Editor's Note
Medicine’s Magicians
For years, neurologists have been the magicians of medicine. Clutching their black bags, they strode into patients’ rooms to tap tendons, tickle feet, and test strength. Those bags held a mysterious array of instruments, and as they meticulously pulled out each one they seemed like stage magicians yanking objects out of a top hat. After the show of the bedside exam came the real magic as the neurologist would elegantly define “the lesion,” parsing the mild loss of strength in the hand muscles here and the subtle decrease in pain sensation there and arriving at a lesson in neuroanatomy that defined which nerve, ganglion, or gyrus was diseased. Such showmanship fostered legends, titans of diagnostic acumen who could see a fasciculation no one else could, uncover a slight slowing of rapid alternating movements, or point out a droopy eyelid missed by all previous examiners to solve the clinical puzzle. Yet in past years, once the diagnosis was made, neurologists had little to offer their patients except a trip to the physical therapist.
Neurology is different today. Neurologists still carry black bags and tap, tickle, and test, but their bedside diagnosis has been supplemented by diagnostic tools such as MRI that make the paraphernalia inside those bags look like dowsing rods. And neurologists have an ever-expanding armamentarium of pharmaceuticals to treat even the most refractory migraine headaches (p. 36) and seizure disorders (p. 46). When drugs for neurological conditions fail, neurosurgeons can step in, probing the electrical centers of the brain to find the lesion and using deep-brain stimulation to treat it and put a concert violinist back in his orchestra chair (p. 8). In today’s neurology, there is treatment after diagnosis, and patients can live better, more productive lives.
Neurology patients still visit physical therapists, and, in fact, the benefits of physical exercise are being rediscovered (pp. 6, 22). Putting Parkinson’s patients on bicycles or having them engage in other forms of exercise can slow the progression of the disease and add months, if not years, of functional life. Indeed, recent evidence suggests that exercise expands not just biceps and quads, but minds as well.
Like many specialties, neurology is at risk of being swamped by the technical. White densities clearly delineated on an MRI are cleaner, more objective proof of disease than an exaggerated reflex or decreased position sense. Why even open the black bag when one picture can tell the whole story? Why even listen to the patient’s history, laden with missing details and irritating repetition, when all that matters is finding the lesion? Part of the answer is that there’s a human behind that hazy memory who needs more than just technicians to help her. Another part is that if we lose our sense of medicine as an art, we lose some of the richness and fun of what it means to practice.
Magicians wear lots of different costumes. Minnesota Orchestra associate concertmaster Roger Frisch certainly wouldn’t give back the technical marvel implanted by neurosurgeons at Mayo Clinic that brought back his virtuosic violin playing. But we still need those wily, magical clinicians striding into patients’ rooms with their mysterious, and very useful, black bags.
Charles R. Meyer, M.D., editor in chief Dr. Meyer can be reached at cmeyer1@fairview.org.