on 03-Dec-2023 (Sun)

Part I. Tutorial: Chapter 1. Getting Started (whole chapter)

Part I. Tutorial: Chapter 2. The SQL Language (whole chapter)

Chapter 3. Advanced Features

When the hierarchical ascent of nature to mind and to ideal forms was disturbed by the con- viction that the subject-matter of natural science is exclusively physical and mechanistic, there arose the dualistic opposition of matter and spirit, of nature and ultimate ends and goods.

In him, more than in any modern thinker, there are exhibited complete loyalty to the essential element in the Hebraic tradition ultimate and self-sufficing Being as the standard of all human thought and action with perpetua- tion of the Greek theory of knowledge and its exaltation of reason over experience, together with enthusiastic adherence to the new scientific view of nature. Thus he thought to obtain from the very heart of the new science aconclusive demonstra- tion of the perfection of Being through which the human soul can alone obtain absolute security and peace. Ascientific com- prehension was to give, in full reality, by rational means, that assurance and regulation of life that non-rational religions had pretended to give.

ertain, enduring and unalloyed Good through the union of mind with the whole of nature is the theme developed in detail in the Ethics. There results aphilosophy which unites the Greek idea that man's highest good is demonstrative ra- tional knowledge of immutable Being jthe Hebrew and Chris- tian conviction that the soul is capable of away of life which secures constant and pure blessedness, and the premises and method of the new science, as he saw the latter. Nature was completely intelligible jit was at one with mindj to apprehend nature as awhole was to attain acognitive certainty which also afforded acomplete certainty of good for the purpose of con- trol of appetite, desire and affection this latter specification being one which Greek thought did not include and which it doubtless would have thought the height of presumption to lay claim to. Right ordering of human conduct, knowledge of the highest reality, the enjoyment of the most complete and unvarying value or good, were combined in one inclusive whole by means of adoption of the ideas of the complete interdepen- dence of all things according to universal and necessary law an idea which he found to be the basis of natural science.

Spinoza exemplifies with extraordinary completeness the nature of the problem of all modern philosophies which have not deserted the classic tra- dition, and yet have made the conclusions of modern science their own. What makes Spinoza so admirably the exponent of this problem is that he adopted with ardor and without the res- ervations displayed by most modern thinkers the essential ele- ments in the Greek tradition of intellectualism and naturalism, the Hebrew-Christian idea of the priority and primacy of the properties of ultimate Being which concern the control of hu- man affection and endeavor, and the method and conclusions of the new natural science

asingle underlying problem: the adjustment to each other of two unquestioned convictions: One, that knowledge in the form of science reveals the antecedent properties of reality ;the other, that the ends and laws which should regulate human affection, desire and intent can be derived only from the properties possessed by ultimate Being.

Before the rise of the new science of nature there was de- veloped amethod for adjusting the claims of natural reason and moral authority by means of adivision of the field: the doctrine of "the two-fold nature of truth." The realm of the ends and values authoritative for conduct was that of the revealed will of God. The organ for its apprehension was faith. Nature is the object of knowledge and with respect to it the claims of reason are supreme. The two realms are so separate that no conflict can occur. The work of Kant may be regarded as aperpetuation of the method of adjustment by means of partition of territories. He did not of course de- marcate the realm of moral authority on the ground of faith in revelation. He substituted the idea of faith grounded in practical reason. But he continued the older distinction of one realm where the intellect has sway and one in which the re- quirements of will are supreme. He retained also the notion of an isolation of the two fields so complete that there is no possible overlapping and hence no possibility of interference. If the kingdoms of science and of righteousness nowhere touch, there can be no strife between them.

Heine's view that the subject-matter of the practical critique was an afterthought, aconcession to the needs and fears of the multitude represented by his manservant

the neat way in which the elements of each dovetailed into those of the other was to him aconvincing proof of the necessity of the system as awhole. If the dovetailing was the product of his own intellectual carpentry, he had no suspicion of the fact.

The Kantian method is of course but one of anumber of the philosophic attempts at harmonization. There is one phase of it which may be said to continue the Cartesian attempt to find the locus of absolute certainty within the knowing mind itself, surrendering both the endeavor of the ancients to dis- cover it in the world without, and of the medieval world to find it in an external revelation. In his search for forms and categories inherent in the very structure of knowing activity, Kant penetrated far below the superficial level of innate ideas in which his predecessors had tried to find the locus of certainty. Some of them were conditions of the possibility of there being such athing as cognitive experience.

Solution by the method of partition

Fichte was wholly in the Hebraic tradition of the supremacy of the moral. He accordingly attempted unification of the cognitive and the practical from the side of moral self, the self from which issues the imperative of duty. The "is" of knowledge is to be derived from the "ought to be" of morals.

The moral task of man is not to create aworld in accord with the ideal but to appropriate intellectually and in the substance of personality the meanings vand values already incarnate in an actual world. Viewed historically, HegePs system may be looked on as a triumph in material content of the modern secular and positi- vistic spirit. It is aglorification of the here and now, an indica-

tion of the solid meanings and values contained in actual in- stitutions and arts. It is an invitation to the human subject to devote himself to the mastery of what is already contained in the here and now of life and the world, instead of hunting for some remote ideal and repining because it cannot be found in existence. In form, however, the old tradition remains intact. The validity of these meanings and values, their "absolute" character, is proved by their being shown to be manifestations of the absolute spirit according to anecessary and demonstrative logical development: even though Hegel had to create anew logic to establish the identity of meaning and being.

Perhaps there is no system more repugnant to the admirers of Spinoza than the Hegelian; and yet Hegel himself felt, and with considerable reason, that he was simply doing in aspecific and concrete way what Spinoza had undertaken in aformal and mathematical way. However, the point important for our purpose is that in both Fichte and Hegel there is expressed the animating spirit of modern ideal- ism in dealing with the basic problem of all modern philoso- phies. They have sought by examination of the structure of the knowing function (psychological structure in the subjective idealisms and logical structure in the objective idealisms and usually with aunion of both strains) to show that no matter what the detailed conclusions of the special sciences, the ideal authority of truth, goodness, and beauty are secure possessions

There have been attempts at adjustment of the results of knowledge and the demands of ethico-religious authority which have not been mindful of the classic tradition. Instead of bringing nature within the fold of value, the order has been reversed. The physical system has been treated as the supporter and carrier of all objects having the properties which confer authority over conduct. Aword about the system of Herbert Spencer among the moderns is appropriate in this connection, as one about Lucretius would be if antiquity were the theme.

Spencer's in- sistence on the evanescence of evil

method of isolation. In detail, however, the method pursued is unlike that of Kant in that it does not start from the knowing mind but rather from the objects of knowing. These, it is argued, show aradical division into the existential and the non-existential. Physical science deals with the former; mathe- matics and logic with the latter. In the former, some things, namely sense-data, are objects of infallible apprehension; while certain essences or subsistences, immaterial in nature because non-existential and non-physical, are the subjects of an equally assured cognition by reason. Uncertainty appertains only to combinations of ultimate and simple objects, combinations formed in reflective thought. As long as we stick to the self- guaranteed objects, whether of sense or of pure intellect, there is no opening for any uncertainty or any risk.

alues are so intimately connected with human affections, choices and endeavors, that there is ground for holding that the insincere apologetic features of historic philosophies are connected with the attempt to combine atheory of the values having moral authority with atheory of ultimate Being.

There is afatal ambiguity in the conception of philosophy as apurely theoretical or intellectual subject. The ambiguity lies in the fact that the conception is used to cover both the attitude of the inquirer, the thinker, and the character of the subject-matter dealt with.

Except, then, on the premise that the subject-matter of philosophy is fixed properties of antecedent Being, the fact that it is an intellectual pursuit signifies nothing beyond the fact that those who engage in it should respect the canons of fairness, impartiality, of internal consistency and external evi- dence. It carries no implication with it except on the basis of aprior assumption save that of intellectual honesty. Only upon the obverse of the adage that whoso drives fat oxen must himself be fat, can it be urged that logical austerity of personal attitude and procedure demands that the subject-matter dealt with must be made lean by stripping it of all that is human concern. To say that the object of philosophy is truth is to make amoral statement which applies to every inquiry. It implies nothing as to the kind of truth which is to be as- certained, whether it be of apurely theoretical nature, of a practical character, or whether it concerns the bearing of one upon the other. To assert that contemplation of truth for its own sake is the highest ideal is to make ajudgment concerning authoritative value. To employ this judgment as ameans of determining the office of philosophy is to violate the canon that inquiry should follow the lead of subject-matter.

the fundamental ground for the disparaging view held of practical activity. Depreciation is warranted on the basis of two premises: first, namely, that the object of knowledge is some form of ultimate Being which is antecedent to reflective inquiry and independent of itj secondly, that this antecedent Being has among its defining characteristics those properties which alone have authority over the formation of our judgments of value that is, of the ends and purposes which should control conduct in all fields intellectual, social, moral, religious, esthetic. Given these premises and only if they are accepted it fol- lows that philosophy has for its sole office the cognition of this Being and its essential properties.

Traditional religion does refer all ultimate authoritative norms to the highest reality, the nature of Godj and failure on the part of those professedly accepting this religion to carry this reference over to concrete criticism and judgment in special fields of morals, politics and art, is only an evidence of the confusion in which modern thought is entangled. It is this fact which gives the strict ad- herents to old beliefs, such as those trained in the Catholic faith, an intellectual advantage over "liberals." For the latter have no philosophy adequate for their undertakings and com- mitments.

The failure to employ standards derived from true Being in the formation of beliefs and judgments in concrete fields is proof of an isola- tion from contemporary life that is forced upon philosophy by its adherence to the two principles which are basic in the classic tradition. In the middle ages there was no such isolation. Philosophy and the conduct of life were associated intimately with one another jthere was genuine correspondence. The out- come is not fortunate for philosophy jit signifies that its subject- matter is more and more derived from the problems and con- clusions of its own past history} that it is aloof from the problems of the culture in which philosophers live. But the situation has astill more unfortunate phase. For it signifies intellectual confusion, practically chaos, in respect to the criteria and principles which are employed in framing judgments and reaching conclusions upon things of most vital importance. It signifies the absence of intellectual authority.

hen Isay "authority" Ido not mean afixed set of doc- trines by which to settle mechanically problems as they arise. Such authority is dogmatic, not intellectual. Imean methods congruous with those used in scientific inquiry and adopting their conclusions jmethods to be used in directing criticism and in forming the ends and purposes that are acted upon.

Why has modern philosophy con- tributed so little to bring about an integration between what we know about the world and the intelligent direction of what we do? The purport of this chapter is to show that the cause resides in unwillingness to surrender two ideas formulated in conditions which both intellectually and practically were very different from those in which we now live. These two ideas, to repeat, are that knowledge is concerned with disclosure of the characteristics of antecedent existences and essences, and that the properties of value found therein provide the authoritative standards for the conduct of life.

Both of these traits are due to quest for certainty by cogni- tive means which exclude practical activity namely, one which effects actual and concrete modifications in existence. Practical activity suffers from adouble discrediting because of the perpetuation of these two features of tradition. It is amere external follower upon knowledge, having no part in its de

dards and tests of validity are found in the consequences of overt activity, not in what is fixed prior to it and independently of it.

Modern communication systems vary widely in their applications and complexity, but they are all accurately represented by the block diagram shown in Figure 1.5:
1. A variety of information sources feed a transmitter with the message signal to be transmitted.
2. The transmitter transforms the message signal into a form that is compatible with the type of communication system and that is suitable for passage through the transmission medium with an acceptably small distortion.
3. The output of the transmitter, known as the transmitted signal, is placed into the transmission medium, which conveys it to a receiver located at the intended destination.
4. The received signal at the output of the transmission medium and input of the receiver is a distorted version of the transmitted signal. Noise, distortion, and reduction in strength have been introduced by the medium.
5. The receiver has the task of removing (as far as possible) the transmission impairments and undoing each operation performed by the transmitter. It then delivers an exact or close copy of the original message to a user or information sink. The receiver is also selected to match the characteristics of the transmission medium and to be compatible with the type of communication system.

Information about the natural history of untreated syphilis in humans derives from data collected from several sources:

● In the late 19^th century, a Norwegian physician described the evolution of infection in more than 1400 patients with primary and secondary syphilis. Because he believed that the available therapies at the time were highly toxic and of little benefit, patients received no treatment [1].

● Additional data were collected from a study of 382 adults with syphilis who underwent autopsies between 1917 and 1941 [2]. This compilation provided pathologic confirmation of the late manifestations of syphilis.

● Finally, the Tuskegee study conducted between 1932 and 1972 collected data on 431 Black men whose syphilis was untreated [3]. This project was initiated prior to the availability of effective therapy for syphilis, but it profoundly violated ethical standards by not providing study participants with treatment proven to be effective once it became available. Moreover, the study participants were not given sufficient information about the study to provide informed consent. These ethical concerns significantly impacted clinical research by engendering distrust between investigators and potential study participants that persists to this day; efforts to address these concerns have led to major reforms in clinical research standards and requirements.

T. pallidum, the causative organism of syphilis, was first identified in 1905 [4]. It is a bacterium from the order Spirochaetales and is one of several closely related treponemes that cause human disease [5]

The organism can be seen with darkfield microscopy, a technique that employs a special condenser that casts an oblique light. When visualized by this method, T. pallidum is a delicate, corkscrew-shaped organism with tightly wound spirals (picture 1). It exhibits a characteristic rotary motion with flexing and back-and-forth movement, features considered sufficiently characteristic to be diagnostic [6].

As of 2014, the median case rate was 17.2 cases per 100,000 females and 17.7 cases per 100,000 males [8]. The highest prevalence was reported in the WHO Western Pacific region (93 cases per 100,000 adult population), followed by the African region (46.6 cases per 100,000 adult population), and the region of the Americas (34.1 cases per 100,000 adult population).

Transmission of T. pallidum usually occurs via direct contact with an infectious lesion during sex. In addition, T. pallidum readily crosses the placenta thereby resulting in fetal infection. The acquisition of syphilis through transfused blood is very rare because all donors are screened and T. pallidum cannot survive longer than 24 to 48 hours under blood bank storage conditions.

Sexual transmission requires exposure to open lesions with organisms present, features seen with the primary chancre and with some of the manifestations of secondary syphilis (mucous patches and condyloma lata). These lesions are very infectious, with an efficiency of transmission estimated at approximately 30 percent [3,17]. By contrast, the cutaneous lesions of secondary syphilis contain few treponemes, and the risk of transmission through intact skin is low.

Patients with early latent syphilis are considered infectious due to concern for recently active lesions that are no longer present or active lesions that were missed on the initial evaluation.

T. pallidum can initiate infection wherever inoculation occurs. Thus, contact of infected secretions with almost any tissue can lead to a primary syphilis lesion at that site, and syphilis can be spread by kissing or touching a person who has active lesions on the lips, oral cavity, breasts, or genitals. As an example, transmission of syphilis has been identified in men who have sex with men (MSM) who have reported oral sex as their only risk factor for acquisition [18].

Syphilis is also associated with the transmission and acquisition of other sexually transmitted infections (eg, HIV). As an example, in a study examining the HIV incidence among men with new primary and secondary syphilis, 1 in 20 MSM were diagnosed with HIV within one year of a syphilis diagnosis [19].

Early local infection — T. pallidum initiates infection when it gains access to subcutaneous tissues via microscopic abrasions [21]. Despite a slow estimated dividing time of 30 hours, the spirochete evades early host immune responses and establishes the initial ulcerative lesion, the chancre (picture 2). During the period of early local replication, some organisms establish infection in regional draining lymph nodes with subsequent dissemination

Compared with peripheral blood, lesional fluids were enriched with CD4+ and CD8+ T cells, activated monocytes, macrophages, and dendritic cells. Many of these dendritic cells also expressed HIV coreceptors (eg, CCR5 and DC-SIGN), which may help explain the epidemiologic link between syphilis and HIV transmission.

After acquisition of T. pallidum, humoral immune responses are also generated. This leads to the development of a variety of antibodies that can be detected relatively early in the course of syphilis.

In some respects, the immune response to T. pallidum is paradoxical. On one hand, the various immune responses during early infection appear to be efficacious, since they coincide with resolution of the primary chancre, even in the absence of therapy. However, despite this apparent immune control, widespread dissemination of spirochetes occurs at the same time, leading to subsequent clinical manifestations of secondary or tertiary syphilis in untreated patients.

Gummas, or late benign syphilis often involving the skin, viscera, or other tissues (eg, bone, brain, abdominal viscera), are characterized pathologically by the presence of granulomas, a finding that is consistent with a cellular hypersensitivity reaction (see 'Gummatous syphilis' below). Experimental studies with human subjects who were inoculated cutaneously with live T. pallidum found that gummas developed only in those who had previous syphilis [20]

Cardiovascular syphilis with involvement of the ascending arch of the aorta and aortic valve is a consequence of vasculitis of the vasa vasorum ("endarteritis obliterans"). Small vessel vasculitis is a common manifestation of secondary and later stages of syphilis as evidenced by the presence of lymphocytes and plasma cells infiltrating blood vessels and perivascular tissues.

The prolonged latent period that is characteristic of most types of late syphilis suggests that immune mechanisms may be involved in one of two ways. Waning immunity with aging may facilitate recrudescence of a small number of treponemes that had survived in sequestered sites. Alternatively, a partially immune hypersensitive host may react to the presence of treponemes, engendering a chronic inflammatory response

Syphilis is generally divided into early and late stages (table 1).

Early syphilis comprises primary and secondary syphilis, which typically occur within weeks to months after initial infection as well as early latent syphilis (asymptomatic infection that was acquired within the previous 12 months).

When patients are untreated during the earlier stages of syphilis, they can progress to late latent disease (which is asymptomatic) or develop major complications of the infection (eg, tertiary syphilis). The clinical events occurring as a consequence of late syphilis may appear at any time from 1 to 30 years after primary infection and can involve a wide variety of different tissues.

Following acquisition of T. pallidum, the initial clinical manifestation of infection is a localized skin lesion termed a chancre. The median incubation period before the chancre appears is 21 days (range 3 to 90 days) [25].

The lesion begins as a papule, which is typically (but not always) painless, appearing at the site of inoculation. This soon ulcerates to produce the classic chancre of primary syphilis, a 1 to 2 centimeter ulcer with a raised, indurated margin (picture 3A-C). The ulcer generally has a nonexudative base and is associated with mild to moderate regional lymphadenopathy that is often bilateral. Such lesions usually occur on the genitalia, but occasionally patients may develop chancres at other sites of inoculation (picture 4). These sites may include areas that may not be noticeable to the patient, including the posterior pharynx, anus, or vagina. Infrequently, multiple chancres occur, particularly in the setting of HIV infection.

Chancres heal spontaneously within three to six weeks even in the absence of treatment. Since the ulcer is painless, many patients do not seek medical attention, a feature that enhances the likelihood of transmission.

Secondary syphilis — Within weeks to a few months after the chancre develops, approximately 25 percent of individuals with untreated infection develop a systemic illness that represents secondary syphilis [1]. Patients with secondary syphilis may not have a history of a preceding chancre since the primary infection may have been asymptomatic and/or gone unnoticed.

Similar to primary disease, the acute manifestations of secondary syphilis typically resolve spontaneously, even in the absence of therapy, except in the case of severe cutaneous ulcerations called lues maligna (picture 5A-C). Occasionally, untreated patients experience additional episodes of relapsing secondary syphilis, which can occur for up to five years after their initial episode [1].

Constitutional symptoms – Patients with secondary syphilis may develop systemic symptoms including fever, headache, malaise, anorexia, sore throat, myalgias, and weight loss. These clinical manifestations probably reflect the brisk immunologic response resulting from widespread dissemination of T. pallidum.

Adenopathy – Most patients with secondary syphilis have lymph node enlargement with palpable nodes present in the posterior cervical, axillary, inguinal, and femoral regions (picture 6). The finding of epitrochlear nodes is particularly suggestive of the diagnosis. These nodes are generally minimally tender, firm, and rubbery in consistency.

Rash is the most characteristic finding of secondary syphilis. However, in one series of 105 patients with secondary syphilis, more than 20 percent had lesions that were not appreciated by the patient [27].

The rash can take almost any form, although vesicular lesions are uncommon. As examples:

• The rash is classically a diffuse, symmetric macular or papular eruption involving the entire trunk and extremities (picture 7A-F) including the palms and soles (picture 8A-D). Although involvement of the palms and soles is an important clue to the diagnosis of secondary syphilis, localized lesions can also occur [28].

Individual lesions are discrete copper, red, or reddish-brown and measure 0.5 to 2 cm in diameter [26,27]. Although lesions are often scaly, they may be smooth. In addition, nodular lesions also may be seen. On occasion, the rash may be pruritic.

• Pustular syphilis can take the form of small pustular syphilide, large pustular syphilide, flat pustular syphiloderm, and pustular-ulcerative syphilide (ie, malignant syphilis) [28].

• Secondary syphilis can also affect mucosal surfaces [27]. Patients may develop mucous patches, whitish erosions on the oral mucosa or tongue (picture 9A-C), and split papules at the oral commissures. Large, raised, gray to white lesions called condylomata lata may develop in warm, moist areas such as the mouth and perineum (picture 10A-D). Condylomata lata occur most often in areas proximate to the primary chancre and may reflect direct spread of organisms from the primary ulcer [26]. Mucous patches and condylomata lata contain large numbers of T. pallidum organisms (picture 11).

• In patients with HIV, a more severe ulcerative form of secondary syphilis termed "lues maligna" has been reported (picture 5A-D) [29]. It occurs principally in persons with severely compromised immune systems and presents with nonresolving severe ulcerative skin lesions.

Alopecia – So-called "moth-eaten" alopecia is occasionally seen among patients presenting with secondary syphilis (picture 12A-C). This may be noted on the scalp, eyebrows, or beard and is usually reversible with treatment.

Hepatitis – Syphilitic hepatitis is characterized by a high-serum alkaline phosphatase level on laboratory examination, often with normal or only slightly abnormal transaminases [30,31]. Mild clinical hepatitis resolves with treatment.

Gastrointestinal abnormalities – The gastrointestinal tract may become extensively infiltrated or ulcerated; this can be misdiagnosed as lymphoma.

Musculoskeletal abnormalities — Synovitis, osteitis, and periostitis can occur but usually resolve after treatment [32].