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!