OSullivan - Brainstorm: detective stories from the world of neurology

The brain is a world consisting of a number of unexplored continents and great stretches of unknown territory.

Santiago Ramn y Cajal (18521934), pathologist and neuroanatomist

There were three doctors working at the clinic with over fifty patients to be seen. I was the most junior doctor. John, the senior registrar, was in a room next to mine. He was a few years ahead of me in training. Experience counts for a great deal as a doctor so his knowledge was far greater than mine. The third doctor was the consultant for whom we both worked.

As usual there were far too many people to be seen in the time allotted. We all had to work more quickly than we were comfortable with. I was required to discuss any difficult problem with John or the consultant. It was a time in my career when I thought that a good doctor was one who worked quickly and wasnt a nuisance to their senior colleagues. I avoided asking for help if at all possible.

The patients notes were piled high on a trolley outside the consultants room. They were visible to all the anxiously waiting people. Everybody turned to look as I took a set off the top of the pile and brought them into my office to read. They contained only a few pages. I was relieved. A thick file meant years of history to understand and a chronic problem that might not be solvable. So many neurological conditions are incurable and very challenging to treat. A thin file could indicate a minor issue that had disappeared since the patient was last seen. When I opened the notes, though, I sighed. The man had only been to the clinic once before and I was the doctor who had seen him that time too. The tests I had ordered then came back as normal, which meant I hadnt found the source of the problem. I would have preferred one of the other doctors to see him this time. Maybe they would notice what I had missed.

My letter recording our conversation said that he had odd sensations in his right arm. I had examined him and found nothing amiss. I had wondered if the problem might be a trapped nerve in his neck. I ordered electrical tests to examine the integrity of the nerves traveling into the arm. Those tests found that the nerves seemed to be working as they should. I knew that if the man was no better since that first meeting I wouldnt really know what to do next. My only hope was that he had recovered without my help. I called him into the room.

How have you been? I asked.

The same, he told me, and my heart sank.

Okay. Wellcan you explain the problem to me again?

I get goosebumps running down my right forearm. Very noticeable goosebumps. Thats all of it.

He made it sound so simple but the symptoms just didnt speak to me.

Is there any numbness? I asked.

No.

In between the goosebumps, does your arm feel otherwise normal?

Mostly, except when the goosebumps arrive.

He opened and closed his fist and stared at the offending arm. I was trying to feel my way through the problem. Trying to understand. I was not succeeding.

Is your hand or arm weak?

Nomaybeno. When I have the goosebumps it feels weird enough that I think, if I was holding something, I would drop it.

How often do you get the goosebumps?

Only for a minute or two once a day. Maybe twice.

The man was in his thirties. He looked well and had no medical problems in his past. I wondered why he was so worried about symptoms that only lasted one minute a day. What he described seemed almost trivial to me.

Well, the good news is that the tests are totally normal, I told him. I dont think you have anything to worry about.

I was revving up my reassuring speech, hoping that he was one of the worried well. Maybe all he needed was to be told that everything was okay.

But what is it then?

Oh no. His voice was anxious. A normal test result was not good news to him. He wanted a better explanation than I could give.

Im not convinced that what you describe can be fully explainedbut most symptoms that cant be explained just disappear when left alone. I meangoosebumps? Is it the temperature in your officethe air conditioning?

I was clutching at straws and we both knew it.

I dont think you understand, his voice was getting higher, they are goosebumps that stand up like anthills on my skin. It isnt normalitsitsunnatural.

I blush easily when I am uncomfortable and out of my depth. I felt the redness crawl up my neck towards my face. I felt goosebumps creeping over my own skin.

Let me look at your arms again, I suggested, buying myself some thinking time. I asked him to sit on the couch and take off his shirt. I looked at his muscles and they seemed normal. I tapped his reflexes with my tendon hammer and they were normal too. I poked at his arm with a blunt pin to check sensation. Normal. I tested his strength. It was possible his grip was not as strong in the right hand as the left but I had a sense that he wasnt trying very hard. Perhaps he needed me to find something wrong.

I dont think I can explain this, I said eventually.

Just for a second I thought I saw him roll his eyes. I took that as my cue that I needed help.