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Staphylococcus aureus is the most commonly impli- recently being widowed cheap priligy 60 mg on line, he has no pertinent social his- cated organism in postsplenectomy sepsis buy priligy 60 mg overnight delivery. He is not able to generate an erec- complete blood count; electrolytes cheap 90 mg priligy fast delivery, renal function, liver 16 I. Maculopapular rash that begins on the face and trunk chest x-ray, which are unrevealing. He is up to date on his and spreads to the extremities (centrifugal spread) routine cancer screening. Upper endoscopy cisella tularensis is cultured from both patients’ sputum samples. You are conducting research on a novel nonsteroidal mesticated animals in the past 2 weeks. To ascertain the safety the following except profile of the drug you recruit 100 volunteers who lack the ability to produce IgE. The IgE receptor in the patients with anaphylaxis is fects of smoking marijuana except constitutively activated. On examination, his pupils are dilated game arrive at the emergency department complaining of and he has a heart rate of 143 beats/min. From the reports of the other passengers and flight attendants on the plane, she was normally interactive I-123. Typical Variola major (smallpox) infection can be dis- throughout most of the flight but was difficult to arouse tinguished from Varicella (chicken pox) infection based on from sleep upon landing. Upon trying to exit the plane, she which of the following clinical characteristics? Lesions in the same stage of development at any location rival at the emergency department 1 h later, she appears I. Which of the following is true regarding drug effects anxious but is alert, oriented, and appropriate. Drug effects begin earlier, peak earlier, and last longer beats/min, respiratory rate is 22 breaths/min, and oxygen B. Drug effects begin earlier, peak later, and last longer saturation is 99% on room air. Drug effects begin later, peak later, and last longer a regular heart beat with normal S1, S2, and no extra heart sounds. Her skin is normal without any track lithium, is found in his room 2 days after not showing up marks or rash. Further evaluation should include: the emergency department, he has a grand mal seizure. Which of the following statements regarding gastric end-organ damage in the absence of hallucination decontamination for toxin ingestion is true? Anion gap metabolic acidosis with a normal lactate therapeutic endoscopy may also be warranted. A patient with metabolic acidosis, reduced anion gap, and increased osmolal gap is most likely to have I-134. What is the main contributor to the resting energy which of the following toxic ingestions? By obtaining information about the prevalence of the disease in the population—the specificity and sensitivity—one can generate a two-by-two table, as shown below. In this case the table is filled in as follows: Disease Status Test Result Present Absent Positive 42 237 Negative 8 713 Total number of patients with disease Total number of patients without disease = 50 = 950 I-3. This has the potential to encourage physicians to take on more patients but to provide patients with fewer services because the physician is liable for expenses. Out-of-pocket services not covered by insurers are available only to patients with adequate means to receive the service. Each point on the curve represents a cutoff point of sensitivity and 1 – specificity. The area under the curve can be used as a quantita- tive measure of the information content of a test. The pretest probability quantitatively describes the clinician’s certainty of a diagnosis after doing a history and physical examination. The equation is Pretest probability × test sensitivity Posttest probability = --------------------------------------------------------------------------------------------------------------------- Pretest probability × test sensitivity + ( 1 – disease prevalence × test false-positive rate 18 I. A 45° line would indicate a test with no information (sensitivity = speci- ficity at every test value). By in- serting numbers into the equation, one can see that a low pretest probability combined with a poorly sensitive and specific test will yield a low posttest probability. However, the same test result, when combined with a high pretest probability, will yield a high posttest probability. This theorem does not take into account the useful information that is gained from nonbinary test results. Further, it is cumbersome to calculate the posttest probability for each individual circumstance and patient. Perhaps the most useful lesson from Bayes’ theorem is to take into account pretest probability when ordering tests or interpreting test results. To be clinically useful, a clinical scenario with a low pretest probability will require a test with high sensitivity and specificity. Con- versely, a high pretest probability presentation can be confirmed by a test with only aver- age sensitivity and specificity. Disease prevalence in a certain region contrib- utes to the patient’s pretest probability. However, other factors such as the patient’s age, clinical history and risk factors for the disease in question are also important in deter- mining pretest probability. Armed with an estimated pretest probability and a positive test with a known likelihood ratio, the clinician can estimate a posttest probability of dis- ease. Generally, diagnostic tests are most useful in patients with a medium pretest proba- bility (25–75%) of having a disease. For example, in a patient with a low pretest probability of disease, a positive test can be misleading in that the patient’s posttest prob- ability of disease is still low. The same applies for a patient with a high pretest probability of disease with a negative test: the negative test usually does not rule out disease. It is therefore incumbent upon the physician to have a rough estimate of the pretest probabil- ity of disease, positive likelihood ratio of the diagnostic test, and negative likelihood ratio of the diagnostic test prior to ordering the test. This is the difference in mortality (or another endpoint) between the treatment and the placebo arms. The test should not have been ordered in the first place and is an example of defensive medicine. Any further testing could expose the patient to undue invasive testing and further anxiety. Her aspirin should be stopped; she should be reassured; other causes of chest pain in a healthy young woman should be evaluated. This may be partly re- lated to the observation that physicians are less likely to suspect heart disease in women with chest pain and are less likely to perform diagnostic and therapeutic procedures in women. Cholesterol-lowering drugs are as effective in women as in men for primary and secondary prevention of coronary heart disease.

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Early studies with the neurotoxin M P T P cheap priligy 30mg on-line, injected into the carotid artery of baboons generic 90mg priligy mastercard, left the post-synaptic receptors intact cheap 60 mg priligy otc, but destroyed the pre-synaptic neurons. O n e could chemically resolve abnormalities in structures that wer e only micrometres apart. Several reports at this S y m p o s i u m s h o w e d that in the earliest stage of Parkinson’s disease, that is, w h e n only half of the bod y w a s involved, there w ere major deficiencies in pre-synaptic neurons, examined by injection of radiotracers that are accumulated by the pre-synaptic dopa­ m in e transporter. T h e tracer studies w ere m o r e sensitive than clinical manifestations Using the tracer n C W I N 35428, even in patients with stage I Parkinson’s disease, that is, w h e n half of the bod y function remains normal, there are striking reductions in the binding of the tracer to the transporters in the anterior and particularly the posterior putamen, which are remarkably different from normal persons. T h e decline in dopaminergic pre-synaptic neurons with increasing age even in normal persons supports the hypothesis that Parkinson’s disease occurs w h e n an environmental factor is superimposed on the normal decline in pre-synaptic neurons in the process of ageing. T h e similar effects of the neurotoxin M P T P on pre-synaptic dopaminergic neurons increases the possibility that a neurotoxin m a y play a role in Parkinson’s disease. T h e clinical manifestations of Parkinson’s disease are correlated with the degree of impairment of dopaminergic pre-synaptic neurons. Because drugs such as m o n o a m i n e oxidase inhibitors are effective iftreatment is begun early in Parkinson’s disease, the finding of the great sensitivity of a molecular diagnosis prior to s y m p ­ toms of Parkinson’s disease represents one of the most important advances in neurology in the past t w o decades. T h e accumulation of radiotracers that bind to dopamine transporters — both positron and single photon emitting radiotracers — can be used as markers to examine the role of genetic and environmental factors in Parkinson’s disease. These tracers cannot be used to assess secre­ tion of endogenous dopamine by its competitive effect in binding to the dopamine receptors. O n the other hand, if one is interested in assessing dopamine release, one uses a tracer with a lower affinity so that the endogenous dopamine can compete with the tracer. Investigators at K y u s h u University, Japan, have provided an excellent example of the use of receptor imaging to differentiate deafferentation from neuronal damage. In a patient with a thalamic infarction, there w a s a decrease in cerebral blood flow and ,8F-deoxyglucose (18F D G ) accumulation in the ipsilateral cerebral hemisphere, but normal accumulation of 123I-iomazanil, a tracer that binds to benzodiazapine receptors, in both cerebral hemispheres, indicating that the neurons themselves were intact. In this process of communication, nuclear medicine involves molecules with messages. T h e molecule that is the initiator of the molecular process is D N A , which eventually results in the production of neurotransmitters or ho r mones that continue the process of information transfer within and between cells. T h e process of communication exists even in unicellular organisms, and ‘de-differentiation’of the biochemical process within specialized cells can result in cancer. It is becoming increasingly clear that m e m b r a n e receptors are often expressed in great numbers in cancer cells. T h e next landmark will be to m o v e to the study of intracellular c o m ­ munication systems. Investigators at K yoto University produced an oligonucleotide that would bind to m R N A expressing peripheral benzodiazepin receptors, and labelled with 35S. Using the technique of in situ hybridization, these investigators found that hypoxia induced brain d a m a g e resulted in increased m R N A for these receptors which are k n o w n to be increased in glial cells in response to neuronal damage. T h e next step will be to try to extend these in vitro results to ex vivo studies in which the experimental animals are injected with this oligonucleotide. Developing single photon or positron emitting tracers of m R N A will not be easy because the numbers of binding sites are small and non-specific binding m a y be high. Nevertheless, w e are m o v i n g along this pathway, with m o r e and m o r e studies of small peptide molecules [2, 3] and oligonucleotides. D I S E A S E A S D I S S O N A N C E O n e can easily m o v e from neurosciences to oncology because both can be viewed as communication disorders — disease as dissonance. T h e fact that so m a n y neuroreceptors have been found o n so m a n y different types of neoplasms leads one to view the h u m a n nervous system as having evolved from unicellular organisms to facilitate intercellular molecular communication. Cells b e c o m e cancerous because they do not get the right messages, either because of a deficiency in the D N A transcription process or because of a failure in execution of the instructions. This finding opens up a whole n e w approach to the care of patients with metastatic thyroid carcinoma, s o m e of w h o m m a y have an increase in serum thyroglobulin with no other indication of where the métastasés are located. Hippocrates wrote: “It is disgraceful in every art and m o r e especially in medicine, after m u c h trouble, m u c h display and m u c h talk, to do no goo d after all. C O S T E F F E C T I V E N E S S O n e m a y ask w h o is going to pay for all these expensive studies in this era of cost containment? O n e might also think that there could not have been a worse time to introduce a new, expensive, high-tech procedure into medical practice. Paradoxi­ cally, nothing could be m o r e helpful than studies of cost effectiveness in increasing the use of nuclear medicine procedures. While there is clearly an overcapacity in m u c h of the supply of medical care, there is undercapacity and underutilization of nuclear medicine capacity, which is w h y it has been called the ‘best kept secret in medicine’. For example, one can exchange the cost of the nuclear medicine studies for surgery costs, which are far greater. Operative complications can be reduced by increasing knowledge of the extent of the spread of cancer. O n e can n o w be certain that w h e n the patient is operated upon, he or she will not be found to have lesions that m a k e the surgery fruitless. O v e r 30 0 0 0 thoracotomies are performed where the patients are found to have inoperable lung cancer. Every year, 25 0 0 0 thoracotomies are performed in the U S A for solitary pulmonary nodules that prove to be benign. There w a s a change in stage in 2 6 % of the patients (19/71), s o m e patients going to a higher and s o m e to a lower stage. T h oracotomy w a s avoided in 1 5 % of patients (16/104) with non-small-cell lung cancer. T h e sensitivity w a s 9 4 % , w hich w a s sufficiently high to avoid surgery, w h e n c o m bined with other data such as the appearance of the lesion in the radiograph, and the clinical history and physical examination of the patient. In 15 of 52 patients, they found one or m o r e foci of abnormal 18F D G accumulation beyond the lungs and mediastinal structures. Lasagna wrote: “Often w e d o n ’t k n o w h o w to tailor specific drugs to specific patients very well; w e could do that better and m a k e a qua n t u m j u m p in efficacy without even c o m i n g u p with any n e w drugs. For example, at Johns Hopkins w h e n patients are to have a partial hepatectomy for cancer metastatic to the liver, 25 % are found at surgery to be inoperable for one of the following reasons: (1) Both lobes of the liver w ere involved; (2) l y m p h nodes were involved; or (3) there were peritoneal or other extrahepatic métastasés. Others reported on the cost effectiveness of l8F D G imaging in recurrent colorectal cancer. T h e imaging studies resulted in major changes in the patient’s care in 4 0 % of the patients; surgery w a s avoided in 2 0 patients, the type of surgery changed in 2. Partial hepatectomy w a s avoided in 12 patients, laparotomy in 6 and thoracotomy in 2. O n e of the advantages of radiotracer studies in patients with cancer is that whole body imaging can be routine. For example, in 31 patients with elevated tumour markers, including carcinoembryonic antigen ( C E A ) and СA 125, 5 3 % of lesions were detected b y 18F D G studies [8]. A b o u t 5 0 0 0 w o m e n are operated upon every year in the U S A for a ‘second look’to see if they have residual ovarian cancer. H u b n e r [9] examined such patients with ovarian cancer to find out whether they had metastatic disease.

Also example purchase priligy 60mg fast delivery, a lumpectomy is the surgical removal of a known as atopic dermatitis order 60mg priligy mastercard. Eczema is a very com- lump order priligy 30 mg line, a tonsillectomy is the removal of the tonsils, mon skin problem that may start in infancy, later in and an appendectomy is removal of the appendix. There are numerous types of eczema, including atopic dermatitis, contact eczema, seborrheic ectopic In the wrong place, out of place. For eczema, nummular eczema, neurodermatitis, stasis example, an ectopic kidney is a kidney that is not in dermatitis, and dyshidrotic eczema. Usually, ectopic pregnancies contact with a substance that the immune system occur because a fertilized egg settles and grows in a recognizes as foreign, such as poison ivy or certain Fallopian tube. Also known as occur in other locations, such as the ovary, cervix, allergic contact dermatitis. An ectopic pregnancy is usu- ally due to the inability of a fertilized egg to make its eczema, contact A localized reaction that way through a Fallopian tube into the uterus. A major concern with ectopic pregnancy characterized by clear, deep blisters that itch and is internal bleeding. The pain, which is usually sharp and stabbing, is often one-sided and may occur in the pelvis, eczema, nummular Coin-shaped patches of abdomen, or even the shoulder or neck (due to irritated skin that may be crusted, scaling, and blood from a ruptured ectopic pregnancy building extremely itchy. Nummular eczema appears most up under the diaphragm and the pain being commonly on the arms, back, buttocks, and lower “referred” up to the shoulder or neck). Ultrasound can also help edema The swelling of soft tissues as a result of determine whether a pregnancy is ectopic, as can excess fluid accumulation. Edema is often most culdocentesis, the insertion of a needle through the prominent in the lower legs and feet toward the end vagina into the space behind the uterus to see of the day because fluid pools while people maintain whether there is blood there from a ruptured an upright position. Treatment includes surgery, often by laparoscopy, to remove the ill-fated pregnancy. A edema, hereditary angioneurotic Localized ruptured Fallopian tube usually has to be removed. The outlook for future pregnancies normally prevents activation of a cascade of proteins depends on the extent of the surgery. Patients can develop recurrent attacks of swollen tissues, eczema An inflammatory reaction of the skin in pain in the abdomen, and swelling of the voice box which there are tiny blister-like raised areas in the (larynx) that can compromise breathing. The diag- early stage followed by reddening, swelling, bumps, nosis is confirmed when abnormally low levels of C1 crusting, and thickening and scaling. The most common symp- Treatment options include antihistamines and male toms of pleural effusion are chest pain and painful steroids (androgens). Pleural effusion can be caused by heart and kidney failure, hypoalbuminemia (low levels of albumin in edentulous Being without teeth. Complete loss of the blood), infections, pulmonary embolism, and all natural teeth can substantially reduce quality of malignancies. Wounds must be efferent nerve A nerve that carries impulses tended to with great care, and infections must be away from the central nervous system. Joint efferent vessel A vessel that carries blood away injury must be avoided, and bracing may sometimes from the heart. For example, a pleural effusion is an abnormal accumulation of fluid in the pleural space between ehrlichiosis An acute tick-borne disease first the lungs and the chest wall, while a knee effusion is reported in humans in 1986. A infection by the rickettsia microbe, Ehrlichia canis, hemorrhagic effusion contains blood in the fluid. Erlichiosis is similar to Rocky Mountain spotted effusion, pericardial Too much fluid within the fibrous sac (pericardium) that surrounds the heart. A pericardial effusion involves the presence of an excessive amount of pericardial fluid, a pale yel- ejaculation Ejection of sperm and seminal fluid low serous fluid, within the pericardium. Only about two-thirds of the blood is spread thinly over the visceral and parietal pleurae normally pumped out with each beat, and that frac- and acts as a lubricant between the two membranes. The ejec- Any significant increase in the quantity of pleural tion fraction is an indicator of the heart’s health. If elbow bursitis is not caused by infection, treatment includes rest and the use of ice and med- elbow The juncture of the long bones in the mid- ications for inflammation and pain. The bone of the sitis is treated with antibiotics, aspiration, and arm (humerus) meets both the ulna (the inner bone surgery. The biceps muscle is the major crime that all health and social services profession- muscle that flexes the elbow hinge, and the triceps als are mandated to report. The pri- mary stability of the elbow is provided by the ulnar elective mutism Complete lack of speech, collateral ligament, located on the medial (inner) believed to be chosen on the part of the patient. The outer bony prominence of the True elective mutism may be a reaction to a trau- elbow is the lateral epicondyle, a part of the humerus matic event, the aftermath of damage to or pain in bone. Tendons attached to this area can be injured, the mouth or throat, or a symptom of extreme shy- causing inflammation or tendonitis (lateral epi- ness. The inner portion of the found not to be chosen, but rather a symptom of elbow is a bony prominence called the medial epi- damage or deformity of the speech apparatus or of condyle of the humerus. Electric elbow, arthritis of the Inflammation of the shock can cause burning at the site of entry of the elbow joint. If a person many systemic forms of arthritis, including rheuma- may be in contact with high voltage, no one else toid arthritis, gouty arthritis, and psoriatic arthritis. Using a dry, nonconductive object such as a swelling, pain, tenderness, and decreased range of wooden stick, the switch should be switched off, to motion. Immediate emergency medical help is elbow, golfer’s Medial epicondylitis caused by required. Electrodes elbow, tip of the The bony tip of the elbow, are placed on the skin of the chest and connected in which is formed by the near end of the ulna, one of a specific order to a machine that, when turned on, the two long bones in the forearm (the other is the measures electrical activity all over the heart. Output usually appears on a long scroll of paper that displays a printed graph of activity on a com- elbow bursitis A common form of bursitis that is puter screen. Electrolyte monitoring is important in before the patient starts taking the medicine, and treatment of anorexia and bulimia. Normal muscles produce a electroconvulsive therapy The use of con- typical pattern of electrical current that is usually trolled, measured doses of electric shock to induce proportional to the level of muscle activity. Convulsions so induced can sometimes of muscle and/or nerves can produce abnormal treat clinical depression that is unresponsive to electromyogram patterns. An electron microscope permits greater magnification electrodiathermy See cauterization. The results are either printed electrophoresis A method used in clinical and out or displayed on a computer screen. Different research laboratories for separating molecules patterns of electrical impulses can denote various according to their size and electrical charge. Each kind of electrogastrogram A test in which the electrical molecule travels through the medium at a different current generated by the muscle of the stomach is rate, depending on its electrical charge and molec- sensed and recorded in a manner very similar to ular size. Separation of the molecules occurs based that of an electrocardiogram of the heart. Recordings from the muscle are cal potentials generated by the retina of the eye are stored and analyzed by a computer. Although electrolysis is promoted as a permanent electroshock therapy See electroconvulsive process, many people find that hair does grow back therapy. Electrolysis may be done by a dermatologist, by an electrolysis techni- elephant nails See pachyonychia congenita.

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Gottschalk (private correspondence) points out to me that the doctrine of the limits of causal explanation order priligy 60mg on-line, which is a very sophisticated piece of philosophy discount 30 mg priligy with visa, is presented by Aristotle as his invention generic 60mg priligy amex, whereas Diocles alludes to it very briefly: ‘his sentence presupposes a knowledge of Aristotle or something very like it’. The latter are either – in the case of real undemonstrable principles such as definitions or logical postulates – concerned with the avoidance of an infinite regress or with the consideration that within the limits of a particular branch of study some things should be accepted as starting-points, the demonstra- tion of which belongs to another discipline: the ignorance of this is seen by them as a sign of ‘being uneducated’ (ˆpaideus©a). While Aristotle’s warnings against pursuing causal analysis too far in these latter contexts look like methodological prescriptions based on considerations of fruit- fulness and economy (one should not ask for a cause here because it is useless – although it may be possible to state one), Diocles’ point is that in the field of dietetics many things simply do not allow of explanation, because when pursuing the search for causes too far, one passes the level of the ‘whole nature’ of a foodstuff and loses the connection with the actual explanandum. On the other hand, it is not unlikely that some sort of contact between Diocles and the Lyceum took place. Diocles enjoyed a good reputation in Athens – although our source for this does not specify in what times he did. It has been doubted whether this should be taken as applying to the Carystian physician, seeing that the name Diocles was very common in Greek and that several persons named Diocles in fourth- century Athens are known from literary and epigraphical sources. The fact that he is credited by Theophrastus with an opinion on a mineralogical topic is a weak argument, which is based on doubtful presuppositions concerning a ‘division of labour’ between the sciences. Diocles may have had various interests, just as Theophrastus himself, or Aristotle, or the authors of such 48 (Pseudo-)Vindicianus, On the Seed 2: ‘Diocles, a follower of Hippocrates, whom the Athenians gave the name of younger Hippocrates’ (Diocles, sectator Hippocratis, quem Athenienses iuniorem Hippocratem vocaverunt). The use of the Attic dialect may be an indication that Diocles lived or practised in Athens (although several fragments preserved in Oribasius also – in some manuscripts – show Ionic forms [see van der Eijk 2001a, xxiv n. The fact that Theophras- tus refers to Diocles without further specification is regarded by Eichholz as evidence that the Carys- tian is meant (1965) 107–8; but this argument will not do, for two different people named Diocles are also mentioned in the will of the Peripatetic Strato (Diogenes Laertius 5. We can only say that it must have been evident to Theophrastus and his audience which Diocles was meant [see van der Eijk (2001a) 416–19]. Diocles of Carystus on the method of dietetics 97 Hippocratic writings as On Fleshes or On Regimen for that matter. Of course we cannot prove that the Diocles mentioned by Theophrastus is the Carystian physician; but then there are a great number of other testimonies about a Diocles where this proof cannot be given. What we can say, I think, is that Diocles marks a methodological aware- ness of the limits of causal explanation that was not anticipated in the Hippocratic Corpus and that showed several significant resemblances to remarks found in Aristotle and Theophrastus. These resemblances may have been the result of intellectual exchange and discussion between them (the existence of which is likely), but this cannot be proved, and we are in no position to decide who was ‘influenced’ by whom. Finally, it seems that any association of Diocles with Empiricism or Scepticism should be abandoned once and for all. Those who have read the fragment in this way not only seem to have extrapolated Diocles’ re- marks about dietetics to all other branches of medicine (on the question whether this is justified, see above), but also, as far as dietetics itself is con- cerned, to have been guided by Galen’s presentation of it, that is, as propa- ganda for an exclusively empirical approach to the search for the powers of 50 It has been argued by von Staden (1992, 253) that there is no independent evidence of mineralogist interest by Diocles. The fragment is quoted by Galen in the context of embryology, but there is no evidence that in its original context it just served the purpose of analogy (as it does for Galen). Moreover, as von Staden concedes, in the immediate context of the Diocles fragment in On Stones, Theophrastus mentions dietetic and physiological factors affecting the magnetic force of the lyngourion – although I agree that this does not prove that the Diocles mentioned was Diocles of Carystus. In fact, when reading Galen’s own discussion of the right method of dietetics in the pages following on the fragment, it turns out that Diocles’ position as reflected in the fragment (especially in his crit- icism of claims one and two) perfectly meets the requirements of what Galen himself calls ‘qualified experience’ (diwrism”nh pe±ra; see chapter 10 below). By this concept, which Galen presents as his own innovation, he means an empirical approach which takes into account the conditions un- der which a dietetic statement like ‘rock fish are difficult to digest’ is true. All these should be considered, Galen points out, before any generalising statement about the power of a particular foodstuff is allowed. Galen represents Diocles as being completely unaware of these factors and as being more one-sided than he actually was – and it would seem that Galen is doing so not for lack of understanding but in order to articulate his own refined position as against Diocles’ unqualified acceptance of experience as the only way to get to know the powers of foodstuffs. But here too there is a highly useful qualification, itself, too, not mentioned by Diocles, just as also none of the others we have discussed until now [was mentioned by him]’ (t‡ to©nun m”sa ta±v kr†sesin oÉdem©an –pikratoÓsan ›conta poi»thta Diocles of Carystus on the method of dietetics 99 the ‘highly useful distinction’ (diorism»v) between ‘foodstuffs’ (trofa©) and ‘drugs’ (f†rmaka) – that is to say, for not having pointed out under what circumstances a particular substance acts like a foodstuff (which only preserves the state of the body) or as a drug (which changes the state of the body) – just as he failed to deal, Galen adds maliciously, with the other distinctions discussed by him in the previous paragraphs. In fact, in the context of another treatise, namely On Medical Experience (De experientia medica, De exp. For if everything which is ascertained is ascertained only by reasoning, and nothing is ascertained by experience, how is it possible that the generality, who do not use reason, can know anything of what is known? And how was it that this was unanimously asserted among the elder doctors, not only by Hippocrates, but also by all those who came after him, Diogenes, Diocles, Praxagoras, Philotimus, and Erasistratus? For all of these acknowledge that what they know concerning medical practice they know by means of reasoning in conjunction with experience. In particular, Diogenes and Diocles argue at length that it is not possible in the case of food and drink to ascertain their ultimate effects but by way of experience. In this testimony, the view of Diocles and the other ancient authorities is obviously referred to in order to support Galen’s argument against an exclusively theoretical approach to medicine. And although we should not assign much independent value to this testimony – which, apart from its vagueness, is a typical example of Galen’s bluffing with the aid of one of his lists of Dogmatic physicians – it is compatible both with the picture of Diocles’ general medical outlook that emerges from the collection of fragments as a whole and with his approach to dietetics as reflected in our fragment 176. Diogenes and Diocles are mentioned by Galen in particular trofaª m»non e«s©n, oÉ f†rmaka, mžqì Ëp†gonta gast”ra... This reference to the ‘ultimate effects’58 is in accordance with the in- terpretation of section 8 given above: this ultimate effect does not admit of further causal explanation; we can only make sure what it is by experience, by applying the foodstuff in a given case and seeing how it works out. Postscript Discussions of this fragment that came out after the original publication of this paper can be found in Hankinson (1998a), (1999) and (2002), in van der Eijk (2001a) 321–34, and in Frede (forthcoming). But a re-examination of the Arabic would seem to make this interpretation less plausible. A literal translation of the Arabic would read as follows: ‘It is not possible to ascertain in the case of food and drink where their last things (akhiriyatuha? The idea is then that although a Dogmatist might speculate theoretically about the power (dÅnamiv)ofa particular foodstuff, e. Thus the position attributed to Diocles here corresponds closely with that attributed to him by Galen in fr. This would suggest that Galen is referring to how foods and drinks are ultimately disposed of; but this would seem to be quite inappropriate to the context. Principles and practices of therapeutics in the Hippocratic Corpus and in the work of Diocles of Carystus 1 introduction In a well-known passage from the Hippocratic Epidemics, the doctor’s duties are succinctly characterised as follows: [The doctor should] declare what has happened before, understand what is present, and foretell what will happen in the future. As to diseases, he should strive to achieve two things: to help, or to do no harm. The (medical) art consists of three components: the disease, the patient, and the doctor. It is succinctly summarised here in the words ‘to help, or to do no harm’ (Ýfele±n £ mŸ bl†ptein), a formula which is often quoted or echoed both in the Hippocratic Corpus and in later Greek and Roman medical literature. The Hippocratic Oath, which explicitly mentions the well-being of the patient as the doctor’s This chapter was first published in slightly different form in I. Thus, according to the Oath, the doctor is not allowed to give a woman an abortive, nor to administer a lethal poison, not even when being asked to do so; and the doctor is instructed to refrain from every kind of abuse of the relation of trust that exists between him and the patient. Yet it is also possible – as the word ‘or’ suggests – to take the formula in the sense of unintended harm: ‘To help, or at least to cause no harm’, that is to say, the doctor should be careful when treating the patient not to aggravate the patient’s condition, for example in cases that are so hopeless that treatment will only make matters worse, or in cases which are so difficult that the doctor may fail in the execution of his art; and as we shall see, there is evidence that Greek doctors considered this possibility too. In this chapter I will examine how this principle ‘to help, or to do no harm’ is interpreted in Greek medical practice and applied in cases where it is not immediately obvious what ‘helping’ or ‘causing harm’ consists in. I will study this question by considering the therapeutic sections of a number of Hippocratic writings (most of which date from the period 425–350 bce) and in the fragments of the fourth-century bce medical writer Diocles of Carystus. This passage has received ample attention in scholarship, and it is not my in- tention to give a detailed interpretation or an assessment of its historical reliability. By this I mean the position and relative importance of therapeutics within the field of medicine as a whole, which gives rise to 3 ‘I will use dietetic measures to the benefit of the patients... I will keep them from harm and injustice’ (diaitžmas© te cržsomai –pì Ýfele©h€ tän kamn»ntwn... For more general assessments of Celsus as a source for the history of medicine see Smith (1979) 226–30 and (1989) 74–80; von Staden (1994b) 77–101 and (1999b); Stok (1994) 63–75; Temkin (1935) 249–64.

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