die with her throat cut open. And I will never be able to prove she would have died anyway, and that I didn’t harm her…”. A midwife silently wiped my forehead. “Put down the scalpel and say you don’t know what to do next” I thought. Then I pictured the mother’s eyes. I picked up the scalpel again and mechanically made a deep cut in Lidka’s throat. The tissues parted and there before me, to my great surprise, was the windpipe.

“Hooks!” I cried hoarsely.

My assistant handed them to me. I fixed a hook to each side and gave one to the assistant to hold. Now I focussed on one thing only: the greyish rings of the windpipe. I thrust the sharp scalpel into it and froze – it was rising out of the wound. I thought my assistant had taken leave of his senses: he was tearing it out. Both midwives gasped behind me. I looked up and grasped what was happening: the assistant was about to faint from lack of oxygen and, with the hook still in his hand, was tugging at the windpipe. “Everything’s against me. I thought. “Fate has it in for me. Now we’ve definitely killed her.” And as an afterthought “Once I get back to my room, I’ll shoot myself…”. Then the senior midwife, who was evidently very experienced, somehow darted over to the medical assistant, wrenched the hook from him and said through clenched teeth:

“Carry on doctor…”.

The medical assistant fell to the ground, his head thudding on the floor, but we didn’t look round. I pushed the scalpel into the windpipe and then fed a small silver tube into the incision. It slid in easily, but Lidka remained motionless. The air wasn’t entering her windpipe as it should have done. I sighed deeply and stopped: there was nothing more I could do. I felt like begging someone’s forgiveness, like repenting for my bright idea, repenting for having done medicine at all. Everyone was silent. I could see Lidka turning blue. I was ready to give up and burst into tears, when suddenly she gave a violent shudder and sprayed a fountain of disgusting lumpy matter through the tube: the air shrilled into her windpipe. As she breathed, the little girl began to sob. At that moment my assistant staggered to his feet. Pale and sweaty, he took one aghast look at the windpipe and helped me sew it up.

Through a blur of fatigue and sweat, I saw the midwives’ happy faces, and one of them said to me:

“Well, doctor, that was a brilliant operation”.

I thought she was being sarcastic and glowered at her. Then the doors were thrown open and fresh air was let in. As Lidka was being carried out wrapped in a sheet and her mother appeared in the doorway. She had the look of a wild beast about her. She was demanding to know what had happened. When I heard her voice, I felt a cold sweat run down my back when I realised what it would have been like if Lidka had indeed died on the table. But I answered her very calmly:

“Calm down, she’s alive. And she’ll survive, I hope. The only thing is we’ll have to leave the tube in for the time being. She won’t be able to talk, but don’t be frightened.”

At this point the old woman materialised from nowhere, crossing herself before the door handle, me, the ceiling. But now she no longer made me angry. I turned away and ordered them to give Lidka a camphor injection, and to take turns on duty at her bedside. Then I went back across the yard to my room. I remember the dark blue lamp burning in my office, Doderlein lying there, and piles of books stacked everywhere. I walked over to the couch, lay down on it fully clothed, and flopped out immediately. I slept the sleep of the dead.

A month passed, then another. By then I’d already seen a stack of things and some more awful than Lidka’s throat. I’d even forgotten about it. All around was snow, and my surgery got busier by the day. Then one day, already into the New Year, a woman came into the surgery holding by the hand a little girl, wrapped up as tight as a barrel. The woman’s eyes shone. I took a better look at her and recognised her.

“Ah, Lidka! So how are you doing?”

“Everything’s fine.”

We unwrapped Lidka’s throat. She was scared and cowered from me, but I still managed to lift her chin and take a look. Her pink neck bore a brown vertical scar with two fine suture marks across it.

“Everything’s fine” I said. “You don’t need to come back.”

“Thank you, doctor. Thank you” the mother said and ordered Lidka: “Say thank you to the nice man!”

But Lidka didn’t want to say anything to me.

I never saw her again and I began to forget all about her. The number of patients wanting to see me kept on growing. Then the day came when I saw one hundred and ten people. We started at nine in the morning and finished at eight in the evening. Reeling with tiredness, I was taking off my white coat when the senior midwife said to me:

“You’ve got the tracheotomy to thank for that waiting room. Do you know what they are saying in the villages? They say you gave a steel throat to Lidka when she was ill, and sewed it in instead of her own. They come to her village just to see her. That’s fame, doctor. Congratulations.”

“So they think she’s walking around with a steel throat now?” I asked.

“Yes, a steel one. And you, doctor, are a hero. You do everything so coolly. It’s marvellous!”

“Yes….well, I never let things get to me” I said, not really knowing why I’d said that. Now I was too tired even to feel ashamed. I just looked away, said good night, and went off to my room. Snow was falling in thick flakes, falling like a blanket over everything. The hospital light was burning and my house stood its own, imperturbable and imposing. And as I walked over to it I was yearning for one thing only. Sleep.

Published in The Body in the Library: A Literary History of Modern Medicine (ed. Iain Bamforth), Verso Books, 2003 ISBN9781859845349.