Toronto, April 9, 2001

Sirs Eduardo Contreras, Carmen Hertz, Hugo Gutierrez, Juan Bustos, Boris Paredes, Hiram Villagra and Alfonso Insunza.

Santiago, Chile

 

Dear Sirs:

In accepting your request to comment on the medical and psychological situation of Mr. Augusto Pinochet Ugarte on the basis of the tests conducted in the Military Hospital of Chile, January 10-13, 2001, as well as a brief hospitalization after that date and subsequent appraisal of the patient’s state of health suggesting that the fingerprinting ordered by the court could negatively affect him, I present the following report.

My professional merit for offering my comments is based on my dual functions as neurologist and psychiatrist, for which I earned my professional degrees both in Chile and Canada, where I am a specialist in the treatment and research of dementia. As you know, I am a member of the "International Working Group", which evaluates procedures in the research of dementia in various countries upon request from the World Health Organization and the World Neurology Federation.

 

First:

Unlike what occurred in London with the same patient, during the three and a half days of tests the patient was subjected to standard medical-neurological tests and a series of physical, neurological, and mental examinations, as well as a battery of intense neuro-psychological tests. On that occasion the subject exhibited an interest, willingness, a cooperative spirit and physical strength beyond what I expected of a patient who had been described as suffering "severe diabetes, hypertension and afflicted by serious disturbances, from a severe diabetic neuropathy."

However, the most significant aspect of my examination was having detected a high degree of analytic capacity of situations unknown to him, in addition to a power to associate facts with the distant past, in the course of the tests conducted by eight examiners. His responses were exceptionally good and quite adequate for the occasion. By way of example and without committing a breach of confidentiality all patients deserve, it is important to recall his appropriate and incisive remarks related to the situation of the tests.

His remarks made reference to my participation as expert, as proposed by the plaintiffs, my family, and my origins in Iquique and references to the current mayor of that port city, who he called "Choro Soria".

In these statements, the patient showed judgment, reasoning and the ability to employ different forms of memory, quickly, and with great efficiency to establish temporary associations related to place, as well as mechanisms of long-term biographic memory.

Considering that this exercise was conducted with a person he did not know, and only by association with my fairly uncommon last name was able to make such a complex association on the first day of the tests, when we met for the first time in our lives. Undoubtedly, the patient’s cognitive functions were operating well. This initial impression was confirmed on the second day of tests. When he entered the room assisted by a cane and with great self-confidence, he commented this time on my resemblance to Spanish sociologist Joan Garces, who was advisor to President Salvador Allende and maintains good ties of friendship with Judge Garzon in Spain. On this occasion I asked him to explain what he meant by my supposed resemblance to Garces. He replied that the resemblance is not only physical — which might have been the case — but also, he explained very abstractly and aptly that the resemblance is in "belonging to the accusing party." Furthermore, in an important demonstration of handling attention span and projection in time, he added: "...and you as neurologist and psychiatrist, may contact me later if you need further explanation."

This exercise undoubtedly confirmed the efficiency of various types of memory, beyond the testing situation, and executive type abilities of judgment and very adequate memory. It is my view that these are practically normal for an 85-year-old male with his level of education.

 

Second:

All the results of the tests conducted during those days exhibited a vascular, subcortex dementia, as the lesions from millimetric strokes are located in areas under the brain cortex, therefore affecting activities related to movement, while not affecting superior brain functions such as memory, reasoning, judgment, etc.

The assessment of the patient suggests that the severity of the situation corresponds to a "slight dementia." However, due to the location of the micro-strokes, it would be more accurate to classify it as "slight to moderate."

As you know, this diagnosis was verbally accepted by all the examiners in Santiago on the date the tests were conducted, as certified by the document signed by the Judge and Court Secretary. It is curious that, as you also know, the final report prepared in Chile by the Director of the Medical Legal Service, Dr. America Gonzales and sent to me for my signature, changed the final conclusion to "moderate severity."

As was publicly known, not only did I disagree with that change in degree of severity — "they made the patient worse in less than two days." From a professional standpoint I believe they committed a serious technical error in discounting the report of the patient’s caregiver who was in daily contact with him for more than 10 days and was fully aware of his activities each day. This person indicated that the patient’s functions were very well intact. As an example, the caregiver’s report notes that the patient was perfectly capable of choosing the clothes to put on each day, could handle money, credit cards, his bank account, remember birthdays and give appropriate gifts to his grandchildren, among other activities.

I should note that the Medical Legal Service experts’ lack of familiarity with assessment procedures and universally accepted criteria used in diagnosis of dementia frankly surprised me. My astonishment increases in light of the fact that such criteria are widely used every day by Chilean academics. Evidence of this fact was the work presented by groups that study dementia at the Universities of Concepcion and Valparaiso at the most recent symposium on dementia organized by the University of Toronto last March.

On the other hand, in the discussion we had in January, those professionals argued that "there is only one kind of dementia", and that "there is only one memory and dementia can destroy it" and "if memory is lost, all types of memory are lost." These are concepts that were clarified by science at least twenty years ago, and are no longer employed by academics, not even historically. What is most serious is that the professionals failed to accept the opinion that the patient’s affliction, if adequately and medically controlled, can be and should be arrested.

 

Third:

In this particular case, medical conditions such as hypertension, diabetes, pacemaker, etc., are risk factors, especially as this is a geriatric patient.

However, all such conditions are controlled every day by any moderately equipped medical center, research and integration of various kinds of specialists in the geriatric field today. This is exceptionally important in vascular dementia, as these fall among the few cases of reversible dementia that may be corrected.

In other words, it does not have the progressive and irreversible characteristics common to neuro-degenerative conditions such as Alzheimer.

In today’s medical practice, these afflictions are neither lethal nor absolutely terminal. Nor must patients live in artificial situations far removed from everyday reality.

 

Fourth:

Regarding the patient’s emergency hospitalization in the Military Hospital last January 26, reports made known officially by the Hospital itself which should have presented the opinions of the doctors who treated the patient, reveal an interpretation that departs from reality or significantly ignores the pathology experienced by the patient.

One example is observed in the section that states the patient suffered "a severe headache", "a light and passing loss of consciousness", "a slight loss of strength on his left side." The next sentence suggests a "possible pre brain crisis isquemica transitory and possible pre brain stroke." I do not wish to enter into technical detail at this moment. But having maintained a patient of this age, with the medical infirmities he has, less than 24 hours under observation in a Hospital, knowing his history of subcortex strokes, and with the suspicion that he could suffer another transitory crisis, appears to be bad medical practice.

However, the information presented, and particularly the severe headaches and slight loss of conscious, suggests to me that these are not symptoms characteristic of a transitory crisis. Moreover, it is not clear how they were able to assess a sudden slight loss of strength in the patient’s left side. Two weeks earlier, when I examined him in the same hospital, he already had a marked weakness — nearly paralysis on that same left side — due to a subcortex lacunar stroke that everyone who examined him noted in the brain scan conducted January 11, in the Las Condes Clinic Radiology Department.

 

Fifth:

In direct response to one of your questions and taking into consideration all these factors, I draw the following conclusion from a medical point of view, in light of intellectual, cognitive and mental conditions, particularly the good spirits and physical conditions exhibited by the patient. This patient can be questioned by Judge Juan Guzman without risk to his health condition. The procedure would not place at risk his diabetes, hypertension, or transitory brain crisis if proper medical precautions are taken. Such precautions should not constitute any kind of obstacle in the patient’s daily life.

Suggestions that "trauma and psychic stress" or "oxilant deterioration" or that even taking his photograph or fingerprints might "affect psycho-physical conditions of the patient" are not compatible with current practice of metabolic and cognitive disturbances of the elderly.

Lastly, the statement recently made public suggesting that the late inception diabetes that affects the patient could alter mental and cognitive capacities is arbitrary and hardly scientific. It seems to me almost irresponsible that someone should suggest it, considering that the days we examined Mr. Pinochet the diabetes was under control despite long and tedious tests for hours and hours at a time.

Hoping to have answered your concerns, most sincerely,

Dr. Luis Fornazzari MD FRCPC.

Clinical Director of Neuropsychiatry
Department of Neurology and Psychiatry
University of Toronto Mental Health Center