THE MYSTERY OF CLEAR VISION IN PEOPLE WHO WERE BLIND - THE CHARLES BONNET SYNDROME

I got a letter from my cousin Nirmala, about her mother. I reproduce it verbatim unchanged. I have only highlighted a few things. 

"Periodically she gets visions (hallucinations) with audio. About bhajans, gods and goddesses, patterns on the ceiling, monsters, and now insects big and small on her bed and clothes, plastics hanging from the ceiling, and the cupboards becoming buildings and falling on her. She tries to get off the bed on her own and go out of her room. She can barely walk with the walker and one attendant to the toilet. 

She is aghast that we cannot see these things. She also sees a child and a man standing in the corridor. She has lost orientation her room and is worried about how to go out of it and come back.

She is wheelchair driven and is taken to the to to see Animal Plant, Just for Laughs and Planets Funniest Animals without sound as she cannot hear and her semi dentures do not fit.

Is fairly lucid and clear while speaking to us and neighbors.

She has  back pain and knee pain off and on and not much strength in the legs. Cannot read or write legibly, cannot read. 

Poor hearing - hearing aid not satisfactory; Poor eyesight and eye doctor has said no more can be done for her macular degeneration. 

Please see if anythings can help her. I will talk to her physician here.

Best, Nirmala"
  Obviously, the lady is seeing things which others do not, because, they do not exist - a phenomenon called hallucinations. Hallucinations are reported in people with normal eyesight sometimes caused by some medications, drugs, alcohol withdrawal and some other events.This is a unique situation where a person with a poor eyesight starts seeing things very clearly and these are not visible to the others. This is known as Charles Bonnet syndrome. Charles Bonnet was a Swiss naturalist and a good observer. He was the first person to describe this unusual syndrome. This is commonly seen in elderly patients with a poor vision and appears and disappears without warning. These hallucinations can be common, mundane or funny and rarely threatening.  The images could be in black and white or in color and can even be clearer than normal! The person seeing them fully believes them to be real! Sometimes they seem to fulfill a unfulfilled desire - like a lady who repeatedly 'saw' her deceased husband and a childless lady who 'saw' a boy and a girl as her children (she was longing to have children). They are able to 'see' these people / events even while speaking to others (who obviously cannot see them)!Sometimes the images may be of animals and inanimate objects like boats, houses. They may even be in the form of spinning lights!One person could see cartoons in  his scotoma - a completely blind part of his visual field! 
     These therefore are like usual hallucinations - probably the patients are 'filling in' as they are blind! What is astonishingly different in these people is that the filling in is done by using high level stored memories - like pulling out an old album and seeing the images with great clarity and in a great detail! These stored internal images therefore make up for the otherwise lack of vision = but they can never substitute the real vision! To quote Shakespeare 'You cannot cloy the hungry edge of appetite by bare imagination of a feast". These perceptions are probably an end result of an dynamic interplay between sensory signals and high level stored information about the visual images from the past! The higher visual centres therefore probably substitute  the 'best fit' to the lower centres which have failed in their duty of enabling the person to see normally (for whatever reason, these persons always have a poor eye sight). 
     Why I am enamored by this syndrome is because I encountered it in my own father - a very intelligent and accomplished doctor know for his clarity of thought and judgement. During the final phase of his life, he experienced these images which I later realized were due to the Charles Bonnet syndrome . He was a very well read person. One day he was very excited - he called me to tell me that he is able to read the front page of the New York times very clearly and believed it to be a miracle! Only there was no New York Times and he was a;most totally blind! Only when you experience these in a close friend or a relative you understand how important to identify it in the first place. The lady mentioned above is my father's sister. 
     There is no need to treat this if the patient is able to rationalize. That was what was done successfully to both my father and his sister.
      Coming  back to the story of my aunt , my friend, Dr. Gurudutt Kamath opined thus 
with poor eye sight and description of vivid pictures it looks like Charles bonnet syndrome
      I reassured my cousin about her mother and wrote to her 

"Dear Nirmalakka

     My dad also had it. These are NOT hallucinations. They are OLD IMAGES STORED IN THE BRAIN released due to some unknown reason ( like seeing old albums). Unfortunately the patient thinks it is really happening! Patient counselling is the best way out of it. This even has a name - Charles Bonnet syndrome. It is otherwise harmless. It does not indicate stroke. It poses a challenge to the caregivers. 

      Raghu

      Both my aunt and my father improved. But the Charles Bonnet syndrome continues to exist and haunt people out of the blue!

MYSTERY OF THE HIGH MORTALITY FOLLOWING ROBERT LISTON'S SURGERY!

     Sometimes, a patient can die following a surgery. There are many reasons why this can happen. Most of the times, death comes with a warning - a seriously ill patient, an underlying organ failure, associated critical illness, old age , multiple coexisting conditions to name a few.In these situations, the death is somewhat expected though unpleasant. There are some situations where the death is unexpected. These include cardiac arrest due to vagus nerve over activity, severe allergic reactions to drugs or chemicals. These are the situations where the death is both unexpected and unpleasant and sometimes leads to litigation's and court battles. Usually the surgeon is taken to task and has to suffer infamy and also loss of money and reputation. Today's story is about a surgeon who became famous (or rather infamous?) with an unexpected unusual mortality!
     Robert Liston was a Scottish surgeon. He was known for  speedy  surgeries he used to conduct. He lived at an era (1794 - 1847) when there was not much effective anesthesia was available. Therefore speed was a required faculty for a surgeon to be successful.  A noted surgeon, Richard Gordon, in his book written in 1983 describes some cases which made Liston famous.
     There was a patient with a huge scrotal swelling. After removal, this weighed 45 kilo grams and had to be taken away using a wheel barrow!
     Then  there was a young boy with a red, pulsating' tumor' in the neck. Liston diagnosed it as an abscess and was ready to drain it immediately.  A young but sensible house surgeon suggested that the 'tumor' could be an aneurysm as it was pulsatile. Impatient and irritated, Liston argued saying that aneurysm was highly unlikely in such a young patient. "Whoever heard of an aneurysm in one  so young?" were his exact words. He promptly pulled out a knife from the pocket of his waist coat and lanced it . The disaster that followed has been promptly recorded by the house surgeon "Out leaped the arterial blood and the boy fell!" The patient promptly died. The aneurysmal artery still lives on as specimen no 1256 at the Pathology museum of the university college hospital!
     Amputation of the limbs required both speed and efficiency and therefore a special skill required by the surgeon intending to do it. Usually these operations were witnessed by doctors, medical students and some distinguished spectators who would be surprised and enamored by the spectacle! One day Liston was amputating a limb. He completed the swift amputatoin in less than 2 and a half minutes! Then a most unexpected event took place - the knife not only amputated the intended  limb but also his testicles which was unintentional but disastrous!
     The cake is taken by the mother of all disastrous case wherein Liston wherein Liston swiftly amputated the leg in under 2 1/2 minutes. The patient died from gangrene due to hospital acquired infection ( after all it was in the pre - Listerian era). This was no big deal. though the mortality was 100%, it was acceptable. This story has an incredible ending - a 300% mortality! Wondering how it happened? Liston accidentally amputated the fingers of his young assistant who also succumbed to gangrene following gangrene due to hospital acquired infection. If that leaves you wondering how did a third person die in this unique episode, I will gladly explain. One of the invited distinguished spectators was intently watching the event. The tip of the swinging knife slashed his coat tails so close to his 'vitals' that he thought that his 'vitals' have also been amputated and died in sheer fright! Therefore this surgery had a 300% mortality! Incredible story - very strange but true!

WHO BENEFITS WHEN I UNDERGO STENTING FOR MY HEART ATTACK?

     Indeed the question is who benefits when I undergo stenting for my heart attack? I thought the answer is obvious - Me! If the answer is so obvious, I would not have posed this question in the first place.
     To the uninitiated, STENT is a way of making sure that blood flows once again in the vessel (coronary artery supplying blood to a portion of the heart in this instance). This is based on a sound principle that the heart attack is indeed caused by the sudden stoppage of the blood supply to the heart muscle in the first place. (A reduction usually happening slowly not amounting to a sudden block would result in a less dangerous 'warning signal'of  ( the possibly oncoming) heart attack - known as 'Angina pectoris (meaning 'chest pain'). The process of removing the block and preventing a further block is done using 'clot busters' - chemicals that dissolve the clot. However these on their own cannot prevent this from happening again. It is precisely for this purpose permanent measures are undertaken to make sure that  that enough blood flows through the arteries of the heart once again - these procedures are called 'revascularisation' procedures. An angiogram ( dye injection to visualize the arterial tree oft he heart ) is done first. This helps in making sure that there is a block ( or many blocks) in the first place and the size and location of these blocks. Depending on the feasibility, the patients are taken up for the medical procedure of Angioplasty (by which the blocks are removed) and stenting is done  to make sure the vessels which have been opened up are prevented from getting blocked again.There are many  types of shunts available - the ordinary ones wich keep the artery open ; the drug eluting ones  which hopefully prevent the blockade from happening once again by having a small dose of anticancer drugs which are known to slow down the cell multiplication ( the basic principle of treating cancer anyway). These are many times more expensive than the ordinary stents. Then there are the so called 'vanishing stents' which are supposed to merge with the arteries and keep them open longest. These are priced highest - in fact, many times more than the ordinary ones.
     Now we come to the basic point - HOW ARE THE STENTS PRICED? Basically there are 2 priciples of pricing anything - 1. The costs incurred. 2. The exclusivity. It is the neighbour's selling price that often determines the cost of the item most of the times. Thus a logical balance is struck - depending on the demand and supply position. This delicate balance is sometimes offset by EXCLUSIVITY of the product and the SERIOUSNESS OF THE SITUATION. In the case of stents BOTH these factors operate. This gives a free hand for the manufacturers to grossly overprice the product. This is what exactly happened to the 'Vanishing stents' sold by Abbot in India. The customers were royally fleeced to the core because there were no rivals. The worse news is that it has been found that even the so called vanishing stents get blocked many times defeating the basic purpose. Now we come to the point - the unsuspecting client is made to pay for the CONCEPT which has NOT been proved! You might ask me the question how on earth is this possible because even the drugs undergo extensive trials and attempts are made to obtain adequate proof before these are used on the patients. How then the stents get away? Brings us to a glaring fact that there is NO NEED to conduct trials before the DEVICES are used on human beings - and believe me, stent is one such device. How then can we remedy this seemingly iremediable problem where the ABBOT COMPANY MAKES HUGE PROFITS WHETHER THE END USER ( THE PATIENT WHO SUFFERED A HEART ATTACK) LIVES OR DIES OR BENEFITS OR NOT.The Abbott company DOES NOT EVEN MENTION THE MRP which has to be compulsorily mentioned by even products like toothpaste! I discussed this issue with legal authorities and patients who had suffered. I felt very sad after I was made to know that there is NO LIMIT ON THE MRP OF PRODUCTS CREATED BY ESEARCH for which there are no alternatives. I then understood that the ball is in the court of the consumer - the patient and addresssed may fora on this and related topics. No one saw the urgency in the issue till a kit or kin of theirs developed a heart attack and there was no time for these discussions.
     When I almost gave up, I found a good news on the newspapers today that the MRP OF THE DEVICES HAS TO BE COMPULSORILY MENTIONED. Now there is some kind of a hold on the companies like Abbott. I am not for a moment saying that they are the only ones in this dirty game. There are many other devices like pacemakers, intra cardiac defibrillators, artificial joints, ocular implants, heart valves, disposable syringes and many more items manufactured  by many companies. Now some sort of regulations will come int place. It has been also mentioned that attempts are being done to notify these products as drugs and compulsorily bring them under the Drugs and Cosmetics act1940. If this happens, their prices will be monitored and regulated making the whole process fair to all concerned including the stake holder - the patient. Therefore with this single act of the government, there will be more people benefitting fairly when a person undergoes stenting!

THE IMPORTANCE OF "COUGH!"

     You may wonder what is this all about! After all, what is the importance of cough, such a common happening? Is there anyone who has not had cough sometime or the other? None, I am sure. Then what is this about?
     I am not referring to the 'cough' you are thinking of - cough as a mark of disease. Cough is called a 'symptom' if the patient complains of it and a 'sign' if the doctors discovers that the patient is coughing too much. This happens in various situations some acute like acute bronchitis and pneumonia. and some chronic like tuberculosis or occupational lung disorders. Pneumonia has replaced tuberculosis as the 2nd most important killer!
     The cough I am referring to is a special cough - for example a cough by a girlfriend is a means of attracting the attention of her boyfriend particularly when she is forgotten in the company of his friends!  The cough by  a wife is a even more serious event - it is brake - a remote control even before actual remote control was even thought of - an effective means of telling her spouse "You are talking too much - Stop!". Most of the times, it has a magical effect!
     One of my patients once told me of an event where a patient had a bout of violent cough and fell down clutching his chest - he was taken to a hospital immediately - In all probability, the violent cough had ruptured his lung resulting in the escape of air outside his lung into the surrounding pleural space - a very serious condition called "tension pneumothorax" - a killer. He survived only because of a good medical attention!
     Cough may sometime  be the end point of a crisis! When someone is choked on something - say, a morsel of food, one can try a life saver called Heimlich maneuver - a type of a squeeze below the middle of the chest - which can effectively dislodge the substance blocking the critical airways and throw it out with a cough - a life is saved following that cough!
     Some coughs are telling - Bovine cough a cough resembling a cow's cough is said to suggest pressure on the recurrent laryngeal nerve deep inside the chest - an ominous sign indicating possible cancer. Our generation I am sure, has not forgotten the Whooping cough a dramatic event where a series of coughs in quick  succession  is  is followed by a distinct unforgettable sound of air rushing in - a whoop!This potential killer seen particularly in children has  become a lesser offender now due to vaccination though it is trying to raise its ugly head again!
     There is an interesting neurological condition called Pseudobulbar palsy which results from damage to the higher centres of the brain where the patient cannot cough to order but the reflex cough is preserved!
     Once one of my friends claimed that the best medicine for cough was brandy! In fact he was trying to justify his daily dose of brandy with a plausible medical reason!

" '"DOCTOR IN TROUBLE! "

     Gone are the days when a doctor was considered as God. Later he was revered and adored  though not treated as divinity. He formed a part of the family and was invited for all festivals and functions and consulted for all medical and even social problems. I remember distinctly an occasion when a patient died at home. He was regularly being treated by my father as his family doctor. It was a Sunday and my father had taken all of us to the beach at the evening. All of a sudden there was chaos on the beach. Two people were running, who we later realised, were desperately looking for my father. I was really surprised when I realised that they were looking for my father after the patient  had died! My father explained this phenomenon  to me describing it as a 'bond' between the doctor and the patient. It was imperative that the doctor who has treated the patient must see the patient after death so that 'soul rests in peace'. This was in the mid 60s when I was a primary school student. I was really overwhelmed!
     Later I completed my MBBS and went in for Post graduate studies in Medicine. I saw and treated patients at the Government Wenlock Hospital. It was a very heartening and a satisfying experience. The patients selected the government system knowing full well that it was far from perfect. The doctors knowing this, went out of the way to compensate with compassion and the nurses and the other paramedical staff also did their best. The team work seemed to satisfy the patients who came from far and wide. Of course, some were unhappy, they shifted their patients out to other hospitals. Some patients died - often this event was predictable. Sometimes death was unexpected but doctors were around at the time and shared the sorrow of the patients. The trainee doctors acted as a buffer between the patients and the treating doctors never letting down their teachers whom they held in high esteem.
     Now there is a complete change of the scenario. The patients do not respect the doctors in the same set up. Doctors are 'uncomfortable ,. Patients demand more. Even when they are aware of the limitations, their demands are unrealistic. They expect the senior doctors to be around all the time. It is unreasonable. The doctors belong to a cadre known as Honorary doctors who are not paid anything by the Government for teir services lent to the Government system. On the other hand the they are 'part time employees' of the teaching institution which limited responsibilities and limited emoluments. Obviously they have look elsewhere to make a comfortable living - which is the basic expectation of any professional with 15 years input into training (leave alone the cost). They do some private practice. In any professional system, there is a hierarchy and the system is closely followed. This happens in all government offices including the DC office, RTO, etc.
     Not only the doctors are expected to be present all the  time, they are also expected to solve all problems
medical and otherwise. One cannot expect a 5 star treatment at no cost. Shortage of medicines, non availability of space in the ICU, shortage of beds cannot be addressed to by the doctors. A road traffic accident is a case in point - Death or injury results from an accident. Such a patient is brought to the hospital and the relatives are naturally emotionally upset  Doctors become the target of any shortcomings of the hospital or the system and any adverse outcome of the event. First of all take the larger picture - why did the accident happen at all? Because an unscrupulous person bought a non roadworhty painted up bus and got it certified fit for use by a corrupt officer of the RTO. City corporation officials made a road out of what was left after sharing most of the sanctioned money at various levels. The so called road is a true mutant with many holes. An unsuspecting two wheeler rider who is innocently trying to avoid a pothole and find the road or what is left of it is mercilessly hit and knocked down by a speeding bus often from the wrong side. He is rushed to the hospital and the relatives are not prepared for the event, outcome, or the expenses. In this emotionally charged condition they try to vent the anger on the easily available person  - the doctor! Naturally the doctor who is trying to do his best against all odds gets naturally emotionally upset - after all, he is also a human being and an accidental easy target in the whole show!  Every one is unhappy and the real corrupt antisocial culprits have got scot free! Nothing ever has happened to the bus owner, bus driver, RTO official, corporation road contractor, or road tax collector, DC ever! Only the doctor is targeted. All these culprits should be made accountable - at least they must be given the responsibility of transportation of the patient and must be made to bear the expenses of all the expensive treatment modalities, diagnostic tests and costly medicines and also the cost of treatment in a higher, greater equipped center  if the need arises!
     This is my personal opinion. A beautiful honorary system will die down if the steps are not taken at the right time which is now!
   
     

THIS IS NO MONKEY "BUSINESS"

     We (my wife Shobha and me) are just back from a trip to Malaysia and Bali. We were specifically told to watch sunset aat Uluwatu at Bali. On the last day of our trip to Bali we planned this after checking out of the hotel before reaching the airport.
     There are 2 things to see at Uluwatu - an old Shiva temple for which the entry is highly restricted. There is a specific dress code which  we were not aware of and so we could not enter the temple as such. Then however, there was the sunset to watch and it can be watched from many points. You get a good view of the ocean too.
     There are many monkeys at Uluwatu. In fact they are encouraged and pampered. There is an exclusive swimming pool for the monkeys - something I have not seen anywhere. And there are very many monkeys. One an sit and relax in the benches provided from where the sunset is not visible. One could watch from the edge of the wall but it is not possible to sit there. We were sitting on one of the open benches when we net a family of 3 French ladies 2 sisters and their mother. The mother had a bandage on her little finger. On inquiry, she revealed that the injury was due to the monkey attempting successfully to snatch a banana in her hand. In the process he scratched and bit the little finger. She had to visit a hospital meant for the foreign tourists and and was given a shot of tetanus toxoid and one of ARV. The whole thing cost her a whopping 100 $! The monkey's prank turned out to be expensive indeed!
     As the sun set was approaching, I called my wife to stand near the wall so that the sunset can be viewed better. She did so. She was busy talking to me and the people around us. Then she moved back to the open benches saying that there is still more time. 2 guides belonging to 2 other groups were sitting beside her on both sides. Just then in one swift move she felt her glasses being snatched from her face suddenly. Before she could realize it was a monkey, he fled with the glasses and sat above the wall  near which I was standing. On the other side of the wall below the spot where the monkey was sitting, there was the ocean in full glory. There was a patch of grass just beside the wall where I was standing.
     The monkey carrying the Cartier glasses which  indeed was an expensive gift, jumped up and sat exactly above me and started to examine the glasses. My wife was desperate as there was no way we could reach the monkey and get the glasses back. There was very little time and little we could do. I wa about to shout at the monkey when a local man advised me to remain calm. He gave the monkey a small chocolate in his right hand. The monkey gladly took the chocolate, for a while held the chocolate in his roght hand and the glasses in the left hand and examine both. He must have found the chocolate more interesting and therefore threw the glasses down and was busy eating the chocolate. Now came the second hurdle. The glasses fell down into the patch of grass behind which was a cliff leading to the ocean. There was no way we could reach the spot where the glasses lay. The same man helped again. He jumped the wall  and in one swift move retrieved the glasses and jumped back to safety and returned the glasses to us. The whole thing was so sudden that we were stunned. Even before we could recover and thank him or offer him a gift, the man had vanished. All along, a Chinese tourist was video recording the whole thing and he had his dark glasses on his forehead. The monkey came back and in one swift move removed his dark glasses, jumped up to the same high spot, turned round the gasses, had a good look  cut it into 2 parts and sincerely gave one part back to the gentleman and threw the other part into the ocean. The glasses were destroyed forever.
     I shudder to think what would have happened if that fate had befallen my wife's glasses. In fact, my heart was beating in my mouth when the monkey was examining the glasses. It was a stroke of good luck that the unknown gentleman came along and helped us. My only regret was that we could not thank him properly.
     Need I say that we immediately proceeded to the airport without caring to watch the sunset. We proceeded to the airport in a taxi driven by Made Yasa who by then had become our friend. I made fun of my wife all along the way. We reached the airport, completed the security formalities and I found a newspaper and settled down to read it as there was time for departure. That is when  I realized that my gasses with the case were missing. Obviously, the monkey had taken it even without my knowledge! I am not too sure who had the last laugh - my wife or the monkey!

THE SWEET MEMORIES OF VISIT TO A MOVIE THEATRE

     The day on which all of us were taken to a movie in a theater was a big day. It was a family outing much looked forward to. It was a rare occasion and had its own special appeal. As a young boy maybe in the early primary school, I remember accompanying my dad to a classic - "Benhur". I was awed by the war scenes and the seriousness of the movie what if I understood nothing! The settings were great and I thought that the war scene was real!I also remember going to some Hindi movies with my mother and aunt. The dressed worn by the actress were displayed in the theater. I understood nothing of the hindi movies but felt very bad when almost every one cried in the theater! The movies I really enjoyed were the Kannda movies with Narasimha Raju a comedian playing some role usually with Raj Kumar. I was so fond of him that on a trip to Bangalore when my aunt, a doctor at Bowring Hospital asked me what I would like to visit most in Bangalore I replied "Of course, Narasimha Raju!" She politely told me she did not even know where he stayed and I tried to convince her that maybe he lived on the road they had just named after him! This was during my 7 th standard vacations. Any movie would begin with a "News Reel" a black and white depiction of news. One of the news surely would be about "Rashtrapathi Radhakrishnan". For some reason the black and white news played much faster than natural. I was really impressed by the 'speed' of the old polititians till I later understood that it is a technical problem!
     In the school they would rarely show us some excellent black and white movies. Usually they were about some scientific discoveries or about rockets, space travel etc. I would eagerly wait for that rare day. I still remember some scenes from those movies clearly. My beloved uncle would take us ( my cousin and myself) to some English movies at the New Chitra talkies. Usually they were spy movies. Enemy was always more intelligent than what the hero assumed him to be. However after all the action (usually mindless - ending in a large factory which produced God knows what) the hero always won convinsingly! This was during the high school, PUC and MBBS days. During the Post Graduation I would go to movies with my friend Gurudutt who was studying to be an Ophthalmologist. We would see an English movie on most Fridays. It would cost us Rs. 3.50 each for the balcony ticket (in the front portion). Reaching the theater from the hospital would cost less than a rupee. One packet of Masala ground nut and a cold drink each would be around Rs 2. So Rs. 10 in all saw us through a movie session. We walked home after the movie which was healthy and free.
     I just cannot come to terms with the present day scenario of going to a movie theater. Gone are the days of cheap tickets and simple eats. You are forced to take a huge packet of popcorn and a big coke. Some times one wonders whether people go there to eat or t watch the movie. Movies themselves are insipid. They are made by the people with questionable IQ s for people with even lower IQ s. Rarely we find gems among the muck. 100 crore club probably is another social club like Rotary or Lions nothing to do with the actual collections! However there are no superstars any more. No wonder people do not take the trouble of visiting movie theaters regularly. Any 3 Hindi movies seen in the course of 1 year will give you material and ideas sufficient for that year's releases. Once in a way however, a Lunch Box , a Dirty Movie, a Kahani will surface keeping the hope alive and faith intact. No wonder we hardly remember recent movies and never forget the movies like Lawrence of Arabia, Titanic, Inferno, and the like!