Review | Reaching Down the Rabbit Hole – Dr Allan Ropper and Dr Brian Burrell

Reaching Down The Rabbit Hole is a collection of medical stories from patients at the renowned Brigham and Women’s Hospital. Jointly written by neurologist Allan Ropper and neuroscience researcher Brian Burrell, the book melds Ropper’s perspective and experiences with Burrell’s extensive notes and related information.

“If (an aneurysm) 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.”

Ropper and Burrell provide clear explanations of the medical conditions suffered by patients, and of the longer-term consequences the patients often face. While there is a fair amount of medical jargon in descriptions and conversations, the essential aspects of each story are made clear. Descriptions of patients conditions are grounded in the real-life effects and consequences of their symptoms.

“The (patient) would live in a world of past memories, unaware that he had a problem forming new ones. By way of compensation, like many Korsakoff’s sufferers, he would fill in gaps by confabulating plausible but nonetheless crazy stories. “I think I saw you at the ball park,” he might say to someone he had just met.”

One newspaper review described this book as “Oliver Sacks meets Gregory House”. I loved this analogy, as it’s accurate for both the author’s methods and his perspective on medicine. Sacks dived into the minutinae of each patient’s lived experience and their narrative, then built these into intimate, poetic descriptions. House focused on the mechanics of symptoms, behaviours and functioning, and famously (often correctly) dismissed patients’ narratives with the motto “everybody lies”.

Ropper’s stories lie in-between these two poles of intuitive humanism and cynical mechanistry. In some chapters he explores the backstories of his patients and discusses the sociological contexts that affect their symptoms or their decisions about treatment. In other chapters, he deals more brusquely with patients who knowingly fake illness to access medication, and families who force relatives into the patient role.

He also shows how in modern hospitals, neurologists are usually the man-in-the-middle rather than an inspired lone wolf. Balance is a common theme: Ropper talks about balancing each patient’s individual story and their need to be heard against the rush to solve problems efficiently. He often contrasts the idiosyncratic lone neurologists of history with today’s inter-reliant diagnostic teams, for better and for worse.

“What (patients) hope, what they expect, what they deserve, is that we take the time to listen, because the act of listening is therapeutic in itself.”

Reaching Down the Rabbit Hole also acknowledges how our advanced ability to keep seriously ill people alive can cause problems for patients and for medical ethics. What happens when a patient doesn’t want to be “kept alive at any cost”? More importantly, how do you know a patient is truly dead? (Does knowing that the patient is an organ donor change how you answer that question? ).

“The practice of my craft, the clinical part of it, is the systematic logical, deductive method that was in the past applicable to all branches of medicine, but now resides mainly in neurology.”

Ropper eloquently describes the challenge and pleasure of neurology, and the skills involved in deducing a patient’s diagnosis. But he has much less time for other fields, especially for psychiatry. When he discussed patients with conversion disorders – symptoms which look like neurological issues but which are actually caused by psychiatric illnesses or dysfunctional living situations – Ropper often appeared condescending towards patients who had psychiatric issues rather then neurological ones.

The case studies and medical conditions featured in this book are interesting, and the ethical sections are thought-provoking. However, my favourite aspects were the interviews with past patients, which allowed me to see narratives that are usually overlooked, and the interactions with junior staff and students, which helped me see more about how modern-day neurology works and how many people are involved. Reaching Down The Rabbit Hole lets readers understand a little of the complexity and chaos of modern-day neurology. It is a tribute to both the past and the present craft of the science, and to the people who carry out that craft.

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