105

CHAP. VIII.

ON THE ABUSE OF PURGATIVE MEDICINES.

In a preceding chapter I have spoken of the excess or indiscriminate use of bleeding in affections of the brain. I allude here to another instance, in which the use of a most important class of remedies is converted into a frequent abuse, by wrong and indiscriminate employment;—without due regard to the natural powers of the body in health, or to the peculiar course of morbid actions in disease. If asked whether the use of purgative medicines, beneficial beyond all others under certain conditions, is not carried too far in modern English practice, I must affirm my belief that it is so; and each successive year of experience strengthens this conviction. It may be noticed as one of those instances of fashion in medicine, so largely sanctioned by reason and experience as to last beyond the ordinary term of mere novelties; yet so far carried into excess, that the same reason requires much abatement of the abuse. Two or three works of merited reputation on this subject; - the success of antiphlogistic treatment in many diseases which had formerly been dealt with otherwise; and especially the great benefit of purgatives, ascertained in certain cases where such treatment had before been deemed injurious, all these circumstances concurred, about the same time, to give new reputation to this mode of practice. It may be added, that the simplicity of the treatment favoured its adoption by medical practitioners; while it had further countenance from the pre

judices of the world, always prone to accredit a method from which there are obvious and speedy results, however doubtful the benefit thence derived.

We cannot wonder that fraudulent advantage should be taken by empirics of a feeling thus general, and so far sanctioned by the habits of more regular practice. The mischiefs which have thence arisen are, in fact, notoriously great. One form of purgative drugs succeeds another in noxious fashion; a fictitious need is created; and the functions of nature are injuriously supplanted, even under reputed health, by the compounds of quackery and fraud. This evil can be lessened only by a reasonable employment of these medicines among the profession at large: and hence a further motive for weighing well what is really their use, and what their abuse, in our present practice.

One of the greatest abuses undoubtedly is the system of giving daily purgatives, and insisting upon daily evacuation; making this the habitual management in health, and treatment in disease. Under both conditions, it is a notion fertile in mischief. Looking first to that of health;-it is certain that the natural constitution of different persons is very various as to this point, as well as the constitution of the same persons at different periods of life. To seek therefore by medical means for any thing like a common rule, is in most cases an absurd and injurious interference with the natural functions. The cases are common of individuals in perfect health who have action of the bowels only every second or third day. I have known cases much more remarkable from the length of interval; yet without the impairment of a single function of life; and where mischief was produced by any frequent or forced interference with this habitual state. The practice of habitual purgatives unhappily prevails most in the cases,

where default of natural action arises from torpor of the intestinal canal. Yet these cases, so frequent among the higher classes of society, ought especially to be exempt from the irritation of strong or frequent medicine. Dyspeptic symptoms, with increased torpor, are the more immediate effect; and disease frequently comes on as the sequel and consequence of a long continued habit.

The colon, perchance, cannot readily or quickly propel its contents, though the earlier stages of digestion are well and easily performed. To remedy this defect, it is goaded by the constant use of cathartics, which injuriously excite and fret the stomach and long tract of bowels, through which they have to pass before reaching this part. This habitual irritation of the mucous membrane, and of the intestinal glands, alters and depraves their secretions throughout the whole course of the alimentary canal, becoming thereby a further source of mischief and suffering to the patient. These disordered secretions are too often urged in proof of the need of further evacuation (an error sometimes arising from inexperience, sometimes from a much graver source); and thus the practice proceeds in a vicious circle of habit, from which the patient is rarely extricated without more or less of injury to his future health.

It is not enough considered, either by physicians or patients, that a certain distension of part of this canal by solid contents is even necessary to its healthy state. It is probable that this is more especially true as respects the colon and rectum. I cannot doubt, from observation, that these bowels, even if not actually assuming diseased state from constant irritation of the mucous membrane, are often much injured in their functions by the want of equable and sufficient distension, which the habit of purging implies. Distension by air, which

is the alternative, produces various irritation, and impedes the proper peristaltic motions.*

In effect of the causes of disorder cited above, the nutrition of the body generally suffers; the processes of digestion are imperfectly performed; the ingesta are hurried forward without the due amount of change and separation taking place; and there is usually decay of flesh and strength. The expressions of Celsus, quoted below, are common to all the ancient medical authorities, and founded on the observation of facts. +

The effect of sudden and violent diarrhoea in depressing the vital powers is well known. Syncope is a frequent consequence; - death, when there is already great exhaustion, an occasional one. I have seen instances where a strong purgative, given directly after a severe and protracted operation, or after a shock to the nervous system from accident, has produced very urgent danger by aggravating the tendency to collapse. In cases where there is the habit of constant irritation by purgative medicines, the tendency of result is the same, though the immediate effects are less rapid and obvious. The extent of highly sensitive surface, forming the canal of the bowels, gives great scope to this influence; and few consequences can be stated more certain than the gradual undermining of the vital powers by the abuse in question.

Disordered action of the heart, whether depending on disease, or on mere irritability of the organ, is often much aggravated by the habitual use of purgatives. Very fre

* Το υποχωρεον εστω σκληρον πλῆθος δε κατα τα εισιόντα. Prædic.

+ Purgationes, ut interdum necessariæ sunt, sic, ubi frequentes sunt, periculum afferunt. Assuescit enim non ali corpus; et ob hoc infirmum erit; cum omnibus morbis obnoxia maximè infirmitas erit.

quently I have known it produced by this cause in nervous or dyspeptic constitutions, where the relinquishment of the habit has been found the only effectual cure. Such effects are readily explained, not only from the flatulence and acrid secretions thereby produced in the stomach and bowels; but also from the unequal balance and sudden changes in the venous circulation of these viscera, which always attend purging, and which affect directly the regular transmission of blood to the right side of the heart; - and further, it may be, by an impression upon the nervous centres, producing that sudden sinking which I have already noticed as frequent under any inordinate action of the bowels. A discreet judgment is the more needful here, because there are other cases where disturbance of the heart is the effect of congestion about the liver and other chylopoietic viscera, requiring large evacuation for its relief. Firmness of practice, also, is essential in these instances, the persons who thus suffer being such as are least capable of interpreting their own cases, or persisting in any principle of treatment.

Every physician must be familiar with the frequent confession of patients, even of those most wedded to the habit, that they feel better on those days when there is no action of the bowels. Of such avowal we are bound to take advantage, unless there are circumstances especially to prevent us. It is difficult, in truth, to find a footing for relief in cases of this kind. The notion of instant remedy clings pertinaciously to such patients, and the mind becomes morbidly engaged to the habit. I have sometimes been successful in checking it, by expressly enjoining an action only on alternate days, as needful to health; thereby giving a new course to the sensations, and to the imaginations which attend them. In regarding the extent to which this abuse exists, I am well persuaded that the judicious physician may do almost as much