From the Editor

Two deaths, more or less heroic.

JASON PONTIN

Edward Gibbon, author of The Decline and Fall of the Roman Empire, learned of the death of his old friend, Lady Sheffield, in April 1793. Lady Sheffield had lived in England; Gibbon was in retreat in Lausanne, Switzerland. But the 18th century placed a high value on friendship, and although Europe was at war, Gibbon decided that he must console the widower. Passing within the sound of artillery at the Siege of Mayence, he hurried to London, where he was able, according to Lord Sheffield in his continuation to Gibbon�s Memoirs of My Life, “to soothe me by his most generous sympathy, and to alleviate my domestic affliction.”

Gibbon�s medical history is interesting. He was so enormously fat that on one occasion, when he dropped to his knees to propose to an elegant lady, he had to admit, when she commanded him to rise, that he could not. (Servants were called, and they hoisted him to his feet.) Since 1761, Gibbon had also suffered from a hydrocele, or a testicle swollen with fluid, which by 1793 had become so large that he would support it on a small foot-stool when he was seated. Gibbon always refused to hear any allusion to his testicle, even from his valet de chambre, but that winter in London he became alarmed by its continuing growth and at last determined to take action.

But in an age before antisepsis and anesthesia, operations were rationally detested, and Gibbon was uneasy. Writing to Lord Sheffield, then in Sussex, Gibbon asked, somewhat disingenuously, “Have you never observed, through my inexpressibles, a large prominency, circa genitalia? [The surgeons] pronounce that it must be let out by the operation of tapping. If the business should go off smoothly, I shall be delivered from my burthen (it is almost as big as a small child), but it has occurred to me that you might wish to be present till the crisis was past.”

Sheffield was there when the liquid in Gibbon�s hydrocele was aspirated in two operations. The surgery seemed a success; Gibbon retired to Sussex for Christmas; but he soon became dull, feverish, and without appetite. A third operation became necessary, and Gibbon traveled to London, where his surgeons drained a further six quarts from the inflamed and ulcerated tumor. At first Gibbon seemed to recover, but on January 16th, Sheffield received a letter stating that his friend had had “another attack” and was not likely to live. “I reached his lodgings in St. James about midnight, and learned that my friend had expired that day.” Gibbon was 56.

Sheffield describes the historian�s last night and morning:

“Mr. Gibbon . . . said that he thought himself good for 10, 12, or perhaps 20 years. At six he ate the wing of a chicken and drank three glasses of Madeira. After dinner he became very uneasy and impatient. Soon after nine, he took his opium draught, and went to bed. After ten, he almost incessantly expressed a sense of pain till about four o�clock in the morning . . . Mr. Farquhar [his surgeon] came at the time appointed, and he was then visibly dying. When the valet de chambre returned, after attending Mr. Farquhar out of the room, Mr. Gibbon said, �Pourquoi est-ce que vous me quittez?� At 12, he desired his favorite servant to stay with him. These were the last words he pronounced articulately . . . He was quite tranquil, and did not stir; his eyes half-shut. About a quarter before one, he ceased to breathe.”

Gibbon probably died from sepsis, or a toxic inflammation of the blood. Modern medicine can supplement Sheffield�s account with details less gratifying to the sentiments of the 18th century. The early symptoms of sepsis include fever, chills, and a rapid heartbeat. As the infection spread, Gibbon would have panted and shaken. His entire body would have ached. He would at first be confused, then delirious. His kidneys, his liver, and his heart would have faltered. As his brain began to fail, he would have passed into a coma before he died.

Yet the wonderful thing is that all contemporary accounts speak of Gibbon�s death without horror. They applauded his achievements in life, and marveled at his stoicism in death. It was, they thought, a fittingly Roman ending for the elegist of Rome. Nor did they regret the works that Gibbon planned but never lived to write: a volume of English historical portraits, from the reign of Henry VIII to the period of George III. They had no sense of a life cut short.

Today, physicians first attempt to aspirate a hydrocele, as did Gibbon�s doctors. If that fails, as it often does, they remove it in a simple operation. A patient would leave the hospital in good health and return to life. To us, Gibbon�s sickness and death are grotesque.

Contrast Gibbon�s death with the modern death of my friend Sidone Edwards, who died in a hospital of congestive heart failure, complicated by emphysema, six years after a successful coronary bypass. In her last years she was a regular visitor to the emergency room of Alta Bates Hospital in Berkeley, California, where, increasingly querulous and gaga, she was wildly unpopular. She trundled an oxygen tank behind her and lashed out with her walking cane. Interns and nurses would scurry away when she was admitted. This wounded her, because she had been a Southern belle in her youth. When she died, at 80, she was not herself.

For centuries, medicine heroically fought acute events. Patients like Gibbon were necessarily heroic, too. But for the last 50 years, medicine has been treating the chronic conditions of a less heroic population. While modern medicine means we need no longer fear Gibbon�s death, it has given us something new to dread: a long, mewling old age. Many of the stories in this issue of the Acumen Journal of Life Sciences are about aging, and they argue a similar thing in different ways: the costs of chronic care for the elderly cannot be sustained much longer.

A baby born today can look forward to living perhaps 78 years. But the last years of life are spent suffering from debilitating, chronic diseases. As Sherwin Nuland, M.D., writes in his essay “How to Grow Old,” (page 48), our institutions for caring for the elderly are “filled with men and women so incapacitated that they require help with the simplest of needs.” Many of them are quite demented, unaware of where, or who, they are. These are the human costs, and they are unbearable. The economic costs to society are impossible to bear, too, as Steven Weber tells us in “Aging Gracelessly,” (page 32). We spend around $470 billion caring for our elderly. Nearly two-thirds of funding for public health for the elderly goes toward the care of people with five or more chronic conditions. Insurance economics, which prices events that might happen or whose severity or timing are unknown, cannot pay for health care when sickness is inevitable, chronic, and indefinite.

There are possible solutions for the elderly and for our political economy. Doctors know that remaining physically and intellectually active ameliorates or postpones many of the chronic diseases of old age: in their professional jargon, this is the “compression of morbidity.” Economists and policy makers know they must devise a new health care system founded on investment by individuals, companies, and governments that rationally pools risk. Both these private and public prescriptions demand greater investment in preventative medicine. New science, in searching (probably unsuccessfully) for ways to extend our lives, may also cure some of the diseases associated with old age (see “The Pursuit of Longevity,” page 40 of the Journal, Issue 2).

We look back at Gibbon�s death and we flinch. We should wince at Edwards�s death, too. Gibbon died of ignorance and shame, and in pain, but fully himself; Edwards died comfortably, after medical science had done what it could, but she lost everything. If our grandchildren contemplate our last years with incomprehension, and future editors write about our deaths with pity, we should be pleased. It will mean that their old age and deaths are different.

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