Cancer Ward (14 page)

After that the gamma-apparatus technicians barred her way in the corridor, and she signed their chit for them. She felt it was time to look in on the X-ray laboratory assistants, so she sat down and began to make a few calculations. Fundamental technical instructions laid it down that an apparatus should work one hour and then rest thirty minutes, but this rule had long been abandoned and all the apparatuses worked nine hours at a stretch, that is for one and a half X-ray shifts. But even with this overloading, and with the well-trained assistants rushing the patients through under the apparatus, there was still no way of fitting in as many sessions as they wanted. They had to find time for the outpatients once a day and for certain inpatients twice a day (like Kostoglotov from now on), to intensify the attack on their tumors and to speed up the turnover of hospital beds. To do this they had gone on to a twenty-milliamp instead of a ten-milliamp current, concealing the fact from the technical supervisor. This moved things along twice as fast, although the X-ray tubes obviously wore out quicker too. But even so they couldn't fit everyone in. So today Ludmila Afanasyevna had come to mark the lists—for which patients and for how many sessions the millimeter skin-protecting copper filter could be totally dispensed with (which would shorten the sessions by half), and for which a half-millimeter filter could be substituted.

After that she went up to the second floor to see how Rusanov was doing after his injection. Then she went to the short-focus apparatus room where patients were being irradiated again. She was trying to get down to her letters and articles when there was a polite knock on the door and Elizaveta Anatolyevna asked permission to speak to her.

Elizaveta Anatolyevna was just an orderly in the radiotherapy department, but there wasn't a single person there who dared address her familiarly or call her “Liza” or “Aunt Liza,” as even young doctors are used to addressing quite elderly orderlies. She was a well-educated woman who spent the hours of her night duty reading French books. For some reason she was working as an orderly in a cancer clinic and did her work very well indeed. It was true the job was paid on a time-and-a-half basis, and for a while the clinic had paid a 50 per cent supplement as radiation danger money. Now the supplement had been reduced to 15 per cent, but Elizaveta Anatolyevna still stuck to the job.

“Ludmila Afanasyevna,” she said, slightly bowing her head in apology, as excessively polite people sometimes do, “I'm sorry to trouble you with such a small thing, but it really is enough to drive one to despair. There are no cleaning rags, absolutely none. What am I to clean with?”

So here was something else to worry about! The ministry had the cancer clinic supplied with radium needles, a gamma gun, “Stabilivolt” machines, the newest blood-transfusion equipment and the latest synthetic drugs, but there was no place for ordinary rags and brooms on so elevated a list. Nizamutdin Bahramavich used to say, “If the ministry failed to allow for it, what am I to do? Buy it out of my own pocket?” At one time they used to take worn-out linen and tear it up for dust rags, but the domestic equipment department caught on and forbade it, suspecting that new linen was being plundered. Now they required all worn-out linen to be carried up and delivered to an office where an authorized commission could check it out before tearing it up.

“I have a plan,” said Elizaveta Anatolyevna. “Perhaps all of us who work in the radiotherapy department ought to bring one rag each from home. That way we'll solve the problem, won't we?”

“Well, I don't know,” sighed Dontsova. “But I suppose there's no other way. All right, I agree. Will you please suggest it to Olympiada Vladislavovna?”

Yes, and what about Olympiada Vladislavovna? How could she get her out of the seminar? It was insane to take their best and most experienced nurse off work for ten days.

She went to telephone about her, and once again she got nowhere. Then she went straight off to have a look at the patient from Tashauz. First of all she sat in the darkness to accustom her eyes. Then she looked at the barium meal in the patient's small intestine—first with him standing, then, lowering the protective screen like a table, she turned him first on one side, then on the other for photographing. Finally she ran her rubber-gloved hands over his stomach, co-ordinating his cries of “It hurts!” with the blurred tones of dim spots and shadows on the film which to her were like a code. Ludmila Afanasyevna bound all this together into a diagnosis.

Somewhere in the midst of all this her lunch break had been forgotten; she never took any notice of it or went out into the garden with a sandwich, even in summer.

At that moment somebody came to call her to a consultation in the dressings room. First of all the senior surgeon briefed her on the case history, then they called in the patient and examined her. Dontsova came to the conclusion there was only one way of saving her—removal of the womb. The patient, who was not more than forty years old, burst into tears. They let her cry for a few minutes. “But this'll be the end for me.… My husband is sure to leave me.…”

“Well, don't tell your husband what the operation is.” Ludmila Afanasyevna drummed it into her. “How will he discover? He'll never know. You can easily hide the whole thing.”

She was there to save life, no more and no less. In their clinic it was nearly always life that was at stake, nothing less than that. Ludmila Afanasyevna was unshakably convinced that any damage to the body was justified if it saved life.

Today, however much she bustled about the clinic, there was something gnawing at her self-confidence, and at her sense of responsibility and authority. Was it the pain she could clearly feel in her stomach? Some days she didn't feel it at all, other days it was weaker, but today it was stronger. If she wasn't an oncologist she'd have dismissed it or else had it investigated without fear. But she knew the road too well to take the first step along it: to tell her relatives, to tell her colleagues. When it came to dealing with herself she kept herself going with typical Russian temporizing: Maybe it'll go away. Maybe it's only my nerves.

But it wasn't just that, it was something else that had been gnawing at her all day, like a splinter in the hand, faintly but persistently. Now that she was back in her own little den, sitting at her own table and reaching out for the file on “Radiation Sickness” which the observant Kostoglotov had noticed, she realized that all day she had been more than upset, really wounded by that argument with him about the right to treat.

She could still hear his words: “Twenty years ago you gave radiation treatment to some old Kostoglotov who begged you not to do it. You didn't know about radiation sickness then!”

And in fact she was due shortly to give a lecture to the society of X-ray specialists on “The Late Aftereffects of Radiotherapy.” It was almost exactly what Kostoglotov had reproached her with.

It was only recently, a year or two ago, that she and other X-ray specialists here and in Moscow and in Baku had begun to observe certain cases that could not immediately be understood.

A suspicion arose. Then it became a guess. They began to write letters to each other and to speak about it, not in lectures at this stage but in the intervals between lectures. Then somebody read a paper in an American journal, and somebody else read another. The Americans had something similar brewing. The cases multiplied, more and more patients came in with complaints, until suddenly it was all given a name: “The late aftereffects of radiotherapy.” The time had come to speak of them from the rostrum and to reach a decision.

The gist of it was that X-ray cures, which had been safely, successfully, even brilliantly accomplished ten or fifteen years ago through heavy doses of radiation, were now resulting in unexpected damage or mutilation of the irradiated parts.

It was not so bad, or at any rate it was justifiable, in the case of former patients who had been suffering from malignant tumors. Even today there would have been no other solution. They had saved the patient from certain death in the only way possible; they had given large doses because small doses would not help. And if the patient reappeared today with some sort of mutilation, he had to understand that this was the price he must pay for the extra years he had already lived, as well as for the years that still remained ahead of him.

But then, ten, fifteen or eighteen years ago, when the term “radiation sickness” did not exist, X-ray radiation had seemed such a straightforward, reliable and foolproof method, such a magnificent achievement of modern medical technique, that it was considered retrograde, almost a sabotage of public health, to refuse to use it and to look for other, parallel or roundabout methods. They were afraid only of acute, immediate damage to tissue and bone, but even in those days they rapidly learned to avoid that. So—they irradiated! They irradiated with wild enthusiasm! Even benign tumors. Even small children.

And now these children had grown up. Young men and young women, sometimes even married, were coming with irreversible mutilations of those parts of the body which had been so zealously irradiated.

Last autumn a fifteen-year-old boy had come in, to the surgical not the cancer wing, but Ludmila Afanasyevna had heard about the case and had managed to have a look at him. The arm and leg on one side of his body had not kept pace in growth with the other, and the same applied to the bones of his skull, so that from top to bottom he looked bow-shaped, distorted like a caricature.

Ludmila Afanasyevna had checked his case records and identified him as a two-and-a-half-year-old boy who had been brought into the clinic by his mother with multiple lesions of the bones and disturbed metabolism. No one knew the origin of the lesions, but they were certainly not of the tumor type.

The surgeons had sent him to Dontsova on the offchance that X rays might help. Dontsova had taken charge of the case and X rays had indeed helped—so much so that the mother wept with joy and promised she would never forget the woman who had saved him. And now he had come in alone—his mother was no longer alive—and no one had been able to do a thing for him. Nobody could take that early dose of irradiation out of his bones.

Quite recently, no later than the end of January, a young mother had come in complaining that her breast gave no milk. She hadn't come straight to Dontsova but had been sent from one department to another until finally she reached oncology. Dontsova did not remember her, but in the clinic the card index of cases was kept permanently. So someone went to the records annex, rummaged around and found her card, dated 1941. It emerged that she had come in as a child and had lain trustingly under the X-ray tube for treatment of a benign tumor no one would dream of using X rays on today.

All Dontsova could do was make an addition to the old card. She wrote that the soft tissues had become atrophied and that as far as she could see it was a late aftereffect of radiotherapy. Of course no one told the deformed youth or the cheated mother that they had been incorrectly treated as children. Such an explanation would have been useless from the personal point of view, while from the general standpoint it might have done great harm to health propaganda among the population.

But these incidents had greatly shocked Ludmila Afanasyevna. They had left her with a gnawing feeling of deep-rooted and unpardonable guilt. And it was right there that Kostoglotov had struck home today.

She crossed her arms, hugging her shoulders, and walked round the room from door to window and back again, across the free strip of floor between the two apparatuses that were now switched off.

Was it possible? Could the question arise of a doctor's
right
to treat? Once you began to think like that, to doubt every method scientifically accepted today simply because it might be discredited or abandoned in the future, then goodness knows where you'd end up. After all there were cases on record of death from aspirin. A man might take the first aspirin of his life and die of it! By that reasoning it became impossible to treat anyone. By that reasoning all the daily advantages of medicine would have to be sacrificed.

It was a universal law: everyone who
acts
breeds both good and evil. With some it's more good, with others more evil.

Reassure herself as she might—she knew that these accidents, combined with cases of mistaken diagnosis and of measures taken too late or erroneously, comprised no more than perhaps 2 per cent of her activity, while those she had healed, the young and the old, the men and the women, were now walking through plowed fields, over the grass, along the asphalt, flying through the air, climbing telegraph poles, picking cotton, cleaning streets, standing behind counters, sitting in offices or teahouses, serving in the army and the navy; there were thousands of them, not all of whom had forgotten her or would forget her—and yet she knew that she would sooner forget them all, her best cases, hardest-won victories, but until the day she died she would always remember the handful of poor devils who had fallen under the wheels.

It was a peculiarity of her memory.

No, she couldn't do any more preparation today for the lecture. The day was nearly over anyway. Perhaps she should take the file home? No, she'd taken it home and brought it back to work hundreds of times, she knew it wouldn't do any good.

This was what she had to find time to do though: she had to finish
Medical Radiology
and return it to the library, then read a few short articles, then write and answer that inquiry from the
feldsher
in Tahta-Kupir.

The light through the gloomy windows was getting bad, so she lit her table lamp and sat down. One of her internes, who had already changed out of her white coat, looked in: “Aren't you coming, Ludmila Afanasyevna?” Then Vera Gangart dropped by: “Aren't you coming?”

“How's Rusanov?”

“He's asleep. He didn't vomit but he's running a temperature.” Vera Kornilyevna took off her close-buttoned white coat. She was left in a gray-green taffeta dress, too good for working in.