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.

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. E
verybody 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.

© 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: The Secrets Hiding in the Simplest Animal Brains

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.

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Thursday, October 25, 2018

Balicasag Island, Philippines.

9.5161° N, 123.6833° E

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.

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 and they did well too. There was little doubt that for many the years of training in the top hospitals here will guarantee them nice top jobs in Hong Kong or the rest of the commonwealth. 


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:

Tuesday, May 24, 2011

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 United Kingdom
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.

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.

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 after the Christmas of 2009 there were 4 million unsold hams.

©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 based): Tell tale tooth: Teratoma.
     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 for Nervous Diseases), 
             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.

Here is an extract from my book The Cockroach Catcher:  Chapter 29 The Power of Prayers
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 if not in the world and the doctor would stay with her in the ambulance. She would be fine.

“........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:

Wednesday, October 3, 2018

Autism: Challenges & Obstacles!

© 2012 Am Ang Zhang

 To me the meanest flower that blows can give
  Thoughts that do often lie too deep for tears.

OdeIntimations Of Immortality From Recollections Of Early Childhood.


      One day a referral came of a boy called Anthony Wordsworth.  He had just turned three.
      “You will like Mrs Wordsworth.”  No reason was given. “Mr Wordsworth will probably not come to see you as he has a very important job in the City.  Anthony is such a handsome boy, a bit quiet, and I think you will like him too.”

      The Wordsworths lived in one of these big houses and Mrs Wordsworth looked very young for a mother with two children, the older one being nine. I marvelled some years later how with all the hard work her two children put her through she still managed to look that young. The wonders of modern make-up together with smart dresses might have deceived me.

      Anthony was truly autistic. At that time one of my juniors had just returned to work with me after having her twins.  She sat through the first session.
      She said to me afterwards, “I thought they did not make Kanner’s classics anymore.” Anthony was a Kanner’s Classic. Leo Kanner first described the classical autistic child in 1943 and there had not been a better description since. Not many children have all the classical symptoms, but one finds the diagnosis of Autistic Spectrum Disorder (ASD) more and more common place[1].
      I said, “Yes, even down to the good looks.” 

      I often wondered if our creator really has such a sense of humour or is everything just chance.

      One could not but feel sorry for the mother.  Later I found out that she came knowing that autism would be my diagnosis, and if I had come to anything different, I probably would have never seen her or Anthony again.
      She knew of the diagnosis from very tragic personal experience. Her own brother was diagnosed such in London by our very eminent Professor who was the world’s authority on autism.
      In other words, she had lived, breathed and dreamed autism all her life and now her worst nightmare was realised. Her own child had turned out to be autistic like her own brother. 

      Perhaps her years of looking after her brother had prepared her for this day. Perhaps our creator made sure that for those who were going to have difficult children, they were made tough enough. 

      Anthony’s older brother was smart and clever. She felt good then that perhaps genetics was not at play, and her worst fear was unfounded.

      I was once consulted by a grandmother on a very tragic situation. She had two daughters. One was severely autistic, and the other was very intelligent and a high achiever. The latter became an academic, married and received the best genetic counselling from the same university where she was a professor. Minimal chance, she was told. She went ahead and the first child was subsequently diagnosed as suffering from Retts Syndrome[2].  She was not really seeking any second opinion but wanted to know if Retts and Autism were the same.  This case reminded me of the old Yiddish saying “Men tracht un Got lacht” – If you want to make God laugh, tell him your plans.

      Anthony’s mother went on to tell me she was going to take matters into her own hands because she would not want her son to deteriorate like her own brother, who was thirty five then and living in an institution. 

      “Mrs Wordsworth, I belong to that small group of doctors who believe that the brain is really capable of a good deal more. But we have to give it the right input.” 

      This principle has been applied to the treatment of autism over the last fifteen years and the results are really quite exciting. We do not pretend to know the cause or causes of autism but I have been with some great pioneer workers and I believe that the old thinking that things cannot change is not entirely true.

      She started crying and Anthony came towards her.

      Even with the best breeding there was only so much one could hold back.
      It was a moving sight, more because Anthony moved towards mum. What a positive sign.

      “I would like to arrange for Anthony to see the same Professor that saw your brother. This is not because I do not trust my own diagnosis, but I think it may be what you would like but dare not request. It would be good for our future work together if you do go and see him.

      “Before the appointment which could be a while, there is something you can start if you are not doing already. Do not stop talking to Anthony. Give him running commentaries on what you are doing even if it is about tidying the place, getting his dinner or doing his laundry.”

      “Don’t wait for his response,” I emphasized.

      Many new parents tend to parent by responding to cues given to them. There is nothing wrong with that. We talk to our kids when they talk to us and we leave them alone if they want to play on their own. Sometimes parents insist that quiet play is actually good for their children when they themselves want some peace and quiet.

      With autistic children one may have to wait a very long time for those cues and they may never come.

      “To be honest, I have been doing quite a bit of that, but I was not sure if it was right or wrong and I never dare tell anyone, not even my husband.”

      It is always that much better to suggest something that a parent is already doing. First you are no longer instructing her and second you are more likely to succeed. She had been using her instinct and using it well. 
      She cried even more and told my secretary later that she was more moved because I seemed to know what she wanted and I saved her the embarrassment of having to ask me herself. She was planning to pluck up courage to ask me for a referral to the Professor towards the end of the session. It was not so much that she doubted my diagnosis but that she thought the Professor needed to know that there were now two cases in her family.

      Mrs Wordsworth did get her appointment pretty quickly. No surprises. The diagnosis was confirmed. The Professor thought some of my suggestions seemed interesting enough and Anthony would be best served attending the clinic locally. He was grateful for the update on her brother’s family history. He thought that Anthony’s major long term handicap would probably be his speech.

      With the Professor’s blessing, we could now start.

      We were aiming for very small changes but the feed would come from the parents and I wanted to get her husband involved if possible.
      “I told him everything after our first meeting. It’s a good job you referred us to London. I think he will be upset for a while but he will come round.”

      Denial is a useful if ineffectual defence, but now we needed to get results.   

      It was time to have something for show.
      “Do you think Anthony will have a speech impediment or handicap in that area?”
      “You’ve heard the Professor but we are not going to stop doing things just because problem was predicted. The best doctors do not mind being proved wrong now and again.”
      Mother produced a video tape.  A recording of a 90-minute period of her at home with Anthony.
      “At this rate he will speak before three and a half, don’t you think?” I joked.
      “Like my brother you mean.”  She has already told me that her brother had a serious speech problem.
      At three years and four months Anthony spoke. He did not just speak. He was in full sentences.
      I said to mother, you have delivered.

      Father came to see me the following session. I listened and picked out as many positive aspects as I could and encouraged him to just get on the floor and play with him. It was easy for me as I was already on the floor helping Anthony sort out a complex rail system that we had just acquired. 

      In our work, you sometimes just have to have fun. 

      One little boy once observed, “Do you live here, Dr Zhang? It must be fun, with so many toys to play with.”

      We worked on entrenchment and we worked on expectation. We also ventured into something newer – putting challenges and obstacles through play into Anthony’s life.

      Then we tried something even more daring – introducing imagination.


          About eight months after first seeing Anthony I had another full blown autism case referred to me at a different clinic.

          Steven was the younger of two brothers. His older brother had been a bit of a model child who never gave mother any trouble. Father was a pilot. Mother used to fly but had now switched to ground work. They had help at home.

          Mother realised that there was trouble when she found that Steven was counting lamp posts or rather reading the numbers on lamp posts. If for any reason she deviated from his normal route he would become very upset. Speech was otherwise minimal but he could read numbers from an early age, too early for mother to remember when.  One day he was counting as he was piling up building blocks, one of these early learning ones with alphabets on them.  He counted beyond twenty. But not much of anything else, no interest in colour, only numbers.

          He liked lining up his brother’s Dinky  cars. The main enjoyment was in the counting. One day the parents realised that it was the way the two brothers communicated and they felt his brother was responsible for helping him with the counting.

          But then reading the numbers – do we have a genius or what?

          The answer was we had a boy who suffered from autism.

          I tried to be frank and open with the parents, but I was probably a bit too frank for them. Both parents admitted later to the initial shock but felt that because I put it so confidently they might as well accept it. They said it would have been worse if I had suggested some tests to stall the time only to give them the diagnosis a week or two later. Those two weeks of “is he, is he not?” would have been more damaging.

          What helped them was my positive attitude towards the future and they could not wait to get started.

          One of Steven’s problems was coping with change and mother often had to endure two to three hours of crying until he fell asleep from the exhaustion, only to have him wake up two hour later to resume the crying. 
          By then I had developed various strategies and tactics with which I could bring the parents on board. Steven’s parents were exceptional, and they tried to come to appointments together, changing appointments if they clash with his flight schedule.
          We had been working hard on imaginary things – of fake cups of tea that was too hot or too sweet; of food that burnt the baby; and of the hurt when a child fell.  He was beginning to buy into a lot of that.
          Coming to the clinic still posed some problems for Steven. He found it difficult that the doctor needed to see someone else.  I was certainly responsible for his reluctance to leave. We had such fun together.
          One day both parents arrived with big grins on their face. They told my secretary Marjorie that I had to wait till the end of the session but they hoped it would work.
          I could hardly wait.
          “Steven, five minutes,” mother warned him as per usual practice.
          No response.
          “Two minutes.”
          No response.
          The suspense was killing me.
          “One minute.”
          Steven went over to his school bag. He took out something. I could not see what it was as it was imaginary. How stupid of me.
He put in two batteries. I could not see those either.
          With his other hand, he drew a big squarish thing in front of him that would have included most of me and my background. He aimed his thing and pressed.
          “Swish-swosh-swish .”
          “Ready. Mummy and daddy.”
          Steven had turned the session into a TV episode. He was now in control with his remote control. I was basically switched off.
          Two very proud parents walked off very swiftly with Steven in tow.
          “See you next time Marjorie,” Steven waved to my secretary. She approved. No crying from Steven.
          I was left standing there shell shocked.
          They have done it!

                                                                                 From the book, The Cockroach Catcher.    

Autism posts:

Autism: Somalis in Minnesota and Sunshine
Autism, the Brain and Tiger Woods
Autism and Money

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

[1] Diagnosis of Autism Spectrum Disorder - There is a belief that Kanner’s criteria remained the strictest, though other advocates for government funding of provisions for Autistics argue otherwise. Doctors can no longer rely on “clean” data.

[2] Retts Syndrome - Andreas Rett first described the syndrome in 1965, first thought to be a severe form of Autism now known to be related to MECP2 mutation.