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By N. Corwyn. Ohio Northern University.

If more than1Loffluid is removed then intravenous albumin or plasma expander is re- Clinical features quired to prevent hypovolaemia generic 100 mg fildena fast delivery. Chapter 5: Clinical 189 Investigations and procedures Obstruction r Bilirubin: Raised bilirubin levels indicate abnor- Liver function testing malities in its synthesis order fildena 100 mg otc, metabolism or excretion order fildena with a visa. It often rises in causes of obstructive (cholestatic) Liver function testing includes blood tests to look for ev- jaundice purchase fildena with american express, but it is not specific for obstruction or idence of hepatocyte necrosis, as well as assessing the even for liver disease (see Table 5. For assessing the synthetic function surement is also raised as it shares a similar pathway of the liver, two other blood tests are needed, the pro- of excretion. Alternatively, it is possible to r Aminotransferases: Two are measured, aspartate differentiate the bone and liver isoenzymes. These are raised by most causes of this enzyme even when there is no liver damage. It liver disease, but paradoxically, in severe necrosis may be used to detect if patients continue to drink or in late cirrhosis levels may fall to normal in- alcohol,butitdoeshavealonghalf-life. It falls Haemolysis in both acute and chronic liver disease, although Bilirubin Haemolysis levels may be normal early in the disease. Other osteomalacia, metastases, causes of hypoalbuminaemia include gastroin- hyperparathyroidism) testinal losses or heavy proteinuria. IgM is Albumin Malnutrition Nephrotic syndrome particularly raised in primary biliary cirrhosis, Congestive cardiac failure whereas IgG is raised in autoimmune hepatitis. Parenteral gallbladder, or may be seen after endoscopic or surgical replacementofvitaminKshouldleadtoimprovementof instrumentation. It is partic- Pancreatic function tests ularly useful in patients who have r jaundice or abnormal liver function tests where it is Exocrine function r Serum amylase is a marker for pancreatic damage. Ultrasound may also be the more complex triglyceride is not, then the steator- used for liver biopsy, and doppler ultrasound is used to rhea is caused by pancreatic disease. Tests for endocrine function in this context taken in case of allergy or risk of contrast nephrotoxicity. Pancreatic polypeptide is raised in all of useful for assessing focal lesions of the liver, staging of these types of tumour and see page 222 for specific malignancy, and it is more sensitive for pancreatic le- tests. Pancreaticcalcificationmay times used as a non-invasive alternative to endoscopic be seen in chronic pancreatitis. Complications include haemorrhage, patients suspected of having biliary obstruction, stone bile leakage, bacteraemia and septicaemia. This is followed by checked and a sample sent to transfusion for group real-time radiography. Hepatitis B and C surface antigen sta- Further diagnostic and therapeutic manoeuvres: r tus should be known. Percutaneous aspiration of an abscess is approximately 1%, but this rises with any therapeutic occasionally performed. Haemorrhage and perforation occur less cedure the patient should rest on their right side for 2 commonly. Ascending cholangitis may be prevented by hours in bed and should gently mobilise after bed rest antibiotics, which are given prophylactically to all pa- for a further 4 hours. However, in many cases of Percutaneous transhepatic cholangiography is used to malignant tumours only complete removal of the liver image the biliary tree, particularly the upper part, which and liver transplantation is curative. Localised metas- is not well outlined by endoscopic retrograde cholan- tases may also be resected. For example in obstruc- The liver is composed of several segments, as defined tive jaundice with obstruction of the upper biliary tree by the blood supply and drainage, this is important in and when malignancy of the biliary tract is suspected liver resection. Prior to the procedure the clotting have a left and right branch and these supply the left and profile is checked and the patient is given prophylactic righthemi-livers respectively. The im- comprises of the remainder of the right lobe and is also age can be followed by real-time radiography and still further divided into four segments (see Fig. The T-tube allows drainage of Right lobe Left lobe bile and also allows a cholangiogram later. Laparoscopic cholecystectomy requires three or four cannulae inserted through the anterior abdominal wall, Caudate and for visualisation and access with operative instruments. Open cholecystecomy often requires quite a long stay Gallbladder Hepatic artery and in hospital, possibly a week or more, whereas laparo- portal vein scopic cholecystectomy may be conducted as a day case. Laparoscopic tech- This means that right hepatectomy, left hepatectomy nique reduces the incidence of respiratory problems and and extended right hepatectomy (right lobe plus cau- surgical site infection. The appropriate vessels for the segment(s) Disorders of the liver are ligated and divided before the segment(s) are dis- sectedawayfromtheremainderoftheliver. Carefuliden- Introduction to the liver and tification and ligation of biliary ducts and smaller vessels liver disease is required to reduce blood loss and therefore morbidity and mortality. Drainage is required postoperatively, to Introduction to the liver prevent bile from pooling intra-abdominally. It has two blood supplies: 25% of Cholecystectomy its blood originates from the hepatic artery (oxygenated) Surgical removal of the gallbladder and associated stones and 75% originates from the portal vein that drains the in the biliary tract may be by open surgery or laparo- gastrointestinal tract and spleen. Cholecystectomy is also considered in The functions of the liver are carried out by the hepa- younger patients with asymptomatic gallstones in or- tocytes, which have a special architectural arrangement. Blood enters the liver through the portal tracts, which Carcinoma of the gallbladder is treated by wider resec- contain the triad of hepatic artery, portal vein and bile tion, including neighbouring segments of the liver and duct. The lobule is classically used to Open cholecystectomy is usually performed through describe the histology of the liver (see Fig. Cholangiography may be used to The hepatocytes in zone 1 of the acinus receive well- visualise the duct system. The gallbladder is removed oxygenated blood from the portal triads, whereas the with ligation and division of the cystic duct and artery. The liver has multiple functions, which may be im- Aetiology paired or disrupted by liver disease: The causes of acute hepatitis: r Carbohydrate metabolism: The liver is one of the ma- r Acute viral hepatitis may be caused by the hepa- jor organs in glucose homeostasis under the control totrophic viruses (A, B and E) or other viruses such as of pancreatic insulin. Excess glucose following a meal Epstein–Barr virus, cytomegalovirus and yellow fever is converted to glycogen and stored within the liver. The liver is also involved in the breakdown of amino acids producing ammonia, which is converted Pathophysiology to urea and excreted by the kidneys. Cellular damage results in impairment of normal liver r Fat: The liver is involved in synthesis of lipoproteins function: bilirubin is not excreted properly resulting in (lipid protein complexes), triglycerides and choles- jaundice and conjugated bilirubin in the urine, which terol. Swelling of the liver results in stretching of the liver capsule which may result in pain. Patterns of liver disease Clinical features The features of acute liver damage are malaise, jaundice, Acute hepatitis anorexia, nausea, right upper quadrant pain and in se- Definition vere cases, evidence of liver failure. However,itissometimesdiagnosed may be an enlarged, tender liver, pale stools and dark earlier than this. Stigmata of chronic liver disease should be looked for to exclude acute on chronic liver disease. Aetiology The main causes of chronic hepatitis: Microscopy r Viral hepatitis: Hepatitis B virus (+/− hepatitis D), Acute viral hepatitis has a histological appearance which hepatitis C virus. Cell r Toxic:Alcohol-inducedhepatitis(rare),drug-induced death is by apoptosis and results in the formation of hepatitis (methyldopa, isoniazid, ketoconazole, anti- Councilman bodies. Complications Clinical features Fulminant liver failure, chronic hepatitis, and cirrhosis. Patients may present with non-specific symptoms (malaise, anorexia and weight loss) or with the compli- Investigations r cations of cirrhosis such as portal hypertension (bleed- Serum bilirubin and transaminases (aspartate ing oesophageal varices, ascites, encephalopathy). Asymp- Ultrasound may be needed to exclude obstructive tomatic patients with chronic viral hepatitis may be de- jaundice, if applicable. This includes careful fluid balance, which is likely to progress rapidly to cirrhosis with adequate nutrition and anti-emetics. Where possible re- chronic inflammatory cells infiltrating the portal moval of the causative agent, e. Patients require se- to central veins or central veins to each other (bridging rial liver function tests (including clotting) to follow the necrosis). Chapter 5: Disorders of the liver 195 Inflammation of the portal tracts with spotty inflam- disease, galactosaemia, cystic fibrosis, Wilson’s disease mation in the parenchyma of the lobules, but there is and drugs. Pathophysiology Complications All the liver functions are impaired (bilirubin meta- Cirrhosis is the most common complication. There is bolism, bile salt synthesis, specialised protein synthesis, increased risk of hepatocellular carcinoma in patients detoxification of hormones, drugs and toxins). Femini- Investigations sation in males and amenorrhea in females are common Chronic hepatitis is diagnosed by a combination of per- in alcoholic liver disease and haemochromatosis due to sistently abnormal liver function tests and the findings alterations in the hypothalamic–pituitary–gonadal axis. Other investigations are aimed at diag- Reduced immune competence and increased suscepti- nosing the underlying cause and providing a prediction bility to infection also occur. Patients may present with complications such as bleed- ingfromoesophagealvaricesorencephalopathy.

Records of the specifics of therapy with unsealed radionuclides should be maintained at the hospital and given to the patient along with written precautionary instructions buy fildena online now. In the case of death of a patient who has had radiotherapy with unsealed radionuclides in the last few months discount fildena 100 mg mastercard, special precautions may be required buy discount fildena online. Primum non nocere buy fildena 150 mg mastercard, the old Latin motto meaning ‘first, do no harm’ should be prevalent in the medical uses of radiation. Deriving from the maxim, one of the principal precepts of radio-diagnostic and radio-therapeutic practitioners should be non-maleficence or mischief, namely that given a medical problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good. It reminds the practitioner that other diagnostic or therapeutic procedures may be available and that they must be taken into consideration when debating the use of any procedure that carries an obvious risk of harm but a less certain chance of benefit. Prevention of accidents to patients undergoing radiation therapy Many accidents and mis-administrations have occurred involving patients undergoing treatment from external beam or solid brachytherapy sources. Therapy involving unsealed sources is also a cause of mishaps, but affects a different kind of professional and should be treated separately. An effective approach for preventing such situations is to study illustrative severe accidents, discuss the causes of these events and contributory factors, summarize the sometimes devastating consequences of these events, and provide recommendations on their prevention. Challenges include institutional arrangements, staff training, quality assurance programmes, adequate supervision, a clear definition of responsibilities and prompt reporting. It addresses a diverse audience of professionals directly involved in radiotherapy procedures, hospital administrators, and health and regulatory authorities. In many of the accidental exposures that have occurred, a single cause cannot be identified. Usually, there was a combination of factors contributing to the accident, for example, deficient staff training, lack of independent checks, lack of quality control procedures and absence of overall supervision. Such combinations often point to an overall deficiency in management, allowing patient treatment in the absence of a comprehensive quality assurance programme. The use of radiation therapy in the treatment of cancer patients has grown considerably and is likely to continue to increase. Major accidents are rare, but are likely to continue to happen unless awareness is increased. Explicit requirements on measures to prevent radiotherapy accidents are needed with respect to regulations, education and quality assurance. Preventing accidental exposures from new external beam radiation therapy technologies New external beam radiation therapy technologies are becoming increasingly used. These new technologies are meant to bring substantial improvement to radiation therapy. However, this is often achieved with a considerable increase in complexity, which, in turn, brings with it opportunities for new types of human error and problems with equipment. It is based on lessons learned from accidental exposures, which are an invaluable resource for revealing vulnerable aspects of the practice of radiotherapy, and for providing guidance for the prevention of future occurrences. Dissemination of information on errors or mistakes as soon as they become available is crucial in radiation therapy with new technologies. In addition, information on circumstances that almost resulted in serious consequences (near misses) is also important, as the same type of event may occur elsewhere. Sharing information about near misses is, thus, a complementary and important aspect of prevention. Disseminating the knowledge and lessons learned from accidental exposures is crucial in preventing recurrence. This is particularly important in radiation therapy; the only application of radiation in which very high radiation doses are deliberately given to patients to achieve cure or palliation of disease. Notwithstanding the above, disseminating lessons learned from serious incidents is necessary but not sufficient when dealing with new technologies. It is of the utmost importance to be proactive and continually strive to answer questions such as: ‘What else can go wrong? While the recommendations specifically apply to new external beam therapies, the general principles for prevention are applicable to the broad range of radiotherapy practices in which mistakes could result in serious consequences for the patient and practitioner. The recommendations provide elements for mobilizing for future effective work as outlined below. Independent verification should be performed of beam calibration in beam radiation therapy. Independent calculation should be performed of the treatment times and monitor units for external beam radiotherapy. Prospective safety assessments should be undertaken for preventing accidental exposures from new external beam radiation therapy technologies, including failure modes and effects analysis, probabilistic safety assessment, and risk matrix, in order to develop risk informed and cost effective quality assurance programmes. Moderated electronic networks and panels of experts supported by professional bodies should be established in order to expedite the sharing of knowledge in the early phase of introducing new external beam radiation therapy technologies. A collaborating team of specifically trained personnel following quality assurance procedures is necessary to prevent accidents. Maintenance is an indispensable component of quality assurance; external audits of procedures reinforce good and safe practice, and identify potential causes of accidents. Accidents and incidents should be reported and the lessons learned should be shared with other users to prevent similar mistakes. The available data on doses received by people approaching patients after implantation show that, in the vast majority of cases, the dose to comforters and carers remains well below 1 mSv/a. Moreover, due to the low activity of an isolated seed and its low photon energy, no incident/accident linked to seed loss has ever been recorded. A review of available data shows that cremation can be allowed if 12 months have elapsed since 125 103 implantation with I (3 months for Pd). If the patient dies before this time has elapsed, specific measures must be undertaken. However, although the therapy related modifications of the semen reduce fertility, patients must be aware of the possibility of fathering children after such a permanent implantation, with a limited risk of genetic effects for the child. Patients with permanent implants must be aware of the possibility of triggering certain types of security radiation monitor. Considering the available experience after brachytherapy and external irradiation of prostate cancer, the risk of radio-induced secondary tumours appears to be extremely low, but further investigation might be helpful. Only the (rare) case where the patient’s partner is pregnant at the time of implantation may need specific precautions. Specific recommendations should be given to patients to allow them to deal adequately with this event. As far as cremation of bodies is concerned, consideration should be given to the activity that remains in the patient’s ashes and the airborne dose, potentially inhaled by crematorium staff or members of the public. Specific recommendations have to be given to the patient to warn the surgeon in case of subsequent pelvic or abdominal surgery. The wallet card including the main information about the implant (see above) may prove to be helpful in such a case of triggering certain types of security radiation monitor. The risk of radio-induced secondary tumours following brachytherapy should be further investigated. Avoidance of radiation injuries from medical interventional procedures Interventional radiology (fluoroscopically guided) techniques are being used by an increasing number of clinicians not adequately trained in radiation safety or radiobiology. Many of these interventionists are not aware of the potential for injury from these procedures or the simple methods for decreasing their incidence. Many patients are not being counselled on the radiation risks, nor followed up when radiation doses from difficult procedures may lead to injury. Some patients are suffering radiation induced skin injuries and younger patients may face an increased risk of future cancer. Interventionists are having their practice limited or suffering injury, and are exposing their staff to high doses. In some interventional procedures, skin doses to patients approach those experienced in some cancer radiotherapy fractions. Injuries to physicians and staff performing interventional procedures have also been observed. Acute radiation doses (to patients) may cause erythema, cataract, permanent epilation and delayed skin necrosis. Protracted (occupational) exposures to the eye may cause opacities in the crystalline lens. The absorbed dose to the patient in the area of skin that receives the maximum dose is of priority concern. Each local clinical protocol should include, for each type of interventional procedure, a statement on the cumulative skin doses and skin sites associated with the various parts of the procedure.

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They give contextual commentary to the study buy fildena with paypal, but 100mg fildena fast delivery, because they are written by an expert who is giving an opinion order 25 mg fildena mastercard, the piece incor- porates that expert’s biases cheap fildena online mastercard. Editorials should be well referenced and they should be read with a skeptical eye and not be the only article that you use to form your opinion. Clinical review A clinical review article seeks to review all the important studies on a given sub- ject to date. It is written by an expert or someone with a special interest in the topic and is more up to date than a textbook. Clinical reviews are most useful for new learners updating their background information. Because a clinical review is written by a single author, it is subject to the writer’s biases in reporting the results of the referenced studies. However, if you are familiar with the background literature and can deter- mine the accuracy of the citations and subsequent recommendations, a review can help to put clinical problems into perspective. The overall strength of the review depends upon the strength (validity and impact) of each individual study. Meta-analysis or systematic review Meta-analysis or systematic review is a relatively new technique to provide a comprehensive and objective analysis of all clinical studies on a given topic. It attempts to combine many studies and is more objective in reviewing these stud- ies than a clinical review. The authors apply statistical techniques to quantita- tively combine the results of the selected studies. Components of a clinical research study Clinical studies should be reported upon in a standardized manner. Clinical epidemiological quality in molecular genetic research: the need for methodological standards. Components of reported clinical studies (1) Abstract (2) Introduction (3) Methods (4) Results (5) Discussion (6) Conclusion (7) References/bibliography Introduction, Methods, Results, and Discussion. First proposed by Day in 1989, it is now the standard for all clinical studies reported in the English-language literature. Its purpose is to give you an overview of the research and let you decide if you want to read the full article. These include the introduction, study design, population studied, interventions and comparisons, outcomes measured, primary or most important results, and conclusions. The abstract may not completely or accurately represent the actual findings of the article and often does not contain important information found only in the arti- cle. Therefore it should never be used as the sole source of information about the study. Introduction The introduction is a brief statement of the problem to be solved and the pur- pose of the research. It describes the importance of the study by either giving the reader a brief overview of previous research on the same or related topics or giv- ing the scientific justification for doing the study. Too often, the hypothesis is only implied, potentially leaving the study open to misinterpretation. Therefore, the null hypothesis should either be explicitly stated or obvious from the statement of the expected outcome of the research, which is also called the alternative hypothesis. It includes a detailed description of the research design, the population sample, the process of the research, and the statistical methods. There should be enough details to allow anyone reading the study to replicate the experiment. Careful reading of this section will suggest potential biases and threats to the validity of the study. The processes of sample selec- tion and/or assignment must be adequately described. This includes the eli- gibility requirements or inclusion criteria (who could be entered into the experiment) and exclusion criteria (who is not allowed to be in the study and why). The site of research such as a community outpatient clinic, specialty practice, hospital, or others may influence the types of patients enrolled in the study thus these settings should be stated in the methods section. Randomization refers to how the research subjects were allocated to different groups. The blinding information should include whether the treating professionals, observers, or participants were aware of the nature of the study and if the study is single-, double-, or triple-blinded. All of the important outcome measures should be examined and the process by which they are measured and the quality of these measures should all be explicitly described. In studies that depend on patient record review, the process by which that review was carried out should be explicitly described. Results The results section should summarize all the data pertinent to the purpose of the study. This part of the article is not a place for commentary or 30 Essential Evidence-Based Medicine opinions – “just the facts! The description of the measurements should include the measures of central ten- dency and dispersion (e. These values should be given so that readers may determine for themselves if the results are statistically and/or clin- ically significant. Discussion The discussion includes an interpretation of the data and a discussion of the clinical importance of the results. It should flow logically from the data shown and incorporate other research about the topic, explaining why this study did or did not corroborate the results of those studies. Unfortunately, this section is often used to spin the results of a study in a particular direction and will over- or under-emphasize certain results. The discussion section should include a discussion of the statis- tical and clinical significance of the results, the non-significant results, and the potential biases in the study. As the sample size increases, the power of the study will increase, and a smaller effect size will become statistically significant. Also, a study with enough subjects may find sta- tistical significance if even a tiny difference in outcomes of the groups is found. In these cases, the study result may make no clinical difference for your patient. What is important is a change in disease status that matters to the patient sitting in your office. A study result that is not statistically significant does not conclusively mean that no relationship or association exists. It is possible that the study may not have had adequate power to find those results to be statistically significant. On the whole, absence of evidence of an effect is not the same thing as evidence of absence of an effect. Conclusion The study results should be accurately reflected in the conclusion section, a one-paragraph summary of the final outcome. The reader should be aware that pitfalls in the inter- pretations of study conclusions include the use of biased language and incorrect interpretation of results not supported by the data. Studies sponsored by drug companies or written by authors with other conflicts of interest may be more prone to these biases and should be regarded with caution. All sources of con- flict of interest should be listed either at the start or at the end of the article. Bibliography The references/bibliography section demonstrates how much work from other writers the author has acknowledged. This includes a comprehensive reference list including all important studies of the same or similar problem. You will be better at interpreting the completeness of the bibliography when you have immersed yourself in a specialty area for some time and are able to evaluate this author’s use of the literature. Be wary if there are multiple citations of works by just one or two authors, especially if by the author(s) of the current study. The New England Journal of Medicine is a great place for medical students to start. It publishes important and high quality studies and includes a lot of correlation with basic sciences.

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Extrahamusb succum arthimesie buy 25mg fildena overnight delivery, saluie buy fildena paypal, pulegii cheap fildena 150mg on-line, per- siccarie order fildena overnight delivery, et aliarum herbarum huiusmodi, et faciamusc crispellas et demusd ad comedendum, et collocemuse eas frequenterf in balneis,g et predicto modo ad restringendumh sanguinem subuenimus. Et si fluxerit sanguis per nares, de hoc em- plaustro ponimus superd frontem et timpora, [va] ex transuerso timporae et frontemf attingendo. Matrici uinum calidum ponimusi in quo butyrum bullierit, et diligenter fomentamus quousque matrix efficiturj mollis, et tunc suauiter reponimus;k post modum rupturaml interm anum et uuluam tribus locis uel quatuor suimus cum filo serico. Et rupturam sanamus cum puluere facto de simphito, id esto de consolida maiori et minori,p13 et cimino. Nevertheless, the juice itself has such a power that it is sufficient for expulsion. On Excessive Flow of Blood After Birth [] There are other women who after birth have an immoderate flow of blood, to whom we give aid thus. Let us extract the juice of mugwort, sage, pennyroyal, willow-weed, and other herbs of this kind, and let us make little wafers and we give them to eat. And let us place them frequently in baths, and in the above-mentioned manner we aid them in order to restrain the blood. And if the blood flows through the nose, we place some of this plaster on the forehead and the temples, stretching sideways across the temples and the forehead. On the Dangerous Things Happening to Women Giving Birth [] There are some women for whom things go wrong in giving birth, and this is because of the failure of those assisting them: that is to say, this is kept hidden by the women. We put on the womb warm wine in which butter has been boiled, and diligently we foment it until the womb has been rendered soft, and then we gently replace it. Afterward we sew the rupture between the anus and the vagina in three or four places with a silk thread. And we heal the rupture with a powder made of comfrey, that is, of bruisewort, and daisy12 and cumin. The powder ought to be sprinkled [on the wound], and the woman should be placed in bed so that her feet are higher [than the rest of her body], lecto] om. Decet etiam abstinere ab omnibus quew tussim faciunt etx indigestibilibus, et maxime hoc faciendum est. Et si picem non habeamus, accipimuse pannum et iniungimus oleo [ra] calido puleginof uel muscelino, et inprimimus et illi- nimus uelg inponimush uulue, et ligamus quousque matrix recesseriti perseet calefacta fuerit. Vnde contingit quod Trotulab15 uocata fuitc quasi magistra operis16 cum quedam puella debuit incidid proptere huiusmodi uen- tositatem quasi ex ruptura laborasset, et admirata fuit quamplurimum. Fecit ergo eam uenire in domum suam ut in secretof cognosceret causam egritudi- nis, quag cognita quod non esset dolor ex ruptura uel inflatione matricis17 sed ex uentositate comparuit,h18 fecit itaque ei fierii balneum in quo cocte fuerunt maluaj et peritaria et eam intromisit, et eas partes frequenter et satis plane trac- tauit mollificando, et diu [rb] fecit eam in balneo morari, et post eius exitum, fecit ei emplaustrumk de succo rapistri et farina ordei, et totum talel ad ipsamm ¶a. On Treatments for Women  and there let her do all her business for eight or nine days. And as much as nec- essary let her eat; there let her relieve herself and do all customary things. It is necessary that she abstain from baths until she seems to be able to tolerate them. Also, it is fitting that she abstain from all things that cause coughing and from all things that are hard to digest, and this especially ought to be done. Let a cloth be prepared in the shape of an oblong ball and place it in the anus, so that in each effort of push- ing out the child, it is to be pressed into the anus firmly so that there not be [another] solution of continuity of this kind. On the Entry of Wind into the Womb [] There are some women who take in wind through the vagina, which, having been taken into the right or left part of the womb, generates so much windiness that they seem to be suffering from a rupture or intestinal problem. Therefore, she made her come to her own house so that in secret she might de- termine the cause of the disease. Whereupon, she recognized that the pain was not from rupture or inflation of the womb but from windiness. And so she saw to it that there be made for her a bath in which marsh mallow and pellitory- of-the-wall were cooked, and she put her into it. And she massaged her limbs frequently and smoothly, softening them, and for a long time she made her re- main in the bath. And after her exit, she made for her a plaster of the juice of wild radish and barley flour, and she applied to her the whole thing somewhat  De Curis Mulierum uentositatem consumendam aliquantulum calidum apposuit,n et iterum in bal- neo predicto insistere fecit, et sic curata remansit. Primo fomentemus patientem cum decoctione uini, in quo bullierit absinthium, et cum hac decoctioneb fomentemusc anum, et bened liniamus per totum cum incausto ad restringendum. Post factum cinerem de salice et radice eius et arista alicuius piscis salsi, superaspergimuse et reponamus anum cum panno lineo. Cum adhuc est tepidum, linum uelg lanam uel bombacem in eo intinge et ano inpone;h idi mitigat dolorem et inflationem anij aufert. Post pistamus cum sagiminee calido uel butyro sine sale uel oleo, et super ignem apponimus, et calidum super folium caulisf et super pannum lineumg positum, membrumh uirile circumdamus. Deinde prepucio euerso, cum aqua calida lauamus collum prepucii ulcerosum uel uulnerosum et puluerem de pice greca et cariej lignorum uel uermium et rosa et radice tapsi barbati et mirtillisk superasperge. Et si mirtil- lisl care[vb]as, ista quatuor sufficiant, et sic fiat bis uel term singulisn diebus donec sanetur. And again she made her sit in the above-mentioned bath, and thus she remained cured. On Exit of the Anus [] Protrusion of the anus is an affliction common to men as well as women, and it causes the blood to flow. First, we should foment the patient with a de- coction of wine in which wormwood has been boiled, and with this decoction we should foment the anus, and we smear it well all over with ink17 in order to constrict it. After having made ashes from willow and its root and the spine of any sort of salty fish, we sprinkle them [over the anus] and replace the anus with a linen cloth. While it is still lukewarm, dip linen or wool or cotton in it and place it in the anus; this diminishes the pain and takes away the swelling of the anus. On Swelling of the Penis []19 There are some men who suffer swelling of the virile member, having there and under the prepuce many holes, and they suffer lesions. We boil marsh mallow in water and, having boiled it, we squeeze it out so that no water remains. Afterward we grind it up with warm suet or butter without salt,or with oil, and we place it on the fire. Having placed it warm on cabbage leaves and on a linen cloth, we wrap it around the virile member. Then,with the prepuce turned out, we wash the ulcerous or wounded neck of the prepuce with warm water, and sprinkle on it powder of Greek pitch and dry rot of wood or of worms and rose and root of mullein and bilberry. Nas- turcium aquaticum coctum superinponimus pectini,c et in decoctione ipsius locemus patientem. Femine uero eadem passione laborant, quibusd facimus fu- migium de mentastro, nepita et pulegio. Tam mulieribus quam uiris stupham faciamus, et eos in aqua collocemuse in qua bullierint iuniperus, nepita, poli- caria et mentastrum, folia lauri, pulegium, absinthium, arthimesia, et in balneo simplicem damus benedictam. Et sic liberatur patiens etf si lapidemg habuerith dum modoi non sitj confirmatus, quia patientes per urinam purgantk quasil harenulas eiciendo. Accipe maluam, cretanum,c cauliculum agres- tem,d saxifragam, peritariam, et senationes,e id est, nasturcium aquaticum, ameos, urtice semen,f23 decoque ista in liquore cuius tercia pars sit uinum, et tercia oleum, et quartag24 aqua marina uel aqua salsa; cum hac decoctione fo- mentemus bene, maxime circa partes illas herbas ducendo. Hac cura liberauit quendamh25 habentem lapidemi in uesica, quemj post longam fomentationem ¶a. We place cooked watercress on the pubic area, and we put the patient in a decoction of the same [herb]. Women, indeed, labor from this same afflic- tion, for whom we make a fumigation of horsemint, catmint, and pennyroyal. For both men and women we should make a steambath, and place them in water in which juniper, catmint, fleabane and horsemint, laurel leaves, penny- royal, wormwood, [and] mugwort have been boiled, and in the bath we give [to them] uncompounded hemlock. On the Stone [] Likewise for the stone we cook saxifrage in water, which we give in a drink to those suffering from the stone. It should be noted that if they do not urinate, a sign is given to us that the stone has solidified. Take marsh mallow, rock samphire, wild cabbage, saxifrage, pellitory-of-the-wall, and senationes, that is, watercress, cowbane, [and] nettle seed. Cook these in a liquor of which a third part is wine, a third oil, and a fourth seawater or saltwater; with this decoction we should foment well, drawing those herbs especially around the parts. With this treatment he [Master Ferrarius] freed a certain man23 having a stone in the bladder, which after a long fomentation he had extracted by sucking through an opening made around the perineum, and he had the penis i. Cum enim eisb menstrua negentur, loco menstruorum propter earum frigiditatem saniem emittunt, ac si ab epate fluxus calidus descenderet. Et notandum quod quedam mulieres calide steriles facte sunt nec laborant huiusmodi fluxu, sed sicce tamquam uiri permanent. Accipe pulegium puluerizatum et in saccello ponatur qui in tantuma longus et latus fiat, ut utraque pudibundab ligari possint, quemc patiens ferred debet super uuluam ad fluxuume prohibitionem, et priusquamf ligaturg debeth ad ignem calefieri, ut confortenturi tam anus quam uulua.