Recovering Nicely.

[Swerd]

Today is the 17th post op day. I came back to the lake last Monday.

The discomfort is subsiding. The only bothersome pain is around the ilio/psoas flexor tendon by the anterior incision.

I fail to understand how the regulatory authorities including the FDA passed off on this. Johnson and Johnson are now knee deep in law suits and will likely go bankrupt in the end. I understand a criminal investigation is ramping up.

Wonderful to read of your excellent post-op experience. I hope your recovery is full.

I'm not defending the FDA, but I can understand how they were slow on the learning curve for what they call "medical devices", a topic much newer than drugs and vaccines. Apparently the all metal hip replacements and J&J's role has been the education the FDA needed. Thanks for the link about Sir John Charnley.

Last night I was at a concert, the Baltimore Symphony Orchestra at Strathmore. The program:

Christopher Theofanidis – Dreamtime Ancestors (a new composition)
Elgar – Falstaff
Rachmaninoff – Piano Concerto No 2 in C Minor – Andre Watts, Piano

There were quite a few Russian speaking members of the audience who were clearly there for the Rach 2 piano concerto. Andre Watts, who may be looking his age (roughly 70?), is still masterful, and he always draws a big crowd. Many of them last night were elderly and some had a lot of difficulty walking. As I watched them, I thought of you and your hip replacement. I'm glad to read of your excellent progress.

The guest conductor was Robert Spano, who has been conductor & music director of the Atlanta Symphony Orchestra for 16 years. He was quite likeable, and I thought the orchestra musicians and Andre Watts also liked him a lot.

 

[TLS Guy]

Wonderful to read of your excellent post-op experience. I hope your recovery is full.

I'm not defending the FDA, but I can understand how they were slow on the learning curve for what they call "medical devices", a topic much newer than drugs and vaccines. Apparently the all metal hip replacements and J&J's role has been the education the FDA needed. Thanks for the link about Sir John Charnley.

Last night I was at a concert, the Baltimore Symphony Orchestra at Strathmore. The program:

Christopher Theofanidis – Dreamtime Ancestors (a new composition)
Elgar – Falstaff
Rachmaninoff – Piano Concerto No 2 in C Minor – Andre Watts, Piano

There were quite a few Russian speaking members of the audience who were clearly there for the Rach 2 piano concerto. Andre Watts, who may be looking his age (roughly 70?), is still masterful, and he always draws a big crowd. Many of them last night were elderly and some had a lot of difficulty walking. As I watched them, I thought of you and your hip replacement. I'm glad to read of your excellent progress.

The guest conductor was Robert Spano, who has been conductor & music director of the Atlanta Symphony Orchestra for 16 years. He was quite likeable, and I thought the orchestra musicians and Andre Watts also liked him a lot.

Thank you for your kind words, and everybody else's. They are most welcome.

It sounds as if you went to a wonderful concert.

Elgar's Falstaff is a wonderful piece and not often done. Elgar is finally starting to be programmed around the globe now.

Daniel Barenboim who gave excellent performances of Elgar's first and second symphonies this year, was complaining that Elgar is always referred to a the English composer. He says Brahms, for instance, is never referred to as the German composer. Anyhow I'm glad you enjoyed it all.

Finally I'm not prepared to give the FDA the pass you are. The real issue is that far too many know too much about too little. Anyone who has ever taken an engine apart would know instantly how absurd a concept an all metal hip prosthesis is. There is soft white metal interposed between main engine bearings and all the piston rod bearings. If not the engine would be lucky to run for an hour.

Which brings me to my final story as how I got to be a physician. Well in the Christmas break the professional colleges put on programs to help children decide about careers. I did the rounds in 1962.

I went to the Institute of Mechanical Engineers, the institute of Electrical Engineers and to the Royal College of Surgeons. It happened the then President was Lord Russel Brock. He was one of the great pioneers of heart and lung surgery, and later to be a great mentor to me.

He did not put on a show about his specialty of cardio thoracic surgery, but talked all about hip surgery and Charnley's work. It was a wonderful program and I was sold.

So I applied and got interviews at Charing Cross Hospital, the Middlesex Hospital and Guys Hospital.

The Charing Cross interview was nondescript and hard to read. The Middlesex was a "fake out job." All the physicians were in casual clothes, a lot of them shoe less with their feet up on the table. It was all sounding me out on the "touchy feely" stuff. I think I did a poor job hiding my irritation. I got prompt rejections from Charing Cross and Middlesex.

Now that summer of the interviews I happened to be doing a top overhaul on the diesel engine in our launch. Carefully as a cleaned up it still left my hands a bit grubby.

So I went to Guys and the Dean Sir Rowan Bolan was cutting a fine figure, and everything seemed as it should be. The sub dean Prof. John Trounce noted that my hands did have a little residual grub on them. He commented on it right away and asked what I had been doing. So I told him about the top overhaul on the boat. He immediately said, "That is just what we need in medicine, people who can fix things!"

I received an acceptance letter in short order. I believe Professor Trounce was entirely correct.

 

[Swerd]

Elgar's Falstaff is a wonderful piece and not often done. Elgar is finally starting to be programmed around the globe now.

Daniel Barenboim who gave excellent performances of Elgar's first and second symphonies this year, was complaining that Elgar is always referred to a the English composer. He says Brahms, for instance, is never referred to as the German composer. Anyhow I'm glad you enjoyed it all.

I did enjoy Falstaff. It was unlike anything I've heard. In fact, I don't think I'm familiar with Elgar's music. Is/are there any Elgar cello concertos? I'll look into Elgar 1st & 2nd symphonies.

Finally I'm not prepared to give the FDA the pass you are. The real issue is that far too many know too much about too little. Anyone who has ever taken an engine apart would know instantly how absurd a concept an all metal hip prosthesis is. There is soft white metal interposed between main engine bearings and all the piston rod bearings. If not the engine would be lucky to run for an hour.

I didn't mean to give the FDA a pass. But I do understand how they work in general. When there is new technology, such as a new way to mass produce monoclonal antibodies, the FDA is at first as ignorant as anyone else. They learn from the industry that they regulate. They have long been criticized for this, because it can cause a pro-big pharma bias. In essence they allow the industry to define the state-of-the-art for a new technology, and that definition of state-of-the-art then becomes a barrier to any new smaller start-up companies.

The work I did for a (now defunct) biotech company was audited by the FDA. It was a week-long ordeal, and passing it was essential for our future. They were inspecting the smallish manufacturing facility we had built to manufacture a monoclonal antibody of use in cancer diagnosis and treatment. We did pass. But that later became irrelevant as sufficient financial backing evaporated.

As I shepherded the auditors around it became clear to me that they knew great amounts about clean and sterile air filtration systems, clean steam generation, and sterile water-for-injection generation systems. These functions are common to any pharmaceutical manufacturing, and they've inspected many of them elsewhere. They knew much more than I did. It would have been impossible to pull the wool over their eyes. It was up to us to meet their idea of state-of-the-art, no matter how costly. They asked many questions and probed aggressively until they were satisfied that we were not attempting to hide anything. Later on, after the auditors made it clear that they were going to approve us, they even offered some useful hints about clean steam, air, and water.

But they knew nothing about the central processes that we performed – the large scale cell culture and biochemical purification of large proteins. These processes were essential to the final product and involved much of my effort. I noticed their entire demeanor changed as we covered these processes. Instead of aggressively probing, their questions showed a curiosity and an eagerness to learn. As this was my first FDA audit, I was surprised by the shift in attitude. At the end, I commented about that, and they answered, that's how they learn – by listening to those they audit. I took it as a compliment, smiled, and said nothing further on the subject.

In my example, it worked well for me, but I can see how the same approach might have allowed the FDA's smaller and less experienced medical devices group to give J&J too much credit at the time. It probably took years before the medical adverse effects of the metal hip joints became impossible to ignore.

 

[TLS Guy]

Thanks for that insight into the FDA. So that is just another useless government agency. They could have at least looked at Charnley's original papers. If that had an IQ of at least 80 they would have seen that an all metal implant would be a disaster.

Back to Elgar.

Yes, Elgar wrote arguably the greatest work for cello and orchestra.

The recording to have is absolutely the recording by Jacqueline Du Pre with Glorious John and the London Symphony Orchestra. It is coupled with a wonderful rendition of the song cycle Sea Pictures with Mezzo Dame Janet Maker.

Elgar essentially wrote himself out with this work. The emotions run very deep. Probably no other work exposes such deep emotional waters. It is certainly very much a reflection of loss, which certainly includes the deep losses of the first World War and the changes wrought in British Society for ever changed by this loss and trauma. I also detect a requiem for the loss of melody. There are certainly brief dismissive parodies of that awful bunch the "New Viennese School." I think that crowd annoyed Elgar to the core. It seems as if he thought he was writing some of the last great melodies the world would ever hear, it at least for some time. In a sense he was correct. Pathos and nostalgia for an age passed hang over this work.

In a similar vein Ralph Vaughn Williams wrote his third symphony the "Pastoral". I have written a symphony in four movements all of them slow ones. Actually the symphony is brimming with suppressed rage. The game is clearly given away by a passage with tortured twisted bugle calls.
This is the sort of work the Germans seem incapable of understanding and dismiss this sort of work as what they call "English Cow Pat Music." It just blows right over their heads.

By far the best performance of Falstaff is by Sir John Barbirolli.

The two Symphonies are difficult recommendations. Both Sir Adrian Boult and Sir John Barbirolli left fine versions of both. Sir George Solti left a very fine first.

Daniel Barenboim has just recorded both Symphonies with his Staartskapelle Berlin, to great acclaim.

Symphony No 1.

Symphony No. 2.

I have not heard these discs, but watched listened to and recorded his performances at the BBC Proms this year with the same orchestra. They were fantastic performances

A performance if his Enigma Variations is a must in every collection.

Elgar's greatest work is his Dream of Gerontius. At the end of the score he wrote "This is the best of me."

Sir Simon Rattle ranked it up right along side Mahler's 8 symphony and Berlioz Faust before his Proms performance 2016.

Daniel Barenboim has just recorded that also with the three soloists English speakers. The latter is important as Elgar's scoring is so skillful the voices never get covered by the huge forces involved. It is essential every word is heard.

John Barbarolli left a really good version that has Janet Baker in the role of the Guardian Angel. It is not likely Janet Baker's interpretation will ever be bested. It is the role for which she will always be best remembered. The melody of the Angel's Farewell has to be one of the greatest in all music.

Sir John also turned in the best performance of the Demon's Chorus which is truly terrifying. I've written "One Hell of a Fugue" Elgar wrote to a friend and the pun was clearly intended.

That will be enough for now, it is getting late.