 Daniels for additional discussion regarding the application of Rawls’ Theory of Justice to health and health care.

28 Conscious means that the individual is able to make an informed decision with regard to their consent.

44 System accountability implies that harms generally result from multiple failures in the system rather than solely from the actions of one individual.

46 See glossary for definition of bias.

CONTRIBUTING AUTHORS

Eldesia L. Granger, MD, MPH, FAAP, FACP
The MITRE Corporation

Jessica S. Skopac, JD, PhD, MA
The MITRE Corporation

Susan U. Mbawuike, MS, CHES
The MITRE Corporation

Anna T. Levin, JD
The MITRE Corporation

Susan Dwyer, PhD
Department of Philosophy, University of Maryland, College Park, MD

Arnon S. Rosenthal, PhD, MS
The MITRE Corporation

Jillian Humphreys, MA
The MITRE Corporation
ACKNOWLEDGMENTS

Gwen Darien, Executive President, Patient Advocacy and Engagement, Patient Advocate Foundation

Susan B. Frampton, PhD, President, Planetree International

Merilyn D. Francis, BSN, MPP

Danny van Leeuwen, RN, MPH, also known as Health Hats

Christoph U. Lehmann, MD, FAAP, FACMI, FIAHSI, Vanderbilt University

Russell C. Libby, MD

Thomas H. Murray, PhD, President Emeritus, The Hastings Center

Carolyn Petersen, MS, MBI, FAMIA, Mayo Clinic, Rochester, MN

W. Nicholson Price II, JD, PhD, Assistant Professor of Law, University of Michigan Law School

Ben Yelin, JD, Senior Law & Policy Analyst, University of Maryland Center for Health and Homeland Security

Bev Acree, MBA, CHIE The MITRE Corporation

Cathy Becker The MITRE Corporation

Cathy Buck The MITRE Corporation

Mallory Carellas, MPH, BSN, RN The MITRE Corporation

Sarah T. Corley, MD, FACP The MITRE Corporation

Linda Desens, PhD, RN The MITRE Corporation

Suzanna Dungan, MPH, MBA The MITRE Corporation

Susan Haas, MD, MSc The MITRE Corporation

Bernard J. Horak, PhD, FACHE, CPHQ The MITRE Corporation

Edith A. Hughes, DSc The MITRE Corporation

Adrienne D. James The MITRE Corporation

Neeraj Koul, PhD The MITRE Corporation

Sybil Klaus, MD, MPH The MITRE Corporation

Amanda Mason-Singh, PhD, MS The MITRE Corporation

Julie S. McEwen The MITRE Corporation

Laura Munro, RN, MHSA The MITRE Corporation

Phuong Ngo, MHA The MITRE Corporation

Janice Nsor, JD The MITRE Corporation

Nichole Persing The MITRE Corporation

Catherine M. Petrozzino The MITRE Corporation

Candace J. Rosen, JD The MITRE Corporation

Stuart S. Shapiro The MITRE Corporation

Jayme Squire The MITRE Corporation

Nichole Sweeney, JD The MITRE Corporation

Patrick Tramma The MITRE Corporation

Haleh Vafaie, PhD The MITRE Corporation

Erin D. Williams, JD The MITRE Corporation<|endoftext|>[REMOVED]<|endoftext|>Influence of age on outcome of psychological treatments in first-episode psychosis

GILLIAN HADDOCK, SHON LEWIS, RICHARD BENTALL, GRAHAM DUNN, RICHARD DRAKE and NICHOLAS TARRIER

Background Psychological treatments have been shown to be effective in patients with psychosis. However, the studies published to date have included participants across wide age ranges, so few conclusions can be reached about the effectiveness of such treatments in relation to age.

Aims To evaluate outcomes by age in a randomised controlled trial designed to evaluate the effectiveness of cognitive–behavioural therapy (CBT), supportive counselling and treatment as usual.

Method Outcomes were evaluated in terms of symptoms, social functioning, insight and therapeutic alliance according to age at 3- and 18-month follow-up.

Results Younger participants responded better to supportive counselling than to treatment as usual and CBT over 3 months. Older participants responded better to CBT than to supportive counselling over 18 months. Younger participants showed a greater increase in insight after CBT compared with treatment as usual and supportive counselling, and were more difficult to engage in therapy.

Conclusions Young people may have different needs with regard to engagement in psychological treatments. Treatment providers need to take age-specific factors into account.

Declaration of interest None. Funding detailed in Acknowledgements.

Psychological treatments for psychosis, particularly cognitive–behavioural therapy (CBT), have been shown to be effective in patients with chronic treatment-resistant psychosis and recent-onset psychosis (Lewis et al., 2002; Cormac et al., 2004). However, evaluations of psychological treatments have not usually examined outcomes in relation to a particular patient age group, even though people of different ages may have different therapeutic needs. For example, young adults may have significant developmental issues which may need to be taken into account when developing and delivering treatments. The aim of this study was to evaluate the interaction between age and symptomatic and functioning outcomes in a randomised controlled trial designed to evaluate the effectiveness of CBT and supportive counselling plus treatment as usual compared with treatment as usual alone in first-and second-episode patients with schizophrenia (the Study of Cognitive Reality Alignment Therapy in Early Schizophrenia (SoCRATES) trial).

METHOD

The study design was a multi-centre, prospective, rater-masked, randomised controlled trial with an 18-month follow-up. Eligible patients were randomly allocated to one of three treatments, namely CBT and treatment as usual, supportive counselling and treatment as usual, or treatment as usual alone. Phase 1 of the study presented the recovery data for the first 70 days (Lewis et al., 2002). Patients were then followed up and re-assessed by psychiatric interview and examination of hospital records and case notes 18 months after randomisation (Tarrier et al., 2004). A detailed description of the entire SoCRATES sample and methodology has been provided (Lewis et al., 2002), so will be only briefly described here.

Participants, recruitment and assignment

Participants were recruited over a period of 26 months. Inclusion criteria for entry to the trial were as follows: either first or second admission (within 2 years of a first admission) to in-patient or day-patient unit for treatment of psychosis; DSM–IV criteria for schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder or psychosis not otherwise specified (American Psychiatric Association, 1994); positive psychotic symptoms for 4 weeks or more; a score of 4 or more on the Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1989) target item for either delusions (P1) or hallucinations (P3); neither substance misuse nor organic disorder judged to be the main cause of psychotic symptoms.

Assessment measures

A number of assessment measures were employed as part of the SoCRATES study at baseline and during the 18-month follow-up period (Lewis et al., 2002; Tarrier et al., 2004). However, only the following measures will be reported here. Measures of symptoms and functioning at baseline and follow-up included the PANSS (Kay et al., 1989) total, positive, negative and general sub-scale scores, the Psychotic Symptom Rating Scales (PSYRATS; Haddock et al., 1999a), the Social Functioning Scale (SFS; Birchwood et al., 1990), the Birchwood Insight Scale (BIS; Birchwood et al., 1994) and two measures of therapeutic alliance, namely the California Therapeutic Alliance Scales (CALPAS; Gaston, 1990) and the Psychotherapy Status Report (PSR; Frank & Gunderson, 1990). Data on demographics, substance use and duration of untreated psychosis were also collected at baseline.

Intervention groups

The interventions were based on those evaluated in previous treatment studies (Tarrier et al., 1998; Haddock et al., 1999b). The CBT was manual-based and was undertaken by five therapists trained in CBT for psychosis, who were supervised by experienced cognitive–behavioural therapists. At the beginning of the study the therapists were trained in both interventions, and throughout the study they received separate expert and peer supervision on a regular basis to maintain treatment quality. The
aim was for a ‘treatment envelope’ of 15–20 hours within a 3-week post-admission period, plus ‘booster’ sessions after a further 2 weeks, and after 1, 2 and 3 months. Details of the CBT have been provided by Haddock et al (1999b). Supportive counselling was used as a comparison intervention to control for non-specific elements of therapist exposure. The same five research therapists administered both CBT and supportive counselling interventions, according to randomisation. All treatment sessions, both for CBT and for supportive counselling, were audiotaped if participants had given their consent, and the treatment fidelity as judged by independent, expert raters was good (Lewis et al, 2002).

Analysis

Baseline data were compared according to age using a cut-off point of age 21 years (i.e. 'over 21' and '21 years


ocele if necessary (2-0 PDS); apply TFS anchor at insertion of CL to ATPF sited approximately 2cms superior and 1cm lateral to the ischial spine. Close tunnel and incision in layers.

Table 1. – Patient demographic.

Parameter
Values

Age (years, range)
60 (37-86)

Parity (median, range)
3 (2-7)

Weight (kg, range)
77.9 (57-142)

Previous hysterectomy (No., %)
21 (52.5)

Sexually active (No., %)
22 (55)

Chronic illness* (No., %)
28 (70)

* Diabetes, asthma, hypertension, macro/morbid obesity, COAD, GORD, depression & anxiety.
TFS U Sling procedure - for support of mid/lateral pelvic defects:

Use same incision as for cardinal ligament; dissect toward ATFP at its most medial aspect – lcm superior to superior notch of obturator foramen. Deploy TFS into position, adjust without tension and close tunnel and incision.

TFS Uterosacral ligament procedure:
Create transverse incision (5-6cm) lcm above vestibule. With aid of hydro dissection of rectovaginal septum grasp and evert inside of posterior vaginal mucosa with 2 tissue forceps progressively whilst dissecting to posterior apex until USLs are identified. With a finger in rectum palpate lateral border of sacrum at approximately S3 facilitating identification of USL insertion. This also enables the surgeon to protect rectum whilst tunneling and inserting prosthesis.

TFS Deep Transverse Perinei Procedure (perineal body repair):
Using same incision described in USL TFS, the ano rectal junction is separated from perineal body. Under tension, identify DTP with its attachment to lower 1/3 of posterior medial border of descending pubic ramus. With finger in rectum create a tunnel through DTP to just posterior to ramus in the direction of inferior notch of obturator foramen. Apply TFS prosthesis, tension appropriately, trim tape, close tunnels. Plicate and repair the perineal body if appropriate.

Ethics approval was obtained by the Ethics Committee, The Northern Hospital / Northern Health. Safety of the study was monitored throughout.

Written informed consent was obtained from all patients.

RESULTS

40 women followed up at a minimum of 24 months (Table 2).

70% of cohort suffered from significant medical co-morbidities. 35% had one or more past pelvic organ prolapse procedures.

Perioperative and operative data was predicated on the use of 105 TFS sling applications with the mean of 2.6 slings per patients.

Operative time per sling: 12.5 minutes.
Blood loss average: 50 mls.

Hospital stay average: 60 hours, and this was dependent on the extent of surgery ranging from 12 hours to 72 hours. Postoperative interval before return to normal duties ranged from 72 hours to 2 weeks.

Operative data

Symptomatology of the patient cohort was often multiples of voiding dysfunction, symptoms of prolapse and bowel dysfunction as summarized in table 3.

Patient outcomes

Improvement rates at 24 months expressed figure 3. There was an average >85% cure rate of urogynaecological prolapse and stress urinary incontinence. Of the patients sexually active (50%), one patient had transient dyspareunia. There were no tape erosions, anchor slippage or anchor migrations noted in our cohort.

Recurrent symptomatic prolapse in 3 out of 4 patients was due to cervical hypertrophy >4cms requiring cervical amputation at 18 - 24 months. This has lead to our conclusion that concomitant cervical amputation should be considered if cervical length >4cms.

85% of patients who complained of stress urinary incontinence as a symptom were cured at follow up. Only half of this group had urodynamic demonstrable stress incontinence, the others complained of SUI but this was not demonstrable on urodynamic studies. The first group had a definitive pubourethral TFS tape, the other group only had anterior compartment repair (Cardinal ligaments/U sling) and yet this group post-operatively had a cure in stress incontinence symptoms not demonstrable with urodynamics.

Complications

One rectal mucosal buttonhole injury sustained at initial dissection was treated successfully with primary repair. One rectal serosal penetration with prosthesis was recognized and removed immediately and successfully (Table 4). Both patients had previous multiple perineal and posterior compartment procedures. No implant was inserted under these

Parameter
Values

Anterior compartment prolapse (POPQ ≥2* No., %)
24 (60)

Posterior compartment prolapse (POPQ ≥2* No., %)
24 (60)

Anterior & Posterior compartment prolapse (POPQ ≥2* No., %)
15 (37.5)

Apical prolapse (POPQ ≥2* No., %)
16 (40)

Anterior & Posterior & apical prolapse (POPQ ≥2* No., %)
6 (15)

Previous POP reconstructive surgery (No., %)
14 (35)

According with the ICS POP-Q system.

Parameter
Values

Sub-Urethral TFS (No., %)
9 (22.5)

U-Sling (No., %)
15 (37.5)

Cardinal Ligament TFS (No., %)
25 (62.5)

Utero-sacral TFS (No., %)
34 (85)

Deep Transverse Perinei TFS (No., %)
22 (55)

Vaginal Hysterectomy for Non prolapse reason (No., %)
3 (7.5)

Cervical amputation (Manchester repair) (No., %)
2 (5)

Table 2. – Clinical details.

Table 3. – Operative details.
circumstances. Retention of urine (failed trial of void) x 2 patients after the pubourethral neoligament procedure; both cases were transient and resolved. There was one case of midurethral release after 21 days with 100% resolution of voiding dysfunction at 4 months. There was one case of trigger point pain of the inferior margin of pubic rami which resolved within 21 days. No haemorrhage, haematoma or tape rejections or infections have been noted.

DISCUSSION:

Many techniques have been devised to address the high failure rates of POP repair using native or biological tissue. Repairs such as sacrospinous fixation have been shown to be anatomically incorrect and have postoperatively caused symptoms such as dyspareunia and other complications including haemorrhage, haematoma, small bowel obstruction and mesh erosion.\(^6\) Implantation of mesh sheets for POP seemed promising initially, but complications, sometimes major, have resulted in FDA warnings about the use of large mesh kits within the pelvic floor. These warnings have revived the question “Are large mesh sheets necessary for POP repair?”\(^5\)

The surgical reconstruction of the anatomy is almost exclusively focused on the restoration of lax pelvic floor ligaments. Exact preoperative identification of the anatomical lesions is necessary to allow for exact anatomical reconstruction with respect to the muscular forces of the pelvic floor.\(^7\)

We have found the TFS procedures to be simpler and more anatomically correct than other procedures. From a structural perspective, the small volume of polypropylene tapes provide excellent support and function for grade IV and the more challenging recurrent POP and visceral incontinence.

In our study 36/40 patients needed multiple anatomical site reconstruction and the with majority requiring apical support. There is evidence that apical repair impacts on anterior vaginal wall prolapse as shown in previous studies comparing sacrospinous ligament fixation and abdominal sacral colpopexy


 each case we discuss how it illustrates a key challenge in the process of aligning concerns.

Our goal is to illustrate how the differences that underpin the understanding and conceptualization of symptoms and disease between patients and health professionals come to signify central aspects of patient-physician relations and thus the use of eHealth.

4.1. Case #1 – Concepts and meaning differ

With this case, we bring forth the difference in how illness is experienced by patients and how clinicians conceptualize disease and how this differentiation then comes to designate what is perceived as important and meaningful to each part.

Louis is 51 years of age and has had his ICD for only a year, after suffering a sudden heart attack. The experiences of becoming a heart patient and an ICD-patient in his case melt into each other. Louis suffers from various symptoms related to the heart disease itself, the device, and the medication as well as recovering from the heart attack. Besides this, Louis feels anxious and depressed which he partly ascribes to the trauma of experiencing his own mortality and partly to the lack of continuity of care and the lack of coherence of the information he receives from health professionals and institutions.

Because of this, Louis is enthusiastic about the prospect for new ways and means of communicating with clinicians and engages very actively in the use of myRecord. He makes several notes on symptoms with the logbook feature (ranging from feeling tired, loss of breath, swollen legs, anxiety, and impotence) and is eager to utilize the preparation module prior to his upcoming in-clinic follow-up. Besides this, he explores the network feature to connect and share experiences with other patients. He praises the potential of the system and explicitly links his positive assessment of its value to his position as a new patient with a great need to feel secure and “in control” and to be able to raise urgent questions and seek continual professional guidance.

Having completed the preparation via myRecord where he has written an extensive prose text about his symptoms and concerns, Louis has high expectations for the upcoming consultation at the clinic. However, afterwards he is greatly disappointed, as he did not feel that the clinician responded to all the concrete concerns he had raised nor attended to his situation at large:

“I was prepared for the consultation. And that thing regarding vitamin D, he didn’t mention it. He
didn’t say anything to me. And regarding the legs, it was me who insisted, insisted, insisted [...] So, I was disappointed with the consultation, really.” (Final interview with Louis, February 2013)

The cardiologist on the other hand felt that he was able to react to the patient’s primary concern (which he perceived to be the experience of dizziness and loss of breath and which he linked to a possible regulation of medication) and then leave the rest unspoken, since it was not something for him to act on:

“Because he was allowed to write about it and he had made that list, I could just say to him; ‘I can see you’ve written something about this and that. This is the main thing for you,’ and we could then go straight to that topic without having to start all over. So, I think it’s a good way to manage the contact.” (Final interview with cardiologist, local hospital, February 2013)

The cardiologist further indicates that he thinks the very act by Louis of writing down his concerns would make him feel better. And that Louis would further “feel heard” by knowing that the cardiologist had read through his preparation.

This case illustrates how the clinician and patient have conflicting perspectives on 1) which concerns are meaningful in the sense of important and relevant for the consultation, and 2) what constitutes proper (re)action. The cardiologist perceives his role as to manage the consultation in the most productive and meaningful way, which in respect to the cardiologist is to ensure that his most important concerns are attended to. Besides this, he acts as a passive listener through myRecord as an act that will indirectly satisfy the patient. The patient, however, feels quite differently and finds much of the follow-up meaningless, stating that in order to be meaningful to him his efforts must result in a “real” (re)action at “the other end.”

From the case, we also learn that even though a concern is meaningful to one party, does not mean it becomes meaningful for the other to attend to. This is also a matter of what is allowed (or not allowed) to be put to the front both by patients and clinicians.

4.2. Case #2 – On action and feasibility

With this case, we take the matter of proper reaction a bit further by illustrating the second challenge that plays an important part in the process of aligning concerns. Namely, that it is not enough for a concern to be meaningful – it needs to be actionable as well.

In a distributed care scheme clinical concerns are formally, and often also practically, distributed. This means that even if a certain concern of a patient may be of great clinical relevance (e.g. critical side-effects of medication) it will only be relevant for certain clinicians. When patients then write questions and state concerns in a system like myRecord, where a certain clinician is the receiver, the patient must be able to assess what is relevant to whom. In other words, the patient must at some level understand the infrastructure of the distributed care scheme, or the IT-system should indicate or assist in this.

Ben (aged 60) is preparing for the upcoming in-clinic device follow-up at the Heart Centre by filling out the step-by-step preparation form in myRecord. When he reaches the section where he can state his most important questions for the clinician he writes that he is very concerned with his blood pressure because he finds himself increasingly exhausted at work when performing his daily tasks. His job is very important to him and he is eager to find a solution so that he can keep working. Ben therefore asks to have it monitored over the course of a day at work. He also poses a question about some over-the-counter-drugs he has been advised to take by a friend. He then finishes the rest of the preparation form and sends it off digitally to the clinic.

During the consultation at the out-patient clinic, the lab technician and the cardiologist quickly browse through Ben’s preparation form on their computer screen, while they ask him about his general well-being, his medication and specific symptoms related to the ICD. Ben then asks about the possibility of having his blood pressure monitored and brings forth a referral letter for a local hospital he has received from his general practitioner. The cardiologist briefly answers that it is not something she can get into, and that he will have to take it up with the local hospital.

Afterwards Ben states how he was “disappointed about the fact that they hadn’t read it through carefully. It just goes helter-skelter, you know. [...] They don’t talk about over-the-counter drugs or anything. Then it’s just ridiculous to write about it.” (Final interview with Ben, February 2013)

Now that Ben with great effort had prepared so well using myRecord, he was expecting the clinicians to be prepared too and address his concerns. But he felt that the clinician had not prepared properly and that their lack of interest and action in relation to his concern about this blood pressure and over-the-counter-drugs made his preparation meaningless.

The cardiologist on the other hand, stated how she, while being with the patient, was able to “browse through what he had written,” and that the preparation form “worked well.” Although she admitted to not having read it beforehand. (Final
The cardiologist was not bothered by the fact that she was presented with a concern of the patient that she was not able to act on for organizational reasons, but rather she found it useful to be able to quickly browse through the patient’s concerns and screen out those she did not have to pay attention to.

In this case we learn that although the concern raised was both meaningful to the patient and the clinician and in fact also clinically actionable, it was not organizationally feasible. One party, the cardiologist, is pleased with the myRecord system and not bothered by being confronted with a concern that she is not able to take action on. But the patient, on the hand, finds the encounter demoralizing and disappointing due to what he perceived as an unsatisfactory “absence of action.”

The case thus illustrates how some patients are neither able to assess what could become a concern to certain clinicians, nor to accept that the concerns they have articulated are not responded to and acted on by the clinicians. Subsequently, using this version of myRecord entailed great disappointment for the patient in this case and led him to lose his motivation for further use. This supports our claim that motivation for use rests on the existence of aligned concerns and of the system’s ability to support these. In this case it fails to do so as it fails to account for, or compensate for, the distribution of care by facilitating a ‘match’ between the concern of the patient and the concern, in the sense of ability to act, of the clinician in question.

4.3. Case #3 – Alignment of concerns with myRecord

While the two previous cases illustrate how myRecord was unsuccessful in supporting meaningful patient participation in some situations, the following case presents how other features of the system used in other situations provided for enhanced collaboration. In remote monitoring, patients are excluded from engaging with clinicians, both parties thus rely primarily on data recorded by the ICD device, which is transmitted for interpretation to lab technicians and cardiologists at the Heart Centre. Patients can therefore no longer ask questions regarding the ICD and raise concerns such as potentially relevant symptoms in the time between the remaining in-clinic follow-ups every second or third year. In design interventions with different version of myRecord we experimented with ways to fulfill the needs of both patients and clinicians by enabling patients to qualify transmissions with their own experiences and by enabling lab technicians and cardiologists to respond in


 scintigraphic approach to melanoma detection with these reagents was made in the 1970s (4,5). The major drawback of this technique is due to the normal binding of these reagents to all melanin-containing cells (including normal tissues, such as ocular uvea and skin) (6,7).

Because tyrosine is a melanin precursor, radiolabeled derivatives of this compound (e.g., iodinated alpha-methylytyrosine) (8) have also been tested for melanoma imaging because it is known that this tumor often displays a high rate of melanin synthesis. In addition, numerous attempts have been made to synthesize "false precursors" of melanin, for example, thioamides (thiouracil and its derivatives) (9–11). However, none of these radiopharmaceuticals was successful in the detection of malignant melamomas.

A new class of compounds that seems to show interesting properties is the group of benzamides. These tracers have been synthesized to provide specific imaging of the structures of the brain with a high expression of dopaminergic receptors (basal ganglia) (12).

The ectodermic origin of melanocytes and the presence of melanin in the substantia nigra are the theoretic bases for the application of benzamides in the scintigraphic evaluation of melanoma in humans (13,14). Preliminary results on the use of a tracer of this group ([I23I] N-(2-diethylaminoethyl) 4-iodobenzamide (BZA) were recently presented by Michelot et al. and Brandau et al. in patients with cutaneous and ocular melanomas (15–17).
The aim of this study was to evaluate the possibility of using \( ^{123}\text{I} \)\{(S)-2-hydroxy-3-iodo-6-methoxy-N-\{1-ethyl-2-pyrrolidinyl\} methyl] benzamide (\( ^{123}\text{I} \)\{(S)-IBZM\}, a tracer usually employed for the study of neuropsychiatric disorders (e.g., Parkinson's disease, schizophrenia, progressive supranuclear palsy and multiple system atrophy), to detect melanomatous lesions in humans.

### MATERIALS AND METHODS

**Tracer**

Iodine-123\{(S)-IBZM\} is a radiopharmaceutical synthesized by de Paulis et al. \( (18) \) and subsequently proposed by Kung et al. \( (19,20) \) for the imaging of dopamine \( D_2 \) receptors with a traditional gamma camera instead of the expensive and high-technology PET systems. The tracer is the commercially available liquid solution produced by Cygne BV (Eindhoven, The Netherlands)-DuPont Pharma Italia. The radiopharmaceutical had a specific activity greater than 1.85\( \times 10^6 \geq \text{GBq/mole}, \) (mean activity concentration = 74 \text{ MBq/ml}). Quality control procedures performed with thin-layer chromatography showed values of radiochemical purity of more than 97%. A mean dose of 205 MBq of the tracer was slowly injected into the antecubital veins of the patients.

**Patients**

Eleven patients with histologically proven metastatic melanoma entered the study. The aim of the study was to verify the effective possibility of imaging metastatic melanoma with radio-labeled benzamides.

The main characteristics of the patients are shown in Table 1. Short details about their clinical history are summarized in Appendix A. In their clinical history, all patients had undergone surgical treatment of a primary cutaneous melanoma. At the moment of scintigraphy, they showed one or more lesions, which were clinically and instrumentally (with ultrasonography, radiography, CT or MRI) documented as indicating the presence of melanoma metastases. Six of the discovered lesions were cutaneous, and six were lymph node metastases. Three patients had pulmonary localizations, and two presented also had hepatic metastases. The dimensions of the lesions ranged between 5 and 100 mm. Except for the lung and liver metastases, all lesions were surgically removed within a few days (1–4 days) after scintigraphy, and histopathologic analysis was performed to confirm the nature of the lesions. To reduce the thyroidal uptake of radio-iodine, the gland was blocked with potassium perchlorate (400 mg orally) 30 min before the radioactive drug was injected.

**Scintigraphic Technique**

Imaging was performed 2, 4 and in some cases 24 hr after the injection with a dual-head, large-field gamma camera (Sopha DSX Bodytrack, Buc Cedex, France) equipped with an ultrahigh-resolution collimator for low energies. Whole-body scans were acquired with a constant speed of 15 cm/min\(^{-1}\). Regional planar images were fitted over the lesions and acquired for 10 min with a matrix of 256 \times 256 \text{ (zoom = 1.00, pixel dimension = 2.24 mm).}

SPECT was performed in each patient (matrix = 64 \times 64, 30 sec/step, 64 steps over 360\degree; zoom = 1.14, pixel dimension = 7.84 mm). Transaxial images were reconstructed by filtered backprojection with a Hamming/Hann filter characterized by a cutoff frequency of 0.5 cycles/pixel (a low-pass filter useful for medium-noise level images). No attenuation and scatter correction were made.

For radiation dosimetry, we applied the method proposed by the Medical Internal Radiation Dose (MIRD) Committee (Appendix B).

**Blood Clearance and Biodistribution Evaluation**

Radiopharmaceutical kinetic and biodistribution studies were performed in only three cooperating patients. In regard to the study of the tracer's biodistribution, regions of interest (ROIs) were drawn on digital whole-body images 0, 1, 2, 4 and 6 hr after the injection, which surrounded the brain, lungs, liver and gall-bladder. The percentage activity in the organs at any time was obtained by the following formula:

\[
\frac{\text{geometric mean counts in organ}}{\text{geometric mean counts in whole body at } t = 0} \times 100
\]

The blood clearance was determined by venous samples taken at 5, 10, 15, 20, 30, 60, 90, 180, 240, 360 and 420 min. The total blood volume was estimated by means of a formula based on body weight and height \( (21) \). The clearance at any time was expressed as a percentage of the injected activity.
Tumor-to-Background Ratio Evaluation

A semiquantitative analysis was performed to define the best tumor-to-background (T/B) ratios, using the ROI method. An important problem in regard to accurate quantitation of tumor uptake is due to the finite point response function of the gamma camera, i.e., the image of the lesion is larger than its true physical size. If the ROI is reduced to the physical dimension of the lesion, not all counts are included. However, if the ROI is made larger, there will be a significant contribution of counts from adjacent normal tissues. To overcome this difficulty and also to minimize the interobserver variability, the tumor uptake was studied by drawing isocontour ROIs around lesions.

A manual ROI was drawn to define the whole tumor area. With respect to the highest count pixel in the ROI, a threshold (percent of the maximum) was fixed. All pixels with values greater than this threshold were attributed to the first area. Another four areas were created by varying the threshold (20%, 40%, 50% and 60% of the maximum). In this way, five different ROIs were obtained for each tumor.

Background ROIs were drawn near the tumor or in a contralateral region to estimate the binding of the agent and the image contrast of the lesion. Every time, T/B ratios were calculated by dividing the total counts contained in each tumor ROI by the total counts in the background ROI to account for the different number of pixels in the different ROIs.

RESULTS

Neither immediate nor delayed side effects were noted after the administration of the radiopharmaceutical. No cerebral lesions were present in the patients evaluated, and no pathologic uptake was documented in the SPECT studies of the brain. The basal ganglia were normally imaged because of the high selectivity of $[^{123}\text{I}](S)$-IBZM for $D_2$ receptors.

After intravenous administration, the tracer is rapidly cleared from the blood pool. Figure 1 shows that, after 5 min, only about 10% of the injected activity is still circulating. Between the first and second hour after the injection, there is a slight increase in blood activity, which lasts for 1 hr. Thereafter, a slow but continuous decrease characterizes the remaining curve.

Images and biodistribution data indicate a relatively high concentration of the compound in lungs, liver and gallbladder. The hepatobiliary excretion of the tracer is due in part to the high lipophilicity of the compound and explains the presence of its high activity in the intestinal tract. The time–activity curves plotted in Figure 2 show that 24.5% of the injected activity


to test their degree of deafness.
A person with severe or total hearing loss in one ear but normal hearing in the other ear will have no or minimal hearing impairment. They can compensate for the deaf ear by turning their head. Any test of hearing, including formal testing by audiometry, needs to ascertain the loss in each ear separately. The overall degree of hearing impairment is then determined by considering the effects of both deficits in combination.

The chart below permits this to be carried out and arrive at the percentage disablement based on the occupational deafness scheme used in industrial injuries disablement benefit. In order to be 80% the person has to have a hearing loss of 87 dB or more in each ear. The hearing loss in the better ear is plotted along the vertical axis and the loss in the worse ear along the horizontal axis allowing the degree of disablement to be read from the chart. For example someone with 55 dB loss in the better ear and 88 dB loss in the other (worse) ear would have a 40% degree of disablement. Those with 80% disablement are likely to have very severe hearing difficulties. They would be unlikely to hear normal conversation, hear the television without special aids or understand a shout at one metre in a busy street.
The DM should decide the degree of disablement using the following table.

1, 2, 3, kHz average
Pure tone dB
50-53
54-60
61-66
67-72
73-79
80-86
87-95
96-105
106+

Pure tone HL

50-53
20
22
24
26
28
30
32
34
36

54-60
22
30
32
34
36
38
40
42
44

61-66
24
32
40
42
44
46
48
50
52

67-72
26
34
42
50
52
54
56
58
60

73-79
28
36
44
52
60
62
64
66
68

80-86
30
38
46
54
62
70
72
74
76

87-95
32
40
48
56
64
72
80
82
84

96-105
34
42
50
58
66
74
82
90
92

106
36
44
52
60
68
76
84
92
100

If a person normally wears or could wear a hearing aid, the test to assess the degree of deafness is carried out with the hearing aid being used¹.

¹ SS (DLA) Regs, reg 12(2)(b)
Severely mentally impaired with severe behavioural problems

61350 To satisfy this test for the higher rate of the DLA mobility component a person must be entitled to the highest rate of the DLA care component\(^1\), be severely mentally impaired\(^2\) (see DMG 61351 - 61370) and have severe behavioural problems\(^3\) (see DMG 61376 - 61379). The test is cumulative and if any part of the test is not satisfied a person cannot satisfy the test.

\[^1\] SS CB Act 92, s 73(3)(c); \[^2\] s 73(3)(a); \[^3\] s 73(3)(b)

Severely mentally impaired

Arrested development or incomplete physical development of the brain

61351 The first test towards treating a person as being severely mentally impaired is whether they have a state of arrested development or incomplete physical development of the brain, which results in severe impairment of intelligence and social functioning\(^1\). Further guidance is available in the Children and Adult Medical Guidance.

\[^1\] SS (DLA) Regs, reg 12(5)

61352 The disabilities counting towards severely mentally impaired are defined as

1. **incomplete physical development of the brain** - where a person’s brain has failed to grow properly and this can be seen and assessed

2. **arrested development of the brain** - where a person’s brain is not functioning properly but no physical deficiency is apparent.

61353 There is no precise age at which an individual’s brain stops developing. The DM is entitled to apply the balance of probabilities and consider the age at which brain development ceases as a broad age range, at least into the fourth decade of life and in some cases perhaps into the fifties.

61354 A person cannot satisfy the severely mentally impaired condition unless it can be established that the cause of the mental impairment (for example accident, disease, injury) happened before the person’s brain was fully developed. Degenerative diseases such as Alzheimer’s Disease that begin after the brain is fully developed do not satisfy the severely mentally impaired condition. Difficult cases should be referred to Medical Services for advice.

61355 If a person has arrested development or incomplete physical development of the brain, the DM must then consider whether this results in severe impairment of intelligence and social functioning\(^1\).

\[^1\] R(DLA) 1/00; SS (DLA) Regs, reg 12(5)
Arrested development or incomplete physical development of the brain and schizophrenia

The severity of schizophrenic disorders can vary from severe chronic deteriorating illnesses to a group of psychoses which are shorter in duration, easier to treat and leave little after effects. Most schizophrenics will not have arrested development or incomplete physical development of the brain. But for those suffering from the most severe type of schizophrenia (in about 30% of all cases), there is neurodevelopmental damage which is arrested development of the brain.

Where it can be established that there is arrested development of the brain, the person still has to show that this results in severe impairment of intelligence and social functioning to satisfy the severely mentally impaired test for the higher rate of DLA mobility component (see DMG 61366 - 61369). Medical advice is that below average intelligence or IQ is not a normal feature of schizophrenia. Schizophrenics may respond or react to others in an unusual or different way but this has no bearing on their intelligence. Therefore, someone whose only disability is schizophrenia will not normally be able to satisfy this part of the severely mentally impaired test.\(^1\)


 STENTS

Esophageal carcinoma accounts for most cases of dysphagia due to cancer, and usually the tumor is...
unresectable. Dysphagia may also result from extrinsic compression due to lung cancer or malignant lymphadenopathy. Among many endoscopic and nonendoscopic treatment alternatives for palliation of dysphagia due to cancer, expandable metal stents are one of the main options. They are useful for patients with poor functional status who cannot tolerate radiation or chemotherapy, who have advanced metastatic disease, or in whom previous therapy has failed.6

The small diameter of expandable metal stents before deployment makes aggressive dilation of the esophagus before or after deployment unnecessary. Despite the substantially higher cost of expandable metal stents as compared with traditional rigid plastic esophageal stents, there are substantial overall cost savings resulting from the reduction in the number of days of hospitalization due to complications.7-9 One study showed that the rate of complications associated with stent insertion was lower overall for expandable metal stents than for plastic stents, but the rate of subacute complications was higher.10 In the United States, expandable metal stents have replaced plastic stents for use in the esophagus.11 Dysphagia is relieved in approximately 90 percent of patients who receive expandable metal stents.7-9

The data from comparisons of different options for the palliation of dysphagia due to cancer are limited. A retrospective study compared expandable metal stents with a variety of conventional endoscopic palliative techniques in patients with inoperable esophageal carcinoma without tracheoesophageal fistula. Patients with expandable metal stents underwent significantly fewer procedures and spent fewer days in the hospital.12 In a prospective, randomized, controlled trial of patients with esophageal carcinoma, patients with expandable metal stents had significantly more improvement in symptoms and a lower rate of reintervention than those treated by esophageal laser recanalization.13 An advantage of expandable metal stents over other endoscopic palliative methods is that they can be used to treat dysphagia due to compression caused by cancer,14,15 although the improvement in dysphagia is less than for patients with esophageal cancer.14

Esophageal expandable metal stents are also used to treat tracheoesophageal fistulas due to cancer (Fig. 4A).16,17 Tracheoesophageal fistulas develop in patients with advanced esophageal and lung cancer and lead to continuous aspiration of saliva. Tracheoesophageal fistula is the only condition in which covered expandable metal stents may increase survival as compared with other therapies. Although there have been no prospective trials comparing covered metal stents with other types for the treatment of tracheoesophageal fistulas, the covered metal stent is now accept-
ed as the primary treatment option. Closure of the fistula is successful in 70 to 100 percent of patients. For persistent fistulas, placement of an airway stent to close the fistula or surgical esophageal bypass for physiologically fit patients are additional palliative options.

Expandable metal stents are best suited for mid-esophageal lesions. Tumors at the gastroesophageal junction are amenable to stent placement with a high rate of technical and clinical success, but stents at this location produce an open conduit for free reflux of gastric contents, with consequent severe regurgitation and aspiration. Newer stents prevent reflux and aspiration by means of a one-way flap valve on the gastric side of the stent. Placement of expandable metal stents for very proximal esophageal lesions is technically difficult because of the proximity of the stent to the upper esophageal sphincter and the lack of an uninvolved proximal margin. However, in studies of small numbers of patients with dysphagia due to esophageal obstruction caused by cancer high in the cervical esophagus, expandable metal stents were successfully placed and improved symptoms in most patients.

Placement of an esophageal expandable metal stent can lead to severe complications. Intraprocedural complications include those associated with conscious sedation, aspiration, malpositioning of the stent, and esophageal perforation. Immediate postprocedural complications may include chest pain, bleeding, and tracheal compression, with resultant airway compromise and respiratory arrest. Late complications include distal stent migration, formation of an esophageal fistula, bleeding, perforation, and stent occlusion. Although most migrated stents can be retrieved endoscopically or will simply pass through the gastrointestinal tract, small-bowel obstruction develops in some patients. Approximately 0.5 to 2 percent of patients who undergo the procedure die as a direct result of placement of an expandable metal stent (Fig. 3).

Several studies strongly suggest that the rates of delayed esophageal complications caused by expandable metal stents are higher in patients who have previously been treated with radiation, chemotherapy, or both. These complications are presumably due to stent-induced pressure necrosis within devitalized esophageal tissue. Unfortunately, patients who have recurrent or persistent dysphagia or a tracheoesophageal fistula after chemoradiation therapy often have no alternative to a stent for palliation of their symptoms. In contrast to other studies, one prospective study found that patients undergoing chemoradiation therapy after placement of an expandable metal stent had significantly longer survival than patients who received only a stent. However, shrinkage of the tumor by chemoradiation therapy could increase the risk of stent migration.

Patients with esophageal stents must modify their diet to prevent large boluses of food from becoming impacted within the stent. If a stent without an antireflux valve crosses the gastroesophageal junction, strict antireflux precautions and aggressive acid suppression are needed to prevent gastroesophageal reflux and aspiration. If the stent lumen becomes occluded by tissue ingrowth, overgrowth, or hyperplasia, a second stent may be placed through the first stent with good results. Alternatively, endoscopic laser therapy, electrocautery, or photodynamic therapy may be used to treat stent occlusion.

**BILIARY STENTS**

Treatment of obstructive jaundice due to cancer relieves pruritus, improves appetite, and reduces fat malabsorption. Surgical palliation of this condition involves the creation of an anastomosis between the bile duct and the duodenum or jejunum to bypass the obstructed biliary tree. Nonsurgical palliation is achieved by placing stents endoscopically (with the use of endoscopic retrograde cholangiopancreatography), or with radiologic guidance (by the percutaneous transhepatic approach) across the cancerous stricture to restore biliary continuity (Fig. 4B). Insertion of plastic biliary stents provides an effective alternative to open palliative surgical bypass of the biliary tree for the management of obstructive jaundice due to cancer. Unfortunately, bacterial encrustation frequently leads to occlusion of plastic stents, requiring their replacement in terminally ill patients. Plastic stents of larger diameter take longer to become occluded.

The maximal stent diameter is limited by the endoscopes that must accommodate them and the size of the tract made through the liver when they are placed percutaneously. In comparison with plastic stents, expandable metal biliary stents have a smaller diameter before placement and a larger diameter after placement. Their small diameter before placement makes percutaneous placement less traumatic and permits them to be completely placed during one procedure. Their large diameter after placement eliminates occlusion by bacterial biofilm.

Expandable metal biliary stents are much more costly than plastic stents. In two randomized, prospective trials comparing endoscopically placed, uncovered metal biliary stents and plastic stents for the palliation of jaundice in patients with previously untreated distal malignant bile-duct obstruction, the metal stents had significantly longer patency. Decreases in the rates of endoscopic procedures and rehospitalization offset the initial high cost of metal stents. Similar results were found in a large prospective, randomized trial in which stents were placed by the percutaneous transhepatic route for palliation of distal cancerous biliary obstruction. Expandable metal stents are more cost effective for patients who survive longer than four to six months, whereas a single procedure with placement of a less costly plastic stent would suffice in pa-
tients expected to have shorter survival.\textsuperscript{34,35} Another disadvantage of a metal stent in the biliary tree, as compared with a plastic stent, is that the device cannot be removed once it is implanted. Therefore, in patients with potentially resectable cancer, removable plastic stents should be used.

Expandable metal biliary stents may become occluded because of tumor ingrowth or biliary epithelial hyperplasia induced by the stent. Occlusion from either cause may be treated by the insertion of a plastic stent or another metal stent through the original stent.\textsuperscript{31,35,36} Preliminary studies suggest that occlusion due to tumor ingrowth or epithelial hyperplasia may be prevented by the use of partially covered metal biliary stents.\textsuperscript{37} Overgrowth of tumor beyond the ends of the stent may result in reobstruction, necessitating placement of another stent.

Prolonged patency has been observed in expandable biliary stents used to treat low- or distal-bile-duct obstruction, but not in cases of obstruction by a tumor involving the proximal biliary system at or above the bif


 of values. At first, it appears that Europe doesn’t teach abstinence education — educators will even tell you they don’t. To understand the subtle way it’s presented there, you have to look at how it’s taught here. There are basically two different approaches: the fear-based tactics that had repulsed me, and responsibility-based tactics that I had never had a chance to experience.

At no time did the European educators I met specifically say “Don’t have sex.” Instead, they’d say “Don’t have sex when you aren’t ready.” Programs offered advice like “Don’t have sex because your partner wants to, have sex because you want to” and “The most important thing is that you be in a committed relationship before having sex.” Not many 15- and 16-year-olds find themselves in strong, committed relationships. So this responsibility-based approach does encourage abstinence, in the most meaningful way. In fact, most recent statistics say that American teenagers first have intercourse one to two years before European teenagers.

These messages resonate with students because they acknowledge that, in the end, it’s the teenager’s choice to have sex or not. The programs teach teens to make their own decisions. Young people are constantly hearing values from friends, family, and the media. If you pit teacher versus friend, the teacher’s message will probably lose out, but if individuals are taught to make choices for themselves, they’re more likely to postpone having sex.

After the trip, I realized that we do teach the responsibility-based approach here too. Often, both strategies exist in the same course. Some programs teach students that having sex before marriage is wrong and explain how “violators” will be punished. Others teach such skills as how to resist peer pressure and how to make your own choices.

I think the European approach is successful because they really take the “responsibility” part seriously. It’s impossible to teach someone to resist social pressure and make their own choices if at the same time you’re trying to pressure them to let you make the choices for them. The teenagers either fail to learn how to make their own choices, or they learn to reject persuasion and ignore the messages they’re being sent.

The answer is not to find new ways of pressuring teenagers, but to give them the information they need to make their own choices. This may be scary for some adults and parents, but it is time for parents to learn that the values they’ve instilled in their children are alive, and the only way teenagers will act like adults is for adults to stop treating them like children.
The Oregon Department of Human Services will be featuring the third edition of the Teen Pregnancy Prevention Action Agenda in the spring of 2002. The updated document serves as a “driver” for the teen pregnancy prevention efforts at the state and community level and has been expanded to seven key strategies:

Strategy 1: Positive community values
Strategy 2: Comprehensive sexuality education and youth development
Strategy 3: Abstinence education
Strategy 4: Contraceptive access
Strategy 5: Male involvement and leadership
Strategy 6: Balancing health, safety, and legal issues
Strategy 7: Young-parent services

The strategies were developed through a collaborative process featuring the dedication and hard work of many partners from around the state: To view the entire document, visit www.hr.state.or.us/tpp/action_agenda

In addition to promoting the Directions guidebook for use statewide, the Oregon Teen Pregnancy Task Force is designing training that will help teen pregnancy service providers implement its activities.

Looking in the Right Directions

We all wonder sometimes where to turn for sound information and resources to use in our work with young people. Now comes this superb service providers’ guidebook on pregnancy prevention for young parents. Appropriately titled Directions, it’s based on lessons learned through many years of cumulative experience by a number of community-based agencies.

Inside, you’ll find topics like:
- Personal Values and Choices
- Self Worth
- Personal Relationships
- Sexual and Reproductive Health
- The Emotional Aspects of Sexuality

There’s also an extensive bibliography; notes for facilitators; and resource information including Web sites, books, and videos.

Directions is available via e-mail or on diskette in PDF format (requires Adobe Acrobat; available free on the Web). A limited number of binder-ready printed copies are also available. Contact Travis McAlister at Insights Teen Parent Program by phone (503) 239-6996 x238, or by e-mail: travism@insightstpp.org. Please specify the format you want.
I'm sitting at my desk at the clinic when a group of unfamiliar teen males comes in. A couple are dressed all in black except for the obscene words on their T-shirts. Some look sullen or hostile; others wear an unreadable game face. At least one has lots of metal on his face. They're loud and boisterous - laughing, joking, punching each other and looking as if they might crash into the walls. I tense up and start to deal with them as if they're an annoyance at best and a threat at worst. They react and leave and, big surprise, never come back. What we have here is a failure in adolescent services, because of male profiling.

We've all heard about profiling, of course. In the case of males, it exists when we assume the worst about the intentions and potential behavior of the young men we encounter. In adolescent health care, it often shows up as programs that ignore the appropriate developmental needs of males, but do focus on getting them to stop whatever it is they're doing that's risky, wrong, or harmful. Granted, these are all appropriate goals when applied to pregnancy and STD prevention, anger management, and violence prevention. But if that's where our services for guys start and stop, we're seriously shortchanging them.

Boys make up the vast majority of school suspensions and expulsions, special education classes, dropouts, abusers of alcohol and drugs, victims of violence and bullying and successful suicides. They commit most of the vandalism and acts of violence in the school community. There is clearly a need for male-oriented services, yet it seems most school programs and health and social services (outside of sports and corrections) have been developed by females for females.

But the issue goes beyond lack of appropriate services. Boys are conditioned to believe that “real men are tough.” The most damaging consequence of this is that young men are often cut off from knowing and expressing their feelings, other than anger. Because vulnerability is equated with weakness, they're unable to ask for help with their problems.

Imagine the stresses of navigating the teen years while trying to cope with the damaging and limited vision of manhood that seems to prevail in American popular culture. In a sort of psychological “piling on,” many boys lack humane and nurturing male role models to help them through this difficult time.

It’s no secret that boys learn and act differently from girls. They tend to be more physical, socialize in larger groups, and have an active learning style. Surging hormones can make their behavior unpredictable and, yes, baffling at times. This is all normal, and we need to make allowances for it while setting reasonable limits.

To give boys their due, we should assess our programs, facilities, and services. Do they invite males in? Are they guy-friendly? Are they aware of young men’s struggles and needs? If not, we can take steps to correct the imbalance.

A good place to start is with the excellent report by Howard Hiton, a Portland-area counselor and expert in male adolescent development. Building on Strengths, Helping Boys Succeed in Portland Schools provides specific strategies and approaches that address the needs and struggles of adolescent males. It lists valuable and helpful local and national resources, appropriate for health and social service agencies as well as schools. Copies are available for $15.00/issue + $1.00 shipping & handling. (Originals are spiral bound). Contact person is Bonnie Randolph, Student Services Office of Portland Public Schools, (503) 916-5840, x328.

Malachy Grange is a community health nurse at The School-Based Health Center, Marshall High School.
Male Profiling Can Show Up Anywhere

A quick inventory of the posters in my own teen health center showed this: a guy throttling a girl (dating violence); a guy abandoning his pregnant girlfriend (irresponsibility); a guy doping a girl’s drink (date rape). The only positive image was that of a football player saying no to drugs. These posters were created by well-intentioned professionals to address serious issues. But by concentrating so heavily on the negative side of male behavior, they create a male-unfriendly environment and reinforce an unhealthy image of manhood that’s becoming a stereotype in American media and society. -MG

Dealing With Reality

Surgeon General’s Call to Action

Last June, U.S. Surgeon General David Satcher released a long-awaited report encouraging Americans to respect “a diversity of sexual values,” recognize what science shows to be effective, and engage in an open discussion about sexuality.

*The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Behavior* details the current landscape of sexual activity: 12 million Americans are infected by sexually transmitted diseases each year, including 40,000 cases of HIV; nearly half of all pregnancies are unwanted; over 100,000 children are victimized by sexual abuse annually. Dr. Satcher suggests that thorough and medically accurate sexuality education is critical to combating these social ills.

The report encourages abstinence until people are involved in a “committed, enduring, and mutually monogamous relationship, unlike programs that urge abstinence until marriage.” “I have to deal with reality,” Dr. Satcher noted. In fact, studies show that students who have been instructed on both abstinence and contraception are more likely to postpone sexual involvement and


 and nature, the past, the present, and the future—in the profound synthesis of all knowledge, and the ideal coordination of human society as a whole—here he stands supreme. And it is doubtless on this ground that Comte has called the Divine Comedy "the incomparable epic, which still forms the highest glory of human art."

This is no place to dilate on the supreme gifts of Dante as poet, or to enter on the wide field of his numerous works. It is with the poet only that we are here concerned, and with the Vision alone. Nay, since this in itself is an inexhaustible field, we will confine our present notice to a single point, the relation of the Divina Commedia to the evolution of modern history. It is an accepted truism that this "Sacred Poem" sums up the spirit, the knowledge, the religion of the Middle Age, whilst it created the Italian language, inspired religious art, and founded modern literature. Its influence is still growing, six centuries after the manhood of the poet, and it idealised all that man had felt, believed, and done in at least as many centuries before his birth. The whole range of Catholic Feudalism seems to defile before our eyes, and beyond it we see visions of the heroes and poets of antiquity and the prophets and lawgivers of the East. Dante, it is often said, knew all that could be known, in an age when this was a feat still possible for a single mind. We need no testimony to convince us of the vast range of his learning. "He was," as Villani truly says, "perfect poet and philosopher, with the most exquisite style that the language ever produced." He seems to have absorbed all philosophy, all theology, all science, all poetry, all art and all history, as these were then understood by the greatest intellects. And it was an age of great men: for during Dante's life there were living Roger Bacon, Albert the Great, Aquinas, Duns Scotus, Giotto, Petrarch, Saint Louis, Rudolph of Hapsburg, and Edward I.
In form, in colour, perhaps in design, the Vision represents the Catholic Feudalism which culminated in the Crusades. But Catholic Feudalism in its essence had expired about the time of Dante's birth with such men as Saint Louis and Simon de Montfort; and when Dante wrote a new era had begun. There is profound significance in this, that Dante's place in the Polity is with the Western Revolution and not with the age of the Crusades, the Friars, and Innocent III. The Vision, indeed, is saturated with the spirit of modern thought, of secular and not clerical morality, of civic energy, and of the supremacy of science. It is true that Dante could not foresee the results of later time, and the mould of his imagination is Catholic in religion and Feudal in association. But no reformer of Church and State more fiercely denounced Popes and Cardinals, was more zealous for the right of private judgment of all things belonging to God or man, or more proudly true to republican simplicity and civic right. Enough has been said of Dante as Catholic mystic and as Imperialist liege-man. He was all this; and there are whole cantos which breathe the spirit of St. Bernard and of Godfrey de Bouillon. But we are too apt to forget that the deeper and more potent spirit of the Vision is the inquiring mind of Roger Bacon, Aquinas, and Montaigne; that Dante cares for authority as little as Francis Bacon or Hobbes; that he is as redolent of the Renascence as Raphael or Shakespeare; that he is a gentleman, a soldier, a lover, and a citizen. As Villani finely says: "For his virtues, science, and worth he seems to us so great a citizen, that it is befitting to give him perpetual remembrance."

Of the man himself, his own writings, the most pathetically personal in all literature, give us a vivid knowledge. He was born neither saint nor mystic: he was a man of the world, of audacious brain, of varied culture, with an exquisite taste for all forms of beauty and enjoyment. If remorseless criticism finds no authority for the portrait of the man of sorrows which is indelibly associated with our conceptions of the poet, it is difficult to resist the impression that, in the recovered fresco of the Bargello at Florence, we have the true features of the youth of such exquisite sensibility and genius before pain had hardened them into the stern mask that is familiar to us as the Poet of Hell. He suffered cruel disappointments, and he fell into many errors. He seems deeply conscious of his own faults, of pride, passion, and ungentleness. He seems unconscious how utterly unfit he was for the political and public career to which he devoted the first half of his life; and the famous State letters of his mature years, with all their noble enthusiasm and passion, are amazing instances of the philosopher who meddles with affairs. In truth, the saepe indignatio, which never ceases to lacerate his heart, not a little detracts from the poetic beauty of his work. History and tradition record the strange awe with which his contemporaries watched the lonely man "who had seen hell"; and we can well understand how his fellow-citizens, with Villani, found his learning somewhat too "arrogant, super-subtle, and disdainful, and found him, as philosophers are apt to be, rather ungracious in converse with the unlearned."

Truly he had his faults as well as his griefs. Yet indignation with him seems ever ready to blossom into most intense tenderness, pride towards men reaches forth into ideal humility in the sight of God, and
that saturnine outside covered profound depths of love inexhaustible and pure. Thus it comes to pass that, with all its obscurity, bitterness, and gloom, the Vision has become the centre of a literature more full than that which gathers round any other poem, and that it is hailed by Positivism as the foundation of the Bible that is to be. [P. E.]"
TROUBADOURS, from the end of the 11th to the end of the 13th Century.

Auguste Comte has remarked (Pos. Pol. iii. 373-4) on the fitness of the Middle Age for poetry in all respects but one. Defensive war supplied nobler themes than aggressive war; the ethical tone had been raised by chivalry and respect for womanhood. On the other hand, the social state was too unsettled for permanent work; language itself, the index to so much else, was rapidly shifting. The Middle Age produced the Nibelungen-Lied and the Chanson de Roland. But the modes of life portrayed in these two poems were, like their language, undergoing rapid and often violent transformations.

The case was otherwise with that southern part of Gaul whose name of Provence indicates its early reception of Roman civilisation, and which stood somewhat aside from the central stream of barbaric invasion which devastated Italy. Yielding to the Goths, the most sympathetic of the northern invaders, it was saved from the Vandals and the Huns. In that favoured climate a civilisation grew in which Roman culture was more peacefully blended than elsewhere with the new life of the West. It is not surprising, therefore, that the Provençal language should have reached maturity earlier than any of the Romance languages, and that Dante should have been tempted to use it in preference to the common speech of Tuscany for his great poem. In Dante's time this language possessed a vast poetical literature, written and oral, extending over at least two centuries. Epic romance and love-songs were the principal themes, though political satires (sirventes) were not wanting. The composers passed under the name of troubadours (finders, inventors), corresponding to the word trouvères applied to the minstrels of northern France. They wielded great social influence; were patronised by monarchs like Richard I. of England and Alfonso II. of Arragon, and their society was courted by ladies of the highest rank, sometimes with tragic results.

Two of those poets are mentioned by Dante. The first was Arnaut Daniel, whom he meets in Purgatory (canto xxvi.), and addresses as "the best workman of his mother-tongue, who surpassed all the rest in songs of love and tales of romance." Arnaut replies in the Provençal tongue. In his treatise on language, Dante says that he owes to him the lyrical form of some of his poems. He composed epical romances, one on the Rinaldo, of Carlovigitian legend; another on Lancelot, perhaps the one which proved fatal to the lovers of Rimini. The second was Bertram di Born, a fierce warrior of Gascony, who fomented dissension between Henry II. of England and his eldest son, and is on that account placed by Dante in the Inferno with Mahomet and other dividers of men (canto xxviii.). Others of note were Peire Vidal (1150-1210 A.D.), Guillem de Cabestan, of the same date, and Folquet, afterwards Bishop of Toulouse, and a fierce crusader against the Albigensian heretics. The same causes which brought into Southern France a premature Renaissance brought also a premature religious revolt, suppressed by Innocent III.
with stern severity. There were good reasons for the Albigensian crusade, stained though it was with needless cruelty. But it was fatal to the growth of troubadour poetry.

**BOCCACCIO (Giovanni


>

Juvenal
64

Kamiša Mera
26

Kant
528

Kempis, Thomas à
362

Kepler
590

Klopfstock
359

Kosciusko
574

Lacaille
880

Lafayette, Mme. de
555

INDEX OF BIOGRAPHIES

La Fontaine, 322
Lagrange, 613
Lamarc, 638
Lambert, John, 570
Lambert, Mme. de, 566
Lanfranc, 238
Lea-tae, 21
Le Valette, 265
Lavoisier, 626
Leibnitz, 522
Leo the Great, St., 382
Leo IV., 383
Leonidas, 199
Lercy, Georges, 509
Lercy, Pierre, 361
Le Sage, 457
Lessing, 438
Lesseur, 383
Laundrupus, 90
L' Hopital, 554
Linnena, 683
Locke, 503
Longus, 50
Louis of Granada, 354
Louis, St., 264
Louis, St., 254
Louis, xiv., 564
L' Ouverture, Toussaint, 577
Loyola, Ignatius, 241
Lucan, 72
Lucian, 65
Lucretius, 68
Luke, St., 209
Lully, 470
Lully, Raymond, 489
Lycurgus, 10
Lylyippus, 56
MADISON, 675
Mecenas, 108
Magellan, 978
Mahomet, 87
Maistre, J. de, 482
Malebranche, 504
Manco-Capac, 25
Mansoni, 847
Marcian, 258
Maria de Molina, 545
Marina, 276
Mariette, 400
Maritius, 188
Matilda of Tuscany, St., 297
Maupertuis, 514
Maximil., 502
Menander, 63
Mencius, 21
Menu, 15
Mercer, Elisa, 398
Metsastasio, F., 445
Michael Angel, 329
Miltiades, 169
Milton, 364
Moliere, 463
Monge, 410
Monica, St., 214
Montague, Lady, Mary, 456
Montaigne, M. de, 492
Montalvan, 480
Montesquieu, 518
Montgolfier, 490
More, Sir Thomas, 406
Moro, 401
Morgan, 654
Moses, 8
Motteville, Mme. de, 453
Mozart, 475
Murillo, 384
NAPIER, 378
Nasir-ad-Din, 149
Nearchus, 148
Nerva, 195
Newton, 615
Numa, 11
Oden, 591
Origen, 115
Orpheus, 9
Ossian, 18
Otho the Great, 260
Ovay, 489
Ovid, 71
Oxenstier, 561
PALESTINA, 467
Palissy, Bernard de, 410
Papin, 402
Papinian, 197
Pappus, 187
Pascal, 501
Paul, St., 206
Pelayo, 269
Penn, W., 247
Perigeuse, 466
Pericles, 178
Peter the Hermit, 298
Petarch, 351
Phaedrus, 64
Phidias, 58
Philp, 177

Name
Page

Philo of Alexandria
111

Philolaus
97

Philopæmen
160

Phocion
178

Pilpay
61

Findar
47

Plato
117

Plautus
62

Pliny the Elder
159

Pliny the Younger
105

Plutarch
158

Poinsof
609

Polo, Marco
372

Polybius
181

Pombal
566

Pousain
333

Praxiteles
55

Priestley
619

Prometheus
7

Ptolemy
148

Ptolemy I.,
179

Pulcheria, St.
222

Pythagoras
98

Pytheas
142

Rabelais
318

Racine
441

Raleigh
278

Ramus
491

Raphael
336

Regulus
186

Rembrandt
322

Richard Coeur de Lion
273

Richardson
462

Richelieu
567

Riquet
412

Ritter
625

Robertson
524

Römer
598

Rojas
431

Roland, Mme.
453

Romulus
11


3 B.C. on the great temple of Zeus at Olympia, where he made the gold and ivory colossal statue of Zeus, the wonder of antiquity, and an even greater and more imposing work than the Athene of the Parthenon. He seems to have died in 432 B.C., in prison, on the second charge of impiety, though by some accounts he was condemned and executed by the people of Elis.

The principal works of Phidias, besides the sculptures of the Parthenon, were the three colossal figures: the bronze Athene Promachos of the Acropolis, the outline of which is preserved to us on coins, and the two chryselephantine statues, that of Athene inside the Parthenon, and that of Zeus at Olympia. Of the former we have the general outline in existing statuettes, and of the latter we have indications on coins, and busts supposed to be imitated. Of the effect of this extraordinary form of art, which Phidias is said to have invented, one which could arise only out of an almost idolatrous mythology, we can have but a vague conception. In these chryselephantine statues the figure was made of a framework of hard wood, cypress or ebony. On this were superimposed plates of ivory and gold—the whole of the uncovered parts of the figures being of ivory, and the robes of gold; precious stones, chasing, and various metals being also employed. The Olympian Zeus was regarded as one of the wonders of the world; it survived for some seven or eight centuries, well into the Christian period; and it was uniformly spoken of with enthusiasm by the ancients who saw it. However much so complex and artificial a mass differs from our conception of plastic art, we cannot doubt the unerring genius of Phidias, and the unanimous verdict of antiquity; and we are forced to believe that these stupendous figures were the most imposing and beautiful ever produced by man.

The other principal works of Phidias were the statues of the Parthenon, of which the ruined fragments, known as the Elgin Marbles, in the British Museum, present us with a basis of conception. Although we are unable to say that any single work is from the hand of the sculptor himself, it has never been doubted that the colossal figures of the two pediments, and the fragments of the frieze, spring directly from the brain of the master. The world is agreed that they exhibit every quality of the sculptor's art in absolute perfection. Technical execution, sublimity of conception, beauty, truth, dignity, fitness, unerring judgment, fertility of invention, and mastery of composition are all displayed in equal power, and in the highest conceivable perfection. If there be one quality which impresses the beholder first as well as last, it is ideal beauty and grandeur. Phidias is said to have declared that he drew his ideal of the gods from the description of Homer. And it is in the Homeric quality of serene majesty and simple beauty that his art excels.

His work is as free as that of Homer himself from any taint of exaggeration, affectation, false emphasis, or sensuousness. It is always at once sublime and perfect. It was a saying of the ancients that "the hand of Phidias alone of men could make the image of the gods." With this power of ideal majesty, he combined a full technical mastery over
every form of plastic art. He himself claimed no other superiority except that of "accuracy of work." We are told that his skill was equally surpassing in representing the grasshopper and the bee as the gods of Olympus. He was a consummate master in marble, bronze, ivory, gold, or ebony; in sculpture, in relief, in engraving, in chasing, in enamelling; in colossal statues, and in the most delicate ornamentation of a moulding or a fringe. He had working under him, we are told, architects, sculptors, masons, bronze-founders, goldsmiths, ivory carvers, chasers, enamellers, and dyers. His genius was able to bring the work of all into perfect harmony.

His influence over all subsequent art was almost equal to that of Homer in poetry. Whilst all subsequent masters and schools had the defects of their qualities, the ancient and the modern worlds have never suggested a shortcoming in Phidias, or a single quality in which he was weak. Consummate judgment and unerring taste control the most sublime and lovely visions of beauty. It is significant that, whilst his representations of the nude surpass in knowledge and technical mastery any others known, we have no single extant example in which he presented the female form, even partially undraped. His Venus on the frieze, like all his other goddesses, is completely draped. Nor must it be forgotten that we have no single statue by Phidias, in the true sense of the word. The Elgin Marbles are all, without exception, architectural decorations. Even the so-called Theseus and the River God, sublime as they are, are the ornaments of a group placed in a pediment, 50 feet above the spectator; and, consequently, like the figures in the metopes or the frieze, they are entirely subordinated to the conditions of the architect.

Nor are we able to judge whether the great artist was equal to present human expression and emotion with the same power that he has presented the human form. No single head has survived to us uninjured of any of the larger figures that we can certainly ascribe to Phidias. But in the extant busts of Jupiter we may recognise faint copies of the majesty which he could give to the King of the Gods. We cannot assume that even Michael Angelo or Raphael surpassed Phidias in power of expression; and they assuredly did not surpass him in invention, in knowledge, or in sublime and serene beauty. There is every reason to believe that Phidias was the most perfect and complete genius who ever appeared in the arts of form: the one artist in whom we find nothing wanting, and of whom we know no failure. [F. H.]

ÆSOP: PILPAY

ÆSOP, possibly the 6th century B.C.

Æsop is the reputed author of a collection of moral fables, which, in various forms, has had a wide vogue and great influence in Europe. About the man we know absolutely nothing. The fables were shown by Bentley to be probably of Indian or Persian origin. The form of imagination which gives speech and other human characteristics to the lower animals is common and congenial to the early stages of thought, but it appears very rarely in Greek literature. We have an instance in both Hesiod and Æschylus, and in one or two other early Greek poets, but not elsewhere. In placing Æsop at the head of the series of writers of whom Aristophanes is chief, we may recognise the fact that in this "beast epic" is the earliest form of that humorous description of the faults of human life which, in its fully developed shape, we call "comedy" (see Pos. Pol. iii. 234). The Fables of Æsop were versified in later years by Phaedrus in Latin, and by Babrius in Greek. But it was another writer, now almost forgotten, who kept these fables alive during the Middle Ages, enjoying for many centuries a celebrity second only to Virgil—the half-barbarous elegiac fabulist, Avianus. [F. S. M.]

Mahaffy: History of Greek Literature, i. 98, etc.

PILPAY.

The name of Pilpay or BIDPAI is entirely unknown to the Hindoos. The Fables and Proverbs which pass under his name consist mainly of the Pancha Sutra, or Five Sections, and the Hitopadesa, or Friendly Instructor, which were translated into Persian in the fifth century A.D. They were afterwards translated into Arabic; and in 1709 the Persian version was translated into French under the title of Les Consels et les Maximes de Pilpay, which appear in English as The Instructive and Entertaining Fables of Pilpay. The name of Pilpay appears to have been first attributed to the collection in Persia, the reputed Hindoo author being Vishnu-Sarma.

These fables are the earliest collection in the world, and greatly surpass in humour and in variety of matter and of lesson the Fables of Æsop. There is at the same time similarity enough between the two collections to make us believe in a common source. The Sanskrit fables are supposed to be told by their author for the education of the children of a certain rajah, and form a wonderfully interconnected series. The animals introduced relate other stories to one another, and deliver many proverbs and practical moral precepts, which form a much more important part of this collection of fables than of any other. [F. S. M.]

PLAUTUS (Titus Maccius Plautus), abt. 254-184 B.C.

Plautus was born in Umbria about the middle of the third century B.C. He is said by some to have been a slave and afterwards a stage carpenter. But these may be stories invented to account for his knowledge of slave character and his connection, though a man of humble origin, with the theatre. He produced his first play in 224 B.C., and wrote without a rival till his death forty years later. Twenty of his plays remain.

Like his successors, Cecilius and Terence, he was largely indebted to Menander and the later comedians of Athens, though he is probably more original than either of them. This method of


. It consists of thirteen books, of which the first two treat of the earth as centre of the universe, of the motion of the stellar spheres by which the day, the year, and the precession of the equinoxes is explained; his table of chords is described and applied; astronomical time is defined, the dependence of climate on latitude is shown. The third book deals with the theory of the sun; the fourth and fifth with that of the moon; the sixth is given to eclipses; the seventh and eighth to the stars; the last five books to the planets.

Ptolemy frequently mentions Hipparchus; but it has been shown in detail by Delambre and others that he has borrowed from him far more than he has acknowledged. But what remains as his own is of much importance. He discovered the second inequality of the moon's motion called evocation; the first inequality, due to the excentric position of the earth in the lunar orbit, and called, as in the case of the sun, the equation of the centre, had been discovered by Hipparchus. Ptolemy found that the equation of the centre was diminished when the moon was in conjunction with or opposition to the sun, and was increased in quadrature, i.e. when the angular distance between the moon and sun was 90°. The amount of this inequality depended also on the combination of the places of the lunar apsesides with that of the conjunctions. Ptolemy's estimate of this second irregularity, called by astronomers evocation, was very nearly accurate, and is a discovery of great value.

Ptolemy represented lunar as well as planetary motions by supposing the body considered to move on the circumference of a small circle, the centre of which was carried round the earth; a mode of representing complicated periodic motions first suggested by Apollonius. By varying the size of the subsidiary circle and the direction of motion, all these irregularities became susceptible of geometrical treatment. The hypothesis was strictly legitimate; the more so that none but circular arcs were amenable to calculation. A further discovery of vital import to astronomy is due to Ptolemy—that of the refraction of rays of light when passing from a thinner to a denser medium. It is spoken of not in his astronomical work, but in his *Optics*, which therefore must have been written later. Arranging at the extremities of one of the diameters of a circle and at the centre three coloured spots, so that when the circle was half immersed in water, they appeared to be in a straight line, he was able to determine with precision the refraction for each angle of the incident ray. Applying this to astronomy he shows that refraction, greatest at the horizon, and diminishing as the star approaches the zenith, disappears when the ray is vertical.

ALBATEGNIUS, 380 A.D.

In the ninth century begins the fertile period of Arabian science, protected and encouraged by the Khalifs of Baghdad, especially by Al Mamun, son of Harun-al-Raschid, who spent much time in forming a collection of Greek works on science. Ptolemy's *Syntaxis* was translated in 817 by Isaac ben Honain, and was carefully studied by the astronomers of Baghdad and Damascus. His observations were carefully repeated, but without any marked advance of science till the time of Mohammed ben Geber Albatani; so called from Batan, in Mesopotamia, the place of his birth; in Western style he is known as Albategnius. He was a Syrian prince; able and willing to spend wealth on costly observatories established at Aracte and also at Antioch. The result of his labours is contained in a treatise on the science of the stars and their motions.

In trigonometry, Albategnius introduced an important innovation—the use of the semi-chord of the double arc for the chords employed by Hipparchus and Ptolemy. This semichord was called in Arabic *gib*, i.e. pleat or fold, translated into Latin as *sinus*; such, at least, is the most probable explanation of the word. The introduction of the sine simplified the labour of calculation. Of the other trigonometrical lines, the tangent appears to have been known to him, but not used; the cosine and secant were of later invention.

In astronomy, Albategnius, repeating with greater accuracy and better instruments the observations recorded by Ptolemy, determined the annual amount of precession as 54″, instead of 36″; a very much nearer approximation to the true amount. He discovered also what in Ptolemy's time was unknown—the annual motion of the solar apogee, which he fixed at 25″. His determinations of the eccentricities of the solar orbit, of the obliquity of the ecliptic, and of the length of the year, were superior in accuracy to those of the Greeks. The year as fixed by him was two minutes and a half too short, an error much smaller than that of Hipparchus, and which, when examined, appears to be due to an incorrect, or even fictitious, observation of Ptolemy.

[J. H. B.]

Delambre: *Astron. du Moyen âge*.

NASIR-ED-DIN (Mohammed Ben Hussein), b. 1201, d. 1274 A.D.

Mohammed, the son of Hussein, Al-Thussai (of Thous), from the place of his birth, was a Persian astronomer of the thirteenth century. He was a favourite of Holagou Khan, grandson of Zingis, the great Mogul who overran Persia, and destroyed the Abbasid dynasty in A.D. 1258 (Gibbon, ch. lxiv.). The chief fixed his government at Maragha, where he collected men of science and built an observatory, over which Nasir-ed-Din presided until 1271. He there constructed hydraulic and engineering machines and a variety of improved astronomical instruments, described by Delambre, and collected a fine scientific library.

He also wrote on Philosophy, combining Aristotle with Plato, and
made a Persian translation of the *Almagest* of Ptolemy. And he translated into Arabic the *Elements* of Euclid. He compiled a body of *Tables* of astronomical observations, taken over twelve years. They were dedicated to the Mogul Sultan, were known as the *Ilkhanic Tables*, and enjoyed a great reputation in the East. He also wrote on geography, determining longitudes and latitudes. [F. H.]

**HIPPARCUS, abt. 150 B.C.**

Hipparcus was born at Nicaea in Bithynia, and from his astronomical observations it appears that he was living in the interval 180-125 B.C. His observations appear to have been almost entirely taken from the island of Rhodes. Whatever communication he had with Alexandria, there is no evidence that he resided there.

Of the numerous astronomical memoirs which he is recorded to have written, the only one that is extant is his commentary on the poem of Aratus, recording the observations of Eudoxus. Hipparcus was probably young when he wrote this work: it does not mention any of the discoveries that have made him famous. Pliny, writing in the first century A.D., speaks of him with enthusiasm, as a man whom it was impossible to over-praise, and mentions specially his audacious enterprise of constructing a map of the stars. Ptolemy, in the following century, calls him a laborious searcher after truth, and makes continual references to his results. But in the great historical work of Delambre, it was for the first time shown in detail that Ptolemy had acknowledged but a small instalment of his debt; and that the immense reputation enjoyed by him through the times of Arabian and medieval astronomy rested in great part on the discoveries of Hipparcus.

These discoveries are numerous; but the two most important of them, the institution of Trigonometry and the establishment of the precession of the equinoxes, are, as Comte has pointed out, intimately connected with each other. He found, by comparing his own observations of the stars with those made 150 years previously by Aristillus and Timocharis, that their positions as measured perpendicular to the equator and parallel with a fixed point in it (i.e. their declinations and right ascensions), showed notable variation of an apparently irregular kind. The case altered, however, when the two positions of the star were referred not to the equator, but to the ecliptic. Measured perpendicularly to the ecliptic the position of the star—in other words, its latitude—had not changed; but the measurement parallel to the ecliptic, that is to say its longitude, showed a variation amounting to a degree and a half in the period examined. This remarkable phenomenon was geometrically represented by supposing the intersections of the equator with the ecliptic—in other words, the equinoctial points—to alter their positions yearly in a direction opposite to that of the sun's path. They were said to retrograde, so that the equinoxes occurred every year some-
what earlier than would be the case if they remained stationary. The conversion of declinations and right ascensions into latitudes and longitudes shows that Hipparchus had the power of solving the spherical triangle produced by the intersections of the equator and the ecliptic with a meridian; in a word, that he was acquainted with the principles of spherical trigonometry.

But for the further discoveries of Hipparchus on the solar and lunar motions, plane, as well


 own hair. Other similar figures at Archelaos I’s court included the poets Agathon, Choerilus of Samos, and Timotheus of Miletus, as well as the painter Zeuxis of Ephesus. Perhaps to these should be added the sculptor Callimachus, if the identification of an inscribed epigram found in Aegae as his funerary inscription is correct.

The circulation of intellectuals and artists throughout the Hellenic territory was a matter of course. In the sphere of political thought, during the 5th century the ties between many of them and democratic leaders were strong. However, after the death of Pericles there was a gradual shift towards other sorts of governments, a trend that continued at the beginning of the 4th century. The relationship between authoritative rulers and intellectuals became stronger; we know of many cases all over the Greek world, such as Plato in Syracuse. It is in this context in which Archelaos I should be framed. Antisthenes, one of the disciples of Socrates, was interested in the monarchy, and wrote a book, now lost, about the Macedonian king, as well as another about Cyrus. This should not be interpreted as a mere coincidence.

The aim of Archelaos I’s attempts to attract intellectuals and artists to his court was not just to expand his network of contacts or the mere celebration of symposia, but also to learn from them and to introduce reforms in his kingdom following their advice. That is why, for example, Euripides is supposed to have overseen the financial administration of the kingdom. Archelaos I’s reign coincided with a moment when places like Macedon might have been perceived as being safer than others such as Athens, where the ravages of war were becoming increasingly more conspicuous and where some intellectuals did not encounter an atmosphere conducive to the development of their ideas. At the same time the connections of the kings with the Greek community would improve their reputation.

Not everybody accepted Archelaos I’s invitation to join his court, though. According to Aristotle, Socrates rejected such a proposal, arguing that it was disgraceful not to be in a position to return a favor, as well as an injury. In the same vein, the contemporary

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48 D.S. 13.103.5; Paus. 1.2.2; Plu. De ex. 604d-e. In this connection, SCULLION 2003, 389-399 discusses a possible misinterpretation of the sources and holds that Euripides might have actually remained and died at Athens, but his arguments are not convincing. For this debate and previous bibliography, see LAMARI 2017, 46, who states that the strongest argument in favor of this theory is the reference to the presence of Euripides at Archelaos I’s court made by Aristotle, who had lived there when his father was a physician to King Amyntas III. STEWART 2021, 95-97 goes further and suggests that Euripides’ stay in Macedon should be divided into two periods, approximately from 412/411-410 and 408-406.

49 Solin. 9.15.

50 Ar. Ran. 83-5; Pl. Symp. 172c; Ael. VH 13.4. Although the presence of Agathon in Macedon is not certain; in this respect, see MULLER 2016, 175-181.

51 ROISMAN 2010, 156-157; MOLONEY 2014, 603.

52 Plin. HN 35.36.62.

53 PASPALAS 2011, 185.

57 LURAGHI 2013, 139-140. As PRINCE 2015, 162-163 suggests, the form of the title, Ἄρχελαος ἢ Περὶ βασιλείας, implies that this work was probably written as a dialogue between Archelaos I and, possibly, Socrates.

59 Arist. Rhet. 1398a [25].
sophist Thrasymachus called Archelaos I a barbarian in his speech in defense of the Larissaeans, who ran the risk of being enslaved by the monarch.

The conspiracy that supposedly ended with the death of Archelaos was hatched precisely in this circle of intellectual companions. The attack was orchestrated by Decamnichus, who was furious at the king for having handed him over to Euripides to be flogged after the young favorite had remarked on the playwright’s bad breath. The plotters also included the above-mentioned Crataeas, a resentful lover of the monarch and the one who killed him, as well as Hellanocrates for similar reasons. In both cases, Archelaos I had made them promises that he subsequently broke.

Another aspect that should be considered in the cultural field is the creation of agones. Dion, the main sacred site of Macedon, became the seat of the Olympia, a festival in honor of Zeus and the Muses. The existence of these agonistic competitions is attested in both the literary and epigraphic sources. The nature of the extant accounts of the Olympia makes it difficult to paint a detailed picture of the organization and sequence of the festival, and especially so to determine its real origin. It is Arrian who mentions Archelaos I as the founder, although in his account the historian refers to the agones of Alexander the Great at Aegae, before the expedition to Asia and immediately after performing sacrifices to Zeus Olympios. Assuming the reliability of Arrian’s account of this episode, since he had access to first-hand sources, this information can be interpreted as a reference to a special edition of the Olympia at Aegae, whereas the traditional one would have taken place at Dion. In fact, that Archelaos I did not found the agones, but may have instead reorganized them, should not be ruled out.

Archelaos I is supposed to have been interested in Panhellenic games. According to Solinus, he obtained victories in the chariot races at the Pythian and Olympic Games. This account, albeit difficult to accept, is certainly in keeping with the king. Archelaos I may have chosen Dion for the Olympia due to its proximity to Mount Olympus, an iconic place for all Greeks. Although some scholars have considered this festival as a sort of counter-Olympics, it was more likely an attempt to forge stronger links with the southern neighbors, thus allowing for a more fluid communication, as well as to create a flagship festival for the Macedonians. There is no reason to believe that those

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60 Thrasy. fr. 2 DK / D18 B2 Laks–Most: “δοιλεόσομεν Ἐλλήνες ὄντες βαρβάρους”.
61 Arist. Pol. 1311b.
62 Thuc. 1.126.5 (Scholia); D. 19.192; D.S. 17.16.3-4; Dio Chrys. 2.2; Arr. An. 1.11.1; Philostr. Ap. 1.34; Steph. Byz., Δiov; SEG XLVIII 781; IG IV 682, ll. 5-6; BE 1939, No. 139. Perhaps also Luc. Her. 7; IG VII 2486; IG XI 4, 1059; I. Sardis 79, ll. 11-15.
63 The most thorough attempt to examine the origin, nature, and organization of this festival can be found in MARI 1998.
64 Arr. An. 1.11.1.
65 MARI 1998, 148-149.
67 Solin. 9.16.
68 BADIAN 1982, 35. This is connected with the debate on the participation of Alexander I in the Olympic Games (Hdt. 5.22). To put it succinctly, there is no evidence of the presence of the king. In fact, the passage in Herodotus should be read from a political perspective. For further information on this debate and a previous bibliography, see FEARN 2011, 116-118, esp. n. 34.
69 ALBANIDIS 2009, 8. GRAZ 2016, 67 wonders whether Dion became the federal sanctuary of the Macedonians as a result of the introduction of the Olympia.
70 BADIAN 1982, 35-36; BORZA 1993, 240-241, who initially supported the thesis, but then changed his mind.
71 ALBANIDIS 2009, 9; MARI 1998, 164-165.
games could compete with the Great Games and, at the time, the Olympia may have been