Sunday, July 30, 2017

Medicine & Orthodoxy: Heresy & Knowledge!


It is often inconceivable that a small bird of the warbler family can play host to the Cuckoo, which obviously outsizes it by at least three to four times.


Collared Redstart©2008 Am Ang Zhang
This picture was taken in Panama, famed for the abundance of different bird species and as far as I know there are 14 species of Cuckoos in the country.

“It is as foolish to chuck out the old as it is to fully embrace the new.” 

My early guru was referring to the changes happening in the field of psychiatry as the new benzodiazepines were being introduced. How right he was and the same view could well apply to other branches of medicine as well as psychiatry today.

“There is much we can learn from the past. One may even save a life.” 
A Brief History of Time: CPR (Cardiopulmonary Resuscitation)
We have come full circle to some ancient Chinese CPR practice going as far back as 403 B.C.




I mentioned in passing in my book “The Cockroach Catcher” Jenner’s observation and the stir it caused. When I visited his home in Glouscestershire, the curator of the small museum, who was extremely knowledgeable, took pride in telling us how Jenner’s great work on Cowpox vaccination upset the medical establishment on the one hand, and how his observation on the murderous ways of the Cuckoo newborns upset the gentlemanly world of the Ornithologists on the other. It was the Royal Society that awarded him a Fellowship for his keen observation.


©2015 Am Ang Zhang
His work on Cowpox vaccination in the prevention of Smallpox was met with hostile responses. The medical world that was dominated by London at the time could not accept that a country doctor had made such an important discovery. Jenner was publicly humiliated when he brought his findings to London. However, what he discovered could not be denied and eventually his discovery was accepted – a discovery that was to change the world.


It is worth having another look at Brian Martin’s view on:
Dissent and heresy in medicine.
 

Social Science and Medicine, vol. 58, 2004, pp. 713-725.

Brian Martin is Professor of Social Sciences in the School of Social Sciences, Media and Communication at the University of Wollongong, Australia.

Brian uses models on politics and religion to illustrate the model of orthodoxy versus dissent/heresy. You can read his views here.

He noted that challenges from the inside - heresy and dissent - are far more threatening to an establishment than outside challenges. This is true of all establishments, not least medicine.

But why should it be? In a more co-operative environment, these differences become opportunities for learning. Medicine in particular will not progress if all dissenting views are suppressed and smallpox may have indeed killed for another 20 or 30 years or more.

After the discussion on politics and religion he turned his focus medicine.
He then analysed some methods of domination in medical research:


• State power
• Training
• Restriction on entry
• Career opportunities
• Research resources
• Editorial control
• Incentives
• Belief system
• Peer pressure


“Training to become a doctor is a process of enculturation and indoctrination. The heavy work-load of memorisation and intensive practical work discourages independent thinking.”

“Examinations provide a screening process that encourages orthodoxy. For those who pursue a research path through the PhD, the process of writing a thesis or dissertation further weeds out those who might challenge orthodoxy. Some dissidents and even fewer heretics may slip through the training and credentialing system, but then there are few desirable career paths.”

“In order to have a chance, dissidents and heretics need to understand that science and medicine are systems of knowledge intertwined with power, and that if their alternative relies entirely on knowledge, without a power base, it is destined for oblivion.”

FremantleMedical Heresy & Nobel

Peptic ulcer – an infectious disease!
In 2005, Nobel Prize in Physiology or Medicine went to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study.
In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now firmly established that Helicobacter pylori causes more than 90% of duodenal ulcers and up to 80% of gastric ulcers. The link between Helicobacter pylori infection and subsequent gastritis and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies.
Difficult 10 years:
The medical establishment was difficult to persuade - everyone accepted that ulcers were caused by acid, stress, spicy foods, and should be treated by drugs blocking acid production. The big Pharmas were not happy to see any change as patients will have to take medication for life.


He went to the US to try and persuade the US doctors.

A big battle was still going on. I went to America to fight the battle there, because unfortunately the American medical profession was extremely conservative: ‘If it hasn’t happened in America, it hasn’t happened’. We needed people in the United States to take the treatment which we had developed.



“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. Dry Falls-Thinking Outside The Box


Also, thinking out of the box can be a good idea. Sometimes it’s better not to know all the dogma, all the things about a very difficult disease. If it’s very difficult, that means people have been working on it for years and they haven’t figured out the cure, which means they haven’t figured out the cause. So having all that knowledge that’s been accumulated in the last 10 or 20 years is really not an advantage, and it’s quite good to go and tackle a problem with a fresh mind when no-one else has had any luck.
                                                                                      Barry Marshall




From a doctor friend:

The Cockroach Catcher has evoked many images, memories, emotions from my own family circumstances and clinical experience.

Your pragmatic approach to problem solving and treatment plans is commendable in the era of micro-managed NHS and education system. I must admit that I learn a great deal about the running of NHS psychiatric services and the school system.

Objectively, a reader outside of the UK would find some chapters in the book intriguing because a lot of space was devoted to explaining the jargons (statementing, section, grammar schools) and the NHS administrative systems. Of course, your need to clarify the peculiar UK background of your clinical practice is understandable.

Your sensitivity and constant reference to the feelings, background and learning curves of your sub-ordinates and other members of the team are rare attributes of psychiatric bosses, whom I usually found lacking in affect! If more medical students have access to your book, I'm sure many more will choose psychiatry as a career. The Cockroach Catcher promotes the human side of clinical psychiatric practice in simple language that an outsider can appreciate. An extremely outstanding piece of work indeed.           More>>>>

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Thursday, July 27, 2017

The Hong Kong Paradox: Poor Air Quality & Longevity.


We all know about the French Paradox by now and basically, by right the French for what they eat should have the highest heart disease rates despite their fondness of cheeses and dare we mention Foie Gras. At least we now have some idea that it was the trans fat that is the culprit. Then there was a hint that it could be the red wine and when a programme was shown in the US, within a year, red wine sale went up 44%. The rest as they say is history.

What about the Hong Kong Paradox?

No, I am not talking about SIDS, yes, it was a bit of a paradox. Nor am I talking about the low infant mortality rate of 1.3 per thousand. That would be seen as a paradox from the point of view of countries like US or UK. Well the paradox is that the doctors used to be trained in specialism in the UK.

But unlike red wine, I doubt if anyone is going to take up this paradox.

On a good day in Autumn© 2013 Am Ang Zhang

As China is now the main manufacturing country for the rest of the world, it is only obvious that its factories pump out all sorts. Hong Kong in the autumn and winter months suffer from serious air pollution. Every medical research would confirm your suspicion, it is bad for health. But wait:


Hong Kong’s women and men enjoy the longest life expectancy in the world, according to data released by Japan’s health and welfare ministry on Wednesday.

The average lifespan for women in Hong Kong is 87.32 years, and local men on average can expect to live to 81.24. Japanese women took second place at 87.05, while Icelandic and Swiss men shared the second position in the men’s category at 81 years.

The overall life expectancy gap between women and men fell by 0.07 year last year, compared with the previous year’s figures.

Polluted air anyone? Good for longevity.



The famous new bridge in Autumn © 2013 Am Ang Zhang
By the way, there is no tax on wine in Hong Kong. Perhaps that is why!!!

Sunday, July 23, 2017

Music & Knowledge: Mozart & Brain!


© 2005 Am Ang Zhang
As the cock crowed, the grandfather left the house on his half mile walk to the little park by the river for his morning Tai Chi with a group of seniors. He was in fact the leader of the group and it fell upon him, a young looking 83 year old to go through the sequence of Tai Chi moves that had been passed down by his grandfather and others before him. His wife sometimes accompanied him but today she had to baby sit the grand-children as their parents were on an early shift. When they finished they sat around for some social chat and drank green tea from their thermal flasks. He walked home refreshed from the morning’s exercise and social gossips. As he neared home he could hear his grand-daughter practicing the piano. What lovely Mozart! He stepped into the house to find his grandson busy at a Nintendo game.

“Why aren’t you practicing your violin? If you just play computer games, your brain will turn into water.”

His grandson shut down the Nintendo, “Grandma, you should try it some time. It will be good for your brain.”
 “I am too old for it. My brain is all water anyway, according to grandpa!” She just remembered that she had to take her Ginkgo capsules.


The grandson played some scales on the violin and then the Vivaldi A minor. From memory, as that was how he was trained.

At breakfast, the young children listened to Grandpa reciting ancient classical Chinese poems - a long standing family tradition. Soon the grand-children left for school.
Grandma now cracked some walnuts while grandpa got ready to go to the market to see what fresh fish he could buy that day. The walnut was to go with their home reared free range chicken. They grew their own vegetables too.

Later that day they would be having a good game of Mahjong with a retired couple.

Much of what they did would help to maintain their brain fitness.

Ginkgo biloba with its romantic botanical history is no longer the Dementia buster it promised to be. (Those who know of the village in Japan where there are loads of Ginkgo trees could have told you that. The village has the highest Alzheimer rates in Japan.)

I was reminded of Woody Allen’s film, Radio Days, where the young Allen (who else) was brought before the Rabbi by his mother for his advice because Allen was hooked onto the radio. The Rabbi’s skepticism was perhaps not that dissimilar to ours nowadays about iPhones, computer games and brain exercises. Indeed the young Allen should be concentrating on his upcoming Bar Mitzvah and the Torah memorizing.

The Old views on Brain.

When I was training in London in the 70s, I spent some time at Queen Square. Those in the know will recognize it as the place for neurology this side of the Atlantic. It was drilled into us then that sadly we were given a number of brain cells when we were born and it was all downhill from then on or something to that effect. It was well known that neurologists were great diagnosticians but for most neurological conditions, not much could be done. How depressing indeed. Even as recently as four weeks ago, I heard a young doctor told his father that there was nothing he could do with his brain cells. One is given so many at birth and no more can be expected. Lord Brain (1895-1966) would have been so proud.

Yet it was also London that shook the world with new discoveries about the brain, and the study was on the most unlikely group of people: Taxi drivers. Their “KNOWLEDGE” was the basis of our knowledge on brain plasticity today. The “KNOWLEDGE” is a term officially used to describe the test the Taxi Drivers had to take to get the licence to drive Taxis in London. Streets in London have evolved over time and are not on any grid system at all. Early postmortem examinations led some pathologists to note the small size of the Taxi drivers’ frontal lobes. Yet actual weight measurement showed that size was all relative. It was the enlarged hippocampal region that created that impression. Later work using modern scanning techniques confirmed the early impressions.

If two to four years of “KNOWLEDGE” acquisition can change the size of the brain in a grown adult, what else could we do?

The rest, as they say, is history.



The book covers the changes to the brains of musicians and medical students. It tells us that just three months of memory work can have noticeable effect on the brain of medical students, and music memory work has similar impact on musicians. I was pleased to learn that Bilingualism helps too. From infancy, I and my siblings were brought up with speaking two Chinese dialects at home.

Will medical schools that have abandoned traditional teachings please bring back Anatomy-the old way?

Mozart & Music
Is the piano China’s answer to the problem that is facing many parents in the west, i.e. ADHD? Could it be a novel substitute for Ritalin and other stimulants? With the advent of unproven modern approaches to education at all levels, very few subjects require memory work. Yet in the last decade or so, memory work has been shown to be beneficial to “brain power”, leading to a whole new approach to neuroplasticity. Learning a musical instrument is one way to give the brain the right amount of training. 

Did the 300,000 or so that took up piano this year in China know a thing or two about brain plasticity? Currently 30 million children are reported to be learning the piano in China.

For now, just as the west is abandoning classical music training as part of the school curriculum, parents in China are paying for their children to have piano lessons. By some reckoning, North America probably consumes 90% of Ritalin and similar stimulants, whereas China is probably consuming 90% of the pianos produced. One factory in the south of China is currently producing 100,000 pianos a day.

As a child psychiatrist, I find the ones on ADHD showed great promise but I doubt if we are ever going to see the end of the stimulants’ hold on the condition in the West. It is interesting to note that Stimulants never took off in China, a country with a fifth of the world’s population. Computer games, on the other hand, have really taken off there.

Bridge and Sudoku were mentioned in passing, along with other favourites like crosswords. There is no mention of Mahjong although in the East it is all the rage, nor the memory work required in some religions. Their gods might know a thing or two about the brain.

Mozart's birthday: 27 January 1756


Thursday, July 20, 2017

Proms: Finland & England.

The Proms has just started. And what a start. Sibelius will feature prominently. As the Cockroach Catcher started his listening career on Violin Concertos, it was doubly exciting to hear Lisa Batiashvili’s (1739 Guarneri del Gesu violin) exhilarating Sibelius Violin Concerto.

© 2012 Am Ang Zhang


From Finland:


March 13, 2015
Helsingin yliopisto (University of Helsinki)

Although listening to music is common in all societies, the biological determinants of listening to music are largely unknown. According to a new study, listening to classical music enhanced the activity of genes involved in dopamine secretion and transport, synaptic neurotransmission, learning and memory, and down-regulated the genes mediating neurodegeneration. Several of the up-regulated genes were known to be responsible for song learning and singing in songbirds, suggesting a common evolutionary background of sound perception across species.
Listening to music enhanced the activity of genes involved in dopamine secretion and transport, synaptic function, learning and memory. One of the most up-regulated genes, synuclein-alpha (SNCA) is a known risk gene for Parkinson's disease that is located in the strongest linkage region of musical aptitude. SNCA is also known to contribute to song learning in songbirds.
"The up-regulation of several genes that are known to be responsible for song learning and singing in songbirds suggest a shared evolutionary background of sound perception between vocalizing birds and humans," says Dr. Irma Järvelä, the leader of the study.

In contrast, listening to music down-regulated genes that are associated with neurodegeneration, referring to a neuroprotective role of music.
"The effect was only detectable in musically experienced participants, suggesting the importance of familiarity and experience in mediating music-induced effects," researchers remark.

The findings give new information about the molecular genetic background of music perception and evolution, and may give further insights about the molecular mechanisms underlying music therapy.
                                                      

But:



The Guardian:Why we are shutting children out of classical music.
April 2, 2009 Tom Service is a 33-year-old classical music critic. For 25 years of concert-going he found himself to be amongst the youngest in the audience.

But there is something else that is strange:

“I've noticed that bus and train stations now pipe canned classical music, day-in, day-out, through their speakers as a way of stopping young people hanging around. So toxic have the associations become, that this experiment actually works: there is evidence that playing Beethoven and Mahler has reduced antisocial behaviour on the transport network.”

He went on:

“An entire generation, aged between 10 and 30, seems radically disenfranchised from classical music. How, and when, did this happen?”
Then in Finland:

“A couple of years ago, I saw a class of seven-year-olds in Helsinki enthusiastically learning Finnish and maths by performing sophisticated little songs with astonishing tuning and rhythm. And this wasn't a music school - just a typical Finnish state primary. Finland only developed its curriculum in the postwar period, but it works: today, the Finns are classical music world-beaters, and their education system has produced more great instrumentalists, conductors and composers per capita than any other country on earth.”

Esa-Pekka Salonen is of course the Principal Conductor of the Los Angeles Philharmonic Orchestra and Finland’s most famous music export in recent times.
I was at a concert recently and a large numbers of players in the orchestra were Koreans. Well apart from steel and TV and cars, the Koreans are now into golf and music in a big way. The LPGA is certainly dominated by Koreans. Could it be that music gave them the edge in golf as well, not just the chopsticks?


Tom again:

“Here is a ready-made answer to the problems of renewing classical music's role in society. Make them statutory requirements for every local authority, and give them the responsibility for rebuilding the network of classical musical possibility that used to resound throughout the country.”
And perhaps throw in golf for good measure.

It was in 1990 that American troops played deafening pop and heavy metal music day and night outside the Vatican Mission to Panama City that Noriega surrendered.


In future, this strategy might have to be changed, Beethoven, Mahler and God forbid even Bach.


Tom Service’s last words:


“We've already lost one generation - we can't afford to lose another.”


Old and New: Multiple Sclerosis & Elgar
The Ring: Child Psychiatry & Human Behaviour
Nobel: Kandel and Lohengrin
Lohengrin: Speech Disability, Design & Hypertension
Easter Passion: Bach, Beethoven and Mahler
'The Knowledge' and the Brain


Monday, July 17, 2017

Portraiture: Rule Breaking!

© 1998 Am Ang Zhang
"You must never shoot up the nostrils!"

Strange I should win the Club's Portrait Competition!

Hasselblad/150mm lens.

Film: Kodax TMax 100

Printed on Record Rapid paper/ Selenium Toned

Selenium Toning is for archiving prints and imparts a lovely tone depending on concentration.


Link: Silverprint
Photography: