In connection with the legal battles over the use of the gas chamber in California, John M. Friedberg examined the prison records of 113 California gassings. They showed an average time to death of 9.3 minutes, and stated that unconsciousness set in after 1.6 minutes on average. Friedberg questioned the prison record's descriptions in connection with consciousness, and claimed that consciousness lasted around five minutes on average. Part of the difficulty is the ambiguity inherent in the term "unconscious" - there may be more of a continuum than a sharp line dividing consciousness from unconsciousness. There is also an incentive for prison authorities to present executions as humane. Friedberg cites some examples of witness who believed the execution process was slower than the authorities stated, and I've seen other similar claims.
Friedberg's web site is down, but I found the report on the internet archive:http://web.archive.org/web/201207080443 ... anide.html
I'll copy it here in case it gets taken down.CRUEL AND UNUSUAL
The following paper on Cyanide was prepared after many months of intensive preparation for testifying as a Neurologist on the question of whether death by Cyanide is cruel and unusual because consciousness isn't lost, in many cases, for several minutes.
In 1993 Judge Marilyn Patel of the San Franciso Federal Court agreed and just recently, on February 22, 1996 the 9th Circuit Court of Appeals upheld her decision as follows:
"...we conclude that execution by lethal gas under the California protocol is unconstitutionally cruel and unusual and violates the 8th and 14th Amendments. The district court's permanent injunction against defendants is AFFIRMED."
While I'm proud of this small part I played in the overall effort to abolish the anachronistic, demeaning, ineffective and downright disgusting practice of capital punishment, the effort must be redoubled. Just two nights ago, the state of California killed another prisoner. But the United States as a whole would have to kill ten people per day just to clear the backlog and this would be practically and politically unacceptable. Execution generally is a ritual of retribution.
What follows was intended to be a journal article based on my review of the dark subject which was returned for revision of the statistics section. I haven't had the time or personal ability to do that. If any statistician reading this is inspired to help, please contact me.
May 4, 1996Cyanide, Consciousness and Pain: Is Execution by Lethal Gas Cruel?
John M. Friedberg, M.D., Berkeley, California
I used 113 San Quentin Prison "Lethal Gas Chamber - Execution Records" to estimate the duration of consciousness and awareness of pain experienced by prisoners executed by hydrogen cyanide gas over the past 50 years. Estimations were based on notations completed by 31 prison physicians. Prison records indicated that average survival time is 9.3 minutes, including 1.6 minutes during which the prisoner is reported to be conscious. In contrast, my estimates also derived from the records coupled with the extensive medical literature on cyanide indicate that consciousness persists for almost 5 minutes. Prison estimates of time to certain unconciousness did not correlate with times to death. Additional comparisons show that physiologically-based estimates of minimum consciousness are not correlated with the original estimates from the prison forms. The persistence of consciousness and the pain of myocardial and skeletal muscle ischemia and tetany, induction of autonomic reflexes (e.g., drooling, defecating, emesis), and the terror of slow asphyxiation qualifies this form of execution as cruel and unusual. Physician involvement in executions is briefly discussed.Introduction
In 19761 the United States Supreme court upheld the death penalty in part to satisfy society's "moral outrage" at murderers. The court did not then and never has equated capital punishment with pain and suffering. On the contrary, the passage of the Eighth Amendment to the constitution in 1789 abolished such painful practices as burning at the stake,2 and since then the court has followed an evolving standards of decency doctrine. In 1890 it articulated the principle that execution should not involve "torture or a lingering death."3
Execution by cyanide gas was adopted in California in 1937 as more humane and less mutilating than hanging, shooting or electrocution.4 Despite a "flight from gas"5 to lethal injection after World War II, fives states - Arizona, California, Maryland, Mississippi and North Carolina - still operate gas chambers.
Currently in California, if the condemned prisoner will not choose, the default method is the gas chamber. Despite the fact that execution by injection is acknowledged by the Department of Corrections to be "state of the art,"6 it remains California's official position - communicated to the courts, the public and the prisoner - that death by cyanide is quick and painless. But is this true?
In 1990, the American Civil Liberties Union (ACLU) brought an action7 to block the resumption of executions at San Quentin after a 25 year moratorium (Fig. 1). In the course of challenging the constitutionality of execution by cyanide gas, the ACLU collected data and affidavits from various sources (e.g., witnesses, medical experts). I was asked to review materials provided by that organization with regard to duration of consciousness.Materials and Methods
The 113 available records were prepared by San Quentin's Chief Medical Officers to estimate consciousness and pain as required by California law,8 and follow a standard form which has not changed over fifty years.
Entries were made by 31 different prison doctors and include times for "gas strikes face," "apparent unconsciousness," "certain unconsciousness," and "dead." There were also lines for "remarks." (see Illustrations 1 and 2)
Major motor seizure are not described in these records. The question of cyanide-induced seizures is important because most seizures abolish consciousness and in the absence of true seizures, consciousness in cyanide execution appears tantamount to pain. Notations of "gasping," "grimacing", "twitching," "writhing" are frequent as are descriptions of "violent" head movements (arms and legs are restrained). The word "convulsion" is used non-technically in various witnessed lay accounts such as "convulsions while awake,"9 but only the word "clonic" appears once in the official records.
All calculations were based on these entries where available. Some records had to be excluded due to illegibility and omissions. Thus, 112 were usable for calculating the time from "gas strikes face" to "dead," and 97 records for the time from "gas strikes face" to "certain unconsciousness."
As EEG monitoring and neurologic data such as the Glasgow Coma Scale are not available, I re-computed duration of consciousness and pain by using the shortest time by any of the following three criteria: heart rate equal to or less than 45, slumping without recovery, or a respiratory rate equal to or less than 6 per minute. Obviously, the exact moment of unconsciousness (defined simply as "awareness of what is going on around one,"10) could not be estimated with precision; my criteria provided the only possible physiologic approximations. 54 reports included at least one of the three endpoints.
One EKG rhtyhm strip (that of David Masson, who was executed at San Quentin in August, 1993) was available for examination.Statistical analyses
A simple statistical test was done to determine whether or not the reported "certain consciousness" was correlated with death (P= 0.05; n = 97). Simple linear regression was also used to estimate coefficients of the linear model y = a + bx where a is a constant, y is time to death and x is certain consciousness from prison records.
The second test was whether or not my re-estimate of consciousness was significantly different from original prison estimates (n = 54); this comparison was done by regression analysis in which the model was y = a + bx where a is a constant, y is my estimate of pain and x is the prison estimate. (If the linear regression is not significantly different from zero, the relationship between the variables is not significant). Finally, I calculated the correlation coefficient for x and y.Results
Parameters of the regression analysis of time to death (y) and time of certain unconsciousness (y) were y = 8.24 + 0.47x. Mean time (± SD) of certain unconsciousness was 2.2 ± 1.1 minutes, whereas the mean (± SD) of death was 9.3 ± 1.7. The correlation coefficient of these variables, 0.32, indicates that the prison record of certain consciousness bears no relationship to the time of death. The large coefficient of variation (SD/mean) for y (50.7%) indicated that this variable was measured imprecisely. In contrast, the coefficient of variation for time of death (x), 17.7%, indicates considerably more accuracy.
For the 54 cases used, prison records suggest that pain lasted for 1.4 ± 0.8 minutes, whereas my re-evaluation indicated that pain persisted for 3.7 ± 2.7 minutes. Correlation between the two estimates was -0.03; the prison records and my medically-based estimates were thus not related. The results are shown as histograms in Fig. 2.
Although technically flawed, the Masson EKG, (Illustration 3), is consistent with other reports11,12 of the cardiac effects of cyanide: anticipatory tachycardia is fleetingly augmented followed by bradycardia. By inference from comments on other standard report forms, bradycardia may be quite profound and rapid [15 seconds - 2 minutes] but is sometimes transient. This cardiac effect may account for repeated observations of short-term "recoveries," e.g. "Head extended violently, Grimaces. Head falls forward body relaxed. Head again extended then falls forward."(record A 39039:Foster Dement executed 10/2/57 signed M.D. Willcutts, M.D.)
Arrhythmias, heightened T waves, loss of P waves and decreased myocardial contractility are apparent. Electromechanical dissociation may have occurred in the two most recent cases accounting for the fact that when the EKG monitor rather than a stethoscope was used to determine death, survival was apparently lengthened by several minutes. (Fig. 2)Discussion
Witnesses, including one San Quentin Warden,13 frequently disagree with San Quentin physicians as to the duration of consciousness. Howard Brodie, veteran journalist for Life Magazine and the San Francisco Chronicle, witnessed the execution of Aaron Mitchell in 1967 and swore that "as the gas hit him, his head immediately fell to his chest. Then his head came up and he looked directly into the window. For nearly seven minutes he sat up that way, with his chest heaving, saliva bubbling between his lips. He tucked his thumbs into his fists, and finally his head fell again..."14 Another source quotes Brodie: "I believe he was aware many minutes......He appeared to be in great anguish...."15 The official time for consciousness from Aaron Mitchell's record was five minutes. (Illustration 1)
The general belief that the brain cannot function anaerobically, that neurons die in 4 minutes without oxygen, that the lack of glycogen stores in the brain somehow precludes glycolysis, is probably incorrect. The principle determinant of consciousness in the structurally intact brain is perfusion.16
While there are reports of cyanide associated white matter abnormalities,17,18 human basal ganglia damage,19,20,21 and seizures,22,23,24 (the latter most consistently in rats and mice25,26) cardiorespiratory arrest with cerebral ischemia cannot be excluded as the cause.27,28 To the extent that cerebral damage or dysfunction of any kind can be singled out, white matter is more vulnerable than neurons29 and the dysfunction is reversible.
In Brierly's many careful experiments with monkeys,30,31,32,33 cyanide did not cause seizures or, absent ischemia, direct brain damage leading that investigator to question whether the "notion of histotoxic hypoxic" brain damage was not the result of "constant repetition."34
Anaerobic metabolism of glucose is not affected by cyanide and supports cerebral electrical function somewhat better than myocardial mechanical contraction. In the presence of cyanide, neurons fare better than myocytes. In fact, in human neurons in vitro, anoxia induces a protective decrease in neuronal excitability and an increase in gluconeogenesis.35
According to the most recent edition of Robbins definitive textbook of pathology: "In animal experiments in which the circulation is artificially maintained, the brain is actually quite tolerant of hypoxia, but ischemia can be tolerated for only a very short time."36 Furthermore, cyanide is found in higher concentrations in the heart than the brain at autopsy.37
By contrast, cyanide's profound cardiac toxicity is unquestioned.38,39 When the rate of infusion is progressively slowed, cardiac effects always precede cerebral effects.40
Cyanide in any form is among the most poisonous of substances ranking with military anti-cholinesterases and hydrogen sulfide which is also a "chemical garotte."41,42 As little as 37 mg of NaCN orally can be lethal43 and sniffing for the almond scent is discouraged because of the knockdown effect: "...men have been overcome at the first step of this system of analysis."44
The lowest concentrations of cyanide gas (20-40 ppm) produce dysphoria and panic, nausea or vomiting, vertigo, headache, tachypnea45,46 and tachycardia. A few prisoners appear to stop breathing and slump head forward in the first 30 seconds - the "apoplectic form"47 of cyanide poisoning. Most exhibit signs of global dysautonomia, with hyperventilation, alkalosis with tetany,48 salivation, retching and incapacitation;49 the heart rate may drop to the point that the individual "dims out" in the first 1-2 minutes, sometimes to recover in a state of asphyxiation.
Richard Traystman, M.D., Professor of Anesthesiology at Johns Hopkins Medical School, has written: "During this time (several minutes of hypoxia), a person will remain conscious and immediately may suffer extreme pain throughout his arms, shoulders, back and chest. The sensation may be similar to pain felt by a person during a massive heart attack."50
In some the tetany is probably painful as carpal-pedal spasms were noted in the records. To this must be added the well documented terror associated with asphyxiation.51
Eventually consciousness is lost without recovery and death ensues.Implications for Physicians
Attaching stethoscopes and filling out execution records is only one of several interfaces between capital punishment and physicians. Doctors are universally proscribed from any professional involvement with, or even presence at executions. They are permitted only to "certify" death after the fact.52,53,54 This position is based on the principle first do no harm and because "execution is not a medical procedure and is not within the scope of medical practice."55,56 As the number of executions increase, these written ethical standards have placed physicians in a "visible clash"57 with the letter of the law.58Conclusion
In 1764 Cesare Beccaria advocated the abolition of execution calling it a "useless prodigality of punishment."59 Certainly, execution by hydrogen cyanide gas is a prodigality, neither quick nor painless. Whether it is also unconstitutional is under consideration1 by Judge Marilyn Hall Patel in the Federal District Court of Northern California.
The experience of death by cyanide inhalation could be summed up by the first prisoner to be executed in California's chamber in 1938. His last words as lip-read by a reporter for the San Francisco Chronicle (Dec 10, 1938) were "too slow." Acknowledgements
I thank Haiganoush K. Preisler, Ph.D. and Jacqueline L. Robertson, Ph.D. for assisting me in the statistical interpretation of these data and Dr. Robertson and Robert J. Grimm,MD,FACP,PC for their editorial comments on earlier drafts of this article.References
1 At the time of submission April, 1994
1. Gregg v Georgia U.S. 153(1976)
2. Bedau H: The Death Penalty in America. NY, NY, Oxford University Press, 1982
3. In re Kemmler, 136 U.S. 436, (1890)
4. Gardner MR: Executions and indignities - an eighth amendment assessment of methods of inflicting capital punishment. Ohio State Law J 1978;(39)96:126-128
5. Zimring FE, Hawkins GH: Capital punishment and the American Agenda. Cambridge, England, 1986
6. Depue JR Perry RX: Possible relocation of condemned row/gas chamber and alternative method of execution. California Department of Corrections November 13, 1987.
7. Fierro v Gomez: US District Court for the Northern District of California. (U.S. Suprreme Court Docket No. A-767)
8. Department of Corrections Policy Statement No. OP-090901: "Procedures for the Execution of Inmates Sentenced to Death." Cited in: Medicine Betrayed: The Participation of Doctors in Human Rights Abuses, Zed Books, 1992. London, England
9.Humphry D: The cyanide enigma, Chap 5, in Final Exit. 1991, The Hemlock Society, Eugene, OR, 38-46
10. Webster's unabridged dictionary, second edition, 1983, Simon and Schuster New Nork, NY
11. Wexler J, Whittenberger JL, Dumke PR: The effect of cyanide on the electrocardiogram of man. Clinical Research Section of Medical Division. Chemical Warfare Service. 1946; 163-173
12. Pirzada FA, Hood WB, Messer JV, Bing OHL: Effects of hypoxia, cyanide, and ischaemia on myocardial contraction: observations in isolated muscle and intact heart. Cardiovas Res 1975; 9:38-45
13. Babcock JR: Declaration of Witness, April 17, 1982 in Fierro v Gomez: Exhibits V2 No.14
14. Reporter's Daily Transcript, People v. Bobby Maxwell, Los Angeles Superior Court, No. A 350010, July 24, 1984
15. Gray I, Stanley M: A punishment in search of a crime: Americans speak out against the death penalty. 1989;55-63
16. Brierly JB: Comparison between effects of profound arterial hypotension, hypoxia, and cyanide on the brain of Macaca mulatta, in Meldrum BS, Marsden CD: (Eds) Adv Neuro, 1975, New York, Raven Press 213-221
17. Levine S: Experimental cyanide encephalopathy. Presented at the Annual Meeting of the American Association of Neuropathologists, Washington D.C.,June 12, 1966
18. Fowler RC, Durbetacki AJ: Elevated cyanide levels in multiple sclerosis. Amer J Physiol 1952;171:724
19. Him YH, Foo M, Terry R: Cyanide encephalopathy following therapy with sodium nitroprusside. Arch Pathol Lab Med, 1982;106:392-393
20. Feldman JM, Feldman M: Sequelae of attempted suicide by cyanide ingestion: a case report. Int'l J Psych Med 1990;20(2)183-179
21. Braico KT, Humbert JT, Terplan KL, et al: Laetrile intoxication, report of a fatal case. N Engl J Med 1979; 300: 238-240
22. Nakatani T, Kosugi Y, Tajimi K, et al: Changes in the parameters of oxygen metabolism in clinical course recovering from potassium cyanide. Am J Emerg Med 1993; 3:213-117
23. Geller RJ, Ekins BR, Iknoian RC: Cyanide toxicity from acetonitrile-containing false nail remover. Am J Emerg Med, 1991; 9; 268-270
24. Hall AH, Doutre WH, Ludden T et al: Nitrite/thiosulfate treated acute cyanide poisoning estimated kinetics after antidote. J Toxicol Clin Toxicol, 1987;25121-133
25. Yamamoto H: Protective effect of NG-nitro-L-arginine against cyanide-induced convulsions in mice. Toxicology 1992, 71(3): 277-283
26. D'Mello GD: Neuropathological and behavioral sequellae of acute cyanide toxicosis in animal species, chap 6, in Clinical and Experimental toxicology of Cyanides. Bristol, UK, Wright Publishers, 1987, 156-183
27. Levine S, Stypulkowski W: Effect of ischemia on cyanide encephalopathy. Neurology 1959;9: 407-411
28. Tuchen SG, Manoguerra AS, Whitney C: Severe cyanide poisoning from the ingestion of an acetonitrile-containing cosmetic. Am J Emerg Med 1991;9(3):264-267
29. Earnest MP: Neurologic Emergencies. NY, NY, Churchill Livingstone, 1983, p 417
30. Brierly JB, Brown AW, Excell BJ: Brain damage in the rhesusmonkey resulting from profound arterial hypotension. Brain Res. 1969,13: 58-100
31. Brierly JB, Brown AW, Meldrum BS: The nature and time course of the neuronal alterations resulting from oligemia and hypoglycemia in the brain of Macaca mulatta. Brain Res, 1971, 25: 483-499
32. Brierly, JB, Prior PF, Calverly J, Brown AW: Cyanide intoxication in macaca mulatta: physiolgocial and neuropathological aspects. J Neuro Sciences 1977;31:133-157
33. Adams JH, Brierly JB, Connor RCR, Treip CS: The effects of systemic hypotension upon the human brain: clinical and neuropathological observations in 11 cases. Brain, 1989: 235-268
34. Brierly JB: op cit reference 16
35. Cummins TR, Jiang C, Haddad G: Human neocortical excitability is decreased during anoxia via sodium channel modulation. J Clin Invest 1993;91:608-615
36. Cotran RS, Kumar V, Robins SL: Robbins Pathologic Basis of Disease, 4th Edition. Phila, PA, W.B.Saunders Co, 1989, p 1403
37. Ansell M, Lewis FAS: A review of cyanide concentrations found in human organs. J of Forensic medicine 1970; 17:148-155
38. MacMillan VH: Cerebral energy metabolism in cyanide encephalopathy. J Cerebral blood flow and metabolism 1989;9:156-162
39. Ballantyne B: Toxicology of cyanides, Chap 3, in Clinical and Experimental toxicology of Cyanides. Bristol, UK, Wright Pub, 1987, 41-126
40. Ward AW: Sodium cyanide: time of appearance of signs as a function of the rate of injection 1922: 190-193
41. Stryer L: Biochemistry, Second Ed. WH Freeman, SF, CA, 1981. 317-318
42. Piantadosi CA, Sylvia AL: Cerebral cytochrome a,a3 inhibition by cyanide in bloodless rats. Toxicology, 1984;33:67-79
43. Ansell M, Lewis FAS: A review of cyanide concentrations found in human organs. J of Forensic Med 1970; 17:148-155
44. Wolfsie JH, Shaffer CB: Hydrogen cyanide: hazards, toxic- ology, prevention and management of poisoning. J Occup Medicine 1959; 281-187
45. Levine S: Nonperipheral chemoreceptor stimulation of ventilation by cyanide. J of Applied Physiology 1975;(39)2:199-220
46. Traystman RJ, Fitzgerald RS: The role of carotid and aortic baroreceptors and chemoreceptors in the cerbrovascular response to hypoxia. J Cereb Blood Flow Metab 1981; 1: S309-310
47. Arena JM, Thomas CC: Poisoning: Toxicology, Symptoms, Treatments. Illinois, Charles C. Thomas
48. Brierly, JB: Comparison between effects of profound arterial hypotension, hypoxia, and cyanide on the brain of Mucacca mulatta,in Meldrum BS, Marsden CD: (Eds); Advances in Neurology. New York, Raven Press,1975; pp 213-221
49. Purser DA, Grimshaw P, Berrill KR: Intoxication by cyanide in fires: a study in monkeys using polyacrylonitrile. Arch Environ Health 1984:39(6)394-400
50. James Gomez and Daniel Vasquez v. United States District Court for the Northern District of California, et al: On Application to Vacate Stay (April 21, 1992), Supreme Court of the United States (Docket No. A-767) Justices Stevens and Blackmun dissenting
51. Reimringer MJ, Morgan SW, Bramwell PF: Succinylcholine as a modifier of acting-out behavior. Clin Med 1970; 77;28-29
52. Thorburn KM: Physicians and the death penalty. West J Med 1987;146:638-640
53. Troyen RD, Brennan TA: Participation of physicians in capital punishment. New Engl J Med 1993; 329:1346-1349
54. Council on Ethical and Judicial Affairs. Physician participation in capital punishment. JAMA 1993; 270:365-368
55. US physicians and the death penalty. Editorial, Lancet, 1993, 343:743
56. Curran WJ, Casscells W: The ethics of medical participation in capital punishment. N Engl J Med, 1980; 302: 226-230
57. Breach of trust: physician participation in executions in the United States. American College of Physicians, Human Rights Watch, National Coalition to Abolish the Death Penalty, Physicians for Human Rights, 1994. ISBN-564321258 p 11
58. US physicians and the death penalty. Editorial, Lancet, 1993, 343:743
59. Beccaria C: Of Crimes and Punishments. H. Paolucci, trans. London, UK, 1964, pp 45-62 ??