solicitude with which he cared for his parents, his work to reform the inhumanity of Russia's penal system, his contribution to famine relief ,ind to the prevention of cholera, his construction of schools and planting of trees, and his campaign to build a sanatorium for tuberculosis sufferers – all speak of a highly developed ethical philosophy which was perhaps partly the legacy of his Christian upbringing. Chekhov may have rejected the dogma of the Church in .idulthood, but under the influence of people like Father Vasily in Ihganrog even his artistic activities were guided by the same, highly discreet, humanitarian goals.
II Dr Chekhov's Casebook
Moscow was the city where Chekhov began his literary career, and where he made his stage debut as a dramatist. Moscow was also the city where he studied and practised medicine. Chekhov's medical practice may not have given him very much in monetary terms (in fact, hardly anything at all), but the experience of treating patients was to prove invaluable for his creative work, not only in terms of subject matter but technique. As he said in a typically pithy autobiographical note he compiled for a Moscow University almanac published in 1900:
I do not doubt that my medical activities have had a powerful influence on my work as a writer; they have significantly expanded my field of observation, enriched my knowledge, and only people who are doctors themselves will be able to appreciate the true value of all this; medicine has also been a guiding influence, and I have probably avoided making many mistakes as a result of my close relationship with it. My acquaintance with the natural sciences and the scientific approach has always kept me on my toes, and I have tried, wherever possible, to deal with scientific facts; where that has not been possible I have tried not to write at all. I should point out in this connection that the conditions of creative work do not always allow complete agreement with scientific
facts; you cannot depict a death from poisoning on stage as it happens in real life. But you must be able to sense there is an agreement with scientific facts even when you have to resort to convention, that is to say, the reader or the spectator must realize that it is only convention, but that the author writes from a position of knowledge.31
Only immediately after graduating did Chekhov ever seek a full-time position as a doctor. Once he started becoming successful as a writer, medicine receded into the background, but it remained a constant presence in his life, and never lost its importance for him. He was friendly with numerous doctors throughout his life, depicted scores of them in his stories and plays, did his best to support the cause of public health, and helped a medical journal when it was threatened with closure.
His choice of medicine as a career had been rather arbitrary to begin with, as he confessed in his autobiographical note, but it was not one he regretted. The most important thing was for him to acquire a university education which could open up avenues, both professional and social, that would otherwise have been closed to him as a lower-class meshchanin. In other words, a university degree, to which his gymnasium education gave him access, was Chekhov's passport to freedom. He toyed for a while with the idea of studying medicine in Zurich, and then considered the German university town of Dorpat (modern day Tartu in Estonia), which was part of the Russian Empire. As a boy in Taganrog he had been treated by a German doctor from Dorpat;32 it was also where Dr Nikolai Pirogov, Russia's greatest nineteenth-century medical scientist, had taught for many years. But Moscow University was the natural choice, and it turned out to be a good one. If Moscow was becoming a dynamic and powerful city in the closing years of the nineteenth century, thanks to the forces of capitalism, medicine was also undergoing a profound transformation in Russia, and some of its most brilliant figures were linked to Moscow University. The 1880s when Chekhov was a student, were a time when its medical school particularly flourished.
When Chekhov graduated with his doctor's certificate in 1884, after five years of rigorous training, he was entering a highly respectable profession. This had not always been so. The practice of medicine, like so much else, was very backward in Russia and only began to enjoy a degree of prestige after the great reforms of the 1860s. Until the
beginning of the eighteenth century, indeed, the doctors were all foreign. It was in Moscow that Peter the Great set up the first training institution for Russian doctors; eventually there were five others: the Medical-Surgical Academy in Petersburg, and the medical faculties of Dorpat, Vilna (present-day Vilnius – another city with a largely foreign population), Kharkov and Kazan. But the status of Russian doctors remained very low compared to that of their foreign colleagues, and their activities were strictly controlled by the state via the Table of Ranks. Status was made visible through the different uniforms for differing medical posts.
The medical profession offered commoners the possibility of social betterment: acquiring a degree brought with it some desirable privileges, such as exemption from the demeaning poll tax and the hated military service. But it was rare for doctors to rise above the lowest position in the Table of Ranks, and the profession therefore attracted few members of the gentry. State remuneration in addition was extremely modest. Since most medical personnel did not even make it on to the bottom rung of the Table of Ranks, and therefore lacked any kind of official recognition (the regime wished to protect the privileges of the noble class), even having completed the five-year degree, their position in society was significantly lower than lawyers, civil servants and army personnel. In the 1860s doctors were still being lumped together with piano tuners and typesetters when it came to classifying professions, and it was almost axiomatic that doctors came from poor backgrounds. All these factors together conspired to produce a recruitment crisis, and it was partly to solve it that a law was passed in 1876 which enabled the country's medical faculties to provide student scholarships.
Chekhov was the beneficiary of a scholarship from Taganrog, and he was one of the first generation of Russian doctors who did not have to become lowly government functionaries, their status and income determined by a controlling state. First of all the reforms of the 1860s led to the establishment of zemstvo medicine: a free national health care service administered by the new units of elective local government established all over Russia. Medical provision in rural areas was primitive, to say the least, with one doctor to tens of thousands of patients, so the influx of doctors and the building of clinics and hospitals funded by the zemstvo was a major step forward. From its position of backwardness, Russia suddenly vaulted itself into a position
where it had taken the lead: no other European country had yet developed an equivalent of public zemstvo medicine. The Swiss-born F. F. Erisman, who founded hygiene science in Russia, was a leading figure in the movement for community medicine. He settled in Russia in 1875, four years before Chekhov matriculated, and that same year began the publication of long articles on public health in the leading journal Notes of the Fatherland. In 1882 he became Professor of Hygiene at Moscow University, and so was one of Chekhov's teachers. Another major advance in Russian medicine came when doctors started to professionalize their activities and develop autonomy. The Pirogov Society, formed in 1881 when Chekhov was in his second year as a medical student, was named after the surgeon and educator who had just died. It was a national organization that committed itself to continuing Pirogov's quest to improve standards in public health and advance medical education. The first Congress, held in St Petersburg in 1885, attracted 573 delegates, only 44 of whom worked as zemstvo doctors, with twice as many working for hospitals and universities. The 1902 Congress, by contrast, the Society's eighth (which featured a special matinee performance of Uncle Vanya) attracted 1,994 delegates, 412 of whom worked for the zemstvo, with approximately 300 employed in either private practice, hospitals or universities.
When Chekhov later moved out of Moscow to his country estate at Melikhovo, he became an active supporter of the zemstvo medicine programme being developed in the Moscow province, which earned a reputation for being a model of its kind. And he played his part in helping to erase the huge chasm that existed between the educated population and the people by treating peasants himself. In her book on nineteenth-century Russian medicine, Nancy Mandelker-Frieden provides a graphic example of this divide:
