Upon arriving home from work one day, Ivan encounters his brother-in-law unpacking his suitcase. His brother-in-law's utterly surprised expression at seeing Ivan's face reveals to him the true state of his physical degeneration. Taking a portrait of him and his wife, Ivan compares it to the image he sees in the mirror. He is horrified by the change in his appearance. Ivan overhears a private conversation between Praskovya and her brother in which the visitor refers to him as a "dead man." Ivan decides to see one final doctor, and after learning that the problem is a "small thing" with his vermiform appendix that can be righted if he only stimulates the activity of one organ and checks the activity of another, he returns home feeling somewhat better.
After dinner he returns to his study, but is bothered by the consciousness that he has put aside an "intimate matter" which he would return to when his official work is done. Later, he remembers that this matter is the thought of his vermiform appendix. After tea with some company, Ivan turns in for the night. While lying in bed, Ivan falls into deep thought. He visualizes his vermiform appendix, imagines the desired improvement, and begins to feel a little better. But suddenly, the familiar pain in his side and the "loathsome taste" in his mouth return. He comes to the conclusion that it is not a question of his appendix, but a question of life or death.
Visited by the first thoughts of his own mortality, a chill comes over him and his breathing ceases. He jumps up and tries to light a candle, but it falls from his hands to the floor. He hears the noise from the company outside his room and grows angry and even more miserable. To calm himself, he tries to think over the onset of his illness from the very beginning. But as thoughts of death crowd in, terror seizes him. He overturns the bedside stand while grasping for matches, falls to his bed in despair, expecting death at any moment. Praskovya, hearing the noise, comes to investigate. She lights a candle and asks if anything is wrong, but not understanding Ivan's circumstance, she leaves to see her guests off. Several minutes later she returns. While Praskovya is kissing Ivan on the forehead and wishing him goodnight, Ivan barely manages to suppress his hatred for her.
This chapter marks an interesting shift in the narrative strategy of the novel. Up to this point, the narrator has described Ivan's situation from the outside, relating his actions and feelings from a distance. Now, however, the narrator begins to describe Ivan's situation by reporting his thought processes and mental reflections directly. The narrator closes the distance between the audience and Ivan by providing a glimpse of Ivan's internal dialogue. The absence of such internal dialogue prior to Chapter V seems to suggest that Ivan lacked (or was unaware of) an inner life. The prevalence of internal dialogue after Chapter V suggests that here Ivan is slowly becoming aware of an inner life.
The narrator reveals Ivan's growing awareness of a private world separate from the external one of daily activity by introducing Ivan's consciousness of an important, "intimate matter." The fact that he can only turn his attention to this matter when his official work is done reinforces the mutually exclusive nature of the two worlds. Yet when Ivan remembers that this private matter is nothing more than the thought of his appendix, it is clear that Ivan's understanding of his inner world is still severely limited. Once again, that understanding, or misunderstanding, is called into question by the pain and suffering brought on by his illness. Almost as soon as Ivan begins contemplating his appendix, the familiar pain recurs. This time, however, it marks a turning point in the progress of Ivan's disease. Ivan realizes for the first time that his illness is not a question of health or sickness, but of life or death. He confronts his own mortality, and the thought terrifies him. Tolstoy makes use of several phrases throughout this part of the text that both signify and symbolize his imminent death: "[T]ried to light the candle," "staring with wide-open eyes into the darkness," and "his breathing ceased."