Ivan begins to experience some discomfort in his left side and an unusual taste in his mouth. The discomfort gradually increases and soon Ivan is both irritable and quarrelsome. As his ill humor begins to mar the easy and agreeable lifestyle he has worked so hard to construct, volatile disputes with his wife occur more and more often. Praskovya, "with characteristic exaggeration," comments that Ivan has always had a dreadful temper. Ivan now starts all the arguments. Realizing that her husband's uncontrollable rages are making her life miserable, Praskovya begins to feel sorry for herself. She hates Ivan and would like to see him die, if only his salary would not cease.
One day Ivan goes to see the doctor. At the doctor's office Ivan is struck by the similarity between his attitude toward the accused in the law courts and the doctors attitude toward him. To Ivan, the only important question is whether or not his case is serious. But ignoring Ivan's concern, the doctor focuses on the strictly medical question of whether Ivan's problem is a floating kidney or appendicitis. This question the doctor answers brilliantly, and as Ivan thinks, in favor of the appendix. Ivan gets the feeling that his case is very serious and he is struck by the doctor's indifference and utter lack of sympathy to a matter of such importance.
Ivan heads home, depressed and fearful. He begins to tell his wife about the examination, but before he can finish, his wife leaves with their daughter to go out. Ivan takes medicine and strictly follows the doctor's orders, but more tests reveal that the doctor's initial prognosis was incorrect. Ivan then attempts to deal with his sickness by forcing himself to think that he has gotten better, but any unpleasantness with his wife, lack of success in work, or bad cards at bridge bring to mind his disease. Ivan goes to see more doctors, including a homeopath, but each doctor diagnoses his illness differently from the others. Ivan becomes annoyed with himself one day when he starts to believe that a wonder-working icon can affect miracles.
Ivan realizes that those around him think everything is normal, and do not understand nor care to understand his condition. Ivan's wife and daughter are annoyed at his depression and intolerance. Praskovya adopts a formal attitude to Ivan's illness. It consists of the beliefs that Ivan's condition is his own fault and that if he strictly follows doctor's orders he will improve.
At the law courts Ivan notices people looking at him inquisitively as if his post might soon be vacant. At other times, his friends, and especially Schwartz, joke about his illness as if it were a trivial and temporary condition. Even card playing ceases to hold its previous allure. One night when playing bridge with friends, Ivan is on the verge of making a grand slam. Suddenly, he becomes aware of the pain in his side and the disagreeable taste in his mouth, and it seems ridiculous to him that he should derive pleasure from a grand slam. Ivan misplays the hand and misses the grand slam. And despite his partner's distress, Ivan realizes that he does not care, "and it was dreadful to realize why he did not care." Conscious that his life is "poisoned" and is poisoning the lives of others, he feels alone on the "brink of an abyss," with no one who understands or pities him.
The symptoms that mark the onset of Ivan's illness coincide curiously with the symptoms ascribed to Praskovya during her pregnancy, i.e., fits of anger, a strange taste in the mouth, and a tendency to disrupt the pleasant and easy course of life. And just as Praskovya's symptoms were the result of burgeoning life, so too, the sickness that is causing Ivan's physical death seems somehow associated with growing new life. It is interesting to note that Praskovya's reaction to Ivan's sickness mirrors Ivan's reaction to the unpleasantness introduced by Praskovya's pregnancy. Praskovya sees Ivan's condition as an unseemly burden. She minimizes the amount of time spent in his company and retreats from him as soon as an occasion arises. Recall Praskvoya's hasty departure in the middle of her husband's account of his visit to the doctor. Reminiscent of Ivan's formal attitude toward marriage, Praskovya adopts a "definite line in regard to his illness." Even Ivan's colleagues at work maintain a nonchalant and superficial attitude toward Ivan's illness. Tolstoy seems to imply that for Praskovya and Ivan, as well as for bourgeois society as a whole, formal and concrete attitudes toward life replace sympathetic and emotional connections.
This conclusion is only strengthened by Ivan's visit to the doctor. The doctor treats Ivan just as he treats the petitioners that come before him in court, in a coldly external, detached, and formalized manner. Ivan is principally concerned with whether or not his illness is life threatening. He wants to know the individual significance of his condition. But the doctor cannot engage Ivan on a personal level, he can only comment on the formal, medical aspects of his patient's case. Just as the doctor's focus is of secondary importance to Ivan, when the diagnoses of other doctors come into conflict with one another, one begins to wonder whether the physiological approach itself is of secondary importance. We are left with the impression that Ivan's condition is more than just a physiological problem.
Ivan's attempts to deal with the disruption caused by his illness are also revealing. By following the doctor's orders in a scrupulous and exact fashion, he not only takes up the position that his illness is purely physiological, but he also demonstrates his belief that life is well regulated and predictable. With Praskovya's pregnancy, Ivan managed to adopt a perspective that ignored the disagreeable aspects of her behavior. And when the proper channels of complaint failed to gain Ivan notice when he was passed over for promotion, a sudden and miraculous reorganization of the government landed him a better position. Yet unlike the previous incursions of unseemliness and unpredictability into his life, Ivan's illness resists such decorum restoring measures. When meticulous attention to the doctor's instructions fails to help, Ivan tries to force himself to think that he is better. But even self-deception is unsuccessful when problems with his wife, difficulty at work, or bad cards at bridge make him conscious of his disease.
The fact that life's unpleasantness causes the pain that Ivan experiences is a key to Ivan's condition. If Ivan's condition is not physiological, but is truly caused by a misperception of the nature of life, i.e., if Ivan's illness stems from his belief that life is always proper, formal, decorous, and neat, then any signs to the contrary would serve to aggravate his symptoms. A close look at Ivan's night of bridge seems to point to the same conclusion. Ivan enjoys bridge because it mirrors his perception of reality. Bridge, in a sense, is a metaphor for Ivan's ideal of a proper life. Thus, when Ivan realizes that his excitement at making a grand slam (the best possible bridge hand) is ridiculous in light of his present condition, bridge seems to lose all its appeal. Ivan's illness makes him conscious of the fact that bridge does not reflect the true nature of life. Missing a grand slam, as Ivan does when he misplays his hand, is really a trivial occurrence. Ivan simply does not care. And the reason that "it is dreadful to realize" why he does not care is because that realization implies the destruction of his worldview. Although Ivan has not yet completely relinquished his view of life as neat and predictable, his illness is gradually making him aware that a world and a reality exist outside of the one he occupies.