A Case of Broca’s Aphasia

On Sept. 14, 2000, at the age of 72, Lester Schwartz, a psychoanalyst working in New York City, underwent a simple operation for a benign fatty tumor in his stomach. He woke up the next morning in the hospital and realized he had lost his ability to speak. He immediately reached out to his son, who happened to be a neurosurgeon.

I was awakened from a deep sleep that Saturday morning by a call from an unidentified number. The voice on the other end of the line was familiar yet also unrecognizable. I thought I could make out a few words, but the staccato phrases were halting and garbled. Each utterance was distorted, requiring enormous effort. Although I couldn’t understand what the voice was saying, I had no doubt that it belonged to my father.

“I’m on my way,” was all I could manage to say as I jumped out of bed. I felt a pit growing in my stomach. I’d heard that type of distorted speech before, and I knew something was terribly wrong inside my father’s brain. I also knew that time was not on his side.

Lester was born in 1928, in the South Bronx, which at the time was a primarily working-class Jewish neighborhood. Neither of his parents had attended college. Lester, a gifted child, was admitted to the selective Townsend Harris High School. He went on to receive his medical degree from New York University before training in psychiatry and psychoanalysis. He settled on Manhattan’s Upper West Side, which was to psychoanalyze what Texas is to American football.

When I arrived at his bedside, I noticed that my father looked distressed. I began by asking him a few questions, probing his ability to comprehend and convert thoughts into speech. He tried to speak but the words just wouldn’t come. A disconnect seemed to stand between his brain and his mouth. He just stared at me, wide-eyed, with a pleading sense of profound helplessness and fear.

My father’s stomach surgery had been performed at a different hospital from mine, so I didn’t know the staff, and they had no knowledge of my professional training. To them, I was just another concerned family member to manage. I ran over to the nurses’ station, found my father’s nurse, and implored her to contact my dad’s doctor and ask him to order a CT scan immediately. She tried to calm me down and told me they had called in a private neurologist and were waiting for his response. It was Saturday morning, and I knew it was unlikely the neurologist would respond as rapidly as my father’s condition demanded. I had no way of ordering a CT scan myself, so I asked for the neurologist’s name and contact information. I was able to reach him by phone and explained that my dad had just developed the acute onset of Broca’s aphasia.

As is typical in a case of Broca’s aphasia, my father was not only unable to verbalize his thoughts; he was also acutely aware and disturbed by his deficit. The look of fear on his face was haunting, and I could only imagine what was running through the mind of this widely read and erudite student of Freud, now rendered a near mute. The irony and cruelty of his affliction was only exacerbated by the fact that my father’s interest in the brain and its organization was one of the primary inspirations for my own career choice.

After reaching my father’s neurologist, I convinced him that he needed to order a CT scan stat. I ran back to the nurses’ station and informed the nurse that the scan had been ordered. I knew that if my dad had a stroke, every passing minute meant that more neurons in his speech areas were dying from lack of oxygen. She checked the computer and, sure enough, the order had been placed, but she then informed me that now we had to wait for someone to come transport him to the scanner.

I could feel my blood pressure rising. I asked her, in as calm a voice as I could muster, where exactly the CT scan was located. “Fifth floor,” she said.

I ran back to the room and packed up all the IVs and unplugged the monitors, as I had done countless times during my training. Then I pushed the bed headfirst out the door toward the elevator with my dad facing me the same way I’d faced him as a toddler when he used to push me around the supermarket in a grocery cart.

“You can’t do that!” the nurse was yelling behind me. I was already in the elevator before anyone could stop me. I was acutely aware of how inefficiently some hospitals run on the weekends and I was not going to let my dad become some administrator’s areas-for-improvement statistic. I located the scanner and let the technician operating the machine know I was a doctor (I may have left out that I wasn’t a doctor at this particular hospital).

I found myself sitting in the control room, watching as my father’s brain appeared on the viewer, one slice at a time. This psychoanalyst’s brain was so familiar to me, but in such a different way. It belonged to the man who had raised me, who had held my hand and walked me to school when I was a boy and taught me how to hold a razor and shave when I became a young man. He had bequeathed to me not only his love and his wisdom but also his love of wisdom, as well as his passion for books, movies, science, philosophy, art, and music. How he loved to discuss every new idea I ran by him, always able to provide a fresh angle or perspective that I had overlooked. It was no coincidence that I had become a neurosurgeon — a way to touch the human brain in a way my father never could, a way to show him up in a defiant Oedipal challenge. Or perhaps just a little boy’s attempt to win his father’s affection?

CT scan images of the head are displayed as horizontal slices emerging one after the other, from the bottom up. Each appears about 10 seconds before being replaced by the next. I had viewed and interpreted hundreds if not thousands of CT scans in my career, and I knew exactly what I was hoping not to see.

The first ten slices looked clean. The normal brain appears gray on a CT scan. Blood is white, and a stroke looks black. As the frontal lobe came into view, there it was: a big black spot sitting in the left posterior inferior frontal lobe, also known as Broca’s area.

On slice after slice, the same black hole appeared, so I couldn’t pretend it was an artifact. There was no doubt. It was a stroke.

Further tests revealed that he’d developed a hypercoagulable state following his stomach surgery, meaning his blood was clotting more rapidly than normal. Another test uncovered a previously undetected lung cancer that was releasing proteins into his blood, which promoted clotting. He was placed on an anticoagulant, started on chemotherapy, and died 3 weeks later, surrounded by his family, all of us holding hands at his bedside.

Everything happened so quickly. Throughout those 3 weeks, I struggled to remain positive, trying to convey as best I could a sense of optimism. I wanted him to believe that his situation might improve, even as I knew it probably would not. As a result, we never had that final conversation where I could let him know how much he meant to me. I maintained the stalwart veneer of the professional I was becoming at the expense of the son, who needed to let his guard down and bare his soul one last time to his father. My dad’s aphasia prevented him from expressing his thoughts at the time. What was my excuse? To this day, my inability to have a heart to heart conversation with my dad in the last weeks of his life is one of the regrets I still carry with me.

Theodore H. Schwartz, MD, is a neurosurgeon at Weill Cornell Medicine in New York City. This essay is adapted from his new book, Gray Matters: A Biography of Brain Surgery, published by Dutton.

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