Social changes that followed the peasant reforms of the 1860s allowed the medical profession in imperial Russia to expand its reach in new ways. Isolated doctors who were educated in Europe and treated the wealthy had long ceased to be an institutional norm.Footnote 1 The state maintained agency for training physicians, for increasing their number throughout the empire, and for maintaining medical institutions. A new national strategy, developed in concert with activist doctors themselves, involved transferring significant control of the medical sphere to local governing bodies, or zemstva.Footnote 2 Administrators native to defined regions managed the zemstva, which generated revenue through taxes and could effectively articulate local needs related to health care, education, and other social infrastructure.Footnote 3 New waves of physicians working through these bodies managed medical facilities and began to consider connections between health and the environmental conditions produced by imperial Russia's rapid modernization. State officials, zemstva managers, and medical professionals agreed that more physicians were needed across the empire in order to offset the effects of the dire living and working conditions they uncovered. In 1876, an imperial mandate expanded the available seats in university medical programs.Footnote 4 Scholarships, living stipends, and medical instruments incentivized students from all regions, regardless of class, to undertake training in these programs.Footnote 5 Anton Chekhov, one of these students, received a scholarship in 1879 to study medicine at Moscow University after he finished gymnasium in Taganrog, a port town of the Black Sea region.Footnote 6 The funds supported his train journey across the southern steppe, and gave him a living stipend that was enough, with boarders, to support himself and members of his family who had also relocated to Moscow.
A medical education offered Chekhov an opportunity to acquire unique training and gain social status. His grandfather was a serf whose deft management of a small income allowed him to purchase his family's freedom. His father was an unsuccessful shopkeeper, however, and drove the family into poverty. Medicine offered Chekhov a way out of his low position and a way in to Moscow's bustling cultural scenes. Though a diligent student, he also found time for other occupations during his studies. For example, he wrote creatively to earn extra money. As early as January of 1880, his first winter in Moscow, he published a parody about a scientist settling into the countryside for the comic newspaper The Dragonfly.Footnote 7 He disguised his writing under the pen name Chekhonte, reserving his real name for his identity as a student-physician.Footnote 8
In light of the historical circumstances surrounding Chekhov's early writing career and his own declaration that, “if I did not have medicine, it is unlikely that I would give my spare time or thoughts to literature,” we know surprisingly little about how medicine shaped his prose.Footnote 9 Biographical and formal studies have not fully excavated the crucial context of Russian medical history, its approaches to health and relationship to zemstvo organization, leaving open questions about the connection between medicine and Chekhov's creative writing.Footnote 10 What idea did Chekhov encounter in medical school and how did he apply them as a physician? Which of these might have held sway on him as he turned to writing fiction? Does Chekhov's medical training play a role in the artistic vision he articulates in his early prose? If so, how might this connection be elucidated? Answering these questions can help us understand how Chekhov transcodes between medicine and literature, giving rise to new ways of reading his creative work, while also filling lacunae in Russian social history by investigating late-imperial medical practices and environmental thought.Footnote 11
This article takes on this project by identifying those areas of medicine that had the most discernible influence on Chekhov as he undertook his training. Records of his work, including archived case histories he wrote as a student, indicate that he was drawn to branches of medicine—hygiene, clinical medicine, and psychiatry—that strove to articulate relationships between health and material environments as zemstvo medicine developed. Hygiene, or what we might call environmental medicine, was creating objective means to catalog the conditions of daily life and their influence on health at local, regional, and national levels. At the same time, innovators in clinical medicine brought new rigor to patient observation, case history reports, and treatment plans, training students to depict their subjects in formalized narratives as they attended to patients’ conditions and needs. In psychiatry, physicians struggled to adapt diagnostic methods to new concepts about mental life as they explored the relationship between the body and the mind. The most progressive psychiatrists reformed institutions and pursued research on hypnosis and suggestion that offered insights into how the mind-body relationship changed in response to dynamic environmental contexts. It was the contrast between the objective methods of hygiene and clinical practice and psychiatry's speculations into the subjective sphere of mental life that especially drew Chekhov's interests.
Medicine opened Chekhov to deep awareness of our subjective, embodied reality, attuning him to the capacity of environments to shape subjects physically and mentally, and also to the psychological distortions of our surroundings that can accompany the experience of illness. Not surprisingly, as he explores medically the mind's connection to the body and their mutual connection to their surroundings, he also begins using fiction to experiment with new psychological models that portray subjects environmentally. This article argues that Chekhov draws on medical insights in early stories such as “Agaf’ia” (1886) and “Tif” (1887) by mobilizing suggestive everyday details that evoke connections between characters’ outer material worlds and their inner mental lives. His methods for constructing subjects in relation to their environments articulate an environmental psychology that pushes the bounds of realism as it draws on insights about the power of suggestion and the effects of material environments on perception and behavior. As he took case histories, treated patients, and circulated through zemstva hospitals in the mid-1880s, Chekhov carried medicine into the arena of literature in ways that go beyond character or theme: they form the core of an innovative method for constructing human subjects that established him as a leading literary voice in late-nineteenth century Russia.
Hygiene and Environments
Chekhov attended medical school in Moscow when medicine was beginning to consider the relationships between individual and social health more systematically. Following the insights of John Snow and Louis Pasteur, most disciplines Chekhov studied had embraced the idea that environmental conditions and concrete materials could be investigated to understand and prevent the transfer of disease. Hygiene in particular presented to the public research on those circumstances that cause poor health and facilitated the spread of disease. In this capacity, it was rapidly becoming a vehicle for transforming unhealthy living conditions. At Moscow University Chekhov’s professor, Fyodor Erisman (1842-1915), headed this research. A Swiss born ophthalmologist who immigrated to St. Petersburg in the 1860s, Erisman recognized the dire epidemiological situation of the developing empire immediately after he arrived. Rates of disease and infant mortality in Russia were double those of other European nations and few effective measures had been taken to regulate health.Footnote 12 Erisman's response was to commit to activism and bring statistical methodologies to medicine.Footnote 13 He was convinced that studies of living and working conditions, especially of factories and other labor settings, would reveal their impact on public health.Footnote 14 He assembled a team of surveyors that worked through zemstva agencies to collect data on over 1,000 factories. They interviewed 114,000 workers over the course of several years, monitoring the impact of industrial development on surrounding populations.Footnote 15 The data demonstrated unequivocally that factories affected the health of those around them: they increased physical and mental illness in workers and created health hazards such as the pollution of water supplies.Footnote 16 The clear correlation between changes in surroundings and the health of populations, in combination with efficient collection of data, won Erisman the respect of his peers. He was invited to a professorship at Moscow University, where he established Russia's first laboratories devoted to hygiene and bacteriology. A student of Erisman, Chekhov became engrossed in his lectures and met the famous professor in person through his work in zemstvo hospitals.Footnote 17
Erisman was a charismatic lecturer who developed a dynamic conception of health within hygiene. A healthy state, he argued, entails the “harmonious equilibrium of the human organism” that might be influenced “by changes in environmental surroundings (izmeneniia v okruzhaiushchei nas srede).”Footnote 18 This idea of an integrated relationship between humans and the material world emerges from a naturalist tradition that can be traced to Goethe's concept of “Umgebung,” or the connection between humans and their environment.Footnote 19 Although the corresponding Russian notion of “sreda,” or environment, had been freighted with a deterministic premise in Russian social discourse of the 1860s and 70s, Erisman restored the idea's original dialectical sense to medical discourse, viewing humans and their environments as mutually shaping agents, each open to change.Footnote 20 This shifted emphasis from opposition and hierarchy to influence and balance. This holistic sense emerges in Erisman's definition of hygiene: “the study of all those phenomena of nature (priroda) or the factors of social life (sotsial’naia zhizn’) that contribute in any way to the disturbance of the physiological functions of the human organism and accordingly that influence morbidity and mortality.”Footnote 21 Hygiene encompasses social life but also adheres to medical traditions that go back as far as the “Airs, Waters, Places” theory of Hippocrates, which considered health and culture to have spatial elements, correlating strongly with climate, diet, and living conditions.Footnote 22
The modernized discipline of hygiene maintains a broad understanding of health, but also takes into its scope developments in bacteriology, and the tracking and prevention of disease through mapping statistics over time. Erisman focused much of his attention on gathering data and involved students in his statistical studies. Chekhov and his peers used summers between courses to trek through the rural regions around Moscow, assessing soil quality, water sources, rainfall, heating, lighting, ventilation, diet, and clothing in addition to rates of disease, morbidity, and mortality.Footnote 23 Analyzing these factors, which together created the “conditions of daily life” (bytovye usloviia), facilitated understanding of how illness spread. But it also offered Chekhov access to an ethnographic cross-section of Russian society upon which he would often draw to establish the details of everyday life with such accuracy and vibrance.Footnote 24 These scientific analyses also provided the means for addressing problems with the living conditions identified by zemstvo physicians. Indeed, hygiene's functions of collecting and presenting data to the public and those in power gave it a marked social character comparable to literature: Erisman was a professed Marxist who considered the mission of medicine to be integrated with social change.
Clinical Observation
Rigorous analysis of everyday living and working conditions was one of several innovations in medical observation that emerged during Chekhov's training. Russia's leader in clinical medicine and Chekhov's favorite professor, Grigorii Zakharin (1829–1898), stayed abreast of developments in hygiene, but he also introduced new methods of diagnosis and treatment. Zakharin updated the form of the case history, increasing its prominence as a tool for physical examinations. His lectures, which walked students through individual cases, so impressed Chekhov that he likened the physician's talents in medicine to Lev Tolstoi's talents as a writer of fiction.Footnote 25
In concert with environmental medicine, Zakharin systematized medical observation by offering a rubric that allows doctors to render their patients’ spatial and social environments. This involved a set of carefully organized questions:
Inquiring about the present condition, I begin by seeking information about the most important conditions concerning the patient's life and mode of life. 1) The locality in which the patient lives—is it damp, malarial, dry, or dusty? Is it closed or open to the wind, and so on? 2) Dwelling quarters: what are their dimensions, flooring, locations of bedrooms, temperature and ventilation, conditions of the latrine, etc.? Quarters in which the working hours of the day are spent? 3) How does the patient bathe: in an outdoor bath, in a public bathhouse, in a home tub, or sponge bathing? 4) Clothing in general, and specifically that which relates to the abdomen (belts and corsets) and feet (footwear—warm weather or cold weather, wide or narrow)? 5) What nervines [agents used to soothe or stimulate the nerves—M. M.] does the patient normally take: tobacco, tea, coffee, wine, vodka, beer? 6) Drinks: still water or alkaline (soda, seltzer, and so on), kvass [drink made from fermented bread—M. M.], milk? 7) Nutrition—Lenten or non-Lenten, light or heavy (what exactly), how often are meals taken? 8) Family life or single, living alone? 9) Children, miscarriages? 10) Does the patient get enough sleep? How often does the patient sleep? How often is the patient inclined to sleep? Is the sleep full? 11) Physical and mental activity? Relaxation? 12) Length of daily stay in confined quarters and in fresh air?Footnote 26
Zakharin situates patients in spatial and social matrices based on categories that range from dwelling to clothing to how the patient spends work and free time. He includes eating, drinking, and sleeping habits, nerve stimuli, and family life. Implied throughout is a relationship between health, the conditions of everyday life, and the habits of patients. Zakharin goes on to argue that constructing these conditions and behaviors is essential because “changes in the patient's mode of life and surroundings” will likely be necessary “if any cure is to be obtained.”Footnote 27 Like Erisman, Zakharin bases his understanding of health largely on environmental influence. And the influence of environments is broad: anything from damp quarters to corsets, from sex to coffee, tea, and alcohol.
The second phase of clinical practice focuses on healing patients, which required physicians to aggregate symptoms, put forward diagnoses, and treat illnesses, all while keeping the details of the patient's environments and mode of life in mind. In this arena Zakharin battled what he viewed to be pervasive uncritical observation and “routine habit” in diagnosis. In order to reverse these trends, he trained his students to enter an “active, searching condition of mind” that moves systematically from questions about a patient's living and social conditions to their particular symptoms.Footnote 28 As Vladimir Kataev has noted, Zakharin encouraged the individualization of every case and the treatment of specific people rather than diseases: there is no “disease in general,” the physician argued, only “concrete patients.”Footnote 29 This increased attention on the particularities of patients allowed Zakharin to shift the dominant cocktail approach in treatment to one that tailored to cases.Footnote 30 Zakharin's clinical practice winnowed medicine as a formulaic practice to specific treatments for individualized patients.
Zakharin frames diagnosis, the central focus of clinical medicine, in terms similar to the imperative of all scientific endeavor, directly and boldly challenging his students to “find the unknown, which will demand a solution.”Footnote 31 His method for doing so revolves around tact in observation, or the ability to decipher precisely and arrange symptoms into meaningful forms: “In order not to fatigue the patient and himself and to spare his energy, which is so necessary for producing calm and ready conclusions, the beginner must try to acquire the needed tact (takt) in examination—avoiding unnecessary and petty details, and what is superfluous and disorderly.”Footnote 32 Henri Huchard, who introduced Zakharin's method to their European contemporaries, illuminates its practical and theoretical rigor by arguing that, far from “a mechanical putting together of various facts,” tact involves “questioning that has been elevated to the height of an art.”Footnote 33 Tact required physicians to be precise in questioning and observation, while not losing sight of the specific environmental conditions of patients: symptoms may be correlated with these conditions, even as they are drawn together into diagnoses. Tact is equally applied in writing case histories, which, to use the classic formulation of narratology, relied on isolating and privileging a story of illness from the patient's discursive relation of symptoms, living conditions, and personal history and inserting it into the orderly form of the medical report.Footnote 34 Case histories are only those specific details carefully assembled to document spatial conditions and progressions of symptoms that reveal a disease, its likely causes, and its course of treatment. With only details that matter about environments and patients filling these histories, they become narratives of concrete unfolding relationships, vivid acts of storytelling in which all things are connected.
The physician's pedagogical style reinforced his insights about clinical observation. As the writer of a detective story withholds the solution to a crime, Zakharin withheld diagnoses, slowly unfolding the case so as not to “deprive the student of that mental stimulus, which spurs him on to seek the solution.”Footnote 35 He masterfully performed each step of formal observation in the lecture hall: constructing the patient's environment and clinical record in an anamnesis, analyzing the patient's current physical and mental state in a status praesens, and assembling a timeline and series of developing symptoms in a decursus morbi.Footnote 36 The diagnosis was the climax of this form of documentary storytelling, a form that was complete with an environmental setting, a central character, and a story of illness, all written in concrete, concise prose.Footnote 37 It should come as no surprise that Chekhov compared Zakharin's skill to Tolstoi's, another master storyteller, nor should it be a surprise that Zakharin's students listened to his lectures with rapture. He inspired each to become a deft observer of the human body, and an efficient writer, following his methods for transforming the unknown into recognizable forms.
Psychiatry and Mental Illness
The sciences of the mind joined hygiene and clinical medicine to emphasize the role of environments in shaping health, with attention to surrounding conditions and patient histories in their cases too. Deciphering the influence of the external world on inner life and of inner life on the body, however, required speculation into a subjective realm that lacked clear material demarcations. Because psychological illnesses could evade or deceive the empirical gaze, the field's primary challenge was the development of theoretical approaches for identifying causes of illness and charting the mind's relational functions.Footnote 38
Ivan Merzheevskii (1838–1908), whose work Chekhov knew well, compelled psychiatry to research the effects of modernization on mental health, especially the mass rural to urban migration and rapid industrial developments that followed the peasant reforms.Footnote 39 Movement from “native locales” into “entirely different climatic and daily living conditions (bytovykh uslovii)” led to new stresses in mental life and mental illnesses became widespread in urban environments.Footnote 40 Aligning psychiatry with hygiene and clinical medicine, Merzheevskii advocated for studying the “influence of surrounding environments (vliianie okruzhaioshchei sredy),” along with alcohol abuse, and the mechanisms of degeneration as sources of mental illness. This shift away from isolation and restraint of mental patients to searching for causes and cures had two important consequences: increased clinical focus on poorly understood diseases including hysteria, alcoholism, and neurasthenia, and research into the psychological phenomena of hypnosis and suggestion.Footnote 41
Jean-Martin Charcot's studies of hysteria, circulating in the Russian presses in the 1880s, found patients with the disorder to be prone to hypnotism and considered that it may involve self-hypnosis.Footnote 42 Many characteristics of hypnosis overlapped with symptoms of hysteria: diminishment in voluntary control of thoughts and movements, deception (obman) in physical sensation, mimicry of the hypnotizer, intensified memory followed by an inability to remember events under hypnosis, and notable openness to suggestion (vnushenie).Footnote 43 Yet, while some researchers worked to codify the hypnotized state to understand how the mind relates to the body and its surroundings, the tendency among most physicians in Russia, as Cathy Popkin has argued, was to localize organic symptoms, “the visible—and verifiable—manifestations of the disease, rather than its emotional underpinnings.”Footnote 44 Given this emphasis, deception and performance remained ingrained accusations in case histories, rather than being interpreted within broader biographical contexts.Footnote 45
Despite such professional bias, an urgency to discover cures persisted, shaping progressive aspects of the field.Footnote 46 Understanding suggestion as a psychological function was key to transferring emphasis on the visible and organic to viewing physical symptoms as expressions of mental distress. The phenomenon fits into an environmental approach to mental illness by conceptualizing how the mind relates to its material and psychological surroundings. Broadly, suggestions are impressions from the outer world on a subject's mental state, from the weather to immediate everyday social conditions extending to the gestural, the verbal, and the textual.Footnote 47 Experimental psychologist Vladimir Bekhterev would argue that, through the “movements of surrounding people, through books, newspapers,” wherever we are in the “surrounding society (okruzhaiushchee obshchestvo) we are exposed.”Footnote 48
Studying suggestion forged new, clinically-relevant notions of how physical, emotional, and intellectual environments shaped the mind's relationship to the body. Listening seriously to the narratives of patients, discursive windows into their pasts and inner lives, could uncover links between certain suggestions and the nervous system's “expression of suffering” in the body.Footnote 49 In one case Popkin analyzes, a traumatized soldier who had vowed to quit smoking later accepts a cigarette from a friend. The suggestion that smoking is a sin induces an “intense sense of suffocation” when the vow is broken.Footnote 50 Rather than focus on the visible organ of the throat, however, the treating physician investigates the patient's narrative and makes a connection between the suggestion and the symptom. The physician deciphers a psychological dimension in the case, discloses the story of illness, and the mind's relational nature. Sigmund Freud and Josef Breuer's “talking cure” was on the horizon, but efforts in which treating physicians viewed patients’ narratives as mediations between the material world, the subjective emotional realm, and corporeal symptoms were circulating in the Russian medical press as Chekhov developed his practice.
Chekhov in the Clinic
As a student of medicine, Chekhov trained diligently to observe environments, bodies, and minds, attaining a broad view of the medical fields and ample clinical experience. Two case histories he wrote during medical school disclose how he applied the range of his knowledge, his particular interests in the confluence of environmental medicine and psychiatry, and his ability to capture that in his writing. The first is of Anna Yakovleva, a patient with pneumonia admitted to Moscow's Katherine Hospital in the fall of 1883. It was Chekhov's fourth year in medical school. He attends carefully to environmental factors and to the details of Anna's physical condition and mental state:
[from the Anamnesis]…Before the time of admittance to the hospital the patient lived in the Sretenk Section on Golovin Lane and, with her daughter, occupied a two-room apartment with a kitchen in a two-story stone building. At first they lived on the upper floor; later they lived on the lower floor. The apartment is warm, a little damp. The rooms are well lit and the ceilings are high. The toilet in the inner hall is cold. From fear of catching a chill, when it gets cold the patient passes feces in the bedroom.
[Until admittance] the patient usually drank tea 2–3 times a day. She ate lunch every day. Her lunch consisted of soup and, sometimes, braised meat. She did not eat supper. She did not smoke and did not use hard alcohol. She slept 9–10 hours a day.
On September 19th the patient felt a strong chill lasting from morning until evening. In the evening the chill gave way to a fever. On the advice of the doctor, she drank raspberry tea that evening. On the 20th she felt a strong pain on her right side, she applied a compress, and on the 21st she turned to the Katherine Hospital for help.
[from the Status Praesens] The patient is of medium height, 61 years old; she lies on her left side. She raises herself with difficulty. She speaks quietly and conversation noticeably fatigues her. One observes in the respiratory organs the following deviations from the norm: the right half of the chest functions more weakly than the left. The right fremitus pectoralis is stronger. Percussion gives a dulled tympanic sound on the whole right side; on the entire left side the sound is clear. The size of both lungs is normal. On auscultation, one can hear bronchial respiration and crepitant wheezing throughout the upper right lung (especially in the back).…
Assuming from the noted facts of the anamnesis and the objective examination, we can conclude that this is a case of pneumonia cruposa.Footnote 51
Chekhov constructs his patient within spatial and social matrices, locating her apartment in the quarters of the city, describing the dwelling, its lighting, heating, moisture in the rooms, and sanitation, all factors that fall into the domain of environmental medicine. The report echoes Zakharin's questionnaire as it moves through the spatial environment to diet, nervines, and sleeping habits. In the physical observation, Chekhov finds that one of Anna's lungs performs abnormally, a symptom he isolates and, aggregating it with others, uses to offers a diagnosis. The details in the case neither meander nor exhaust: as Chekhov presents the essential medical story, a vivid picture of Anna in her surroundings emerges. He points, in particular, to the cold toilet in the inner hall and the dampness of the apartment, concrete details that suggest correlations between Anna's illness and her environment. The case history unfolds as a story with a dynamic setting, focused on an individualized patient with symptoms that form the particular constellation of an illness, one that also makes sense within the given environmental context. The record is compact and evocative because Chekhov chooses concrete details tactfully, leading to the succinct, vibrant prose that we recognize as good writing. Almost every word tells.Footnote 52 Chekhov takes from medicine an understanding of humans as integrated in spatial and social contexts and a method for conveying this in details that gain their vividness by suggesting concrete relationships between environments, illness, and the patient's mode of life. Indeed, the case history already sounds like Chekhov because the principles of clinical prose are frequently coded into the type of writing we often associate with him: concrete, concise, with details calibrated to create vivid pictures in which the material world always seems to be intimately connected to the lives of characters.Footnote 53
Chekhov as Psychiatrist
Later that fall, Chekhov treated a patient suffering from a neurosis. Aleksandr Bulygev, a nineteen-year-old railway clerk, entered Katherine hospital on account of back pain, a depressed state, mucous discharge, and general weakness. Chekhov treated him for several weeks, drawing up the following history:
[from the Anamnesis] The patient is nineteen years old. He was born in Tsarevokokshaisk in the Kazan’ Province to healthy parents who are still alive. Five years ago he arrived in Moscow where he entered the trade house of the Yaroslav railroad. In childhood the patient survived measles and smallpox. At fifteen he suffered colic of the stomach and diarrhea; at sixteen he suffered typhus. After having typhus he was deaf for some time and suffered headaches, vomiting, and an eye infection. At fourteen the patient began to practice onanism [masturbation—M.M.] and continued to practice it until he was seventeen, indulging in it daily, sometimes 2–3 times per day. At seventeen, on the advice of a doctor, he made an attempt at conjugationem, but his attempt, due to the absence of an erection, turned out unsuccessful. Following this, his subsequent attempts had the same result.Footnote 54 Over the last two years the patient claims he has not practiced onanism and has suffered only from nightly emissions that happen 5–6 times a month. At first the emissions accompanied dreams and voluptuous sensations; then they began to appear without one or the other of these. The patient began to feel the pain in his back while stretching when he stopped practicing onanism. In general, one should note that the patient did not notice this illness—the weakened memory and general weakness—until he read a book describing the effects of onanism.
…The patient lives with a family. The apartment is in a wooden home; it is warm. He has a separate room, sleeps alone on a mattress and covers himself with a quilted blanket.…In the morning he goes to work at 9 and returns at 2 p.m.; after dinner he is busy with work from 6 until 11 p.m. His work consists of writing. He writes sitting down with breaks; his evening work is carried out without breaks.
[from the Status Praesens] The nervous system presents no deviation from the norm in the sphere of sensitivity and motion. The same can be said regarding the organs of higher sensations. Headaches occur now and then, as does dizziness during fatigue and a ringing in the ears.
Concerning the patient's psychic activity one can say the following: he is talkative, he answers questions willingly, he spends more time sitting and walking about than lying down, and he enjoys reading.…In the sphere of feeling one can observe a few deviations. The patient is merry only in company; when he is alone he is melancholy. The subject of his worry is the consequences of onanism. He is very hypochondriac. The book he read about the effects of onanism aroused in him a constant fear for his health.
[from the Diagnosis] In examining the patient, we do not find any kind of pathological change on which we could build an exact diagnosis. We are forced to be guided by subjective symptoms only. In the given case these symptoms are diverse: weakened memory, general weakness, fatigue after walks of short duration or physical work, impotence, pain in the back when stretching, some suppression of mental function in the emotional sphere, frequent sleeplessness, etc. Besides the diversity of these symptoms, they are also not constant. For example, the pain in the back is not constant. Fatigue, also, is not always present.
From the anamnesis it is clear that the patient practiced onanism; there is insufficient reason to deny that the patient practices it now. The fear of the effects of onanism has oppressed the patient for two years. Given this anamnesis, it is clear that the patient, since he was fourteen, has been working all day without rest in the evenings or on holidays. Consequently he spent the period of sexual maturation in conditions that are not favorable for health. Taking into consideration the subjectivity, diversity, and inconsistency of the symptoms, and also the given anamnesis, we can establish the diagnosis of neurasthenia.Footnote 55
Chekhov again situates the patient in environmental matrices, focusing on Aleksandr's rural to urban migration, his everyday living and working conditions, and social environment. We see in this history the same focus on the particulars of the individual that lent such vividness to Anna Yakovleva's case, but the physical exam turns up no organic aberrations. Instead, details about Aleksandr's mental life are in focus. Chekhov chooses to enter the subjective narrative of his patient's illness, where he deciphers influences of Aleksandr's psychological environment that allows him to consider suggestion as a factor in the case. He links the patient's symptoms with dictates about onanism that likely made strong impressions during Aleksandr's reading: for instance, correlations between onanism and illness in No More Onanism, Venereal Disease, Pollution, Male Impotence, or Female Infertility. This and similar popular treatises circulating the Russian press espoused a restrictive sexual morality based on André Tissot's eighteenth-century rhetoric promoting abstinence as a moral ideal.Footnote 56 If the command from his previous doctor to engage in sex with a prostitute had not produced sufficient apprehension in Aleksandr, the suggestion that onanism causes illness fixes him in cyclical neurosis.
Fortunately, Chekhov differs from Aleksandr's previous physicians by oscillating between focus on objective, organic manifestations of illness and using Aleksandr's subjective narrative as context to inform an interpretative diagnosis. In arguing that “there is insufficient reason to deny” that the patient ceased to masturbate, Chekhov discloses his belief that Aleksandr's narrative and symptoms form a story that remains hidden: Aleksandr's physical symptoms likely have psychological origins. The patient's denial supports the hypothesis that he has transformed emotionally the restrictive suggestions he encountered in his reading into his constellation of physical complaints. Chekhov's skill as a clinical observer and psychiatrist are on full display: as he moves between objective observation—recognizing the importance of migration, environmental contexts, and a brutal work schedule—and interpreting a subjective narrative that offers only clues to the workings of suggestion, he suggests a story about the environmental and psychological underpinnings of Aleksandr's illness. With this idea in mind, Chekhov establishes a diagnosis and outlines a plan for treatment.
Chekhov prescribes Aleksandr a series of baths and to adjust working conditions: the traces of modern life in the form of extended seated labor is a clear culprit in the illness. With significantly reduced symptoms, his patient leaves the hospital after just under two months, likely enough time for Aleksandr to ease out of his restrictive lifestyle. We learn from these two cases that Chekhov is not only professionally attuned to reading patients’ material surroundings and physical symptoms, but is also drawn to interpreting the contours of his patients’ inner lives and the relation of the mind and emotions to their surroundings. As a physician, Chekhov is a deft observer of material conditions, a perceptive interpreter of mental life, and a tactful storyteller.
A perceptive remark from one of Chekhov's supervising physicians, Pavel Arkhangelskii, who managed the Chikinsk zemstvo hospital during Chekhov's service there in the summer of 1883, supports this case. Arkhangelskii notes how “the mental state of the patient always drew [Anton Pavlovich's] particular attention, and along with conventional medicine, he attached great significance to the effects the doctor and the surrounding environment (okruzhaiushchaia sreda) had on the psyche of the patient.”Footnote 57 Arkhangelskii verifies Chekhov's interest in drawing together environmental medicine and psychology in the medical sphere. But to truly see how Chekhov explores this intersection we must turn to his creative writing, where he develops his interest in the mind's relation to its material, social, and psychological environments into some of his most compelling early fiction.
Medicine and Fiction
When Chekhov turned to literature in his “spare time and thoughts,” there can be little doubt that medicine followed him. In line with the medical profession's expanding social presence, doctors often appear in his early humorous sketches, though initially he uses them simply for situational comic effect.Footnote 58 The mechanics of writing, however, already transfer across disciplines: Chekhov built initial success with the humor presses by churning out brief, well-structured prose on short deadlines, exercises he rehearsed in the clinic. Some themes relevant to his medical interests also begin to appear in his earliest stories. He bases “Na magneticheskom seance” (“At the Magnetism Séance,” 1883), written as ideas about hypnotism circulated in the medical press, on a clear understanding of suggestion as an aspect of hypnosis (PSS 2:30–32).Footnote 59 Not long after, “V apteke” (“In the Pharmacy,” 1885) marks a turn in his prose by focusing on a teacher who, denied medicine he cannot afford, returns home to fall into a deadly sleep. In the story's harrowing final lines a deceptive feeling of calm overcomes the teacher as he dreams he is in the pharmacy getting the medicine he needs (PSS 4:54–57). Chekhov codes into the story the subjective experience of a patient, the hallucinatory psychology of the dying man, and medicine's social role, with literature becoming a means to advance medicine's agenda of increased access to care.
While Chekhov's earliest stories include physicians and medical themes, as his prose develops, medical insight plays a more critical role in how he constructs settings and characters. In particular, his stories draw attention for their dexterity with details. Realist writer and Chekhov's first advocate from among the literary elite, Dmitri Grigorovich, wrote in 1886 that he was deeply impressed with his young protégé’s skill in creating “feelings of plasticity, where from a few lines appears a full picture: clouds on a setting sun, ‘like ashes on dying coals…’”Footnote 60 This development in Chekhov's prose opens a window for examining how his clinical training, where details also played a central role, may have facilitated such deft description.
In Anna Yakovleva's case history, the detail “the toilet in the inner hall was cold,” creates a vivid picture by connecting setting, character, an unfolding story of illness, and mood, all in a few short lines. Similarly, the detail of clouds on the setting sun “[trembling] like ashes on coals” (kak ugol’ia [podergivat’sia] peplom), chosen by Grigorovich from the story “Agaf’ia,” about an illicit village affair, intimates a density of connections. It describes the threshold between dusk and night as it evokes a languid mood in the story's ending. It also forms a network with other descriptions of the sky: “the sunset had still not entirely died out, and the summer night already enveloped nature with its soothing, lulling caress” (PSS 5:26). These descriptions are not inserted arbitrarily, but suggest that daily and seasonal change forms natural rhythms in the village environment.Footnote 61 At the same time, the image of coal passing to ash evokes a tension in the transition of time that can be mapped onto the tensions created by recent social transformations. The village is modernizing; the pull toward industrial development and even urbanization is signaled primarily by the railroad that now passes through it. But where the dark field meets the dark sky, Chekhov also places a “small light” that “flickers” (mertsal) constantly, a rhetorical contrast to the coals, which tremble as they fade (PSS 5:26). The railroad and this unidentified, steady light disclose that the rhythms of day and night and the ephemeral glow of summer's dusk are dying.
The tension in the changing nature of time's passage maps onto the behavior of the characters. Savka, a lazy idler, refuses the trends of progress. He will not work and, outcast from the village, has become a scarecrow in its communal garden. His mastery of bird calls and skill at catching nightingales keep him in unison with the dynamic natural world: “he cast his gentle, thoughtful gaze on the grove, on the willow-bush, slowly took a whistle from his pocket, placed it in his mouth and made a nightingale trill. And just then, as if in answer to his trill, on the opposite bank a corncrake started crekking” (PSS 5:27). As Savka immerses himself in the natural environment, he attracts others to his idyllic routines. The story's conflict centers on Agaf’ia, whose unhappy marriage to the night-shift railway switchman draws her to Savka while her husband is absent. She meets the loafer under the cover of darkness, gets drunk on his vodka, and, even after the early morning train's distant whistle signals her husband's impending return, she is compelled by some “invincible and implacable force” into Savka's embrace (PSS 5:33). Agaf’ia is enfolded into a traditional pastoral rhythm, where time seems to slow, fleeing a marriage emptied of passion by the regimented and alienating schedule of modernity. The coals fading into ash at night and the unwavering light on the horizon that in morning still glows “red” (like coals) delineate the poles that tear Agaf’ia apart. The contrast also suggests the devastating psychological effects and ensuing sexual pathologies of modernization, even as these two differing flickers remain concrete illuminations in the landscape.Footnote 62
Details for Chekhov are not simply random objects that authenticate an external world, as realist writers often employ them, nor do they depart from materiality to create wholly symbolic planes of meaning. Instead, they create a subtle rhetorical dimension in which the material and the psychological intersect in ways that we might characterize as concretely relational. By this I mean that details flesh out concrete but pliable environments while suggesting psychological and emotional connections between characters and these surroundings, one reason for their plasticity and success in creating full pictures with few words.Footnote 63 As Vladimir Nabokov has noted about Chekhov's later prose, Chekhov establishes atmosphere through details deliberately, inviting readers into a mood created through conscious or unconscious interactions between characters and the places they inhabit.Footnote 64 The notion of details going beyond detached depictions to function as entryways into subjective inner lives is an integral part of Chekhov's method for constructing environments as dynamic and often disruptive forces. This method aligns remarkably well with hygiene, clinical medicine, and psychiatry, all of which considered environments as integral in shaping physical and mental health. Working like Anna Yakovleva's toilet in the inner hall, environmental details in “Agaf’ia” demarcate intersecting layers of significance: we must decipher them too, to grasp their potential meanings. Chekhov codes insight from clinical description and environmental medicine into creative narrative by carefully fashioning such details, which vibrate with materiality that is at once concrete, suggestive, and essential to understanding the story's implications.
We can see Chekhov's process of constructing active environments through concretely relational details within a specifically medical framework in another early story, “Tif,” whose creative method and medical theme warrant careful analysis. Published less than three years after Chekhov finished medical school and while he was establishing his medical practice, “Tif” recounts the case of the eponymous illness as it infects a young lieutenant, Klimov, who is returning from St. Petersburg to his home in Moscow. Klimov convalesces, but during his illness he infects his sister. The news of her death utterly devastates him as he contemplates his surroundings after recovering. One of his most clinical stories, “Tif” reveals Chekhov coding medical understanding of how environments and illness influence physical and mental life into creative articulations of these relationships, while also experimenting with the case history as a device for structuring fiction.Footnote 65
“Tif” opens in the smoking car of a postal train “slowly moving from Petersburg to Moscow.” “A Finn or Swede” smoking a pipe besets young Klimov with questions about his service. “Ha, you are an officer! My brother [brat] is also an officer, but in the navy… He is a sailor [mor’iak] and serves in Kronshtadt.” The repetition of “ofitsir” and staccato assonance of “brat,” “mor’iak,” and “Kronshtadt” intensify the repetitive onomatopoetic sounds in the train, “shedshem iz Peterburga” with its hypnotic “clang [stuk]” of wheels and “knocking [khopan’e]” of doors (PSS 6:130). The movements, sounds, and smells deftly evoke a familiar environment, but these details are also entry points into Klimov's inner life. Through “the heavy haze in his head,” we find “the noise, the creaking, the Finn, the tobacco smoke—all of it was mixed in a threatening and flashing hazy form, the character of which could not be felt by a healthy person” (PSS 6:131). “Tif” builds its meaning by keeping in tension objective description of places and people and the subjective effects of these environmental stimuli on Klimov's ailing mind. This undertaking creates the story's particularly claustrophobic atmosphere, while also revealing Chekhov's medical awareness of typhus and its symptoms.
Klimov's vulnerability makes the environment around him intensely suggestive, with different sights, sounds, and smells drawing him repeatedly toward feelings of nausea (toshnota). Disgust at the smoking foreigner inspires escapist fantasies, the mixture of outer and inner life provoking in Klimov deeper unease: “and the thought about the Finns and Greeks produced in his whole body something akin to nausea [toshnota]” (PSS 6:130). The feeling intensifies throughout the next scenes, with new environmental details as catalysts. The train stops in a small town where the thirsty young officer leaves to find water. The smell of frying cutlets saturates the station café and a woman in a red hat and those chewing their food stir the feeling again: “‘and how can they eat!’—he thought, trying not to whiff in the air and trying not to look at their chewing mouths,—each of which repulsed him to the point of nausea [do toshnoty]” (PSS 6:131). These new details create another familiar environment, but they also reflect Klimov's tunneling vision and follow his weakening mind as he travels further. Finally at home, Klimov cannot get away from what he has seen and sensed: “he threw himself onto his pillow. The Finn, the red hat, the woman with white teeth, the smell of the frying meat, flittered in spots through his consciousness and he already had no idea where he was and did not hear the alarmed voices” (PSS 6:133).
At home, the feeling of nausea reemerges with new smells. “The whole time he could smell the fried meat and the Finn's pipe, but then, once, Klimov smelled the sharp smell of incense. He jerked from nausea [ot toshnoty] and started to cry: the incense! Take away the incense!” (PSS 6:134). The incense seems to evoke a new potential symbolic plane of meaning—a sign of the church and the rites of death—but Klimov's reaction forces us also to recognize it as a material substance akin to tobacco, its decontextualization lending it this concrete status. The detail creates a rhetorical space where material, memory, and symbol intersect to form a dynamic environment that haunts and assails Klimov, his inner feeling overwhelming his body until he is completely disoriented and mentally collapses.
Readers witness a threatening environment that actively destabilizes Klimov physically and mentally, yet likely realize that illness causes distortions in his perception. A more objective rhetorical plane outside of Klimov's perspective exists in the story, but the environment here is no less active. The train, for example, rapidly modernizing the empire, is a locus of precarious migrations and encounters that transmit disease. Statistics had shown that army barracks and wide use of mass transportation facilitated the spread of typhus in the late 1870s and early 1880s, and that Moscow's position as a hub of the railway “made it an ideal point for disease diffusion.”Footnote 66 Chekhov embeds Klimov in these spatial and social environments to help readers see how on this more objective plane he becomes an environmental force himself. In the third scene, “not answering [his sister's or aunt's] questions or greetings, but only panting from the heat, [Klimov] aimlessly wandered through all of the rooms” (PSS 6:133). The soldier unwittingly serves as an environmental agent of transmission and, by infecting his sister, continues the story of illness.
By situating Klimov in environmental matrices and describing the conditions at the onset of his illness, Chekhov not only establishes objectivity in relation to his character, he also borrows from the forms of the anamnesis and decursus morbi in a case history. Other moments of description that offer an objective view of Klimov as a typhus case align with the components of a case history too. Just before we are drawn into the character's thoughts and feelings, the narrator succinctly delineates his symptoms. In the wagon car, “[Klimov's] arms and legs somehow did not fit on the divan, even though the whole divan was his to use, his mouth was dry and viscid, and a heavy fog was settling in to his head” (PSS 6:132). Klimov's symptoms and behaviors—dry mouth, irascibility, a headache that moves into the body, a feeling of cramping—parallel the status praesens of a typical typhus case. His hallucinatory perception indicates the illness's fever stage, where distortion of time and space, delirium, and coma become prominent.Footnote 67 Finally, after he convalesces at home, Klimov inquires about what happened and receives a diagnosis: “what did I have?” Klimov asks. “Typhus [sypnoi tif]” (PSS 6:135), his aunt responds despondently, reporting the attending physician's pronouncement.
These elements reveal the form of a case history and, with the frame of Klimov's military service and his sister's infection, a broad epidemiological arc to “Tif.” But while the medical case history privileges the bare facts of the story and its documentary form over the patient's discursive reporting and, behind that, inner experience of illness, “Tif” inverts the hierarchy of story and discourse to favor the patient, as it considers how Klimov and his surrounding environments interact. Chekhov blended onomatopoetic sounds into the description of the train, intensifying its hypnotic qualities, and readers have wide-ranging access to the shifting coherence of Klimov's inner thoughts. Further, a connection between the Finn's assailing speech and the physician's muttering intimates that the environment's suggestive effects are not tied exclusively to illness. “De, de, de…—said the doctor.—excellent, excellent…Now we're back to health…Tek, tek. The lieutenant listened and laughed joyfully” (PSS 6:135). The Finn's monosyllabic “ga…ga” from the opening is recast in this “de…de…tek… tek,” but instead of inducing nausea, the sounds induce a new physical response: Klimov laughs. His surroundings still actively impress his mind and shape his body, the environment, mind, and body remaining interconnected beyond the trigger of illness. Now the type of environmental details that once oppressed him—“a carafe, the ceiling, a ray of light, a ribbon on a curtain. God's world, even in the cramped corner of his room”—construct and reflect a new atmosphere, the lightness and accompanying joy in a defamiliarized experience of everyday life. The inner experience of the patient remains central well beyond his convalescence, extending the facts of the story beyond the explicit interests of medicine so as to capture a dynamic image of the interaction between Klimov and his environment in both illness and health.
“Tif” recounts the story of typhus, how it is contracted, how it affects the body and mind, and how it transfers to others. It reveals the tragedy of contagion and suggests how it might be avoided with wider awareness of hygienic practices, including “prompt removal of the sick to hospitals and disinfection of their persons, clothes, and premises.”Footnote 68 But just as important as this story of illness, an environmental psychology emerges in “Tif” through the tension between active, objective environmental forces and Klimov's dynamic, subjective experience of his surroundings. It is a dialectical interaction in which environments shape a subject physically and psychologically, even as his shifting inner states inform his subjective physical experience, changing the atmospheres of the story. We feel the layered effects of this psychology as profoundly in the story's ending as in its onset. As Klimov mournfully processes his sister's death he gazes out the window and hears the “unpleasant clang [stuk]” of workers on the railroad. This everyday scene connects the intense distortions of Klimov's past, in which he heard the same “clang” hypnotically repeating in the railroad car, to a present without his sister. His contentment vanishes: “my God, how unhappy I am! And his joy yielded its place to common tedium and the feeling of unrecoverable loss” (PSS 6:136).Footnote 69 Klimov's objective environment in the form of this suggestive sound interacts with his perception and now his memory. This last scene reveals the psychological and symbolic potential latent in everyday materiality as Chekhov articulates the effects of illness on an individual, a home, and a community of readers.
“Agaf’ia” speculates on the origins of psychological pathology in the unsettling influence of modernization on social and sexual behavior, echoing the insight of psychiatry and hygiene that illness accompanies industrialization. In this same period, “Tif” explores the subjective psychological and emotional experience of illness, layering the form of the case history into its structure as it discloses typhus's symptomatology and patterns of transmission. Both stories code insights from medicine into their construction of plots, characters, and settings, disclosing how Chekhov's two disciplines overlap and inform each other. Perhaps the most salient feature of medical concepts marking these early works, however, comes at the juncture between medical and literary narrative: their shared interest in the mobilization of details.
The details of medical case histories tactfully disclose living, working, and physical conditions, assembling symptoms into forms as they suggest relationships between conditions and illness. Case histories become vivid acts of storytelling by eliminating superfluous details and meandering ideas, insights about narrative that Chekhov mobilizes to make his medical and literary language so succinct and concrete. At the same time, details serve as moments in his stories that articulate relationships between environments and minds: they are often points of passage between the outer material world of characters and their subjective inner lives. Highly suggestive, they gain exceptional plasticity through their layers of interconnected significance. This method of mobilizing concrete details to construct subjects in relation to their environments goes beyond realism's strategy of enumeration to create dialectical relationships between human subjects and their material and psychological environments. Environments have specific effects on the bodies and minds of patients and characters, while the subjective experience of characters plays a defining role in the construction of atmosphere, mood, and even the material environment itself. These methods for constructing places and characters create an environmental psychology that, positioned between medical science and literary experimentation, is an original and rigorous articulation of the relationship between human subjects and the spatial and social surroundings in which they are embedded.
While my focus has been on stories written during Chekhov's medical education and early career, his environmental psychology is far from confined to them. Chekhov's interest in writing about the relationships between inner and outer life, in fact, unfolds steadily over the course of his literary career. He continues to experiment with these same relationships in the constellation of works “Grisha” (“Grisha,” 1886), “Spat’ khochetsia” (“Sleepy,” 1888) and “Step’” (“The Steppe,” 1888), all stories of children who are shaped by dynamic environments during key times of their psychological development. Chekhov also carries similar ideas into his longest work of prose, Ostrov Sakhalin (Sakhalin Island, 1890), a documentary exploration of the role environments play in the experience of exile on Sakhalin. After his return, the psychological experience of illness and the shaping power of environments surface in works such as “Gusev” (“Gusev,” 1890), “Palata No. 6” (“Ward No. 6”), “Chernyi monakh” (“The Black Monk”), and “Arkhierei” (“The Bishop,” 1902). A more mature and contemplative version of this psychology that dwells on problems of space and social development then continues into some of his most revered late stories: “Chelovek v futliare” (“The Man in a Case,” 1898), “Kryzhovnik” (“Gooseberries,” 1898), “About Love,” and “Sluchai iz praktiki” (“A Case from Practice”), among others. While analysis of these works lies beyond the scope of this article, I hope to have established a starting point for such research based on the original documentation of Chekhov's medical training and the history of environmental medicine that forms its context.
