Freud and anesthesia

Gabriel M. Gurman
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Few of our anesthesiology peers know that Freud was the physician who
published the first analytical and scientific research on cocaine and was the
first investigator to predict its use as local anesthetic.
But Sigmund Freud became worldwide known because the discovery of
the existence of an unconscious mind referred sometimes in the popular
literature as subconscious, an entire dynamic world of thoughts, fears and
behavior that exists in every person below the surface of his conscious
mind.
There is no normal access to this part of our mind, but it reveals itself in a
flamboyant charade in our dreams. For many years this was considered the
only window to this unique inner life. The entire process of psychoanalysis is
the exploration of conscious desires and fears.
Anesthesia and the unconscious mind
Anesthesia provides a unique interplay between the conscious and unconscious mind. In a daily clinical practice the anesthesiologist is happy to believe that the anesthetic produces a total lost of sensation and consciousness.
Do we have, however, reasons to challenge this concept?
We have no real measure of this behavior in the brain, but we assume
that the anesthetic agents produce a shift from consciousness to oblivion,
bypassing the unconscious mind.
To wake from an anesthetic oblivious of all the events that have taken
place during the operative procedure without any memory or awareness
of discomfort, is the natural expectation of all anesthesiologists. This is the
expected magic of the chemicals.
 Ben Gurion University of the Negev and Mayney Hayeshuah Medical Center, Israel
gurman@bgu.ac.il
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But does really the patient wake up from anesthesia without any storage
of information produced during surgery ?
Regarding memory, there are two possibilities that can occur during general anesthesia. The first is true awareness or explicit memory which means
complete recall of the events occurring during anesthesia. Depending on
the patients inner strengths, past history and general resourcefulness, the
implications of accidental awareness during general anesthesia can be far
reaching.
The patient may present himself for psychiatric care months later with all
the stigmata of a major depressive illness, such as, massive irritability, insomnia, nightmares, bubbling anxiety, an overwhelming sense of impending
doom and a preoccupation with death, all signs of the well known posttraumatic stress syndrome (PTSS).
The implicit memory during general anesthesia
But traumatic events that are held in the unconscious area have a far more
profound and often inexplicable effects on the patients psyche. This is the area
of major concern for the anesthesiologist: the world of implicit memory.
Implicit memory is defined as changes in performance or behavior that
are produced by prior experiences or tests and do not require a conscious,
intentional recollection of these events.
During clinically adequate anesthesia the brain is capable of receiving
auditory stimuli and processing them at a fairly complex level.
Hearing is the first senses to develop, starting at 28 weeks of intra uterine
age. We hear during sleep and during coma.
The research on implicit memory during anesthesia is not new. In the
mid 20th century researches on perception, therapeutic suggestions and a
response to crisis during general anesthesia were published in the medical
literature. More recently, together with Gidron and others, we have studied
the ability of the patients to recall words or association of words given repetitively during anesthesia, proving that many patients could adequately
recall them when anesthesia was conducted based on clinical signs only, but
this phenomenon is reduced when a cortical electrical activity monitor was
used for monitoring the adequacy of general anesthesia.
What are the implications of the implicit memory? Surgery itself is stressogenic.
Sleep disturbance and occasional depression are well known phenomenon
after surgery. In this setting, untoward events and the devastating power of
the words spoken during surgery can dramatically change the patients life,
but no one has any proof that this hypothesis is true.
Recomandri i Protocoale n Anestezie, Terapie Intensiv i Medicin de Urgen

Implicit memory and Freud theories

Freud would have understood this. He joined Breuer in treating their famous patient, the young Anna O, a 21 years-old lady who was defined as
the virginal instance of psychoanalytical diagnosis. Anna O. complained of
paralysis of the right arm, blurred vision and difficulty of swallowing. Under
hypnosis a childhood conjectural situation was discovered (death of hers
beloved father), the patient was explained the nature of the symptoms and
eventually she was cured.
Now lets take a completely different case. A 65 years-old man visits a
psychiatrist for a high level of anxiety, hearing voices and feeling as he
wasnt going to pull through it. Under hypnosis his story becomes evident.
Some months earlier he had a lumbar sympathectomy under general anesthesia. A possible need for a leg amputation was discussed by the surgical
team during surgery. Anesthesia was considered completely uneventful and
the patient could not recall any event from the operating room. However,
he stored subliminal information as an expression of implicit memory. The
nature of his complains was explained, the patient improved and soon all
the symptoms disappeared.
The analogy between the two cases is striking. Both patients accumulated
negative experiences during traumatic episodes and in both situations the
exteriorization of the pathological condition took the form of a complex
of clinical symptoms. In both cases the patients were completely unaware
of the true cause of the complaints and only the treatment under hypnosis
solved the problem.
We all are bombarded by stimuli. Much of it is trivial, innocuous, totally
familiar and can be damped down by our natural sensor mechanism of the
brain.
When the stimuli are threatening or in anyway ominous they can be responded to or stored away in the unconscious mind. Sometimes this information is so threatening or frightening that it is repressed and kept hidden. This
is a protective mechanism to save the individual from painful thoughts
In massively threatening situations, and the operating theater could certainly fall into this category, the patient might be hyper-aware and is listening intently. So intently that apparent unimportant sounds may become
frightening. A sudden silence or the loud clatter of a tray on the floor could
create a startle effect. Unguarded words are latched onto and held.
The patient wakes, feels comfortable and is happily unaware of anything
that had transpired. This unfortunately may only be the tip of the memory
iceberg. The evidence is mounting that information can be heard, stored
away and can influence patients at every level of their lives.
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Factors influencing our knowledge on implicit memory during anesthesia

We do not know exactly the magnitude of the subclinical (subliminal)
effects of implicit memory during general anesthesia. There are various reasons for this lack of information.
First, the average patient is not aware of a possible correlation between
his complaints and the surgical/anesthetic procedure. Second, the anesthesiologist does not visit too often his patients in the immediate postoperative
period and has no chance to collect such complaints. Third, testing recall is
not part of the postoperative routine. In addition, the use of benzodiazepines either in premedication or during induction of general anesthesia might
decrease the ability of the patient to bring out the information collected
during anesthesia.
Hypnosis was sought to become the solution, even partial, to measure the
magnitude of the problem. As in Freuds famous case, hypnosis can uncover
postoperatively the intraoperative information stored as implicit memory
during anesthesia.
Unfortunately hypnosis proved to offer data which might be inaccurate.
In 1985 a panel of the council of Scientific Affairs of the American Medical
Association declared that recollection obtained during hypnosis can involve
confabulations and pseudo memories and not only fail to be accurate, but
actually appear to be less reliable than non-hypnotic recall.
Beside, even if postoperative hypnosis could serve to obtain information
stored as implicit memory during surgery under general anesthesia, the workload would prevent this method of becoming the gold standard.
Conclusions
We are trained to interact with our patients in the most caring therapeutic manner. This dare not be put on hold because we believe our patients are
unable to hear us. The patient is listening. Can this be altered by deepening
the anesthesia? Can hearing be blocked with newer chemical agents or a
combination of agents? There are no clear unequivocal answers yet. Until
then it is wise to believe that the patient is listening and storing our worlds
away in their unconscious mind.
Can we prevent the harmful effects of implicit memory? Already many
surgeons and anesthesiologists have carefully structured the operating
theatre to make it less frightening. Frequently silence is observed, music is
played and unnecessary talks are avoided during surgery.
Since evidence suggests that transmission of information during anesthesia demands a minimum contribution from the brains arousal system
it would seem appropriate to protect the patients from all sources of inforRecomandri i Protocoale n Anestezie, Terapie Intensiv i Medicin de Urgen

mation that might further lessen their morale.

The so-called Operating Room Etiquette is to be respected. The OR personnel must refrain from referring to the anesthetized patient as he/she was
not present. In addition, the OR staff must do everything for preventing the
patient being exposed to external stimuli of a disturbing kind.
If Freud had not conceived of such an amazing secret storehouse eternally
awake and listening in the mind, then surely it would have been discovered
by present day anesthesiologists in their need to explain the mystery of
implicit memory.
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