Terra Incognita


In Memoriam

Remembering Sherwin Nuland, the author of How We Die, who died last week.



I attended the Yale School of Medicine when Shep Nuland taught there, and despite our both being surgeons, I know him best in my capacity as a reader. I don’t recall when I first read How We Die—I was just finishing high school when it came out—but I do know that few books I had read so directly and wholly addressed that fundamental fact of existence: all organisms, whether goldfish or grandchild, die. His description of his grandmother’s illness showed me how the personal, medical, and spiritual all intermingled. As a child, Nuland would play a game in which he indented her skin to see how long it took to resume its shape—a part of the aging process that, along with her newfound shortness of breath, showed her “gradual slide into congestive heart failure … the significant decline in the amount of oxygen that aged blood is capable of taking up from the aged tissues of the aged lung.”

But “what was most evident,” he continued, “was the slow drawing away from life… By the time Bubbeh stopped praying, she had stopped virtually everything else as well.” With her fatal stroke, Shep Nuland remembers Browne’s Religio Medici: “With what strife and pains we come into the world we know not, but ’tis commonly no easy matter to get out of it.”

I studied literature at Stanford, and later history of medicine at Cambridge, to better understand the particularities of death, which still seemed unknowable to me—and yet vivid descriptions like Nuland’s convinced me that such things can only be known face to face. How We Die brought me into medicine to bear witness, as Shep Nuland had done, to the twinned mysteries of death, its experiential and biological manifestations: at once deeply personal and utterly impersonal.

I like to think of Nuland, in the opening chapters of How We Die, as a young medical student, alone with a patient whose heart had stopped. In an act of desperation, he cut open the patient’s chest and tried to pump the patient’s heart manually, to literally squeeze the life back into him. The patient died, and Shep was found by the intern, his supervisor, covered in blood and failure.

Medical school has changed since Shep’s time, and such a scene is unthinkable now: medical students are barely allowed to touch patients. What has not changed, though, I hope, is the heroic spirit of responsibility amid blood and failure. This is the true image of a doctor. It is not the idealized happy profession in which we always cure diseases and ease suffering, our patients invariably leaving us better than we found them. It is also doctors facing the enormity of patient problems, seeing the crudeness of our tools, and, inevitably, watching our patients die, usually either in agony or under sedation.

I had dinner with Shep Nuland once, along with several other Yale students. It was right after he had given a talk on his battle with depression, his near complete loss of will. “All my major surgical cases,” he said, “I was scheduling them for twelve, one o’clock in the afternoon, because I couldn’t get out of bed before about eleven … I clearly became increasingly depressed until I thought, my God, I can’t work anymore.” He was admitted to a psychiatric hospital, where every treatment failed: “it got so there was a throbbing, there was a ferocious fear in my head. You’ve seen this painting by Edvard Munch, The Scream … Every moment was a scream.” He nearly had a lobotomy but a resident physician convinced the staff to try electroconvulsive therapy, and after twenty cycles, “I’ve never forgotten—I never will forget—standing in the kitchen of the unit … and thinking, ‘I’ve got the strength now to do this.’”

Shep’s books did not make him immune to tragedy, of course—to address suffering so directly is not to become impervious to it. To ward off depressive thoughts, he used a talismanic phrase: “Aw, fuck it.” Not the most literary of phrases, and I suspect there is a lesson in that.

We discussed none of this over dinner. I was too shy to speak a word the entire meal. I was still lost in the nakedness of his story—today I remember the talk primarily for its therapeutic effect. My closest friend from this time had attended the talk with me. She had been suffering from depression for years, alone in a crowd, cold in the warmth of friends, as the truly depressed are. Shep’s frank description of his experience, and my friend’s identification with it, convinced her to seek treatment. She has gone on to live a happy life.

I’m now a neurosurgical resident; I’ve removed scores of brain tumors, and Nuland’s descriptions of cancer often return to me. Cancer took his brother’s life, and, finally, his own, and he describes the disease not just as a body eaten away by monstrous forces, but as a civilization crumbling as it is increasingly overrun by ravenous juveniles: “Cancer cells are fixed at an age where they are still too young to have learned the rules of the society in which they live. As with so many immature individuals of all living kinds, everything they do is excessive and uncoordinated with the needs or constraints of their neighbors … they are reproductive but not productive. As individuals, they victimize a sedate, conforming society.”

What a perfect metaphor! Every time, a brain tumor looks like a young invader. My goal is eradication. Few things are as satisfying as completely excising a tumor, leaving only the glistening appearance of a healthy brain. Yet, in brain cancer, we know the system carries the disease and the reprieve is temporary: the society will likely be overrun. 

Almost exactly twenty years after the publication of How We Die, I was diagnosed with lung cancer, and as I looked at images of my own body riddled with cancerous lesions, Shep’s compelling descriptions returned to me. His metaphor has helped me see the cancer as part of me, both literally and figuratively. At times I think of it as a native insurgency—something to be quelled. But every so often, my attitude is more charitable, and I’ll find myself spastic with pain, pitching a coughing fit, or overwhelmed with nausea, saying quietly, “Now, now, children … ”

By sharing his life as a doctor openly, Nuland demonstrated the power of honest self-appraisal, something I have always tried to replicate: to admit my failures to myself and others, to recognize that I will fail, to find the dedication to improve. Shep has shown us that writing allows the physician to fulfill another duty. Doctor derives, of course, from the Latin docere, “to teach”; he once wrote, “Only by a frank discussion of the very details of dying can we best deal with those aspects that frighten us the most. It is by knowing the truth … that we rid ourselves of that fear of the terra incognita of death.” No doctor or writer did more to draw the map. Condolences to Dr. Nuland, his family, and those who knew him. I hope he was one of the lucky few to find death with dignity. But I am glad that, until my own time comes, I have his voice in my head; and if I need an extended conversation, it is just a bookshelf away.

Paul Kalanithi is the chief resident of the Department of Neurological Surgery at Stanford Hospital and Clinics, in Stanford, CA.