Gynecology and obstetrics
University of Split, Croatia
This essay is reprinted from Medicine from Inside (Medicina iznutra) by Matko Marusic, 2006, and translated from Croatian into English by Dr. Mario Malicki.
A mountain farmer’s voice reached me from the window of the student hall: “We cannot play on Saturday.”
I could not believe it! I had arranged for a soccer match on Saturday, “Dalmatians vs. Bosnians,” and now they were canceling the game!
“Are you out of your mind?! Who's gonna' arrange a new game? My Saturday will go to waste!”
At the time, I had been organizing soccer games for a group of students from Dalmatia, a region of Croatia. In those days you could not do it by phone or email, but by foot or by tram, going from one player to the other, making tough negotiations that could not later be broken. I think that the tradition of missing a game as most dishonorable behavior most likely arose from the difficulties in organizing such matches. Nowadays this is different, for students and even children have cell phones and think it not dishonorable to cancel a game at the last minute. But in my time, a cancelled game was viewed as a defeat for the canceling side, regardless of what excuses were made. So why was this passionate and responsible soccer player cancelling a match from the window of the student hall?
“We can't play. We'll recognize your victory if you insist.”
“What do we need the stupid victory for?! What the hell is wrong with you? You are not some wimpy nerds. Bosnians cancel exams, not soccer matches!”
“We can't play. Two of our players are in the hospital.”
“I don’t believe you! You are all chiseled from mountains; your people don’t go to hospitals.”
“Come on,” he said, and with a mysteriously lowered voice he waved me to his room.
There, with the trained voice used by storytellers who secretly talked of the prosecutions of Croatian Catholics that occurred most viciously in Bosnia and Herzegovina, a voice tuned to tell terrible secrets, he revealed the mystery that justified canceling the game: Two of their best players, from the highest of mountains, from the most persecuted Croatian Catholic families, and with the largest and assuredly thickest heads, had hit their heads, simultaneously, on the same iron table, had fainted, and had ended up in hospital (after a long wait in the students’ polyclinic).
But how could this happen? How could two huge, healthy medical students hit their heads on an iron table and end up in a hospital? Well, they were attending their first practical gynecology teaching session and were pushing their way to the first row, ignoring the protests that the size of their heads evoked from other students. A nurse brought in, on some kind of iron table with wheels, an old patient with a gynecological cancer. As soon as the professor began his examination, all the men in the front row fainted—but only two hit the edge of the iron table in their free-fall and ended up in hospital.
They clearly could not play, despite the best intentions. Besides, there was little point in playing with lacerated scalps when their heads were their team’s best assets. I have to admit I felt a bit relieved: their fantastic head shots worried me; none of our players were so tall or had such perfectly chiseled round heads from which the ball could rebound in any desired direction. So I forgave the Bosnians for their cancellation, on condition they would show up for the next match, despite any practicals they might have. Unfortunately, we never played our match, for we had to graduate, and then serve in the army, and then half of their team went to work in Germany, never to return.
Shortly thereafter, my own gynecology practical lessons began. The professor brought in the same patient. But my previous experience with the Bosnian soccer incident saved me from fainting. As soon as my vision began to blur, I turned my eyes toward the most beautiful female student in the group. But that made me feel even worse, and so I looked toward a tall colleague—also a soccer player—only to watch him faint. Managing to hold on to him, I felt the dizziness leave us both. I even earned a compliment for being clear-headed. Given the political climate of the time, the professor had been anxious that the previous incident not repeat itself. Realizing the trouble that would ensue if yet another male student were to fall—especially the Communist party youth leader, whom I had just rescued—he gave up presenting cancer patients from that point forward. Party youth leaders were not expected to pass out, hitting their heads on hard iron tables.
The practical rounds then became simpler, as we examined only women coming in for abortions. A nurse helped the Communist party leader and me to put on gloves, impatiently and with disregard for sterile conditions, the whole atmosphere making it impossible to relax or gather our senses. The woman was already lying on the table, and we avoided looking her way. The junior physician was explaining how we are supposed to do the examination and what we are supposed to feel, when the woman said with a clear, cultured, and determined voice, “I do not want to be examined by students!”
The possibility of skipping out on the examination overcame our feeling of fear and humiliation. We merrily clasped our right hands, which were already prepared for vaginal exam, hid them behind our backs, and prepared ourselves for an honorable dismissal.
“Lady Comrade, they are the commission—the assistant said politely and coldly to the woman. She immediately lowered her head in approval.”
The title of members of commission for abortion approval was granted to us on the basis of legal grounds, which stated that abortions for unwanted pregnancies had to be approved by a commission that declared the abortion necessary. This made us enormously important to the woman, despite our nerdy looks, our uncontrollably shaking hands, and our averted gaze. The woman now accepted us with an amazing calm, and so we, one by one, examined her, feeling nothing of what we were supposed to feel. And so the whole thing happily ended as I swore to myself that I would never be a member of such a commission.
The assistant authoritatively concluded that the commission approved the abortion, and then performed the exam himself while the two of us watched on. We left the practical without asking to be excused, determined never to come back. We drank grappa and talked of life. We decided we would forever maintain that only women should be allowed to become gynecologists, contrary to the advocates of the male-chauvinist theory that men would make better gynecologists as they had longer middle and second fingers.
In my obstetrics practical exam I had a woman with a breech presentation, meaning the child was coming out bottom first. This is a serious problem, as the hard bony head paves a proper canal for the child, while the soft buttocks expand it only slightly, making the childbirth dangerous for both child and mother. I knew all this, theory was not the problem. I felt the child’s foot—wonderful small toes, a small angelic foot, and a difficult birth ahead. I said it was the foot, and the professor looked at me coldly and disappointingly—one does not say “foot” but “breech birth with a leg presentation.” But I still felt that sweet soft foot on my hand, the foot of a creature, of a mother struggling in pain and of a father unaware of what his loved one was experiencing. And what gives anyone the right to touch a child’s foot while it is still in its mother’s womb, or to touch that beautiful, pale, exhausted, screaming, and sighing woman?
But within the world of obstetrics, one soon discovers interesting and beautiful things: for instance, the nurses, without whom the babies would fall off the table—for no man would know what to do. These nurses are called midwives and are the most amazing creatures: they know and can do everything, and they call the doctors only out of politeness, only to do surgery (a cesarean section) or a vacuum extraction, or to pull a baby out if all is not going as planned. Everything else is done by midwives, exquisitely, properly, and with a female touch. It seems that the only reason they do not throw doctors out of the delivery room is a certain female respect toward elderly men. Toward young doctors they have no such respect; young doctors eagerly wait to be dismissed, so that they would not have to do that indescribably responsible, vital, intimate, horrible, and unbearably exciting work.
One also discovers that pregnant women are extremely beautiful. They may have large bellies, but their bellies are white, smooth and beautiful, more beautiful than any dress that pregnant women may wear. They may be puffed; they may be scared; they may have eye bags and scream in pain. Yet only in the delivery room can one see a woman when she is completely serious, honest, and dedicated to something she believes in without doubt or reserve. Only here can one see how strong a woman is, how beautiful, and how holy.
The screaming never stops, the delivery room is always full, and each moment is colored by screams of more than one woman. But that is only on the surface; each woman’s surroundings are clearly defined: she has someone by her side or no one, as she awaits the midwife’s arrival. She knows she has six hours to go, that her cervix has just started to dilate, and that she does not need to scream at the top of her voice just yet, there are still six hours left, and she needs to save her screaming for the last few minutes.
And only when the cervix is dilated for a full palm width is the doctor is called, out of respect. The doctor comes right away, and when he hears how dilated she is, he boastfully announces that the childbirth is almost done. The midwife then takes over. Only at the end the doctor bears down on the stomach of a pregnant woman, stressing how that is a man’s job, as a man is stronger and heavier. But this is just a formality, as the midwife does it all, shouting “push, push” and “now, now” and “don’t push, don’t push” and “breathe, breathe.” The pregnant woman then breathes exactly the way she had been taught in her maternity classes—which during the delivery she has entirely forgotten, along with her own name and that of the damned husband’s, whose fault this all is. Were it not for midwives, women would be breathing incorrectly and pushing incorrectly and there would be no one to tell the doctor when to perform the perineotomy.
And so, slowly, that magical, bittersweet world of the delivery room opened before me. Pretty soon I stopped being afraid, even ashamed. No one noticed me. With a mask on my face, no one asked me what I knew or didn’t know. But I used caution when approaching the woman when she was in the company of the midwife. I once found myself screaming alongside one woman, exactly when she was pushing, and the head appeared, and the midwife was shouting “push, push, now, now.” No one heard me, no one took offense, and my screaming seemed natural, a kind of participation or help. And so I screamed all night, throughout my shift, till the early morning hours, but only at the exact moment when the head would appear and the woman would scream the most, and when the midwife would shout the most, and the doctor would take his horrid, huge, shiny scissors up in the air . . . .
And then a child is born. Everything is colored with lights and reflectors, everything soaked in blood and excrement, everyone shouting—and, for the mother, everyone except the midwife disappears. Then when the head comes out, the midwife performs an important procedure. Using both hands, she takes the child’s bloody, gluey, indescribably sweet and precious head; by putting her fingers on the small cheeks, firmly as a midwife and gently as a mother she turns the child's head on its side. And then the child’s body is born, as if by magic, and it looks as if it would say: “Well, why didn’t you turn my head at the beginning?”
With one hand the midwife grabs both feet of the child (placing her finger between the legs not to crush them), lifts the child up and gently slaps it on the buttocks, and then that small, bloody and slimy creature lets out a cry, and when it cries, so do I. There is no more screaming and no nonsense, this is more holy than baptism.
Not to spoil the beauty of the moment before the child is lifted, the doctor jumps in to cut the umbilical cord, tying it tentatively, to be completed by the midwife. Even bloody and distraught, the mother wants to hold the child immediately, but it is not the time yet. The midwife cannot be sidetracked: the child angrily screams with its absurdly weak voice, becoming red due to the strain—one cannot tell if it is blood or the color of the skin. The midwife takes it on the side, puts it in some kind of a drawer and yells its height and length. And then she firmly and gently wipes it, covers it in innocent white garb and holds it in her arms in a way that has been practiced and written in the genes since the beginning of time.
Then the mother suddenly transforms into another creature! Into a real, the most real of women! A complete metamorphosis. No longer in pain, she does not care if she is bleeding or if the placenta is out or not. The eye bags disappear, the tears dry off, the body takes a proper posture, and the honest male realizes that no one of his gender will ever understand the true pain and difficulty of childbirth. When the midwife and the mother bond in sisterhood, men step back. They know they are no longer needed (and never were). We depart. We dare not ask if we may kiss the child.
As the morning trams emerged on to the streets, the midwife would send me and my colleague home. We readily washed ourselves, changed our clothes, and stepped into the cold foggy Zagreb morning. We both sighed in wonder, as if we had just fought off a tank assault barehanded. We almost stopped at the train station’s bar for a drink, even so early in the morning.
Gynecology and obstetrics is the most concrete and the hardest of medical professions! Obstetrics is a practical branch, and obstetricians work in blood, in sweat, in screams and pain, in suffering, shame, and urgency. At the examination, theoretical questions were not at all difficult. But the baby’s foot was still giving me trouble; the professor could not forgive me for mixing it with breech birth with legs presentation. I was not ashamed of my mistake, but of my audacity. Thoughtlessly, I had touched that poor, small, gentle, beautiful, foot with its small toes, and I surpassingly recognized them and kept my peace, gently caressed them, and apologized. I did not want to admit that that beautiful small foot was a breech birth, and I got a “B.” For my academic transgression, I deserved this “B,” and yet, given the opportunity, I would have done it all over again.
MATKO MARUSIC, MD, PhD, served for many years as a professor of physiology and immunology in Zagreb University School of Medicine and in 2008 transferred to University of Split School of Medicine. He has published four fiction books. This essay, translated from Croatian, is a story from his 2006 book Medicine from Inside (Medicina iznutra), a 630-page anthology of 31 humorous stories about medicine. This excerpt is based on his experiences as a medical student at Zagreb University School of Medicine from 1965 to 1970. Zagreb, now the capital city of Croatia, was part of Yugoslavia at the time of Dr. Marusic’s studies. Croatia remained under Communist rule until 1990. The author’s hometown is Split, on the Adriatic coast, some 200 miles south of Zagreb. The long-time residence of his parents, Split remains Dr. Marusic’s home.