How We Die

by Sherwin B. Nuland

We are irresistibly attracted by the very anxieties we find most terrifying; we are drawn to them by a primitive excitement that arises from flirtation with danger. Moths and flames, mankind and death—there is little difference.

The stoppage of circulation, the inadequate transport of oxygen to tissues, the flickering out of brain function, the failure of organs, the destruction of vital centers—these are the weapons of every horseman of death.

EVERY LIFE IS different from any that has gone before it, and so is every death.

Poets, essayists, chroniclers, wags, and wise men write often about death but have rarely seen it. Physicians and nurses, who see it often, rarely write about it.

When an organ’s activity increases, its oxygen requirements go up, and so does its need for blood. If narrowed arteries cannot widen to accommodate this need, or if for some reason they go into tight spasm that further restricts flow, the organ’s demands are not met, and it rapidly becomes ischemic. In pain and anger, the heart screams out a warning, and continues to do so until its shrieking exhortations for more blood are met, usually by the natural stratagem of the victim, who—alarmed by the distress within his chest—slows or stops the activity that is tormenting his cardiac muscle.

The backpressure of inadequately ejected blood causes the heart’s chambers to balloon out and remain dilated. The ventricular muscle thickens in an attempt to compensate for its own weakness. Thus the heart becomes enlarged and appears more formidable, but it is now only a thing of blustering braggadocio.

Half a century ago, for people like us to so banish an aged parent was considered a coldhearted circumvention of responsibility, and a denial of love.

The force of life fills out our tissues with its pulsing vibrancy and puffs them up with the pride of being alive. Whether it departs with a bang, as it did for Irv Lipsiner, or a prolonged whimper, as it did for Bubbeh, it often leaves behind an object of shrunken unrealness.

Thomas Browne’s words, or Lamb’s, might have reassured me at my grandmother’s coffin. That day would surely have been a lot easier for me, and its memory less painful, had I but known that not only my own grandmother but indeed everyone becomes littler with death—when the human spirit departs, it takes with it the vital stuffing of life. Then, only the inanimate corpus remains, which is the least of all the things that make us human.

“With what strife and pains we come into the world we know not, but ‘tis commonly no easy matter to get out of it.”

“Death may be due to a wide variety of diseases and disorders, but in every case the underlying physiological cause is a breakdown in the body’s oxygen cycle.”

“The race of men is like the race of leaves. As one generation flourishes, another decays.”

We are dealing not with a punishment but with a crime—one of those random crimes that nature now and then perpetrates on its own creatures. And nature, as Anatole France reminds us, is indifferent; it makes no distinction between good and evil.

As early as the days of Hippocrates and even before, the ancient Greek physicians had a clear understanding of the ways in which a malignant growth so often pursues its inexorable determination to destroy life. They gave a very specific name to the hard swellings and ulcerations they so commonly saw in the breast or protruding from the rectum or vagina; they based that name on the evidence of their eyes and fingers. To distinguish them from ordinary swellings, which they called oncos, they used the term karkinos, or “crab,” derived, interestingly enough, from an Indo-European root meaning “hard.” Oma being a suffix referring to “tumor,” karkinoma was used to designate a tumorous growth that was malignant. Centuries later, the Latin word for “crab,” cancer, came into common usage. Oncos, meantime, came to be applied to tumors of any kind, which is why we call a cancer specialist an oncologist.

Hope is an abstract word. In fact, it is more than just a word; hope is an abstruse concept, meaning different things to each of us during different times and circumstances of our lives.

The greatest dignity to be found in death is the dignity of the life that preceded it. This is a form of hope we can all achieve, and it is the most abiding of all. Hope resides in the meaning of what our lives have been.

Nature has a job to do. It does its job by the method that seems most suited to each individual whom its powers have created. It has made this one susceptible to heart disease and that one to stroke and yet another to cancer, some after a long time on this earth and some after a time much too brief, at least by our own reckoning. The animal economy has formed the circumstances by which each generation is to be succeeded by the next. Against the relentless forces and cycles of nature there can be no lasting victory.