by Atul Gawande
There is, however, an alternative view held by a growing number of scientists. The effect of intensifying embarrassment may not be incidental; perhaps that is what blushing is for. The notion isn’t as absurd as it sounds. People may hate being embarrassed and strive not to show it when they are, but embarrassment serves an important good. For, unlike sadness or anger or even love, it is fundamentally a moral emotion. Arising from sensitivity to what others think, embarrassment provides painful notice that one has crossed certain bounds while at the same time providing others with a kind of apology. It keeps us in good standing in the world. And if blushing serves to heighten such sensitivity, this may be to one’s ultimate advantage.
The puzzle, though, is how to shut it off. Embarrassment causes blushing, and blushing causes embarrassment—so what makes the cycle stop? No one knows, but in some people the mechanism clearly goes awry. A surprisingly large number of people experience frequent, severe, uncontrollable blushing. They describe it as “intense,” “random,” and “mortifying.” One man I talked to would blush even when he was at home by himself just watching somebody get embarrassed on TV, and he lost his job as a management consultant because his bosses thought he didn’t seem “comfortable” with clients. Another man, a neuroscientist, left a career in clinical medicine for a cloistered life in research almost entirely because of his tendency to blush. And even then he could not get away from it. His work on hereditary brain disease became so successful that he found himself fending off regular invitations to give talks and to appear on TV. He once hid in an office bathroom to avoid a CNN crew. On another occasion, he was invited to present his work to fifty of the world’s top scientists, including five Nobel Prize winners. Usually, he could get through a talk by turning off the lights and showing slides. But this time a member of the audience stopped him with a question first, and the neuroscientist went crimson. He stood mumbling for a moment, then retreated behind the podium and surreptitiously activated his pager. He looked down at it and announced that an emergency had come up. He was very sorry, he said, but he had to go. He spent the rest of the day at home. This is someone who makes his living studying disorders of the brain and the nerves. Yet he could not make sense of his own condition.
There is no official name for this syndrome, though it is often called “severe” or “pathological” blushing, and no one knows how many people have it. One very crude estimate suggests that from 1 to 7 percent of the general population is afflicted. Unlike most people, whose blushing diminishes after their teenage years, chronic blushers report an increase as they age. At first, it was thought that the problem was the intensity of their blushing. But that proved not to be the case. In one study, for example, scientists used sensors to monitor the facial color and temperature of subjects, then made them stand before an audience and do things like sing “The Star-Spangled Banner” or dance to a song. Chronic blushers became no redder than others, but they proved significantly more prone to blush. Christine Drury described the resulting vicious cycle to me: one fears blushing, blushes, and then blushes at being so embarrassed about blushing. Which came first—the blushing or the embarrassment—she did not know. She just wanted it to stop.
In the fall of 1998, Drury went to see an internist. “You’ll grow out of it,” he told her. When she pressed, however, he agreed to let her try medication. It couldn’t have been obvious what to prescribe. Medical textbooks say nothing about pathological blushing. Some doctors prescribe anxiolytics, like Valium, on the assumption that the real problem is anxiety. Some prescribe beta-blockers, which blunt the body’s stress response. Some prescribe Prozac or other antidepressants. The one therapy that has been shown to have modest success is not a drug but a behavioral technique known as paradoxical intention—having patients actively try to blush instead of trying not to. Drury used beta-blockers first, then antidepressants, and finally psychotherapy. There was no improvement.
By December of 1998, her blushing had become intolerable, her on-air performance humiliating, and her career almost unsalvageable. She wrote in her diary that she was ready to resign. Then one day she searched the Internet for information about facial blushing, and read about a hospital in Sweden where doctors were performing a surgical procedure that could stop it. The operation involved severing certain nerves in the chest where they exit the spinal cord to travel up to the head. “I’m reading this page about people who have the exact same problem I had, and I couldn’t believe it,” she told me. “Tears were streaming down my face.” The next day, she told her father that she had decided to have the surgery. Mr. Drury seldom questioned his daughter’s choices, but this sounded to him like a bad idea. “It shocked me, really,” he recalls. “And when she told her mother it shocked her even worse. There was basically no way her daughter was going to Sweden and having this operation.”
Drury agreed to take some time to learn more about the surgery. She read the few articles she could find in medical journals. She spoke to the surgeons and to former patients. After a couple of weeks, she grew only more convinced. She told her parents that she was going to Sweden, and when it became clear that she would not be deterred her father decided to go with her.
The surgery is known as endoscopic thoracic sympathectomy, or ETS. It involves severing fibers of a person’s sympathetic nervous system, part of the involuntary, or “autonomic,” nervous system, which controls breathing, heart rate, digestion, sweating, and, among the many other basic functions of life, blushing. Toward the back of your chest, running along either side of the spine like two smooth white strings, are the sympathetic trunks, the access roads that sympathetic nerves travel along before exiting to individual organs. At the beginning of the twentieth century, surgeons tried removing branches of these trunks—a thoracic sympathectomy—for all sorts of conditions: epilepsy, glaucoma, certain cases of blindness. Mostly, the experiments did more harm than good. But surgeons did find two unusual instances in which a sympathectomy helped: it stopped intractable chest pain in patients with advanced, inoperable heart disease, and it put an end to hand and facial sweating in patients with hyperhidrosis—uncontrollable sweating.
Because the operation traditionally required opening the chest, it was rarely performed. In recent years, however, a few surgeons, particularly in Europe, have been doing the procedure endoscopically, using scopes inserted through small incisions. Among them was a trio in Göteborg, Sweden, who noticed that many of their hyperhidrosis patients not only stopped sweating after surgery but stopped blushing, too. In 1992, the Gotebörg group accepted a handful of patients who complained of disabling blushing. When the results were reported in the press, the doctors found themselves deluged with requests. Since 1998, the surgeons have done the operation for more than three thousand patients with severe blushing.
The operation is now performed around the world, but the Göteborg surgeons are among the few to have published their results: 94 percent of their patients reported experiencing a substantial reduction in blushing; in most cases it was eliminated completely. In surveys taken some eight months after the surgery, 2 percent regretted the decision, because of side effects, and 15 percent were dissatisfied. The side effects are not life-threatening, but they are not trivial. The most serious injury, occurring in 1 percent of patients, is Homer’s syndrome, in which inadvertent damage to the sympathetic nerves feeding the eye results in a constricted pupil, a drooping eyelid, and a sunken eyeball. Less seriously, patients no longer sweat from the nipples upward, and most experience a substantial increase in lower-body sweating in compensation. (According to a longer-range study that surveyed hand-sweating patients a decade after undergoing ETS, the proportion who were satisfied with the outcome drops to only 67 percent, mainly because of the compensatory sweating.) About a third of patients also notice a curious reaction known as gustatory sweating—sweating prompted by certain tastes or smells. And, because sympathetic branches to the heart are removed, patients experience about a 10 percent reduction in heart rate; some com
plain of impaired physical performance. For all these reasons, the operation is at best a last resort, something to be tried, according to the surgeons, only after nonsurgical methods have failed. By the time people call Göteborg, they are often desperate. As one patient who had the operation told me, “I would have gone through with it even if they told me there was a fifty percent chance of death.”
On January 14, 1999, Christine Drury and her father arrived in Göteborg. The city is a four-hundred-year-old seaport on Sweden’s southwest coast, and she remembers the day as cold, snowy, and beautiful. The Carlanderska Medical Center was old and small, with ivy-covered walls and big, arched wooden double doors. Inside, it was dim and silent; Drury was reminded of a dungeon. Only now did she become apprehensive, wondering what she was doing here, nine thousand miles away from home, at a hospital that she knew almost nothing about. Still, she checked in, and a nurse drew her blood for routine lab tests, made sure her medical records were in order, and took her payment, which came to six thousand dollars. Drury put it on a credit card.
The hospital room was reassuringly clean and modern, with white linens and blue blankets. Christer Drott, her surgeon, came to see her early the next morning. He spoke with impeccable British-accented English and was, she said, exceedingly comforting: “He holds your hand and is so compassionate. Those doctors have seen thousands of these cases. I just loved him.”
At nine-thirty that morning, an orderly came to get her for the operation. “We had just done a story about a kid who died because the anesthesiologist had fallen asleep,” Drury says. “So I made sure to ask the anesthesiologist not to fall asleep and let me die. He kind of laughed and said, ‘OK.’ ”
While Drury was unconscious, Drott, in scrubs and sterile gown, swabbed her chest and axillae (underarms) with antiseptic and laid down sterile drapes so that only her axillae were exposed. After feeling for a space between the ribs in her left axilla, he made a seven-millimeter puncture with the tip of his scalpel, then pushed a large-bore needle through the hole and into her chest. Two liters of carbon dioxide were pumped in through the needle, pushing her left lung downward and out of the way. Then Drott inserted a resectoscope, a long metal tube fitted with an eyepiece, fiber-optic illumination, and a cauterizing tip. It is actually a urological instrument, thin enough to pass through the urethra (though never thin enough, of course, for urology patients). Looking through the lens, he searched for her left sympathetic trunk, taking care to avoid injuring the main blood vessels from her heart, and found the glabrous, cordlike structure lying along the heads of her ribs, where they join the spine. He cauterized the trunk at two points, over the second and third ribs, destroying all the facial branches except those that lead to the eye. Then, after making sure there was no bleeding, he pulled the instrument out, inserted a catheter to suction out the carbon dioxide and let her lung re-expand, and sutured the quarter-inch incision. Moving to the other side of the table, he performed the same procedure on the right side of her chest. Everything went without a hitch. The operation took just twenty minutes.
What happens when you take away a person’s ability to blush? Is it merely a surgical version of Merle Norman Cover Up Green—removing the redness but not the self-consciousness? Or can a few snips of peripheral nerve fibers actually affect the individual herself? I remember once, as a teenager, buying mirrored sunglasses. I lost them within a few weeks, but when I had them on I found myself staring at people brazenly, acting a little tougher. I felt disguised behind those glasses, less exposed, somehow freer. Would the surgery be something like that?
Almost two years after Drury’s operation, I had lunch with her at a sports bar in Indianapolis. I had been wondering what her face would look like without the nerves that are meant to control its coloring—would she look ashen, blotchy, unnatural in some way? In fact, her face is clear and slightly pinkish, no different, she said, from before. Yet, since the surgery, she has not blushed. Occasionally, almost randomly, she has experienced a phantom blush: a distinct feeling that she is blushing even though she is not. I asked if her face reddens when she runs, and she said no, although it will if she stands on her head. The other physical changes seemed minor to her. The most noticeable thing, she said, was that neither her face nor her arms sweat now and her stomach, back, and legs sweat much more than they used to, though not enough to bother her. The scars, tiny to begin with, have completely disappeared.
From the first morning after the operation, Drury says, she felt transformed. An attractive male nurse came to take her blood pressure. Ordinarily, she would have blushed the instant he approached. But nothing of the sort happened. She felt, she says, as if a mask had been removed.
That day, after being discharged, she put herself to the test, asking random people on the street for directions, a situation that had invariably caused her to redden. Now, as her father confirmed, she didn’t. What’s more, the encounters felt easy and ordinary, without a glimmer of her old self-consciousness. At the airport, she recalls, she and her father were waiting in a long check-in line and she couldn’t find her passport. “So I just dumped my purse out onto the floor and started looking for it, and it occurred to me that I was doing this—and I wasn’t mortified,” she says. “I looked up at my dad and just started crying.”
Back home, the world seemed new. Attention now felt uncomplicated, unfrightening. Her usual internal monologue when talking to people (“Please don’t blush, please don’t blush, oh God I’m going to blush”) vanished, and she found that she could listen to others better. She could look at them longer, too, without the urge to avert her gaze. (In fact, she had to teach herself not to stare.)
Five days after the surgery, Drury was back at the anchor desk. She put on almost no makeup that night. She wore a navy-blue woolen blazer, the kind of warm clothing she would never have worn before. “My attitude was, This is my debut,” she told me. “And it went perfectly.”
Later, I viewed some tapes of her broadcasts from the first weeks after the surgery. I saw her report on the killing of a local pastor by a drunk driver, and on the shooting of a nineteen-year-old by a sixteen-year-old. She was more natural than she’d ever been. One broadcast in particular struck me. It was not her regular nighttime bulletin but a public-service segment called “Read, Indiana, Read!” For six minutes of live airtime on a February morning, she was shown reading a story to a crowd of obstreperous eight-year-olds as messages encouraging parents to read to their children scrolled by. Despite the chaos of kids walking by, throwing things, putting their faces up to the camera, she persevered, remaining composed the entire time.
Drury had told no one about the operation, but people at work immediately noticed a difference in her. I spoke to a producer at her station who said, “She just told me she was going on a trip with her dad, but when she came back and I saw her on TV again, I said, ‘Christine! That was unbelievable!’ She looked amazingly comfortable in front of the camera. You could see the confidence coming through the TV, which was completely different from before.” Within months, Drury got a job as a prime-time on-air reporter at another station.
A few snips of fibers to her face and she was changed. It’s an odd notion, because we think of our essential self as being distinct from such corporeal details. Who hasn’t seen a photo of himself, or heard his voice on tape, and thought, That isn’t me! Burn patients who see themselves in a mirror for the first time—to take an extreme example—typically feel alien from their appearance. And yet they do not merely “get used” to it; their new skin changes them. It alters how they relate to people, what they expect of others, how they see themselves in others’ eyes. A burn-ward nurse once told me that the secure may become fearful and bitter, the weak jut-jawed “survivors.” Similarly, Drury had experienced her trip-wire blushing as something entirely external, not unlike a burn—“the red mask,” she called it. Yet it reached so deep inside her that she believed it prevented her from being the person she was meant to be. Once the mask was removed, she see
med new, bold, “completely different from before.” But what of the person who all her life had been made embarrassed and self-conscious at the slightest scrutiny? That person, Drury gradually discovered, was still there.
One night, she went out to dinner with a friend and decided to tell him about the operation. He was the first person outside her family she had told, and he was horrified. She’d had an operation to eliminate her ability to blush? It seemed warped, he said, and, worse, vain. “You TV people will do anything to improve your career prospects,” she recalls him saying.
She went home in tears, angry but also mortified, wondering whether it was a freakish and weak thing to have done. In later weeks and months, she became more and more convinced that her surgical solution made her a sort of impostor. “The operation had cleared my path to be the journalist I was trained to be,” she says, “but I felt incredibly ashamed over needing to remove my difficulties by such artificial means.”
She became increasingly fearful that others would find out about the operation. Once, a coworker, trying to figure out what exactly seemed different about her, asked her if she had lost weight. Smiling weakly, she told him no, and said nothing more. “I remember going to a station picnic the Saturday before the Indy 500, and thinking to myself the whole time, Please, please let me get out of here without anyone saying, ‘Hey, what happened to your blushing?’ ” It was, she found, precisely the same embarrassment as before, only now it stemmed not from blushing but from its absence.
