On 11 August 1999 the patients on an orthopaedic ward in Cornwall were restless. An acute confusional state in an elderly postoperative patient is not uncommon, but what is unusual is when half the occupants of a 28 bed unit lose the plot within five minutes of each other. The first to become muddled, at 10 15 am, said he wanted his bedtime cocoa. Then a woman who had been sharp as a button an hour earlier started getting disoriented. I had seen her that morning, and she had been fine. So why was she now screaming about the war and hiding behind the bed? A patient who was progressing well with physiotherapy stopped midway through it and climbed under the covers into bed, another began to brush her teeth, and a third started rocking backwards and forwards in her chair.
The global confusion went as quickly as it arrived. Within half an hour everyone was back to normal. Examinations and investigations gave no clues to the cause of their cognitive impairment. There were no signs of infection or biochemical abnormality. No one had any new neurological signs, and the theory that all had experienced synchronised transient ischaemic attacks seemed unlikely.
The only explanation could be what was happening outside. I was standing on the hospital roof with colleagues witnessing a total solar eclipse. It was a strange experience, watching a band of darkness rapidly approach. Most eerie was the silence. As darkness took hold, the birds stopped singing and fell asleep. Dogs stopped barking, and cattle presented themselves to farmers expecting to be milked again.
I telephoned a nearby community hospital that was responsible for the rehabilitation of the elderly orthopaedic patients. Despite their experiencing similar lighting, only one of their inpatients had become transiently confused. It transpired that the ward had been participating in a week long celebration of the eclipse, culminating in a party that day. The patients had been looking forward to the eclipse, and the changes outside were anticipated.
Every house officer will be familiar with the term sundowning syndrome, when patients become more muddled as the evening draws in. This is a particular problem in patients with dementia, since their cognitive impairment impedes their ability to anticipate changes around them. Changes in a elderly patient's environment are a well recognised cause of confusion. It seems that, although the eclipse caused confusion in some patients, adequate forewarning and anticipation of environmental changes could prevent this. The next total solar eclipses will take place on 29 March 2006 in Africa and 1 August 2008 in Canada. I welcome sponsorship to travel to these places and test this important hypothesis.
We welcome articles up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. Please submit the article on http://submit.bmj.com Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.