Powerful memoirs by such eloquent doctors as Oliver Sacks, Atul Gawande, Henry Marsh, Gabriel Weston and Paul Kalanithi have whipped the bed curtains open on a previously secretive profession. Steeped as medicine is in uncomfortable facts about debilitating illness, pain and the stress of treating intractable conditions, it was a subject ripe for exposure.
Under the Knife and Anaesthesia admit to the fallibility of medicine and the responsibilities, flaws and complex emotions of its practitioners. Arnold van de Laar does not rely on personal experience. Instead, he explores the world of surgery through 28 clinical conditions; its historical scope makes for a fascinating book.
Did you know that when Louis XlV was found to be suffering from an anal fistula, his nervous, inexperienced surgeon asked for six months in which to practise on 75 citizens? That Houdini had acute appendicitis at the time of his last performance? That a Dutchman was so frenzied by the agony of his bladder stone that he cut it out himself? In the days before prosthetics, Albert Einstein was saved from near certain death from acute abdominal aortic aneurysm (a swelling of the main artery of the body that precedes rupture) by a surgeon who wrapped the bulging vessel in cellophane. The Shah of Iran’s painful death was hastened by his summoning to Egypt a famous American vascular surgeon with no experience in operating on spleens. The surgeon, catastrophically, removed pancreatic tissue along with the spleen. Bob Marley died because he refused to have his big toe with melanoma amputated.
The author’s sense of humour is as sharp as his scalpel. He recounts how, when a surgeon famous for speed, accidentally sliced open his assistant’s fingers, an onlooker collapsed and died, as did, eventually, the assistant and the patient, so that a single operation resulted in three deaths.
But I have a few quibbles with some of his assertions. Not all bladder stones are caused by infection. The statement that in cardiac tamponade ‘the heart will not only beat less frequently but less powerfully’ is misleading: when the heart is compressed by fluid in the surrounding sac, it beats furiously fast to try to compensate for the decrease in cardiac output, although slow heart rhythm can occur early and late in the condition. I question Van de Laar’s certitude that Houdini’s appendix rupture wasn’t a result of being punched in the abdomen before he had a chance to tense his abdominal muscles, and query his use of ‘ileus’ for mechanical bowel obstruction. The term is used nowadays almost solely for the absence of peristalsis.
Kate Cole-Adams is obsessed by general anaesthesia (GA); especially the concept of ‘awareness’, a relatively rare phenomenon whereby an anaesthetised patient is awake during some of the operation, but usually can’t move, because of drugs causing muscle relaxation. Most anaesthetists believe that awareness arises through insufficient drugs having been given. This is sometimes because frail patients with low blood pressure may not tolerate the usual doses of hypnotics, or, in pregnant women, out of concern for the baby.
Advances in monitoring mean that awareness is less common than it was. However, Cole-Adams is right: those who have suffered it should be treated with sensitivity, honesty and offers of therapy. Her voice is expressive, empathetic and smart; but occasionally her lack of medical knowledge trips her up. If one visual hemisphere is damaged, it doesn’t cause blindness in the opposite eye; it causes the opposite field of vision to be impaired. Her musing on what happens to ‘self’ during anaesthesia implies belief in the soul, whereas scientists would argue that ‘self’ is comprised of the activity of neurones and chemicals, influenced by genes and environment.
She talks of the ‘reductive dualism’ of western scientific thought around consciousness. But scientists grade sleep and GA into stages, and conscious levels in head-injured patients according to the Glasgow coma scale. We are now very alert to the fact that people are not simply ‘conscious’ or ‘unconscious’.There is good evidence that patients under GA are capable of taking in information subliminally: careless words by theatre staff can lodge in the subconscious. A recent theory suggests that, under GA, links between the thalamus, which receives sensory information from the body, and the cortex, which interprets this information, become disconnected.
And what of consciousness at death? Experiments on rats show that in early brain death there’s an increase in conscious perceptive activity — which might account for the rush of images reported by people revived from cardiac arrest. From a slightly lugubrious start, though, Cole-Adams develops a compelling book.