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Authors: Sherwin B Nuland

BOOK: How We Die
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It is well known that very old people die of diseases they might easily have conquered had they been somewhat younger, but the extent to which this happens in the case of perfectly straightforward sickness is surprising: One of the people in our study died of a ruptured appendix, two of infections following gallbladder or bile-duct surgery, one from the complications of a perforated peptic ulcer, and another of diverticulitis. Every one of these diseases is an infection. Infection is exceeded only by atherosclerosis as the most frequent cause of death in people eighty-five or older. Two additional patients died of hemorrhage—one in a duodenal ulcer and one as the result of a fractured pelvis. Having been in the midst of a very active surgical practice during the period when these autopsies were done, I can attest to the probability that none of the seven individuals being treated in this university hospital would have succumbed had they been in their mid-fifties.
Only two of Walker Smith’s twenty-three patients escaped significant destruction of brain tissue. One of them proved, in fact, to be remarkably resistant in general to atherosclerosis, at least of the brain and heart. The degree of calcification in this eighty-nine-year-old man’s coronary arteries was only moderate and he had sustained “less cerebral atrophy than might be expected in a brain of this age,” to quote the autopsy report. But he had taken it in the kidneys, which were not only the site of a chronic infection (called pyelonephritis) that constantly seeded his urinary tract with intestinal bacteria but were also victimized by destruction of their tiny arterial branches and filtering units, as well as by marked scarring. Yet it was not his chronic kidney disease that did this fellow in—he succumbed to a malignancy called multiple myeloma, complicated by pneumonia. And so, like every other one of these twenty-three very old men and women, this fellow was carried off by several of the seven horsemen.
The other escapee from the ravages of cerebral senescence was an eighty-seven-year-old professor of Latin and former Yale dean. Seemingly spry and well (and without clinical evidence of heart disease), he was discovered at autopsy to have been actually within a hair of myocardial infarction, with the interesting coupling of “severe [atherosclerotic] involvement of the coronary arteries and minimal involvement of the cerebral vessels.” His coronaries, in fact, were described as “pipe-stem,” with one of them being completely occluded. The heart had undergone a brownish discoloration due to atrophy; the kidneys, too, looked their age. The professor had been awakened from sleep one cold December night by the sudden onset of severe abdominal pain. The diagnosis of perforated peptic ulcer was made in the emergency room and confirmed at autopsy four days later, after his tired immune system and barely nourished heart proved insufficient to protect him from the peritonitis that ensued. And so the professor’s relatively unscathed brain was of no avail to him when his life was challenged elsewhere.
The lesson taught by the twenty-three case histories is simply confirmation of the lesson that daily experience teaches. Whether it is the anarchy of disordered biochemistry or the direct result of its opposite—a carefully orchestrated genetic ride to death—we die of old age because we have been worn and torn and programmed to cave in. The very old do not succumb to disease—they implode their way into eternity.
Since there are so few pathways to an old man’s grave, and since there is such an intermingling of their basic paving stones, it is reasonable to wonder why the development of one of them brings with it such a high risk of harboring the others. Is it perhaps that all of these pathologies may share a common cause that becomes more active as we grow older? This consideration has, of course, been incorporated into the various theories of aging. One of the theories, for example, proposes that the process by which we develop and grow is part of a metabolic pattern controlled by an inner part of the brain called the hypothalamus, which can regulate hormone activity. This mechanism, beginning when life itself begins, allows the body to adapt to its external environment. The progression of these adaptations necessarily leads, as though following a schedule, to development, maturity, and then aging. If there is truth to this neuroendocrine thesis of aging, the occurrence of the diseases of the elderly is the price an organism pays for its lifelong ability to adapt to its surroundings and to changes occurring in its own tissues.
The entire process unfolds as though part of a master plan, a grand strategy that oversees an organism’s development from early embryonic stages to the instant of mortality, or at least to the anarchy that immediately precedes it. In this, the theorists of physiology are at one with the bereavement counselors who point out the value of the maxim that death is part of life.
Considerations of this sort echo, albeit in a more somber vein, a few sentences from a passage in the appendix of my volume of Thomas Browne. In a book entitled
Merchant and Friar
, the nineteenth century historian Sir A. Palgrave wrote: “Coeval with the first pulsation, when the fibres quiver, and the organs quicken into vitality, is the germ of death. Before our members are fashioned, is the narrow grave dug, in which they are to be entombed.” Dying begins with the first act of life.
These are possibilities that give rise to speculations of major significance in decision-making about our own lives. When an elderly man is offered the possibility of cancer palliation or even cure, providing that he is willing to endure debilitating chemotherapy or radical surgery, what should be his response? Will he suffer through the treatment, only to die of his ongoing cerebrovascular atherosclerosis the following year? After all, the cerebrovascular disease is likely the result of the same process that so decreased his immunity to malignant growth that he developed the cancer that is trying to kill him. But then again, different manifestations of the aging process proceed at different rates, so it may be somewhat longer than he anticipates before his stroke exerts its claim. Such possible eventualities can be estimated only by evaluating the present state of his nonmalignant process, such as the degree of his hypertension and the status of his heart disease. These are the kinds of considerations that should go into every clinical decision involving older people, and wise physicians have always made careful use of them. Wise patients should do the same.
Whether the result of wear, tear, and exhaustion of resources or whether genetically programmed, all life has a finite span and each species has its own particular longevity. For human beings, this would appear to be approximately 100 to 110 years. This means that even were it possible to prevent or cure every disease that carries people off before the ravages of senescence do, virtually no one would live beyond a century or a bit more. Although the psalmist sings that “The days of our years are three score and ten,” it seems not to be remembered that Isaiah was a better prophet, or at least a better observer, proclaiming to all who would but listen that “the child shall die an hundred years old.” He is here speaking of the New Jerusalem, where there will presumably be no infant mortality and no disease: “There shall be no more thence an infant of days, nor an old man that hath not filled his days.” Were we to heed Isaiah’s warning and eschew every bit of McCarty-like behavior, solve the problems of poverty, and love our neighbor, who knows how close we might come to making a prophet of the prophet? Medical science and improved living conditions have already brought us a long way. Western society has in less than a hundred years more than doubled a child’s life expectancy at birth. We have changed the face of death. In the modern demographic pattern, the great majority of us now reach at least the first decade of old age, and we are fated to die of one of its ravages.
Though biomedical science has vastly increased mankind’s
average
life expectancy, the
maximum
has not changed in veriflable recorded history. In developed countries, only one in ten thousand people lives beyond the age of one hundred. Whenever it has been possible to examine critically the claims of supposed record-breakers, they have not been substantiated. The highest age thus far solidly confirmed is 114. Interestingly, that figure comes from Japan, whose citizens live longer than those of any other country, with an average life expectancy of 82.5 years for women and 76.2 for men. The comparable figures for white Americans are 78.6 and 71.6, respectively. Even the home-cultured yogurt of the Caucasus cannot vanquish nature.
There is plenty of other evidence to support the thesis of a species-determined limit to life span. Among the most obvious clues is the great variability in the maximum attainable age between differing animal groups, existing coincident with the highly specific longevity of each individual species. Another suggestive biological observation is the average number of offspring of any animal form, which proves to be inversely related to the form’s maximum life span. An animal like man, needing not only a considerable gestation period but an inordinately long time before its young are biologically independent, requires a prolonged reproductive life span to ensure survival of the species, and that is exactly what we have been given. Humans are the longest-living mammals.
If the processes of aging are, within relatively narrow limits, resistant to any but certain well-known changes in personal habits, why do we persist in heretofore-vain attempts to live beyond the possible? Why cannot we reconcile ourselves to the immutable pattern of nature? Although recent decades have seen our concern with our bodies and their longevity reach a fever pitch unknown to previous generations, these kinds of hopeful seekings have always motivated at least some members of those societies that have left records of their existence. As early as the days of ancient Egypt, there is evidence of attempts by elders to prolong their lives—the Ebers Papyrus of more than 3,500 years ago contains a prescription for restoring an old man to youth.
Even as science was beginning to light the dawn of a new kind of medicine in the seventeenth century, Hermann Boerhaave, the leading physician of his time, recommended that an aging patient seek to regain his health by sleeping between two young virgins, recalling King David’s futile attempt to do the same kind of thing. History has taken us through the pastoral period of mother’s milk and the pseudoscience of monkey glands to rejuvenate flagging juices, and now we are in what might be called the vitamin era, both C and E. Never yet has anyone succeeded in borrowing any time. Most recently, a few researchers have been telling us that growth hormone may hold the promise of increasing lean body mass and bone density, and some among us insist that it will therefore also make people younger. We now hear early rumblings that so-called gene therapy is the answer, whereby cutting and splicing DNA will add decades or more to the maximum life span. In vain do the Sober scientists try to convince the clamorers that it just ain’t true, and it shouldn’t be. The lesson is never learned—there will always be those who persist in seeking the Fountain of Youth, or at least delaying what is irrevocably ordained.
There is a vanity in all of this, and it demeans us. At the very least, it brings us no honor. Far from being irreplaceable, we
should
be replaced. Fantasies of staying the hand of mortality are incompatible with the best interests of our species and the continuity of humankind’s progress. More directly, they are incompatible with the best interests of our very own children. Tennyson says it clearly: “Old men must die; or the world would grow moldy, would only breed the past again.”
It is through the eyes of youth that everything is constantly being seen anew and rediscovered with the advantage of knowing what has gone before; it is youth that is not mired in the old ways of approaching the challenges of this imperfect world. Each new generation yearns to prove itself—and, in proving itself, to accomplish great things for humanity. Among living creatures, to die and leave the stage is the way of nature—old age is the preparation for departure, the gradual easing out of life that makes its ending more palatable not only for the elderly but for those also to whom they leave the world in trust.
I am not arguing here against an old age that is active and rewarding. I do not advocate going gentle into that enveloping night which is premature senility. Until it becomes impossible, vigorous exercise of body and mind magnifies each living moment and prevents the separation that makes too many of us become older than we are. I speak only of the useless vanity that lies in attempts to fend off the certainties that are necessary ingredients of the human condition. Persistence can only break the hearts of those we love and of ourselves as well, not to mention the purse of society that should be spent for the care of others who have not yet lived their allotted time.
When it is accepted that there are clearly defined limits to life, then life will be seen to have a symmetry as well. There is a frame-work of living into which all pleasures and accomplishments fit—and pain, too. Those who would live beyond their nature-given span lose their framework, and with it lose a proper sense of relationship to those who are younger, gaining only the resentment of youth for encroaching on its careers and resources. The fact that there is a limited right time to do the rewarding things in our lives is what creates the urgency to do them. Otherwise, we might stagnate in procrastination. The very fact that at our backs, as the poet cautions his coy mistress, we “always hear / Time’s wingèd chariot hurrying near” enhances the world and makes the time priceless.
The originator of the literary form we call the essay, the sixteenth-century Frenchman Michel de Montaigne, was a social philosopher who viewed mankind through the scrutinizing lens of unadorned and unforgiving reality and heard its self-deceits with the ear of a skeptic. In his fifty-nine years, he gave much thought to death, and wrote of the necessity to accept each of its various forms as being equally natural: “Your death is a part of the order of the universe, ’tis a part of the life of the world . . . ’tis the condition of your creation.” And in the same essay, entitled “To Study Philosophy Is to Learn to Die,” he wrote, “Give place to others, as others have given place to you.”

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