How to Kill a Football Player

January 26, 2009

The above is the title of a paper publisher by Jim Knochel in 1975 – (Knochel J.P. Dog days and siriasis. How to kill a football player. JAMA 1975 23:513-515). It immediately became a classic. The reason I bring it up in the depths of winter is because of the criminal indictment of a Kentucky football coach in connection with the death of one of his players from heat stroke.

The pathophysiology of heat injury has been understood for decades. The death of an athlete from heat injury is always preventable yet it still happens. Even the National Football League is not immune as the death of Korey Stringer shows. The lawsuit resulting from his death was just settled.

Knochel was and is the world’s leading authority on heat and exercise induced muscle injury. He spent years studying the factors which cause muscle injury. He used this experience to outline exactly how lethal heat injury occurs in football players. His point was, of course, to show how not to kill a football player. Interestingly, Knochel himself had played football. If my memory is correct he was a fullback and a line backer.

Heat injury (heat stroke is it’s most extreme incarnation) is far better prevented than treated. In football players almost all of heat related injuries occur in August. This is when football practice starts. The players after a long layoff are apt to be deconditioned. The weather is likely to be hot. It takes about two weeks of gradually increasing exercise to become heat acclimated.

Football practice should start at the coolest part of the day. Early morning is the best time. The duration of practice should initially be brief and gradually increased. Fluids should be freely available and fluid intake encouraged. But coaches and players should be aware that fluid losses cannot be fully replaced while the practice is underway. It may take a day for all the loss to be replaced. This is because losses continue during the practice and because blood flow is diverted from the gut to the muscles during exercise slowing fluid absorption.

Loose fitting clothing should be worn during the period of acclimation. Sweating and evaporation are what cools the athlete. Full uniforms should not be worn during hot weather. Drugs which cause vasoconstriction and decrease sweating (eg amphetamines) should be avoided. Practices when the humidity is very high should be curtailed. The higher the humidity the less evaporation and less cooling from sweating.

Heat stroke can develop suddenly if extreme care during exercise in hot weather is not taken. Heat cramps and heat exhaustion are milder forms of heat injury. These too are preventable. Sports Medicine Australia has a policy statement that covers the problem in detail and which is well referenced. This is a problem that has been solved. No football player should die from heat injury.

Preventing heat injury in sports

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Orfeo Ed Euridice in HD

January 25, 2009

orfeo-ed-euridiceGluck’s opera received its 91st performance at the Met on Saturday January 24, 2009, it’s first was in 1885. Ninety one performances over 124 years puts Gluck’s opera in a special category. Is it a masterpiece that somehow frequently gets forgotten or is it a castor oil opera? Orfeo ed Euridice is not hard to cast. There are only three soloists. None of these three parts is very difficult. So why is it performed so infrequently?

I think the opera is close to being a castor oil opera – ie, take it even if it tastes awful; it’s good for you. Critics and conductors are always forcing operas on the public that the public either avoids or attends just to appear enlightened. Examples of such operas are Wozzeck, Lulu, Pelléas et Mélisande, and anything by Britten other than Peter Grimes. All new operas written over the past half century belong to this category. Opera is either a dead art form or is in a extraordinarily protracted barren stretch. Only the appearance of a genius will prove it’s not deceased.

Back to Orfeo. It has some real virtues. First it’s short. The Met did it (the 1762 version) in about 90 minutes with no intermission. It has a great part for a mezzo-soprano (castrati are in short supply right now). The music is uniformly good. I know that’s a terrible thing to say about a classic opera, but it’s true. It has a stateliness and a refined grace about it.

The singers were outstanding. The opera belongs to Orfeo who is on stage virtually all the time. blythe-orfeoMezzo-soprano Stephanie Blythe sang the part with complete vocal control and beauty. The audience loved her. The opera’s most famous number “Che farò senza Euridice” would have brought tears to Berlioz’s eyes. He, of course, was Gluck’s most rabid fan. While Berlioz could conjure a passion about almost anything, it’s hard to be passionate about Gluck. He elicits admiration rather than love. Blythe who is a large lady looked pretty butch in a dark suit. She used a guitar instead of a lyre to get by the furies.

Danielle de Niese

Danielle de Niese

Danielle de Niese is a very young American soprano who was born in Australia. Though only 28 she’s been singing at the Met since 1998 – mostly very small roles. She sang Cleopatra in Handel’s Giulio Cesare at the Met in 2007 and is Euridice in this run of the Gluck opera. She’s so beautiful that you can understand why Orfeo is ready to go to hell and back to change her from a spirit to a flesh and blood woman. She was dressed in a white shmatah that looked like a shredded wedding gown. It didn’t matter she looked great in it. Her singing was as good as her looks. She has a supple lyric soprano that holds great promise.

The last character in this brief opera is Amor. She’s the deus ex machina that runs the plot. There really isn’t much of a story here. It’s so slender that I won’t bother with it. Amor was sung by Heidi Grant Murphy who looked like Fritz Frelang had designed her. She wore a pink shirt and a pair of little wings. I expected to hear Mel Blanc say “I taut I taw a puddy tat” when she opened her mouth, but instead heard a pleasant soprano.  She was lowered by a cable during her first entrance. Actually, she looked like a life-sized rubber ducky.

Choreographer Mark Morris directed and choreographed the dances. A self proclaimed “Old opera queen” – that’s what he said about himself when interviewed by Joyce Di Donato (who is a very good interviewer) before the show – did better with the staging than he did with the dances. The latter looked more like calisthenics than dancing or maybe it was Tai chi. Whatever it was that the dancers where doing it most closely resembled exercise.

The chorus was pretty odd as well. They were placed on three tiers of platforms. What’s with the Met and bleachers? They seem to be in every production this year. Doesn’t a carpenter there have a new idea? Each chorister had his/her own costume representing some figure from history; they also were speaking (in addition to singing) MOSL – Metropolitan Opera Sign Language. They’d point, gesticulate, and make bizarre gestures at fairly frequent intervals. They looked like they belonged at an inaugural. Since I don’t understand MOSL I have no idea what they were up to. Maybe they were dressed up and signing to distract the audience from Gluck’s relentless homophony. Handel said that his cook knew more about counterpoint than did Gluck. According to Charles Rosen the cook did.

James Levine conducted with authority. He obviously likes this opera, but he seems to like everything. And if you could take your eyes off them – in this production they should treated like a gorgon – the chorus sang with their usual skill. I hope to live past the Met’s 100th performance of Orfeo ed Euridice, but I wouldn’t bet on it.

The video direction by the same Ms Sweete who messed up the Damnation of Faust was unobtrusive. It was ok.


The Recordings of Enrico Caruso 1905 – 1907

January 22, 2009

Caruso portraitCaruso’s only recording session in 1905 took place in New York on February 27th. He recorded just five numbers. He was again accompanied only by a piano. Though still singing French arias in Italian, the two French selections are the most successful. Caruso’s vocal control was getting more secure. Still he fell back on falsetto in an unexpected place – the end of the Brindisi from Cavalleria Rusticana. Part of the problem was that his high notes still were not properly placed as they would be by the following year. There is a throaty quality to some of them.

Bianca al par di neve alpina (Plus blanche que la blanche hermine) is beautifully sung with the soft passages fully supported. The solo viola is missed; this unavoidable omission reduces the romance’s overall effect, nevertheless it’s the best performed of the five arias from this 1905 session.

By 1906 Caruso had his technique completely under control and was obviously comfortable in the primitive recording studios of the time. This year also marks the beginning of an “orchestral” accompaniment to his singing. The few instruments that the recording horn could pick up added a little bit for the listener and perhaps more for the singer. He also started to sing French arias in that language.

Lionel in Martha

Caruso's caricature of himself as Lionel in Martha

M’appari from Flowtow’s Martha show Caruso in fine form. He sustains a long line and modulates his tone to the demands of the piece. It was a best seller even for Caruso. Incidentally, there’s more to this opera than its famous tenor aria. It deserves more performances than it gets.

His first recording in French was Salut, demeure chaste et pure from Faust. The arias high C is taken as written even though he transposed two other high Cs at the same session down a half tone. The high note is attacked in an unusual way. It starts out almost as head tone but is swelled to almost a full voiced note.

Also new in 1906 were recordings that featured other singers. The first of these, and perhaps the most celebrated, was the duet, with his friend and fellow Neapolitan Antonio Scotti, from La Forza Del Destino Solenne in questora. This is the duet were people were said to have trouble telling the tenor part from that of the baritone so well blended are the two.

Richard Barthélemy

Caruso's caricature of Richard Barthélemy

In December of 1906 Caruso recorded two songs –Triste ritorno by Richard Barthélemy and Ideale by Paolo Tosti. Both are beautifully sung; the former shows off Caruso’s baritone like lower register while the latter is sung with a wonderful line and sweetness of tone. They show the tenor at the start of his vocal maturity and mastery.

In 1907 Caruso recorded two selections from French operas. As they were typically given at that time in Italian, it was in that language that he recorded them. Caruso give O paradiso from Meyerbeer’s L’Africana a virtually perfect reading except for the final release of the aria’s last syllable. His ability to blend soft singing with a clarion tone is brilliantly displayed here. That it’s Caruso singing is instantly realized. The duet from The Pearl Fishers Del tempio al limita – (Au fond du temple saint) with Mario Ancona is as good or better than any that followed. A second performance of Vesti la giubba was put to disc that year. It is more dramatic and powerful than that of 1902. It includes the extended orchestral postlude that concludes the aria.

Caruso’s fully rounded tone from top to bottom is unlike that of any tenor who suceeded him. When I was very young I knew a number of opera goers who had heard Caruso in performance. They all said that his recordings left out more than half of what was there in the auditorium.

More later.


Fitzcaraldo and Opera

January 17, 2009

Somehow I didn’t get around to seeing Werner Herzog’s movie Fitzcaraldo, released in 1982, until now. I thought it was about a mad attempt to haul a steamboat over a small mountain. While moving the boat over the obstacle that separates one river from another is a central part of the story, the film is really about opera.

Everything Fitzcaraldo (real name Brian Fitzgerald which the locals find difficult to pronounce) does is to support his dream of building an opera house in Iquitos Peru which will be inaugurated by his hero Enrico Caruso. Fitzcaraldo lives for opera which perfect because he is mad and opera is primarily a mad art which in turn makes it the greatest of art forms. It portrays people at the most intense moments of their lives when they are more than usually mad. Along the same vein the movie’s director is mad and its star Klaus Kinski is even madder.

The film starts with Fitzcaraldo and his mistress Molly (Claudia Cardinale looking beautiful but unrecognizable because of all the top of the line cosmetic surgery she’s had). Molly runs a brothel; a profession which requires a similar skill set to that needed to run an opera house. They are paddling up to the Teatro Amazonas, which is 1000 miles up the Amazon from the Atlantic in Manaus Brazil, to hear a performance by Caruso. And they don’t even have a ticket. Fitz, which is what Molly calls him, pleads with an usher to be admitted recounting how he’s come 1000 miles from Peru to hear the great Neapolitan tenor. He’s allowed in just in time to hear the opera’s end.

Things get even madder in the opera house. It is, of course, redundant to say anything in an opera house is mad. Caruso is singing in the final trio at the end of Ernani’s third and last act. It’s the moment when he kills himself rather than consummate his marriage to the love of his life.  First Caruso likely never sang in Manaus. Second Ernani was not in his repertoire. And finally Elvira is mimed by a man in drag and sung by a soprano in the orchestra pit. No explanation is offered for this unusual (even by the standards of opera in the jungle) arrangement.

Kinski and Caruso

Kinski and Caruso

Kisnki takes his primitive phonograph almost everywhere he goes and plays Caruso at any chance. He gets to go mad atop a church which gets him thrown in jail for a couple of days. Kinski was particularly good at going crazy. In fact he probably really was nuts. He plays Caruso at a reception which gets him thrown out. He plays Caruso to Indian children – they seem nonplussed. He plays Caruso from the steamer he takes up the Pachitea River. The tenor part of the quartet from Rigoletto calms the normally hostile Jivaro Indians in the region and prevents them from their usual practice of killing outsiders.

Fitzcaraldo’s plan is to move the boat from the Pachitea River to the Ucayali River at a point where they’re only 200 meters apart. (The geography is wrong but this has little to do with illusion and art.) This change of rivers will allow him to travel the Ucayali bypassing their deadly rapids and thus exploit a rubber plantation claim he’s made with the Peruvian government and get rich in the process which will then allow him to fund his opera house. He’ll have to carry the boat back across the heights but that’s for another day. The Indians agree to help him move the boat because they have a plan of their own.

After the Indians help him move the boat over the mountain (it’s really more a steep incline) they cut the boat loose with some of them still on it – to appease the evil spirits of the river. The steamer miraculously gets through the rapids of the Ucayali only to be back where it started from in Iquitos.

The Jivaros being uncivilized are the only sane people in the movie. They are concerned with painting their faces red, killing intruders, and shrinking heads. They have a rational goal and they achieve it. We can’t be sure they like Caruso.

There’s more Caruso singing as the boat spins out of control through the rapids. Back in Iquitos, Fitz sells the boat back to its original owner and with the resultant money, which is really Molly’s as she paid for the expedition, he brings a European opera company to town; they were on a gig at the Manaus house.kinski-and-cigar They arrive playing and singing “A te o cara” from Bellini’s I Puritani. Fitz is jubilant and smokes a cigar and waves his hat. He’s at another opera whose heroine is again named Elvira who goes mad in the next act confirming her standing in Herzog’s masterpiece. Everybody in sight is happy, perhaps in anticipation of Elvira’s upcoming lunacy. Even Molly despite her financial hit is happy or insane if you prefer.

Fitz is the guardian of culture. He’s gotten no where and accomplished nothing and in doing so he (and the film) has achieved transcendance which is why he’s so triumphant at the end. Earlier he made a toast to “Verdi, Rossini, and Caruso.” The whole movie is a toast to them and their few peers.


The Recordings of Enrico Caruso 1902 – 1904

January 14, 2009

young-carusoIn the mid 1950’s RCA records issued a deluxe compilation of many of Enrico Caruso’s recordings. The multi-disc set was enclosed in a faux leather case and contained a well illustrated booklet written (though not with strict accuracy) by the Met’s then assistant general manager Francis Robinson. Since purchasing that collection, I’ve been buying different releases of the same Caruso recordings for longer than the great Neapolitan tenor lived.

Having multiple copies of every recording Caruso made I decided to systematically relisten to them in chronological sequence. Caruso’s relationship with the phonograph was the ultimate in symbiosis. He made the recording industry and it made him the most famous artist in the world.

His first recording session was in a hotel room in Milan in 1902. The 10 recording he made on April 10 of that year are full of miscues and errors of style, but they do show a beautiful lyric tenor that does not have the baritonal richness that characterizes his later work. They were made in one take each which eliminated any chance to fix problems.

Caruso's caricature of himself as Federico Loewe in Franchetti's Germania

Caruso's caricature of himself as Federico Loewe in Franchetti's Germania

Caruso had scored a big success in the premiere of Franchetti’s Germania
the month before he recorded Ah vieni qui… No, non chiuder gli occhi from that now forgotten opera. The Germania aria is much better sung than some of the other more familiar selections from the first session. There’s a sweetness to the voice in this aria that was later replaced by power. The same is true Una furtiva lagrima. He kept Nemorino in his repertoire until the end of his career.

The initial recordings were a financial, if not completely an artistic, success. Accordingly, Caruso made seven new recording – again in Milan – on November 30, 1902. Two were repeats of botched numbers from the first session. The concluding high note of “Celeste Aida” was taken falsetto the first time around and omitted entirely on the second go. He eventually got it right.

Caruso and Giordano

Caruso's caricature of himself and Umberto Giordano

Caruso had created the role of Loris in Giordano’s Fedora in 1898. He recorded  Amor ti vieta with the composer at the piano. He doesn’t end the piece as written but slows it down. A much more effective conclusion which Giordano must have realized since he went along with it. He also recorded Vesti la giubba for the first time. Pagliacci, of course was the role most closely identified with him. In this recording his voice is free and his breath control spacious.

Caruso’s October 1903 recording of Qui sotto il ciel from Meyerbeer’s Les Huguenots shows the further development of his voice. There’s less vibrato and more of the trumpet like tone associated with his voice at full blast. In 1904 he signed an exclusive contract with the Victor company and made all of his recordings thereafter in the United States with the exception of two he made in Milan in April of the same year. He made his Met debut in 1903 on opening night and in effect became the house tenor for the next 17 years.

His first session for the Victor Talking Machine Company was on February 1, 1904 in Carnegie Hall. The first recording he made for Victor was Questa o quella from Rigoletto, the opera of his American and Met debut five weeks earlier. Here the voice is pure lyric. He sings with complete security no longer intimidated by the recording process. Equally impressive and lyrical is the  Siciliana from Mascagni’s Cavalleria Rusticana an opera he never sang at the Met.

Leoncavallo’s Mattinata was the first of the last two recordings Caruso made outside of the US. The composer accompanies him. The song presents no technical difficulties for Caruso. Nevertheless he sings it with the same style and vocal beauty as would the most challenging aria. The second aria was “Je crois entendre encore” from Bizet’s The Pearl Fishers. In Italian Mi par d’udir ancor. It’s not nearly as good as Gigli’s famous reorcing of the piece nor is it as good as Caruso would make it when he recorded it again. The falsetto high note near the aria’s end is poorly done.

More later.


Nephritic Edema

January 13, 2009

Yesterday I mentioned Ludwig Eichna. One of his great contributions to medical pathophysiology was the delineation between congestive heart failure and a congestive state. He built on the ideas of John Peters an Yale. Peters observed that while all measurable fluid compartments in patients with CHF were expanded their kidneys acted as if volume were contracted. He then propounded the concept of effective arterial blood volume (EABV). Patients with CHF have a contracted EABV which explains their salt and water retention.

The concept of EABV was disseminated by Peters great student Donald Seldin of Southwestern Medical School in Dallas and in turn by Seldin’s many students who exerted (and still do) a great influence over modern nephrology.

The article below examines the difference between CHF and a congested state using acute salt retaining glomerulonephritis as an example of the latter. Physicians often have trouble making this distinction though once the concept of EABV is firmly grasped it’s not difficult.

Nepritic edema


Racing Odysseus – Nothing New Under the Sun

January 12, 2009

Racing Odysseus is a book by Roger H Martin. Four years ago Martin took a sabbatical from his job as president of Randolph-Macon College to enroll as a freshman at St John’s College in Annapolis, MD. He was not really a student – he didn’t participate in seminar discussions and he only stayed for a short while.

My only point in mentioning this is that it has already been done in spades by Ludwig Eichna. Eichna was one of the most distinguished academic physicians of the last century. Following his retirement as Chairman of the Department of Internal Medicine at Downstate Medical Center in Brooklyn in 1974 he enrolled as a full time medical student and was awarded a second MD in 1979. No academic dilettante he. He stayed for the duration.

His experience as a second time medical student at a place where he used to be a very big wheel must have been surreal. He published his impression of being a medical student as an old man in the New England Journal of Medicine in 1980. Eichna’s capacity for punishment seems to have been limitless.

So if you’re retired and bored, if the senior’s center is too slow for you – go to medical school. It’s a lot easier to get into these days and there’s a cap on work hours. Almost no one flunks out now and solicitude is in every classroom and lab – scratch the lab, medical students rarely see the inside of one nowadays.   Going to medical school is just what the doctor ordered to enliven your golden years. The AARP will soon issue a medical student Visa card for it’s members who choose medicine as a second career. The card will carry a Medicare discount as an extra incentive.

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