Anton Chekhov begins his tale by taking his readers on a tour of the mental ward of a hospital in a provincial Russian town. His initial description stresses the filth and disorder prevailing in the institution, as well as the cruel barbarity that the caretaker Nikita shows toward the helpless patients in the ward. One patient in particular draws the narrator’s interest. This is Ivan Dmitrich Gromov, a polite but very agitated young man who suffers from a persecution complex. The narrator recounts how Gromov came to be placed in the mental ward: As a sensitive individual acutely conscious of the backwardness and hypocrisy permeating rural Russian life, he began to fear that he could be arrested and imprisoned through someone’s error or through a miscarriage of justice. Increasingly paralyzed by this irrational anxiety, he was eventually institutionalized in Ward No. 6, where he now languishes with the other patients, neglected by the medical authorities.

As the narrator continues, he states that one man has unexpectedly begun to visit Gromov. This is the doctor in charge of the institution, Andrei Efimych Ragin. Now the reader learns of Ragin’s life and personality. A heavily built, powerful man, Ragin possesses a curiously passive disposition. When he was appointed to the post of medical supervisor for the hospital, he was appalled by the primitive, unsanitary conditions he found there. However, he lacked the strength of character to push for reform, and after an initial period of zealous work he “lost heart” and ceased going to the hospital. Gradually he developed a consoling rationalization for his own failure to strive for change: Illness and death are an inevitable part of the human experience; the current state of medical knowledge is relatively limited; therefore, there is no real point in trying to improve things—he himself figures as only a minor element in an entire system of inescapable social injustice. Bored and disillusioned, Ragin discovers one day that an interesting individual is lodged in the mental ward. Thus, he begins visiting Gromov to conduct extended discussions with him about life and philosophy.

The conversations between Ragin and Gromov provide the ideological core of the story. Ragin tries to convince Gromov that the human intellect is a self-contained organ that allows one to find peace of mind in any environment, even prison. Gromov counters this notion by pointing out that humans are made up of flesh and blood, and that to reject the pains of the flesh is to reject life itself. Descrying, in Ragin’s words, an empty philosophy of expediency, he accuses Ragin of laziness and of ignorance about real life. Caustically he declares that Ragin may talk about intellectual peace of mind, but that if the doctor were to squeeze his finger in a door, he would certainly scream at the top of his lungs.

Gromov’s prediction is borne out when Ragin himself is forced into the mental ward after antagonizing his friend the postmaster and a fellow doctor with a streak of erratic and unsociable behavior. Now Ragin undergoes a chilling awakening. Staring through the bars of the asylum window, he sees the blank stone walls of a nearby prison and the dark flames of a distant bone mill. In a flash he realizes that this is true reality. Panicked by his discovery, he tries to leave the ward, but he receives a beating from Nikita instead. The next day he suffers a stroke and dies. Chekhov concludes his gloomy tale by commenting that only the postmaster and Ragin’s maid attend the doctor’s funeral.