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© Nederlands Tijdschrift Voor Geneeskunde 2 Phillips 2nd LH, Torner JC, Anderson MS, Cox GM. The epi- 11 Newsom-Davis J. Therapy in myasthenia gravis and Lambert-Eaton demiology of myasthenia gravis in central and western Virginia. myasthenic syndrome. Semin Neurol 2003;23:191-8. Neurology 1992;42:1888-93. 12 Lewis RA, Selwa JF, Lisak RP. Myasthenia gravis: immunological 3 Batocchi AP, Evoli A, Palmisani MT, Lo Monaco M, Bartoccioni M, mechanisms and immunotherapy. Ann Neurol 1995;37 Suppl 1: Tonali P. Early-onset myasthenia gravis: clinical characteristics and S51-62. response to therapy. Eur J Pediatr 1990;150:66-8. 13 Drachman DB. Myasthenia gravis. N Engl J Med 1994;330:1797-810. 4 Adams C, Theodorescu D, Murphy EG, Shandling B. Thymectomy 14 Badurska B, Ryniewicz B, Strugalska H. Immunosuppressive treat- in juvenile myasthenia gravis. J Child Neurol 1990;5:215-8. ment for juvenile myasthenia gravis. Eur J Pediatr 1992;151:215-7. 5 Sanders DB, Howard jr JF. Disorders of neuromuscular transmis- 15 Lindner A, Schalke B, Toyka KV. Outcome in juvenile-onset sion. In: Bradley WG, Daroff RB, Fenichel GM, Marsden CD, myasthenia gravis: a retrospective study with long-term follow-up of editors. Neurology in clinical practice. Ch 82. 3rd ed. Boston: 79 patients. J Neurol 1997;244:515-20. Butterworth-Heinemann; 2000. p. 2167-85. 16 Rodriguez M, Gomez MR, Howard jr FM, Taylor WF. Myasthenia 6 Anlar B, Ozdirim E, Renda Y, Yalaz K, Aysun S, Topcu M, et al. gravis in children: long-term follow-up. Ann Neurol 1983;13:504-10. Myasthenia gravis in childhood. Acta Paediatr 1996;85:838-42. 17 Brearley S, Gentle TA, Baynham MI, Roberts KD, Abrams LD, 7 Hijdra A, Koudstaal PJ, Roos RAC, redacteuren. Neurologie. 3e dr. Thompson RA. Immunodeficiency following neonatal thymectomy Maarssen: Elsevier Gezondheidszorg; 2003. in man. Clin Exp Immunol 1987;70:322-7. 8 Andrews PI, Massey JM, Sanders DB. Acetylcholine receptor anti- 18 Andrews PI, Massey JM, Howard jr JF, Sanders DB. Race, sex, and bodies in juvenile myasthenia gravis. Neurology 1993;43:977-82. puberty influence onset, severity, and outcome in juvenile myasthe- 9 Herrmann DN, Carney PR, Wald JJ. Juvenile myasthenia gravis: nia gravis. Neurology 1994;44:1208-14. treatment with immune globulin and thymectomy. Pediatr Neurol 19 Anlar B. Juvenile myasthenia: diagnosis and treatment. Paediatr 1998;18:63-6. Drugs 2000;2:161-9. 10 Andrews PI. A treatment algorithm for autoimmune myasthenia gravis in childhood. Ann N Y Acad Sci 1998;841:789-802. Aanvaard op 13 november 2003 Geschiedenis der geneeskunde ‘De dreuning der daverende hersenen’; behandeling van traumatisch schedel-hersenletsel in Nederland in de 17e eeuw: 7 ziektegeschiedenissen uit Observationes medicae van Nicolaes Tulp e.j.o.kompanje en a.i.r.maas Nicolaes Tulp (figuur 1) is nationaal en internationaal vooral bekend van De anatomische les van dr. Nicolaes samenvatting Tulp, door Rembrandt in 1632 geschilderd (onlangs is In Nederland verschenen in de 17e eeuw diverse bundels met dat schilderij nog in het Tijdschrift afgebeeld (2003: medische casuïstiek, de meeste van de hand van chirurgijns. 2541)).1 Tulp werd op 9 oktober 1593 als Claes Door de veelal gedetailleerde beschrijvingen krijgt de lezer een Pieterszoon te Amsterdam geboren en werd in 1611 als goede indruk van het medisch handelen in die tijd. Een van de bekendste auteurs van een dergelijke bundel is de arts Nicolaes medisch student ingeschreven aan de Universiteit van Tulp (1593-1674). In de laatste druk van zijn Observationes me- Leiden. Hij promoveerde op 6 oktober 1614 tot medisch dicae (1739) worden 229 casussen beschreven, waaronder 7 met doctor op een dissertatie met de titel Disputatio inaugu- betrekking tot traumatisch schedel-hersenletsel. Deze casussen ralis de cholera humida en vestigde zich als doctor geven een duidelijk beeld van de praktische behandeling van medicinae in Amsterdam, welke praktijk hij 40 jaar dit letsel in het Amsterdam van de 17e eeuw. De casussen zou uitoefenen. In 1654 werd Tulp burgemeester van betreffen schedel-hersenletsel als gevolg van vallende voor- Amsterdam (in 1656, 1666 en 1671 volgden respectieve- werpen, een val door dronkenschap, een schotwond en een val lijk het 2e, 3e en 4e burgemeesterschap). Tulp overleed op een brug door gladheid. De behandeling van traumatisch op 12 september 1674 te ’s-Gravenhage en ligt begraven schedel-hersenletsel was in de tijd van Tulp opvallend invasief, gezien het uitlepelen van gecontusioneerd hersenweefsel, het in de Nieuwe Kerk te Amsterdam. Tulp heeft twee boe- ontlasten van impressiefracturen en het frequente trepaneren, ken geschreven: Pharmacopoea Amstelredamensis (1636) waardoor epidurale en acute subdurale hematomen werden en Observationes medicae (1e druk 1641, laatste (6e) ontlast en waarbij in sommige gevallen de bloedende vaten op druk 1739).23Het eerste werk was gericht op een ge- de dura werden gecoaguleerd. Uit de omschrijvingen blijkt dat structureerder gebruik van geneesmiddelen door de Tulp zich in belangrijke mate beriep op de medische inzichten met betrekking tot de bloedbeweging van Galenus (129-199 n.Chr.). Erasmus Medisch Centrum, afd. Neurochirurgie, Postbus 2040, 3000 CA Rotterdam. Hr.dr.E.J.O.Kompanje, klinisch ethicus; hr.dr.A.I.R.Maas, neurochi- Amsterdamse apothekers. Het tweede werk is een weer- rurg. Correspondentieadres: hr.dr.E.J.O.Kompanje gave van 25 jaar medische praktijkvoering in Amster- ([email protected]). dam (figuur 2). Het is een bundel casuïstiek in 4 delen, Ned Tijdschr Geneeskd 2004 3 april;148(14) 677 van de zoon van een zekere Pieter de Wit beschreven. Deze onfortuinlijke knaap kreeg een ‘zwaar venster, omhoog uit zijn hengsel geschoten’ op ‘de linkerzijde van het bekkeneel niet ver van de keper of winkelnaad’ [sutura lambdoidea]. Tulp omschrijft hoe de stukken en brokken van dit venster tussen de schedel en de dura mater geraakt waren en de hersenvliezen ook door- boord hadden, waardoor de onderliggende hersenen verwond waren. Een ‘wondheler’ [een chirurgijn] ver- wijderde dagelijks zoveel van het ‘verslenderd murg’ [gekneusd merg; hiermee bedoelt Tulp zeer waarschijn- lijk gecontusioneerd hersenweefsel] als er in een ‘halve okkernootdop’ ging. Op de 3e dag na het ongeval werden niet minder dan ‘twee volle lepels’ verwijderd zonder ‘enige ontroering van het verstand of de minste andere toeval’. Dezelfde dag ontwikkelden zich bij de patiënt wat wij nu zouden omschrijven als een contra- laterale hemiparese en een motorische afasie of coma. Kort hierna overleed de jonge man plotseling. Tulp geeft zich er rekenschap van dat deze hemi- parese contralateraal optreedt (‘een beroerdheid aan de rechte zijde, hoewel de slag op de linker was gevallen’). Hij schrijft dat dit verschijnsel gelijk na het trauma kan ontstaan of enige dagen hierna. Als het gelijk na het trauma ontstaat, ‘wordt de vochtigheid van de kracht van dit dreunend en daverend geweld voortgedreven naar de allerverste plaatsen: óf tot de holligheden van ’t brein [waarschijnlijk bedoelde hij hiermee verplaatsing figuur 1. Dr. Nicolaes Tulp, geschilderd in 1633 door van de hersenventrikels], óf ook wel in de uitgegraven Nicolaes Eliaszn Pickenoy (collectie Six, Amsterdam). sleuf van de ruggepit’ [tot in het wervelkanaal]. Aanne- melijk is dat Tulp hier beschrijft wat wij nu het acute waarin een aantal bijzondere gevallen is beschreven; zo posttraumatische hersenoedeem met verplaatsing van vindt men in dit boek het eerste gebruik van de term de ventrikels zouden noemen. ‘spina bifida’ en de eerste uitvoerige beschrijving van de Vervolgens omschrijft Tulp de situatie waarin een pa- ileocoecale klep. De 1e druk had 164 hoofdstukken, tiënt met een ernstig schedel-hersenletsel primair goed de 6e 229. Zeven ziektegeschiedenissen in het boek reageert (zoals in de beschreven casus van de zoon van van Tulp handelen over traumatische schedel-hersenlet- Pieter de Wit), maar secundair hard achteruitgaat. Deze sels. In dit artikel geven wij een analyse van die casus- secundaire verslechtering wordt door Tulp verklaard sen. als het gevolg van infectie (‘allengsjes en van lieverlede meer en meer ontstekend met hitte, óf uit de verrotting, materiaal en methode óf van de koorts’), zodanig dat de ‘verwekte brand ten Voor dit artikel is gebruikgemaakt van de laatste (6e) langen leste ook geperst en gedrongen wordt naar de druk van Observationes medicae, die in 1739 – dus lang overkant’. Gezien het gebrek aan hygiëne tijdens het na de dood van Tulp – is uitgegeven.3 Deze druk staat als wondtoilet (waarbij de chirurgijn gecontusioneerd her- beste van de 6 Latijnse drukken bekend.4 De nummering senweefsel uitlepelde) is het aannemelijk dat de patiënt van de boekdelen en capita in dit artikel is naar deze een meningitis en cerebritis kreeg. De acute contra- uitgave. Voor de Nederlandse tekst van het boek is de laterale hemiparese en het coma of de afasie die na het transcriptie gebruikt die Apeldoorn en Beijer hebben ruime wondtoilet op de 3e dag ontstonden, zouden wij gemaakt van het originele, niet eerder gepubliceerde, heden ten dage verklaren als gevolg van de (te) uitvoe- Nederlandstalige manuscript van Tulp.5 De exacte da- rige verwijdering van weefsel uit de temporaalkwab of tum van dit manuscript is onbekend, maar uit data en ge- van een hierdoor ontstane intracerebrale bloeding. beurtenissen die in de casussen vermeld zijn, blijkt dat Casus 2 (libri primi caput II: occulta capitis rima). In het in ieder geval na 1655 geschreven moet zijn – dus de Nederlandse vertaling heeft Tulp dit hoofdstuk de later dan de eerste Latijnse versie. titel ‘Een verholen panscheur’ [een verborgen scheur in het schedeldak] gegeven. In deze casus wordt de ziekte- resultaten: casuïstiek uit observationes geschiedenis van Jacob Bex beschreven. Deze man werd medicae met een ‘roer’ [een geweer] in het achterhoofd gescho- Casus 1 (libri primi caput I: calvaria fracta). In zijn Ne- ten, waarna hij gelijk neerviel; vervolgens kreeg hij ‘een derlandse vertaling gaf Tulp dit hoofdstuk de titel ‘Een koorts [.
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