Closing Time

• How We Die by Sherwin Nuland
  Chatto, 278 pp, £15.99, May 1994, ISBN 0 7011 6169 8

‘He had never had a moment when death was not terrible to him,’ reports Boswell on the occasion of needling his famous friend with the news that the atheist philosopher David Hume had died well and without repentance. ‘The horror of death, which I had always observed in Dr Johnson, appeared strong tonight.’ Sherwin Nuland a surgeon from Yale, speaks to the Johnson in each of us, to our hunger for knowledge of our inevitable end: ‘Everyone wants to know the details of dying ... we are irresistibly attracted by the very anxieties we find most terrifying.’

Socrates tried to convince his students that it is irrational to fear death: ‘true philosophers make dying their profession.’ But his argument depends on a loathing of the body and on a belief that death is nothing but the soul’s separate existence under happier conditions in the next world. Neither position is likely to resonate favourably with many of us. As Socrates’ own students pointed out, this equanimity in the face of death was regarded by many as a sign of the philosopher’s madness.

Erasmus offers two suggestions, less eschatological, more psychologically and indeed physiologically informed than that of Socrates. ‘Is death as horrible a thing as it’s commonly asserted to be?’ asks Marcolphus the naive character, in one of the Colloquies. No, says Phaedrus, the voice of wisdom: ‘If a man dismisses from his thought the horror and imagination of death, he will have rid himself of a great part of the evil.’ And in any case, in the last stages, when the soul has already separated from the body, ‘nature dulls and stuns all areas of sensation.’

This is also the conclusion reached in one of the very few systematic studies we have of ‘the modes of death and the sensations of dying’: the survey conducted between 1900 and 1904 at Johns Hopkins University Hospital by Sir William Osler, one of the founders of modern clinical medicine and perhaps the most distinguished physician of his time. He found – based on reports by his colleagues and students – that while 90 out of about five hundred people experienced some sort of bodily distress, 11 ‘mental apprehension’, two ‘positive terror’, and one ‘spiritual ecstasy’, ‘the majority gave no sign one way or the other; like their birth, their death was “a sleep and a forgetting”.’

Dr Nuland sharply contests these reassuring assessments. He writes to ‘de-mythologise’ death; ‘to present it in its biological and clinical reality’; to stress the ‘physical deterioration’ of the body not its ‘emotional traumas’; to rescue death from culture. ‘Poets, essayists, chroniclers, wags and wise men often write about death but seldom see it.’ he declares in order to warrant passing the narrative torch to doctors. ‘Only within the pages of professional journals are to be found the descriptions of the actual processes’ by which we die.

This is fine, and others may have got it wrong, but in his grounds for denying the authority of experience to others Dr Nuland, too, is mistaken. Before our century there would have been no adult who had not seen – literally seen – some of his or her children, friends and, of course, parents die. Death behind institutional walls, death confined largely to those over the age of sixty, are phenomena of our century. Poets and essayists may not have had all the physiological details right but they, and more ordinary people as well, had seen their share of pain and suffering.

To be sure, lay voices are heard, insistently and often discordantly, throughout this book. There is the young Nuland who witnessed the death of his mother and his grandmother; there is the adult Nuland whose physician’s sang froid deserts him in the face of his beloved older brother’s death. The book may teem with quotations from Rilke. Tolstoy, Montaigne and other giants, but the voice of the doctor holds unquestioned narrative authority here. Stripped of myth, emotion and false hope, ‘death is simply an event in the sequence of nature’s ongoing rhythms.’ These rhythms are modulated by the processes of ageing and by the pathophysiology of particular diseases or injuries – heart disease, stroke, cancer, Aids, Alzheimer’s and traumas of various sorts – which Nuland describes in engrossing detail. In addition, we are taught how, at the molecular, cellular and gross anatomical and physiological levels, these diseases bring us low: that is, function as the ‘weapons of every horseman of death’, the universal processes we all experience as we are dying – stoppage of circulation, inadequate transport of oxygen to tissues, the failure of organs, the destruction of vital centres. Sometimes we are brought low by one, more often, as in old age, ‘by several of the seven horsemen’. (Bad as things are, there are not, despite Nuland’s insistence, seven horsemen: seven seals, seven candles and a seven-headed dragon – but only four horsemen of the Apocalypse.)

The fascination of this book lies not primarily in its biology lessons for the layman but in the stories it tells of the mysterious places where we die: the insides of our bodies. A layman might watch Lillian Hellman’s Little Foxes and see the death of Horace Giddens being made more miserable by his wife’s shrewishness. But Nuland tells us what he imagines going on behind Giddens’s breastbone: an enlarged, flabby heart no longer able to beat with anything resembling vigour; scars; an SA node struggling to maintain its declining authority; ischaemia. All this explains why the patient’s nostrils flare, why his gait is shuffling, why he is in pain, why his oxygen-starved heart muscle stops in an agonising cramp. Or, we learn how an Aids virus does its work, how sepsis comes to be the terminal event in a cancer patient’s life and why she is so thin, why Dr Livingstone being attacked by a lion probably felt no pain (endorphins). And in being made privy to the lives of those in whose bodies these universal forces do their work we are made privy, too, to the life and complex sensibilities of Dr Nuland.