William McGhee, PharmD, Clinical Pharmacy Specialist, Children’s Hospital of Pittsburgh of UPMC
Beta activ ity normally increases during drowsiness medications xyzal generic diltiazem 60mg visa, light sleep nioxin scalp treatment generic diltiazem 180 mg line, and with mental activation osteoporosis treatment purchase diltiazem 60mg line. Persistently reduced voltages of >50% suggest a cortical gray matter abnormality within the hemisphere having the lower amplitude; however medicine for uti generic diltiazem 60mg free shipping, lesser asymmetries may simply reflect normal skull asymmetries. A skull defect may produce a breach rhythm with focal, asymmetrical, higher amplitudes (this relative increase may be more than three times) beta activity without the skull to attenuate the faster frequencies. The appearance of frontal theta can be facilitated by emotions, focused concentration, and during mental tasks. Intermittent 4 to 5-Hz activity bitemporally, or even with a lateral ized predominance (usually left > right), may occur in about one-third of the asymptomatic elderly and is not abnormal. Notice the frequent "scanning" eye movement artifact in the F7 and T8 derivations. These potentials have a duration of 160 to 250 msec, and may at times be quite sharply contoured, asymmetrical, with higher amplitudes than the resting posterior dominant rhythm. They are best observed in young adults when seen, although they are more frequently found in children. Lambda waves are best elicited when the patient visually scans a textured or complex picture with fast saccadic eye movements. Placing a white sheet of paper in front of the individual will eliminate the visual input that is essential for their genesis. Intermittent left mid-temporal delta during transition to drowsiness in a normal 84-year-old patient evaluated for syncope. In the waking states, delta can be considered a normal finding in the very young and in the elderly. The normal elderly may have rare irregular delta complexes in the temporal regions. It is similar to temporal theta in the distribution, often left > right temporal head regions, but nor mally is present for <1% of the recording. Some delta is normal in people older than 60 years, at the onset of drowsiness, in response to hyperventilation, and during slow-wave sleep. Excessive generalized delta is abnormal and indicates an encephalopathy that is etiology nonspecific. Focal arrhythmic delta usually indicates a structural lesion involving the white matter of the ipsilateral hemisphere, espe cially when it is continuous and unreactive. They are bilateral, synchronous, and symmetrical, and may be induced by auditory stimuli. Vertex waves can appear spiky (especially in chil dren) but should normally never be consistently lateralized. Other features include attenuation of the alpha rhythm,greater frontal prominence of beta,slow rolling eye movements, and vertex sharp transients. These are surface posi tive, bisynchronous physiological sharp waves with voltage asymmetries that may occur over the occipital regions as single complexes or in repetitive bursts that may be present in both stages 1 and 2 sleep. This stage has the same features as stage 1 with pro gressive slowing of background frequencies. Sleep spindles are tran sient, sinusoidal 12 to 14-Hz activity with waxing and waning amplitude seen in the central regions with frontal representation by slower frequencies of 10 to 12 Hz. A K-complex is a high amplitude diphasic wave with an initial sharp transient followed by a high amplitude slow wave often associated with a sleep spindle in the fron tocentral regions. Hyperventilation and intermittent photic stimulation are routinely performed to augment slowing and/or epileptiform abnormalities, although sleep deprivation, pharmacological, and other methods may be employed. The purpose is to create cerebral vasocon striction through respiratory means promoting systemic hypocarbia. Hyperventilation normally produces a bilateral increase in theta and delta frequencies (build-up) that is frontally predominant, and often of high amplitude. Hyperventilation may produce focal slowing in patients with an underlying structural lesion. It should not be performed in patients with severe cardiac or pulmonary disease, acute or recent stroke, significant large vessel cerebrovascular, and sickle cell anemia or trait, and it should be used with caution during pregnancy. Response depends upon background illumination and the distance of the light source from the patient. Distances of <30 cm from the patient are used to optimize the effect of stimulation. Flashes are very brief, and delivered in sequence from 1 to 30 Hz flash frequencies for approximately 10 sec before stopping the stimulus. Photic driving is usually greatest in the occipital location, in frequencies approximating the alpha rhythm, when the eyes are closed. Photomyoclonic (or photomyogenic) responses con sist of a frontally dominant muscle artifact that occurs when the flash evokes repetitive local contraction of the frontalis musculature (pho tomyogenic). The periocular muscles may also be affected with single lightening-like head jerks (photomyoclonic). Myogenic spikes occur 50 to 60 msec after the flash and increase in amplitude as the stimu lus frequency increases. The response is normal, although it may be seen is withdrawal syndromes or states of hyperexcitability. It is maximal in the mid temporal derivations and was referred to as rhythmic mid-temporal theta bursts of drowsiness. It is an interictal pattern that does not evolve spatially or temporally, although it may be represented bilater ally or independently over both hemispheres. Central theta (maximal at Cz) seen during the awake state in a 35-year-old patient with migraine headaches. While morphologically it may resemble a mu rhythm, it is not similarly reactive, and is slower in frequency, and occurs both in drowsiness or the alert state. While initially felt to be a projected rhythm in temporal lobe epilepsy, it has been seen in a heterogeneous population and is therefore of nonspecific clinical significance. Bilateral, synchronous, 6-Hz spike-and-wave discharges may range from 5 to 7 Hz, although with a typical repetition rate of 6 Hz lasting briefly for 1 to 2 sec. When the spikes are of low amplitude and occur only during drowsiness, they usually represent benign finding. When they are seen with high-amplitude spikes and occur with less than a 6-Hz frequency, or occur during wakefulness and persist into slow-wave sleep, there is a greater association with seizures. Fourteen and 6-Hz positive bursts maximal in the T6 elec trode derivation in a linked-ears reference montage. The 14-Hz fre quency is most prevalent, and the 6 Hz burst may appear with or without the faster frequencies. They are most common during adoles cence, although they may persist into adulthood and decrease with age. The bursts are usually unilateral or bilaterally asynchronous with a shifting predominance involving one hemisphere to a greater degree. A contralateral ear reference montage and greater interelectrode dis tance best demonstrate these bursts. Note the higher amplitude in the T1 and T2 channel with a longer interelectrode distance. They appear as a unilateral discharge but are almost always independent when they are bilateral. They may possess a field that may correspond to an oblique transverse dipole resulting in opposite polarities over opposite hemispheres when they are bilateral. They are seen over the temporal regions during drowsiness and light sleep and are usually bilateral and inde pendent. They typically occur in bursts, although they may be con fused with interictal epileptiform discharges, especially when they occur independently or as isolated waveforms. No focal slowing or aftergoing slow-wave component is seen, and they likely represent fragmented temporal alpha activity.
The latter was chosen because the irradiations typically extend over a total period of approximately six-eight hours stretched over two consecutive days treatment 2 lung cancer order diltiazem 180mg with amex. Nigg Idaho National Engineering and Environmental Laboratory treatment zinc overdose diltiazem 180 mg sale, Idaho Falls medicine symbol diltiazem 60mg sale, Idaho C medications janumet buy diltiazem paypal. Rossmeier Montana State University, Bozeman, Montana United States of America Abstract. The necessary methods have, however, been developed and have been successfully employed both for research applications as well as human trials. However further improvements in speed and results presentation are still needed for routine clinical applications, particularly when optimization of dose pattern is required. Fast line rasterization methods, implemented largely with integer arithmetic, are used to allow rapid particle tracking through the univel geometry. Univels along the particle track are investigated, and precise region intersection points can be rapidly calculated as the particle moves from one region to the next. This speedup factor holds even though the new univel model may consist of several million elements. This information can be registered with the anatomical images used for the patient geometry construction and thereby incorporated into the treatment planning calculations. The new capability thus will offer the potential for increased fidelity in the boron dose computations. Image Modeling (seraModel) the purpose of the seraModel module is to easily and rapidly divide an image set into regions of interest. The image matrix used for display in this program has been generalized to work on systems with different color depths. Images may be viewed at an arbitrary zoom level, in an arbitrary window, and with an arbitrary number of columns. Various tools are provided to aid in the manual/automatic definition of regions including region copying, scaling, overwriting, and painting by fill or borders. Thresholding-based segmenting, 3D region growing, and margin definition operations are also provided. The regions are painted in colors chosen by the user, with an option of viewing just the borders of the regions to see the underlying image. These tools are being extended to make region creation by treatment planners as intuitive and efficient as possible. Other features include the ability to: (1) set and save the preferences for the program, (2) maintain a list of the recently used files for quick access, 225 (3) undo one or more operations as may be necessary, (4) save disk space by transparently reading compressed files, (5) look at axial, sagittal, and corneal slices, and (6) use control panels to give the user easy access to important functions. Another feature of the program saves the regions in a uniform volume element format that lends itself to fast geometry interrogation. A resultant univel (uv/uvh) file format has been developed to describe the voxelized regions. A set of library routines (libuv) has been written to handle reading and writing the uv/uvh files, and to interrogate the geometry of the bodies represented in these files. By maintaining a high resolution set of univels, the accuracy of the simulation is maintained. Three Dimensional Viewer (sera3d) 6 the three dimensional viewer, sera3d, provides flexible three dimensional displays of the univel-based solid models (see Figure 3) and isodose contour data after all of the bodies are created with seraModel. Points, solid regions, hollow regions, or polygonal surfaces can be used to view the geometry. The beam line and selected particle paths may also be displayed in the viewing window. A surface colouring feature for viewing two and three dimensional isodose contours is also provided. The main purpose of the viewer is to provide the user with a fuller understanding of the proposed treatment plan. Various rendering options provide varying levels of reconstruction performance and detail. User defined region transparency allows a view through the outer regions to inner regions of interest. Similarly, six orthogonal clipping planes provide a defined "cut" out of the regions to see the regions inside. Full rotational capabilities, various camera positions including a beam line view, and multiple rendering windows provide additional control. An additional advancement in the program is the ability to inlay the original medical image into its corresponding location within the reconstructed geometry and to optionally display dose contours on selected planes. The method allows a slice plane to be drawn in an arbitrary direction through the "medical slice volume", resulting in an oblique slice. This ability has been extended to the loaded beam line, and slices perpendicular to the beamline are now available. The addition of the new contouring library allows for more customization of the contour displayed levels. This includes the selection of specific percentage levels at which contour lines are to be placed, the ability to color individual isodoses, and the option of viewing various sizes of contour line labels the user also may save their specific settings in a preferences file for later use. An image/results directory scheme has been developed for improved file organization and easier manipulation of multiple slices. Dose Plots (seraPlot) the seraPlot module provides the integrated control of dose-depth and dose-volume plotting utilities that post-process the results of the treatment simulation. Dose-depth plots can be shown for any or all of the following dose-components: total dose Group 1 fluence boron-10 dose Group 2 fluence gamma dose Thermal fluence nitrogen-14 dose Gamma production hydrogen dose Ultrafast gamma dose other dose 2. Field and Fraction Combinations (seraPlan) the seraPlan module allows the user to statistically combine fields and fractions for final treatment planning so that single effective dose can be presented. The user may select between 1 and 6 fractions and between 1 and 4 fields per fraction. In only one instance, the simulation of ultra-fast recoil proton transport (where the incident neutron has energy > 16. Calculation of Pointwise Dose Patient treatment planning requires the ability to determine pointwise dose. Monte Carlo, in general, computes volume-integrated values since the variance at a single point is infinite. There are methods to determine pointwise dose in Monte Carlo but it is not practical to use these since so much detail is required. In addition, to provide detail, a virtual edit mesh is imposed over all anatomical regions. For every particle path, the contribution to flux and all dose 228 components for each edit cube intersected by the ray is tallied. After the Monte Carlo simulation, pointwise dose is then determined as a function of the volume-integrated values determined for the edit cubes. The value at a point is determined as a function of the nearest 7 edit cubes in orthogonal directions. This point value may be the minimum dose in the target (treatment volume) which may represent a goal of treatment planning or the point value could represent a constraint in treatment planning. A one dimensional edit may be a dose-depth relationship, such as shown in the example presented in Figure 5. For Figure 5, the boron concentration was set to 50 ppm in the edit even though it was 14. It is usually assumed that the boron concentration is low enough that the thermal neutron flux is not perturbed by the boron and edits can be obtained for any reasonable boron concentration. If this is not the case and the boron distribution is 229 known then it can be set to that value for the transport simulation and the flux perturbation would be properly accounted for. An example of a two dimensional edit is the important isodose display, such as previously presented in Figure 4. This grid is often a 40 by 40 grid over the field of view and the pointwise dose components are written to the file at each grid line intersection. The seraDose module then determines the contour lines as interpolated values from the grid points. The results from this integration provide perhaps the most important information for treatment planning. The dose space is divided into N + 1 percentile bins where N defaults to 10 to give bins of width 10 percent but N can also be set by the user.
Considerable fluctuations in pain medications you cant crush cheapest generic diltiazem uk, even dur (in the remitting stage of hemicrania continua); cervico ing the late symptoms early pregnancy purchase generic diltiazem online, nonremitting stage treatment hypothyroidism purchase diltiazem with a mastercard. Because the structures of the two systems differ significantly symptoms gluten intolerance discount 180 mg diltiazem, correspondence is often not easy to determine or is definitely not available. Where the only corresponding item is a "catch-all" or residual category, an entry is not necessarily made. Differential diagnosis from local conditions (see above) and general conditions. Definition Signs Pain following trauma in the region of a calcified stylo Carotid bruit, transient ischemic episodes. Benign, intractable if styloid process not excised or frac tured, partial relief from stellate ganglion local anes Main Features thetic infiltration, and acetylsalicylic acid. Prevalence: among patients with calcified stylohyoid ligament and history of trauma to mandible and/or neck. Start: evoked by swallowing, opening mandible, turning head toward pain and down, with palpation of stylohyoid Social and Physical Disability ligament. Pain Calcified stylohyoid ligament, carotid-external carotid seemingly identical, may be triggered by neck move branch arteritis. Time Pattern: pain episodes are of greatly Summary of Essential Features and Diagnostic Cri varying duration, from hours to weeks, even intraindi teria vidually, the usual duration being one to a few days. The Presence of calcified stylohyoid ligament, tenderness of varying duration of attacks is a characteristic feature of superficial vessels, history of trauma. In the later phase, there is characteristically a Differential Diagnosis protracted or continuous, low-intensity pain, with super Myofascial pain dysfunction, carotid arteritis, glosso imposed exacerbations. Intensity: moderate to severe pharyngeal neuralgia, tonsillitis, parotitis, mandibular pain. Precipitating Factors Code Pain similar to that of the "spontaneous" pain episodes 036. X6 or even attacks may be precipitated by awkward neck movements or awkward positioning of the head during sleep. The headache usually appears in episodes of Reduced range of motion in the neck, in one or more varying duration in the early phase, but with time the directions. Occasionally, edema and redness of the skin headache frequently becomes more continuous, with below the eye on the symptomatic side. Symptoms and signs such as mechanical precipitation of attacks imply involve Tests and Laboratory Findings ment of the neck. Such blockades reduce or take away or back of the head but soon moves to the frontal and the pain transitorily, not only in the anesthetized area temporal areas. It occasionally extends into the infraor (the innervation area of the respective nerve) but also in bital area. Unilaterality without alternation of sides is the nonanesthetized, painful Vth nerve area. This repre typical, but occasionally moderate involvement of the sents a diagnostic test. There are reasons to believe that den System ervation of the periosteum of the occipital area on the Probably the peripheral nervous system. Musculoskele symptomatic side may provide permanent relief in a tal system is probably also involved. Main Features Usual Course Prevalence: probably rather frequent, but exact figures Persistence and intensification of the pain syndrome are lacking. Many of the patients have sustained neck trauma a Complications relatively short time prior to the onset. Often radiologi Patients can frequently do some routine work during cal evidence of a tumor in the apex of the lung. Pathology Probably related to various structures in the neck or pos System terior part of the scalp on the symptomatic side (C2/C3 Nervous system. Age of Onset: usu and rather stereotyped, the pathology varies in that pa ally in the decades corresponding with the occurrence of thology in the lower part of the neck may also be the carcinoma of the lung. It is usually progressive, requiring narcotics Combination of unilateral headache, ipsilateral diffuse for relief, and becomes excruciating unless properly shoulder or arm pain, reduced range of motion in the managed. Differential Diagnosis Common migraine, hemicrania continua, spondylosis of Associated Symptoms the cervical spine. Other unilateral headaches, such as the cervical sympathetic is involved with a Homers cluster headache, are less important in this respect. Atrophy of the small muscles of the hand, ulnar sensory Code loss, ulnar paresthesias and pain, and Homers syn 033. The diagnosis is made on chest X-ray by the appearance of a tumor in the superior sulcus. Electromy References ography will demonstrate denervation in the appropriate Bogduk, N. Definition Summary of Essential Features and Diagnostic Cri Progressively intense pain in the shoulder and ulnar side teria of the arm, associated with sensory and motor deficits the essential features are unremitting, aching pain of and Homers syndrome due to neoplasm. Homers der, or elbow, in time expanding to the whole ulnar side syndrome occurs associated with damage to T1 and C8 of the arm. Exacerbations of sharp lancinating pain in Page 96 and occasional neurological loss; the diagnosis is made pain is generally aggravated by exercise and relieved by by chest X-ray demonstrating tumor at the apex of the rest. Rarely, peripheral vascular insufficiency syndromes are Code found, and occasionally, the subclavian axillary vein 102. X4a complex can be compressed, and the patient presents with swelling and blueness consistent with symptoms of Reference venous obstruction. Color change may also (includes Scalenus Anticus Syndrome, Cervical Rib appear with other maneuvers. This is performed by maximal extension of the chin and deep Definition inspiration with the shoulders relaxed forward and the Pain in the root of the neck, head, shoulder, radiating head turned towards the suspected side of abnormality. Due to compression of the Obliteration of the pulse, or at least diminution, should brachial plexus by hypertrophied muscle, congenital occur. This sign is not always found and may occur in bands, post-traumatic fibrosis, cervical rib or band, or normal individuals also. Angiograms are indicated when there is an arterial or venous obstruc Site tion but are very poor diagnostic maneuvers, the milder Ipsilateral side of head, neck, arm, and hand. Age of Onset: the thoracic outlet syndrome is characteristically found Usual Course in young to middle-aged adults but may affect older the usual course is one of continued persistent discom adults also. Physiotherapy may strengthen the shoulder girdle root of the neck, or shoulder, and radiates down the arm, and relieve symptoms, and this should be tried at first, but it may also affect the head. The ulnar aspect of the but ordinarily symptoms will persist until the entrapment arm is the most commonly involved, but the pain may of the plexus is relieved. The pain occurs irregularly, usually Complications include arterial compression with throm with activity. The distribution of the paresthesias or pain in the shoul Pathology der or arm is varied and can be associated with a particu A variety of anatomical abnormalities will compress the lar nerve root, or with many nerve roots. Often it is neurovascular bundle at the thoracic outlet and may rather baffling in that it cannot readily be related to spe cause this syndrome. Hemiplegia from stroke secondary to vascular Social and Physical Disabilities thrombosis and propagation of the clot may occur. The the patients are often unable to work because of dys function of the extremity involved. Page 97 Summary of Essential Features and Diagnostic Main Feature Criteria Age of Onset: usually in the fifth, sixth, and seventh Patients with this syndrome suffer from compression of decades-corresponding to the occurrence of carcinoma the brachial plexus for which many causes exist. Pain Quality: the pain teristically, they develop pain and paresthesias in the is usually described as a continuous dull ache or a con upper extremity, sometimes associated with headache. It may radiate up into the neck or down into the most common diagnostic criteria are tenderness the anterior chest wall. An expanding lesion in the hu over the brachial plexus in the neck, reproduction of the merus may radiate into the forearm. The cardinal feature pain by the maneuver of abduction and external rotation is acute exacerbation of the pain by any movement of of the arm, and pain on stretching the brachial plexus.
Instead after a week he simply released Romanos to go home with an escort medications going generic in 2016 generic 180mg diltiazem visa, in exchange for his personal promise that he would pay a ransom medicine pictures discount 180 mg diltiazem with mastercard, the cession of a slice of territory in eastern Anatolia medications on backorder buy diltiazem 60mg with visa, and a ge neric promise of friendship medicine x boston order 180mg diltiazem overnight delivery. In the ensuing civil war, Turkoman bands and organized Seljuk forces had ample opportunities to advance deep into Anatolia and indeed all the way to Nicea, modern Iznik, and Cyzicus on the Sea of Marmara, within a days ride from Constantinople. It could have been the end for the empire even then, as rival contend ers for the imperial title competed for Seljuk support against each other by conceding more territory, while expending dwindling imperial reve nues to ght each others forces. But three unconnected forces were to change the balance of power between Byzantines and Seljuks in unex pected ways. First, the Seljuk offensive against the Fatimids gave them Jerusalem by 1071, but in the ensuing chaos the Holy Land became insecure for western pilgrims evoking, along with any other set of causes one wishes to assert, the crusading movement in western Europe. Twenty-six years after Mantzikert in 1097, the ghters of the First Crusade arrived, just as lusty for war as any Turkoman raider or Ghazi holy warrior. They would conquer western Anatolia on their way to distant Antioch and the Holy Land. Moreover, the Seljuk exposure to the chronic instability of the great steppe would have disastrous conse quences: in the Qatwan steppe near Samarkand, the Seljuk sultan Sinjar lost an army on September 9, 1141, at the hands of the Qara Xitay. Had they done so, the empire could not have lasted long, because Anatolia was its indis pensable demographic and tributary base. At differ ent times, he intervened effectively in Italian politics though he had to abandon an attempted invasion; he fought alliances of Normans, Serbs, Hungarians, and Kievan Rus, gaining territory in the process, both in the Balkans after defeating the Hungarians at Semlin (in modern Kosovo) in 1167 and by reestablishing a Byzantine presence in the Cri mea. Most importantly, he increased Byzantine control of all the coastal plains of Anatolia, reducing the territory of the Sultanate of Rum to its interior, and he strengthened the Byzantine hold on Cilicia and western Syria. It was in this context that Manuel I attempted a theater-level offen sive to nish off the Sultanate of Rum and reestablish imperial rule over all of Anatolia. He had already succeeded in regaining territory from the sultanate in a series of small operations. The reaction in the city was enthusiastic: [It was] something tremendous and wonderfully extraordinary, such as I know never happened to the Romans before. Of the many magni cent em perors, who is not outdone, that a man who rules so much land and lords it over so many tribes should appear at the [court of the Roman Emperor] in the guise of a servant Only a procession to the Hagia Sophia was prohibited by the patriarch Louka Chrysoberges, whose authority was undoubtedly en hanced by the coincidence of a serious earthquake. During the 1162 visit a pact of peace was added to a merely per sonal amity, but the entente broke down, and in 1176 Manuel decisively abandoned the path of gradualism recommended by Byzantine strategic manuals to mount a deep-penetration offensive to conquer the Seljuk capital of Iconium, the modern Konya. Elaborate preparations assem bled stone-throwers and engineering equipment for the siege of Iconium, a reported three thousand carts of supplies, from extra arrows to food, and at least ten thousand, and possibly twice as many, infantry men both light and heavy, and cavalry including kataphraktoi, the ar mored cavalry trained to charge with the lance, and for close combat with mace and sword, that could scatter any number of light horse men. After that, how ever, Manuels forces would be able to spread out in the more open ter rain leading down to Iconium, and nearer to the city the kataphraktoi would nd at ground suitable for their devastating charges. The Seljuks, moreover, had reached the Tzibritze Pass that would be the battleground ahead of time, positioning bowmen on the slopes on both sides, ready to release their arrows against the en emy below, or charge down to attack weaker elements. The Seljuks had averted the immediate threat to their capital but lacked the strength to ght off Manuels army. It mostly did survive to retreat, but the offen sive momentum of the empire was no more. Defeat in the Tzibritze Pass did not lead to any immediately momen tous consequences. But in subsequent years the empire could not reconstitute its military strength to regain the initiative. That required, rst of all, political unity under effective emperors, administrative efficiency in collecting taxes, and more ef ciency in raising armed forces. Instead of political cohesion within the ruling elite, indeed within the court, there was murderous factionalism that drove the losing faction to seek help from the forces of the Fourth Crusade, a transnational gathering of quarrelsome, hungry, predatory knights and hapless pilgrims brilliantly manipulated by the Venetian doge Enrico Dandolo, who succeeded in extracting real gains for his city from the chaotic violence of the Crusaders. It was by no means the rst time that foreign forces summoned by contenders for the throne determined who would rule Byzantium. Khazars, Bulghars, and Russians had all served in that capacity without lasting consequence, as the strong Byzantine sense of identity, resilient morale, and enduring administrative abilities each time achieved an am ple restoration. But in 1204 the outcome of foreign intervention was fa tal, in part because Catholics no longer accepted the legitimacy of Or thodox rule. The colossal re silience of the Roman empire of the east had nally been defeated not by pagan steppe nomads from Central Asia or in amed Muslim jihadists but by fellow Christians, rival claimants to the same Roman tradition. The extreme uidity of the strategic environment that the Byzantines had to contend with was again exempli ed by what happened in 1204. The empire had come very close to destruction several times before, only to recover very quickly, but there was no real recovery from the downfall of 1204. A few years later, Osman, a talented warrior-chief, started to gather and lead followers as one more Ghazi, albeit in dubious standing as a jihadist: he had Christians riding with him. A sultan of Konya lingered until 1308, but by the time Osman died in 1326, his Osmanli ("Otto man") followers had started building a powerful state that accommo dated the increasing sedentarization of the Oeuz and other Turkic mi grants, and had a de nite capacity for important military innovation. None was more important than the invention of uniformed, regi mented, "new soldiers," yeniceri ("janissary"), the ancestors of all mod ern armies, marching bands included. The territory controlled by the in creasingly misnamed emperors in Constantinople on both sides of the straits kept shrinking amidst endemic dynastic struggles, as the cumula tive loss of tax revenues enfeebled the remnant. Surrender to Sultan Bayezid dubbed "Yildirim" (thunderbolt) seemed imminent by 1402, when the irruption of Timur-i-lenk, the Tamerlaine of Western memo ries, claimant to both Cinggisid Mongol and Turkic ancestry, destroyed the army of Bayezid at Ankara on July 28, 1402. That allowed an em peror to linger in Constantinople until 1453, to then ght and die with the utmost heroism. W part three the Byzantine Art of War In organizing and training their forces, in devising their tactics and op erational methods, in evaluating their strategic choices, the Byzantines were informed by an entire military culture rooted in ancient Greece and the earlier Roman empire, but increasingly of their own making, and sharply different. As successive layers were added from the fth century onward, this distinctive culture was preserved and transmitted, as cultures always are, in all sorts of ways, by institutions, by customs, by norms, and by word of mouth, but most durably by the written word. Ancient Greek military texts were duly honored, and there were some Roman writings, but the Byzantines increasingly relied on their own growing body of military literature, which included detailed handbooks. We do not have any veritable Roman eld manuals, that is, guidebooks written by expe rienced soldiers for the use of soldiers, but we do have several Byzantine manuals of evident practical value; each is examined in what follows, and not all their recommendations are entirely obsolete. The most direct bene t of this accumulated military culture was to broaden the repertoire of Byzantine armies and navies, endowing them with a greater variety of tactics, operational schemes, and practiced stratagems than any of their opponents could command. Sometimes this enabled Byzantine forces to surprise and overwhelm their enemies by employing tactics or methods or stratagems or weapons entirely un known to them. Its powerful implications are manifest in what the Byzantines did, in what actually happened, and sometimes in what Byzantine voices reportedly said, but they emerge more clearly and more fully in the varied texts of their military literature. On the whole, they were probably less educated than the ordinary soldiers of the Ro man army in its better years, judging by its voluminous record keeping and the personal letters and varied writings that have survived on papy rus and bark. In the later sixth century, at any rate, we can presume from the nest of Byzantine military handbooks, the Strategikon attri buted to the emperor Maurikios, that illiteracy was the norm even in fairly senior eld ranks, because the author writes that merarchs should be "prudent, practical, experienced, and, if possible, able to read and write. Buy diltiazem uk. “Depression Is A Symptom”: Dr. Amen On Diagnosing Diseases Of The Brain. |
