A recent visit to this ''movie' has awakened my desire to write about my own experience as neurologist and it is no less entertaining, I think
It all started in 1954-55, my third year in MBBS. We had just started the clinical experiences, going to the wards/OPD (outpatient departments) in the hospital, knowing nothing of medicine. Two outpatient clinics were of interest that I remember, one: VOD (Venereal Outdoor) where we learned intravenous injections (Arsenic I.V. to the Syphilitic patients) and the MOD (Medical out door) where some days Parkinsonian patients were brought by their relatives with tremors and drooling of saliva from one angle of mouth or the other. We would give intramuscular injections (Hyoscine Hydrobromide) for relief of salivation.(they were also on Artane orally I would learn later) As (in pharmacology) we were told about anticholinergic (antimuscarinic) drugs. That was all treatment available for Parkinsonism. The Neurotransmitters knowledge was very basic at that time. I learned later about Parkinsonism problems.
Briefly there is deficiency of Dopamine (Loss of cells in Substantia Nigra in the brain, that produce it). Dopamine is formed from DOPA (Di HydroxyPhenyl Alanine) by the enzyme (dopa)decarboxylase. DOPA is formed from Tyrosine (Tyrosine hydroxylase) which is formed from Phenyl Alanine (hydoxylase).
In its turn Dopamine can be acted upon by Beta hydroxylase into NorEpinephrine which turns into Epinephrine (PEN-Methyl Transferase)
In other parts of the brain AcetylCholine (AC)is formed and it is there, that Cholinesterase enzyme works. Making it simple under normal circumstances there is a remarkable balance of these ( and other) neurotransmitters in the brain but from our point of view regarding Parkinson's syndrome it is our understanding that a strict balance exists between Dopamine and AcetylCholine to make smooth usual movements (muscular activity) of the body which gets disturbed in Parkinson's.
In Parkinson's, deficiency of Dopamine may result in overactivity of AC and the first drugs used for this disorder were anticholinergic drugs (see above) which will decrease the effects of AC.
Next medicines were those that increase Dopamine availability and that is where 'Awakenings' comes in.
I went to England (1961-2) where I tried, unsuccessfully, to get into Neurology training but saw a lot of Parkinson's patients but as I flew in to USA in 1969 I ended up first into a chronic sick hospital where there were lot of Parkinsonian (and other severely disabled) patients. Some Parkinsonian patients may be physically disabled to the extent of being bed-ridden but mentally they may or may not be as much affected. There I had one of my patient's complaint that she wrote (typed) over a period of 3 days in which she expressed quite eloquently her disgust of some visitors who talked in front of her in uncomplimentary terms thinking she was not understanding them. That had both amusing and teaching effects on me. Later I was to become more ethical in my practice. From 1969 to 1972 I rotated and also functioned as regular neurology resident in the university of Cincinnati hospitals. As you will recall from 'Awakenings' This was similar timing as of the doctor Sayer (Played strangely and wonderfully by Robin Williams) I also participated in Post surgery evaluations of Demented patients and evaluation of L-DOPA for various Parkinson's patients. I may relate one of the examples as I experienced the dramatic effects of this drug on these disabled patients who I was so familiar with from my long experience.
One fellow who was a BS as well as MA (well-educated) patient with advanced Parkinsonian Syndrome. Bed-ridden due to immobility with classical rigidity of muscles as well as marked Tremor. I would go with juniors and students into his room and as if the whole room was in tremor. He would be in his bed half propped up and I will declare Good morning Mr. So-and-so. Then we all observed in the next few seconds tremor reduction to almost nil and then his speech come out slurred with "good morning doctor". Anyway this was before he was started on L-DOPA and as he improved, started walking with help etc. and speaking better he was discharged home to the care of his wife. Later as I was to record the impressions of our patients who had been treated. Now problem was that he had lost some intelligence also. (This was pre-CT scan time)
So I asked his opinion, how effective this medication had been to you Mr. So-&-So.
He turns round to his wife and says
Honey has there been any beneficial effect of it?
Robert de Niro did a very convincing job of patient like other patients shown in the movie (with the usual exaggeration to enhance the desired effect on the audience)- but I thought de Niro would have been better as doctor and Robin better as patient but that is my opinion
Please visit my Urdu blog at خیالات و احساسات
In its turn Dopamine can be acted upon by Beta hydroxylase into NorEpinephrine which turns into Epinephrine (PEN-Methyl Transferase)
In other parts of the brain AcetylCholine (AC)is formed and it is there, that Cholinesterase enzyme works. Making it simple under normal circumstances there is a remarkable balance of these ( and other) neurotransmitters in the brain but from our point of view regarding Parkinson's syndrome it is our understanding that a strict balance exists between Dopamine and AcetylCholine to make smooth usual movements (muscular activity) of the body which gets disturbed in Parkinson's.
In Parkinson's, deficiency of Dopamine may result in overactivity of AC and the first drugs used for this disorder were anticholinergic drugs (see above) which will decrease the effects of AC.
Next medicines were those that increase Dopamine availability and that is where 'Awakenings' comes in.
I went to England (1961-2) where I tried, unsuccessfully, to get into Neurology training but saw a lot of Parkinson's patients but as I flew in to USA in 1969 I ended up first into a chronic sick hospital where there were lot of Parkinsonian (and other severely disabled) patients. Some Parkinsonian patients may be physically disabled to the extent of being bed-ridden but mentally they may or may not be as much affected. There I had one of my patient's complaint that she wrote (typed) over a period of 3 days in which she expressed quite eloquently her disgust of some visitors who talked in front of her in uncomplimentary terms thinking she was not understanding them. That had both amusing and teaching effects on me. Later I was to become more ethical in my practice. From 1969 to 1972 I rotated and also functioned as regular neurology resident in the university of Cincinnati hospitals. As you will recall from 'Awakenings' This was similar timing as of the doctor Sayer (Played strangely and wonderfully by Robin Williams) I also participated in Post surgery evaluations of Demented patients and evaluation of L-DOPA for various Parkinson's patients. I may relate one of the examples as I experienced the dramatic effects of this drug on these disabled patients who I was so familiar with from my long experience.
One fellow who was a BS as well as MA (well-educated) patient with advanced Parkinsonian Syndrome. Bed-ridden due to immobility with classical rigidity of muscles as well as marked Tremor. I would go with juniors and students into his room and as if the whole room was in tremor. He would be in his bed half propped up and I will declare Good morning Mr. So-and-so. Then we all observed in the next few seconds tremor reduction to almost nil and then his speech come out slurred with "good morning doctor". Anyway this was before he was started on L-DOPA and as he improved, started walking with help etc. and speaking better he was discharged home to the care of his wife. Later as I was to record the impressions of our patients who had been treated. Now problem was that he had lost some intelligence also. (This was pre-CT scan time)
So I asked his opinion, how effective this medication had been to you Mr. So-&-So.
He turns round to his wife and says
Honey has there been any beneficial effect of it?
Robert de Niro did a very convincing job of patient like other patients shown in the movie (with the usual exaggeration to enhance the desired effect on the audience)- but I thought de Niro would have been better as doctor and Robin better as patient but that is my opinion
Please visit my Urdu blog at خیالات و احساسات
1 comment:
That was some yrs ago I wrote this blog but recently my interest was aroused seeing "Freezing" of McConnel in his interviews(another sign/symptom of Parkinsonism) and I see he did not show any expression of embarrassment
Poor fellow, but it made prominent news for the media people
Post a Comment