I have been coughing more and indulging more in the gentle pain of nostalgia. As my muscle abilities decline, I have become more dependent on caregivers for basic activities. In the morning, I may be passive for two hours or more while I am stretched, showered, toiletted, dressed, shaved, transferred with the Hoyer, and so on. Between coughs, I often close my eyes and reflect or reminisce. Because of my emotional incontinence, I may startle my caregiver with tears.
Bob (Robert) and Joan came for dinner, bringing Thai food. We had suggested cancelling because of my cough, but they were in town from LA for only a few days and decided to come anyway. As usual, it was great to catch up and eat good food with good friends, but terribly frustrating to me to be unable to talk.
The food, abundant and just spicy enough, came from Thai Bloom located at 333 N.W. 23rd Avenue, which happens to be the building where Bob and I practiced together for nearly a decade. My father opened his office there in 1948. In the early 1950s my Uncle Bill, a general surgeon, finished his training in Chicago and moved with his wife, Bob, and younger son Tom to join the practice.
Bob is three and a half years older than I Growing up, we lived about a block apart, if you took the shortcut. Many of my teachers in grade school and high school called me ‘Robert.’ In high school he went out of his way to socialize me, getting me to go to youth group meetings or dances despite my introversion.
He went to medical school at Johns Hopkins. When I visited him once there, he took me to Hopkins hospital. We passed a patient sitting in the hall who had aphasia. Bob introduced me to him, showing me his speech deficit. That was the closest we ever came to discussing future careers as neurologists.
Bob did his neurology training at the Mayo Clinic in Rochester, one of the finest training programs in the country. He did two years of service at the US Public Health Service hospital in San Francisco then returned to Portland where he began to practice with his father, my father, a rheumatologist, and other internists.
When Lois, our son, and I moved to Portland in 1977 for me to practice with my family, Bob socialized me again. He taught me how to relate to referring physicians. He and Joan introduced Lois and me fto their friends. We bought a house about a block away from them.
To commemorate starting practice at 333, I wrote a haiku:
3-leafed trillium
3 birthroots in Northwest woods
3 love, work, and grow
My brother Jim has reminded me that I was not born in Oregon. Lois is from New Jersey, and my son was born in Washington, DC. “3 re-roots… “ would be more truthful, but my earliest memories are Oregonian, and I like that birthroot is a traditional name for trillium because it was used by indigenous midwives to treat postpartum hemorrhage.
Bob and I learned to work together as interchangeable parts. We often lunched together or jogged after work to discuss patients and our practice. To save money, we had a one-line listing in the Yellow Pages: R. Rosenbaum – neurology. When I saw other physicians in the hospital, quite a few called me ‘Robert’ or thought we were brothers. I explained that although I was taller, heavier, balder, more scholarly, and less genial than he, we were identical cousins.
I will give an example of our coherence. I will set up the story with an embarrassing anecdote from medical school.
Fourth Year of Medical School
I enjoyed my first neurology rotation so much that I signed up for an extra elective month, which I did at the Massachusetts General Hospital in the spring of my fourth year of medical school. I was assigned to a single attending faculty member and went to see his consults and then brought him in to meet the patient and examine the patient after I described my findings.
One day we consulted on a man who was rapidly developing difficulty moving his eyes and difficulty walking. After examining him, we agreed that he was probably having a stroke affecting his brain stem. Today we would quickly get a brain scan to confirm the diagnosis and plan the best therapy, but CT and MRI scans were not yet available in 1971, and we made recommendations for his care based on the clinical diagnosis.
When I came to work the next morning, the attending was furious with me. He said that I had made a serious diagnostic error. He seemed to forget that he had also examined the patient, checked my history and physical examination, and agreed with me on the diagnosis of brain stem stroke.
Apparently during the night, another neurologist on the staff, C. Miller Fisher (1913-2012), had for some reason stopped in and examined the patient. Dr. Fischer was famous for his meticulous examinations and his habit of returning to the hospital very late in the evening to double check on his patients. He would gather his residents and fellows around him and might spend hours at the bedside of an individual patient, studying how the illness evolved as the hours passed. Even in his late 70’s, he might spend 48 hours without leaving hospital, carefully watching a patient.
In 1956, Dr. Fisher had described a new syndrome with a triad of findings: impaired eye movements, unsteady gait, and depressed tendon reflexes. In his honor, the syndrome was named Miller Fisher syndrome.
The depressed tendon reflexes in Miller Fisher syndrome show that it is an illness that affect peripheral nerves, which a brain stem stroke would not do. We now know that Miller Fisher syndrome is a very rare form of autoimmune attack including the peripheral nervous system, a relative of acute inflammatory demyelinating polyneuropathy, which is also known as Guillian Barre syndrome.
Miller Fisher syndrome differs from brainstem stroke because in Miller Fisher syndrome the tendon reflexes are decreased. Also, a brain stem stroke usually occurs suddenly whereas Miller Fisher syndrome may develop over hours or days. I doubt that my attending and I were sloppy in checking the tendon reflexes of our patient. I suspect that the reflexes had decreased between when we saw the patient during the day and when Dr. Fisher saw the patient at night.
In those days there was no treatment for Miller Fisher syndrome and no treatment for brain stem stroke, so no damage was done by our error, but my attending physician was clearly embarrassed and blamed it all on me.
I have seen only one other case of Miller Fisher syndrome in my career. A man came to my office and described his symptoms; after examining him, I was able to tell him the diagnosis without any additional imaging studies or blood tests. He was a very smart physicist and asked me how I made diagnosis so certainly after spending a few minutes with him in my office. I explained to him that that is why neurologists spend years studying the natural history of neurological disease and perfecting the neurological examination. To illustrate my point, I called Robert from his office down the hall to come join us. I told him the patient’s history and let him examine the patient, including of course, eye movements, gait, and tendon reflexes. I asked him to tell the patient the diagnosis, and the patient was amazed that my partner came to exactly the same conclusion that I had reached. The physicist joked that since his illness affected one in million people, the chance of two neurologists making the same diagnosis in one day was one in trillion.
I often asked Robert for his opinion like this. With an additional question or examination finding, he might clarify a challenging patient problem. I would do the same for him.
When Robert retired at the end of 2012, shortly before his seventieth birthday, I felt a tremendous loss, even though I understood his decision. His father had worked until he was ninety, so I had expected to practice together for twenty more years. We are not very demonstrative. It is ironic that I had to lose my speech to write how important our relationship has been to me.
Bob and I were friends with Peter Fisher, a kidney specialist at our hospital and Miller’s son. Peter retired even younger than Bob. One day they met in the exercise room of our club. I was at work so have only secondhand knowledge of their conversation:
Peter: Did your dad give you grief about retiring young?
Bob: Not much.
Peter: My father asked if I read The Lancet. I said that I stopped reading journals when I retired. My father said that was a shame because I had missed his recent article.
December 31: New Years Eve
December 31, we had 15 people for New Year’s Eve dinner. Everyone brought something. Our house was the venue because no one else has a wheelchair accessible house. Stan brought the wine, including a 1976 Chateau Haut Brion. People raved about it, but the bitterness of Relyvrio ruined my palate. Larry’s wife Linda brought tasty hors d’oeuvres. Gregg and Eleonore brought their daughter, son-in-law, granddaughter, creamed spinach, salad, and baked potatoes. I learned to add potato skin to my hard-to-swallow list. Lois made beef tenderloin that lived up to its name, easily minced by my molars. My daughter and grandson baked cross-cultural desserts – rugelach that put Zabar’s to shame and a gorgeous sumptuous chocolate yule log, sprouting meringue mushrooms. I made it through dinner without coughing all over the table.
In former years we would party past midnight, but at 8:55 we turned on TV to watch the midnight ball drop in Times Square. People left shortly thereafter.
Happy 2024 to all!