The Death of Ivan Ilyich and the concept of ‘total pain’

The Death of Ivan Ilyich by Leo Tolstoy,¹ first published in 1886, is well known for its remarkable insight into the suffering of a dying man and can be considered a ‘medical classic’.² But can a reading of this short story over a hundred years later give any insight into contemporary medical practice or is it an historical curiosity?

One interpretation is to consider the story a depiction of a man experiencing ‘total pain’, a concept central to the practice of modern palliative care in which ‘the sense of hopelessness and fear of impending death may add to and exaggerate the pain, which contributes to the overall suffering of the patient’.³ But is such an interpretation warranted? Or is it wresting a concept from the second half of the twentieth century and applying it to imaginative literature without justification, falling into the trap of imposing a diagnosis retrospectively on a character in an act of ‘medicalisation’ that detracts from other interpretations of the story?

Ilyich's pain is central to Tolstoy's tale, a pain that involves a search for possible meanings. It is left-sided abdominal pain that leads him to seek a medical opinion. But Ilyich and his doctor are in different camps concerning the meaning of the pain:

To Ivan Ilyich only one question was important: was his case serious or not? But the doctor ignored this misplaced enquiry. From the doctor's point of view it was a side issue not under consideration. The real issue was the assessing of probabilities to decide between a floating kidney, chronic catarrh or appendicitis. It was not a question of Ivan Ilyich's life or death but one between a floating kidney or appendicitis. (p 127)¹

Ilyich's doctor ignores his main concern. Whilst Tolstoy has been viewed as pejorative and unfair in his attitude to doctors,² it is Ilyich who leaves the consultation in a dejected state, which intensifies his pain and distress:

And this pain, this dull gnawing ache that never ceased for a second, seemed, when taken in conjunction with the doctor's enigmatical utterances, to have acquired a fresh and far more serious significance. With a new sense of misery, Ivan Ilyich paid constant heed to it. (p 128)¹

The cause of Ilyich's pain is unlikely to have changed during his consultation, but its significance for him certainly has. The story is said to have been based on a 45-year-old lawyer who died from cancer,² but what is wrong with Ilyich remains to the end a matter of conjecture: ‘The doctors couldn't say – at least they could, but each of them said something different’ (p 102).¹ In view of Ilyich's deterioration after the onset of the pain, a diagnosis of cancer is possible but it is not pinpointed by Tolstoy's account, and the power of the tale is not dependent on such a diagnosis but emerges through the unfolding existential crisis of its protagonist.

His gnawing pain turns into an entity, and Ilyich ‘would try to drive the thought of it away, but it went on with its business. It would come and stand before him, and he would find himself rigid with fear and the light would die out of his eyes’ (p 138).¹ Thus the pain equates with fear and causes him to suffer: ‘Ilyich's physical sufferings were terrible, but worse than his physical sufferings were his mental sufferings, which were his chief torture’ (p 157).¹

The pain and his illness cause social isolation:

There was no deceiving himself; something terrible, new and significant, more significant than anything that had ever happened in his life, was taking place within him of which he alone was aware. (p. 130)¹

What tormented Ivan Ilyich most was the pretence, the lie, which for some reason they [friends, family and his doctors] all kept up, that he was merely ill and not dying. (p 142)¹

In his isolation he looked at those about him and ‘saw himself — all that he had lived for — and saw plainly that it was all wrong, a horrible, monstrous lie concealing both life and death. This consciousness increased his physical suffering tenfold’ (p 157).¹ Such isolation is another feature of total pain.

This existential or spiritual dimension to his suffering does not respond to medication: ‘they gave him opium and began injections of morphine, but this did not relieve him’ (p 140).¹ It is Ilyich's servant, Gerrassim, who provides a healing, empathic presence, by his words and actions. He would sometimes support his master's legs all night long, affording him relief:

Gerrassim alone told no lies; everything showed that he alone understood the facts of the case, and did not consider it necessary to disguise them, and simply felt sorry for the sick, expiring master (p 143).¹

Ilyich's pain is more than its sensory component, located in the left side of his abdomen. It has affective dimensions, powerfully conveyed by Tolstoy in emotional, psychological and spiritual terms, aspects not relieved by morphine but by the humanity of his servant. The pain causes Ilyich to question how he has lived his life (or not lived it) in the face of his impending death, which adds to his suffering. This can be interpreted as a description of ‘total pain’. Only when Ilyich finally accepts his pain and its meaning (or meaninglessness) is he able to be at peace with himself and die.

When Cicely Saunders formulated the concept of ‘total pain’ in the 1960s, she derived it from listening to the stories of those in pain. Crucially, ‘total pain was tied to a sense of narrative and biography emphasizing the importance of listening to the patient's story and of understanding the experience of suffering in a multifaceted way’.⁴ Similarly, the narrative of the pain and how it relates to suffering, the ‘total pain’, of this fictional lawyer is unique and can be understood and interpreted only in the context of his life and death.

• © 2012 Royal College of Physicians