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By Z. Felipe. California College of the Arts.

It is important to distinguish between the corrective discount sildigra line erectile dysfunction at age 30, ‘cathartic’ criticism of traditional religious beliefs and the exposition of a positive theology buy sildigra uk erectile dysfunction treatment chennai. It seems that the author of On the Sacred Disease has been regarded too much as an exponent of the latter buy sildigra 120mg line erectile dysfunction drugs nz, and that he has been regarded more as a philosopher or a theologian than as a physician. Instead, I propose to regard as the author’s primary concern the disengagement of epilepsy from the religious domain (which implies claiming it as an object of medicine) and his accusations of impiety as one rather successful way to achieve this goal; in this way the corrective criticism of a traditional idea (viz. Even if this interpretation is convincing, it cannot be denied that there remains a tension between the author’s belief in gods who cleanse men from their moral transgressions and his statements about the divine character of the disease. This tension becomes especially manifest when we confront his categorical rejection of the idea that holy beings like gods send diseases (which he labels as highly blasphemous) with his assertion, ten lines further down, that diseases are divine in virtue of having a nature. The problem is how this ‘being divine’ of diseases is related to the purifying influence of the gods mentioned in 1. The author does not explain this, and we may wonder whether he, if he was aware of this problem, would have been capable of solving it. Of course, there are several possible solutions which we might suggest, and we could speculate about the author’s unexpressed ideas on theodicy and on the relation between the gods and the world in terms of providence, deism, determinism, and so on. Thivel draws an almost Aristotelian picture of the author’s world-view: ‘ces dieux... But it will by now have become clear for what reasons (apart from those mentioned ad loc. We have seen that the interpretation of the author’s statements about the divine character of the disease, as well as the attempt to deduce his theological ideas from these statements, involved many problems. We have also seen the difficulties involved in the evaluation of the author’s accusations of asebeia, and I have shown that it is possible to discern, in spite of the hypothetical character of most of these accusations, elements of the author’s own conviction. If the results of this discussion (especially my views on the range and on the rhetorical impact of the assertions about the divinity of diseases) are convincing, the discrepancy noted at the beginning of this paper has decreased considerably, though it has not disappeared. Yet we are now in a much better position to formulate the problem more adequately and to look for an explanation that is more to the point than the one offered in section 1. It is certainly wrong to hold that the author of On the Sacred Disease systematically exposes his religious beliefs and his ideas on the nature of divine causation in this text. The writer believes in gods who grant men purification of their transgressions pr»fasin), et le monde celeste, sejour des dieux incorruptibles, qui habitent sans doute les astres. On the Sacred Disease 71 and who are to be worshipped in temples by means of prayer and sacrifice. The text is silent on the author’s conception of the nature of these gods, but there is, at least, no textual evidence that he rejected the notion of ‘personal’ or even ‘anthropomorphic’ gods. Diseases are not the effects of divine dispensation; nevertheless they have a divine aspect in that they show a constant and regular pattern of origin and development. How this ‘being divine’ is related to ‘the divine’ (or, the gods) which cleanses men from moral transgressions is not explained. The idea of divine dispensation as such is nowhere questioned in the text of On the Sacred Disease. Gods are ruled out as causes of diseases; whether they are ruled out as healers as well is not certain, since the text is silent on this subject. As I remarked earlier, the author does not believe that epilepsy can be cured by natural means in all cases: on two occasions (2. Of course we can only speculate what he would do in such cases, but it does not seem alien to Hippocratic medicine to make an appeal to the gods in such hopeless cases. Nor is the combination of ‘natural’ therapeutic measures with prayers and sacrifices unattested in the Hippocratic collection. Thus the writer of On Regimen explicitly recommends this combination, and among his thera- peutic remarks dietetic precepts and instructions concerning the gods to whom one should pray are found side by side. But the recognition that in some cases medicine fails to help is frequently attested (see On the Art of Medicine 8). An important point is that the author of On Regimen recommends prayers in various sorts of diseases, whereas the writer of On the Sacred Disease would probably do so only – if ever – in hopeless cases. On the other hand it must be conceded that the author of On Regimen substantiates his claim to the ability to cure far more elaborately than the author of On the Sacred Disease, who confines himself to just a few general remarks on therapy which may apply to any disease. The sole object of mentioning On Regimen is to show the danger of us- ing apparent differences in ‘theology’ or ‘religiosity’ between the various Hippocratic treatises as evidence for establishing the relative dates of the treatises. While some scholars (Hankinson, Jouanna, Roselli) have accepted my position regarding the author’s religious beliefs, others (Laskaris, Lloyd) prefer to read the author’s arguments in chapter 1 predominantly as rhetor- ical and not necessarily expressing the author’s own views. One of the interesting characteristics of On Regimen 4 is that the author states that he will not deal with divine dreams, but only with those dreams which have a physical origin, while at the same time incorporating religious instructions among his therapeutic remarks. This is, of course, not an inconsistency or a sign of the alleged ‘compilatory’ character of the book (as van Lieshout (1980, 186–7) seems to think), but an interesting example of the surprising relations between science and religion of which Greek medicine provides evidence (see Lloyd (1979) 42). On the Sacred Disease 73 Laskaris and Jouanna prefer to keep the other reading taÓta. According to Jouanna, the author in the course of his argument develops the notion of prophasis in the sense of external catalyst (‘cause declenchante´ due aux facteurs exterieurs’) and in the end distinguishes it from that of´ phusis, the natural cause or ‘law’ determining the development of the disease (‘cause naturelle et lois de developpement de la maladie’). He concludes that there´ is no contradiction, since both external causal factors and the internal ‘na- ture’ of the disease are subject to the same natural laws and therefore divine (‘Il n’y a aucune contradiction selon l’auteur entre une maladie divine a` cause de sa phusis ou a` cause de sa prophasis. Tout cela est de l’ordre du divin dans la mesure ou tous ces phenomenes obeissent a des lois naturelles` ´ ` ´ ` qui sont les memes aussi bien a l’exterieur de l’homme qu’en l’homme, loisˆ ` ´ qui sont independantes´ de l’intervention humaine’ (2003, 130–1)). I still think that this does not fully address the problems I raise in my discussion of this passage and reads too many elements in the text which are not ex- plicitly stated (e. I have discussed the relationship between On the Sacred Disease and Airs, Waters, Places in van der Eijk (1991), arriving at the view that there is no reason to believe that the two treatises are by different authors; similar conclusions have been arrived at (apparently independently) by Bruun (1997); see also Jouanna (1996) 71–3 and (2003) lxx–lxxiv. I have discussed the similar structure of the argumentation in On the Sacred Disease and in Aristotle’s On Divination in Sleep in van der Eijk (1994) 294–5 (see also Hankinson (1998c) making a similar point). I have dealt at greater length with the religious beliefs of the author of On Regimen in van der Eijk (2004a). On the question of ‘the divine’ in other Hippocratic treatises see Lichtenthaeler (1992)onPrognostic, and Flemming and Hanson (1998) on Diseases of Young Women. To be sure, later reports on his doctrines often represent him as being in perfect agreement with ‘Hip- pocrates’ on various subjects;2 but the fragments of his works that have been preserved, show that the authority of ‘the great Coan’ did not prevent him from taking issue with some ideas and practices that are similar to what is to be found in texts which we call Hippocratic. It is not even certain that Diocles had ever heard of Hippocrates or was familiar with any of his genuine works. The Diocles fragments are numbered according to my edition (2000a, 2001a), which replaces the edition by Wellmann (1901). Yet it throws some light on my reasons for selecting Diocles’ fragment 176 for discussion in the context of an examination of the relationship between Hippocratic medicine and ancient philosophy, and it may serve to illustrate an approach to it which I would rather try to avoid. For the fragment in question – one of the few longer verbatim fragments of Diocles we possess – has repeatedly been interpreted as being related to, and perhaps even directed against, certain Hippocratic texts. It has, for instance, been read as a foreshadowing of medical Empiricism or even Scepticism,7 or as the culmination of the Aristotelian development from speculative philosophy to an empirically minded study of particular phenomena. However, although Diocles addresses someone in the second person singular, we cannot be certain that his objection was originally directed against Hippocrates. For caution with regard to Diocles’ acquaintance with the name and reputation of Hippocrates see Smith (1979) 187ff. The reactions Jaeger’s views provoked are conveniently discussed by von Staden (1992). Further discussions of the fragment (other than the ones already mentioned) can be found in Deichgraber (¨ 1965) 274 n.

In this setting we may say compromised or non-functioning right or left kidney (according to the kidney damaged right or left) buy genuine sildigra on-line erectile dysfunction causes psychological. Sometimes we say solitary functioning right or left kidney (according to the side of the healthy kidney) buy sildigra 100 mg cheap erectile dysfunction filthy frank. Primary glomerular diseases: Such as idiopathic crescentic glomerulonephritis purchase 120mg sildigra otc impotence treatment after prostate surgery, primary focal segmental glomerulosclerosis and primary mesangiocapillary glomerulonephritis. Tubulo-interstitial diseases: These include the following: • Chronic heavy metal poisoning such as lead, cadmium and mercury may result in chronic tubulo-interstitial nephritis and renal failure. Renal vascular diseases: Bilateral advanced renal artery stenosis or a unilateral renal artery stenosis in a solitary kidney. Renal artery stenosis usually occurs due to advanced atherosclerosis which is more common in elderly males or due to fibromuscular dysplasia which is more common in middle aged females. Bilateral renal vein thrombosis; which is more common in patients with nephrotic syndrome. Nephrosclerosis secondary to long standing hypertension (very common), polyarteritis nodosa (less common). Chronic urinary tract obstruction: This may be upper or lower urinary tract obstruction. Causes of upper urinary tract obstruction include bilateral ureteric or renal stones, bilateral neoplasms and bilateral ureteric stricture. Causes of lower urinary tract obstruction include bladder tumour, senile prostatic enlargement, huge bladder stones and stricture urethra Association of infection and obstruction is the most common cause of renal failure as obstruction may invite infection and infection may lead to obstruction. Analgesic nephropathy is a cumulative effect needing a long term drug administration. Nearly an amount of 2-3 kgm of aspirin is needed for chronic renal failure to occur. This condition is frequently seen in patients with chronic pain as those with osteoarthritis and rheumatoid arthritis. Mouth: The high concentration of urea in saliva causes unpleasant taste (taste of ammonia) and uraemic odour of the mouth (ammoniacal smell). This occurs due to the high concentration of urea in saliva and gastric juice causing chronic irritation of the gastric mucosa. The cause of hiccough in uraemic patient is most probably due to irritation of the phrenic nerve or may be due to a central effect induced by uraemic toxins. This is due to urea deposition in the mucosa of the colon which leads to mucosal ulceration which is liable to superadded infection which may cause diarrhea. Neurological manifestations: These include the following: a- Cerebral: Headache, lassitude, drowsiness, insomnia, sometimes inverted sleep rhythm, and vertigo are common manifestations of uraemia. Hematologic and cardiovascular Manifestations: a- Anaemia: Anaemia is a common feature of uraemia and is usually normocytic normochromic. It is partly responsible for many of the debilitating symptoms of uraemia such as lethargy, tiredness and exertional dyspnea. The main causes of anaemia in uraemic patient are the followings: • Bone marrow depression by the uraemic toxins and due to erythropoietin deficiency. B12, and folic acid) • Iatrogenic causes as frequent blood sampling in hospitalized patients and the blood loss in the dialyzer at the end of each haemodialysis session. In uraemics, hypertension is characterised by resistance to drug treatment and by tendency to develop malignant hypertension more than in other forms of hypertension. Hypertension aggravates the renal disease which further increases the blood pressure and a vicious circle is produced. Continuous friction between the visceral and parietal pericardium during cardiac systole and diastole results in dry pericarditis which manifests by pericardial pain and pericardial rub on auscultation. Later, haemopericardium develops which progresses to cause cardiac compression (tamponade). Progressive hypotension due to reduction of stroke volume as venous return is progressively decreasing. Echo cardiography shows that the increase is mainly due to fluid collection in the pericardium. Cutaneous manifestations: • Muddy face (sallow skin), due to retention of some toxins (urochromogens). Musculo-Skeletal and soft tissue manifestations: These include the following: a- Muscular : fatigue, and wasting (myopathy) which is mainly proximal in lower limbs (Waddling gait). It is due to retained uraemic toxins, electrolyte disturbances, vitamin D deficiency, hyperparathyroidism and nutritional deficiency. Gonadal disturbances: The following gonadal disorders are commonly seen in uraemic patients: • In males: decreased libido, impotence, gynecomastia, reduced spermatogenesis. Endocrinal disturbances: The following are the endocrine disorders which are common in uraemic patients: • Hyperparathyroidism • Lack in activation of vit. The second is decreased renal tubular degradation of insulin with a consequent increase in the insulin half life. The upper hand is usually for the second effect with consequent fall in insulin requirement (insulin daily dose) in diabetic patients when they become uraemic. Urine examination may show the following : • Polyuria especially nocturia and anuria in terminal cases. Blood Changes: There is an increase in blood urea, creatinine and uric acid levels, metabolic acidosis, normochromic normocytic anaemia, hyperkalaemia, and hyperphosphataemia. Serum calcium may be normal or low in early phases, but it becomes high in stage of tertiary hyperparathyroidism. Renal biopsy is indicated in cases with average kidney size and unknown etiology of uraemia. History: A long history of renal disease suggests chronicity while absent previous history suggests acute renal failure. Kidney size as detected by ultrasonography: A small atrophic kidney favours the diagnosis of chronic renal failure, while a normal sized kidneys is more in favour of acute renal failure. Magnitude of the increase in serum creatinine in relation to the presenting symptoms: High serum creatinine with minimal symptoms is in favour of chronic renal disease, while relatively low serum creatinine with severe symptoms is in favour of acute renal disease. Renal biopsy: extensive renal interstitial fibrosis and tubular atrophy in renal biopsy are features of chronic cases. Renal causes factors such as: • Active glomerular disease • Active tubulo-interstitial disease • Pyelonephritis c. Postrenal factors: Causing obstruction of urine flow from both kidneys such as: • Stone • Stricture ureters • Enlarged prostate • Bladder neck obstruction Step 3. Extra 200 ml fluid should be added in febrile patient for every one degree centigrade increase in the body temperature. Treatment of Bone disease: • Phosphate Binders such as aluminium hydroxide, magnesium oxide and calcium carbonate or acetate which combine with phosphorus in the gut and are excreted with the stool. Calcium containing compounds are better than aluminium and magnesium salts which could be dangerous on long term use. Three glands and part of the fourth are removed and the remaining is implanted subcutaneously. The first line of treatment is by giving proper nutrition, iron, folic acid, and vitamins especially B12.

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