The Neutered 23 Psalm

September 28, 2009

The King James version of the 23 Psalm:

The Lord is my shepherd; I shall not want.
He maketh me to lie down in green pastures:
He leadeth me beside the still waters.
He restoreth my soul:
He leadeth me in the paths of righteousness for his name’s sake.
Yea, though I walk through the valley of the shadow of death,
I will fear no evil:
for thou art with me; thy rod and thy staff they comfort me.
Thou preparest a table before me in the presence of mine enemies:
thou anointest my head with oil; my cup runneth over.
Surely goodness and mercy shall follow me all the days of my life:
and I will dwell in the house of the Lord for ever.

The Gender Corrected Version of the same:

You are my shepherd, I shall not want
I lie down in green pastures
and am lead besides the still waters.
My soul is restored.
You guide me on my way
Yea, though I walk through the valley of the shadow of death,
I will fear no evil.
For you are with me.Your rod and Your staff, they comfort me.
You have arranged a table before me
in the presence of my enemies.
You have anointed my head with oil, my cup runneth over.
May goodness and mercy follow me all the days of my life;
May I dwell in Your house forever.

Res ipsa loquitur

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A Nap at the Opera

September 25, 2009

We are the stuff as dreams are made on; and out little life is rounded with a sleep.

Guilt and shame – those daggers of self destruction. Once you’re over them you’ll find that nothing is as restful and conducive to revitalization as a sleep in the opera house. A proper operatic snooze is better than a day at a spa and cheaper as well. I might as well get it out in the open – I’ve been sleeping through operas for decades. I can hear you saying “So what’s new? We could tell that by reading your reviews.” But as we age we feel the need to confess our secrets.

One might reasonably suppose that Wagner’s operas are the most suitable for sleeping, but you’d be incorrect. If you chose the wrong one you’ll have nightmares and wake up with a panic attack. Lohengrin and Die Walküre are the only Wagner operas I think that one can expect pleasant dreams from. Why? I don’t know. Why does one photon go through a piece of glass while another is reflected?

The only composer really dangerous to the operatic napper is Debussy. I’ve only been to one performance of Pelléas et Mélisande and being young and inexperienced I soon fell asleep. The next thing I knew I was in the Metropolitan emergency room – the hospital not the opera house. I was strapped to a gurney, a central line was in, two IVs were running full out, I was intubated, and connected to a heart monitor. I was told that I had died twice, but had been brought back each time. Being young I soon recovered and regained full health, but I never went anywhere near Pelléas et Mélisande again.

I subsequently learned that reactions like mine were relatively common in people foolish enough to nap during Pelléas et Mélisande. In Pelléas sensitive subjects sleep can induce a full fledged anaphylactic reaction. Even worse is that all American health insurance policies carry a Pelléas exclusion, thus if you end up in the ER because of sleeping during the opera you have to bear the full expense of treatment. Most people don’t know that. Europe’s government subsidized health care systems may pay for a Pelléas reaction – I don’t know. The Canadians will pay for anything; they’ll just make you wait 18 months. That Debussy never completed another opera likely contributes to the increase in life expectancy characteristic of the 20th century.

Mozart is a mixed sleeping bag. I’ve dozed through all of Idomeneo and La Clemenza di Tito and awoken refreshed knowing that I’ve missed nothing. The Da Ponte operas are hard to sleep through, though there are few spots in Le Nozze di Figaro where I’ve had a few winks. The same is true of Die Zauberflote.

Mature Verdi offers little to the furtive dozer. The first act of the five act version of Don Carlos presents an opportunity, but you’ll want to stay awake for the rest of the piece. I suppose you could nap during any five act opera. Of course, there’s always Verdi’s I Due Foscari and Attila to fall back on. The latter is particularly napworthy because there’s not much to disturb you after the beautiful and short prelude. If you plan to sleep through the opera, you might you want to have someone wake you up for “Avrai tu l’universo, resti l’Italia a me.” (You can have the universe, but leave Italy for me.) It has historical rather than musical interest, so you can sleep through it if you wish. But don’t forget all those mid 19th century Italians going crazy and jumping out of balconies when they heard the line. I hope I don’t appear boastful when I declare that I’m one of the few people in the world who’s slept through Attila more than once.

All things considered, Rossini is the composer of choice when you need the honey-heavy dew of slumber, as long as you watch out for the crescendos. More than once I’ve found myself jolted out of my seat by Signor Crescendo. I’ve found that slumping increases my vulnerability to the more raucous of his fortes.

To commemorate the Rossini bicentennial The San Francisco Opera presented a mini-Rossini festival. Cenerentola, The Barber, and William Tell were performed in quick succession. I had delightful naps during the first two of these operas, but was as wide awake as a lamb in a lion’s den during all of Tell. Similarly, I got no sleep at all during the Met’s Semiramide. So, as is true in everything in life, you have to pick carefully which opera you’re going to rest through. Other good candidates for guiltless slumber are Ermione and La Donna del Lago, but they’re not comedies and my knowledge of their hypnotic powers is theoretical as it’s very hard to find a live performance of these operas outside of Pesaro. Sleeping through a recording of them doesn’t have heavy recuperative powers. There’s nothing like a live performance. I’ve also found that the quality of the performance has little effect on its suitability for slumber. Thus, a student matinee is a bargain alternative to the pricey Saturday night gala

While they’re not opera, Schubert’s lieder are almost as good for napping as Rossini’s operas. The more depressing they are the better you’ll sleep. Die Winterreise is far and way the best choice among lieder. I’d stick with Rossini over Schubert, though, because the seats in most opera houses are more comfortable than those in concert halls. We have Wagner to thank for that. Performing Wagner in a hall with uncomfortable seats is a human rights abuse.

Etiquette is important here as in most of human intercourse. Snoring must be avoided which is why I drag my wife with me when I plan to nap at the opera. Of course, how to proceed if both of us fall asleep remains an unsolved problem. It’s important that a companion be instructed not to nudge you just because you’re asleep. A jab in the ribs is only needed if you show signs of imminent snoring (drooping of the jaw and forming your mouth into a circle should be blinking red lights) or if it appears likely that you are about to fall off your seat – another serious breech of etiquette. I once missed a ski trip when I broke my patella after falling out of my seat during Billy Budd. I had foolishly gone to the show by myself convinced I couldn’t fall asleep during Britten and somehow thinking that because I wore my seat belt in my car that I’d be protected in the opera house should the unexpected happen.

I realize I’ve been hard on European stage directors, but I am grateful that they have reduced the number of intermissions, probably because the musicians want to get out of the theater as soon as possible. Five act operas are typically given with just two intervals. Nothing is more annoying than being awakened by an audience stampeding to the bar or the lavatories. I’d be happy if all intermissions were eliminated. Though, going through Parsifal without a break requires the bladder capacity of a horse.

While nothing beats opera, there are other opportunities for short naps. Chamber music by Brahms will put you to sleep faster than ether. Lectures are also good places to nod off. People, however, sometimes get quite huffy when you fall asleep during a lecture that’s keeping them awake. Last week a complete stranger poked me in the back when I was blissfully sleeping through a lecture on — well I forget what it was about. I wasn’t snoring. I checked that out with the guy next to me – after he woke up. She (the lady that poked me) was obviously jealous that I was enjoying the talk more than she was. When sleeping through talks, it’s best to sit in the back where it’s harder to get at you.

I’ve saved Puccini for last. With the exception of the first half or so of Suor Angelica, it’s impossible to sleep through Puccini. It just can’t be done.

Nessun dorma.

Anyone suffering from sleep apnea should stay out of the opera house.

And you’ve been sufficiently warned about Debussy.

Top photo: Dirk van der Lisse (1607-1669): Excerpt from Sleeping Nymph, after 1642. Oil on canvas. Where? – Mauritshuis, The Hague, Netherlands. Source: Web Gallery of Arts.

Originally published April 8, 2005 at Grandi

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Hepatorenal Syndrome

September 22, 2009

The September 24th issue of the New England Journal of Medicine has an excellent review article by Ginès and Schrier on Renal Failure in Cirrhosis. It reviews the pathogenesis of the circulatory events by which severe liver disease compromises renal function. Surprisingly, the authors omit a key step in the pathophysiology of compensated cirrhosis.


Look at the left panel and you see the cartoon go from low effective arterial blood volume to both increased cardiac output and increase blood volume which then restores effective arterial blood volume to normal. What’s left out is the means that allows cardiac output and blood volume to increase, ie transient renal salt retention. Without a period of positive salt balance neither cardiac output or blood volume could increase. There is no doubt that the authors of this piece are fully aware of this phenomenon, it just got lost somehow. But it’s an important event which deserves emphasis. For blood volume to expand, absent an infusion of fluid, the kidney must retain salt. To be precise, the sequence should be low volume, renal salt retention, increased blood volume which increases cardiac output resulting in a new steady state of normal effective arterial volume.

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New Doctors Poll

September 16, 2009

There’s been some back and forth in the comments section of Medicare’s Overhead about what doctors think of the healthcare reforms bills now before congress. It started when I said that I didn’t think many practicing physicians favored any of these proposals. A new poll commissioned by Investors Business Daily says that two thirds of doctors oppose this legislation and that 45% would consider quitting if it passed.

It’s not hard to find a poll that supports your preconceived notion of anything important, but I still think it unlikely that most doctors would support the kind of “reform” that may be forced on them and their patients. An interesting finding is that More than seven in 10 doctors, or 71% — the most lopsided response in the poll — answered “no” when asked if they believed “the government can cover 47 million more people and that it will cost less money and the quality of care will be better.” The other 29% must have flunked math – a subject that has always bedeviled physicians.

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Health Insurance Industry Profits

September 15, 2009

This post was suggested by an article by Mark J. Perry professor of economics at the University of Michigan. In it he lists the profit margins of the top 86 industries in the US. He stops at 86 because that’s the spot occupies by health insurance. If you want to see the complete list you can go here.

It’s become a a popular blood sport on Capitol Hill to demonize health insurance companies. A profit margin of 3.3% seems to suggest only two conclusions – don’t invest in this sector and if you’re in the business consider getting out. Now add to their business model the need to conform to a vast new federal health bureaucracy, new mandates, and a public system of health insurance and what is the likely result? More profits, greater rewards to shareholders, business health and prosperity? Hardly. A public plan will eventually, sooner rather than later, drive the private health insurers out of business.

Here is a quotation from Speaker Nancy Pelosi on the health insurance business.:

They are the villains in this. They have been part of the problem in a major way. They have been doing everything in their power to stop a public option from happening. The public has to know that. They can describe their arguments any way they want, but the fact is they don’t want the competition. They don’t even want anti-trust laws. They have had a good thing going for a long time at the expense of the American people and the health of our country. Our members have to go out there ready to take on a big special interest that has not made our country healthier and have made our cost spiral upward and for whom that is coming to an end.

You’d think that if these malefactors of great wealth were so powerful they’d be able to make a little more money. If they’d made the American medical scene like the plains of Troy during the time of Achilles and Hector why have the spoils of their carnage not materialized?

Then you will know the truth, and the truth will set you free (John 8:32) seems not to apply to politics.

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Recording of the Week – Carmen Suite

September 8, 2009

Schedrin - Carmen Suite
Arrangements of Bizet’s masterpiece are so common that I expect one soon in American Sign Language. In 1967 the Russian composer Rodion Schedrin (born 1932) arranged a suite from Carmen as a one act ballet for his wife the incomparable Maya Plisetskaya. The instrumentation is very unusual – strings and percussion. When the first recording of the work was released shortly after its premiere it garnered a lot of attention. This 2002 rendition is performed by the Chamber Orchestra Kremlin under the direction of Misha Rachlevsky.

Schedrin achieves a dazzling effect with his clever orchestration. When listened to on a very good audio system with the sound turned way up it sweeps the listener away. Here’s part of the piece’s sixth number titled Scene.

The suite lasts a little more than half an hour. The remainder of the disc contains Schedrin’s Four Moscow Photographs and his Glorification.

For a complete list of his work go here.

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Investing For the Long Term

September 3, 2009

Just think about this for a while. In 1969 the Dow-Jones Industrial average was a little shy of 1000. The price of an ounce of gold was about $41 an ounce. Today the Dow is a little more than 9300. Gold closed today at a little more than $990 an ounce. In 40 years the Dow is up about 10 fold while gold has risen 24 times. Thus gold has outpaced the stock market by 240%. Put another way the stock market has lost a huge part of its value to inflation.

When an adviser tells you to invest your retirement money in an index fund show him these data. The only way to make real money in the stock market is to get lucky and invest in a start-up company that hits the jackpot, like Apple, Microsoft, or Berkshire-Hathaway at their inception. The problem is that for every really successful company like the above there are thousands that don’t make it.

So how should one invest? How should I know? This site is about music and medicine.

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