Friday, December 21, 2018
La Traviata & La Bohème: Illness & Morality
As I am heading to the performance of La Traviata at the Met, I will reprint an earlier blog.
As I am heading to the performance of La Traviata at the Met, I will reprint an earlier blog.
A reprint from Dec. 17 2013
La Traviata & La Bohème: Illness & Morality
In The Cockroach Catcher:
“It would not be a great surprise to anyone who has any inkling of the history of medicine that sooner or later any medical condition with an alleged aetiology of pure psychological origin will prove to have a non psychological cause. This is particularly true of those conditions classified by non-psychiatrists.
In the past, ignorance has led to belief that certain conditions are either punishment by god, visions of great religious significance or simply madness. Accordingly you might be burnt, become a saint or simply be given one of the psychiatric medications.”
Tuberculosis is one such condition that came to mind, more so as last Sunday we saw a production of La Traviata by one of opera’s grandest composers, Giuseppe Verdi.
In 1897, a young nun Thérèse Martin in a convent of Lisieux was dying of tuberculosis. She was essentially writing the equivalent of the modern day blog in the form of a diary. She was 24 then and had led an uneventful and sheltered life, taking the veil at only 15 and in contrast to most saints, she experienced and accomplished little. With her tuberculosis, her health deteriorated rapidly and she spent her last five years in the convent’s infirmary, continuing to diarise her innermost thoughts and emotions up until her death. The convent published her writings as an autobiography: Story of a Soul. After her death, many miracles were attributed to her intervention. In 1925, she became Saint Thérèse of the Child Jesus and of the Holy Face, and during World War II, Pope Pius XII proclaimed her co-patron saint of France, along with Joan of Arc.
Yet not long before the Industrial Revolution, in folklore, tuberculosis had been regarded as vampirism. As people with TB often had red, swollen eyes, pale skin and coughing blood, stories abounded that the afflicted could only replenish this loss of blood by sucking blood.
All of this changed in the nineteenth century – Mimi in La Bohème, Violetta in La Traviata (from Murger’s Scènes de la vie de Bohème, and Alexander Dumas’ novel La dame aux Camélias) and of course Hugo’s Fantine in Les Misérables. Tuberculosis became the preferred cause of death for a certain type of female character.
Verdi at 38 began an affair with a singer who was later to become his wife. Many viewed La Traviata as Verdi’s own way of testing public opinion. His new wife was luckier than Violetta.
Verdi of course was an opera revolutionary and in a letter to his friend Cesarino de Sanctis early in 1853, he wrote, “For Venice I am writing La Dame aux Camélias, a contemporary subject. Another composer might not want to do it perhaps because of the costumes, the period, and a thousand other awkward scruples … But I am doing it with total pleasure. Everybody screamed in horror when I suggested putting a hunchback on the stage. Well, I was happy to compose Rigoletto.”
He was not so lucky with Venice as they insisted on 1700 costume when Verdi wanted contemporary ones. In that production, Violetta was nowhere near consumptive although it might well be a reflection of sopranos of the time: big and fat.
Luckily for us, his threat to withdraw the opera completely was rescued by a second performance that fitted in with Verdi’s ideal and the opera world was blessed with one of the three most performed operas; La Boheme and Rigoletto being the other two. All three operas remain my favourites.
Carlos Kleiber’s Traviata starring Ileana Cotrubas and Placido Domingo has to be the all time best in my eyes (or more correctly to my ears), closely followed by Angela Gheorghiu’s amazing performance under Sir Georg Solti.
In 1993 we went to Boheme at the Met. A very beautiful and slim Mimi appeared and you could hear the silence in the audience as she started to sing. It was one of the best Boheme’s: Angela Gheorghiu’s debut at the Met.
Tuberculosis sells.
Opera in the end is still one of the best medium as Dumas is hardly known nor performed nowadays.
Friday, December 14, 2018
Learning from Nature: Chiton Brain & Eyes.
The Cockroach Catcher was on Cable Beach in Broome, Australia and found a creature he has never come across before and put the picture on Facebook. Luckily within a few minutes the answer came from his friend who generally knows most birds and plants. I raise my hat to him for knowing this: Chiton.
Then from
Chitons don’t have anything we’d generally consider to be heads, and it’s long been thought they don’t have brains, either, and instead sport a rudimentary, ladder-like nerve network. Sumner-Rooney and Sigwart argue in their paper that chitons aren’t really brainless, but rather have a brain that defies our expectations and understanding.
Most eyes in nature are made of organic molecules. In contrast, the Chiton’s eyes are inorganic and made of the same crystalline mineral called aragonite that also assembles the body armor. They enable the Chiton to perceive changes in light and thus to respond to approaching predators by tightening their grip to surfaces under water.
Using a suite of highly resolving microscopic and crystallographic techniques, the team unraveled the 3-dimensional architecture and geometry of the eyes, complete with an outer cornea, a lens and an underlying chamber that houses the photoreceptive cells necessary to feed focused images to the Chiton’s nervous system. Importantly, the researchers found that aragonite crystals in the lens are larger than in the shell and organized into more regular alignments that allow light to be gathered and bundled.
© 2018 Am Ang Zhang
I did some research and what I found was most interesting:
Chitons may be found mainly in the littoral surf zone. About 750 species of this primordial mollusc class are known today. The largest one is Cryptochiton stelleriwith 33 cm (about 14 in.), living on the American north western coast.
In colloquial language, chitons are also called coat-of-mail shells, their shell resembling the segmental armour on a knight's gauntlet, though, as we shall see later, the shell of a chiton is not segmented in the biological sense of the word.
Not only chitons' shells are hard. Chitons, like snails, possess a rasp tongue (radula), which they use to rasp food off the ground, if they are not among the few carnivorous species, such as Placiphorella rubra
Then from Oxford
Chitons don’t have anything we’d generally consider to be heads, and it’s long been thought they don’t have brains, either, and instead sport a rudimentary, ladder-like nerve network. Sumner-Rooney and Sigwart argue in their paper that chitons aren’t really brainless, but rather have a brain that defies our expectations and understanding.
Then from Harvard: Creating a new vision for multifunctional materials.
Most eyes in nature are made of organic molecules. In contrast, the Chiton’s eyes are inorganic and made of the same crystalline mineral called aragonite that also assembles the body armor. They enable the Chiton to perceive changes in light and thus to respond to approaching predators by tightening their grip to surfaces under water.
Using a suite of highly resolving microscopic and crystallographic techniques, the team unraveled the 3-dimensional architecture and geometry of the eyes, complete with an outer cornea, a lens and an underlying chamber that houses the photoreceptive cells necessary to feed focused images to the Chiton’s nervous system. Importantly, the researchers found that aragonite crystals in the lens are larger than in the shell and organized into more regular alignments that allow light to be gathered and bundled.
Thursday, October 25, 2018
Balicasag Island, Philippines.
Ideas without precedent are generally looked upon with disfavour.
and men are shocked if their conceptions of an orderly world are challenged.
Bretz, J Harlen 1928.
and men are shocked if their conceptions of an orderly world are challenged.
Bretz, J Harlen 1928.
We have always been led to believe that bleaching of the world's coral reefs is final proof of global warming. Not quite according to the NOAA:
When corals are stressed by changes in conditions such as temperature, light, or nutrients, they expel the symbiotic algae living in their tissues, causing them to turn completely white.
Warmer water temperatures can result in coral bleaching. When water is too warm, corals will expel the algae (zooxanthellae) living in their tissues causing the coral to turn completely white. This is called coral bleaching. When a coral bleaches, it is not dead. Corals can survive a bleaching event, but they are under more stress and are subject to mortality.
In 2005, the U.S. lost half of its coral reefs in the Caribbean in one year due to a massive bleaching event. The warm waters centered around the northern Antilles near the Virgin Islands and Puerto Rico expanded southward. Comparison of satellite data from the previous 20 years confirmed that thermal stress from the 2005 event was greater than the previous 20 years combined.
Not all bleaching events are due to warm water.
In January 2010, cold water temperatures in the Florida Keys caused a coral bleaching event that resulted in some coral death. Water temperatures dropped 12.06 degrees Fahrenheit lower than the typical temperatures observed at this time of year. Researchers will evaluate if this cold-stress event will make corals more susceptible to disease in the same way that warmer waters impact corals.
The Great Barrier Reef at 18.2871° S is hitting the news with much bleaching.
Tioman Island vs The Great Barrier Reef!
Tuesday, October 9, 2018
NHS : World Class Medicine without trying!
Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US Hong Kong or the rest of the commonwealth.
Why?
We provided World Class Medicine without trying. A quote from a fellow blogger, Dr. No.
Dr No said...
Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?
What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.
Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals.
Can we continue to practise World Class Medicine even if we wanted to?
Here is a reprint:
It is well known that we as doctors do not have all the answers and we can only base our diagnosis and treatment on current knowledge.
Patients or their relatives are used to trust the judgement of doctors and always hope for a better or even miraculous outcome. Their faith in their doctor is often supplemented by their own religious faith.
David Cameron is no different and he has stated so on record.
I am not here to analyse his faith.
I am here to re-tell one of the stories of hope and faith I have experienced as a very junior consultant in 1978
The Mayo of the
The year was 1978 and I was employed by one of the fourteen Regional Health Authorities. The perceived wisdom was to allow consultants freedom from Area and District control that may not be of benefit to the NHS as a whole so the local Area or District Health did not hold our contracts. Even for matters like Annual Leave and Study Leave we dealt directly with RHA.
Referrals were accepted from GPs and we could refer to other specialists within the Region or to the any of the major London Centres of excellence. Many of us were trained by some of these centres and we respected them. They were the Mayos and Clevelands and Hopkins of the United Kingdom
Money or funding never came into it and we truly had a most integrated service.
We used to practice real, good and economical medicine.
We used to practice real, good and economical medicine.
The unusual cases:
Child Psychiatry like many other disciplines in medicine does not follow rules and do not function like supermarkets. Supermarkets have very advanced systems to track customer demands and they can maximise profit and keep cost down. In medicine we do sometimes get unusual cases that would have been a nightmare for the supermarket trained managers.
As it is so difficult to plan for the unusual it will become even more difficult if the present government had its way (and there is every sign that they will), not only will the reformed NHS find it difficult to cope with the unusual, it will find it extremely difficult to cope with emergencies.
Supermarket:
Why? These cases cost money and in the new world of Supermarket Styled NHS, they have to be dealt with! For that reason, not all NHS hospitals will be failed by Monitor. Some will need to be kept in order that someone could then deal with unprofitable cases. They will be the new fall guys.
But supermarkets can get things wrong too. In Spain
©Am Ang Zhang 2010
Back to the patient:
Would my patient be dealt with in the same way in 2011?
GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.
Paediatrician to me: ? Psychosis or even Catatonia.
Seen same day and admitted to Paediatric Ward, DGH.
Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.
Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.
Radiologist (Hospital & no India
Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.
Patient unconscious and transferred to GOS on same day. Seen by various Professors.
Patient later transferred to Queen’s Square (National Hospital
Seen by more Professors.
Regained consciousness after 23 days.
Eventually transferred back to local Hospital.
None of the Doctor to Doctor decisions need to be referred to managers.
We did not have Admission Avoidance then.
How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.
The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.
Not to mention the operation etc. and the transfer to the Centres of excellence.
Just like Mayo Clinic:
“…….Mayo offers proof that when a like-minded group of doctors practice medicine to the very best of their ability—without worrying about the revenues they are bringing in for the hospital, the fees they are accumulating for themselves, or even whether the patient can pay—patients satisfaction is higher, physicians are happier, and the medical bills are lower.”
But it is probably too late:
…………Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.
Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.
A good doctor is one who is not afraid to ask for help but he must also know where to ask.
“Get me Great Ormond Street
“I already did.”
She is going to be a good doctor.
“Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”
Who needs consultants when juniors have that kind of network? This girl will do well.
“Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”
“Yes, you do and thanks a lot.”
I told mother that we were transferring her daughter to the best children’s hospital in England
“........Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.
"I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often."
David Cameron, if it was your plan not to have an integrated service, then there is not much we ordinary people could do except pray. If it was not your intention, then could you let us have an integrated service! That way you would not need many accountants and you will save money in doing so.
Pulse: GP consortium chairs are overwhelmingly opposed to any requirement to include hospital consultants on their boards, viewing it as a serious conflict of interest that would undermine the commissioning process, finds a Pulse survey.
King’s Fund: Million £ GP.
See also:
