The Death of Ivan Ilyich ” and multiple dimensions of illness

The short story “The Death of Ivan Ilyich” (1886), Leo Tolstoy (1828-1910) provides key elements for a reflection on the meaning of long-term illness. Based on Tolstoy’s short story the present paper analyzes the multiple dimensions of the process of illness. It starts with the argument that illness is not an a priori totality, but a trajectory of associations between the sick person, the doctor, family members, friends and caregivers. Acting, being affected, thinking and feeling all come together in the development of these associations. The analysis of the Ivan Ilyich’s illness will consider the following points: (a) illness as otherness and incomprehensibility (growing unfamiliarity with one’s body and the stages by which the body is gradually objectified); (b) illness as trajectories in an field of practices that involves the development of skills and the “education of attention”; (c) modes of health care as a set of techniques, objects and discourses that are put together or associated throughout trajectories concerned with the establishment of health. Longterm illness is therefore a mode of immersion of the sick person in networks of relations that come to be a part of her everyday life.


Introduction
The short story "The death of Ivan Ilyich" (1886) 1 by Leo Tolstoy (1828-1910), is well known to the reading public and widely praised by literary critics.For Vladimir Nabokov, for example, it is one of the most artistic and perfect literary works.In addition to being the object of innumerous literary analyses, the story has been scrutinized from diverse angles.Its reading raises questions regarding the meaning of life and death 2 , law 3 and health care 4 .Our focus is to look at how illness is understood in the story.What does this literary work tell us about the process of becoming ill?
The story is relatively simple: a detached Russian magistrate suddenly sees his life turned upside down due to illness subsequently leading to his death.The narrative sequence (the compositional structure of the text) can be summarized in the following manner: (a) initial situation (a judge in St. Petersburg, Ivan Ilyich, leads a life with little excitement and few difficulties); (b) the triggering moment (as the result of a fall, he starts to feel pain one day in his lower abdomen on the right hand side); (c) action and evaluation (at the beginning, the pain seems temporary and trivial; over time however, it worsens; he rejects medical treatment; his physical state deteriorates; in agony, he starts to realize the seriousness of his situation); (d) outcome (looking back over his life, the values he held, and the social world he inhabited); final situation (death).In summary, the narrative is fundamentally centered on the gradual process of transformation of a human being.Ill, abandoned by his family and friends, Ivan Ilyich ends his days under the care of a humble mujique, Guerássim.Moribund, he evaluates his relationships with his companions and comes to realize the insignificance and fragility of human existence.At the conclusion, taking stock of his life, he has a "surprising revelation" that leads to his life gaining meaning.He undertakes, as Miranda 5 observes, a philosophical analysis of existence.Tolstoy uses this analysis to draw anunflinchingportrait of "bourgeois life" in 19 th century Russia and even of "western civilization" in general.
Tolstoy wishes to give us an understanding of the meaning of human existence.However, the message is somewhat ambiguous.For Rónai, it is probable that Tolstoy "wants to help his readers, engraving on their soul an unforgettable image of agony, so as to always have present for the spirit, a reminder of death.(…) A special lesson seems to be contained in Ivan Ilyich's final moments, when feelings of hate and resentment suddenly disappear from the soul of the moribund givingwayto an understanding of the suffering of the living and a profound compassion" 6 , a teaching with a Christian basis.However, Ronái himself observes that for some critics, (such as Tolstoy's own son), the story evokes a strong sensation of for boding, a feeling that all death is horrible and that the only reality of the world is death; not an authentically Christian message therefore.
"The death of Ivan Ilyich" was written during Tolstoy's maturity, when, far from the urban centers, he lived on his property (Yasnaya-Polyana) and dedicated himself to educating.The short story was published after "A confession" (1882), the text in which he portrayed his growing spiritual confusion.It was a significant moment of his life, a period during which he criticized various aspects of society and the culture of his time.He vehemently condemned the Orthodox Church, the existing system of land ownership and other "bourgeois" practices and values.He proposes a type of "mystical communism", a faith in love.Beginning from "A Confession", his writing shows a stronger moralizing, pragmatic and educational intention.Subsequently, in the essay "What is art?" (1989), Tolstoy condemns almost all existing forms of art, including his own.He proposes an art based on morality, in which the artistwould transmit the religious feelings and conscience of his people.
The doctrinal concern with raising thereader's "awareness" was a strong literary trend at the end of the 19 th century.It was expected that the writer would teach something, transmitting "wisdom" or a "lesson".With this objective in mind, the text should be immediately accessible or understandable and familiar; have a simple and convincing story; be written in language without verbal refinements,whichflowswell.Such a pedagogical mission sought to unite fictional aspectsand believability.We should remember that believability is plausibility; it is not a determined pointsituated between "true" and "false",but rather a possible modality of fact.From this perspective, it starts from the principle that literature should seek elements in extra-textual references that would allow the reader to see the fictional fact always in analogy to a given referent.Through these effects of believability, the writer seeks to facilitate the acceptance of the work by the public 7 .In Russia, one of the first great theoreticians of this "realist" trend was the writer Vissarion Grigorovich (1822-1900), a friend of Dostoyevsky's.His short story, "Anton Goremyka" (1874) made a considerable impact at the time.The realist treatment made by Grigorovich of Russian farming life was highly esteemed by Tolstoy.
"The death of Ivan Ilyich" is a short story that gives us valuable insights to be able to reflect on the meaning of illness.The experience of "being ill" is a dramatic dimension -the tension -of the story.This dimension is shown through the day-to-day life of Ivan Ilyich with doctors, family members, friends and work colleagues.Tolstoy is not particularly interested in exploring the representations of the character regarding his illness.Although Ivan Ilyich attempts to name and define his illness, the short story focuses on narrating and describing his trajectory, the way in which he deals with his body and its afflictions, his encounters with "others" and the at times sudden improvisations by which he deals with specific situations.In summary, Tolstoy makes us understand the disease beyond simply a medical explicative model.In the short story, illness is fundamentally understood according to the coordinates of day-to-day life, through the practical knowledge of dealing with social situations and structures.Tolstoy's work leads us to think about the multiple dimensions of the process of illness of the protagonist.The main objective of the present article is precisely to identify some of these dimensions.As we will seek to argue, illness is not a totality constituted a priori or a mere question of representation or projection but a flow of associations between the patient, the doctor, family, friends and caregivers.In the short story, Ivan Ilyich's actions, his being affected, thoughts and feelings regarding the situation are always described as phenomena derived via these associations.
We use literature because we start from the idea that narrative can present us with rich and subtle lay knowledge regarding health, because, amongst other aspects, it describes knowledge as constructed via the diverse mediations by which actors are related to the institutional contexts of diagnosis and care 8 .

Literature and the social sciences: brief considerations
Exploring literature to understand illness from the perspective of the social sciences requires some initial considerations.Firstly, we are not concerned with developing a literary or critical analysis, of breaking down or separating constitutive elements of a text to better under-stand its literary aspects or judge the aesthetic principals and standards of taste of a certain era.Nor do we wish to mount a discussion regarding Tolstoy's short story with the aim of identifying and characterizing the sociocultural basis on which the content is based, the forms, the genres or the institutions of literary production.It is unnecessary to reaffirm that all literary creation is a product of an epoch and that the writer's creative capacity develops in a field of possibilities that circumscribe their life.However, as we will seek to briefly argue, literature is much more than the mirror of a society.
The idea of a relationship between the social sciences and literature does not constitute something new in the academic world 9 , though there are many scientists who continue to maintain an attitude of indifference, or even hostility regarding the possible contributions that literature can offer a socio-anthropological investigation.This does not mean to say that these two areas of knowledge do not hold important differences.The literary work goes beyond the parameters by which the social sciences could understand it.Maybe, given this, literature always has something to say to the social sciences.
In recent decades, philosophers and scientists such as Feyerabend, Davidson, Putnam, Richard Rorty, Homi Bhabah, Alasdir Mac Intyre and Charles Taylor have sought to reestablish dialogue between the social sciences and literature.In the area of social studies, researchers such as Horton and Baumeister ("Literature and the political imagination"), Tom Paulin ("Minotaur: poetry and the nation state") Stephen Ingle ("Socialist thought in imaginative literature"), Maureen Whitebrook ("Real toads in imaginary gardens"), amongst many others, have extensively used literary sources to theoretically and methodologically sustain their investigations.Regarding the relationship of the social sciences and literature with medicine, in addition to the existence of an important periodical ("Literature and Medicine"), it is worth noting the research developed by Nouzeilles 10 , Davis 11 and Clarke & Aykock 12 .In Brazil, Tulo Montenegro 13 , Paula Beiguelman 14 , Renato Ortiz 15 , and Maria Ângela D'Incao 16 , to cite just a few names, are significant examples of social scientists who sought to use the heuristic resources provided by fictional literature in their research.
We begin from the understanding that literature provides new perspectives regarding things and people, instituting social imaginaries.It moves us, entertains us, provokes surprise and affects our ways of thinking, collective attitudes and ideologies.Literary narratives contain ideas, descriptions, interpretations and personal and collective events that are, in themselves, a valuable way of understanding cultural phenomena.As Marías suggests: "in poetry, in narration, in theatre, especially in the short story, life is made transparent to itself " 17 .Human life is "poetic work?" -to cite the expression of Ortega y Gasset 18 .According to this philosopher, the human being is a novelist of herself, since she cannot live without inventing the character and the story.Similarly, she cannot live with other people without imagining them and projecting onto them "stories of fundamental urgency" to make them intelligible for her.
As Merleau-Ponty 19 highlights, the artist makes us aware of the subjective experience that we have of simple objects (such as Cézanne's lemons and bunches of grapes) that pass us by unnoticed, raising questions about the experiences that we normally have of them, leading us to look at them in a new light.Merleau-Ponty observes: "the perceived world is not only the set of natural things; it is also the paintings, music, books, everything that the Germans call the 'cultural world' .By immersing ourselves in the perceived world, far from narrowing our horizon or limiting ourselves to the pebbles or water, we find ways of contemplating literary art works and culture in its autonomy and in its original richness" 19 .Through their artwork, the artist stimulates us to look behind the concepts that we construct based on our direct experience and to recover this experience.Therefore, it is via the conventional meaning of words that literature creates parallel worlds, permitting us to see in a different way the world in which we liveand amplifying our sense of the possible meanings of experience.This characteristic of the literary work helps us to be more "reflexive" when we refine our perception of the world, in other words, -how art in general has the power to make us aware that there are different ways of being "reflexive" beyond those that we usually recognize in social life.In this respect, the writer extends the idea of what is rational or "reasonable" according to the already constituted reasons by which we live.However, it should be highlighted that it is fundamental that the vision of the writer should not stray too far from the generally accepted vision in the day-today world at the risk of no longer communicating with their public.The artistic vision exploits something that we have in common so that it can present new modes of perception.

Illness, rupture and practical contexts
The main observation about the short story regards Ivan Ilyich's initial way of life, that is, the public persona that he adopts, his detached way of being.We could say that Ivan Ilyich was a man immersed in what Oretega Y Gasset called the state of alteration 20 .Governed by his form, consigned to his circumstances and to his preconceived conduct, he is immersed in the things of the world as one of them.He is absorbed by the exterior impressions, oriented by the usual, by the expected, by the values and principals of everybody and nobody in particular.
Prior to his illness, Ivan Ilyich led a "carefree and refined" existence, a "decent, life, legitimated by society", a life that gave him "that decency of the exterior formalities determined by public opinion" 1 .
"He had a new connection in the province with the local ladies (…) and there was drinking (…) and trips to a distant street, after supper; he flattered his boss and even his boss' wife, but all of this imbued with suchan elevated tone of good manners that it could not be defined using evil words, all of this fell within the rubric of the French adage: il faut que jeunesse se passe.Everything happened with clean hands, with French words, and especially, in the highest of society, therefore with the approval of the most privileged people" 1 .He was offered another position in another province as an investigating judge."In his role as judge, Ivan Ilyich was equally comme il faut, decent, capable of separating professional responsibilities and personal life (…)" 1 .He married "according to his own wishes: managing such a wife, doing what pleased him and, at the same time, doing that which the most highly placed people deemed correct" 1 .At his home, there was "what there is in the houses of all not quite wealthy people, but who wish to seem as such and for this only end up resembling one another: apricots, blackwood, flowers, rugs and bronzes, dark and bright shades; that is, everything that all people of a certain type do to try to be like people of a certain type" 1 .
The illness causes an interruption in Ivan Ilyich's life, an interruption in terms of his usual way of being with others.His body acquires an otherness, manifesting itself as an independent entity that resists his will and understanding.His body is gradually objectified, becoming a source of discomfort and pain and an obstacle to his daily projects.This interruption however, is also temporal, whereby the past and the future seem strange to him, in comparison with what happened prior to his illness.The past and the future are perceived through another lens.The illness leads him to questioning, to a radical torsion, shutting himself up in himself and considering his own interior.He remembers his youth, the School of Law, his marriage… and everything "which seemed happy melted before his eyes, becoming something worthless and often despicable" 1 .Ivan Ilyich "theorizes", internalizing himself as Ortega would say.
Tolstoy does not present a medical definition of the illness to describe Ivan Ilyich's conduct, afflictions, values and representations of his own state of health.What is this illness exactly?In the short story, this question is unimportant.
As a biological phenomenon, the illness is described in a somewhat vague manner."They all enjoyed good health.One could not call it illness, the fact that Ivan Ilyich occasionally said that he had a strange taste in his mouth and a certain disagreeable sensation in the right hand side of his stomach" 1 .The aggravation of his state of health is narrated according to the growing pain and mood swings.The illness is not only presented as a natural entity that assails the individual and is capable of destroying them, that is, a substance evoked by a model of medical knowledge that indicates the information produced by the body and the spirit.Therefore, as a "constant" that subsists, that remains the same throughout the different situations and behaviors of the subject.In summary, the "being of the illness" is not reduced to an "essentialist model", a "morbid entity", defined according to a "biological explicative model".
We observe how Tolstoy describes the diagnoses given by the doctors,of Ivan Ilyich's problem.The retelling of the checkup with the first doctor consulted by Ilyich is exemplary."The doctor said: this and that also indicate that you have in your insides this and that as well; but if this is not confirmed by the investigation of this and that as well, we will have to suppose this and that also.And we suppose that we have this and that as well …etc." 1 .However, the short story goes on "(…) he sought another renowned name: this second renowned name said almost the same as the first (…)" 1 .Another doctor, "a friend of a friend of his, classified the illness in a completely different way and, though he had promised clarification, left Ivan Ilyich even more confused (…)" 1 .
Nor did Tolstoy denaturalize or deconstruct the illness as a natural entity.He does not abandon the physical body, the organic vicissitudes to only retain the interpretations, representations and points of view of the protagonists.If he acted in this way, he would reduce the illness to a question of perspective, of different meanings that the subjects attribute to a state of health 21 .
Instead of describing the illness as a reality adjacent to the differences of meaning or defining it within a "category" or "abstract explicative model", Tolstoy narrates as the characters, collectively, develop practices and meanings in their life worlds.The illness is constructed by the relationships of the characters between themselves and with their surroundings; it is made of a series of heterogeneous actors.Therefore, Tolstoy gives special attention to the interactions between different agents in concrete social situations.He focuses on Ivan Ilyich's day-to-day life.We could say that he is concerned with what Hannah Arendt calls the "vita activa" 22 .In Arendt's philosophy, this expression refers to the three fundamental human activities: work, creation and action.Each one of these corresponds to one of the basic conditions of human life.Briefly, work is the activity that corresponds to the biological process of the human body; creation provides an 'artificial' world of things and action corresponds to the human condition of plurality, "to the fact that men, and not the Man, live on Earth and inhabit the world" 22 .
Illness has a strange nature: it seems to be something, an otherness that is within the body.The body manifests itself as something independent of Ivan Ilyich's will and comprehension.
In his "carefree and refined life" a "strange taste in the moth and a certain disagreeable sensation in the right hand side of his stomach" emerges "but this disagreeable sensation started to increase and become no longer a pain, but an awareness of a permanent weight on his side and a bad mood" 1 .The pain did not cease to torment him, becoming increasingly strong."He remembered the medicine, stood up, took it, lay on his back, paying attention to how it acted favorably and diminished the pain.'Just take it regularly and avoid damaging influences; now, I already feel a little better, much better even' .He started to feel his side: he did not feel pain any longer.'Yes, I do not feeling any pain, indeed I'm already better.'He blew out the candle and lay on his side… the cecum was reestablishing itself, there was reabsorption.Suddenly, he felt pain, well known, dull, muffled, insistent, constant, severe.In his mouth too, the same abject sensation that he already knew.Something gripped his heart, his head spun.'My God, my God! -he said -Once again, again, it never has an end'" 1 .He managed to deceive himself, while nothing disturbed him.But it was enough that there was a setback (…) and he flew into a fury against his misfortune or against the people who had caused him displeasure and who were killing him, and felt that this fury was killing him; but he could not get rid of it" 1 .
The disease is "made" within a series of practical and relational contexts in which different actors participate.One of these contexts is family life: "This bad mood, that grew continually, started to spoil the quality of his carefree and decent life that had rooted itself in the Golovin family once upon a time.Husband and wife started to fight with ever greater frequency, and soon the carefree and agreeable disappeared, leaving only the decency" 1 .The "visibility" of the illness is in his growing irritability, bad moods and pettiness."Now he observed that a dish was not spotless, now that the food wasn't quite right, now his son put his elbows on the table, now he had something to say about his daughter's hair.And in everything he blamed Prascóvia Fiódorovna [wife]" 1 .Irritable states that were not restricted to the family spread to other spheres of his life."It was enough that there was a mishap in his relationship with his wife, a failure in service, bad cards at whist, that he immediately felt all the force of his illness; at another time, he bore such failures, expecting to be able to correct what went wrong, overcoming the difficulties, achieving success, managing to play a grand slam.But now any failure set him low, left him in despair (…) and he became furious with his misfortune or with the people who caused him displeasure and who were killing him, and felt that this fury was killing him; but he could not get rid of it" 1 .
The illness also showed itself differently in the contexts of work and leisure."At work, he perceived or thought he perceived the same strange relationship with his person: now he had the impression that they were paying attention to him like someone who, soon, would be leaving his post; now, his friends began to affectionately tease his hypochondria, as if that which was most terrible, frightening, unprecedented, that took root in him, that drained him incessantly and drove him irrevocably to some region, was the most agreeable pretext for foolery.He became particularly irritated with Schwartz, with his jokes, his vitality, his air of comme il faut, that reminded him, Ivan Ilyich, of his own person, ten years prior" 1 .In leisure, the illness manifests itself through the solicitude of his friends, through the care they take with him.During the game of whist, everyone seems not to feel well."Ivan Ilyich felt that he inspired this dark mood and that he could not dissipate it" 1 .
In another sphere of his relationships, this time with his doctors the illness is also "constructed" through Ivan Ilyich's interactions.As previously observed, the diagnoses are vague, exacerbating his state of irritation.The medical discourses objectify his body, reducing it to a functioning of organs, tissues, bones and blood.For the doctor "there is only an evaluation of the possibilities between a mobile kidney, chronic catarrh, and a condition in the cecum.It was not Ivan Ilyich's life that was at stake, there was a discussion between the mobile kidney and a condition of the cecum".He tried to "translate into simple language all those confusing scientific terms and read in them a response to the following: I am very bad or, for the moment, it is not serious?(…) And this pain, a dull muffled pain, that did not stop for even one second, seemed to receive, in consequence of the imprecise words of the doctor, a new, more serious meaning.Ivan Ilyich now paid attention to it with a different heavy feeling" 2 .However, the diagnoses did not correspond to his concerns: was his situation dangerous?
Ivan Ilyich took on the "condition of patient".He sought to fulfill precisely the prescription given by the doctors."Ivan Ilyich's main occupation, since he had gone to the doctor, became the exact monitoring of his medications, followed by the observation of his pain and of all the functioning of his organism.Human illnesses and health become Ivan Ilyich's main interests.When sick people, deceased or who had reestablished themselves spoke in his presence, especially in the case of illnesses similar to his own, he sought to hide his emotion, paying attention to the conversation, interrogating the other and comparing their cases with his own" 1 .
His body and appearance changed, his condition becoming noticeable to others."Entering into his office, he found his brother in law, a hardy type, radiating health, able to unpack his suitcase by himself.Hearing Ivan Ilyich's footsteps, he raised his head and looked at him for a second in silence.This look said everything for Ivan Ilyich.His brother in law opened his mouth to say "ah", but restrained himself.This movement confirmed everything.
-So, I'm different?-Yes, there is a difference 1 He becomes increasingly dependent on others.He needs help to get up, clean himself and change his clothes.He loses his privacy."Special adaptations were also made to his excretions, and this increasingly constituted suffering.Suffering because of the dirtiness, of the indecency and the smell, of the awareness that another person had participated in the process" 1 .The domestic help Guerássim -"a young mujique, clean, radiating freshness and goodness" -is the only one to understand and sympathize with him.
In summary, the illness does not appear to be an isolated entity, but appears within the horizon of human projects and trajectories, being understood in practical contexts.Therefore, there is not a meaning in itself, but rather it is its way of appearing that constitutes its meaning.Its meaning can only be understood in the context of interactions.

Conclusion
There is a pragmatic, educational and moralizing intention in "The death of Ivan Ilyich".Concerned with indoctrinating the reader, Tolstoy wrote an accessible text, immediately comprehensible and familiar.As already mentioned, the fictional aspect is allied with believability; Tolstoy seeks elements from extra-textual references that allow the reader to view the fictional occurrences always in analogy with a given referent.In this manner, Tolstoy seeks to facilitate the work's reception (and, consequently, its message) by the public.
Illness is a guiding thread throughout the novel, though the presence of death is a "pivot" by which Tolstoy seeks to transmit his moralizing project.In a somewhat Heideggerian vision, death is the privileged possibility to understand the meaning of life in its relation to time.It is through the eminence of death that Ivan Ilyich re-signifies his past, changing his stance in relation to himself and to others.However, illness is the driving force in the compositional structure of the text.
The process of becoming ill is narrated as a trajectory, as activities or movements of the protagonist in his different interactive processes with others, with the travails of his day-to-day life.In other words, illness is something that is made practically and through practices, via its materiality, in the associations that the actors create in given, concrete situations.Therefore, illness ceases to be viewed from an "essentialist" perspective (a fixed entity about which we can formulate diverse points of view) so as to be understood as an open totality in a field of practices, a becoming, as Deleuze would say.The experience of being ill includes a complex configuration of tensions and conflicts that Ivan Ilyich has to navigate.
Tolstoy's short story reveals to us an aspect of illness, the peculiar experience of incomprehensibility.It has a strange quality, in the sense that something happens within Ivan Ilyich, an otherness.It is an independent "entity" that resists his will and comprehension, and which does not have a ready, predefined explanation.It is a lack of meaning that is experienced as a rupture in understanding that manifests itself concretely as pain, fatigue and anxiety, etc. Ceasing "to be at ease" with one's own body, it now becomes an obstacle in the interactions of day-to-day life.Discomfort, pain, feelings and moods was hover Ivan Ilyich and cannot be easily changed by him.These are the basic strata by which Ilyich engages with the world.
It is precisely through being engaged with the world that illness acquires meaning.As Annemarie Mol observes [23][24][25] , there is no illness independent of what one thinks and does.In this sense, acting, being affected, thinking and feeling are phenomena that go together in the development of the processes of illness and treatment.Mol argues that in the body, the coherence (as an organic system possessed of a given totality) is not self-evident, but rather something to be always sought after.The body houses a complex configuration of tensions and conflicts that need to be negotiated.There are tensions between the body's organs, between the internal controls and the unstable character of its behavior and, notably, between the various necessities and desires that bodies attempt to combine with the aim of achieving this totality.Therefore, Mol argues that maintaining integration of the body is something that requires work (realization) from people.Just as there is no unified body a priori in a given totality, it is also not possible to encounter an integrated system of meaning that defines illness once and for all.The idea of illness depends on the environment where the "illness" is situated.It is configured according to the space where questioning is formulated.It is in these spaces that the patient acquires abilities, the ability to associate or regiment different mediators (other humans, objects, techniques, discourses) that allow him to act and achieve certain ends.These spaces demand, in a certain manner, a practical learning experience to deal with the set of new arrangements.In this sense, "The death of Ivan Ilyich" has much to tell us about the process of becoming ill.Therefore, given that it provides us with a way of approaching the world of illness, it also has something to say about medicalized humanity.