Reaching Down the Rabbit Hole: Extraordinary Journeys into the Human Brain

by Allan H. Ropper

Psychosis is a special type of confusion with its own reality, an internal reality that is consistent only with itself. It does feature a connected, ever-flowing “stream of thought,” to use William James’s term (not a stream of consciousness, a phrase that James came to dislike). In his Principles of Psychology, James claimed that all of us carry on a virtually continuous internal conversation. While a psychotic’s internal stream may seem bizarre and disconnected, it has its own internal logic. Anyone could follow it, according to James, if they were standing in the waters of the stream.

Symptoms are what a patient reports. Signs are what a physician sees in an examination. Symptoms are thus subjective, and signs objective. When a patient reports a symptom, we have to take it at face value: a headache, dizziness, numbness, lower back pain. We have no tests for such things, and accept them as real until something in the patient’s behavior gives the game away.

The claim of blindness, on the other hand, can be tested. People follow the image of their own eyes in a mirror. Not only that, even if they don’t flinch when I bring my hand toward their face quickly, most will involuntarily glance at a $100 bill that I wave in front of them. An old-school neurologist tested this effect. What denomination will get a blind hysteric to follow the bill? A $1 bill doesn’t work; a $100 bill works almost all of the time. So he always carried a C-note in his wallet just for that purpose.

Study - Relation between GDP and amount of local currency that makes testing blind people reliable.

Nomenclature: Hysteria, psychosomatic, and pseudoseizure are OUT. Neurologists still use these words all of the time, just not in front of patients and their families. Other words we take pains to avoid are psychiatric and psychiatrist. People tend to hear these as crazy and shrink, and this rarely goes over well with anyone. Terms that are IN include: conversion disorder instead of hysteria, functional instead of psychosomatic (the two are not equivalent in any case), and psychological non-epileptic seizure— or P-NES (I kid you not)—instead of pseudoseizure, as in, “This lady has a P-NES.”

It's terrible that we judge simple but also relatively understandable terms we have a bias against and have to resort to overly complicated, technical ones to not be judged. As a side effect we sometimes have no idea who would be a good specialist for them.

The mother shuffles to the side of the bed, level with her daughter’s waist, and will not let me go any further. “We go through this all the time. New doctors thinking they have a better solution and trying to get her off her pain medicine.” “We go through this all of the time, too,” I’m tempted to say. “Mothers who poison their daughters so that they can nurse them through recovery.” What I wouldn’t give to be Irish right about now.

In one of his sessions, he was sitting across the room from the shrink, articulating how much trouble he was having with his patients’ anger, their problems, their complaints. The psychiatrist didn’t say a thing, but he took a fancy fountain pen out of his shirt pocket and held it out in front of him at arm’s length, as though presenting it. He just held it there. My friend, who was about twenty-six or twenty-seven at the time, got up from his chair, walked over to the psychiatrist, and took the pen. The shrink said, “Did you want that pen?” My friend said, “No, not really.” “Then why did you take it?” “I thought I was supposed to take it.” “The patients are holding out their troubles. They are not really asking you to take them. You should only take them if you want or need to take them. Otherwise, leave it. They’ll get along without your suffering. You have another job to do.”

The most brilliant way to demonstrate how ultimately we (not only medical professionals) are not responsible for carrying other people's troubles. Doesn't mean we can't help in other, more constructive ways.

At about the same time, when I was an intern in San Francisco, we treated a farmer from the Sacramento area who had coccidioidomycosis meningitis, also known as valley fever. Stockton, California, was ground zero for the disease. It is carried by airborne dust particles that settle into the lungs, causing a pneumonia-like infection that can develop into an inflammation of the brain’s lining. The treatment involves a lumbar spinal tap that allows medicine to be injected into the spinal canal daily, a very invasive regimen requiring a long stay in the hospital. As serious as this was, the farmer had a more pressing problem. His wife was in the early stages of dementia, and she was alone on their farm with their two German shepherds. He desperately needed the treatment, and she desperately needed him. Every day, when the team dropped by on rounds, the senior resident, whose name was Chin, told the farmer he was doing better, that his lungs were getting better, and every day the farmer would reply by asking, “Can I go home today?” The first time this happened, Chin said: “You have to understand that you have a serious infection, and you have to get antibiotic injections for the next two weeks.” On rounds the following day, when the farmer again asked his one and only question: “Can I go home today?” Chin went through it all again, but less patiently: “Two weeks.” After several days of this routine we were all frustrated, but Chin, who saw the world and all the people in it in ...

You can tell when someone is about to die. Their vessels constrict as blood pressure starts to fall, and the kneecaps get a little bluish. Louise made a few furtive coughs, almost like huffing. Then I heard a noise, a hiss, and she whispered, “I . . . I . . . love you. Good-bye.” Henry hadn’t moved.

The unfortunate truth about life is that sometimes there's so much beauty in death

“My secretary just buzzed me and said, ‘Doctor, there’s a man out here who thinks he’s invisible.’ ‘Tell him I can’t see him.’”

Ha!

Because the patient had a collar on, and might have a broken neck, we couldn’t move his head from side to side, so we did the caloric reflex: squirting ice water into one ear, then the other. This provides a potent stimulus to eye movements through a hardwired circuit in the brainstem, if it’s functioning at all.

The person must have an apnea test. Then you can prove to yourself that the whole brain, including the brainstem, is gone. Just remember, when you take a patient off a ventilator, either for an apnea test or after a declaration of death, make sure that family members are out of sight, and forewarn the nurses. Many brain dead patients, once the ventilator is removed, exhibit the so-called Lazarus sign, where their arms spontaneously contract and their hands come up to their chest as though they’re grasping for the endotracheal tube. It’s creepy no matter how many times you’ve seen it.

Fun of nightmares and medicine.