The Museum of Clear Ideas
How We Die: Reflections on Life’s Final Chapter
Donald Hall’s brief memoir, Life Work, is, as he himself declares, a bit of a brag about the amount of work—poems, books, lectures—he has been able to accomplish since giving up an academic job. On this point he can expect widespread corroboration from graybeards scattered around the country. An awful lot of academic activity falls under the head of make-work and routine busyness. By giving up the salary and the schedule one automatically gains four days out of every week for real work, if that’s what one happens to prefer. (But “work” in this context means the very reverse of “labor.”) Mr. Hall in his elected leisure organized himself like a oneman dynamo; few poets can ever have gone about their trade more systematically. What with secretaries and typists, programs and research assistants, lecture tours and grant applications, he kept his corner of New Hampshire awhirl with the doings of the Muses. I think he would be appalled to know he reminded this reader all too often of Arnold Bennett’s little self-help book, How to Live on 24 Hours a Day.
For a fact, the life of a free-lance writer is a helter-skelter of occasions; if he is to meet his daily obligations, he has to accept opportunities as they come along. In adapting to this existence, Mr. Hall was enormously stimulated by the example of his New Hampshire forebears, who had to turn a hand to every chore that turned up on a family farm in a sparse part of the world. From canning beans to getting in hay, from collecting eggs to milking cows to picking blueberries and hunting wild mushrooms, the farmer and his family work sunup to sundown seven days a week. In his journalistic endeavors Donald Hall emulated them.
It may be customary to say, in some circles, that so much energy so widely diffused tends to produce perfunctory performances but not much deeply labored achievement. I don’t think this wiseacre criticism applies to Donald Hall. He is not John Keats, but whatever he could achieve he has labored with all his might to achieve. He has worked over his poems with the singleminded devotion of a diamond cutter, and the fact that at the same time he was writing children’s books and giving talks to women’s clubs hasn’t limited his accomplishment. It’s a record over which he has every right to crow.
Still, work is the theme of only the first half of this very personal memoir. Halfway through it the author is struck with a dangerous, possibly fatal, cancer of the liver; and the second half of the volume is written under the shadow of this fearful ailment. Perhaps this is why Donald Hall dwells with particular relish on the strong, clear record of his grandparents. To talk about his own invalid condition cannot be very exhilarating; he gives few clinical reports. The topic of dying well used to be, in the long-ago Renaissance, a performance which men practiced assiduously and described in detail. Nowadays the drama seems to have gone out of it. Mr. Hall has faced the Great Perhaps with the quiet stoicism which seems today to befit the occasion. His friend the Protestant pastor who is dying slowly and painfully nearby dwells only lightly on dogma but represents a strong personal identity in extremis.
Another aspect of this experience is represented by Donald Hall’s most recent book of poems, The Museum of Clear Ideas. It is a recollection of verses by no means entrapped by the misfortunes of his personal life but rather strong and independent in its handling of two different aspects of the outside world. Bold, witty, and forceful beyond his previous work, the new book consists of two good-sized poems, one modeled on the first book of Horace’s Odes, the other on the pattern of a baseball game, with nine innings of nine stanzas each and a couple of extra innings at the end.
The “Baseball” poem does not follow the episodes, adventures, and moralities of a particular contest. Rather, it alludes freely to episodes of the pastime and parts of its mythology, generally from the outlook of a partisan of the Boston Red Sox over the past couple of decades. Not every reader will get all the allusions; there are glancing comments on Billy Herman, Wade Boggs, and Curt Davis, but nothing about Ted Williams or other well-known Boston heroes. Still, the poem, which is mostly about the game of life, makes colorful allusion to doings in the big leagues, and can’t be expected to cover a single season’s doings at Fenway Park. One of its first premises is that it will try to explain the rules of the game to the German collagist Kurt Schwitters (1887–1948), who, while he would surely have been gratified and flattered, could not have been much enlightened by the fragmentary information in the poem. No matter: baseball is a hearty outdoors pastime. Donald Hall’s enthusiasm for it is infectious, and the versification is invigorating.
Rather more intricate is the set of poems imitating Horace’s first book of odes and subtitled, after a minor figure in a Walt Disney cartoon, “Horsecollar’s Odes.” If one has enough Latin to compare Latin and English versions, it’s worth doing. Donald Hall makes a considerable point of saying that he lacks Latin and has simply imitated the verse-form of Horace’s stanzas, but that’s not right. Hall knows Horace about the same way Pound knew Propertius, and that’s well enough to make most of the useful macaronic puns and cross-cultural allusions. Hall is also much more interested in his American friends and contemporaries than in the Roman scene. As a result his poems read much more like modern-day sardonic American action-scenarios than like pieces of ancient history. Every so often he appends to one of Horace’s poems a brief poetic afterthought or counter-statement which either caps the joke or reverses its angle. The interplay of imitation and original is by no means simple-minded. At the end of the little poem “Who’s This Fellow,” modeled on Horace’s “To Pyrrha,” Hall can make his comic point simply by referring to himself as wet. But Latin makes the social situation clear; the redheaded lady is a stormy handful; the poet has escaped the storm, and now hangs up his dripping garments by the altar in gratitude for his escape. The classical imitations of Hall set no solemn example; they are more playful than not, and seem trained to maintain a mode of civilized, witty discourse. Yet they also maintain a metrical pattern which is more formal than English commonly allows. The effect could be called marmoreal.
This is an ingredient of what the current buzzword likes to call “dying with dignity,” and if there’s a fashion in these things, it’s very much the modern mode, at least in a manner of speaking. Not only is our language full of euphemisms for avoiding the intimation of death, but our social arrangements are contrived to keep it out of sight and, so far as possible, out of mind. Not very many of us are familiar enough with the process of death as it actually happens to separate reality from stylizing. One person who knows whereof he speaks is Dr. Sherwin B. Nuland, who teaches surgery and the history of medicine at Yale. He has written a quiet and careful book called simply How We Die which describes in some specific detail a few of the major exit processes. His book is by no means sensational or horrifying but he does not indulge many fantasies of our being able, as we would like,
To cease upon the midnight with no pain.
Death, for Dr. Nuland, is a messy business, often horrifying. Some of the worst agonies can be sedated; some of the violent crises can be stretched out, slowed down, postponed. But at its best dying is a grisly business; and Dr. Nuland, who has written an always understanding and frequently tender book about it, cannot be recommended as diversionary reading, particularly not for those past their middle years.
The rationale for the old ars moriendi studies was the general assumption of personal immortality. If one could look forward confidently to an eternity of bliss or agony, there was every reason to take steps, at the end of this life, to get off to a good start on the next. But belief in personal immortality being out of the question for most of us, there’s nothing to do but to get over the disagreeable business as quickly and decently as possible. Dr. Nuland, who is nothing if not systematic, examines the various alternatives patiently and in some clinical detail, starting with heart attacks and strokes, progressing through senility to Alzheimer’s disease and suicide and euthanasia, before tackling the really tough nut, cancer.
Following his progress, in which all roads lead to one unwelcome conclusion, one is bound to start wondering how much one really wants to know about the various processes. That the doctors know so much about them is wonderful; but one of the few advantages of being a patient is that in the normal course of things a single death suffices. One of the problems with having the different ways of dying set out before us, like capsules on a counter, is the tacit implication that we can have our choice. Actually, our choices, by the time they present themselves, are very limited indeed. Many of the big ones are made for us, like it or not. Dr. Nuland is careful not to suggest that we can pick and choose, as is technically possible these days. He has few kind words for Dr. Kevorkian or for the Hemlock Society. Not that he would have that alternative shut off; but careful consultation and deliberate analysis are at the heart of his recommendations. It is not a proposition with which anyone can lightly quarrel, but it puts a heavy burden on the patient’s psyche at a time when, most likely, his major impulse is denial.
For this reason it is somewhat surprising that Dr. Nuland devotes relatively little space to the now-familiar legal instrument of the living will. Admittedly this document, like any other, means more or less according to the determination and intelligence of those who execute it. But doing what can be done before the stage of emotional crisis is reached is important; and one way is to get it in writing. In this respect, Dr. Nuland’s book itself represents a major step over the preliminary hurdles of avoidance and denial. Not everyone will want to read every grisly detail of every degenerative ailment. But to have read it through will arm anyone for the several parts, one of which at least all of us will ultimately have to play.
I am confident there are readers who will not be able to finish the first ten pages of the first chapter of How We Die; they should avoid the book entirely. This is how he describes his own state of mind after struggling, as a third-year medical student, to keep his first dying patient alive.
Alone in that room with a corpse, I looked into its glazed eyes and saw something I should have noticed earlier—McCarty’s pupils were fixed in the position of wide black dilatation that signifies brain death, and obviously would never respond to light again. I stepped back from the disordered carnage on that bed and only then realized that I was soaking wet. Sweat was pouring down my face, and my hands and my short white medical student’s coat were drenched with the dark lifeless blood that had oozed out of McCarty’s chest incision. I was crying, in great shaking sobs. I realized, too, that I had been shouting at McCarty, demanding that he live, screaming his name into his left ear as though he could hear me, and weeping all the time with the frustration and sorrow of my failure, and his.
On the other hand, it’s not just morbid curiosity that keeps one reading. How we die is an index of sorts to how we have lived, and that is a matter to be curious about. Perhaps this mixture of emphases is one reason why the pages of Dr. Nuland’s book are frequently touched with quotations from those seventeenth-century authors for whom psychology and medicine were closely interwined disciplines. It is a mournful procession of moribunds whom he parades before us, but he can evoke a measure of spiritual triumph from thoughts of their endurance and the nobility of those who, against better knowledge, enabled them to persist to the end. Against his own precepts, Dr. Nuland often makes use, and very effectively, of military metaphors to describe the advance of a disease:
Although people with AIDS are highly susceptible to well-known diseases such as tuberculosis and bacterial pneumonia, they are also set upon by a group of otherwise unusual sicknesses due to a variety of parasites, fungi, yeasts, viruses, and even bacteria that physicians rarely encountered before the advent of HIV. For some of these organisms, there was no effective treatment until the late 1980’s, when the efforts of university laboratories and the pharmaceutical industry were finally rewarded with the development of a group of drugs that have shown varying degrees of clinical success.
Every variety of microbial invader attacking the shattered defenses of the immune-compromised person with AIDS is equipped with its own unique assault weapons and directs its onslaughts against specific objectives. With little remaining CD4 cell resistance to bar their way, the individual divisions and regiments of opportunistic killers devastate the territory that comprises the patient’s tissues. Sometimes by exhausting a person’s energy and small supply of reserve firepower, and sometimes by knocking out a central structure like the brain, the heart, or the lungs, the swarming bits of infection will have their way. Though the pestilential offensives may be slowed or halted for a while by one or another of the newer pharmaceutical agents, they will always in time resume, if not in one form, then in another. A skirmish may be won here and there, or a battle prevented by timely use of prophylactic drugs, and some months of stability thereby achieved—but the eventual outcome of the struggle is preordained. The determined microbial aggression will accept nothing less than the unconditional surrender that comes only with the death of their involuntary host.
There is no way to describe the working of the AIDS infection except as the diabolically resourceful marshaling of legions of infectious agents, against which all the resources of human ingenuity can achieve no more than a momentary remission. When we consider that the disease was first recognized little more than a decade ago, the strides that have been taken in analyzing its structure and behavior seem enormous, but they have not altered the shattering prognosis that AIDS is now with us for the duration of human history.*
Just a few years ago medical men were jubilantly anticipating the end of bacterial and viral infections as the source of human disease. No more terrible epidemic has attacked the human race since the Black Death; Dr. Nuland’s survey of the different ways to die could not come on a more opportune or a more sinister occasion.
This verdict (p. 175) is not only Dr. Nuland's, but that of a colleague who directs the AIDS unit at Yale. Like all prophetic judgments it may turn out to be wrong, and if it is, the discovery of a cure will be greeted everywhere with immense jubilation. But for the moment a somber outlook on the future seems to be the only realistic one.↩
This verdict (p. 175) is not only Dr. Nuland’s, but that of a colleague who directs the AIDS unit at Yale. Like all prophetic judgments it may turn out to be wrong, and if it is, the discovery of a cure will be greeted everywhere with immense jubilation. But for the moment a somber outlook on the future seems to be the only realistic one.↩