Reaching Down the Rabbit Hole – Allan Ropper

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A Book Review

Why would anyone choose to be a neurologist?

Setting out to explain this to the public, Allan Ropper has some famous footsteps to follow. The late Oliver Sachs immortalised a series of his most interesting patients, the most famous being the man who mistook his wife for a hat. Henry Marsh, a British Neurosurgeon, has written about the almost religious experience of navigating inside a living person’s head.

Ropper’s book meanders gently through a series of cases he encounters during a few weeks on the wards – a tiny sliver of his career. Readers meet two confused patients in next-door rooms. One will recover, the other will not. The clues are in their minds, and the only access is by listening. We meet a man who fell on the ice, and irreversibly damaged his brain, but left his body untouched. Is he dead or alive? There is room for some philosophy here, before cold hard facts intervene and parts of his body are used to help others. We encounter two people with motor neurone disease, and come to understand their different decisions about life and death.

The book is not just a series of case presentations. It is shot through with the history of neurology, including Dr Parkinson’s original description of his disease. Clearly nearing the end of his career, Dr Ropper looks forward to the next generation of neurologists, but also back to the previous generation who taught him. There are pearls of wisdom from the past and the future.

Some of chapters contain triumphs. Ropper orchestrates a dramatic “save” when a patient develops life-threatening pressure inside her brain. What she needs is a hole in the head to release the pressure. He steps in where others have failed, and makes instant diagnoses. He spots things that others have missed. But he is not afraid of describing failures. The patient with the hole in her head should have been treated more quickly, and the drama wouldn’t have taken place. He talks a man into having surgery that he doesn’t want, and the surgery leaves him badly damaged. He agonises when he misses a rare diagnosis for 18 hours, and his patient becomes paralysed.

Ropper is clearly an extraordinary and successful doctor. Compared to other recent medical books, such as Marsh’s Do No Harm, or Paul Kalanithi’s When Breath Becomes Air, this book does not have such elegant prose, or the same originality of voice. It is co-written (for which I read ghost-written), which may dilute the book’s power.

The cases are well chosen to illustrate some of the amazing things the human brain can do, and what happens when parts of it go wrong. But that is not really what this book is about – it’s about the highs and the lows, the exhilaration and exhaustion, the privilege and the burden, the camaraderie and the loneliness of being a doctor. It’s about the wonder of sitting and listening to a patient’s brain telling you what is wrong with itself.

When talking with a mentor about which specialty to choose for his career, Ropper is told “Why would you choose nephrology over neurology? The kidney makes urine, but the brain makes poetry.”

This book is not quite poetry, but it will do.

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