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We have become very interested in epileptic patients during the last three years and almost 60 patients have been examined with diagnosis of epilepsy order 40mg levitra extra dosage fast delivery erectile dysfunction treatment karachi. One patient was injected ictally and the others were investigated interic- tally (several patients post-ictally) buy discount levitra extra dosage 40mg on line erectile dysfunction pumps review. Sagittal and coronal slices were also routinely reconstructed and evaluated, and the possi­ bility of semiquantitative analysis has been utilized in the last two years. All of them were treated with various anti-epileptic drugs (monotherapy in 20 patients, two anti-epileptics in 32 patients, and 2 patients took a combination of 3 drugs). This therapy had completely no effect on 35 patients, who suffered from several seizures per month or even per week. The neurological clinical status was normal in 52 patients, and light hemiparesis was found in two patients. The findings in 13 other patients (24%) were highly suspicious of perfusion changes — in 7 patients hypoperfusion and in 6 patients hyperperfusion zones (Figs 1 and 2). Localized defects of brain perfusion were revealed in 70% of the pathological cases and hyperperfused zones were detected only in seven patients (30%). This finding correlates with the fact that most of the patients were investigated interictally. Ten patients benefited from these procedures — seven of them became seizure- free after changing the therapy on the strength of correct localization of the focus, and three patients in our group have undergone successful neurosurgery intervention so far. The localization of extratemporal neocortical epileptogenic foci is more difficult than that of temporal lobe epilepsy. The final epileptogenic foci were considered as determined when either all three tests were concordant or two tests were in agreement while the remaining was non-lateralizing. The final epileptogenic focus was in the frontal lobe in eight patients, lateral temporal in six, parietal in three, occipital in three and undetermined in three patients. Epilepsies with partial seizures are divided into temporal lobe epilepsy and extratemporal (neocortical) lobe epilepsy. However, a very few reported studies in patients with neocortical epilepsy [3, 4]. All patients were admitted to the Seoul National University Hospital between September 1994 and May 1995. The acquisition was started not earlier than 30 min after tracer injection to allow sufficient washout from extracerebral tissue, and the acquisition time was 30 min. The final epileptogenic foci were considered as determined when either all three tests were concordant, or two tests were in agreement while the remaining were non-lateralizing. In the case of the thalamus, similar hyper- perfusion was found in 20% of the patients. These findings were common especially in patients with frontal and occipital lobe epilepsies (Table I). Most epilepsies with partial seizures are those with seizures presumably originating from a restricted, structurally abnormal cortical region and, therefore, are the epilepsies that might benefit from restrictive surgery [1]. If syndromatic subclassification is attempted, most probably two epilep­ sies with partial seizures can be distinguished. This syndrome is characterized by relatively homogeneous clinical fea­ tures, a characteristic set of findings in paraclinical tests (including histology), and an excellent outcome following surgical therapy. Most important, however, is the association with primary limbic (hippocampal) pathology. It resembles ‘limbic seizures’ without noticeable initial symptoms that might suggest a frontal, parietal, or occipital onset [6]. When considering surgical resection for medically intractable epilepsy, the region of seizure origin must be localized with as much precision as possible. Locali­ zation of the epileptogenic region in patients with typical temporal lobe epilepsy is not particularly difficult. Strictly defined unilateral temporal scalp/sphenoidal electrode recorded ictal patterns, together with the findings of other tests, were able to correctly predict findings of depth electrode examination in 82-94% of the cases. The same situation does not exist in patients with extrahippocampal (neocorti­ cal) epilepsy. Potentially epileptogenic regions are not well defined and localization of seizure origin for those who do not have lesions detected with neuroimaging can be very difficult [7-9]. When intracranial recording is planned, the cortical areas that need to be covered are extensive and often bilateral. In this study, we found localized hypoperfused areas in 28% of the patients, which was similar to other reports. Ipsilateral hyperper­ fusion in the basal ganglia and contralateral cerebellar hyperperfusion have been reported [2, 10]. We also found ipsilateral subcortical hyperperfusion and contralateral cerebellar hyperperfusion and used them as the second source of evidence. Locating the epileptogenic focus in patients with drug resistant temporal lobe epilepsy is essential for pre-surgical evaluation of such cases. La localización del foco epileptogénico en pacientes con epilepsia del lóbulo temporal fármaco-resistente es esencial para la evaluación pre-quirúrgica de estos casos. Durante las crisis parciales se ha observado un aumento de la perfusión alrededor de la zona epileptogénica y en las crisis generalizadas un aumento global del flujo sanguíneo cerebral [1-3]. Durante el período interictal los pacientes con epilepsia del lóbulo temporal generalmente presentan disminución de la perfusión en el foco epilep­ togénico [2-4]. La preparación del radiofármaco se realizó de acuerdo a la información del fabricante. El estu­ dio de perfusión cerebral se realizó durante el período interictal, con al menos 24 h sin crisis. Previo a la administración del radiofármaco se mantuvo al paciente en reposo por 30 min con mínima estimulación visual y auditiva. La reconstruc­ ción de la imagen se realizó por retroproyección con filtro Gaussian (frecuencia de corte: 0,38 nyquist). Se hizo corrección de atenuación en los cortes transversales con el método de Chang (coeficiente = 0,12 cm“1) [13] y se obtuvieron cortes trans- axiales, coronales y sagitales. En ocho pacientes se realizó monitoreo video/electroencefalográfico com­ putado prolongado (programa monitor®, versión 3. Se aplicaron electrodos de plata dorada con técnica de Colodión, dispuestos según el sistema internacional 10-20, además de electrodos esfenoidales insertados según técnica establecida [14]. Posteriormente se repitió el estudio de perfusión cerebral con el paciente en el período interictal (sin crisis por al menos 24 h). En los pacientes con estudios ictales e interictales se analizó independientemente la perfusión cerebral basai y luego en relación con la crisis epiléptica. Los hallazgos se correlacionaron con los focos de actividad eléctrica ictal e interictal. En ellos se describe hiperperfusión en la zona epileptogénica durante la crisis y, generalmente, hipoperfusión de la misma en el período intercrítico. La sensibilidad de los estudios ictales es mucho mayor que los interictales, llegando en algunas series hasta un 97% para la detección del foco.

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This restriction is significant in that it may indicate that in the author’s opinion an appeal to divine cleansing is only (or pri- marily) appropriate in cases of moral transgressions discount levitra extra dosage amex erectile dysfunction exam what to expect. I would suggest order 60mg levitra extra dosage visa erectile dysfunction protocol foods, as a hypothesis, that the author of On the Sacred Disease here aims at marking off the vague boundaries between medicine and religion: in his opinion it 50 See Parker (1983) 19; Ginouves (` 1962) 299–310. At any rate, the phrase oÉc Þv miain»menoi obviously expresses a reaction against the admittedly strange idea that the sprinkling of water entails pollution (on the prohibition to take baths see Ginouves (` 1962) 395 n. However, as Ginouves points out, there is a difference between a` loutr»n and a perirrantžrion. Versnel has suggested to me, to interpret the sentence as an extreme statement of the author’s belief (expressed in 1. There is still another possible interpretation which might be considered, which makes the sentence apply to the practice of temple medicine: ‘while entering the temple [for the healing of a disease], we sprinkle ourselves, not as if we were polluted [by the disease, i. This would suit the author’s aim of distinguishing between moral transgressions (which are, in his opinion, forms of pollution, mi†smata) and physical diseases (which are not) and would make sense of the words ¢ ti peponq»v in 1. However, on this interpretation pr»teron is difficult, and it would presumably require a perfect participle (memiasm”noi) instead of the present miain»menoi. On the Sacred Disease 67 is wrong to regard epilepsy (or any other disease) as a pollution (this seems to be the point of the words ãsper m©asm† ti ›contav in 1. He obviously thinks that no moral factor (punishment for crime or transgressions) is involved,53 and that, as a consequence, one should not believe that it can be cured by the gods alone. As for the author’s religious notions, we may deduce from these passages that he believes in gods who grant men purification of their moral trans- gressions and who are to be worshipped in temples by means of prayer and sacrifice. It is difficult to see how this conception of ‘the divine’ (to theion) can be incorporated within the naturalistic theology with which he has often been credited. But instead of concluding, therefore, that the statements of the first chapter are merely rhetorical remarks which do not reflect the author’s own religious opinion (which is apparently the course taken by most interpreters), I would throw doubt on the reality of this ‘naturalistic theology’ – for which I have given other reasons as well. It seems better to proceed in the opposite direction, which means starting from the religious assertions of the first chapter and then trying to understand the statements about the divine character of the disease. In this way, the text can be un- derstood as motivated by two interrelated purposes. First, by claiming that epilepsy is not god-sent in the traditional sense, the author does not intend to reject the notion of divine dispensation as such; his statements are to be regarded as a form of corrective criticism of a traditional religious idea. The author claims that it is blasphemous to hold that a holy and pure being like a god would send diseases as a form of pollution; thus his re- marks may be compared with statements by Plato which aim at correcting and modifying the traditional concept of divine dispensation (theia moira) without questioning the existence of this divine dispensation as such. To a certain extent this may be viewed as an attempt to ‘secularise’ the sacred disease; and from this point of view the positive statements about the divine character of the disease may be regarded as reluctant or even derogatory concessions rather than as proclamations of a new advanced theology. And from this perspec- tive it can further be understood why the author states that epilepsy is not more divine than the other diseases instead of saying that all diseases are just as divine as epilepsy. As we have seen, on the first interpretation of the divine character of the disease (which posits its divine character in its being caused by climatic factors), this restricted con- ception of divinity may well be connected with the fact that the influence of these factors is rather limited (and with the use of the word prophasis). On the second interpretation (and on the reading taÅth€ d’–stª qe±a, ‘in this respect they [i. On both views the derogatory tone of the statements can be understood from the author’s attempt to mark off the boundaries between medicine and religion and to purify the concept of divine dispensation. And it can now also be understood why he defines the divinity of the disease only in those contexts where he tries to point out the difference between the sense in which his opponents believe it to be divine and the sense in which he himself believes it to be so. This does not imply that the sincerity of the author’s statements about the divine character of the disease should be doubted. Nor should their relationship with developments in natural philosophy and with other con- temporary ideas on religion and the divine be questioned. It is precisely the philosophical search for unity and regularity in natural phenomena, the enquiry into cause and effect, and the belief, expressed by at least some of these philosophers, that in manifesting regularity and constancy these phenomena have a divine aspect, which may have led the author to assign a divine character to the disease in question. But the danger of stressing this relationship with natural philosophy is that we read into the text ideas 56 Contra Norenberg (¨ 1968) 26 and 49, who ignores the rhetorical impact of these statements. This danger is increased when this reading is guided by modern ideas about what is ‘primitive’ or ‘mythic’ and what is ‘advanced’ and ‘rational’, so that by labelling an author as advanced or enlightened we are too much guided in our interpretation of the text by what we expect him to say. Nowhere in On the Sacred Disease do we find statements such as that ‘Nature is divine’; nowhere do we find an explicit rejection of divine intervention in natural processes or of divine dispen- sation as such. It is important to distinguish between the corrective, ‘cathartic’ criticism of traditional religious beliefs and the exposition of a positive theology. It seems that the author of On the Sacred Disease has been regarded too much as an exponent of the latter, and that he has been regarded more as a philosopher or a theologian than as a physician. Instead, I propose to regard as the author’s primary concern the disengagement of epilepsy from the religious domain (which implies claiming it as an object of medicine) and his accusations of impiety as one rather successful way to achieve this goal; in this way the corrective criticism of a traditional idea (viz. Even if this interpretation is convincing, it cannot be denied that there remains a tension between the author’s belief in gods who cleanse men from their moral transgressions and his statements about the divine character of the disease. This tension becomes especially manifest when we confront his categorical rejection of the idea that holy beings like gods send diseases (which he labels as highly blasphemous) with his assertion, ten lines further down, that diseases are divine in virtue of having a nature. The problem is how this ‘being divine’ of diseases is related to the purifying influence of the gods mentioned in 1. The author does not explain this, and we may wonder whether he, if he was aware of this problem, would have been capable of solving it. Of course, there are several possible solutions which we might suggest, and we could speculate about the author’s unexpressed ideas on theodicy and on the relation between the gods and the world in terms of providence, deism, determinism, and so on. Thivel draws an almost Aristotelian picture of the author’s world-view: ‘ces dieux... But it will by now have become clear for what reasons (apart from those mentioned ad loc. We have seen that the interpretation of the author’s statements about the divine character of the disease, as well as the attempt to deduce his theological ideas from these statements, involved many problems. We have also seen the difficulties involved in the evaluation of the author’s accusations of asebeia, and I have shown that it is possible to discern, in spite of the hypothetical character of most of these accusations, elements of the author’s own conviction. If the results of this discussion (especially my views on the range and on the rhetorical impact of the assertions about the divinity of diseases) are convincing, the discrepancy noted at the beginning of this paper has decreased considerably, though it has not disappeared. Yet we are now in a much better position to formulate the problem more adequately and to look for an explanation that is more to the point than the one offered in section 1. It is certainly wrong to hold that the author of On the Sacred Disease systematically exposes his religious beliefs and his ideas on the nature of divine causation in this text. The writer believes in gods who grant men purification of their transgressions pr»fasin), et le monde celeste, sejour des dieux incorruptibles, qui habitent sans doute les astres. On the Sacred Disease 71 and who are to be worshipped in temples by means of prayer and sacrifice. The text is silent on the author’s conception of the nature of these gods, but there is, at least, no textual evidence that he rejected the notion of ‘personal’ or even ‘anthropomorphic’ gods. Diseases are not the effects of divine dispensation; nevertheless they have a divine aspect in that they show a constant and regular pattern of origin and development. How this ‘being divine’ is related to ‘the divine’ (or, the gods) which cleanses men from moral transgressions is not explained. The idea of divine dispensation as such is nowhere questioned in the text of On the Sacred Disease. Gods are ruled out as causes of diseases; whether they are ruled out as healers as well is not certain, since the text is silent on this subject. As I remarked earlier, the author does not believe that epilepsy can be cured by natural means in all cases: on two occasions (2.