HISTORY OF MEDICINE
Femi Oyebode*
National Centre for Mental Health, University of Birmingham, Birmingham, United Kingdom
Anton Chekhov was born on 16 January 1860 in Taganrog, the third child in a family of seven children. His grandfather was a serf. Chekhov was enrolled as a medical student at the Moscow University Medical School in 1879 and graduated in 1884. He practised medicine throughout his life, and he indicated how special medicine was to his approach towards literature.
In a letter to G.I. Rossolimo from Yalta on 11 October 1899, he wrote [1]:
I have no doubt that the study of medicine has had an important influence on my work; it has considerably enlarged the sphere of my observation, has enriched me with knowledge the true value of which for me as a writer can only be understood by one who is himself a doctor.
In this reference to the value of being a doctor to his writing, I believe that Chekhov is talking about the fact that in his descriptions of medical situations and of clinical encounters within his short stories, there is indubitable accuracy and verisimilitude that is often not the case with writers without a medical background. And he is emphasising that only a medical person would appreciate this aspect of his writing. That is not to say that his descriptions that deal with medical matters are ever tedious or unduly technical, rather that he is careful to ensure that his accounts are factually correct.
He further discussed the importance of accuracy in other letters. He wrote to D.V. Grigorovitch in 1887 [1]:
I have just read ‘Karelin’s Dream’ and I am very much interested to know how far the dream you describe really is a dream. I think your workings of the brain and of the general feeling of a person who is asleep are physiologically correct and remarkably artistic. I remember I read two or three years ago a French story, in which the author described the daughter of a minister, and probably without himself suspecting it, gave a correct medical description of hysteria. I thought at the time that an artist’s instinct may sometimes be worth the brains of a scientist, that both have the same purpose, the same nature, and that perhaps in time, as their methods become perfect, they are destined to become one vast prodigious force which now it is difficult even to imagine.
And in another letter, this time addressed to A.S. Suvorin, his friend and publisher, dated 15 September 1888, Chekhov wrote:
My ‘Party’ has pleased the ladies. They sing my praises wherever I go. It really isn’t bad to be a doctor and to understand what one is writing about. The ladies say the description of the confinement is true [emphasis in the original]. In the story for the Garshin sbornik I have described spiritual agony.
This view regarding the importance of medicine to his writing belies the tension there was between the writer in him and the doctor who continued to practice medicine, until his death. In another letter to A.S. Suvorin, he wrote on 11 September 1888 [1]:
…You advise me not to hunt after two hares, and not to think of medical work. I do not know why one should not hunt two hares even in the literal sense…I feel more confident and more satisfied with myself when I reflect that I have two professions and not one. Medicine is my lawful wife and literature is my mistress. When I get tired of one I spend the night with the other. Though it’s disorderly, it’s not so dull, and besides neither of them loses anything from my infidelity. If I did not have my medical work I doubt if I could have given my leisure and my spare thoughts to literature. There is no discipline in me.
His short stories often dealt with the lives of sick people, the power of doctors in clinical situations and the implications of their work for others and sometimes, for themselves, and occasionally dealt with the ethical dimensions of clinical practice. In such stories as ‘The Bishop’, ‘The story of a nobody’, ‘Ward No. 6’ and ‘The Black Monk’, he explored issues that continue to be of interest to doctors: what the features of delirium are, the denervating effect of tuberculosis (TB) on the sufferer, the restrictive and inhuman environment of mental asylums and the impact of bipolar disorder on personal life, respectively.
Chekhov’s short stories are important because they illustrate much of what the medical humanities, this new and emerging discipline, argue for, namely the creation of space for the subjective in medical education and practice. I mean by this, the need to enrich medicine by an approach that allows the subjective experience of the patient to be given validation and weight within the clinical encounter. At present, objectivity that detached scientific method has come to dominate medicine to the exclusion of what disease means for the patient. There is an assumption that generalising principles are far more important than subjective experience and accounts. The humanities emphasise the humane and the particular in contrast to the cold and general.
I want now to focus on Chekhov’s writing about the cholera epidemic of 1892. I draw on his letters partly to show that the medical humanities rely as much upon fictional and autobiographical accounts as they do on letters and journals. Chekhov’s thoughts on the cholera epidemic of 1892 are particularly relevant today, as the whole world confronts the tragedy of the coronavirus disease 2019 (COVID-19) pandemic, a truly unprecedented state of affairs that has had extraordinary impact on life in general and caused desperate hardship and grief. These adverse effects have also been borne particularly by healthcare workers including doctors. It has been estimated by Amnesty International [2] that by September 2020, over 7,000 healthcare workers had died, and this included 1,320 in Mexico, 1,077 in USA, 634 in Brazil, 240 in South Africa and 573 in India. Hence, Chekhov’s account is relevant in that it illustrates what a practising doctor’s experience of an epidemic is like.
Chekhov moved with his family to Melikhovo, an estate 45 miles from Moscow in 1892. This was also the same year of the cholera epidemic that is estimated to have claimed 267,890 Russian lives. This was a lesser epidemic compared to the third cholera pandemic (1846–1860) that is thought to have originated in India and which claimed the lives of 1 million people in Russia alone. In London, 10,000 people died, and in Great Britain, 23,000 people in total died. It is a famous pandemic in Britain because it is associated with Jon Snow’s discovery of the role of a single water pump in one neighbourhood in Soho in the spread of cholera.
Chekhov’s role in the fight against the 1892 pandemic is described in letters to his friend and publisher Alexey Suvorin. These letters show Chekhov the doctor and not merely Chekhov the writer but also illustrate the tension between the two roles. It is worth remarking that Chekhov suffered from TB of the lungs practically all of his adult life and that his immense contributions to literature and the physical burden of medical practice all occurred within this context. The symptoms of TB first became obvious in 1884 as he was graduating from medical school, but he ignored the symptoms, if not denied them. In a letter to Alexey Suvorin on 20 May 1890, he wrote [1]:
I shall nevertheless start from the beginning. They told me in Tyumen that there would be no steamer to Tomsk until 18 May. I had to take horses. For the first three days every joint and tendon in my body ached, but then I got used to it and had no more pain. But as a result of the lack of sleep, the constant fussing with the luggage, the bouncing up and down and the hunger, I suffered a haemorrhage that rather spoilt my mood, which was not in any case particularly sunny.
Earlier that month, on 16 May, he had written to his sister, Misha, from Tomsk [1]:
From the first three days of my journey my collarbones, my shoulders and my vertebrae ached from the shaking and jolting. I couldn’t stand or sit or lie…But on the other hand, all pains in my head and chest have vanished, my appetite has developed incredibly and my haemorrhoids subsided completely. The overstrain, the constant worry with luggage and so on, and perhaps the farewell drinking parties in Moscow, had brought on spitting of blood in the mornings […].
These two letters were written whilst Chekhov was travelling to Siberia, specifically to the convict camps at Sakhalin to study the life and health of convicts. This was a journey of thousands of miles. But the point is, he was already suffering from TB. In other words, he was not physically robust yet had taken on a physically demanding task. Surprisingly, for a doctor, he seemed not to be aware of the real cause of his coughing up of blood, a well-known sign of severe lung infection with TB. What is important is that despite this disease and the known deleterious effects on stamina, energy and motivation, he wrote and published the stories and plays that he is rightly recognised for.
Now, to turn to Chekhov’s role in the cholera epidemic of 1892, it is justifiable to say that he worked jointly with others to try to limit the effects of the epidemic. He wrote to Alexey Suvorin on 1 August 1892 [1]:
[…] there is cholera in Moscow and about Moscow, and it will be in our parts some day soon. In the second place, I have been appointed cholera doctor, and my section includes twenty-five villages, four factories, and one monastery. I am organizing the building of barracks, and so, and I feel lonely, for all the cholera business is alien to my heart, and the work, which involves continual driving about, talking, and attention to petty details, is exhausting for me. I have no time to write. Literature has been thrown aside for a long time now; and I am poverty-stricken, as I thought it convenient for myself and my independence to refuse the remuneration received by the section doctors.
Here we see the extent of his responsibilities and the administrative requirements of being in charge. And there is also description of how the new responsibilities interfered with his true purpose which was literature. Nonetheless, he persevered with his responsibilities. Chekhov wrote, too, about the beneficial effects of medicine as a benevolent project, about the technically interesting aspects of a deadly disease such as cholera. This sentiment is, of course, mirrored today as we marvel at what medicine and science can achieve, witness the invention of new methods of developing vaccines and the rapid re-purposing of old drugs to stem the rise in deaths [1]:
I am bored, but there is a great deal that is interesting in cholera if you look at it from a detached point of view […] At the fair at Nizhni they are doing marvels which might force even Tolstoy to take a respectful attitude to medicine and the intervention of cultured people generally in life. It seems as though they had got a hold on the cholera. They have not only reduced the number of cases, but also the percentage of deaths. In immense Moscow the cholera does not exceed fifty cases a week, while on the Don it is a thousand a day-an impressive difference.
Then there is the disparity in the resources available to district doctors such as Chekhov in contrast to the doctors practising in Moscow. This account reminds us too of the differences in resources between the West and the lower- and middle-income countries. This is illustration of the fundamental injustice in the distribution of resources in the world and the real-world fatal consequences of these disparities. These self-same disparities are on show within countries too and are demonstrable in the unequal impact of deaths across economic classes [1]:
We district doctors are generally ready; our plan of action is definite, and there are grounds for supposing that in our parts we too shall decrease the percentage of mortality from cholera. We have no assistants, one has to be doctor and sanitary attendant at one and the same time. The peasants are rude, dirty in their habits, and mistrustful; but the thought that our labours are not thrown away makes all that scarcely noticeable. Of all the Serpuhovo doctors I am the most pitiable; I have a scurvy carriage and horses, I don’t know the roads, I see nothing by evening light, I have no money, I am very quickly exhausted, and worst of all, I can never forget that I ought to be writing, and I long to spit on the cholera and sit down and write to you, and I long to talk to you. I am in absolute loneliness […] Nothing has been heard of cholera riots yet. There is talk of some arrests, some manifestoes, and so on […].
Chekhov’s exhaustion, his complaint about his working conditions and the self-pity that very clearly comes through in his letter once again point to the under-reported but true exhaustion in today’s healthcare workforce and the emotional burden of relentless work in the face of a lot of dying.
On 16 August, Chekhov wrote [1]:
[…] Well, I am alive and in good health. The summer was a splendid one, dry, warm, abounding in fruits of the earth, but its whole charm was from July onwards, spoilt by news of the cholera […] While you were inviting me in your letters to Vienna, and then to Abbazzio, I was already one of the doctors of the Serpuhovo Zemstvo, was trying to catch the cholera by its tail and organizing a new section full steam. In the morning I have to see patients, and in the afternoon drive about. I drive, I give lectures to the natives, treat them, get angry with them, and as the Zemstvo has not granted me a single kopeck for organizing the medical centres I cadge from the wealthy, first from one and then from another. I turn out to be an excellent beggar, thanks to my beggarly eloquence, my section has two excellent barracks with all the necessaries and five barracks that are not excellent but horrid. I have saved the Zemstvo from expenditure even on disinfectants. Lime, vitriol and all sorts of stinking stuff I have begged from the manufacturers […].
The anger at the ‘natives’ as Chekhov puts it is very present today too, in the feelings of anger of over worked doctors and nurses, directed at anti-vaxxers and people who claim that COVID-19 is a hoax, at the people who fail to stick to the rules of social distancing and the wearing of masks that are meant to limit the spread of the disease. But, at least in the rich West, healthcare workers are not required to raise money in order to provide care or to rely the altruism of businesses or charities. The same is not true for the rest of the world, though. The extent of the preoccupying force of the pandemic in colonising the attention and concern of doctors and other healthcare professionals is well illustrated in Chekhov’s writing [1]:
My soul is exhausted. I am bored. Not to belong to oneself, to think about nothing but diarrhoea, to start up in the middle of the night at a dog’s barking and a knock at the gate … to drive with disgusting horses along unknown roads; to read about nothing but cholera, and to expect nothing but cholera, and at the same time to be utterly uninterested in that disease […].
There is also the distinction between the theory of a disease and the fact of its brute presence. Where one might be intellectually elegant, the harsh reality of the disease ravaging a population is another matter entirely. Chekhov wrote not only about his delight in medical advances but also about the moral dilemma involved in focusing on the individual at the expense of the population at large. In Manaus, Brazil, in the context of inadequate intensive care beds and extremely limited supply of oxygen, the same dilemma is being re-experienced [1]:
I was overwhelmed with enthusiasm when I read about the cholera. In the good old times, when people were infected and died by thousands, the amazing conquests that are being made before our eyes could not even be dreamed of. It is a pity you are not a doctor and cannot share my delight – that is, fully feel and recognize and appreciate all that is being done. But one cannot tell about it briefly. The treatment of cholera requires of the doctor deliberation before all things – that is, one has to devote to each patient from five to ten hours or even longer. As I mean to employ Katani’s treatment- that is clysters of tannin and sub-cutaneous injection of a solution of common salt – my position will be worse than foolish; while I am busying myself over one patient, a dozen can fall ill and die […].
In Chekhov’s case, the epidemic came to an end, and he could write that his station had closed. This is not yet something that we can say in our own time, the vaccination programme notwithstanding. On 18 October, Chekhov wrote [1]:
I have undertaken to be the section doctor till the fifteenth of October – my section will be officially closed on that dy […].
It is apposite to read Chekhov’s account of the part that he played during the cholera epidemic of 1892, given our own situation today. Much has changed since his time, in terms of our approach to an epidemic or indeed to a pandemic but much too remains the same. The human, emotional responses of the doctor, particularly the lone doctor acting with little support or resources but with incredible responsibilities and against the odds are still very much the same. This is the challenge for a lot of doctors in lower- and middle-income countries as the true cost of coronavirus pandemic unfolds. But everywhere too there is exhaustion, there is doubt about the value of clinical practice, there is hope too in the face of the grim reality of mounting deaths and then there is belief in medicine as an agent for good. It is very easy to think that what we face today is exceptional but we need not look very far to discover immense suffering, extraordinary altruism and the unbelievable capacity to survive in hopeless situations. Finally, the medical humanities allow us to incorporate subjective accounts to enrich our understanding of the purpose of medicine and inspire us to seek a wider more humane approach to clinical practice.
The authors declare no potential conflicts of interest.
Citation: Journal of Global Medicine 2021, 1: 21 - http://dx.doi.org/10.51496/jogm.v1.21
Copyright: © 2021 Femi Oyebode. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
Competing interests and funding: The authors declare no potential conflicts of interest.
*Femi Oyebode, National Centre for Mental Health, University of Birmingham, 25 Vincent Drive, Birmingham B152FG, United Kingdom. Email: f.oyebode@nhs.nt
Published: 26 February 2021