ART. I.-ABUSE OF CATHARTICS IN COLIC.

By S. A. Cook, M. D., oF BUSKIRK'S BRIDGE, N. Y.

No. 7.

Dr. Gooch informs us that he "remembers when a boy reading a story of two knights-errant, who arrived on the opposite side of a pedestal surmounted by a shield; one declared it was gold, the other that it was silver growing angry they proceeded to blows, and after a long fight, each was thrown on the opposite side of the shield to that where he began the fight; when both immediately detected their error: the knight who had said it was silver finding that on the opposite side it was gold; and the knight who said it was gold finding that on the opposite side it was silver." I cannot, however, subscribe to the sentiment that "this story presents a good illustration of the state of medical opinion in this age-perhaps in all ages," as such an acknowledgement amounts to nothing more or less than a concession that medicine has no facts-is a mass of baseless and contradictory theories. Medical science is a progressive science, and hence arises necessarily something of a variety in medical opinion; yet generally it is only a difference in progress; a circumstance which has its origin, not only in the state of the science in different ages, but in the extent of its cultivation by different individuals in the same age. Hence it is a consistent conclusion, and one founded on the evidence of all experience, that however well the nature and treatment of any variety of disease may now be understood, there exists a probability that future observation may throw still more light upon it;-a consideration presenting an ample field for enquiry to such as pursue the profession with a laudable ambition for its improvement.

I am desirous of calling the attention of medical men to the ordinary, or at least the too frequent, treatment of colic by active purgatives, believing that however favourable such a plan may occasionally operate, it is founded on an erroneous conception of the nature of the disease: and that it not only frequently fails of success, but is often injurious to the patient where a more judicious practice would be entirely successful. To illustrate my meaning, I shall present sketches of the history of several cases that have fallen under my observation, not doubting that the experience of almost every practitioner furnishes similar instances.

CASE I.-Feb. 1834. I was called to a gentleman about 10 A. M., suffering severely with colic. He informed me that he had lately recovered from remittent fever, that his appetite had been somewhat sharp, though he supposed he had not eaten more than he usually did in a state of health, yet he remarked that he had taken his dinner the day before with an excellent

relish; and that while riding during the afternoon he had felt occasional pains in the bowels, which became severe in the evening, when he took a small dose of castor oil, which operated sparingly about 11 P. M., with a slight temporary relief. His physician, who had been with him since about midnight, had bled him, applied fomentations, given active cathartic doses of calomel and jalap, administered a variety of enemas; notwithstanding which the pain had increased in severity, the pulse in frequency, the abdomen had become tender, and no fæcal discharges had been obtained. In this state of the case, I recommended a farther use of the lancet, the warm bath, a combination of castor oil and oil of turpentine to be repeated pro re nata, and a continuation of the enemas. The warm bath afforded temporary relief; yet the disease continued, and as the patient was an eminent divine, and among strangers, other physicians were called and stronger measures resorted to: the lancet continued to be plied, croton oil in large doses by the mouth and per anum repeated, until, about forty hours from the attack, the bowels were moved freely, but without relief: the patient died fifty-four hours after the commencement of the disease.

CASE II.-G. G., a farmer, aged 36, generally of robust health, (had an attack of colic June, 1837, from which, after several days of severe suffering he recovered through the instrumentality of the lancet, active cathartics and enemas, some of which were sent per tube into the colon à la O'Bierne) was taken with colie, January 1, 1839. I first saw him on the evening of the 5th. Up to this morning he has directed his own treatment. During this time he has taken thirteen empirical cathartic pills, seven ounces of castor oil, about the same quantity of sulph. magnesiæ, and to day, by the direction of a physician who saw him this morning, a large dose of calomel and jalap, endeavouring during the whole time to assist the operation of these various remedies, by enemas. He has had constant tenesmus, voiding small quantities of morbid mucus, during the last two days, and his bloated and tender abdomen presents evidence of extensive abdominal inflammation. The treatment to which I resorted, was as free a use of the lancet as the constitution of the patient and the stage of the disease would permit, united to a liberal employment of calomel and opium; and though this treatment was, within twelve hours, followed by free fæcal discharges and relief of the pain, yet he sank into a state of collapse and died on the morning of the 12th. The post mortum appearances were those of extensive inflammation of the large and small intestines with numerous gangrenous spots near their union.

CASE III.-Called to Miss H. F., 16th March, 1840, aged 16 years, from her attending physician obtained the following history, "She was taken a week ago this evening, with acute pain in the region of the ascending colon, near the top of the right ileum. Saw her first about twenty-four hours after the attack and immediately bled, when the pain subsided. I now undertook to evacuate the bowels, which was found very difficult, and was only effected by administering active purgatives and enemas during fortyeight hours, when diarrhoea supervened without pain, but attended with great restlessness, and which continued till last evening, notwithstanding mild astringents, as marsh rosemary, &c., in conjunction with pulv. Ipec. comp. were used. Last evening, the diarrhoea suddenly ceased, followed by acute pain in the region of the pyloric orifice of the stomach. The temperature of the skin, which has at no time been much, if any, above the healthy standard, at this time sank considerably below it," and it is to day cold and damp, the patient being in a stage of collapse, in which she continued about five days and died.

The above cases are but cursorily sketched from notes taken at the time, in order to call the attention of the reader to a single point, viz. the frequent consequences of a treatment based upon a supposed necessity of

Rev. Cowles Carpenter of the Methodist Episcopal Church.

evacuating the alimentary canal, as a primary indication in colic. Before enquiring how far such a necessity exists, or what plan of treatment promises the most successful issue in this fearful disease, it may not be improper to examine how far that adopted in the cases already related is in conformity with the opinions and directions of our elementary writers. I shall quote indiscriminately. "The bowels have their discharges interrupted by spasmodic constrictions, denominated colic. Without engaging in the enquiry, relative to the varieties of this disease, I shall state that in all such cases, cathartics are indispensable. Being customary, here, to direct the more active articles, it is important to know that in some instances, the most lenient are to be preferred. There is a certain relation between the power of a medicine and the tone of the system, which seems sometimes to be graduated with extreme nicety and precision. What operates at one time, we find inert at another, under apparently similar circumstances, and in the same person. This is owing to a want of harmony in the case."

Dr. Mackintosh on this subject says "It is a most essential point to obtain free evacuations from the bowels speedily, particularly by means of injections; certainly the best is composed of tobacco, in the proportion of half a dram infused, for ten or fifteen minutes, in eight or ten ounces of boiling water, to be strained and exhibited when sufficiently cool." * * * "The advantage of opium is very doubtful till the bowels have been properly moved and the evacuations examined."

Dr. Gregory, in treating of bilious colic, recommends, where full vomiting has not taken place, an emetic of ten or fifteen grains of ipecacuanha, "which may be followed by a pill containing calomel and rhubarb, a dose of castor oil, or the common senna draught. If there be much irritability of the stomach it is better to commence with a saline draught in a state of effervescence, containing a few drops of laudanum. This will enable the practitioner to administer the aperient medicine subsequently with more advantage. When the operation of purgatives on the bowels is manifest by the appearance and odour of the evacuations, a full dose of laudanum may be given with the happiest effects." Dr. Gregory cautions practitioners against the use of opium until the bowels be evacuated, asserting that "experience will show that though it will afford relief in the first instance, its exhibition is in most cases succeeded by increased feverishness, and an aggravation of headache, and uneasiness of the bowels. In the treatment of bilious colic, the object is to free the bowels from the load which oppresses them."

Dr. Colhoun in a running note to the above, adds-" Active enemata, of turpentine rubbed up with the yolk of an egg, of salt and water, the tobacco suppository made by rolling up some wet tobacco leaves, and sewing them together in a proper form, will be useful in assisting the operation of purgatives according to the judgment of the practitioner."

Dr. Eberle advises, that" when the pain is confined to the bowels, occupying the colon, an active purgative in union with aromatics, or with some of the more volatile anti-spasmodics, ought to be given; and purgative enemata administered at short intervals, until the bowels are freely moved. Castor oil, with spirits of turpentine is an excellent purgative in colic from the irritation of acrid substances, or imperfectly digested articles of food lodged in the bowels. I have often employed this mixture with prompt and complete success. In some instances, however, the sufferings of the patient are so extremely great, that we cannot wait for the operation of a cathartic to procure relief. In such cases, almost the only remedy, on which any reliance can be placed, is opium given in large doses. From two to three grains should be given at once, or what is better an equivalent dose of laudanum; this will always procure relief in forty or fifty minutes;

1 Chapman's Elem. of Therap. 5 edit. vol. i. p. 203.

2 Mackintosh's Principles of Pathology and Practice, p. 179.

3 Gregory's Elements of Theory and Practice, 2d. Amer. edit. vol. ii, p. 324.

and in many instances of this severe character, nothing but this remedy in enormous doses will allay the extreme agony of the patient. The opium, when given in large doses in this affection, does not materially impede the subsequent operation of cathartics, and the administration of a purgative should never be neglected, as soon as the violence of the disease is moderated."

The early evacuation of the intestinal canal is made the primary indication in the treatment of colic by a great majority of our most eminent writers, though something of a variety of sentiment exists with regard to the best means of effecting this object. While some recommend mild aperients in repeated doses, either with or without carminatives, anti-spasmodics, or sedatives; or, where the patient is seen early, while the stomach contains a portion of the offending matter, either in the form of ingesta, or of depraved secretions, that these be preceded by mild emetics; others direct us to proceed at once, and especially in the more violent cases, to the use of the most powerful irritating and depressing of the class of purgatives, either by the mouth or per anum. Two drops of croton oil, oil of turpentine combined with castor oil, tobacco injections, and suppositories,5 &c., means, which if early used, may frequently prove successful, but which, as every practical man must have repeatedly witnessed, are not only often unavailing, but absolutely injurious. Nor is the general feeling among practitioners less favourable to the use of purgatives in this disease, under its various forms of severity: almost all following in the way thus laid out for them, without taking the trouble to observe or think for themselves, consider evacuation of the alimentary canal as the object, and end of all medical treatment.

PATHOLOGY.

A judicious prescription in any disease can only originate in a sound pathology; and as the physician who is called upon to prescribe for colic is required to act promptly, when the extreme agony of the patient, the anxiety of friends, and his own sympathies all tend to confuse his mind, he should have clear and accurate perceptions of the nature of the case before him. The exciting and predisposing causes, the present pathology and the changes to which it tends, the constitution and habits of the patient are all subjects of careful consideration; and a successful termination frequently depends upon the tact with which the predominant symptom (pain) is subdued by such remedies as diminish the existing disposition to progressive change. Few diseases possess more completely what may be termed a transition pathology; and, at whatever period of its progress the case may have come under consideration, we are to look forward to the effects of the present morbid action, as the cause of additional and different phenomena at some future time: and hence the subsidence of a prominent symptom, unless that symptom have been subdued early, is frequently no evidence of improvement, but on the contrary the harbinger of more intense morbid action. To this circumstance may be attributed the often observed circumstance (and one which frequently deceives the friends, and may the physician, if he be not on his guard,) of a sudden cessation of pain, perhaps a free evacuation of the bowels, after they have for many hours resisted the most powerful purgatives; and that too while the disease is still rapidly advancing to a fatal termination.

Without purposing to notice the varieties of colic, which different medi

1 Eberle's Practice, 2d edit. vol. ii, p. 323.

2 Dewees's Practice, p. 798-9.

3 Eberle, op. cit.

4 Mackintosh op. cit. and Abercrombie.

5 Colhoun's Notes on Gregory, op. cit.

cal writers have made more or less numerous, and some of which have undoubtedly a real existence in fact, while others probably find only a habitation in the imagination of nosologists, I shall proceed to a brief examination of its pathology.

"There appear to be three morbid conditions of the intestinal canal, which more or less exist in the simplest, as well as in the most severe and complicated forms of colic, and which evidently depend upon depressed vital power of the digestive canal.

"1. Morbidly increased sensibility and irritability of some part, or the whole of the bowels.

"2. Irregular distention and spasmodic constriction of their canal.

"3. More or less copious generation of flatus in their track, occasioning great distention and irregular reaction-the second morbid condition adduced."

1. Of the existence of the first condition, "a morbidly increased sensibility and irritability of some part, or the whole of the bowels," there may or may not be sensible evidences, previous to the developement of the prominent phenomena of the disease, or second morbid condition. There may have been during several days slight headach, a bitter taste in the mouth, eructation of sour or acrid matter from the stomach, trifling pains during digestion; or the individual may be suddenly seized, without any of these premonitory symptoms, with severe colic pains, after eating a hearty meal, and these sensible phenomena might be considered as the first link in the chain of morbid actions, had not his previous history frequently exhibited him indulging in like trespasses with impunity—a fact most reasonably accounted for, by considering the alimentary canal, or some portion of it, as previously suffering from a morbidly increased sensibility, though unrecognised by the mind.

2. The second morbid condition, or "an irregular distention and spasmodic contraction of the alimentary canal," or of some portion of it, constitutes the prominent character of colic, and it is only where this condition is exhibited that the disease can be said to be completely developed. Pain, usually violent in the extreme, sometimes permanent, while at others paroxysmal, a sensation of twisting or irregular contraction about the umbilicus, and more or less obstinate constipation are the most constant features of this stage.

The infrequency of a fatal termination, before inflammation produces structural changes, makes it extremely difficult to determine upon what morbid condition the pain of colic depends. The sensation of twisting and constriction are so evident to the patient, that it is difficult to dismiss the idea of spasm from the mind, while the feeling of fulness, not only recognisable by the patient, but also by the hand of the attendant pressed upon the abdomen, shows that distention of the canal by a secretion or evolution of gas constitutes an important item in the pathology of the disease.

3. Indeed so prominent is this third condition-the copious generation of flatus in the track of the alimentary canal, that a late eminent writers has advanced the opinion that the condition of the parts in a fatal case of "ileus (or colic) consists in a state of simple distention, without any visible change in the structure of the part," and that the doctrine of spasm, as applied to this subject, must be admitted to be entirely gratuitous. He also contends, that the contraction, or collapsed state of certain portions of

1 Sauvages presents twenty-two varieties. Cullen seven. Good six. M. Pariset twelve. M. Chomel about the same. Schettman six species, which are divided into several varieties; while Abercrombie includes under the common term ileus, all varieties, considering their difference to depend upon the degree or extent of morbid action.

2 Copland's Dic. Prac. Med.

3 John Abercrombie, M. D., Path. and Prac. Res. on Dis. of Stomach, &c.