Anton Chekhov (1860-1904) dealt in many of his short stories and plays with various phenomena as encountered in everyday medical practice in late 19th century Russia. In A Case History (1898) Chekhov illustrates the physician's many positions in relation to his patient. According to Mikhail Bakhtin's philosophy of language, a speaker occupies a certain position from which he or she addresses the listener. A phenomenon may gain different meanings depending on the position from which it is addressed. In his story Chekhov describes how the patient was at first addressed solely from a medical point of view, without any relief to her suffering. Only when the physician was able to shift his position in a manner which offered the patient an opportunity to be heard as a person was she able to express the true nature of her illness and to find new ways for palliation and cure.
- Mikhail Bakhtin
- doctor-patient communication
- medical consultation
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Physician novelists1 offer us a unique insight into physicians' ways of thinking and proceeding in their clinical work. The Russian author Anton Chekhov (1860-1904) was, alongside his literary work, a practising physician with a deep insight into the social conditions of his time and country and into their consequences for the health of its people.2 In many of his short stories and plays he dealt with issues of illness and healing as encountered in late 19th century Russia. In this essay I shall analyse how Chekhov illustrates the physician's many positions in relation to his patient as presented in the short story A Case History (1898).3 For my analysis I shall draw on some aspects of Mikhail Bakhtin's philosophy of language and apply these to the problems of medical practice.
A Case History
The story opens with the arrival of a mill-owner's telegram to a professor of medicine, requesting him to come and see the daughter of the family urgently. The professor decides not to go himself but sends one of his house-surgeons, Dr Koryolov, instead. When the doctor arrives at the mill-owner's house he is first met by the lady of the house, Mrs Lyalikov, and by Miss Christine, the governess of the house, who subtly gives her opinion of the matter. (All quotations are from the edition cited at reference three.)
“Miss Christine … was in a great hurry to rehearse the causes of the disease in niggling minor detail. Who the patient was, though, what this was all about … that she didn't say.” (p 180)
The doctor listens politely to the lay opinion of Miss Christine, who makes great efforts to define the nature of the problem but the identity of the patient is not revealed as yet. Eventually the doctor learns that
“it was a girl of twenty—Liza, Mrs Lyalikov's only daughter and heiress—who was ill. She had been unwell for some time, she had been under various doctors, and during the entire previous night she had suffered heart palpitations so acute that no one in the house had slept—they had feared for her life.” (p 180)
Whatever the problem is, it has touched the life of the family deeply. The problem has expanded from a single person's bodily symptoms to affect those around her to the utmost. Many doctors had been consulted but the problem, as yet, remains to be solved. Miss Christine goes on explaining her view of the matter:
“She's always been poorly since she was little, as you might say … . The doctors call it nerves. But if you ask me it may be the scrofula she had as a child—drove it right inside her, them doctors did.” (p 180)
Before even seeing the patient Dr Koryolov is provided with two opinions on the nature of the case, that of the professionals, “nerves” as a medical diagnosis, and that of a lay nature derived from medical vocabulary, childhood scrofula, mixed with lay observations, “poorly” since a child. They went to see the patient whom they found lying in bed, “hair uncombed, blankets up to her chin”.
“‘Well, here we are,’ began Koryolov. ‘We've come to make you well. Good evening.’ He gave his name, took her hand: her large, cold, ungainly hand. She sat up—long used to doctors, obviously, not caring that her shoulders and chest were uncovered—and let him examine her. ‘It's palpitations’, she said. ‘I felt terrible all night, nearly died of fright. Do give me something to take.’” (p 180)
The patient gives her opinion of the problem by using a medical term “palpitations”, as if this simple diagnosis would completely decipher her malady. But we also learn that the problem is not only the palpitations but also terror. She “nearly died of fright”.
(Koryolov) “Yes, yes, don't worry.” (p 181)
The doctor acknowledges the patient's opinion but it is certainly not enough for him to draw any conclusions as yet. Dr Koryolov performs a physical examination and finds himself in agreement with his colleagues who have seen the patient previously.
“‘There's nothing wrong with the heart’, he said .
‘Everything's fine—no cause for worry. Your nerves must have been playing up a bit, but that's nothing. The attack must have ended, so you lie down and get some sleep.’” (p 181)
Dr Koryolov takes a plain medical position in accordance with the emerging modern biomedical theory of disease. In his opinion there is no organic problem in the heart. The treatment consists of reassurance and advice to get some sleep. According to medical reasoning the case is closed. But suddenly the doctor is thrust into a new position.
“Then a lamp was brought into the bedroom. The sick girl squinted in the light, suddenly clutched her head in her hands—and burst out sobbing. … He saw a gentle, suffering look so wise, so moving that she seemed all feminine grace and charm—he wanted to soothe her, now, with a few simple kind words: not with medicines or advice.” (p 181)
The doctor is now confronted, not with a nameless dysfunctioning organ, but with a suffering fellow human being. This touches him not as a detached scientist, but as an empathetic man willing to care for her no matter what the underlying organic pathology may or may not be. But it was not only the patient who was in need of understanding and care.
“The mother clasped her daughter's head and clutched her to herself. What grief, what despair was in the old lady's face! …‘You're crying again, Liza,’ she said, clasping her daughter. ‘My own dearest little darling, tell me what's the matter. Tell me, for pity's sake.’ Both wept bitterly.” (p 181)
The crucial question emerges, shared by both the mother and daughter. What is causing the problem? What is the problem?
“Koryolov sat on the edge of the bed and took Liza's hand. ‘There, there, don't cry’, he said kindly. ‘There's nothing on earth worth all of those tears, now, is there? So don't let's cry then. No need to—.’ The thought struck him that it was ‘time she got married’.” (p 181)
The doctor moves a step closer from his professional, we might say scientific, distance and he soothes the patient as best he can, touching her and saying a few comforting words. Then, a diagnostic clue strikes him: a young woman at her age should be preparing for a marriage. His thoughts are interrupted by Miss Christine's voice:
“‘Our works doctor's been giving her potassium bromide,’ said the governess. ‘But it only makes her worse, I notice. If it's heart trouble, then it's my opinion she should have those drops—what are they called? Convallamarin, or something?’” (p 181)
Dr Koryolov is offered a lay opinion again, derived from fragments of professional medical details and mixed with personal beliefs and convictions. Dr Koryolov listens to Miss Christine patiently but he does not let her influence his judgment. He holds on to his professional medical position and passes the problem to the colleague who had been treating the patient previously. He gives his second opinion, sustaining the one already given.
“‘I don't see anything to worry about,’ said he, leaving the bedroom and addressing the mother. ‘If the works doctor has been treating your daughter, let him carry on. The treatment's been all right so far, I see no need to change doctors. There is no point anyway—it's quite a common ailment, nothing serious.’” (p 182)
For Koryolov the case is finalised as to medical diagnosis and treatment. The bottom line is “nothing serious”, indicating that whatever is causing the palpitations it will not cause any threat to the patient's life or her ability to perform her ordinary daily duties.
“He spoke slowly, putting on his gloves, while Mrs Lyalikov stood motionless and looked at him with tear-filled eyes. ‘I have half an hour to catch the ten o'clock train’, he said. ‘I hope I shan't miss it.’” (p 182)
Dr Koryolov is indicating the end of the consultation by putting on his gloves and noticing the time to catch the train. Then the mother approaches him.
“‘Can't you stay with us?’ she asked, and tears again flowed down her cheeks. ‘I don't like troubling you, but do be so kind—. For God's sake,’ she went on in a low voice, glancing round at the door, ‘do stay the night here. She's all I have, my only daughter. She did scare me so last night, I can't get over it. For pity's sake don't leave us.’” (p 182)
The doctor is now challenged with an ethical dilemma. According to his sound professional opinion “there is nothing to worry about”. But he is simultaneously faced with the deepest existential problem of the family, the fear, the terror of losing the “only one”. Still, he had every reason to leave the family on their own and go.
“He wanted to say that he had a lot to do in Moscow, that his family was expecting him home. To spend an entire evening and night in a strange house for no reason … it would be an ordeal. But he looked at her face, sighed—and silently removed his gloves.” (p.182)
Dr Koryolov responds to the plea of the family by staying. His decision is based not on scientific reasoning but on ethical choice. He sees the core of doctoring as residing not in technical manipulation of human biology but in the care of his fellow-men in pain and in distress. He offers himself, his doctorhood, for the use of the family, to endure the night's anticipated fear and terror.
He dines with Miss Christine and learns that she has been with the family for some years and that there has been no man in the house since Mr Lyalikov passed away eighteen months ago.
Now the doctor's position shifts from studying a particular physical problem to considering the human relations and conditions in which the patient lives. He notices the “dim, glib, uninspired” atmosphere of the house. The father and husband of the family has passed away not so long ago and the three lonely women are living together in the midst of depression and confusion.
After dinner Koryolov takes a walk around the mills. He succumbs to his thoughts and contemplates the nature of late 19th century Russian industrialism and its consequences for the people who work in the mills and also for those who own them. Eventually, the context of the palpitations expands further, reaching metaphysical and religious shades, when he ends up meditating upon man's fate in the world in general.
When Koryolov comes back to the house he hears the patient weeping and he is brought back to the particular. He enters her room and asks how she is.
“‘All right, thank you.’
“He felt her pulse, pushed back the hair which had fallen on her forehead.
“‘You can't sleep,’ he said. ‘There's wonderful weather outside—spring, nightingale song—but you sit brooding in the darkness.’ She listened, gazed into his face. Her eyes looked sad and wise, she obviously wanted to tell him something.” (p 186)
With a small, almost unconscious movement, pushing back the young woman's hair in a caring manner and acknowledging her loneliness in the midst of a lovely spring, Koryolov posits himself in the centre of the patient's misery, offering himself to listen to whatever there was for her to tell. And the patient accepts the doctor's offer. The connection is formed and the stage is set for mutual understanding to develop, to make visible and to share that which is mute and hidden in the patient's loneliness. Koryolov takes the initiative.
“‘Does this happen to you often?’ he asked.
“She moved her lips. ‘Yes, I feel depressed almost every night.’” (p 186)
Here we witness the patient's first effort towards opening herself to the doctor. The patient reformulates her problem by saying she feels “depressed”. (In the original Russian text Chekhov uses the term tiazhelo which means more like “feeling heavy in one's soul”. The translator's choice of “depressed” is a modern expression, unlikely to be used by a rural Russian woman in the late 19th century.) Now a small incident takes place.
“Then the watchmen began striking two o'clock outside. Hearing those blurred thuds, she shuddered, and he asked whether the banging bothered her. ‘I don't know. Everything bothers me here, everything,’ she answered, gathering her thoughts.” (p 186)
The doctor observes the patient's reaction. He takes the initiative again and with a short exchange of words a new horizon is opened. The problem shifts from palpitations to the very basic question of her being. “Everything bothers me here”, she says and as though to underline her problem, she repeats the word “everything”. From this point on, the patient enters a terrain which seems to be alien for her. She is “gathering her thoughts” as though in order to find an expression of her feelings, dreams and fears which most likely have never been truly expressed in a living dialogue with another person. Why this is taking place at this particular moment with this particular person, the doctor, is disclosed by the patient:
“‘Your voice sounds sympathetic, and from the moment I saw you I've somehow felt I could talk to you about things.’” (p 186)
Dr Koryolov seizes this unique moment. He presents himself to the service of the patient with three simple words.
“‘Talk then. Do.’” (p 186)
With these words and through the doctor's genuine commitment the patient is given the opportunity to find form and expression for her chaotic experience of illbeing. She bursts out by saying:
“‘I want to tell you what I think. I don't think I'm ill at all. Why am I worried and scared? Because it has to be, because it can't be helped. … I'm always seeing doctors. … I'm most grateful, of course, I don't disbelieve in medicine. But I don't so much want to talk to a doctor as to someone close to me: a friend to understand me and show me whether I'm right or wrong.’” (p 186)
The patient calls Koryolov again into a new position, that of someone to understand her, and opens her inner world to him. Up to this point her malady has been approached solely as a bodily phenomenon, but now she reveals that her misery is not medical in the sense that it could be reduced to her tissues and cells. The problem emerges as existential in nature. She is grappling with questions which need to be heard and shared with someone close to the patient rather than by a detached physician who approaches the patient as a body, neglecting the value and meaning of her personal experience.
“She smiled again, raised her eyes to the doctor, and looked at him so sadly and wisely that he felt she trusted him, shared his outlook, and wanted to tell him what she really thought. But she said nothing, perhaps wanting him to speak.” (p 187)
Koryolov has formed an opinion of what ought to be done:
“He knew what to say to her now. Clearly she should run away from her five mills and her million roubles. … Clearly, too, she had the same ideas as he—and she was only waiting for someone she trusted to confirm them.” (p 187)
But Koryolov hesitates. Even though the idea itself seemed clear and the solution simple, and all that was needed was to confirm the secret wishes of the patient, there was something more he could not grasp and, therefore, could not express.
“But he didn't know how to put it. What could he say …‘What shall I say?’ wondered Korolyov. ‘Need I say anything, actually?’” (p 187)
At this very point Koryolov is confronted with one of the most fundamental problems of doctoring. He is confronted with the hopes, desires and dreams of a patient which urge a response. But how should he respond? And even more, should he say anything at all? Where are the boundaries and limits of his responsibilities as a physician towards his patient? There are no clinical guidelines available to establish these.
“So he said what he had to say indirectly and obliquely.” (p 187)
Koryolov enters into a short monologue, redefining the patient's problem. He posits it as a general problem of the young people of their time. He says that the reason for the patient's misery is her struggling with the questions of right and wrong, questions she has not been able to solve and which are causing her palpitations and keeping her awake during the long and lonely hours of the night. Koryolov finishes by contemplating the future. In the world to come, he says, for their grandchildren, the solution would be very likely just to drop everything and run away. Liza responds by asking, where will they run to.
“‘Where to? Why, anywhere!’ laughed Koryolov.
‘There's no lack of horizons for a decent, intelligent man.’ He looked at his watch. ‘I say, the sun is up. It's time you went to sleep. You undress and have a really good sleep. I'm very glad to have met you,’ he went on pressing her hand.6 You're a fine, interesting woman. Good night’. He went to his room and bed.” (p 188)
Koryolov brings the consultation to an end with a few affirmative words and touches her, as if to put a seal on what he has just said. The doctor closes the case and goes to get some sleep.
The last encounter between the doctor and the patient takes place in the final scene of the story. It is a beautiful Sunday morning with birds singing and church bells pealing. The doctor is leaving in a carriage and the patient is standing on the porch.
“She looked pale and languid. She gazed at him sadly and wisely, as on the previous night, smiling and speaking with the same air of wanting to say something special, something vital, something for his ears only.” (p 188)
What her ultimate secret was we shall never know. We can only hope that having being heard something new will emerge for her and her nightly symptoms and terror will eventually vanish. Koryolov has done the best he can as a doctor and as a man. He drives away, leaving another case behind him.
“How pleasant, thought he, to drive in a fine carriage pulled by three horses, sunning oneself on such a fine spring morning.” (p 188)
In A Case History Chekhov illustrates the whole network of human relations within which the patient's distress occurs, is given meaning and is dealt with. While doing this he also makes visible the many positions in which the attending physician stands in relation to the patient and to those involved with her life. I shall examine Chekhov's story further by applying some aspects of Mikhail Bakhtin's (1895-1975) literature theory in the discussion which follows.
Mikhail Bakhtin was a Russian philosopher of language4, 5 who has gained international recognition since the late 1960s through the translation of his major works on Dostoyevsky,6 Rabelais,7 and treatises on the use of discourse in the novel,8 among others. Since we cannot penetrate deeply into Bakhtin's philosophy within the scope of this essay, I shall concentrate on using two of Bakhtin's central concepts, “voice” and “polyphony”, for the analysis.
For Bakhtin a “voice” represents one's expressed consciousness in a dialogue.9 Human consciousness is formed through dialogic relationship with other consciousnesses and, as a result of this dialogic formation, it is penetrated by the voices of others.10 These voices do not, however, present themselves in a chaotic and incoherent manner. What becomes audible depends on to whom the expression is addressed and for what reasons. Bakhtin calls the multitude of voices (as expressed ideas, opinions, convictions etc) present in a dialogue polyphony.11 Because of its polyphonic nature, no expression is finalised but remains essentially dialogic, open, dynamic and context-dependent.
In Bakhtin's thinking the idea of polyphonism is not a matter of literary theory only. It is a central feature of human communication, since artistic expression is a way of visualising aspects of human life as they appear in “the polyphonic nature of life itself”.12 We may borrow, therefore, the notion of polyphony from its use in literary theory to characterise medical practice as well.13
Doctor-patient communication is inevitably polyphonic in nature. A doctor's task is to apply a general medical theory of health and illness to a particular patient's situation. These situations are penetrated by the voices of all those related to this particular event—voices as expressed points of view, opinions, convictions, beliefs, fears, or any other human ways of deciphering the reality within which we live.
Medicine tries to reduce this polyphony of voices to a “systematic monologised whole”,14 that is, to the prevailing theory of medicine. (Bakhtin uses the term “monologic” rather than “monophonic” to make a clear contrast with the term “polyphonic”. This is accepted standard usage in Bakhtin literature). However, if the patient's voice is being heard or incorporated in the monologic context of biomedical theory of disease only, it may reduce the patient to a solely biological object. In his story Chekhov describes how various doctors had been consulted with no real relief for the patient. The problem had, from the biomedical point of view, been accurately diagnosed as “palpitations” caused by “nerves” and treated by potassium bromide. The adherence of previous physicians to the monologising theory of biomedicine had denied the possibility for the patient to be heard as a person, and to be offered the chance to re-examine the problem in order to find new ways for palliation and cure.
Applying biomedical theory mechanically and rigorously as a monologic principle may transform the patient to a “voiceless object”15 of medical examination. However, the patient is not closed and internally finalised and for that reason she does not fit wholly into the procrustean bed of any diagnostic conclusion, which needs in any case to be conceived as only one of the many possibilities for defining the problem at hand. Polyphonism should not, therefore, be suppressed in medical consultations but needs instead to be recognised and studied.
According to Bakhtin, the way we address a phenomenon depends, ultimately, on the position or point of view from which we address it. A word is uttered and gains its meaning not only through the person who utters it but also through the person to whom it is addressed in a particular dialogic situation.16 This can be seen in the way the dialogue between Koryolov and his patient develops during their encounter. First the patient addresses the doctor from a bodily point of view. “It's palpitations. …” The physician responds from a biomedical position, which leads to a diagnostic conclusion of “nerves”. But this conclusion leaves the patient's fear and terror virtually untouched and, therefore, untreated. Only when the doctor is able to perceive the problem from a different position, acknowledging the patient as a person, a lonely heiress with “a gentle, suffering look … with all feminine grace and charm … eyes sad and wise … wanting to tell him something”, does he offer the patient the chance of a new dialogue to reveal what is really bothering her.
Chekhov describes how the doctor was repeatedly called to shift his position when examining the case. First, he was called upon to respond to the voices of those involved with the patient's life. Second, when the patient burst out crying the doctor moved in from his professional distance to soothe the patient as best he could. Third, when the mother appealed to him the doctor responded to her plea by staying in the house for the night. And finally, when visiting the patient again, the doctor was called to listen to the patient's innermost thoughts and to respond to them. This gave the patient an opportunity to open herself in a way which eventually led to a new definition of the patient's problem and created new possibilities for cure and redemption.
It seems, then, that while the patient had long been vaguely aware of what was the matter with her, it was only when Koryolov entered the scene, willing to listen to whatever she had to say, that she was able to get in touch with her inner feelings and thoughts and share them with another person. In Bakhtin's understanding the silent thoughts of a person will appear and find form and expression if there is a responsive other willing to encounter them. This responsive understanding creates a space in which unspoken voices take shape and become audible.17 It is noteworthy, however, that while serving as a responsive other Koryolov did not abandon nor devalue his biomedical assessment in the slightest. He was able only to shift his position in relation to the patient in a manner which offered the patient an opportunity to be heard and to enter into a living dialogue with the doctor. This dialogue helped the patient to restructure her chaotic inner world towards a more coherent and liberating self experience.
A Case History ends with the doctor leaving the house and the patient is seen standing on the porch and smiling sadly, as if hiding her innermost secrets. We are not allowed to know the nature of her thoughts, nor was there any heroic healing depicted by the author. The story remains open-ended as real-life stories do, underlining the ultimate realism of the author's artistic genre.
I wish to express my gratitude to Mikael Leiman, PhD, and Anna-Maija Oranen-Leiman, MA, for their constructive criticism and advice while preparing the manuscript.
Raimo Puustinen, MD, is a General Practitioner in Outokumpu, Finland.