Howard Fischer
Uppsala, Sweden

“During the years of war and revolution it was hard to find a hospital without morphine-addicted patients.”¹
– Vladimir Gorovoy-Shaltan, physician specialist in addiction medicine

Mikhail Afanasyevich Bulgakov (1891–1940) was a Russian physician, novelist, and playwright. He earned his medical degree from the University of Kiev (now Kyiv) in 1916. In 1919 he contracted typhus, probably from a patient, and in 1920 he stopped practicing medicine and became a full-time writer, starting out as a journalist in Moscow. He wrote a dozen novellas and short stories, three novels, and four plays. The best known of his works is the long novel The Master and Margarita, begun in 1928, finished in 1940, and finally published posthumously in the USSR in 1973. He was a critic of communism, and much of his work was banned in the Soviet Union.² His story “Morphine” (1927) was the last of his writings published in the USSR in his lifetime.³

Bulgakov served as a physician in the Russian army during the Great War. Later, he was sent to an isolated rural clinic and was the only physician. His own initial contact with morphine was either for pain relief from injuries received during the war or for the treatment of a painful reaction to an injection of anti-diphtheria serum, which he needed after a close exposure. Both versions of this story are told by authors writing about Bulgakov.^4,5,6

“Morphine,”⁷ a thirty-page story, begins with Dr. Bomgard, a physician in a hospital in a small village, getting a desperate letter from Dr. Sergei Polyakov, a former classmate, asking for help. Polyakov is working in the isolated rural clinic where Bomgard had recently worked. Bomgard makes plans to travel there the next day, but during the night, Polyakov is brought into the casualty department, dying of a self-inflicted gunshot wound. Before dying, he gives Bomgard his diary, covering the past year (January 1917 – February 1918). The diary describes Polyakov’s addiction to morphine after a medically necessary first dose and a possibly necessary dose the following day. Polyakov steals and uses morphine from the clinic’s pharmacy. He starts injecting himself—the first two doses were administered by the clinic’s nurse—increasing the strength of the drug and the frequency of administration.

Within two months, his nurse recognizes that he is addicted, but he denies it. He tries to end his addiction by substituting cocaine for morphine but is unsuccessful. He increases his morphine dose, visits pharmacies in other villages to buy morphine “for his clinic,” and gets “funny looks” from pharmacists. He continues increasing his dose. Without morphine he is depressed, irritable, forgetful, and thinks only about obtaining more morphine. Eleven months after his first dose, he enters a detoxification ward in a Moscow hospital, but steals morphine from their pharmacy and leaves to go back to resume his practice. Polyakov starts having visual and later auditory hallucinations. He is weak, his hands tremble, and he has lost 20 kg (down to 54 kg). He thinks that “attempting a cure now would kill me” (January 1918). He is covered with abscesses at the injection sites on his arms and thighs. His self-pity and despair grow, and he shoots himself in the heart.

Bulgakov did, in fact, in 1915 witness a close friend unexpectedly fatally shoot himself.⁸ It is interesting to note that in Czarist Russia, alcohol (for consumption) was not legally sold during World War One, which may account for the significant increase in drug use. Drug use declined to prewar levels in 1924 when “prohibition” ended.⁹

The “official view” of Bulgakov’s own morphine addiction is that it lasted from 1914–1918, when he successfully stopped being dependent.¹⁰ There were, however, “widespread rumors in Russia” that he remained addicted his entire life.¹¹ Supporting this notion is a 2016 article about the surface of the last draft of The Master and Margarita being tested for the presence of morphine, which was found in trace amounts.¹²

In 2008, “Morphine” (Morfii) was filmed in Russia. To create a full-length film from thirty pages of a doctor’s diary, the filmmakers also used some of Bulgakov’s other medical stories that portrayed a doctor’s life in rural Russia. Dr. Polyakov saves the life of a child asphyxiating from diphtheric croup by performing a tracheotomy and inserting a canula (“The Steel Windpipe”). He performs a “podalic version” maneuver to change the transverse position of a fetus so that the child can be delivered (“Baptism by Rotation”). He must, and does, amputate the leg of a young girl who fell into a farm machine (“The Embroidered Towel”), and shoots at a menacing wolf pack during a nighttime sleigh ride to a patient’s cottage in a blizzard (“The Blizzard”). The well-acted film resembles the short story regarding the morphine addiction, with the escalating doses, the dependence, and the suicide.

“Morphine” (the novella) has also been seen as an example of the “conflicting roles” a doctor has when becoming a patient. Doctors, when ill, seek care later than others, tend to self-medicate, abuse narcotics, and take less sick leave.¹³ One Swedish physician writes, “If one wants to understand something about the relentlessness of addiction, this a priceless source of information.”¹⁴

References

1. Oleg Yegorov. “Flying high: how did revolutionary Russia become drug-addicted.” Russia Beyond, Aug. 17, 2017. https://rbth.com/politics_and_society/society/2017/08/19/flying-high-how-did-revolutionary-russia-become-drug-addicted_824760.
2. “Mikhail Bulgakov.” Wikipedia.
3. Lesley Milne. Mikhail Bulgakov: A Critical Biography. Cambridge: Cambridge University Press, 1990.
4. Victoria Tischler. “Dr. Junkie. The doctor addicts in Bulgakov’s Morphine: What are the lessons for contemporary medical practice?” Journal of Medical Humanities, 36(4), 2015.
5. Yegorov. “Flying high.”
6. “Mikhail Bulgakov.” Wikipedia.
7. Mikhail Bulgakov. A Country Doctor’s Notebook. London: Harvill Press, 1975.
8. Milne. “Critical biography.”
9. Yegorov. “Flying high.”
10. “Mikhail Bulgakov.” Wikipedia.
11. Dimitris Michalopoulos. “Mikhail Afanasiyevich Bulgakov, his life and his book,” International Journal of Russian Studies, 2(3), 2014.
12. Gleb Zilberstein et al. “Maestro, Margarita, morphine: The last years in the life of Mikhail Bulgakov,” Journal of Proteomics, 131, 2016.
13. Jonatan Wistrand. “Läkaren som patient – en beskriven rollkonflikt,” Socialmedicinsk Tidskrift, 3, 2016.
14. PC Jersild. “Tre ryska klassiker inspirerar dr Jersild,” Läkartidningen, 94, 1997.