Читать книгу Pharmacologia - John Ayrton Paris - Страница 33

Medicines which quicken or increase the evacuation from the intestines, or which, when given in a certain dose, occasion purging.

These remedies, from a general difference in their modes of operation, have been classed under two divisions—Laxatives and Purgatives. The former operate so mildly that they merely evacuate the contents of the intestines, without occasioning any general excitement in the body, or even stimulating the exhalant vessels of the canal; the latter produce a considerable influx of fluids from these vessels, and extend their stimulant effect to the system in general; and where these effects are very violent, the purgative is further distinguished by the epithet Drastic. Laxatives then may be said to empty the bowels simply, and to carry off extraneous matter, which is out of the course of the circulation; but purgatives, as they occasion a constitutional effect, may be made subservient to very important purposes. The effects of a purgative may depend upon three different modes of operation; viz.

1. By stimulating the muscular fibres of the Intestines, whence their peristaltic motion is augmented, and the contents of the bowels more quickly and completely discharged.2. By stimulating the exhalent vessels, terminating in the inner coat of the intestines, and the mouths of the excretory ducts of the mucous glands; by which an increased flow of serous fluids takes place from the former, and a more copious discharge of mucus from the latter; the effect of which is to render the fæcal matter thinner and more abundant.3. By stimulating the neighbouring viscera, as the Liver and Pancreas, so as to produce a more copious flow of their secretions into the intestines.

It appears that different purgatives have very different powers in relation to the several modes of operation above specified; some medicines, for example, urge the bowels to evacuate their contents by an imperceptible action upon the muscular fibres, and little or no increase of serous discharge attends the evacuation, such are Manna, Sulphur, and Magnesia; there would seem, moreover, to be certain bodies that have the property of increasing the peristaltic motions by operating as mechanical stimulants upon the fibre; it would not be difficult to derive many illustrations of this fact, from the history of herbivorous quadrupeds, and I have been disposed to consider the harsh and coarse texture which certain grasses assume in moist situations, as a wise provision in Nature to furnish an increased stimulus to the intestines of the animals who feed upon them, at a time when their diminished nutritive qualities must render such a result desirable; but the operation of a mechanical laxative may be demonstrated by a more familiar example; the addition of bran to our bread, constituting what is known by the name of Brown bread, induces laxative effects, merely from the mechanical friction of the rough particles, or scales of the bran, upon the inner coats of the intestines, for the wheat without the bran in bread is not particularly laxative.^[154] Other cathartics stimulate the fibres to a much greater degree, and the effects are either confined to a part of the canal, or communicated to the whole range of the intestines, from the duodenum to the extremity of the rectum; Aloes will furnish a good example of the former, and Colocynth may be adduced as an instance of the latter mode of operation. Other cathartics, again, direct all their stimulus to the exhalant vessels, and are accordingly distinguished by the force with which they produce serous evacuations; and for which they were formerly denominated Hydragogues, such are Saline Purgatives, and certain vegetable bodies to be hereafter described. Dr. Cullen has even supposed that some of these medicines may act solely in this way, and without increasing directly the peristaltic motion; there is, however, as Dr. Murray very justly remarks, no proof of such an hypothesis, and it seems scarcely probable that any substance should act as a stimulant on these vessels, without at the same time stimulating the mobile fibres of the intestines. Mercurial Purgatives appear to possess, in an eminent degree, the power of exciting the functions of the liver, and of thereby occasioning an influx of bile into the intestines. From the indications which cathartics are capable of fulfilling, their utility in many diseases must be apparent; the extent of their importance and value were, however, never justly appreciated until the valuable publication of Dr. Hamilton on this subject, in which the author has pointed out with more precision than any preceding writers had done, the therapeutic principles which should regulate their administration. His practice has clearly proved that a state of bowels may exist in many diseases, giving rise to a retention of feculent matter, which will not be obviated by the occasional administration of a purgative, but which requires a continuation of the alvine stimulant, until the healthy action of the bowels is re-established. Since this view of the subject has been adopted, numerous diseases have received alleviation from the use of purgatives that were formerly treated with a different class of remedies, and which were not supposed to have any connection with the state of the alvine evacuations; thus in fever, the peristaltic motion of the intestines is diminished, and their feculent contents are unduly retained, and perhaps, in part, absorbed, becoming of course a source of morbid irritation; this fact has long been understood, and the practice of administering cathartic medicines under such circumstances has been very generally adopted; but until the publication of Dr. Hamilton, physicians were not aware of the necessity of carrying the plan to an extent beyond that of merely emptying the primæ viæ, and they did not continue the free use of these remedies through the whole progress of the disease.

Cathartics are essentially serviceable also in several diseases of the class Neuroses, which are generally intimately connected with a morbid condition of the alimentary passages; Chorea and Hysteria have been very successfully treated in this manner. The diseases incident to puberty in both sexes are also best relieved by a course of purgative medicines, and their effects in Chlorosis have conferred upon many of them the specific title of Emmenagogues.

But the therapeutical utility of Cathartics extends beyond the mere feculent evacuations which they may occasion. In consequence of the stimulating action which some of them exert upon the exhalent vessels, they abstract a considerable portion of fluid from the general current of the circulation, and are, on that account, beneficial as Anti-phlogistics. For the same reason they may act as powerful promoters of absorption, for there exists an established relation between the powers of exhalation and absorption, so that when the action of one is increased, that of the other is augmented.

Certain Purgatives, as I have just stated, exert their influence upon the neighbouring organs, and are calculated not only to remove alvine sordes, but to detach and eliminate foul congestions from the biliary ducts and pores.

With such facts before us, it is impossible to concede to the opinion of Dr. Hamilton,^[155] that the different species of purgative medicines do not possess distinct powers over the different species of matter to be evacuated; on the contrary, there is reason for reviving the ancient theory, too inconsiderately abandoned, and which acknowledged these different distinctions in the operations of cathartic medicines, under the appropriate names of Hydragogues, Cholagogues, &c.

The importance of cathartic medicines having been shewn, and the distinctions in their modes of operation established, it only remains to say a few words upon the subject of their abuse. All the remedies of this class, but more especially those of considerable power, require caution in their administration, even in those diseases where they are indicated by peculiar symptoms, especially if there be any tendency to inflammation, or to extreme debility, although this latter symptom is often rather apparent than real, and is at once removed by the brisk operation upon the bowels; during pregnancy and immediately after delivery, and during the flow of the menses, the prudent practitioner will use a discretionary caution in their exhibition. The too frequent use of these medicines will induce marasmus, and render the bowels so morbidly irritable, that purging is easily excited by the ordinary stimulus of our aliments; while in some habits the contrary obtains, and the resource to which the valetudinarian flies for relief only increases the torpor of the intestines, and confirms his costiveness.

The mode of adapting, combining, and administering Cathartics, will present subjects for our future consideration.