Physicians in literature. Part VII: the mortal woes and timeless writing of Anton Pavlovich Chekhov By W.E. Swinton The Gulf of Taganrog passes 110 km tivity." It is usually recorded of him he had the honour (and presumably north-eastward from the Sea of Azov. that though medically qualified he the compensation) of talking to the At its head is the city of Taganrog. never practised except in the cholera countess. Today this is a busy port for the iron epidemic of 1892-93. This is not so; By about 1888 his medical practice and steel works of the district, but a despite literary activity and continuous was interfering with his literary work. century ago it was quiet, with a humbler associations with literary personalities Patients "were coming in droves and trade in country produce, and the town in 1886, when he was seriously engaged I am sick of the sight of them, espe¬ was a place of lesser government of¬ as a writer, his medical hours were cially the women." Further, they were ficials and shopkeepers. It was here known, and he had a wide range of pa¬ not paying, so his practice was running that in the middle of the 19th century tients, most of whom were poor and at a loss. He wrote despondently, "All Pavel Chekhov settled and brought up were treated free. I need is an unhappy love affair." And his family. He was the son of a serf His early days of practice seem hard. he got that in January 1889. who had bought his freedom, and the At this time he discovered the delights Despite his diatribes, he seems to desire to prosper was ingrained in him, of a friend's country viilage Babkino, have tried to accommodate patients to though his grocery shop gave him only where he walked in the woods, wrote, his literary timetable, and even in 1892 a tenuous hold in the community. enjoyed his meals and music and often he was reported as seeing 49 patients There were six. children, of whom Anton a day, with office hours from 5 to 9 Pavlovich was born on Jan. 17, 1860. CMAJ continues the series by Dr. in the morning! About this time he was The family ties were strong, as they Swinton on physicians who have con¬ talking of writing a history of medicine. had to be, and a good education was tributed to literature. The articles, His life's literary work was mainly considered essential. The town had a sponsored by the Jason A. Hannah in association with A. Suvarin who was ' sizable Greek community, so it was institute for the History of Medical the editor of Novoye Vremia (New not strange that the young Anton and Related Sciences, were stimulated Times). He travelled in Russia and in should go to a Greek school, at which by the interest of the CMA committee 1888-89 went so far as Sakhalin Island, he received a classical education, before on archives. Illustrations are courtesy where for 3 months he studied the life of the Metropolitan Toronto Library going to the local gymnasium. The gro¬ Board. and conditions of the convicts. This led cery shop failed in 1876, and Pavel to the publication in 1891 of "Island and family left for Moscow while of Sakhalin", which in turn led to some Anton remained to complete his played croquet far into the night by measures of penal reform. The journey studies. He supported himself by coach- candlelight. He stayed all summer here, was an exhausting one, and signs of ing junior boys in the gymnasium and largely because he had not the money pulmonary and cardiac weakness be¬ eventually left Taganrog in 1879 to enter to return to Moscow. In the summer of came evident. None the less, he con¬ the medical school of the University 1886 he found a two-storied house in tinued to write and see patients, but of Moscow. The need for money was Sadovo-Kulrinskaya, where he stayed he purchased a small estate or farm pressing; like others before and after until 1890, paying 650 roubles a year outside Moscow at Melikhovo, where him, he sought it in literary contribu¬ rent. He had some money through his he lived with his parents from 1891 tions to papers and magazines. He de¬ practice. He saw patients from 10 am until 1897. Here he was happy as veloped a gift for comedy and his stu¬ to 3 pm and continued writing, for viilage squire and benefactor and as dent essays became a stream of short both were necessary to him. He could physician with the entire population as stories and articles in comic papers. not write without the support of med¬ his patients. The peasants flocked to The earliest of these was "Letter to a ical practice and, one supposes, only the viilage on foot and in carts, and Scholarly Neighbour" published in literature made practice tolerable to there were nearly always women and 1880 in Strekoza (Dragonfly). Shortly him. children at his gate. He spent much afterward he became a contributor to Whether he made money or not, he time in consultation and much money Oskolki (Fragments), and later he pub¬ was now buying books "in sackfuls" on medicines, which he gave free. Ar¬ lished some comic stories under the from St. Petersburg. "My medical col¬ rangements were made early in the 90s title "Fairy Tales of Melpomene". Most leagues sigh when they meet me, talk to combat an expected epidemic of of these were successful and were pub¬ to me about literature and assure me cholera. Chekhov was put in charge lished under his pseudonym Antosha they are sick and tired of medicine." of 25 villages, 4 factories and a monas- Checkhonte. Thus by 1884, when he Occasionally his practice extended to tery, but the disease did not come. graduated in medicine, he was an es¬ veterinary work when the vet was ab¬ However, in 1892 and 1893 cholera tablished writer. sent. He made visits to Moscow and arrived, and he gave great assistance He has written, "I do not doubt that was snobbish enough to record a visit in the countryside. the study of medical sciences has had to the nurse of a countess there, and The years at Melikhovo were happy a serious influence on my literary ac¬ though he was paid only 3 roubles ones in which he developed a sense of 366 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114 Valium* Roche' (diazepam)

Rx summary: Indications Symptomatic management of mild to moderate degrees of anxiety in conditions dominated by tension, excitation, agitation, fear or aggressive- ness. Spasm in muscular disorders of central or peripheral origin. Contraindications Myasthenia gravis, glaucoma, known hypersensitivity to the drug, and because of lack of sufficient evidence, in children under six months. Adverse reactions Drowsiness, ataxia, fatigue, dizziness, slurred speech, tremors, hypotension, tachycardia and phlebitis. Paradoxical reactions in psychiatric patients. Precautions Abstinence from alcohol during treatment. Caution wherever mental alertness or physical coordination is required. Periodic blood counts and liver function tests advisable in long-term Anton Chekhov and Maxim at Yalta in 1900 use. Caution in severely depressed Gorky patients or those with suicidal union with nature, but were He had married in tendencies. they Olga Knipper Dosage (oral) Depending upon marred by increasing ill health. Even 1901, and though the marriage was severity of symptoms. Adults 2 mg to as a student he had suffered from happy they were compelled to live sep¬ 10 mg, 2 to 4 times daily. Elderly and "convulsions" on failing asleep, and in arately, he being in Yalta and she act- debilitated patients 2 mg, 1 or 2 times 1885, just after his he had daily initially; increase gradually as graduation, ® needed and tolerated. Children -1 mg tuberculosis and melancholia. After to 21/2 mg, 3 or 4 times daily initially; that, at intervals, he was compelled to increase gradually as needed and go to Yalta for tolerated. increasingly long pe¬ Noludar Parenteral or riods for relief and Here dosage Acute anxiety recuperation. tension states or non psychotic he could renew his acquaintance with emotional disorders: 2 mg to 10 mg i.m. Tolstoy (whom he had first met at or i.v. Repeat in 3 to 4 hours if necessary. Roche Acute alcoholic withdrawal: 10 mg i.m. Melikhovo), and he became influenced or i.v. initially then 5 to 10 mg in 3 to by Tolstoyism, the blend of simple 4 hours if necessary. Relief of muscle Christianity that held him for a time. (methyprylon) spasm: 5 mg to 10 mg i.m. or i.v. However, he weakened in this belief initially then 5 mg to 10 mg in 3 to 4 and wrote in 1894 to "Reason hours if necessary. Status Epilepticus Suvarin, Rx summary: and severe recurrent seizures: 5 mg to and justice tell me that there is more 10 mg i.v. or i.m. and repeat in 2 to 4 humanity in electricity and steam than Indications Insomnia due to mental hours if necessary. Children: 2 mg to in chastity and vegetarianism." unrest, excitement, fear, worry or 10 mg i.m. or i.v. or 0.25 mg/kg. extreme fatigue. Elderly and debilitated: 2 mg to 5 mg Nevertheless, his association with Tol¬ Adverse reactions Nausea, headache, i.m. or i.v. stoy and his principles and with Maxim drowsiness, vertigo, paradoxical excita- Supply Tablets, 2, 5, 10 mg; 100, 1000. Gorky led to a general belief that these tion, and skin rash. Suspension, 5 mg/5 ml; 100, 400 ml. three were the liberal intellectuals Precautions As with other hypnotic Ampoules 10 mg/2 ml; 5, 25. great agents, patients should be advised to Disposable Syringe 10 mg/2 ml, in¬ against czarism. In 1900 Chekhov was abstain from alcohol during treatment dividually packed, 10. elected an honorary fellow of the Aca¬ with 'Noludar' as the individual response Complete prescribing information demy of Science but felt compelled to cannot be foreseen. available on request. resign when the government (or the Dosage * Reg. Trade Mark for chlordiazepoxide Adults: 1 capsule at bedtime. 'Roche' czar) vetoed the election of Gorky. Children: over 6 100 at In 1897 the years mg **Reg. Trade Mark for flurazepam 'Roche' relatively happy days at bedtime. ®Reg. Trade Mark Melikhovo were over, and ill-health 2 to 6 years 75 mg at his retreat to the Crimea. bedtime. compelled 6 months to 2 years 50 mg Now there came a flurry of play writ¬ at bedtime. ing, with the production of "The Sea- Supply Capsules, 300 mg; 100, 500. gull" (that had been written in 1896), Elixir, 50 mg/tsp. (5 ml); 400 ml. "Uncle Vanya" in 1899, "The Three Complete prescribing information Sisters" in 1900 and "The Cherry available on request. Orchard" in 1904. "The Seagull" failed ®Reg. Trade Mark in Leningrad but was later a triumphant Hoffmann-La Roche Limited RflPHF X Hoffmann-La Roche Limited success in the Moscow Arts Theatre. Vaudreuil, Quebec /fe Vaudreuil, Quebec CMA JOURNAL/FEBRUARY 21, 1976/VOL 114 367 ing in Moscow. But the end was near; etc." On qualification, his greatest shortly after the completion of "The worry was whether he would or could Cherry Orchard" he moved to what was make a living at medicine; he was not thought to be a better location at sure he could maintain himself by writ- Badenweiler in the Black Forest, and ing, either. he died there July 2, 1904. His funeral Nonetheless, he always thought of in Moscow was attended by such great medicine as his lawful wife and litera- crowds that traffic was disrupted; but ture as his mistress. Tolstoy is said to this was due to his cortege's being have believed that Chekhov would have mixed up from the railway station with been a better writer had he not been a procession in honour of some gen- a doctor, but it is difficult to believe erals. However, he was buried July 9 this. Medicine and an interest in it was in the cemetery at Nova Devichy. His ingrained in him, much as he com- coffin was exhumed and reburied Nov. plained, and his knowledge was useful 16, 1933 in the Moscow Arts Theatre to him in his stories - for example, portion of the cemetery. He was thus his obstetric experience as shown in belatedly honoured by a theatre that "Name-Day" and his neurological owed its earlier growth and success to knowledge in "Nervous Breakdown". him more than any other. His 600 short stories and articles are His portrayal of the Russian middle not by any means predominantly med- class and the struggles of the "little ical, but it is notable that each of his man" have made his writings timeless plays contains a character who is a and have influenced many modern doctor. Despite writing, "I am unfor- writers, including George Bernard tunate enough to be a medical man and Shaw. One of them, the physician- Anton Chekhov everyone I know feels it is incumbent author Somerset Maugham, has written upon him 'to have a chat' about med- ("A Writer's Notebook", 1949), "With it is a scene seen through the fingers icine with me", he had a contempt for Chekhov you do not seem to be reading which you know continues this way writers without a scientific background. stories at all. There is no obvious clev- and that though you only see a part of In his neighbourhood there were many erness in them and you might think it." white-and-coffee-coloured pigeons and that anyone could write them, but for Chekhov's health must have long a white-and-coffee-coloured cat, and the fact that nobody does. The author been suspect. At the university he com- Chekhov found that the local inhabit- has had an emotion, and he is able so plained of convulsions when going to ants would readily believe this was due to put it into words that you receive sleep, but these were probably caused to crossbreeding. it in your turn. You become his col- by the press of his studies, his recrea- He must have been a satisfactory, laborator. You cannot use of Chekhov's tions and worries about making a liv- if not successful, physician and surgeon, stories the hackneyed expression of the ing. He wrote that there were "opera- yet his diagnostic and analytical skill slice of life, for a slice is a piece cut tions every day. I read, write, go seems not to have been applied to off and that is exactly the impression a-roving in the evenings, drink vodka himself, though he felt that his personal you do not get when you read them; in moderation, listen to music, singing, experiences would have made him a good teacher. "I suffer from gastric catarrh and I know what it feels like. If I were a lecturer I should have tried to make my students understand the subjective feelings of a patient." He would have liked a university appoint- ment but lacked the higher qualifica- tions that were required. During much of these later years, he suffered from what must have been symptoms of tuberculosis, for he re- cords, "Hemoptysis: not a white spittle for 3 days. Probably a burst blood vessel" and generalized, "Every winter, autumn and spring, and on every damp day, I cough. But this alarms me only when I see blood.., the point to bear in mind is that consumption, or any other serious affection of the lungs, can be recognized only by a combination AL Xl £AlNT.MARTlN . that does not exist in my case." There is some contemporary evidence that this conclusion was intended to delude others and that he never quite believed it himself. Pictured is R/Admiral R.H. Roberts, left, surgeon general of the Canadian Forces, who presented for the Defence Medical Association of Canada and himself a portrait Bibliography in wood of Alexis St. Martin to L/Gen R.R. Taylor, US surgeon general. Maurice I. MAGARSHACK D: Chekhov: A Life, London, Faber and Faber, 1952 Boisvert, Montreal, was the carver of the portrait, which represents the widely known 2. KOLBY C: European Authors 1000-1900, New story of the first major series of experiments on digestion in modern medicine. The York, wilson, 1967 3. MAUGHAM ws: A Writer's Notebook, Lon- presentation was in honour of the bicentennial of the US Army Medical Department. don, Heinemann, 1949 368 CMA JOURNAL/FEBRUARY 21, 1976/VOL 114