Daudet tried all sorts of therapy, including mashed bulls’ testicles and elixir of guinea pig. Nothing worked, with the exception of large quantities of morphine and chloral hydrate, which made his life bearable. Daudet also coped with his intractable pain by writing about it. He planned to write a complete memoir of his life with pain, but by the time of his death in 1897, he hadn’t gotten farther than 60-odd pages of notes and reflections. About twenty-five years ago, the English author Julian Barnes translated and collected these fragments into a small jewel of a book called In the Land of Pain.¹

The title is illustrative. Those who suffer from chronic pain live in a different country from the healthy, and they gradually find themselves speaking a language that others don’t understand. At first, Daudet introduces details of his discomfort into conversation but soon realizes how repetitive and boring this is to his friends. “Pain is always new to the sufferer,” he writes, “but loses its originality for those around him. Everyone will get used to it, except me.” (p. 19) Daudet finds himself living in a land where suffering is pervasive, “Pain finds its way everywhere, into my vision, my feelings, my sense of judgment; it’s an infiltration.” (p.23) Toward the end he writes, “I’ve passed the stage where illness brings any advantage or helps you understand things; also, the stage where it sours your life, puts a harshness in your voice, makes every cogwheel shriek.” (p. 65)

Although Daudet was not known as a poet, many of these presumably random notes are, in fact, miniature poems. Consider this example: “In the dining room: the man who quite suddenly finds himself unable to read the menu. His wife bursts into tears and leaves the table…” (p. 63) And here is another: “The hotel. The bell-board. The bath times. / Solitude. / Encroaching darkness.” (p. 65)

One of the more depressing aspects of medicine today is the fact that many doctors are still “very poor at discerning things,” at least when it comes to pain. I get a knot in the pit of my stomach whenever I hear a resident discussing whether a patient’s pain is “real” or “imaginary,” or making a cynical comment about drug seeking behavior, especially when the resident herself has prescribed a grossly inadequate course of analgesia. Some of my colleagues believe that a person has to be visibly anguished before they take seriously his reported experience of severe pain. And others get exasperated with patients who describe having more pain than their condition (according to the doctor) warrants, and tell them, “You’re overreacting,” or “It’s all in your head.” When I hear this, I want to shake the physician by their shoulders and yell, “Of course it is! All pain, no matter what causes it, exists in the head. Where else could the experience be generated?”

In the Land of Pain illustrates that chronic pain sufferers can live calm, productive lives despite constant agony. Daudet continued writing, publishing, and socializing until the end of his life, even though he wrote, near the beginning of his journal, “My friends, the ship is sinking, I’m going down, holed below the water line.” (p.7) At the same time, the author’s strength, compassion, and humor illuminate his little book. He emerges as a generous person, who was well loved by his contemporaries. If you were his physician, what would your assessment be?

Would you accuse him of exaggerating his pain because he doesn’t appear desperate?

Daudet refers to his pain as an “unwanted guest,” to whom he intends to give “no special attention.” (p. 79) At another point he reflects on “the ingenious efforts a disease makes in order to survive.” (p. 26) The writer never questions his enemy’s ultimate victory, but neither does he turn in upon himself. He remains a source of joy to others, especially his family, as indicated in this note: “I only know one thing, and that is to shout to my children, ‘Long live life!’ But it’s hard to do so while I am ripped apart by pain.” (p.49)

Chronic pain remains challenging for doctors to treat. One set of barriers are the moral and legal concerns about overuse of opioid analgesics. Questions about the threat of addiction, or the possibility of being manipulated, favor resisting the patient’s suffering, rather than responding with compassion. Many are uncertain about how to proceed because they lack knowledge of treatment protocols that include nonpharmacologic modalities, or referral to pain control clinics for invasive procedures. Alphonse Daudet’s little book invites us to imagine ourselves living, at least for a little while, in the land of pain.

1. Daudet A. In the Land of Pain. Edited and translated by Julian Barnes. New York, Alfred K. Knopf, 2002. (page numbers indicated in the text).

Photo of Alphonse Daudet from Wikicommons.

Although Stevenson’s fieldwork was unusually thorough, mainstream scientists rejected reincarnation as a viable explanation and instead focused on potential methodological weaknesses such as retrospective testimony, cultural influence, and the difficulty of ruling out information leakage. Stevenson described the cases as “suggestive,” but he made clear that reincarnation—or at least the survival and transfer of some aspect of personality—was, in his view, the most plausible interpretation.

The twenty cases in the 1966 volume represented only a fraction of the material Stevenson had been collecting since 1960. His early publications had attracted the attention of Chester Carlson, the inventor of the Xerox process, who left a bequest of one million dollars to the University of Virginia upon his death in 1968. The Department of Psychiatry used the gift to establish the Division of Perceptual Studies (DOPS), with Stevenson as its founding director. The name provided an academically respectable umbrella for research that included, but did not explicitly advertise, the study of children’s past-life memories.

Over the next three and a half decades, Stevenson and his colleagues expanded their investigations across Asia, the Middle East, Africa, Europe, and the Americas. By the time of his death in 2007, Stevenson had published twelve additional books and more than three hundred papers, documenting over 2,000 cases. In 1999, journalist Tom Shroder’s detailed investigation, Old Souls. The Scientific Evidence for Past Lives offered an intimate portrait of Stevenson’s fieldwork and helped bring the research to wider public attention.²

Leadership of the program passed to child psychiatrist Jim Tucker in 2002, when Stevenson retired.³ Tucker became Director of DOPS in 2014 and, in 2021, published Before, an updated synthesis of his own two earlier books. ⁴ Tucker reports that the DOPS database now includes more than 2,500 cases worldwide, including many from North America. Only a minority—roughly 15–25 percent—qualify as “strong cases,” meaning that the child’s statements were independently verified as matching a specific deceased individual.

The strongest cases share several converging features: verified statements about the previous life, verified identification of the deceased individual, physical correspondences such as birthmarks or birth defects, behavioral continuities, and early onset of statements. One of Stevenson’s most striking findings involved physical correspondences. By 1997, he had documented 210 cases in which a child had a birthmark or birth defect corresponding to a wound on the deceased individual, and in 49 of these, he obtained autopsy reports confirming the precise wound locations.⁵ These findings were presented in detail in Where Reincarnation and Biology Intersect and in his massive two-volume monograph Reincarnation and Biology.⁶

Here is an example of one of Ian Stevenson’s earlier strong cases. When Swarnlata Mishra was three years old, she began singing unfamiliar songs and performing dance steps her family had never seen, dances from a region of India more than a hundred miles from the family’s home. Soon she was describing a former life as a woman named Biya Pathak, recalling the layout of Biya’s house, the names of her children, and even a stash of money hidden in a wall. Stevenson documented her statements before any contact with the Pathak family, and when they eventually visited, Swarnlata greeted them with an ease and specificity that startled everyone present. She correctly identified family members, teased one man with a childhood nickname only Biya had used, and pointed out a brother’s limp. The encounter had the uncanny feel of a reunion rather than an interview, and for Stevenson it became one of the clearest examples of a case where detailed memories, personality traits, and verifiable facts converged before any possibility of normal information transfer.

More than half a century later, Jim Tucker encountered a very similar pattern in the case of “Ryan,” a young boy from the American Midwest. At age four, Ryan began speaking urgently about a previous life in Hollywood—describing movie sets, agents, and a bustling life in Los Angeles. His parents, who had no interest in reincarnation, tried to reassure him, but the boy’s distress grew until Tucker became involved. Using Ryan’s spontaneous statements, Tucker and the family identified a long-forgotten bit-part actor and Hollywood extra from the 1930s and 40s. Ryan had given more than fifty details about this man’s life, including the street he lived on, the name of a restaurant he frequented, and the fact that he had danced on Broadway before moving west. Many of these details were later verified in archives and autobiographical sources unavailable to the family. What made the case especially compelling to Tucker was not only the accuracy of the statements but the emotional tone: Ryan spoke of the former life with longing and confusion, as if caught between two identities, until the memories gradually faded around age six.

Here is an example of a case in which the child had birthmarks corresponding to the deceased person’s wounds. In rural Burma, a young boy began speaking at age three about having been a man who was shot from behind while walking along a road. His parents were startled not only by the specificity of his statements but by his two unusual birthmarks: a small, round mark on his chest and a larger, irregular one on his back. When Stevenson later investigated, he found that the boy’s descriptions matched the death of a man from a nearby village who had been killed by a close-range gunshot. Eyewitness accounts and medical documentation confirmed the wound pattern, which corresponded closely to the boy’s birthmarks. The child also showed a deep, visceral fear of guns and loud noises, reacting with panic in ways that seemed disproportionate to anything in his current environment. The case combined early and detailed verbal statements, independently verifiable information about a violent death, and physical marks on the child’s body that mirrored the trauma he described.

Stevenson’s long-term research program—and Tucker’s continuation of it—poses a direct challenge to the assumption that consciousness is wholly generated by the brain. Across more than 2,500 investigated cases, they documented young children who spontaneously described memories, behaviors, and emotional dispositions corresponding to identifiable deceased individuals. While most cases are incomplete or ambiguous, a substantial minority meet stringent evidential criteria, and more than two hundred combine multiple independent lines of evidence: verified statements, behavioral continuities, and physical correspondences. Critics have proposed cultural contamination, suggestion, fraud, or loose investigative methods, but none of these explanations plausibly account for the best-documented cases, especially those with medical records, multiple independent witnesses, and physical anomalies. Even the most skeptical reviewers have struggled to articulate a coherent alternative hypothesis that explains the full pattern of data.⁷

For more than sixty years, however, mainstream scientists have dismissed the research. Critics argue that the stories of past lives are most likely due to coincidence, misinterpretation, parental influence, observer bias, or other sources of error. They emphasize the complexities of contextualizing and translating these “memories,” especially in cultures with strong beliefs in reincarnation.⁷ Yet critics rarely engage with the case narratives themselves; instead, they rely on hypothetical sources of error. To attribute all of these cases solely to flawed methodology would require assuming that Stevenson, Tucker, and DOPS have repeatedly committed the same errors for six decades despite their detailed rebuttals of such claims.

The deeper criticism, however, is philosophical. Although surveys show that most Americans and physicians believe in a soul or spirit, most philosophers and neuroscientists endorse a materialist-reductionist view: the brain creates the mind through electrochemical activity, and consciousness ends with the death of the body. Clinically, there is ample evidence that consciousness depends on a functioning brain—brain injuries and diseases clearly alter mental states, and imaging techniques reveal neural pathways associated with various emotions and thoughts. For clinical purposes, consciousness appears entirely dependent on the physical brain.

Yet this dependence does not settle the metaphysical question of what consciousness is. Critics of Stevenson and Tucker often assume, without argument, that the physical world as described by contemporary physics is the totality of what exists, and that consciousness must therefore be a byproduct of physical interactions. But subjective experience—the interior world of personal identity—does not obviously follow from any known property of quarks, electrons, photons, neutrinos, or the forces that govern them. The gap between third-person description and first-person experience is conceptually radical. No arrangement of particles, however complex, seems to entail subjectivity, i.e. interior life, in the way that arrangements of particles entail objects, organisms, or chemical bonding. To assume that this gap will close through further study of neural circuitry is to smuggle in a metaphysical conclusion under the guise of scientific optimism.

The quantum world is exceptionally weird – in many ways it violates common sense. Particles are also waves and waves are particles. An electron can be in multiple places at once. The behavior of one particle may determine the behavior of another, even though they are too far apart for a message to pass between them. Particles can tunnel through barriers apparently without having enough energy to do so. However, none of this weirdness suggests that large accumulations of particles (e.g. atoms, molecules, brains) could generate an interior world of personal identity There must be a deeper, more complete, theory of what exists in the universe that does account for the generation of consciousness; a quantum of subjectivity, if you will. As science writer Jim Holt summarized in Why Does the World Exist?, “The properties of a complex system like the brain don’t just pop into existence from nowhere; they must derive from the properties of the system’s ultimate constituents. Those ultimate constituents must therefore have subjective features themselves.”⁸

This is why the possibility that consciousness has a fundamental place in the universe is not mystical speculation but a legitimate philosophical alternative. Some philosophers and neuroscientists propose that consciousness may be an intrinsic aspect of matter, or that the universe contains a fundamental “interior” dimension alongside its measurable exterior. Panpsychism—the view that consciousness is woven into the structure of matter—is endorsed by a small, but growing, minority of philosophers, including David Chalmers⁹, Philip Goff¹⁰, and Galen Strawson.¹¹ Another group, notably Thomas Nagel¹² and John Searle¹³, acknowledge that our current physical ontology is incomplete, although not fully endorsing panpsychism. Physics has repeatedly revised its understanding of matter; it is not unreasonable to suspect that consciousness may require a similarly deep revision. To quote Thomas Nagel, “Consciousness is the most conspicuous obstacle to a comprehensive naturalism that relies only on the resources of physical science. The existence of consciousness seems to imply that the physical description of the universe, despite its richness and explanatory power, is only part of the truth.”¹²

Given these considerations, the continuation of consciousness, at least in some form, after death seems at least a possibility. Stevenson and Tucker’s work may well represent the identification of a previously unknown natural phenomenon, perhaps analogous to reported near-death experiences — well-documented yet difficult to explain. To my mind, this conclusion is more likely than is six decades of repeated errors.

However, that doesn’t mean the “former lives” data necessarily support a traditional doctrine of reincarnation, in which a unitary soul passes from one body to another. If a psychic dimension of the cosmos exists, a one-to-one transmission of “mind-stuff” to a newborn baby in the same country and culture seems overly simplistic, more in line with supernatural beliefs than with an unknown natural phenomenon. It is notable that the phenomenon is rare and the memories transient and strongly associated with traumatic death. Could it be that, under certain conditions, a “package” of psychic impressions may transfer from a dying person to a newborn, occasionally even influencing the child’s body? This, like any other scenario, is speculative, given our ignorance of the origin and meaning of consciousness in the physical world.

The broader point is that most philosophers and neuroscientists begin with an unexamined premise: that everything real must be physical in the sense described by current physics. But consciousness—the one phenomenon we know from the inside—does not obviously fit within that framework. Before declaring that mind must be reducible to matter, we should ensure that our conception of matter is adequate to account for mind at all. Consequently, Stevenson’s and Tucker’s six-decade quest to understand the experience of children who report having lived former lives should, if anything, leave us wondering whether we really know what we think we know about the way the universe works.

References 

1. Stevenson, Ian Twenty Cases Suggestive of Reincarnation, University of Virginia Press, 1980 [First published in 1966] 
2. Schroder, Tom. Old Souls. The Scientific Evidence for Past Lives. New York, Simon & Schuster, 1999 
3. Tucker, Jim B. Ian Stevenson and Cases of the Reincarnation Type, Journal of Scientific Exploration. 2008; 22: 36-43 
4. Tucker, Jim. B. Before: Children’s Memories of Previous Lives, St. Martin’s Press, 2021 
5. Stevenson, Ian. Where Reincarnation and Biology Intersect. Westport. Praeger, 1997 
6. Stevenson, Ian. Reincarnation and Biology: A Contribution to the Etiology of Birthmarks and Birth Defects, Westport, Praeger, 1997 [Two volumes] 
7. Matlock, J. G. ‘Reincarnation Case Studies: Criticisms’. Psi Encyclopedia. London: The Society for Psychical Research. <https://psi-encyclopedia.spr.ac.uk/articles/criticisms-reincarnation-case-studies/>. (2022, retrieved 24 March 2026) 
8. Holt, Jim. Why Does the World Exist? London, W. W. Norton & Company, 2012, p. 194 
9. Chalmers, David J. The Conscious Mind: In Search of a Fundamental Theory. Oxford University Press, 1997 
10. Goff, Philip. Galileo’s Error. Foundations for a New Science of Consciousness. New York, Pantheon Books, 2019 
11. Strawson, Galen. Consciousness and Its Place in Nature, Imprint Academic, 2024 
12. Nagel, Thomas. Mind & Cosmos. New York, Oxford University Press, 2012, p. 35 
13. Searle, John. Mind: A Brief Introduction, Oxford University Press, 2005 

Web image by Medhum.org

What is Colombo’s heresy? True, he has consistently violated the Papal Bull of Pope Boniface VIII that forbad obtaining cadavers for dissection, but his scholarly eminence and friendship with Pope Paul III have protected him from recrimination. His heresy is far worse than simply ignoring a Papal Bull; in fact, Mateo Colombo has discovered a dangerous new anatomical structure, the clitoris! 

Mateo was called to the bedside of an unconscious holy woman named Inés de Torremolinos. In the process of examining her, the physician was amazed to discover “between his patient’s legs a perfectly formed, erect and diminutive penis.” (p. 105) He took hold of the strange organ and began massaging it. As he did so, there was an amazing response in his patient: “(Her) breathing became hoarser and then broke into a loud panting… Her lifeless features changed into a lascivious grimace…” (p. 107) Subsequent research undertaken with Mona Sofia, the resplendent whore, as well as with cadavers, confirmed the significance of Colombo’s discovery. 

At his hearing before the High Tribunal, Colombo explains his findings, which are far too complex and subtle to summarize in a short review (pp. 138-165). The finding of greatest interest, however, is that “there is no reason to believe that there exists in women such a thing as a soul.” (p. 151) In fact, Colombo contends he has proven that the “amor veneris” or clitoris performs in women “similar functions to those of the soul in men,” although its nature “is utterly different since it depends entirely on the body.” (p. 153) 

This novel was highly controversial when it first appeared in Argentina, and its denunciation by the sponsor of a major literary prize in that country sparked a literary scandal. The novel’s basic conceit is the analogy between Christopher Columbus’ “discovery” of the geographical New World in 1492, and Mateo Columbo’s discovery of the anatomical New World, the clitoris, a generation later.  

Like his explorer namesake, the Renaissance anatomist ventured forth into new territory, setting aside prejudice and popular opinion, as well as (in Mateo’s case at least) the weight of church authority. However, although the anatomist struck a blow for objectivity in observation, his interpretation of the findings was compromised by cultural bias, in this case, by pervasive misogyny. The human soul is the seat of reason; since women are controlled by passion rather than reason, perhaps they lack souls. When Colombo concluded he had discovered the organ that produces passion (“amor veneris”), he assumed that, since the clitoris generates female behavior, it must be analogous to the soul, which generates male behavior. Needless to say, this theory guaranteed some heated discussion. If you thought Descartes’ concept of the pineal gland as the seat of the soul was bizarre, try this one. 

Historical note: Matteo Colombo (c. 1515 – 1559) was an Italian professor of anatomy and a surgeon at the University of Padua between 1544 and 1559. While Colombo was not the first anatomist to describe the clitoris, he is credited as being the first who correctly identified the clitoris as a predominantly sexual organ. He was never tried for heresy. In fact, he was the personal physician of Pope Paul IV and his major work, De re Anatomica (1559), was published in Rome with ecclesiastical approval. The correct English translation of his Latin text reads “the clitoris is the site of women’s delight,” not “soul.” However, Andalhazi’s fictional re-imagining of Columbo’s life and work makes for a very provocative story.  

The Anatomist
Frederico Andahazi
New York, Doubleday, 1998 (215 pages) 

Web image by Tim Schmidbauer

When the Food and Drug Administration (FDA) was created in 1930, its mission was to ensure the safety of prescription medications. In 1962, with the passage of the Kefauver-Harris Amendments to the Federal Food, Drug, and Cosmetic Act, the FDA also became responsible for certifying drug effectiveness. Positive results in one or more randomized double-blind clinical trials became the gold standard for approval. Thus, patients were assured that when their doctor prescribed a “hot” new drug that had appeared on the market, it had met the FDA’s rigorous safety and effectiveness criteria.  

Yet, sixty-three years later, near the beginning of Rethinking Medications (2025), Dr. Jerry Avorn writes:  

“In 2021, the Food and Drug Administration (FDA) gave its approval to Aduhelm, a new drug for Alzheimer’s disease that didn’t work, could cause brain damage, and was poised to cost the nation each year a sum the size of NASA’s annual budget. How did the world’s once best prescription drug regulatory body fall so low” (p. 31) 

The FDA not only approved Aduhelm but did so over an almost unanimous negative vote of its scientific advisory panel. What had happened to the promise of safety and effectiveness? Jerry Avorn MD, founder and director of Harvard’s Division of Pharmacoepidemiology and Pharmacoeconomics, argues that the Aduhelm approval resulted from a longstanding decline in the FDA’s regulatory standards, a slippery slope greased by social, political, and especially pharmaceutical industry pressures. Rethinking Medications is a comprehensive assessment of the pharmaceutical industry, the FDA, and their complex relationship in the 21^st century. Much of the book addresses three core issues: Does a new drug work? Is it safe? And what should it cost? Other chapters deal with education, patient empowerment, and the specific examples of psychedelics and pain killers. 

According to Avorn, the FDA’s rigor began to break down during the late 1980s when the agency initiated an accelerated or “fast track” review process in response to the AIDS epidemic, a reasonable change in light of the rapid spread of this incurable and deadly disease. (pp. 30-32) Initially, “fast track” approval involved greater FDA monitoring and quicker action but still required evidence of clinical effectiveness. In the case of AIDS, a hematological marker, CD4 T-cell count, was highly correlated with clinical outcome, which made it an excellent index of effectiveness. 

However, not long afterward, the FDA opened its accelerated approval pathway to medications for chronic, progressive diseases and to use a favorable change in such surrogate markers (e.g. blood tests or images) as substitutes for clinical improvement. For example, in the case of Alzheimer’s disease, reduction in the number of amyloid plaques was considered a sufficient reason to approve Aduhelm, though the study had not documented symptom reduction or slower decline in functioning. While some surrogate markers are good predictors of outcome (e.g. Hb A1c in diabetes), most markers used for chronic disease drug approvals lack strong predictive evidence.¹ 

However, the accelerated track includes a presumed fail-safe mechanism. The pharmaceutical company is required to complete a long-term confirmatory study to confirm clinical effectiveness. By 2022, more than half of new drug applications were being processed in the expedited track, and over 80% of these were approved. (p. 77) The confirmatory study requirement, even if honored by the companies, allowed medications to be prescribed for years before a negative finding might cause approval to be revoked. According to Avorn, the increasing use of surrogate markers as endpoints tells the industry, “You can market your drug if it makes a lab test look better in a short study, compared to a placebo. We won’t be on your case too much about those confirmatory follow-up studies.” (p. 37) [Avorn engages in hyperbole here. Aduhelm was shown to be ineffective and withdrawn from the market in 2024.]² 

Avorn next addresses the safety of newly approved drugs. Serious side effects must be recognized, if possible prior to approval. However, according to the author, the profit motive sometimes outweighs evidence of significant harm. He discusses the case of Vioxx (Merck Pharmaceuticals, 1998), a COX-2 inhibitor approved because it had fewer GI bleeding side effects than other NSAIDs. Several studies subsequently showed that patients taking Vioxx had almost double the number of myocardial infarcts and strokes of those taking other NSAIDs. Nonetheless, Merck rigorously disputed this evidence for several years before finally removing Vioxx from the market in 2004. Largely as a result of the Vioxx scandal, Congress passed the FDA Amendments Act in 2007, which introduced several safeguards for ensuring drug safety. These included (a) creating a nationwide system for monitoring adverse effects, (b) preventing companies from hiding clinical trial results by requiring that all trials be registered in a federal registry, and (c) insisting that companies complete follow-up studies after the drug has been approved. (pp. 167-170) 

In 2007, a far more widespread safety failure was still a decade from being revealed. When Oxycontin was approved in 1995, the FDA believed the long-acting form of oxycodone would result in less abuse potential, since the drug would be absorbed slowly without an immediate “rush” to promote abuse. This belief had a theoretical basis, but there were empirical findings that strongly suggested otherwise. Over twenty years later, a presidential commission (2017) “concluded that the FDA’s mishandling of the evaluation, approval, and use (of oxycontin) was an important cause of the nation’s opioid crisis” (p. 393). 

Anyone who watches broadcast television today will find it difficult to believe that prior to 1997, essentially no prescription drug advertising appeared on television. In 1997, the Food and Drug Administration approved a new rule allowing pharmaceutical companies to state only “major risks” in their ads, rather than its previous requirement of a full list of all possible risks, contraindications, and side effects, which had effectively precluded direct-to-consumer advertising. The industry quickly learned how to package major risks into brief statements aired sotto voce at the end of their commercials under images of smiling patients picnicking in a park. Since then, ads for expensive new pharmaceuticals have spread like wildfire.  

Aggressively promoted new drugs are mostly treatments for chronic, malignant, or degenerative diseases that require continued use over many months or years. The producers, in essence, have monopolies on these products because they are protected by patents from competition for a certain number of years. Without competition, companies are able to charge very high prices, which they justify as necessary to compensate for costs of research and development.  

Avorn identifies several reasons to doubt that excessive R & D costs are a determining factor in pricing new drugs. First, many Big Pharma companies spend more on marketing, most of which is direct-to-consumer advertising on TV and other media, than they do on research and development. Thus, much of the actual “investment” is spent in devising ways to convince consumers that new is better.  

Secondly, most newly approved medications are not innovative, but rather modifications of existing drugs for which the patents will soon expire. The manufacturer seeks to have a replacement drug with a claimable advantage (e.g. fewer side effects, fewer daily doses) sufficiently different to be patented and approved before it loses patent protection on a profitable product. When generic versions of the product appear on the market costing up to 60% less than the original, the manufacturer attempts to maintain profits and market share by heavily promoting its “new, improved version.”  

Third, “breakthrough” medications that employ a newly discovered mechanism, or work dramatically better than available alternatives, are generally the result of NIH-funded basic science and clinical trials performed by university faculty. While the Bayh-Dole Act (1980) allows universities to patent promising new drugs, only pharmaceutical companies have the ability to develop and market the drug commercially. When a company purchases the patent from its home university, the scientists and the university profit from the purchase, but lose control over the medication that results. Although Big Pharma does invest significantly in developing these drugs and bringing them to market, the basic research and initial clinical trials are supported by federal grants. “The largest engine driving the nation’s prodigious ability to bring new drugs to market is the hundreds of billions of taxpayer generated dollars in the National Institutes of Health and other public and philanthropic of biomedical discovery.” (p.197) Not Big Pharma.  

Finally, retail prices for the same drugs in Canada, Europe, Australia, and Japan average about 60% lower than in the United States, even though their manufacturers presumably still make a profit. The real reason they set prices much higher in the United States is simply because they can. Most other countries have mechanisms to control drug prices based on realistic cost/benefit estimates.  

Rethinking Medications is a compelling analysis of today’s pharmaceutical industry and its regulation by the FDA. Big Pharma is clearly the “heavy” in Avorn’s analysis. The FDA failures result from some combination of responsiveness to the need for new therapies in chronic diseases, inadequate resources and personnel to enforce the requirement for confirmatory studies, and the withholding of critical data by pharmaceutical companies. The FDA Amendments of 2007 corrected many of these problems, although the FDA’s fate under the Trump administration is yet to be seen. The prospects are not promising because the Department of Health and Human Services is directed by a man who aggressively promoted hydroxychloroquine as a treatment for Covid and doubts the effectiveness of vaccines.  

Despite Dr. Avorn’s focus on failures and deficiencies, the reader should keep in mind that the American pharmaceutical industry does have a remarkable track record of producing innovative and effective medications. This, of course, does not justify the industry’s rampant profiteering and deceptive practices. It would require strong federal regulation, especially regarding pricing, to address these problems. Here again, the current administration’s anti-regulatory stance makes progress in the near future improbable.  

Notes 
1, Wallach JD, Yoon S, Doernberg H et al. Associations Between Surrogate Markers and Clinical Outcomes for Nononcologic Chronic Disease Treatments. JAMA, 2024; 331 1646-1654. 
2, Two anti-amyloid monoclonal antibody medications, Legembi and Kisunla, have now been approved for treatment of early Alzheimer’s disease. Both have been shown to slow its progression by several months.  

RETHINKING MEDICATIONS
Jerry Avorn MD 
Simon & Schuster, 2025: 512 pages 

Web image by Jaretuz 

Many modern physicians minimize, or are unaware of, a second source of historical medical success: the power of language and ritual to facilitate physical and psychological healing. Assisted by his priests, Aesculapius, the Greek god of medicine, healed the sick through poetry, narrative, and ritual. Even Hippocrates, the father of naturalistic Western medicine, paid tribute to Aesculapius in his famous Oath, and emphasized in many of his case histories the importance of interpersonal and contextual factors in patient care. While the healing power of language and context was rarely explicit in the subsequent history of Western medicine, it finally emerged into consciousness during the last two hundred years, when it was given the name placebo effect. Initially considered a minor aberration in suggestible people, more recently this component of healing has been recognized as an almost universal human facility (or reaction) of varying and sometimes amazing power.  

In this essay I present a case study of a traditional healing ceremony in which the therapy consists entirely of language, especially poetry, and the ritual context in which the language is spoken and chanted. I argue that this is a very powerful example of contextual healing. I then examine our contemporary understanding of the placebo effect, which is also a form of contextual healing, albeit ordinarily much less striking and more “dilute” than the Navajo example. Finally, I comment briefly on some features of healing miracles in the Catholic Church, arguing that these, too, are powerful instances of contextual healing that suggest at their upper limit, so to speak, such mechanisms may actually be able to reverse disease processes, like cancer or neurological impairment. Of course, this outcome is rare, unpredictable, and not at all understood.  

Sarah Mailcarrier and the Night Way 

Dark cloud is at the door. 
The trail out of it is dark cloud. 
The zigzag lightning stands high upon it. 
An offering I make. 
Restore my feet for me. 
Restore my legs for me. 
Restore my body for me. 
Restore my mind for me. 
Restore my voice for me. 
This very day take out your spell for me.  

Happily, I recover. 
Happily my interior becomes cool. 
Happily I go forth. 
My interior feeling cool, may I walk. 
No longer sore, may I walk. 
Impervious to pain, may I walk. 
With lively feelings may I walk. 
As it used to be long ago, may I walk.¹ 

These lines constitute a small segment from one of the poems chanted during the Night Way, a nine-day Navajo healing ceremony. In the early 1970s, Sarah Mailcarrier was the matriarch of an extended family whose camp was at Cornfields in Beautiful Valley near Klagetoh Mesa. A healthy woman well into her 60s, she developed severe lower abdominal pain, vaginal bleeding, poor appetite, and swelling of her legs over a period of two to three months. Her family took her to Fort Defiance Indian Hospital, some 50 miles from home, where she was discovered to be suffering from cancer of the cervix, which had spread widely, blocking lymphatic ducts in her legs and partially obstructing her kidneys. The recommended treatment was palliative radiation at Gallup Indian Medical Center, a larger hospital in Gallup, New Mexico, another 30 miles distant from Cornfields. Sarah and her family declined this option and, instead, consulted a hand trembler, who diagnosed her problem and recommended a Night Way Sing or healing ceremony. The family hired a ha’a’tali or traditional healer who, along with his assistants, conducted the ceremony over nine days and nights at her camp in Cornfields.² 

According to Navajo diagnostic taxonomy, Sarah had fallen out of harmony with the cosmic narrative that defines the proper relationships among the Earth Surface People, the Holy People, and the natural world. This likely was the result of certain traumatic exposures and events in her life. Healing would require restoration of harmony through the chants, rituals, images, and stories that the Holy People had given to the Navajo for just this purpose. The ceremony was successful. Sarah’s symptoms were relieved, her energy restored, her anxiety disappeared, and she continued to function in her role as matriarch for several months until she drifted into a long sleep and died. 

To explore the nature of Sarah’s healing, I have to explain a little more about Navajo medical beliefs. In traditional Navajo thought, all illness represents disharmony, in essence a snag or gap in the interconnectedness that characterizes the dineh (people), the harmonious Navajo Way. While there are many causes of disharmony (e.g. witchcraft, demon possession, soul loss, taboo violation, and traumatic exposure, as with Sarah Mailcarrier), the goal of treatment is always the same—to restore proper harmony at all levels, from within the patient’s own heart, to his or her relationship to the cosmos.  

The ceremonies, which can last up to nine days, require the patient and family to hire an ha’a’tali and his assistants, and to invite friends and clan members to set aside their other responsibilities and participate in songs, dances, prayers, and other rituals appropriate to the ceremony. Sung by the ha’a’tali these are magnificent narrative poems that tell of the creation of the Navajo people, and how all things were originally placed into their proper order. Likewise, in ceremonial dances, men impersonate Yei Be Chai, intermediaries between the Holy People (whom we might call “gods”) and the Earth Surface People (us), and channel their healing power.  

However, the dineh have never rejected Western medicine. Instead, they have integrated Western physicians, clinics, and hospitals into their overall worldview, considering them synergistic with, rather than antagonistic to, traditional ceremonies. The dineh believe that Western health care has simply added a different set of stories and a different network of ceremonies (e.g. clinic visits, x-rays, penicillin shots, arthritis pills) onto their already existing—and far more important—traditional healing practices. The Navajo were quick to observe that bilighani treatments were effective in alleviating outward manifestations, or what we would call symptoms, of disharmony, but they also maintained that such treatments had no influence on the underlying existential disorder. In other words, penicillin shots and arthritis pills are only symptomatic treatments. While bilighani methods could make the fever or rash or cough disappear, at least for a time, the fundamental issue of disharmony would remain. Why me? What does this illness mean in my life? How does this illness reflect my relationship to the cosmos? These questions could only be answered with reference, for example, to the story of Spider Woman, or the Hero Twins, or other narratives of Navajo cosmogony.  

Returning to Sarah Mailcarrier, it appears that by undergoing a Night Way Sing, she experienced a dramatic improvement in her quality of life. From a Western perspective, why might this be the case? First, the lengthy ceremony provided extensive and intense social support, represented by the participation of her extended family and friends, their contributions of time and money³, and overall solidarity. An extensive body of research indicates that high level of social support and prosocial behavior are associated with longer life, less morbidity, less disability, and greater satisfaction. Second, Sings are integral components of religious practice. For a person like Sarah Mailcarrier, religious belief (in the Western sense of the term) and cultural practices were inextricable. Once again, considerable research indicates that frequency and intensity of religious practice is associated with the same positive outcomes. Third, the ritual chants, vivid poetic images, storytelling, sandpainting, and dancing of the Night Way embody a belief system that generates positive expectations—and restores coherence to the patient’s life.⁴  

These components—social support, core beliefs, and positive expectations—all rely on language and communication. Empathy, the human ability to “intuit” what another person is thinking or feeling⁵, is a more basic neurological property than language, but without language humans could not have created the rich symbolic world in which we live. In the 1980s the psychiatrist Donald Sandler distinguished between Navajo symbolic healing, based on an integrated cultural narrative, including symbol and ritual; and scientific healing, which he believed could be clearly distinguished from the latter and which relies solely on specific instrumental effects of drugs, surgery, and so forth.⁶ Like Sandler, today’s physicians are quite willing to make allowances for the beliefs of patients from other cultures, but at the same time they cling to the belief that scientific medicine transcends culture and our effectiveness as healers is solely, or almost solely, explained by the instrumental effects of drugs and procedures. Thus, there is a widespread belief that scientific medicine is, as a system of curing disease, intrinsically culture-free. Antibiotics kill bacteria whether the patient is a middle-class American or an Amazonian Indian. Culture may enter into the picture for the Indian, e.g. because of his mistaken beliefs about illness, but has no effect on the American, whose beliefs (whatever they are) are medically invisible.  

From Placebo Effect to Contextual Healing 

For over 200 years Western physicians have been explicitly aware of the so-called placebo effect, but for most of that time have considered it a minor and somewhat disreputable factor on the medical scene. The first person to recognize and demonstrate the placebo effect was English physician John Haygarth in 1799, who was curious about the purported benefit a popular medical treatment of his time called “Perkins tractors,” metal pointers supposedly able to ‘draw out’ disease from the patient’s body. They were sold at the extremely high price of five guineas, and Haygarth set out to show that the high cost was unnecessary. He did this by comparing the beneficial results obtained by using dummy wooden tractors with those obtained with a set of allegedly active metal tractors. There was no difference. He published his findings in a book called On the Imagination as a Cause & as a Cure of Disorders of the Body.⁷ Subsequently, the term placebo (“I will please”) was coined to mean, as in this 1811 definition, “an epithet given to any medicine adopted more to please than to benefit the patient.” 

The modern understanding of the power of placebo intervention probably originated with Henry K. Beecher‘s 1955 classic paper, “The Powerful Placebo,” in which he described his experience as a medic during World War II⁸ After running out of pain-killing morphine, in desperation he replaced it with a simple saline solution, while continuing to tell the wounded soldiers that the injection was morphine. He often found that saline appeared to be almost as effective as morphine in relieving his patients’ pain and anxiety. Despite this dramatic demonstration, the orthodoxy surrounding placebo effects for the next several decades came to include three major components:  

• A focus on the specific intervention as its cause, i.e. the pill or the procedure itself “carried” or “transmitted” the placebo effect. 

• Importance of patient vulnerability, i.e. only suggestible persons were placebo-responders. 

• Miscommunication, i.e. the patient must deceived, directly or indirectly, into believing that he or she was receiving an “active” treatment.  

However, research in the last 30 years has completely exploded this orthodoxy and replaced it with a much more complex understanding that sheds light, for example, on the power of traditional medical systems, like the Navajo, that rely on poetry, narrative, and ritual to heal. To quote Franklin Miller and Ted Kaptchuk, two of today’s most prominent investigators in the field: “To promote a more accurate understanding of the elusive and confusing phenomenon known as the placebo effect, we suggest that it should be reconceptualized as contextual healing… Factors that may play a role in contextual healing include the environment of the clinical setting, cognitive and affective communication of clinicians, and the ritual of administering treatment.”⁹ Elsewhere, Kaptchuk added, “Research also suggests that (narrative and) ritual healing not only represents changes in affect, self-awareness, and self-appraisal of behavioral capacities, but involves modulations of symptoms through neurobiological mechanisms.”¹⁰  

Contextual healing, as the term implies, occurs in the context of expectations that arise from a network of beliefs. Moerman and Jonas, highlighting the fact that context can communicate therapeutic meaning to the patient, prefer using the term “meaning response.”¹¹ In some cases these beliefs may be based on past experience, but isolated from, or not intimately connected to, deeply meaningful worldviews (e.g. that penicillin cures a sore throat). In other cases they may closely connected to robust belief systems about the nature and origin of illness and healing (e.g. the Navajo Night Way). The latter are obviously more important than the former. The net valence of one’s beliefs determines the meaning of any medical interaction or treatment and, therefore, one’s expectations of its effect. Language, communication, empathy, narrative, and ritual determine the healing context. The universality of contextual effects on symptom relief has been demonstrated convincingly in neurobiological studies, especially those dealing with pain reduction. For example, on fMRI “placebo” treatment reduces activation of pain-related areas of the brain, e.g. the dorsolateral pre-frontal cortex.^{12, 13}  

Contemporary research on contextual healing has also revealed a number of unexpected features that are inconsistent with the earlier orthodoxy regarding placebo effects. For example, 

• Placebo effectiveness does not require deception; patients may report relief of symptoms even when told they are receiving placebo treatment.¹⁴ 

• There may be a link between genetic variants in the dopamine, opioid, serotonin, and endocannabinoid pathways in the brain and placebo responsiveness.¹⁵ 

• Placebo effects (as well as nocebo, or harmful effects) can exist in routine clinical practice, even if no “intervention” is given.^{16, 17} 

• Placebo response is greater when observed in clinical practice than when measured in randomized clinical trials.^{8, 19}  

This last feature requires some clarification. This is precisely the opposite of specific medication effects, which are almost always more prominent in clinical trials than in routine practice because the populations in trials are highly homogenized (e.g. limited age range, selected to exclude co-morbidities), adhere to highly structured protocols (e.g. frequent follow-up, expert clinicians. methods to insure, or at least measure, compliance) and include only highly motivated subjects. These conditions are ideal for demonstrating the drug’s maximal specific benefit (efficacy), while at the same time somewhat less ideal for showing contextual healing power, since individual variation and personal narrative are minimized. The specify potency of a drug tends to be less in ordinary clinical practice (effectiveness) where there are a mixture of patients with different ages, backgrounds, comorbidities, and levels of compliance. However, the latter less-than-standardized conditions are likely to enhance the power of contextual healing. For example, “It seems likely that the effectiveness of placebo for pain relief in osteoarthritis can be considerably larger than its efficacy. The artificial conditions of a clinical trial constrain the extent to which context effects…” can be manifested.²⁰ 

Can Language Spoken in Context Cure Disease? 

Given that contextual or narrative healing may be a powerful force in relieving symptoms and improving quality of life, can it ever cure chronic or progressive disease? It is unlikely that Sarah Mailcarrier’s Night Way ceremony damaged her cancer cells or had any influence on their progress. However, it seems clear that narrative healing may in many cases “cure” at least some cases of major depression, generalized anxiety, post-traumatic stress syndrome, substance abuse, and perhaps even schizophrenia. Since these disorders are all characterized by abnormal concentrations or function of neurotransmitters, it is safe to say that contextual healing influences brain chemistry. Likewise, fMRI studies have shown that placebo treatments alter brain function. For example, placebo treatment in Parkinson’s disease may result in demonstrable changes in imaging, primarily resulting from increased dopamine release in certain areas of the basal ganglia.²¹ These changes may be associated with improvements in patient function. Likewise, placebo has also been shown to modulate physiological processes, like lowering blood sugar in diabetics and treatment enhancing immune responses, which may be related to neurophysiology in complex ways. ^{22, 23} 

There is a long history of rare, unexplained, but yet well-documented, cures in medicine. As medical knowledge has increased, the number of such inexplicable or “miracle” cures has diminished. Nonetheless, instances of the disappearance of widely metastatic cancer, or the resolution of aggressive autoimmune disease, do occur. Religious persons attribute these unexplained cures to supernatural intervention. Jacalyn Duffin’s 2009 book Medical Miracles: Doctors, Saints and Healing in the Modern World describes her investigation in the Vatican archives of 1400 cases of miracle cures that were cited as evidence in canonization proceedings between 1588 and 1999.²⁴ Of these, 503 cases occurred in the 20^th century and 220 of them between 1975 and 1999, the final year of her study. Most in the 1975-1999 group were extremely well-documented. 20^th century cures included 41 cases of cancer or leukemia, 109 neurological diseases (e.g. multiple sclerosis, myasthenia gravis, Parkinson’s disease), and 89 obvious orthopedic conditions. The unifying factor was that every “miracle” was associated with narrative and ritual. Prayer to Jesus, Mary, or another person, i.e. the candidate for sainthood, took place in various contexts, solitary or communal narrative associated with Masses, novenas, relics, monuments, tombs, etc. These features are all analogous to Navajo healing ceremonies. The same sort of analysis has been applied to “miracle” cures at Lourdes, a pilgrimage site in France, with similar results: a relatively small number of thoroughly documented and inexplicable cures among many thousands of claims.²⁵ 

A Note on Nocebo 

Traditional cultures also recognize the power of language to harm, as well as heal. This includes spells, hexes, curses, and similar verbal insults that produce harmful effects on the person to whom they are directed. Since the phenomenon of “Voodoo death” was described by Cannon in 1942²⁶, various other syndromes of illness and death based on witchcraft and curses were re-evaluated or newly described have been reported; for example, “bone-pointing” (kurdaitcha) in Australia and “breaking tapu” in New Zealand. Among Aboriginal people an individual targeted by bone pointing may die within 24 hours or may decline inexorably over a period of days. ²⁷ Such a curse can only be reversed by the intervention of an appropriate sorcerer. Among the Navajo, many serious illnesses are caused by curses that lead to “soul loss” or “possession.”  

Likewise, in Western medicine the words of physicians or other health care professionals, and the context in which they are spoken, may actually increase a patient’s symptoms, anxiety, and suffering. The eminent internist Eric Cassell, paraphrasing an old childhood chant, taught “Sticks and stones may break your bones, but a word can kill you.” (Personal communication) There is no room here to discuss nocebo-inducing language in medical practice, which is analyzed in detail in chapter 13 of Coulehan and Block.^{28, 29} 

Conclusion 

In this essay I make the claim that contextual healing (aka the placebo effect) plays a major role in medical practice and that language, either spoken verbally, or used internally to represent beliefs and personal meanings, is the carrier or operative agent of contextual healing. In most circumstances contextual healing has a limited, but clinically significant, range of effects. The clinician by employing “skillful means” (to use a Buddhist expression) can promote and enhance contextual healing in the clinical setting.^{20, 31} Navajo medicine is an example of a traditional medical system built almost entirely on exploiting the vast resources available to contextual healing. To a greater or lesser extent, Curanderismo, Vodun, homeopathy, Christian Science, and many other approaches to the treatment of illness are based on contextual healing. The upper limit of this healing power is normally modest, but under certain circumstances for certain people it may be quite spectacular, as in presumptive miracle cures.  

Notes 

1. Navajo Night Way Song, https://www.lindavallejo.com/wp-content/uploads/2018/12/Chants-Prayers-Poems-2011-2.pdf, accessed on 3 December 2025. 
2. Coulehan J. May I Walk in Beauty. Humane Medicine, 1992; 8: 65-69. 
3. Kaptchuk TJ. Placebo studies and ritual theory: a comparative analysis of Navajo, acupuncture and biomedical healing. Phil Trans R Soc B. 2011; 366: 1849-1858 
4. By “intuit” I mean the development of a theory of mind (i.e. others have minds just like me). Primates and perhaps some other mammals have an analogous ability, but presumably without a symbolic language. 
5. A Sing is expensive. The patient’s family must hire an ha’a’tali and his assistants and also provide food and drink for a large number of participants and attendees. Some participants must also take time off from their jobs or other pursuits for several days. 
6. Haygarth J MD. On the Imagination as a Cause & as a Cure of Disorders of the Body, Bath; R. Cruttwell, 1801. 
7. Sandler D. Navaho Symbols of Healing. New York, Harcourt Brace Jovanovich, 1979, pp. 265-273.  
8. Beecher HK. The powerful placebo. JAMA. 1955;159(17):1602-1606 
9. Miller FG, Kaptchuk TJ. The power of context: reconceptualizing the placebo effect. JRSM. 2008; 101: 222-225, p. 223. 
10. Kaptchuk TJ. Placebo studies and ritual theory: a comparative analysis of Navajo, acupuncture and biomedical healing. Phil Trans R Soc B Biol Sci. 2011; 366: 1849-1858, p. 1849. 
11. Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning response. Ann Intern Med 2002; 471-476. 
12. Brody H, Miller FG. Lessons from recent research about the placebo effect—from art to science. JAMA 2011; 306 (23): 2612-2613 
13. Colagiuri B, Schenk LA, Kessler MD, Dorsey SG, Colloca L. The placebo effect: From concepts to genes. Neuroscience. 2015; 307: 171-190 
14. Pecina M, Zubieta JK. Molecular mechanisms of placebo responses in humans. Mol Psychiatry. 2015; 20: 416-423 
15. Miller FG, Coilloca L, Kaptchuk TJ. The placebo effect: illness and interpersonal healing. Perspect Biol Med. 2009; 52: 518 
16. Stub T, Foss N, Liodden I. “Placebo effect is probably what we refer to as patient healing power”: a qualitative pilot study examining how Norwegian complementary therapists reflect on their practice, BMC Complementary and Alternative Med. 2017; 17:262 
17. Benedetti F, Pollo A, Lopiana L, Lanotte M, Vighetti S, Rainero I. Conscious expectation and unconscious conditioning in analgesic, motor, and hormonal placebo/nocebo responses. J Neurosci. 2003; 23: 4315-4323 
18. Dieppe P, Goldingay S, Greville-Harris M. The power and value of placebo and nocebo in painful osteoarthritis. Osteoarthritis and Cartilage. 2016; 24:1850-1857 
19. Haake M, Muller HH, Schade-Brittinger C et al. German acupuncture trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Arch Intern Med. 2007; 167: 1892-1898 
20. Dieppe et al, p. 1852. 
21. Fuente-Fernandez R, Ruth TJ, Sossi V, Schulzer M, Calne DB, Stoessl AJ, Expectation and Dopamine Release: Mechanism of the Placebo Effect in Parkinson’s Disease. Science. 2001; 293: 1164-1166. 
22. Skvortsova A, Veldhuijzen DS, van Dillen LF, Zech H, Derkson SM, Sars RH, Meijer OC, Pijl H, Evers AWM. Influencing the Insulin System by Placebo Effects in Patients With Diabetes Type 2 and Healthy Controls: A Randomized Controlled Trial. Psychosomatic Medicine. 2023; 85: 551-560 
23. Smits RM et al. The role of placebo effects in immune-related conditions: mechanisms and clinical considerations. Expert Rev Clin Immunol. 2018; 14(9): 761-770. 
24. Duffin J. Medical Miracles. Doctors, Saints, and Healing in the Modern World. New York, Oxford University Press, 2009. 
25. François B, Sternberg EM, Fee E. The Lourdes medical cures revisited. J Hist Med Allied Sci. 2014 Jan;69(1):135-62.  
26. Cannon WB. “Voodoo” death. American Anthropologist, 1942; 44: 169-181. Reprinted in Am J Public Health. 2002; 92 (10): 1593-1596. 
27. Spencer, Baldwin; Gillen, F.J. Native Tribes of Central Australia. Cambridge University Press, 2010 [1899], pp. 476–477. 
28. Coulehan J, Block M. The Medical Interview. Mastering Skills for Clinical Practice. Philadelphia, F.A. Davis Company, 5^th edition, 2006, pp. 21-44 and 249-278.  
29. Hansen E, Zech N. Nocebo effects and negative suggestions in daily clinical practice – forms, impact and approaches to avoid them. Front Pharmacol. 2019 Feb 13; 10:77. 
30. Coulehan J, Clary P. Healing the healer: Poetry in Palliative Care, J Palliative Medicine, 2005; 8: 382-389. 
31. Blasini M, Peiris N, Wright T, Colloca L The role of patient-practitioner relationships in placebo and nocebo phenomena. Int Rev Neurobiol. 2018; 139:211-231.  

Web image created by Medhum.org

Rumor is a major source of vaccine rejection. The author discusses in detail the case of Andrew Wakefield and his contention that MMR (measles, mumps, rubella) vaccine causes autism. This belief, based on a 1998 paper in The Lancet (later retracted) has been shown to be false by numerous large-scale studies, but is accepted by perhaps millions of people throughout the world.    

In Stuck, Dr. Larson makes a strong case that vaccine hesitancy and rejection are widespread and growing global problems. The book is much weaker in proposing effective solutions. It’s clear that simple solutions, based on the premise that resistance will fade away as soon as public health agencies “educate” people, have failed.  Dr. Larson recommends listening more carefully to antivaxxers’ concerns and developing creative pro-vaccine messaging. Since the publication of her book, the massive initiative to vaccinate the American population against Covid has confirmed the extent and multiplicity of antivaccine beliefs in our society. It has also led public health agencies to develop more sensitive and engaging messaging than in the past. Nonetheless, the core problem remains.  

Stuck
Heidi J. Larson 
Oxford University Press, New York, 2020:  155 pages. 
A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.
Web image by Medhum.org

The artist depicts Chekhov as he was in the early 1890’s, soon after he had purchased a small, dilapidated estate and moved there from Moscow with his family. In addition to serving as country doctor and public health official in Melikhovo, Chekhov at that time was composing many of the stories and plays that made him one of Russia’s most well-loved writers and a major influence on 20^th century literature. How was he able to pursue two such different and demanding careers? Several years earlier, at the height of Chekhov’s early literary success, his friend Alexi Suvorin had urged the young writer to give up medicine. Don’t spread yourself too thin, he said. You’ll never reach your potential unless you concentrate on writing. In response, Chekhov wrote, “You advise me not to chase after two hares at once and to forget about practicing medicine. Well, I don’t see what’s so impossible about chasing two hares at once… Medicine is my lawful wedded wife and literature my mistress. When one gets on my nerves, I spend the night with the other. This may be somewhat disorganized, but then again, it’s not boring, and anyway, neither loses anything by my duplicity.” (1) In this famous passage, the 28-year-old writer dances lightly over a fundamental truth of his life and identity. In fact, Chekhov’s career was not so much a matter of jumping from one bedroom to another, as was the case perhaps with the poets Wallace Stevens and T. S. Eliot, or the composer Charles Ives. Rather, Chekhov thrived on the effective, if not always seamless, integration of the arts of medicine and writing, which reinforced one another throughout his creative life. This essay explores that integration, and the manner in which Chekhov’s cold eye (objectivity) and warm heart (compassion) reveal themselves in his medical and literary lives. 

DOCTOR CHEKHOV  

“Medicine Is My Lawful Wife” 

When he graduated from the Moscow State University School of Medicine in June 1884, Chekhov was already earning his living as a professional writer. The grandson of serfs, Anton was the third of six children in a poor merchant family from Taganrog, a southern provincial town on the shore of Sea of Azov. His father had moved the family to Moscow after going bankrupt in 1877. By the time Anton entered medical school on a scholarship in 1879, the Chekhovs were living in squalor. His father had a dead-end job. His older brothers were alcoholics and generally unemployed. Anton soon discovered that he could ameliorate the situation by selling comic sketches to local magazines for eight kopecks per line. This was a type of moonlighting he loved. He wrote obsessively, often knocking off a story or two each night, after spending the day listening to lectures or working in the hospital. Chekhov ultimately published more than 200 pieces while a medical student, most of them under his preferred pseudonym, Antosha Chekhonte. 

Chekhov was a natural storyteller. Thus, it wasn’t surprising that the newly minted Doctor Chekhov continued to write, even after he opened his office and patients began to arrive. “Continued to write” is an understatement. Chekhov published 54 stories in 1885, 76 in 1886, and 57 in 1887. His work evolved from humorous sketches to longer, more serious stories for leading literary journals. In 1888 Chekhov won the prestigious Pushkin Prize and published “The Steppe,” his longest and most innovative story to date. Ivanov, his first full-length play, had a successful premiere in St. Petersburg in January 1889. By that time the young doctor had become one of the best known writers in Russia. 

Yet Chekhov always saw himself as a physician, even though in 1889 he did, in fact, retire from a normal paying practice; after that, he offered his medical services at no charge, even though the generous Chekhov often found himself financially strapped. He took care of the peasants near Melikhovo (as depicted in the painting), donated his services to the government as a district physician, and engaged regularly in public health initiatives. In less than five months in 1891, Chekhov reported seeing 453 patients at a district health center and making 576 house calls, in addition to his home practice. (2) Throughout his life, Chekhov also was heavily involved in grass roots activism, building schools for peasants, raising funds to help famine victims, and, later, near the end of his life, supporting the establishment of a sanitarium for tuberculosis victims at Yalta.  

“My Debt To Medicine” 

One of the best known of these public health efforts was his 1890 epidemiological survey of health and social conditions in the prison colonies on Sakhalin Island. Traveling by himself, Chekhov journeyed six weeks by train, steamboat, and horse-drawn carriage across Siberia to reach the 1000-km long Pacific island on which the Czarist government had recently established a notorious gulag. There, he embarked on a one-man, three-month survey of the population, tenaciously picking his way from settlement to settlement and from house to house, often by foot.  

Biographers have long tried to pinpoint his motivation for this perilous journey. During the year prior to the trip, Chekhov had undergone a crisis of confidence. In a letter to Suvorin, he opined, “I don’t love money enough for medicine, and I lack the necessary passion—and therefore talent—for literature. The fire in me burns with an even, lethargic flame; it never flares up or roars… I have very little passion. Add to that the following psychopathic trait: for two years now, seeing my works in print has for some reason given me no pleasure.” (3) He reported symptoms suggestive of clinical depression, perhaps precipitated by grief over the death of his brother Nicholas from tuberculosis. There was also a literary issue. The master of the short story had promised himself that he would create a Tolstoy-like novel that would confirm his status as a serious writer. But he was unable to do so.  

Undoubtedly a major factor for choosing Sakhalin was Chekhov’s desire to pay his debt to medicine. He had recently developed a scientific interest in penology and had read about the dismal conditions in the Siberian gulag. He saw an opportunity to influence this situation by obtaining accurate data on the health status of Sakhalin convicts. He had never completed the research thesis (the equivalent of a Ph.D.) that would make him eligible to be a medical specialist or professor. Hence, his notion of “my debt to medicine”—he would perform a survey, write his thesis, and become a teacher. 

Ultimately, Chekhov claimed to visit every settlement and survey every household on Sakhalin Island, using a 12-item data collection form. He said he completed over 10,000 of these forms in three months, a feat that (if true) qualifies Chekhov as the speediest shoe-leather epidemiologist of all time. After his return to European Russia, the author found it difficult to organize his data into a coherent study. While he had planned to write a strictly scientific monograph, his creative spirit struggled with the limitations of science. What about his personal experience? What about the interesting stories? After struggling for years, in 1895 Chekhov published The Island of Sakhalin, a curious (but engrossing) mixture of journal, geography, history, medicine, statistics, and travelogue. (4) Unfortunately, the faculty of the University of Moscow was unimpressed.  

“As I Grow Older, the Pulse of Life in Me Beats Faster” 

Picture the mature Chekhov—a middle-aged bachelor, longish face, rather neatly trimmed beard, a prince-nez clipped to the bridge of his nose. His household included his aging parents and his sister Masha, an unmarried schoolteacher who had become his confidant and secretary. His three surviving brothers looked to him for guidance and financial help. Anton was popular, witty, and generous. Among the guests at Melikhovo, there were frequently female admirers. Chekhov’s encounters with women were flirtatious and obviously enjoyable. He had teasing, sexually charged relationships with several women, but whether any of these liaisons are actually “affairs” is uncertain.  

The doctor in the painting already suffered from the tuberculosis from which he would die at the age of 44 years. In fact, he first coughed blood as a medical student. Yet, Chekhov dismissed that episode and each subsequent episode that occurred with disheartening regularity as “influenza” or “bronchitis,” steadfastly refusing to label himself consumptive. As a physician Chekhov must surely have understood the meaning of his symptoms. Was his denial simply a face to show others? Or was his denial so great that it made him unaware? The cat finally came out of the bag in early 1897. While dining at a restaurant in Moscow, Chekhov had a violent spell of hemoptysis that left him critically ill. For the first time, he sought medical treatment and entered the clinic run by Dr. Ostropov, one of his medical school professors. Chekhov’s chronic illness progressively worsened. At the insistence of his doctors, Chekhov left his beloved Melikhovo after 1898 and lived mostly at a new home in the sunny Black Sea resort of Yalta. 

It was also during these last years that the bachelor writer courted and married Olga Knipper, an actress with the Moscow Theater Arts Company. Even after their marriage in 1901, Olga remained at work in Moscow during much of the year, while the invalid Chekhov lived in Yalta, theirs being perhaps one of the earliest examples of the modern two-career commuter marriage. Chekhov found himself able to devote less and less of his waning energy to writing, especially since he refused to give up his social and philanthropic activities. Nonetheless, between 1898 and his death in 1904 Chekhov completed some of his greatest work, including several stories, two novellas (“Peasants” and “In the Ravine”), and his last plays, The Three Sisters (1900) and The Cherry Orchard (1903).  

COLD EYE, WARM HEART 

Chekhov’s Doctors 

Several characteristics of Chekhov’s work reveal the influence of medical training and practice. He used clinical knowledge to lend accuracy to his descriptions of disease and medical situations. This characteristic is perhaps most clearly seen in the characterization of mental disorders. For example, the title character in Ivanov is a subtle portrait of a man suffering from clinical depression, who eventually commits suicide. The young heiress in “A Doctor’s Visit” presents symptoms we would now label as generalized anxiety or panic disorder. The title character in Uncle Vanya appears to have a neurotic depression, a condition that meets today’s DSM 5 criteria for Persistent Depressive Disorder. In the peculiar story called “The Black Monk,” Chekhov describes a psychotic condition, presumably schizophrenia.  

Chekhov also drew from his medical experience in creating a multitude of physician characters. Doctors play significant roles in nearly 30 stories and in all of his major plays, except The Cherry Orchard. The author’s sensibility as a medical insider gives insight and poignancy to these characters, who range from committed altruists to lazy bureaucrats to burned out cases. Chekhov knew too much about the contemporary state of medical science to portray his doctors as curing many people. Thus, they often appear impotent. Yet, at their best Chekhov’s doctors convey the seamless fabric of tenderness (compassion) and steadiness (detachment) that lies at the heart of good medical practice. They also demonstrate courage, altruism, and self-effacement. For example, in “The Grasshopper” (1892) Dr. Dymov dies as a result of contracting diphtheria from a patient. Dr. Kirilov in “Enemies” (1887) demonstrates extraordinary devotion to duty by leaving his distraught wife and dead son in order to make an emergency house call.  

Perhaps Chekhov’s most textured portrait of a good physician appears in “A Doctor’s Visit” (1898). The protagonist, Korolyov, is a young doctor substituting for his boss, the professor of medicine. During the course of the story he moves from being a careful observer (detached concern) who ascertains that his young patient has nothing wrong but a “case of nerves,” to making an imaginative leap by which he connects more deeply with her. This empathic connection allows him to relieve some of her suffering by re-framing her illness. While he cannot solve her existential problems, his demonstration of solidarity leads her to trust him and to gain insight. Korolyov is like Chekhov himself. Dr. Pavel Archangelsky, who supervised Chekhov’s first job as a physician, captured the author’s ability to listen carefully when he later commented: “… he did everything with attention and a manifest love of what he was doing, especially toward the patients who passed through his hands. He listened quietly to them, never raising his voice, however tired he was and even if the patient was talking about things quite irrelevant to his illness.” (5)  

At the other end of the spectrum, some of Chekhov’s doctors are insensitive, incompetent, or impaired. Mayer, the callous medical student in “A Nervous Breakdown” (1889) is a disaster. Mayer can rattle off statistics on the number of whores in London and Moscow, but he is unable to “see” (empathize with) the suffering of the living-and-breathing whores he encounters. Shelestov in “Intrigues” (1883) and the public health doctor in “Darkness” (1887) are examples of self-centered physicians a little further along in their professional lives. The former is superficial and pompous; the latter is narrow-minded and detached.  

Chekhov’s most complete insensitive and acquisitive social climber is found in “Ionych” (1898). Dr. Startsev, when the reader first meets him, is a young physician setting up practice in a provincial town. After surviving an unrequited infatuation with the daughter of a wealthy townsman, Startsev devotes himself entirely to work. His practice prospers and he branches out into real estate. As he grows corpulent and wealthy, Startsev loses touch with his patients (and his own humanity): 

“Probably because his throat is covered with rolls of fat, his voice has changed; it has become thin and sharp. His temper has changed, too; he has become ill humored and irritable. When he sees his patients, he is usually out of temper; he impatiently taps the floor with his stick, and shouts in his disagreeable voice: ‘Be so good as to confine yourself to answering my questions! Don’t talk so much!’” (6) 

“Ionych” traces the progressive destruction of a medical practitioner who finds that medical affluence is more to his liking than the emotionally and physically difficult path of medical virtue.  

Some of Chekhov’s most interesting doctors are tortured by existential or spiritual conflict. Chekhov accurately depicted professional burnout, a syndrome characterized by depletion, detachment, depersonalization, denial, and depression. (7) Dr. Kirilov, who chooses to “go to the office” instead of mourning with his wife, may illustrate the relatively early phase of emotional detachment. Dr. Ovchinnikov in “An Awkward Business” (1888) demonstrates the more advanced symptom of depersonalization when he slugs his assistant in response to the man’s incompetence. The overworked Ovchinnikov reacts to his personal depletion by objectifying and dehumanizing his assistant, a response that compromises the medical care he is trying to protect. Chebutykin in The Three Sisters (1900) illustrates the extreme of alcoholism. Though still employed as a military physician, Chebutykin convincingly asserts that he has forgotten all the medicine he ever learned.   

Ragin in “Ward #6” (1892) and Nikolai Stepanovich in “A Dreary Story” (1889) are complex characters in whom depression and burnout are superimposed on a deep sense of existential failure. Like many of Chekhov’s characters, these physicians suffer from a lack of self-knowledge; they move through life relying on one form of self-deception or another. When they were younger, they committed themselves to noble ideals—Stepanovich to teaching and Ragin to practice in a provincial hospital. But in the long run they never “found” themselves. Professor Stepanovich yearns for a unifying moral principle that would knit together the fragments of his life. Dr. Ragin experiences his failure as emotional numbness. He yearns to suffer, assuming that if he experienced pain, he would be freed from his inability to feel. Thus, the academic physician pines for salvation in the cognitive sphere; the practitioner yearns for emotional redemption. In each case the focus remains inward, rather than turning outward to others, in whom salvation might actually be found.  

Medical Sensibility 

Medical attitudes and methodology play a larger role in Chekhov’s work than does medical knowledge. He believed that his duty as a writer was to present his observations clearly and accurately; in other words, to lay out the data in an objective fashion and allow readers to reach their own conclusions, rather than providing an author’s interpretation. He wrote, “The artist should not be a judge of his characters and what they say, but only an objective observer.” (8) 

This objective attitude put him in conflict with most other Russian writers of the time. It was a major source of conflict with Tolstoy, who was widely revered at the time as a living saint. The two men enjoyed a close personal bond but approached writing with radically different philosophies. After his mid-life religious conversion, Tolstoy viewed literature as a way to communicate his moral vision. He preached the gospel of a radical Christianity, in which all men work together to achieve economic and social equality. However, he rejected the concept of material progress and was particularly skeptical of medicine and doctors. Chekhov, on the other hand, strove to be objective, to present people as they are and the world as it is. His medical training taught him to be a careful observer; his medical attitude made him leery of judging others.  

Other Russian writers and intellectuals spoke out against the czarist government’s repressive social institutions. While this protest was disguised in various ways in order to satisfy the state censors, late 19^th century Russians (like their 20^th century counterparts) learned to speak and understand a subtle code of insurrection. The intellectuals addressed “big issues”—democracy, education, social revolution. They wrote articles, organized meetings, and gave speeches. Here again, Chekhov found himself on a different wavelength. He rarely engaged in theoretical discussion and did not advocate radical social change. Rather, he preferred a pragmatic, case-based approach. His goals were relatively limited, but achievable. Treat the sick patient. Document and publicize the abysmal condition of prisoners. Contain the cholera epidemic. Provide financial assistance to keep farmers afloat during the famine. Raise money for a new school. On and on, but always specific and personal.  

In “About Love” (1898), the narrator speculates on the essence of love. Are there universal characteristics that identify love wherever it occurs? “What seems to fit one instance doesn’t fit a dozen others,” the narrator concludes. “It’s best to interpret each instance separately in my view, without trying to generalize. We must isolate each individual case, as doctors say.” (9) Indeed, Chekhov’s stories and plays rigorously follow this dictum. While many of his Russian contemporaries used fiction to advance moral or social theories, Dr. Chekhov focused on the complexities of human interaction. In Chekhov’s world, biology and circumstance constrain freedom. People often do not listen. Acts performed with good intentions frequently result in hurtful outcomes. And yet occasionally and in unexpected places, one finds a glimmer of love, courage, spirituality, or healing. “Never generalize,” Chekhov tells his readers. “Never theorize. Pay attention to the particulars. Focus on the concrete.” In this respect, the 19^th century physician-storyteller presages the 20^th century physician-poet, William Carlos Williams, who coined the aphorism, “No ideas but in things.”  

In the long run, Chekhov’s objectivity and aversion to theory played a major role in the development of modern literature, as 20^th century writers followed Chekhov in attempting to describe the world of human character and relationship objectively, and allowing that world to speak for itself. To the extent that Chekhov’s “lawful wedded wife” contributed to his sensitivity, skills, and attitudes, perhaps medical education and practice played an unanticipated role in the history of literature, his delightful “mistress.” 

Adapted in part from Coulehan J. (Ed.) Chekhov’s Doctors, Kent State University Press,  2003

Sir Luke Fildes’ “The Doctor,” is in the Tate: File:The Doctor Luke Fildes crop.jpg – Wikimedia Commons 

Portrait of Chekhov: File: Chekhov 1898 by Osip Braz.jpg – Wikimedia Commons 

REFERENCES 
1, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p.  
2, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p.  
3, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 81. 
4, Chekhov A. A Journey to Sakhalin, translated by Brian Reeve, Cambridge, Ian Faulkner Publishing, 1993.  
5, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p. 27. 
6, Chekhov A. Ionych. In: The Tales of Chekhov. Volume 3, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 91. 
7, Coulehan JL. Being a Physician. In: Mengel MB, Holleman WL (Eds.) Fundamentals of Clinical Practice. A Textbook on the Patient, Doctor, and Society, New York, Plenum Medical Books Company, 1997, pp. 73-101. 
8, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 54. 
9, Chekhov A. About love. In: The Tales of Chekhov. Volume 5, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 290.

Reviews of Chekhov’s Stories

Cold Eye, Warm Heart: Medicine and Anton Chekhov  

Aug 6, 2025 6032

An Awkward Business by Anton Chekhov 

Jun 11, 2025 1251

The Grasshopper by Anton Chekhov

May 11, 2025 1070

Ionych by Anton Chekhov 

Mar 11, 2025 1878

A Doctor’s Visit  by Anton Chekhov 

Mar 11, 2025 1543

Ward No. 6 by Anton Chekhov

Mar 11, 2025 3032

A Nervous Breakdown by Anton Chekhov 

Feb 11, 2025 1267

Enemies by Anton Chekhov

Jan 11, 2025 1390

Painting an Ideal: Luke Fildes’ The Doctor with Hannah Darvin

Dec 28, 2024 1047

As The Ghost Road begins, Prior has been cured of shell shock and is preparing to return to the front in France. Rivers takes care of his patients and his invalid sister, amid memories of his experience ten years earlier on an anthropological expedition to Melanesia (Eddystone Island). He befriended Nijiru, the local priest-healer who took Rivers on his rounds to see sick villagers and also to the island’s sacred Place of the Skulls.

Rivers entertains very un-British thoughts about the morality of these headhunting people, and about the power of symbolic healing. As these thoughts intrude upon his consciousness, Rivers is himself in the process of curing by suggestion a soldier with hysterical paralysis. Meanwhile, Billy Prior returns to the front. It is the autumn of 1918 and the last inhuman spasms of the war are in progress. In a futile battle that takes place a few days before the Armistice, Billy and his friend Wilfred Owen are killed.

To me The Ghost Road, which won the Booker Prize in 1995, is the most gripping and fastest paced of Pat Barker’s trilogy. The first two novels are Regeneration (1991) and The Eye in the Door (1993). As W. H. R. Rivers reflects on the culture of death on Eddystone Island, World War I, a culmination of the culture of death in Europe, grinds to a close, taking with it the poet Wilfred Owen. Of course, the characters in The Ghost Road are unaware of the new heights (or depths) that the culture of death will attain later in the 20th Century.

The Ghost Road
Pat Barker
Dutton, 1995
New York, 256 pages

Web image by  Claudio Carrozzo 

Mental Cases by Wilfred Owen

Carol Donley Aug 11, 2025

Owen’s stark poem portrays shell-shocked soldiers haunted by war, exposing both their torment and society’s complicity in their suffering.

A country doctor, Gregory Ovchinnikov, begins his daily rounds in the hospital. He soon notices that his assistant, Smirnovsky, is drunk. When the assistant refuses to obey an order and verbally snaps back at him, Ovchinnikov hits the man in his face. The angry physician then rushes out of the ward and goes back to his lodgings, abandoning his patients.  

At first, Ovchinnikov considers demanding that the town council fire Smirnovsky. Later, after he calms down and goes back to work, he begins to appreciate the enormity of his unprofessional act — perhaps the town council will fire him for assaulting his assistant. Strangely, when the assistant comes to apologize, the doctor indicates that it is he, the doctor, who has behaved inexcusably. The assistant is stunned but decides to report Ovchinnikov to the council. Of course, the council demands that the lower-class Smirnovsky apologize to the upper-class Ovchinnikov. 

This story illustrates both a conflict of conscience and a conflict between social classes. With regard to the latter, it is quite clear that the town council would never rule against the gentleman-physician in favor of the drunken, lower class medical orderly. The physician, however, struggles with his own conscience: was he justified in hitting the man? If not, what should he do to make amends?  

Originally Published 1888 
Jack Coulehan (Ed.) Chekhov’s Doctors, Kent State University Press, 2003. Translated by Ronald Hingley.  

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).

Reviews of Chekhov’s Stories

Cold Eye, Warm Heart: Medicine and Anton Chekhov  

Jack CoulehanAug 6, 2025

An Awkward Business by Anton Chekhov 

Jack CoulehanJun 11, 2025

The Grasshopper by Anton Chekhov

Jack CoulehanMay 11, 2025

Ionych by Anton Chekhov 

Jack CoulehanMar 11, 2025

A Doctor’s Visit  by Anton Chekhov 

Jack CoulehanMar 11, 2025

Ward No. 6 by Anton Chekhov

Jack CoulehanMar 11, 2025

A Nervous Breakdown by Anton Chekhov 

Jack CoulehanFeb 11, 2025

Enemies by Anton Chekhov

Jack CoulehanJan 11, 2025

Then one day Dymov develops diphtheria, evidently contracted by “sucking up mucus through a pipette from a boy with diphtheria. And what for?  It was stupid… just from folly.”  Dymov soon becomes seriously ill and then dies. Suddenly, Olga is overcome with guilt and grief. Too late, Olga realizes that her husband was a hero.

Chekhov based this story on the real-life love affair between his good friends Isaak Levitan, a well-known (and married) artist, and Lika Mizinova, a young unmarried teacher, who had for many years been infatuated with Chekhov while he toyed with her affection.  In this interpretation, Chekhov bases the character of Dymov largely on himself, portrayed as a dedicated and disciplined worker who has no time to spare for frivolous romance. However, in reality, Chekhov had playful relationships with many women, but eschewed commitment until late in life. 

Another way of looking at the story is the dramatic tension between practicality (science, public health, and social consciousness), as exemplified by Dymov; and emotion (art, adventure, romance), as exemplified by Ryabovsky.  Olga at first chooses the latter, but Dymov’s death turns the tables.  After he becomes a martyr to science, she suddenly finds him more interesting and mourns her loss.  Was his death the result of a foolish mistake?  Did her infidelity play a role, perhaps by distracting him while he was aspirating the pus?  Or might Dymov have deliberately performed the foolish procedure, realizing that the infection would cause his death?  

The Wife & Other Stories. The Tales of Chekhov. Volume 5, New York, The Ecco Press, 1985.
Translated from the Russian by Constance Garnett.  
Shelby Foote (Ed.) Chekhov’s Later Short Stories. 1888-1903, New York, The Modern Library, 1999.
Translated from the Russian by Constance Garnett.  

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).

Reviews of Chekhov’s Stories

Cold Eye, Warm Heart: Medicine and Anton Chekhov  

Jack CoulehanAug 6, 2025

An Awkward Business by Anton Chekhov 

Jack CoulehanJun 11, 2025

The Grasshopper by Anton Chekhov

Jack CoulehanMay 11, 2025

Ionych by Anton Chekhov 

Jack CoulehanMar 11, 2025

A Doctor’s Visit  by Anton Chekhov 

Jack CoulehanMar 11, 2025

Ward No. 6 by Anton Chekhov

Jack CoulehanMar 11, 2025

A Nervous Breakdown by Anton Chekhov 

Jack CoulehanFeb 11, 2025

Enemies by Anton Chekhov

Jack CoulehanJan 11, 2025