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The tenacious young men and women see their patient's pupils become unresponsive to light and then widen until they are large fixed circles of impenetrable blackness. Reluctantly the team stops its efforts, and the entire scene becomes transformed from a vital image of imminent heroic rescue to the dejected gloom of failure.
The patient dies alone among strangers: well-meaning, empathetic, determinedly committed to sustaining life - but strangers nonetheless. There is no dignity here. By the time these medical Samaritans have ceased their strenuous struggles, the room is strewn with debris of the lost campaign...

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To call a natural process by the name of a disease is the first step in the attempt to cure it and therebye thwart it. To thwart it is the first step towards thwarting the continuation of exactly that which we try to preserve, which is, after all, the order and system of our universe

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The quest of every doctor in approaching serious disease is to make the diagnosis and design and carry out the specific cure. This quest, i call the Riddle, and i capitalize it so there will be no mistaking its dominance over every other consideration

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The challenge that results in the dogged pursuit of a diagnosis and a cure; the challenge that resulted in the astounding progress of late-twentieth-century clinical medicine - that foremost of challenges is not primarily the welfare of the individual human being, but rather, the solution to The Riddle of his disease.

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We die so that the world may continue to live. We have been given the miracle of life because trillions upon trillions of living things have prepared the way for us and then have died for us. We die, in turn, so that others may live. The tragedy of a single individual becomes, in the balance of natural things, the triumph of ongoing life.

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The dignity that we seek in dying must be found in the dignity with which we have lived our lives. Ars moriendi is ars vivendi: The art of dying is the art of living

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So live, that when thy summons come to join
The innumerable caravan, which moves
To that mysterious realm, where each shall take
His chamber in the silent halls of death,
Thou go not, like the quarry-slave at night,
Scourged to his dungeon, but, sustained and soothed
By an unfaltering trust, approach thy grave,
Like one who wraps the drapery of his couch
About him, and lies down to pleasant dreams.

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McCarty greeted me with a thin, forced smile, but he couldn't have found my presence reassuring. I have often wondered over the years what must have gone through the mind of that high-pressure boss of large, tough men when he saw my boyish face and heard me say that i had me to take his history and examine him. Whatever it was, he didn't get much chance to mull it over. As i sat down at his bedside, he suddenly threw back his head and bellowed out a wordless roar that seemed to rise up out of his thrat from somewhere deep within his stricken heart. He hit his balled fists with startling force up against the front of his chest in a single synchronous thump, just as his face and neck, in the flash of an instant, turned swollen and purple. His eyes seemed to have pushed themselves forward in one bulging thrust, as though they were trying to leap out of his head. He took one immensly long, gurgling breath, and died.
I shouted out his name, and then i shouted for Dave, but i knew no one could hear me in the hectic polio room all the way down the corridor. I could have run down the hallway and tried to get help, but that would have meant the loss of precious seconds. My fingers felt for the carotid artery in McCarty's neck, but it was pulseless and still. For reasons i cannot explain to this day, i was strangely calm. I decided to act on my own. The possibility of getting into trouble for what i was about to attempt seemed a great deal less risky than letting a man die without at least trying to save him. There was no choice.
I tore open the thoractomy kit's sterile wrapping and grabbed the scalpel placed for ready access in a separate envelope on top. What i did next seemed absolutely automatic, even though i had never done it, or seen it, before. With one suprisingly smooth sweep of my hand, i made a long incision starting just below the left nipple, from McCarty's breastbone around as far back as i could without moving him from his half-upright position. ONly a little dark ooze leaked out from the arteries and veins as i cut through, but no real flow of blood. Had i needed confirmation of the fact of death by cardiact arrest, this was it. Another long cut through the bloodless muscle, and i was in the chest cavity. I reached over to grab the double-armed steel instrument called a self-retaining retractor, slipped it between the ribs, and turned its ratchet just far enough to allow my hand to squeeze inside and grasp what i expected to be McCarty's silent heart.
As i touched the fibrous sack called the pericardium, i realized that the heart within was wriggling. Under my fingertips could be felt an uncoordinated, irregular squirming that i recognized from its textbook description as the terminal condition known as ventricular fibrillation, the agonal act of a heart that is becoming reconciled to its eternal rest. With unsterile bare hands, i grabbed a pair of scissors and cut the pericardium wide open. I took up Mr. McCarty's poor twitching heart as gently as i could and began a series of firm, steady, syncopated compressions that is called cardiac massage, intended to maintain a flow of blood to the brain until an electrical apparatus can be brought in to shock the fibrillating heart back into good behavior.
I could tell by its rapidly decreasing resistance to the pressure of my squeezes that the heart was not filling with blood, and so my efforts to force something out of it were useless, especially since the lungs were not being oxygenated. But i still kept at it, and suddenly, something stupefying in its horror took place -- the deat McCarty, whose soul was by that time totally departed, threw back his head once more and, staring upward at the ceiling with the glassy, unseeing gaze of open dead eyes, roared out to the distant heavens a dreadful rasping whoop that sounded like the hounds of hell were barking. Only later did i realize that what i had heard was McCarty's version of the death rattle, a sound made by spasm in the muscles of the voice box, caused by the increased acidity in the blood of a newly dead man. It was his way, it seemed, of telling me to desist - my efforts to bring him back to life could only be in vain.
Alone in that room with a corpse, i looked into its glazed eyes and saw something i should have noticed earlier - Mr. McCarty's pupils were fixed in the position of wide black dilation that signifies brain death, and obviously would never respond to light again. I stepped back from the disordered carnage on that bed and only then realized that i was sopping wet. Sweat was pouring down my face, and my hands and my short white medical student's coat were drenched with the dark lifeless blood that had oozed out of McCarty's chest incision. I was crying, in great shaking sobs. I realized, too, that i had been shouting at him, demanding that he live, screaming his name into his left ear as though he could hear me, and weeping all the time with the frustration and sorrow of my failure, and his.
The door swung open and Dave rushed into the room. WIth one glance, he took in the entire scene, and understood it. But all i can remember is what he said, with that gentle softness in his voice. "Shep, now you know what it is like to be a doctor"

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