When Iván Ilych's brother-in-law comes to visit before New Years, he is shocked to see how Iván Ilych has changed. After admitting that he sees a change, the brother-in-law refuses to speak more about it to Iván Ilych. Iván Ilych locks himself in a room to examine his reflection in the mirror, comparing it to a portrait of himself taken with his wife. The change is immense. He then goes out and eavesdrops on his brother-in-law and wife in the drawing room. Though Praskóvya Fëdorovna denies that the change is great, her brother insists: "Why, he's a dead man! Look at his eyes there's no light in them" (143).
Iván Ilych returns to his own room, lies down, and tries to imagine the "floating kidney" some of the doctors have diagnosed. He tries to imagine reattaching it. He decides to go see Peter Ivánovich, a friend who is friends with a doctor. This doctor tells him that the illness is a small thing in the vermiform appendix, and curing it requires the stimulation of one organ and checking another organs activity, so that absorption can take place.
That evening, after completing some work, Iván Ilych has tea, followed by piano-playing and singing with the family and friends. He seems more cheerful than usual. That night, Iván Ilych retires to the single bedroom by his study, the bedroom that has been his since the illness began. He tries to imagine his appendix. He tries to cure it mentally, and takes his medicine, but despite his positive thinking the pain and disgusting taste in his mouth seem to become stronger. Then the issue transforms for him, from a matter of diagnosis to a question of philosophy and metaphysics: "It's not a question of appendix or kidney, but of life and . . . death. Yes, life was there and now it is going, going, and I cannot stop it. . . . When I am not, what will there be? There will be nothing. Then where shall I be when I am no more? Can this be dying?'" (145). Iván Ilych despairs, asking "What's the use?" and mentally condemning his friends and family for not caring, and for not recognizing their own deaths in his. He tries to think about the illness, remembering that first day when he bumped his side, but nothing helps. He is always led back to staring death in the face. He works himself into a frenzy, short of breath, and falls.
His wife comes to investigate the noise. She asks what's bothering him, but Iván Ilych does not try to explain, because he realizes that his wife wouldn't understand. She suggests bringing in Leshchetítsky, the famous specialist, in on a house call. The specialist would be expensive. She kisses Iván Ilych on the forehead to say goodnight. At that moment, Iván Ilych hates her "from the bottom of his soul" (147). He can barely keep himself from pushing her away.
Iván Ilych attempts to cure himself with the power of positive thinking in this chapter, but he soon realizes that mortality is not a problem that can be overcome with the mind. The pain and the foul taste in his mouth are metonymies for approaching death. Despite some initial success in making himself feel better, the insistent return of his symptoms drives home that forced hope and optimism will not change the inevitable.
His inability to overcome his symptoms leads him to thinking about death. Iván Ilych drives himself into a frenzy when thinking about mortality; his futile frenzy reminds one of a fish thrashing in a net, and probably is based on Tolstoy's own contemplation of death.
Because he is facing death, Iván Ilych's perception of life is altered. His despairing question, "What's the use?" is not the only result of his struggle with mortality. He also sees hypocrisy and stupidity more clearly. When his wife speaks of the specialist, "regardless of the expense," she is trying to comfort him by expressing that money matters less than his life. In their marriage, such a thing needs to be said, and a Iván Ilych is aware now of the hollowness that suggests. Her words also seem to be partially intended to demonstrate her own benevolence as a wife. She apparently thinks that paying an extra bit of money is a grand and generous gesture. The theme of misplaced priorities is subtly here, as Praskóvya Fëdorovna has no idea of how trivial her considerations are. For the sensitive reader, who sees the situation by Tolstoy's lamplight, the truth is clear: of course life is more valuable than money, and the only surprise is that the specialist has not been brought sooner.
From Iván Ilych's perspective, this expression of his wife's supposed concern and love is disgusting. It taints the other gesture of love, the kiss on the forehead, because the hollowness of the verbal expression of love lays bare the emptiness of the kiss. No wonder Iván Ilych hates her at this moment.
"Caius is a man, men are mortal, therefore Caius is mortal." This old syllogism, learned in Logic class, flashes now before Iván Ilych with new immediacy. While he certainly felt the syllogism to be true to Caius before, accepting that it applies to himself is considerably more difficult. He remembers the emotions and the sensations of his whole life, from boyhood on, and cannot believe that a creature with such experiences must also die.
The former screens against mortality (work, propriety, decorous and amiable living) no longer work. He is distracted at work, and "It" (the specter of death) continually haunts him.
He searches for consolations, "new screens" (149), but nothing works for long. He tries to fuss over the drawing room, where he now is forced to reflect ironically that he died for decorating, as the illness began that day he feel while hanging some drapes. He argues with his wife over arrangement. These distractions don't work for long, and he is always left facing death.
Chapter Six scarcely needs analysis, as Tolstoy is stating themes directly and forcefully.
Iván Ilych's new understanding of the classic syllogism illustrates the theme of Denial. Much of this chapter deals with man's denial of death, achieved in part through the use of "screens" that shield men from thinking too hard about mortality. Now that he is sick, Iván Ilych is no longer protected by the usual screens.
Also clear to him now is the triviality of much of what previously occupied all of his time and energy. Tolstoy juxtaposes the silly fussiness of Iván Ilych's previous concerns with the grim "It" facing Iván Ilych now. As Iván Ilych considers the accident that started his illness, he cannot believe the irony, the terrible contrast between his superficial old world and the new grim truth facing him: "It really is so! I lost my life over that curtain as I might have done when storming a fort. Is that possible? How terrible and how stupid. It can't be true! It can't, but it is'"(149).