How We Die (22 page)
Authors: Sherwin B Nuland
The ambulance sped Katie to the nearest hospital, which was only a few minutes away. Although she was clearly pulseless and brain-dead on arrival, and beyond clinical death, the appalled emergency room team did every possible thing to bring her back, even with the certain foreknowledge that their attempts would be futile. When they finally gave up, their frustration and rage turned to grief. Tearfully, one of the doctors told Joan what she already knew.
The man who murdered Katie Mason was a thirty-nine-year-old paranoid schizophrenic named Peter Carlquist. Two years earlier, he had been acquitted by reason of insanity in the attempted knife murder of his roommate, whom he accused of putting poison gas into their radiator. He had a long history of such attacks on people, including his sister and several high school classmates. As early as age six, he had told a psychiatrist that the devil had come up out of the ground and entered his body. Perhaps he was right.
Following the assault on his roommate, Carlquist had been institutionalized in a unit for the criminally insane on the sprawling grounds of the state mental hospital situated at the outskirts of the city visited by Katie Mason on that fateful July day. Only a short time before, an advisory board had judged him sufficiently recovered to be transferred to a unit housing an assortment of the mentally ill, where patients were permitted to sign themselves out for several hours at a time. On the morning of the assault, Carlquist strolled off the grounds, took a municipal bus into town, and walked into a local hardware store. After buying a hunting knife, he came upon the street fair. And there in the crowd outside Woolworth’s he saw the two pretty little girls wearing identical dresses. Somewhere in his deranged mind lies the secret of why he chose the dark-haired Katie to be his victim instead of blond Laura. Rushing forward, he grabbed her by the arm, threw her to the ground, and began his demonic work.
Katie Mason died of acute hemorrhage leading to hypovolemic shock. Although she had been cut in many places on the upper part of her body, the main source of bleeding was a completely severed carotid artery emptying itself into a laceration of her esophagus. The blood passed down the esophagus into her stomach; it was the source of the huge regurgitation.
A specific sequence of events takes place in people who bleed to death. At first, they will usually hyperventilate, which is the body’s compensatory attempt to saturate the decreasing volume of circulating blood with as much oxygen as possible; the heart rate will speed up for the same reason. As more blood volume is lost, the pressure in the vessels begins to fall rapidly and the coronary arteries receive less and less of it. Were an electrocardiogram to be running, it would show evidence of myocardial ischemia; the ischemia causes slowing of the poorly oxygenated heart. When the blood pressure and pulse rate become low enough, the brain ceases to receive enough oxygen and glucose, and unconsciousness ensues, preceding brain death. Finally, the ischemic heart slows to a stop, usually without any fibrillation. With the stilling of the heartbeat, circulation is arrested, breathing ceases, there are a few agonal events, and clinical death has occurred. When a vessel the size of the carotid artery has been cut wide open, the entire sequence can take less than a minute.
All of this explains how Katie Mason died. But it does not explain a phenomenon witnessed by her mother, one that matches the descriptions of many other witnesses to such horrendous events. Why should a child who has suddenly been set upon by a knife-wielding psychopath obviously intent on her murder die not only without a look of terror on her face, but actually in a state of apparent tranquillity and release, an appearance of surprise rather than horror? Especially considering the savageries being perpetrated on her face and upper body during the brief time when she must have been fully conscious and seen what was being done to her—why was there no evidence of panic, or even fear?
What was described by Joan Mason has been a source of wonderment, in fact, for hundreds of years. For some soldiers, the absence of pain and fear has been the determining factor in their ability to fight on in spite of crippling wounds, feeling nothing except perhaps the euphoria of battle until the immediate danger is over, whereupon physical and mental agonies finally make their appearance, or death. There is far more at work here than the well-known “fight or flight” of a rush of adrenaline.
In his essay “Use Makes Perfect,” Michel de Montaigne suggests that a lifelong acquaintance with the ways of death will soften one’s final hours:
I fancy there is a certain way of making it familiar to us, and in some sort of making trial what it is. We may gain experience, if not entire and perfect, yet such, at least, as shall not be totally useless to us, and that may render us more confident and more assured. If we cannot overtake it, we may approach it and view it, and if we do not advance so far as the fort, we may at least discover and make ourselves acquainted with the avenues.
Montaigne recounts an experience of being thrown from his mount by a horseman “thundering full speed in the very track where I was rushing.” Battered and bleeding, he thought at first that he had been shot in the head with a harquebus. But to his surprise, he remained quite calm: “Not only did I make some little answer to questions which they asked me, but they moreover tell me that I was sufficiently collected to order them to bring a horse to my wife, whom I saw struggling and tiring herself on the road.”
He describes a sense of tranquillity, even though he refused the soporifics offered to him, “certainly believing that I was mortally wounded in the head. My condition was, in truth, very easy and quiet, I had no affliction on me, either for others or myself; it was an extreme languor and weakness, without any manner of pain.” He passed a serene two or three hours awaiting the death that never came, quite content to “glide away so sweetly and after so soft and easy a manner.” At the end of that time, “I felt myself on a sudden involved in terrible pain, having my limbs battered and ground with my fall, and was so ill for two or three nights after, that I thought I was once more dying again, but a more painful death.”
Whatever was the influence that had so tranquilized the mind of the grievously wounded Montaigne, it had worn off. After that initial period of a few hours, he suffered intense pain. Gone was the serenity, the languor, and the acceptance of an anticipated easy death. The reality of his suffering and fear became inescapable.
Stories like Montaigne’s are not rare—they are sometimes given a mystical quality by those who tell them, as though some unexplainable and perhaps supernatural event has taken place. But to a doctor who has spent his career in the company of trauma inflicted in the name of surgical cure, and those other traumas inflicted by the violence of modern life, there is a prototype for these tales of serenity and languorous comfort in the face of what would seem to be frightful and agonizing wounds. The prototype is the aftermath of the injection of an opiate or some other form of powerful narcotic painkiller. When the medication is well chosen and the dose is high enough, fear passes and the distress of even the most unbearable incision or injury recedes into a soft cloud of indifference. Many patients report a sense of well-being, and I have even seen mild euphoria following a proper dose of a morphinelike narcotic.
It is not farfetched to believe that the human body itself knows how to make those morphinelike substances and knows how to time their release to correspond with the instant of need. The “instant of need,” in fact, may be the very stimulus that sets off the process.
Such self-generated opiates do, in fact, exist, and they are called endorphins. They were given that name shortly after their discovery about twenty years ago—by contracting the two words that describe them: They are
endogenous morphine
-like compounds.
Endogenous
appeared in the lexicon of medicine at least a century earlier, adapted from the Greek
endon
, meaning “within” or “inner,” and
gennao
, meaning “I produce.” Accordingly, it refers to substances or conditions we create within our own bodies.
Morphine
, of course, recalls Morpheus, the Roman god of sleep and dreams.
endogenous morphine
-like compounds.
Endogenous
appeared in the lexicon of medicine at least a century earlier, adapted from the Greek
endon
, meaning “within” or “inner,” and
gennao
, meaning “I produce.” Accordingly, it refers to substances or conditions we create within our own bodies.
Morphine
, of course, recalls Morpheus, the Roman god of sleep and dreams.
Several structures in the brain are capable of secreting endorphins in response to stress, including the hypothalamus and an area called the periaqueductal gray matter, as well as the pituitary gland. Together with ACTH, a hormone that activates the adrenal glands, endorphin molecules are known to bind themselves, as do the other narcotics, onto foci, called receptors, on the surfaces of certain nerve cells. The effect is to alter normal sensory awareness. Endorphins seem to play a significant role not only in raising pain threshold but also in altering emotional responses. In addition, there is evidence that they interact with the adrenaline-like hormones, as well.
In the normal nonstressed, noninjured person, there is no evidence of the pain-relieving and mood-altering action of endorphins. It requires some definitive degree of trauma, whether physical or emotional, for them to swing into action. The level, or even the quality, of the necessary trauma has not yet been ascertained.
For example, it may be that the mere stimulation of acupuncture needles results in an outpouring of endorphins. During the course of a series of professional travels to Chinese medical schools over a period of years, I became interested in acupuncture after seeing several demonstrations of its effectiveness as an alternative to anesthesia in major surgery. In 1990, I visited Professor Cao Xiaoding, a neurobiologist who heads Shanghai Medical University’s Acupuncture Anesthesia and Analgesia Research Coordinating Group, an establishment of thirty faculty members and six laboratories of neuropharmacology, neurophysiology, neuromorphology, neurobiochemistry, clinical psychology, and computer science. Professor Cao’s team has produced a vast body of rather impressive experimental and clinical evidence indicating that the basis of acupunture’s undoubted success in certain applications is the stimulation of endorphin secretion by manipulation of the vibrating or rotating needles. Although a significant rise in endorphin levels during acupuncture has been repeatedly documented not only in Shanghai but also in several Western laboratories, the neurological pathway by which the turn-on signal reaches the brain has not yet been elucidated. It may be similar to the mechanism that activates the familiar stress-induced response.
Since the late 1970s, endorphins have been shown to make their appearance in the presence of shock due to major blood loss or septicemia; their elevation in physical trauma of all sorts is well documented in the surgical literature. Until fairly recently, this phenomenon had not been studied in children, but a recent report from the University of Pittsburgh demonstrates the same pattern as in adults—namely, a significantly higher increase in endorphins among patients whose injuries were most severe, as compared with those sustaining minor trauma. Some children whose only injuries consisted of abrasions were also shown to have somewhat elevated their levels.
We will never know the level of Katie Mason’s endorphins (and some of my proof-demanding clinical colleagues will no doubt find fault with my assumption that it was high), but I am convinced that nature stepped in, as it so often does, and provided exactly the right spoonful of medicine to give a measure of tranquillity to a dying child. Endorphin elevation appears to be an innate physiological mechanism to protect mammals and perhaps other animals against the emotional and physical dangers of terror and pain. It is a survival device, and because it has evolutionary value it probably appeared during the savage period of our prehistory when sudden life-threatening events occurred with frequency. Many a life has no doubt been saved by the absence of panicky response to sudden danger.
Joan Mason, too, seems to have been protected by her endorphins. She told me that had it not been for her own feeling of almost supernal warmth and the sense of being surrounded by a thick insulating aura, she believes that she might have had a heart attack and died there on the street alongside her daughter. The primitive prehuman whose heart and circulatory system did not succumb to sheer terror at the moment of an animal attack was the one who survived to have offspring whose responsiveness was much like his own.
Although there are many narratives of this kind of thing, there has been very little attempt to study it in any systematic way. We read the philosophical lesson of a Montaigne, or a soldier’s story, or perhaps the account of a mountain climber who experienced an unaccustomed inner peace while free-falling to an expected sudden death. Some of us have our own tales to tell. And then, of course, there are the times when endorphins fail and death comes in its full unrelieved anguish.
Because to some, endorphins would seem to involve matters of the body, and to others matters of the spirit, it is instructive to examine the experience of an articulate man whose goal was to heal both. Many tend to forget that the great explorer David Livingstone was a medical missionary. He survived a number of close calls during his African forays, but there is one that exemplifies the way in which protoplasm and ectoplasm sometimes work most closely with each other just at the moment when they seem about to part ways forever.
In February 1844, when Livingstone was thirty years old, he was one day set upon by a wounded lion from which he was trying to protect several native tribesmen in his party. The jaws of the enraged animal seized him by the left upper extremity, and he felt himself lifted off the ground and shaken violently as the lion’s teeth sank deeply into his flesh, splintering the underlying humerus and ripping eleven jagged lacerations into the bleeding skin and muscle. One of Livingstone’s party, an elderly convert named Mebalwe, had the presence of mind to pick up a rifle and discharge both barrels, which sufficiently frightened the animal that he dropped his prey and dashed off, only to die a short distance away of the bullet wound Livingstone had inflicted just before being pounced upon.
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