Monday, November 13, 2017

Pre-Raphaelites: Puerto Rico & A Profound Secret!

Last year we spent a week in Puerto Rico before our Caribbean Cruise thinking it will be food and beach adventure and some Spanish historical sights. Imagine our surprise when we were told that the Ponce Museum of Art is a must see.



Edward Burne-Jones's The Sleep of Arthur in Avalon







Burne-Jones last work was sold at auction when the Tate had the opportunity to buy it for £1,000. It was purchased for the Museo de Arte de Ponce in Puerto Rico by the island's governor and founder of the museum, Don Luis Ferré, in 1963.

In life one should value chance encounters.
One year in June we spent some time with our friends in Dorchester. Somehow the after dinner conversation turned to the Pre-Raphaelitesand our hostess promptly produced a book with an amazing painting on its cover.

In a chance encounter with Andrew Lloyd WebberJosceline Dimbleby asked him bluntly if she could go and see the portrait he had of her great-aunt, Amy Gaskell.

“Ah, that wonderful dark picture,” Andrew said. “Yes, please come……Well, I think she looks rather like you......”

“Did you know that she died young?” Josceline asked Andrew.

“Of a broken heart.”

She told Andrew that she would try to find out more. This led her to start researching into the life of Amy, her mother May and the famous Pre-Raphaelite painter Edward Burne-Jones and the result was the book A Profound Secret.

I looked at the book cover and thought the portrait reminded me of the Picasso I used for my Anorexia Blog.



Amy Gaskell by Edward Burne-Jones

Leighton House Museum 2004/Andrew Lloyd Webber







                              Girl in a Chemise Picasso

Tate


It is said that as a young man Picasso admired the pre-Raphaelites and Edward Burne-Jones so much that in 1900 he would have gone to London rather than Paris had he had the fare.
“There was a hint in the book that she might well have died of Anorexia!” My hostess said.
It was a fascinating book, like good family biographies are, as long as you accept that it is not going to be as organised as fiction. A good writer helps and Josceline Dimbleby is a well established food and travel writer.

For a psychiatrist, it is especially interesting as he is allowed glimpses into the various personalities, their psychiatric problems and the resulting family dynamics, without the interference of the usual psychiatric labelling or coding. Unfortunately self medicating with alcohol, opium and other fancy substances was rife in that era and the result could often be tragic.
Indeed Josceline thought at one point in the book that Amy might have suffered from Anorexia although it was not a known condition at the time. She left it till the end of the book to let us into the final secret. You will have to find out for yourself.


Without the effect of drugs that would double the bodyweight, we have in the end one of the most beautiful portraits of the Pre-Raphaelites. Burne-Jones’ life is of course another psychiatric book: his mother died when he was six days old and many felt that all his life he was searching for the perfect mother he so missed. It is indeed ironical that the art world has been much enriched by what was essentially untreated bereavement.
Psychiatry may need to look again at what we have been doing, as we do not seem to have found another Burne-Jones.

Reference: "There had been a considerable vogue in Barcelona for the Pre-Raphaelites and the young Andalusian had been an admirer in particular of the white-skinned maidens of Burne-Jones, whom he had seen in reproduction."
........"Picasso assured me, when he was staying in London in 1950, that for him his [1900] trip to Paris was merely a halt on a journey that would take him further north to London. He had conceived a great admiration for England and . . . some English painters, especially Burne-Jones." 
                                                   Roland Penrose: Life and Work of Picasso.


Other References:




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Friday, November 10, 2017

In Flanders fields...........


© Am Ang Zhang 2016

In Flanders fields the poppies blow
Between the crosses, 
row on row,
That mark our place; 
and in the sky
The larks, still bravely singing, fly
Scarce heard amid the guns below.

Wednesday, November 8, 2017

Best Medicine & Listening: It's Not Viral!


..….listen to the patient
and
the patient will give you the diagnosis……
 
William Osler 1849 – 1919


I suppose in life, it is lucky to have school friends that might one day save your life.
 
Medicine.
 
I suppose without sounding racist, it helps if you are Jewish, went to a Jewish school as you are likely to have Jewish school friends who are good doctors.
 
As they say, God works in mysteriously ways!
 
I was in the middle of some Scandinavian Fjord on a cruise when I came across a book called Open Heart. Yes, old habits die hard and I still find myself drawn to books about medicine or other people’s medical stories.
 
The Cruise ©2012 Am Ang Zhang


It is peculiar that the commonest diagnosis the average punter, sorry patient is going to hear from their doctor is:
 
Yes: It’s viral.
 
Well, remembering my biology, these creatures are smaller than bacteria and is not really easy to cultivate.
 
Or is it just a way of saying to the punter/patient, go home and do not ask for the antibiotic.
 
Now, it may well be OK if it were a simple cough. But what if you were told it is a viral cardiomyopathy?  
 
 
Now, this is getting serious.
 
Yet this is what happened and it happened to Jay Neugeboren
after some investigations by two doctors, one a cardiologist.
 
About Jay Neugeboren:
Did he smoke?  No!
Was he overweight?  No! 5’7 150lb.
Did he exercise?  Yes, swims a mile every day and plays tennis  full court basketball regularly.
 
He must have a high cholesterol or BP or family history, it just is not right: No, he had no family history of heart disease, and had normal blood pressure, and better-than-normal levels of cholesterol (both 'good' and 'bad').
 
His symptoms:
 
“I had, however, for two months prior to the surgery, been concerned about some shortness of breath I experienced, if intermittently, while swimming, and by an unfamiliar, sporadic pain -- more like a burning sensation -- in my back, between my shoulder blades. When my family doctor suggested I have a check-up with a cardiologist, the cardiologist performed an echo-cardiogram and diagnosed 'a viral cardiomyopathy.' But he saw no urgency in my situation.”
 
Call his friend 3000 miles away:
At the same time, I had been talking regularly with a childhood friend, Richard Helfant, who was a cardiologist in Los Angeles, and had been Chief of Cardiology at Cedars-Sinai Hospital in Los Angeles. When I told him of the viral cardiomyopathy diagnosis, he shouted into the phone, "It's not viral, goddamnit -- I want you in the hospital as soon as possible."

So, to cut the long story short, a health New York Times author of some 20 books with no family history of heart disease, a better than normal cholesterol level non smoking 1 mile swimmer that would have been classed as healthy by NICE standards had at the age of 60 --had two of his three major coronary arteries turned out to be 100% shut down, and the third major artery, the LAD (Left Anterior Descending Artery, the so-called 'widow-maker') was more than 95% shut down.

His life was saved by emergency quintuple bypass surgery.
 
What went wrong or what went right?

His childhood friend had made an accurate diagnosis from 3000 miles away because he knew his friend and thus could place his specific symptoms in the context of his full story. What the cardiologist who had misdiagnosed him had done was to pay more attention to tests and numbers and, thus, to forget about the pain between his shoulder blades, which symptom -- referred pain from the heart -- was inconsistent with a diagnosis of viral cardiomyopathy.

His operation took six and half hours at Yale, New Haven Hospital: Medicine at its best and that was over 13 years ago.


It is also not comforting that a study in 1997 of 453 residents in internal medicine and family practice revealed that they failed to identify the distinctive sounds of common heart abnormalities with a stethoscope 80 percent of the time. True, using a stethoscope, listening to the patient and taking a careful history may not be the only ways to accurately diagnose heart disease. But in the words of Dr. Bernard Lown, inventor of the defibrillator, listening to the patient and taking a careful history remains ''the most effective, quickest and least costly way to get to the bottom of most medical problems.''


My old friend the cardiologist has similar concerns. ''The diagnostic acumen of the physician at the bedside, on the phone or in the office, has been severely compromised,'' he told me. ''Because the mind-set has become, 'Well, the tests will tell me anyway, so I don't have to spend a lot of time listening.' ''


…….I worry that our continued focus on medical testing and prescription drugs as the primary ways of preventing heart disease will distract us from a more important element in treating illness: the well-trained doctor who knows his patient.





Tuesday, November 7, 2017

Anorexia Nervosa: Let Her Die!


A reprint:

©2016 Am Ang Zhang 

Can a patient be allowed to die? 
Can a seventeen year old patient be allowed to die?
Can a seventeen year old Anorexia Nervosa patient be allowed to die?

Are we not supposed to save lives?

Could doctors be held to ransom? By?

Here is a Play: Let Her Die!

The Players:

The parents:
Father used to run a business security agency specialising in industrial counter espionage. Or was it espionage? I cannot be sure.

Too often there is this bizarre desire by some parents to make sure that if they cannot do it, no one else should either. We need to recognise it early enough. We are doomed otherwise, and so is the patient.

The patient: Nicola
It was really quite painful to sit there and talk to someone who looked worse than the worst they showed from Auswitz. Why could Nicola not realise that if she wanted any man to like her she would need to look a lot better, which involved doubling her weight for starters.

The Doctors:
Dr Hillman:

This was a family given up even by Dr Hillman, my most fervent supporter of family therapy. Father used to run a business security agency specialising in industrial counter espionage. Or was it espionage? I cannot be sure.

The Consultant:
        I did not go round looking like a hippie or pretending that I liked the music the teenagers listened to. I told them to me it was trash. I did not pierce my ear or have a tattoo. I certainly did not wear trainers to work.
       
        In short, you do not have to gain respect by becoming like them or worse, by pretending that you are like them.

The Experts:
I spent one session with them and agreed with Dr Hillman. They were good. We looked like a bunch of amateurs dealing with professionals. None of the family therapy tricks work, Minuchin or Haley.
        Impenetrable!

The NHS Trust & GMC

To me, suspension on full pay is a risk every doctor takes nowadays, as the basis is no longer limited to bad practice. It is no longer a reflection on whether you are good or bad clinically. Many psychiatrists are no longer prepared to use techniques that might upset their patients or parents of their patients.

The Main Action:

A family meeting was called and it lasted only a few minutes.
          I was in top form.

          “Nicola has been eating but after two months has not put on any weight. I cannot see any reason for her to continue to stay here. She might as well do the eating at home. She can then sort out for herself why she is not gaining weight without the pressure from us.”
          I tried to put it in the calmest way possible.
          “You mean you will let her die?” Father sounded a bit annoyed.

        With that father got up and left the room without saying another word.

          “What do I do now? You have upset him!” said mother.
          Good, something got to him at last, but I did not say it.
         
Nicola gave a wry smile to me as if to say, “You found me out.”
          She turned to mum, “Let’s pack and leave this dump.”
          We all kept still.
         
Six months later, one of the nurses bumped into Nicola in a nearby town. She was kicked out by father and moved in with another ex-anorectic. She was with a boy friend. More importantly she was wearing a very sexy dress to show off her then very good figure.
          She did not die.

                                           Based on an extract from my book The Cockroach Catcher
The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Saturday, November 4, 2017

Cello & Bach: Anorexia Nervosa

Listen to your patient: literally!

Cape Floristic Region (CFR) of South Africa
 ©Am Ang Zhang 2005
South Africa reminds me of my Anorexia Nervosa patient.

In The Cockroach Catcher I got my Anorectic patient to play the cello that was banned by the “weight gain contract”:



                 Jane got on well with me.

          She had to, as nobody understood that to her achieving was not a hardship but something she secretly enjoyed. She was no longer allowed to pick up her books as she had not put on any weight since her admission.
         
          Cello would be banned too, if her nurse was to have her way.

          For the unit to function the nurse must have her way. After all I was not there all the time to watch her. To watch if she was eating, vomiting, exercising or whatever else they did to avoid gaining weight.
          But I was determined that it would be the first privilege she would get if she put on half a gram.  Or any excuse I could think of.
          Brutal confrontation is often what happened in many adolescent units dealing with Anorexia Nervosa. The brutality is not physical.
          But these patients are intelligent and have such strong will power that confrontation generally fails and the failure can be a miserable one.  Yet it is the kind of condition that hurts. It hurts those trying to help. It hurts because these patients deserve better for themselves. It hurts because they are not drop-outs of society. 
          Was it too hard for Jane to keep at the top academically? Someone offered that as an explanation. Perhaps she should be moved to a state school.
          The idea horrified me.
          A fourteen year old non-smoking, non-drinking, non-drug taking, intelligent Audrey Hepburn look alike virgin turning up at your local comprehensive.  It sounded like a major disaster to me.
          I had to take the matter into my own hands. She did put on some weight and at the earliest opportunity I decided she should get back to the cello which had always been by her bed at the unit.

          She missed the cello, the only thing she could use to shut out her worries.


          Fourteen and carrying the burden of the world.


          Then she started playing.


          “Ah. The Bach G-major!”


          “So you know it.”


           Of course I do. The hours I spent listening to Yo Yo Ma and it was such amazing music, melancholic and uplifting at the same time.

          For a moment I forgot that I was her psychiatrist and she forgot she was my patient.


          “My grandma gave me Casals.”

          I knew Casals was even more emotional than Ma, but Ma is Chinese and he was less affecting, allowing the listener to tune in to his own mood.

She played from memory. What talent! What went wrong?”


          “I wish my dad could hear me.”

          It was the first time she could talk about her father. They had a very comfortable life in South Africa when father was alive. It was very difficult to imagine what he would have looked like. It was never clear what he did but he was involved in a number of ventures. The plantation Jane’s grandfather ran was sold when apartheid came to an end. He was involved in some private reserve and he was a photographer of sorts but my junior told me that mum started to cry when she talked about him so she did not pursue too deeply.






A Brief History of Time: Anorexia Nervosa



Bach - Cello Suites:  Yo Yo Ma