Personal accounts

Literature touches our emotions and perhaps this is what people consider to be its greatest characteristic. Yet the power of the arts is ambivalent. It can blind the reader to sentimental trash. Who has not cried at the death of Bambi's mother in the Walt Disney cartoon? Which girl – it seems only girls read it – has not wept over the demise of Beth in Louisa M. Alcott's Little Women? Who, in other words, would disagree with the sense of Noel Coward's famous bon mot: ‘It is extraordinary how potent cheap music is’? Dickens was one of the greatest of all writers but, like many Victorians, he was very susceptible to sentimentality. Here, he describes the death of the impoverished child, Little Nell, in The Old Curiosity Shop. Dickens owed a great and direct debt to Shakespeare in his work. Note the similarities between this death and that of Cordelia, above. The first speaker is the old man whom Nell has befriended.

But, like Lear, the old man is mistaken:

If this does not move us to abject surrender and sentimental tears, the emotions evoked might be more complex and less forgiving. ‘Who’, as Oscar Wilde once remarked, ‘can read the death of Little Nell without laughing?’ Perhaps. And it is the mix of complex embarrassment, humour and dismay that colours our response to both this and amateur verse, or the attempts of the poorly equipped to strike a formal note of gravity. The inscriptions on headstones in a typical graveyard can move the most earnest person to giggles.

This does not mean that poverty of expression is the same as poverty of feeling. One of the lessons of King Lear, after all, is that true feelings lie too deep for words: beware those who, like Lear's wicked daughters, can articulate their love. Trust rather the saintly Cordelia, the daughter whose love is deep beyond expression. By extension, for just this reason a dying patient or a bereaved relative may welcome the release that literature brings. They may feel that their own power to express themselves has failed and that there is relief in the words of others and the possibility of saying, ‘This is what I mean’.

This makes for an ambivalence in much of the writing about death and dying. Sometimes it is profoundly felt, sometimes it is profoundly expressed, but not often is it both. This is exemplified in an excellent anthology of poems on bereavement, The Long Pale Corridor (Reference Benson and FalkBenson & Falk, 1996). The range of poems, in terms of quality, is from the adequate to the outstanding, but nobody could describe the book as easy reading. This example is by the American poet, Jack Hirschman, whose son died of leukaemia when in his twenties.

There is a good deal to respond to in this poem. The idea that love is laughter is a particular delight – and if the poem lacks immediacy to a UK reader, it is partly because it is North American; the glove is a baseball glove and the central image is that most American of rituals, a father and son playing baseball. A non-American audience may miss the references altogether and, even if they do pick them up, may catch only a glimmer of the rich network of associations conjured up by the sport, and thus the poem about the sport. The point here is that literature does not deal with facts, things which are true at all times for all conditions and every reader.

Clinicians and patients alike evidently share the greatest difficulty when they turn to literature as a way of sharing experience. Barriers of context can impose themselves more or less completely between the most well-intentioned reader and the text.

This means that we turn most easily to writing where the barriers effectively vanish, because the culture is our own and the kind of reading the text demands of us is the kind of reading we do anyway.

For examples, we turn to accounts of their illness by contemporary, articulate people. Sometimes, as with the journalists John Diamond and Oscar Moore, victims of throat cancer and AIDS, respectively, an easy sophistication hangs over their work (Reference MooreMoore, 1996; Reference DiamondDiamond, 1999). But this is a game whose rules many of us understand, and the writing – essentially very clever versions of the volubility of the chattering classes – therefore has an immediate power, closely linked to our confidence that we know what is going on. This is Moore, talking about going blind:

The writing is self-consciously able and literate. Moore effortlessly strings his war metaphors together, for example. At the same time, the issue of quality, whether this is ‘good writing’, seems to be beside the point and a text like this is perhaps, above all, a way of putting sufferers and their relatives in touch with another experience; of relieving the burden of loneliness. It is not unkind to observe that Moore actually says little which is very insightful – nothing there the healthy could not have guessed about what the dying feel. In the end, it is not for the quality of his thoughts or feelings that we read this, but for their authenticity and the sense of the person which shines through. In that respect, it matters less what is said than who says it.

This is writing at its most immediate. One is granted permission to watch as the writer dies and there is no doubt that this contributes to its impact. Even more immediate, perhaps, are the possibilities that the internet gives us to write interactively. Here is a posting from an HIV bulletin board:

The expression of sentiment is commonplace yet profound in a way that we can easily understand.

Making sense of death

One of the central tasks of literature is to impose a structure on life and death, giving meaning to both. Indeed, literature as a discipline aims just as certainly as science does to understand the world in which we live and to interpret our own role as participants in the human condition. The difficulty for the non-specialist is understanding the various ways in which literature works and, once more, this is particularly true when it comes to the question of understanding across time and space.

Here is one example, which is fairly well-known and relatively approachable. Perhaps it also corresponds to a certain idea of what poetry is in its effortless rhythmical dexterity and command of sound:

Tennyson wrote this long – very long – series of short poems (published in 1850) following the death, at just 22, of his close friend, Arthur Hallam. Hallam was a brilliant young man in his own right and it seems clear that Tennyson expected to spend the rest of his life in close contact with him. The deeply felt grief makes it a personal account, but deep feeling refined into literature. A little more cynically, it could be seen as an instance of the French poet and man of letters Paul Valery's description, ‘A poem is a machine for reproducing an emotion’. Note, in particular, a much-quoted example of Tennyson's genius in the way that the easy, gentle rhythms are subverted in the last line by the sudden abruptness of ‘bald’ and ‘blank’. In a sense, the poem is held together by poetic technique; the feelings behind it are so bleak that it is hard to see how they found expression at all.

Behind the sadness, hovering off-stage for much of the time in the poems of In Memoriam, and entirely absent in this one, is the apparatus of Victorian life and, in particular, the solace of the Christian faith. This, of course, has been the backdrop to a great deal of Western literature about death and dying. Christianity has offered a way of understanding grief and our own death in the context of eternity.

At its literary best, faith lends a power and conviction to writing which speaks clearly to those of other faiths, or none. This is John Donne, who became a cleric in later life. He is often regarded as one of the greatest of all English poets. The poem is perhaps best read aloud, with passion and speed, to reveal the power of that triumph over death it celebrates:

This poem also works through the force of its sounds – for example, by the way the sounds ‘p’, ‘b’ and ‘d’ are deployed in the opening lines (phonetically these are ‘stops’, because the passage of air is stopped then suddenly released by either the lips or tongue). Here, the effect is of passion and a kind of driven commitment, one might say, reinforced by the tight verse form of the sonnet, which is handled effortlessly and compacts a great deal of meaning into a short space. The poem works because of technique. What guarantees the value of the writing is not who is writing but what is said and how.

It also works because of the shared understanding that most readers will have of the cultural and religious context, even if they do not actually share the belief system. In other words, cultural familiarity is of substantial importance.

Contrast this with, for example, inscriptions from other cultures, whose social value is now lost to us. The Ancient Egyptians set great store by the account of themselves written on their tombs, but these texts, sometimes called ‘autobiographies’, have no real meaning to us now, unless we are archaeologists or historians. The following is a poem written by Basho, the great Japanese writer of haiku, as death approached. It is extremely famous, much translated and, without a knowledge of Japanese culture, fairly vacuous:

What do such things mean? – very little without the shared culture; without, for example, a sense of the resonance of the word ‘dream’ (‘yume’, in the original), which pervades the short Japanese poem and has been picked up, played with and enriched by author after author over centuries.

Symbolic deaths

Clearly, much of what is quoted above is literature striving to demonstrate that particular deaths fit into some kind of overall scheme. This may be an eschatological account of the world or merely a matter of taking death seriously because we, in turn, hope that our death will be taken seriously. At any rate, what matters is the context in which death is placed. But literature itself is such that death has many functions. In other words, the context of literature gives death and dying many roles to play.

At one end of the scale is one of the most common types of death in all fiction, the discovery of the body in the ‘whodunnit’ or murder mystery. This may require us to expend no deeper emotion than we do on a crossword puzzle, or it may, as in the next example, aim to do more. This is from Smiley's People by the great novelist of the spy-story, Reference Le CarréJohn le Carré (2000). His hero, Smiley, has just discovered a second body:

This is almost a meditation on the nature of death. However, the focus immediately changes to death as a puzzle:

One stage further on is the kind of book, often called a ‘whydunnit’, in which the identity of the killer is not as important as his or her motivation. Bear in mind here that the greatest of all constraints on the writers of whodunnits is that they cannot describe the motivations of their characters well, or it will be at once clear who is the killer. The complete blandness of Agatha Christie characters is necessary, in this respect, to fulfil the genre's requirements – or at least it is a happy accident. Contrast this with Charles Dickens’ The Mystery of Edwin Drood, which is, among other things, a whodunnit. Famously, Dickens died before revealing the identity of the killer, but it can be determined with near certainty from the imagery and symbolism with which Dickens surrounds him throughout the book.

The greatest master of the whydunnit is probably Dostoevsky, whose Crime and Punishment is sometimes described as one of the first detective novels.

The function of the hero's death in tragedy and epic is one of the oldest literary conventions. We have looked at King Lear but it is worth reminding ourselves of the way the idea of the good death varies from society to society. This is the death of the Trojan hero, Sarpedon. Homer's text is here translated by Alexander Pope, whose urbane 18th-century style puts a neo-classical veneer on Homer's more direct original:

The ‘pity of war’, in Wilfred Owen's famous phrase, was seldom mentioned until this century and its principle exponent is Owen himself, who gave death a new kind of meaning. ‘Strange Meeting’ is linked to the conventions associated with the literature of dreams and ghosts. It begins:

Indeed, the death scene in literature is just as much a convention as is the finding of the body. Among the finest death scenes in fiction are the death of Joachim in Thomas Mann's Magic Mountain and the death of Paul Dombey in Dickens’ Dombey and Son. The following, however, is part of the death scene of the consumptive Ralph Touchett, in Henry James's exquisite novel, The Portrait of a Lady. When his close friend, Isabel, visits him, she finds at first that his face on his deathbed is, in an astonishing phrase, ‘as still as the lid on a box’. Then, after some days, he is briefly well enough to talk:

A few mornings later, Ralph is dead. Isabel tries to comfort Ralph's mother, a cold and patrician lady, but is rebuffed as follows – again, a sudden, piercing moment, quietly stated: ‘”Go and thank God you've no child,” said Mrs Touchett, disengaging herself’.

To make the obvious point: even without the context of knowing precisely who these characters are, the generosity of spirit is clear, as is a kind of maturity of feeling which is missing in the case of Little Nell. Note how different the angels are in this novel compared with those that hover around the deathbed in Dickens’ tale.

Sometimes, however, the conventions take us away from death itself entirely. Novels are full of deaths which symbolise the death of some good thing in society, and there are times when references to death are so casual or mannered that they have no real power at all – from the love songs of the Renaissance to those of the present day. An excellent, brief and extremely clever example of this kind of mannerism is Samuel Beckett's poem from the Dieppe series:

The desire to pose as a person experiencing grief is itself a kind of posturing we all recognise, no doubt.

Selected reading

An excellent starting point for anyone interested in medical humanities is a website at New York University (http://endeavor.med.nyu.edu/lit-med/medhum.html). A number of journals discuss issues relevant to health care, notably Literature and Medicine and Medical Humanities (although their papers can sometimes be a little precious for some tastes). JAMA regularly includes poetry, often of a high order.

These days, all the great writers – and some of the not-so-great – are represented on the internet and this is a good starting place for those who, faced with the thousands and thousands of books on Shakespeare, for example, do not know where to start. One example is the website ‘Mr William Shakespeare and the Internet’ (http://shakespeare.palomar.edu) which is a place where most of us could happily lose ourselves for an hour or two.

Conclusions

Death in literature is a varied thing, just as is death in society. Death is also an inescapable destiny for each of us as individuals and, for this reason, has always permeated our thoughts at all levels, from the immediate sense of devastation that personal bereavement gives us to the ways in which we manage the fact of death by pushing it onto the surface, as familiarly and comfortably spooky as the deaths in Hammer horror films.

One of the uses of literature in the health professions is to help people to become more articulate about their concerns and their worries: to help them to ‘talk about their feelings’. It is often said that reading literature will help health professionals as well, perhaps particularly when they are young and lack experience; or perhaps when they are older and crusted over with the cynicism of experience. These are valuable functions, of course, but they tend to pull us away from a real sense of what literature is and can do if we actually repay it with study and read repeatedly. The fact of the matter is that literature is difficult and, if we fail to understand it, this may be because we know too little about the cultures that have brought it into being or cannot recognise or appreciate the techniques through which it is realised, rather than because we lack the finer sentiments.

It follows from this that the role of literature as part of the growing movement in ‘medical humanities’ can be interpreted too narrowly. Literature, if we trust its strength and accept that to become its student is to undertake something always rich and often difficult, is a way of understanding what it is to be human. One central gift it can give to those with a scientific training is that, because it is not reductive, it can bring home the fact that there are ways of understanding which cannot be tested by MCQ. It is the role of literature to observe that the world as we experience it is irreducibly complex. An abstract of a scientific paper is one thing; an abstract of Hamlet is quite another, and certainly is not Hamlet.

Multiple choice questions

(Choose the answer most relevant in the context of this paper)

1. 1 MCQs are very bad for testing:

   1. a a knowledge of fact

   2. b an understanding of literature

   3. c a student's ability to memorise lists

   4. d clinical information

   5. e most things.

2. 2 Literature is easier to understand when:

   1. a it is well-written

   2. b it is unsentimental

   3. c it is written from within a familiar culture

   4. d it expresses deep feelings

   5. e it is read quickly.

3. 3 Literature exists:

   1. a only as a way of expressing feelings

   2. b as a way of helping us make sense of the world

   3. c primarily as a form of entertainment

   4. d because sometimes words fail us

   5. e to pass the time.

4. 4 We make sense of literature if:

   1. a we read it expecting to find precise answers to precise questions

   2. b we make no effort to understand the context in which it was written

   3. c we believe that only science gives us understanding

   4. d none of the above is true

   5. e it is simply and straightforwardly written.

5. 5 Because literature is not reductionist, both literary texts and commentaries on them:

   1. a make little sense

   2. b are inferior kinds of knowledge

   3. c run the risk of being muddled

   4. d need to be read several times to be fully appreciated

   5. e are often confused.

It follows from 5d that you should read this paper again!