The Project Gutenberg eBook, Dissertatio medica inauguralis de ictero, by William MacOubrey This eBook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org. If you are not located in the United States, you'll have to check the laws of the country where you are located before using this ebook. Title: Dissertatio medica inauguralis de ictero Author: William MacOubrey Release Date: July 17, 2016 [eBook #52593] Language: Latin Character set encoding: ISO-646-US (US-ASCII) ***START OF THE PROJECT GUTENBERG EBOOK DISSERTATIO MEDICA INAUGURALIS DE ICTERO***
Transcribed from the 1825 edition by David Price, email ccx074@pglaf.org
Auctore Guilielmo Macoubrey.
Icterus, de quo scribere mihi proposui, morbus est ex antiquo tempore medicinæ notus. Celsus, medicus Romanorum præclarus, familiariter de eo disseruit, clareque eum delineavit. Pars corporis autem quam occupat scriptori ei patefacta non fuit; si ex silentio ejus fas sit judicare.
Seculorum experientia desideratum id nobis expsuit. Atque hodie certum est, ductus ad intestina p. 2bilem vehentes, et duodenum, sedes esse morbi.
Indicia morbi hæc sunt: cutis et oculorum flavedo, fæces argillaceæ spissitatis propriæ, sensus in stomacho satietatis gravis, dolor ex pressu et post cibum, sitis assidua, vomitus, spiritus difficultas, singultus frequens, membrorum resolutio, corporis totius languor maximeque intestinorum, et urina rubicundula, lintea colore luteo tingens. Hæc signa sunt quæ morbum in genere designant, nonnunquam autem nonnulla eorum desunt; morbusque noster, sicut alii, multis varietatibus obnoxius est.
Hæc variatio morborum est, quæ artem Hippocraticam, medicinæ tironi, tam difficilem reddit; quæ super causas abditas velum pandit, solo experientiæ oculo penetrandum; et quæ ei, qui scientia artis scripta exhausta, eam applicare aggreditur, studium ejus omne vanum esse, persuadet; sapientiamque colligendam esse, non tantum ex scriptis, sed etiam ex paginis latis Naturæ.
In Ictero difficultas hæc non multum tenet: cutis flava, defectusque in fæcibus bilis, satis illum denotant, et symptomata hæc semper adsunt. “Color autem eum morbum detegit, maxime p. 3oculorum, in quibus, quod album esse debet, fit luteum.”—Cels.
Divisio, quam in hac re tractanda sequi volo, hæc est. Primo, Morbi causas scrutari: Secundo, Effectus ejus: Tertio, Modos quibus amovendi sunt.
Sect. I.—Secundum opiniones hodie maxime receptas causæ proximæ icteri sunt, obstructio ductus hepatici, ductus cystici, aut ductus communis choledoci, per calculum biliarem; tumorem hepatis aliusve partis; vel per ductus ipsius constrictionem spasmodicam; et præterea bilem in duodeno collectam morbum inducere, alii dicunt.
Calculi præsentia causa frequentissima certe est, ideoque locum primum postulat. Sæpissime calculi in vesica biliari, sed non semper, formantur; in ductu hepatico interdum enim apparent. Morbus, ex obstructione ductus cystici oriens, multum differt ab eo, ductus hepatici, aut ductus communis choledoci obstructione, effecto. In illo flavedo multa, ac vomitus adsunt. In his duobus, multo minus apparent. In omnibus, intestinorum torpor fæcesque argillaceæ adsunt.
p. 4Flavedo effectus est bilis in constitutitonem absorptæ. Secretione omni hepatis per ductum hepaticum transeunte, sequitur, ut ductu eo clauso, haud multum bilis absorbi posset, eum hepar in re tali munus brevi tantum impleret. Vomitus qui fluxu in stomachum bilis factus est, aut in duodeno ejusdem irritatione, etiam afforet. Sed torpor intestinorum, et color fæcum proprius, inopia in intestinis bilis producti, necessarie occurrunt.
In ductu hepatico attamen calculus raro fit. Quod ibi bilis non longum permanet, et quod ei, illic, non ea nutura est ut depositum faceret. In vesica fellis frequentissimi sunt, unde in ductum cysticum progrediuntur. Bilis, per intervallum non breve, in vesica remanens spissa fit, ita ut facile depositum formet. Cum ab hac causa morbus exoriatur, vomitus frequenter incidit, et cutis color plane ostenditur flavus.
Fac igitur calculum in vesica formatum ductum claudere, quid accedit? Primo nec bilis in visicam intrare, nec ab eadem exire potest. Vas hec autem munus non desinit implere, et partes aquosas ex bile contenta absorbere perstat, quæ aptior sic concreta formare, morbumque proferre reddetur. p. 5Secundo hepate adhuc bilem secernente, quantitas in duodenum fusa major erit, ut nihil ab ea detractum est vesica. Sed bilis ea non satis potens sine actione vesicæ, intestina stimulare nequit, statque digestio. Fæces in intestina stagnant, et paulo post corpus totum languore ejus inficitur. Bilis hepatica in duodeno congreditur, unde in constitutionem absorpta, cutem oculosque color ejus luteo tam morbi characteristico tingit. Pars hujus in stomachum per pylorum transit, id viscus irritat, vomitumque causat, qui tam communiter occurrit.
Concretum per ductum hepaticum aut cysticum quandoque laborat; in ductu tamen communi choledoco hæret. Species hæc morbi similis foret ei in ductu hepatico orienti; at eam, distensionis inflammationisque dolor ductus, fere distinguit.
Causa secunda quam memoravi accumulatio est bilis in duodeno. Doctor Cullen de hac causa sic locutus est. “How far the latter cause can take place, or in what circumstances it does occur, I cannot clearly ascertain; and I apprehend, that jaundice is seldom produced in that manner.” Nunc opinioni cedens illius viri celeberrimi omne p. 6quod debet, clare mihi videtur quomodo evenire posset. Primo fieri posset fæcibus in intestinis confertis, quæ exitum bilis obstarent; et sic mentis demissæ homines videmus, per intestinorum stipationem factæ, vel forsitan eam facientis, morbo huic obnoxios. Ita ut, animi anxietas inter causas icteri posita est. Secundo, oriri posset ex bilis ipsius conditione mala, in qua, (ut evenit ductu cystico clauso) actionem intestinorum excitare nequit. Conditio talis, ab vesicæ aut hepatis ipsius morbo, aut etiam ab decompositione bilis, oriri posset.
Causa alia icteri, constrictio est spasmodica quorundam ductuum. Hæc causa haud certa est, et profecto raro fit. De statu animi pendere supposita est.
Antequam partem hanc rei dimittam, animos intendere forsitan nos oportet causæ per vulgus late creditæ, qui opinantur icterum exesis cum fastidio magno oriri, vel etiam ex iis cum fastidio visis. Dictumque fastidii magni in opinionem conditum est “dare icterum.”
Modus operandi hujus causæ visu haud facile est. Potestne contractio vel in se retractio totius corporis per fastidium excitata, sic alicui ductuum p. 7impertita sit, ut constrictionem ejus spasmodicam faceret? aut hepar an sic afficit, ut actionem ejus morbidam redderet, et bilem per id secretam imperfectam, nimisque debilem munus implere? Opinantur multi medicorum celeberrimorum, et inter eos Bichat, multitudinem sensuum animique affectuum hepati pertinere; et certe non sine causa sic putant.
Sect. II.—Causis jam expositis quæ morbum inducere saltem plerumque videntur, effectus ejus, ut initio mihi proposui, considerare progredior.
Icterus, hominibus qui existimant eum in flavedine cutis consistere tantum, momenti minimi videbitur morbus. Sed iis qui opinantur, eo negatum esse corpori principium sine quo vita non longum durare potest, notio accurata erit periculi quod ex eo manat. Si bilis obstructio perfecta fuerit, nisi adhibeantur alvum solvere actionemque corporis sustinere remedia, mors pede festina aderit. Tamen ab bilis mero defectu occurrit rarissime mors. Effectus fere orientes supra, ut symptomata per quæ morbus distinguitur, dicti sunt. Ideoque nunc de paucis magnis, ab eo quandoque, nascentibus, tantummodo dicam.
p. 8Ductuum inflammatio gravis, vel etiara vesicæ biliaris, eventus est quem medici maxime timere videntur. Eam ad multum posse, si concretum magnum sit vel asperum, planum est. Et omnia inflammationis sequentia adesse possent, etiam partis affectæ destructio. Doctor Thomas, in libro ejus de Medicinæ Praxi, casum consternantem dat vesicæ inflammationis quo per tumorem prope umbilicum calculi evaserunt, fistula inter eum vesicamque bilarem formata.
Febris satit vehemens in ictero nonnunquam incidit, et forsitan inflammatione ob præsentiam calculi orienti; forsitan a congestu in intestinis fæcum; vel etiam a bile in constitutione accumulata excitatur.
Cum longum extiterit morbus, tumores aquosi corporis, et nonnunquam ascites, eum sequuntur.
Sect. III.—Causis nunc scrutatis effectibusque tractatis morbi hujus, ad ultimam maximamque rei nostri portionem provehimur; modos per quos amovendi sunt.
Modis medendi semper ad causas morbum producentes, et ad symptomata comitantia respicientibus, p. 9sic eos considerabo. Et in eo, ordinem quam secutus sum in causis exponendis, pergam sequi; sed primo observationem hanc generalem præferam, ad species omnes æque referentem; medicus res duas in medendo ante oculos habere debet: Primo, morbum et sequelas ejus extirpare: Secundo, ne redeat curare.
Ictero orto ab calculo in ductibus aut vesica formato, curatio tentatur per modos duos, expulsionem calculi solutionemque ejus: primus autem gradus est intestinorum expurgatio, quæ ægrum levat effectu bilis in duodeno accumulatæ si fuerit id; eum certe levat alvi astrictione, actionemque corpori dat.
Ratione ea, purgantia calculum detrahere prodesse nonnulli putaverunt; at si iis effectus talis sit, præcipue in causa est, compressio in fæcibus demittendis facta; nonnihil in actionem quam inter operationem excitant pendet, et aliquid forsitan in absorptionem evacuatione productam; magna hæc tamen non posse.
Emetica, in expulsione calculorum a vesica aut ductibus, fidem maximam obtinuerunt. Id optatum p. 10vim eorem proferre, dubitari non potest. Ieteri exempla multa sunt, ab causa hac orti, emeticis sanata, modo prudenti administiatis.
Suspicata sunt agere, primo, per nauseam excitatam. Notum est experientia aliquorum principum qui artem medicinæ excoluerunt, inter nauseam absorptionem maximam esse. Sic calculum diminuere, eumque probabiliter laxare possent. Effectus alter nauseæ inflammationem allevare est. Ea tamen quæ pro eventu nostro potentissima est, relaxatio est quam causat nausea, quæ ductum dilatando calculi descensum facilitat.
Secundo, inter vomendum, per ductum urgeretur calculus, visceribus abdominalibus compressum, stomacho expellere quod habet, levatis. Hic certe modus est princeps in quo remedia hæc prosunt. Opus est cavere in usu eorum; nam si calculus in uno ductuum fixus magnus sit, vi vomitus idem rumpi posset: aut si id non inciderit, inflammatio vehemens sequeretur.
Sanguinis detractio adjuvat, præterea, concreti descensum, non solum inflammationem levando; sed etiam absorptionem augendo, ductumque relaxando.
p. 11Thermæ auxilium est excellens venæsectionis, et mire potens dolorem levare; maxime tamen fructum affert, cum morbus a spasmo ductus ortus sit.
Remedia hæc principia sunt, per quæ calculi descensus coactus sit, vel facilior fiat. Via altera per quam morbi speciei hujus curatio conatur, parum hodie tentatur. Non multum creditur (ut scientia nunc se habet), solventia ad punctum internum convehi posse, in mole sanguinis, tam pura et in quantitate tam magna quam potentiæ aliquid chymicæ exercerent. Olim antequam re mediorum vires tam austere investigatæ sunt, aut tam bene notæ; solventibus utebantur fere medici. Exercitatio in Gallia secuta præcipue per Dominum Durande tentare ea persuaderet, saltem cum certiora alia defuerint. Remedia quæ adhibet ille, Æther Sulphuricus nempe, et Oleum Terebinthinæ, calculum extra corpus certe solvunt, ut Doctor Darwin confirmavit: sed minime credibile est, id perfici posse in ductu cystico.
Quum tumores hepatis partiumve vicinarum, obstructionem ductus effecti sint, spes morbum amovendi fere abest: eamque rem in causa esse p. 12horrendum est, si affectio hæc ex morbis diu præsentibus orta fuerit, iisque, præcipue, viscera obstructa exhibentibus. In re tali tumorem hydrargyri usu discutere conandum est.
Si morbus ex constrictione ductus spasmodica ortus fuerit, quod tamen raro accidere putatur, tunc ad remedia spasmo solvendo propria, uti venæsectionem, balneum calidum, fomenta calida, confugiendum est. In hoc loco, ut mihi videtur, ponendus est casus a Doctore Darwin sanatus, qui sequitur. Vir annos circiter quadraginta quinque natus, per hebdomadas sex sub ictero, sed sine dolore, nausea, vomitu, aut febre laborarat, et seriem pene omnem remediorum in hoc morbo communium, emeticorum nempe, purgantium, mercurialium, medicamentorum amarorum, tonicorum et stimulantium, sine fructu percurrerat. Ratus igitur ia hoc ægro morbum ex ductus choledoci communis paralysi procedere, effectum electricitatis tentare decrevit; ideoque impetus electricos fortes per hepar ductumque impelli fecit. Primo die fæces luteæ dejectæ sunt; impetusque electrici per paucos dies repetiti, symptomata morbi omnia devicerunt. p. 13Hic casus, ut mihi apparet, ex quodam spasmo, vel obstructione ductus peculiari, ortus est; quomodo enim potuit paralysis exitum bilis prohibere? Ex ea historia tamen colligimus, electricitatem non semper negligendam esse.
Species nunc consideranda ea est ex bili in duodeno accumulata oriens. In hac purgantia præcipue prosunt, maximamque fiduciam merentur. Quacunque a causa orta fuerit, vel quibuslibet rebus comitantibus, hoc certe planum est; primum salutis gradum in bilem cumulatam removendo constare; etiamque patet, canalem intestinam viam esse per quam removenda est. Hac re facta, remanet corpus tonicorum usu roborare, cibo nutriente facilique concoctu, exercitatione modica, equitatione præcipue, denique usu aquarum chalybeatarum. Si bilis ipsius natura in causa sit, parum credo fieri potest, quiddam, tamen conandum est.
Intestinorum actio purgantibus promovenda est; diæcta nutriens et concoctu facilis usurpanda est; et omne denique corpori roborando, actionemque viscerum excitando, adhibere necesse est, uti tonica, exercitationem, et colloquium amœnum. p. 14Animus contentus in omni corporis morbo, sed præ aliis in Ictero, valetudini maxime conducit.
Adhuc hunc morbum uti abstractum totum, ex corpore eradicandum, consideravi. Sed per cursum ejus, nonnunquam necesse est medico attentionem ejus ad symptomata a morbo distincta, tametsi ex eodem orientia, adhibere. In parte priori hujus tractamimis notavi, horum præcipua esse inflammationem ductus, aut vesicæ fellis ex concretionibus ibi infixis, orientem. Inflammatio hic eodem modo tractanda est ac in aliis corporis partibus, nempe, sanguinis detractione generali, aut topica, prout res postulent, balneis calidis, fomentis calidis parti dolenti applicatis, purgantibus, medicamentis nauseantibus; vomitus autem certe præcavendus est, uti malum sæpe gravius redditurus.
Febris nonnunquam est etiam sequela; cum oriatur, purgantia atque diaphoretica adhibenda sunt. Si symptomata sint violentia, ægerque robustus et plethoricus, sanguinis detractio usui foret.
Anasarca et Ascites, raro, ut mihi videtur, in p. 15Ictero causam habent; sed si aliquando habeant, remedia earum propria usurpare licet.
Ex omnibus autem symptomatis in hoc morbo occurrentibus, difficultatem maximam affert vomitus. Si enim, quod haud raro accidit, ventriculus omnia ingesta rcjiciat; “hic labor hoc opus est.” Si bilis eo ex duodeno fluens in causa sit, vomitum paululum promovere licet, emetici lenis exhibitione; post cujus operationem, haustus salini, et etiam sedantia, si necesse, adhibenda sunt. Simil ac ventriculus his remediis in ditionem redigatur, purgantibus fortibus, et pro re nata repetitis opus sit, eoque modo duodeno dapleto, reditus hujus symptomatis difficilis præcaveatur.
Sequela icteri altera diarrhœa, quæ morbum sæpe moderans, aut etiam efferens, haud temere prohibenda est. Quum autem in modum redigere necesse sit, hoc caute atque lente nos oportet facere; sæpe enim ut ait poëta, “Incidit in Scyllam qui vult vitare Charybdim.”
Labore jam peracto quem mihi initio proposui; causis scrutatis, effectibusque icteri consideratis, p. 16modisque expositis, per quos illæ extirpatæ, et hi sanati sunt; forsitan me oportet, sine re altera, finire. At nonnullis videatur ut de modo, quo eam perfeci, dicerem. Alii generalem esse, alii non ei novitatem esse, ei objicant. Primum horum objectorum evitasse, opus molis non magnæ fuisset. Historiam morbi ab auctore primo qui eum attigit usque ad tempora nostra persequi; et folia, de viribus suppositis rerum haud raro inertium, quibus freta ignorantia nisa est morbum curare, oblinire potuissem. Sed in impressione sumptus inutilis factus fuisset, lectionisque professorem inutiliter tæduisset, cui fuisset examinatio. Objecto secundo sic responderem, novitatem verumque in re nota, secum pugnantia; et novas in arte res, non a tirone, sed medico in medicina sero, expectandas esse. Non mihi erat in animo alios docere; sed artis medicinæ principiorum scientiam, me ipsum obtinuisse, experimentum dare.
FINIS.
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