With the compliments of the writerT CLINICAL STUDIES WITH LARGE NON-EMETIC DOSES OF IP E C A C U A N H A. RE-PRINTED FROM THE ATLANTA MEDICAL AND SURGICAL JOURNAL. ATLANTA, GEORGIA: DUNLOP, WYNNE k CO., PRINTERS, 11 NORTH BROAD STREET 1875. CLINICAL STUDIES vrrpa ; LARGE NON-EMETIC DOSES OF IPECACUANHA. By ALFRED A. WOODHULL, M.D., Assutmt Surgeon U. S. Army. RE-PRINTED PROM THE ATLANTA MEDICAL AND SURGICAL JOURNAL, ATLANTA, GEORGIA': DUNLOP, WYNNE & C.O., PRINTERS, 11 NORTH BROAD STREET. 1875. MEMORANDUM. This paper, prepared as a Special Report to the Surgeon General of the Army, was completed early in October, 1874. It was forwarded to that officer, and the retained copy was read before the Atlanta Academy of Medicine 19th and 26th of the same month. While transcribing it for the press Dr. Duckworth’s papers and the original French documents referred to came into my hands, requiring certain interpellations and additional notes, and delaying the MS. until this date. I believe that no essential fact in this new matter has been overlooked, and I am glad to say that I have detected nothing requiring a change in my previously expressed opin- ions, while some apparent confirmations have been discovered. I am under great obligations to Assistant Surgeon Billings, U. S. Aimv, in charge of the Surgeon General’s Library, for the use of books in that •collection otherwise inaccessible to me. The references marked with an asterisk (*) are derived at second-hand. Those not so marked I have personally examined. McPherson Barracks, Atlanta, Ga., 28th November, 1874. A. A. W. CEHNUCAL STUDIES WITII LARGE NON-EMETIC DOSES OF IPECACUANHA: WITH A CONTRIBUTION TO THE THERAPEUSIS OF CHOLERA. These clinical notes, and what seems to me a reasonable de- duction from them and from certain appended quotations, are respectfully offered for the consideration of the profession. Much that follows is not new, but merely corroborates the re- corded experience of others. Reading and observation, however, teach me that the influence that ipecacuanha exerts over dysen- tery and certain forms of diarrhoea is not practically recognized by many physicians who, while they have read of its power, hes- itate to employ the remedy. Notes of such cases may, therefore, be useful by inviting renewed attention to a subject which, in -some parts of our country, is of vital interest. The opportuni- ties at my disposal were taken advantage of to press the use of the drug further than is commonly done; and, that others may form an intelligent judgment, all the circumstances attending its administration have been carefully noted, although in some in- stances it may be that no positive benefit followed, and the cases have been narrated in greater detail than would be proper in a .report simply covering admitted therapeutic ground. It follows, therefore, that, besides the confirmatory cases, oth- ers are recorded which, so far as I know, belong to a new class. Whatever similar experience other medical men may have had, ibis is certainly original; and attention is invited to the route by which it was reached, but especially to the results attained. Fi- nally, a suggestion of possible value is advanced for the consid- eration of those who may have the opportunity to use it. The cases are entered chronologically. All in which the drug was 4 NON-EMETIC USE OF IPECACUANHA. need in- this way ai’e reported, and no essential condition that was observed, either for or against the method, is omitted. Having had at other posts a moderate experience that was favorable in the treatment of dysentery by large doses of ipecac- uanha, and being acquainted with the East Indian reports on the subject, I resorted to it here at the beginning of the warm season. Case I.—C. D., who had suffered with a severe diarrhoea sev- eral days, cxme upon the sick list lOtli May, 1874, and was at once admitted to hospital. He had fever, severe pain in the bowels, small bloody discharges with straining—in short, dysen- tery. He was at once put to bed, and was given tinct. opii to. xv., followed in half an hour by pulv. ipecacuardia? gr. xx., in as little water as possible, and a sinapism was applied to the stomach. This was repeated four hours afterward. There was no emesis; the bloody discharges at once ceased; the pain and tenesmus gradually passed away; a stool, soft but not dysenteric, occurred in the middle of the day; by evening he expressed him- self as feeling very comfortable. No more medicine was given, but he was kept in bed two days. He was sent to quarters ‘22d, and returned to duty 24th May. Case II.—J. H. F., a soldier of twenty years* service, sea- soned, and in good general health, although an occasional hard drinker, came upon the sick report 29tli May, 1874, with a typi- cal case of acute dysentery. The attack was recent, but the symptoms were severe, and he was suffering extremely. He was immediately put to bed and was given tinct. opii m. xx., followed in twenty minutes by pulv. ipecac, gr. xxv., in a small quantity of water, and by a sinapism. The bloody stools ceased forth- with, and he began to perspire and to feel relieved. The dose was repeated in six hours, and ten grains more were given at 9 p. m. There was no vomiting. One or two copious evacuations, without pain and bloodless, occurred during the day, and by noon he declared himself much better and free from pain. The next day (30th), with no other treatment, he was quite well, but very weak. The prostration remained several days, but there was no return of the disease itself. Case III.—A. II. was admitted to hospital 7th June, 1874, for a severe attack of diarrhoea with a dysenteric tendency. He was first given magnes. sulph. 3iv., olei ricini f.3ij., tr. opii vi. v.; but no particular improvement following, the ipecacuanha was resorted to, as in the previous cases, with prompt relief. He was returned to quarters 10th, although a bronchial catarrh kept him on the report till 16th June. Case IY.—AY. II., in hospital with a severe diarrhoea, The ordinary remedies not relieving him, and as he complained of a XOX-EMETIC USE OF IPECACUANHA. 5 severe pain in the transverse colon, although no blood was passed nor were there anv direct symptoms of dysentery, the ex- periment was tried of giving, with the tincture of opium and mustard as usual, twenty-five grains of powdered ipecacuanha, at 9 p. m., 19th June, 1874. He slept well that night, felt much better the next day, was returned to quarters 21st, and to duty .23d June. Case V.—B. R., admitted with a severe diarrhoea, 19th June, and, complaining almost identically with the preceding case, re- ceived two large doses of ipecacuanha, on 20tli. One of these induced some vomiting, but the severe pain in the colon ceased, although the diarrhoea lingered a number of days longer. Re- turned to duty 9th July, 1874. (See Case X V.) Case YI.—"VV. B. O. was admitted to hospital, 16th June, 1874, in a jaundiced condition from some functional hepatic de- rangement. He improved sufficiently to be returned to quarters 24th. At sick call, 27th, however, he was so changed in appear- ance and condition as to require immediate re-admission to hos- pital. He asserted that the greater part of the previous day and night he had suffered frequent and painful purgings and vomitings. He was at once (6:30 a.m.) given a bed. On visiting him at eight o’clock he said that he had had seven stools and as many attacks of vomiting within the past hour and a half. These wTere painful, the discharged matter was dark brown, there were constant abdominal pain and great thirst, his face was haggard and pinched, his skin was cold and bluish, his pulse very feeble, and his general condition one of great prostration. Having Cases IY. and V. in mind, where severe abdominal pain, although much less in degree, subsided after the use of ip- ecacuanha, and believing, as I did, that this drug exerted a di- rect influence upon the intestinal excreting surface, and possibly upon the liver, I regarded this as a fair case in which to employ it, provided it could be retained. He was therefore at. once given tr. opii m. xx. as preliminary. In a few minutes he threw , the intense intestinal congestion of collapse] were produced by a special poison acting upon the nerve centres, even, which regulate the supply of blood in the arteries generally, how does it happen that the nerves and arteries of the intestines are either exempted from the peculiar influence or are acted upon in just the reverse manner; the small intestines (and in a less degree the large intestines) being the only portion of the body to which an active determination of blood has occurred?” (p. 530.) This question finds a positive an- swer in Flint’s words, where he discusses the experiments of Cyon on the depressor nerve: “ We are sufficiently familiar with reflex paralysing action upon the blood-vessels through the sym- pathetic system; and when we call to mind the immense extent of the abdominal vascular system we can readily understand how, if the resistance to the flow of blood be diminished by paralysis of the muscular coats of the small arteries, the pressure in the large arteries would be reduced ” (iv., p. 232). Dr. Jeaftreson, in the same article, describes the whole ab- normal condition thus: “The chain of causation appears to be the following: A poison in the alimentary canal acts there as a direct irritant, causing more or less rapidly-developed congestion and inflammation of the whole small intestine, to which much blood NON-EMETIC USE OF IPECACUANHA. 37 is determined. The intestine, meaning by the term the tissue of the various coats, becomes full and turgid, and acutely oedeinat- ous, whereby a strong rapidly-developed impression, resulting in shock, is made upon the innumerable and widely-spread branches of the sympathetic from the solar plexus by which the duodenum, jejunum and ileum are supplied. [I do not understand that the shock is necessarily or probably due, as Dr. Jeaffreson expresses it, to afflux of blood, but that, rather, the afflux follows the par- alysis of the abdominal sympathetic from some toxic principle directly affecting it.—a. a. w.] The well-known intimate con- nection of the solar plexus with the splanchnic and pneumogas- tric nerves, and also with the posterior roots of the correspond- ing spinal nerves, insures the diffuse spread of this impression, amounting to a shock, from which results a general slow contrac- tion of the organic muscular fibres of the whole arterial system, affecting not only the pulmonary artery but the systemic arteries, including those of the kidneys and spleen, which are found anse- mic after death, and also including, in all probability, the hepatic artery, though, from the peculiar nature of the circulation in the liver, the effects there are less manifest ” (p. 531). Mr. Sedgwick, in a very valuable article ‘ On Some Analogies of Cholera in which Suppression of Urine is not accompanied by symptoms of Uraemic Poisoning,’ {Med. Chir. Trans., li., 1868, p. 1,) very clearly shows that the ingestion of certain sub- stances which might be presumed to cause blood-poisoning, such as decaying animal and vegetable matters, milk that has under- gone some morbid change, various fungi, but also violent irri- tants,f as excessive doses of arsenic, nitric acid and other cor- rosive poisons, and, further, many severe accidents and incidents attending on disease, as wounds of the abdomen, and lacerations and perforations of the stomach and upper intestines, induce a collapse that in no essential respect can be distinguished from that of cholera. He says: “There will not, however, be much difficulty in recognizing, on further inquiry,- that, whether the mischief be the result of perforation or of obstruction of the small intestine, the suppression of urine which results from it I To speak of ‘ “irritants,” “irritating substances,” etc., in the bowels,’ often misleads. Usually irritation is looked upon as akin to stimulation; but as used in the text the facts will be quite as well understood by describ- ing them as ‘paralysing,’ which is the state of the case as far as the nervous system is concerned. —a. a. w. 38 NON-EMETIC USE OF IPECACUANHA. must be regarded chiefly as an indication of the intensity of tke- collapse, consequent on the comparative suddenness of the mis- chief, and its nearness to the abdominal centre of the sympa- thetic nervous system; in the same way that a corresponding suppression occurs in severe cases of cholera, whilst in mild cases of this disease which it has been customary to refer to as- choleraic diarrhoea, there may be, and usually is, the character- istic flux without any suppression of urine” (p. 27). Among other contingencies in which the collapsed condition with urinary suppression occurs is intestinal obstruction, and it has generally been accounted for by the degree of peritoneal inflammation or the amount of vomiting: but Mr. Sedgwick points out “that any correlation which may exist between vomiting and suppression of urine in these cases appears to be simply the result of both conditions being primarily dependent on the affection of the ab- dominal nervous system ” (p. 34). Attention is particularly invited to this opinion, as consonant with the original views to be expressed later in this paper. And in reply to those authors who suppose “that the suppression of urine, if not the collapse itself, is essentially dependent in cases of cholera on the flux from the stomach and bowels,” he asserts that “not only is there ample evidence derived from direct observation to refute it, in addition to the evidence which has been adduced from analogy, but that there is, moreover, a self-destructive fallacy in thus sup- posing that the digestive canal could serve for the complete es- cape of excrementitial matter usually discharged by another out- let, whilst the elimination of excrementitial matter proper to the canal itself is completely checked. For just in the same way that jaundice results from the increasing accumulation of the essential elements of bile in the blood, and imemic poisoning from the increasing accumulation of urea, so the absence of these two morbid conditions shows that during collapse there is no excess of excrementitious matter for either the kidneys or the liver to eliminate, and therefore no urine is conveyed to the blad- der and no bile to the alimentary canal” (p. 41). We may well agree with Mr. Sedgwick that “ although anal- ogy can only be referred to for the purpose of supplying indirect evidence, yet, on the present occasion, this is so strongly in favor of cholera being primarily due to an affection of the sympathetic nervous system developed through the medium of the digestive canal, as scarcely to need any further evidence to support it”‘ NON-EMETIC USE OF IPECACUANHA. 39 (p. 42). And we may credit the statement of Dr. Davey, whom he quotes, that “ the fatal depression in cholera, consisting in the complete annihilation of the action of all the vital organs, may be at any time simulated by pressing the solar ganglion on the fore part of the bodies of the vertebrae over which it lies ” (p. 43). And, as Mr. Sedgwick remarks in a postscript, important evidence in support of that argument has been supplied by M. Moreau’s experiments (already cited) on section of the abdom- inal nerves in relation to intestinal ilux. When death does not occur in the condition of collapse, the stage of reaction sets in. This is generally admitted to be a febrile state that is to be treated on general principles, bearing- in mind both the nervous prostration lately undergone and the possibility of reinducing it by want of care. This recapitulation, containing nothing that is original or has not been published before, may seem superfluous; but it is made a part of this paper for convenience of reference. We have now reviewed the experimental use of ipecacuanha in bowel affections, and have presented an outline of the pathol- ogy of Asiatic cholera as at present held. It remains to bring the two into efficient accord. The present* state of medical science does not permit us to generalize nor even to frame a plausible hypothesis upon the correlation of diseases, except in a very limited and doubtful de- gree. But neither does it allow us to consider them as isolated foreign entities, that may be implanted or plucked out of the human system as integers. There is often an undeniable blend- ing, and the distinction between members of many well-marked groups is frequently one that implies affinity as well as diversity. Thus, erysipelas and puerperal fever, diphtheria and scarlet fever, are examples of such rudimentary consanguineous grouping. These collections of symptoms, fusing with more or less com- pleteness, connect pathological classes that in appearance are quite distinct. And the real object of this portion of this paper is to invite attention to the presumed benefits that will accrue from the employment in epidemic cholera of ipecacuanha, which is known to be strikingly useful in other diseases that, in my opinion, may claim kinship with that pestilence. This will be attempted by the citation of authentic cases and by quoting state- ments and opinions of reliable observers in illustration of the different steps of the problem. 40 NOE-EMETIC USE OF IPECACUANHA. The first, reported by Mr. John Higginbottom (Lancet, 1845, p. 732,) under the title, “Ipecacuanha, in Emetic Doses—as a Powerful Restorative in some cases of Exhaustion and Sinking,” is reproduced in detail on account of its intrinsic interest, and from the comparative inaccessibility of the original. He says: “ In the year 1814, I was first led to see the extraordinary bene- ficial effects of ipecacuanha as an emetic, in a female forty years of age, who was in a sinking state in the last stage of cholera [morbus]; her countenance was shrunk, extremities cold, cramp in the legs, and other symptoms of approaching dissolution. I had previously attended two similar cases, where I had given opium, brandy and medicinal cordials, and both patients died. I was induced, in this instance, to give a scruple of ipecacuanha, from having frequently seen the good effects of it in the early stage of the disease. After the lapse of two or three hours, I again visited my patient, fearing I should find her dead, but, to ray great pleasure and surprise, so great a change for the better had taken place as to appear almost incredible; the whole'of her body was of a natural warmth, the dangerous symptoms had dis- appeared, and she made no complaint, except that she was very weak. She had no further unfavorable symptom of the disease, and was soon convalescent. [Compare with cases VI. and VIII. ante.] My confidence in the ipecacuanha, as a remedy in such cases, has now [1845] been confirmed during the practice of thirty years; the purging, vomiting and cramp often entirely cease after the emetic operation of the ipecacuanha, but I have thought it proper to give, in about two or three hours after the emetic, a pill, with a grain of opium and five grains of blue pill, to allay any remaining irritation of the stomach and intestines, and an aperient with one scruple of rhubarb and two of the sul- phate of potash, to assist the natural action of the bowels, and a simple saline effervescent draught every two or three hours after- wards; weak tea, well-boiled gruel, milk, with sago or arrow-root as nutriment, and diluents.” This case appears to be typical, and was reported not as being unique but as an example. In the same paper Mr. Higginbottom cites the case of a lady who was sinking rapidly from post partum haemorrhage in 1827, whom he had previously attended in a similar condition in 1821 and 1823, using then various remedies; and having observed that in the former instances “there was no amendment until she had ejected the contents of the stomach,” gave her half a drachm of EON-EMETIC USE OF IP EC A CUE AN A. 41 ipecacuanha as an emetic. A full vomiting followed and “the haemorrhage ceased directly, and did not return.” He also gives the case of a very delicate lady, aged 23, who, undergoing a severe labor with puerperal convulsions (for which twenty ounces of blood was taken), and embryotomy also having been performed, “was exceedingly low afterwards.” His record reads: “About the ninth day she complained of severe pains in the course of the colon, particularly at the caput coli and the sigmoid flexure.” “Mustard plasters were applied and active purgatives, with benefit, but a continued vomiting came on at- tended with considerable lowness. Dr. Hutchinson was called in to visit her with me. Injections of half-a-pint of beef-broth with half an ounce of turpentine were administered every four hours; a common blister of canthai’ides was applied to the scro- bicuius cordis; plain gruel and other light nutriment was given, as most likely to remain on the stomach. The vomiting still con- tinued; the turpentine injections occasioned much pain after they were administered, and there "was an alarming increase of exhaustion and sinking. In this case it occurred to me that an emetic dose of ipecacuanha was the most probable remedy to rally the sinking powers and, with the concurrence of Dr. Hutch- inson, I gave half a drachm and remained with her during its operation. A fuller vomiting occurred than I could have ex- pected although it was small in quantity, yet it occurred to me that the natural effort had long been exerted in vain to accom- plish what the ipecacuanha directly effected—that of completely emptying the stomach. I remained with my patient an hour, and left her somewhat better. After I had gone she turned her- self on the left side and remained so still for several hours as to alarm her husband, who sent for me directly, fearing she was dying. I found her pulse much improved; she was still lying on her left side; the sickness had abated.” She rapidly and fully recovered.j" It is ungracious to criticise a record so valuable, but it appeal's to me that the action of the drug and, in a degree, the condition f Duckworth states (St. Barth. Eosp. Rep. vii., p. 121,) that Mr. Higgin- bottom (Brit. Med. Jour., Feb. 1869,*) reports ca°es of post partum flooding “where it checked the bleeding after ergot of rye had failed.” He adds, however, (p. 122,) that Mr. Higginbottom also reports a case of flooding “at once checked by the vomiting induced from the irritation of the fauces by a feather. ” 42 XOX-EMETIC USE OF irECACUAXHA. of the patients have been misinterpreted by the reporter. In the first, or cholera morbus case, which is set up as a precedent “confirmed during the practice of thirty years,” it is probable that the use of the drug “ as an emetic ” was an unnecessary ex- hibition of its powers. If the same quantity had been given with the precautions that now are taken, it is altogether likely that the same effect, without the vomiting, would have been at- tained. It seems to have been given in that case as a last resort, because emesis often relieves the disease in its earlier stages by removing the irritating ingesta which may then be the exciting cafise. But here the conditions were wholly different, for she “ was in a sinking state in the last stage of cholera.” Nor is there any record of the ejection of such offending matter. How far the succeeding medication of opium, blue pill, aperients, saline effervescents, etc., may be necessary must depend upon the indi- vidual cases. But even in Mr. Higginbottom’s opinion they are but secondary and incidental. In the second, or the post par turn haemorrhagic case, it is not at all clear that the vomiting qua vomiting was the cause of the improvement. It seems to me that here the propter hoc and the post hoc have again been confused. A reason why improvement and recovery followed, and how the ipecacuanha and not the vomiting may have been the efficient cause, will be presented later. In the third case it really appears that the emesis had noth- ing to do with the cure, for that function had repeatedly been, exercised without benefit. As the case progressed, it is recorded, “ a continued vomiting came on, attended with considerable low- ness.” This was clearly a pathological condition and it was chiefly to relieve it, the sign of marked vital depression, that the later efforts of her physicians were directed. There is no history of irritating ingesta here, and to suppose that the pathological vomiting was cured by the artificial vomiting would be the purest homoeopathy. Moreover, it is expressly noted that, although it was fuller than could be expected, “ it was small in quantity.” I must, in this case also, regard the vomiting as incidental. It, further, seems to me that the puerperal of this patient is chiefly significant in that it damaged her general health and depressed the sympathetic, and that the suffering in the colon, which has made no special impression on the reporter, and the fSee Trousseau’s views, to be noted presently. RON-EMETIC USE OF IPECACUANHA. 43 intestinal disturbance generally, bring the case into direct rela- tion with some of those that make up the original reports of this paper. More than twenty years later (in 18G8) Mr. Higginbottom read before the British Medical Association a paper upon “ Ipe- cacuanha in Emetic doses as a Stimulant, Restorative, Elimina- tive, and Adjuvant, in various cases of Disorder and Disease.” I have been unable to consult the original memoir, but it is thus somewhat vaguely epitomized; {Brit. Med. Jour., 22d Aug., Rankings’ Abst., xlviii., p. 92.) “The author inferred that the interests and advancement of the profession could not fail to be greatly promoted by a long, careful, and practical investigation of a single therapeutic agent. He was of opinion that emetics were much less used than formerly. Ipecacuanha, besides its specific properties as an emetic, expectorant and diaphoretic, had other valuable properties which he believed had not been partic- ularly noticed by the profession. He had constantly, for more than half a century, administered ipecacaunha in English cholera,, fevers, erysipelas, neuralgia, periodical drunkenness, uterine haemorrhage, complaints in old age, syncope, senilis, etc. The main efficacy of ipecacuanha is in stimulating and restoring the normal action of the capillary system.” Although the notion of necessary emesis is very manifest in this abstract, the last sentence contains the kernel of his fifty years’ experience—its main efficacy is in stimulating and restor- ing the normal action of the capillary system. Further teaching as to the power of this drug may be found in a Clinical Lecture on Parturition, by Tyler Smith (Lancet, 1848, ii., p. G58). “ 2. Ipecacuanha is another medicine which is sometimes given in uterine haemorrhage. This medicine, by its emetic action excites contraction of the abdominal muscles and compression of the uterus, which in turn may re-excite some amount of uterine reflex action, but over and beyond this it ap- pears to have a special action upon the uterus, increasing its contractile power beyond what we could imagine to occur from the merely secondary effects of vomiting. Ipecacuanha, then, appears to influence both the medulla oblongata and the lower medulla spinalis. This double action of ipecacuanha upon the extremities of the spinal centre is very extraordinary.” This is 44 NON-EMETIC USE OF IPECACUANHA. a direct recognition of its possession of virtues beyond, if not in- dependent of, its emetic quality, f In internal haemorrhages generally, Mr. Trenor (Waring, op. ■cit., p. 3G0; fr. Dublin Jour.,* xviii., p. 481,) “gives it in such doses as to produce nausea, without actual vomiting; and this procedure was attended with marked benefit, arresting the haem- orrhage, and restoring heat and life to patients who were in a state of collapse from excessive loss of blood.” Dr. Osborne gives in uterine haemorrhage and menorrhagia twenty grains of the powder “in the evening, followed by an acidulated draught in the morning. The discharge usually ceased in twenty-four hours; and if a relapse occurred, a repetition of this emetic never failed to render the cure permanent.” (Waring, op. cit,., p. 300; fr. Trans. Irish Col. Pliys.,* v., p. 18.) If it is a mere evacuant, it is contradictory to attach to it such attributes. Very weighty testimony to the haemostatic property of the drug is given by Trousseau (Clinical Medicine, Eng., fr. 3d Fr. ed., i., p. 540,) where, treating of haemoptysis, he says: “When the parenchymatous haemorrhage is obstinately recurrent ipecac- uanha [in small doses] is a remedy which seldom fails. I am not at present referring to ipecacuanha administered as an emetic, which is more to be relied on in what is called bronchial haemor- rhage.” He then cites a case of the latter sort where a patient “twice within the space of six months had frightful haemoptysis: twice it was immediately arrested by four grammes (rather more than a drachm) of powder of ipecacuanha, administered within the space of half an hour in such a way as to cause violent vom- iting.” He also details several other cases with the same result and proceeds: “Should, however, there be a relapse of the haemop- tysis, the use of the ipecacuan must be resumed. I never hesi- tate in such circumstances to return to it two or three times, if necessary, and I have never seen the least inconvenience result from the proceeding. Gentlemen, this is not a new method of f Doulcet and Desormeaux used it successfully iu epidemics of puerperal fever in 1782. Trousseau and Recamier employed it in all the conditions of puerperal origin, regardless of their cause or nature, and always with bene- fit. Polichronie, citing these facts, (op. cit., pp. 20-21,) attributes the good results to the relief of the gastric embarrassment [by emesis]. Trousseau asserts that ‘nearly all the complications [accidents] that accompany the puerperal state are charmed away by ipecac.’ (Considerations sur VIpecacu- anha en Medicine. These par V. Decugis. Montpellier, 1866, p. 45.) NON-EMETIC USE OF IPECACUANHA. 45 treatment. For the last two centuries, physicians have lauded the Brazilian root as a remedy in all forms of haemorrhage; and Baglivi [1696] says: 1 Radix ipecacuanhce est specificum et quasi infallibile remedium influxibus dysentericis, aliisque hcemorrhagiis.’ Nevertheless, gentlemen, the hand trembles when it administers this remedy for the first time in the hsemoptyses. We are accus- tomed to prescribe the greatest quietude to our haemoptoic pa- tients : we counsel them to keep absolute silence: we tell them to restrain the slightest effort to cough: the very most wre allow them to do is to breathe, and so frightened are we for congestion, even passive congestion of the lung, that we act as if we placed them in peril by permitting them to make the slightest effort. Yet here we are giving a medicine which produces vomiting, during which the face swells, the blood stagnates in the veins by which it is being conveyed to the auricles: and consequently, the pul- monary veins become distended. One might expect that such treatment would cause the haemoptysis to return in a much more profuse degree; but in place of this, it is stopped in nearly every case. Here is one proof more of the small reliance to be placed on theoretical explanations, and of the value of empirical facts, without which, indeed, therapeutics would be a nullity.”f It may not, perhaps, be presumptuous to suggest that the time is approaching when theory, as well as empiricism, will support the practice. The latest clinical record as to this feature of that medicine that has fallen under my notice is by Dr. William Martin (New York Medical Journal, xiv., 1871, p. 177,) who reports a case of wound of the right tonsil, to the apparent depth of two-thirds of an inch, by a bamboo pipe-stem. No serious immediate haem- orrhage occurred. Twenty-one hours afterward there was “pos- itive jutting arterial haemorrhage from back and upper surface of the wound which altogether presented a most discouraging and alarming appearance.” There was general tumefaction, headache in the region of the lateral meningeal arteries, and the patient was “in a state of prostration and fear.” There were prescribed twenty grains of chloral, and a gargle containing one part in four of muriated tincture of iron. Nine hours afterward there was no change except suffocation was complained of, and fDuckworth (St. Barth. Hosp. Rep., vii., 1871, pp. 117-121,) cites an interesting collection of authorities on this point, and reports three success- ful cases of his own where small doses were used. 46 NON-EMETIC USE OF IPECACUANHA. Dr. Martin writes “(and being quite certain that haemorrhage was not from the carotid) I gave two-grain doses of ipecac, every hour, till third dose caused gentle vomiting, and with it immediate contraction of the tonsil (thus lessening wound) and causing haemorrhage at once to stop.” The bleeding did not recur and no other haemostatic was used. Dr. Martin adds these remarks: “ * * I am quite convinced, from the experience of nineteen years, that the theory and practice of my lamented teacher, Sir ‘William Lawrence, Bart., that in such cases where capillary haemorrhage occurs and the position of the main artery danger- ous, that after the administration of small doses of ipecac., until a gentle vomit is caused, natural plugging follows, contraction of tissues and safety is insured, for in such cases and under such treatment muscular contraction never fails. I have tried it many times (even so late as last week) in obstinate contraction [?] of uterus and never experienced ill effects.” In his lately published papers, {Prog. Med., Nos. 12, 16, 25, 28, 29, 30, 1874,1 and this is a very interesting confirmation of the views herein expressed, M. Chouppe reports the successful use of ipecacuanha in ten out of twelve cases of excessive per- spiration in phthisis. See also Polichronie {op. cit., pp. 46-50.) We have no .v collected sufficient testimony to illustrate the possession by ipecacuanha of peculiar powers, and powers that are not generally appreciated. It is evident that the incredulity with which the accounts of its extra-emetic properties are gen- erally received, is largely due to the want of a plausible theory broad enough to cover the apparently antagonistic conditions. It remains, then, to offer a reasonable explanation for the recon- ciliation of some seeming discrepancies, and to present an hy- pothesis that may assist in the treatment of the cholera. And in this matter the latest systematic writer (H. C. Wood, op. cit., pp. 364-5,) gives us license for speculation when he announces ex cathedra that “its physiological action is not, as yet, well made out” and “it is evident that until further studies are made it is impossible to frame any accurate theory as to the action of ipe- cacuanha. ”f fTlie following are the views of some of the later students as to the action of this drug: Trousseau and Pidoux regard it as a styptic when used in internal haem- orrhages (Duckworth, St. Bari. Jlosp. Bep., v., 1809, p. 220). NON-EMETIC USE OF IPECACUANHA. 47 The common understanding of the action of this drug, in other than very small doses, is that it vomits. Ipecacuanha and emesis are as synonymous, popularly, as opiate and anodyne, but that it is not inevitably an emetic, there are fifty proofs in this single record. It is notorious that the nausea of ipecacuanha, when vomiting does occur, is of short duration and is not intense. To diminish the force of the circulation, to deplete, to locally irritate the stomach, which are the modes of action attributed to Pecholier (Mecherches experimentales sur Vaction physiologique de i’ipecacu- anha, par G. Pecholier. Professeur, etc., 1862,) explains (p. 7) its reputed benefit in many diseases by its emetic and evacuant effects in those which are complicated with gastric disorder. He finds it very depressing (hypos- iiimisante tres-proncmcee) upon rabbits and frogs, and considers its legitimate action to be temporarily depressant upon the nervous system, the ephemeral duration depending on its elimination (pp. 47-9). In some cases there is a temporary reaction after the severe depression (p. 51). Its good effect in pneumonia is due to its revulsion upon the intestine (p. 53 ). He believes that its irritant effect is so great as to render it hurtful in true gastritis and enteritis, but that its usefulness in dysentery arises by the revulsion it in- duces from the large to the small intestine (p. 39). He claims (p. 50,) Gia- comini and the whole Italian school as agreeing with him in classing it among the counter-stimulants. Duckworth (op. cit., v., p. 222, ) supposes that emetia excites the vaso- inkibitory filaments of the vagus, resulting in inaction of the motor branches and a condition of paralysis or passive dilatation of the blood-vessels presided •over by this nerve. But the same writer also says of it (vii., p. 100,) “an irritant action may directly excite the vaso-motor centre [medulla oblongata?] and so cause increased contraction of the smaller arteries and possibly of the capillaries” either directly or by reflex action through the vagus, These suppositions appear to attribute directly opposite properties to the drug. Chouppe (Progres Medical, No. 29, 18th July, 1874,) says: Ipecac, ab- sorbed by any channel seems at the very moment of its absorption to produce an anaemia with dryness of the intestinal mucous membrane; perhaps if the action of the medicine is prolonged, it is eliminated more abundantly by the .gastro-intestinal mucous membrane (which is not yet irrefutably proved) than by the other emunctories, and it may produce inflammation and haemor- rhages. He acknowledges (No. 30,) the great difficulty of determining how it acts in the pro use sweating of consumption, but suggests that it may be through the vaso-motor system. Polichronie (op. cit-, p. 97,) concludes that no vaso-constrictor action is exerted by it, but that it diminishes arterial tension, and it probably induces a revulsive action which results in inflammation of the mucous membrane of the intestine; and that it acts in the diarrhoeas by substituting for the patho- logical inflammations an open (franche) inflammation which spontaneously •tends to recovery. He thinks it checks profuse sweating either by being eliminated through the sudoriporous glands, thus drying up (t irir) their se- cretion, or by its revulsive intestinal action. 48 FOX-EMETIC USE OF 1FECACUAX1IA. it by those who hold that its curative action in dysentery depends on emesis, all would be much better accomplished by other agen- cies than this; while the coup de grace to the emetic idea is given by the fact that the less the emesis the more effectual is the treat- ment. Anjr one who has seen all the characteristic and painful symptoms of dysentery subside in a few hours, and commonly with- out vomiting, under a full dose of this drug,would neither anticipate nor obtain similar results from any emetic as such.f As we have already seen, Dr. Tyler Smith, twenty-five years ago, ascribed to ipecacuanha a peculiar power over “ the lower medulla spinalis ” entirely independent of its emetic properties, which he attributes to its action upon the medulla oblongata. It seems to me, speak- ing modestly, that emesis is one of its accidental and non-essen- tial qualities. Now while the dynamics of vomiting, the mechanical opera- tion of the function, is fairly understood, its essential cause or causes are yet obscure. Flint observes (Phys., iv., p. 30G,) “It is undoubtedly induced by causes which operate through the nervous system * *. Irritation of the sympathetic nerves, particularly of the abdominal ganglia, will produce vomiting. * * there are many avenues for the passage of these impressions to the nervous centres. * *. The action of emetics which operate through the blood * * is probably induced by the direct im- pression made by these substances on the nervous centi’es.” Pro- fessor Carson, discussing the action of emetics, says (Phi!a. Med. Times, ii., p. 344): “In many cases a state of exhaustion or loss of nerve-generating force is at the foundation of this excessive susceptibility to impressions that occasion vomiting.” “This is seen in the sickness of stomach attendant on the loss of biood.” “Disagreeable sights, odors or tastes, or even recollections of them may affect the brain sensationally and operate in the same way.” This, we are to presume, occurs by retlex action on the sympathetic, as in like manner fear sometimes causes intestinal or cutaneous relaxation. Now, although the incidents that are the precursors of ordinary vomiting are well enough known, I, for one, have in my own mind no perfectly clear conception of the exact method in which ipecacuanha exerts its various powers, powers that are remarkable if not unique. But we may imagine, for illustration’s sake, the nervous influence in health to be rep- resented as in a state of equipoise, and that as it is deranged in f Nor from any substitutive intestinal inflammation, however set up. NON-EMETIC USE OF IPECACUANHA. one direction or the other emesis will occur. In this view ipe- cacuanha instead of being a sedative, as it is so often styled, is a sympathetic [ganglionic] stimulant that exalts one side of the beam, and with the disturbed balauce tonic vomiting, so to speak, occurs. The vomiting of irritability or exhaustion, on the other hand, results from the depression of the beam, and its equilib • rium is restored by the positive influence of the drug. A more comprehensible comparison may, perhaps, be found, in what we know relative to the human temperature. When that is below a certain point we are ill; the addition of heat carries it up to the norm and we are well; but the same degree of heat added in health creates illness. Figures at best are imperfect guides and these are very rude, but it is only by some such comparison that I can bring myself to understand how our ordinary experience with the drug can be reconciled with its well-established control over the morning-sickness (irritability) of pregnancy, with its influence in certain forms of atonic dyspepsia, and with (as I believe) its efficacy in the vomiting of cholera morbus and allied diseases. It seems to me that we must either fall back upon some such notion, or must suppose that there is another prin- ciple besides and antagonistic to the well-known emetia, the re- puted and generally-recognized essence of the drug. This paper treats of ipecacuanha as a whole. Some of the later therapeutical experiments have been made with emetia, “ pure” and “impure,” which is certainly an active agent; but in whatever form administered it is usually, and often violently, emetic, and in excessive or repeated doses it is certainly danger- ous. I have had no experience with it, but I greatly question whether the chemical mutilation to which the vegetable is sub- jected by its extraction does not radically destroy some essential quality. Although analysis seems to leave no room for any other active principle, it might be worth while to institute a series of careful experiments with the residuum after emetia is removed.] I therefore regard ipecacuanha as a peculiar hut direct nervous stimulant, acting chiefly and probably entirely through the medium of the sympathetic system f Dr. Squibb, of Brooklyn, informs me under date of 11th November, 1874, that “there is very much Ipecac now in the market that is of very doubtful character. It is a large size root, produced in the West Indies, is cheap, and is used either as a substitute or adulterant of the true Rio Ipecac. Perhaps halt the powdered Ipecac sold may be made from this variety.” t Sunderlin, of Berlin, (Ifandbvch der Speziellen Ileilineltellehre,* 1825, ii., NON-EMETIC USE OF IPECACUANHA. The empirical fact remains, whatever explanation we may at- tach to it, that ipecacuanha is a valuable remedy in the sweats of phthisis, (and why not in others that are colliquative?) in passive haemorrhages from the uterus, lungs, etc., in certain active haem- orrhages on the authority of Trousseau, in the collapse of cholera morbus, and in various forms of diarrhoea and dysentery. It does no violence to any known physiological or pathological fact to suppose that all these morbid states may be different manifesta- tions of deranged sympathetic [ganglionic] action. For, as the ordinary malarial poisoning shows itself sometimes in an inter- mittent, sometimes in a remittent, and again in a neuralgia or hemi-crania—all disappearing under the influence of quinine—so, these various just-mentioned, but not necessarily identical, con- ditions may admit a common causative chain binding them to- gether and leading them to yield to the same element of cure. That is to say, we may look upon those classes of disease, includ- ing serous diarrhoeas and cholera infantum, and also the profuse cold (or passive) perspirations of consumption, cholera and fright, as brought into existence by various, and it may be dissimilar, direct or reflex disturbances of the ganglionic system. These may be generated by any impression, moral or physical, operating upon a nerve-centre. Where it is from irritating ingesta, the causes operate as long as the foreign bodies remain: where it is from an emotion, like fear, the effect passes off as equanimity returns. It is unnecessary, by multiplying illustrations, to trace the family likeness through all its gradations to the fully-devel- oped type of the profoundest sympathetic disturbance. And I here interject a paragraph, framed after this paper was written, that at least abuts upon, if it may not actually be an ex- tension of, our theme. Dr. Wilson Fox, in his work on Diseases of the Stomach, now re-printing in the Medical News and Library, treating of haemorrhage from that viscus, writes (Oct,, 1874, pp. 248-9,) to this effect: in some of those capillary haemorrhages which arise from congestion, there is probably, in addition to the congestion, “some alteration in the coats of the capillaries * “In the same manner are probably produced the haemorrhages of yellow fever, and of other [?] malignant intermittents, as also those which occur in relapsing fever, typhus fever, cholera, pur- pura, scurvy and haemorrhagic variola. In other cases, though p. --.8,1 nearly fiitv years ago taught that emetia exercised an exhausting stim- ulus over the eighth pair of nerves. (Duckworth, op. cit., v., 1869, p. 221.) NON-EMETIC USE OF IPECACUANHA. 51 probably referable to the same source, its mode of origin is less explicable; as when it follows severe surgical operations or blows upon the back or epigastrium, or even a remarkable case reported by Empis, where the invasion of tubercular meningitis was asso- ciated with uncontrollable vomiting with hfematemesis.” I have no desire to appear wise above what is written, but it appears to .me that a profound sympathetic [ganglionic] derangement is an essential factor in all these conditions. The alterations in the blood that may occur in the various diseases named are of course to be reckoned, but the want of nervous power [paralysis, shock,] is roost probably an important element—and that, to my mind, is the only rational explanation of the “less explicable” cases noted.]- Why sometimes the outpouring is serous, sometimes htematoidal, jpid sometimes of pure blood, our present knowledge is not suffi- ciently refined to demonstrate. Now cholera is sui generis only in the peculiarity of its repro- ductive power. Professor Stille, in a comprehensive lecture on this disease, asks (Phila. Med. Times, iii., p. 648,) “In what does sporadic cholera differ from malignant epidemic cholera?” and answers, “ only in its cause and its degree. Its mechanism is the same,” and that the epidemic “ differs from the sporadic form chiefly by the intensity of its cause, the gravity of its symptoms and the nature of the special cause that produces it.” Meigs and Pepper (op. cit., pp. 378-399,) make a strong argument for f I would account for the case of ipecac-cured dysentery, occurring after an operation for hernia, in St. Bartholomew’s Hospital (Sl.B. Rep., vii., 117,) in this manner, i.e., by the nervous shock: and I suppose that the diarrhoeas of the tuberculous that have been cured by ipecacuanha depended not on ulceration, but on irritation, perhaps from morbid deposits. I suppose also that “ the puerperal state,” in the complications of which unquestionably ipecacuanha has been used with advantage, especially in France, has its peculiarity in the shocked and susceptible condition in which the abdominal sympathetic is placed as the result of the profound uterine disturbance lately undergone. And in like manner the purest form of dysentery is that induced by cli- matic or epidemic influences, and not that caused mechanically (by irritating ingesta). The occurrence of bloody stools, often regarded as evidence of inflammation, is not such proof. And it outrages all analogy to suppose that a violent form of such disturbance yields at once to a medicine whose general antiphlogistic properties are no better proven than those of the drug Ja question. Is it not more reasonable to regard dysentery at its inception as the manifestation of a peculiar ganglionic intoxication, and to consider the intesti- nal inflammation, with its consecutive ulceration, a result of the malady, but not he primary or radical affection ? 52 NON-EMETIC USE OF IPECACUANHA. the practical identity, saving the feature of self-propagation, of cholera infantum with the epidemic disease.f Dr. Da Costa re- ports (Am. Jour. Med. Sci., no. cxv., 1869, p. 124,) a case of sporadic cholera with intestinal lesions found at the autopsy identical with those of epidemic cholera, although in life the discharges were not similar nor were there cramps. Dr. Edward Goodeve says* (Reynolds’ System, i., p. 172,) “It must be granted that symp- toms similar to collapse may be produced by poisons without any purging. I have seen people under the influence of malarious poison in Calcutta lie for hours as cold and pulseless and as embarrassed in breathing as in cholera.” As once before quoted' in this paper, the “ rice-water flux * * may occur also in othei cases in which, as in cholera, there is a neuro-paralytic condition of the digestive canal” (Sedgwick, Lancet, Dec., 1871, p. 644). Aud the large number of cases cited by Mr. Sedgwick in bis Analogy show one or another pathological phase of the pestilence duplicated in some other affection. But there is more than a casual or accidental relation between cholera and certain other so-called blood diseases, and particu- larly are septic cholera from poisonous gases and epidemic chol- era closely allied. Singularly, it has been suggested! that cholera and dysentery are antagonistic; but really one tends to increase the liability to and the daDger of the other, and the latter is a not infrequent sequel to the more dreaded disease. And in attempt- ing to develope this feature of the case I trust that I may not seem to be pressing the doctrine of the correlation of diseases too far, nor may I, by an indiscreet advocacy, bring ridicule upon the powers of a valuable medicine. Just as our scientific vision gains a wider range, do we better see the alliances that seemingly different conditions sustain with each other. If such a figure may be tolerated in a serious paper, I would say that, possibly, cholera, dysentery and the periodic fevers are a triune daemon, each of whose faces represents a peculiar influence to be propitiated by especial offerings. We may never detect the real essence of tliis- malignant trinity, and may never weave a spell that shall com- pletely exorcise it: but all things are possible to the patient and the f Polichronie, (op. cit., p. 33,) writing of the different forms of diarrhoea in children, speaks of “ le cholera infantile, qu'il est souvent presque mj)ossible- da di sting iter da veritable cholera asiutique.” f I have met with this opinion in my reading, but have mislaid the refer- ence. XOX-EMETIC USE OF IPECACUANHA. 53 flaring, and it is a worthy ambition to unravel such a secret and to compose such an incantation. There are certainly some very remarkable similarities in the apparent origin if not in the outward expression of these diseases ;f and, speaking generally, not universally, we may include cholera morbus or the sporadic form under the wider •category; just as the ordinary catarrhal dysentery is but a variety of the epidemic disease. lu both, the contagious or catholic estates embrace the subdivisions. Niemeyer distinctly asserts that epidemic dysentery is closely allied to cholera (op. .cit., ii., p. 007,) and points out some marked constitutional similarities. Dr. Woodson noted in connection with his series of dysenteric cases near Gallatin, Tenn., treated by ipecacuanha in the summer of 1873, (ante,) the interesting fact that “previous to their outbreak a diarrhoeal tendency had been observed in the same district which if not a consequence of was at least coinci- dent with the prevalence of epidemic cholera at Nashville and Gallatin.” It is well known that by a number of very respect- able medical men it has always been held that Asiatic cholera is essentially a malarial disease; that it is only a virulent modifica- tion of the ordinary swamp fevers. And, as Niemeyer says, (op. cit., ii., p. 622,) “we do not know why, but great epidemics of intermittent have often preceded epidemics of Asiatic cholera. In hot countries cholera and intermittent and oftener dysentery and intermittent frequently prevail at the same time;” and later (p. 637), speaking of the course of the severer forms of remit- tent fever, he states that in some cases there are “ symptoms of cholera or dysentery.” “ Herseh [HirscliJ says it is a well-known fact, that malarial fever has preceded outbreaks of cholera, not t While this paper is passing through the press I have received the Brit- ish Army Medical Department Reports for 1872, (London, 1875, pp., 557,) and find that Deputy Surgeon-General Munro therein (pp. 266-274,) expresses frhe opinion that remittent, intermittent, congestive remittent [pernicious], cholera, yellow fever and heat apoplexy [insolatio] are different degrees of paralysis of the sympathetic nervous system, and that quinine is the remedy roost to be relied on in all of them. He does not include dysentery in the *group, and he denies the existence of malaria. And I find that 1 have overlooked until the last moment the comprehen- sive remark of Professor Maclean who, speaking of malaria, in which he is a firm believer, says (Reynolds’ System, i., p. 52,) “It is the cause of inter- mittent and remittent fevers, and their sequels: it ‘underlies’ the cause of dysentery and cholera:” etc. This was printed in 1866, and fairly coincides with the views expressed in the text as well as far antedates them. 54 NO IS1-EMETIC USE OF IPECACUANHA. only in single places or particular regions, but in an almost pan- demic distribution, and there is every reason to believe that mala- ria and cholera devastate the same ground.” (Peters, op. cit., p. 127). Now (Aitken, 1st Am. ed., i., p. 381,) “it may be stated, as a general proposition, that there is no country where paludal fever exists in which dysentery is not an endemic and prevailing dis- ease. * * This connection is so intimate that a given number of persons being exposed to the action of paludal miasmata—as, for example, a boat’s crew sent ashore in a tropical climate—the probabilities are, that of the men returning on board, part will be seized with dysentery and part with remittent fever. Paludal fever and dysentery, moreover, are not only conjoined in locality, but they often co-exist, precede or follow each other in the same individual, so that the fever frequently ends in dysentery and the dysentery in remittent fever.” Further, M. Marey (Gaz. Hebdom.,* Nov. 24 and Dec. 1, 18(55; by Burral, op. cit., p. 137,) finds a re- semblance “between cholera and paroxysmal fevers, which latter he considers as under the control of the vaso-motor system of nerves.” Now the vaso-motors themselves, although not derived, from, are in great measure influenced by the sympathetic. And in this connection there is invited study of a valuable paper by Dr. Enrique M. Estrazulas, in the American ■Journal of the Medi- cal Sciences for July, 1873, (no. cxxxi., p. 74,) clearly detailing the spontaneous origin of epidemic cholera in the camps of the allied and the opposing armies at and near Estero Bellaco, at the junction of the Paraguay and Parana rivers, in 18GG, during the Paraguayan war, and the circumstances under which it occurred. He makes no claim for the purely paludal origin of the disease, but the facts presented distinctly show, I think, that for this pes- tilence along with the dysentery and malarial fevers that ravaged the forces, there could be found, in the general subtropical de- composition that prevailed, a common factor of production.f And if we may speculate upon etiological affinities, we may certainly dream over therapeutical resemblances. There are few drugs limited to a single or specific action. The more familiar that we become with the materia medica, the more clearly do we see that classes of remedies operate in the same general manner, that few medicines are limited in their usefulness to any solitary pathological indication, and that individual remedies often have t See also an article on Cholera: Does it originate de novo ? by Dr. \V. Al- ston. (A. Y. Med. Jour., xxi., 2, Feb., 1875, p. 12(>.) NON-EMETIC USE OF IPECACUANHA. 55 very varied action. It is in this very province, tlie action of medicines, that there is the least accurate knowledge. Even the so-called specific, quinine, has other powers than simple anti-pe- riodicity, and these come into operation as necessities vary. We are justified in supposing that it is thus with ipecacuanha. As a specific it may be an emetic, but it has other applications. Final analysis may ultimately prove that the same drug always exerts the same kind of influence; but the conditions under which it is exerted so fluctuate that we are authorized in calling the modi- fied manifestations different powers. Nor need we multiply illustrations of the unexpected modifications that size of dose and. and condition of patient induce. Twenty grains of calomel will produce no annoyance, when a fourth of that amount would he painful and irritating; half an ounce of the tincture of digitalis will restore strength to the trembling pulse in delirium tremens, when half a drachm would cause the heart to flutter more wildly. The tolerance of opium in peritonitis, and of alcohol in snake- bite, are well known. The frequent tolerance of ipecacuanha in dysentery is established; its rejection in cholera is not proven, and is by no means necessary. If the pathological and therapeutical views here expressed are well-founded, we are not to look for one drug as a cholera-specific or antidote—a neutralizer, as vaccination antagonizes variola— but we will find that various ganglionic and vaso-motor stimuli may profitably be employed in cholera, and that ipecacuanha may be used in other disturbances of the sympathetic and vaso-motcr systems, as indeed I believe has already been illustrated. Just where its maximum of power with the minimum of resistance are to be found, is yet entirely unsettled. In confirmation of this general view is explained the action of atropia, which is under- stood to cause contraction of the capillaries, and which has been used hypodermically with a certain degree of success, f But the .most valuable therapeutic contribution hitherto made to this sub- ject is the employment of the bromide of potassium, based on the pathological hypothesis herein expressed. Thus, in 1873, Dr. William Pepper, on theoretical grounds, suggested (Phila. Med. Times, iii., pp. 651, 742,) its intravenous injection in solution. I do not know that this has been put in practice. Dr. Pepper, however, has been anticipated in its general use by Dr. James f Ergot, whose action is of the same general character, has also been Vised, but not very successfully. 56 NON-EMETIC USE OF IPECACUANHA. Begbie, of Scotland, (Edin. Jour., 1866, xii., pp. 488, 49U,) who, from identical reasoning, recommended it, and on whose recom- mendation it was used in the Leith and Edinburgh Cholera Hos- pitals. Dr. Begbie says that “ although not possessing the prop- erties of an antidote to the poison of cholera, though not a specific to the shock of this terrible disease, [it] has certainly stript it of some of its terrors.” This view has received an independent but strong support by a series of cases published by Dr. Salvator Caro, (Mod. Record, iv., p. 195,) in 1869. That paper gives in detail twenty out of one hundred and sixty-tliree cases, running through all the morbid states, from a simple serous diarrhoea to cholera infantum, dysentery and septic cholera, and embracing young and old, where it was successfully used. And the conclu- sions of one of the latest investigators, Dr. Robert Amory, (1872,) give abundant theoretical confirmation. He has satisfied himself, (Phil a. Med. Times, ii., p. 335,) that: “The effects of the drug are produced by its direct action upon the blood-vessels or the ■vaso-motor system which controls the contraction of those vessels, which explanation may account for all the physiological or therapeutical conditions brought about by the exhibition of the drug.”f But recurring to M. Marey’s opinion, that both cholera and the periodic fevers are due to vaso-motor disturbances, we find that Dr. John Murray, late Inspector General of Hospitals, Ben- gal, in his Observations on the Pathology and Treatment of Cholera* (1874,) strongly advises in the premonitory stage the use of two- grain doses of quinine three times a day (Review in Pliila. Med. Times, iv., 1874, p. 636); and, on the other hand, we are reminded that the emetic action of ipecacuanha, under the idea of produc- ing ‘a shock’ or of ‘breaking up the habit,’ (an explanation savoring more of mediaeval mysticism than of modern therapeu- tics,) has been frequently invoked in the treatment of an ague, especially when obstinate. And in the Indian Medical Gazette* tor June, 1872, (Philo. Med. Times, ii., p. 416,) Udhoy Cliand Dutt, a civil medical officer in India, reports the cure of seventy- four out of seventy-six cases of intermittent, in from three to five days, by the administration of minute doses of ipecacuanha.J It f H. C. Wood considers (op. cit., pp. 281, 283,) “no decisive proofs have, however, yet been offered of the truth of this favorite .dogma.” t It was formerly an English, and is yet a common Italian, practice to administer an emetic of ipecacuanha at the beginning of an intermittent afc- NON-EMETIC USE OF IPECACUANHA. 57 is perfectly conceivable that the sympathetic maybe affected in a way to give rise to the intermittent phenomena of miasmatic [paludal] disease, although it does not follow that we can explic- itly describe or accurately paint the actual histological conditions involved, and that moderate [or ‘alterative’] doses may correct that state. Such an hypothesis explains the pseudo-choleraic collapse of certain grave forms of the disease, and encourages in them the non-emetic employment of the drug. For the absence of the choleraic discharge does not militate against the idea that the same division of the nervous system may be deranged with different manifestations. And as, returning to the pathology of dysentery, which in grand outline resembles cholera and where the general fever and so-called inflammatory condition of the first stage are not pro- portional to the suffering, we find that when ipecacuanha is prop- erly given before organic changes [ulcerations] occur relief is speedy, so we are bound to consider that the drug in some way, directly or indirectly, antagonizes the toxic principle, allowing health to return. If anything in practice is certain, it is that bleeding and calomel will not abort acute dysentery and that ip- ecacuanha fairly abolishes it. We have at the least, therefpre, a fair presumption in our favor when we anticipate that the hy- drorrhagia of the more alarming pestilence may cease f as promptly as the smaller and more haematoic discharges of the commoner disease. But it requires faith and a certain kind of courage to administer to a patient, already sadly vomiting, what for two hundred years has been the type of an emetic. But, used with care, I am confident that it checks that symptom if it de- tack; and although the French think that it is only useful by relieving gas- tric embarrassment, many claim that it has a febrifuge action analagous to that of quinine. Polichronie {op. cit., p. ‘it,) regards it of sufficient interest to merit renewed research. Note. —Between the time of writing this paper and that of printing this portion of it, I have experimented with non-nauseating doses of ipecacuanha in intermittents, and have found in more than twenty consecutive cases that it controlled the disease as promptly as quinine would have done. I hope to be able soon to publish the details. Meanwhile clinical studies, with careful notings of pulse and temperature, could easily be made, and would probably compensate for the trouble. f It is to be remembered that, during this very summer [1874] cholera infantum, so analagous to Asiatic cholera in its manifestations, yielded promptly to ipecacuanha in the hands of MM. Chouppe and Huchard {vide supra.) 58 NON-EMETIC USE OF IPECACUANHA. pends on no extrinsic cause. It is the first step that counts; that taken, the rest are easy. Authentic empirical illustrations of its power dot medical records for at least sixty years. Give ipecac- uanha freely but cautiously—cautiously does not mean timidly— in the vomiting of exhaustion, and it will arrest it. There is no invariable human formula, but anti-emesis quite as often as emos’s will be the expression of its function. There are two additional fragments that I desire to introduce into this mosaic before it leaves my hands, imperfect and perhaps unintelligible to others as it may even then remain. The first concerns the condition of the gall-bladder in col- lapse and the absence and reappearance of bilious stools. An essential, if not the pathognomonic, symptom of the disease, not- withstanding its misnomer, is the absence, not the flow, of bile; and a large section of the profession has sedulously occupied itself, by the employment of calomel and other presumed choi- agogues, in the attempt to re-establish that discharge; for the reappearance of bilious stools is universally hailed as a sign of convalescence. Now the gall-bladder is generally found filled hi collapse, (notwithstanding that vomiting is supposed to mechan- ically force out its contents,) and the retention of bile is only the sign, not the cause, of the disease. Undoubtedly bile flows lie- cause convalescence begins; health does not return because bile flows. And we may readily understand why this is so when v o remember that the muscular tissue of the gall-bladder is un - striped, and is under the nervous control of the sympathetic. If that nerve is paralyzed this receptacle does not give vent to its contents; when the sympathetic r« isserts its power the discharge reappears. The second is the following. Mr. Sedgwick, (Lonoi, Dec., 1871, p. 646,) in a sentence opposing the purgatives of the John- sonian teaching, uses these words: “a careful and scientific inves- tigation of the stage of convalescence, especially with reference to the occurrence of temporary glycosuria,” etc. From this I do not understand whether he refers to temporary glycosuria as a well-known and admitted fact, or means to suggest that it may occur and should be looked for. I have found no other refer- ence to its existence in the authorities that I have been able to consult. For myself, I do not know whether sugar is present in the urine that begins to appear with the establishment of reac- BOX-EMETIC USE OF IT ECACUAX IIA. tion, but, if this should be the case, it seems to me susceptible of an explanation, curious from the nice interplay of somewhat com- plicated conditions and affording another argument for the em- ployment of the drug. (It may seem presumptuous to seriously ask attentionjto so much that is supposititious. But the sugges- tion may at least lead to investigation by those better prepared for investigation.) We know, or at least we believe, that diabetes depends on the dilatation of the capillaries of, and on the conse- quently more rapid circulation of blood through, the liver, and that it follows the paralysis or exhaustion of that part of the sympathetic that supplies it. Professor Cyon {Brit. Med. Jour.,* Dec. 23, 1871, quoted in Phil. Med. Times, ii., p. 196,) has shown that the fibres composing the annulus of Yieussens particularly preside over the hepatic circulation, and that their irritation in- duces the diabetic condition. But if the entire sympathetic is cut or paralyzed diabetes does not occur, because “those parts of the nervous system contain the vaso-motor fibres for the ves- sels of the intestines: and when they are cut, the vessels dilate, and blood accumulates in them to such an enormous extent that there is either too little blood remaining, or it is under too low pressure for the circulation in the liver to become increased above- its normal, even though its vessels be dilated.” We know, how- ever, that the liver is found gorged with blood when death occurs in collapse, or, that is to say, when its sympathetic fibres are paralyzed. We may therefore naturally infer that when reaction begins and the circulation tends to recover its usual tone, more blood than usual passes through the liver under the combined effect of the partly dilated vessels and the increased force of the circulation, and we might therefore look then for the temporary glycosuria that could occur neither in the profound stage nor when the health and the normal circulation are restored. And this pathological condition gives support to the therapeutic view here advocated, when we remember that, as long ago as 1862,. Pecholier announced (H. C. Wood, op. cit., p. 364; fr. Gaz. Med.,*) “that in animals killed by it [ipecacuanha] no hepatic glucose can be found.”f The inference of course may be drawn that it suspends the glucogenic function because it acts upon the vaso-motors (through the sympathetic) in directly the reverse manner in which traumatic injury or cholera poison is active.. f Pecholier, (op. cit., p. 40,) “ novs avons constate des efforts des vomisse— ments, * * * la ilisparilion da sucre dans le foie.” NON-EMETIC USE OF IPECACUANHA. The disease paralyses the nerves and dilates the vessels; the drug stimulates the nerves and contracts the vessels. These explanations of the two conditions just described sat- isfy my own mind and, so far as I am aware, have never hereto- fore been published. As a matter of course, the whole materia medica has been ransacked for a cure for the pestilence that has girdled and de- vastated the globe. And in these trials so common a drug as ipecacuanha has been frequently employed, but generally, if not universally, as an emetic. Dr. George Johnson has used it in his eliminative practice (and it would be interesting to analyze his statistics with a view to observe if the so-called tolerance was established, and whether there was any observable connection between the degree of his success and the amount of this medi- cine that was retained). Peters writes (op. cit., p. 139,) “War- ing says, the mortality has been very large under its use when given in full emetic doses. Others say it has been given success- fully in five or ten grain doses every, five or ten minutes. It causes violent attempts at vomiting, but after three or four doses tolerance is established. In the Paris hospitals, in 1865, ten to twenty grains were given whenever there was much vomiting.” I have not been able to discover the originals or the particulars of any of the three statements just cited, but they all seem to refer to its emetic use.f Waring, however, after reprobating its emetic use as an eliminative, does sav (Prac. Therap., p. 361); “A far more promising practice is to administer it in very small, often-repeated doses, in the manner employed in haemorrhages by Mr. Trenor. In the latter affections, even when a state of collapse supervened, the vital powers recovered themselves in a striking manner under the use of ipecacuanha; and the same remedy seems to merit a trial in cholera, even in the stage of collapse; the many points of sim- ilarity between cholera and profuse haemorrhage would alone f M. Decugis writes (loc cit., p. 40.) “Cholera.—At its first appearance, in 1832, the physicians, struck by its resemblance to dysentery, proposed ipecac. M. Grisolle believed the remedy to be a specific (oral a la specijieite de ce medicament) against the cholera; but in 1849 he was obliged to recog- nize the slight utility of the administration of that substance. M. Briguet employed it also at the Charite with as little success: for ourselves, we have known, during the epidemic that scourged Toulon in 1865, that ipecac did not more than other remedies succeed in assuaging the grievous attacks of that .terrible disease. ” NON-EMETIC USE OF IPECACUANHA. 61 auggest its probable utility. The more recently ascertained facts with regard to the power of minute doses to arrest vomiting are strongly in favor of its probable efficiency. ”f If it is allowable to discuss hypothetical conditions in the absence of practical demonstration, I should say that one of the differences between the haemorrhagic and choleraic conditions is, that in the former the capillary lesion is, so to speak, passive, the result of exhaus- tion; while in the latter it is active, being impressed by the posi- tive toxic element: and that, while small doses might be trusted to restore the capillary tone in the one or negative condition, unless we embrace the homoeopathic doctrine of attenuations and potencies, we must use larger quantities to antagonize the active morbific influence. It is my belief that emesis is influenced less by the size of the dose than by the manner of its administration. “The doses given by Mr. Trenor varied from gr. j.-ij. every fif- teen or thirty minutes until nausea was felt,” (Waring, op. cit., p. 360,) while in a large series of cases published by Dr. Samuel Pye, “ The average quantity which he gave was only two grains, yet it generally produced vomiting three or four times, and some- times oftener.” (Stille, op. cit., ii., p. 391.) On the other hand, I have repeatedly given twenty-five grains without inducing vom- iting, and one and two drachms have been similarly administered in East Indian practice. A corroborative suggestion to the therapeusis proposed in this article I have found in a paper by George Barnard, Esq., Surgeon 6th B. L. I., (Am. Jour. Med. Sci., no. cxiii., Jan., 1869, p. 246,) who takes the ground that cholera is practically an in- tense inflammation of the mucous membrane, and advocates its treatment by grain doses of tartar emetic every fifteen minutes until vomiting ceases, and further says: “ 30 grains of antimony’s ally, ipecacuanha, will have the same effect given in the same way every quarter of an hour. See Docker’s case of forty grains ipecac in advanced collapse, (Lancet) and 392 cases by Dr. Carl Muller, Vienna.” I should hardly be willing to subscribe to the t Of this, although it occupies a prominent place in his valuable article on the drug in question, it is proper to observe that I was unaware when I used it in large doses in tne cases of cholera morbus, and when it occurred to me that it might be available in epidemic disease. It may also be noted that Dr. Waring regards ipecacuanha as a sedative, (op. cit., p. 356,) and offers no rationale for its presumed action in such cases, except indirectly and by implication. NON-EME'LIV USE OF IPECACUANHA. pathology advanced or to the antimonial treatment advocated, but the implication that ipecacuanha has been actually employed in this manner is extremely interesting. The references are so indefinite that I have been unable to verify them; but if it should prove that three hundred and ninety-two ruccesxfal cases of the use of ipecacuanha in large doses are on record, that ought to settle the question empirically, whatever may be ultimately de- monstrated as its mode of operation. I earnestly entreat of those who may be tempted by anything that has been said in these pages to use large doses of ipecacu- anha in the diseases discussed, that they will carefully adhere to the non-emetic method. Without doubt untold suffering has been endured during the past two centuries from the gradual abandonment of the remedy after its triumphant introduction into Europe and before its recent revival in Asia—a disuse for which this disagreeable and wholly unnecessary concomitant is chicfiv responsible. In practical medicine the least things are sometimes important. I neither have the opportunity nor claim the ability to pre- pare an exhaustive essay upon these interesting subjects, but I have made this paper as complete as my means would allow, knowingly omitting nothing pro or contra. I have preferred to err on the side of prolixity, by actually quoting the authorities and carefully explaining my own meaning, than to be charged with misrepresentation or assumption as to the views of others, or with ambiguity and cloudiness upon my own part. And I have -entered every reference as I have consulted it. I trust that I may not be charged with that vaulting ambition which o’erleaps itself, in the choice of a subject. Tim subject indeed forced itself upon me, and being present, I have sought to treat it honestly and fairly, with a simple desire to increase the means of relieving human suffering. If, as I sometimes hope, the work that the theoretical part of this paper represents has any value, it is chiefly due to those skilful and earnest laborers in the domain of science who have collected the material and have unselfishly offered it for the pub- lic good. I have merely selected certain cuttings, and have drawn them into relationship. The little portal that I have built I hope may prove a minor entrance to the great cathedral of the common weal. It may be but a doorway to some subterranean or useless non-emetic use of ipecacuanha. gallery, or at best be fit only for transformation into a fantastic gargoyle to carry off the waste water of the scientific skies. Should it be so, the material has not been damaged and it can easily be re-wrought. If happily the former, but little praise belongs to the lucky designer who lias stumbled upon the care- fully-hewn and generously-given blocks.