LAZILY or self-protectively, we think of death, when we think of it at all, as monomorphic - as the one thing, or no-thing, that puts an end to everything. But forms of death can be as various as forms of life. 'Death hath ten thousand several doors / For men to take their exits' it's said in The Duchess of Malfi, and though Sherwin Nuland might want to quarrel with the mathematics - for him there are essentially half a dozen exits - he is of John Webster's party: a man much possessed by death, who wants to peer more closely through its doors.
Dr Nuland first saw the skull beneath the skin as early as 11, when his mother died of colon cancer. He began writing this book after his brother died of the same disease nearly half a century later. In between, as a consultant surgeon at the Yale-New Haven Hospital, he has seen, and overseen, many other deaths. The first patient he had to deal with, as a 22-year-old medical student, was in a stable condition following a suspected coronary - stable until eager- beaver young Nuland entered the room, at which point the patient 'suddenly threw his head back and bellowed out a wordless roar that seemed to rise up out of his throat . . . He took one immensely long, gurgling breath, and died.' Dr Nuland's thoracotomy and cardiac massage did not save his patient, but he can be forgiven for thinking that death in this moment had picked him out, and that his task thereafter would be to act as its intermediary and explicator.
Like most thanatologists, he makes the point that death these days is a 'hidden secret', packaged, cleansed and removed from sight. Unlike most thanatologists, he is not primarily concerned to help people cope with bereavement, but wishes rather to present death 'in its biological and clinical reality'. How We Die is not a how-to book - some of its harshest words are for Derek Humphry, founder of the Hemlock Society, and for his 'ill-advised cookbook', Final Exit. But it is enabling: here is the kind of detailed analysis of death normally found only in medical journals.
Nuland has little patience with the idea of dignified or easeful deaths, and his accounts, while never gratuitous, spare us little. You may not have realised before that 'the sensation imparted by a fibrillating heart is like holding in one's palm a wet, jellylike bagful of hyperactive worms'; nor perhaps did you realise that 'the corpse of a drowning victim will always sink headfirst to the bottom and remain floating in that position until putrefaction produces enough gas in the tissues to create a buoyancy that makes it rise to the surface'. Aids, angina, bedsores, brain death, carcinoma, death rattle, dementia, edema: the index is grimly comprehensive. But whenever the facts threaten to overwhelm, Nuland colours the text with a vivid metaphor (cancer cells are 'the juvenile delinquents of cellular society'), or draws on a case of his own (the chapters on Aids, Alzheimer's and near-death experiences are particularly affecting), or turns to art and literature. He describes coronary ischemia as dramatised in Lillian Hellman's The Little Foxes. He contrasts the honesty of Goya's painting Diphtheria with Luke Fildes's prettifying The Doctor. He praises the psychological authenticity of Tolstoy's lonely, stranded Ivan Ilych.
Two strong convictions pulse through his book. One is that, politically incorrect though it may be to say so in an age of medical intervention, people really do die of old age. He does not decide whether ageing is the result of commonplace wear and tear, or - the rival theory - of a 'genetic tape' reaching its preordained end. But with the help of autopsy reports he concludes that, whatever the different diseases old people die from, their bodies become similarly rusted and crusted, until 'they implode their way into eternity'. Yes, says Nuland, old age sometimes brings its rewards, but there is a dangerous vanity in pretending we can exceed our natural span. He quotes Tennyson: 'Old men must die; or the world would grow mouldy, would only breed the past again.'
His other passionate belief, long held in principle and reinforced by his failure to practise it in the case of his brother, has to do with hope. Offering words of 'hope' to the terminally ill - that is, telling lies to them - is the opposite of kindness: 'Unless we are aware that we are dying and so far as possible know the conditions of our death, we cannot share any sort of final consummation with those who love us.' Similarly, offering technological hope - that is, surgery or short-term respite - to those too old or sick to benefit often ensures merely that they die not at home but in hospital, isolated among strangers. Hi-tech can be the enemy of release.
Despite blips of bedside blandness and medico-speak, Sherwin Nuland has written a lively study of the end of living. Death itself remains a mystery, the one human experience of which we can't leave behind our impressions. But anyone who reads this book will know quite enough about the varieties of dying to be going on with.
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