How We Die_ Reflections On Life's Final Chapter Part 2

Even without teeth, Bubbeh somehow managed to eat most food. Toward the end, she lacked the strength even for that, and her nutrition suffered. The inadequate intake added to the usual decrease that aging causes in muscle ma.s.s, and it changed the configuration of her body, making her seem shriveled in comparison with the stalwart, slightly stoutish old lady I had once known. Her wrinkling increased, her complexion faded into a uniformity of mild pallor, the skin of her face seemed to hang ever more loosely, and the old-world beauty she had retained until her nineties was finally lost.

There are simple clinical explanations for the many things I saw during my grandmother's declining years, but somehow they seem unsatisfactory even now. It is all very well to speak of such causative factors as decreased circulation to the brain or senescent degeneration in cerebral cells so subtle that electron microscopy is needed to demonstrate it-there is a certain intellectual detachment to be found in the stark biological description of the death of that very tissue that once enabled a nonagenarian to think clear and sometimes audacious thoughts. The researches of physiologists might here be cited, as well as the work of endocrinologists, psychoneuroimmunologists, and the rapidly evolving modern breed of gerontologists, to explain everything that was unfolding before my adolescent eyes. But that actual seeing is what demands attention, the seeing of a process in the midst of which all of us constantly live. Surrounded by it though we may be, there is for each of us that something within that turns the face of consciousness away from the reality of our own concomitant aging. Something within us will not accept the immediacy of awareness that, even as we bear witness to it in the obviously old, our own bodies are simultaneously and subtly undergoing the same inexorable process that will lead eventually to senescence and death.

And so my grandmother's brain cells had long before this time begun to die, even as mine are dying today, and yours. But because she was much older than I am just now, and because she was withdrawing from the stimulation of the world around her, her decreased number of brain cells and their decreased responsiveness led to very obvious changes in her behavior. Like all old people, she became increasingly forgetful and was annoyed when reminded of it. Always known for the forthrightness of her dealings with people, she grew overtly irritable and impatient with those few outside our immediate family with whom she still came into contact, and she seemed to rouse herself by offending even those who had in years past looked to her for guidance. Then the time came when she began to sit silently even in company. Eventually, she spoke only when she absolutely had to, distantly and with little emotion.

What was most evident, but only in retrospect, I confess, was the slow drawing away from life. When I was a small boy, and even into my early teens, my grandmother prayed in the synagogue on the High Holy Days. As difficult as the five-block pilgrimage became, she would somehow manage it, negotiating cracked areas in the Bronx pavement with her worn prayer book held very snugly under one armpit lest she sin by letting it fall to the ground. I would take her there. How I regret every murmur of complaint, how I wish I was not sometimes-no, not sometimes, but often-ashamed of being seen with this black-kerchiefed, shuffling remnant of a shtetl culture that was all but gone even as she stubbornly refused to join it in the grave. Everyone else's grandparents seemed so much younger, they spoke English, and they were independent-mine was a reminder not only of the lost world of Eastern European Jewry but of my own turbulent conflict about the load of emotional detritus I nowadays euphemistically call my heritage.

With her free hand, Bubbeh would hold tightly onto my arm, sometimes gripping the cloth of my sleeve as I guided her with agonizing slowness through the streets, then down the stairs into the synagogue's vestry (our family prayed in the cheap seats, and could barely afford even those), and then to her chair amidst other ladies we called elderly, but very few of them nearly as foreign or as careworn as she. A few moments later, I would leave her there, her head already bowed over the old tearstained book she had prayed from since girlhood. Its words were printed in both Hebrew and Yiddish, but she prayed from the Yiddish side of the page because it was the only language she knew. Through the long ritual of those holiday services, she quietly murmured the words that became with each pa.s.sing year more laborious to read, and finally impossible. About five years before her death, Bubbeh could no longer make the long walk to the synagogue, even with both grandsons to help her. Relying largely on her still-intact long-term memory, she recited the liturgy at home, sitting by the open window as she had done every Sat.u.r.day morning during all the years I knew her. After a few years, even that became too much. She could barely see the sentences and her memory for the prayers learned in her youth was giving out. Finally, she stopped praying altogether.

By the time Bubbeh stopped praying, she had stopped virtually everything else as well. Her food intake had become minimal-she spent most of each day seated quietly at her window, and she spoke sometimes of death. And yet she had no disease. I'm sure some eager physician might have pointed out her chronic cardiac failure and added to it the probability that there was an element of atherosclerosis, and perhaps he would have prescribed some digitalis. To me, that would have been like dignifying the degeneration of her joints by calling it osteoarthritis. Of course it was arthritis, and of course she was in chronic failure, but only because her pinions and springs were giving way under the weight of the years. She had never been sick a day in her life.

The government statisticians and the scientific clinicians insist that proper names must be applied to sluggish circulation and an antique heart. I have no quarrel with that, so long as they do not also insist that a.s.signing a name to a natural biological state means a priori a priori that it is a disease. Like the nerve cell, the muscle cell of the heart is one of those that cannot reproduce-as it gets older, it simply wears out and dies. The biological processes that throughout life have been making replacement parts for dying structures within each cell can no longer do their job. The mechanism by which a newly generated piece of cell membrane or intracellular structure can take the place of a section dead of too much use finally becomes inoperative. After a lifetime of regenerating spare parts, the nerve and muscle cells' capacity of rejuvenation gradually shuts down. The tactic of continuous renewal within each heart-muscle cell is then defeated by the overwhelming strategy through which aging is achieving its ultimate objective of destruction. One after another, like my grandmother's teeth, the cardiac muscle cells cease to live-the heart loses strength. The same process takes place in the brain and the rest of the central nervous system. Even the immune system is not immune to aging. that it is a disease. Like the nerve cell, the muscle cell of the heart is one of those that cannot reproduce-as it gets older, it simply wears out and dies. The biological processes that throughout life have been making replacement parts for dying structures within each cell can no longer do their job. The mechanism by which a newly generated piece of cell membrane or intracellular structure can take the place of a section dead of too much use finally becomes inoperative. After a lifetime of regenerating spare parts, the nerve and muscle cells' capacity of rejuvenation gradually shuts down. The tactic of continuous renewal within each heart-muscle cell is then defeated by the overwhelming strategy through which aging is achieving its ultimate objective of destruction. One after another, like my grandmother's teeth, the cardiac muscle cells cease to live-the heart loses strength. The same process takes place in the brain and the rest of the central nervous system. Even the immune system is not immune to aging.

Changes that are at first only biochemical and intracellular become manifest in the function of entire organs. There is a gradual decrease in the cardiac output while at rest, and when the heart is stressed by exercise or emotion, its ability to increase is less than required by the needs of arms, lungs, and every other structure of the body. The maximal rate attainable by a perfectly healthy heart falls by one beat every year, a figure' so reliable that it can be determined by subtracting age from 220. If you are fifty years old, it is unlikely that your heart can manage much more than 170 beats per minute, even under the most extreme conditions of emotion or exercise. These are only some of the ways in which the aging and stiffening myocardium loses its ability to adapt to the challenges presented to it by everyday life.

The rapidity of circulation slows down. The left ventricle takes longer to fill and longer to relax after a contraction; each heartbeat pushes out less blood than it did a year earlier, and even a smaller fraction of its content. Perhaps in an attempt to compensate, the blood pressure tends to rise somewhat. Between the ages of sixty and eighty, it increases by 20 millimeters of mercury. One-third of people over the age of sixty-five have hypertension.

Not only the muscle of the heart but also its conduction system dies out as the decades pa.s.s. By the age of seventy-five, the sinoatrial node may have lost as much as 90 percent of its cells; the bundle of His contains fewer than half of its original fibers. There are related electrocardiographic changes that go along with all of this loss of muscle and nerve tissue, and they can easily be identified on the inked tracing.

As the pump ages, its inner lining and valves thicken. Calcifications appear in the valves and muscle; the color of the myocardium changes somewhat as a yellow-brown pigment called lipofuscin is deposited in its tissues. Like the face of a weather-beaten old man, a heart looks its age. It acts its age as well. There is no need to invoke a disease to explain its failure. Cardiac failure is ten times as common in people older than seventy-five than in those between forty-five and sixty-five years of age. That is precisely the reason I could so easily indent the tissues of my grandmother's skin, and it was unquestionably the source of her easy shortness of breath. It is probably also the reason that the most common symptom of a heart attack in elderly patients is severe failure, rather than the cla.s.sic picture of unremitting chest pain.

Not only the heart itself but the blood vessels, too, are affected by the pa.s.sing years. The walls of the arteries thicken. Like the person in whom they dwell, they lose their elasticity; they can no longer constrict and dilate with the enthusiasm of youth, and so it is more difficult for the body's regulatory mechanisms to control the amount of blood going to muscles and organs to satisfy their ever-changing needs. Moreover, atherosclerosis continues on its inexorable way with each pa.s.sing year. Even without the cholesterol-rich obesity or the cigarettes or diabetes that make it appear at a younger stage, the arterial walls gradually narrow as more and more atheroma acc.u.mulates with the prolonged contact of decade upon decade of coursing blood.

Before long, every organ is getting less nourishment than it needs to do the job intended for it by nature. Total blood flow to the kidney, for example, decreases by 10 percent for every decade after the age of forty. Actually, only some of that organ's decline is caused by the lessened cardiac output and narrowed vessels, but those factors worsen the effect of certain aging changes within the kidney itself. For example, between the ages of forty and eighty, the normal kidney loses some 20 percent of its weight and develops areas of scarring within its substance. Thickening of the tiny blood vessels that are inside the kidney further decreases blood flow and results in destruction of the organ's filtering units, which are, of course, the crux of its ability to clear the urine of impurities. In time, some 50 percent of the filtering units will die.

The changes in its structure decrease the kidney's effectiveness. With increasing age, it loses its ability not only to get rid of excess sodium but even to retain it in the body when needed. The result is an instability of the aged person's salt and water volume, tending to increase the possibility of either heart failure on the one hand or dehydration on the other. This is one of the main reasons that cardiologists treating the elderly have so much difficulty treading the narrow frontier between the Scylla of sodium overload and failure and the Charybdis of parched old tissues.

The result of all of these inadequacies is an increased propensity of the kidney to default in its responsibilities. Even when it does not fail outright but merely falters, it recovers more slowly than a younger organ, and is more p.r.o.ne to let its host down altogether under severe stress-death from kidney failure is a common pathway of exit when an aged person is weakened by some other pathology, such as late-stage cancer or liver disease. The blood's impurities build up; the other organs, particularly the brain, are poisoned; and death from so-called uremia is inevitable, often preceded by a variable period of coma. The terminal event in uremic patients is most commonly an irregularity of cardiac rhythm (an arrhythmia) caused by the kidney's inability to rid the blood of excess pota.s.sium. Victims of kidney failure usually slide into it imperceptibly, then are suddenly dead in a flash of cardiac instability. Only rarely are there any last words or deathbed reconciliations.

Although the kidney is the most significant part of the urinary tract to develop changes with age, the bladder, too, is affected. The bladder is essentially a thick balloon whose wall is made of flexible muscle. As it ages, the balloon loses its distensibility and can no longer hold as much urine as before. Old people need to urinate more frequently, and this is the reason my grandmother got up once or twice each night to grapple in the dark with her coffee can.

Aging also affects the finely tuned coordination between the bladder muscle and the shutter mechanism whose function is to keep urine from leaking out. The result is the occasional incontinence of the aged, which in some people becomes a major problem, especially if complicated by infection, prostate trouble, mental confusion, or medication. Disturbances of the bladder's emptying capacity are often a major factor in producing urinary-tract infections, a dangerous enemy of the debilitated elderly.

Like the muscle of the heart, brain cells are unable to reproduce. They survive decade after decade because their various structural components are always being replaced as they wear out, like so many ultramicroscopic carburetors and plugs. Though cell biologists use more abstruse terminology than do mechanics (words like organelle organelle and and enzyme enzyme and and mitochondrium mitochondrium), these ent.i.ties nonetheless require just as efficient a replacement mechanism as do their more familiar automotive a.n.a.logues. Like the body itself and like each of its organs, every cell has the equivalents of pinions and wheels and springs. When the mechanism to exchange the aging parts for new wears out, the nerve or muscle cell can no longer survive the constant destruction of components that goes on within it.

That parts-replacement mechanism requires the partic.i.p.ation of certain molecular structures within the cell. But the molecules in biological systems have a finite life span. Beyond that prescribed period, their constant collisions against one another change their character enough so that they can no longer generate new spare parts. By the process of wear and tear, they reach the limits of their longevity, thus limiting the longevity of the brain cell they serve. This is the biochemical process that scientists call cellular aging. The cell gradually dies and its fellows do the same. When enough of them are gone, the brain begins to show its age.

For every decade after age fifty, the brain loses 2 percent of its weight. When my Bubbeh died at ninety-seven, her brain weighed some 10 percent less than it did when she arrived in this country. The gyri, those twisting, raised convolutions in the cortex within which we do so much of the receiving and thinking that makes us different from the rest of G.o.d's creatures, suffer the greatest atrophy and loss of prominence. Concomitantly, the valleys between them (the sulci) become larger, as do the fluid-filled chambers deep in the brain's substance, known, like those in the heart, as ventricles. As though it were a biological marker of advancing senescence, lipofuscin stains the cells of white and gray matter alike, imparting to the shrinking brain a creamy yellow tinge that deepens with advancing age. Even senescence is color-coded.

As obvious as are the grossly visible changes in the withering brain, it is in microscopic appearance that aging is most evident. Particularly striking is the decrease in the number of nerve cells, or neurons, that results from the lethal spare-parts failure just described. The events that take place in the cortex are representative of the whole. The motor area of the frontal cortex loses between 20 and 50 percent of its neurons; the visual area in the back loses about 50 percent; the physical sensory part on the sides also loses about 50 percent. Fortunately, the higher intellectual areas of the cerebral cortex have a significantly lower degree of cell disappearance, much of which seems to be compensated for by overlap and redundancy of function. It may even be that the fewer neurons increase their activity, but whatever the reason, such intellectual capacities as reasoning and judgment are quite often unimpaired until late senescence.

Interestingly, recent research suggests that certain cortical neurons seem actually to become more abundant after maturity has been reached, and these cells reside in precisely the areas in which the processes of higher thought take place. When these findings are added to the confirmed observation that the filamentous branchings (called dendrites) of many neurons continue to grow in healthy old people who don't have Alzheimer's disease, the possibilities become quite intriguing: Neuroscientists may actually have discovered the source of the wisdom which we like to think we can acc.u.mulate with advancing age.

Except in highly localized areas, therefore, the cortex not only loses neurons but almost all of those it does retain exhibit signs of aging, as replacement of intracellular parts becomes gradually less efficient. The end result is that the brain is smaller than it was in youth, and doesn't work as well. In everyday life, this is manifest in all of that mult.i.tude of slowings that we see daily in our elderly a.s.sociates, and too soon in ourselves. The brain is thus sluggish in its function and sluggish as well in its ability to spring back from biological insult-it recovers less efficiently from events that threaten its survival.

One of the most dangerous of those events is an interference with blood supply. When blood flow to some specific region of the brain is cut off (a catastrophe that usually happens suddenly), there is immediate dysfunction or death of the nerve tissue supplied by the obstructed artery. This is precisely what is meant by the term stroke stroke. Strokes may occur for any of a number of reasons, but the most common among the elderly is atherosclerosis blocking branches of the two large vessels that nourish the brain, the right and left internal carotid arteries. Approximately 20 percent of hospitalized stroke victims die soon after the episode and another 30 percent require long-term or inst.i.tutional care until death.

Though the death certificates of stroke victims have often been adorned with such terms as cerebrovascular accident cerebrovascular accident or or cerebral thrombosis cerebral thrombosis (these days, the proper word is the simpler and all-encompa.s.sing (these days, the proper word is the simpler and all-encompa.s.sing stroke stroke), more significant than the nomenclature on the legal paper is the number written into the blank s.p.a.ce for Age Age: It is almost always high. Men and women beyond the age of seventy-five suffer ten times the incidence of strokes as do those between fifty-five and fifty-nine.

"Cerebrovascular accident," in fact, was what was written on my grandmother's death certificate. But I know better, and I knew better even then. Although the doctor explained what his scribbled words meant, his diagnosis made little sense to me, and it makes even less sense today. Had he wanted to call my Bubbeh's CVA the "terminal event" or some similar construct, I would have understood what was meant, but to tell me that the process I had been watching for eighteen years had ended in a named acute disease-well, it was illogical.

This is not simply a problem of semantics. The difference between CVA as a terminal event and CVA as a cause of death is the difference between a worldview that recognizes the inexorable tide of natural history and a worldview that believes it is within the province of science to wrestle against those forces that stabilize our environment and our very civilization. I am no Luddite-I glory in the magnificent benisons of modern scientific achievement. I ask only that we use our increasing knowledge with increasing wisdom. In the seventeenth and eighteenth centuries, the first of the early exponents of the experimental method, and therefore of science, spoke often of what they called the animal economy, and of the economy of nature in general. If I understand them correctly, they were speaking of that kind of natural law which exists to preserve the earth's environment and its living forms. That natural law, it seems to me, evolved by straightforward Darwinian principles of planetary survival, very much as did every species of plant or beast. For this to continue, mankind cannot afford to destroy the balance-the economy, if you will-by tinkering with one of its most essential elements, which is the constant renewal within individual species and the invigoration that accompanies it. For plants and animals, renewal requires that death precede it so that the weary may be replaced by the vigorous. This is what is meant by the cycles of nature. There is nothing pathological or sick about the sequence-in fact, it is the ant.i.thesis of sick. To call a natural process by the name of a disease is the first step in the attempt to cure it and thereby thwart it. To thwart it is the first step toward thwarting the continuation of exactly that which we try to preserve, which is, after all, the order and system of our universe.

And so, Bubbeh had to die, as you and I will one day have to die. Just as I had witnessed the decline of my grandmother's life force, I was present when it gave the first signal of its finality. It was early on an ordinary morning; Bubbeh and I were doing ordinary things. Having finished breakfast a few minutes before, I was still hunched over the sports section of the Daily News Daily News when I became aware that there was something very strange in the way Bubbeh was trying to wipe clean the surface of the kitchen table. Even though we had long since realized that such household tasks were beyond her, she had never quite given up trying, and seemed oblivious to the fact that one or another of us always repeated the work after she laboriously shuffled out of the room. But when I looked up from the tabloid, I saw that her wide circular strokes were even more ineffectual than usual. Her sweeping hand had become aimless, as though acting on its own with no plan or direction. The circles ceased to be circles and soon became mere languid, useless drags of the moist cloth that was barely held in her flaccid hand, adrift on the table without purpose or weight. Her face was turned straight ahead. She seemed to be looking at something outside the window behind my chair instead of at the table in front of her. Her unseeing eyes had the dullness of oblivion; her face was expressionless. Even the most impa.s.sive of faces betrays something, but I knew at that instant of absolute blankness that I had lost my grandmother. I shouted, "Bubbeh, Bubbeh!," but it made no difference. She was beyond hearing me. The cloth slipped from her hand and she crumpled soundlessly to the floor. when I became aware that there was something very strange in the way Bubbeh was trying to wipe clean the surface of the kitchen table. Even though we had long since realized that such household tasks were beyond her, she had never quite given up trying, and seemed oblivious to the fact that one or another of us always repeated the work after she laboriously shuffled out of the room. But when I looked up from the tabloid, I saw that her wide circular strokes were even more ineffectual than usual. Her sweeping hand had become aimless, as though acting on its own with no plan or direction. The circles ceased to be circles and soon became mere languid, useless drags of the moist cloth that was barely held in her flaccid hand, adrift on the table without purpose or weight. Her face was turned straight ahead. She seemed to be looking at something outside the window behind my chair instead of at the table in front of her. Her unseeing eyes had the dullness of oblivion; her face was expressionless. Even the most impa.s.sive of faces betrays something, but I knew at that instant of absolute blankness that I had lost my grandmother. I shouted, "Bubbeh, Bubbeh!," but it made no difference. She was beyond hearing me. The cloth slipped from her hand and she crumpled soundlessly to the floor.

I bounded to her side and called her name again, but my shouting was as futile as my attempts to comprehend what was happening. Somehow, and I remember not a moment of it, I gathered her up and staggered to the room we shared. I laid her down in my bed. Her breathing was stertorous and loud. It blew in long, forceful blasts from only one corner of her mouth, and it flapped her cheek out like a buffeted wet sail each time she exhaled from that noisy bellows somewhere down deep in her throat. I can't recall which side it was, but one entire half of her face seemed toneless and flaccid. I rushed to the phone and called a doctor whose office was not far away. Then I contacted my aunt Rose at the Seventh Avenue dress factory where she worked. Rose got there before the doctor could free himself from a waiting room filled with early-morning patients, but we knew there was nothing he could do anyway. When he arrived, he told us that Bubbeh had suffered a stroke, and wouldn't live more than a few days.

She outsmarted the doctor, and hung on. We hung on with her, refusing to let go-it never occurred to anyone to do otherwise. Bubbeh remained in my bed, Aunt Rose occupied the double bed she had shared with her mother, and Harvey brought in his folding cot for me from the room in which he and my father slept. This left him adrift and he spent the next fourteen nights on the living room sofa.

Within forty-eight hours, we began to witness the most disheartening of the many cruelties by which life begins to desert its oldest friends-Bubbeh's worn-out immune system and her rusty old lungs were unable to withstand the blitzkrieg of microbes that now hurled itself against her. The immune system is the invisible force that allows us to respond to the a.s.saults of potentially lethal enemies who are themselves invisible to the naked eye. Without our knowledge or conscious partic.i.p.ation, the silent cells and molecules of immunity are ever adapting to the changing circ.u.mstances of daily life and its unseen terrors. Nature, our strongest s.h.i.+eld and perforce our strongest enemy, has cloaked us and soaked us in them so that we may survive those constant encounters with the environment she has created (and is attempting to preserve), at the same time challenging each living thing to overcome the lurking perils of her constant testing. When we get older, the cloak becomes threadbare and the soak dries up-our immune system, like everything else, increasingly fails us.

The decline of the immune system has been a major focus of research by gerontologists. They have demonstrated defects not only in the elderly body's response to attack but even in the mechanisms of surveillance by which it recognizes its attackers. The enemy finds it easier to penetrate the perimeter by eluding immunity's aged watchmen; once inside, they overwhelm the weakened defenders. In my Bubbeh's case, the result was pneumonia.

William Osler was of two minds about pneumonia in the elderly. In the first of fourteen editions of The Principles and Practice of Medicine The Principles and Practice of Medicine, he called it "the special enemy of old age," but elsewhere he stated something quite different: "Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old escape those 'cold gradations of decay' that make the last stage of all so distressing."

I have no recollection of whether the doctor ordered penicillin to combat "the friend of the aged," but I doubt it. Selfishly perhaps, I didn't want Bubbeh to die, and neither did anyone else in our family. The doctor would have been much more realistic and a good deal wiser than we who refused to let go.

Bubbeh's immobile comatose state and the loss of her cough reflex prevented her from clearing the viscous mucilage of secretion that rattled in her windpipe with every breath. Harvey went off to the corner drugstore and discovered there a device that could be used to aspirate the increasingly purulent products that were rising from Bubbeh's lungs in a gurgly announcement of impending death. The instrument, made of two lengths of rubber tubing separated by a gla.s.s chamber, allowed him to suck out the phlegm each time it reacc.u.mulated. It required him to put one rubber end of the device into Bubbeh's windpipe and the other into his own mouth. Even Aunt Rose couldn't bear to do it, and I could manage it only now and then, so it became Harvey's gift to his Bubbeh, or at least we thought of it as a gift.

By this means, and undoubtedly because of a change of heart by the Angel of Death himself (a figure of fancy to me, but a very serious reality to Old World believers), Bubbeh survived the pneumonia, and she even survived the stroke. Perhaps our tears and our prayers were more important than Harvey's mouth-operated suction device and the residual shreds of strength in that wheezing immune system of hers. Whatever it was, she slowly came out of her coma, regained a great deal of her speech and a small degree of mobility, and lived much as before for a few additional months, more for us than for herself. Finally, the days of her life ran out, and she succ.u.mbed to a second stroke in the early-morning hours of a chilly February Friday. In accordance with Jewish law, her body was in the ground by late afternoon of that day.

I have what some call a photographic memory. Although it sometimes deserts me when I am most in need of its collected transcripts, it has been for the most part a dependable ally in the record-keeping of my life. But there are some in my vast store of images I would rather lose. One of them is of an eighteen-year-old boy standing alone by the plain pine coffin of an ancient lady he can hardly recognize, even though he had tearfully kissed her unresponsive cheek scarcely twelve hours earlier. The object in the coffin looks so different from the Bubbeh it is said to be. It is contracted, and as white as candle wax. This corpse has shrunken away from life.

Nowadays, doctors are trained to think only about life and the diseases that threaten it. Even the autopsy pathologists who dissect corpses are looking for clues to cure, which are ultimately for the benefit of the living; in essence, what they do is to turn back the clock a few hours or a few days to a time when the heart still beat, in order to reconstruct the crime that stole their patient's life away. Those among us who think most clearly about death are usually such as philosophers or poets, not physicians. Nevertheless, there have been a few doctors who understood that death and its aftermath are not beyond the limits of the human condition and are, therefore, worthy of a healer's attention.

Such a one was Thomas Browne, who lived in that extraordinary seventeenth century when the scientific method and inductive reasoning first began to affect the thinking of educated people and made them question the truths so dear to their fathers. In 1643, Browne published a small literary jewel of contemplation, Religio Medici Religio Medici, "The Religion of a Doctor," which he described as "a private exercise directed to myself." That little masterpiece is usually published together with a compilation on the lingering agonies of a dying man, ent.i.tled "A Letter to a Friend," in which the author writes: "He came to be almost half himself and left a great part behind him which he carried not to the grave." How often have I stood with families at a deathbed and witnessed their disbelief at this process unfolding its too-often-agonizing panorama before them. They question why it is different from their expectation and why seemingly they alone should have to endure what they conceive to be a uniqueness of suffering. It was that uniqueness I thought I had been forced to live through with Bubbeh's death and then later with the image of that alien corpse.

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. When Charles Lamb beheld the corpse of the popular English comedian R. W. Elliston, he was moved to write, "Bless me, how little little you look. So shall we all look-kings, and kaisers-stripped for the last voyage." Browne himself wrote, "I am not so much afraid of death, as ashamed thereof; 'tis the very disgrace and ignominy of our natures, that in a moment can so disfigure us, that our nearest friends, wife, and children, stand afraid and start at us." you look. So shall we all look-kings, and kaisers-stripped for the last voyage." Browne himself wrote, "I am not so much afraid of death, as ashamed thereof; 'tis the very disgrace and ignominy of our natures, that in a moment can so disfigure us, that our nearest friends, wife, and children, stand afraid and start at us."

Thomas Browne's words, or Lamb's, might have rea.s.sured 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.

Reviewing those years just ended, I might also have recognized the commonality of death's experience in a sentence to be found a few pages earlier in Browne's book: "With what strife and pains we come into the world we know not, but 'tis commonly no easy matter to get out of it."

IV.

Doors to Death of the Aged

MY GRANDMOTHER HAD chosen a way "to get out of it," to use Thomas Browne's expression, that is hardly unique. Stroke is the third most common cause of death in the developed countries of the world, as listed by the World Health Organization. More than one hundred and fifty thousand Americans die of it each year, representing approximately one-third of all those who suffer a stroke. Another third will be left with permanent severe disability. Only cardiac disease and cancer exceed its marauding power. Following a long period during which its incidence declined, a plateau has been reached in recent years: approximately 0.51.0 stroke per 1,000 population each year. But that figure represents the entire spectrum of our citizenry. As people age, their propensity to stroke naturally increases. There are no probability estimates for sedentary Jewish ladies who have kept themselves on a high-cholesterol kosher diet for almost a century, but we do know that of a random group of one thousand American or Western European men and women over the age of seventy-five, between twenty and thirty will suffer a stroke each year-among our eldest elders, the risk is some thirty times as great as it is for the rest of us. chosen a way "to get out of it," to use Thomas Browne's expression, that is hardly unique. Stroke is the third most common cause of death in the developed countries of the world, as listed by the World Health Organization. More than one hundred and fifty thousand Americans die of it each year, representing approximately one-third of all those who suffer a stroke. Another third will be left with permanent severe disability. Only cardiac disease and cancer exceed its marauding power. Following a long period during which its incidence declined, a plateau has been reached in recent years: approximately 0.51.0 stroke per 1,000 population each year. But that figure represents the entire spectrum of our citizenry. As people age, their propensity to stroke naturally increases. There are no probability estimates for sedentary Jewish ladies who have kept themselves on a high-cholesterol kosher diet for almost a century, but we do know that of a random group of one thousand American or Western European men and women over the age of seventy-five, between twenty and thirty will suffer a stroke each year-among our eldest elders, the risk is some thirty times as great as it is for the rest of us.

Stroke is such a ubiquitous term that there is sometimes a little fuzziness about the way it is used. To a physician, a stroke is a deficit in neurologic function resulting from a decrease in blood flow through some specific artery supplying the brain. Further, the deficit must last longer than twenty-four hours for the episode to be called a stroke. Anything else is cla.s.sified as a transient ischemic attack, or TIA. Although TIAs usually clear up within an hour, a few do last somewhat longer before their symptoms disappear. is such a ubiquitous term that there is sometimes a little fuzziness about the way it is used. To a physician, a stroke is a deficit in neurologic function resulting from a decrease in blood flow through some specific artery supplying the brain. Further, the deficit must last longer than twenty-four hours for the episode to be called a stroke. Anything else is cla.s.sified as a transient ischemic attack, or TIA. Although TIAs usually clear up within an hour, a few do last somewhat longer before their symptoms disappear.

If all of this has a familiar ring, there is good reason. It is basically the same mechanism by which the heart's deficit is produced when one of its arteries fails to deliver the required volume of blood. It is that universal mechanism of ischemia, the quenching of blood flow and the parching of tissues, that is so common a denominator in the killing off of cells in so many parts of the body. It carried off James McCarty, it carried off my Bubbeh, and, in one form or another, it will carry off most of us now living. It does its work by suffocating the tissues of its victim. The blood flow stops for much the same reason it does in the coronary arteries of the heart. The buildup of atheroma has reached the critical point at which a branch of one of the internal carotid arteries becomes completely occluded. The occlusion may be due to a completion of the atherosclerotic process in that branch itself, or it may occur because a bit of plaque has separated from the wall of a larger artery and been propelled as an embolus up into the brain, plugging an already-compromised vessel.

Or the stroke and its attendant ischemia may be caused by quite another manifestation of this vast syndrome of cerebrovascular disease, namely a hemorrhage into the substance of the brain, which in the elderly is almost always due to long-standing hypertension. Its wall already weakened by the long years of abnormally high pressure against it, the fragile atherosclerotic vessel finally gives way at some specific point, resulting in an outrush of blood into the surrounding brain tissue. Such an intra-cerebral bleed carries a mortality rate of twice the 20 percent that is usually estimated for occlusive strokes. Hemorrhage accounts for approximately 25 percent of strokes, and vascular occlusion for the rest.

It takes a great deal of energy to keep the brain's engine functioning efficiently. Almost all of that energy is derived by the tissue's ability to break down glucose into its component parts of carbon dioxide and water, a biochemical process that requires a high level of oxygen. The brain does not have the capacity to keep any glucose in reserve; it depends on a constant immediate supply being brought to it by the coursing arterial blood. Obviously, the same is true of the oxygen. It takes only a few minutes for the ischemic brain to run out of both before it suffocates. Neurons are extremely sensitive to ischemia; irreversible destructive changes begin within fifteen to thirty minutes of the onset of the deprivation. After no more than an hour of the beginning of ischemia, infarction of significant segments of brain tissue becomes inevitable.

The symptoms caused by the cell destruction vary, depending upon which vessel is occluded. Although at least half a dozen branches of the internal carotid are particularly susceptible to obstruction, most frequently involved in ischemic stroke is one of the paired middle cerebral arteries. The middle cerebral (MCA) supplies blood to most of the lateral surface of the cerebral hemisphere and some of the centers that lie deep beneath the cortex. The MCA feeds the major sensory and motor areas of the cortex-areas that are involved in hand and eye movement, and also the specialized sensory tissue for hearing. It nourishes the region involved in what are called the "higher mental functions," such as perception, organized thought, voluntary movement, and the integrated coordination of all these abilities. On the dominant side of the brain (the right side for lefties and the left for the other 85 percent of us), the MCA supplies the sensory and motor areas for language. This particular bit of geographic distribution explains why so many stroke victims lose their powers to express and comprehend spoken and written language.

Many MCA strokes are caused not by actual occlusion at the site but by bits of material broken off from the crusted atheroma in the main internal carotid artery, or from the heart itself in the form of small bits of old organized clot. The released particle then becomes an embolus. Here we encounter another of those terms contributed by Rudolf Virchow, from the Greek embolos embolos, signifying a wedge or plug, which in turn is derived from two words meaning "to cast or throw in." Literally, then, a plug has been thrown into the artery and will be propelled by the bloodstream until it wedges itself into a narrowed portion of the vessel, which it will completely block off. In the more common cases where the plugging is not caused by an embolus, it results from the final completion of atheroma buildup. In either situation, the tissue supplied by the vessel instantly loses its source of oxygen and glucose, and within a few minutes becomes wounded enough to cause symptoms. If the blockage is not relieved rapidly, the area of brain dies by infarction.

If one were to name the universal factor in all death, whether cellular or planetary, it would certainly be loss of oxygen. Dr. Milton Helpern, who was for twenty years the Chief Medical Examiner of New York City, is said to have stated it quite clearly in a single sentence: "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." Simplistic though it may sound to a sophisticated biochemist, this p.r.o.nouncement is all-encompa.s.sing.

Many strokes are so small that there are few or no immediate significant symptoms to indicate what has taken place. But with time, such little strokes acc.u.mulate, and the evidence of gradual deterioration becomes clear to even the most casual observer. Walter Alvarez, the great Chicago clinician of a generation ago, once quoted "a wise old lady" who said to him, "Death keeps taking little bits of me." As his clinical description so clearly states: She saw that with each attack of dizziness or fainting or confusion she became a little older, a little weaker, and a little more tired; her step became more hesitant, her memory less trustworthy, her handwriting less legible, and her interest in life less keen. She knew that for 10 years or more, she had been moving step by step towards the grave.

Of those so betrayed by their cerebral circulation, William Osler is reported to have said, "These people take as long to die as they did to grow up."

Almost 10 percent of elderly people diagnosed with dementia owe their situation to a series of such small strokes, a concept popularized by Alvarez in 1946, after observing it in his own father. Now called multi-infarct dementia, the process is characterized by an irregular series of abrupt little worsenings. Interestingly, this form of cerebral arteriosclerosis was first described by Alois Alzheimer in 1899, eight years before he introduced the quite different type of intellectual decline that we now call by his name.

The subtle process of infarcting brain may go on and on, acc.u.mulating irregular stepwise degenerations in cerebral function for as long as a decade or more, until a major stroke or some other lethal process intervenes to bring abrupt fulfillment of the slow progression's ultimate purpose.

Major infarction by MCA stroke results in sensory loss and weakness that are most prominent in the part of the face and in the extremities opposite to the side of the brain where the stroke has occurred; such infarction causes as well a condition called aphasia-the loss of power of expression-although comprehension tends to remain reasonably well preserved. Occlusion of other vessels produces a whole range of symptoms, determined not only by the area served by the vessel but also by the amount of nutrition brought in by a collateral blood supply that may be available from nearby unscathed vessels. Language and visual disturbances, paralysis, sensory losses, difficulties in balance-all of these are the more common manifestations of stroke.

Large strokes often result in coma. If the stroke is extensive enough or if further complications ensue, such as decreased blood pressure or cardiac output due to failure or arrhythmia, recovery is prevented and the area of ischemia may actually increase. If it becomes large enough, the brain tissue begins to swell. Being compressed in the unyielding confines of the skull, a swollen brain is further damaged by being pushed up against its covering membranes and bony encas.e.m.e.nt, and part of it may actually be forced down through a fold in those membranes that separates the "higher" brain from the "lower," or brain stem-the part that thinks from the part that is involved with more automatic mechanisms such as cardiac and respiratory control, digestive and bladder function, and a group of others. When this happens, the pressure causes so much damage to the brain stem's centers controlling the heart and breathing that death follows soon thereafter, from either arrhythmia or cardiac and respiratory failure.

Collapse of vital function is only part of the array of possible mechanisms by which strokes kill approximately 20 percent of their victims, or even more when the cause is hypertensive hemorrhage. If brain damage is ma.s.sive enough, all kinds of normal controls go awry. Preexisting diabetes sometimes goes so much out of control that blood acidity rises enough to be incompatible with life; the functioning of the lungs is sometimes impaired by paralysis of the muscles of the chest wall; the blood pressure may become elevated to dangerous levels-these are among the most common lethal complications of major strokes.

And then there is my Bubbeh's way-pneumonia. More than any other organ system excepting skin, the lungs of elderly people are subjected to every insult our polluted environment is capable of inflicting. Whether elasticity is lost for that reason or simply by the ordinary process of aging, the pa.s.sage of time results in a decreased ability to inflate or deflate completely. Mechanisms for clearing mucus are weakened, and the already-narrowed airways are more p.r.o.ne to become filled with debris-laden material. The situation is worsened by an inability to maintain proper humidity and temperature in the finer bronchial branches. These strictly physical debilities are complicated by a depressed production of local antibodies as part of the old person's generally lessened immune response.

The microbes of pneumonia lie in wait for the appearance of any added insult that might inhibit further the already-damaged defenses of the aged. Coma is their perfect ally. It takes away every conscious way of resisting their predations, and even destroys so basic a safety device as the cough reflex. Any bit of regurgitation or foreign matter that under ordinary circ.u.mstances would be forcefully ejected at the first sign of its invasion of the airway now becomes the vehicle on which the germs ride triumphantly into the respiratory tissues. The microscopic air sacs called alveoli then swell and are destroyed by inflammation. As a result, proper exchange of gases is prevented, and blood oxygen diminishes while carbon dioxide may build up until vital functions can no longer be sustained. When oxygen levels drop below a critical point, the brain manifests it by further cell death, and the heart by fibrillation or arrest. Pneumonia triumphs.

Pneumonia's blitzkrieg has yet another way to kill-its putrid headquarters in the lung serves as a focus from which the murderous organisms can enter the bloodstream and be dispersed into every organ of the body. Called sepsis or septicemia by doctors and blood poisoning by the rest of the world, this process sets off a series of physiologic events that results in collapse of the integrity of heart, lungs, blood vessels, kidneys and liver, with an ultimate drastic drop in blood pressure to shock levels, followed by death. In sepsis, even the most powerful antibiotics are often no match for the microbes' overwhelming a.s.sault.

Whether the terminal event is pneumonia, heart failure, or the acidosis of uncontrollable diabetes, the salient fact about stroke is that it is always to be found in the company of its friends-the ubiquitous corps of killers of the old. A stroke is simply one part of the wide spectrum of end-stage cerebrovascular disease, which, while it may be hastened by self-abuse, can never be stopped in its determined course. Henry Gardiner, who compiled my 1845 edition of Thomas Browne's writings, has bound into its appendix a long quotation from Francis Quarles, a seventeenth-century literary figure, who properly said: "It lies in the power of man, either permissively to hasten, or actively to shorten, but not to lengthen or extend the limits of his natural life." And then in a sublime bit of wisdom, Quarles added, "He only (if any) hath the art to lengthen out his taper, that puts it to the best advantage." There is no way to deter old age from its grim duty, but a life of accomplishment makes up in quality for what it cannot add in quant.i.ty.

Many doctors, especially those who spend much of their time in laboratories, share with statisticians the disbelief in the necessity of death from old age. Reading my account of my Bubbeh's last days, they will by now undoubtedly have pointed out that pneumonia and other infections become, after all, the second most common identifiable cause of death once people reach the very great age of eighty-five, and atherosclerosis is the first. My grandmother had both, and therefore, they may claim, her mode of death supports their worldview and argues for vigorous intervention to treat the named pathologies in order to prolong life. To me, this is more sophistry than science.

I grant these doctors their perspective, but there is plenty of evidence that life does have its natural, inherent limits. When those limits are reached, the taper of life, even in the absence of any specific disease or accident, simply sputters out.

Fortunately, most bedside doctors who restrict their practice to the care of the aged have come to understand this. The geriatricians are to be applauded for the great contributions they have already made to elucidating the pathologies afflicting those who are slowly being overwhelmed by the defects in their waning senescent powers, but even more so do they deserve our admiration for the compa.s.sion they bring to their work. I recently discussed this with my school's professor of geriatric medicine, Dr. Leo c.o.o.ney, who later summarized his viewpoint in two pithy paragraphs of a letter: Most geriatricians are at the forefront of those who believe in withholding vigorous interventions designed simply to prolong life. It is geriatricians who are constantly challenging nephrologists [kidney specialists] who dialyze very old people, pulmonologists [lung specialists] who intubate people with no quality of life, and even surgeons who seem unable to withhold their scalpels from patients for whom peritonitis would be a merciful mode of death.

We wish to improve the quality of life for older individuals, not to prolong its duration. Thus, we would like to see that older people are independent and lead a dignified life for as long as possible. We work to decrease incontinence, manage confusion, and help families deal with devastating illnesses like Alzheimer's.

Basically, geriatricians can be viewed as the primary care doctors for elderly people, this generation's solution to the problem of the absence of the old family doctor who knew his patients as well as he knew their diseases. If a geriatrician is a specialist, his specialty is the entire elderly person. In late 1992, there were only 4,084 certified geriatricians in the United States; at the same time, there were some 17,000 heart specialists.

One might question certain portions of my evidence for saying that the natural limits of an individual's life permit little tampering. There are in fact some very elaborate studies that have been conducted on aging people who have remained well. In those investigations, age-specific changes in function were evaluated in men and women who had no disease process that could be expected to affect that function. The results are as I have described them-the aging process goes on, regardless of anything else that may be happening. Aging may be said to be both independent and codependent, in the sense that it certainly contributes to disease and may in turn be accelerated by it. But disease or no disease, the body continues to get older.

My disagreement with the viewpoint of many of those laboratory researchers who study the physiology of aging centers around the philosophy of treatment. When it is possible to identify a disease by giving it a name, its ravages become the subject of treatment, with the potential aim of cure. And that, after all, is the real reason a modern scientific doctor becomes a specialist. No matter his stated interest in relieving human suffering and no matter the sincerity of his efforts, the average specialist physician does what he does because he is absorbed by the riddle of disease and longs to conquer it by solving each puzzlement it presents to his inquisitive mind, whether he is a researcher or a clinician. At each end of life, the pediatric and geriatric age groups, patients are fortunate to be guided by one of today's equivalents of the family doctor.

The diagnosis of disease and the quest for overcoming it with his intellect are the challenges that motivate every specialist who is any good at what he does. He is fascinated with pathology. When faced by the certainty of his own impotence to treat it, the would-be healer too often turns away. If a riddle is by its nature insoluble, it cannot long hold the interest of any but a tiny fraction of the doctors who treat specific organ systems and disease categories. Old age is as insoluble as it is inevitable. By giving scientific names of treatable diseases to its manifestations, too many of the specialists from whom the elderly seek care retain their riddle and their fascination. They also believe they give patients some kind of hope, though in the end the hope must always prove to be unjustified. These days (if I may steal a term from the jargon of the contemporary rialto), it is not politically correct to admit that some people die of old age.

Can there be any doubt that the intrinsic physical processes a.s.sociated with aging inevitably cause an individual to become progressively more vulnerable to mortality? Can there by any doubt that every year we grow less able to marshal the forces required to fight off the lethal dangers that lurk constantly around us? Can there be any doubt that this growing inability is the result of gradually incremental debilitation in the powers of our tissues and organs? Can there be any doubt that the debilitation is due to a general running down of normal structure and function? Can there be any doubt that a general running down, whether in a motor or a man, will eventually lead to nonfunction? Can there be any doubt that Thomas Jefferson knew what he was talking about?

The understanding expressed by Jefferson is in fact millennia-old. In the oldest extant medical book of China, or anywhere else-the Huang Ti Nei Ching Su Wen Huang Ti Nei Ching Su Wen ( (The Yellow Emperor's Cla.s.sic of Internal Medicine), written some 3,500 years ago-the mythical emperor is being instructed about old age by the learned physician Chi Po, who tells him: When a man grows old his bones become dry and brittle like straw [osteoporosis], his flesh sags and there is much air within his thorax [emphysema], and pains within his stomach [chronic indigestion]; there is an uncomfortable feeling within his heart [angina or the fluttering of a chronic arrhythmia], the nape of his neck and the top of his shoulders are contracted, his body burns with fever [frequent urinary-tract infections], his bones are stripped and laid bare of flesh [loss of lean muscle ma.s.s], and his eyes bulge and sag. When then the pulse of the liver [right heart failure] can be seen but the eye can no longer recognize a seam [cataracts], death will strike. The limit of a man's life can be perceived when a man can no longer overcome his diseases; then his time of death has arrived.

The major question is not whether whether aging leads to debility, the inability to overcome disease, and then death, but aging leads to debility, the inability to overcome disease, and then death, but why why individuals age in the first place. The Preacher of individuals age in the first place. The Preacher of Ecclesiastes Ecclesiastes was among the first in the Western tradition to point out that "To every thing there is a season, and a time to every purpose under the heaven: A time to be born, and a time to die," but the theme is so commonplace as to echo through our literature in every era. Before the Preacher, Homer had written, "The race of men is like the race of leaves. As one generation flourishes, another decays." And there are good reasons that one generation must give way to the next, as made clear in another of the letters Jefferson wrote to the equally venerable John Adams near the end of his life: "There is a ripeness of time for death, regarding others as well as ourselves, when it is reasonable we should drop off, and make room for another growth. When we have lived our generation out, we should not wish to encroach on another." was among the first in the Western tradition to point out that "To every thing there is a season, and a time to every purpose under the heaven: A time to be born, and a time to die," but the theme is so commonplace as to echo through our literature in every era. Before the Preacher, Homer had written, "The race of men is like the race of leaves. As one generation flourishes, another decays." And there are good reasons that one generation must give way to the next, as made clear in another of the letters Jefferson wrote to the equally venerable John Adams near the end of his life: "There is a ripeness of time for death, regarding others as well as ourselves, when it is reasonable we should drop off, and make room for another growth. When we have lived our generation out, we should not wish to encroach on another."

If it is the way of nature that we not "encroach on another" (and simple observation confirms that it is), then nature must of necessity provide some means of certainty that we, like Homer's leaves, progressively attain a stage at which we "drop off, and make room for another growth," as gentleman farmer Jefferson put it. Scientists of every stamp have attempted to identify the mechanism by which living things do this, and we still don't know for certain what it is.

Basically, there are two distinct lines of reasoning to explain the aging process. One emphasizes the continued progressive damage done to cells and organs by the commonplace process of carrying out their normal functions in the ordinary environment of everyday life. This is often called the "wear and tear" theory. The other suggests that aging is due to the existence of a genetically predetermined life span that controls not only the longevity of individual cells but of organs and entire organisms, like ourselves, as well. In descriptions of this latter thesis, the image is often invoked of a "genetic tape" that begins to run at the instant of conception and plays out a sequential program that preordains not only the hour of death (at least in the metaphoric sense) but even the hour at which the death-dealing notes begin to he heard. Carried to its most specific implication, this theory might mean, for example, that the day or week of a cancer's first cell division has already been determined at the time the same event is happening in the just-fertilized egg.

As used by the proponents of the "wear and tear" theory, the word environment environment may refer to the environment of this planet or the environment within and around the cell itself. It may be that such factors as background irradiation (both solar and industrial), pollutants, microbes, and toxins in the atmosphere slowly result in damage that changes the nature of the genetic information transmitted by cells to their offspring. It may even be that the environment plays no part-the misinformation may result from random errors in transmission. Either way, the acc.u.mulated alterations in DNA might then cause the errors in a cell's function that lead to its death and those obvious changes in the whole organism that manifest themselves as aging. This process of frank cellular death is called by some the "error catastrophe." may refer to the environment of this planet or the environment within and around the cell itself. It may be that such factors as background irradiation (both solar and industrial), pollutants, microbes, and toxins in the atmosphere slowly result in damage that changes the nature of the genetic information transmitted by cells to their offspring. It may even be that the environment plays no part-the misinformation may result from random errors in transmission. Either way, the acc.u.mulated alterations in DNA might then cause the errors in a cell's function that lead to its death and those obvious changes in the whole organism that manifest themselves as aging. This process of frank cellular death is called by some the "error catastrophe."

Some of the environmental hazards originate within our tissues and inside the cell. I have already described the constant bombardment that affects the basic nature of molecules, but there are other mechanisms as well. In order to continue in