Monday, June 26, 2017

Mahler: Sadness & Pleasure Principle

©2016 Am Ang Zhang

Farewell                      Wang Wei (701-761)
Dismounting, let me share your farewell wine  
Where, friend are you heading now?
Choking, fate has not been kind to me
Will retire to the southern slopes to seek rest
Enquire no more when I am gone 
Till the end of clouds, endless white clouds!

Pleasure Principle:

Sigmund Freud’s Pleasure Principle is well known, but his other small “contribution” to mankind, i.e. his unofficial discovery of Cocaine, is probably less so. He in fact became quite an enthusiastic user of cocaine, in addition to smoking a large quantity of cigars, up to 20 a day. He developed jaw cancer and had to endure 33 operations and eventually died of it. 
I am not here to encourage the use of cocaine or cigars (as if people who used them needed encouragement). 
Instead I am going to talk about some of my pleasure pursuits. I have from an early age been interested in music though I have never played any instrument except the “gramophone” if you can call it an instrument. It can also be said that I play these instruments by “proxy” through my children. I have always had a multitude of hobbies: photography, electronics (I built my own radios and valve amplifiers), and snorkeling to name a few. Arriving in London in the early 70s allowed for easy access to France and French wine and food remains one of my most pleasurable pursuits, though my interest in wines has now been extended to Port and other non-French wines. 


In life one goes through difficult times and we Chinese are fairly philosophical about it – unhappiness is often viewed as something secondary to external circumstances such as loss and bereavement, political injustice (which has afflicted most of our families) and other life events that are beyond our control. Our classical poets wrote about such sadness and generally accepted what life befell them. 

When life events do not go our way, some turn to religion, although more and more people nowadays turn to the “happy pill” (drugs). One can also seek comfort in Music, Poetry, Photography, Writing (and blogging), Painting, Fishing, Knitting, Travel and of course Food and Wine. 

In an age when people sought happiness in all ways possible we need to remind ourselves that sadness has been the driving force behind many writers and composers.

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 18th 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.

Tuesday, June 20, 2017

Oporto & Hippocratic Past: Do No Harm!

We were in Oporto last summer and in this beautiful place famous for its Port, I stumbled upon a museum that reminded me of our Hippocratic Past. 

It was the medical museum right in the middle of Oporto. 

The following is extracted from The Cockroach CatcherChapter 30  Religious Fanaticism

n our work we have some unusual referrals now and again and sometimes they require unusual handling.
         I had an urgent call to deal with a serious suicide attempt at a well known local boarding school.
         No, the child was not admitted to hospital as would be the usual practice, but was kept at the infirmary at the school instead. I arranged to make an immediate visit to see her there.  She was only twelve.
         This was one of the few Church Schools that catered for able children who could not afford expensive private schools. Part of the intake were bright children of church personnel from all over the country. It still had rather medieval costumes for uniform and you could spot the school children a mile away with their long dark blue gowns. Boys and girls had the same outer costumes, but different belts and buckles according to the pupil's year group.
         The school had the feel of a monastery and was quite overpowering as you entered. Individual boarding houses lined up neatly. It read: “We mean business. You are here to learn.”
         The infirmary was even more imposing. It was part of the main block. The main door as you could imagine was at least 15 ft tall and weighed a ton.  The old wrought iron handle had seen a few centuries of use and yet its hinges were well oiled so that when the matron greeted me, she had no problem opening it and it did not produce the squeak I expected.
         The dark double height ceiling made darker by a few centuries of candle and oil smoke would make you think twice before falling ill.  I was led through a couple of archways before I reached the infirmary. There were glass cabinets with all kinds of ancient medical equipments. I was once fortunate enough to archive by photo the small museum at our psychiatric hospital and had since been interested in ancient medical tools. This place seemed to have more and one wondered what they used those tools for. Then I realised that this was a hospital before it became a school, and during the war it was a military hospital.
         At least I am in good company today, I thought, and I had better not let down my colleagues from the Hippocratic past.
         It was early March and spring had not quite arrived in southern England that year. There was not much light coming through the small oval windows. Matron seemed to have read my mind.
         “This was not in fact a proper hospital ward as the main hospital buildings are now the dormitory. This was the staff chapel, but as we all now use the main chapel, it seems such a good idea to turn this into an infirmary. Very good for migraines and headaches and that is normally what we deal with.” Matron said.
         I thought - mmmmm, neither condition can be confirmed by any medical investigation.
         Still it was quite a big room and with the neatly made beds and their white sheets, was speaking loudly – this is an infirmary; you are here to be ill and hopefully to recover.
         Ruth was sitting in one of the middle beds and with her nurse.
         “We have kept a nurse with her since last night, doctor.” Matron assured me.
         There we were, a rather petite looking girl in her hospital outfit sitting on the rather high bed trying to read.  She had a small face and as I approached, slipped off the bed and stood to attention. That said a lot about what kind of school this was. She was reading a French novel but I could not really tell which one it was. She looked cheerful, certainly too cheerful for someone who had tried to get to the other side less than twelve hours ago.
         It was a job to persuade matron to let me speak to Ruth on my own. When she realised that I meant what I said she sent the nurse to sit outside the door just in case and still hoped that I would let her keep it ajar an inch or so. She eventually agreed to have it closed but the nurse would just be outside.
         Ruth herself was not too bothered and I suspected that when you lived in a big dormitory, privacy was not a big concern.
         It was not my style to jump straight to what happened. This disappointed her a bit.
         “Don’t you want to know what happened?” she asked.
         But she agreed to do it my way and in fact it was a better idea, she later agreed.  She thought I was going to ask about the night before and then send her to a mental institution.
         Matron had informed the parents of my visit and mother, who was a social worker, was driving up from the coast and hoped to meet me within the hour.
         There is a very simple rule when we assess attempted suicide. We have to decide if this is the usual or the unusual.
         The usual – probably late teenage, made up to look twenty one, argument with boyfriend, got drunk and took eighteen Paracetamol or whatever was handy including the rest of the month’s pill. Most survived but now and again they were unlucky, were found too late and died a rather painful death. I was lucky – I never had to deal with those. I heard of one though, but she was dead when found. She left mum a note but mum was out with her boyfriend all night and the next day she came home to find a dead girl. Luckily these cases were rare and for that we had to thank our lucky stars. The virtual disappearance of barbiturates and tricyclic antidepressants meant that we had to deal with fewer accidental deaths, though Paracetamol remained the most potent killing agent.
         This girl was not like the usual. She tried to hang herself with the very belt with which she was meant to tie her cloak. Luckily for her the light to which she tied the belt did not hold her weight and she fell to her bed and tripped out the mains. Most of the other girls were asleep but her best friend saw her. She was too scared to say anything at first but now she could not stop crying and had been kept in her own dorm away from my patient’s influence.
         She was one of the star pupils of her year. Her father was the chaplain at a church near the coast. She was the only child. She was also a very good swimmer and represented the school in competitions. She was very talkative and despite what happened was quite at ease telling me about herself and her views of life.
         For three nights before going to sleep she heard a voice telling her to hang herself.  The previous night she actually saw a shadow telling her she must do it to keep her parents from harm. She thought it would not matter as her parents were more important.
         I did not think she was making it up. She did try to hang herself.
         What should I do?  Was this the start of a psychotic illness? Did she have a fast growing brain tumour?  If I made the wrong decision, she might end up dead one way or another.
         No, there was no other sign of either a depressive illness or psychosis. Why were the parents not here for something so serious? Why was mother still at work? Why was father not on his way here? Perhaps they did not take this seriously and maybe I should not either.
         This was an otherwise well put together girl, clever, good looking and had a good prospect of achieving well.
         Would this be someone you put on an antidepressant or antipsychotic?  Would I need to send her to a mental institution?
         One of the most important things we learned in medicine is: when in doubt, do nothing.
         To be more precise, do not do anything that is not reversible. What was the rush?
         I had for years an arrangement to admit my patients, if necessary, to our paediatric ward which normally took in tonsils and dental patients. The hot cases were appendicitis, and then there were my patients who did not require psychiatric inpatient treatment; they had mostly been anorectic patients who, incidentally, had done well over the years. They were often there without other anorectics and that was perhaps one of the reasons they did well.
         A number of O/Ds (overdoses) used to go through the paediatricians, and I would be consulted before any of them could be discharged – a sort of safety valve approach. There were no seriously ill patients. The nurses were a fairly stable group.  It was an ideal place for mothers returning to a nursing career. Over the years, they had got to like my special group of patients, including infants with a sleep problem.
         That would be the ideal place for Ruth. It was a modern hospital. And we could observe her. Like they say, something is going to give.
         Mother turned up. She did look like a social worker. She explained that if this was a hysterical gesture she did not want the girl to think that she could do something like this and get her attention.
         But that was not how I saw it. No, this was no textbook case.
         It was very interesting talking to mother. Half the time I was talking to a colleague and the other half to a very frustrated modern woman married to a very strictly religious man.
         She and her husband were at college together. They were idealists. They were CND members. They marched against this war and that and eventually he studied theology and she, social work. Ruth was a perfect baby, bright and cheerful. She was their only child. She obeyed all rules and she was diligent.  She was every mother’s dream. She was cute, charming, clever and full of life, never demanding in any way and had always been the top achiever in everything she did, academic or sport. She had quite a following in school and what happened came as a shock, and a serious shock to a boarding school.
         A religious boarding school.
         Such behaviour could be infectious and more so when a natural leader did it.
         This is particularly true of psychiatric patients and more so adolescents in an institution. Some years ago a colleague’s two daughters sadly committed suicide one after another in a boarding school.
         I had to come up with a solution.
         A friend once said to me, “You often have to do certain things when a patient is referred to you, not because it is necessary for the patient, but because it is important for the referrer, the parents or the people around the patient.”
         I could not leave Ruth in the boarding school. I could not send her to a mental institution. So I had to admit her to the paediatric ward.
         Mother agreed. Matron was most relieved. Ruth of course would not object. I felt happier getting her out of that rather imposing place.
         An MRI did not reveal any lurking growth and you would be surprised how many parents would have been disappointed with that. Luckily not this mother.
         Ruth became extremely helpful on the ward assisting with the younger kids distressed by their ops and she would be patiently reading them stories. Schoolwork was sent in regularly and I did not think she suffered much from being absent.
         Visiting was rather restricted, not by the hospital but by the school for obvious fear of contamination, contamination of the minds of the innocent ones.
         She soon revealed the figure she saw was that of her father. She said she was afraid to tell me before.
         Now I understood the reasons I never once saw father. 
         She told me that over an extended period of time she would be shut in with him in an under-stairway cupboard when he would recount biblical passages of hell and damnation. The idea was to give her a real taste of hell. 
         “Why was it necessary?” I wondered to myself, “Why do this to a girl who by all standards is perfect?”
         I wish I knew and I wish I had made up the story. But real life could be very strange indeed.
         With her permission, I brought mother in and she started crying when Ruth said, “I told him.”
         Mother assured me later that she did not think there was any sex abuse but it did cross her mind that all the dramatic teaching of Revelation might have something to do with her daughter’s hearing voices and especially those of her father.
         At that time I had just come back from Peru, with images of Juanita[1] still fresh in my mind.  The tribal rituals of virgin sacrifice in the Andes, visions and religious fanaticism suddenly took on a new meaning.
         She respected her father and what he said had to be done, even if it was hallucination.  Sacrifice would be nothing and if she was to go to heaven anyway, she would have avoided the torture of hell.
         I continued to see her and her mother. We seldom talked about religious matters, but more about studies, literature, sport and current affairs. Father never came to any of the appointments.  I did not force him to come to see me. I believe it was sometimes more revealing to let things unfold. Often things that did not happen told a story too.
         There were two more sightings of the devil but she was not distressed.
         I never pronounced any judgment on the origin of her symptoms and school soon gave up asking me. There was an unspoken understanding with Ruth and mother and I preferred to leave it that way. I felt that my job was not to destroy but to help recovery.
         Was it ethical? Could I have missed what is called Satanic Abuse? We do know what happened to some of those who were so sure of their views of abuse. How much harm was caused? How many children were wrongfully taken away never to return to their parents?
         Of course doctors could be wrong and of course my views might change in time but for now things were working out. 
         Bad parents are generally easier to deal with. It is easier for children to know from early on that they are better off not taking any notice of them and they will, at least the resilient ones will, survive. Many children of psychotic parents become independent and tough from an early age. “Good parents”, on the other hand, are more difficult to handle and if they already have a position in society, what are the poor children supposed to do?
         Ruth had been sheltered in her upbringing. She was not streetwise and staying in a highly religious institution, she did not have the chance to mix with any rebellious children.
         As a first born, she followed rules and orders.
         I continued to see them.  Later, without any direct instruction by me, mother worked out that it would be better to move her from her current school to another church school. This one was less austere and the focus was more on education than on religion. She blossomed and now as she was not boarding, she began to go out and meet boys. Soon enough she was dating a boy. With mother’s help they kept this from father whom I still had not met. She achieved some exceptional GCSE results, moved on to a state sixth form college which her now boyfriend also attended. He wanted to be an engineer and she was aiming for languages.
         She went on the pill and father still had no idea she had this boyfriend.
         Her A Level results were straight A's and she got her place at a top university. She came to see me during the Christmas break.  She settled in very well and was enjoying her course.  I did not ask her about her hallucinations. Sometimes we need to know what not to say.
         Mother left father as soon as Ruth got to university and continued to work as a social worker. Father was transferred to the north.
         Perhaps I should have raised alarms about father.
         I was lucky she came to no harm.
         Sometimes one may not be so lucky.

[1] Juanita (also known as "The Ice Maiden") was discovered on the top of Mount Ampato near Arequipa, Peru, on September 8, 1995 by Johan Reinhard. She was 12 to 14 years old when she was sacrificed and is believed to have died about 500 years ago.
    Although she was frozen in the frigid temperatures on Mount Ampato, her body was discovered because a nearby volcano had caused Ampato's snowcap to melt. The undisturbed site of her burial included many items left as offerings to the gods. Two other children's bodies were discovered near her.

May 30, 2016 ... In The Cockroach Catcher, in the opening chapter I recalled an Anorexia Nervosa patient that has been “dumped” by her Private Health Insurer.

Jun 14, 2016 ... ... of childhood psychological problems. Indeed it was a sad day when the unit closed. From The Cockroach Catcher: Chapter 48 The Last Cook ...

Dec 1, 2015 ... The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers. Some time in early February of 1978 I was called to ...
Apr 25, 2014 ... ... then the Tate also rejected Picasso………” The Tate now of course has several Mondrian works. Now you can read the whole chapter here: ...

Jun 29, 2011 ... 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.

Dec 1, 2015 ... The following is extracted from The Cockroach Catcher: Chapter 29 The Power of Prayers. Some time in early February of 1978 I was called to ...

Jul 20, 2016 ... The following is an extract from The Cockroach Catcher: “Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he ...

Monday, June 19, 2017

Over Hydration!!!

It is HOT! HOT! HOT!

©2017 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. 

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.

“Few afflictions have attracted as much attention and impacted on as many societal and biomedical areas as cholera…….The finding that cholera was due to the ingestion of contaminated water lent to the demise of the prevalent ‘miasmatic theory of contagion, set the platform for the ‘germ theory of disease,’ and promoted the growth of public health concerns for water purification and sanitation. More recent attention to this disease led to the notion of ‘secretory diarrhea’ and the translation of basic principles to the development of oral rehydration therapy and its ‘spin-offs’ (Gatorade and Pedilyte).
Stanley G. Schultz University of Texas Medical School
Cholera is caused by the organism Vibrio cholerae. Alert readers will note that Vibrio has caused much excitement because of the phenomenon of Quorum Sensing.

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 skeptical 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 millionrefugees 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 re-hydration therapy (ORT) as "the most important medical discovery of the 20th century".
NEJM: Marathon Runners:

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. On multivariate analysis, hyponatremia was associated with weight gain (odds ratio, 4.2; 95 percent confidence interval, 2.2 to 8.2)....


Loquat, Winter Melon & Sapote

Germany: Health Care & Smoking!

Germans contributes 7% of salary before tax and employers match that amount.

In return, patients get access to care which is so rapid that national waiting data is not collected.

Germany's spending on health care is relatively high, just over 11% of its wealth, compared to 9.8% in the UK and it has more doctors and hospital beds per patient than the UK.

The Caesarean rate is higher, so is the use of MRI for diagnosis and the length of hospital stay.

Many doctors in Germany set up in practice on their own, as GPs or out-of-hospital specialists, but as cities are more popular that leaves rural areas with a shortage.

Most patients feel they can see a doctor easily, so for example the number of visits to the equivalent of A&E is very low compared to the UK.

While out of hours care has been reorganised, GPs and other out of hospital doctors are often still involved in helping provide cover on a rotation.

All Photos: 

©2017 Am Ang Zhang 

Apart from Greece, they have the highest % of smokers in the First World and they are between 20 to 24. Patriotic??