SECT. L.—ON JAUNDICE.
Jaundice is a diffusion of bile over the whole body, sometimes of black, as we stated when treating of diseases of the spleen, and sometimes of yellow. There are many varieties of this complaint, the causes and diagnosis of which are as follows: If jaundice occurring suddenly in a febrile complaint diminish the fever, it is critical, being occasioned by a metastasis of the matter from the deep-seated parts, and, therefore, stands in no need of medicines, but is soon removed by baths and friction. But if it is attended with fever and bilious evacuations from the bowels, and if there be a sense of weight in the right hypochondrium, a hot inflammation of the liver is indicated, by which the blood, being rendered bilious, is conveyed over the whole body. When there is heat in the part without a sense of weight, the affection is occasioned by a hot intemperament alone of the liver. If it is without fever, and the alvine discharges are white, an affection of the gall-bladder, or of its ducts, is indicated. When there is a sense of heaviness in the right hypochondrium, it indicates that the ducts are obstructed; but when without heaviness, weakness of some of its powers is indicated, either of the attractive, by which it attracts the bile from the liver, or of the expulsive, by which it propels the bile to the intestines. For when the blood is not purged of bile, it is diffused over the whole body (as we stated respecting the black jaundice); in which case the urine is voided very much mixed with bile. But jaundice is also occasioned by a hot intemperament of the solid parts, which convert into bile whatever is brought to them in place of food, in like manner as in anasarcous complaints a conversion to a pituitous fluid takes place. This variety of jaundice is recognized by its not occurring at once but by degrees, none of the afore-mentioned symptoms being present. Moreover jaundice is occasioned also by drinking certain deleterious medicines, and by the external application of poison from some venomous animal. The cure of a hot intemperament of the liver, and of inflammation of it, and of weakness of its powers, we have treated of under the head of the affections of it; and what we said there is to be applied here without alteration, that we may not be obliged to repeat the same thing. When both the ducts of the gall-bladder are obstructed, or either of them only, we must let blood from the right arm. But some, both in this case and in jaundice from inflammation of the liver, open the vessel near the middle finger of the right hand. And we must use anti-inflammatory cataplasms, and purge with hiera. But persons affected with jaundice must take the propomata from a decoction of parsley, maiden-hair, or dock, or of wild thyme, reduced to a third part; or sprinkle wormwood on the potion. Two cyathi of the juice of radish, drunk with a cyathus of wine, is also of great use; also two or three cyathi of succory alone, and with wine. In cases of jaundice from inflammation of the liver, give a draught of mulse, or of a decoction of slender birthwort, or of St. John’s wort, or of maiden-hair, or of fuller’s herb, or of madder, in like manner; or a drachm of the shavings of hartshorn with wine, or the decoction of carrot boiled in wine to one third; or they may take a drachm of native sulphur in eggs. These things are of great use also in obstruction. But viij scruples of the seed of orache, with Chrysattic, or any other must, if drunk when in the bath, effect a proper evacuation. But the picra may be properly given in powder, or with oxymel, and the one called Theodoret; likewise the trochisk from bitter almonds. Give also of cinnamon what can be lifted with three fingers in a cyathus of mulse, or in mixed water; or of myrrh, the bulk of a bean, with twenty seeds of pepper, and the same quantity of cinnamon. Those affected with jaundice, owing to a warm intemperament of the solid parts, are to be treated with gentle friction, moderate exercise, unction and baths, with a moistening and moderately cooling diet, the juice of ptisan, intybus, endive, succory, fish, and light watery wine. The treatment of those who are affected with jaundice from drinking some deleterious substance, or from the bite of some venomous animal, will be laid down in the [Fifth Book]. When bile is lodged in the vessels of the face and eyes, inject elaterium to the size of a vetch, with a woman’s milk, into the nose while in the bath, and then direct the person to descend immediately into it, but not to immerse his head; and after the bath, having given him a recruiting diet, again inject the errhine in the sun. The juices of sow-bread, of horehound, and of gith act in like manner. But let him draw into his nostrils, while seated in the bath, some acrid vinegar, and compress his nostrils for a short time, and it will produce a wonderful discharge.
Commentary. See Hippocrates (de Locis in Homine, 40); Galen (de Med. sec. loc. ix); Aretæus (Morb. Chron. i, 15); Celsus (iii, 24); Cælius Aurelianus (Tard. Pass. iii, 5); Aëtius (x, 18); Oribasius (Cur. Loc. Affect. iv, 99); Actuarius (Meth. Med. i, 11); Nonnus (188); Pliny (H. N. xi, 37; xxvi, 76; xxviii, 64); Ruffus Ephesius (ii); Palladius (de Feb. 6); Alexander Aphrodisiensis (Probl. i, 90); Octavius Horatianus (ii, 14); Scribonius Largus (31); Marcellus (de Med. 22); Serapion (iv, 9); Avicenna (iii, 15, 1); Avenzoar (i, 14, 6); Haly Abbas (Theor. ix, 33; and Pract. vii, 41); Alsaharavius (Pract. xviii, 11); Rhases (Divis. i, 64; Contin. xvi.)
With regard to the etymology of the term icterus: in the first place, Aretæus derives it from the animal ictis, which the Scholiast on Nicander pronounces to be a wild ferret. On the identity of the mustela and ictis, see further Pliny (H. N. xxix, 16.) Schneider determines it to be the mustela furo. (Ad Aristot. H. A. vi, 30.) Isodorus would seem to agree with Aretæus, in his derivation of the term Orig. Suidas, however, derives the word from ἰκτῖνος, a species of kite, and Pliny from some unknown bird of the imaginary name of icterus (H. N. xxx, 11.) We have no hesitation in saying that we are disposed to follow the authority of Aretæus.
Hippocrates directs us to give at first fatty things, and to use the bath for three days; then to abstain from these things, and purge both the belly and the head, and give diuretics. But he forbids cholagogues, which, he says, only increase the disorder of the system. We have stated in the [Second Book, Sect. IV], his views regarding jaundice occurring in fever. His commentator Theophilus explains that jaundice arises from obstruction of the ductus choledochus. Hippocrates lays it down as a rule that in cases of jaundice it is a bad symptom when the liver is hard. (Aphor. vi, 42.)
Our author follows closely the views of Galen. He remarks that, when in fever the bile is suddenly determined to the skin, it proves critical, and is easily removed by baths of sweet water, and friction with a discutient or rarefying oil. When the disease proceeds from obstruction of the vessels of the liver, he directs the administration of hot and detergent things, such as gentian, birthwort, and centaury. When occasioned by inflammation of the liver, the remedies suitable to that disease will be proper. When inflammation and obstruction are combined together, they are to be removed by relaxants and detergents. He gives from Andromachus and Archigenes a long list of compositions for jaundice; but we must be content with explaining his general principles without entering upon the detail of his practice. Galen, in another place, remarks that the poisons of certain reptiles occasion jaundice. (De Loc. Affect. vi, 8.) This fact is confirmed by modern observation. See Van Swieten (Comment. 916); Dr. Simson (paper on Jaundice, vol. i of the Medical Essays and Observations); and Rogerius (i, 47.) By the way, the ancients maintained that the primary action of certain poisons is exerted upon the liver. (See [Book Fifth, XLII].)
Aretæus insists that jaundice is produced not only by disease of the liver, as generally supposed, but likewise by affections of the spleen, stomach, kidneys, and colon. He further states that jaundice is sometimes engendered by the condition of the general system. He appears to allude to non-elimination of the bile. When the biliary ducts are obstructed, the bile regurgitates from the gall-bladder, and mixes with the blood in the liver, whence it is carried all over the body. In this case the alvine discharges are white, owing to their not being mixed with bile. When the spleen is the seat of the disease, the skin is of a dark yellow colour. He maintains that jaundice likewise arises from affections of the stomach and also of the colon, as digestion is partly performed in the latter viscus. But we must not follow out his description any further, as it is too long for our limits.
Celsus having described the disease, directs us to cure it by abstinence for one day, and then by opening the bowels; if fever is present, the suitable remedies are to be applied, but otherwise scammony or bitters, such as wormwood, are to be given. Some, he says, cured the disease by attenuant food and diuretics, but Asclepiades rejected the latter, and gave salt water as a purgative. Celsus approves of a salt Greek wine, baths, and so forth. During the whole course of the complaint he directs the patient to use friction, and take exercise; and if it is winter to have recourse to the bath, but in summer to swim in the sea. He approves of all kinds of exhilarating sports and amusements, whence the disease, he says, has got the name of regius morbus. Isidorus, in like manner, says of it: “Regium autem morbum inde estimant dictum quod vino bono et regalibus cibis citius curatur.”
Pliny directs us to cure jaundice by producing perspiration with the root of the cyclaminus or sow-bread.
Cælius Aurelianus says that jaundice is brought on by indigestion, or by cathartic medicines which have been taken and have not operated. Sometimes, he says, it is attended with enlargement or scirrhus of the liver, and sometimes, though rarely, the spleen and stomach are affected sympathetically. If the attack is violent, he does not disapprove of venesection; after which the sick are to be restored by soothing treatment, exercise, and food of easy digestion. The accessory symptoms, such as hardness of the liver, spleen, and stomach, are to be attended to; and the bile is to be carried off from the system by administering acrid clysters, and giving infusions of wormwood or wild succory. He also approves of sternutatories such as elaterium; of masticatories given while in the warm bath, and of determining to the skin by sudorifics and medicines which produce pruritus. He also recommends change of air, gestation, swimming in water, frequent vomiting excited by simple means, and acrid food such as capers, squills, &c. He approves likewise of giving a thin wine, and the decoction of hellebore when the disease is protracted; but disapproves of the indiscriminate use of cholagogues, cathartics, and diuretics, such as scammony, and colocynth, with wormwood, birthwort, St. John’s-wort, anise, &c. He thinks mental relaxation and serenity of great consequence to the cure.
Aëtius gives an accurate account of the disease, but his views are very similar to those of Aretæus. He maintains that there are other causes of jaundice besides obstruction of the duct of the gall-bladder. When the affection is not critical, he recommends bleeding and purging. He says that strong purging with colocynth, scammony, and other drastics is required to produce revulsion from the skin. He also approves of deobstruents and diuretics, which are to be given while the patient is in the hot bath. He speaks of sternutatories and sialogogues, like our author. He likewise strongly recommends emetics (iii, 119.)
The treatment recommended by Oribasius, Actuarius, Nonnus, and Octavius, is very little different from our authors. According to Actuarius, the colour of the urine which is characteristic of jaundice is the cærulean, that is to say, the colour of a ripe cherry, or of a dark-coloured wine. (De Urinis, vi, 7.) Theophilus in like manner states that the cærulean-coloured urine indicates jaundice. (De Urin. 6.)
Ruffus the Ephesian describes very correctly the situation and use of the gall-bladder, and remarks, that when its duct is obstructed jaundice is produced, in which case the stools are white and clayey. Aëtius’ recommendation of emetics is upon his authority.
Alexander Aphrodisiensis states that the constipation of the bowels in jaundice is occasioned by the want of the natural bile, which serves as a stimulant to the intestines. For the same reason, he adds, the stools are of a whitish colour.
According to Leo, jaundice arises either from obstruction or from the conversion of the blood into bile by the heat of the system. He also adds that jaundice is sometimes critical.
The poet Lucretius (iv, 333) and the philosopher Aristippus take it for granted that persons in jaundice see every object tinged with yellow. (Sextus Empiricus, adv. Math. vii, 195.)
According to Serapion, a redundance of yellow bile in the body is occasioned either by the system’s not being properly purged of it, or by an over-secretion of it, or by a combination of these causes. Obstruction, he says, may take place either in the liver itself or in the gall-bladder. Sometimes, he remarks, the liver having been inflamed, becomes as hard as a stone, or its ducts are obstructed so that the blood becomes mixed with bile, and in this state is carried over the whole body. He adds, that perhaps the whole gall-bladder is affected, or only one of its ducts, namely, either the superior one, by which it receives bile from the liver, or the inferior, by which the bile passes down to the intestines. In like manner he afterwards states, that sometimes the superior duct losing its tone and becoming obstructed, the bile becomes mixed with the blood; or, the inferior being obstructed, the bile regurgitates to the superior, and becomes intermixed with the blood. And sometimes, he says, the affection arises from the gall-bladder being over-distended in like manner as the urinary bladder sometimes is. When the disease is from obstruction he recommends attenuants, purgatives, emetics, and the other remedies directed by the Greeks. A similar account is given by Avicenna. Like Aëtius, he approves of venesection in certain cases, in opposition to Galen, who, as a general rule, forbids to let blood in jaundice. (De Purg. Virt.) Avicenna also describes the species of jaundice connected with disorder of the general system, described by Aretæus. Avenzoar says that the ducts are obstructed aut verruca aut pustula. The exact signification of these terms cannot easily be determined, but it seems probable that they refer to gall-stones. But the following passage of Haly Abbas puts it beyond a doubt that the ancients were acquainted with hepatic calculi or gall-stones: “Some,” he says, “relate that calculi are formed in the liver, cæcum, and colon.” (Theor. ix, 34.) Haly directs us, when jaundice is connected with inflammation, to bleed, and purge with myrobalans, hepatic aloes, &c. He also makes mention of emetics among his general remedies. When connected with obstruction, particularly of the gall-bladder, he recommends bleeding at the arm, a decoction of wormwood, hiera, scammony, and various remedies of a like nature. To remove the yellow colour of the eye he recommends the tepid bath, and the application to the eyes of the fumes of vinegar. For the cure of jaundice of the spleen, he prescribes the common remedies, and mentions one which he says he learnt from a woman, and found very effectual. It was a draught containing lentils, fennel, and the urine of a boy not come to puberty. Jaundice being a disease which often goes off without any remedies, has been, in all ages, a favourite with empirics. Alsaharavius treats of the disease in much the same terms; recommends bleeding when it is connected with an inflammatory cause, and attenuants, bitters, purgatives, and the hot bath according to circumstances. Rhases, who gives a very full account of jaundice, states that the disease generally arises from obstruction either in the liver or its ducts. He particularly recommends drastic purgatives, such as scammony, along with wormwood, fennel-seed, and the like. When inflammatory symptoms are present he approves of bleeding and the warm bath.