Most chapters are titled after a medical condition (exceptions are “Hubris” and “Melodrama”). Some of the headings are familiar – Trauma, Infarct, Aneurysm, Meningioma. Other chapter titles flaunt delicious medical terminology that mingles the mysterious and the poetic with nomenclature such as Angor animi, Neurotmesis, Photopsia, and Anaesthesia dolorosa.

Included are riveting accounts of both mundane and seemingly miraculous patient outcomes. One success story involves a pregnant woman losing her sight due to a brain tumor that compresses the optic nerves. Her vision is restored with an operation performed by the author. Her baby is born healthy too. But tales of failure and loss – malignant glioblastomas that are invulnerable to any treatment, operative calamities including bleeding of the brain, paralysis, and stroke – are tragically common. The author describes his humanitarian work in the Ukraine. He admits his aggravation with hospital bureaucracy and is frequently frustrated by England’s National Health Service.

Sometimes the shoe falls on the other foot, and the doctor learns what it is to be a patient. He suffers a retinal detachment. He falls down some stairs and fractures his leg. His mother succumbs to metastatic breast cancer. His three month old son requires surgery for a benign brain tumor.

As his career winds down, the author grows increasingly philosophical. He acknowledges his diminishing professional detachment, his fading fear of failure, and his less-hardened self. He becomes a sort of vessel for patients to empty their misery into. He is cognizant of the painful privilege it is to be a doctor.

The title of Do No Harm is spot-on. After all, this commandment is a crucial caution to all doctors. And for neurosurgeon Marsh, it signifies the restraint he must exercise in his medical decision-making. His approach to the doctor-patient relationship features a gentle medical paternalism that incorporates plenty of honesty and kindness. He writes about his struggle (and occasional clumsiness) with breaking bad news.

His professional life is portrayed as paradoxical – constant anxiety and contagious confidence, phases of futility and strings of inspiring operative accomplishments. The gift of forgiveness, how uncertainty tortures doctors, and the process of dying are significant topics for Marsh. In the last few decades, there has been a proliferation of medical memoirs. Do No Harm rises above them all. The book informs doctors that it’s okay to be vulnerable and fallible, as long as they are also compassionate, truthful, and caring. 

Primary Source Do No Harm: Stories of Life, Death, and Brain Surgery 
Publisher Thomas Dunne Books/St. Martin’s Press 
Place Published New York 
Edition 2015 
Page Count 288 

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.   
Web image by Medhum.org.

Two hidden stories by two famed authors written decades apart in two countries eventually became widely known. One, Anton Chekhov’s, At the Pharmacy, was translated into English in 1998, about one-hundred years after it was published in Russia. The other, Raymond Chandler’s, It’s Alright–He Only Died, was unearthed from its unpublished state by Strand Magazine in 2018, about sixty years after it was written. Though written in different times, and using different scenarios, both stories warn of the barrier money creates to urgent and necessary health care, and of the corrosion in professionalism it causes in providers. They tell of what was to become a defeating feature of Western health care because of financial incentives, social prejudices, and human folly.

Six Kopecks or Your Life

Peter Constantine reached back from the 1990s into the 1880s to assemble a translated anthology of some Chekhov short stories not available to English-speaking audiences. Among the chosen stories in The Undiscovered Chekhov: Thirty-Eight New Stories, is At the Pharmacy.

The story begins when Egor Alexeyitch Svoykin becomes sick. His physician prescribes medicine that a pharmacy would need to prepare. Svoykin felt some relief being in a large Russian city during the late nineteenth century that would have pharmacies he could count on. This feeling of relief dissipated just after entering the pharmacy and coming before the imperious pharmacist there. 

The pharmacist eventually raises his head from a newspaper, looks at the prescription, shouts instructions to his assistants, and then returns his gaze to the newspaper while at the same time informing Svoykin the prescription will be ready in an hour. Svoykin is the only person waiting at such a late hour as it was, and he was deteriorating.

His mouth was on fire; there was a drawn-out pain in his arms and legs; foggy images tumbled about like clouds and shrouded human figures in his heavy head. He looked as if through a veil at the pharmacist, the shelves of jars, the gas burners, and the cabinets. The monotonous pounding in the marble mortar, and the slow ticking of the clock seemed to him to be coming not from the outside but from inside his head. (p. 129)

When Svoykin reports to the pharmacist that he is becoming feverish and feeling weaker, “the pharmacist “remained stock-still and, leaning his head farther back, kept on reading his newspaper. He didn’t respond to Svoykin with word or movement—it was if he hadn’t heard him.” (p. 130) When Svoykin subsequently approaches the pharmacist pleading with him to hurry the prescription, the pharmacist again brushes him off saying, “It’ll be ready soon enough…excuse me, but there’s no leaning on the counter.” (p. 131)

The next half hour was “unbearable” before the prescription came and then made more so by the dubious rituals the pharmacist performed in adorning the prescription container. The pharmacist charged one ruble and six kopecks, but Svoykin was short the six kopecks. 

Under the circumstances…I would be grateful if you would let me bring you, or maybe send you, the six kopecks tomorrow…

I’m sorry, we don’t accept credit here.

What am I supposed to do?

Go home, get the six kopecks, and then you can have your medicine.

But…I’m having difficulty walking, and I don’t have anyone I can send…

That’s your problem.

pp. 132-133

Svoykin returned home, though with difficulty. The Kopecks were there on the table, but his illness kept him from returning to the pharmacy.

Just Drunk

Strand Magazine is a source for “unpublished works by literary masters.” The October-February (2017-2018) issue includes an unpublished Raymond Chandler short story. Chandler wrote crime fiction for the most part, and the stories usually involved the fictional detective, Phillip Marlowe. This story, however, written between 1956 and 1958, is about a person brought to a hospital emergency room and denied service for financial and social reasons.

As the story opens, a man who has been hit by a truck is brought into the emergency department at General Hospital. He arrives just before shift change and so the admitting clerk is already annoyed about having to assess him. The clerk checks the patient’s pockets for the required $50 deposit and finds nothing, so she could now send the patient to the county hospital, and that would be that. But, before she initiates the transfer, she asks a passing private attending physician to look at the patient. He sees that the patient is dirty, smells of alcohol, and would cost a lot to work up. Mindful of an admonition from a major donor that the “hospital is not run for charity,” the physician surmises the patient is “just drunk,” and agrees the patient should be moved to the county hospital. Off the patient goes.   

The next day, the same admitting clerk at General Hospital gets a call from the county hospital. She’s informed that the patient they transferred had a head injury requiring surgery, and that the patient had $4,000 in a money belt inside his undershirt. The patient couldn’t be saved, however, because of the delay involved in the transfer to the county hospital. “It’s all right—he only died.”

Fast Forward

If they could have foreseen the current time when they wrote these stories, 140 years ago for Chekhov and 70 years ago for Chandler, they would have realized that the scenarios they created became commonplace and institutionalized in many ways.

Pharmacists may not go unseen behind a newspaper as Chekhov’s pharmacist did, but they may be buried under insurance company paperwork or piles of prescriptions needing to be filled. And certainly in a few situations, perhaps only independents, do pharmacists have ways to cover costs when patients are short on cash, credit, or insurance coverage. They are very likely to send patients away to get money even when they are very sick.

Hospital personnel do not now actually reach into the pockets of unconscious patients to see if there’s enough cash for admission as Chandler conjures in his story, but he would see them still check for money in the form of insurance cards or proof of sufficient financial means. He would also see that the scenario he described in which patients without money get transferred to county hospitals had progressed to a degree that people are moved around among different health care providers based on health care insurance plan coverage or lack thereof. But the poor treatment of patients in need of emergency care can even occur in the “right” hospitals when they are held for hours to days in hallways or holding wards for beds to become available.

Scenarios such as these can and have been addressed to varying degrees through government welfare programs, regulatory requirements, technology advances, and professional practice standards among other responses. The two stories, though, also expose human folly not so amenable to these actions. What can be done about the pharmacist who won’t put the newspaper down to address the needs of a person seeking help for an acute illness? What can be done about the physician who after a cursory evaluation brushes off an unconscious patient as “just drunk?”

Chandler makes an attempt at addressing the human folly he and Chekhov reveal by describing how it fails humanity on both professional and personal levels, and in shaming the character, who is ostensibly standing in for those behaving as this doctor in the story did.

All he had done was disgrace himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long–acquired skill might help or save…Why should a doctor in such circumstances be better than other men? The answer is simply, that if he isn’t, he is not a doctor. The $4,000 would have made quite a difference in this case, wouldn’t it?  Should it?  

Chekhov and Chandler are perhaps hoping that those in the care of others will exhibit more humane and professional behaviors when they ask themselves many decades later: “Am I a doctor?”“Am I a pharmacist?” “Am I a human being?” Would it make a difference? Should it?

Notes

Title image:
A young girl waiting for a pharmacist to make up a prescription.
Photogravure, 1912, after J. Jendrassik, 1896
Licensed under the Creative Commons Attribution 4.0 International

End image:
Nurse Aide Rocky FordHospital CO
Mennonite Church USA Archives, No restrictions, via Wikimedia Commons

On the one hand, if the doctor is physically unable to treat, then he is not responsible for withholding treatment. On the other hand, by being rendered professionally helpless, perhaps he is being punished for not taking a moral stance against his patient. This interpretation seems to have validity because the last line recalls Psalm 137, which warns, “If I forget thee O Jerusalem, let my right hand forget her cunning.” 

For drawing attention to the biblical reference, I am grateful to Dr. Danielle Ofri (clinical professor) and Lara DeLong (Class of 2001), both at NYU School of Medicine. Dannie Abse (1923-2014) was a practicing physician and poet. 

Reading by Dannie Abse

Case History
‘Most Welshmen are worthless,
an inferior breed, doctor.’
He did not know I was Welsh.
Then he praised the architects
of the German death-camps–
did not know I was a Jew.
He called liberals, ‘White blacks’,
and continued to invent curses.

When I palpated his liver
I felt the soft liver of Goering;
when I lifted my stethoscope
I heard the heartbeats of Himmler;
when I read his encephalograph
I thought, ‘Sieg heil, mein Fuhrer.’

In the clinic’s dispensary
red berry of black bryony,
cowbane, deadly nightshade, deathcap.
Yet I prescribed for him
as if he were my brother.

Later that night I must have slept
on my arm: momentarily
my right hand lost its cunning.

Commentary

“Sometimes it’s very difficult to like some patients. Patients imagine that they’re always likable, but in fact there are some one has great difficulty with, I think. And indeed there was one patient that bugged me so sufficiently that I wrote two poems about him.”

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.
Web image created by Medhum.org

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

“Prof. William Osler, of the University of Pennsylvania, was summoned by telegraph this afternoon to go to Walt Whitman’s bedside. The aged poet had a relapse, and it was feared that he was dying. When the doctor came away from the little frame house at 328 Mickle Street, Camden, at 8 o’clock tonight, he said the poet was resting easily and about holding his own.” 

Osler first visited Whitman in 1884, shortly after moving to Philadelphia to take up his position as Professor of Medicine at the University of Pennsylvania. Dr. Maurice Bucke, a Canadian psychiatrist and mutual friend, had asked Osler to look in on Whitman, who was complaining of dizzy spells and fatigue. The professor obligingly ferried across the Delaware River to Camden and made a house call. Osler reported that the poet had no residual neurological deficits from his earlier stroke. He was unimpressed with Whitman’s current symptoms and, in fact, later described him as “a fine figure of a man who had aged beautifully, or more properly speaking, majestically with a large frame and a well-shaped, well-poised head…“ ^{1, p. 21} 

However, four years later the situation was more serious. On June 14, 1888, Whitman developed slurred speech, prostration, and confusion “such as we know are not uncommon with sclerosis of the arteries of the brain.”^{1, p. 178} When Osler was called in, he recommended general supportive care and issued a cautiously optimistic prognosis (as the Times reported), but evidently did not present his patient with a specific diagnosis or discuss pathophysiology. Whitman recovered over the following weeks, but his health gradually deteriorated over the next several years until his death in 1892. 

During the years Osler served as the poet’s primary care physician, their relationship was respectful, but not ideal. Whitman frequently complained about the great clinician’s rosy bedside manner. “Osler made light of my condition,” the poet wrote. “I don’t like his pooh-poohs. The professional air of the doctor grates on me.” ^{1, p. 50} On another occasion he told his friend Horace Traubel, “I confess I do not wholly like or credit what he (Osler) says. I do not fancy the jaunty way in which he seems inclined to dismiss my troubles.” ^{2, July 3, 1888} Evidently, Osler continued to speak in generalities, rather than addressing specific concerns that Whitman raised as he became progressively feebler.  

This situation contrasts with some of the poet’s earlier medical experience. For example, shortly after his stroke in 1873, Whitman consulted Dr. Mathew Grier who must have explained the etiology of the problem. Whitman later wrote to his friend Peter Doyle, “Did I tell you that Dr. Grier here says that my real disease is the brain not being properly furnished and nourished with blood…” ³ The poet’s other physicians included Drs. Silas Weir Mitchell and his son John Kearsley Mitchell. The famous neurologist and champion of neurasthenia made house calls on Whitman twice in 1878 when the poet reported symptoms of rheumatism and prostration, which he had self-diagnosed as a recurrence of his previous stroke. Mitchell assured him that the stroke, which had resulted from a ruptured blood vessel in the brain, was not responsible for the current symptoms. These, Mitchell claimed, were caused by chronic stress, perhaps exacerbated by anxiety over a public lecture that the poet was just then preparing to give.³ In other words Mitchell considered the illness a manifestation of neurasthenia. He prescribed travel, mountain air, and vigorous outdoor activity, which was Mitchell’s generic regimen for neurasthenia in males, quite the opposite of his more famous regimen of complete bed rest for female neurasthenics. ³ The poet took Mitchell’s advice seriously and embarked on a trip to Colorado, after which he professed himself cured.  

While Osler’s optimistic persona must have pleased many patients, it irritated Whitman. He judged his doctor’s cheerfulness to be insincere, or at least questionable. The elderly poet was an eccentric who fiercely valued his independence. While at times he showed a sweet and gentle side, he could also be touchy, irascible, and assertive. As the poet grew progressively frailer during 1888 and 1889, Traubel recorded a series of house calls during which Osler assured him that he would soon recover. “Do not take a gloomy view of Whitman’s case,” Osler told Traubel, “he will come around.” ^{2, July 3, 1888} In this short poem, I try to resurrect the poet’s attitude toward his famous doctor: 

Walt Whitman Reflects on His Doctor’s Bedside Manner 

As an old rat that must be allowed to die 
in his own way, I start with a prejudice 
against doctors. Never mind worrying 

about your sickness, he scolds me,  
I’m seeing to all that. The man tinkers  
with platitudes and conceals his thoughts.  

In his gospel of encouragement 
I’m supposed to be agreeable and dumb 
while he puts the best construction  

on what’s happening. What does he know 
about Whitman, the old rat? A shoemaker  
tells his customer the shoe fits just right 
but the shoe pinches the fellow wearing it.  

Whitman was a master of self-promotion. He appeared to encourage members of his inner circle who viewed him as a prophet, as well as a poet. Dr. Maurice Bucke even wrote a book claiming that his friend was one of the few humans who had achieved “cosmic consciousness.” The others included Jesus, Mohamed, and the Buddha. Did Osler fail to understand that his one- size- fits- all approach to physician-patient communication might not be appropriate for a patient with Whitman’s complex and eccentric personality?  

Although dissatisfied with Osler’s bedside manner, the poet respected his doctor’s clinical abilities. Several months after the medical crisis in 1888, Whitman wrote, “As for Osler: he is a great man—one of the rare men. I should be much surprised if he didn’t soar way, way up—get very famous at his trade—someday. He has the air of something about him—of achievement.”^{2, December 26, 1888} Indeed, by that time, Osler had already accepted the position of Professor of Medicine at the new Johns Hopkins medical school in Baltimore.  

Osler was a sensitive, cultivated man, but also a rationalist, who initially looked askance both at Whitman’s exuberant poetry and the cult that had grown up around its author. Although he admired the man, he had no wish to become a disciple. He loved poetry and enjoyed quoting passages from Shakespeare and the Romantic and Victorian poets. Regarding his first impressions of Leaves of Grass, Osler later wrote, “Whether the meat was too strong, or whether it was the style of cooking—‘twas not for my pampered palate.” ^{1, p. 22} He found his new patient’s long, unruly poems and earthy subject matter self-indulgent and lacking in discipline. The boisterous persona reflected in Whitman’s poems jarred Osler’s methodical mind. In the following poem, I imagine the clinician’s response to his early encounters with the Good Grey Poet: 

Dr. William Osler Remembers His Call on Walt Whitman 

I took the ferry that day and found him 
in the front room of a small house 
on Mickle Street, buried to his chest 
in papers, magazines, and musty  
brown bundles. Push yourself a path, 
he said. I reckon you’re a friend of Bucke’s. 

His famous head had aged majestically— 
unkempt white beard; smooth, clear cheeks; 
a fissured, geographic forehead. 
His voice was pitched a shade too high,  
but strong like the rest of him. Of symptoms 
he said but little–remarkable 

for a man of 65. For a moment 
I felt that sweet aromatic presence 
his disciples spoke of–for me, though, 
the edge of chaos. I sometimes wish 
the man had made a difference in my life, 
opened me up, but how could I forego 

my restraint? Or professional kindness? 
For a man like me, a man of substance, 
what could be worse than falling in love 
with Whitman? I listened to the music 
of his tongue, but could never cross the line 
that reads, Who enters here, abandons discipline. 

Yet, in his later years, Osler grew to respect his one-time patient’s poetry, as well as his charismatic personality. In fact, at the time of his death from pneumonia in 1919, he was in the process of writing an appreciative reminiscence of his encounters with Whitman. 

The uneasy, but respectful, relationship between these giants in their respective fields provides interesting material for reflection. If the poet was so dissatisfied with Osler, why didn’t he go back to Weir Mitchell or his son, who were more easy-going and communicative? Mitchell’s reputation as a clinician easily equaled Osler’s, and he was a poet as well. Could it be that Whitman benefited in some way from Osler’s staunch optimism, or had developed deep trust in Osler’s judgment, despite the constant complaints he issued to Traubel and others? Alternatively, why didn’t Osler modify his paternalistic approach, since it seemed clear that Whitman preferred to play a more active role in the relationship? And those time-consuming house calls that required taking a ferry across the river! Why not recommend a more pliable colleague?  

References 

1. Philip Leon, Walt Whitman & Sir William Osler, ECW Press, Toronto, 1995. 

2. Horace Traubel, With Walt Whitman in Camden, vol. 2, at http://whitmanarchive.org/criticism/disciples/traubel (accessed December 30, 2024) 

3. Feinberg CE. Walt Whitman and his doctors. Arch Intern Med 1964; 114: 834-842. 

Photo of Sir William Osler and Walt Whitman from WikiCommons.