A Doctor Unlocks Mysteries Of The Brain By Talking And Watching
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 has 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.
STEVE INSKEEP, HOST:
Today in Your Health, we meet a doctor who uses special tools to diagnose problems in the nervous system. His tools are his eyes, his ears and his brain. This Harvard neurologist contends that old-style listening and observation are at least as valuable as high-tech medical testing. NPR's Jon Hamilton reports.
JON HAMILTON, BYLINE: It looks like a scene from one of those TV medical dramas, a pack of students, residents and fellows are striding down a hallway at Brigham and Women's Hospital in Boston. Leading the pack is Allan Ropper, a professor of neurology, whose hair is nearly as white as his hospital coat.
ALLAN ROPPER: So a slightly slow I would say, and somewhat pedestrian morning, but you never know what's going to happen.
HAMILTON: Over the next few hours, Ropper and company will see everything from tumors to seizures. The hospital let me record their day as long as I didn't use patient names.
ROPPER: Who are we seeing first?
HAMILTON: The team checks on a woman with pain and numbness that could be from a stroke. An examination shows that it's not.
ROPPER: Good, let's keep moving. Shamik, let's move on.
SHAMIK BHATTACHARYYA: Yes, absolutely. Let's go to eight.
HAMILTON: We take the elevator to a patient with a more serious problem.
ROPPER: Hello. Good morning.
HAMILTON: Nearly a dozen doctors and students cram into the room of a heavyset man with clogged arteries. The day before, surgeons had succeeded in routing blood around a dangerous blockage in his neck, but something's still not right.
ROPPER: Can I sit on your bed? I don't - well, I don't usually like to. You know, it's your bed. You're sleeping in it.
HAMILTON: Ropper takes the man's hand and studies his face.
ROPPER: Let's go back to the spell that brought you into the hospital originally. Tell us about it.
UNIDENTIFIED PATIENT #1: I was talking to somebody. I was talking to my - and I...
ROPPER: Are you having trouble finding words right now?
HAMILTON: Ropper has the man lie back. That sends more blood to a brain that's not getting enough. Then Ropper begins a series of tests.
ROPPER: Let me hear you say la, la, la, la, la very quick.
PATIENT #1: La, la, la, la, la, la, la.
ROPPER: Me, me, me, me, me.
PATIENT #1: Me, me, me, me, me, me.
HAMILTON: Now that the man is reclining, most of his language skills are pretty good. But there's still one thing he can't do.
ROPPER: Can I hear you say no ifs, ands or buts?
PATIENT #1: No ifs, no ifs...
HAMILTON: Later, Ropper explains that this inability to repeat a simple phrase told him precisely where a small stroke could damage the man's brain.
ROPPER: What we did was on clinical grounds, we nailed this down to a piece of real estate the size of a quarter.
HAMILTON: A brain scan confirms the damage. But Ropper says no scan would have shown that other parts of the man's brain were in danger every time he sat up.
ROPPER: The rest of medicine has moved very strongly toward laboratory diagnosis. It ends up in neurology being a mistake because the system's just too complicated to believe that by looking just at the images you can sort out what's going on for an individual patient.
HAMILTON: The next patient is several floors up. But the elevator is slow and time is short, so everyone takes the stairs.
UNIDENTIFIED PATIENT #2: Hi.
ROPPER: How are you?
PATIENT #2: Good.
HAMILTON: This woman, in her late 60s, came in for back surgery, but ended up with another problem.
PATIENT #2: I came out of surgery and I opened my eyes and everything was double - everybody was double, everything was double.
HAMILTON: The surgeons thought her double vision might be from a stroke. Ropper asks how she's doing.
PATIENT #2: I was just saying today, my eyes - I can see straight, but they feel wobbly.
ROPPER: OK, we're going to...
PATIENT #2: You know what I mean? They feel a little - I can't explain it.
ROPPER: Well, let's see. We're going to try to get to the bottom of that.
HAMILTON: Ropper checks the muscles that control her eyes and realizes they're being affected by something other than a stroke. So he goes in a different direction.
ROPPER: Do you have trouble with your eyelids drooping?
PATIENT #2: One.
ROPPER: Do you have trouble with your head staying upright at the end of the day? Does it tend to loll backward?
PATIENT #2: It lolls.
HAMILTON: Ropper suspects she has a disease that causes muscles to weaken rapidly with repeated use, so he improvises a test using a blood pressure cuff.
ROPPER: No, no, we're actually not going to check your blood pressure, we're going to do a little neurological parlor trick.
PATIENT #2: OK.
HAMILTON: He rolls up the cuff and puts it in the woman's hand.
ROPPER: Squeeze it 10 times slowly. One, two, three...
HAMILTON: Everyone watches a gauge, showing the pressure of each squeeze.
ROPPER: ...Five, six, seven, eight, nine, ten. Well, if that's not fatigue ability, I don't know what is. It's getting a little less every time you squeeze it.
PATIENT #2: It is?
ROPPER: Just a little.
HAMILTON: Ropper's pretty sure the woman has myasthenia, a serious but treatable disease. A blood test will eventually confirm his bedside assessment.
ROPPER: That's an example of the craft of neurology. You know, there's no book that would've extracted that diagnosis from that lady.
HAMILTON: Ropper says that when someone develops a serious brain problem, it can be like falling down a rabbit hole and entering in "Alice In Wonderland" world, where nothing looks or works the way it's supposed to. He says a neurologist's job is to explore the odd landscape of a damaged brain.
ROPPER: 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. That's the "Alice In Wonderland" part. You've got to figure out what's mirrors and metaphors how to get at the problem.
HAMILTON: And how to pull each patient back out. Ropper and a co-author describe that process in their new book called "Reaching Down The Rabbit Hole." An entire chapter is devoted to people like the next patient we meet, a soft-spoken woman in her 30s.
ROPPER: Hi there. I'm Dr. Ropper, one of the neurologists. I'm going to let Shamik chat with you. I'll hold your Bible, OK?
UNIDENTIFIED PATIENT #3: Thank you.
ROPPER: It's too valuable to put down, beautiful book.
HAMILTON: He turns the exam over to Shamik Bhattacharyya, a senior resident. It's a part of Ropper's mission to make sure that the next generation of neurologists also knows how to reach down the rabbit hole.
BHATTACHARYYA: So I understand that the primary thing that brought you in was left leg weakness, is that right?
PATIENT #3: Yes.
BHATTACHARYYA: Anything else that was bothering you?
PATIENT #3: Well, I have this shooting pain from my buttocks down.
HAMILTON: She says the pain has been intense and unrelenting.
PATIENT #3: This week I went shopping - it's just - I cry all day. But I go out and I do everything I got to do.
HAMILTON: The woman had a similar episode a few months earlier and went to another hospital. They performed nerve conduction studies, ultrasound, MRI, pretty much everything medical technology has to offer. Bhattacharyya's approach is low-tech - a tuning fork.
PATIENT #3: Oh, that hurts my feet.
BHATTACHARYYA: So tell me when it stops.
PATIENT #3: Yeah, stop.
HAMILTON: He asks a few more questions. Then he places one hand under her left heel and administers a test doctors have been using for 100 years.
BHATTACHARYYA: Try to lift the right leg up as much as you can. Lift it. You're doing a great job, great job. Excellent.
HAMILTON: As she tries to lift her healthy leg, she involuntarily pushes down with the other leg. It's known as Hoover's sign, and it confirms what Bhattacharyya suspected. The problem isn't physical, it's psychological. Ropper gently steps in.
ROPPER: Well, it's a tough problem. Let's talk about how to get you out of this jam.
HAMILTON: Out of the rabbit hole. Later, Ropper says that won't be easy because the weakness and pain are very real to this woman.
ROPPER: We've got a normal functioning brain that somehow goes out of its way to produce blindness, paralysis, tremor, walking difficulty and so on. There's no other organ that does that, right? Your liver doesn't decide one day to wake up and say I'm going to feign liver failure.
HAMILTON: But the brain isn't like other organs. And Ropper says that's why he gets up and goes to work each day. Jon Hamilton, NPR News. Transcript provided by NPR, Copyright NPR.