Hanging accomplishes much the same thing, but by a mechanism significantly less gentle. The weight of the victim’s body provides enough force to tighten the noose and bring about mechanical obstruction of the upper airway. The obstruction is sometimes caused by compression or fracture of the windpipe, but it may also be the result of upward displacement of the base of the tongue, which blocks off the ingress of air. Because the constricting noose cuts off drainage through the jugular and other veins, deoxygenated blood is dammed back up into the tissues of the face and head. The discovery of a grotesquely hanging corpse whose swollen, sometimes bitten tongue protrudes from a bloated blue-gray face with hideously bulging eyes is a nightmarish sight upon which only the most hardened can gaze without revulsion.
In a legal, or judicial, hanging, the executioner attempts to avoid asphyxia, but sometimes he fails. When the knot of the noose is properly positioned just beneath the angle of the condemned man’s jaw, the sudden drop of five to seven feet should fracture and dislocate the spinal column at the base of the skull. The spinal cord is thereby torn in two, causing immediate shock and paralysis of respiration. Death, if not instantaneous, is very quick, although the heart may continue to beat for a few minutes.
The sequence of events in suffocation by suicidal hanging is similar to that in all cases of mechanical asphyxia, intentional or not, such as smothering or choking. Nonsuicidal choking is exemplified by the well-known “café coronary,” in which a bulky chunk of food suddenly obstructs the windpipe of a diner, often drunk. Made panicky by his inability to take in a breath, the agitated, hypercarbic victim, in a futile attempt to help himself, grabs at his throat and chest as though he is having a heart attack (hence the name café coronary). He will rush toward the bathroom, hoping to vomit up the suffocating plug in his windpipe, because even in his dying moments he remains too embarrassed to do it in front of his gaping fellow diners, who may be sitting there aghast and unable to act. If he is at home and alone, he will probably die, but the Heimlich maneuver may save him if he is in a public place and a bystander can manage it.
If the food plug is not forced out, the process of suffocation continues unchecked. The pulse quickens, the blood pressure rises, and the level of carbon dioxide in the blood increases rapidly to a state called hypercarbia. Hypercarbia produces extreme anxiety, and the decreased oxygen makes the frightened victim appear blue, or cyanotic. He makes increasingly strenuous attempts to pull air past the obstruction, which only serve to wedge the plug even more firmly in place. Just as in a hanging, unconsciousness supervenes, and sometimes convulsions triggered by the unoxygenated and hypercarbic brain. In a short time, the efforts to breathe become weaker and more shallow. The heartbeat becomes irregular, and finally stops.
Drowning is, in essence, a form of asphyxia in which the mouth and nostrils are occluded by water. If the drowning is suicidal, the victim will not resist the inhalation of water, but if accidental, as is usually the case, he will fight it by holding his breath until becoming too exhausted and hypercarbic to continue. At this point, the air passages all the way down into the lung become obstructed by water. If the struggle takes place while the drowning person is thrashing about near the surface, enough air may be sucked in to create a barrier of foam. The foam and water in the airway can set off the vomiting reflex, which adds to the problem by forcing the acid stomach contents up to the mouth, from where they can be aspirated into the windpipe.
If the drowning takes place in fresh water, the water is absorbed into the circulation through the lungs, diluting the blood and upsetting its delicate equilibrium of chemical and physical elements. Red blood cells are destroyed by the imbalance, resulting in the release of large amounts of potassium into the circulation, an element that functions as a cardiac poison by inducing the heart to fibrillate. Should the drowning occur in seawater, the process is virtually the reverse. Water leaves the circulation and enters the alveoli of the lung—the picture produced is that of pulmonary edema. Pulmonary edema may also occur during drowning in a swimming pool, because chlorine acts as a chemical irritant on the lung tissue.
In the struggles of a drowning victim, the aspiration of water is at first delayed and then abetted by one of the body’s inherent survival mechanisms. When the first bit of water enters the airway, the larynx reflexly goes into spasm and closes off in an effort to prevent further intake. But within two or three minutes, the decreasing blood oxygen relaxes the spasm and water rushes in. It is this so-called terminal gasp phase that allows the aspiration of so much water that its absorption in a freshwater drowning may account for as much as 50 percent of the blood volume.
A lifeless human body is heavier than water, and the head is its densest part. Accordingly, the corpse of a drowning victim will always sink headfirst to the bottom and remain floating in that position until putrefaction produces enough gas in the tissues to create a buoyancy that makes it rise to the surface. This process takes anywhere from a few days to a few weeks, depending on the temperature and condition of the water. When the body returns, it is difficult for its appalled discoverer to believe that this rotted thing once contained a human spirit and shared nature’s life-giving air with the rest of healthy humanity.
Drowning kills almost five thousand people in the United States each year, and alcohol is involved 40 percent of the time. Except in cases of suicide or murder, it almost always occurs under conditions of suddenness, and usually without warning. Nevertheless, the great majority of drowning victims do at least have some sense of its possibility, since it ordinarily takes place when they are in proximity to deep water. The approximately one thousand Americans who yearly suffer lethal electrocution, however, almost never suspect they are about to die, even when they are working around high-tension equipment. By far the most common cause of death following electric shock is ventricular fibrillation caused by the passage of current through the heart. Fibrillation or arrest may also be caused by high-voltage electricity reaching the cardiac center of the brain. If the brain’s breathing center is injured, respiratory cessation is the cause of death. Although most lethal electrocutions occur among men who work around high-voltage cables, electrical accidents in the home kill many children and adults each year.
In these various ways, the victims of homicide, suicide, and accidents are deprived of the oxygen supply that maintains existence. This recital of cause and physiological effect hardly exhausts the roll call of soldiers in the squadrons of violent death. Nor does a brief discussion of terminal equanimity, near-death experiences, or assisted suicide more than begin to address the many new issues that have lately been added to the already-lengthy catalog of concern that merits the attention—more than the attention, the scrutiny—not only of philosophers and scientists but of all of us. In matters touching on death, the clinical and the moral are never so far apart that we can look at one without seeing the other.
VIII
A Story of AIDS
C
ALL ME
I
SHMAEL
.” She smiled at the recollection of that irony, and looked beyond me with wistful eyes into the room where the father of a young family lay dying.
“It was only four months ago, but it’s a lifetime, really. I walked into the clinic that day, and there he was, sitting in a cubicle waiting for the great miracle-doctor who was coming to help him. The doctor was me. ‘Good morning, Mr. Garcia,’ I said, just as bright and breezy as a new interne is supposed to be. And he jumped up, this little Hispanic guy with a great big smile on his face. ‘Call me Ishmael’ was what he said—imagine it! I guess he never read the book. Melville’s Ishmael survived, and mine never had a chance. He’ll be dead in a few days, but I’ll remember him the rest of my life.” She paused; I could tell that the next words were caught on some jagged thing in her throat, because they sounded lacerated when she was finally able to force them out. “He was my first patient with this fucking goddamn disease!”
One crisis after another had taken place since that summertime afternoon when Ishmael
*1
Garcia leaped up from the chair and stuck out his open palm to shake hands with Dr. Mary Defoe, and both of them had vastly changed from what they had been. Though she had seen plenty of AIDS patients while in medical school, Mary never quite realized the full magnitude of individual catastrophe until she actually took on the intimidating responsibilities of a newly graduated doctor.
From the sunny July afternoon when he first presented himself to the AIDS clinic until the chilly gray November morning when she was destined to pronounce him dead, Mary Defoe and Ishmael Garcia would be doctor and patient. Whether hospitalized or being followed in the outpatient clinic, he thought of her as his personal physician. From time to time, other internes assumed his care for brief periods when Mary rotated to a different service, but they always found each other again and resumed their journey toward the grim conclusion they both knew lay ahead.
Early in training, most doctors develop relationships with patients that become models on which they will base their responses to sickness and death for the rest of their careers. For Mary Defoe, Ishmael Garcia will surely represent a reawakening of an old image long lost to modern generations of healers—impotence in the face of a plague of death upon the young.
In the calculus of death, no one before 1981 could have factored in HIV, the human immunodeficiency virus. The first hints of its gathering fury struck just at the instant when biomedical science was beginning to offer cautious congratulations to itself on having achieved a state of advancement where the final conquest of infectious disease seemed at last within sight. AIDS not only confounded the microbe hunters; it shook the confidence held by all of us that technology and science can keep humanity safe from the whims of nature. In a very few explosive years, virtually every young doctor in training was treating his or her share of those dying who were meant to live.
Dr. Defoe and I stepped into Ishmael’s room—noiselessly, though he was far beyond hearing any sound we might have made. It was more out of respect than necessity that we were so quiet. When a man is dying, the walls of his room enclose a chapel, and it is right to enter it in hushed reverence.
How different this scene from the frenzied drama so often played out during a patient’s last moments, as desperate attempts are made to revive him to yet another few weeks or months of waiting for death—and sometimes only hours or days. After the incalculable miseries of Ishmael Garcia’s descent into the valley of fever and incoherence, this oblivion was earned; it was fitting that the end, at least, should be undisturbed.
The room’s overhead illumination had been turned off and the blinds were closed against the glare of midday autumn sunshine, bathing the entire space in a uniformity of subdued daylight. The unconscious man in the bed had a high fever—the yellowish skin of his forehead glistened against the stark whiteness of his freshly changed pillowcase. Ravaged as he was by the wasting effects of his disease, it could be seen that he had once been very handsome.
I had read Ishmael’s chart, and I knew that with his very last breath, the tranquillity would be shattered by a full-scale attempt at resuscitation. In a moment of terror months earlier, he had begged his wife to see to it that the doctors did everything possible to preserve his life—that she not allow them to give up. And now, Carmen could not make herself believe what the AIDS team was telling her: that the possible had become impossible. She clung to that part of her pledge which would destroy the easy exit of an essence in which she devoutly believed—the immortal soul of her husband.
Though Ishmael had been separated from his wife for three years prior to his illness, she was nevertheless his legal next-of-kin, and she spoke for his family. In reality, she spoke only for herself, because Carmen and her husband had together made the unyielding decision to keep the diagnosis to themselves. Neither Ishmael’s parents nor his two sisters knew the name of his disease. If they did, they never spoke of it.
When she realized just how sick Ishmael was, Carmen had let him return home. Somehow, she found the strength to put aside his years of unfaithfulness and drug dependence, and even the near-poverty into which his irresponsibility had thrown her and their three daughters. He came back so that she could be his nurse and the only one of his family or friends to share his knowledge of the ultimate end. In spite of everything, he had been a good father, she said, and she owed him this much. For the sake of their three girls and for the recollections of a life that once had been, she permitted her dying husband to return.
In refusing to let him die when his time came, Carmen insisted that she was doing one last kindness for Ishmael—it was, after all, what she believed she had promised him. She refused to discuss with the doctors why she would not listen to their reasoned arguments, and none of them had the heart to press her. They supposed, they told me, that somewhere in the depths of her awareness, Ishmael’s obvious devotion to their girls made Carmen feel some unjustified element of guilt about her rejection of her prodigal husband and her obdurate refusal to respond to his sputtering intervals of good behavior and promises of reform. The staff had gone so far as to seek a consultation with the chairman of our hospital’s Bioethics Committee, but when they told him that a successful resuscitation might be possible, he would not overrule the dictates of Carmen’s heart. In circumstances like this, who knows where wisdom lies?