Medical Nemesis

5

Death
Against Death

 

Death as Commodity

   In every society the dominant image of death determines the prevalent concept of health.1 Such an image, the culturally conditioned anticipation of a certain event at an uncertain date, is shaped by institutional structures, deep-seated myths, and the social character that predominates. A society's image of death reveals the level of independence of its people, their personal relatedness, self-reliance, and aliveness.2 Wherever the metropolitan medical civilization has penetrated, a novel image of death has been imported. Insofar as this image depends on the new techniques and their corresponding ethos, it is supranational in character. But these very techniques are not culturally neutral; they assumed concrete shape within Western cultures and express a Western ethos. The white man's image of death has spread with medical civilization and has been a major force in cultural colonization.

   The image of a "natural death," a death which comes under medical care and finds us in good health and old age, is a quite recent ideal.3 In five hundred years it has evolved through five distinct stages, and is now ready for a sixth. Each stage has found its iconographic expression: (1) the fifteenth-century "dance of the dead"; (2) the Renaissance dance at the bidding of the skeleton man, the so-called "Dance of Death"; (3) the bedroom scene of the aging lecher under the Ancien Régime; (4) the nineteenth-century doctor in his struggle against the roaming phantoms of consumption and pestilence; (5) the mid-twentieth-century doctor who steps between the patient and his death; and (6) death under intensive hospital care. At each stage of its evolution the image of natural death has elicited a new set of responses that increasingly acquired a medical character. The history of natural death is the history of the medicalization of the struggle against death.4


The Devotional Dance of the Dead

   From the fourth century onwards, the Church struggled against a pagan tradition in which crowds, naked, frenzied, and brandishing swords, danced on the tombs in the churchyard. Nevertheless, the frequency of ecclesiastical prohibitions testifies that they were of little avail, and for a thousand years Christian churches and cemeteries remained dance floors. Death was an occasion for the renewal of life. Dancing with the dead on their tombs was an occasion for affirming the joy of being alive and a source of many erotic songs and poems.5 By the late fourteenth century, however, the sense of these dances seems to have changed:6 from an encounter between the living and those who were already dead, it was transformed into a meditative, introspective experience. In 1424 the first Dance of the Dead was painted on a cemetery wall in Paris. The original of the Cimetière des Innocents is lost, but good copies allow us to reconstruct it: king, peasant, pope, scribe, and maiden each dance with a corpse. Each partner is a mirror image of the other in dress and feature. In the shape of his body Everyman carries his own death with him and dances with it through his life. During the late Middle Ages, indwelling death7 faces man; each death comes with the symbol corresponding to his victim's rank: for the king a crown, for the peasant a pitchfork. From dancing with dead ancestors over their graves, people turned to representing a world in which everyone dances through life embracing his own mortality. Death was represented, not as an anthropomorphic figure, but as a macabre self-consciousness, a constant awareness of the gaping grave. It was not yet the skeleton man of the next century to whose music men and women will soon dance through the autumn of the Middle Ages, but rather each one's own aging and rotting self.8 At this time the mirror9 became important in everyday life, and in the grip of the "mirror of death" the "world" 10 acquired a hallucinating poignancy. With Chaucer and Villon, death becomes as intimate and sensual as pleasure and pain.

   Primitive societies conceived of death as the result of an intervention by an alien actor. They did not attribute personality to death. Death is the outcome of someone's evil intention. This somebody who causes death might be a neighbor who, in envy, looks at you with an evil eye, or it might be a witch, an ancestor who comes to pick you up, or the black cat that crosses your path.11 Throughout the Christian and Islamic Middle Ages, death continued to be regarded as the result of a deliberate personal intervention of God. No figure of "a" death appears at the deathbed, just an angel and a devil struggling over the soul escaping from the mouth of the dying. Only during the fifteenth century were the conditions ripe for a change in this image,12 and for the appearance of what would later be called a "natural death." The dance of the dead represents this readiness. Death can now become an inevitable, intrinsic part of human life, rather than the decision of a foreign agent. Death becomes autonomous and for three centuries coexists as a separate agent with the immortal soul, with divine providence, and with angels and demons.


The Danse Macabre

   In the morality plays,13 death appears in a new costume and role. By the end of the fifteenth century, no longer just a mirror image, he assumes the leading role among the "last four things," preceding judgment, heaven, and hell.14 Nor is he any longer just one of the four apocalyptic riders from Romanesque bas-reliefs, or the batlike Maegera who picks up souls from the cemetery of Pisa, or a mere messenger executing the orders of God. Death has become an independent figure who calls each man, woman, and child, first as a messenger from God but soon insisting on his own sovereign rights. By 1538 Hans Holbein the Younger15 had published the first picture-book of death, which was to become a best-seller: woodcuts on the Danse Macabre.16 The dance partners have shed their putrid flesh and turned into naked skeletons. The representation of each man as entwined with his own mortality has now changed to show his frenzied exhaustion in the grip of death painted as a force of nature. The intimate mirror-image of the "self" which had been colored by the "new devotion" of the German mystics has been replaced by a death painted as the egalitarian executioner of a law that whirls everyone along and then mows them down. From a lifelong encounter, death has turned into the event of a moment.

   During the Middle Ages eternity, together with God's presence, had been immanent in history. Now death becomes the point at which linear clock-time ends and eternity meets man. The world has ceased to be a sacrament of this presence; with Luther it became the place of corruption that God saves. The proliferation of clocks symbolizes this change in consciousness. With the predominance of serial time, concern for its exact measurement, and the recognition of the simultaneity of events, a new framework for the recognition of personal identity is manufactured. The identity of the person is sought in reference to a sequence of events rather than in the completeness of one's life span. Death ceases to be the end of a whole and becomes an interruption in the sequence.17

   Skeleton men predominate on the title pages of the first fifty years of the woodcut, as naked women now predominate on magazine covers. Death holds the hourglass or strikes the tower clock.18 Many a bell clapper was shaped like a bone. The new machine, which can make time of equal length, day and night, also puts all people under the same law. By the time of the Reformation, postmortem survival has ceased to be a transfigured continuation of life here below, and has become either a frightful punishment in the form of hell or a totally unmerited gift from God in heaven. Indwelling grace has been turned into justification by faith alone. Thus during the sixteenth century, death ceases to be conceived of primarily as a transition into the next world, and the accent is placed on the end of this life.19 The open grave looms much larger than the doors of heaven or hell and the encounter with death has become more certain than immortality, more just than king, pope, or even God. Rather than life's aim, it has become the end of life.

   The finality, imminence, and intimacy of personal death were not only part of the new sense of time but also of the emergence of a new sense of individuality. On the pilgrim's path from the Church Militant on earth to the Church Triumphant in heaven, death was experienced very much as an event that concerned both communities. Now each man faced his own and final death. Of course, once death had become such a natural force, people wanted to master it by learning the art or the skill of dying. Ars Moriendi, one of the first printed do-it-yourself manuals on the market, remained a best-seller in various versions for the next two hundred years. Many people learned to read by deciphering it. The most widely circulated version was published by Caxton at the Westminster press in 1491: over one hundred incunabula editions were made before 1500 from woodblocks and from movable type, under the title Art and Craft to knowe ye well to dye. The small folio printed in neat Gothic letters was part of a series to instruct the "complete gentleman" in "behaviour, gentle and devout," from manipulating a table knife to conducting a conversation, from the art of weeping and blowing the nose to the art of playing chess, of praying, and of dying.

   This was not a book of remote preparation for death through a virtuous life, nor a reminder to the reader of an inevitable steady decline of physical forces and the constant danger of death. It was a "how-to" book in the modern sense, a complete guide to the business of dying, a method to be learned while one was in good health and to be kept at one's fingertips for use in that inescapable hour. The book is not written for monks and ascetics but for "carnall and secular" men for whom the ministrations of the clergy were not available. It served as a model for similar instructions, often written in much less matter-of-fact spirit, by people like Savonarola, Luther, and Jeremy Taylor. Men felt responsible for the expression their face would show in death.20 Kunstler has shown that about this very time an unprecedented approach was developed in the painting of human faces: the Western portrait of countenance, which tries to represent much more than just the likeness of facial traits. The first portraits, in fact, represent princes and were executed immediately after their death, from memory, in order to render the individual, atemporal personality of the deceased ruler present at his state funeral. Early Renaissance humanists wanted to remember their dead, not as ghouls or ghosts, saints or symbols, but as a continuing, personal, historical presence.21

   In popular devotion a new kind of curiosity about the afterlife developed. Fantastic horror stories about dead bodies and artistic representations of purgatory both multiplied.22 The grotesque concern of the seventeenth century with ghosts and souls underscores the growing anxiety of a culture faced with the call of death rather than the judgment of God.23 In many parts of the Christian world the dance of death became a standard decoration in the entrance of parish churches. The Spaniards brought the skeleton man to America, where he fused with the Aztec idol of death. Their mestizo offspring,24 on its rebound to Europe, influenced the face of death throughout the Hapsburg Empire from Holland to the Tyrol. After the Reformation, European death became and remained macabre.

   Simultaneously, medical folk-practices multiplied, all designed to help people meet their death with dignity as individuals. New superstitious devices were developed so that one might recognize whether one's sickness required the acceptance of approaching death or some kind of treatment. If the flower thrown into the fountain of the sanctuary drowned, it was useless to spend money on remedies. People tried to be ready when death came, to have the steps well learned for the last dance. Remedies against a painful agony multiplied, but most of them were still to be performed under the conscious direction of the dying, who played a new role and played it consciously. Children could help a mother or father to die, but only if they did not hold them back by crying. A person was supposed to indicate when he wanted to be lowered from his bed onto the earth which would soon engulf him, and when the prayers were to start. But bystanders knew that they were to keep the doors open to make it easy for death to come, to avoid noise so as not to frighten death away, and finally to turn their eyes respectfully away from the dying man in order to leave him alone during this most personal event.25

   Neither priest nor doctor was expected to assist the poor man in typical fifteenth- and sixteenth-century death.26 In principle, medical writers recognized two opposite services the physician could perform. He could either assist healing or help the coming of an easy and speedy death. It was his duty to recognize the facies hippocratica,27 the special traits which indicated that the patient was already in the grip of death. In healing as in withdrawal, the doctor was anxious to work hand-in-glove with nature. The question whether medicine ever could "prolong" life was heatedly disputed in the medical schools of Palermo, Fez, and even Paris. Many Arab and Jewish doctors denied this power outright, and declared such an attempt to interfere with the order of nature to be blasphemous.28

   Vocational zeal tempered by philosophical resignation comes through clearly in the writings of Paracelsus.29 "Nature knows the boundaries of her course. According to her own appointed term, she confers upon each of her creatures its proper life span, so that its energies are consumed during the time that elapses between the moment of its birth and its predestined end. . . . A man's death is nothing but the end of his daily work, an expiration of air, the consummation of his innate balsamic self-curing power, the extinction of the rational light of nature, and a great separation of the three: body, soul, and spirit. Death is a return to the womb." Without excluding transcendence, death has become a natural phenomenon, no longer requiring that blame be placed on some evil agent.

   The new image of death helped to reduce the human body to an object. Up to this time, the corpse had been considered something quite unlike other things: it was treated almost like a person. The law recognized its standing: the dead could sue and be sued by the living, and criminal proceedings against the dead were common. Pope Urban VIII, who had been poisoned by his successor, was dug up, solemnly judged a simonist, had his right hand cut off, and was thrown into the Tiber. After being hanged as a thief, a man might still have his head cut off for being a traitor. The dead could also be called to witness. The widow could still repudiate her husband by putting the keys and his purse on his casket. Even today the executor acts in the name of the dead, and we still speak of the "desecration" of a grave or the secularization of a public cemetery when it is turned into a park. The appearance of natural death was necessary for the corpse to be deprived of much of its legal standing.30

   The arrival of natural death also prepared the way for new attitudes towards death and disease which became common in the late seventeenth century. During the Middle Ages, the human body had been sacred; now the physician's scalpel had access to the corpse itself.31 Its dissection had been considered by the humanist Gerson to be "a sacrilegious profanation, a useless cruelty exercised by the living against the dead."32 But at the same time that Everyman's Death began to emerge in person in the morality plays, the corpse first appeared as a teaching object in the amphitheater of the Renaissance university. When the first authorized public dissection took place in Montpellier in 1375, this new learned activity was declared obscene, and the performance could not be repeated for several years. A generation later, permission was given for one corpse a year to be dissected within the borders of the German Empire. At the University of Bologna, also, one body was dissected each year just before Christmas, and the ceremony was inaugurated by a procession, accompanied by exorcisms, and took three days. During the fifteenth century, the University of Lerida in Spain was entitled to the corpse of one criminal every three years, to be dissected in the presence of a notary assigned by the Inquisition. In England in 1540, the faculties of the universities were authorized to claim four corpses a year from the hangman. Attitudes changed so rapidly that by 1561 the Venetian Senate ordered the hangman to take instruction from Dr. Fallopius in order to provide him with corpses well suited for "anatomizing." Rembrandt painted "Dr. Tulp's Lesson" in 1632. Public dissection became a favored subject for paintings and, in the Netherlands, a common event at carnivals. The first step towards surgery on television and in the movies had been taken. The physician had advanced his knowledge of anatomy and his power to exhibit his skill, but both were disproportionate to an advance in his ability to heal. Medical rituals helped to orient, repress, or allay the fear and anguish generated by a death that had become macabre. The anatomy of Vesalius rivaled Holbein's Danse Macabre somewhat as scientific sex-guides now rival Playboy and Penthouse magazines.


Bourgeois Death

   Baroque death counterpointed an aristocratically organized heaven.33 The church vault might depict a last judgment with separate spaces reserved for savages, commoners, and nobles, but the Dance of Death beneath depicted the mower who used his scythe regardless of post or rank. Precisely because macabre equality belittled worldly privilege, it also made it more legitimate.34 However, with the rise of the bourgeois family,35 equality in death came to an end: those who could afford it began to pay to keep death away.

   Francis Bacon was the first to speak about the prolongation of life as a new task for physicians. He divided medicine into three offices: "First, the preservation of health, second, the cure of disease, and third, the prolongation of life," and extolled the "third part of medicine, regarding the prolongation of life: this is a new part, and deficient, although the most noble of all." The medical profession did not even consider facing this task, until, some one hundred and fifty years later, there appeared a host of clients who were anxious to pay for the attempt. This was a new type of rich man who refused to die in retirement and insisted on being carried away by death from natural exhaustion while still on the job. He refused to accept death unless he was in good health in an active old age. Montaigne had already ridiculed such people as exceptionally conceited: " 'Tis the last and extreme form of dying . . . what an idle conceit is it to expect to die of a decay of strength which is the effect of the extremest age, and to propose to ourselves no shorter lease on life . . . as if it were contrary to nature to see a man break his neck with a fall, be drowned by shipwreck, be snatched away with pleurisy or the plague . . . we ought to call natural death that which is general, common and universal."36 Such people were few in his time; soon their numbers would increase. The preacher expecting to go to heaven, the philosopher denying the existence of the soul, and the merchant wanting to see his capital double once more were all in agreement that the only death that accorded with nature was one which would overtake them at their desks.37

   There is no evidence to show that the age-specific life expectancy of most people in their sixties had increased by the middle of the eighteenth century, but there is no doubt that new technology had made it possible for the old and rich to hang on while doing what they had done in middle age. The pampered could stay on the job because their living and working conditions had eased. The Industrial Revolution had begun to create employment opportunities for the weak, sickly, and old. Sedentary work, hitherto rare, had come into its own.38 Rising entrepreneurship and capitalism favored the boss who had had the time to accumulate capital and experience. Roads had improved: a general affected by gout could now command a battle from his wagon, and decrepit diplomats could travel from London to Vienna or Moscow. Centralized nation-states increased the need for scribes and an enlarged bourgeoisie. The new and small class of old men had a greater chance of survival because their lives at home, on the street, and at work had become physically less demanding. Aging had become a way of capitalizing life. Years at the desk, either at the counter or the school bench, began to bear interest on the market. The young of the middle class, whether gifted or not, were now for the first time sent to school, thus allowing the old to stay on the job. The bourgeoisie who could afford to eliminate "social death" by avoiding retirement, created "childhood" to keep their young under control.39

   Along with the economic status of the old, the value of their bodily functions increased. In the sixteenth century "a young wife is death to an old man," and in the seventeenth, "old men who play with young maids dance with death." At the court of Louis XIV the old lecher was a laughingstock; by the time of the Congress of Vienna he had turned into an object of envy. To die while courting one's grandson's mistress became the symbol of a desirable end.

   A new myth about the social value of the old was developed. Primitive hunters, gatherers, and nomads had usually killed them, and peasants had put them into the back room,40 but now the patriarch appeared as a literary ideal. Wisdom was attributed to him just because of his age. It first became tolerable and then appropriate that the elderly should attend with solicitude to the rituals deemed necessary to keep up their tottering bodies. No physician was yet in attendance to take on this task, which lay beyond the competence claimed by apothecary or herbalist, barber or surgeon, university-trained doctor or traveling quack. But it was this peculiar demand that helped to create a new kind of self-styled healer.41

   Formerly, only king or pope had been under an obligation to remain in command until the day of his death. They alone consulted the faculties: the Arabs from Salerno in the Middle Ages, or the Renaissance men from Padua or Montpellier. Kings, however, kept court physicians to do what barbers did for the commoner: bleed them and purge them, and in addition, protect them from poisons. Kings neither set out to live longer than others, nor expected their personal physicians to give special dignity to their declining years. In contrast, the new class of old men saw in death the absolute price for absolute economic value.42 The aging accountant wanted a doctor who would drive away death; when the end approached, he wanted to be formally "given up" by his doctor and to be served his last repast with the special bottle reserved for the occasion. The role of the "valetudinarian" was thereby created, and with genteel decrepitude, the eighteenth-century groundwork was laid for the economic power of the contemporary physician.

   The ability to survive longer, the refusal to retire before death, and the demand for medical assistance in an incurable condition had joined forces to give rise to a new concept of sickness: the type of health to which old age could aspire. In the years just before the French Revolution this had become the health of the rich and the powerful; within a generation chronic disease became fashionable for the young and pretentious, consumptive features43 the sign of premature wisdom, and the need for travel into warm climates a claim to genius. Medical care for protracted ailments, even though they might lead to untimely death, had become a mark of distinction.

   By contrast, a reverse judgment now could be made on the ailments of the poor, and the ills from which they had always died could be defined as untreated sickness. It did not matter at all if the treatment doctors could provide for these ills had any effect on the progress of the sickness; the lack of such treatment began to mean that they were condemned to die an unnatural death, an idea that fitted the bourgeois image of the poor as uneducated and unproductive. From now on the ability to die a "natural" death was reserved to one social class: those who could afford to die as patients.

   Health became the privilege of waiting for timely death, no matter what medical service was needed for this purpose. In an earlier epoch, death had carried the hourglass. In woodcuts, both skeleton and onlooker grin when the victim refuses death. Now the middle class seized the clock and employed doctors to tell death when to strike.44 The Enlightenment attributed a new power to the doctor, without being able to verify whether or not he had acquired any new influence over the outcome of dangerous sickness.


Clinical Death

   The French Revolution marked a short interruption in the medicalization of death. Its ideologues believed that untimely death would not strike in a society built on its triple ideal. But the doctor's newly acquired clinical eyeglasses made him look at death in a new perspective. Whereas the merchants of the eighteenth century had determined the outlook on death with the help of the charlatans they employed and paid, now the clinicians began to shape the public's vision. We have seen death turn from God's call into a "natural" event and later into a "force of nature"; in a further mutation it had turned into an "untimely" event when it came to those who were not both healthy and old. Now it had become the outcome of specific diseases certified by the doctor.45

   Death had paled into a metaphorical figure, and killer diseases had taken his place. The general force of nature that had been celebrated as "death" had turned into a host of specific causations of clinical demise. Many "deaths" now roamed the world. A number of book plates from private libraries of late nineteenth-century physicians show the doctor battling with personified diseases at the bedside of his patient. The hope of doctors to control the outcome of specific diseases gave rise to the myth that they had power over death. The new powers attributed to the profession gave rise to the new status of the clinician.46

   While the city physician became a clinician, the country physician became first sedentary and then a member of the local elite. At the time of the French Revolution he had still belonged to the traveling folk. The surplus of army surgeons from the Napoleonic wars came home with a vast experience, looking for a living. Military men trained on the battlefield, they soon became the first resident healers in France, Italy, and Germany. The simple people did not quite trust their techniques and staid burghers were shocked by their rough ways, but still they found clients because of their reputation among veterans of the Napoleonic wars. They sent their sons to the new medical schools springing up in the cities, and these upon their return created the role of the country doctor, which remained unchanged up to the time of World War II. They derived a steady income from playing the family doctor to the middle class who could well afford them. A few of the city or town rich acquired prestige by living as patients of famous clinicians, but in the early nineteenth century a much more serious competition for the town doctor still came from the medical technicians of old—the midwife, the tooth-puller, the veterinarian, the barber, and sometimes the public nurse. Notwithstanding the newness of his role and resistance to it from above and below, the European country doctor, by mid-century, had become a member of the middle class. He earned enough from playing lackey to a squire, was family friend to other notables, paid occasional visits to the lowly sick, and sent his complicated cases to his clinical colleague in town. While "timely" death had originated in the emerging class consciousness of the bourgeois, "clinical" death originated in the emerging professional consciousness of the new, scientifically trained doctor. Henceforth, a timely death with clinical symptoms became the ideal of middle-class doctors,47 and it was soon to become incorporated into the aspirations of trade unions.


Trade Union Claims to a Natural Death

   In our century a valetudinarian's death while undergoing treatment by clinically trained doctors came to be perceived, for the first time, as a civil right. Old-age medical care was written into union contracts. The capitalist privilege of natural extinction from exhaustion in a director's chair gave way to the proletarian demand for health services during retirement. The bourgeois hope of continuing as a dirty old man in the office was ousted by the dream of an active sex life on social security in a retirement village. Lifelong care for every clinical condition soon became a peremptory demand for access to a natural death. Lifelong institutional medical care had become a service that society owed all its members.

   "Natural death" now appeared in dictionaries. One major German encyclopedia published in 1909 defines it by means of contrast: "Abnormal death is opposed to natural death because it results from sickness, violence, or mechanical and chronic disturbances." A reputable dictionary of philosophical concepts states that "natural death comes without previous sickness, without definable specific cause." It was this macabre hallucinatory death-concept that became intertwined with the concept of social progress. Legally valid claims to equality in clinical death spread the contradictions of bourgeois individualism among the working class. The right to a natural death was formulated as a claim to equal consumption of medical services, rather than as a freedom from the evils of industrial work or as a new liberty and power for self-care. This unionized concept of an "equal clinical death" is thus the inverse of the ideal proposed in the National Assembly of Paris in 1792: it is a deeply medicalized ideal.

   First of all, this new image of death endorses new levels of social control. Society has become responsible for preventing each man's death: treatment, effective or not, can be made into a duty. Any fatality occurring without medical treatment is liable to become a coroner's case. The encounter with a doctor becomes almost as inexorable as the encounter with death. I know of a woman who tried, unsuccessfully, to kill herself. She was brought to the hospital in a coma, with a bullet lodged in her spine. Using heroic measures the surgeon kept her alive, and he considers her case a success: she lives, but she is totally paralyzed; he no longer has to worry about her ever attempting suicide again.

   Our new image of death also befits the industrial ethos.48 The good death has irrevocably become that of the standard consumer of medical care. Just as at the turn of the century all men were defined as pupils, born into original stupidity and standing in need of eight years of schooling before they could enter productive life, today they are stamped from birth as patients who need all kinds of treatment if they want to lead life the right way. Just as compulsory educational consumption came to be used as a device to obviate concern about work, so medical consumption became a device to alleviate unhealthy work, dirty cities, and nerve-racking transportation.49 What need is there to worry about a murderous environment when doctors are industrially equipped to act as life-savers!

   Finally, "death under compulsory care" encourages the re-emergence of the most primitive delusions about the causes of death. As we have seen, primitive people do not die of their own death, they do not carry finitude in their bones, and they are still close to the subjective immortality of the beast. Among them, death always requires a supernatural explanation, somebody to blame: the curse of an enemy, the spell of a magician, the breaking of the yarn in the hands of the Parcae, or God dispatching his angel of death. In the dance with his or her mirror-image, European death emerged as an agent independent of another's will, an inexorable force of nature that men and women had to face on their own. The imminence of death was an exquisite and constant reminder of the fragility and tenderness of life. During the late Middle Ages, the discovery of "natural" death became one of the mainsprings of European lyric and drama. But the same imminence of death, once perceived as an extrinsic threat coming from nature, became a major challenge for the emerging engineer. If the civil engineer had learned to manage earth, and the pedagogue-become-educator to manage knowledge, why should the biologist-physician not manage death? 50 When the doctor contrived to step between humanity and death, the latter lost the immediacy and intimacy gained four hundred years earlier. Death that had lost face and shape had lost its dignity.

   The change in the doctor-death relationship can be well illustrated by following the iconographic treatment of this theme.51 In the age of the Dance of Death, the physician is rare. In the only picture I have located in which death treats the doctor as a colleague, he has taken an old man by one hand, while in the other he carries a glass of urine, and seems to be asking the physician to confirm his diagnosis. In the age of the Dance of Death, the skeleton man makes the doctor the main butt of his jokes. In the earlier period, while death still wore some flesh, he asks the doctor to confirm in the latter's own mirror-image what he thought he knew about man's innards. Later, as a fleshless skeleton, he teases the doctor about his impotence, jokes about or rejects his honoraria, offers medicine as pernicious as that the physician dispensed, and treats the doctor as just one more common mortal by snatching him into the dance. Baroque death seems to intrude constantly into the doctor's activities, making fun of him while he sells his wares at a fair, interrupting his consultation, transforming his medicine bottles into hourglasses, or taking the doctor's place on a visit to the pesthouse. In the eighteenth century a new motif appears: death seems to enjoy teasing the physician about his pessimistic diagnoses, abandoning those sick persons whom the doctor has condemned, and dragging the doctor off to the tomb while leaving the patient alive. Until the nineteenth century, death deals always with the doctor or with the sick, usually taking the initiative in the action. The contestants are at opposite ends of the sickbed. Only after clinical sickness and clinical death had developed considerably do we find the first pictures in which the doctor assumes the initiative and interposes himself between his patient and death. We have to wait until after World War I before we see physicians wrangling with the skeleton, tearing a young woman from its embrace, and wresting the scythe from death's hand. By 1930 a smiling white-coated man is rushing against a whimpering skeleton and crushing it like a fly with two volumes of Marle's Lexicon of Therapy. In other pictures, the doctor raises one hand and wards off death while holding up the arms of a young woman whom death grips by the feet. Max Klinger represents the physician clipping the feathers of a winged giant. Others show the physician locking the skeleton into prison or even kicking its bony bottom. Now the doctor rather than the patient struggles with death. As in primitive cultures, somebody can again be blamed when death triumphs. This somebody is no longer a person with the face of a witch, an ancestor, or a god, but the enemy in the shape of a social force.52 Today, when defense against death is included in social security, the culprit lurks within society. The culprit might be the class enemy who deprives the worker of sufficient medical care, the doctor who refuses to make a night visit, the multinational concern that raises the price of medicine, the capitalist or revisionist government that has lost control over its medicine men, or the administrator who partly trains physicians at the University of Delhi and then drains them off to London. The witch-hunt that was traditional at the death of a tribal chief is being modernized. For every premature or clinically unnecessary death, somebody or some body can be found who irresponsibly delayed or prevented a medical intervention.

   Much of the progress of social legislation during the first half of the twentieth century would have been impossible without the revolutionary use of such an industrially graven death-image. Neither the support necessary to agitate for such legislation nor guilt feelings strong enough to enforce its enactment could have been aroused. But the claim to equal medical nurturing towards an equal kind of death has also served to consolidate the dependence of our contemporaries on a limitlessly expanding industrial system.


Death Under Intensive Care

   We cannot fully understand the deeply rooted structure of our social organization unless we see in it a multifaceted exorcism of all forms of evil death. Our major institutions constitute a gigantic defense program waging war on behalf of "humanity" against death-dealing agencies and classes.53 This is a total war. Not only medicine but also welfare, international relief, and development programs are enlisted in this struggle. Ideological bureaucracies of all colors join the crusade. Revolution, repression, and even civil and international wars are justified in order to defeat the dictators or capitalists who can be blamed for the wanton creation and tolerance of sickness and death.54

   Curiously, death became the enemy to be defeated at precisely the moment at which megadeath came upon the scene. Not only the image of "unnecessary" death is new, but also our image of the end of the world.55 Death, the end of my world, and apocalypse, the end of the world, are intimately related; our attitude towards both has clearly been deeply affected by the atomic situation. The apocalypse has ceased to be just a mythological conjecture and has become a real contingency. Instead of being due to the will of God, or man's guilt, or the laws of nature, Armageddon has become a possible consequence of man's direct decision. Cobalt, like hydrogen bombs, creates an illusion of control over death. Medicalized social rituals represent one aspect of social control by means of the self-frustrating war against death.

   Malinowski56 has argued that death among primitive people threatens the cohesion and therefore the survival of the whole group. It triggers an explosion of fear and irrational expressions of defense. Group solidarity is saved by making out of the natural event a social ritual. The death of a member thereby becomes an occasion for an exceptional celebration. The dominance of industry has disrupted and often dissolved most traditional bonds of solidarity. The impersonal rituals of industrialized medicine create an ersatz unity of mankind. They tie all its members into a pattern of "desirable" death by proposing hospital death as the goal of economic development. The myth of progress of all people towards the same kind of death diminishes the feeling of guilt on the part of the "haves" by transforming the ugly deaths that the "have-nots" die into the result of present underdevelopment, which ought to be remedied by further expansion of medical institutions.

   Of course, medicalized 57 death has a different function in highly industrialized societies than it has in mainly rural nations. Within an industrial society, medical intervention in everyday life does not change the prevailing image of health and death, but rather caters to it. It diffuses the death-image of the medicalized elite among the masses and reproduces it for future generations. But when "death prevention" is applied outside of a cultural context in which consumers religiously prepare themselves for hospital deaths, the growth of hospital-based medicine inevitably constitutes a form of imperialist intervention. A sociopolitical image of death is imposed; people are deprived of their traditional vision of what constitutes health and death. The self-image that gives cohesion to their culture is dissolved, and atomized individuals can now be incorporated into an international mass of highly "socialized" health consumers. The expectation of medicalized death hooks the rich on unlimited insurance payments and lures the poor into a gilded deathtrap. The contradictions of bourgeois individualism are corroborated by the inability of people to die with any possibility of a realistic attitude towards death.58 The customs man guarding the frontier between Upper Volta and Mali explained to me this importance of death in relation to health. I wanted to know from him how people along the Niger could understand each other, though almost every village spoke a different tongue. For him this had nothing to do with language: "As long as people cut the prepuce of their boys the way we do, and die our death, we can understand them well."

   In many a village in Mexico I have seen what happens when social security arrives. For a generation people continue in their traditional beliefs; they know how to deal with death, dying, and grief.59 The new nurse and the doctor, thinking they know better, teach them about an evil pantheon of clinical deaths, each one of which can be banned, at a price. Instead of modernizing people's skills for self-care, they preach the ideal of hospital death. By their ministration they urge the peasants to an unending search for the good death of international description, a search that will keep them consumers forever.

   Like all other major rituals of industrial society, medicine in practice takes the form of a game. The chief function of the physician becomes that of an umpire. He is the agent or representative of the social body, with the duty to make sure that everyone plays the game according to the rules.60 The rules, of course, forbid leaving the game and dying in any fashion that has not been specified by the umpire. Death no longer occurs except as the self-fulfilling prophecy of the medicine man.61

   Through the medicalization of death, health care has become a monolithic world religion62 whose tenets are taught in compulsory schools and whose ethical rules are applied to a bureaucratic restructuring of the environment: sex has become a subject in the syllabus and sharing one's spoon is discouraged for the sake of hygiene. The struggle against death, which dominates the life-style of the rich, is translated by development agencies into a set of rules by which the poor of the earth shall be forced to conduct themselves.

   Only a culture that evolved in highly industrialized societies could possibly have called forth the commercialization of the death-image that I have just described. In its extreme form, "natural death" is now that point at which the human organism refuses any further input of treatment. People63 die when the electroencephalogram indicates that their brain waves have flattened out: they do not take a last breath, or die because their heart stops. Socially approved death happens when man has become useless not only as a producer but also as a consumer. It is the point at which a consumer, trained at great expense, must finally be written off as a total loss. Dying has become the ultimate form of consumer resistance.64

   Traditionally the person best protected from death was the one whom society had condemned to die. Society felt threatened that the man on Death Row might use his tie to hang himself. Authority might be challenged if he took his life before the appointed hour. Today, the man best protected against setting the stage for his own dying is the sick person in critical condition. Society, acting through the medical system, decides when and after what indignities and mutilations he shall die.65 The medicalization of society has brought the epoch of natural death to an end. Western man has lost the right to preside at his act of dying. Health, or the autonomous power to cope, has been expropriated down to the last breath. Technical death has won its victory over dying.66 Mechanical death has conquered and destroyed all other deaths.

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   1 Robert G. Olson, "Death," in Encyclopedia of Philosophy, ed. P. Edwards (New York: Macmillan, 1967), 2:307-9, gives a short and lucid introduction to the knowledge of death and of the fear of death. Herman Feifel, ed., The Meaning of Death (New York: McGraw-Hill, 1959), gave a major impetus to the psychological research on death in the U.S. Robert Fulton, ed., Death and Identity (New York: Wiley, 1965), is an outstanding anthology of short contributions which together reflect the stage of English-language research in 1965. Paul Landsberg, Essai sur l'expérience de la mart, suivi de Problème moral de suicide (Paris: Seuil, 1951), is a classic analysis. José Echeverria, Réflexions métaphysiques sur la mart et le problème du sujet (Paris: J. Vrin, 1957), is a lucid attempt at a phenomenology of death. Christian von Ferber, "Soziologische Aspekte des Todes: Ein Versuch über einige Beziehungen der Soziologie zur philosophischen Anthropologie," Zeitschrift für evangelische Ethnik 7 (1963): 338-60. A strong argument to render death again a serious public problem. The author believes that death repressed, rendered private and a matter for professionals only, reinforces the exploitative class structure of society. A very important article. See also Vladimir Jankelevitch, La mort (Paris: Flammarion, 1966), and Edgar Morin, L'Homme et la mart (Paris-Seuil, 1970).

   2 For the study of the antique death-image in our general context, the following are useful: Fielding H. Garrison, "The Grfeek Cult of the Dead and the Chthonian Deities in Ancient Medicine," Annals of Medical History 1 (1917): 35-53. Alice Walton, The Cult of Asklepios, Cornell Studies in Classical Philology no. 3 (1894; reprint ed., New York: Johnson Reprint Corp., 1965). Ernst Benz, Das Todesproblem in der stoischen Philosophic (Stuttgart: Kohlhammer, 1929), XI, Tübinger Beiträge zur Altertumswiss. 7. Ludwig Wachter, Der Tod im alien Testament (Stuttgart: Calwer, 1967). Jocelyn Mary Catherine Toynbee, Death and Burial in the Roman World (London: Thames & Hudson, 1971). K. Sauer, Untersuchungen zur Darstellung des Todes in der griechisch-römischen Geschichtsschreibung (Frankfurt, 1930). J. Kroll, "Tod und Teufel in der Antike," Verhandlungm der Versammlung deutscher Philologen 56 (1926). Hugo Blummer, "Die Schilderang des Sterbens in der griechischen Dichtkunst," Neue Jahrbücher des klassischen Altertums, 1917, pp. 499-512.

   3 This chapter leans heavily on the masterful essays by Philippe Aries: "Le Culte des morts à 1'époque moderne," Revue de I'Académie des Sciences morales et politiques, 1967, pp. 25-40; "La Mort inversée: Le Changement des attitudes devant la mort dans les sociétés occidentales," Archives europeennes de sociologie 8, no. 2 (1967); "La Vie et la mort chez les français d'aujourd'hui," Ethnopsychologie 27 (March 1972): 39-44; "La Mort et le mourant dans notre civilisation," Revue française de sociologie 14 (January-March 1973); "Les Techniques de la mort," in Histoire des populations françaises el de leurs attitudes devant la vie depuis le XVIIIe siècle (1948; Paris: Seuil, 1971), pp. 373-98. A synopsis in English: Philippe Aries, Western Attitudes Towards Death: From the Middle Ages to the Present, trans. Patricia Ranum (Baltimore: Johns Hopkins, 1974; London: Marion Boyars, 1976). "La Mort inversee" appeared in a translation by Bernard Murchland as "Death Inside Out" in Hastings Center Studies 2 (May 1974): 3-18 (the bibliography is absent from the translation).

   4 In this chapter I am interested, above all, in the image of "natural death." I am using the term "natural death" because I find it widely used between the sixteenth and early twentieth centuries. I oppose it to "primitive death," which comes through the activities of some fey, eerie, supernatural, or divine agent, and to "contemporary death," which more often than not is conceived as a result of a social injustice, as the outcome of class struggle or of imperial domination. I am interested in the image of this natural death, and its evolution during the four centuries in which it was common in Western civilizations. I owe the idea of approaching my subject in this way to Werner Fuchs, Todesbilder in der modernen Gesellschaft (Frankfurt: Suhrkamp, 1969). On my disagreement with the author, see note 54, p. 202 below.

   5 Thomas Ohm, Die Gebetsgebärden der Völker und das Christentum (Leiden: Brill, 1948), pp. 372 ff., especially pp. 389-90, collects evidence on dances held in cemeteries and the struggle of the church authorities against them. A medical history of Occidental religious choreomania: E. L. Backman, Religious Dances in the Christian Church and in Popular Medicine (Stockholm, 1948); trans. E. Classen (London: Alien & Unwin, 1952). A bibliography of the religious aspects of dancing: Emile Bertaud, "Danse religieuse," in Dictionnaire de spiritualité, fascicles 18-19, pp. 21-37. A. Schimmel, "Tanz: I. Religiongeschichtlich," in Die Religion in Geschichte und Gegenwart (Tübingen: 1962), 6:612-14: For the history of dances in or around Christian churches, see L. Gougaud, "La Danse dans les églises," Revue d'histoire ecclésiastique 15 (1914): 5-22, 229-45. J. Baloch, "Tänze in Kirche und Kirchhöfen," Niederdeutsche Zeitschrifi für Volkskunde, 1928. H. Spanke, "Tanzmusik in der Kirche des Mittelalters," Neuphilosophische Mitteilungen 31 (1930). Germanic precedents to Christian cemetery dances: Richard Wolfram, Schwerttanz und Männerbund (Kassel: Barenreiter, 1937); only partly in print. Werner Danckert, "Totengräber," in Unehrliche Leute: Die verfehmten Berufe (Bern: Francke, 1963), pp. 50-6.

   6 Johan Huizinga, "The Vision of Death," in The Waning of the Middle Ages: A Study of the Forms of Life, Art, and Thought in France and the Netherlands in the XlVth and XVth Centuries (New York: St. Martin, 1924), chap. 11, pp. 124-35.

  7 Gerhart B. Ladner, The Idea of Reform: Its Impact on Christian Thought and Action in the Age of the Fathers (Cambridge: Harvard Univ. Press, 1959). Consult p. 163 for the two currents within the Church about the relation of death to nature since the fourth century. For Pelagius death was not a punishment for sin, and Adam would have died even had he not sinned. In this he differs from Augustine's doctrine that Adam had been given immortality as a special gift from God, and even more from those Greek Church Fathers according to whom Adam had a spiritual, or "resurrectional," body before he transgressed.

   8 So far the deceased had appeared ageless on his funeral monument. He now appears as a decaying corpse. Kathleen Cohen, Metamorphosis of a Death Symbol: The Transi-Tomb in the Late Middle Ages and the Renaissance (Los Angeles: Univ. of California Press, 1973). Gruesome tombs meant to teach the living appear first in the last years of the 14th century. J. P. Hornung, Ein Beitrag zur Ikonographie des Todes, dissertation, Univ. of Freiburg, 1902. The encounter between the living and the dead takes on importance in a new literary genre: Stefan Glixelli, Les Cinq Poèmes des trois marts et des trois mfs (Paris: H. Champion, 1914); J. S. Egilsrud, Le Dialogue des marts dans les littératures française, allemande et anglaise (Paris: L'Entente linotypiste, 1934); Kaulfuss-Diesch, "Totengespräche," in Reallexikon der deutschen Literaturgeschichte, 3:379 ff.; and finds a new visual expression: Karl Kunstle, Die Legende der drei Lebenden und der drei Toten (Freiburg: Herder, 1908); Willy Rotzler, Die Begegnung der drei Lebenden und der drei Toten: Ein Beitrag zur Forschung über mittelalterliche Verganglichkeitsdarstellung (Wintertur: Keller, 1961); Pierre Michault, Pas de la mart, ed. Jules Petit (Société des Bibliophiles de Belgique, 1869); Albert Freybe, Das memento mori in deutscher Sitte, bildlicher Darstellung und Volksglauben, deutsche Sprache, Dichtung und Seelsorge (Gotha: Perthes, 1909). The fact that around 1500 death assumes strong skeletal features and a new autonomy does not mean that it had not always borne anthropomorphic features, if not in art, then in legend and poetry. Paul Geiger, "Tod: 4. Der Tod als Person," in Handwörterbuch des deutschen Aberglaubens (Berlin: W. de Gruyter, 1927-42), 8:976-85.

   9 The one great book on the mirror in painting is G. F. Hartlaub, Zauber des Spiegels: Geschichte und Bedeutung des Spiegels in der Kunst (Munich: Piper, 1951). Chap. 7, sec. iii, "Spiegel der Vanitas," deals particularly with the mirror as reminder of transitoriness. See also G. F. Hartlaub, "Die Spiegel-bilder des Giovanni Bellini," Pantheon 15 (November 1942): 235-41. The interpretation of Bellini's use of the mirror to depict the intensity of the new awareness of the ambiguity of human anatomy. Henrich Schwarz, "The Mirror in Art," Art Quarterly 15 (1952): 96-118. Specifically on "vanity."

   10 Wolfgang Stammler, Frau Welt: Eine mittelalterliche Allegoric, Freiburger Universitatsreden, 1959. The "world" depicted as a female figure in medieval art—half angel, half demon—represents the power of this-worldly goods, the beauty of nature, but also the decay of all that is human.

   11 For a bibliography on attitudes towards death among primitive people, see Edgar Herzog, Psyche and Death: Archaic Myths and Modem Dreams in Analytical Psychology (New York: Putnam, 1967). Primitive death is always conceived of as the result of intervention by an agent. For the purposes of my argument, the nature of this agent is unimportant. Though dated, Robert Hertz, "Contribution a une étude sur la représentation collective de la mort," L'Année sociologique 10 (1905-1906): 48-137, remains the best repository for older literature on this point. Complement with E. S. Hartland et al., "Death and the Disposal of the Dead," in Encyclopaedia of Religion and Ethics (1925-32), 4:411-511. Rosalind Moss, The Life After Death in Oceania and the Malay Archipelago (1925; Ann Arbor, Mich.: University Microfilms, 1972), shows that the burial forms tend to influence beliefs about the cause of death and the nature of the afterlife. Hans Kelsen, "Seele und Recht," in Aufsätze zur Ideologiekritik (Neuwied/Berlin: Luchterhand, 1964), suggests that the universal fear of murderous ancestors underpins social control. Consult also the following works by James George Frazer: Man, God and Immortality (London: MacMillan, 1927); The Belief in Immortality and the Worship of the Dead, vol. 1, The Belief Among the Aborigines of Australia, the Torres Straits Islands, New Guinea and Melanesia (1911; reprint ed., New York: Barnes & Noble, 1968); The Fear of the Dead in Primitive Religion (New York: Biblo & Tannen, 1933). Also Claude Lévi-Strauss, The Savage Mind (Chicago: Univ. of Chicago Press, 1966), especially pp. 30-3, 237-52. Sigmund Freud, Totem and Taboo (New York: Norton, 1952).

   12 Robert Bossuat, Manuel bibliographique de la littérature française du moyen âge (Melun: Librairie d'Argences, 1951), "Danse macabre," nos. 3577-80, 7013.

   13 For the evolution of the Jederman motif see H. Lindner, Hugo van Hqffinannstahls "Jederman" und seine Vorgänger, dissertation, Univ. of Leipzig, 1928.

   14 Alberto Tenenti, // senso delta morte e I'amore nella vita del Rinascimento (Turin: Einaudi, 1957). Alberto Tenenti, La Vie et la mart è travers l'art du XVe siècle (Paris: Colin, 1962).

   15 Hans Holbein the Younger, The Dance of Death: A Complete Facsimile of the Original 1538 Edition of Les Simulachres et histoiresfaces de la mort (New York: Dover, 1971).

   16 Walter Rehm, Der Todesgedanke in der deutschen Dichtung vom Mittelalter bis zur Romantik (Tübingen: Niemeyer, 1967), gives evidence of a major change in the image of death in literature around the year 1400 and then again around 1520. See also Edelgard Dubruck, The Theme of Death in French Poetry of the Middle Ages and the Renaissance (Atlantic Highlands, N.J.: Humanities Press, 1965), and L. P. Kurtz, The Dance of Death and the Macabre Spirit in European Literature (New York: Institute of French Studies, 1934). For the new death image of the rising middle classes of the late Middle Ages see Erna Hirsch, Tod und Jenseits im Spämittelalter: Zugleich tin Beitrag zur Kulturgeschichte des deutschen Búrgertums, dissertation, Univ. of Marburg (Berlin, 1927). Specifically on the Dance of Death: Hellmut Rosenfeld, Der mittelalterliche Totentanz: Entstehung, Entwicklung, Bedeutung (Münster Koln: Bohlau, 1954), illustrated. Hellmut Rosenfeld, "Der Totentanz in Deutschland, Frankreich und Italien," Littérature Modeme 5 (1954): 62-80. Rosenfeld is the best introduction to the research and gives a detailed up-to-date bibliography. For older literature complement with H. F. Massman, Literatur der Totentänze (Leipzig: Weipel, 1840). See also Gert Buchheit, Der Totentänz, seine Entstehung und Entwicklung (Berlin: Horen, 1928), Wolfgang Stammler, Die Totentänze des Mittelalters (Munich: Stobbe, 1922), and James M. Clark, The Dance of Death in the Middle Ages and the Renaissance (Glasgow: Jackson, 1950). Stephen P. Kosaky's three volumes: Geschichte der Totentänze, vol. ). Lieferung: Anfänge der Darstellungen des Vergänglichkeitsproblems; vol. 2, Lieferung: Danse macabre Einleitung: Die Todes-didaktik der Vortotentanzzeit; vol. 3, Lieferung: Der Totentanz van heute, Bibliotheca Humanitatis Historica, vols. 1, 5, and 7 (Budapest: Magyar Torteniti Muzeum, 1936-44), contains a mine of information, quotations from ancient texts, and nearly 700 pictures (greatly reduced and badly reproduced) of the Dance of Death up to World War II. J. Saugnieux, L'Iconographie de la mort chez les graveurs françalis du XVe siècle (1974), and Danses macabres de France et d'Espagne et leurs prolongements littéraires, fasc. 30, Bibliothèque de la Faculté des Lettres de Lyon (Paris: Les Belles Lettres, 1972). Dietrich Briesenmeister, Bilder des Todes (Unterscheidheim: W. Elf, 1970): reproductions are very clear and are organized according to different themes. Consult the standard iconographies on Western Christian art: Karl Kunstle, Ikonographie der christlicher Kunst, 2 vols. (Freiburg: Herder, 1926-28); Emile Male, L'Art religieux a la fin du moyen âge en France: Étude sur I'iconographie du moyen âge et sur ses sources d'inspiration (Paris: Colin, 1908), vol. 1, chap. 2, "La Mort," p. 346 (see also the three other volumes on religious art in France). Compare Eastern iconography (Mount Athos): Dionysios of Fourna, Manuel d'iconographie chrétienne, grècque et latine, with introduction and notes by A. N. Didron, trans. by P. Durand from a Byzantine manuscript (1845; reprint ed., New York: B. Franklin, 1963). T. S. R. Boase, Death in the Middle Ages: Mortality, Judgement and Remembrance (New York: McGraw-Hill, 1972).

   17 See Helmuth Plessner, "On the Relation of Time to Death," in Joseph Campbell, ed., Papers from the Eranos Yearbooks, vol. 3, Man and Time, Bollingen Series XXX (Princeton, N.J.: Princeton Univ. Press, 1957), pp. 233-63, especially p. 255. On the impact of time on the French death-image, see Richard Glasser, Time in French Life and Thought, trans. C. G. Pearson (Manchester: University Press, 1972), in particular p. 158 and chap. 3, "The Concept of Time in the Later Middle Ages," pp. 70-132. On the growing impact of time consciousness on the sense of finitude and death, see Alois Hahn, Einstellungen zum Tod und ihre soziale Bedingtheit: Eine soziologische Untersuchung (Stuttgart: Enke, 1968), especially pp. 21-84. Joost A. M. Keerloo, "The Time Sense in Psychiatry," in J. T. Eraser, ed., The Voices of Time (New York: Braziller, 1966), pp. 235-52, Siegfried Giedion, Space, Time and Architecture: The Growth of a New Tradition, 4th ed. (Cambridge, Mass.: Harvard Unv. Press, 1962).

   18Jurgis Baltrusaitis, Le Moyen Age fantastic/tie: Antiquités et exotisme dans I'art gothique (Paris: Colin, 1955).

   19 Martin Luther, interpretation of Psalm 90, WA 40/III: 485 ff.

   20 The response to "natural" death was a profound transformation of behavior at the hour of death. For contemporary literature, see Mary Catherine O'Connor, The Art of Dying Well: The Development of the Ars Morimdi (New York: AMS Press, 1966). L. Klein, Die Bereitung zwn Sterben: Studim zu den evangelischen Sterbebüchem des 16. Jahrhunderts, dissertation, Univ. of Göttingen, 1958. For customs see Placidus Berger, "Religiöser Brauchtum im Umkreis der Sterbelitur-gie in Deutschland," Zeitschrift fur Missionswissenschaft und Religionswissenschqft 5 (1948): 108-248. See also Manfred Bambeck, "Tod und Unsterblichkeit: Studien zum Lebensgefühl der französischen Renaissance nach dern Werke Ronsarde," ms. dissertation, Univ. of Frankfurt, 1954. Hildegard Reifschneider, "Die Vorstellung des Todes und des Jenseits in der geistlichen Literatur des XII Jh.," ms. dissertation, Univ. of Tübingen, 1948. Eberhard Klass, Die Schilderung des Sterbens im mittelhochedeutscken Epos: Ein Beitrag zur mittelhochdeutschen Stilgeschichte, dissertation, Univ. of Greifswald, 1931.

   21 Gustav Kunstler, "Das Bildnis Rudolf des Stifters, Herzogs von Österreich, und seine Funktion," excerpt from Mitteilungen der Osterreichischen Galerie 1972 (Vienna: Kunsthistoriches Museum, 1972), about the very first such portrait.

   22 G. and M. Vovelle, "La Mort et 1'au-delà en Provence d'après les autels des âmes du purgatoire: XVe-XXe siècles," Cahiers des Annales 29 (1970): 1602-34. Howard R. Patch, The Other World According to Descriptions in Medieval Literature (Cambridge, Mass.: Harvard Univ. Press, 1950).

   23 For the "judgment" in the history of religions, see Sources Orientales, Le Jugement des morts (Paris: Seuil, 1962); Leopold Kretzenbacher, Die Seelenwaage: Zur religiösen Idee vom Jenseitsgericht aufder Schicksalwaage in Hochreligion, Bildkunst und Volksglaube (Klagenfurt: Landesmuseums fur Karten, 1958).

   24 Merlin H. Forster, ed., La muerte en la poesía mexicana: Prológo y selectión de Merlin Forster (Mexico: Editorial Diogenes, 1970). Emir Rodriguez Monegal, "Death as a Key to Mexican Reality in the Works of Octavio Paz," mimeographed, Yale Univ., n.d. (about 1973).

   25 In rural areas these customs live on: Arnold van Gennep, Manuel de folklore français contemporain, vol. 1, Du berceau à la tombe (Paris: Picard, 1943-46). Lenz Kriss-Rettenbeck, "Tod und Heilserwartung," in Bilder und Zeichen religtosen Volksglaubms (Munich: Callwey, 1963), pp. 49-56. See articles by Paul Geiger, on "Sterbegaläute," "Sterben," "Sterbender," "Sterbekerze," "Tod," "Tod ansagen," "Tote (der)," "Totenbahre," in Handwörterbuch des deutschen Aberglaubens (Berlin: W. de Gruyter, 1936-37), vol. 8. Albert Freybe, Das alte deutsche Leichmmahl in seiner Art und Entartung (Gütersloh: Bertelsmann, 1909), pp. 5-86.

   26 For an introduction to the function of the Catholic priest at the deathbed, see C. Ruch, "Extrême onction," in Dictionnaire de Théologie Catholique (1939), 5, pt. 2:1927-85. Henri Rondet, "Extrême onction," in Dictionnaire de Sfriritualité (1960), 4:2189-2200.

   27 Magnus Schmid, "Zum Phänomen der Leiblichkeit in der Antike darges-tellt an der 'Facies Hippocratica,' " Sudhoffs Archiv, suppl. 7, 1966, pp. 168-77. Karl Sudhoff, "Eine kleine deutsche Todesprognostik," Archiv für Geschichte der Medizin 5 (1911): 240, and "Abermal eine deutsche Lebens- und Todesprognostic," ibid., 6 (1911): 231.

   28 Joshua O. Leibowitz, "A Responsum of Maimonides Concerning the Termination of Life," Koroth (Jerusalem) 5 (September 1963): 1-2.

   29 Paracelsus, Selected Writings, trans. Norbert Guterman, Bollingen Series XXVIII (Princeton, N.J.: Princeton Univ. Press, 1969).

   30 Heinrich Brunner, Deutsche Rechtsgeschichte (Berlin: Von Duncker & Hum-bolt, 1961), 1:254 ff. Paul Fischer, Strafm und sichemde Massnahmen gegen Tote im germanischen und deutschen Recht (Düsseldorf: Nolte, 1936). H. Fehr, "Tod und Teufel im alten Recht," Zeitschrift der Savigny Stiftung fur Rechtsgeschichte 67 (1950): 50-75. Paul Geiger, "Leiche," in Handwörterbuch des deutschen Aberglaubens (Berlin: W. de Gruyter, 1932-33), vol. 5. Karl König, "Die Behandlung der Toten in Frankreich im späteren Mittelalter und zu Beginn der Neuzeit (1350-1550)," ms. dissertation, Univ. of Leipzig, 1921. Hans von Hentig, Der nekrotrope Mensch: Vom Totenglauben zur morbiden Totennähe (Stuttgart: Enke, 1964). Paul-J. Doll, "Les Droits de la science après la mort," Diogène, no. 75, July-September 1971, pp. 124-42.

   31 The contrast appears clearly when Loren C. MacKinney, Medical Illustrations in Medieval Manuscripts (Berkeley: Univ. of California Press, 1965), is compared with Millard Meiss, Painting in Florence and Siena after the Black Death: The Arts, Religion and Society in the Mid-Fourteenth Century (Princeton, N.J.: Princeton Univ. Press, 1951). Art, liberated from the need to represent dogma, now shows the human figure, its actions, and even the dead things which surround it as intimately interwoven in the representation of the fleeting moment (Vergänglichkeit).

   32 Maurice Bariety and Charles Coury, "La Dissection," in Histoire de la médecine (Paris: Fayard, 1963), pp. 409-11.

   33 Hermann Bauer, Der Himmel in Rokoko: Das Fresko im deutschen Kirchmraum in 18. Jahrhundert (Munich: Pustet, 1965).

   34 Reflection of death in 17th and 18th century literature: Richard Sexau, Der Tod in deutschen Drama des 17. und 18. Jahrhunderts: Van Griphius bis zum Sturm und Drang (Bern: Francke, 1906). Friedrich-Wilhelm Eggebert, Das Problem des Todes in der deutschen Lyrik des 17. Jahrhunderts (Leipzig, 1931). W. M. Thompson, Der Tod in der englische Lyrik des 17. Jahrhunderts (Breslau: Priebatsch, 1935).

   35 Ariès, "La mort inversée": "In the late Middle Ages (in opposition to the first Middle Ages, the age of Roland, which lives on in the peasants of Tolstoy) and the Renaissance, a man insisted upon participating in his own death because he saw in it an exceptional moment—a moment which gave his individuality its definitive form. He was only the master of his life to the extent that he was the master of his death. His death belonged to him, and to him alone. From the 17th century onward, one began to abdicate sole sovereignty over life, as well as over death. These matters came to be shared with the family which had previously been excluded from the serious decisions; all decisions had been made by the dying person, alone and with full knowledge of his impending death."

   36 Michel de Montaigne, Essays, bk. 1, chap. 57.

   37 G. Peignot, Choix de testaments anciens et modemes, remarquables par leur importance, leur singularité ou leur bizarrerie, 2 vols. (Paris: Renouard, 1829). Michel Vovelle, Mourir autrefois: Attitudes collectives (Levant la mort aux XVlle et XVIIIe siècles (Paris: Archives Gallimard-Julliard, 1974), and Piété baroque et déchristianisation en Provence au XVIIIe siècle: Les Attitudes devant la mort d'après les clauses des testaments (Paris: Plon, 1974). Frederick Pollock and Frederic W. Maitiand, "The Last Will," in The History of the English Law Before the Time of Edward I (Cambridge: University Press, 1968), vol. 1, chap. 6, pp. 314-56.

   38 Ariès, "Les Techniques de la mort."

   39 Philippe Ariès, Centuries of Childhood: A Social History of Family Life (New York: Knopf, 1962), chap. 2.

   40 Killing the aged was a widespread custom until recent times. John Koty, Die Behandlung der Alien and Kranken bet den Naturvölkem (Stuttgart: Hirschfeld, 1934). Will-Eich Peuckert, "Altentötung," in Handwörterbuch der Sage: Namens des Verbandes der Vereine für Volkskunde (Gottingen: Vandenhoeck & Ruprecht, 1961). J. Wisse, Selbstmord und Todesfurcht bei den Naturvölkem (Zutphen: Thieme, 1933). Infanticide remained important enough to influence population trends until the 9th century. Emily R. Coleman, "L'lnfanticide dans le haut moyen âge," trans. A. Chamoux, Annales Économies, Sociétiés, Civilisations, 1974, no. 2, pp. 315-35.

   41 Erwin H. Ackerknecht, "Death in the History of Medicine," Bulletin of the History of Medicine 42 (1968): 19-23. Death remained a marginal problem in medical literature from the old Greeks until Giovanni Maria Lancisi (1654-1720) during the first decade of the eighteenth century. Then quite suddenly the "signs of death" acquired extraordinary importance. Apparent death became a major evil feared by the Enlightenment. Margot Augener, "Scheintod als medizinisches Problem im 18. Jahrhundert," Mitteilungen zur Geschichte der Medizin, nos. 6 and 7, 1967. The same philosophers who were the minority which positively denied the survival of a soul also developed a secularized fear of hell which might threaten them if they were buried while only apparently dead. Philanthropists fighting for those in danger of apparent death founded societies dedicated to the succor of the drowning or burning, and tests were developed for making sure that they had died. Elizabeth Thomson, "The Role of the Physician in Human Societies of the 18th Century," Bulletin of the History of Medicine 37 (1963): 43-51. One of these tests consisted of blowing with a trumpet into the dead man's ear. The hysteria about apparent death disappeared with the French Revolution as suddenly as it had appeared at the dawn of the century. Doctors began to be concerned with reanimation a century before they were employed in the hope of prolonging the life of the old,

   42 Theodor W. Adorno, Minima Moralia: Refiexionm aus dan beschädigten Leben (Frankfurt am Main: Suhrkamp, 1970).

   43 E. Ebstein, "Die Lungenschwindsucht in der Weltliteratur," Zeitschrift für Bücherfreunde 5 (1913).

   44 Alfred Scott Warthin, "The Physician of the Dance of Death," Annals of Medical History (new series) 2 (July 1930): 350-71; 2 (September 1930): 453-69; 2 (November 1930): 697-710; 3 (January 1931): 75-109; 3 (March 1931): 134-65. Deals exclusively with the physician in the Dance of Death. Werner Block, Der Arzt and der Tod in Bildem aus seeks Jahrhunderten (Stuttgart: Enke, 1966), studies the doctor's encounter with death in and outside a formal dance.

   45 See above, note 130, p. 77.

   46 Richard H. Shryock, The Development of Modem Medicine: An Interpretation of the Social and Scientific Factors Involved, 2nd ed. (New York: Knopf, 1947).

   47 Hildegard Steingiesser, Was die Ärzte alter Zeiten vom Sterben wussten, Arbeiten der deutsch-nordischen Gesellschaft für Geschichte der Medizin, der Zahnheil-kunde und der Naturwissenschaften (Greifewald: Univ. Verlag Ratsbuch-handlung L. Bamberg, 1936).

   48 Bernard Ronze, "L'Antitragique ou Phomme qui perd sa mort," Etudes, November 1974, pp. 511-28, argues that the endeavor to program death is an attempt to sap the human capacity for hope and anguish, for solitude and transcendence.

   49 Siegfried Giedion, Mechanization Takes Command: A Contribution to Anonymous History (New York: Norton, 1969), On mechanization and death, see pp. 209-40.

   50 Alfred Adler, "Bin Beitrag zur Psychologie der Berufswahl," in Alfred Weber and Carl Furtmüller, eds., Heilen und Bilden (Frankfurt: Fischer, 1973).

   51 See especially Block, Der Arzt und der Tod; Warthin, "The Physician of the Dance of Death"; Briesenmeister, Bilder des Todes.

   52 I have selected these examples from among hundreds of reproductions collected by Valentina Borremans in Cuernavaca, all representing the traits and gestures of anthropomorphic death.

   53 For a bibliography on death in contemporary society consult above, notes 186 (p. 97), 188 (p. 97), 191 (p. 98), 207 (p. 102), 209 (p. 103). Also John McKnight, "A Bibliography of 225 Items of Suggested Readings for a Course on Death in Modern Society in a Theological Perspective," mimeographed, 1973, lists contemporary Christian writings on death in an industrial society. John Riley, Jr., and Robert W. Habenstein, "Death: 1. Death and Bereavement; 2. The Social Organization of Death," in International Encyclopedia of the Social Sciences (New York: Macmillan, 1968), 4: 19-28. Joel J. Vernick, Selected Bibliography on Death and Dying, U.S. Department of Health, Education and Welfare, Public Health Service, National Institutes of Health, 1971. Complements Kalish and Kutscher.

   54Werner Fuchs, Todesbilder in der modernen Gesellschaft, denies that death is repressed in modern society. Geoffrey Gorer, Death, Grief and Mourning (New York: Doubleday, 1965): Gorer's thesis that death has taken the place of sex as the principal taboo seems to Fuchs unfounded and misleading. The thesis of death repression is usually promoted by people of profoundly anti-industrial persuasions for the purpose of demonstrating the ultimate powerlessness of the industrial enterprise in the face of death. Talk about death repression is used with insistence to construct apologies in favor of God and the afterlife. The fact that people have to die is taken as proof that they will never autonomously control reality. Fuchs interprets all theories that deny the quality of death as relics of a primitive past. He considers as scientific only those corresponding to his idea of a modern social structure. His image of contemporary death is a result of his study of the language used in German obituaries. He believes that what is called the "repression" of death is due to a lack of effective acceptance of the increasingly general belief in death as an unquestionable and final end.

   55 The irrational approach of a society in dealing with death is reflected in its inability to deal with apocalypse. Klaus Koch, Ratios vor der Apokalyptik (Gütersloh: Mohn, 1970).

   56 Bronislav Malinowski, "Death and the Reintegration of the Group," in Magic, Science and Religion (New York: Doubleday, 1949), pp. 47-53.

   57 Eric J. Cassel, "Dying in a Technical Society," Hastings Center Studies 2 (May 1974): 31-36: "There has been a shift of death from within the moral order to the technical order. . . . I do not believe that men were inherently more moral in the past when the moral order predominated over the technical."

   58 Edgar Morin, L'Homme el la mort (Paris: Seuil, 1970), develops the argument.

   59 Dora Ocampo, "Cuando la tristeza se mezcla con la alegría," manuscript, Mexico, November 1974.

   60 Industrialized humanity needs therapy from crib to terminal ward. A new kind of terminal therapy is suggested by Elisabeth Kubler-Ross in On Death and Dying (New York: Macmillan, 1969). She maintains that the dying pass through several typical stages and that appropriate treatment can ease this process for well-managed "morituri." Paul Ramsey, "The Indignity of 'Death with Dignity,' " Hastings Center Studies 2 (May 1974): 47-62. There is a growing agreement among moralists in the early 1970s that death has again to be accepted and all that can be done for the dying is to keep them company in their final moments. But beneath this accord there is an increasingly mundane, naturalistic, and antihumanistic interpretation of human life. Robert S. Morison, "The Last Poem: The Dignity of the Inevitable and Necessary: Commentary on Paul Ramsey," Hastings Center Studies 2 (May 1974): 62-6. Morison criticizes Ramsey, who suggests that anyone unable to speak as a Christian ethicist must do so as some "hypothetical common denominator."

   61 David Lester, "Voodoo Death: Some New Thoughts on an Old Phenomenon," American Anthropologist 74 (June 1972): 386-90.

   62 Pierre Delooz, "Who Believes in the Hereafter?" in André Godin, ed., Death and Presence (Brussels: Lumen Vitae Press, 1972), pp. 17-38, shows that contemporary French public speakers have effectively separated belief in God from belief in the hereafter. Paul Danblon and Andre Godin, "How Do People Speak of Death?" in Godin, ibid., pp. 39-62. Danblon studied interviews with 60 French-speaking public figures. The cross-denominational analogies in their expressions, feelings, and attitudes towards death are much stronger than their

   differences due to varying religious beliefs or practices. Joseph F. Fletcher, "Antidysthanasia: The Problem of Prolonging Death," Journal of Pastoral Care 18 (1964): 77-84, argues against the irresponsible prolongation of life from the point of view of a hospital chaplain: "I would myself agree with Pius XII and with at least two Archbishops of Canterbury, Lang and Fisher, who have addressed themselves to this question, that the doctor's technical knowledge and his 'educated guesses' and experience should be the basis for deciding the question as to whether there is any 'reasonable hope.' That determination is outside a layman's competence. . . . But having determined that the condition is hopeless, I cannot agree that it is either prudent or fair to physicians as a fraternity to saddle them with the onus of alone deciding whether to let the patient go." The thesis is common. It shows how even churches support professional judgment. This practical convergence of Christian and medical practice is in stark opposition to the attitude towards death in Christian theology. Ladislaus Boros, Myslerium mortis: Der Mensch in der letzen Entscheidung (Freiburg: Walter, 1962); Karl Rahner, Zur Theolagie des Todes (Freiburg: Herder, 1963).

   63 Daniel Maguire, "The Freedom to Die," Commonweal, August 11, 1972, pp. 423-8. By working creatively and in ways as yet unthought of, the lobby of the dying and the gravely ill could become a healing force in society. Jonas B. Robitscher, "The Right To Die: Do We Have a Right Not To Be Treated?" Hastings Center Studies 2 (September 1972): 11-44.

   64 Orville Brim, et al., eds., The Dying Patient (New York: Russell Sage, 1960). They deal first with the spectrum of technical analysis and decision-making in which health professionals engage when faced with the task of determining the circumstances under which an individual's death should occur. They provide a series of recommendations for making this engineered process "somewhat less graceless and less distasteful for the patient, his faniily and most of all, the attending personnel." In this anthology the macabre turns into a new kind of professionally conducted obscenity. See also David Sudnow, "Dying in a Public Hospital," in ibid., pp. 191-208.

   65 David Sudnow, in his study of the social organization, reports: "A nurse was observed spending two or three minutes trying to close the eyelids of a woman patient. The nurse explained that the woman was dying. She was trying to get the lids to remain in a closed position. After several unsuccessful attempts, the nurse got them shut and said, with a sigh of accomplishment, 'Now they're right.' When questioned about what she was doing, she said that a patient's eyes must be closed after death, so that the body will resemble a sleeping person. It was more difficult to accomplish this, she explained, after the muscles and skin had begun to stiffen. She always tried, she said, to close them before death. This made for greater efficiency when it came time for ward personnel to wrap the body. It was a matter of consideration towards those workers who preferred to handle dead bodies as little as possible" (ibid., pp. 192-3).

   66 Brillat-Savarin, "Méditation XXVI, de la mort," in Physiologic du gout. Brillat-Savarin attended his 93-year-old great-aunt when she was dying. "She had kept all her faculties and one would not have noticed her state but for her smaller appetite and her feeble voice. 'Are you there, nephew?'  'Yes aunt, I am at your service and I think it would be a good idea if you had some of this lovely old wine.'  'Give it to me, my friend, liquids always go down.' I made her swallow half a glass of my best wine. She perked up immediately and turning her once beautiful eyes towards me, she said, 'Thank you for this last favor. If you ever get to my age you will see that death becomes as necessary as sleep.' These were her last words and half an hour later she was asleep forever."