Laxatives and Bowel Consciousness 'A Clinical Study" By

MANFRED KRAEMER, M.D., F.A.C.P.-; ~

T H E unrestricted and indlscrlmlnate sale and use of I laxatives has resulted in purgative addiction by a

large proportion of the American public. In order to obtain some facts in regard to the prevalent use of cathartics and the relation of constipation to the use of laxative drugs, a detailed laxative history was taken, along with the history of bowel habits in a series of 300 consecutive patients in private practice. Similar histories were taken on a number of patients at the gastro-intestina] clinics of the Newark Presby- terian and the Flower-Fifth Avenue hospitals. In view of the difficulty in obtaining accurate stories from clinic patients, the figures obtained from them are not reported. Their habits parallel those of the private~ group.

Nothing in this paper must be construed to re fer to const ipat ion due to organic obstruction (s t r ic ture or tumor) ' , or constipation resul t ing from spinal cord disease.

Ear ly in this study we ceased to regard constipation as a disease ent i ty and dropped the differentiation be- tween spastic, atonic, and rectal types as not worth considering ei ther from the point of view of etiology or t reatment . We have concluded tha t constipation as a disease ent i ty does not exist ; tha t constipation is a symptom ar is ing in a person's mind. Every pat ient had a different conception of constipation. The use of laxatives is evidence of bowel consciousness, not of constipation.

This study represents a fa i r cross section of the public (Table I ) . 61 different diseases were repre- sented. Of the 300 pat ients studied, 161 were males and 139 females. Table II shows the number in each age group. Only 2 pat ients declared tha t they had never taken a physic. Of the 300 eases, 36 females and 43 males took laxatives less frequently than 4 times a year (Table I I I ) . These 79 pat ients were excluded from the stat is t ics regard ing habit formation, for pat ients taking physics less often than once in 3 months can scarcely be considered bowel conscious. The incidence, therefore, of laxative addiction for the ent i re group was 73%. The proport ion in males and females was exactly the same. This is in contradiction of the general opinion that more women take laxatives than men. Since laxative addiction and bowel con- sciousness go hand-in-hand, we can conclude tha t over 70c<:j of our pat ients are sufficiently bowel conscious to take a laxative more frequently than once every 3 months. Fur the r , in regard to the frequency of taking laxatives (Table I I I ) : of the 300 patients, 71 or 21% took laxatives daily. 161 pat ients or 53% of the whole group took laxatives weekly or more often.

We thought it of interest to determine how many

"~From the :Newark Presbyter ian Hospital and the Depar tment of Gastro-Enterology of the New York Medical College and Flower Hospital.

7Chief, Gastro-Intest inal Clinic, Newark Presbyter ian Hospital. In- s tructor in Medicine, New York Medical College and Flower Hospital.

$Since the wr i t ing of this article 474 additional cases have been inter- viewed with essentially the ~ame findings.

TABLE I

Chief Chnical Diagnosis

Irr i table Cohm

Gast ro-Intestinal NeuroMs

Cases

37

34

Duodenal Ulcer

Hylmrten~lve Cardiac

Neurasthenia

Gastric Hyperacidi ty

Ulcerati~ e Colitis

Rheumatic Cardiac

Cholecystitls

Acute Appendicitis

Arteriosclerotic Cardiac

Chronic Ar thr i t i s

Grippe

Cholehthiasis

Gastri t is

Chronic Appendicitis

Syphilis

Achlorhydria

Diabetes Mellitus

Cathartic Habi t

Hemorrhoids

Proctit is

'2 Each :

33

25

18

16

11

9

9

S

7

7

5

5

5

5

3

3

3

"i

3

3

Cancer of Rectum, Chromc Nephri t is , Amebiasls, Duodenitis, Gastric Ulcer, Bronchial Asthma, Pulmonary T.B., Urt icaria , Manic Depressive Psychosis.

1 Each : Esophageal Cellulitis, Skin Cyst, Duodenal Dlvertlculum, Nephrolithiasis, Cancer of Esophagus, Incisional Hernia . Cancer of Stomach, Neuro- circulatory Asthenia, Migraine, Tonsillitis, Hysteria, Corryza, Polycystic Kidney, Hepatic Cirrhosis, Salpyngitis, Strain of Abdominal Muscles, Cancer of Prostrate , Pregnancy. Mesenteric Thrombosis, Cardiac Neur- osis, Hyperthyroidism, Sympatheticotonia, P remature Ventr icular Con- tractions, Cerebral Arteriosclerosis, Acute Gastro-Intest inal upset, Cancer of Vagina, Neurit is , Lymphat ic Leukemia, Lobar Pneumonia, Thyroid Cancer. Total : 300.

different laxatives were taken regular ly (Table IV) . 95 or 43% of the group took only one type or brand of laxative. 72 or 32% took two brands of laxatives regularly, and two of the group took more than 8 dif- ferent laxatives. A frequent reply to the question, "How many laxatives do you take?" is, "I take every thing I hear of."

While the common age of onset of the laxative habi t for both males and females was between the ages of 20 and 30 (Table V), there is a g rea te r disposit ion on the par t of girls than of boys to form the habi t under 20. This is probably due to the misconception tha t proper menstrual act ivi ty can pers is t only if asso- ciated with a daily copious bowel excretion.

As to the years of durat ion of the laxat ive habi t (Table VI) : 113 of the pat ients had been addicted for

9

1 0 A M E R I C A N J O U R N A L OF D I G E S T I V E D I S E A S E S

less t han five years , but 108 had been t a k i n g laxa t ives f rom 6 to over 40 years . There was no s igni f icant sex v a r i a t i o n in the d u r a t i o n of the habi t .

Table V I I shows the va r ious reasons given by p a t i e n t s fo r t a k i n g laxa t ives . The most f r equen t

T A B L E I I

Age of Pa t i en t

0-10

11-20

21-30

31-40

41-50

51-60

61-70

71-80

Total

Male

2

8

25

4(k

40

17

18

5

16l

Female

1

8

33

,%

21

23

14

3

139

answer to the quest ion, " W h y do you t ake l a x a t i v e s ? " was, "my bowels can ' t move wi thou t one," and the next most f r equen t answer was, "When I ge t a pa in in my s tomach ." Cur ious ly enough 6 pa t i en t s took laxa t ives fo r d i a r r h e a and 9, mere ly because they thought , " they were good for you," and 2 on "gene ra l p r inc ip les . "

A s tudy of the va r ious l axa t ives t aken (Table V I I I ) revealed tha t c leans ing enemas were the most popular , wi th mine ra l oil a close second. E n e m a s were not popula r w i th those who took laxa t ives f requen t ly , and were r a r e ly the only l axa t ive taken. In e n u m e r a t i n g the laxa t ives taken, the p a t i e n t would usual ly conclude, "and occasionally, an enema." No d i f fe ren t i a t ion was made be tween enemas and so called "h igh colonics." Those t a k i n g l axa t ives on a phys ic i an ' s order , usual ly took mine ra l oil or mi lk of magnes ia .

The ma in purpose in s t u d y i n g these pa t i en t s was to d e t e r m i n e on whom to place the b l a m e / o r the c rea t ion of bowel consciousness . F o u r g roups a re d i rec t ly re- spons ib le : a d v e r t i s e r s of laxat ives , the medical p ro fes - sion, p a r e n t s and f r iends . In the las t g roup a re in- eluded husband or wife . I t is difficult to accu ra t e ly d e t e r m i n e how much the o ther t h r ee groups a re in- fluenced by adve r t i s ing . We t r i ed as bes t we could in each ease to place the b lame where i t belonged. The a d v e r t i s e r s (Table IX) were respons ib le as o f ten as t he o the r t h r ee g roups combined. 21 of our pa t i en t s

TABLE I I I

Frequency of T a k i n g Laxa t ive s

Daily

Al t e rna te Days

Twice Weekly

Weekly

Twice Monthly

Monthly

Every 3 Months

Total

Number of Pa t i en t s

71

24

23

43

10

36

14

221

Less Than Once Every 3 Months

Males 43

Females 36

Total 79

t r aced the or ig in of t h e i r l axa t ive h a b i t to t h e i r paren ts . Mothe r s of ten ins i s t t h a t the ch i ld ren l ake a physic once a week, "to get a good c leaning out."

T A B L E I V

Var ie t ies of Laxa t ives Taken

I

2

3

4

5

6

7

8

Over 8

Total

Number of Pa t i en t s

05

72

22

15

5

6

2

2

2

221

Several pa t i en t s have told a s imi l a r s t o r y : "On S a t u r - day n i g h t a f t e r our ba th we were all l ined ul and given a t ab lespoonfu l of cas to r oil ."

A second ins tance where p a r e n t s can be b lamed fo r s t a r t i n g the l axa t ive curse is d u r i n g pube r ty . At th i s t ime many g i r l s look below pa r for reasons we cannot now go into. Mothe r asks, "Did you r bowels move today?" , and i f the answer is "no" or "only a l i t t le ," mothe r replies , "Oh my, you ' r e go ing to have the ~ame t roub les I had. I had the same difficulty and had to t ake phys ics and have been forced to take them ~very o the r day for twen ty yea r s since." Mother then pre - scr ibes he r f avor i t e physic and d a u g h t e r bec,)mes bowel conscious and the laxa t ive hab i t is s ta r ted .

Many o ther examples migh t be quoted r e g m d i n g the e s t ab l i shmen t of bowel consciousness and laxa t ive hab i t s by paren ts . In the presence of common colds, gr ippe , acute " s tomach upset ," or g a s t r o - e n t e r i t i s the pa r en t s f irst impulse is to a d m i n i s t e r a purge . No t only is th is "c lean ing out" followed by cons t ipa t ion fo r which the child will of ten take a n o t h e r c a t h a r t i c in a few days, but i t also assoc ia tes some malific influence in the chi ld ' s mind be tween the fecal contents and these diseases, i t is well known, t ha t colds, gr.:ppe, and acute g a s t r o - i n t e s t i n a l d i s t u r b a n c e s a re se l f - l imi t - ing and t h a t c a tha r t i c s a re of no p a r t i c u l a r benefit.

A c o n t r i b u t i n g cause of A m e r i c a ' s bowel conscious-

T A B L E V

Age of Onset of Laxa t ive Habi t

0-10

11-20

21-30

31-40

41-50

51-60

61-70

71-80

Males

3

9

45

26

19

9

7

l l S

Females

12

22

35

15

10

6

2

1

103

K R A E M E R - - L A X A T I V E S A N D B O W E L C O N S C I O U S N E S S - - A C L I N I C A L S T U D Y 11

ness is the a t t i t u d e of the medical p rofess ion . Th is a t t i t u d e mus t be expressed f r o m many angles . The phys ic i an not only f r equen t ly causes bowel conscious- ness on the p a r t of the pa t ien t , bu t in the t r e a t m e n t of the ave rage ease of cons t ipa t ion he cont inues an

T A B L E V I

Years Durat ion Laxat ive Habi t

0-5

6-10

11-15

16-20

22-25

26-30

31-35

36-40

Over 40

Males

70

21

9

II

3

]

1

2

11~

Females Total

43 113

17 38

13 22

16 27

3 6

3 4

1 1

3 4

4 6

103 221

a l r eady well es tab l i shed habi t . I confess t h a t I have r a r e l y i f ever wi tnessed any o rgan ic change resu l t f r om the use of laxa t ives and many may ask, " W h y bother abou t the sub jec t i f l axa t ives never h u r t any- body." My a n s w e r is, t ha t as p l )ys ic ians we mus t not only cure o rgan ic disease, bu t m u s t help our pa t i en t s over menta l difficulties. The l i fe of the ave rage ca- t h a r t i c hab i tue is of ten made mise rab le and is as lack- ing in happ iness as t h a t of many sufferers f rom chronic o rgan ic disease.

How do phys i c i ans in i t i a t e bowel consciousness? How of ten on a p p r o a c h i n g the sick bed, we f irst ask, "Did his bowels move t o d a y ? " Immedia t e ly , both pa t i en t and f ami ly are made bowel conscious. Pos t - opera t ive ly does not the su rgeon put on his most sober express ion and i n t e r r o g a t e the nurse, "Have the bowels moved y e t ? " Many su rgeons recommend the rou t ine

use of mineral oil or milk of magnesia post-operatively, and in many of our patients we have traced the onset of the laxative habit to this pernicious practice.

Physicians are markedly influenced toward the pre- scription of laxatives by the tremendous amount of

T A B L E V I I I

Names Laxat ives Taken Pat ients

Enemas

Mineral Oil

Milk of Magnesia

Epsom Salts

Cascara

Pills (name unknown)

Ex-Lax

Alopben

Castor Oil

Agarol

Magnesium Citrate

Feenamint

Petrolagar

Caroid and Bile Salts

Kondremul

Sodium Phosphate

Pluto Wate r

Liver Pills

Senna

Sodium Sulphate

Herb~

Sal Hepatica

N.R.

Glycerine Suppositories

76

65

52

37

28

22

18

15

15

13

13

8

Seidlitz Powders, Eno Frui t SaIts, A. B. and S. Pi l ls : 4 each. Syrup of F ig s : 3. Capsules {unknown type) , Serutan, Saraka, Rexall Orderlies, Regulin, Magnesium Oxide. Bile Salts, Licorice Po~vder: 2 each. Veracolate. Edrolax. Dr. Humpbreys Pills, Beeehmans Pills, Calomel, Norol Psyllium. Psyllium, Alpine Tea, Phenolax, Nee Cultol. Casearets, Mineral Water. Tar ran t s Effervescent Salts, I talian Effervescent Salts, l,netonts, I)oans Laxat ive Pills: 1 each.

TABLE VII

P a t i e n t ' s Reason for Takin~ l ,axatives

Bowels can ' t move

Pain in stomach or dibtress

Gas

Get cleaned out

Good for you

Distended abdomen

Pat ients

74

61

12

11

9

8

Headache

Hemorrhoids

Diarrhea

Rectal pain

Hear tburn

Feel filled up

Nausea, General principles, Hard stools: 2 each. Colds, Loss of pep, Af te r liquor, Acid stomach, Nervousness, Gall bladder attacks, Dropped colon, Don' t feel well, Palpitat ion, Biliousness: 1 each. Total : 221.

a d v e r t i s i n g which is d i rec ted a t them. One month ' s accumula t ion of l axa t ive a d v e r t i s i n g a r r i v i n g by mai l and cl ipped f rom Scientif ic J o u r n a l s fills a legal sized folder. T ry as he m i g h t the phys ic ian cannot escape the cons tan t b o m b a r d m e n t which d raws his a t t en t ion to " H a b i t Time," "Spas t i c Col i t is ," "The most pre- valent a i lment , " and the s u p e r i o r i t y of "Misc ib i l i t y , " Ol- "The phys io logica l r e s to r a t i on of bowel r h y t h m . "

In severa l ins tances in our series, in those eases l is ted as o r i g i n a t i n g t h r o u g h the phys ic ian , we have ob ta ined the fo l lowing type s tory. " A f t e r my opera- t ion I had t roub le wi th my bowels and unt i l I le f t the hospi ta l , I received an enema every day. When I a r r i ved home my bowels did not move for two days, so I called the su rgeon and he told me to t ake some mag- nesia. Later , when I went to his office he told me to take P e t r o l a g a r every night , and I have been t a k i n g i t ever s ince." Unwi t t ing ly , the well mean ing su rgeon has s t a r t e d a pern ic ious habi t .

The converse to wha t I s t a t ed p rev ious ly is also t rue. while I have never known a c a t h a r t i c to p roduce

12 A M E R I C A N J O U R N A L OF D I G E S T I V E D I S E A S E S

serious organic change, I have never found the reten- tion of feces for five or six days to result in any fu r the r hardship than a mild headache, a sense of full- ness or a difficult passage.

The obstetr icians are often the responsible par ty in the production of bowel consciousness. On the direc-

T A B L E I X

Etiological Factors Stimulating Bowel Consciousness

1. Advertising

2. Physician

3. Parents

4. Friends

Total

Patzent~

112

72

21

16

221

tions issued to expectant mothers, the following state- ment often appears. " I f the bowels do not move every day a mild laxative should be taken, either mineral oil, or milk of magnesia, or a low enema." How much bet ter it would be to omit any mention of the bowels or to state, " I f the bowels do not move for a day or two, do not become alarmed, they will eventually move of the i r own accord." I t is routine on the par t of many obstetr icians to prescr ibe laxatives or enemas daily, post-partum. This practice had best be discontinued.

There is still another way in which we, as phy- sicians, s t imulate bowel consciousness and that is, in the t rea tment of constipation itself. Instead of be- l i t t l ing the pat ient ' s complaint, we take it seriously and prescribe measures to combat the "disease." This insistence on our par t s to t rea t the condition, again is an instance of the provocation of the pat ient ' s imagi- nation toward the association of retained feces and some dreadful scourge.

This paper does not touch on therapy, but as a

general rule the prescr ibing of cascara or bran or regulin or mineral oil preparat ions merely subst i ;utes one laxative for another.

Lastly, we must touch on the influence of adver- t is ing on the establ ishment of bowel consciousness. 112 cases were traced directly to this source. The drug houses have taken advantage of the public's newly aroused health consciousness. Commercial succes.,~ ac- crues to any manufac ture r who can, by meant of adver t is ing create sufficient bowel consciousness ir the public mind to sell a person only a few doses of his product. Since laxatives are usually habit forwing, repeat orders pile up and a business is establishec.

Misbranding laxatives as candy and advertisin:~ to mothers to give regular doses of this or tha t purge assures not only one single sale, but continuous business even a f te r the adver t is ing stops. Some of our pat ients are taking "Liver Pills," and other proprie- t a ry prepara t ions which have been advert ised ei ther to physicians or to the public for twenty or more years.

CONCLUSIONS

A program for the prevention of bowel conscious- ness on the pa r t of the American public must be aimed at the source of this condition. F i r s t , parents musl be educated agains t the use of laxatives and must be cautioned agains t over-emphasizing bowel functmn. Second, physicians must be more guarded in prescrib- ing laxatives. They must show less concern regard ing the functional act ivi ty of the colon. They must t rea t constipation by wi thdrawing laxatives and not by l~re- scribing addit ional ones. Third, there must be a legal curb to the adver t is ing of laxatives, in the press, and the radio, and by mail.

Imaginary diseases and symptoms are real to ;he patient. Pa t ien ts ' lives have been made miserable be- cause of constant bowel consciousness and the constant use of laxatives. With 70% of our publie addicted to laxation by drugs or enemas, it is high t ime that sorae- thing be done about it.

The Treatment of the Individual in the Care of Peptic Ulcer By

JACOB MEYER, M.D.S and

J. KASANIN, M.D.w CHICAGO, ILLINOIS

A LTHOUGH it is generally recognized that there is no specific medical t rea tment for peptic ulcer, the

alkali management with a dietetic regime as suggested by Sippy, is accepted as a s tandard form of therapy. In ternis ts and surgeons at present agree tha t there are definite complications o~ peptic ulcer which require surgical t r ea tment but tha t in any case of peptic ulcer, a long period of carefully supervised medical t rea t - ment should precede any form of surgery. The surgeor~ ~are. p r imar i ly interested in the various types

-~From the Stomach Study Group and the Depar tment of Psychiatry, Michael Reese Hospital, Chicago, Illinois.

~Read at the Chicago Society of In ternal Medicine, February g2, 1937. :~Attending Physician--Michael Reese Hospital, Chicago. Illinois. w Psychiatrist--Michael Reese Hospital, Chicago, Illinois.

of operations, and the controversy has largely been as to the respective meri ts or- gas t ro-enteros tomy and gastr ic resection.

I t is our purpose in this communication to empha- size the importance of the t r ea tmen t of the individual as a whole. In addit ion to any accepted form of ulcer therapy, we feel it impor tant to t rea t the individual as well as the ulcer. The t rea tment of the individual 'is not advocated as a specific method for the therapy ,~f peptic ulcer, but follows the same principle as in other fields of medicine. However, i t is our impression tha t such t rea tment has its greates t field in the domain c f gastro-enterology.

Numerous observers have called at tention to the