The heavyset man with a bandage on his throat is having trouble repeating a phrase. “No ifs…” he says to the medical students and doctors around his bed at Brigham and Women’s Hospital in Boston.
“Can I hear you say no ifs, ands or buts?” says Dr. Allan Ropper, the Harvard neurologist in charge. The patient tries again. “No ifs, buts, ands or,” he says.
Ropper’s heard enough. “I think he’s probably had a little left temporal, maybe angular gyrus-area stroke,” he tells the students and doctors, once they’re assembled outside the patient’s room. A brain scan confirms his diagnosis.
Later, Ropper tells me that the patient’s inability to repeat that simple phrase told him precisely where a stroke had damaged the man’s brain. “What we did was, on clinical grounds we nailed this down to a piece of real estate about the size of a quarter,” he says.
This reliance on bedside observation and conversation is what makes neurology such a remarkable specialty, Ropper says. “The rest of medicine has moved very strongly toward laboratory diagnosis” and scans like MRI and CT, he says. But the brain, he says, “is too complicated to believe that by looking just at the images you can sort out what’s going on for an individual patient.”
Ropper shows me example after example of this as I follow him on rounds. The hospital allowed me to record what I saw and heard so long as I didn’t use the names of any patients.
In one room, we meet a woman in her late 60s who came in for back surgery, but ended up with another problem. “I came out of surgery and I opened my eyes and everything was double,” she says.
The surgeons thought her double vision might be from a stroke. But Ropper checks the muscles that control her eyes and realizes they’re being affected by something else.
“Do you have trouble with your eyelids drooping?” he asks. “Do you have trouble with your head staying upright at the end of the day?” The woman answers yes to both questions.
Ropper suspects she has myasthenia, a disease that causes muscles to weaken rapidly with use. So he has her repeatedly squeeze a rolled-up blood-pressure cuff. The pressure gauge on the cuff shows that each squeeze is weaker than the previous one.
That clinches the diagnosis for him, although a blood test will eventually confirm his bedside assessment. “That’s an example of the craft of neurology,” Ropper says. “There’s no book that would have extracted that diagnosis from that lady.”
When someone develops a serious brain problem, Ropper says, it can be like falling down a rabbit hole and entering an Alice-in-Wonderland world — where nothing looks or works the way it’s supposed to. A neurologist’s job is to find a way to understand the odd landscape of a damaged brain, he says.
“You’re querying the organ that has the problem and you’re asking it to talk to you, but it can’t do it properly because of that damage,” he says. “That’s the Alice in Wonderland part. You have to figure out with mirrors and metaphors how to get at the problem.”
Ropper and coauthor Brian Burrell describe that process in a new book called Reaching Down the Rabbit Hole. An entire chapter is devoted to patients whose problems cannot be detected by any test or scan.
We meet one of these patients during morning rounds. She’s a charming, soft-spoken woman in her 30s who says her left leg is so weak she can’t move it.
Ropper turns the exam over to Dr. Shamik Bhattacharyya, a senior resident at Brigham and Women’s. It’s a part of Ropper’s mission to make sure the next generation of neurologists also knows how to reach down the rabbit hole.
During a long conversation, the woman tells Bhattacharyya about a similar episode a few months earlier. At the time, doctors ordered nerve conduction studies, ultrasound, MRI — pretty much everything medical technology has to offer. Nothing turned up a problem.
So Bhattacharyya tries a low-tech approach that doctors have been using for a century. He has the woman lie on her back and lift her healthy leg. When the woman does this, she involuntarily pushes down hard with the supposedly disabled leg.
Neurologists know this as Hoover’s sign and it confirms what Bhattacharyya suspected. The problem isn’t physical; it’s psychological. But it’s hard to treat, Ropper says, because the weakness is very real to the person experiencing it.
“You’ve got a normal functioning brain that somehow goes out of its way to produce blindness, paralysis, tremor, walking difficulty and so on,” he says “There’s no other organ that does that. Your liver doesn’t decide one day to wake up and say, I’m going to feign liver failure.”
But the brain isn’t like other organs. And Ropper says that’s why he gets up and goes to work each day.