Divison I. Class II. Cathartics.

Cathartics are those agents which, by increasing the peristaltic action of the bowels, cause alvine evacuations. They embrace a very extensive class of remedial agents, and one, too, which is probably in greater use than all others taken together. In relation to the extensive, and we might say almost unlimited use, as well as paramount importance of this class, they are deservedly the most popular class of remedial agents in the materia medica. No disease afflicts frail mortality in which either the milder or more active agents are not thought to be either highly important curative or palliative means during most periods of its continuance.

Their employment is by no means confined to the practitioner of medicine; on the contrary, they are resorted to in domestic practice, in some of the infinite varieties of pills in common use, powders, salts, sulphur, magnesia, extracts, bitters, infusions, sirups, decoctions, etc., etc., either as active cathartics or as laxatives, more frequently, we presume, than all other remedial agents. They have been introduced into such general use from the fact that they are easy of administration, and so readily suggest themselves to the minds of the ignorant, and that their employment is so rarely followed by any immediate injurious consequences. They afford temporary relief in so many diseases, that they are considered as an universal panacea for every ailment. Every variety of cathartic agents have been employed in manufacturing cathartic pills, and colossal fortunes have been made by their preparation and sale. It may be said that the Americans are a drug-taking people—"pills" being considered by a majority almost as essential to well-being as bread, and more so than water applied externally, exercise, fresh air, etc. That great injury results from this indiscriminate use of cathartics is obvious, and it should be the duty of every conscientious physician to instruct the public mind on these and other subjects pertaining to health.

When used, however, with a definite object in view, and with a correct knowledge of the pathology of the disease for which they are given, they may be made to serve a useful purpose in medicine.

Action of Cathartics.—Cathartics may exert their influence in three different ways: 1st. By their irritant effect upon the intestinal tube; 2d. By absorption they are conveyed into the blood, and having a special affinity for the intestinal canal, they are excreted through it, and stimulate it to increased action; 3d. By causing an endosmosis from the capillaries to the alimentary canal, causing distention, irritation and evacuation.

Irritant cathartics are those agents which, being insoluble, are not absorbed after being taken into the stomach. They produce a topical irritation of the mucous membrane of the intestinal tube; this irritation is extended to the muscular coat (either directly or through the reflex action of the nerves), and the peristaltic action is quickened, their propulsive power is increased, and defecation accomplished. This action may in some cases only remove the contents of the bowels; but in others the stimulation is extended to the glands of the intestines, and they prove eliminative. They may also cause an endosmosis of the blood-serum, and prove hydragogue.

Specific cathartics are those agents which will produce catharsis, whether introduced into the stomach, thrown into the serous cavities, injected into the veins, or absorbed through the skin. They are soluble in the fluids of the alimentary canal, and hence are absorbed and act from the blood; having a special affinity for this portion of the system, they pass to it, and are excreted by the intestines. Why these agents have an affinity for the intestines, it is useless for us to speculate; we know the fact that certain agents pass to the bowels, others to the kidneys, to the skin, and other organs, and are excreted by them, but the cause of this will always remain a mystery.

This class of cathartics are nlways eliminative, stimulating the part through which they are excreted to increased action. What is the value of this elimination? It has been shown by Mekel that the mucous surface of the intestinal canal consists of about 1400 square inches, covered with a closely packed glandular apparatus; and from this large surface secretion and excretion is constantly going on. Of the function of these numerous glands, but little is positively known, yet it has been clearly proved by physiologists that the larger part of the feces is excreted from the blood through some part of it; that instead of this excretion being composed of undigested food, it is formed of the nitrogenized tissues of the body, which being worn out, are eliminated from the system in this manner. The advantage to be derived from this class of cathartics is, then, very apparent: they stimulate this immense glandular apparatus to increased action, and eliminate from the blood the products of disintegration and decay; they may also act as depletives, if this action is maintained, lessening the quantity of the blood.

The cathartic salts are supposed by many eminent authors to act by causing an endosmosis from the blood (the lighter fluid) to the solution (the heavier fluid), and by thus increasing the contents of the intestines their natural action is called into play, and their contents are excreted. It is also maintained that when the solution contains less than five per cent. of the salt it does not prove purgative, but diuretic, and is excreted by the kidneys. We do not feel willing to admit the entire physical action of this class of agents, and we think that a little consideration will convince any one that this is not a faithful description of their operation. For instance, an ounce of some purgative salt is placed in the stomach in a saturated solution; it will first cause an endosmosis of the blood-serum to the salt, but as the dense fluid has an affinity for the membrane, and passes to it, the part next the membrane becomes diluted, and is absorbed by the blood; we have thus an exosmose of the blood-serum to the salt, and an endosmosis of the solution to the vessels. Some portion, then, of the purgative agent is absorbed, and as the solution passes through the length of the intestinal canal, we might reasonably suppose that a considerable portion of it would be absorbed. This, then, acts specifically from the blood, and might be the cause of the purgative action, but most probably acts in conjonction with a portion which remains in the bowels.

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This class of agents may be divided with much propriety into laxatives or aperients, and cathartics proper, according to their mildness or efficient mode of action.

Laxatives are but a subdivision of cathartics, and embrace agents which act but feebly or very gently upon the bowels, simply evacuating their contents without materially increasing any of the secretions. Among this class of agents we may name the manna, rhubarb, castor-oil, sweet-oil, sulphur, magnesia, etc.

Cathartics are those agents which act briskly and efficiently upon the bowels, not only evacuating their contents, but causing an increased secretion from them. Their influence extends to surrounding parts; they arouse the neighboring glands to increased action, stimulate the intestinal exhalants to increased secretion, and produce a very decided impression upon the general system. To this division of cathartics belong the podophyllum, jalap, iris versicolor, gamboge, croton oil, elaterium, etc.

This division is again subdivided according to the different effects which specific articles produce upon the system, and hence the terms purgative, drastic, hydragogue and cholagogue.

By purgatives is meant the mildest of the cathartics, as senna, castor-oil, rhubarb, etc.; the two last being purgative as well as laxative, if administered in suitable doses.

Drastics are those cathartics which are exceedingly harsh in their action, operating violently, and not unfrequently producing nausea, vomiting, tormina and tenesmus, and even gastro-enteric inflammation. Gamboge, scammony, podophyllum, and most of the resinous cathartics, are examples of this division.

Hydragogues are such cathartics as greatly augment the exhalation of fluid into the intestinal canal, and cause copions liquid evacuations. Jalap, elaterium, and some purgative salts belong to this division.

Cholaqogues are such as exert a specific action on the liver by removing obstructions and arousing it to action, thus causing copious bilious discharges. Podophyllum, podophyllin its active principle, and colocynth, are examples of this class.

These subdivisions are quite arbitrary, and might with much propriety be rejected; for the same article often possesses two or more of these particular properties, as the gamboge, colocynth, etc.

The same article often acts very differently on the same person at different times. At one time a particular agent may act as a mild purgatice, and at another it may operate as a powerful and even drastic cathartic; depending upon the acute or diminished sensibility of the nervous system, or morbid irritability of the bowels.

Cathartics are also said to be refrigerant, when they greatly lessen the heat of the body, as the sulphate of soda, sulphate of magnesia, and supertartrate of potassa.

Those which determine the vascular afflux to the pelvic viscera, and act either directly or indirectly upon the uterus, promoting the menstrual secretion, are called emmenagogue cathartics. The aloes, black hellebore, etc., are examples of this class.

Cathartics vary much in regard to the part of the intestinal tube upon which they tend to act. Some act mostly upon the stomach and upper intestines, producing nausea, and not unfrequently bilious vomiting, or as emeto-cathartics. This effect arises from their influence being mostly exerted upon the superior part of the alimentary canal, as is the case with the podophyllum, gamboge, colocynth, etc. Others exert their principal influence upon the lower portion of this canal—the colon and rectum—as the aloes; while others act upon each and every portion of the intestinal tube, as the jalap, elaterium, colchicum, etc.

The reason why different cathartics seek out and act upon different portions of the intestinal canal, is involved in much obscurity. Some have attempted to account for it on the ground of the difference in solubility of the different agents; those most soluble being supposed to act most readily, and consequently upon the upper part of the canal; while those of difficult solubility act principally upon the lower portion of the canal, because they pass the upper portion without absorption. These explanations are by no means satisfactory; for the cathartic principle of the aloes is very soluble, and yet it acts upon the colon and rectum. It will likewise, as will other specific cathartics, affect the same portions of the intestinal tube, when absorbed from a serous cavity, from the skin, or when injected into the veins. We can only account for these different effects in the same manner that we account for the action of a specific cathartic. They have a special affinity for certain portions of the mucous membrane or glands, and are excreted by this part, thus stimulating it to increased action.

From what has already been said relative to the modus operandi of the different varieties of cathartics, it will readily be seen that the proper selection and adaptation of certain ones to the multiplied and ever-varying forms of diseases, is a matter of the first importance to the practitioner of medicine. Thus, if the patient be of a plethoric habit, if a high grade of febrile or inflammatory excitement exists, if the bowels are torpid, or there is an undue determination to the brain, or a dropsical effusion exists, a very different class of cathartics will be indicated, from those required where there is great exhaustion, as in the advanced stages of fever, in chronic diseases attended with great debility, in diarrhea and dysentery, and especially in cases of irritation or gastro-enteric inflammation.

Therapeutic Indications.

In treating of the therapeutic application of cathartics, we shall speak of the different states of the system to which particular ones are adapted, and at the same time advert to the solid objections resting against others in the same or similar cases. As when describing emetics, we shall notice a few of the particular diseases in which cathartics are employed with advantage.

I. Action in Torpor of the Bowels.—In cases of torpor and inactivity of the bowels these agents are of primary importance. In this condition digestion is imperfectly performed, and frequently food is retained in an imperfectly digested condition much longer than the laws of health will tolerate, while retaned it is mingled with the various products of secretion eliminated from the blood through the walls of the canal. This heterogeneous mass becomes more acrid and irritatiug, and we may add, disease-creating, in proportion to the time it is retained in the bowels. The more liquid portions are reabsorbed into the blood, contaminating that fluid, causing sick-headache, pain in the back and limbs, fever, loss of appetite, etc. We may have the same results produced by the non-elimination of effete matters from the blood, owing to the torpid condition of the bowels; and in either case, if this condition continues, it may be the cause of many of the acute diseases; it also aggravates the symptoms in many chronic affections.

Thus, in this condition of the bowels, cathartics mitigate the symptoms in many inveterate chronic diseases; and in the milder acute diseases, such as colds, headache, jaundice, foul-stomach, slight attacks of a febrile and inflammatory character, they are often found entirely adequate to the relief of the patient without any, or with but very little other medicine.

II. Action in Fevers.—Too much importance can not be attached to the judicious use of cathartics in every variety, of either idiopathic or symptomatic fever. Thus in intermittent, bilious remittent, continued, typhus, typhoid, and in every variety of the exanthemata, as measles, scarlatina, variola, etc., either cathartics or laxatives are of great utility, and we might say almost indispensable.

In febrile and inflammatory diseases the bowels are usually constipated, and a continual accumulation is taking place in them. The great extent of surface, and the innumerable number of glands that are continually pouring out large quantities of excrementitious matter into it, renders it the common sewer of the system, the great receptacle into which most of those materials which have been worn out, or degenerated in the body are thrown. It is as one writer not inaptly remarks, "The great storehouse of disease;" in it all the redundant portions of our food are lodged, and into it most of the decayed particles of our organs, after they can no longer prove subservient to the purposes of the animal economy,—but if retained must necessarily act as foreign and disease-creating agents,—are thrown by the action of the intestinal exhalants.

While this vitiated mass is retained in the bowels, the fluid parts of it are constantly absorbed and conveyed back into the circulation, where it adds fuel to the excitement already existing. It not only vitiates the blood by its own presence, but by increasing the chemical changes that are taking place in that fluid, it thus predisposes to febrile and inflammatory diseases and often produces them. Cathartics very effectually counteract these morbid conditions by thoroughly evacuating the bowels.

An active cathartic is said to reduce the amount of circulating fluid from one to three pounds; in this way they act as powerful depletives. They serve to depress the vascular and nervous excitement, and moderate the intensity of febrile and inflammatory disease. These effects seem to arise in part from throwing off the vitiated accumulations in the bowels, and thus removing a source of irritation; and in part from stimulating the intestinal exhalants, and thus causing an abstraction of large quantities of serum; in this way they act as depletives and indirectly as sedatives.

Inasmuch as we are opposed to depletion by the lancet in the class of diseases termed sthenic, it may be said, If cathartics are such powerful depletives and carry off such large quantities of serum, they are quite as debilitating and therefore as objectionable agents as the lancet. The comparative physiological importance of the two constituents of the blood, viz.: the crassamentum and serum, readily unmasks the error, and enables us to answer the question satisfactorily. While the crassamentum or solids of the blood furnish all the materials for nutrition and secretion, supplying the waste of the body, stimulating the entire system to normal action, it is evident that the removal of any portion of it would produce a lasting and pernicious influence upon the system. On the contrary the serum serves rather as a medium or vehicle to transmit the crassamentum through the system to supply its wants, and is therefore comparatively unimportant. Not only so, but if largely diminished it may be speedily replenished by the free use of diluents. But this is not the case with the fibrine, albumen, and red corpuscles of the blood, highly elaborated and vitalized parts; if they are abstracted they are restored only by a very slow, vital process.

In depletion by the lancet, the entire blood is removed, both solid and fluid; by cathartics, the watery portions only are abstracted. In the one case the great restorative principle has been needlessly removed; in the other, an aqueous and less essential part, one which furnishes none of the materials of nutrition or reparation. The speedy recovery which follows from the loss of the serum, and the tardy recovery supervening upon the loss of the albumen, fibrine and globules, fully sustains us in the position we have taken. In one case, a few hours, or at most a few days are sufficient to restore the lost energies of the system; while in the other as many weeks, or even months may be required to accomplish the same desirable object.

If there is torpor, or congestion of the liver, and consequently congestion of the spleen and the entire portal system of veins, we have a class of cathartics that act directly upon this viscus. Almost any cathartic, however, will act indirectly upon the liver; this they do by causing an irritation of the duodenum, which is conveyed to the liver; and increased action is generally the result. Cholagogues are supposed to act directly upon this orgau; thus podophyllin, leptandrin, etc., we suppose have a special affinity for it, and are probably partially excreted by it.

Cathartics exert a very powerful influence over the secretions of the glandular system, and also over the various secreting surfaces. In short, they act as depletives, and indirectly as sedatives; while at the same time they increase, and often effectually and speedily restore all the secretions.

Another important influence exerted by cathartics is their revulsive effects. In cases of inflammation, congestion, or any undue excitement in the brain, the strong impression which an active cathartic makes upon the bowels, renders them powerfully derivative, as well as depletive agents; and hence they often afford prompt relief. In such cases an active hydragogue cathartic should be prescribed.

In cases of congestion of any of the abdominal, or thoracic viscera, occurring during the progress of febrile disease, their influence is transmitted from the bowels to the neighboring organs, by contiguous sympathy, and relief obtained. They act as revulsives, and as direct topical depletives.

If the nervous system is oppressed, or overpowered by the presence of vitiated material in the blood, or by any morbid accumulation in the bowels, or by congestion of any organ; or if the vascular and nervous energies are concentrated upon any particular part, cathartics are exceedingly valuable in removing the oppression, and equalizing nervous and vascular excitement.

In the treatment of febrile and inflammatory diseases, the constitution and habit of the patient, or state of the system at the time, will enable the judicious physician to select the proper cathartic to meet the indications that may be present. In an attack of bilious remittent, or a synochal grade of continued fever, if the constitution is vigorous, and the patient plethoric, very active and powerful hydragogue cathartics, if administered early, will be found most effectual in arresting the progress of the disease. An emeto-cathartic will fulfill more indications than those of an opposite character; they do this by acting more efficiently on the various secretory organs, and by the shock which they impart to the nervous system. They often break the chain of morbid associations, and arrest the disease when milder agents would fail.

In the early stages of fevers, active cathartics may be repeated every second or third day, if required; but as the disease advances less active agents, as the mild purgatives, and if there is much prostration, laxatives, will be found the most appropriate evacuants.

If the constitution of the patient is naturally feeble, or has become enfeebled by a protracted disease, or gastro-intestinal inflammation exists, the active, drastic hydragogue, or cholagogue cathartics would be inadmissible; none but aperients, or the milder purgatives should then be administered.

It may be proper to state, that this class of agents were at one time regarded as objectionable in the treatment of typhus and typhoid fevers, from the debility which they were supposed to produce, in addition to that already existing. Experience, however, has long since decided in favor of their employment in these diseases. Dr. Hamilton, in his remarks on their use in typhus fever, says: They cleanse the tongue, mitigate thirst, restlessness and heat, by removing vitiated matters from the intestines, which would morbidly impress the nerves, and produce debility if retained. They render recovery more certain and speedy, and instead of debilitating, actually increase the strength. The new excitement in the nervous system weakens the train of morbid sympathies, and hastens convalescence, independent of their evacuant effect.

In the early stage of yellow fever, cholagogue cathartics are employed with advantage; in the advanced stages, mild laxatives only should be used.

In the exanthematous fevers, as variola, rubeola, scarlatina, etc., active cathartics can not be employed without great danger of increasing the severity and danger of the disease. If they are employed during the stage of eruption they determine the circulation to the intestines; and if they do not produce a retrocession of the disease, they produce a similar eruption on the mucous membrane to that which exists in the skin. In the early stages, however, the bowels should be evacuated; but this should be accomplished by using such agents as produce the least irritation. After this the bowels should be kept in a soluble condition by the use of the mildest laxatives. These diseases are self-limited, and by no mode of medication that we can adopt can we expect to arrest their progress. They run a specific course, and by the administration of medicines our sole object should be to moderate the intensity of the symptoms, prevent congestions, retrocessions, etc., and not with a view of cutting short its course, as is our aim in other varieties of fever.

III. Action in Dropsy.—Cathartics are by no means an unimportant class of remedial agents in hydropic affections. Perhaps there is no class of therapeutic agents which so effectually arouse the absorbent system as the one under consideration. We think we hazard nothing when we say they occupy the front rank in the treatment of these complaints. If it is said that diuretics should have the preference, we must determine this question by referring to the salutary effects following the independent administration of each. Their relative importance can be ascertained by administering them separately, and comparing the effects resulting from the use of each respectively. The utility of diuretics in dropsy is greatly increased by being preceded by the use of proper cathartics. Cathartics stimulate the secretions of the entire alimentary canal; they remove congestions, determine the circulation to the large mucous surface of the intestinal tube, and cause an endosmosis from the capillaries to the intestines, by which it is removed from the body. This irritation and determination of the blood to the bowels gives increased motion to the circulation, and by the removal of large quantities of fluid from the vessels, the mass of the circulating fluids is decreased. As soon as there exists a depletion of the sanguiferous system, there is an immediate absorption by the veins, to restore the lacking fluid; this absorption, if there is not large quantities of fluid ingested, will be taken from the dropsical effusion. A sluggish circulation of the blood always predisposes to dropsy, and without the circulation is stimulated, absorption does not take place. Here we have a marked difference between the two classes of agents: diuretics will remove the watery parts of the circulating fluid, but they do not stimulate the circulation, and consequent absorption; while cathartics not only remove the fluid, but stimulate the circulation and produce rapid absorption. After cathartics have produced the effects just referred to, diuretics will exert their full influence in removing the fluid.

The most useful cathartics in these diseases are such as not only produce watery discharges, but stimulate or irritate the intestinal surface. These agents are termed hydragogues, from producing large fluid discharges. These, with the exception of the purgative salts, are all acrids. When the purgative salts are employed for their hydragogue properties, they are generally combined with some irritant cathartic, as jalap, colocynth, etc. Elaterium may be referred to as the type of hydragogue cathartics.

Dropsy is a morbid, serous effusion, or accumulation of serum in any of the cavities of the body, or in the cellular tissues—following as the sequel of many chronic diseases, particularly those of the kidneys, and not unfreqnently from a subinflammatory action of some of the serous membranes. It is in many cases dependent either upon local or general debility.

It seems to be a physiological law that the relative proportions between the solids and fluids, and also between the different constituents of the fluids, should be maintained. If blood be abstracted by the lancet, or by hemorrhage, or if the serous portion alone be removed by the action of a cathartic, or by any other cause, increased absorption from internal cavities immediately follows, to replenish the loss, and restore the equilibrium. If no dropsical effusion exists, and fluids be taken into the stomach, or injected into any of the cavities, they are rapidly absorbed to supply the place of that removed, and to maintain the relative proportions between the different constituents of the blood. It may be proper to state that, in cases of ascites, for instance, where the effusion is great, causing a deficiency of serum in the blood, this deficiency is counterbalanced by the diminished action of the kidneys and cutaneous exhalants.

Pathological observation and direct experiment both confirm the position that absorption is tardy when there is vascular repletion; and that it is accelerated in proportion to the extent to which depletion is carried.

Cathartics stimulate the intestinal mucous exhalante, and cause them to pour into the bowels large quantities of serum, and consequently a deficiency of fluid must exist in the bloodvessels. The constant efforts of the system to maintain the due amount of serum in the blood by absorption, and the increased activity of this process, in proportion to the reduction of the serous fluid, enables us to explain satisfactorily the modus operandi of cathartics in dropsies. They destroy the balance existing between the different constituents of the blood, by removing the serum, and at the same time greatly diminish the amount in circulation; and in proportion to these effects will be the activity of absorption of effused serum from the cavities in which it is deposited. The serum, after being reabsorbed, often stimulates the kidneys to increased activity, and in this way they act indirectly as diuretics. Cathartics, if given in conjunction with diuretics, often greatly increase their diuretic powers; absorption continues more active for several days after the action of the cathartic has ceased—increased diuresis being the result.

The derivative power of cathartics also renders them important agents in diminishing dropsical effusions. The part from which effusion takes place necessarily becomes the center of fluxion; but by the action of a cathartic upon the bowels, the point of fluxion is changed; at least a new, though temporary one is established. The action of a cathartic upon the intestinal exhalants exerts a powerful derivative influence, and while the bowels are the seat of derivation as well as exhalation, the dropsical effusion and local determination must necessarily be reduced; the materials to supply exhalation and the morbid action being diverted from the point of original excitement. In this way, an opportunity is afforded for the enfeebled organ or part to recover its tone, and for its functions to become improved. In all cases a fixed irritation or point of excitement is attended with accompanying loss of action in other parts of the system—abnormal or redundant secretion of one organ or tissue is accompanied with a diminution of the secretory action of other organs; or if one organ becomes diseased, and its normal secretion is arrested or reduced in quantity, it is compensated by the vicarious action or corresponding activity of some other organ, to supply its place.

IV. Action in Diseases of the Brain.—In all cases attended with an undue determination to the brain, as in apoplexy, phrenitis, cerebral congestions, etc., they are preeminently important. In these cases, the most powerful drastic hydragogue cathartics should be employed, if no symptoms are present to contraindicate their use.

Their salutary effects are dependent upon their depletive and revulsive powers. In most cases of oppression of the brain arising from a congestion of the cerebral vessels, large quantities of the most active class of cathartics will often be required to produce even moderate purgation. The nervous sensibilities are so deadened that all medicines fail to produce their ordinary effects upon the patient; hence the necessity of administering cathartics without regard to their usual doses; the only criterion to determine the quantity to be used, being the results which follow from their employment. The same remarks apply in cases where the narcotic poisons have been taken in over-doses. Derivation and depletion are the most important indications fulfilled by the employment of cathartics in these diseases.

V. Action in Diseases of the Liver.—In chronic hepatic diseases their importance is fully established. When the liver is torpid, or when it fails to furnish the proper quantity of the biliary secretion, or when there is jaundice, or congestion of the portal veins, and consequently of the abdominal viscera (all of which are of frequent occurrence), cathartics are of unquestionable utility. For restoring the biliary secretion, and removing the hepatic and portal congestion, the materia medica furnishes no agents equal to cholagogue cathartics. They act directly upon this organ, in addition to their cathartic effect, stimulate its secretion, and thus facilitate the passage of the portal blood through it. Their derivative action on the mucous membrane of the bowels, likewise assists to increase this secretion, by causing a determination of blood to this part; they increase the quantity which has to pass through the liver, and thus indirectly cause a determination to the liver.

The beneficial action of those agents which, while they act directly upon the liver, do not produce any irritation of the bowels, is very marked in many diseases. Thus, in chronic inflammation of the stomach, small intestines, etc., accompanied by torpor of the liver, such an agent as the leptandra virginica or leptandrin, which will stimulate the liver to increased action, increase the flow of blood through it, and thus remove the venous congestion of the inflamed organs, without increasing the inflammation by direct irritation, can not but be considered as meeting most of the indications to be fulfilled. As an example of such a condition, we may refer to the diarrhea or cholera infantum of children: in this disease we have a low form of inflammation of the small intestines, which in nearly every instance is accompanied by hepatic torpor. The agents just referred to remove this torpor without irritating the bowels, and by thus removing the congestion, a cure often results. This same class of agents prove very beneficial in hemorrhoids for the same reason: they increase the flow of blood through the portal veins, and thus the congestion of the hemorrhoidal, which is the lowest part of the portal circulation, is removed.

In acute or chronic inflammation of the liver, cathartics that produce an irritation of the bowels are contraindicated. They prove injurious by causing an increased determination of blood to the mucous membrane of the bowels, which blood has no means of returning into the general circulation but by passing through the liver in the portal veins; the action of such a cathartic then, is to cause a venous congestion of the liver, thus directly increasing the disease. Instead of such cathartics, those only which exert a very mild action should be employed—the purgative salts with some slightly stimulating, vegetable agent, being the most useful. Such a combination evacuates the bowels without producing irritation, and at the same time causes an endosmosis of the blood-serum to the canal; and thus proves directly depletive to the liver, by removing that which would otherwise pass through it.

VI. Action in Chronic Disease.—In chronic diseases, as in marasmus, scorbutic affections, scrofulous and cancerous habits, herpetic disorders, in all the various forms of inveterate and protracted cutaneous diseases, in obstinate and illconditioned ulcers, syphilitic and mercurial cachexy, in short in all the varied forms of disease manifested by a vitiated or depraved condition of either fluids or solids, cathartics are valuable auxiliary medicines. They act as depuratives, cleansing the stomach and bowels of any morbid materials lodged or generated in them, they excite the glands to increased action and thus eliminate morbid material from the circulating fluid. They are thus important depuratives, and with propriety might be called alteratives—at all events they prepare the way and act as auxiliaries to the proper alterative agents.

VII. Action in Amenorrhea.—This is another disease in which cathartics may be prescribed with advantage. Emmenagogue cathartics are preferable in some cases, while in others, the refrigerant, deobstruent and hydragogue classes are those to which experience points as being best calculated to fulfill the desired indications. If the patient becomes, languid or phlegmatic, and a chlorotic state supervenes, tonic and emmenagogue cathartics are proper. In this state of the system there is evident inactivity of the uterine vessels, evincing the want of a due concentration of the vital and vascular afflux to the pelvic viscera; such agents, therefore, as the aloes, black hellebore, etc., by causing a determination to the pelvis will prove the most efficient. It must be remembered, however, that the system is in such a condition that it can not bear depletion, and therefore these agents must be combined with chalybeates, tonics and stimulants, nutritious food and exercise.

On the contrary if a sudden suppression arises from cold, from an attack of some other disease, or from sudden and strong mental emotions, as grief, fear, anger, etc., in a patient of a plethoric habit and a vigorous constitution, then some of the hydragogue and refrigerant cathartics should be employed, aided by nauseating diaphoretics, perhaps emetics, warm fomentations to the pubic region, hipbaths, etc. In such cases depletion and relaxation are indicated. The object is to subdue exalted organic action, and remove the spasm of the extreme uterine vessels, when the arrest is dependent upon cold and torpor of these vessels; and when it results from some strong mental impression, the object is to restore the vascular and nervous afflux to the uterine system from which it has been withdrawn.

VIII. Action in Dysentery.—Cathartics are important therapeutic agents in the treatment of dysentery. Generally, the upper portion of the alimentary canal is in an obstinate etate of constipation, while some portion of the large intestines is in a state of high inflammatory excitement. The morbid secretions mingled with the imperfectly digested aliment, constitute a vitiated and highly irritating mass, which if retained in the bowels would augment the intensity of the disease. There is, likewise, in a majority of cases, torpor of the liver, and consequently congestion of the portal veins; the veins of the lower bowel being the most dependent of these, we have a constant venous congestion at the seat of the inflammation. The bowels become tumid and painful, and a high grade of arterial excitement follows. To remove this vitiated accumulation, stimulate the liver to action, and thus remove the venous congestion, and moderate vascular excitement, we have no substitutes for cathartics. Violent dysenteric tenesmus is likewise often speedily relieved by their action. They make a new impression upon the bowels, which is substituted for the original and morbid one.

In the early stages of dysentery, active, but not drastic cathartics are indicated—such as act principally upon the upper portion of the intestinal canal, and specifically on the liver. Subsequently the milder ones, or the proper laxatives—as rhubarb, magnesia, castor-oil, etc.—should be substituted.

IX. Action in Puerperal Fever.—In puerperal peritonitis active and even powerful purgatives are of immense importance. If administered early they not unfrequently arrest the disease with the aid of but very little other medicine. The evacuant, and consequently the depletive and sedative powers of refrigerant hydragogue cathartics, in lessening vascular excitement, and reducing the inflammatory action attendant upon this disease, render them one of the most, if not the most important class of medicinal agents.

X. Action in Rheumatism and Gout.—Arthritic and rheumatic affections demand the use of this class of agents—at least they are valuable auxiliaries to other remedies. Gout is generally connected with torpor of the liver and portal circle, together with functional derangement of the digestive organs; consequently suitable cathartics are of much utility in that affection. In arthritic and rheumatic complaints, the antiphlogistic power of cathartics tends much to the reduction of the inflammation. Their revulsive as well as cathartic and depletive properties, may aid in satisfactorily explaining their modus operandi in these affections.

XI. Action in Pneumonia.—In pneumonia, during the early stages of the disease, cathartics are a valuable class of auxiliary medicinal agents in reducing the inflammation. In the advanced stages of pulmonic inflammation, after free expectoration is established, there is strong objection to active purging, from its debilitating effects. In the early stages of the disease, they prove advantageous, principally from their derivative effect, and from lessening the amount of the circulating fluids. The irritation which they produce causes an increased flow of blood to the mucous membrane of the bowel, and hence the lungs are more or less relieved. As the disease progresses, however, nothing but the mildest purgatives should be employed, and these only to keep the bowels in a soluble condition; and when given they should always be combined with a sufficient stimulant, to counteract their debilitating effects.

XII. Action in Hypochondriasis.—In this disordered condition of the system, cathartics which act freely, without causing irritation of the bowels, have been found useful. In these diseases there seems to be a disordered state of the nervous system, arising probably, in most cases, from a dyspeptic and depraved condition of the stomach, functional derangement of the liver and torpor of the portal circulation, a costive state of the bowels, and disordered functional condition of the entire chylopoiëtic system. All of these symptoms will frequently yield to a persevering course of cathartics. Much advantage may be derived by combining them with antispasmodics—particularly with the fetid gums.

There are numerous other diseases in which cathartics prove very advantageous; but having pointed out, and as we trust, clearly illustrated the most prominent therapeutic indications which they fulfill in arresting disease, we shall leave he practitioner to apply them, as his judgment may direct, in the many various conditions of the system in which they may be indicated—but recollecting that as they are powerful agents for good when rightly applied, they produce much injury when improperly used.

Recapitulation.

The importance of this class of agents, and the great length of this chapter, may render a synopsis of the indications which they are supposed to fulfill, not only interesting to the student, but highly instructive.

1st. They remove the vitiated accumulations in the primae viae, and thus free the system from a frequent source of irritation and fever.

2d. They stimulate the glands of the bowels to increased action, and thus cause the elimination of morbid material from the blood.

3d. Some of them, termed cholagoguee, act specifically upon the liver, stimulating it to increased action; they thus increase the secretion of bile, and by permitting the free flow of blood through this organ, remove congestion of the portal system of veins.

4th. They reduce the quantity of the circulating fluids; acting as depletives they reduce the momentum of the circulation. If there is congestion or inflammation of any of the abdominal viscera, they act as topical or local depletives. For these reasons they are of great importance in febrile and inflammatory diseases.

5th. They act as revulsives. Hence their great value in apoplexy, phrenitis, cerebral congestions, and thoracic and abdominal engorgements.

6th. They promote absorption: first, they lessen vascular repletion, and absorption is active in proportion to the reduction of the circulating fluids; second, they remove the serous portion of the blood exclusively, and thus destroy the balance between the different constituents of the blood. The laws of physiology require the maintenance of each of its constituents in due proportion, and for this reason the activity of the absorbents is increased, to restore the lost balance between the constituents of this fluid, as well as between it and the solids.

7th. They equalize the circulation, and thereby counteract local congestion and inflammation.

8th. They are deobstruent and depurative, tending to remove any obstructions in the glandular or lymphatic systems, and promote all the secretions.

9th. They promote nutrition by a direct, and also a sympathetic action, which they exert upon the entire digestive apparatus; they cleanse, energize, newly impress and restore its functions.

10th. In diseases of a general character, either acute or chronic, they newly impress the nerves, arrest existing morbid impressions, break up abnormal sympathies between. different organs of the body, or so weaken them as to greatly assist the action of other remedies.

The American Eclectic Materia Medica and Therapeutics, 1898, was written by John M. Scudder, M.D.