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Member since Jun-04-08 · Last seen Aug-01-14
Good Day to All! Ma-ayong adlaw sa tanan. And my thanks to for this excellent website. Salamat Opinions:

1. World Chess Championship

The true Chess World Champions are the holders of the Traditional Title that originated with Steinitz & passed on in faithful succession to Lasker, Capablanca, Alekhine, Euwe, Botvinnik, Smyslov, Tal, Petrosian, Spassky, Fischer, Karpov, Kasparov, Kramnik, Anand, and Carlsen. The sacredness of this Title is what makes it so valuable.

And how does one become the true Chess World Champion? In general, by beating the previous Titleholder one on one in a Match! Matches are preferred over Tournaments because of the Tradition of the WC Succession & because the chance for pre-arranging a Tournament result is more likely. The only exceptions to this rule:

A. In case where the Candidates and World Champion participate in an event that all the participants agree to be a World Championship event because of extraordinary circumstances.

Thus, the 1948 World Championship Tournament was justifiable because of the death of the Title holder Alekhine.

Likewise, the 2007 WC Tournament was justifiable under the extraordinary circumstances of the Chessworld trying to heal its internal rift over the 1993 Kasparov Schism. Anand himself became the World Champion in this 2007 Tournament & not in 2000 when he won a knock-out FIDE Tournament. Caveat: Some chess fans deem the 2007 WC Tournament as illegitimate, considering that Anand became the World Champion only in 2008, when he beat the previous Titleholder Kramnik in a WC match. From this perspective Anand only became the Undisputed World Champion in 2008.

Karpov lost his Title to Kasparov in 1985, & never regained it in the 1990s events that FIDE labeled as 'world championships'. All solely FIDE Champions that emerged outside WC Traditional Succession elaborated on above, strong as they were, were not true World Champions (eg., Bogolyubov 1928, Khalifman 1999, Ponomariov 2002, Kasimdzhanov 2004, Topalov 2005).//

B. In case the previous Titleholder defaults an event that the Chessworld largely deems as a World Championship event in the Tradition of the World Championship Succession. Thus, Karpov was the true successor to Fischer who defaulted their WC Match in 1975.

2. The strongest chess events in different eras of chess history?

Because of the brain's limitations explained below, the best professional (amateurs don't matter much in top level chess) chess players of each generation beginning in the Lasker era have always played at a similar level - near the maximum allowed by human standards. Now there are larger cohorts of chess professionals post WW2 than preWW2 thanks to government state funding in the Soviet era and presently corporate funding. The result is that large preWW2 tournaments had numerous 'bunnies', relatively weak players. By the Kasparov era, super-tournaments that featured most of the top ten, and no bunnies, had became more common. However, the top 4 or 5 since Lasker's time have always been very strong.

Consequently the smaller the top-player-only tournament, the stronger it gets. For any era. If there was a double round robin tournament in 1914 featuring Lasker, Capablanca, Alekhine, and Rubinstein, and no other, it would be as strong as any present day super-tournament.

Now weed out everyone except the two strongest players in the world. What we (usually) get is the chess World Championship match.

There has been talk of elite tournaments, composed only of the strongest top masters and no weaker bunnies replacing the World Championship match in prestige, probably because of the assumption that they would be the strongest chess events possible. False assumption. The strongest chess events in chess history generally have been World Championship matches. Even the strongest masters in each generation usually do not match the world champion and challenger in chess strength. In a World Championship match, the contestant has to meet the monster champion or challenger over and over again, with no weaker master in between. Capablanca vs Lasker 1921 was just as strong a chess event as the recent Carlsen vs Anand 2013, and far stronger than Zurich 2014. (Imagine having to play 14 straight games with a computer-like errorless Capablanca at his peak.)

3. The strongest chess players in chess history?

IMO the 1919 version of Capablanca & the 1971 version of Fischer, both of whom played practically error-free chess, are it; updated in opening theory, they should beat anyone in a match.

If computers were self-aware, I have no doubt that they would unanimously choose the 1916 to 1924 Capablanca as the strongest chess player in history. And please no red herring remark that Capa played only 'simple' chess. This young Capablanca played some of the most complicated, sharp, double edged, and bizarre positions possible; and played them without making a single losing error (and by all accounts with unsurpassed quickness), something that has always befuddled my mind when I got to peruse through his games.

We have to take this question in the context of the limits of the human Anatomy and Physiology. A concrete example would be the one hundred meter dash. The human body is designed such that the limit it can run is about 9 seconds. In order for a human being to run faster, we would have to redesign the human anatomy into that of say a cheetah. One can rev up the human Anatomy and Physiology, say with steroids, but this regimen would hit an eventual Stonewall too; the same way that we could rev up human proficiency to learn openings with computer assistance.

Since the Nervous System has physiological limits (example of a limit- neuronal action potential speed don't go up much more than 100 m/s) and so limits the human chess playing ability, increasing the number human chess players, thus expanding the normal curve of players, simply creates more possibilities of players playing like a Fischer in his prime, but will not create a mental superman who plays chess at computer levels. This explains why human and computer analysis indicate that Lasker was playing on a qualitatively similar level as more recent WCs.

'Worse' in chess, any computer assistance ends once the opening is over. After a computer-assisted opening prep, every GM today has to play the game the way Lasker did a hundred years ago, relying on himself alone, with the same fundamental chess rules and chess clock. An Encyclopedic opening repertoire is not a necessity to be a top player. In fact, there are World Champions who did not do deep opening prep; they just played quiet but sound openings that got them into playable middlegames and then beat their opponents in the midlegame or endgame. Just look at Capablanca, Spassky, Karpov, and now Carlsen.

Because of subconscious adherence to the narcissistic generation syndrome, the belief that everything that is the best can only exist in the here and now, many kibitzers would not agree to the above theses. While it is true that there have been more active chess professionals and consequently larger cohorts of top chess masters on a yearly basis since WW2 thanks to Soviet state funding and present corporate funding, the very top chess masters since Lasker's time have always played at a similar level- within the limits imposed by the human brain. There is no physical law that bars a pre-WW2 chess master from playing chess as well as today's generation. The human brain has not changed in any fundamental manner in the past tens of thousands of years.

4. The greatest chess players in history?

A related question is who is the greatest chess player in history. The answer depends on the criteria one uses. Since I place great emphasis on the ability to play world class chess for the longest period of time, Lasker would be it. He was playing at peak form from 1890 age 22 (when he began a remarkable run of match victories over Bird, Mieses, Blackburne, Showalter, and culminating in his two massacres of Steinitz) until 1925 at age 57 (when he nearly won Moscow after winning new York 1924). Kasparov (high plateau from 1980 to 2005) and Karpov (high plateau from 1972 to 1996) would follow. (At their very peak though, I believe that Kasparov was stronger than Karpov, and both were stronger than Lasker; and the peak Capablanca and Fischer were stronger than any of them.)

5. Computers vs Humans, who is stronger?

Another related question is how history's top masters would fare against computers. It's obvious from Kasparov's time that computers would totally crush them all. Opening knowledge would not matter much. Computers swamp human opponents in the middle game, simply by calculating more variations more rapidly by several orders of magnitude. Peak Capablanca probably would have the best score among humans. Talk about another level of playing is fans' subjective and IMO wrong words for their favorite players, unless one talks about chess computers. Chess computers do play at a higher level.

6. On the game and chess players young and old, past and present:

The proposition that an older player would not be able to adjust to the openings and methods of a younger generation is false, as evidenced by the observation of strong masters whose careers happened to span generations beating the tar out of weaker masters of the next generations. Lasker provides a classic example; he was beating Mieses, Blackburne, and Steinitz in the 1890s, and crushing masters versed in the hyper-modern teaching of controlling the center indirectly- Reti, Bogolyubov, and Euwe in the 1920s. In more recent times, we have Victor the Terrible, who learned most of his chess in the 1940s and 1950s, whom we have seen competing successfully with the so-called computer generation even at an advanced age.

The notion that computers are more advantageous to younger players IMO is not quite right. Younger players should have more energy and stamina in studying chess openings and endgames for long hours everyday compared to older players without computers, but the use of computers would tend to make the learning process easier for every one including the older ones.

As a corollary, computers also make it easier today for very young players in their early teens to peak at a younger age than in past eras, although they tend to level off in their early 20s to their high plateau, defined by their inborn talents and determination.

In brief. computers tend to level chess learning for everyone, young and old.

This is not a rigid rule. The best games I have ever seen played by a 12-13 year old are Capablanca's; and Tal, Karpov, and Kasparov reached their high plateau in their early 20s in a computer-less era, similar to computer age Carlsen. However let it be noted that Carlsen reached his peak sidestepping intensive computer-prepped tactical openings and beating his competitors in the old fashioned way in the middlegame and endgame. These masters peaked early not because of computers by because of their immense chess talent. Perhaps normal rules do not apply to these geniuses.

Another false notion is that the nature of the middlegame today is somehow different from the middlegame in the past. The easiest way to prove the wrongness of this proposition is by observing CG's daily puzzles. Do not peek at the names of the players that played these puzzles, and don't look at the dates. Can you glean from the middlegame play and combinations in the puzzles the date they were played? You can't. You would not know if it was played in 2014, 2000, 1950, or 1900. Chess combinations don't just suddenly change their stripes just because a hundred years have passed.

Another observation is that when the best masters of the past, Lasker and Capablanca met the occasional 'modern' structures of the Sicilian Scheveningen and Dragon, KID, Modern Benoni, Benko Gambit, they played strategically perfectly, in just the way these opening structures should be played. So how did these masters play openings and the resulting middlegame structures that are deemed incomprehensible to them by some of today's dogmatically 'modern' kibitzers? The answer is that chess rules and principles have not changed. Center, rapid development, open files and diagonals, holes, weak pawns, piece activity, initiative and attack, positional sacrifices and all types of combinations were as familiar to them as to us.

Instead, it is the frequencies of a few middlegame pawn structures have changed since WW2. Not the Ruy Lopez or QGD, but obviously Sicilians and KIDs are much more common post-WW2. Since so many games nowadays begin with the Sicilian and KID, people associate these with being 'modern' (which is a rather vague undefined term IMO). But certainly Lasker and Capablanca understood the middlegame principles behind them and when they did get these positions they played them excellently, like the top masters they are.

7. On ratings:

Elo ratings reflect relative and not absolute chess strength.

Chessplayers are naturally arranged in populations partitioned by geopolitical regions & time periods that have infrequent contacts with one another. Within such a population, players get to play each other more frequently, thus forming a quasi-equilibrium group wherein individual ratings would tend to equilibrate quickly; but not with outside groups. With caveats & in the proper context, FIDE/Elo ratings are simply fallible descriptors & predictors of an active player's near-past & near-future performances against other rated players, & only within the same quasi-equilibrium group.

As corollaries: the best way to evaluate a player's strength is to analyze his games & not his ratings; one cannot use ratings to accurately compare the quality of play of players from the past and present, or even the same player say a decade ago and today; & care should be taken in the use of ratings as a criterion in choosing which players to seed into the upper levels of the WC cycle. All the above often entail comparisons between players from different quasi-equilibrium groups separated by space and/or time.

Regarding inflation deniers, they imply that Elo ratings reflect absolute and not relative chess strength. Professor Elo himself would condemn their view. If the top 20 players were to suffer a serious brain injury and begin playing like patzers, but play no one else for the next decade, they would more or less retain their 2700s ratings, although they would be playing terrible patzerish chess.

8. Best Qualifiers?

The credible, fair, tried & tested Zonals - Interzonals - Candidates (with known strong players directly seeded into the Interzonals & Candidates; & here ratings may be used with caveats) over the random World Cup and the elitist Grand Prix. If possible long Candidate matches and 16 to 24 game World Championship matches. However, with the passing of the state-funded chess era of Soviet times, I begin to doubt if the strict money guzzling qualification process above can be re-installed.

9. The 1993 Chess Rift and Kramnik:

Regarding the Rift in the chessworld after Kasparov split in 1993, I believe that Kramnik has done more than any other individual in helping heal it by concrete actions - agreeing to a WC Match with Topalov in 2006 & not walking out when he could have done so with the support of most of the world's top GMs after getting accused of cheating; & agreeing to Defend his Title in a WC Tournament in 2007, the first time a living Titleholder has agreed to do so in chess history. My eternal gratitude to him.

10. Finances of a would-be Challenger:

Regarding all kinds of problems chessplayers outside of Europe & the USA face in their quest for the Title, Capablanca & Anand have proven it's possible for a non-European non-USA chessplayer to be World Champion; but apparently only if you have the chess talent of a Capablanca or Anand! For others, I guess they would have to try to get monetary support & good seconds somewhere to have some hope for a Title shot.

11. Ducking a World Championship re-match:

Alekhine vs. Capablanca - Not definitively resolved. If pushed, I would tend to favor Capablanca given that pre-WW 2, there was no definitive cycle to choose the Challenger &, after all is said and done, it was the Champion who set the conditions & who chose his Challenger. AAA could & should have chosen Capa; & there was ample time, more than a decade, to do so before WW2. On the other hand, Capa's pride may have caused him to behave arrogantly & thus offend AAA. The issue is very much debatable. //

Kramnik vs. Kasparov - For me, it's resolved. Kudos to Kramnik for trying his best to install a decent Qualifying Event. Kasparov for his reasons clearly did not want to go through the Qualifying Event that he himself had pledged before losing his Title; & did not even seem serious in playing the solely FIDE champions. Why? I can only speculate that Kasparov would rather retire than risk a loss in a Qualifier or a match to either a FIDE champion or to Kramnik. If he regained his Title, he would be the greatest Champion in history, but there was risk involved. If he retired, he would still be the greatest Champion in history, but there would be no risk involved. Kasparov chose the latter & no one should blame him for that decision; & more so don't blame Kramnik!

12. Predictions for Hypothetical World Championship Matches:

Lasker vs. Pillsbury, Rubinstein, Maroczy - Lasker wins 2, loses 1 match //

Lasker vs. Capablanca (inexperienced) 1914 - Lasker close win //

Capablanca (not overconfident & not having TIAs) 1929 to 1937 vs. Alekhine or any other master - Capa win //

Alekhine (sober & prepared) vs. Capablanca (w/ severe HPN & numerous past strokes), Botvinnik, Keres, Fine, Reshevsky, Flohr 1939 - Alekhine win //

Alekhine (alcoholic, ill, & depressed) vs. Botvinnik 1946 - Botvinnik win //

Fischer (inactive for 3 years) vs. Karpov 1975 - Karpov win//

Kasparov vs. Shirov 2000 - Kasparov win. (But GKK should still have given it to Shirov. And don't blame Kramnik. Had Kramnik declined, GKK would have chosen another; & Shirov would still be frustrated.)


I have opened a <'multi-experimental' forum> below. Its nature is that of several secret social and psychological experiments, whose objectives and parameters, and the rules that follow, are strictly defined and which I may or may not reveal. Readers of this forum might be able to deduce some of these rules. Accordingly messages shall be retained or removed with or without explanation, even those from my dear friends here in CG, although I am making it clear here that absolutely no offense is intended to any one in this experiment. I may or may not respond to certain questions and messages, also according to the rules. To my friends: Please bear with me in this matter. There can be a certain amount of disinformation and propaganda in the messages that are retained.

The title of this <'multi-experimental' forum> is:

Biased Journal of a Fourth World Brain Operator

Some abbreviations

CiH = the public City Hospital

PrvH = Private Hospital. There are three main ones. So PrvH 1, PrvH 2, PrvH 3.

ProvH = the public Provincial Hospital

SOL = Space Occupying Lesion

SQ = Subcutaneous tissue layer of the skin or scalp

CVA = Cerebrovascular accident = stroke

EDH = Epidural Hematoma, blood above the dura mater, the outer covering of the brain, and beneath the skull.

SDH = Subdural Hematoma, blood beneath the dura mater.

ASDH = Acute Subdural Hematoma, SDH incurred recently, usually less than a week

CSDH = Chronic Subdural Hematoma, SDH that is more than two weeks old

HCP = Hydrocephalus, too much CSF in the brain's ventricular system

CSF = Cerebrospinal Fluid

CNS = Central Nervous System

CAB = Continuous ambubagging

ETT = Endotracheal tube (for airway purposes)

NGT = Nasogastric tube (for feeding purposes)

NOD = Nurse on duty

The Oracle = personification of the CT (computed tomography) scan.

Magic mirror = the computer monitor where one can see CT scan images.

Witching Hour Admissions or Referrals = 12 midnight to 5am

MF = Motorcycle Fall

Craniectomy = neurosurgical procedure that involves removing a portion of the skull

Tracheostomy = a surgical procedure to create an opening through the neck into the trachea (windpipe)

Uneventful day = Most likely still a busy day, making daily rounds in the hospitals, following up post-op patients, seeing patients in the OPD, answering referrals, admitting all kinds of patients in the hospitals; nevertheless a day in which nothing interesting has caught my attention.

>> Click here to see visayanbraindoctor's game collections. Full Member

   visayanbraindoctor has kibitzed 6484 times to chessgames   [more...]
   Aug-01-14 Annie K. chessforum (replies)
visayanbraindoctor: <Ebola kills senior doctor at Liberia's largest hospital> <Ebola Kills Two Health Workers> A professional hazard. Doctors keep on getting pricked by needles and sliced by scalpels, ...
   Aug-01-14 visayanbraindoctor chessforum
visayanbraindoctor: 1 August 2014. Entry 1. In the morning I removed 60 cc of subdural hygroma on top of 71M's right cerebral hemisphere. He had been hit by a motorcycle. I am always nervous operating on anyone 70 and above. Very high mortality and morbidity rates. <29 July 2014. Entry 1.
   Aug-01-14 twinlark chessforum
visayanbraindoctor: Seems to me that steel production by direct electrolysis of iron oxide (in its molten from) has been demonstrated. It can commercialized but a necessary condition is a very cheap source of abundant electrical energy from a non CO2 producing source. The first thing that ...
   Jul-26-14 Botvinnik - Levenfish (1937)
visayanbraindoctor: Levenfish must have been 48 years old during this match. According to the account above, Botvinnik had already finished his dissertation, and I would assume he came to the match well prepared and motivated to reassert his supremacy among the Soviet players. His ...
   Jul-17-14 Kramnik vs D Baramidze, 2014
visayanbraindoctor: <Captain Hindsight: Better would have been <28.fxg7+ Kg8 29.Qf4! >> That's outright winning for White. It threatens both Q takes rook and Qh6. One has to think only three moves ahead. How can Kramnik miss that?
   Jul-12-14 Vladimir Kramnik (replies)
visayanbraindoctor: Kramnik was again unrecognizable in his game against Meier. There was nothing much tactical about the game; from a bad opening Kramnik emerged into a positionally lost middle game. He has been blundering pretty badly lately. But now it's as though even his positional ...
   Jul-06-14 Saemisch vs Nimzowitsch, 1925 (replies)
visayanbraindoctor: <perfidious: <visayan> Then came scarlet fever for Alekhine in 1943, and he was not at the same level thereafter; possibly Alekhine's age should have led to a decline in his play in any event, but he was decidedly not the same player.> I did not know he had a ...
   Jun-30-14 waustad chessforum (replies)
visayanbraindoctor: <waustad: Is he related to Andronico Yap who I met with Murray Chandler when they played in the World Junior Championship in Austria in 1977 or 78?> I don't think so. IM Andronico Yap (whom I have played in tournaments and whom I believe was one of the strongest ...
   Jun-30-14 Kasparov - Kramnik World Championship Match (2000) (replies)
visayanbraindoctor: <john barleycorn: <To some extent now I of course regret that I acted too nobly just trying to follow my principles> wow!!!> <RookFile: Tell that to Shirov.> GKK is the strongest player ever since the machine-like Fischer of 1969 - 1972, and IMO the most
   Jun-13-14 67th Russian Championship Higher League (2014) (replies)
visayanbraindoctor: 'The 9 round Swiss Open had a qualifying character for the Russian Superfinal 2014. GM Igor Lysyj, GM Vadim Zvjagintsev, GM Dmitry Jakovenko, GM Denis Khismatullin and GM Boris Grachev were the top five to earn spots in the prestigious Superfinal.' ...
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Premium Chessgames Member
  Annie K.: Thanks doc, I always learn something new from you. :)

According to your experience, could you say damage to which hemisphere will disrupt a surviving patient's life more?

Premium Chessgames Member
  visayanbraindoctor: <According to your experience, could you say damage to which hemisphere will disrupt a surviving patient's life more?>

The left.

The dominant hemisphere is usually the left. In it is located Broca's area (for speech) and Wernicke's area (for comprehension), and it controls the contralateral right side of the body. That's why most of us are right handed. Damage to the left hemisphere would cause difficulty in speech and comprehension; and weakness and numbness on our right side.

Premium Chessgames Member
  visayanbraindoctor: 23 July 2014. Entry 1. Uneventful day.
Premium Chessgames Member
  visayanbraindoctor: 24 July 2014. Entry 1. I returned the skull bones on two post-craniectomy patients today, 31M (ASDH first operated on a year ago) and 10M (EDH first operated on 6 months ago). In the case of 10M, his skull may have begun to partially grow back over the dura of his craniectomy site. In younger children, as long as the dura is intact, which it is in cases where I have removed an epidural hematoma without opening the dura, the underlying dura mater grows bone back thus naturally covering the defect; and I don't even have to replace the bone.
Premium Chessgames Member
  Annie K.: Thanks. :) What problems are associated with right hemisphere damage?

Do you remove the dura from the operation area too, like the skull piece, or is that returned to place after the operation, if possible?

Jul-24-14  Pulo y Gata: Hello Doc. A nasty and tragic affair, what happened to Dr. Cris Abbu. Do you know him?
Premium Chessgames Member
  visayanbraindoctor: <Pulo y Gata: Hello Doc. A nasty and tragic affair, what happened to Dr. Cris Abbu. Do you know him?> No, I don't know the doctor. I heard he is an Ortho. That his patient was depressed after he was was not able to regain the use of his legs after two spine operations. The depressed patient then shot him dead. That's tragic.
Premium Chessgames Member
  visayanbraindoctor: <Annie K.: Thanks. :) What problems are associated with right hemisphere damage?> Most common is contralateral left sided weakness and numbness.

<Do you remove the dura from the operation area too?>

Except for epidural hematomas in which the dura is intact, I usually open the dura with scalpel and scissors in order to evacuate subdural or intracerebral hematomas. Such cases are almost always accompanied by brain swelling, as the compressed and often ischemic underlying brain expands out. If so I technically don't close the dura by suturing, or it would compress the swelling brain. Instead I close the the dural defect over the swelling brain by covering it with periosteum or temporalis muscle.

Most Neurosurgeons here that I know cover the dural defect with absorbable hemostatic gel such as Gelfoam, but my old master hated this. He always ordered me close the dura with something organic so that I don't see any brain peeking out. I usually do so with periosteum. That's the covering of the skull; it's of the same connective tissue type as the dura. (The outer leaf of the dura mater is actually the interior perisoteum of the skull's inner table.) I just harvest the perisoteum from the adjacent still intact skull bones. In cases of large dural defects, my old master would make me harvest the fascia lata from the side of the thigh to graft onto the defect, but I would 'cheat' if he was not around, since opening the patient's thigh and harvesting the fascia lata prolongs the operation for an hour and gives the patient another wound on the thigh. Instead, I learned by my own to just flap the temporalis muscle to cover the dural defect if it's quite large.

After 'closing' the dura (covering it with periosteum or temporalis muscle and fascia), I close the galea aponeurotica by simple interrupted suturing in a 'reversed' manner with the knot inside. The galea is the tough fascia-like connective tissue part of the scalp. Then I close the skin, also by suturing, which is the old-fashioned way. The new fashion is to use clips. It's faster. But I prefer closing the skin by continuous interlocking suturing, as it ensures that it's water-tight and air-tight.

In effect, I 'close' the brain three times, the dura, the galea, and the skin. The brain was never meant to see the outside world other than via our senses.

Premium Chessgames Member
  visayanbraindoctor: 25 July 2014. Entry 1. Uneventful day.
Premium Chessgames Member
  Annie K.: Thank you Doc, fascinating accounts. :)

So other than the contralateral weakness, right side hemisphere isn't obviously associated with any cognitive or other mental damage?

This just got me very curious because according to the "pop science" understanding, the left hemisphere is supposed to be in charge of logic and reason, and the right hemisphere is associated more with emotion, creativity, and artistic leanings. Your detailing of left side damage issues fully fits in with that, and of course loss of ability to speak and impaired mental capacity are immediately obvious problems - whereas any loss of artistic tendencies probably wouldn't be nearly so obvious, and you are a doctor, not a psychology researcher. ;)

It would be interesting to try to observe any such issues - loss of emotional depth, or emotion disorders? Reported changes in creativity? - in survivors of right hemisphere damage. If you think back, over your impressions of patients you have met again later, does anything of the sort stand out?

Premium Chessgames Member
  dakgootje: Heyhey,

Just came back from a little vacation - so only saw your extensive response just now.

Many thanks doc! That clarifies <a lot> :)

I might write a more in depth response tomorrow - for some unknown reason I'm in a hurry to leave my laptop <again>. I used to have such a nice lackadaisical life.. :/

Premium Chessgames Member
  visayanbraindoctor: <Annie K.: loss of artistic tendencies, loss of emotional depth, or emotion disorders>

Unfortunately, I don't know as much about this phenomenon as a Psychiatrist would. Usually the family members themselves would complain to me of emotional changes, usually in my patients that have survived severe brain injury. I would advise them to see a Psychiatrist since I am inept in managing such cases. You might even know more than me about this topic if you have had background in Psychology.

<dakgootje> Just curious, were you into Neuroscience?

Premium Chessgames Member
  visayanbraindoctor: 26 July 2014. Entry 1. Uneventful day.
Premium Chessgames Member
  visayanbraindoctor: 27 July 2014. Entry 1. Strong winds. Must be another typhoon coming up.

So far every one I operated on this past week are alive and stable.

Jul-28-14  Pulo y Gata: Thanks, Doc.

Somehow the case reminds me of a doctor who some years back quickly suggested an operation for a bukol on my brother-in-law's waist, without further tests. I advised the patient to seek another opinion or additional tests but the patient, with the support of my in-laws, all fearing the worse and trusting the doctor, decided to go through the knife, just like that. Later the wound wouldn't heal and the doctor again suggested another work on it, again without improvement on the patient's "wound". My wife's family only then decided to consult with another doctor who traced it to some form of TB and prescribed meds that cured the disease (and the wound) in due time.

I'm not saying that what happened in Cebu is a case of incompetence or malpractice, but sometimes one can't help but wonder.

Premium Chessgames Member
  visayanbraindoctor: <Pulo y Gata> Just curious, are you Filipino? A Latin American?

<what happened in Cebu is a case of incompetence or malpractice, but sometimes one can't help but wonder.>

In cases wherein the patient can't walk because of lower extremity weakness (paraparesis), doctors often refer or have referred to Neurologists or Neurosurgeons for their opinions. I don't know about this case though.

When I was a resident, a schizophrenic patient that I was interviewing suddenly punched me in the face. I was totally surprised. We were calmly talking about his medical history, when bam! My glasses were flying off my nose and there was a red fat welt on my cheek. If he had a gun, it could have been much worse. Such things can happen like a freak accident.

Premium Chessgames Member
  visayanbraindoctor: 28 July 2014. Entry 1. Uneventful day.
Jul-28-14  Pulo y Gata: Doc, I am Filipino. Good day and thank you for your answers!
Premium Chessgames Member
  visayanbraindoctor: <Pulo y Gata: suggested an operation for a bukol on my brother-in-law's waist, without further tests. I advised the patient to seek another opinion or additional tests but the patient, with the support of my in-laws, all fearing the worse and trusting the doctor, decided to go through the knife, just like that. Later the wound wouldn't heal and the doctor again suggested another work on it, again without improvement on the patient's "wound". My wife's family only then decided to consult with another doctor who traced it to some form of TB and prescribed meds that cured the disease>

The first doctor was probably a surgeon; the second a GP or internist. Doctors tend to be biased for their specialty. In this case, the conservative approach turned out to be the right one. But not always. Sometimes a GP or internist procrastinates referring a patient to a surgeon when objectively the patient really needs an operation ASAP, and the patient dies after an attempt at conservative management. It's a case to case basis.

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  visayanbraindoctor: 29 July 2014. Entry 1. Unusual case of 63M; he fell off a coconut tree. Not because of the fall off a coconut tree, which often happens in the local setting, but because people over 60 usually don't climb coconut trees anymore. 60M came in comatose, with abdominal breathing, and severely aspirated. I intubated him, suctioning out lots of blood and vomitus from inside the trachea (windpipe), and when the wife managed to buy a tracheostomy tube 3 hours later, I did a tracheostomy. He probably has a cervical spinal cord injury. I ordered a CT scan of the head and cervical spine, but in any case, I doubt if he will survive the pneumonia-sepsis roller coaster ride.
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  visayanbraindoctor: 30 July 2014. Entry 1. I operated on 61F, removing a right basal ganglia hypertensive hemorrhage. The previous night, she had deteriorated in the ER of PrH1, but could not afford private rates. So I intubated her, and then transferred her to the public CiH.
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  visayanbraindoctor: 31 July 2014. Entry 1. A MF patient, 55M came in last night in PrvH1 ER. He had a bifrontal cerebral contusion, which in my assessment was non-operative. During the night he steadily deteriorated, lowered sensorium and productive cough. Next morning during my rounds, he was comatose, anisocoric, and showing signs of respiratory distress. I intubated him. His sensorium improved to the point were he again began exhibiting volitional movements. Unfortunately in the afternoon he pulled out his ETT, and slipped back into a coma. I reintubated him. No money for a craniectomy. The relatives will probably transfer him to the public CiH.
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  dakgootje: Finally had the time for a more in-depth read :)

<If the intracranial pressure is increasing significantly, there's hardly any other solution than to remove part of the skull.>

Makes sense, but I guess I thought someone had come up with a.. less crude solution. I'd be mortified to do drilling and sawing on someone's skull :|

<When I insert a tube into the frontal horn in a tube ventriculostomy operation, I can actually measure the intracranial pressure 'manually', in terms of centimeters water. I just watch CSF flow up the tube, and measure it's height from the external auditory meatus (your ear hole).>

Ah, sure, that makes sense. To go with your shoe-metaphor, I thought you'd have to measure CSF between brain and skull.. which seemed like very little room to work with and rife for errors. Yours seems like a much better method.

<Further on the topic of increased ICP> Thanks - that's very interesting - didn't know a CT-scan could be so useful for this!

<In general, if a patients is stuporous or comatose, I assume there is increased intracranial pressure.>

Simple as I am - I'm sticking with the shoe for a moment. Given time, I suppose my foot will slowly lose the swelling and become more or less normal sized.

On an equal note, is it possible to recover from ICP without intervention. For instance, a patient is comatose (but both uncusses are intact), there's no money for an operation - but over a slow process he awakes from his comatose situation?

<If you review some of my entries, you can note the urgency implied in my writings whenever I see a patient with one pupil dilating. >

Ha yup, I'd come across that! Useful info :)

<<dakgootje> Just curious, were you into Neuroscience?>

No and Yes.

Last year I finished my studies of psychology. In which I always loved the neuroscientific subjects. So I am "into it" insofar that I love the subject a lot and know a fair share for some random layman; but I'm not into neuroscience insofar that I don't actually do something with it.

With luck, I might get a job shortly about the Why and How of tinnitus - and with a double portion of luck [and a cherry], that might include a neuroscience part. But so far I haven't been able to count on my luck regarding jobs - so I'll probably purely stay a layman ;)

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  visayanbraindoctor: <dakgootje: is it possible to recover from ICP without intervention. For instance, a patient is comatose (but both uncusses are intact), there's no money for an operation - but over a slow process he awakes from his comatose situation?>

Yes. The brain contains about 75cc of CSF. If the brain swells, this compartment is the first one to shrink, as CSF is forced out of the skull and into the spine. If the brain stops swelling before this compartment is used up, then perhaps no operation would be needed. (Caveat: Sometimes even a slight increase in intracranial pressure for already brain injured patients results in a precipitous drop in sensorium, and in such cases, an operation may still be needed.)

If you have training as a Psychologist, you might be able to better answer some questions of <Annie> above. Psychology/ Psychiatry has always been a mystery to me, the field in Medicine of which I know the least. Regarding tinnitus, whenever a patient complaints of it, I always think of something wrong with CN VIII (vestibulocochlear), and order a CT scan to see if any tumor is compressing it.

I hope you get your hoped for job.

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  visayanbraindoctor: 1 August 2014. Entry 1. In the morning I removed 60 cc of subdural hygroma on top of 71M's right cerebral hemisphere. He had been hit by a motorcycle. I am always nervous operating on anyone 70 and above. Very high mortality and morbidity rates.

<29 July 2014. Entry 1. Unusual case of 63M; he fell off a coconut tree.> In the afternoon 63M died of pneumonia-sepsis.

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