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

by Allan H. Ropper

the unruliness of his eyebrows

“But you seem a little off, cognitively, and our struggle is, could it be the meningioma that’s doing it?” “As they say, that’s your problem.” He’s right. It is my problem. I am his neurologist. It is my job to parse his convoluted responses, fit them into the clinical picture, prioritize his issues, and come up with a plan that lets him live the life that he wants to live, to the extent that is possible.

In his peculiar way, he has indicated that he is oriented to his location, but not oriented to the time or to his situation. His highly formalized locution, entirely characteristic of his tribe, may seem quaint, but it is exaggerated just enough to suggest that he is compensating for a language deficit that he is aware of but seems indifferent to. He knows that he has a benign tumor in his pancreas that poses less of a threat than the meningioma in his brain. The brain tumor will not kill him anytime soon, but it will continue to diminish his powers of thought.

spent more time in hospitals than he cares to recall.

“My record is eighty-four seizures in a day.” “Is that typical?” “There is no rhyme or reason to it. Some days I have none, some days I have a lot.” “But say in the course of a month.” “You keep wanting me to do that. You keep wanting me to put some pattern to it. Believe me, I wish I could put a pattern to it. Would you like to see my seizure log?”

Hannah presses on. “What I really want to understand is whether you ever have a month without seizures.” “A month? No. I’m lucky if I go a week.”

‘You wouldn’t have seizures if you didn’t miss your doses.’ Is that it?”

I don’t miss doses, and I have seizures.”

How do you begin to understand a sick brain? The only viable answer, as this book will show, is that you do it by engaging the person inside, and you do it on a case-by-case basis.

“You have trouble expressing yourself in language, or expressing yourself in emotion?”

she was soaking up tranquilizers like a sponge.

“Is she salivating like she has rabies?”

Chiropractic neck adjustments are not a common cause of stroke (maybe one in every twenty thousand treatments produces one), but the high rotary force involved, one with just the right vector and amplitude, can strip off the inner layer of a blood vessel, causing it to tear and collapse into the channel, impeding the flow of arterial blood to the brain.

Among the staff, the consensus was:

There is an old joke among stand-up comics that goes: “Dying is easy, comedy is hard.” If we were as inner-directed as comedians, we neurologists might say, “Trauma is easy, neurology is hard.” Every one of our patients has, in effect, fallen into a hole, and it’s our job is to get them out again. In Alice’s Adventures in Wonderland, Alice jumps into a rabbit hole and finds herself in a bizarre realm in which nothing is what it seems, where everything bears little relation to the outside world.

I know that, on any given day, I will be confronted by at least six improbable things before lunch: a smiling man whose speech difficulties seemed to have been brought on by a colonoscopy, a thrashing young woman whose psychosis seemed to come out of nowhere, a figure skater with a slow-fuse time bomb in her body that was knocking off her faculties one by one.

There’s something upstream that’s flicking off debris into the blood vessels of the brain, and we just haven’t found it yet. If you told me she had a myxoma, I wouldn’t be surprised.”

Something had to be giving off small flecks that lodged on the walls of blood vessels, effectively narrowing them. That was what had caused the strokes, and that was what had been misinterpreted as vasculitis.

There are at least three broad categories of stroke: one involving blocked blood vessels, another involving bleeding into the brain, and a third—an aneurysm—involving a ruptured bulge in a blood vessel.

She replied that it was the angiogram, which showed the alarming number of constricted blood vessels and cutoffs in the cerebral arteries.

Do the echo over. It was wrong. If it doesn’t show something abnormal on one of her heart valves or in one of the chambers, I’ll eat my hat.”

You can’t just sit there, so you go down the hole after the patient. Sometimes you can do it right away: you go to the gynecologist and say, “Take out her ovary,” and that gets her out of the hole. It may not get her back out the same hole she went in, but in a case like Cindy Song’s, it gets her out relatively quickly.

Elliott is an odd duck. No one else in the department wears monogrammed shirts with cuff links, sports a Patek Philippe watch, or knows as much about pari-mutuel betting.

bagels, doughnuts, muffins, Danish, and coffee to ensure an elevated glycemic index for the next eight hours.

who seemed genuinely surprised when I told her that Mrs. G had blown a pupil. “This woman needs mannitol!”

Mannitol, a drug administered by IV, is a sugar alcohol used to pull fluid out of the brain in order to reduce the internal pressure.

where it was determined that Gordon’s problem might not be psychiatric.

“can you show us two fingers?” And he gave me the finger with both hands. “Right! He’s got good comprehension.”

Psychosis is a special type of confusion with its own reality, an internal reality that is consistent only with itself.

The Blanche DuBois routine was her way of feigning amnesia, but she didn’t know how to do it correctly. She didn’t know that the one thing people never forget is who they are. She had no idea that this curious thing we call memory works two ways. She would have benefited from reading Lewis Carroll.

her CT angiogram,”

Symptoms are what a patient reports. Signs are what a physician sees in an examination. Symptoms are thus subjective, and signs objective.

CT scan as a routine precaution.

A subarachnoid hemorrhage, or burst aneurysm, is one of the most treacherous diseases in medicine.

An aneurysm is a rounded pouch on one of the blood vessels at the bottom of the brain. If it reaches a critical size and form, it can burst open with the entire force of the body’s blood pressure. Blood then fills the spaces around the brain in a split second and causes a thunderbolt of a headache that no one forgets and many don’t survive. One-third of patients who do survive have a re-rupture in days, and half of those people die.

There are three kinds of patients who show up on the ward: the risk-neutral, the risk-averse, and the risk-resistant. We rarely see a fourth kind, the risk-takers,

Risk-takers don’t come to the hospital of their own volition. They simply refuse to go to a doctor for anything.

risk-neutral people, a term that describes most of our patients, go to the doctor because they believe in modern medicine. They listen, they question, they comprehend, and for the most part, they cooperate. Risk-averse patients, on the other hand, need reassurance. These are the people who have to know everything. They have to call everyone. They need a better opinion. They won’t have the operation until they’ve had five second opinions.

Then there are the risk-resistant, who are simply recalcitrant, and give us the most trouble. They act as if they have something to hide, they often do have something to hide, and they hide it even when it would be in their best interest to let us know about it up front.

One way to deal with the risk-resistant is to have them sign a piece of paper acknowledging that they understand the risks of doing nothing, then send them home.

he had never learned to rea...

He had survived and even thrived in the literate world through a combination ...

Ruby was not going to sign a waiver.

Those who know anything about the oath of Hippocrates, which is still recited at some medical school graduation ceremonies, usually recall its main precept: primum non nocere—“First, do no harm.”

doing nothing with the knowledge we have in a case like Ruby’s risks tremendous harm.

If Ruby had been a “good” patient, a risk-neutral one, he would have agreed to the spinal tap after a bit of reassurance that my residents have done hundreds of them, even on little old ladies,

If the spinal fluid revealed the red-brown color typical of broken-down blood cells, it would have confirmed the diagnosis.

“I have this problem. I think this guy is a danger to himself. I don’t want you to talk him into the spinal tap. I just want you to get him to reconsider the whole situation.” So Edgar and I went to see Ruby to hear why he didn’t want the tap. “Because I don’t want to get paralyzed . . . because I got better the first time . . . because I’ll get better again. I ain’t worried I might die of some burst aneurysm I may not even have.” Ruby was never angry or sarcastic, merely insistent.

His most arresting aspect is the timbre and pattern of his speech. His accent is clearly Caribbean, but measured in its excess so as to allow a British lilt to emerge from the phonation—

but the Bible says the calling of God is without repentance. If God calls, you are never satisfied until you find yourself doing what you feel you are called to do.