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 God’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 accumulate 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 multitude of slowings that we see daily in our elderly associates, 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
. 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 institutional care until death.
Though the death certificates of stroke victims have often been adorned with such terms as
cerebrovascular accident
or
cerebral thrombosis
(these days, the proper word is the simpler and all-encompassing
stroke
), more significant than the nomenclature on the legal paper is the number written into the blank space for
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 antithesis 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
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 impassive 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 assaults of potentially lethal enemies who are themselves invisible to the naked eye. Without our knowledge or conscious participation, the silent cells and molecules of immunity are ever adapting to the changing circumstances of daily life and its unseen terrors. Nature, our strongest shield 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
, 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 glass chamber, allowed him to suck out the phlegm each time it reaccumulated. 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 succumbed 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.