Southern Humanities Review
Volume 41, P. 241

A few weeks into my career as a medical student, I saw naked human lungs for the first time. Stanford’s tedium of labs and lectures was meant to endure for two years, but the curriculum committee decided to spice up our schedule with an occasional hands-on clinical experience, and thus early one morning I was dispatched down the Bay Shore Freeway to Santa Clara Valley Medical Center in San Jose. There I was gowned and masked and led through the whooshing pneumatic doors of an operating room. The air reeked of peculiar substances, substances whose names and purposes I would soon come to know: Phisohex, an antiseptic soap redolent of banana oil; Betadine, a tincture derived from iodide; isopropyl alcohol, a skin prep used before inserting IV needles. In the center of the room, beneath piercing overhead lights, stood an oblong mound covered with blue surgical drapes. In the center of the drapes lay a square of human flesh – the patient’s shaved and sterilized chest, darkened by the burnt umber tint of the Betadine. 

Professor Huett, my assigned mentor, stood across the OR table from his intern and his third-year resident. The Professor and I introduced ourselves to one another, then watched the resident split the patient’s breastbone from sternal notch to xiphoid process with a circular saw. The whirling blade made the same high-pitched whine one might hear in a carpenter’s shop, but instead of sawdust it cast a line of soupy pink marrow onto the drape. The bone itself, heated by friction from a thousand razor-sharp teeth, stank like burning rubber and overcooked meat. I had grown up in Alabama, where gutted deer carcasses hung from many a tree during the hunting season, but this was different. This was human flesh. A surge of nausea prickled my scalp with sweat. 

The resident laid the saw aside, inserted a chrome-plated spreader into the wound, twisted the handle until the edges of split bone gaped over a dark linear hole. With each twist the wound spread wider, wider. The ribs cracked. The hole gaped one inch, two inches, three inches. A final twist gave a final, resounding crack. The OR fell silent except for the rhythmic hiss . . . clunk . . . hiss . . . clunk . . . hiss . . . clunk of the respirator. Doctor Huett leaned over to peer down into the pulsating cavity. 

“Nice job, son,” he said, giving the resident a nod. “You split that sucker right down the middle.” 

Above his surgical mask, Huett had close-set green eyes and a towering forehead crowned by a blue paper cap. I adored the man the instant I heard his slow Georgia drawl: here was a true Southerner, a professor of surgery, no less – my first encounter with a fellow redneck since arriving in California. 

“What we have heah, Doctor Gamel,” he said, looking through a set of cheaters perched low on his long thin nose, “is an oat-cell carcinoma ‘bout the size of a small peach. We’ll have to wait for the frozen sections to be sure, but y’all can take my word for it, this baby’s an oat-cell all day long. There it is, wedged in beside the mediastinum.” 

The patient’s lungs lay deep within the shadowed cavity. Normal lungs are soft, pink, filled with diaphanous sacs, but these were coal black and stiff as leather. I knew they were lungs only because they rose and fell with the hiss of the respirator and cradled between them the beating, vein-laced heart. Professor Huett let me touch the tumor with my gloved finger. It felt like a rock. 

The case went on for a long time. Just before noon, the resident lifted the black lung and its clinging black tumor out of the chest and handed them off to the scrub nurse. An hour later, the sternum bound tight with five twists of bone wire, Professor Huett and the resident rushed from the OR, leaving the intern behind to close the skin. I followed them into the locker room, where they tore off their masks and paper caps, threw their gowns into a laundry hamper – exposing lean freckled arms, curly chest hair peeking above the collars of their blue scrub shirts – then hit the door of the doctors’ lounge like lions after a kill. They flung themselves into folding chairs set around a table littered with ashtrays, paper plates, dirty knives, a box of saltines, an open jar of peanut butter. The aroma from a pot of tomato soup boiling on a hotplate brought saliva to my mouth, but my colleagues were seized by a craving more desperate than hunger. I heard the crinkle of torn cellophane, the tap tap tap of a pack against a palm as two unfiltered Camels inched their way out the open end. 

“Damn, it’s almost one o’clock,” Huett mumbled, the unlit cigarette bobbing up and down between his lips. “We were stuck in there damn near five hours.” 

A match cracked and flared. He took an enormous drag, held it deep in his lungs, smiled. His eyelids drooped with pleasure. His nostrils gave off jets of smoke as he hummed mmmmmm. He took another drag, then – with a delicate mastery of lips and cheeks and diaphragm I had never before seen outside the deep South – blew the smoke slowly out of his mouth, sucking every wisp up his nose in two elegant streams. 

“A hell of a case,” he said. “Mah back hurts.” 

The resident, a handsome young man with pale lashes and curly yellow hair, mumbled “Un-huh,” then took a drag so deep his cheeks caved in, pressing so tightly against his teeth I could count his molars. After two more ravenous drags, the inch-long ash on his cigarette fell to the floor.

* * *

My dear Uncle Melvin, a prosperous lawyer in the oil-boom town of Hobbs, New Mexico, was a wise and generous fellow. Among many kind deeds, he saved me from a lifetime of manual labor in lower Alabama by sending me to prep school, supplementing my college scholarship, and paying my tuition during the first year of medical school. But alas, the poor man was hopelessly, helplessly addicted to food, liquor, gambling, and cigarettes – a true omni-holic. There were rumors of loose women in his past, but by the time I knew him well his ponderous belly and failing lungs had removed infidelity from the list. At his peak, immaculate in a Panama hat, white silk suit, black wing-tip shoes, he was round as a bowling ball. His legal skills earned him eight hundred dollars a day, a princely sum at the time, but he had the self-control of a termite. When his wife bought a Sara Lee cheesecake to celebrate one of my visits, Melvin ate only one slice at the dinner table, but thoughts of that creamy treasure tormented him until – over the course of the evening, skulking again and again to the refrigerator – he had eaten the last crumb. 

Every workday at four p. m., Uncle Melvin closed his law office to head for cocktails at the Mesa Lounge. By dinnertime his round face was cheerful and pink. Late one evening, thick-tongued, deep in his cups, he assured me, “There’s nothin’ in this world better’n four good friends ‘n four quarts of Kentucky bourbon.” All night long his violent snores rattled the house. He never missed a day of work, but at the breakfast table his bites of soft-boiled egg quivered on the spoon, and the morning paper rustled in his unsteady hands. During jaunts to Las Vegas, he played dice and roulette and blackjack; played until dawn, so avidly the MGM Grand Casino gave him a complimentary suite. When his estate was settled, his assets, including major stock in four oil wells, were all but consumed by a mountain of debt. 

Yet Uncle Melvin’s final undoing came from a passion more corrosive than dice or cheesecake or bourbon on the rocks. I witnessed this passion full on, right in the face, one afternoon at the Lee County Court House in Hobbs. It was the last time I saw him alive. My visit was meant to celebrate his recovery from a bout of pneumonia that had kept him in the ICU for two weeks, the fifth of five near-fatal bouts scattered across an emphysematous decade of coughing, wheezing, racking fits that drowned out the sermon on Sunday mornings and left Melvin purple in the face. But now he was reformed. Recovered. Not a pack in the house. He hadn’t touched a cigarette since his recovery. 

“You don’t need to tell anybody about this,” he said. We were standing alone in the stacks of the Lee County Law Library. A moment before there had been a whisper in the librarian’s ear, a furtive gesture as Uncle Melvin slipped the cadged cigarette into his pocket, and now, in a long dim corridor lined with books, he held the flaming match with a steady hand. Off liquor for six months, thanks to a bleeding peptic ulcer, and down thirty-five pounds, his white silk coat sagged across his shoulders. His cheeks were still round, his lips full, the lower lip dark and pendulous – the sunny pink face of an overgrown cherub. 

He took a drag, a deep, sensual puff, crossing his eyes to focus on the smoldering tip. His barrel chest heaved as the smoke rushed into his lungs, straining the fabric of his white shirt. He coughed. Coughed violently, fist to mouth, hack-hack-hack, bowing lower with each hack, until, bent half to the ground, a gasping breath shot him bolt upright. Again, hack-hack-hack, lower, lower, gasp, bolt upright. With each spasm came rales, rhonchi, phlegm in the tubes, a warbling crescendo of blats and whistles from deep in his lungs. The veins in his neck swelled out thick as fingers. His eyes bulged, his face shaded, moment by moment, from lavender to mauve, to indigo, to midnight blue. Beyond endurance, seemingly beyond survival, the attack rocked him to and fro in a writhing fit of suffocation. By the end his face was black, his bloodshot eyes seemed ready to pop out of his head. At last his breath settled into a morbid wheeze. His cheeks slowly faded to their usual cherubic pink. He wiped his mouth with a handkerchief. 

“I’ve got to get rid of these things – they’re not doing me any good at all,” he said, his voice husky, full of rattling, phlegmy overtones. He stared at the cigarette smoldering between his fingers: a searching look, a gaze that spoke of astonishment, eternity, the quizzical confusion of a child in pain. 

He took another drag. 

* * *

Perhaps it was Uncle Melvin’s fate that begat my fascination with voluntary asphyxia. During my early years of medical school, pouring over anatomy, pathology, histology, physiology, I learned the basics: of all human tissues, the lungs – loaded with three hundred million alveoli, delicate sacs whose membranes span an area the size of a tennis court – offer the most vulnerable target to caustic agents. Attacked by smoke and tar, the alveoli thicken, bulge, rupture, merging into mucous-filled blebs that whistle like flutes and croak like frogs in a midnight pond. Asthma adds fuel to the fire, causing spasms that block the bronchioles. At the first whiff of smoke, the few surviving alveoli choke off, forcing the victim to pay for each drag with a suffocating convulsion.  

At the personal level, these minutiae translate into a simple proposition: hold a pillow against your face and keep it there forever, pressing a little harder every day. 

During my internship at Santa Clara Valley Medical Center, half the patients on the respiratory ward were “sitters” – so short of breath they could not lie down, even for an instant. They slept every night sitting up: nodding off, waking, tipping to one side, nodding off, slumping, waking, exploding now and then in a coughing fit as they waited for dawn to bring another day of breathless misery. The rest of our patients were mostly “in-betweeners” – those whose pneumonia or acute bronchitis carried them a step further along the road to suffocation, but whose lungs, still harboring a few pink islands scattered among the black dead scars, allowed them to sleep lying down. The chief of pulmonary medicine took a dim view of the whole business. He insisted that within five minutes of discharge, in the car on their way home from the hospital, most of the sitters and ‘tweeners would be sucking on a cigarette.  

* * *

In Mello Dee’s, a stucco-fronted lounge across the street from Santa Clara Valley Medical Center, an alcoholic leans his elbows on the bar and looks down with jaundiced eyes at the bourbon in his glass. There are bandages on his arms, covering the wounds left by intravenous needles withdrawn only hours before. His throat is raw. The Sengstaken-Blakemore Occluder – a tube thrust down his throat, anchored inside his stomach with a balloon, then inflated to twice the thickness of a garden hose – plugged his esophagus for six terrible days. It saved his life, staunching the esophageal hemorrhage caused by his shrunken, rock-hard liver, but now every swallow brings waves of agony. He lifts the glass, tips it gently side to side, savoring the mellow bouquet of the liquor, the clink of the ice cubes, the faint whorls of melting ice as they lace into the amber liquid. He sips. A fiery pleasure burns his raw and swollen throat like acid. Then, slowly, the precious molecules seep into his bloodstream, carrying their balm to his patient, long-suffering brain. 

Booze is a stern taskmaster, but it allows its acolytes time, a few hours of golden glow before Fate holds out her hand for payment. Smokers like Uncle Melvin have only a few seconds at best: one puff – suffocation. Melvin lived every hour wheezing, coughing, struggling to climb a flight of stairs, but he put that cigarette between his lips, and with one quick drag bartered away the last breath in his tormented lungs. Nor was he alone, but one of thousands, tens of thousands, who smoked themselves right to the end of emphysema’s merciless road. Evidence, I would argue, that nicotine trumps heroin, knocks speed and crack cocaine into a cocked hat. 

* * * 

Wilma O’Malley was the Santa Clara Valley Medical Center’s most fabulous patient: the Queen of Asphyxia, the bravest of women, an institution unto herself. Almost every emphysema victim gives up smoking at least once, surrendering the evil weed for a week or a month or – rarely, alas – forever, but not Wilma. Her integrity was unimpeachable. The only time she surrendered a cigarette was when an ambulance attendant snatched it from her blue fingers or an intern rammed an endo tube down her trachea. For a decade, her calamitous body taught Valley Medical’s doctors more about asphyxia than a library full of journals. 

Wilma was forty-seven years old, a scarecrow with a prune face and streaked iron-gray hair, but she could have passed for sixty. Her skin had a bluish cast, a few drops of India ink stirred into a glass of milk. But that was at her prime. Under duress, as her remaining alveoli choked off one by one, she darkened to purple, then blue-black, then – in the final throes of suffocation – pitch-black. Her emphysema had progressed slowly, with miraculous languor, allowing her iron constitution to tolerate an oxygen level that would kill almost every mammal on earth. Though her arms and legs were sticks, congestive heart failure brought on by the struggle to pump blood through those scarred lungs caused her feet and ankles to swell up like dough-filled balloons. 

When Wilma came to our ward, her man was never far behind – a tall, cadaverous, bronze-skinned fellow of uncertain nationality who stood silently beside her bed for hours at a time. We nicknamed him the Mummy. Every admission followed the same script: Wilma rolled in sitting bolt upright on a gurney, gasping and wheezing and coughing until she vomited into an emesis basin held beneath her chin. The Mummy hovered in a corner while the charge nurse grabbed the denim satchel that lay on Wilma’s gurney and rifled its contents – a ragged toothbrush, a coiled half-empty tube of toothpaste, a flannel nightgown that smelled like an ashtray – all the while ignoring Wilma’s breathless protests: 

“Bitch! . . . wheeze . . . hack hack . . . Don’t you dare . . . wheeze . . . I got my rights . . . hack hack hack . . . wheeze . . . I’m gonna call . . . ” 

Finally, stuck to a greasy, newspaper-wrapped sandwich, Wilma’s stash was discovered – a bag of unfiltered butts scavenged from public ashtrays. After Wilma was relieved of her poison and tucked into bed, I thrust an endo tube down her trachea. A respirator pumped oxygen and aerosolized epinephrine into her lungs. An IV dripped Lasix and prednisone and antibiotics into her veins. At last, as dawn began to break, I stumbled to my own bed, leaving her alone with the hiss . . . clunk . . . hiss . . . clunk . . . hiss . . . clunk . . . of the respirator. Slowly, as the drugs took effect, the bronchospasm gave way, the surviving alveoli perked up, her complexion faded from midnight purple to the bluish translucency of a peeled grape. At rounds a few hours later, her desperate, wide-open eyes waited for me. They followed my every move. She was alive, alive yet wretched, tormented by a heartbreaking need – where was her precious nicotine? 

Day by day, her arterial oxygen inched its way up to a level that might sustain life in a seal or a porpoise, until at last we had to pull out the endo tube, leaving her trachea unguarded. Then the Mummy came out of nowhere, stealthy as a ghost. He had a talent for invisible locomotion. We never saw him walking, but a nurse or orderly would look up to discover his silent form looming over the ward counter or standing in a corner of Wilma’s room. No matter what precautions we took, a bag of pilfered butts would find its way into the hidden folds of Wilma’s bedclothes, and soon she was puffing away. After each drag, she concealed the smoldering cigarette between her mattress and the wall lest an intruder seize her precious contraband. 

Wilma assured me cigarettes had nothing to do with her ravaged lungs. Raised in the Blue Ridge Mountains of Tennessee, she had spent her childhood squatting in a dirt-floor shack, inhaling smoke and creosote fumes from a Franklin stove. 

“That’s what tore up my lungs,” she insisted. “Since then I ain’t never quit coughing. They call it smoke blight. Breathing that stuff just ruint me. Then there’s that mutt I call Tootsie Roll, some kind of rat terrier. He sleeps in my bed every night. I’m allergic to the beast, he chokes me up something terrible, but what can I do? Tootsie’s better company than any man alive. Cigarettes, they ain’t never hurt a bit. You doctors keep going on and on, but you don’t know squat. Nothing relaxes a person like a puff ever now and then.” 

I was not a good doctor to Wilma. In fact, if the chief of pulmonary medicine had known the truth – the ugly, unnatural truth – he would have given me a black mark at the end of my rotation on his service. Approaching Wilma’s room during evening rounds, I paused for a moment outside the door. Entering at last, I looked her in the eye, casting nary a glance at the plume of smoke that snaked its way up from the hidden cigarette. Night by night, without either of us speaking a word of this matter, all subterfuge fell away, until at last I sat by her bed with her chart in my lap, chatting and bantering for ten or fifteen minutes as Wilma smoked at her leisure. All this while the Mummy stood motionless in a corner of the room, his inscrutable face blank as the wall behind him.  

Where did it come from, my indulgence of Wilma? My mother smoked three packs a day for fifty years, smoked until her fingers turned yellow and her bed sheets reeked of tar. A disastrous parent – bitter, vindictive, on occasion breathtakingly cruel – but my mother nonetheless, with a stubborn mouth and a squint-eyed smoking style much like Wilma’s. Was this indulgence of Wilma a vicarious tribute to the loved but dangerous woman who bore me? Or a nostalgic tribute to my childhood in the deep South, where parishioners strode into church exhaling their last puff, where sand-filled ashtrays lined the halls of every hospital, where a pall of gray smoke hovered near the ceiling of every restaurant and movie theater in town? 

At Wilma’s bedside, I watched in fascination as her vice worked through its cycle. She did not suffer the ambivalence that tormented Uncle Melvin. When she looked at the cigarette smoldering between her fingers, there was nothing quizzical in her gaze. No doubt. No hesitation. Her eyes shone with a moist brightness. This was her life, her meaning – her lover. After a few drags, her skin turned dusky, her thin blue lips quivered as they pursed around the soggy butt. She gasped, wheezed, coughed. Then, between coughs, with a wink and a nod and a face that grew darker every moment – “excuse me . . . hack hack hack . . . gasp . . . wheeze . . . for . . . hack hack hack . . . gasp . . . wheeze . . . a second . . . ” – she turned on the Bennett respirator beside her bed. The motor whirred. She clamped the nozzle between her teeth and closed her lips around it, holding the cigarette aside with her free hand. As the Bennett forced in breath after breath, the aerosolized epinephrine blasted open the spastic bronchi, allowing oxygen to soar into her capillaries. Her complexion faded from deep purple to powder-blue. She took the nozzle out of her mouth. The coughing was gone, the wheezing faint and intermittent, subdued for the moment by the massive dose of epinephrine. 

She took another drag. 

Three drags later, her face almost black, she was ready for another refreshing pull on the respirator. 

* * *

Except for the lucky few delivered by Caesarean section, we are all born asphyxiated. I delivered a dozen babies during my internship, and you can take my word for it: when that swollen button-nosed face pops out between its mother’s thighs, the skin is blue, the eyes squeezed shut in the agony of suffocation. How else could it be, with the chest and umbilical cord trapped in the iron grip of the birth canal? Long before love and honor, before power and strife and cruelty, even before mother’s milk – breath. Newborns suck in air like a tidal wave, precious lungsful, then scream with the ecstasy of oxygen, scream to tell the story of their violent, suffocating birth. We breathe, and life begins. 

Oxygen is the ultimate addiction, the craving that never goes away. At Pearl Harbor, after Japanese torpedoes capsized the battleship Oklahoma, all but thirty-two of the 400 men trapped inside were drowned. When divers worked their way down to the flooded midshipmen’s head, they found a nightmare – six upside-down toilets, each containing a bubble of oxygen-free air and the face of an asphyxiated sailor. At the moment of certain death in rising waters, those six men fought for their last breath. I remembered them as I watched a veteran of Utah Beach whose larynx had been removed the week before. He grimaced. Tears of frustration ran down his cheeks. He was struggling to smoke through his tracheostomy, but the cigarette was too small to make a tight seal with the tube in his throat. 

The practice of medicine offers extraordinary – indeed, singular – insight into the human heart. I have witnessed the devotion of parents for their children, the tender bond that binds husband to wife for decades on end. But when I see a jaundiced alcoholic – days after a near-fatal hemorrhage, his belly swollen with ascitic fluid – sentence himself to a blood-vomiting death by again taking up the bottle, I have to wonder: is such self-destruction not evidence of the greatest passion, the greatest devotion of all? 

* * *

Wilma died in 1973, the year after I finished my internship. I never pitied her. We have no right to pity her, those of us who tiptoe through life, cowering in our world of tiny pleasures and skirting every vice that threatens our peaceful descent into a nursing home. Wilma had the guts to go after what she loved. She was willing to pay pleasure’s price every waking moment of every day. I tried a few serious drugs during my youth, but in the end my courage failed. I smoked two to three packs a day for three years, then quit the day after Bobby Kennedy was killed, thanks to a vicious attack of bronchitis. Now, instead of smoking cigarettes, I eat bran, lift weights, ride my bike fifty miles at a clip. I drink four ounces of gin every night and would like to drink a lot more. My internist sighs with envy when he reads my lipid profile. And yet, as I enter my seventh decade, on certain vague fall evenings, I feel a surge of resentment: where is the ecstatic purpose to my life, a purpose so raw and precious I would endure suffocation to possess it?