Anesthesia Read online




  Copyright © 2017 by Kate Cole-Adams

  First published in English as Anaesthesia by The Text Publishing Company, 2017

  All rights reserved under International and Pan-American Copyright Conventions. No part of this book may be used or reproduced in any manner whatsoever without written permission from the publisher, except in the case of brief quotations embodied in critical articles and reviews.

  Library of Congress Cataloging-in-Publication Data

  Names: Cole-Adams, Kate, author.

  Title: Anesthesia : the gift of oblivion and the mystery of consciousness /

  Kate Cole-Adams.

  Description: Berkeley, CA : Counterpoint Press, [2017] | Includes

  bibliographical references and index.

  Identifiers: LCCN 2017034798 | ISBN 9781619029507

  Subjects: | MESH: Anesthesia | Anesthesia—history | Consciousness—drug

  effects | Unconsciousness—chemically induced

  Classification: LCC RD81 | NLM WO 200 | DDC 617.9/6—dc23

  LC record available at https://lccn.loc.gov/2017034798

  Jacket designed by Sandy Cull, gogoGingko

  COUNTERPOINT

  2560 Ninth Street, Suite 318

  Berkeley, CA 94710

  www.counterpointpress.com

  Printed in the United States of America

  Distributed by Publishers Group West

  10 9 8 7 6 5 4 3 2 1

  For Pete, Finn and Frannie

  With love and gratitude

  Contents

  Into the blue

  Going under

  Awake

  Denial

  Paralysis

  Two hearts

  The cold bosom of the ocean

  Questions without answers

  Things you don’t know you know

  Weird science

  Moonless nights

  Lost days

  The most famous anesthesiologist in the world

  Adrift

  The island

  Dreams

  Altered states

  Ghost stories

  Small bright fish

  General amnesia

  A working hypothesis

  The memory keepers

  The perfect anesthetic

  Merging currents

  Coming apart

  The hypnotist

  Regression

  Surfacing

  Pulsations and palpitations

  The shallows

  Blood and blushing

  Ballast

  That younger me

  Sky

  Letting go

  Wings

  Acknowledgments

  Notes

  Sources

  Into the blue

  I am in a smallish, whitish room in a hospital in Brisbane. It is night. On the wall opposite my bed I can dimly make out a crucifix with its limp passenger. Beneath it float wide blank windows through which I watch the synapses of city light: a web of tiny illuminations and extinctions that seem, when I loosen my gaze, almost to form patterns; as if they are about to make sense. I am surprised at how calm I feel.

  In the weeks leading up to this moment I have set my affairs in order. Made a will, written letters for the children, waxed my legs. Said my farewells at the airport and boarded the flight from Melbourne with my mother. July 2010.

  Some months before this, after decades of resistance, I gave in at last to the inevitability of major surgery. My capitulation was sudden and took place in a different wing of this same hospital, where I had come to consult a respected spinal surgeon. The surgeon had a quiet, almost diffident, manner and a moustache that put me in mind of a doleful Groucho. I am not sure what made my mind up, the moustache or the way his finger traced my wayward spine quite gently on the X-ray before him. But just as he began to tell me that I would not be a candidate for the type of noninvasive surgery we had been talking about, I realized with a small thud of certainty that, not only was I going to have this surgery—invasive though it might be—I was going to come back to Brisbane and he was going to do it.

  In the aftermath of my decision, I was buoyed in a backwash of something like relief; a giving up of hope and its attendant efforts, a yielding to forces beyond my will. But when I lay awake at night, disquiet rose around me. It was not just the surgery that was worrying me—the cutting and drilling, the inevitable risk—it was that in some blank corner of myself I felt that I would not wake up afterward. I knew logically, and during the day could convince myself, that for an otherwise healthy forty-eight-year-old, the likelihood of calamity was low. But at night, there in my bed in Melbourne, the conviction multiplied inside me that even if everything went according to plan, the me who woke after surgery would not be the same in some essential way as the me who had been wheeled into the operating theater beforehand. I developed a dread of the moment when the anesthetic drugs would take effect and I would cease to be. I pictured myself in a stark, poorly lit room with two doors, one in, one out, neither of which I could open from within. Otherwise the room was empty. No windows, no furniture. In this darkness—which I now realize had the same sinuous quality as the shadows beneath my childhood bed—I would be trapped alone. Perhaps forever. At least until such time as someone else chose to release, not me but some other, ostensibly similar, version of me who would slip soundlessly into the life that had once been mine.

  Shortly after making my decision I rang a separate Brisbane medical practice. I asked to speak to the doctor whose job it would be to render me unconscious and keep me that way during the long operation. Halting, almost apologetic, I explained to the receptionist that I had spent some years researching the process known as anesthesia, and that I was now rather nervous about what was going to happen to me. “I think I know too much,” I said.

  “Oh dear,” said the receptionist. “That’s not good.”

  •

  This book explores perhaps the most brilliant and baffling gift of modern medicine: the disappearing act that enables doctors and dentists to carry out surgery and other procedures that would otherwise be impossibly, often fatally, painful.

  Anesthesia. The term was appropriated from the Greek by New England physician and poet Oliver Wendell Holmes in 1846 to describe the effect of the drug ether following its first successful public demonstration in surgery. Anesthetize: to render insensible.

  These days there are other sorts of anesthetics that can numb a tooth or a torso simply (or unsimply) by switching off the nerves in the relevant part of the body. But the most widespread and intriguing application of this curious craft is what is now known as general anesthesia. In general anesthesia it is not the nerve endings that are switched off, it is your brain—or at least parts of it. These, it seems, include the connections that somehow enable the operation of our sense of self, or (loosely) consciousness, as well as the parts of the brain responsible for processing messages from the nerves telling us that we are in pain: the neurological equivalent of shooting the messenger. Which is, of course, a good thing.

  More than a good thing. I would not have boarded that plane to Brisbane had it been otherwise. And I don’t assume my fears were greater than those of anyone else in my predicament. But it was also true that for the previous decade I had been deeply preoccupied with a question or series of questions, often nebulous and contradictory, that amounted to this: what really happens to us when we are anesthetized?

  By this I mean not what happens to the pinging, crackling apparatus of our nerves and spinal cords and brains, but what happens to us—to the person
who is me or the person who is you—as doctors go about the messy business of slicing and delving within us? And, fused somehow to this, another odd and stubborn question: can whatever happens (or doesn’t happen) while we are under anesthesia continue to affect us in our waking lives? Can it change the way we feel or think or behave in the minutes, months and even years after surgery? Finally I wondered—a niggling, almost soundless irritation largely obscured by the first two questions—why did I care?

  •

  Not so long ago, if you were unlucky enough to need surgery and strong enough to withstand it, you would be tied down and cut open, usually conscious and probably screaming. Poppy. Hemlock. Hemp. Over the centuries healers tried every imaginable way of preventing or deadening pain: pressing on arteries, pinching nerves, soaking sponges in narcotic herbs for patients to breathe through. Some practitioners favored a blow to the jaw; others rubbed stinging nettles on one part of the body to distract from another. Alcohol. Opium. Hypnosis. Prayer. Until the mid-1800s, surgery was almost always an agonizing last resort. Most of today’s routine operations were impossible, and even when they weren’t, many patients chose death in preference. “Suffering so great as I underwent cannot be expressed in words,” wrote one survivor. “The particular pangs are now forgotten; but the blank whirlwind of emotion, the horror of great darkness and the sense of desertion by God and man . . . I can never forget.”

  In the end a patient’s best hope was often simply speed. A Napoleonic surgeon called Langeback claimed he could amputate a shoulder “in the time it took to take a pinch of snuff.” The brutality of their trade made some surgeons wretched and others hard-hearted, but even amid the burgeoning humanism of the Enlightenment, pain was considered so integral to life that few could imagine surgery without it. “To avoid pain, in surgical operations, is a chimera,” said the French surgeon Velpeau in 1839. “Knife and pain, in operative surgery, are two words which never suggest themselves the one without the other . . . and it is necessary to admit the connection.”

  Surgical anesthesia brought the gift of oblivion.

  Yet 170-odd years after a Boston dentist named William Morton gave the first successful public demonstration—removing a lump from the jaw of twenty-year-old Gilbert Abbott—we still don’t understand fully how anesthetics work. Each day nurse anesthetists and specialist doctors known as anesthesiologists (elsewhere, anaesthetists) put hundreds of thousands of people like you and me into chemical comas to enable other doctors to enter and alter our insides. Then they bring us back again. It is mind-blowing. But quite how this daily extinction happens and un-happens remains uncertain. Researchers know that a general anesthetic acts on the central nervous system—reacting with the slick membranes of the nerve cells in the brain to hijack responses such as sight, touch and awareness. They have nominated areas and processes they know are important: the microscopic channels through which neurons blast their chemical relays; the electrical circuits that pulse and groove between different regions of the brain. But they still can’t agree on just what it is that happens in those areas, or which of the things that happen matter the most, or why they sometimes happen differently with different anesthetics, or even on the manner—a sunset? an eclipse?—in which the human brain segues from conscious to not.

  Nor, as it turns out, can anesthesiologists ultimately measure what it is they do.

  For as long as doctors have been sending people under, they have been trying to fathom how deep they have sent them. In the early days, this meant relying on signals from the body; later, on calculations based on the blood concentration of the various gases used. More recently, brain monitors that translate the brain’s electrical activity into a numeric scale have come on the market—a de facto consciousness meter. For all that, however, doctors still have no way of knowing for sure how deeply an individual patient is anesthetized—or even if that person is unconscious at all.

  •

  I am not an anesthesiologist, or a surgeon or even a doctor. I am, however, one of the hundreds of millions of humans alive today who have undergone a general anesthetic. It is an experience now so common as to be mundane. These days there are gases and vapors and chemical infusions. Drugs to knock you out, to wake you up, to make you lie still in between; drugs to take away pain. There are machines to measure your heart rate, blood pressure, oxygen level, brainwaves; machines to breathe for you when you cannot. Anesthesia has become a remarkably safe endeavor: less an event than a short and unremarkable hiatus. The fact that this hiatus has been possible for fewer than two of the two thousand or so centuries of human history; the fact that only since then have we been able to routinely undergo such violent bodily assaults and survive; the fact that anesthetics themselves are potent and sometimes unpredictable drugs—all this seems to have been largely forgotten. An-es-thee-zha. Most of us can barely pronounce it. Yet it has allowed the body’s defenses to be breached in ways previously unimaginable except during warfare or other catastrophe. Through the use of powerful poisons, it has enabled entry into the secret cavities of the chest and the belly and the brain. It has freed surgeons to saw like carpenters through the bony fortress of the ribs. It has made it possible for a doctor to hold in her hand a steadily beating heart. It is a powerful gift. But what exactly is it?

  Part of the difficulty in talking about anesthesia—not how to do it, but what it actually does—is that any discussion veers almost immediately onto the mystery of consciousness. And despite a renewed focus in recent decades, scientists cannot yet even agree on the terms of that debate, let alone settle it.

  Is consciousness one state or many? Can it be wholly explained in terms of specific brain regions and processes, or is it something more? Is it even a mystery? Or just an unsolved puzzle? And in either case, can any single explanation account for a spectrum of experience that includes both sentience (what it feels like to be—sound, sensation, color) and self-awareness (what it feels like to be me—the subjective certainty of my own existence)? Not to mention the mechanisms by which information and attention wash in and out of these inexact, internal realms. In all this, unconsciousness remains the mute twin. Anesthesiologists point out that you don’t have to know how an engine works to drive a car. But stray off the bitumen, and it is surprising how quickly pharmacology and neurology give way to philosophy: If a scalpel cuts into an unconscious body, can it still cause pain? And then ethics: If, under anesthesia, you feel pain but forget it almost in the moment, does it matter?

  •

  Sitting in my window seat en route to that small room in Brisbane, I was doing my best not to think about any of it. Until this point in my life, I had had three general anesthetics—all short, and all, to my knowledge, uneventful: minor surgery. I had a composite memory of lying on my back on a trolley: the porous white ceiling tiles that have colonized hospitals the world over; the masked figures in caps and faded scrubs; the jokes, the clatter; the sweet, dark swoop. And then, immediately it seemed, waking. Abruptly, and unrefreshed. As if the two parts of my life had been spliced together, and where there should have been something, there was now nothing, a blank. Perhaps it was this absence that worried me—the eviscerated, unaccounted-for minutes or hours—or perhaps, I thought at other times, it was the sense that the absence wasn’t quite as absent as it now seemed.

  I have spoken with people whose eyes gleam at the thought of anesthesia. “Oh my god,” said one woman I know, in a tone that was frankly erotic, “that slide down. That letting go . . .” Others, probably the majority, don’t think about it at all. But a surprising number take on a wary, doubtful look. Early in my research I met a woman who had placed a small newspaper advertisement offering counseling for people facing surgery. This woman dreamed of a fish—more an image than a dream: it was there when she awoke, and there when she went to sleep. A fish being filleted, the knife slicing down the spine. Except it was not a fish: it was her. She had had more than forty operations, she told me, the first in he
r twenties to fuse her lower spine after a fall ruptured the discs. She shrugged, a small, sweet-faced blonde woman in her early fifties. The fish had come to her during the first operation. The surgery had gone smoothly. She remembered nothing. But in the twenty-four years since, she had not been able to shake the image, and each new operation had reinforced it. “I don’t like to ever touch a fish that’s got bones in it. I can’t. I can never go to a restaurant and eat a whole fish, because you’ve got to pull it apart like that, so it’s pulling my back apart. It’s an awful thing.”

  I had heard occasional stories of surgeons stitching up a patient and not realizing they had left something inside—a swab or instrument—that could go on to become an irritant or worse. Now I started to wonder, was it possible that other things sometimes got left behind? Words, perhaps. Feelings. Even beliefs?

  Then I came across the unrepeatable experiment.

  •

  Just over fifty years ago, in a small surgery in Johannesburg, South Africa, a little-known psychiatrist named Bernard Levinson staged a strange and disturbing drama. Levinson, then thirty-nine, persuaded a professor of surgery at the city’s dental hospital to let him use ten of the professor’s surgical patients as unwitting guinea pigs in what would become one of medicine’s oddest studies.

  The evening before the operations, Levinson selected volunteers from the following day’s operating list by taking each aside and asking them to follow a series of instructions. First he counted backward from three and told them to relax. Then he told them that at his command their right arm would rise effortlessly and touch their nose, and that at this point their eyes would close. Once the patients were in a hypnotic trance, Levinson asked each to go back to a happy childhood memory. Most relived long-forgotten birthdays, he reported, often in surprising detail. Then Levinson instructed them, on the count of three, to wake up, relinquishing as they did any memory of what had just happened. He selected the first ten patients he could easily hypnotize, six women and four men. For the purposes of the experiment Levinson told them simply that during the following day’s surgery he would monitor their brainwaves and that later he would again hypnotize them to “explore their feelings” about the operation. He did not tell them what was going to happen.