By L. Cole. University of Orlando.

His view seems to be that discount speman 60 pills with visa, normally speaking generic 60pills speman with mastercard, a sensitive impulse is transmitted from the peripheral sense-organs to the heart order 60pills speman fast delivery, where it is received, recorded and noticed, and co-ordinated with movements from other senses (461 a 31). The transmitting agency is probably the blood (although this is not quite clear from the text). The ‘perception’ or ‘noticing’ of these movements is dreaming in the strict sense. Thus dreams originate from weak sense-movements, which have entered the sense-organs in the waking state, but which were not noticed by the perceiving subject because of their weakness in comparison with stronger movements. By explaining the occurrence of dreams in this way, Aristotle manages to account for the fact that dreams often display many similarities with what the dreamer has experienced in the waking state (because they consist of movements received during the waking state), but that these elements often appear in a distorted, completely ‘unrealistic’ configuration due to the physiological conditions that influence the transmission to the heart. In order to substantiate this explanation, Aristotle has to presuppose, first, that the sense-organs actually receive very slight movements and, second, that these small movements are being ‘preserved’ (soizesthai¯ , 461 a 25)inthe sense-organs from the moment of their arrival (in the waking state) to the moment of their transport to the heart and subsequent appearance in sleep. When we look at our list of empirical ‘data’, we can see that numbers 3–9 are used by Aristotle in order to illustrate the mechanism of ‘linger- ing’ or ‘persisting’ sense-movements after the actual perception has disap- peared; numbers 8–9 point to the receptivity of the sense-organs to small 26 See 461 a 25 and b 11, 27. Number 13 serves as an illustration of the ‘extrusion’ of weak movements through stronger ones. Numbers 14–17 are concerned with the physiological conditions that influence or disturb the transport of sense-movements from the peripheral sense-organs to the central sense- organ. Numbers 10–12 and 18–20 illustrate the ‘experiencing’ or ‘noticing’ of the sense-movements by the dreaming subject: the experiences of illusion in the waking state serve as analogy for the fact that the dreaming subject often does not notice that what (s)he experiences is only a dream. From all this we have to conclude that the dream is a sort of appearance, and, more particularly, one which occurs in sleep; for the images just mentioned are not dreams, nor is any other image which presents itself when the senses are free [i. For, in the first place, some persons actually, in a certain way, perceive sounds and light and taste and contact [while asleep], albeit faintly and as it were from far away. For during sleep people who had their eyes half open have recognised what they believed they were seeing in their sleep faintly as the light of the lamp, as the real light of the lamp, and what they believed they were hearing faintly as the voice of cocks and dogs, they recognised these clearly on awakening. The fact is with being awake and being asleep that it is possible that when one of them is present without qualification, the other is also present in a certain way. None of these [experiences] should be called dreams, nor should the true thoughts that occur in sleep as distinct from the appearances, but the appearance which results from the movement of the sense-effects, when one is asleep, in so far as one is asleep, this is a dream. Thus the dream is defined as ‘the appearance which results from the move- ment of the sense-effects, when one is asleep, in so far as one is asleep. These ‘other experiences’ have been discussed by Aristotle in the preceding lines with the aid of examples (462 a 9–15): in sleep we some- times perceive things which on awakening we recognise as being caused by sense-movements that actually present themselves to our sense-organs, and children often see frightening visions in the dark with their eyes open; and as he says in the passage quoted, in transitional states of half-sleep we may perceive weak impressions of light and sound, we may even give answers to questions which are being asked, and we may have thoughts in sleep about the dream image. How these experiences are physiologically possible is not explained by Aristotle, but what he says about them is highly significant in theoretical respect. Sleep and waking are not absolute opposites: when one of them is present ‘without qualification’ (haplos¯ ), the other may also be present ‘in a certain way’ (pei¯ ). In these transitional states between sleeping and waking, we may, after all, have some sort of direct perception of the actual state of affairs in the external world. Aristotle’s recognition of this possibility entails an implicit modification of his earlier assertions in the first chapter of On Sleep and Waking, where he defined sleep and waking as opposites and sleep as the privation of waking (453 b 26–27), and in chapter 1 of On Dreams, where he said that we cannot perceive anything in sleep. It now turns out that we may actually perceive in sleep, though faintly and unclearly. In accordance with his dream theory, Aristotle here insists that none of these experiences ‘in sleep’ (en hupnoi¯ ) are ‘dreams’, that is, enhupnia in the strict sense. A remarkably modern consequence of this view is that according to Aristotle the state of sleeping can be divided into different stages. Aristotle does not show any awareness of ‘rapid eye movements’; but on theoretical grounds he assumes that the beginning of sleep is characterised by an absence of dreams, because then, as a result of the process of digestion, there is too much confusion and ‘turbulence’ in the body, which disturbs the transport of sense-movements through the blood (461 a 8ff. Appearances that manifest themselves in that early stage are not dreams, Aristotle points out: dreams occur later, when the blood is separated into a thinner, clearer part and a thicker, troubled part; when this process of separation of the blood is completed, we wake up (458 a 10–25). Thus dreams are experiences which we have when in fact we are on our way to awakening. Experiences, however, which we have just before or simultaneously with awakening and 186 Aristotle and his school which are caused by actual perceptions – not, such as in dreams, by lingering sense-movements which derive from previous perceptions in the waking state – are not dreams, because we do not have these experiences ‘in so far as’ (hei¯ ) we are asleep, but in so far as we are, in a sense, already awake. This typically Aristotelian usage of the qualifier hei¯ also provides us with an answer to the other question I raised earlier in this chapter, namely why Aristotle does not explicitly address the possibility of other mental experiences during sleep such as thinking and recollection. The answer seems to be that thoughts, beliefs, perceptions, hallucinations, recollections and indeed ‘waking acts’ (egregorikai praxeis¯ ) performed while sleepwalking (456 a 25–6) are not characteristic of the sleeping state: they do not happen to the sleeper ‘in so far as’ (hei¯ ) (s)he is sleeping. They do not form part of the dream, but they exist ‘over and above’ the dream (para to enhupnion).

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The site also has links to education notes purchase 60pills speman amex, calcula- tion spreadsheets and statistical software speman 60 pills without prescription. There is a section on the site that shows how to Useful websites 383 compute 95% confidence intervals around a median values generic speman 60 pills with mastercard. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. International, Padstow Dedication To my late father George McDonald (1918–1983) whose love of words both ancient and modern was as fine a legacy as any son could ask for. This page intentionally left blank Preface The Oxford Dictionary of Medical Quotations is intended to be a rich source of quotations covering a variety of medically related topics. Those selected have been deliberately kept short in an effort to highlight the pithiest phrase or the sharpest insight. They have been selected on the basis of their use- fulness to modern medical authors, journalists, politicians, nurses, physios, lecturers, and even health managers, who will always have need to season their works with the clever or witty phrases of former colleagues whose intuitions still say as much today as when they were first published. Many reflect the compiler’s tastes and prejudices but there will be something for everyone within these pages. Browsing through many texts to find the most appropriate quotations to include in the Oxford Dictionary of Medical Quotations has afforded an insight into both medical history as well as the nature of the doctors and others who have chiselled these phrases. A glance for the casual reader not looking for a specific quote will be rewarding in itself. Quotations are listed under author, with an index of keywords that permits the reader to access a number of quotes with the same keyword. Wherever possible, biographical information about the author and whence the quote originated are included, although it is acknowledged that there are several omissions in this regard. When the original source is not clear, the secondary source has been substituted if it was thought useful for further study for the reader. If the quotation was deened to merit a place in the Dictionary even without full reference being available, it was included. Indeed, it is not necessary for an author to be particularly well known to be in the dictionary if he or she had given birth to a bon mot or a succinct phrase. The majority of the quotations come from the English-speaking medical worlds of Great Britain, Ireland, and North America but several quotes from other rich medical cultures have been included in translation. Whether readers are looking for a suitable quotation on surgery, science, kidneys, or kindness, they should find much here to satisfy. Medicine is both the narrowest and broad- est of subjects, and I have included examples of both the specific and the general. If I have failed to find that favourite concise quote, please send it fully referenced and it will be included in the next edition. Any corrections of birth dates and deaths will be most wel- come and acknowledged in subsequent editions. This page intentionally left blank Contents Quotations  Bibliography  Index  How to Use the Dictionary The sequence of entries is by alphabetical order of author, usually by surname but with occasional exceptions such as imperial or royal titles, authors known by a pseudonym (‘Zeta’) or a nickname (Caligula). In general authors’ names are given in the form by which they are best known, so we have Mark Twain (not Samuel L. Collections such as Anonymous, the Bible, the Book of Common Prayer, and so forth, are included in the alphabetical sequence. Within each author entry, quotations are arranged by alphabetical order of the titles of the works from which they are taken: books, plays, poems. These titles are given in italic type; titles of pieces which comprise part of a published volume or collection (e. For example, Sweeney Agonistes, but ‘Fragmert of an Agon’; often the two forms will be found together. All numbers in source references are given in arabic numerals, with the exception of lower-case roman numerals denoting quotations from prefatory matter, whose page num- bering is separate from that of the main text. The numbering itself relates to the beginning of the quotation, whether or not it runs on to another stanza or page in the original. Where possible, chapter numbers have been offered for prose works, since pagination varies from one edition to another. In very long prose works with minimal subdivisions, attempts have been made to provide page references to specified editions. Unless otherwise stated, the dates thus offered are intended as chronological guides only and do not necessarily indicate the date of the text cited; where the latter is of significance, this has been stated.

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However buy 60pills speman with amex, up to 20% of individuals with chronic pancreatitis present with symptoms of maldigestion alone purchase speman 60 pills overnight delivery. The evaluation for chronic pancreatitis should allow one to characterize the pancreatitis as large- vs generic speman 60pills otc. Large- duct disease is more common in men and is more likely to be associated with steatorrhea. In addition, large-duct disease is associated with the appearance of pancreatic calcifica- tions and abnormal tests of pancreatic exocrine function. Women are more likely to have small-duct disease, with normal tests of pancreatic exocrine function and normal ab- dominal radiography. In small-duct disease, the progression to steatorrhea is rare, and the pain is responsive to treatment with pancreatic enzymes. Treatment with pancreatic enzymes orally will improve maldigestion and lead to weight gain, but they are unlikely to fully resolve maldigestive symptoms. Narcotic dependence can fre- quently develop in individuals with chronic pancreatitis due to recurrent and severe bouts of pain. However, as this individual’s pain is mild, it is not necessary to prescribe narcotics at this point in time. Angiog- raphy to assess for ischemic bowel disease is not indicated as the patient’s symptoms are not consistent with intestinal angina. Certainly, weight loss can occur in this setting, but the patient usually presents with complaints of abdominal pain after eating and pain that is out of proportion with the clinical examination. Prokinetic agents would likely only worsen the patient’s malabsorptive symptoms and are not indicated. Its high prevalence in Asia and sub-Saharan Africa is related to the prevalence of chronic hepatitis B infection in those areas. The rising incidence in the United States is related to the presence of chronic hepatitis C. Pa- tients often present with an enlarging abdomen in the setting of chronic liver failure. In cases in which there are multiple lesions or resec- tion is technically not feasible, other options, such as radiofrequency ablation, may be tried. Liver transplantation in selected patients offers a survival that is the same as the survival af- ter transplantation for nonmalignant liver disease. Chemoembolization may confer a sur- vival benefit in patients with nonresectable disease. Systemic chemotherapy is generally not effective and is reserved for palliation when other, more local strategies have been tried. They can be grouped into secretory, osmotic, steator- rheal, inflammatory, dysmotility, factitious, and iatrogenic causes. Secretory diarrheas are due to altered fluid or electrolyte transport across the enterocolonic mucosa. They typically are large-volume stools that persist with fasting and occur during the night. Stimulant laxa- tives such as bisacodyl, cascara, castor oil, and senna are very common offending agents for secretory diarrhea. Therefore, the patient’s complete (not just prescribed) medication list should always be reviewed before engaging on an expensive search for causes of chronic diar- rhea. Countless medications may cause diarrhea; common offenders include antibiotics and antihypertensives. Carcinoid, vasoactive intestinal polypeptide-secreting tumors, medullary thyroid carcinoma, gastri- noma, and villous adenoma are uncommon tumors that are on the differential diagnosis of secretory diarrhea. Crohn’s disease can lead to bile salt–induced secretory diarrhea as a pre- senting feature, but this is less common than its usual presentation as an inflammatory diar- rhea. Lymphocytic colitis is an inflammatory disease that causes diarrhea in the elderly. The risk of toxicity is derived from a nomogram plot where acetamino- phen plasma levels are plotted against time after ingestion.

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