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This may suggest that protocol System Design order 5mg enalapril fast delivery, Hino generic 5 mg enalapril amex, Japan cheap enalapril 10 mg overnight delivery, 3Ibaraki University, Department of should focus on increase motion accuracy for good recovery patients Agriculture, Ami-machi- Inashiki-gun, Japan, 4University of Tsuku- but increase speed for general recovery patients. The changes of the motion features related nique using an alternate soaking process that improves tendon-to- to recovery, but the variated trend are different in each group. We bone healing by hybridizing the tendon graft with calcium phos- show that to maximize the gain of therapy, the rehabilitation protocol phate (CaP). However, ankle- term clinical results, because of undergoing active rehabilitation. It is a simple three link mechanism tied to pelvis and affect- 908 ed shank by belts. Material and Methods: The par- 1 1 1 ticipants were fve chronic stroke outpatients with hemiplegia. Wongnor 1Bumrungrad International Hospital, Department of Rehabilitation of them could walk independently outside using cane or ankle foot orthosis. Kinematic data was obtained as sagittal hip, ods: Forty-four neurorehabilitation patients (32 stroke, four spinal knee and ankle joint angles. Among the joint angles, increase of knee fex- ing patients) without cognitive impairment were recruited in this ion during initial swing and hip fexion during terminal swing was study. Results: The patients were 56 years of muscle activation and not obstructing hip extension, the device re- age on average, 68% were male, 39% were Thais. Conclusion: Robotic-assisted gait training could help improve gait ability of neurorehabilitation patients, especially, in 907 stroke patients. Mueller1,2 their body due to brain lack of oxygen and consequently brain cells 1Schoen Klinik Bad Aibling, Motor Research, Bad Aibling, Ger- begin to die. Loss body balance is one of the most problems occur many, 2Ludwig-Maximilians University of Munich, German Center to the patient because the level of anxiety is too high. Material and Methods: This device is having a fexible pad shaped to conform under beneath an insole for three critical Introduction/Background: Pusher behavior is a severe disorder of locations to ensure the good body posture. It hampers the rehabilitation process and Bluetooth communication was used to transferring signals obtains prolongs hospitalization. The sensors were attached under the ate effect of a single-session robot-assisted gait therapy on pusher shoe insole to get the reaction force of body or weight distribution. The aim of this randomized controlled Inserting force sensors in the insole provide specifc information study was to determine the effectiveness of repeated robot-assisted and therefore the point of the sensor placement result in obtaining gait training on pusher behavior compared to conventional physi- the critical part under the insole. The analog inputs were trans- ponent) were randomly allocated to either the intervention group mitted via bluetooth data transmission that gains the force data in (robot-assisted gait training with the Lokomat) or the control group real time on smartphone. During the two-week intervention play all the data obtained from the experiment conducted. Results: period patients received fve times per week the corresponding The reliability of this device is well performing when compared to therapy. Before, after and at a follow-up two weeks after the in- the commercial force plate. Re- to inform the attending doctor, and to monitor the patient’s adher- sults: During the study, both groups signifcantly improved pusher ence to the amount of weight applied to the lower extremity. Paired comparisons revealed a signifcant larger decrease of pusher J Rehabil Med Suppl 55 Poster Abstracts 265 behavior in the intervention group than in the control group from tients (age 56. At the end of with pseudoelastic elements to be worn at least 6 hours a day for the intervention period, 6/14 patients of the intervention group and a month. The orthosis was equipped with an electro-goniometer 1/14 patient of the control group improved in a way that they were (elbow joint axis) and a tri-axial accelerometer (lateral upper arm). At the end of the study Measurements were conducted at the beginning (T0) and at the 9/14 patients of the intervention group and 5/14 patients of the con- end of the study (T1) during three standardised tasks: Reaching trol group were no more diagnosed with pusher behavior. Results: The recordings indicate the evolution of body position during locomotion might recalibrate the disturbed in- elbow fexion-extension angle during the execution of the motor ner reference of verticality in patients with pusher behavior. Timecourses were segmented to the level of movement repetitions and sub-movement phases. Conclusion: This preliminary study shows Tan Tock Seng Hospital, Rehabilitation Centre, Singapore, Singa- that adding wearable sensors to a dynamic orthosis has a potential pore for connecting therapy monitoring to treatment. Results: Altogeth- sity, Department of Rehabilitation, Toyoake, Japan, 5Fujita Health er, 36 patients were enrolled in the programme. Data from 27/36 University Nanakuri Sanatorium, Department of Rehabilitation, who completed the program were included for analysis. There were no adverse robotic device, low-foor treadmill, monitor for patients, naviga- events. It is thought that patient can walk without impairments after stroke with short-term sustainable gains. Discon- feeling negative effect of affected leg if we can get appropriate set- tinuation reasons in 25% of subjects were related to social reasons. However, it has not been demonstrated that gait pattern really change in a positive way. We conducted gait analysis for 3 consecutive and Interphases, Lecco, Italy, 2Politecnico di Milano, Electronics- level of swing assist. These Information and Bioengineering, Milano, Italy studies were approved by the Institutional Review Board and writ- ten informed consents were obtained from all patients. Results: Introduction/Background: This study presents the application of a With the elevation of stance assist, knee buckling and pseudoelastic orthosis for upper-limb repositioning in hemiplegic snapping reduced, but medial whip became larger. The focus of the present contribution is on the possibil- the elevation of swing assist, step length of affected leg became ity to evaluate the dynamic interaction between the patient and the larger, medial whip became smaller, but retropulsion of the hip be- orthotic device during set motor tasks by means of sensors mounted came larger. Pak2 ing, healthy persons marked an average success rate of 56±4%, and 1Korea National Rehabilitation Center, Department of Physical stroke patients demonstrated a success rate of 79±21%. The pur- pose of this study was to investigate wheelchair users’ usability and satisfaction with electric wheelchair. Results: Wheelchair users’ average age a circle is one of the tasks that are used in the robotic therapy of the was 53. Detailed analysis of the drawn subjects can with average use time of electric wheelchair 82. Conclusion: In the present study, the electric wheelchair users were For each assessment, the patient sat comfortably at a desk with his somewhat satisfed with their wheelchairs in terms of usability. A However, they wanted to have more of such services as mainte- circle with the diameter of 16 centimeters was displayed to the pa- nance, repair and follow-up. Starting at 9 or 3 o’clock position, the patient was instructed tained from the usability evaluation and satisfaction survey should to move the target on the screen along the circle circumferentially be met in providing. There was no assistance from the arm robot while the patients carried out the tasks. Each of the 5 914 times repeated tasks was divided into 10 degrees portions or arcs. However, Introduction/Background: An electric wheelchair must meet not training of proximal muscles is also important to achieve practical only its users’ needs but also their caretakers’. Physiologically, proximal muscles this study was to investigate caretakers’ demands and requests in are known to be bilaterally innervated. Material and Methods: Fifty J Rehabil Med Suppl 55 Poster Abstracts 267 caretakers’ demands and requests were obtained by questionnaires Toe-Up! The 5-point Likert scale was used for each question (5-very dis- 918 satisfed, 4-somewhat dissatisfed, 3-neither satisfed nor dissatis- fed, 2-somewhat satisfed, 1-very satisfed). In usability satisfac- Seoul, Republic of Korea tion, mean satisfaction scores of the items ranged from 2. Upper extremity study, the caretakers of electric wheelchair users requested an elec- movements require more cognitive demands and is closely related tric wheelchair to be easier for transfer, not too big and heavy. They to activities of daily living, thus investigations about the dual-task also wanted electric wheelchairs made easier for operation, having performance of upper extremity would be meaningful. We aimed to reduced battery charging time, and more convenient for cleaning explore the motor performance according to cognitive tasks during and carrying. Such issues and several others related to usability of robotic rehabilitation in patients with stroke with longitudinal as- electric wheelchair need to be further identifed which will be very sessments. Material and Methods: A total of 22 patients with frst- helpful in developing electric wheelchairs in the future. These results were not formation and Bioengineering, Milano, Italy, 3Eugenio Medea - different between young and old age group, or between severely La Nostra Famiglia Bosisio Parini, Acquired Brain Injury Unit, motor impaired and mildly impaired group.

This indicates that enalapril 10 mg fast delivery, as shown generic 5mg enalapril free shipping, the raw scores within each condition are relatively close to each other generic enalapril 5mg visa. Therefore, the overall relationship between list length and recall scores is rather strong. Therefore, we would describe this as X 3 X 6 X 9 a less consistent, weaker relationship. A third use of variability is that it communicates the amount of error we have when predicting participants’ scores. Variability and Errors in Prediction You know that the mean is the best score to predict as any participant’s score, so, for example, we’d predict a recall score of 3 for anyone in the 5-item condition. To determine our errors when predict- ing unknown scores, we determine how well we can predict the known scores in the data. As in Chapter 4, the amount of error in one prediction is the difference between what someone actually gets 1X2 and what we predict he or she gets (the X). Because some predictions will contain more error than others, we want to find the average error, so we need the “average deviation. Thus, we have a novel way to view S and S2: Because they measure the difference X X between each score and the mean, they also measure the “average” error in our pre- dictions when we predict the mean for all participants. Similarly, the sample variance is somewhat like the average deviation, although less directly. This is too bad because, technically, variance is the proper way to measure the errors in our prediction. This indicates that X when we predict that participants in the 15-item condition scored 9, our “average error”—as measured by the variance—is about 2. Although this number may seem strange, simply remember that the larger the variance, the larger the error, and the smaller the variance, the smaller the error. If the population is known, then we’ll predict anyone’s score is , and our errors in prediction equal σ2. Or, if we must es- X timate the population using the sample, then we’ll use the sample mean to estimate the we predict for everyone, and we estimate that our errors in prediction will equal. Statistics in Published Research: Reporting Variability 103 Accounting for Variance Finally, we have one other use of the term variance. In research reports you will en- counter such phrases as accounting for variance or the variance accounted for. They are used when researchers describe the usefulness of a relationship when we use it to predict scores. Because a relationship shows the particular Y scores that are naturally paired with an X, if we know participants’ X, we know the Y around which they tend to score. Thus, to some extent we can predict when individuals have one Y score and when other individuals have a different Y score. If we compute the variance of all Y scores in a study, this reflects all of the differences in scores that we want to predict, so this is the variance that we want to account for. How well a relationship helps us to predict the different Y scores is the extent that it “explains” or “accounts” for the variance in Y scores. However, the rela- tionship with list length tends to group similar scores together. Therefore, we know when participants score around 3 (when they recall a 5-item list) and when they pro- duce a different score of, say, 9 (when they recall a 15-item list). By considering list length, our predictions seem very close to each person’s actual score, so we seem to be close to predicting many of the differences among the nine scores. Therefore, in our lingo, we would say that the variable of list length seems to “account for” a sizable portion of the variance in recall scores. However, we still have some error in our pre- dictions because not everyone scored exactly the score we’d predict. Therefore, some differences among scores are not predicted, so we say that some of the variance in re- call scores is not accounted for. On the other hand, consider when a relationship is weaker, such as the relationship between someone’s gender and his or her height. We would predict the average man’s height for any man and the average woman’s height for any woman. However, there is a wide range of women’s and men’s heights, so our predictions each time may not be very close to someone’s actual height. Therefore, this relationship is not all that much help in predicting someone’s exact height, and so it would be described as accounting for little of the variance in height. As these examples illustrate, more consistent relationships account for a greater amount of the variance. Chapters 8 and 12 discuss ways to precisely measure the amount of variance accounted for. For example, recall that the symbol for the sample mean is M, so in a report of our list-length study, you might see this: “The fewest errors were produced when recalling 5-item lists (M 3. With this information, you are largely finished with descriptive statistics because you know the important characteristics of the sample data and you’ll be ready to draw inferences about the corresponding population. Later we will compute the mean and standard deviation in each con- dition of an experiment as part of performing inferential statistics. Measures of variability describe how much the scores differ from each other, or how much the distribution is spread out. The variance is used with the mean to describe a normal distribution of interval or ratio scores. The standard deviation is also used with the mean to describe a normal distribution of interval/ratio scores. It can be thought of as somewhat like the “average” amount that scores deviate from the mean. Transforming scores by adding or subtracting a constant does not alter the standard deviation. Transforming scores by multiplying or dividing by a constant alters the standard deviation by the same amount as if we had multiplied or divided the original standard deviation by the constant. There are three versions of the formula for variance:S2 describes how far the sam- X ple scores are spread out around X, σ2 describes how far the population of scores X is spread out around , and s2 is computed using sample data but is the X inferential, unbiased estimate of how far the scores in the population are spread out around. The formulas for the descriptive measures of variability (for S2 and S ) use N as X X the final denominator. On a normal distribution, approximately 34% of the scores are between the mean and the score that is a distance of one standard deviation from the mean. There- fore, approximately 68% of the distribution lies between the two scores that are plus and minus one standard deviation from the mean. We summarize an experiment usually by computing the mean and standard devia- tion in each condition. When the standard deviations are relatively small, the scores in the conditions are similar, and so a more consistent—stronger—relation- ship is present. When we predict that participants obtained the mean score, our error in predic- tions is determined by the variability in the scores. In this context the variance and standard deviation measure the differences between the participants’ actual scores 1X2 and the score we predict for them 1X2, so we are computing an answer that is somewhat like the “average” error in our predictions. The amount that a relationship with X helps us to predict the different Y scores in the data is the extent that X accounts for the variance in scores. What do measures of variability communicate about (a) the size of differences among the scores in a distribution? Why are your estimates of the population variance and standard deviation always larger than the corresponding values that describe a sample from that population? In a condition of an experiment, a researcher obtains the following creativity scores: 3 In terms of creativity, interpret the variability of these data using the following: (a) the range, (b) the variance, and (c) the standard deviation. If you could test the entire population in question 11, what would you expect each of the following to be? As part of studying the relationship between mental and physical health, you obtain the following heart rates: 73 72 67 74 78 84 79 71 76 76 79 81 75 80 78 76 78 In terms of differences in heart rates, interpret these data using the following: (a) the range, (b) the variance, and (c) the standard deviation. If you could test the population in question 14, what would you expect each of the following to be? Indicate whether by knowing someone’s score on the first variable, the relationship accounts for a large or small amount of the variance in the second variable. Consider the results of this experiment: Condition A Condition B Condition C 12 33 47 11 33 48 11 34 49 10 31 48 (a) What “measures” should you compute to summarize the experiment? Compute the appropriate descriptive statistics and summarize the relationship in the sample data.

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Treatment involves managing pain and affected women contain a number of small cysts generic enalapril 5 mg line. Polycythemia can lead to heart failure order enalapril 10mg without prescription, stroke discount enalapril 10 mg without a prescription, and polycystic kidney disease, adult See polycys- other medical problems when severe. Other features of the disease can leukemia or myelofibrosis, in which the marrow is be cysts in other organs, such as the liver and replaced by scar tissue. Polydipsia occurs in untreated or sive An early-onset disorder that is characterized poorly controlled diabetes mellitus. For example, eye color is polyneuritis, acute idiopathic See Guillain- polygenically controlled because many genes are Barre syndrome. The flat areas of increased skin pigment are called polyhydramnios Too much amniotic fluid. See also sleep polymyositis An autoimmune inflammatory dis- apnea; sleep apnea, central; sleep apnea, ease of muscle that begins when white blood cells obstructive; sleep disorders. Blood testing in a person with polymyositis shows Pompe disease An inherited deficiency of the significantly elevated creatinine phosphokinase lev- enzyme alpha-glucosidase which helps the body els. The diagnosis is further suggested by elec- break down glycogen, a complex carbohydrate that tromyogram testing and confirmed with muscle is converted to glucose for energy. Treatment of polymyositis requires high enzyme, glycogen builds up in the heart and other doses of cortisone-related medications, such as muscles, causing extensive damage. There are sev- prednisone, and immune suppression with medica- eral different forms of Pompe disease which vary in tions, such as methotrexate and cyclophosphamide. Due to popliteal pterygium syndrome An inherited an abnormal aggregation of capillaries, a port-wine condition that is characterized by a web (ptery- stain is a type of hemangioma. See also popliteal pterygium syndrome are cleft palate (with Sturge-Weber syndrome. The opposite of posterior is in an autosomal dominant manner and is due to anterior. See also Appendix B, “Anatomic mutation of the interferon regulatory factor 6 gene. Most porphyrias affect the skin or the nerv- with the chest against the film plate and the X-ray ous system. See patient may suffer rapid heartbeat, mania, muscle also Appendix B, “Anatomic Orientation Terms. Acute attacks are often pre- postherpetic neuralgia See neuralgia, pos- cipitated by the use of certain drugs, such as therpetic. One type of porphyria, acute intermittent occurs together with balanitis, inflammation of the porphyria, may have affected members of the House glans, as balanoposthitis. See also balanitis; bal- of Hanover in England, including “Mad” King anoposthitis. Normally, the veins from the stomach, intestine, spleen, and pancreas postmenopausal After menopause, the period merge into the portal vein, which then branches into of time after a woman has experienced 12 consecu- smaller vessels and travels through the liver. It can cause gastrointestinal bleeding, back of the nose and throat that leads to or gives the ascites, and symptoms related to decreasing func- sensation of mucus dripping down from the back of tion of the liver. Postnasal drip is one of the most common consequences of sinusitis, nasal allergies, and the portal vein A large vein formed by the union of the common cold. It can occur a the body, the attitude or carriage of the body as a few days, weeks, or even months after childbirth. A whole, or the position of the limbs (the arms and woman with postpartum depression may have feel- legs). Treatment involves counseling postural hypotension See hypotension, and/or medications. An abnormal increase in potas- sium (hyperkalemia) or decrease in potassium postpolio syndrome A constellation of symp- (hypokalemia) can profoundly affect the nervous toms and signs that appear years after an initial system and heart, and when extreme, can be fatal. Other symptoms include fatigue, joint pain, and slowly progressive muscle Pott’s disease See tuberculous diskitis. This is an (floppiness), poor sucking and feeding problems in important calculation because if delivery is delayed early infancy, and, later in infancy, excessive eating 3 weeks beyond term, the possibility of infant mor- that, if unchecked, leads gradually to marked obe- tality increases dramatically. Other sypmtoms include developmental delay, mild to moderate mental retar- post-traumatic stress disorder A psychologi- dation with multiple learning disabilities, and small cal disorder that develops in some individuals who gonads. The child can have two vived or witnessed violent crimes, or been through copies of chromosome region 15q11–15q13, but if wars. When the same Although preeclampsia is relatively common, occur- region of the maternally contributed chromosome is ring in about 5 percent of all pregnancies and more missing, the result is a different disease, called frequently in first pregnancies than in others, it can Angelman syndrome. In some cases, untreated preeclampsia can Prayer of Maimonides See Daily Prayer of a progress to eclampsia, a life-threatening situation Physician. The Pregnancy lasts for about 40 weeks, measured from aim of a preclinical study is to collect data in sup- the date of the woman’s last menstrual period. Preclinical conventionally divided into three trimesters, each studies are required before clinical trials in humans roughly 3 months long. There is little to no chance that a first- precocious puberty The onset of secondary trimester fetus can survive outside the womb, even sexual characteristics, such as breast buds in girls, with the best hospital care; its systems are simply too undeveloped. In the first trimester, some women growth of the penis and thinning of the scrotum in boys, and the appearance of pubic hair in both experience morning sickness. With the best medical care, a second-trimester fetus For example, preconceptual counseling is the inter- born prematurely has at least some chance of sur- change of information prior to pregnancy. In the third trimester, preconceptual counseling The interchange of the fetus enters the final stage of preparation for information prior to pregnancy. It increases rapidly in weight, as does the counseling usually occurs for pregnancy planning mother. Swelling of the ankles, back pain, and bal- and care, but sometimes it takes the form of genetic ance problems are sometimes experienced during counseling. See also acute fatty liver of pregnancy; prediabetes A state in which blood glucose lev- birth; birth defect; conception; eclampsia; els are higher than normal but not elevated enough ectopic pregnancy; fetal alcohol effect; fetal alco- to warrant a diagnosis of diabetes. People with prediabetes can prevent the prenatal care; prenatal development; teratogen. Many procedures are available to prevent prema- pregnancy, molar See hydatidiform mole. If prema- ture birth is medically necessary or inevitable, pregnancy, pernicious vomiting of See hyper- however, it may be accomplished via C-section to emesis gravidarum. Tubal pregnancies premature contraction of the heart A single are due to the inability of the fertilized egg to make heartbeat that occurs earlier than normal. Lifestyle changes are recommended for anyone with The premature contraction is followed by a pause as prehypertension. A battery of techniques irritability, tension, sleep and appetite changes, are available to remove or kill the tissue, thereby fatigue, and physical problems such as pain or preventing the development of cancer. Symptoms generally treatment method depends on the particular prema- begin the week before menstruation and end a few lignant tissue involved. The earlier in development that birth support of family and friends, and medications, takes place, the greater the likelihood that life-sup- including diuretics, pain killers, oral contracep- port systems will be needed and the greater the risk tives, drugs that suppress ovarian function, and anti- for birth defects and death. The next 3 weeks see intense cell differentiation, as the cell mass divides into separate primitive sys- presentation, footling See footling birth. At the end of 8 weeks, the embryo takes on a roughly human shape and is called a fetus. For the remaining weeks of develop- prevalence The proportion of individuals in a ment, the fetus continues to gain weight, and its population having a disease or characteristic. Prevalence is a statistical concept referring to the number of cases of a disease that are present in a prenatal diagnosis Diagnosis before birth. A growing number screening for hypertension and treating it before it of birth defects and diseases can be diagnosed pre- causes disease is good preventive medicine. Also Preventive medicine takes a proactive approach to known as antenatal diagnosis. Treatments include medications, anesthesia, and drainage of blood prepuce See foreskin. The first sign of presbyopia is primary care A patient’s main source for regular often the need to hold reading material farther away. All family physicians, and many pediatricians and internists, practice pri- prescription A physician’s order for the prepa- mary care.

Some sweet foods and drinks are laxative cheap 10 mg enalapril with mastercard, others are stopping discount 10 mg enalapril visa, yet others drying enalapril 5 mg otc, 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. Especially in the case of an author, such as Diocles, whose writings have been lost, we should be very careful not to pretend that we can creep into his skin and perceive with his eyes the other text which is supposed to be criticised and which represents only a very small part of a literature that must have been of considerable size. These remarks may appear unduly sceptical or a tedious example of stating the obvious. Yet the practice of ancient polemical writers in cases where they do mention their opponents by name and in which the writings of these opponents are preserved as well (e. Yet the substantial similarity between Diocles’ criticism of the first claim and the critical remarks of the author of the Hippocratic text On Regimen 2. Those that are bitter are rather diuretic, while some of them also have a relaxing effect on the belly. Those that are sour, excretions’ (Mnhs©qeov dì ¾ ìAqhna±ov –n tä€ perª –destäná ‘o¬ ‰luko©’, fhs©n, ‘kaª gluke±v cumoª p†ntev Diocles of Carystus on the method of dietetics 89 While it has also been argued very frequently that Diocles here shares the sceptical attitude towards theoretical approaches of dietetics found in the treatise On Ancient Medicine,35 Fredrich’s view that the third claim Diocles is criticising corresponds with the actual practice of the writer of On Ancient Medicine has been received with mixed feelings. As for On Ancient Medicine, this seems to misunderstand both the claims that Diocles is opposing (especially claim one) and Diocles’ own position. The scope of the Diocles fragment is rather different from what is at issue in On Ancient Medicine. Diocles does not object to the postulation of warm and cold, nor does he object to referring to these pos- tulates as causes per se: he simply warns against premature generalisations. His argument allows for cases in which a thing’s having the quality hot causes it to produce such-and-such an effect, but he points out that this does not imply that all things that have that quality produce that effect (for instance because of the combination with other factors, or because it is only an incidental cause), nor that all cases where this effect is produced are due to this very quality. Diocles points out that one should look for the essential cause: sweet things may cause certain effects, but not necessarily so and not in so far as they are sweet. Nor does Diocles make the distinction between Ëp†gousi t‡v koil©av, o¬ dì ½xe±v kaª drime±v lÅousi tŸn oÎrhsin. On Mnesitheus being a possible target see Smith (1980) 444, and von Staden (1992) 240; a more sceptical attitude is taken by Bertier (1972) 30–1. Denn erstens wird dort nur zu einem geringen Teil eine Erklarung fur die Wirkung bestimmter¨ ¨ Nahrungsmittelgegeben,undzweitensliegtdiesenAusfuhrungenkeinstrenghypothetischesSchema¨ zugrunde(imGegensatzzurFeuer-Wasser-TheoriedeserstenBuches). Besides, there are more general reasons which should make us reluctant to associate Diocles with the author of On Ancient Medicine. The picture of Diocles that emerges not just from this single fragment, but from the more than two hundred that are preserved from him, shows that in matters of physiology and pathology Diocles’ opinions display many speculative characteristics in whose company the author of On Ancient Medicine would have felt himself quite uncomfortable. Diocles’ acceptance of the four primary qualities and of concepts such as innate pneuma and humours is frequently attested, and his use of them in the causal explanation of diseases in his work Affection, Cause, Treatment (P†qov, a«t©a, qerape©a) is well documented. Fragment 176 does not present itself as (nor claims to be) a methodological programme for medical science as a whole: it is concerned with dietetics, with the powers of foodstuffs and with the practical prob- lems the physician has to face. It is far from self-evident that what Diocles says here also applies to anatomy, pathology and general physiology – or even if it would apply, what the implications of this would be. He points out that there are many cases in which causal 37 On Diocles’ physiology see frs. A large number of Diocles’ aetiological views on diseases arereportedinthetreatiseonacuteandchronicdiseasesbytheso-calledAnonymusParisinusFuchsii, edited by Garofalo (1997). Although we should take into account the possibility that in many cases it is the Anonymus who is responsible for the precise wording of the aetiologies, the testimonies nevertheless point to a sophisticated use of causal explanation by Diocles in dealing with diseases. The question of the reliability of the Anonymus (which is too often approached from an a priori negative point of view, for instance by Kudlien (1963) 462) can only be answered on the basis of an unbiased study of the whole text, which has only recently been made available in its entirety by Garofalo (1997); see also van der Eijk (1999b). Diocles of Carystus on the method of dietetics 91 explanation is impossible, and that there are also cases in which it may be possible, but unnecessary for practical purposes – and one could imagine that in this respect the author of On Ancient Medicine would not have been too happy with Diocles’ criticism of claim three, for On Ancient Medicine is one of the first among the Hippocratic treatises to proclaim the urgency of stating the cause in dietetics. As for On Regimen, I believe that Fredrich was right in detecting a very strong, almost indiscriminate application of the search for causes in the chapters on the powers of foodstuffs of this treatise (40–56). The use of words indicating causal links such as ‘because’, ‘since’, ‘as a result of’ (di»ti, Œte, Âti, di†) in these sections is very frequent indeed. But it is especially the nature of these explanations which calls for consideration, for the fact is that many of them suffer from defects that might be interpreted as provoking the kind of criticism Diocles is expressing, such as circularity – no clear distinction being made between the level of qualities and that of powers – shifting the problem, and tautology – explanandum and explanation being stated in the same terms. It warms, because it is vinous, moistens because it is nutritious, and sends to stool because it is sweet and moreover boiled-down’); 2. The most prominent instances where the importance of causal explanation is stated are: 20. Considering these examples, we may be inclined to say that Diocles’ warnings against too automatic an application of causal explanation, as well as his prescription (in section 11 of fr. It rather seems to me that Diocles is arguing against what he believes to be – in the context of dietetics – some undesirable consequences of the search for causes or principles, or to put it in other words, against too strict an application of what in itself – and in Diocles’ opinion too – remains a sound scientific procedure. These consequences seem to have pervaded Greek scientific thought in the fourth century to such an extent that opposition to it was also expressed by Aristotle and Theophrastus (in their case, the opposition is probably directed against certain tendencies in the early Academy). There are a number of passages which reflect a similar awareness in Aristotle and Theophrastus of the limits of causal explanation. Theophrastus, Metaphysics 9 b 1–13: ‘Wherefore this too is problematical or at any rate not easy to say, up to which point and of which entities one should seek the cause, in the objects of sense and in the objects of thought alike: for the infinite regress is foreign to their nature in both cases and destroys our understanding. Both of them are starting-points in some way: and perhaps the one for us, the other absolutely, or, on the one hand, the end and the other a starting-point of ours. Up to some point, then, we are capable of studying things causally, taking our starting-point from sense-perceptions in each case; but when we proceed to the extreme and primary entities, we are no longer capable of doing so, either owing to the fact that they do not have a cause, or through our lack of strength to look, one would say, at the brightest things’ (¨€ kaª toÓtì Šporon £ oÉ ç†€di»n ge e«pe±n, m”cri p»sou kaª t©nwn zhtht”on a«t©av ¾mo©wv ›n te to±v a«sqhto±v kaª nohto±vá ¡ g‡r e«v Špeiron ¾d¼v –n ˆmfo±n ˆllotr©a kaª ˆnairoÓsa t¼ frone±n. For example, Diocles’ way of expressing himself in section 8 certainly reminds us of Aristotle, who also often uses the combination of ‘in a certain way’ (tr»pon tin†) and ‘look like’ (›oike) in order to qualify the similarities he sees between different entities or phenomena; the combination ˆrca±v ›oike (‘look like starting-points’) is also attested several times in Aristotle’s works. Similar searches for combinations of tr»pon tina and a form of ›oika yielded the following results: Aristotle, Gen. For pretty much all animals in some way seem to produce grubs to start with; 94 Hippocratic Corpus and Diocles of Carystus against claims one and two sounds very Aristotelian (although he does not use the typically Aristotelian terminology of kaqì aËt», kat‡ sumbebhk»v, or the qualifier ¨€). The advice not to take unknown, disputed or implausible items as starting-points is perfectly in keeping with the principles and the practice of Aristotelian dialectic. For once the fig is closed neither dew nor drizzle can make it miscarry, and it is dew and drizzle that get warmed and cause the drop, as with the pomegranate blossom. That these are responsible (and they are cited by some people) is indicated by what happens: there is more dropping of the fruit when light rain follows its first appearance’ ( ïEoike dì e­per ¡ Šnoixiv poie± tŸn –pimonŸn eÎpnoi†n te kaª ˆp”rasin poioÓsa paraplžsion tr»pon tin‡ [t¼] sumba±non kaª –pª tän –n A«gÅptw€ sukam©nwná ˆll‡ toÓto diamfisbhtoÓs© tinev Þv Šrì oÉk ˆno©gousin o¬ y¦nev ˆll‡ summÅein poioÓsin Âtan e«sdÅwsin Âqen kaª tŸn a«t©an –stªn –k toÓ –nant©ou f”rein Þv toÅtou c†rin –rinazom”nwná –‡n g‡r summÅwsin oÎqì ¡ dr»sov oÎte t‡ yak†dia dÅnatai diafqe©rein Ëfì æn ˆpop©ptousi diugrain»menoi ãsper kaª o¬ kÅtinoi tän çoäná Âti d• taÓta a­tia mhnÅei t¼ sumba±non Á dŸ kaª l”gous© tinevá ˆpob†llousi g‡r mŽllon Ëdat©wn –piginom”nwn;tr. It seems that of the two opposites, namely sweet and bitter, the sweet is the origin (as it were) of good flavour, whereas the bitter is the origin of fragrance and in some way the bitter is to a greater extent the origin of fragrance. For it is hard to find any fragrant thing that is not bitter, but many non-sweet things have excellent flavour’ ( v –pª pŽn d• t† gì eÎosma p†nta pikr†á toÅtou m•n oÔn tŸn a«t©an Ìsteron lekt”on. I am aware that linguistic resemblances do not prove intellectual exchange or even similarity of doctrine (for the abuse of linguistic ‘evidence’ by Jaeger see von Staden (1992) 234–7) and that the Aristotelian corpus is so much larger than the Hippocratic that the significance of the fact that only occurrences in Aristotle and Theophrastus are found may be doubted (the computer also found Plato, Phaedo 100 e 6–a 1: ­swv m•n oÔn æ€ e«k†zw tr»pon tin‡ oÉk ›oiken, but this passage is not quite comparable with the Diocles fragment). Diocles of Carystus on the method of dietetics 95 Connections of Diocles’ views with Aristotle’s have, of course, been made by earlier scholars, especially by Werner Jaeger, in whose picture of Diocles as a pupil of Aristotle fragment 176 played a central part. He argued that the fragment could not have been written without the influence of the great Stagirite on the Carystian physician, and from this and other considerations drew far-reaching conclusions concerning Diocles’ date. Yet this should not make us a priori hostile to any attempt to associate Diocles with the Lyceum. The resemblance is not so much between Diocles’ ar- gument that knowledge of the cause is often not necessary for practical purposes and similar statements found in Aristotle’s Nicomachean Ethics (which Jaeger emphasised) – it has been shown that what is at issue in those passages is rather different from what Diocles is concerned with.

By T. Marus. Case Western Reserve University.

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