Anesthesia

1. Anesthesia: A Profound Disappearing Act with Unanswered Questions

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.

Modern miracle. Anesthesia is a brilliant and baffling gift of modern medicine, enabling surgery that would otherwise be impossibly painful. General anesthesia, unlike local numbing, switches off parts of the brain responsible for consciousness and pain processing. This daily "extinction" and "un-happening" remains largely uncertain in its precise mechanisms, despite its widespread use.

Beyond the mechanics. The author's core question delves beyond the neurological apparatus, asking "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?" This inquiry extends to the subjective experience and potential long-term effects on our waking lives, a realm often overlooked by medical science.

Historical context. Before 1846, surgery was an agonizing last resort, with many patients choosing death over the knife. The introduction of ether brought the "gift of oblivion," but even with advanced drugs and monitoring, doctors still can't definitively measure how deeply a patient is anesthetized or if they are truly unconscious, highlighting the persistent mystery at its core.

2. The Terrifying Reality of Awareness and Paralysis

It is difficult to imagine a more exquisite form of torture than major surgery with consciousness, pain perception and complete paralysis.

Rachel's ordeal. Rachel Benmayor's story vividly illustrates the horror of intraoperative awareness. During her caesarean section, she was conscious of immense pain and the sounds of the operating room, yet completely paralyzed and unable to signal her distress. This terrifying experience led to years of nightmares, panic attacks, and a profound sense of violation.

The role of muscle relaxants. The introduction of neuromuscular blocking drugs in 1942 revolutionized surgery by keeping patients still, allowing for lighter anesthetic doses. However, these drugs also prevent conscious movement, creating the terrifying possibility of being awake, feeling pain, and being utterly helpless, a state akin to being "buried alive."

Beyond pain. Studies show that the most distressed awareness patients are often not those who felt pain, but those who experienced paralysis. The realization of consciousness while being unable to move, coupled with the staff's apparent obliviousness, can lead rapidly to the conclusion that something has gone seriously wrong, often resulting in severe post-traumatic stress disorder (PTSD).

3. Medical Denial: A Barrier to Understanding Patient Experience

Surveys have shown that they greatly underestimate the chances of patients—particularly their patients—waking up under the knife.

Dismissal of claims. Patients reporting awareness often face disbelief or dismissal from medical staff, being told they "must have been dreaming it all." This denial is partly due to physicians' perfectionist tendencies and fear of making mistakes or facing lawsuits, creating a culture where such incidents are underreported and undertreated.

Systemic denial. The medical system itself, rooted in Cartesian dualism, often separates mind and body, making it easier to objectify patients. This "form of denial that enables them to act upon us in ways that would otherwise be unthinkable," allowing doctors to reduce the magnitude of daily risks and stakes by transforming patients from subjects into objects.

Patient's dilemma. Doctors face a quandary: informing patients about awareness risks can increase anxiety, potentially making anesthesia less effective. However, withholding information or dismissing experiences can lead to lasting psychological harm, as seen in cases like Anthony Messina, an anesthesiologist who was blacklisted for speaking about his childhood awareness.

4. Hidden Memories: The Unconscious Brain Still Processes Information

But the fact that nine of the eleven nonetheless pulled, two of them repeatedly, suggested, said Bennett, a failure of memory retrieval rather than one of memory formation: the memories were there, but unavailable to the conscious mind—or even perhaps to language.

Levinson's experiment. Bernard Levinson's 1965 study, though methodologically flawed, suggested that patients under deep anesthesia could later recall conversations under hypnosis. This hinted at "unconscious learning," where information is processed by the brain but not consciously remembered, challenging the notion of complete cognitive shutdown.

Priming and implicit memory. Modern research, like Hank Bennett's ear-pulling experiment and David Adams's word-pair study, provides evidence for implicit memory during anesthesia. Patients can be "primed" with information (words, suggestions) that influences their later behavior or responses, even if they have no conscious recall, demonstrating that the brain is still active.

Emotional impact. Studies suggest that unconscious perceptions can affect feelings, moods, judgment, and behavior without conscious awareness. The "Robinson Crusoe" study, for instance, hinted at emotional learning more resistant to drugs, suggesting that the emotional context of surgical events might be processed even if the narrative is forgotten, potentially leading to later distress.

5. Anesthesia's Dual Nature: Oblivion and Potential Trauma

Every time you have a general anesthetic, you take a trip toward death and back.

The fine line. Anesthesia aims for oblivion, a temporary "extinction of self." However, the line between this desired state and potential trauma is fine. Too much anesthetic increases risks like heart attack or stroke, while too little risks awareness and its psychological sequelae, creating a constant balancing act for anesthesiologists.

Postoperative cognitive dysfunction. Many patients experience mental fogginess or delirium after surgery, particularly the elderly, with 10-15% still having problems three months later, sometimes forever. This raises concerns that while healing the body, anesthesia might be harming the brain, a view that has gained traction in recent literature.

Amnesia as a double-edged sword. Amnestic drugs like propofol are widely used to ensure patients forget the procedure, even if they were partially conscious. While convenient for doctors and patients (who often prefer not to remember), this "general amnesia" raises ethical questions about whether it merely masks suffering rather than preventing it, and if "unconsciousness might be optional."

6. The "Unbinding" Theory: Anesthesia as Cognitive Disintegration

If consciousness was a process of binding, then anesthesia might be one of unbinding. If consciousness was integration, unconsciousness was disintegration.

Mashour's paradigm. Neuroscientist George Mashour proposes that anesthesia doesn't just suppress brain activity but actively dismantles the "cognitive binding" that integrates disparate sensory inputs into a unified conscious experience. He likens it to an orchestra falling apart, where instruments still play but lose synchronization, resulting in noise rather than music.

Functional disruption. Under anesthesia, sensory information reaches the brain and is processed to some degree, but the ability to synthesize this information into a conscious experience is disrupted. This "functional disruption" means the brain has the "tools for experience" but not the capacity to "assemble that information" into awareness, leading to fragmented perception.

Overlap with psychological unconscious. Mashour speculates a deeper connection between anesthetic unconsciousness and the Freudian "dynamic unconscious," where upsetting thoughts are exiled but remain active. He observed patients releasing suppressed emotions as they went under, suggesting anesthesia might activate a system that normally keeps unwanted information out of consciousness, alleviating distress.

7. Patient Agency: Influencing Your Anesthetic Experience

The point is that it is not just what we as patients take away from the operating table that might matter, but what we bring to it in the first place.

Preoperative preparation. Studies show that patient preparation, including psychological interventions like hypnosis, can significantly improve surgical outcomes. The Mount Sinai study, for example, found that brief hypnosis sessions reduced drug use, surgery time, pain, nausea, and fatigue, saving hospitals an estimated $772.71 per patient.

Mind-body connection. Hank Bennett's "blood shunting" study, though "spooky," suggested that patients could be instructed to consciously direct blood flow away from the surgical site, reducing blood loss by a third. This highlights the potential for patients to actively participate in their own physiological responses during surgery, beyond passive submission.

The power of belief and intention. While not fully understood, these interventions suggest that a patient's mental state, expectations, and even specific intentions can influence their experience and recovery. Communicating with patients, providing reassurance, and empowering them with simple instructions can make a tangible difference in their surgical journey.

8. The Ethical Imperative of Communication and Empathy

We must not only be aware of the inherent limitation of science and technology but, most importantly, also of the inherent dignity of each personal ‘self.’

Beyond technical proficiency. The NAP5 audit, the largest study of awareness, highlighted that communication is a crucial, yet often overlooked, aspect of patient care. Simple acts like informing patients about potential brief awareness, reassuring them during surgery, and listening respectfully afterward can significantly reduce psychological trauma.

The cost of silence. Dismissing patient reports of awareness or using amnestic drugs to erase memories of distress raises ethical concerns. As anesthesiologists Girgirah and Kinsella noted, most doctors would not accept being awake and paralyzed, even without recall, suggesting a double standard in patient care that prioritizes convenience over patient well-being.

Care of the soul. Japanese anesthesiologist Jiro Kurata advocates for "care of the soul," recognizing that a "subconscious self" might be resistant to anesthetics and that patients possess inherent dignity. This calls for a shift from purely technical management to a more holistic, empathetic approach that values subjective experience and human connection.

9. Anesthesia as a Journey into Primal Vulnerability

To be anesthetized is to be about as regressed as you can get.

Loss of control. Entering surgery involves a profound loss of privacy, dignity, and control, reducing adults to a state of infantile helplessness. This psychological regression can be deeply disturbing, triggering childhood fears of abandonment or powerlessness, as experienced by the author's own father during his childhood ether anesthetic.

Psychic armor dismantled. Anesthetics not only suppress higher brain functions but can also dismantle the "psychic armor" that maintains our daily sense of self. This can open unexpected doors to buried emotions or past traumas, leading to experiences like lovesickness for a surgeon or intense emotional release, as observed by George Mashour.

The "bad playground" of the unconscious. The author's own dream of a "bad playground" and the red dog with a sewn-up muzzle symbolizes the voiceless, vulnerable parts of the self that emerge under anesthesia. These experiences, though often dismissed as dreams, highlight the profound impact of this altered state on our deepest psychological landscape, demanding acknowledgment.

10. The Enduring Mystery of Consciousness and Its Altered States

One conclusion was forced upon my mind at that time, and my impression of its truth has ever since remained unshaken. It is that our normal waking consciousness, rational consciousness as we call it, is but one special type of consciousness, whilst all about it, parted from it by the filmiest of screens, there lie potential forms of consciousness entirely different.

Beyond the "easy problem." While neuroscience makes strides in understanding the brain's mechanisms (Chalmers' "easy problem"), the "hard problem" of subjective experience—what anesthesia feels like—remains elusive. Philosophers like Benjamin Paul Blood and William James described "anaesthetic revelations" and "metaphysical illumination" during early anesthetic stupor, hinting at other forms of consciousness.

Visions and delirium. Patients often report vivid hallucinations or visions during or after anesthesia, ranging from benign to terrifying. These experiences, influenced by drugs, anxiety, and personal history, suggest a melding of internal and external realities, blurring the lines between anesthesia, dreams, and waking life, as seen in Michael Wang's "hospital ship" delirium.

The self in flux. The book concludes that consciousness is not a fixed entity but a fluid, multifaceted experience. Anesthesia, by temporarily dismantling our usual conscious self, reveals the "filmiest of screens" separating us from other potential forms of consciousness, emphasizing the profound, often unacknowledged, journey we undertake each time we "go under."

Last updated: February 7, 2026