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By V. Hassan. Harvey Mudd College. 2018.

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 discount 250 mg cefadroxil visa, see above) quality 250 mg cefadroxil, 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.

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From a common-sense point of view it is clear that some situations will arouse more anxiety than others generic cefadroxil 250 mg. For example cheap 250 mg cefadroxil with amex, a fear of heights is relatively common, but it is galling to note that in the United States a study by Agras et al. Clearly then, anxiety about dental care is a problem that we as a profession must take seriously, especially as children remember pain and stress suffered at the dentist and carry the emotional scars into adult life. Research in this area suggests that the extent of anxiety a person experiences does not relate directly to dental knowledge, but is an amalgamation of personal experiences, family concerns, disease levels, and general personality traits. Such a complex situation means that it is no easy task to measure dental anxiety and pinpoint aetiological agents. Questionnaires and rating scales are the most commonly used means by which anxiety has been quantified, although there has been some interest in physiological data such as heart rate. A high score should alert the dental team that a particular patient is very anxious. Therefore there has been great interest in measuring anxiety by observing behaviour. One such scale was developed by Frankl to assess the effect of a parent remaining with a child in the surgery (see Kent and Blinkhorn 1991). Another scale which is popular with researchers is one used by Houpt, which monitors behaviour by allocating a numerical score to items such as body movement and crying (see Kent and Blinkhorn 1991). Recent studies have used the Frankl scale to select subjects for studies, and then more detailed behaviour evaluation systems are utilized to monitor the compliance with treatment (see Kent and Blinkhorn 1991). Behavioural observation research can be problematical as the presence of an observer in the surgery may upset the patient. In addition, it is difficult to be totally objective when different coping strategies are being used and some bias will occur. However, few physiological signs are specific to one particular emotion and the measuring techniques often provoke anxiety in the child patient, so they are rarely used. As yet, there is no standard measure of dental anxiety for children as the reproducibility and reliability of most questionnaires have not been demonstrated, plus observational and physiological indices are not well developed. This is a serious problem as the assessment of strategies to reduce anxiety is somewhat compromised by a lack of universally accepted measuring techniques. Uncertainty about what is to happen is certainly a factor, a poor past experience with a dentist could upset a patient, while others may learn anxiety responses from parents, relations, or friends. A dentist who can alleviate anxiety or prevent it happening in the first place will always be popular with patients. Clearly, the easiest way to control anxiety is to establish an effective preventive programme so that children do not require any treatment. Try to see young patients on time and do not stress yourself or the child by expecting to complete a clinical task in a short time on an apprehensive patient. An increasingly popular choice is the use of pharmacological agents; these will be discussed in Chapter 4. The alternatives to the pharmacological approach are: (1) reducing uncertainty; (2) modelling; (3) cognitive approaches; (4) relaxation; and (5) systematic desensitization. Most children will cope if given friendly reassurance from the dentist, but some patients will need a more structured programme. While it is a popular technique there is little experimental work to support its use. Another technique to reduce anxiety among very worried children is to send a letter home explaining all the details of the proposed first visit so that uncertainty will be reduced. Acclimatization programmes gradually introducing the child to dental care over a number of visits have been shown to be of value. This approach is rather time consuming and does little for the really nervous child. You or I might repeat an action if we see others being rewarded, or if someone is punished we might well decide not to follow that behaviour. If a child could be shown that it is possible to visit the dentist, have treatment, and then leave in a happy frame of mind (Fig. It is not necessary to use a live model, videos of co-operative patients are of value. However, the following points should be taken into consideration when setting up a programme. The model should be shown entering and leaving the surgery to prove treatment has no lasting effect. People may heighten their anxiety by worrying more and more about a dental problem so creating a vicious reinforcing circle. Thus there has been great interest in trying to get individuals to identify and then alter their dysfunctional beliefs.

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The uncomplicated category included simple abscesses buy cefadroxil 250mg without prescription, impetiginous lesions 250 mg cefadroxil mastercard, furuncles, and cellulitis. Compli- cated category included infection involving the deeper layer or requiring significant surgical intervention. Superficial infection in an anatomical site with a risk of gram-negative pathogen or anaerobes such as the rectal area was also considered to be complicated (10). DiNubile and Lipsky classified skin and soft tissue infections to assist clinician in recognizing uncomplicated and complicated infections (11). Classification can also be based according to the severity of local and systemic signs and symptoms of infection, and the presence and stability of any comorbidities. Class 1 patients have no signs or symptoms of systemic toxicity without any comorbidities and can be managed in an outpatient setting. Class 3 patients have toxic appearance, one unstable comorbidity, or a limb-threatening infection, whereas class 4 patients have sepsis syndrome or serious Table 1 Classification of Skin and Soft Tissue Infection Based on Uncomplicated and Complicated Infections and Systemic Syndromes Uncomplicated Complicated Systemic syndromes Superficial: impetigo, ecthyma Secondary infection of diseased skin Scalded-skin syndrome Deeper: erysipelas, cellulitis Acute wound infections: Traumatic Toxic shock syndrome Hair follicle associated: Bite related Purpura fulminans folliculitis, furunculosis Post operative Abscess: carbuncle, Chronic wound infections: Diabetic foot infections cutaneous abscess Venous stasis ulcer Pressure ulcers Perianal infections Necrotizing fasciitis (type 1 and type 2) Myonecrosis (crepitant and noncrepitant) Source: Adapted in part from Ref. Guidelines developed by the Infectious Disease Society of America are written in references to specific disease entities, mechanism of injury, or host factors (13). Classification of skin and soft tissue infections based on uncomplicated and complicated infections, and systemic syndromes is depicted in Table 1. Here we review causes of skin and soft tissue infection with emphasis on severe skin and soft tissue infection, highlighting the clinical presentation, diagnosis, and approach to management in the critical care setting. There are two clinical presentations: bullous impetigo and nonbullous impetigo, and both begin as a vesicle (14). The group A streptococci responsible for impetigo belong to different M serotypes (2,15–21) from those of strains that produce pharyngitis (1,2,4,6,22) (23,24). They are common in exposed areas such as hands, feet, and legs, and are often associated with traumatic events such as minor skin injury or insect bite. Predisposing factors include warm ambient temperature, humidity, poor hygiene, and crowded conditions. Cutaneous infection with nephritogenic strains (2,15,17–21) of group A streptococci can lead to poststreptococcal glomerular nephritis. For extensive bullous impetigo, treatment with antistaphylococcal agents is selected with consideration of susceptibility testing. A carbuncle is a more extensive process that extends into the subcutaneous fat in areas covered by thick, inelastic skin. Multiple abscesses separated by connective tissue septa develop and drain to the surface along the hair follicle. Infections occur in areas that contain hair follicles such as neck, face, axillae and buttocks, sites predisposed to friction, and perspiration. Predisposing factors include obesity, defects in neutrophil dysfunction, and diabetes mellitus. Bacteremia can occur and result in osteomyelitis, endocarditis, or other metastatic foci. Systemic anti-staphylococcal antibiotics are recommended in the presence of surrounding cellulitis and large abscesses or when there is a systemic inflammatory response present. In typical erysipelas, the area of inflammation is raised above the surrounding skin, and there is a distinct demarcation between involved and normal skin, the affected area has a classic orange peal (peau d’orange) appearance. The induration and sharp margin distinguish it from the deeper tissue infection of cellulitis in which the margins are not raised and merge smoothly with uninvolved areas of the skin (Fig. Erysipelas is almost always caused by group A Streptococcus, though streptococci of groups G, C, and B and rarely S. Formerly, the face was commonly involved, but now up to 85% of cases occur on the legs and feet largely due to lymphatic venous disruptions (25,26). Agents such as erythromycin and the other macrolides are limited by their rates of resistance and the fluoroquinolones are generally less active than the b-lactam antibiotics against b- hemolytic streptococci. It often occurs in the setting of local skin trauma from skin bite, abrasions, surgical wounds, contusions, or other cutaneous lacerations. Specific pathogens are suggested when infections follow exposure to seawater (Vibrio vulnificus) (28,29), freshwater (Aeromonas hydrophila) (30), or aquacultured fish (S. Lymphedema may persist after recovery from cellulitis or erysipelas and predisposes patients to recurrences. Recurrent cellulitis is usually due to group A Streptococcus and other b-hemolytic streptococci. Recurrent cellulitis in an arm may follow impaired lymphatic drainage secondary to neoplasia, radiation, surgery, or prior infection and recurrence in the lower extremity may follow saphenous venous graft or varicose vein stripping. In addition, Severe Skin and Soft Tissue Infections in Critical Care 299 Figure 2 Cellulitis of the left thigh in a alcoholic patient, blood cultures grew group B Streptococcus. Uncommonly, pneumococcal cellulitis occurs on the face or limbs in patients with diabetes mellitus, alcohol abuse, systemic lupus erythematosus, nephritic syndrome, or a hematological cancer (22). Meningococcal cellulitis occurs rarely, although it may affect both children and adults (33).

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