NHS Original: Best Health Care!

Friends moved to France after their retirement and lived in one of the wine growing districts.

 ©2008 Am Ang Zhang

They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.

They have moved back to England.

What happened?

Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E (ER) at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

The best health care in the world. 

Now we know.

Let us keep it that way.

NHS & Private Medicine: Best Health Care & Porsche

Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.

My friend was amazed that I gave up Private Health Care when my wife retired.

“I know you worked for the NHS but there is no guarantee, is there?”

Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.

He worked for one of the major utility companies and had the top-notch coverage.

“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”

Porsche official Website

He was very happy with the results.

“He has to be good, he drives a Porsche.”

Then he started feeling dizzy and having some strange noise problems in one of his ears.

“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”

What could one say! We are losing the funny game.

What does he drive?

A Carrera.

Another Porsche.

We are OK then.

Or are we.

He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.

Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.

“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.

He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.

To cut the long story short, he has DAVF.

I asked my ENT colleague if it was difficult to diagnose DAVF.

“Not these days!”

He had a range of treatments and is now much better.

All in the NHS hospital.

“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”

Best health care.

I always knew: Porsche or otherwise.

Best Health Care: NHS GP & NHS Specialist

Does having a good hunch make you a good doctor or are we all so tick-box trained that we have lost that art. Why is it then that House MD is so popular when the story line is around the “hunch” of Doctor House?

Fortunately for my friend, her GP (family physician) has managed to keep that ability.

My friend was blessed with good health all her life.  She seldom sees her GP so just before last Christmas she turned up because she has been having this funny headache that the usual OTC pain killers would not shift.

She would not have gone to the doctor except the extended family was going on a skiing holiday.

She managed to get to the surgery before they close. The receptionist told her that the doctor was about to leave. She was about to get an appointment for after Christmas when her doctor came out and was surprised to see my friend.

I have always told my juniors to be on the look out for situations like this. Life is strange. Such last minute situations always seem to bring in surprises. One should always be on the look out for what patient reveal to you as a “perhaps it is not important”.

Also any patient that you have not seen for a long time deserves a thorough examination.

She was seen immediately.

So no quick prescription of a stronger pain killer and no “have a nice holiday” then.

She took a careful history and did a quick examination including a thorough neurological examination.

Nothing.

Then something strange happened. Looking back now, I did wonder if she had spent sometime at a Neurological Unit.

She asked my friend to count backwards from 100.

My friend could not manage at 67.

She was admitted to a regional neurological unit. A scan showed that she had a left parietal glioma. She still remembered being seen by the neurosurgeon after her scan at 11 at night:

“We are taking it out in the morning!”

The skiing was cancelled but what a story.

Best GP

Best Specialist

NHS

Nanking: December 13, 1937.

82 years ago, the people of Nanking, China's ancient capital city, were in the midst of one of the worst atrocities in history, the infamous Rape of Nanking. The truth of what actually happened is at the center of a bitter dispute between China and Japan that continues to play out in present-day relations. Many Chinese see Japan's election last month of ultraconservative nationalist Shinzo Abe as prime minister as just the latest in a string of insults. And it was recently reported that Japan is considering rolling back its 1993 apology regarding "comfort women," the thousands of women the Japanese army sexually enslaved during World War II.

In 1937, the Japanese Imperial Army, captured Nanking on Dec. 13. No one knows the exact toll the Japanese soldiers exacted on its citizens, but a postwar Allied investigation put the numbers at more than 200,000 killed and at least 20,000 women and girls raped in the six weeks after the city fell.

It was the mass rapes in Nanking and the brutalization of an entire populace that eventually convinced Japanese military leaders that they needed to contain the chaos. Japanese soldiers began rounding up women and forcing them to serve as sex slaves in so-called comfort stations.

This is what most historians believe. But not in Japan, where a large faction of conservatives, led by Abe, denies that the Japanese military forced women into sexual slavery. They maintain that any suggestion to the contrary is simply anti-Japanese propaganda and probably spread by China. At the furthest end of the spectrum, the minimizing turns to flat-out denial; one professor we interviewed at a top Japanese university adamantly insisted there were no killings or rapes in Nanking.

Not surprisingly, all this minimizing and denial enrages the Chinese and others in Asia. But this is a familiar pattern.

                                                                     L.A. Times

                                                                     

Nanking Poster: THINKFilm

On July 2, 1996, the anniversary of Ernest Hemingway’s own suicide, Margaux Louise Hemingway, his grand daughter was found dead in her studio apartment in Santa Monica, California at age 41.

On November 9, 2004, Iris Chang (張純如), who was propelled into the limelight by her 1997 best-selling account of the Nanking Massacre “The Rape of Nanking: The Forgotten Holocaust of World War II”, committed suicide. Earlier she had a nervous breakdown and was said to be at the risk of developing Bipolar illness. She was on the mood stabilizer divalproex and Risperidone, an antipsychotic drug commonly used to control mania. There was a detailed report in San Francisco Chronicle.

My sentiments about the treatment of bipolar illness are expressed in The Cockroach Catcher:

“I am a traditionalist who believes that Lithium is still the drug of choice for Bipolar disorder. Tara’s mother was well for ten years. She was taking only Lithium and no other medication.”

The anti-suicidal effect of lithium has been confirmed by a number of recent studies in both the U.S. and in Europe.

According to the results of a population-based study published in the 2003 Sept. 17 issue of The Journal of the American Medical Association (JAMA. 2003;290:1467-1473, 1517-1519), Lithium reduced suicide rates of patients with bipolar disorder but divalproex did not. Risk of suicide death was about 2.5-fold higher with divalproex than with lithium.

Another paper published in 2005 (Arch Suicide Res. 2005;9(3):307-19) reviewed the existing evidence.

“The article reviews the existing evidence and the concept of the anti-suicidal effect of lithium long-term treatment in bipolar patients. The core studies supporting the concept of a suicide preventive effect of lithium in bipolar patients come from the international research group IGSLI, from Sweden, Italy, and recently also from the U.S. Patients on lithium possess an eight- time lower suicide risk than those off lithium. The anti-suicidal effect is not necessarily coupled to lithium's episode suppressing efficacy. The great number of lives potentially saved by lithium adds to the remarkable benefits of lithium in economical terms. The evidence that lithium can effectively reduce suicide risk has been integrated into modern algorithms in order to select the optimal maintenance therapy for an individual patient.”

The JAMA paper highlighted the declining use of lithium by psychiatrists in the United States and observed that:

"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium.

Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?

Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.

Some felt it has to do with how little money is to be made from Lithium.

My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?

Now back to the Japanese atrocities in the Nanking Massacre in 1937, one of history’s worst but relegated to obscurity. The impact of Iris’ book and her tragic death was such on Ted Leonsis, Vice Chairman of AOL, that he went on to produce a film on the subject. The film, Nanking, premiered in Sundance Festival last year, was shortlisted in the documentary feature category of the Academy Awards, and won the Humanitarian award for documentary in the Hong Kong International Film Festival.

Mariel Hemingway, younger sister of Margaux, read the words of Minnie Vautrin in the film. Minnie Vautrin was an American missionary renowned for saving the lives of many women at the Ginling Girls College in Nanking, China during the Nanjing Massacre. In 1941, Minnie Vautrin committed suicide.

In July, 2007 the film premiered in Beijing. The BBC said:

“It is doubtful, though, it will ever be shown in Japan, where historians claim the massacre has been exaggerated.”

Experts estimate the Japanese killed 150,000 to 200,000 people and raped more than 20,000 women and children, but a group of MPs from Japan's governing party recently said no more than 20,000 were killed. 

First Do No Harm: Antipsychotics-Really?

Primum non nocere: 

I was quoted in HuffPo as far back as 2008: Obama Interviews the Medical Blogosphere on Healthcare Reform.

Cockroach Catcher: I have come to the rather unpleasant conclusion myself that parents nowadays may not have been told the full story about Antipsychotics. How many of them have been made aware of their range of side effects when it is suggested that their very young child should go on such medication?

The Cockroach Catcher & Other Bloggers in The Guardian etc.

Here is a reprint: 

“First do no harm” has always been attributed to Hippocrates. In his Epidemics, Bk. I, Sect. XI, he advised, "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm."
As I mentioned in my last post, schizophrenia is mercifully rare in children under 18. The best estimate is about 1 in 40,000, as opposed to 1 in 100 in adults.

                                   Australia & Cade: Lithium & Toxicity.

I did of course see a few full blown Manic Depressives (Bipolar Disorder) in children between eleven and eighteen - single digit figure for a career in Child Psychiatry spanning 30 years must mean it is rare. With such cases, it is more important to use the right mood stabiliser and with my patients I prescribed mainly lithium.

It is now fashionable for Child Psychiatrists to diagnose Bipolar Disorder and treat with Atypical Antipsychotics, instead of mood stabilizers. Recent figures show that only a third of these so called Bipolars are prescribed mood stabilisers.

I have come to the rather unpleasant conclusion myself that parents nowadays may not have been told the full story about Antipsychotics. How many of them have been made aware of the range of side effects of Antipsychotics when it is suggested that their very young child should go on such medication? How many of them have been made aware that taking an Antipsychotic may in fact induce psychosis, a still disputed finding but one that should be a consideration? (For the latest data on side effects, see below.)

No parent would question an exotic diagnosis that absolves them of any responsibility, and a treatment that uses a fancy new medication. After all Havard is a good name and anything advocated by a psychiatrist from Harvard must be O.K.

“Branding” has inadvertently crept into child Psychiatry.

We bloggers who dare to reveal the hidden agenda cannot be the favourite of the likes of those who push the “new” treatments. So be it.

It is a challenge to the modern day Child Psychiatrist to suggest that their patient’s behaviour problem is caused by faulty parenting or family dynamics. To even suggest that is sure to bring on complaints and possibly litigations. In countries where insurers hold the purse string, writing a prescription saves the doctor valuable time. Psychotherapy or behaviour therapy costs more.

Even before the arrival of the newer Atypical Antipsychotics, their predecessors were used for behaviour control, in Russia and elsewhere. Why else should it be known as chemical lobotomy?

Many doctors feel more comfortable in prescribing Atypicals because of their purportedly better side-effect profiles. I do not mean to criticise the majority of busy Child Psychiatrists, for we have a long tradition of relying on publications of esteemed colleagues around the world.

Unfortunately, the big Pharmaceuticals too know of our trust in our colleagues, and over an extended period of time have engineered publications of favourable papers speaking for licensed and more frequently off-label use of the new drugs, especially Antipsychotics. It should not take a genius to work out that psychosis is a chronic condition that requires life long treatment, thus guaranteeing future income for pharmaceuticals.

There is also another aspect. What if the actual diagnosis of psychosis is suspect? We are entering a new era, when medical ethics seem not so important. I am not alone in doubting the validity of some of the diagnosis of childhood Bipolar Disorder. To put it plainly, the two thirds of the so called Bipolars may be just having behaviour problems and Antipsychotics are prescribed simply to control their behaviour.

The side effects of the newer Antipsychotics on children and young people

For the latest most comprehensive data on side effects of the newer Antipsychotics on children and young people we turn to an earlier article in The USA Today:New antipsychotic drugs carry risks for children
by Marilyn Elias 5/2/2006 USA Today

The USA TODAY's analysis focused on 1,373 cases received by the FDA from 2000 to 2004 in which one of the six atypical anti-psychotic drugs was coded as the primary suspect. These cases were used to count symptoms, diagnoses and deaths.

To learn about patterns in atypical use, USA TODAY asked Medco Health Solutions, a prescription-drug benefit manufacturer, to query its member database.

• A condition called dystonia was most often cited as an "adverse event" suffered by someone taking one of the drugs, with 103 reports. Dystonia produces involuntary, often painful muscle contractions.

• Tremors, weight gain and sedation often were cited, along with neurological effects such as Tardive Dyskinesia (TD). Symptoms of TD can vary from slight twitching to full-blown jerking of the body. (No actual figure was quoted.)

• A condition called neuroleptic malignant syndrome, with 41 pediatric cases over the five years, was the most troubling effect listed, says child psychiatrist Joseph Penn of Bradley Hospital and Brown University School of Medicine. It is life-threatening and can kill within 24 hours of diagnosis. It's been linked to drugs that act on the brain's dopamine receptors, which would include the atypicals, Penn says.

The 45 deaths
Among the 45 pediatric deaths in which atypicals were the primary suspect, at least six were related to diabetes — atypicals carry warnings that the drugs may increase the risk of high blood sugar and diabetes. Other causes of death ranged from heart and pulmonary problems to suicide, choking and liver failure.

There is anecdotal evidence that even Aripiprazole (Abilify), the new Third Generation antipsychotic, still causes weight gain and quite severe extrapyramidal side effects.

There we have it.

There is often an assurance that the side effect listed on the Information Sheet is rare and it is a natural defence of most of us that somehow, bad things only happen to others.

Next time your Child Psychiatrist said, “Antipsychotics.”

I suggest that your answer should be: “Really?”

Links: Reidbord's Reflections----Abilify for depression?

“Researchers Fail to Reveal Full Drug Pay”

Grand Round (5) 12: SHARPBRAINS.
HOT NEWS:The Huffington Post

New York Marathon: Autumn Colours & Drowning!

The views along the New York Marathon route will be spectacular!

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

©2013 Am Ang Zhang 

But please do not overdo the hydration. It is more dangerous than you think!

It is amazing that after over 40 years they are just beginning to realise that. Research on Marathon runners showed that many had low sodium, a sure sign of over-hydration. 

Marathons:

Marathons are often sponsored by bottled water companies and their main aim is to let the public get he image of runners with bottles of their water.

New England Journal of Medicine:

Of 766 runners enrolled, 488 runners (64 percent) provided a usable blood sample at the finish line. Thirteen percent had hyponatremia (a serum sodium concentration of 135 mmol per liter or less); 0.6 percent had critical hyponatremia (120 mmol per liter or less). On univariate analyses,hyponatremia was associated with substantial weight gain, consumption of more than 3 liters of fluids during the race, consumption of fluids every mile, a racing time of >4:00 hours, female sex, and low body-mass index. 

Modern marathon advice is to up the intake of salty food in the pre-race preparation. When dehydrated taking salt and water alone will not work: see below. 

Watermelon:

When I was growing up in the tropics, one of the fruits we were given after a long walk was watermelon with salt sprinkled on it. This was long before the current understanding of Oral Rehydration. My parents were careful to warn us then that just drinking water is no good. Why? They did not know!

Now I do but watermelon is still my favourite and in the tropics you can buy fresh water melon juice in the summer.

Chinese farm workers:

It has to be said that the diet of many Chinese farm workers was generally higher in sodium, from dried salted fish and vegetables. It is likely that the serum sodium of many such workers would have been at the high end of the normal range. Modern advice on cutting down sodium often does not take account of sweating in hot countries. A friend of mine with hypertension had an epileptic seizure when he went to work in Singapore. Luckily the medical services there were alert to the problem and he survived. He was on a low sodium diet and on diuretics amongst other medications.

Free water:

I also remember one very hot August day when we hiked down Grand Canyon to Angel Point. There were warnings everywhere of the risks and even fatalities on such walks. The National Park did have clean drinking water taps along the way and one particular girl overdid the drinking. She had a narrow escape, as the Ranger fortunately knew a thing or two about rehydration. He put some salt in a can of Sprite and reverted a potentially serious situation.

Thailand:

The first time we went to Thailand the most amazing dip was simply a bowl of sugar that has been mixed with salt and some chopped chilies for good measure. This dip was used for serving unripe mangoes, papayas, guavas and other local fruits, and gave me a taste sensation that was unforgettable. Same principle as ORT.

In Thailand, workers in rice fields, fruit orchards and vegetable patches manage to survive temperatures of over 100°F.

Golf:

The Cockroach Catcher plays golf in his holiday home in the tropics and he uses his own mix of diluted Pomegranate juice and a pinch of salt for Oral rehydration. I would never drink plain water alone.  This is one time where a bit of sugar helped the body to absorb salt and fruit juice is higher in potassium.

When the first public golf course was opened on the beautiful island of Kau Sai Chau in Hong Kong, drinking water was provided along the course. One player drank so much that he nearly died of water intoxication (result of drinking excessive amounts of plain water which causes a low concentration of sodium in the blood leading to amongst other problems: ‘brain’ swelling---cerebral oedema).

Cocktails:

It seems wrong to recommend alcohol but has anyone worked out why cocktails from hot countries would be served with the rim of the glass covered in salt!!!

Drowning:

I remember one of my professors telling us: the body survives dehydration much better than drowning. How right he was, as water intoxication is in a sense a kind of drowning.

Cholera:

I well remember Hong Kong’s cholera epidemic in 1961 and the major cause of death was the rapid loss of fluid due to a specific secretive action of the cholera germ. Patients could die in a matter of hours. The medical profession has long been of the strong belief that Intravenous Fluid (IV Fluid) is the only answer. In that situation, the patient is in shock and to find a vein means a cut-down: literally cutting through the skin to find one. It is a messy business as the patient is violently pumping out fluid in the most horrendous fashion.

Johns Hopkins established a centre in Calcutta in the 1960s to study precisely a better way to replenish the fluid. IV fluids were expensive to manufacture and required medical personnel to administer. Their Clinicians sought help from basic physiology and carried out the first carefully controlled study which showed that intestinal perfusion of cholera patients with saline solutions containing glucose strikingly reduced fluid loss. Put simply, the patients could just drink a glucose and salt solution and the glucose would allow the salt to be piggy backed and absorbed, thus sparing the need to use IV fluids.

“……These compelling findings, however, did not convince the medical establishment, who remained sceptical that such a simple therapy could substitute for traditional intravenous fluid replacement in severely stricken patients under epidemic conditions in the field.”

The World had to wait for a war, this time in Pakistan, when Bangladesh fought for its independence in 1971 and 9 million refugees poured into India and with them cholera. When IV saline treatment was exhausted, Dr Mahalanabis, who had worked at the Johns Hopkins Centre in Calcutta, took the gamble and decided to prescribe a simple solution of glucose and salt in the right proportion for the friends and relatives of the cholera patients, thus saving at least 3.5 million people.  Since that time it was estimated that such a simple and cheap remedy saved at least 40 million more lives.

No wonder The Lancet hailed the development of oral rehydration therapy (ORT) as "the most important medical discovery of the 20th century".

The scientists at Johns Hopkins and Dr Mahalanabis received the Pollin Prize of $100,000 in 2002.

“Ideas without precedent are generally looked upon with disfavor and men are shocked if their conceptions of an orderly world are challenged.” 

Bretz, J Harlen 1928. 

Ancient Remedy: Modern Outlook

Chinese farm workers have always worked in the heat of the fields but heat stroke seems to be rather uncommon. I wonder if our dried preserved plum has something to do with this. 

The Chinese preserved plum is said to quench thirst, and as a child I could never really understand the rationale. Now I know. It is preserved with salt, sugar and herbs such as licorice by a complex process. If you suck one of these plums and then drink water, you have the combination of sugar and salt that carries the salt back into the system. Why plums? Like a lot of fruits, plums contain potassium. This is oral rehydration therapy (ORT) the ancient Chinese way, before the science of modern ORT.


It has to be said that the diet of many such Chinese workers was generally higher in sodium, from dried salted fish and vegetables. It is likely that the serum sodium of many such workers would have been at the high end of the normal range. Modern advice on cutting down sodium often does not take account of sweating in hot countries. A friend of mine with hypertension had an epileptic seizure when he went to work in Singapore. Luckily the medical services there were alert to the problem and he survived. He was on a low sodium diet and on diuretics amongst other medications.

I also remember one very hot August day when we hiked down Grand Canyon to Angel Point. There were warnings everywhere of the risks and even fatalities on such walks. The National Park did have clean drinking water taps along the way and one particular girl overdid the drinking. She had a narrow escape, as the Ranger fortunately knew a thing or two about rehydration. He put some salt in a can of Sprite and reverted a potentially serious situation.

When the first public golf course was opened on the beautiful island of Kau Sai Chau in Hong Kong, drinking water was provided along the course. One player drank so much that he nearly died of water intoxication (result of drinking excessive amounts of plain water which causes a low concentration of sodium in the blood leading to amongst other problems: ‘brain’ swelling---cerebral oedema). Marathon runners are at greater risk than most as reported by the New England Medical Journal. There have been other notable cases of water intoxication elsewhere. I remember one of my professors telling us: the body survives dehydration much better than drowning. How right he was, as water intoxication is in a sense a kind of drowning.

The first time we went to Thailand the most amazing dip was simply a bowl of sugar that has been mixed with salt and some chopped chilies for good measure. This dip was used for serving unripe mangoes, papayas, guavas and other local fruits, and gave me a taste sensation that was unforgettable. Same principle as ORT.

In Thailand, workers in rice fields, fruit orchards and vegetable patches manage to survive temperatures of over 100°F.

On the other hand, Chinese dried plums are such neat, little, easy to carry things. Perhaps we should try to popularize this ancient remedy for the benefit of all. Be warned, only those made with sugar and salt work, not the ones with artificial sweeteners.

Latest:

Loquat, Winter Melon & Sapote

Scarlet Fever & Mahler: Sadness and Creativity!

After decades of decreasing scarlet fever incidence, a dramatic increase was seen in England beginning in 2014. Investigations were launched to assess clinical and epidemiological patterns and identify potential causes.                              Lancet.

The strangest finding is that there is no evidence of any genetic mutation of the bacteria concerned nor resistance to antibiotic treatment. Perhaps we need to look closely at Ed Yong’s masterful new book, I Contain Multitudes, which tells the stories of the microbes that swarm within and around us.

Are we too clean? Do we use too much "Antibacterial" laced cleaning things? Or is the new near religious fervour in not using antibiotics to blame? We simply do not know.

But Scarlet Fever reminds me of Mahler.

 ©2013 Am Ang Zhang

Mahler wrote Kindertotenlieder to five poems written by Rückert. Rückert wrote 428 poems following the death of his two children from Scarlet Fever. 

Mahler lived in an age when bacteriology was very much in its infancy. There was still little understanding of the role Streptococcus played in a range of illnesses from Scarlet Fever to Rheumatic Heart Disease and Radium was often used to treat Streptococcal related conditions.  

Mahler’s own daughter tragically died from Scarlet Fever four years after writing Kindertotenlieder and Mahler himself contracted Rheumatic heart disease. When there was still little understanding of the etiology of diseases, superstition came into play so much so that Mahler did not want to write a ninth symphony. It was the start of the Curse of the Ninth Symphony.

Das Lied von der Erde was indeed the result as it was composed after his Eighth Symphony and he did not want to name it his Ninth. 

Mahler conceived the work in 1908 when he was already unwell with his heart condition. A volume of ancient Chinese poetry under the title of The Chinese Flute (Chinesische Flöte) repoetized by Hans Bethge was published in German and Mahler was very much taken by the vision of earthly beauty expressed in these verses. Fate he felt has been unkind to him but he felt able to accept it in his own fashion.

                                                          

Mahler died on May 18^th 1911 in Vienna.

"I think it is probably the most personal composition I have created thus far."    Gustav Mahler

The first performance of Das Lied von der Erde was conducted by Bruno Walter after Mahler's death. 

Bruno Walter described it as: "the most personal utterance among Mahler's creations, and perhaps in all music."

My first encounter was in the early 70s with the recording by Janet Baker and Waldemar Kmentt (with Kubelik conducting the Bavarian Radio Symphony Orchestra). I still think it is one of the very best performances of Das Lied von der Erde.

Easter Passion: Bach, Beethoven and Mahler

Janet Baker
Das Lied von der Erde
Hong Kong
Literary Metamorphosis in Das Lied von der Erde

Proms: Mahler & Nature

Easter Passion: Bach, Beethoven and Mahler

The Cockroach Catcher: Berlin Wall, Appassionata & The Lives Of OthersS