Purgatives - Their Proper And Improper Use
( Originally Published Early 1925 )
Intestinal stasis coming on gradually after the age of 60, says Hurst, can at first be controlled by diet but sooner or later proper purgatives are frequently required. It is also often necessary in intractable cases (to be dispensed with as soon as possible) and in early stages of milder cases where non-medical methods are used, to give an occasional aperient (mild cathartic), as defecation may at first be incomplete, even though it occurs at the proper hour.
Many individuals, particularly if they live sedentary lives and eat to excess, are in the habit of taking a purge once a week or at other intervals even if they are not obviously constipated. The undoubted benefit that results suggests that they are really suffering from cumulative constipation. Such people if put on a moderate, well selected diet and induced to take proper exercise with deep breathing would no longer need the weekly purge.
Many patients take an excessive quantity of drugs in order to pass one or more enormous, fluid stools. They need to be told that they are thus depriving the body of water, salt and nutrient material (and also setting up unnecessary irritation of the mucous membrane of the intestinal tract). A chlorotic patient (green sickness) was given cascara in addition to iron and arsenic for her anemia. Although but one stool a day was passed it was found by x-rays that bismuth taken at break-fast reached the rectum in six and a half hours instead of in forty-eight hours as had been her habit. Food passing thus rapidly through the intestines is not left long enough to be properly absorbed, so the dose was reduced.
A middle-aged lady suffering from abdominal discomfort in the region of the right pelvis was given barium sulphate to take with breakfast with an x-ray examination six hours later. Although she had been told she was suffering from constipation the barium was already found in the rectum. This was proved to be due to the fact that she had taken her ordinary dose of cascara the previous evening as a subsequent examination showed that the passage was normal in rate without any aperient.* Her symptoms were, in fact, the result of constant irritation of the intestines with aperients which were not required. It is not uncommon for patients to get in a state of mind about aperients and use them when they are unnecessary. When finally convinced they succeed in reestablishing normal actions without particular difficulty.'
Aperients should be taken so as to bring on the desired effect after breakfast, so that absorption of food through the day may not be interfered with. The drug selected should be one that does not produce any inflammatory changes in the mucous membrane of the intestine with harmful reactions on the stomach, kidneys or other organs. If large doses are required, in severe cases, they should be given in three parts, after break-fast, after lunch and largest at night. The action of the drug is then less violent with less likelihood of colic or catarrh. Where aperients must be used constantly (or the patient thinks they must he) they should be changed from week to week, so as not to lose their effect.
These occur in plants in combination with plant acids. They are sometimes called the organic bases of plants, as morphine, nicotine, quinine, etc., and are intensely bitter?
(1) Nux vomica, strychnine. Strychnine, which has the properties of nux vomica, sometimes appears useful in those forms of constipation which depend on depression of the nervous system, especially when given in connection with vegetable aperients?
(2) Belladonna, atropine. The active principle of belladonna is due to atropine derived from the leaves of the poisonous nightshade. It is an anti-spasmodic and all its preparations are poisonous. Most vegetable purgatives give rise to more or less griping which can often be entirely overcome by combining them with a small dose of belladonna?
(3) Opium (morphine, codeine, papaverine). Opium is valuable in those cases of constipation which are associated with pain, such as in biliary and renal colic ("stone") in rapidly curable forms of intestinal colic and for that due to lead poisoning. It is generally most effective when given in connection with a saline purgative. The initial good effects are generally re-placed before long by its ordinary constipating action.
These irritate the intestinal mucous membrane and thereby give rise to a local reflex in Auerbach's plexus (a plexus or net work of sympathetic nerves between the coats of the intestine) which results in increased muscular activity. Those most commonly used do not irritate the stomach, as some, such as aloes, only act after they have become dissolved in bile, while others, such as castor oil, after they have been split into active substances by the pancreatic ferments of the pancreas. Vegetable purgatives are supposed to act on both the small and large intestine. X-ray observations show that this is only true of cascara and castor oil, while aloes and senna act on the large intestine only?.
Podophyl'lum. Derived from the roots of the May apple or mandrake. It also contains a resin, podophyllin (accent on the "oph") . It is the slowest acting purge in use. This valuable drug particularly excites the flow of bile. It is best given in constipation when the stools are dark (Sidney Ringer 2) . In children one or two months old with hard, stony stools, podophyllin is the best remedy. A grain of the resin should be dissolved in a dram of alcohol (teaspoonful). Of this 2 drops on sugar are to be given once or twice a day. In children who suffer from watery diarrhoea stools which have a musty smell, the resin in the dose of 1/60 to 1/50 of a grain (1 drop on sugar as above) is of service, often succeeding when all else fails. The resin is the best preparation in adult use also, the best pills containing from 1/8 to 1/10 of a grain.
Aloes, aloin. Alain contains nearly all the active principles of aloes, which is the dried juice derived from the cut leaves of various species of aloe. It was used by the Greeks and Romans and is now probably the most generally useful of all purgatives. A friend of Lauder Brunton had not found it necessary to increase the dose after forty years' continuous use. Aloes acts rather slowly and stimulates the colon only. It is there-fore often best taken after dinner instead of at bedtime. One of the best pills for use in chronic constipation is composed of half a grain of extract of nux vomica and a quarter of a grain of the alcoholic extract of belladonna, with from one-sixth to one grain of aloin, or three times this amount of aloes (dried juice of the leaves of the plant) the exact dose being adjusted to produce a single formed stool each morning.
Cascara sagrada. (Spanish for sacred bark.) This drug is derived from the dried bark of the California buckthorn. It was used by the North American Indians as an aperient but was not introduced into England until 1877. The x-ray shows that it has the disadvantage, when compared with aloes, of acting on both the small and large intestine. Like aloes it acts most efficiently when given with nux vomica and belladonna?.
Senna. Was introduced into western Europe from the Arabs, who used both the pods and leaves. Its action does not begin until it reaches the cecum (beginning of the ascending colon). There appears to be no increase in secretion, the action being solely due to stimulation of the colon movement. It tends to cause griping and nausea. This is due to a resinous element which is absent in preparations made with cold water. The requisite number of pods are allowed to stand in cold water for four hours or more and the infusion is drunk the last thing at night. If any discomfort is produced five or more drops of tincture of belladonna can be added to the infusion just before it is drunk. A patient may start with six pods and easily and accurately increase or decrease, after which the dose should be decreased, one pod at a time as the condition improves.
Castor oil. Herodotus (of ancient Greece) de-scribed its cultivation by the Egyptians. It was introduced in Europe at about 1764. On account of its mild but certain action and the absence of griping, castor oil is perhaps the most valuable of all purgatives for occasional use, with a dosage of a half ounce to an ounce. It is valuable in the constipation of old age and in spasticity (contraction) of and inflammation of the colon especially when belladonna or codeine is given simultaneously. The bad taste can be materially lessened by first rinsing the mouth with lemon juice or eating a piece of peppermint candy. Larger doses are best taken in one swallow with lemon juice or peppermint water, with which the medicine-glass should be first rinsed.
It should be used where bad food has been eaten even if the inflammation set up after taking the food is very active. It tends to produce hemorrhoids if used constantly and its frequent use, or even in a single dose, is generally followed by constipation. This is one reason why it is useful in irritative diarrheas; having swept out the mucus and offending matter it checks the movement of the bowel. The purgative effect is very much increased if a little bicarbonate of soda is given with it. A very effective purge in very obstinate constipation consists of 1 ounce castor oil and the same amount of aromatic syrup of rhubarb. Some cases of neuralgic headache may be cured by small daily doses, of castor oil, given preferably in capsules of from 1/4 to 1 gram.
George W. Crile, the well-known surgeon of Cleveland, Ohio, stated before the surgical section of the American Medical Association that castor oil was recommended to him by John B. Murphy, the late eminent surgeon of Chicago, as a preliminary treatment in operative cases of facial neuralgia, as in a considerable percentage of cases it rendered an operation unnecessary. Dr. Crile stated that he found the advice sound and to this extent con-firms Hare. The only explanation offered by Hare is that the treatment prevents toxemia (which in turn has caused nerve irritation) by unloading the bowels.
Castor oil is, to a certain extent, independent of dose, and the dose is not much influenced by age. An infant may safely be given a teaspoonful or two, a dose that will usually physic an adult. The quantity of oil that exceeds the digestive capacity is passed through unchanged acting like so much paraffin oil. Excessive action is therefore impossible. For an adult the usual dose is 1 or 2 tablespoonfuls. Because of the reliability of its action and the impossibility of excessive effect it is the purgative of choice for delicate invalids, infants, and where hemorrhoids are present. It is a good remedy in intestinal colic.
An outside authority, a practicing physician of high standing and a large practice, says it is always his first remedy when called in digestive cases of children. In about nine cases in ten he finds no other medicine is needed. And yet this old and reliable remedy is notorious for its tendency to leave the bowel sluggish after use. Consequently it should not be used in chronic constipation. The best way to prescribe it is in elastic capsules of agreeable size.
Rhubarb. Contains an astringent that gives it, when used in unloading the bowels, a secondary constipating effect. This quality is useful in some cases, as in children where an ordinary laxative is followed by diarrhea. In summer diarrhea, where it is desired as a preliminary treatment to get rid of fermenting material, rhubarb is useful.
Saline purgatives act mostly as such by causing an in-creased amount of water to remain in the intestine or pass into the intestine through its walls, so that the weight of the increased liquid really causes the purgation. For this very reason a saline will act better if the patient is up and about. The slower the salts in absorption the better they are as purgatives. Salines interfere with the absorption of water from the intestine and if they are in concentrated solution attract water from the blood. Hence when they act all this water is passed and the patient often feels faint and thirsty. They should be well diluted. Three 8-ounce glasses of water are not too much for such a purpose. If concentrated, salines remain in the stomach until there is sufficient water to make them of uniform density with the blood (isotonic), and during this process irritation of the stomach and mucous membrane is caused and the passage delayed. They should not be taken at night.
This interesting observation may prove an adequate explanation of the fluid residue which Hawk elsewhere says may be found in many stomachs in the morningóa lack of dilution in the form of a few sips of water.
A saline taken before breakfast acted in thirty-five minutes, whereas the same dose given another morning, when no breakfast was taken, required seventy minutes. When a dose is given of a saline purgative of proper strength the x-ray shows that the whole of the large intestine, from the cecum on, may be completely emptied. But little acceleration is produced on the chyme in the small intestine. The advantage the salines have over many vegetable purgatives, such as cascara and castor oil, is that they do not interfere with the passage of chyme through the small intestine. Salines do not suit all people as in some cases they produce abdominal discomfort, nausea and headache, without acting on the bowels. Many find them most agreeable, however, while in nervous individuals, owing to the loss of a considerable amount of fluid, they have a tendency to produce depression. If hemorrhoids are present particular care should be exercised that no larger dose than enough to produce one action should be taken?
Sulphate of sodium (Glauber salt) is a saline cathartic more disagreeable but less active than magnesium sulphate, over which it has no material advantage. Dose 4 drams.
Sulphate of Magnesium (Epsom salt) . One of the most active of the saline cathartics. Dose 4 drams. Same in an effervescent solution containing about 7% of magnesium sulphate with syrup of citric acid, potassium citrate and water. Dose, the contents of a bottle, nearly 12 fluid ounces.
Sodium phosphate. As a saline it is less active than magnesium sulphate and sodium sulphate and also less disagreeable to the taste. Dose a rounded teaspoonful divided between two glasses of quite warm water an hour and a quarter before breakfast, half the quantity in each glass. It does not dissolve in cold water. The same in effervescent form represents approximately but 50 per cent of sodium phosphate as described above. If the dose is carefully regulated, more or less than the above to get proper effect, sodium phosphate is very agreeable in its action. In small doses slightly laxative only.
Particularly useful, says Hare, for bottle-fed children who continually alternate between diarrhea and constipation and also useful in rickets to regulate the bowels. The late Roberts Bartholow of Philadelphia believed this to be the best remedy in cirrhosis of the liver and jaundice.
Fothergill observes that for the stimulation of the liver soda is the alkali par excellence .l Significance is given this remark by the fact that bile has as its two principal ingredients two sodium salts that is sodium that has combined with two different acids.
The mild action and agreeable taste of phosphate of soda commend it especially for children to whom it may be given in milk or other food. In chronic gastric catarrh with constipation small doses in hot water before meals often have a very beneficial effect on both the stomach and bowel. Taken in the same way it is a valuable depletive (lessening the fluids of the body) in simple catarrhal jaundice (due to swelling of the bile ducts from catarrh), secondary to inflammation of the duodenum (immediately below the stomach). Dose 2 to 4 drams. (The ordinary dose in health is a teaspoonful, 1 dram, with variations.)
These were formerly believed to act by increasing the flow of bile but more recent observations have shown conclusively that they have no actions on the liver. The belief arose because of the green color of mercurial stools, but this is now known to be due to the prevention of the decomposition of the bile by the antiseptic action of the calomel. Calomel has the great disadvantage of being very uncertain in its action. In some persons even small doses may produce severe poisoning which is very difficult to combat, as there is no method of rapidly getting rid of the mercury. Calomel is valuable for occasional use, particularly in so called biliousness, in which the furred tongue, lack of appetite, general malaise, headache, discolored membrane of the eyeballs and constipation result from gastro-intestinal disorder and not from any liver condition. Mercurial purgatives should never be employed in chronic constipation as they are too irritating and may result in mercurial poisoning?
Hare says calomel should be given in doses of 1/6 to 1/2 a grain every half hour until 1 to 2 grains are taken. Only the calomel that is changed in the intestine into gray oxide is active. As the amount of alkaline juice in the intestine is small only a minor part of a large dose acts, the major portion escaping unchanged. This is the reason that bicarbonate of soda added to the calomel aids the intestinal juice in the reduction of the salt. Other authorities cite cases where calomel and soda administered in 1/10 grain doses for the calomel every 30 minutes up to a total of less than a grain, are effective. Larger doses should be followed by a saline so that no free mercury is left in the system.
In choosing an aperient one can be selected in which aloes or aloin is the active element, one in which podophyllin is, and one in which cascara is. There are many good pills on the market. Here are four:
1. Purified aloes 1 grain
The aloes here is the active element. Hyoscyamus is used instead of belladonna as an anti-spasmodic, to allay excessive secretion and exercise a favorable influence where local inflammations are beginning. Nux vomica is the tonic element. Ipecac in small doses acts as a stimulant to the secretions of the mouth, stomach, intestine and liver. Next
2. Aloin 1/8 grain
Here the active ingredients are the aloin and podophyllin, associated with belladonna (about the same effect as the hyocyamus in No. 1), strychnine in place of the nux vomica as the tonic, and the capsicum (red pepper) as a digestive stimulant, especially in alcoholism. Note the smaller dosage of aloin as compared with aloes.
3. Cascara compound No. 3 (Dr. Hinkle) is as follows:
Cascarin 1/4 grain
The first three are the active agents here with three assisting remedies (adjuvants). The ginger is employed for its flavor and to prevent griping. There are three strengths of this excellent pill. The above is the weakest.
4. An aloin pill without podophyllin with an excellent reputation is as follows:
Aloin 1/4 grain
If plain cascara is desired instead of pills it can be bought in tablets of 2, 3, and 5 grains each. Used steadily the dose will soon have to be strengthened.
If bran is taken freely the ordinary dosage of pills can be reduced. They are used occasionally on the theory that there is generally an accumulating residue even where the bowels are supposed to be in good condition. This observation is easily verifiable.
If any laxative pill is taken with a glass of warm water an hour before dinner, on an empty stomach, the dosage can be lessened a third or more and the time required for action shortened to about 7 hours.
The late Sidney Ringer called attention to the fact that in constipation or "biliousness" with light-colored stools calomel is indicated but in the same condition with dark-colored stools, podophyllin. Hare says he has proved the correctness of this opinion so frequently that he is convinced of its truth.
Much of the comment, some of it adverse, on the guarded use of such useful drugs as aloes, cascara, podophyllin and phosphate of soda avoids the real question. If a patient is well informed and follows the best hygienic practice but finds through the use of charcoal markers or otherwise that the early morning water drinking, bran, abdominal exercises etc., still leave something to be desired, there is ample warrant in authority for the use of a laxative once or twice a week if results are found to warrant such a procedure. In the case of aloes, for instance, the books give the regular dosage at from 2 to 10 grains. Regular resort to such strong dosage is, of course, to be condemned. But we see above that the maximum dosage is but one grain per pill, and this is likely to be sufficient where the other helps are used. So the real question is, which is the better practice, to have the body habitually, chronically poisoned by a putrefying residuum or see to it with care that a good clearance is secured at weekly or bi-weekly intervals by the moderate use of friendly drugs: Of one of these Stevens says: "Aloes is rarely used as a cathartic but in simple, persistent constipation it is very efficacious in combination with other remedies, particularly nux vomica, belladonna, ipecac, rhubarb or podophyllin. Contrary to what was formally believed, aloes is not contraindicated by hemorrhoids unless inflammation has developed. Indeed the drug often benefits indolent piles by overcoming the sluggishness of the bowel that led to their development."
In an extensive clinical study of the subject Thayson says that primary, habitual stasis, usually begins before the age of 26 in women and 31 in men. Those crippled by age, incurable infirmity or chronic systemic disease (affecting the body as a whole) such as kidney, liver, heart or lung affections, require habitual laxatives. So do those suffering from a weak or diseased intestine, just as a person with weak ciliary muscles (of the eye ball) need eye glasses or a person with a weak leg needs a crutch. Such a cathartic should be prescribed with as much care to fit the patient properly as is taken in refracting a patient's eye.
It is a well known fact that intestinal intoxication phenomena are much more prominent in diarrhea than in constipation, and some people feel weak and miserable, as though poisoned for a few days after purgation. Of course this may be only temporary and the theory is that the purgatives stir up the intestinal contents and the poisons are then more readily absorbed into the circulation.
Pruritis ani (an external itching at the discharging end of the intestinal tract) has been widely but not finally ascribed to acid stools. Beyond question many cases are relieved after a demonstrated intestinal disorder has been controlled . An interesting inquiry, recalling the observation of Russell and Strasburger of the presence of in-creased stomach acidity in many cases of stasis (see Chapter XI) has been the presumptive establishment of a relation between pruritis and gastric acidity. It will be remembered that in Russell's opinion there are practically but two classes of digestive disorders, one characterized by excessive acidity of the digestive fluid of the stomach and the other by a deficiency of the acid element (hydrochloric) of the gastric juice. Accurate observastions in many cases are necessary to determine whether pruritis ani is associated generally with this acid condition. In at least some cases it has been found that a teaspoonful of phosphate of soda dissolved in hot water and diluted by two or three glasses of water taken an hour and a quarter before breakfast, every morning for two or three weeks, with no meat in the diet, has produced almost immediate relief. This solution has a mild alkaline reaction.' With this treatment should go absolute cleanliness through the frequent use of a good grade of castile or other bland soap. As to ointments an excellent one is benzoinated vaseline and oxide of zine. It comes in tubes and has enough body to protect the irritated surface for a considerable period, whereas a thin ointment like for instance vaseline and carbolic acid, soon disappears in contact with the heat of the body. Kellogg recommends an ointment consisting of
Lanolin (fat from sheep's wool) : 2 drams
If necessary, he adds, to relieve the itching, menthol may be added in the proportion of 10 grains to the ounces.
Calomel is extolled by Hamburger (quoted by Pennington), the powder being rubbed in on the cleansed parts. After a few applications the itching either disappears permanently or for several months.
Meats of all sorts, says Kellogg, especially the lean meats, tend to acidify the tissue fluids to a marked degree. Eggs, meat extracts, broths, gravies all belong to the acidifying foods although eggs to a less extent than meats. These are foods that, for want of bulk, produce the most pronounced derangements of the intestinal tract.
The condition of alkalinity or acidity of the colon con-tents that indicates health is often a puzzling one.
Many bacteria of the alimentary canal produce putrefactive changes. They render these contents alkaline, produce different gases and elaborate more or less virulent poisons. Other species often set up an acid condition, seldom accompanied by gas or toxin (poison) fermentation. The species that produce acids are more resistant to the action of acid. Thus when the stomach has an excess of free hydrochloric acid (a vital element of the gastric juice) a much larger percentage of putrefactive, disease-producing organisms in the blood are destroyed or rendered inert than of the bacteria of acid fermentation. Diminished stomach acidity allows the entry of a greater number of putrefactive types, with intestinal derangements'
And Kellogg says a slight acidity of the colon contents is a good indication showing that the putrefactive and poisonous germs of protein food have been displaced by the beneficent acid-formers. To this end he recommends three or four actions a day brought about by wheat bran, fruit, vegetables, and the free use of dates which are especially valuable because of the grape sugar they contain. He is firmly of the opinion that the increase in the number of actions a day is one of the surest ways of overcoming putrefaction. The habit can easily be cultivated. This is shown in insane asylums where the in-mates speedily establish the proper habits.