Anna KareninaBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5416 (Published 07 September 2011) Cite this as: BMJ 2011;343:d5416
- Mursheda Mahbub Chowdhury, associate specialist in palliative medicine, St Michael’s Hospice, St Leonard’s-on-Sea, East Sussex
Most people are vaguely familiar with this sweeping novel as the tragic tale of a doomed love affair. However, this is just one story in the book. Other storylines are interweaved, portraying all of life—birth, childhood, love, marriage, illness, and death. Tolstoy was a contemporary of Dickens but his style is very different. There are no caricatures here: people are portrayed as flawed, fallible creatures with shades of good and bad within them and with a realism that is disarming.
As a palliative care doctor, one chapter in particular resonated with me, in which Tolstoy depicts a character’s death from tuberculosis. In the 19th century, tuberculosis was a condition not unlike most cancers in its disease trajectory. The sick man’s brother Levin is struck by his cachexia: “It cannot be that this terrible body is my brother.” Levin feels horror, helplessness, revulsion, pity, and love towards the dying man. He confronts his own mortality and wrestles with his previously unshakeable belief in the non-existence of God. Tolstoy had had firsthand experience: his brother Nikolai also died from tuberculosis.
Tolstoy describes unflinchingly the physical manifestations of approaching death; the bed sores that no longer heal, emaciation, and fatigue. Food and fluids no longer give satisfaction, and “the attempt at satisfaction caused new suffering.” Levin’s wife, Kitty, approaches the sick man differently. She immerses herself in the practicalities. She busies herself in the “physical care, the alleviation of suffering” but also demands “something more important for the dying man,” persuading him to take communion, recognising he might have spiritual needs.
To her, who never knew him in health, he is not defined by his dying but as someone who once had a vigorous life with all its ups and downs. She talks about herself and “smiled, pitied, and caressed him and spoke of cases of recovery,” which meant that “she knew.” The sick man strives for hope and transcendence one moment, is in denial the next, and in other moments of clarity expresses his knowledge of his own inevitable death. He takes out his anger and frustration on his lover who has faithfully stuck by him, but he has more forbearance with strangers.
Those of us who work in palliative care will recognise the physical, emotional, and spiritual aspects of dying that Tolstoy so skilfully and insightfully depicts. At one point, there is an unexpected reanimation and resurgence of life in the dying man. He makes a last ditch attempt to live, demanding food and doctors. The doctor’s assessment is that “he can’t live more than three days,” to which Kitty wisely responds, “But can they really know?” The doctor gets it wrong, and the protracted dying process takes many more days, with its attendant rollercoaster of emotions for all involved—“the physical and moral exhaustion.” The chapter ends with news of Kitty’s pregnancy, a juxtaposition of birth with death, and Levin’s realisation of “the necessity to live and love” in spite of death.
Cite this as: BMJ 2011;343:d5416
A novel by Leo Tolstoy
First published in Russian in 1877
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.