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Mamillo -thalamic tract and the fear of guillotine- Felix Vicq d’Azyr

Through the open window , looking towards the center of the city of Paris ,Felix Vicq d’Azyr could easily appreciate the reddish hue of the festive fire lighting up the evening sky . The festival of the supreme being was reaching the peak of frenzy. He felt a worsening of his breathlessness. Thousands of sandbags were on his chest.The white malady , tuberculosis ,was winning the final round of battle and he slowly slipped into delirium. There were pieces of dissected brain specimen , blurred faces of students – he was explaining a tract connecting the mamillary body to the thalamus – he could hear the boots of soldiers and loud thud of a guillotine .The French neuroscientist suddenly opened his eyes for one last time and then slipped back to eternal sleep.

5 years prior , the crowd of laborers and peasants were yelling their favorite war cry’ Liberte , egalite , fraternite [ liberty , equality, and fraternity] while the gates of Bastille came down. But never did they realize that it was not the end , but just the end of the beginning. What followed in France after that historic event on 14 July, 1789 was nothing short of utmost chaos . Rival factions of revolutionaries , royalists , militia with cross-border funding, revolting citizens , unleashed anti-socials – all those made France a cauldron of miseries , uncertainties, and sufferings .

Emerging from the whirlpool of civil unrest,was the fiercest of all -Maximillian Robespierre , the very man who coined the slogan’ liberty , equality and fraternity’. It is rather ironic that in the following years he never gave freedom of speech to his rivals, never considered anyone equal to him, and did not care for the lives of his fraternity. He had a busy time cornering all the loyalists and his rival revolutionaries . The guillotine worked round the clock and cobblestones of Concord square were always wet with blood. It’s said that the horses feared to tread into the square ,thanks to the disgusting smell of gallons of human blood shed in the name of revolution and reformation of society. And in a short span of one year, 17000  ‘enemies of the revolution ‘ were guillotined .

Waiting in dread for the sound of the boots of the revolutionary guards was the famous physician of the dethroned queen Marie Antoinette – Felix Vic day.He had a brilliant career as a teacher and physician and adorned the position of Perpetual secretary of French Royal Society of Medicine . Vicq d’Azyr had done original work in epidemiology and contagious diseases. What made him a scientist still remembered was his work on the brain.

With crude  instruments and without a microscope , he keenly observed that 1300 gm of jelly-like off white organ placed in spirit jar and draw figures about its convolutions or gyri. He was the one who made us aware of the Substantia Nigra [ the part affected in Parkinsonism] and demonstrated the path connecting the Mamillary body and Thalamus. This tract forms an important component of the much talked about Papez  circuit involved in our emotions and maintenance of memory.Many recognitions and accolades followed. And then came the most  important one-the title of the Royal Physician to the Queen.

It was a well-known fact that the Queen ,  Mary Antoinette was holding the reigns of the country and was more powerful than the King. Becoming the Royal physician gave undue powers to  Vicq d’ Azyr ; but , unfortunately, it was short-lived . The French Revolution led to a new order , even though there was nothing orderly about what ensued. Felix Vicq dAzyr did his best to support the the royal family and did not hesitate to publicly exhibit his faith in the monarchy; but he had a few supporters .All those who were connected with the royal house was viewed suspiciously  ,branded as counter-revolutionaries , arrested unreasonably and guillotined immediately without any trial.Vic D azyr survived the initial turmoil , his services were appreciated and he was given a post to determine the future of study of Anatomy .

The emergence of Robespierre as the absolute power in 1793 and the reign of terror which followed took its toll on Vic d’Azyrs health . His nights were interrupted with nightmares filled with the metallic thud of     guillotine and the sound of  musket shots. He became sick and was diagnosed with tuberculosis and lived in constant fear of death by guillotine .

 Meanwhile ,Robespierre was busy  establishing his power and ideology. He was against atheism and wanted to reinstate the fear of God  and immortality of the Soul.He successfully secured  official acceptance to his theory of Supreme being and organised a mega event -the first festival of the supreme being. He dressed himself up in plumes and was there in the forefront of all celebrations on 20  June 1794.The massive celebration fire that was  lit up reached the clouds . And on the same night ,  while the celebrations  were dying down, the final curtains fell on the life of Vicq d’Azyr . Probably it came as a great relief for the 46 year old French Physician, it was a coup de grace for a petit royalist who had his slot assured on the guillotine table.

The fate spared Felix vicq d’ Azyr a death by guillotine , but not  the one who used it to the maximum. One month later , on July 28 , 1794 when guillotine fell on Robespierre’s neck , he was just 36 yrs old and the revolution a mere five years.

And thanks to the mamillo-thalamic tract of Vicq d’Azyr ,all these events remain etched in our memory and constantly remind us that those who forget the history are condemned to repeat it.

  DR VT HARIDAS , NEUROLOGIST , MEDHA NEUROCLINIC , THRISSUR , KERALA, INDIA

Home-based care strategies amid COVID-19 Pandemic for Dementia Patients

Here are some tips to make it easier for Dementia patients and their caregivers

1 .Control of the infection

  • Stay at home to reduce the risk of infection
  • Keep home as a clean zone
  • Prevent visits from high-risk persons, for example, those with fever or who have had contact with COVID-19 cases
  • Have home-members self-sanitize (e.g., wash hands, change clothes, take a bath) and cleanse personal belongings (e.g., cell phones, handbags) upon returning home; clean the bags of delivered goods, etc.; leave footwear outside the house before entering home

2. Care for basic needs

  • Maintain home support in personal needs (e.g., bathing) or chores (e.g., preparing meals)
  • Nursing care (eg: wound dressing, changing of urinary catheters or feeding tubes) should be continued
  • HCP providing home care should be trained in infection control, wear appropriate PPE. and have regular COVID-19 testing
  • Make use of online services (e.g. grocery shopping, meals delivery)
  • For day care centres that remain open during the outbreak, advice on infection control measures during travels should be given to patients/caregivers or transports should be arranged for them to visit the centres; these centres should implement strict infection control measures

3. Calm down challenging behaviours

  • Ask trained HCPs to provide simple tips (e.g., identify potential triggers to avoid) to caregivers in handling behavioural problems, online training videos on management of behavioural problems
  • Get consultation via phone or videoconferencing if required
  • Video-record the challenging behaviours (e.g., using smartphone) and send it back toHCP for advice
  • Dial emergency health-care numbers for tackling more severe behavioural problems (e.g., any form of violent or suicidal behaviour)
  • Remember delirium/confusion may be a manifestation of COVID-19 among older people

4. Comprehensive cognitive enhancement

  • Replace previous outdoor routines with home-based activities, including maintaining simple exercises (eg, walking, stretching) or cognitive stimulating activities comprising reading, playing card games, or arts and crafts
  • Ask to arrange for videoconferencing with individuals or groups of people with dementia/caregivers for activities including exercises, recreational activities, educational talks
  • Ask to deliver cognitive and physical rehabilitation programs via videoconferencing which are tailored i according to patients’ disabilities (a.g., balance/gait training or stretching exercise for those with concurrent parkinsonism)
  • If outdoor walk/exercise is allowed, avoid crowded areas or maintain physical distancing

5. Managing medical and cognitive problems at home

  • Get educated to monitor simple vital signs like B.P., pulse, temperature, blood glucose, and/or oxygen saturation at home; B.P. monitoring may be particularly important in limiting further vascular contributions to dementia; oxygen saturation may detect desaturation due to pneumonia/COVID-19
  • Secure arrangement for medical doctors could make home visits if deemed necessary, but they need to follow infection control measures and put on proper PPE for home visits
  • Refill and be compliant to prescribed medications: get home delivery of medication if possible
  • Discuss in advance patients and caregivers wishes with respect to receiving life-sustaining treatment including hospitalization, resuscitation, and ventilatory support in the event of respiratory failure due to COVID-19

 

6. Self care for caregivers

  • Regularly screen for anxiety, stress and depression and prompt treatment when there is emerging/significant psychopathology
  • Have regular home-based exercise, recreational activities, and other ways to relieve stress (e.g., listening to music)
  • Ask the trained HCP (e.g., psychologists) to deliver/teach relaxation methods (e.g., mindfulness meditation) via videoconferencing
  • Discuss a contingency plan in caring for the patients in case the caregivers become sick

Doctor’s day once again — but , will there be a change?

My email and WhatsApp inbox had a tough day on July 1. It was more like a Mumbai Suburban train on Saturday evening –all colors, shapes, language, faces and slogans 

And everyone proclaimed the greatness of my profession, untiring services rendered, and the sacrifices made by my companions. This year Doctor’s day saw an unprecedented rise in the number of well-wishers for the doctors. Thanks to the sub-microscopic virus, the world has suddenly realized the relentless work of the healthcare workers ranging from hospital attenders, ambulance drivers,  nurses, and doctors. But, believe me, we have been doing it for the last few centuries. We used to face the same threats and challenges . If not Corona we had other villains like Nipah or Ebola, natural disasters, wars, famines . It may sound rather strange when I say that Covid has made no novel changes in a doctor’s life . We expose ourselves to the same level of risk, we are deprived of sleep and food as before.The only change being that the public has been made a bit more aware of a health care professionals plight. For the first time in my life a patient asked me last week whether I had my lunch. I replied negatively with a shake of my giddy head .And that giddiness was not due to my low sugar levels in the late afternoon but due to the sudden shock made by that question.

I am not sure how long the public will remember Doctor’s day. Maybe a week or a fortnight . And it will be back to square one- attacks on doctors, stories about doctors ”killing patients’ , hospitals looting patients . But dear friends, I can vouch that an average Indian doctor sleeps less than a Soldier, forgo his meals more frequently than any politician, says fewer lies than a lawyer, and breaks laws less than any Godmen!

And at he bottom of the inbox , there was an irrelevant bit of information – more than 600 doctors losing their lives to Covid in the last 2 months . Instead of sitting in the comfort of their cozy little room and watching Netflix movies,those sincere individuals were foolish enough to kill themselves by attending to needy patients.What again hurts me is the fact that many patients hide their symptoms of cough , body ache and fever when they visit me in the Outpatient clinic , knowing very well that they may be harboring Covid infection. Attending outpatient clinics is in fact more dangerous than working in a COVID care unit : because you do not know  about the infection status of the not-so-honest person sitting across the table . With a loose mask hanging well below his lower lip the smile of the patient turns out to be the mischievous giggle of Thanatos for many unfortunate doctors.

And the last one in the inbox was about a young intern in his early twenties succumbing to post Covid myocarditis.When his old school mates pursuing other careers in other fields , were enjoying an un expected holiday with their parents , this young man sacrificed his life for the sake of unknown patients . Will those patients remember this human being at least once in their dream ?Will they have the goodwill of meeting his devastated parents and siblings and say soothing words or place a white rose on his grave ?. If any one did so , it may be much more rewarding and reassuring for all the doctors around you than those colorful Doctors day messages.

Without a mask

Her request sounded very genuine and the tone was sincere even though It left me perplexed and surprised .This was the third visit of the 65 year old lady with troublesome positional vertigo. Fortunately , I could cure her with two repositioning maneuvers .I  suggested her to stop all medicines and declared she no longer needs any visit to my clinic .She stood up with folded hands in the traditional Indian Namasthe posture and said “ Doctor , this is probably my last visit and I still don’t know how you look like. Could you please take off your mask so that I would be able to recognize you if by any chance we meet again ?’

Blame it on that miniscule virus circulating every where on this blue planet, no patients see their doctors face. With a sharp rise in Covid 19 patients I have been covering up myself like a space traveler with PPE kit , mask , glasses, shield and gloves making sure that the virus as well as my patients will not see any part of my physical self. It has severely impaired my communication with the patient. Science says that the content of speech forms only a very small proportion 0f the message conveyed .A significant share is through the facial expressions , body language and your voice modulation .The multilayer filtering by mask , face shield and protective plexi-glass shield on my table{which reminds me of a bullet proof cover in the podium when PM speaks in open air] makes my voice feeble and monotonous. He/She is unable to read my facial expressions and the subtle postural changes I make to emphasize the point goes unnoticed. Gone are those days when I used to give the old Parkinsons patient a reassuring pat on the shoulder while seeing him off. The four year old girl mistook her ‘doctor uncle’ for an alien from the cartoon and was reluctant to sit down. Only the picture of the red little elephant I usually draw at the bottom of her prescription could convince her my identity.

I took off  my face shield and then my mask and glasses and put them on the tray and  felt like Stanley Ipkiss coming out of his mask. The comforting cold breeze probably made my smile more wider and genuine. ’Thank you , son!. May God bless you and your family”. For a moment I put away the ardent atheist in me and accepted her sincere blessings with a gentle bow. I  was busy grabbing a fresh pair of gloves and mask while she reached the door. What she said next with a mischievous smile on her lips made my day.” Mon njan vicharichathinnekkal sundaran anu tto “[Son , you are much more handsome than I guessed]. The very next thing I did was to put up this small poster on my table

WITHOUT A MASK—I LOOK LIKE THIS

An Approach to Children with Neurogenic Bladder Dysfunction

Urinary bladder has a complex innervations with somatic and sympathetic systems and carries out dual functions of storage and emptying of urine. At least 25% of the clinical problems seen in pediatric urology are the result of neurologic lesions that affect the lower urinary tract function. Our increasing understanding of the neurophysiology of bladder coupled with advances in urodynamic techniques specifically designed for infants and young children have provided more accurate assessment of pediatric lower urinary tract disorders.
Neural control of bladder—sphincter unit in children is age dependant and hence much more variable and complex than those of adults. Of the various classifications of bladder dysfunctions the one proposed by International Children’s Continence society in 1997 is well accepted.

Read full article (PDF)

Stroke

A stroke is a condition in which the brain cells suddenly die because of a lack of oxygen. This can be caused by an obstruction in the blood flow, or the rupture of an artery that feeds the brain. The patient may suddenly lose the ability to speak, there may be memory problems, or one side of the body can become paralyzed. Ischemic stroke accounts for about three-quarters of all strokes and occurs when a blood clot, or thrombus, forms that blocks blood flow to part of the brain. If a blood clot forms somewhere in the body and breaks off to become free-floating, it is called an embolus. This wandering clot may be carried through the bloodstream to the brain where it can cause ischemic stroke.

Multiple Sclerosis

Multiple sclerosis affects the brain and spinal cord. Early symptoms of multiple sclerosis include weakness, tingling, numbness, and blurred vision. Other possible warning signs are muscle stiffness, thinking problems, and urinary problems. A multiple sclerosis diagnosis is made by the history of symptoms and a neurological exam, often with the help of tests such as an MRI or a spinal tap. No one’s sure what causes multiple sclerosis, but it may be hereditary. There’s no cure for multiple sclerosis, but treatment can relieve worsening of symptoms.

Epilepsy

Epilepsy is a chronic disorder characterized by recurrent seizures, which may vary from a brief lapse of attention or muscle jerks, to severe and prolonged convulsions. The seizures are caused by sudden, usually brief, excessive electrical discharges in a group of brain cells (neurones). In most cases, epilepsy can be successfully treated with anti-epileptic drugs.

Chronic Headaches

Chronic headache, or chronic daily headache (CDH), is classified as experiencing fifteen or more days with a headache per month. It is estimated that chronic headaches affect “4% to 5% of the general population”.Chronic headaches consist of different sub-groups, primarily categorized as chronic tension-type headaches and chronic migraine headaches. The treatments for chronic headache are vast and varied. Medicinal and non-medicinal methods exist to help patients cope with chronic headache, because chronic headaches cannot be cured. Whether pharmacological or not, treatment plans are often created on an individual basis.