Thursday, April 30, 2009

Lohengrin: Speech Disability, Design & Hypertension

The Cockroach Catcher and his wife were fortunate enough to have seen the controversial production by Robert Wilson at The Met in 1998.

Wagner Opera Website

“Out of the silence rises the shimmer of violins, ethereal yet alive with wonder, tracing a melody of sublime beauty. A soft bar of light ascends across a huge, empty stage, soon crossed by a hard, vertical light box that descends as the music grows richer and more complex, swelling to a rapturous climax before fading back into the stillness from which it arose.

“Characters with masklike faces dressed in sculptural sheaths stand in hieratic poses or glide slowly across the stage, sometimes seeming to float. An immense, blood-red mass – a stage curtain unfurled slowly but inexorably – pursues the cool shades of blue, white and gray in a stately wedding procession.

These are some of the images in Wagner’s opera Lohengrin, as staged by visionary director and artist Robert Wilson. Wilson’s Lohengrin returns to the Metropolitan Opera.” Marion Rosenberg writing for
Panache Privee.

It had the worst booing in Met’s history.

“At its opening night in 1998, Wilson’s Lohengrin earned one of the ugliest receptions in Met history. Playwright and critic Albert Innaurato wrote of ‘banshee shrieks of apparently homicidal intent aimed at the director,’ though lusty cheers greeted the production when the Met revived it the following season. Reached by phone in Baden-Baden, Germany, where he was rehearsing Verdi’s Aida, the soft-spoken Wilson sighed when asked to recall the Lohengrin premiere.

‘I think that, for the most part, we’re quite provincial in the United States. You’ve got some of the world’s greatest directors working right here in Europe, and their work is not known in the United States. By and large, the productions at the Met are still in the 19th century.’ Wilson’s method of taking the production’s visual book as his starting point was perceived as ‘very radical’ in New York, though he pointed out that his basic conceit – a frame that gradually shrinks to enclose Lohengrin and Elsa’s bridal chamber, then expands for the opera’s final, public scene – echoed Wagner’s original pen-and-ink sketches for Lohengrin.”

From the
Design Museum Website:
“Born in Waco, Texas in 1941, Robert Wilson struggled as a child to overcome a speech disability which he finally conquered in his late teens with the help of the dancer, Byrd Hoffman. After studying business administration at the University of Texas in Austin, he switched to architecture and in 1963 he enrolled on a course at Brooklyn’s Pratt Institute. During his time there, Wilson attended lectures by Sibyl Moholy-Nagy, widow of the Bauhaus designer, László, and studied painting with George McNeill at the American Center in Paris as well as working with learning disabled children back in New York.

Some well known architects and designers seem to have speech or other disabilities. I have often wondered if classifying these disabilities as handicaps is itself a hindrance to their development. Richard Rogers, the famous architect, was dismissed as stupid and sent to a school for backward children.

"Having graduated from Pratt, Wilson moved to Phoenix, Arizona to assist the visionary architect, Paolo Soleri. Increasingly he was drawn to the theatre, particularly to the experimental dance scene, which was flourishing in New York.”

The New York Times on the film Absolute Wilson: Austere, Enigmatic Innovator. And Charming Fellow, Really.

Listening to the Prelude to Act 1 of Lohengrin twice will give between 18 to 20 minutes of music for slow breathing that is good for lowering blood pressure and relaxation. Now you know.

Lohengrin opened in
London a few days ago and I plan to be there on the 8th of May.

Wilson’s own website.

Wagner website.

Synopsis: Lohengrin

Other arts posts:

Grand Rounds: Ausmed

Wednesday, April 29, 2009

Swine Flu: WHO Level 5 & The 1976 Vaccine Disaster.

Current level of influenza pandemic alert raised from phase 4 to 5

As WHO raised the alert form phase 4 to 5, just one short of the highest alert, it may be useful to look at the history of Influenza Pandemics and similar Pandemic Scares in recent times.

Let us jump first to 1976:

1976: Swine Flu Scare
When a novel virus was first identified at Fort Dix, it was labeled the "killer flu." Experts were extremely concerned because the virus was thought to be related to the Spanish flu virus of 1918. The concern that a major pandemic could sweep across the world led to a mass vaccination campaign in the United States. In fact, the virus--later named "swine flu"--never moved outside the Fort Dix area. Research on the virus later showed that if it had spread, it would probably have been much less deadly than the Spanish flu.

What is important about this scare was the CDC's reaction to it.

With the blessing of President Ford a vaccine was produced and used as advised by the CDC. The outbreak failed to turn into a pandemic - and the vaccine program turned into a major disaster. The shot was linked to 500 cases of Guillain-Barre syndrome, including at least 25 related deaths, while the swine flu killed only one of the 230 soldiers it sickened. The manufacturer were wise enough to get the government to agree to indemnify them against any claims of adverse reactions from the vaccine.

Perhaps the mask is not such a bad idea. It was effective during the
Hong Kong SARS Epidemic. It raises public awareness if not anything else as they tried to do in Mexico.

1918: Spanish Flu September 1918 to April 1919

The Spanish Influenza pandemic is the catastrophe against which all modern pandemics are measured. It is estimated that approximately 20 to 40 percent of the worldwide population became ill and that over 20 million people died.
One of the most unusual aspects of the Spanish flu was its ability to kill young adults. The reasons for this remain uncertain. With the Spanish flu, mortality rates were high among healthy adults as well as the usual high-risk groups. The attack rate and mortality was highest among adults 20 to 50 years old. The severity of that virus has not been seen again.

1957: Asian Flu

In February 1957, the Asian influenza pandemic was first identified in the Far East. Immunity to this strain was rare in people less than 65 years of age, and a pandemic was predicted. In preparation, vaccine production began in late May 1957, and health officials increased surveillance for flu outbreaks.
Unlike the virus that caused the 1918 pandemic, the 1957 pandemic virus was quickly identified, due to advances in scientific technology. Vaccine was available in limited supply by August 1957. Most influenza-and pneumonia-related deaths occurred between September 1957 and March 1958. The elderly had the highest rates of death.
By December 1957, the worst seemed to be over. However, during January and February 1958, there was another wave of illness among the elderly.

In Hong Kong, an urban myth that went round was the usefulness of mustard green, carrots and parsley and raw green olives and most markets could not keep up the supply.

1968: Hong Kong Flu

In early 1968, the Hong Kong influenza pandemic was first detected in Hong Kong. Deaths from this virus peaked in December 1968 and January 1969. Those over the age of 65 were most likely to die. The same virus returned in 1970 and 1972. The number of deaths between September 1968 and March 1969 for this pandemic was 33,800, making it the mildest pandemic in the 20th century.
Earlier infections by the Asian flu virus might have provided some immunity against the Hong Kong flu virus that may have helped to reduce the severity of illness during the Hong Kong pandemic. Second, instead of peaking in September or October, like pandemic influenza had in the previous two pandemics, this pandemic did not gain momentum until near the school holidays in December. Since children were at home and did not infect one another at school, the rate of influenza illness among schoolchildren and their families declined. Third, improved medical care and antibiotics that are more effective for secondary bacterial infections were available for those who became ill.

1977: Russian Flu Scare

In May 1977, influenza A/H1N1 viruses isolated in northern China, spread rapidly, and caused epidemic disease in children and young adults (<>

1997: Avian Flu Scare

The most recent pandemic "scares" occurred in 1997 and 1999. In 1997, at least a few hundred people became infected with the avian A/H5N1 flu virus in Hong Kong and 18 people were hospitalized. Six of the hospitalized persons died.

Full history
HERE. National Geographic
Fort Dix Vaccine Disaster
Statement by WHO Director-General Full coverage of swine influenza
Other Posts: Hong Kong: SARS and Swine Flu

EBM: Masks, Cathay Pacific Airline, SARS and Influenza A(H1N1)

Popular Posts:
Picasso and Tradition?
Teratoma: One Patient One Disease?
Teratoma: An Extract,
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
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House M.D. : 95% vs 5%

Sunday, April 26, 2009

Hong Kong: SARS and Swine Flu

Lights may go out in Hong Kong ©2009 Am Ang Zhang

From a chapter called Sars, Freedom and Knowledge in The Cockroach Catcher:
“In 2003 the world was in the grip of a new plague that challenged our knowledge of medicine to its limit.

For the first time, doctors and nurses who were normally in the forefront of the fight against diseases were fighting for survival from SARS (Severe Acute Respiratory Syndrome), a new and dangerously contagious disease. The alarm was first raised by its first victim, Carlo Urbani.”

In The New York Times today:

Hong Kong, Minding SARS, Announces Tough Measures in Response to Swine Flu
April 26, 2009
HONG KONG — Hong Kong, the epicenter of a SARS outbreak six years ago, announced some of the toughest measures anywhere on Sunday in response to a swine flu outbreak in Mexico and the United States.

Officials urged residents not to travel to Mexico, and they ordered the immediate detention at a hospital of anyone who arrived with a fever and symptoms of a respiratory illness after traveling in the previous seven days through a city with a laboratory-confirmed outbreak.

At least 20 cases have been confirmed in New York, Ohio, California, Kansas and Texas, according to the Centers for Disease Control and Prevention in Atlanta.
The new policy has the potential to dampen air travel across the Pacific. Hong Kong has Asia’s busiest airport hub for international travel, with Boeing 747s arriving around the clock from cities all over the United States and Canada, though not from Mexico.

Ever since the 2003 outbreak of SARS, or severe acute respiratory syndrome, Hong Kong has used infrared scanners to measure the facial temperatures of all arrivals at its airport and at its border crossings with mainland China.

Dr. Thomas Tsang, the controller of the Hong Kong government’s Center for Health Protection, said Sunday afternoon at a news conference that any traveler who had passed through a city with laboratory-confirmed cases and who arrived in Hong Kong with a fever and respiratory symptoms would be intercepted by officials and sent to a hospital to await testing.

Until that test is negative, we won’t allow him out,” he said.

Do not travel to Mexico unless it is absolutely necessary,” he said.

One legacy of SARS is that Hong Kong may now be better prepared for a flu pandemic than practically anywhere else in the world. Fearing that SARS might recur each winter, the city embarked on a building program to enlarge its capacity to isolate and treat those infected with communicable respiratory diseases.
The city has also expanded its flu research labs, already among the best in the world and leaders in tracking the H5N1 avian flu virus. The so-called bird flu virus, which kills an unusually high share of its victims, has periodically triggered fears over the past decade about a possible pandemic. It is different, though, from the H1N1 swine flu virus now causing illnesses in Mexico and the United States.

I know in Hong Kong, there is no such thing as over reaction. There is tourism, but there is also survival.

See also: ASIA ONE; CDC

Friday, April 24, 2009

House M.D.: Modern Tyranny

The Cockroach Catcher had the honour of being mentioned in DrRich’s Blog Post regarding my post: House M.D. : 95% vs 5%

DrRich looked at patient autonomy, beneficence, medical ethics and how in our modern “enlightened” society “tyranny” still manages to find its way into our governments. The following is my extract from his post.

The notion that the patient’s autonomy is and ought to be the predominant principle of medical ethics, of course, is entirely consistent with the Enlightenment ideal of individual rights. This ideal first developed in Europe nearly 500 years ago, but had trouble taking root there, and really only flowered when Europeans first came to America and had the opportunity to put it to work in an isolated location, where rigid social structures were not already in place. The development of this ideal culminated with America’s Declaration of Independence, in which our founders declared individual autonomy (life, liberty and the pursuit of happiness) to be an “inalienable” right granted by the Creator, and thus predating and taking precedence over any government created by mankind. And since that time the primacy of the individual in American culture has, more or less, remained our chief operating principle. Individual autonomy - or to put it in more familiar terms, individual freedom - is the foundational principle of our culture, and it is one that is perpetually worth fighting and dying to defend.

So the idea that the autonomy of the individual ought rightly to predominate when it comes to making medical decisions is simply a natural extension of the prime American ideal. Of course, most think, this ought to be the governing principle of medical ethics.

But unfortunately, it’s not that easy. There’s another principle of medical ethics that has an even longer history than that of autonomy - the principle of beneficence. Beneficence dictates that the physician must always act to maximize the benefit - and minimize the harm - to the patient. Beneficence recognizes that the physician is the holder of great and special knowledge that is not easily duplicated, and therefore has a special obligation to use that knowledge - always and without exception - to do what he knows is best for the patient. Dr. House is a proponent of the principle of beneficence (though he is caustic and abrasive about expressing it). DrRich believes House is popular at least partly because the benefits that can accrue to a patient through the principle of beneficence - that is, through medical paternalism - are plain for all to see.

Obviously the principles of beneficence and of individual autonomy will sometimes be in conflict. When two worthwhile and legitimate ethical principles are found to be in conflict, that is called an ethical dilemma. Ethical dilemmas are often resolved either by consensus or by force. In our case, this dilemma has been resolved (for now) by consensus. The world community has deemed individual autonomy to predominate over beneficence in making medical decisions.

DrRich’s point here is that Dr. House (the champion of beneficence) is not absolutely wrong. …….Perhaps, some (like House) would say that their autonomy ought not be their chief concern at such times. Indeed, one could argue that in a perfect world, where the doctor indeed has nearly perfect knowledge and a nearly perfect appreciation of what is best for the patient, beneficence should take precedence over autonomy.

It is instructive to consider how and why autonomy came to be declared, by universal consensus, the predominant principle of medical ethics. It happened after World War II, as a direct result of the Nuremberg Tribunal. During that Tribunal the trials against Nazi doctors revealed heinous behavior - generally involving medical “research” on Jewish prisoners - that exceeded all bounds of civilized activity. It became evident that under some circumstances (circumstances which under the Nazis were extreme but which were by no means unique in human history) individual patients could not rely on the beneficence of society, or the beneficence of the government, or the beneficence of their own doctors to protect them from abuse at the hands of authority. Thusly was the ethical precept which asks patients ultimately to rely on the beneficence of others starkly revealed to be wholly inadequate. The precept of individual autonomy, therefore, won by default.
…… Under duress, the Nuremberg Code admitted, societies (and their agents) often behave very badly, and ultimately only the individual himself can be relied upon to at least attempt to protect his or her own best interests.

When our founders made individual autonomy the organizing principle of a new nation, they were also making a negative statement. From their observation of human history (and anyone who doubts that our founders were intimately familiar with the great breadth of human history should re-read the Federalist Papers), they found that individuals could not rely on any earthly authority to protect them, their life and limb, or their individual prerogatives. Mankind had tried every variety of authority - kings, clergy, heroes and philosophers - and individuals were eventually trampled under by them all. For this reason our founders declared individual liberty to be the bedrock of our new culture - because everything else had been tried, and had failed. In the spirit of the enlightenment they agreed to try something new.
…… Autonomous individuals often fail - either because of inherent personal limitations, bad decisions, or bad luck.

Modern Tyranny:
Those of us who defend the principle of individual autonomy - and the economic system of capitalism that flows from it - all too often forget where it came from, and DrRich believes this is why it can be so difficult to defend it. We - and our founders - did not adopt it as the peak of all human thought, but for the very practical reason that ceding ultimate authority to any other entity, sooner or later, guarantees tyranny. This was true in 1776, and after observing the numerous experiments in socialism we have seen around the world over the past century, is even more true today.
More: Jobbing Doctor, NHS Blog Doc, Dr Rant, Ward 87, The Witchdoctor, Northern Doc, Dr Grumble.
Mid-Staffordshire: Media Media Media.
The full post here:
Why We Love Dr. House

New mention in Witch Doctor: End Stage Creep.
Other Posts:
Mid-Staffordshire: Media Media Media.
Mid-Staffordshire: Unbelievable! Unbelievable! Unbelievable!
Mid-Staffordshire: Where Are The Doctors?
House M.D. : 95% vs 5%
Humber Mental Health Teaching NHS Trust: Learning From The Past.

Not Just Cockroaches: Happy Face Spider

The Daily Telegraph: 22 Apr 2009

Darlyne Murawski

(Photo shot on assignment for, but not published in, "Deadly Silk: Spiderwebs," August 2001, National Geographic magazine)

"Found only on the islands of Oahu, Molokai, Maui, and Hawaii, the happy face spider, such as this one guarding its eggs on a leaf in Maui, is known for the unique patterns that decorate its pale abdomen. Scientists believe Theridion grallator may have developed its distinctive markings to discourage birds from eating it."

Other catches:
Hong Kong: Humpback Whale
The Crab Catcher
Cockroaches Hiroshima and Health Maintenance
It’s a Bird, a Reptile, a Mammal: It’s Platypus

Wednesday, April 22, 2009

Hong Kong Earthquake: PCCW.

No, this time the waves are caused by humans: they are the three judges of the appeal court in Hong Kong.
Forbes reported today:
Hong Kong court of appeal topples tycoon Richard Li's $2.1 billion buyout bid.
Richard Li Gets Denied On PCCW
Tina Wang April 22, 2009.

Hong Kong seen in better light ©2008 Am Ang Zhang

“In a stunning, and fittingly dramatic, fashion, Hong Kong's court has stymied tycoon Richard Li's tumultuous $2.1 billion bid to privatize telecom giant PCCW. The court of appeal sided Wednesday with Hong Kong's market regulator, which presented evidence of voter manipulation in the shareholder approval of the buyout.”

PCCW is Hong Kong's biggest fixed-line telecom operator.

“The three-member Hong Kong Court of Appeal overturned a lower court's ruling in favor of. ……Hong Kong's Securities and Futures Commission has accused Li of rigging a shareholder meeting by handing out shares to new investors so that they can participate in the shareholder vote on the buyout.”

“A plan by Li, who is the son of the world's 11th richest billionaire Li Ka-shing, to pay himself and Beijing-backed partner
China Netcom (now part of China Unicom ) up to $2.4 billion in cash dividends from PCCW once it was privatized was also plagued with controversy.”

Li Ka-shing is of course involved in the controversy of the naming of the first medical school in Hong Kong after he donated HK$1 billion.

Back to PCCW:
“Earlier this week, a judge on the appeal court, Anthony Rogers, called this scheme ‘outrageous.’ He also suggested that Li's buyout plan takes advantage of minority shareholders, who have been hurt by the dramatic fall in PCCW's share price, from over 120 Hong Kong dollars ($15.48) to over 2 Hong Kong dollars over most of the last decade.”

"A regulation intended to protect minority shareholders, Hong Kong law says a buyout can be approved if a majority of shareholders, regardless of how much stock they own, other than the buyout partners, vote in favour of the deal. Theoretically, majority investors seeking to privatize a company can split their shareholdings among new investors. Hong Kong regulators say that hundreds of insurance agents at Fortis' Hong Kong unit, once controlled by Li, were handed PCCW shares in exchange for votes. The court's decision may boost some momentum for reform of the market regulations that has been discussed for years.”

Mingpao, the influential local paper in its leader column stated that Hong Kong has become the biggest winner as it has demonstrated to the rest of the world that the rule of law, freedom of speech and expression in this little city of China outshone the rest of the world. And the regulator, Securities and Futures Commission, played its definitive role.

Hong Kong related posts:
House M.D. : 95% vs 5%
Hong Kong: Humpback Whale
Adoption Adoption Adoption
Che Kung Temple (chē gōng miào) and the Power of Prayer
SARS and Quorum Sensing

Monday, April 20, 2009

Teochiu Recipe: Caramelised Taro, Pumpkin and Sweet Potato

From The Cockroach Catcher

“……During Chinese festivals there was always much sharing of food, and that was traditional style Teochiu food that I have come to miss……”
Teochiu is the ancestral home of the Cockroach Catcher. Outside China, Teochiu cuisine may not be as well known as Cantonese, Shanghai, or Peking cuisine. However it is no less tasty. I am of course totally biased. To celebrate New Year Day, my wife made Teochiu Braised Goose.

Recently I met a Teochiu friend who happens to be a master cook of traditional regional dishes and he kindly cooked for me this one, which certainly brought back sweet memories.

Teochiu caramelized taro, pumpkin and sweet potato:

©2009 Am Ang Zhang

In many countries now you can get taro, pumpkin and sweet potato. It may be confusing as in some places taro is called yam and in others sweet potato is known as yam, and so I have avoided that name altogether.

It is a simple enough dish. Cut up the two different root vegetables and the pumpkin into chunky cubes (inch to inch and a half). Fry them in a wok with your oil or fat of choice. For authenticity that should really be goose fat. The biggest secret is the use of chopped spring onion and a light sprinkling of sugar. If you are watching the sugar you can skip that, I suppose. A little water may have to be added depending on the heat you use. The dish is ready when the vegetables are cooked and caramelized.

©2009 Am Ang Zhang
This dish goes really well with cilantro crusted barbecue leg of lamb. You will find the cilantro a refreshing change from the traditional rosemary and more delicate. This fresh herb is used widely in Teochiu cooking but the cilantro barbecue lamb is a Cockroach Catcher invention. To prepare the leg of lamb for barbeque, first rub with salt, and then insert six to eight whole garlic cloves into the meat after making pockets at random intervals with a sharp pointed knife. The paste for the crust is a simple enough affair. Just mix your favourite mustard with pepper and cilantro. Then spread the paste all over the joint. Preheat the kettle barbeque (or barbeque with lid). For a five pound leg, barbecue (indirect heat of at least 450°F) for about two hours for rare, and add another half hour for medium rare. Do not put the joint directly over the charcoal (preferred by the Cockroach Catcher) or gas source.

For a wine to accompany the lamb, my choice right now happens to be: a second wine of Château Prieuré Lichine (4th Growth), Château de Clairefont 2005. The vineyard is located next to Château Brane-Cantenac and Château Palmer. It is a great value wine and is ready to drink now whereas the first wine still needs some bottle years. The vineyard was bought by Alexis Lichine in 1951 for £8000, and sold in 1999 by his son for a handsome sum of $28.5 million. Granted there were additions to the original vineyard, but it was a good story.

What about greens, you might ask. Chinese broccoli briskly braised in good home made chicken stock will do the trick.

Wine posts:
Global Warming: Wine
Bottled Water for Dogs and Birds
Wine, Media and The Mind
The Cockroach Catcher and Pompano
Pleasure Principle and Wine

Teochiu posts:

Chinese New Year and the Goose

Antioxidants and cooking

Teochiu cookery site here.

Grand Rounds: Six Until Me a well known diabetes blog by Kerri

Popular Posts:
Picasso and Tradition?
Teratoma: One Patient One Disease?
Teratoma: An Extract,
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
House M.D.: Modern Tyranny
House M.D. : 95% vs 5%

Friday, April 17, 2009

The Dark Side: Il Trovatore

Another Baby Murdered: Mother threw own baby in fire

“A mother stole a baby from a wealthy family. She proceeded to throw her own baby into a fire and bring up the baby from the wealthy family as her own.”

That was not another Social Services blunder.

That was at the Royal Opera House on the
13th of April 2009.

Verdi’s Il Trovatore is probably well known to most for its Anvil Chorus. For me it is about The Dark Side, the dark side of human nature.

“My hunch is that despite media coverage many of us still fail to grasp the dark side – the dark side of human nature. Until we do, we shall continue to read about child abuse, abductions and murders of the worst kind.” From The Cockroach Catcher.

Much has been written about training others to do the doctor’s work in an attempt to save health cost. What is not covered is the fact that there is training and there is a broader aspect of education. The ability to transmit culture external to genetic coding is what distinguishes Homo sapiens from other animal species on Planet Earth. Many bloggers are well educated in this cultural respect either by design, by choice or by accident. There is now an uncomfortable feeling of de-education in the Brave New World. Will the next generation of doctors, nurses and bloggers be as cultured? I do wonder!

In Il Trovatore, Azucena is the mother who killed her own baby and Manrico was brought up by her. Manrico is the brother of Count Di Luna that burnt Azucena’s mother for being a witch. Azucena had to avenge her mother’s death. How much hate can you hold. She had to throw her own child in the fire, bring up Manrico so that he would one day be killed by his own brother! Unbelievable! The full synopsis here.

Well, that roughly is it, Il Trovatore and the dark side. One of Verdi's best!

London debut: US soprano Sondra Radvanovsky in Il Trovatore

The Royal Opera House. Il Trovatore: unitl May 7, 2009.

Thursday, April 16, 2009

Mid-Staffordshire? Not Just Mid-Staffordshire!

In The Belfast Telegraph:
Tuesday, 7 April 2009
Tragedy of patient who froze to death

“A confused patient froze to death just hours after wandering out of a hospital in his slippers, an inquest has heard.
“Alcoholic William Scott (51) fled the accident and emergency department and disappeared into undergrowth on the perimeter of Lagan Valley Hospital. Police were not informed by staff.
“Coroner Brian Sherrard said steps had been taken to try and prevent a repeat of the March 2005 tragedy in Lisburn, Co Down. ‘There definitely has been a breakdown in communication at some stage,’ he said.
“He said staff at the hospital had been searching for Mr Scott, who was admitted to the hospital on March 12 suffering from alcohol-related seizures, after he went missing from his cubicle the following bitterly cold day. He was agitated and confused.
“His family had to tell police of the disappearance themselves two hours later.
“The victim, from Warren Park, Lisburn, was found dead on March 31 from hypothermia on a steep swampy bank close to the ambulance station and the Lagan River towpath.”

Not that long ago the Healthcare Commission reported on the high death rate in a Hospital Trust in England: The Mid-Staffordshire NHS Trust.

The Independent headline:Patients die in 'third-world' hospital
17 March 2009“Between 400 and 1,200 more people died than would have been expected in a three-year period, the head of the investigation for the Healthcare Commission said.
“Families have described ‘Third World’ conditions at the trust, with some patients drinking water from vases because they were so thirsty and others screaming in pain.
“The Commission launched an inquiry after concerns were raised about higher than normal death rates in emergency care, in particular at Stafford Hospital.
"It was like a Third-World country hospital. It was an absolute disgrace."

Perhaps the Health Secretary should go and look at the Third World hospitals, they may not indeed be as bad. They really do not have ridiculous targets and despite poor financing the doctors and nurses do the best they can. Also in the Third World, there would be riots if things like this happened.

Later in The Sunday Telegraph:
Ten NHS trusts have worse death rates than 'shocking' Mid Staffordshire
29 Mar 2009

“Ten health trusts have worse death rates than the hospital where at least 400 patients died needlessly because of ‘shocking and appalling’ standards of care, the Sunday Telegraph can reveal.”

You won’t believe this:
“Since the data was prepared, Swindon and Marlborough has been renamed Great Western Hospitals NHS Foundation Trust and Bolton Hospital has been renamed Royal Bolton Hospital NHS Foundation Trust.”

Rebranding still cost money in logo and headed papers, money that could be spent on direct patient care. It used to be that criminals change their names after release from prison like this medical student in
Sweden after serving his sentence for murder.

I suppose killing patients is a form of murder.

In the meantime Healthcare Commission has also been rebranded and is now called Care Quality Commission (CQC) and is headed by none other than Cynthia Bowers who used to be head at The West Midlands Strategic Health Authority (SHA) that oversee The Mid-Staffordshire NHS Trust. The best known medical blog NHS Blog Doctor in England had a good post. Read about it
here. Do you think Cynthia might want to change her name too! Jobbing Doctor hade a go too: read about it here.
In England they do not just reward bankers and insurers.

Notable posts:
The Witchdoctor: Yo-Yo Management - The Staffordshire Story
NHS Blog Doctor: How to complain about the NHS; Cynthia Bower : April Fool NHS Blog Doc
The Jobbing Doctor: Stafford - unearthing the reasons; More nonsense
Dr Rant: Central Credit: Local Blame
Dr Grumble: Mid Staffs Investigation
Ward 87: A Big Thankyou to Private Eye
My other posts:Mid-Staffordshire: Media Media Media.
Mid-Staffordshire: Unbelievable! Unbelievable! Unbelievable!
Mid-Staffordshire: Where Are The Doctors?
House M.D. : 95% vs 5%
House M.D.: Modern Tyranny
Humber Mental Health Teaching NHS Trust: Learning From The Past.

Wednesday, April 15, 2009

Autism: Leo Kanner--- A Discussion

The following is an abstract taken form the DISCUSSION SECTION of Kanner's original paper. It may be useful to have another look at what Kanner observed all those years ago. Fortunately for us, he had no other motive except for his keen medical curiosity and observational power:

......The outstanding, "pathognomonic," fundamental disorder is the children's inability to relate themselves in the ordinary way to people and situations from the beginning of life. Their parents referred to them as having always been:

“self-sufficient"; "like in a shell"; "happiest when left alone"; "acting as if people weren't there"; "perfectly oblivious to everything about him"; "giving the impression of silent wisdom"; "failing to develop the usual amount of social awareness" ; "acting almost as if hypnotized."

It is therefore highly significant that almost all mothers of our patients recalled their astonishment at the children's failure to assume at any time an anticipatory posture preparatory to being picked up.

Eight of the eleven children acquired the ability to speak either at the usual age/or after some delay. Three (Richard, Herbert, Virginia) have so far remained "mute." In none of the eight "speaking" children has language over a period of years served to convey meaning to others.

Almost all the parents reported, usually with much pride, that the children had learned at an early age to repeat an inordinate number of nursery rhymes, prayers, lists of animals, the roster of presidents, the alphabet forward and backward, even foreign-language (French) lullabies.

Thus, from the start, language—which the children did not use for the purpose of communication—was deflected in a considerable measure to a self-sufficient, semantically and conversationally valueless or grossly distorted memory exercise.

It is difficult to know for certain whether the stuffing as such has contributed essentially to the course of the psychopathological condition. But it is also difficult to imagine that it did not cut deeply into the development of language as a tool for receiving and imparting meaningful messages.

"Yes" is a concept that it takes the children many years to acquire. They are incapable of using it as a general symbol of assent.

The same type of literalness exists also with regard to prepositions. Apparently the meaning of a word becomes inflexible and cannot be used with any but the originally acquired connotation.

Personal pronouns are repeated just as heard, with no change to suit the altered situation.

The repetition "Are you ready for your dessert?" means that the child is ready for his dessert.

The pronominal fixation remains until about the sixth year of life, when the child gradually learns to speak of himself in the first person, and of the individual addressed in the second person. In the transitional period, he sometimes still reverts to the earlier form or at times refers to himself in the third person.

Our patients, reversely, anxious to keep the outside world away, indicated this by the refusal of food. One child had to be tube-fed until 1 year of age. Most of them, after an unsuccessful struggle, constantly interfered with, finally gave up the struggle and of a sudden began eating satisfactorily.

Another intrusion comes from loud noises and moving objects, which are therefore reacted to with horror. Yet it is not the noise or motion itself that is dreaded. The disturbance comes from the noise or motion that intrudes itself, or threatens to intrude itself, upon the child's aloneness.

The child himself can happily make as great a noise as any that he dreads and move objects about to his heart's desire.

There is a marked limitation in the variety of his spontaneous activities. The child's behavior is governed by an anxiously obsessive desire for the maintenance of sameness that nobody but the child himself may disrupt on rare occasions.

Changes of routine, of furniture arrangement, of a pattern, of the order in which everyday acts are carried out, can drive him to despair.

Once blocks, beads, sticks have been put together in a certain way, they are always regrouped in exactly the same way, even though there was no definite design. After the lapse of several days, a multitude of blocks could be rearranged in precisely the same unorganized pattern, with the same color of each block turned up, with each picture or letter on the upper surface of each block facing in the same direction as before.

This insistence on sameness led several of the children to become greatly disturbed upon the sight of-anything broken or incomplete.

A great part of the day was spent in demanding not only the sameness of the wording of a request but also the sameness of the sequence of events.

It was impossible to return from a walk without having covered the same ground as had been covered before.

Objects that do not change their appearance and position, that retain their sameness and never threaten to interfere with the child's aloneness, are readily accepted by the autistic child.

Two patients began in the second year of life to spin everything that could be possibly spun.

The children sensed and exercised the same power over their own bodies by rolling and other rhythmic movements.

Every one of the children, upon entering the doctor’s office, immediately went after blocks, toys, or other objects, without paying the least attention to the persons present.

The father or mother or both may have been away for an hour or a month; at their homecoming, there is no indication that the child has been even aware of their absence.

After many outbursts of frustration, he gradually and reluctantly learns to compromise when he finds no way out, obeys certain orders, complies in matters of daily routine, but always strictly insists on the observance of his rituals.

There is a far better relationship with pictures of people than with people themselves. Pictures, after all, cannot interfere.

The astounding vocabulary of the speaking children, the excellent memory for events of several years before, the phenomenal rote memory for poems and names, and the precise recollection of complex patterns and sequences, bespeak good intelligence in the sense in which this word commonly used.

They all come of highly intelligent families. All but three of the families are represented either in Who's Who in America or in American Men of Science, or in both.

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Autism: Leo Kanner
Autism: Somalis in Minnesota and Sunshine
Autism: Gene Disruption?
Autism, the Brain and Tiger Woods
Autism and Money

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Tuesday, April 14, 2009

Autism: Leo Kanner

“In 1943 Leo Kanner published a paper that would, with Asperger’s work a year later, form the basis of present day understanding of Autistic Spectrum Disorder. He considered five features to be diagnostic. These were: a profound lack of affective contact with other people; an anxiously obsessive desire for the preservation of sameness in the child's routines and environment; a fascination for objects, which are handled with skill in fine motor movements; mutism or a kind of language that does not seem intended for inter-personal communication; good cognitive potential shown in feats of memory or skills on performance tests, especially the Séguin form board . He also emphasized onset from birth or before 30 months.” From the book, The Cockroach Catcher.

A case extract from his original paper:

Donald T. was first seen in October, 1938, at the age of 5 years, 1 month. "Eating,......has always been a problem with him. He has never shown a normal appetite. Seeing children eating candy and ice cream has never been a temptation to him."

At the age of 1 year "he could hum and sing many tunes accurately." Before he was 2 years old, he had "an unusual memory for faces and names, knew the names of a great number of houses" in his home town. "He was encouraged by the family in learning and reciting short poems, and even learned the Twenty-third Psalm and twenty-five questions and answers of the Presbyterian Catechism." The parents observed that "he was not learning to ask questions or to answer questions unless they pertained to rhymes or things of this nature, and often then he would ask no question except in single words." His enunciation was clear.

He knew the pictures of the presidents "and knew most of the pictures of his ancestors and kinfolks on both sides of the house." He quickly learned the whole alphabet" backward as well as forward" and to count to 100.

It was observed at an early time that he was happiest when left alone, almost never cried to go with his mother, did not seem to notice his father's home-comings, and was indifferent to visiting relatives.

He does not observe the fact that anyone comes or goes, and never seems glad to see father or mother or any playmate. He seems almost to draw into his shell and live within himself.

He seldom comes to anyone when called but has to be picked up and carried or led wherever he ought to go. In his second year, he "developed a mania for spinning blocks and pans and other round objects." At the same time, he had a dislike for self-propelling vehicles, such as Taylor-tots, tricycles, and swings.

He was always constantly happy and busy entertaining himself, but resented being urged to play with certain things. When interfered with, he had temper tantrums, during which he was destructive. He appears to be always thinking and thinking, and to get his attention almost requires one to break down a mental barrier between his inner consciousness and the outside world.

The father, whom Donald resembles physically, is a successful, meticulous, hard-working lawyer who has had two "breakdowns" under strain of work. He always took every ailment seriously, taking to his bed and following doctors' orders punctiliously even for the slightest cold. "When he walks down the street, he is so absorbed in thinking that he sees nothing and nobody and cannot remember anything about the walk." The mother, a college graduate, is a calm, capable woman, to whom her husband feels vastly superior.

When he desired to get down after his nap, he said, "Boo [his word for his mother], say' Don, do you want to get down?' "His mother would comply, and Don would say: "Now say 'All right.' "The mother did, and Don got down.

At mealtime, repeating something that had obviously been said to him often, he said to his mother, "Say 'Eat it or I won't give you tomatoes, but if you don't eat it I will give you tomatoes,' " or "Say 'If you drink to there, I'll laugh and I'll smile.' "And his mother had to conform or else he squealed, cried, and strained every muscle in his neck in tension. This happened all day long about one thing or another

When he wanted his mother to pull his shoe off, he said: "Pull off your shoe." When he wanted a bath, he said: "Do you want a bath?"

The word "yes" for a long time meant that he wanted his father to put him up on his shoulder. This had a definite origin. His father, trying to teach him to say "yes" and "no," once asked him, "Do you want me to put you on my shoulder?" *Don expressed his agreement by repeating the question literally, echolalia-like. His father said, "If you want me to, say 'Yes'; if you don't want me to, say 'No.' "Don said "yes" when asked. But thereafter "yes" came to mean that he desired to be put up on his father's shoulder. He paid no attention to persons around him.

He gave no heed to the presence of other children but went about his favorite pastimes, walking off from the children if they were so bold as to join him. If a child took a toy from him, he passively permitted it.

He was inexhaustible in bringing up variations: "How many days in a week, years in a century, hours in a day, hours in half a day, weeks in a century, centuries in half a millennium," etc., etc.; "How many pints in a gallon, how many gallons to fill four gallons?" Sometimes he asked, "How many hours in a minute, how many days in an hour?" etc.

When asked to subtract 4 from 10, he answered: "I'll draw a hexagon."

The paper is quite a gem and students of child psychiatry are well advised to read it. Leo Kanner continually questioned the given wisdom of the day; couple that with his keen observation power and curiosity and a natural irreverence to authority, it was only natural that he should have created history by being the first to describe Autism.

Leo Kanner “thought what nobody has yet thought, about that which everybody sees.”
Erwin Schrödinger Nobel Prize in Physics 1933

Autism posts:
Autism: Somalis in Minnesota and Sunshine
Autism: Gene Disruption?
Autism, the Brain and Tiger Woods
Autism and Money