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Diocles of Carystus on the method of dietetics 85 causal explanations of the groups mentioned in the above discount 40 mg cialis professional with visa impotence beta blockers. While ‘those who believe that one should state a cause for all [things]’ (to±v p†ntwn o«om”noiv de±n l”gein a«t©an) clearly refers to the group criticised in section 8 discount cialis professional 40 mg line erectile dysfunction doctor cape town, it is less clear who are meant by the words ‘those who state causes in this way’ (to±v m•n oÔn oÌtwv a«tiologoÓsi). The most likely possibility is that it refers to those who are criticised in the sentence immediately preceding it, that is those who make mistakes because their causal explanations are ill-founded; but this is not quite compatible with section 9, where the lack of a change of subject suggests that Diocles’ additional criticism (‘in addition’, pr¼v d• toÅtoiv) still applies to the same group. Another possibility is that ‘those who state causes in this way’ are the ones criticised in the first part of the fragment (the champions of claims one and two), although it is a bit awkward to take the phrase ‘in this way’ (oÌtwv) as referring not to the ill-founded ‘stating the cause’ (l”gein tŸn a«t©an) mentioned just before but to what was discussed in section 7. Perhaps this difficulty becomes less urgent when we consider how the three claims Diocles criticises are interrelated. As I said, at first sight it seems that in his refutation of claim three in section 8, Diocles is arguing against a rather different group from the one which is his target in the earlier part of the fragment (claims one and two). Yet after reading the whole fragment, it is easy to see why he discusses these claims in the same context and in this order. The first claim is the weakest, in that it does not commit itself to the assumption of a causal nexus between quality and power; consequently, its empirical refutation is likewise easy. Subsequently, this empirical refutation is used by Diocles as an argument against the second claim, which is one of the possible implications of the first claim. Finally, this second claim can in its turn be seen as a possible instance of the third 26 See Smith (1979) 184. Bertier rightly concedes that Diocles does not reject causal explanation altogether (1972, 32). I cannot endorse Smith’s translation ‘But we must seek a cause for what we accept. It seems that Diocles is criticising views he believes to be erroneous rather than addressing distinct groups, each of which held one of the views in question. Thus we may understand why Diocles in section 10 syntactically presents the two groups as different, while at the same time marking a close connection between them (‘those who state causes in this way’, to±v m•n oÌtwv a«tiologoÓsi). Both claim one and claim two can easily be understood as manifestations or consequences of too strict an application of the quest for causes, which is what claim three amounts to. As for Diocles’ own position, if the above explanation of the words ‘the whole nature’ and ‘by nature’ is acceptable, both sections of the fragment are closely interrelated and rooted in a consistent conviction. The history of medicine was regarded as an ongoing process of exchange of ideas between members of the same ‘school’, of indiscriminate acceptance of the views of greater authorities (‘influence’) or of vigorous polemics against them. A striking example of this search for identification with regard to the Diocles fragment under discussion is provided by Fredrich. For the foods and drinks that are sweet do not all have the same power, nor is this the case with the fatty or any other such things. Some sweet foods and drinks are laxative, others are stopping, yet others drying, yet others moistening. And in the same way, of those that are heating and all the others some have this power, some have another. It is impossible to give a general account of how these things are: but what power each of them individually has, I will set forth’ (Sit©wn d• kaª pom†twn dÅnamin —k†stwn kaª tŸn kat‡ fÅsin kaª tŸn di‡ t”cnhv æde crŸ ginÛskein. But Fredrich’s construction of the debate becomes problematic when he suggests that Diocles shows a common front with the Hippocratic author of On Ancient Medicine, who in his turn is said by Fredrich to be criticising the author of On Regimen for having the temerity ‘to attribute to individual foods and drinks the properties cold, hot, dry or wet’. On this kind of identification it may be appropriate to quote Josef-Hans Kuhn,¨ who with regard to a similar question concerning the opponents of On Ancient Medicine made the following remark: ‘The tendency to make connections between the few treatises from antiquity that have been preserved is understandable and justified. On the other hand, the sheer number of works dealing with medical topics must have been so large that it would be a great coincidence if the rather arbitrary selection of the tradition had preserved precisely those treatises which refer to each other. Kuhn(¨ 1956)84:‘DieNeigung,innerhalbderwenigenuberliefertenSchriftenderAntikeimmer¨ wieder direkte Bezugsverhaltnisse herstellen zu wollen, ist verstandlich und berechtigt. Andererseits¨ ¨ muß die Fulle der Arbeiten, die sich mit medizinischen Fragen beschaftigen, so groß gewesen sein,¨ ¨ daß es ein großer Zufall ware, wenn die mehr oder minder zufallige Auswahl unserer Uberlieferung¨ ¨ ¨ gerade die Schriften erhalten hatte, welche aufeinander Bezug nehmen. Even if we can find a text A, the contents of which completely correspond with the ideas criticised by the author of another text, say, B, and a text C which only shows some similarities with what is criticised in B, the statement that B is consciously opposing A and not C can at best remain a plausible hypothesis. For we cannot rule out the possibility that B is actually aiming at C in a way which is – according to our standards – just unfair: he may represent the ideas of his opponent in a very distorted and caricaturist way by ignoring several important specifications or relevant details, or by isolating separate items from their context. Such a distortion need not be a manifestation of malevolence; it may also be a result of the fact that the way in which the author of B views text C is rather different from our perception of it.

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Unfortunately many patients and physicians conclude that these symptoms mean that the spirochetes have infected the brain and fear that this will lead to inevitable and progressive neurologic decline buy 20 mg cialis professional with visa erectile dysfunction drugs list. Very rare patients with neuroborreliosis will develop infection within the parenchyma of the brain or spinal cord—encephalomyelitis cialis professional 40 mg low cost erectile dysfunction internal pump. However the rash, erythema migrans, is virtually pathognomonic; in endemic areas patients with this rash should be treated regardless of serologic results (which can be negative in up to 50% of these individuals) (14). In patients without parenchymal involvement (a group that includes those with meningitis) oral doxycycline 200 mg daily for two to four weeks is generally effective. In 158 Halperin children under eight years of age, in pregnant women, and in patients allergic to doxycycline, amoxicillin 500 mg three times daily or cefuroxime axetil 500 mg twice daily are probably as effective, though less well studied. Neurosyphilis Transmitted primarily by sexual contact, syphilis typically begins with an asymptomatic skin lesion at the site of inoculation, the chancre. Spirochetes disseminate quite early in infection, with seeding of the neuraxis in about 40% of individuals (15). Almost all of these patients develop meningitis, which can be variably symptomatic. Meningovascular syphilis tends to occur on average seven years after initial infection and results from inflammatory damage to the blood vessels in the subarachnoid space. This causes a series of primarily small-artery strokes, often somewhat slowly evolving, typically accompanied by chronic headaches from the meningitis. One to two decades after disease onset other patients will develop “general paresis of the insane,” a more diffuse picture thought to result from a combination of chronic hydrocephalus and parenchymal gummas. Finally, some patients will develop tabes dorsalis two to three decades after initial infection—primarily a disorder of the dorsal roots (which cross through the chronically inflamed subarachnoid space). These same patients often develop parenchymal inflammation in the midbrain causing Argyll Robertson pupils. Oral doxycycline (200 mg daily for four weeks) is recommended and used as an alternative in penicillin-allergic patients, despite a paucity of supportive studies. Listeria Listeria is a widely prevalent organism that only rarely causes human disease. Infection most often occurs by exposure to contaminated food, most often dairy products. Infections are particularly problematic in pregnant women (causing miscarriages) and newborns (causing disseminated infection). Neurologic involvement takes several forms, most typically meningitis, being the commonest cause of bacterial meningitis in the immunocompromised and the second most common in healthy adults over age 50. The clinical picture of this meningitis is often more indolent than in other meningitides; patients appear less ill and the time course is more protracted. The organism is very sensitive to ampicillin and penicillin, but perhaps because of its intracellular location, slow to respond. Consequently, gentamicin is often added for synergy and treatment is typically prolonged. Diagnosis is generally by measuring either cold agglutinins or specific antibody titers. Viral Brain Infections Herpes Simplex Encephalitis Human herpes viruses, similar to polioviruses, differ from many other encephalitis-causing viruses in that they have just one host—humans. Because of this it is at least theoretically possible to eliminate these pathogens entirely—primarily through effective vaccines. While sufficiently potent vaccines are not yet available for herpes simplex, this strategy has eliminated smallpox and hopefully will eliminate polio in the not too distant future. Unfortunately, this approach cannot eliminate the innumerable other viruses, such as West Nile and rabies, which are zoonoses, existing in multiple species. Even with successful vaccination, the best that can be hoped for with zoonotic infections is temporary protection of the immunized individuals, not permanent elimination of the virus and therefore the disease. Periodically the virus will migrate back down the axon, causing a recurrent cutaneous eruption. The sensory neurons of the trigeminal nerve, which innervate the lips, also innervate the meninges of the middle and anterior cranial fossa. Experimentally, reactivating virus can be shown to migrate centrally, affecting the medial temporal and frontal lobes, the primary site of involvement in herpes simplex encephalitis. Two important (and probably interrelated) functions of the medial temporal lobes are olfaction and memory. Early manifestations of this necrotizing, localized infection often consist of focal seizures manifest as olfactory hallucinations and perceptions of deja vu or jamais vu.

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Treatment consists of lifelong dietary phenyl- alanine restriction and tyrosine supplementation generic cialis professional 20 mg mastercard impotence related to diabetes. Women with phenylketonuria who become pregnant must maintain strict control before and during pregnancy to avoid congenital defects cheap cialis professional 20 mg line impotence depression, microcephaly, growth retardation, and mental retardation in the baby. Patients may present in their thirties or forties with arthritis and darkly colored urine, as well as tissue pigmentation (ochronosis) from homogentisic acid. The ar- thritis is typically in the large joints such as hips, knees, shoulders, and low back. The gray- brown pigmentation is characteristic and can involve the sclera and the ear. Hawkinsinuria is a re- lated disorder of amino acid metabolism, in which a 4-hydroxyphenylpyruvate dioxygenase enzyme defect leads to failure to thrive in infancy. Tryptophanuria results in mental retardation, skin photosensitivity, and ataxia; however, the enzyme defect leading to this phenotype has not been identified. Hyperprolinemia type I is caused by a proline oxidase defect and is typically benign. Ho- mocystinuria is caused by a cystathionine β-synthase defect and leads to mental retardation. Symptoms usually develop in adulthood as a result of either brief intense activity or sustained exertion. Rhabdomyolysis after intense activity may cause myoglobinuria and subsequent renal failure and is the major clinical risk about which patients should be warned. The most common childhood disorder glycogen storage disease is glucose-6-phosphatase defi- ciency (type I), also known as von Gierke’s disease, which presents at age 3–4 months with growth retardation and hepatosplenomegaly. Lactate dehydrogenase deficiency and pyruvate kinase deficiency present similarly to McArdle disease but are very rare. Clinical manifestations include hepatomegaly, hypoglycemia, short stature, variable skeletal my- opathy, and cardiomyopathy. In most patients, hepatomeg- aly improves with age; however, chronic liver disease and cirrhosis may occur in adulthood, requiring liver transplantation. Treatment consists of dietary management with frequent high-carbohydrate meals and possible nocturnal drip feeding to avoid hypoglycemia. Linkage analysis mark- ers can be used for screening carriers and prenatal diagnosis. The presence of the apolipoprotein E allele (ε4) does not predict with 100% accu- racy individuals who will develop Alzheimer’s; therefore, this patient’s testing is an exam- ple of predisposition testing. Not everyone with this marker will develop the disease, and individuals without this marker may develop Alzheimer’s. The patient does not have any signs or symp- toms of dementia, and he is not being discriminated against in this scenario. The vast majority of trisomic conceptions will spontaneously abort; only trisomy 13, 18, 21 (Down syn- I. Despite this well-described association, little is known about the mechanism that drives it. Deviation in the number or structure of these chromosomes is common and is estimated to occur in 10–25% of all pregnancies. In pregnancies surviving to term, they are the leading known cause of birth defects and mental retardation. Phenotypically, these individuals are male but have eunuchoid features, small tes- tes, decreased virilization, and gynecomastia. The other disorders listed in the question may result in sexual ambiguity, more commonly in males. Testic- ular dysgenesis results from the absence of müllerian inhibiting substance during embryonic development and may be caused by multiple genetic mutations and may be associated with the absence of müllerian-inhibiting substance and reduced testosterone production. Feminization may also occur through androgen insensitivity and mutations in the androgen receptor. Most cases are diag- nosed perinatally on the basis of reduced fetal growth or lymphedema at birth with nu- chal folds, a low posterior hairline, or left-sided cardiac defects. Some girls may not be diagnosed in childhood and come to attention much later in life because of delayed growth and lack of sexual maturation. Limited pubertal development occurs in up to 30% of girls with Turner syndrome, with approximately 2% reaching menarche.

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