EYACUANT 
MEDICATION 
(CATHARTICS AND EMETICS). 
BY \ / 
HENRY M. FIELD, M.D., 
Hi 
Professor of Therapeutics, Dartmouth Medical College ; Corporate Member 
Gynaecological Society of Boston; Non-resident Member 
N. Y. Academy of Medicine, etc., etc. 
“C’est la th£rapeutique qui <516ve et ennoblit notre art! Comment ne pas voir que 
c’est par elle seule qu’il a un but et qu’il devient une science?”—Estachy. 
“ Cseterum quantacunque fuerint aliorum conamina, semper existimavi mihi 
vitalis aurse usum frustra datum fore, nisi et ipse in hoc stadio versatus, sym- 
bolum aliquod, utcunque exiguum, in commune Medicime lerarium contri- 
buerim.’'—Sydenham. 
PHILADELPHIA: 
P. BLAKISTON, SON & CO., 
No. 1012 Walnut Street. 
1887. Copyright, 1887, by H. M. Field, m.d. THIS BOOK 
is 
REVERENTLY AND AFFECTIONATELY 
‘Debicateb 
TO THE MEMORY 
OF 
MY FATHER. PREFACE. 
The Author hopes to place himself in kindly re- 
lations with whomsoever may read his book, by the 
fewest possible words—not so much of preface as of 
apology, i. e., in the old-time and nobler sense of the 
word,—believing, as he does, that whoever proposes 
to add, however slightly, to the burden of those who 
read in this busy and much-pressed age, should 
suggest the consideration of his claim to be heard. 
He has often been urged to offer to a wider audi- 
ence the matter which has been addressed to medi- 
cal classes for many successive years; and the present 
effort is a partial venture in this direction. The 
material of the book has been largely gathered from 
the clinical observation of an active general practice; 
and also from a digest of innumerable clinical mono- 
graphs and notes, chiefly from the French and Eng- 
lish and American journals and standard medical 
works. 
A special purpose has been to provide a practical 
study of the individual action, application and 
contra-indications of the more prominent cathartic 
agencies; a work which cannot well be undertaken 
in connection with a general treatise upon Therapeu- 
tics and Materia Medica for want of space, and which 
will not, unless the author mistakes, be found in any 
other treatise, either in English or the other lan- 
guages commonly familiar. Passing by other fea- PREFACE. 
tures of the book, attention may also be directed to 
the discussion of Cathartic and Emetic Medication, 
and especially to the treatment of Super-vomition, or 
continuous morbid vomiting. 
A constantly repeated allusion to the author Fons- 
sagrives may be pardoned in respect of the fact 
that this writer’s works have not been given to the 
English-reading public, and that they are charged 
throughout with most valuable suggestions and 
statements of rational theory and of fact. 
Once again,—may the author be permitted to 
desire for the reader a small part of the profit and 
satisfaction which have accrued to himself in the 
pursuit of this course of study ! H. M. F. 
Newton, Mass., April 4th, 1887. 
EXPLANATION OF INITIALS USED AS REFERENCES IN THE 
FOLLOWING PAGES. 
F. & H.—Fluckiger & Hanbury (generally in Pharmacographia). 
T. and P.—Trousseau & Pidoux (Trailt de ThSrapeutique et de Mat. Midicale, 
Ninth Edition). 
»P. D. & Co.—‘Parke, Davis & Co., Manufacturing Pharmacists. 
ERRATA. 
Page 113, in Note, for “ Bichl. sod.” read Bicarb, sod. 
Page 223, in Note, for “ with morphia ” read into morphia. 
Page 235, last line, after emetic insert unless in vomiting or in croup. CONTENTS. 
PAGE 
Introductory 13 
Evacuants, No. 1. Cathartics 15 
Cholagogues 86 
Mineral Cathartics 107 
Differential Therapeusis 128 
Cathartic Medication 141 
General Principles 185 
Evacuants, No. 2. 188 
Topical or Irritant Emetics 230 
Emetic Medication L 234 
Arrest of Vomiting ...> 265 
Index 285 EVACUANT MEDICATION. 
That classification would appear to be the most 
feasible and suggestive of actual application which 
admits but two modifications of evacuant medicine; 
viz., that (1) which evacuates the bowels by means 
of the cathartic, and (2) which evacuates the stomach 
by means of the emetic. It is true that prominent 
writers upon therapeutics have attached the evacuant 
idea to the diaphoretic, the expectorant, etc., and so 
have made many classes in this department of ap- 
plied remedies; but to consider the latter, severally, 
as especial stimulants or excitants would seem to be 
both more philosophical and practical. When we 
enquire of the usual intention of the diuretic, the 
expectorant, the diaphoretic, we surely do not find 
that it is to evacuate serosity and, so, to lower blood- 
pressure,—although such indication may now and 
then present as respects the first and last,—but rather 
to stimulate to increased activity, or restore to normal 
working, the glandular structure which it is hoped 
thus to reach. 
On the other hand, it is the exceptional purpose 
which applies the cathartic or emetic to revulsion, 
derivation, a special stimulation of the biliary func- 
tion, etc.; the primal and obvious intention is an 
13 14 
EVACUANT MEDICATION. 
evacuation of the bowels or of the stomach. This 
view of the subject is the more convincing when it 
is the expectorant, the emmenagogue, the balsamic, 
like turpentine or copaiba, with which we have to 
deal; which latter, indeed, may be variously stimu- 
lant to the mucous membrane of respiratory, urinary 
or alimentary tract, but never, properly, an evacuant. EVACUANTS.—NO. 1, CATHARTICS. 
OLEUM TIGLII—CROTON OIL. 
Materia Medica.—An oil expressed from seeds pro- 
duced by a small tree growing in the East Indies, 
belonging to nat. ord. Euphorbiacex. Croton seeds 
were used in medicine in the seventeenth century, 
and again introduced by English medical officers 
the early part of the present; but the oil was not 
used till about 1820. The seeds yield fifty to sixty 
per cent, of oil known as Croton oil, and which 
requires no description; it has a rather complex 
chemical constitution, but its active principles, 
whether as respects its application as a cathartic or 
as a vesicant, have not been certainly determined. 
It is probable that thorough washing with alcohol 
diminishes its acridity, without impairing its purga- 
tive power. 
Special Action.—Although apparently possessing 
the properties of a bland vegetable oil, Croton oil, 
almost at once upon contact with the mucous 
membrane, sets up an irritation, causing an acrid, 
burning sensation deep in the throat. Upon the 
glandular structure of the intestines it acts with 
such energy that it has been classed with hydra- 
gogues; and yet it so augments peristalsis, that its 
operation may be attended with violent colic. It is, 
therefore, a representative of materials of its class,— 
very few in number,—which bring into action in a 
15 16 
EVACUANT MEDICATION. 
very positive and in about equal degree the two 
elements concerned in purgative influence. Farther 
than this, its operation should be characterized by 
promptness and thoroughness; and under favorable 
circumstances, but one to two hours should elapse 
after exhibition before its purgative effect is secured. 
Special Uses.—This purgative is especially appro- 
priate to constipation depending upon an extremely 
enervated condition of the intestines, as particularly 
in constipation of lead poison; also where the bowels 
have been previously abused by various cathartics, 
and there is indication for an agent of slight bulk 
and great power; because the stomach will no 
longer receive, or the bowels will not respond to, 
the ordinary remedies. Again, its faculty to evacuate 
serosity renders it applicable in some cases of apo- 
plexy, where there is urgent demand for what shall 
both operate revulsively and diminish intra-cranial 
blood-pressure; and this with equal speed and 
energy. Croton oil is also directed by the books in 
constipation with impaction; but this is largely an 
error, and one which may have unfortunate results 
for the patient. Its activity as a peristaltic stimu- 
lant is altogether too great to admit of its use in a 
condition which is likely to present obstruction; the 
subject is tortured with aggravated colics, while the 
free serosity which the oil provokes, so far as it is 
poured out at the seat of impaction and below, can 
bring but little influence to bear toward the solution 
and disengagement of the hardened feeeal mass. 
Again, while Croton oil may not be, strictly, 
anthelmintic, its use is a prominent and essential CROTON OIL. 
17 
part of a very effective method for the expulsion of 
tapeworm; which consists, in brief, in the exhibition 
in divided doses of an emulsion containing two to 
three drops of the oil, at a proper interval after the 
ingestion of the oleo-resin of male fern. 
Finally, the great convenience of its use has 
suggested Croton oil as a cathartic in the case of 
children and of the incorrigibly insane; but this is 
a relic of the barbarism of medicine, except so far 
as the coincidence of some special condition might 
warrant recourse to so harsh a material.* 
Inconveniences.—But there are disadvantages pecu- 
liar to Croton oil, aside from such as must inhere to 
a cathartic of so pronounced character. The excep- 
tional promptness of its operation, as frequently 
observed, is one of its strong points, and disappoint- 
ment in this may be especially unfortunate. There 
are, however, few other cathartic materials, and few 
functions of cathartic medication, wherein idio- 
syncrasy introduces such variations as it may in 
respect of the length of time which this oil shall 
require for its operation in an untried subject. 
There may even be a range, in different patients, 
from a half-hour to twenty-four hours. This incon- 
venience, it is true, can be met by giving the remedy 
in fractional doses and repeating at intervals of an 
hour or oftener, until it begins to work. But in a 
case of apoplexy, on the other hand, the physician 
* Nelligan relates that Macnamara was accustomed to use an 
ingenious device in the use of the oil with the insane ; which 
consisted of the insertion of one to two drops into a grape from 
which the pulp had been partly expressed. 18 
EVACUANT MEDICATION. 
has no other option than to order a full dose and 
trust to the good behavior of his medicine. Again, 
an extreme predominance of colic must occasionally 
be referred to idiosyncrasy, i. e., so far as it is not to 
be explained by an error of the physician in select- 
ing this cathartic and introducing it into a canal 
which presents impaction or some allied condition ; 
and such experience should stamp the patient as 
unsuited to a trial with Croton oil upon future 
occasion. The burning, blistering sensation about 
the verge of the anus, which is very apt to follow 
purgative operation, should hardly be considered an 
intrinsic inconvenience; for this annoyance should 
be anticipated and guarded against by thorough 
oiling of the part before the evacuation takes place. 
Contra-indications.—An inflamed state of any part 
of the intestinal tract of necessity and always forbids 
resort to this cathartic; as should also a past ex- 
perience of a positive idiosyncrasy, as suggested in 
the last section. 
Toxic Action.—Croton oil doubtless exercises a 
large part of its action, whether medicinal or toxic, 
through the irritation it causes upon contact with 
the intestinal mucosa; which is of such intense 
character as to extend an excitant influence to the 
muscular coat. But there is much in the dynamics, 
as also in the chemistry, of this oil that we do not 
yet understand; for it is a remarkable fact, that 
fatal poisoning may result and yet no evidence of 
inflammation be left in the alimentary canal. Of 
equal difficulty is the disturbance which this material 
may occasion in the nervous system of an excep- CROTON OIL. 
19 
tional patient who is not purged by it,—and this in 
medicinal use,—a phenomenon which Bartholow 
cites from Husemann, and which is chiefly charac- 
terized by palpitations, giddiness, confusion of ideas, 
headache, etc. The treatment in poisoning is simple, 
but must be energetic, and presents three indications: 
(1) milk in abundance, or a bland, oily emulsion to 
envelope the irritant oil; (2) laudanum to relieve 
tormina and colics, and stop the choleriform diar- 
rhoea,—not to be applied, however, until, presumably, 
all the Croton oil has been evacuated; (3) stimulants 
to sustain strength in the choleraic collapse, which 
is quite sure to set in at an early stage. 
Administration.—The usual full dose is one to two 
drops. This may be placed directly upon the tongue, 
far back in the mouth; but only in emergency, as, 
e. g., in the apoplectic. Otherwise, the particles of 
the oil, subdivided, should be covered up, as in pill or 
emulsion form. The three drops used in the mixture 
for tapeworm should have as much as 5ij vehicle,— 
5ij to each drop,—if a disagreeable burning sensation 
is to be escaped. Croton oil is occasionally prescribed 
in combination, with a view to secure and yet modify 
its peculiar action; of which the Dr. Francis’ Triplex 
Pill, of New York, is sufficient illustration, viz.:— 
R. Aloes socot., 
Scammonii, 
Mass, hydrarg., aa 3 ij 
Olei tiglii, rr\, v 
Olei carui, rt\, xx 
Elix. propriet., q. s. 
Ut mass. ft. in pil. No. c. div. 
Sig.—One to two pills on retiring. 20 
EVACUANT MEDICATION. 
The Germans, who generally avoid castor oil, make 
some use of Croton oil, incorporated with a bland oil, 
like olive or sweet almond, one drop to 5ij-iv. The 
formula for Hufeland’s potion is as follows: Croton 
oil, two to three drops; one yolk of egg; hydrolate 
of mint, 125 grams; simple syrup, 30 grams; dose, 
one teaspoonful and upward. 
EXTERNAL USE OF CROTON OIL. 
Croton oil has a familiar external use, wholly 
aside from its employment as a purgative. Rubbed 
upon the skin, it almost at once causes a feeling of 
warmth, which is soon followed by an active irrita- 
tion, and later, sometimes by many hours, by an 
eruption quite peculiar to the agent used, at first 
vesicular, perhaps finally, pustular. Thus applied 
to the integument, can the oil exert its purgative 
effects? Physiologically, we should not look for 
absorption where so speedy and intense an irritation 
of the skin supervenes; clinically, I have never met 
with such complication in the topical use of Croton 
oil for many years; what is more to the purpose, 
Fonssagrives has never seen this result, and does 
not credit it; but Bartholow, per contra, speaks of 
numerous instances “ in which Croton oil applied to 
the integument produced diarrhoea.” 
This means of procuring counter-irritation is 
much valued on account of its frequent convenience, 
on account of the slight pain inflicted, often much 
less than from an ordinary mustard paste, notwith- 
standing that the action of the former is far more 
protracted, and because of the slight injury done to CROTON OIL. 
21 
the skin, permitting a reapplication in chronic con- 
ditions, after several days. But there are precautions 
which must be kept in mind, and which are too 
seldom emphasized. Occasionally, though rarely, 
the tissue of the true skin is invaded by the inflam- 
mation and a scar follows, and this is most likely in 
subjects of fine and delicate skin. It ought to be 
regarded wholly inadmissible to apply Croton oil to 
the face or exposed parts of the body, particularly 
with the young and with female subjects. And in 
this connection it should be remarked, that idio- 
syncrasy introduces quite as much of variation into 
the counter-irritant as into the purgative action of this 
oil; it is never possible, priori, to predict the degree 
of promptness, the measure, nor indeed, the character 
of response made to an external friction with Croton 
oil; a physician must always be upon his guard in 
ordering a first application, and more especially in 
a patient with whom other remedies are apt to act 
strangely. As some individuals may prove very sen- 
sitive to this irritant, so with others its action is 
secured only with great difficulty. Not to cite my 
own experience, Leon Marchand reports the case of 
a man who did not respond to three successive fric- 
tions of fifteen to twenty-five drops, and Huguier 
gives instances of similar apathy. The claim of the 
latter author has interest in this connection, and is 
probably well established—viz., that repeated appli- 
cations, although to different parts of the body, tend 
to diminish susceptibility to the rash. Once more, 
a very limited application may produce symptoms, 
cutaneous and otherwise, like a general poisoning; 22 
EVACUANT MEDICATION. 
thus Fonssagrives cites the case of a woman who 
suffered from a general exanthematous eruption, with 
dysuria, after friction with a few drops to the abdo- 
men ; and Joret gives four cases of similar character. 
It is insisted that such instances of departure from 
usual action as have been just illustrated are excep- 
tional ; but it is just such results of medical practice 
with which the careful and successful physician must 
be familiar. 
The method of topical use of Croton oil requires 
attention to the following rules and precautions: 
(1) Although while still undisturbed and at ordi- 
nary temperature the oil is torpid, it diffuses itself 
rapidly, through the influence of the heat of the 
surface upon which it is rubbed, and, unless especial 
care is taken, a much more extensive, or an entirely 
different region may be involved in the vesication 
than was designed. After a friction, the limits of 
the proposed vesication should be strictly defined by 
firm rubbing with a dry cloth outside the oiled 
surface. (2) The oil is slow at absorption, and 
although not too freely applied, the region of friction 
must not be too soon covered; or, if covered, a cloth 
must be firmly attached to the part, since a light 
under garment, allowed to rest upon the oil, may 
take it up and carry and apply to a different part 
of the body than was designed to be the seat of 
vesication. (3) The oil should be applied with a 
brush or a gloved finger, and it may be that the 
person making the application will need to guard 
his face against the emanations; the eyelids are 
especially apt to swell after such exposure, and, CROTON OIL. 
23 
now and then, the entire face. It is said that the 
eczematous are most liable to such accidents. 
Crayons of Croton oil are sometimes used, and may 
be composed as follows: one part, each, butter of cocoa 
and white wax, and two parts of the oil. Croton oil 
has also been introduced into liniments, with various 
formulae, but is best used alone, as thus its influence 
can be better controlled. 24 
EYACUANT MEDICATION. 
OLEUM RICINI—CASTOR OIL. 
History, Materia Medica.—A bland, viscid, fixed oil, 
of rather nauseous smell and taste, wholly without 
any irritating property until after digestion; ex- 
pressed from the seeds of Ricinus Communis or 
Palma Christi; of the same nat. ord. as that pro- 
ducing the oil last considered. It is a beautiful 
shrub,—within late years it has been prominent 
as an ornament in our gardens,—and is a native 
of the East, where, under favorable conditions of 
soil and climate, it may attain the dimensions of 
a tree, feet or more in height. The Castor oil 
plant was known to the Egyptians, and its seeds 
are still found in their tombs. It may be remarked 
that the seed has an irritant and toxic property, 
which is absent from the oil. Lugol reports a 
case of poisoning from this source: a woman ate 
six beans, which are said to have an agreeable 
taste, and was seized with vomiting and extreme 
collapse, with all the symptoms of cholera. It is 
believed, by the way, that the word Kikayon, of the 
hook of Jonah, which the translators have rendered 
gourd, is designed to represent this plant,—a plant, 
it may be added, of exceedingly rapid growth under 
favorable conditions. Dioscorides was familiar with 
the process of extracting oil from the seeds; but he 
applies to this member of the Euphorbiacese family, 
and not to that last discussed, the term xporuv, on 
account of resemblance of the seed to an insect. 
Pliny relates that the words castus and agnus castus,— 25 
CASTOR OIL. 
the plant or bean of chastity,—were applied through 
a supposed virtue in repressing the venereal passion. 
Castor oil appears to have come into practical use 
in England, as a purgative, the latter part of the last 
century, and it is now, as also in the United States, 
a familiar domestic medicine; in France, however, 
and certain other continental countries, it is but 
little employed, Ti-ousseau and Pidoux, e. g., speaking 
slightingly of it, and seeming to have no experience 
either of its action or its uses. Various physiological 
experiments have been made by Mialhe, et cet., upon 
man and animals, in which, however, a seed-emulsion 
was used; Dr. Hale, of Boston, introduced a half 
ounce of the oil into a vein upon his own person, and 
caused a grave and alarming disturbance. The bean 
may be expected to yield about half its weight in oil. 
According to Bruce, Castor oil is entirely soluble in 
one volume of alcohol, and in two volumes of rectified 
spirit. 
Special Action.—Among other ingredients, this oil 
contains a fatty acid, upon the disengagement and 
action of which its purgative properties depend,— 
in combination with glycerine, which constitutes 
a greater part of its bulk. Topically applied, it is 
bland and unirritating, as already said, at least when 
pure and fresh, and was apparently much used by 
the ancients in skin disease and otherwise. Nor 
does it exert any irritant action upon the stomach ; 
but in the duodenum it is decomposed, and the 
ricinoleic acid left free to exert the influence peculiar 
to the remedy. Its operation as a cathartic is 
characterized by gentleness, thoroughness and equa- 26 
EVACUANT MEDICATION. 
bility; the two correlatives of influence, increased 
secretion and increased peristalsis, are present in 
nearly equal degree; and it operates with quite 
uniform energy upon the entire intestinal tract, 
at least throughout the extent of the small bowel. 
It should yield its result in four to six hours, although 
a longer, and indeed doubly long, time may be re- 
quired if the patient is inactive and in bed. The 
stools are relaxed, but are feculent rather than 
liquid, and are commonly rendered with but little 
pain. They do not contain bile, except such as was 
previously present in the bowel, and Castor oil can- 
not be depended upon to act upon the liver; in fact, 
in full purgative dose, according to Rutherford, it 
rather depresses bile-secretion. Finally, other organs, 
and especially the organs of the pelvis, are not in any 
way involved in the result of the cathartic influence, 
as they are in the action of some other powerful 
cathartics. Ricinoleic acid enters the blood, and 
may be eliminated through various glands, as, e. g., 
the breasts; the nursling may, therefore, be impli- 
cated in the action of the oil taken by the mother. 
This fact has been especially emphasized in the re- 
cent researches of Dr. Thos. M. Dolan. 
Special Uses.—This cathartic is indicated, in general 
terms, wherever is required promptness and thorough- 
ness of action with a minimum of local and con- 
stitutional disturbance. The more important special 
indications are as follows: It is valuable (1) in the 
Puerperal State. The bowels should not be moved, 
or at least should not be solicited, for fully three days 
after the birth; but a thorough evacuation by this CASTOR OIL. 
27 
time promotes both comfort and safety. Confine- 
ment of posture, perhaps a temporary use of opiates, 
is calculated to make the bowels torpid. There may 
be a greater accumulation than is supposed, and 
than three days’ arrest of function would account for, 
—perhaps approach to impaction of fasces. Castor 
oil meets all the conditions of the case, and it is to be 
regretted that the puerperal patient so often refuses 
to take it; it acts upon the entire canal with equal 
energy, and while it evacuates, it reaches and 
cleanses every part. Its influence upon the uterus is 
kindly or negative. Its operation promotes a return 
of appetite, tends to abate fever, equalizes the cir- 
culation,—thus removes any local stasis of blood,— 
helps to abort a threatened milk abscess (or relieves 
conditions which, later, might lead to abscess); and, 
in a word, procures a status most favorable to the in- 
ception of lactation. With all recent advance in prac- 
tical therapeutics, no substitute has been found for 
Castor oil in this application.* 
* I am aware that Dr. C. E. Shelly has recently published a 
paper (Practitioner, vol. 35), calculated to prove that the use of 
Castor oil tends to arrest or prevent the secretion of milk. “ In 
rural France, it is held that Castor oil arrests the secretion of 
breast milk. A peasant woman in the puerperal state will not take 
Castor oil as an aperient, believing that to do so would prevent 
her Irom being able to suckle her infant, and that she would con- 
sequently he more likely to conceive again at an earlier date.” 
As respects the influence of a frequent or habitual ingestion of oil 
upon this function, I do not express opinion ; but am no less 
assured that a single, emphatic, well-timed exhibition of the rem- 
edy—as proposed above—can have no inhibitory action upon the 
mammary glands and their functions. That the leaves of Palma 
Christi applied to the breast are galactagogue, is an old-time belief. 28 
EYACUANT MEDICATION. 
(2) An occasional application in dysentery is 
equally without real substitute. Its revulsive in- 
fluence along the entire upper tract affords an in- 
terposition of much value; but Castor oil has an 
office more important than this. Both the disease 
and its local opiate treatment tend to produce torpor 
of the upper large bowel, and of the small intestine, 
and allow the formation of scybalous masses ; these 
by their presence cause continuance of and exacer- 
bation in the original malady; indeed, the sponta- 
neous rejection of hard, horny, angular masses which 
have been allowed to form, has more than once, in my 
observation, occasioned local recrudescence, and so 
relapse ; and nothing removes scybalous faeces more 
gently and effectively than the occasional dose of 
Castor oil. With modified indication, the oil may 
be given in subdivided aperient dose, prepared as an 
emulsion. (3) An indication is afforded by the re- 
quirements of abdominal, and especially of rectal 
surgery, as well as by the presence of rectal disease 
or lesion; in respect of surgery, there being equal 
need of a thorough evacuation before the surgical 
work is attempted, and of a thorough, non-irritating 
cathartic action at the right period subsequently. 
(4) The condition discussed under the fourth head 
of Cathartic Medication, suggests Castor oil as fre- 
quently superior to all other cathartic materials. 
(5) A sudden and severe cold is sometimes more 
effectually aborted by the timely dose of Castor oil 
than in any other way; and there are persons wTho 
have become aware of this fact, and are accustomed 
to have recourse to a considerable quantity at bedtime, CASTOR OIL. 
29 
expecting to find a good part of their “ cold ” carried 
off in the revulsive and cathartic operation of the 
next morning. But special precautions should follow 
such interference, in the direction of fresh expos- 
ures to cold, as by means of corroborant doses 
of quinine with meals, for a day or two after. (6) A 
final indication is found in the attempt to cure chronic 
constipation by the use of small, frequent and slowly 
diminished doses of Castor oil, in which, however, 
the author has no experience. The method appears 
to have been first proposed by Cullen, and it has, 
since his time, been mentioned favorably by various 
writers. It consists in taking small doses several 
times, daily, and, as the effect sought for is obtained, 
of lessening the dose by a single drop until, as 
claimed by Dr. A. T. Thompson, a few drops will be 
found to accomplish all that is desired. 
Finally, as in summing up, it may be said that 
the peculiar properties of Castor oil render it the 
purgative for the very young and for the old, for the 
delicate female, for the feeble and for such as require 
cathartic intervention, but to whom it is not wise or 
safe to offer any of the other familiar cathartics of 
equal power. Idiosyncrasy introduces but slight and 
infrequent irregularity into its action. 
Administration.—It would be hard to find any 
actual contra-indication to the use of this purgative; 
but on the part of the patient, contradiction and re- 
fusal are often enough encountered. It is greatly to 
be regretted that its bulk and offensive taste should 
so frequently prove insuperable obstacles. The 
various emulsions and levigations, mixtures with 30 
EVACUANT MEDICATION. 
milk, with coffee, etc., do not much help the matter, 
except with an occasional patient, while they do 
present an offensive remedy in still larger quantity. 
The following simple method, however, if adroitly 
followed, will practically encapsulate the oil and make 
it possible to receive it without taste. Take the juice 
of one lemon and divide equally between two glasses, 
in one of which the dose of oil is to be floated. 
When the patient is ready, the glass containing the 
lemon juice alone is to be emptied upon the oil and 
lemon juice, and if the latter be tossed off at once before 
the oil has time to rise, there will be no contact of oil 
with the tongue or taste imparted to the palate : then 
let teeth and lips be wiped upon a piece of the squeezed 
lemon. The success of this manipulation depends, 
of course, upon the promptness and adroitness with 
which it is done. 
The dose of Castor oil is commonly fixed at oz.| 
for the adult, and dr.j for the young child; but it is 
probably true that an excessive quantity does not 
operate with greater power than does the dose rightly 
proportioned, and equally true that a half table- 
spoonful often proves inadequate. It is better, there- 
fore, to increase the quantity slightly, than to run the 
risk of having to repeat. For the proposed cure 
of chronic constipation, the elastic capsule of Parke, 
Davis & Co.,* containing x, provides an elegant 
resource. It may be remarked that the dejections 
*Tlie same manufacturers provide a larger elastic capsule for 
ordinary cathartic use, each containing seventy minims of Castor oil. 
These are not so large that they cannot be easily swallowed, and 
two or three capsules are often found a sufficient dose. CASTOR OIL. 
31 
which follow the use of this purgative sometimes 
show oily globules floating upon the surface, evidence, 
probably, of excessive dose or of imperfect digestion 
and absorption. The purgative action of this oil is 
apt, in an especial degree, to be followed by constipa- 
tion. 
Castor oil is best, for the most part, given alone, 
and no advantage is gained by combination with 
other purgatives. Dr. Soper, quoted by Ringer, rec- 
ommends Castor oil and glycerine, in equal parts, 
the two slowly rubbed up together in a mortar; and 
claims that thus the taste is covered, and that only 
a half drachm of oil will act as a purgative. The 
following combination has proved serviceable in 
dysentery, when continued laxative action was indi- 
cated :— 
R. 01. terebinth., gtt. lxxx 
01. cinnamom, tt\, v 
01. ricini, 3 v 
Mncil. acac., q. s. 
Syr. simpl., q. s. 
Aq. purse, q. s. ad 
SlG.—Shake thoroughly. One teaspoonful, repeated p. r. n. 
Castor oil will frequently purge when introduced 
by rectum and allowed to remain; this has been 
denied by some writers, and as authoritatively as- 
serted by others, while there is abundant clinical 
evidence of the fact. The dose must be considerably 
raised above that to be given by stomach. The fol- 
lowing allied oils might serviceably be introduced 
into therapeutics, viz.: the oil of Spurge, from seeds 
of Euphorbia Lathyris, of which Fonssagrives says 32 
EVACUANT MEDICATION. 
that it is colorless, nearly tasteless, thirty times 
stronger than Castor oil, and three times less strong 
than Croton: and the oil of Aleurites Triloba, of 
which Oxamendi asserts that it has a pleasant, 
nutty taste, and in dose and action is closely analo- 
gous to Castor oil. JALAP. 
33 
JALAPA, JALAP. 
Materia Medica.—Jalap, or Radix Jalapie, a tuber- 
ous-rooted plant, indigenous to the eastern declivities 
of the Mexican Andes, and belonging to nat. ord. 
Convolvulacese, to which the potato also belongs. The 
root is the only part of the plant used in medicine, 
and was introduced into Europe by the early Span- 
ish voyagers some time in the sixteenth century. 
Jalap owes its purgative energy to a resin, present in 
varying proportion, from twelve to eighteen per cent.? 
and also contains about nineteen per cent, of an 
incrystallizable sugar and, occasionally, crystals of 
oxalate of calcium, among other less important ingre- 
dients. After extraction of the resin, a residuum may 
be obtained by a certain process, to the extent of five 
to seven per cent., to which the terms Jalapin and Con- 
volvulin have been applied, and which has been con- 
sidered by some as the active principle. It exerts the 
properties of Jalap in a high degree of concentration. 
Pharmaceutical Preparations:— 
1. Pulvis Jalapse; dose, gr. x-xx, much less used than for- 
merly, being superseded by the resin, which is much less 
variable and bulky. 
2. Extraction (abstraction) J., although recognized by the Pharm., 
has no especial value. 
3. Resina J.; dose, gr. iij-v. 
4. Pulv. J. compos.; Powdered Jalap, one part; Potassium Bi- 
tartrate, two parts ; Laxative Dose, gr. xv-xx. 
5. Jalapin ; dose, a variable fraction of a grain.* 
* The variability of root and importance of substituting the 
resin is shown in the statement of Dr. Squibb, that in nearly 34 
EVACUANT MEDICATION. 
Special Action.—The action of Jalap is directed to 
the upper bowel, even to the occasional implication 
of the stomach, as shown by the troublesome nausea 
excited in some subjects. It is a true irritant to the 
glandular structure of the small intestine, but proba- 
bly, as claimed by Bruce, only as it is brought in 
contact with the duodenal fluids. In the days of 
arbitrary subdivision of cathartic materials, Jalap 
stood prominent in the class of hydragogues, as an 
agent provoking an abundant serosity; so, physiolo- 
gically, as said above, we recognize it as a glandular 
stimulant, and expect liquid stools in two to four 
hours after its ingestion. It is hard to see how 
Bartholow can liken its action to that of senna, 
which is the type of a peristaltic stimulant, and gives 
feculent dejections. It is true, as with senna, that 
considerable griping may precede and attend the 
operation of Jalap; and in this particular, as well 
as in the time which the operation may demand, 
idiosyncrasy introduces frequent variations. Some 
patients prove to be quite unsuited to Jalap, either 
because of irritation high up and disturbed stom- 
ach, with nausea and vomiting, or the exceptional 
pain induced by its purgative action. 
Special Uses.—It has been shown quite conclusively 
by physiological experiment that Jalap will not act 
except as introduced to the system through the 
stomach; it is not adapted to dermal and rectal 
medication; furthermore, it is not secreted in the milk, 
eight thousand pounds, exhausted in seventeen years, p. c. varied 
10.7 to 26, with av. of 18 p. c. 35 
JALAP. 
and the mother who takes Jalap does not implicate 
her nursling in its effects. Upon the liver it has 
little or no action; and so far as we may trust the 
general truth of the axiom that hydragogues are not 
cholagogues as much might have been anticipated. A 
general indication, first of all, is apparent in that 
form of constipation which suggests deficient secre- 
tion throughout the small intestine, as shown by 
unnaturally dry stools, etc., and if there be deficient 
muscular contractility also in this part of the canal, 
Jalap ought effectively to meet both indications. For 
in its power to stimulate peristalsis, though it be sub- 
ordinate, this purgative possesses a property which 
most hydragogues, and the salines in particular, do 
not possess. 
A first special indication is found in a necessity 
for the evacuation of serous accumulations, whether 
in the form of anasarca or as contained in the cavi- 
ties of the body, as, e. g., ascites. Margrave empha- 
sized the depletory function of Jalap by the term 
panacea hydropicorum. 
(2) Disease of rectum or uterus, in subjects requir- 
ing purgative action, suggests the selection of this 
drug, as also do certain functional disturbances of the 
latter organ, such as stasis of blood, metrorrhagia, 
etc.; for Jalap, on account of the deficiency of its 
action on muscular tissue, and still more because of 
its action being expended high up, causes little dis- 
turbance to the pelvic viscera. Hemorrhoids and 
rectal inflammation, therefore, are not unfavorably 
affected by its operation; indeed, such lesions may 36 
EVACUANT MEDICATION. 
be helped by its revulsive influence in the small 
intestine. 
(3) Jalap may be wisely selected for women at the 
critical time of the menopause, selection being 
based equally upon a knowledge of the properties of 
the drug and attention to the conditions of the pa- 
tient ; it is safe and gentle with young children, and 
elderly people, but with the latter, only so far as they 
are able to bear a direct serous drain from the blood. 
Feeble and amende old men should never take Jalap. 
The writer has more than once seen bad results from 
such misapplication. Finally, it is somewhat of an 
anthelmintic; at least, it deserves its long-established 
repute for the dislodgment and evacuation of worms 
which make their habitat in the upper bowel.* As 
with every cathartic which owes its activity to a 
resinous principle, and which, consequently, is di- 
gested in the small intestine, the energy of Jalap is 
increased by the addition of an alkali. Hence the 
raison d’etre, of the Co. Jalap powder. Thus com- 
bined, the principal drug is effective in smaller dose, 
there is less liability to colics, and the depletory 
power is raised. 
Contra-indications.—Jalap is, in especial degree, 
an irritant cathartic, and is therefore to be avoided 
* Sydenham prescribed Jalap in gonorrhoea, but he also believed 
in a six weeks’ course of treatment. It would be interesting to 
enquire as to the principle of action of the remedy in this capacity, 
as determined by this prince of clinicians. Is it through its revul- 
sive power alone, or its irritant resinous element secreted by the 
kidneys, and thus brought in contact with the inflamed mucous 
membranes, as in the use of the balsamics, and especially of 
Copaiba ? 37 
JALAP. 
in all states of congestion or inflammation of stomach 
and small intestine. The discovery of an individ- 
ual tendency to suffer unduly from colics during its 
operation,—for there is doubtless such an idiosyn- 
crasy—should lead to the selection of another purga- 
tive for such individual. It is also contraindicated 
in the markedly anaemic. 
The old-time combination of Jalap and Calomel, 
gr. x each, has been wisely set aside, for the most 
part if not altogether. It is difficult to justify such 
union of drugs with our present physiological knowl- 
edge ; not only do the elements of the prescription 
tend to conflict with each other (Jalap preventing 
the action of calomel upon the liver, if, indeed, the 
latter in such dose can affect the liver), but their 
combined operation is far too severe for most pa- 
tients. 38 
EVACUANT MEDICATION. 
SCAMMONIUM. 
History, Materia Medica.—Scammony, a concrete, 
milky juice exuded from the root of the Convolvulus 
Scammonia, a climbing plant growing in Asia Minor 
and the Greek islands. It has an interesting history, 
but subordinate value as a purgative, being now 
seldom used except in combination. It was familiar 
to the Greek physicians 300 b.c., and, according to 
Fluckiger and Hanbury, was known as diagrydion, 
from the Greek dd/.(w, a tear; also used by Arabian 
physicians of the mediaeval period, and introduced 
into Great Britain in the time of King Alfred. The 
origin of the word is referred to the Greek Zxd/j./j.a, a 
trench, in allusion to the pit dug about the root in 
the season of incision and collection of the juice. 
Scammony has long been the object of various inge- 
nious frauds, and is extensively adulterated. It is 
nearly tasteless, but leaves a sensation of acridity 
deep in the throat. 
Pharmacy.—Resinse S., dose, gr. v and upwards. 
But Scammony is seldom used except in combina- 
tion. It is an important ingredient in the Co. Ext. 
of Colocynth, and also in the Co. Cathart. Pill, which 
also admits jalap. An agreeable emulsion may be 
made for children by rubbing up the powdered 
resin with sweetened milk and laurel water. Indeed, 
Scammony is a favorite purgative for children with 
English practitioners, and Bruce gives several form- 
ulae calculated to meet such indication. Of the Co. 
Scam. Pill, he remarks that it “ is the only aperient SCAMMONIUM. 
39 
pill in the Pharmacopoeia which does not contain 
aloes.” It is thus constituted :— 
R. Res. scammon., 
Saponis, 
Tr. zingiber, fort., aa 1 pt. 
M. Spirit vin. rect., 2 pts. 
Dose.—5-15 grs. 
Action and Uses.—Essentially the same as those of 
jalap, and Dr. Ringer considers the two drugs in one 
chapter; indeed, both chiefly owe their action to the 
same potent principle, jalapin or convolvulin. Scam- 
monium is, perhaps, the more drastic, and is, doubt- 
less, also digested in the duodenum; and it is prob- 
ably true, as said by Bruce, that it will not act if 
injected into the blood. Like jalap, it is anthelmintic 
in the same range of action; but it is hard to credit 
Ringer’s assertion that it is serviceable for destroy- 
ing thread-worms in the rectum. 40 
EVACUANT MEDICATION. 
ALOE. 
History, Materia Medica.—Aloes, a resinous juice, 
in concrete form, produced by many species of the 
Liliacex family. Several varieties are familiar to 
the trade, and distinguished in the books, e. g., Soco- 
trine, Natal, Barbadoes A.; but such distinctions have 
no value for the physician. The Aloes—aloes wood 
—of the Bible and the American Aloes or Agave of 
Mexico, are plants of wholly different character bo- 
tanically and therapeutically. The medicinal plant 
is a native of dry, sunny spots in South and East 
Africa, from which it has been transplanted into 
regions of soil and climate favorable for its cultiva- 
tion. This purgative was known to the Greeks at 
least 400 b. c., and, in common with jalap, is said to 
have been prescribed to King Alfred by the patriarch 
of Jerusalem; and thus, as early as the tenth century, 
was introduced into Britain. There is an interesting 
legend, derived from Mohammedan travelers and 
other sources, to the effect that when Alexander re- 
turned from his farther victories, he was advised by 
his master, Aristotle, to seek the island Socotria, 
which, he was assured, produced a sovereign remedy. 
Acting still upon this counsel, he removed the 
original inhabitants and replaced them by a colony 
of Ionians, whom he enjoined to devote themselves 
to the culture of the Aloe, from which both health 
and riches would be derived. The colony remained 
under his protection, early embracing the Christian 
religion, and still continued prosperous up to the ALOE. 
41 
date of the legend—about the middle of the 12th 
century. 
Aloes is obtained from the leaf of the plant, and, 
by one method, at least, is thus collected: The leaf, 
which is one to two feet in length, is cut at a stated 
season, and so placed, with the cut end downward, 
that the juice, as it exudes, may trickle into a trough. 
The juice, by evaporation, becoming inspissated and 
concrete, constitutes Aloes. This purgative has a 
smell which, by association, may become as offensive 
as its taste, and a taste at once nauseous and bitter. 
The odor is due to a volatile oil, present in slight 
proportion, which the Smith Bros., of Edinburgh, 
succeeded in eliminating, in 1872,—400 lbs. yielding 
but about one ounce. Aloin serves as active princi- 
ple, and appears to have identical purgative prop- 
erties with those of the drug from which it is de- 
rived. It was first discovered by the Smiths, in 1851, 
in Barbadoes Aloes, of which it constitutes 20 to 25 
per cent. It is a bright-yellow, crystalline body, 
without odor, in taste at first sweetish and afterward 
very bitter, and in physical appearance not unlike 
iodoform. Aloin from other varieties of the drug has 
a different molecular structure, but probably pos- 
sesses the same properties. According to Tilden, 
Barbadoes Aloes has three equivalents of water, 
Socotrine two equivalents, while Natal Aloes is an- 
hydrous. 
Pharmacy.—Aloes has so large a number of prepa- 
rations, simple and compound, as to savor of poly- 
pharmacy ; and yet this very diversity may suggest 
how widely and variously the remedy is used. It is 42 
EVACUANT MEDICATION. 
readily soluble in alcohol and also in hot water; but 
a considerable mass is deposited from the latter on 
cooling—known as the resin of Aloes. Different 
specimens of Aloes yield 60-80 per cent, of bulk to 
water. These solutions become black on contact 
with soluble chalybeates, through the presence of a 
small quantity of gallic acid. The more important 
pharmaceutical preparations, mostly officinal, are as 
follows:— 
1. Pulvis Aloes ; dose, gr. iij-x. 
2. Aloin; dose, gr. ss-ij. 
3. Pil. Aloes, containing gr. ij Aloes, and soap. 
4. “ “ et Asafcet. ; Aloes, Asafoetidse and soap equal 
parts. 
6. Pil. Aloes et Ferri (2 Aloes, 11 Sulph. F. and Co. Cinnam. 
Powd.). 
6. Pil. Stomachiea (Lady Webster Dinner), Aloes and Mas- 
ticbe ; a 5-gr. pill. 
7. Pil. Aloes et Myrrh® (with aromatic powder). 
8. Tinct. Aloes; dose, Sj-^iv. 
9. “ “ et Myrrh® ; dose, p. r. n. 
10. Vinum Aloes ; about 2 grs. in 1 dr. 
11. Pil. Aloin (gr. |), Strychnia (gr. and Ext. Belladonna 
(gr- |). 
Moreover, Aloes is a prominent feature in the 
familiar Comp. Rhubarb pill (v. Rhubarb). 
Special Action.—Aloes performs its first service in 
the stomach, and yet its purgative influence is 
brought to bear at a point much lower down than 
that exerted by the cathartics previously considered. 
Oribasius says of it, Hominem ad cibos sumendos 
promptiorem facit; and Fonssagrives remarks that its 
stomachic properties are too often overlooked, and 
especially its power to arouse the appetite. The ALOE. 
43 
bitter principle is universally eupeptic, whether as 
associated with a purgative material, as in the case 
of Aloes, colocynth or cascara, or as presented by a 
non-purgative body, which may be variously toxic 
or innocuous, as nux vomica, cinchona or columbo. 
But as a purgative, Aloes hardly begins to act until 
it has reached the colon; and upon this tract of the 
intestine it probably expends its entire energy. It 
is slower in its operation than any other cathartic,— 
“ Tarde purgat aloes ”—(Hoffman), and ten to fifteen 
hours, and even longer time, may elapse, before its 
effect is obtained. An excessive dose does not appear 
to yield any larger result than one rightly propor- 
tioned ; but the action of the former may be attended 
with more pain. 
It is upon the muscular coat of the large bowel 
that Aloes chiefly acts, the contents of which are 
evacuated in the form of a soft, pultaceous mass, with 
but slight evidence of implication of the intesti- 
nal glands. In a word, the stools are feculent, like 
those of senna,—senna being a peristaltic stimulant 
of the small intestine;—but the aloetic dejections 
have less fluidity, because the lower tract is less liber- 
ally supplied with glands* The circulation of blood 
*The tendency of Aloes to determine toward the pelvis is illus- 
trated by the effect which even an aperient dose inay have upon 
the circulation of the lower rectum ; to which there is infrequent 
allusion in the hooks. Some hours after the dose has been taken, 
and shortly before its operation, the rectum will he found closed 
upon itself, very much as if it had recently received a supposi- 
tory of tannin. The patient may be unconscious of this condi- 
tion, hut if an attempt he made to pass the tube of a syringe, it 
becomes evident at once. The author has observed this effect 44 
EVACUANT MEDICATION. 
in the pelvis is excited ; and its organs, and the uterus 
in particular, are apt to be involved in the energized 
contractility of the colon. Aloes has been proved to 
have a considerable influence in promoting the secre- 
tion of bile.* Its purgative principle is received into 
the blood through various avenues, as from the rec- 
tum, the areolar tissue, etc., and it is secreted in the 
milk. 
Special Uses.—Aloes is especially indicated in con- 
stipation of the large intestine, which usually 
assumes an habitual or chronic form. It is adapted 
to such chronic constipation for several reasons: 
it influences specifically the part of the bowels 
which is the seat of the difficulty; its purgative action 
interferes but little with the upper or digestive tract, 
and so does not disturb nutrition; its steady use, 
properly directed, does not tire but rather tones the 
bowel; the bitter principle helps to invigorate appe- 
tite and digestion, a favorable action is constantly 
exerted upon the liver, and the purgative power is 
but little abated by habitual application, so that a 
determinate quantity of the drug will often accom- 
repeatedly, produced by small doses of Aloes in a healthy rectum ; 
hut he is not prepared to say that it will always he found. 
* Brim ton endorses the view, which many have held, that Aloes 
can act only as it is mixed with bile. “ It is useless in jaundice, 
where the bile does not enter the intestines, as shown by the white- 
ness of the stools.” Again,—“Aloes has little or no purgative 
action when given alone as an enema, hut is active if mixed with 
ox-bile.” The latter statement seems unphysiological, for Aloes, 
whether exhibited by rectum or skin, is not expected to act by any 
local impact, but only after absorption and conveyance through the 
general circulation and return to the bowel. ALOE. 
45 
plish the desired purpose, in frequent repetition, for 
months together. The subjects for such medication 
are most often met with among the sedentary, the 
middle-aged or those past this period, and in 
women after repeated parturitions or abortions.* 
(2) The power which this material has to stimulate 
the blood supply of the pelvic organs, suggests a 
use which must, however, be applied with intelli- 
gence and caution. In amenorrhcea of the anaemic, 
Aloes may be given alone or in various combina- 
tion,f in slightly aperient dose for many days, or in 
purgative quantity at the time of the molimen, with 
most favorable results. Certain other conditions of 
the uterus, readily recognized by the gynaecologist, 
may find help from the same resource, e. g., passive 
congestion or stasis of blood ; active inflammation, 
per contra, would forbid its use. 
(3) Determination to the pelvis implies revulsion 
from the head and chest; and some writers, and 
Trousseau in particular, advise purging by Aloes, in 
inflammation of the brain or lungs. Finally, since 
the cathartic action of this material is stimulant, 
rather than depressant, it is preeminently the purga- 
tive for the feeble, the anaemic and the old, when 
other conditions favor such selection. Its habitual 
use is apt to excite the sexual appetite, and in 
* Bartholow instances a special form of chronic constipation in 
which Aloes is of high value,—viz., that of the hypochondriacal 
and melancholy, presenting foul tongue, torpid liver and bilious 
tint of skin with impacted colon. Here, a course with this pur- 
gative may introduce great improvement in the mental state, 
f Vide p. 51. 46 
EVACUANT MEDICATION. 
the male to occasion erections. There has been at 
certain times considerable discussion whether a con- 
tinuous use of the drug might not lead to the 
production of hemorrhoids; but it has been quite 
definitively settled that so long as this lesion is not 
already present, and so far as proper contraindications 
are preserved, it is entirely innocent of the charge.* 
Aloes is anthelmintic only as respects worms that live 
in the rectum; Redic found that lumbrici live many 
days in earth wet with an aqueous solution, but 
Pereira ascertained that oxyures are very impress- 
ible to enemata and suppositories of Aloes. Fonssa- 
grives thus summarizes the function of this purga- 
tive in its general application. “ The purgative of 
dyspeptics, of great eaters, of hypochondriacs, of 
the subjects of passive dropsies, of apyretie conditions 
of the liver and of fluxionary dispositions toward 
the head and chest.” 
Contraindications.—But Aloes has contraindica- 
tions of as positive a character as its uses, and no 
other common cathartic requires such strict atten- 
tion to the conditions in which it should not be 
prescribed. (1) In any state of active disease about 
the rectum, its employment is absolutely forbidden ; 
in a healthy rectum, too large a dose may, in its 
operation, be attended with tenesmus and heat and 
bleeding, and a single laxative exhibition, by over- 
* Strangely enough, the name of Dr. Fordyce Barker, of New 
York, has become associated with a method for the treatment of 
hemorrhoids by Aloes, that is, of a certain variety of the affection. 
In this, a nice differential diagnosis is involved, and for most 
practitioners it is probably safer to try other methods. ALOE. 
47 
sight, in a case of hemorrhoids, will give the physi- 
cian an opportunity to observe what discomfort and 
injury the drug is capable of effecting; all the more, 
its frequent or daily use, even in small quantity, will 
necessarily lead to melancholy consequences. 
(2) Inflammation of the womb, active hypersemia, 
hemorrhage or liability to hemorrhage, equally con- 
traindicate ; and so does also a threatened abortion. 
Pregnancy simply suggests caution; in a strong 
woman the occasional use of aloes can do no harm ; 
its frequent and even its habitual use as a regulator 
of the bowels may be advisable; but the possibility 
of danger must be kept in mind and the patient 
properly instructed or kept under observation.* Once 
more, Bartholow says, “irritable or inflammatory 
states of the stomach mucous membrane contraindi- 
cate its use ; ” a strange statement. Surely, if the 
stomach can receive any cathartic at all it will receive 
Aloes (and the more especially as protected by silver 
leaf or mastiche), both because it possesses irritant 
qualities in slight degree, and because it is digested 
and exerts its chief action below the stomach. 
Administration.—Aloes is variously exhibited, both 
as respects method and quantity, according to inten- 
tion. Probably in greater degree than with any 
other purgative, it presents conveniences for admin- 
* Fothergill reprobates the too frequent use of Aloes with 
women ; but Fonssagrives probably has the right view of it when he 
says that its inconveniences in pregnancy have been exaggerated, 
and Delmon shows that small doses have no influence as aborti- 
facient. In a word, in the use of Aloes in pregnancy, intelligence 
and attention to the special case are demanded, as elsewhere. 48 
EVACUANT MEDICATION. 
istration otherwise than by the stomach. Being but 
slightly irritant, it may be applied endermically, and 
it may also be prescribed as suppository or enema. 
Dr. Gerhard, of Philadelphia, advises Aloes in der- 
mal application, ten grs. to a blistered surface; but as 
he thus obtained five or six stools with griping, it 
is probable that a smaller dose would meet the pur- 
poses of a simple purgative. Ringer says Aloin 
can be given hypodermically, in twenty-five parts of 
water, and intimates that in this way a speedier action 
is obtained. As respects suppository use, eight to ten 
grs. may be incorporated with butter of cocoa; and 
this, inserted in the rectum, will operate in about 
the same time as Aloes given by the mouth; this is 
in accordance with the statement of Wedekind, and 
has the support of clinical experience. 
Combination.—As the especial function of Aloes is 
that of a peristaltic excitant and tonic, union with 
whatever other material, whether of itself purgative 
or not, which has a similar physiological property, 
will enhance its power. A combination with nux 
vomica is probably everywhere familiar to the pro- 
fession. Thus effectively combined, gr. i-ij Aloes 
may have equal purgative energy with gr. x acting 
alone. A knowledge of the energizing power both of 
iron and of quinine, less susceptible of explanation, 
was the property of the profession long before the 
days of physiological research; but this expedient 
has been too generally lost sight of in recent years. 
“ How can we theorize on the fact,” remarks Fonssa- 
grives, “that 10 centgr. of Aloes and 10 centgr. of 
quinine rarely fail in purgative effect, while either ALOE. 
49 
taken alone remains inactive nine times out of ten ? ” 
Dorvault et cet. have seen iron energize Aloes in a 
similar way. The olden-time combination of Aloes 
and iron, as in the pill of this name, dropped from 
the last Pharmacopoeia (and perhaps better dropped 
on account of the very general misapprehension 
with which it was used), still affords a valuable 
remedy of various uses, so far as its use is wisely 
directed.* Thus, this pill may perform an important 
service in the condition discussed under the second 
indication of Aloes medication. 
For strictly emmenagogue effect, various formulae 
might be constructed : a combination of Aloes with 
nux vomica for action on general muscular tissue, 
with ergot for action on uterine muscle, and podo- 
phyllin for action on the liver (and perhaps the 
uterus also), is capable of a wide application, if it is 
properly modified according to individual require- 
ment. The following may serve as a type :— 
R. Pnlv. aloes, 
Ext. nucis. vom., aa gr. vij 
Ergotinae, 9 ss 
Podophyllin, gr. iv. 
M. Mass. ft. in pil. No. xx, div. 
SiG.—One pill after each meal, according to the state of the 
bowels. Or, for a parvule :— 
R. Aloin, gr. vij 
Podophyllin, gr. iij 
Strychn. sulphat., gr. f. 
M. Pil. minim. No. xx fiant. 
* The misapprehension that iron is an emmenagogue and that 
Aloes and iron is an emmenagogue resource of especial value, 
has become so widespread and accredited with the profession 50 
EVACUANT MEDICATION. 
The conditions of constipation, whether occa- 
sional or chronic, are too varied and personal to 
make feasible the suggestion of fixed formulte. Still, 
the Lady Webster dinner pill, of renown through 
several generations, is well calculated for this com- 
mon affection; the incorporation together of the 
particles of Aloes and mastiche serving both farther 
to delay purgative action and to render the mass 
more acceptable to an irritable stomach. On the 
other hand, the addition of soap, in equal quantity, 
to the aloetic pill of the U. S. P. provides the alkali 
which makes the solution and digestion of Aloes, 
as of any resinous purgative, more facile and 
prompt. In the construction of a more composite 
pill, to be taken habitually with the meals, once to 
three times daily—and Aloes is a cathartic which 
should always be taken with the meal*—quinine 
or nux vomica may be added, to increase both 
stomachic and aperient property, iron or arsenic, 
for the especial action of either, and belladonna or 
that it is to he feared it will never he wholly set right. Trous- 
seau well says upon this point, ‘ ‘ This error, endorsed by the 
writers of centuries, will prevail for a long time yet, in opposition 
to facts the most patent, and to the most rigorous observation ; for 
we are so constituted that we naturally cling to an error and 
obstinately resist the truth.” In extreme anaemia or in chlorosis, 
it may he necessary to reconstitute the blood before menstruation 
or some other important function can be resumed ; but iron in such 
application is not an emmenagogue ; indeed, in its general in- 
fluence it is haemostatic. 
* Aloes acts more gently thus taken, and Lemery says, more 
promptly. The ancient medical writers, Oribasius, Celsus, Aetius, 
all taught that Aloes should be taken with the repast. Eufus 
says, “Nee cibi, digestionem abolit.” ALOE. 
51 
hyoscyamus, to render less harsh and to act on the 
liver, or ipecac., for action on the liver, e.g.:— 
R. Alo'in, gr. x 
Strychn. sulph., gr. j 
Acid, arsenios., gr. iss 
Ext. hyoscyami, 9 ij. 
M. Mass. ft. in pil. No. xl div.* 
Sig.—One pill after each meal. 
Probably, as previously said, aloin has all the 
properties of the drug from which it is derived, and 
its concentration makes possible the construction of 
a pill of so slight a size, as ought not to be offen- 
* The following formulae are given for illustration only ; for a 
fixed formula is nowhere more out of place than as applied to 
chronic constipation :— 
R. Alo'in, gr. vj 
Ext. belladon., gr. iiss 
Ext. nuc. vomic., gr. vij 
Quinise sulph., 9 ij. 
M. Pil. No. xx ft. 
R. Alo'in, gr. vij 
Podopliyllin, gr. iij 
Strychn. sulphat., gr. f. 
M. Pil. No. xx ft. 
R. Alo'in, gr. vij 
Pulv. ipecac., 
Ferri pr. hydrog., aa J}j. 
M. Pil. No. xx ft. 
R. Alo'in, gr. vij 
Ext. nuc. vomic., 
Ext. physostigm., a a gr. vij 
Ext. hyoscyara., J}j. 
. M. Pil. No. xx ft. 52 
EVACUANT MEDICATION. 
sive to the most fastidious patient. The parvule 
(No. 11 of Pharmaceutical Preparations, p. 42), put 
upon the market by several large New York houses, 
has been widely introduced throughout the country, 
and is extensively used. 
As respects combination with other purgatives, 
Aloes is best, for the most part, when used alone: to 
conjoin it with a material which acts higher up and 
acts more speedily, is largely to make negative the 
action of Aloes. Still, the compound rhubarb pill 
has important uses, which will be discussed under 
Rhubarb. Liquid aloetic mixtures, formerly much 
in vogue, are not received kindly at the present 
day; the comp, decoction,—baume de vie,—once had 
an excellent reputation, which it still deserves, as an 
after-dinner laxative. Some authorities assert that 
the employment of alcohol lessens the purgative 
power of Aloes. One of the most effective tonics 
known to the writer was made of equal parts tr. 
Aloes, tr. ferri chlorid., tr. columbse and simple 
syrup, a mixture which at one time (perhaps it is 
still) was in great demand among the patients of the 
Demilt Dispensary, New York; but the patrons of 
a dispensary may be said not to have an educated 
palate. The rationale of the combination of Aloes 
and myrrh, provided in both pilular and liquid form 
by the U. S. P., is difficult of explanation; perhaps 
myrrh increases the purgative power of Aloes as 
guaiac is said to do. 
The suffering from ascarides may be speedily 
relieved by the use of this purgative in the form of 
an enema of aqueous extract; to which may be ALOE. 
53 
added Aloes by the month, in occasional cases 
where the worms ascend above the sigmoid flexure. 
Aloes has been somewhat used in the form of injec- 
tions for the treatment of gonorrhoea, and Schonlein 
extols the daily rectal injection of 5 ij powdered 
Aloes in several ounces of water for subjects of 
leucorrhoea with passive congestion. 54 
EVACUANT MEDICATION. 
CAMBOGIA. 
Materia Medica, etc.—Gamboge, a drastic, hydra- 
gogue cathartic, with subordinate, and yet powerful, 
determination to the kidneys, but little used except 
in combination; as directed by the U. S. P., it ap- 
pears as an ingredient of the comp, cathartic pill, 
of which it constitutes about one-tenth. Acts upon 
the upper part of the alimentary canal, chiefly upon 
the mucous follicles and glandular structure, and 
has a tendency to irritate the stomach, causing nausea 
and vomiting. Gamboge is a gum-resin, of bright 
yellow color, the product of Garcinia Morelia (F. and 
H.) of nat. ord. Guttiferx; is knowm by the French 
as gommegutte, is produced in the Province Cam- 
boja, Siam, and was early employed by the Chinese, 
but only as a pigment, as it was regarded poisonous; 
its chief commercial value is still that of a pigment. 
Michael Reuden, 1611, writes of its use under the 
name of novum gummi purgans, and Parkinson, of 
London, apothecary, in 1640, has allusion to Gam- 
boge as catharticum aureum, “ a drug of recent impor- 
tation.” Nearly three-fourths of its mass is a gum- 
resin, gambogic acid, in which chiefly resides both 
purgative and coloring principles ; the remainder is 
a gum. Still, Gamboge is somewhat stronger in 
cathartic operation than gambogic acid. It is prob- 
ably the latter ingredient which also stimulates the 
kidneys, imparting its bright yellow color to the 
urine. The dose of Gamboge alone is gr. x-xv. The CAMBOGIA. 
55 
British Pharmacopoeia orders Pil. Gambog. Co., con- 
sisting of Gamboge, aloes and cinnamon. 
Uses.—Gamboge, simply as a cathartic agent, could 
doubtless well be dropped from the list, in our present 
multiplicity of resources. Its absence in the comp, 
cathartic pill might be made good by a slight increase 
of the jalap and scammony. If, however, we were 
to propose a sub-order of purgatives, containing 
purgative materials which are prescribed for some 
ulterior purpose and not chiefly to evacuate the 
bowels and purge, corresponding to a frequent indi- 
cation in practical therapeutics, Gamboge would 
stand high in such a class. For application to condi- 
tions requiring copious discharge of serosity through 
both bowels and kidneys, it has preeminent value. 
It is, indeed, “ the veritable purgative of the drop- 
sical.” Fonssagrives declares its function and appli- 
cation as follows: “ It unites the triple advantage 
of presenting an easy administration, of not occasion- 
ing in habitual use, a gastro-intestinal intolerance, 
and of provoking abundant serous stools. In fine, 
the diuretic action, which accompanies or supple- 
ments its purgative effect, is a farther advantage 
which assures to this substance a superiority very 
marked over other purgatives.” Rayer had already 
signalized Gamboge as a medicine capable of ren- 
dering grand services in albuminuric anasarca, when, 
in 1849, a military surgeon, Abeille, making trial of 
this purgative in serous dropsies, established the fact 
that the dose could with impunity be carried as high 
as one gm., and even one gm. and 50 centgrs., and 
that, “aside from causing superpurgation, it deter- 56 
EVACUANT MEDICATION. 
mines, at the end of several days, together with 
almost normal stools, a very abundant diuresis; as 
a result of which serous accumulations diminish very 
rapidly.” Abeille cites various observations which 
place the fact beyond question that Gamboge has, with 
the dropsical, an incontestable efficacy.* Fonssagrives 
adds the significant statement that, “the diarrhoea pro- 
voked by Gamboge presents, furthermore, the impor- 
tant characteristic that it stops of itself as soon as the 
use of the remedy is suspended.” He has also observed, 
in his own experience, that although nausea and even 
vomiting may be set up at first, still gastric tolerance 
is soon established and the purgative can be con- 
tinued for many weeks without further trouble to the 
patient. 
Gamboge is found in the market in the form of 
small sticks or cylinders, of deep orange color; contact 
with water causes an immediate emulsion of bright 
yellow. At first tasteless, it has an acrid, disagree- 
able after-taste. It yields its cathartic action promptly, 
the motions often being attended with considerable 
pain. After the first evacuation of the bowels, the 
stools may consist almost entirely of a watery fluid. 
In poisoning, the symptoms are closely like those of 
* One of Abeille’s cases was a woman attacked with ascites ; after 
10 days’ administration of Gamboge, the urine was raised to 7 litres 
per diem, and this temporary polyuria was followed by a sudden 
disappearance of the serous accumulation. His method, in brief, 
begins with a dose of 40 centgrs., which he advanced by 10 centgrs. 
daily until a dose 1 gram. 20 centgrs., or 1 gram. 50 centgrs. was 
reached—this for the twenty-four hours. By this time the purga- 
tive action often ceased, to he replaced by an abundant flow of 
urine. CAMBOGIA. 
57 
cholera. Bartholow suggests that few deaths are 
reported because, in gross amount, the drug is speed- 
ily rejected by vomiting; to which we may add, that 
the material is unfamiliar, except as a pigment, and 
exposure to accident is slight. Treatment is con- 
ducted upon like principles with that for poisoning 
with Croton oil and other drastics. One point made 
by Abeille et cet. of the speedy tolerance established 
in the continued use of this drug, ought to be more 
generally familiar to the profession. 58 
EVACUANT MEDICATION. 
COLOCYNTIIIS. 
Materia Medica.—Fructus Colocynthidis, Pulpa C., 
Colocynth, “ the dried, decorticated fruit, freed from 
seeds, of Oitrullus Colocynthis,” of nat. ord. Cucurbi- 
tacese. Appearance of white, light, pulpy balls, of 
size of an orange, odorless, but of very bitter taste. 
The Colocynth gourd is a slender plant, produced 
in sandy soils of warm, dry regions, as in Upper 
Egypt, North Africa, among the Greek islands, etc. 
Colocynth was familiar to the old Greek and Roman 
physicians, also to the Arabians, is mentioned in 
Sanscrit writings, and was probably introduced into 
Britain as early as the eleventh century. Colocynth 
contains a large amount of resin, extractible by alco- 
hol; from which, by especial process, about two per 
cent, of Colocynthin may be obtained, a glucoside of 
very bitter taste, in appearance like a yellow powder, 
and possessing the purgative properties of Colocynth 
in concentration. The seeds, rejected in medicine, 
have about seventeen per cent, of fatty oil, “ and 
roasted or boiled, are the miserable food of some of 
the poorest tribes of the Sahara.” (F. & II). 
Pharmaceutical Preparations:— 
1. Ext. Colocynth ; dose, gr. v-x. 
2. Ext. Colocynth comp. ; dose, gr. v and upwards (containing 
ext. C., scammony, aloes and cardamom). 
3. Pil. cathart. co. ; dose, one to three (containing comp. ext. 
C., ext. jalap ; calomel and gamboge). 
4. Vinous tinct. ; one ounce pulp macerated with one pint 
Hock or other white wine, filtered and made up to full 
pint; dose, one teaspoonful to one tablespoonful. COLOCYNTHIS. 
59 
5. Colocynthin, discovered by Vauquelin, but little used ; dose, 
gr. ss—gr. iss. 
Special Action and Uses.—Colocynth is little used, 
except in combination, that of comp, ext., wherein 
it is present in small proportion and its action 
masked by other powerful purgatives, some of which 
have very different properties. Colocynth acting 
alone causes hydrocatharsis, with operation upon 
the bowels similar to that of gamboge ; but Pereira 
points out, and correctly it is believed, that Colo- 
cynth exerts an elective influence upon the large in- 
testine which gamboge does not possess. Its action 
represents, in prominent degree and very positive 
form, the two elements of cathartic influence, viz., 
that of increased contractility and increased secre- 
tion. The latter element preponderates, of course, 
but still the operation of this purgative may be 
attended with painful colics, and it is a drug which 
should generally be avoided in pregnancy. It is a 
very active irritant, and so is contraindicated in all 
inflammatory affections of stomach and bowels. 
Those who have made trial of Colocynthin com- 
pare its action to that of croton oil. The singular 
power which Colocynth has over the intestinal 
exhalants may be exerted in a degree even as high 
as the mouth, a freer flow of saliva frequently fol- 
lowing ingestion of the remedy. The best approved 
observations go to show that it is not cholagogue but 
has an influence rather to depress the secretion of 
bile. Colocynth is one of the few cathartic materials 
which may be introduced into the blood through 
the skin, although not by a blistered surface, for 60 
EVACUANT MEDICATION. 
which it would be much too irritant. Chrestien, 
of Montpellier, in treatment of mental alienation, 
applied a pomade by frictions to the abdomen and 
obtained liydragogue purgations.* A poultice of 
Colocynth pulp placed upon the same region will 
often be found to help the operation of purgatives 
previously given by the mouth, in cases where there 
is difficulty in obtaining evacuation. 
In Gonorrhoea.—This agent has been found effect- 
ive in the treatment of blenorrhagia, although the 
knowledge of the virtue of the drug and the method 
of its use were for a long time in the hands of char- 
latans. There was formerly in Paris an ignorant 
fellow who enjoyed a wide reputation and a lucrative 
practice for his successes in the cure of gonorrhoea 
by the use of a secret remedy ; which proved on 
analysis to be practically nothing more than a vinous 
tincture of Colocynth. Fabre first published a state- 
ment of the successful use of this preparation in 
gonorrhoea, and especially in its more chronic form. 
His method, in brief, was as follows: one-half to one 
tablespoonful, before breakfast, for three days in suc- 
cession, omit on the fourth day, and then resume for 
three successive days; so continue till twenty to 
twenty-five doses have been taken in all. The ex- 
perience of the author with this remedy has been 
most marked in cases wherein the balsamics had 
failed to accomplish all that was desired; here, often, 
the Colocynth wine alone, or given in conjunction 
with the copaiba treatment, has given full satisfac- 
* His formula was, ext. Colocynth, one part; lard, eight parts. COLOCYNTHIS. 
61 
tion. It is noteworthy how often the patient is 
pleased with the treatment, aside from the fact of 
progressive cure, and this notwithstanding tempo- 
rary pain and weakness. It cleans him out, gives 
a sense of purification and renewal, and arouses 
appetite; indeed, the remark made in the discussion 
of Aloes respecting the stomachic property of the 
bitter principle in certain purgatives, has been es- 
pecially justified in the results obtained in this 
application of Colocynth. 
It has not always been found best to follow Fabre’s 
method altogether, but the occasional omission of 
the morning dose is convenient; for some subjects 
even one-half tablespoonful proves too powerful. 
It is of interest to remember that Sydenham extolled 
jalap, a drug of somewhat allied action (resinous 
and a hydragogue), in this disease. Colocynth is 
poisonous in sufficient quantity, and deaths have 
been reported from its abuse; treatment on the same 
principles as in poisoning from gamboge. 62 
EVACUANT MEDICATION. 
ELATERIUM. 
Materia Medica, etc.—Fructus Ecballii (F. & H.), 
F. Elaterii, Elaterium or Squirting Cucumber,* of the 
same nat. order as colocynth, a cucumber fruit of the 
Momordica Elaterium, resembling the garden cucum- 
ber but of inferior size. The Elaterium plant grows 
wild in various parts of the Mediterranean region; 
was cultivated in English gardens as early as the 
sixteenth century; and is at present an object of cul- 
tivation in several localities for its medicinal product. 
It wras known to the Greek writers, and Dioscorides 
mentions ttarrjfjtov, describing in exact terms the 
process still in use for the extraction of the drug. 
The juice contained in the interstices of the fruit 
—and that in immediate proximity to the seeds is sup- 
posed to be especially rich in the medicinal principle 
—having been expressed and allowed to stand, slowly 
deposits a fecula of faint yellow or green color; and this 
constitutes Elaterium. The product is very small, and, 
in the English experiments, 240 pounds of the fruit 
yielded but about 4| ounces of the drug. Elaterium 
is generally found in the shape of irregular, amor- 
phous tablets, of grayish color, its surface frequently 
* F. & H. give the following account of the peculiarity in which 
originates this name. 1 ‘ The fruit, when ripe, separates suddenly 
from the stalk, and at the same moment the seeds and juice are 
forcibly expelled from the aperture left by the detached peduncle. 
This interesting phenomenon is due to the process of exosmosis, by 
which the juice from the upper part of the fruit gradually passes, ” 
etc., etc. On account of this behavior of the ripe gourd, it is 
necessary to gather the fruit while still green. ELATERIUM. 
63 
showing an impression of the tissue of the paper or 
cloth against which it was pressed on drying; has 
“ an herby, tea-like odor,” and an acrid and intensely 
bitter taste. 
Pharmacy.—As long ago as 1819, Dr. Clutterbuck 
made a chemical examination of Elaterium, which 
is frequently quoted to this day; and the best speci- 
men of the drug, as found in the market, is still 
that which bears his name—E. (Clutterbuck). About 
1831, Morries and Hennell, independently of each 
other, discovered the active principle, Elaterin, which, 
however, contains no nitrogen and is not an alkaloid. 
Pereira observes that when the fresh juice is exposed 
upon a glass plate it soon begins to grow turbid and 
minute rhomboidal crystals of Elaterin make their 
appearance. It constitutes full one-third (33.6 per 
cent.) of the crude drug. The strength of Elaterium 
varies so greatly as to have seriously prejudiced its 
use. According to French authority, Elaterium of 
the French Pharmacopoeia rates as low as 5 or 6 in 
energy, in comparison with that of London, which 
provides for a strength of 44. Still the Elaterium 
(Clutterbuck) ought not to present much variety, and 
the average dose is | gr. The U. S. P. of 1880, howT- 
ever, proposes the substitution of Elaterin and fixes 
the dose at TV gr. A trituration with sugar of milk 
is convenient in general practice. 
Action and Uses.—The office of this purgative in 
medication, as was remarked of gamboge, should 
remand it to a sub-order of materials which are never 
used for the purpose of simple catharsis. Its action 
is much the same as that of colocynth, but it is much 64 
EVACUANT MEDICATION. 
more emphatic,—in fact, it is by all means the most 
powerful and concentrated cathartic known to the 
profession. Like colocynth, it expends its chief 
energy upon the glandular structure of the intes- 
tinal tract, but is more likely to involve the stomach 
in its influence,—a distressing nausea and vomiting 
being a frequent attendant upon its operation. Some 
constitutions escape this largely or altogether. Its 
stimulant action upon secretion is felt in the mouth, 
and Elaterium is sialagogue. Its unfortunate dis- 
turbing influence upon the stomach is too often a con- 
tra-indication to, or demands the suspension of, its use; 
nothing is more depressant than continuous nausea 
and vomiting ; but, this accident aside, Elaterium is 
not a depressant cathartic, as some of the books 
represent, but is possessed of a stimulant quality 
of a high order, which has an important bearing 
upon its use, as will be seen in the discussion of the 
seventh function of cathartic medication. 
It would be hard to conceive of the condition, in 
responsible practice, which would warrant recourse 
to Elaterium solely for evacuation of the bowels; its 
use is rather reserved for certain emergencies, and is 
chiefly addressed to three indications :— 
First.—For the withdrawal of dropsical accumu- 
lations in serous cavities and the relief of venous 
congestion. The immediate relief,—even although it 
be but transient—which follows its interposition in 
dropsy of cardiac origin, is such as cannot be gained 
from any other resource. Dr. Ferrier, who has made 
an especial study of Elaterium, speaks to the point: 
“ Its powers of removing serous accumulations in the ELATERIUM. 
65 
cavities of the human body surpass those of any 
other medicine; and the astonishing relief which it 
affords in the dyspnoea occasioned by hydrothorax 
or ascites, even in persons of the most advanced age, 
must place it first in the class of hydragogues.” The 
French have but little familiarity with Elaterium, 
and Fonssagrives says he considered the statement in 
Dr. Hope’s report exaggerated,—to the effect that a 
dropsy dependent upon heart disease could be drawn 
off in three to four days—until himself had made 
trial with the drug and learned its powder. Hyde 
Salter has the practical suggestion that for such a 
purpose the remedy is best administered every other 
day, as early as five o’clock a. m., so that by ten or 
eleven o’clock the patient will be over its effects. 
A second indication is afforded by a need of giving 
a period of rest to the kidneys, as in uraemia, which 
organs will at times only respond to the use of diu- 
retics after the operation of Elaterium; as well as by 
a purpose to secure, through evacuation of the bowels, 
the more ready and complete removal of toxic ma- 
terial from the blood. Dr. Harley records the obser- 
vation that this remedy shows its utility in albu- 
minuric dropsy near its beginning; if given at an 
advanced period, and the more especially if the acci- 
dents of uraemia are present, it is apt to set up an 
intractable diarrhoea. 
Third.—A demand for sudden and strong revulsion 
and derivation from the head, in cerebral inflamma- 
tion or hemorrhage, may be met by Elaterium. Its 
action wrould be much the same as that of Croton oil, 
which latter would be generally more convenient; 66 
EVACUANT MEDICATION. 
unless the especial indication be to evacuate serosity 
from the blood-vessels and so lower the blood- 
pressure. 
Contra-indications.—Inflammation of stomach or 
small intestines, or an obvious degree of irritability, 
presents the only general contra-indication. No 
measure of debility, senility or prostration should 
forbid its use in those who plainly need its interven- 
tion, if only its irritant effect upon the stomach can 
be escaped. The latter complication is so distressing 
that it is always well to give the remedy tentatively, 
until the patient’s susceptibilities have been ascer- 
tained ; and such a course is imperative in the weak 
subject. A special contra-indication, in individual 
cases, is suggested by knowledge thus obtained ; in- 
ability to take Elaterium on account of disturbance 
of the stomach often constitutes an idiosyncracy; 
there is no evidence that tolerance may be estab- 
lished by use, as with gamboge, but each repetition 
of dose rather makes the distress more severe and 
overwhelming. Such subjects must have recourse 
to some other material.* 
* In respect of the tendency of Elaterium to set up the symp- 
toms of cholera morbus, in stomach as well as in bowels, Lauder 
Brunton remarks the presence of such property in the fruit of all 
plants of nat. ord. Cucurbitacese. It is highly developed in Elate- 
rium and colocynth, hut even cultivated melons and cucumbers 
show a reversion in the same direction, and particularly as respects 
certain individuals. SENNA. 
67 
SENNA. 
Materia Medica.—The leaves, for the most part, of 
two varieties of the Cassia, C. acutifolia and C. angus- 
tifolia, of nat. ord. Leguminosse. The plant is a low, 
bushy shrub, growing in south Arabia, Nubia, the 
Sind and the Punjaub, and attaining a height of 
two to four feet. Three chief sources and modifica- 
tions of the leaf are known to commerce, of which 
the Alexandrian is perhaps the most prominent. 
Knowledge of this purgative can hardly be traced 
back farther than to the ninth or tenth century, and 
it was through Arabian physicians that it was com- 
municated to western Europe. Mediaeval practice 
used both the leaves and pods (folliculi) of the plant, 
preferring the latter, and the Senna pod is still em- 
ployed in some countries. 
In chemical constitution, Senna is very complex. 
Its active principle, cathartin, a colloid body, has been 
finally determined to have little or no activity. 
Cathartic acid, present in about one per cent., has 
much the same properties as Senna, and its salts, 
as the cathartate of ammonia, have concentrated 
power. Its coloring matter, chrysophanic acid, is 
also claimed to be purgative; farthermore it con- 
tains an incrystallizable sugar, tartaric, oxalic acids, 
etc. Altogether, we accept the summing up of Fons- 
sagrives: “ We must conclude that the purgative 
action does not reside solely in this principle,” 
(cathartic acid) “ but we must consider the purgative 68 
EVACUANT MEDICATION. 
property as resident in the ensemble of principles 
•extracted from Senna.” 
Pharmacy.—This material, in its various prepara- 
tions, proprietary and otherwise, is probably more 
familiar in domestic practice than any other purga- 
tive ; and is doubtless more often so taken than as 
prescribed by the physician. 
1. Confedio Sennae, containing S., liquorice, cori- 
ander, tig, prune, tamarind and cassia; when com- 
pounded with care and properly kept, this purgative 
mixture may be quite palatable, but it is often sold 
in very different condition. Dose, p. r. n., 5j-5iv. 
2. Extract. S. Fluid. A preparation which has but 
little raison d’ etre; it does not much advance the con- 
centration of what is, at the best, a bulky and 
nauseous remedy, and it presents it in an exception- 
ally offensive form. Dose, Sss and upward. 
3. Inf. Sennae Comp., (private formula). Two ozs. 
Senna, infused in one pint water and strained; 
made up to Sxij; add two ozs. each common mo- 
lasses and tr. gaultheria. Bottle for use. This is 
designed for habitual use ; will keep without change, 
is not unpalatable, is gentle in action. Dose moder- 
ate, viz., one to two tablespoonfuls. Senna is perhaps 
in more general use at present than ever before; 
the various sugared proprietary mixtures of which 
“ Tamarindien ” is a representative, owing their power 
almost entirely to this ingredient. 
Various compositions formerly in favor have been 
set aside in their use, as being offensive to taste. 
Such is the black draught, containing Senna infusion SENNA. 
69 
and Epsom salts, and the tisane royale, with the same 
ingredients and aromatics added; constructed, it is 
true, on accurate clinical observation, which is often 
more unerring than physiological research, and 
approved by the latter as presenting equivalents of 
purgative power, in peristalsis and secretion; but none 
the less liable to offend a delicate palate and stomach. 
The following cautions should be observed in pre- 
paring Senna infusion: the leaves must not be boiled, 
or macerated, or allowed to stand in infusion after their 
strength is drawn, as thus the draught is rendered more 
drastic and irritating, without increase of purgative 
powrer. Addition of black coffee goes far to cover 
the taste of Senna, and also contributes a little to 
its activity. 
Special Action.—Senna has been classed by some 
writers among “ convulsivant ” purgatives; to empha- 
size the fact that its chief influence is addressed to 
the stimulation of the muscular contractility of the 
bowels. It acts upon the upper tract in much the 
same way that aloes acts upon the colon, i. e., it 
chiefly augments peristalsis in the small intestine. 
It operates much sooner than aloes, frequently in 
four to six hours, and its stools are less solid; but 
still feculent or semi-fluid. The cathartic principle 
is secreted in the milk, and in Dr. Dolan’s recent 
experiments, the infant was seen to suffer severe 
colics from Senna given to the mother. The chry- 
sophanic acid is rendered in the urine, to which it 
imparts a yellow stain. The energized contractility 
of the small intestine may be extended to the colon, 
and indeed, communicated in a measure to the 70 
EVACUANT MEDICATION. 
bladder and uterus,* the urine in particular being 
voided with increased force; although in the latter 
condition it is probable there is concerned local con- 
tact with some irritant resinous principle of Senna 
eliminated by the kidneys. 
Senna has somewhat of a bitter principle, but it is 
present in feeble proportion, is a “ nauseant bitter/’ 
and has little power as a stomachic. This purgative, 
as devoid of irritant properties, might be adapted 
to endermic application could it be presented in 
greater concentration ; cataplasms of Senna applied 
to the bowels have appeared to assist the action of 
purgatives given by mouth. 
Special Uses.—Senna is appropriate to such as re- 
quire frequent cathartic interference, and to those 
who find the operation of other purgatives liable to 
be followed by constipation. It has the double 
advantage that it does not fatigue the bowels and 
does not exert an astringent action with consequence 
of subsequent torpor. It is especially convenient 
with subjects of chronic constipation who are for- 
bidden to use aloes, at the same time that the soft, 
well-concocted dejections which its influence evokes 
are favorable to haemorrhoids and like rectal lesions. 
It should be kept in mind, however, that it is the 
assimilative tract which is swept by this cathartic, 
and in frequent use the administration should be 
so timed as not to deprive the intestine of alimentary 
fluids upon which have been expended the energies 
of digestion. 
* Rectal injections of Senna tea were atone time in favor with 
accoucheurs as an ocytocic to the uterus in tedious labor. 71 
SENNA. 
Many adults find a small quantity of the com- 
pound infusion or of some confection, like that of 
one of the many proprietary Senna fruits, an essen- 
tial daily regulator of the bowels; which, taken up- 
on retiring, hardly disturbs nutrition, as it gives a 
nearly natural movement the next morning; for 
Senna, like castor oil, at least in moderate quantity, 
requires a longer time for its operation when the 
patient is in bed. The Comp, liquorice powder, re- 
cently introduced into American practice,—discussed 
under sulphur,—owes a considerable part of its ac- 
tivity to Senna, and is a convenient aperient with 
children, as it provides small dose, sure and gentle 
action, and taste that is seldom objected to.* 
Contra-indications.—The contra-indications which 
have variously appeared in connection with the 
materials previously considered, can all be set aside 
in the use of Senna. This purgative, however, has 
its own especial disability, which is too often disre- 
garded. Hardly any other selection would be so 
unfortunate in the state which may be termed 
cumulative constipation, where the daily function 
of the bowels has been for some time neglected or 
inadequately performed, and the canal is distended 
with impacted fseces. To such condition a cathartic 
* Bruce, who is generally as concise as he is correct, says of 
Senna, “Its laxative effect is increased by acids, hut diminished 
by alkalies ” ; which is contrary to physiological analogy, and it 
is believed, to clinical observation. Neither can we believe that, 
in frequent use, “ the pelvic structures become hypersemic, lead- 
ing to haemorrhoids.” We are aware of no authority, nor of any 
experience, which supports this assertion. 72 
EVACUANT MEDICATION. 
which is preeminently a peristaltic stimulant is 
peculiarly unadapted ; it yields but little serosity for 
the solution and disengagement of the feces which 
oppose mechanical obstruction and constitute prac- 
tically “ a fecal plug; ” and evacuation can only be 
obtained after an attack of colic of the most violent 
and painful character. Such experience is not in- 
frequent in the domestic use of Senna; it ought 
never to occur in the use of the remedy as directed 
by the physician. In all conditions approaching 
the state described, this agency is formally and 
invariably contra-indicated ; almost any other cathar- 
tic will answer the purpose better. 
Cassia Marilandica, American Senna, cultivated by 
the Shakers, is claimed to have the same properties 
as the foreign leaf. CASCARA SAGRADA. 
73 
CASCARA SAGRADA. 
A comparatively recent contribution of the north 
Pacific Slope to medicine. Variously known as the 
bark, in the Spanish original, holy bark, locally chittem 
bark, of the shrub Rhamnus Purshiana, of nat. ord. 
Rhamnacese. The products of two other members of 
this family have been employed in medicine; the 
expressed juice of the berry of the Rhamnus Catharti- 
cus,* and the bark of the Black Alder or Rhamnus 
Frangula. The former was known and used in 
early Saxon times, as the hartshorn or buckthorn, 
affords the pigment, “sap green,” but has been 
generally discarded by the profession, as being too 
drastic. The R. Frangula, lately introduced, has too 
often disappointed expectation, in the uncertainty of 
its action. The Cascara appears to stand midway 
in the series in potency, and to have established a 
permanent value. Its pharmaceutical preparations, 
worthy of notice, are three, viz.:— 
1. Fluid. Ext. Cascar. Sagrad.; dose, 3j-ij. 
2. Ext. C. S.; dose, gr. ij-iv. 
3. The cordial of P. D. & Co., who have been largely concerned 
in the introduction of Cascara Sagrada to the profession; 
and which presents combination with mild aromatics and 
is sought to be made palatable ; designed for the infant and 
quite young children ; dose, 3 ij-iv. 
Action and Uses.—Cascara has been compared in its 
action to rhubarb, and very inappositely; both its 
action and its application are quite different. If 
* Some authorities give it R. Cathartica. 74 
EVACUANT MEDICATION. 
any comparison is to be made in respect of a purga- 
tive which is mostly mi generis, it may be said to 
present analogy with senna; but it is less drastic than 
senna; the operation is less likely to provoke colics, 
and its stools probably contain more liquid. Like 
senna, its use does not fatigue the bowel, and is not 
followed by constipation. It contains the bitter 
principle, and has pronounced properties as tonic 
and stomachic. Its coloring matter appears in the 
urine and dejections, and its purgative principle is 
probably conveyed in the milk. In respect of its 
office in arousing the appetite, it should be said that 
its dose is as bulky and as nauseous as aloes, at least 
with many patients, and the offense given to the 
taste causes prejudice to the stomach, a difficulty 
which is overcome by substitution of the pill for the 
liquid preparation. Cascara probably has no contra- 
indications ; it is suited to two prominent applications. 
(1) It is, par excellence, the laxative purgative for 
the infant and very young subject; the size of dose 
required being its only inconvenience, but the gen- 
tleness of its action making it an admirable selection 
for this class of patients. It is especially safe with 
the infant of feeble strength;* its frequent use, when 
* In illustration : The author has never forgotten an application 
of the new remedy soon after its introduction. An infant pre- 
maturely born, of low vitality, kept alive from day to day, in 
part by wrappings of wool and inunctions of oil, suddenly pre- 
sented an intractable constipation which would not yield to rectal 
excitation or enemata. The action of any purgative was to be 
feared, but interference was inevitable ; choice was directed to 
Cascara, and the gentleness and thoroughness of its operation, with 
absence of any unfavorable after-effect, justified the selection made. 75 
CASCARA SAGRADA. 
demanded, sustains appetite, and its action seldom 
causes pain. It will frequently be found better to 
give a moderate dose of the cordial, two to three 
times in the day, than to trust to one large dose. 
(2) Cascara is adapted to chronic constipation in 
the adult. Its union of qualities, as just discussed, 
renders it appropriate to such as must have a daily 
regulator, and who cannot take aloes; who, indeed, 
might have recourse to senna, but with whom the 
latter works badly. For there are individuals with 
whom senna is always drastic, in quantity sufficient 
to yield result: with such it is an exceptional irri- 
tant ; they are tormented with pain, and suffer pros- 
tration and malaise after the operation has been 
secured. These subjects have repeatedly found in 
Cascara a mild, effective daily aperient, the con- 
tinued use of which does not make it necessary to 
increase the quantity used. 76 
EVACUANT MEDICATION. 
RHEUM. 
History, Materia Medica.—Radix Rliei, Rhubarb, 
the root of R. officinale, and of other undetermined 
species belonging to the nat. ord. Polygonacese. “No 
competent observer as far as we know,” says the 
Pharmacographia, “ has ever ascertained, as an eye- 
witness, the species of Rheum which affords the 
commercial Rhubarb. R. officinale, from which it 
seems, at least partly, derived, is the only species 
yielding a root-stock which agrees with the drug.” 
It is grown chiefly in certain wide districts of the 
Chinese Empire. Attempts have been made to in- 
troduce its culture into England, but with results 
which were only in part successful. The common 
Rhubarb plant of our gardens is of allied species, and 
its leaf, in size and shape, suggests a species to which 
the Rheum was once referred—R. Palmatum; but 
its root, medicinally considered, is very inferior, 
although its preparation has been taken in hand by 
the Shakers. 
Rhubarb is said to have been familiar to the 
Chinese as long ago as 2500 b. c. ; and they would 
seem to have attached an exaggerated value to it, 
as indicated by the names applied to the drug, “ the 
great yellow” and “the yellow and excellent.” It is 
believed that it is this material which Dioscorides de- 
signates as pa said pf/ov, a term which a writer of the 
fourth century refers in its origin to the river Rha or 
Volga. The terms Rheum barbarum and Rheu barbar- 
um occur in various writings of the sixth and seventh RIIEUM. 
77 
centuries. For a period probably exceeding one hun- 
dred years, a superior quality of the drug was brought 
into Europe by a long overland journey through Rus- 
sia,—the quality being kept up to its standard through 
the combined results of Chinese carefulness and Rus- 
sian supervision,—known as Russian or Muscovitish, 
or Crown, and in England, as Turkey Rhubarb. 
About 1860, misunderstandings, often before threat- 
ened, culminated between the Powers, and Turkey 
Rhubarb “ has now become a thing of the past, which 
can only be found in museum collections.” {Pharma- 
cograph) 
In earlier times, the risks and exposures of travel 
through semi-barbarous countries, contributed to 
make Rhubarb an article of high price. We are 
told that an English monk obtained and sent, as a 
grett tresure, some seeds of the plant to the secretary 
of Henry VIII.; and an official English price-list of 
1657 quotes opium at 6s. per pound, and Rhubarb 
at 16s. At present, the drug is mostly shipped from 
Hankow and other Chinese ports. 
In composition, Rhubarb is of great interest to the 
chemist who, however, has not succeeded in com- 
pletely solving the problem which its constitution 
presents; and to the physician, who finds it the most 
complex substance used in purgative medication, and 
who is practically concerned with at least four of its 
ingredients, if he is to make of it an intelligent 
application. It contains a prominent coloring mat- 
ter, chrysophanic acid and chrysophan, which has 
also somewhat of purgative power; a purgative 
principle, par excellence, perhaps rheumic acid; an 78 
EVACUANT MEDICATION. 
astringent quality, rheo-tannic acid; and oxalate of 
calcium. The latter, together with other mineral 
ingredients, constitute full thirty-five per cent. The 
oxalate of calcium, distributed throughout the mass, 
gives to the root its glistening, micaceous appear- 
ance, imparts the gritty feel to the teeth when it is 
chewed, and may be returned in the urine in the 
form of “ dumb-bell crystals.” 
Pharmaceutical Preparations.— 
1. Rad. and Pulv. Rhei; dose varies greatly according to in- 
tention. 
2. Ext. Rhei; dose,gr. v-xv. 
3. Pit. Rhei ; three parts Rhubarb, and one part soap. 
4. Pil. Rhei Comp. ; containing Rhubarb and aloes in nearly 
equal quantities, myrrh, and oil of peppermint ; dose, one 
to three pills. 
5. Pulv. Rhei Comp. (Gregory’s Powder) ; Rhubarb two, mag- 
nesia six, ginger one ; dose, 3 ss-j. 
6. Syrup. Rhei. 
7. Syrup. Rhei Aromaticus. 
8. Tr. Rhei Dulcis. 
9. 1list. Rhei et Sodii ; 
and many others which might be mentioned, hut which have 
little real value. 
Special Action.—Rhubarb has properties which 
may be enumerated as purgative, astringent, siala- 
gogue, tonic, eupeptic and antiseptic, according to 
dose and application. As laxative and cathartic, its 
operation is quite sui generis, and unlike that of any 
other material of the class. Used in this capacity, 
it combines purgative power with astringent influ- 
ence ; and while either may be chiefly asserted, still 
as the remedy is commonly directed, the purgative 
principle is first to act, while astringency follows RHEUM. 
79 
upon the cathartic impression. Its action begins in 
the mouth—i. e., when opportunity is given, as when 
the root is chewed; and, here and thus, it is both a 
local sialagogue and affords incentive to appetite, 
Again, Rhubarb acts upon the entire course of the 
alimentary canal, and it affects this tract alone—i. e., 
it has no secondary or reflected influence, as has 
aloes, e. g., upon certain other organs. And once 
more, it adds a third quality to the double influence 
which we have seen that other cathartics are capable 
of exerting; a quality strictly, and almost solely, 
peculiar to itself; it prominently energizes peristal- 
sis, quite actively augments secretion, and, thirdly, 
materially modifies as to certain morbid conditions, 
the mucous membrane of the passage. It yields a 
cathartic result in four to six hours, the stools being 
soft and feculent but never watery; such action 
frequently leaves the bowels constipated. It is a 
gentle stimulant to bile-secretion, imparts its purga- 
tive principle to the milk, which it also stains and 
renders bitter; and both dejections and the urine, 
and occasionally the perspiration, eliminate the 
bright yellow color peculiar to the remedy. 
N. B.—The dark orange urine, passed after the in- 
gestion of Rhubarb, should not be accepted as evi- 
dence of biliousness, nor should its oxalate of lime 
justify a diagnosis of oxaluria; but these mistakes 
have been made in practice. 
Special Uses.—The foregoing study of the action 
of Rhubarb goes far to suggest its applications. In 
general terms, it is chiefly indicated in conditions 
which require the intervention of a purge, in the 80 
EVACUANT MEDICATION. 
original sense of the term—i. e., of an agency which 
both removes and cleanses. 
(1) This remedy is adapted to the summer diar- 
rhoea of children, diarrhoea ab ingestis; wherein, as 
prescribed in small and frequent doses, it may 
promptly cure by the exertion of a threefold quality. 
Its purgative property removes crudities of food and 
otherwise; its tonic and antiseptic function prevents 
the re-formation of flatus and acrid secretion; and, 
last of all, its astringency operates to lessen a pre- 
viously exaggerated secretion from the intestinal 
glands. Like conditions in adults are less common, 
but may be reached by the same remedy. 
(2) Rhubarb, properly directed, will serve to 
relieve or cure a disorder often found in the middle- 
aged and those past this period, and which is espe- 
cially frequent with women, where a languid, fermen- 
tive digestion is associated with habitual constipation. 
Here, the root may be presented in certain of the 
familiar combinations discussed under the next 
section, or it may be given by a method peculiar to 
the affection for which it is so well adapted. Rhu- 
barb, as powder or raspings, or, still better, as slowly 
chewed, will best give the result desired; and it is 
often remarkable how small a quantity, thus taken 
with every meal, will do purgative service, even 
remed}dng a constipation which has refused to yield 
to other and harsher cathartics. Some find the 
taste of Rhubarb agreeable, to others it is offensive; 
the latter can take the raspings of the root floated 
upon water. 
(3) This purgative is, in especial manner, adapted 81 
RHEUM. 
to the form of neglected and cumulative constipa- 
tion discussed in the fourth section of cathartic med- 
ication, whether the imprisoned and impacted faeces 
have set up a diarrhoea, or a more serious condition 
is imminent which simulates a mechanical stoppage. 
Nausea and vomiting is a frequent complication, and 
forbids the use of an irritant cathartic, however con- 
centrated, at the same time that the distended and 
paralyzed bowels will not yield to an agency of in- 
ferior power. Indeed, the force which is to dislodge 
and evacuate must be cumulative also, and Rhu- 
barb, in small and frequent quantity, meets all the 
demands of the case. In children, who less often 
suffer from this affection, teaspoonful doses of the 
syrup or, still better, of the aromatic syrup or tincture, 
given every hour, serve a good purpose. With adults, 
the Compound Rhubarb pill by all means! covered 
with silver leaf, if the stomach needs especial pro- 
tection ; one pill every hour will eventually work its 
way, without nausea and without pain, procuring a 
complete evacuation,—although it has sometimes 
required twelve to fifteen pills before the result was 
accomplished. 
Contra-indication.—The older writers classed Rhu- 
barb among the “ hot ” remedies; it must be avoided 
in a state of heat and inflammation of stomach and 
upper intestinal tract, just as it is especially indicated 
in a state of atony and flaccidity of fibre, in this 
portion of the canal. No condition of the blood, or of 
any other organ besides the intestinal tube, forbids its 
use. The following suggestions are worthy of con- 
sideration :— 82 
EVACUANT MEDICATION. 
(1) Germain S6e insists that Rhubarb has the in- 
convenience of provoking a flux toward the hemor- 
rhoidal veins. Per contra, Ringer quotes Stills as 
endorsing this material “ as a remedy of surprising 
efficacy in piles, when laxatives are needed.” He 
also recommends it “ in the costiveness and hemor- 
rhoidal swellings incident to pregnancy.” 
(2) Rabuteau directs attention to the danger of 
the formation of concretions of oxalate of lime, when 
the use of Rhubarb is continued too long. The fact, 
as previously said, that rather more than one-third 
of its mass is made up of mineral ingredients, would 
seem to give support to this caution. 
Administration.—Rhubarb is both moderated and 
energized in its action by means of combination. 
By the soap, with which it is combined in the pill, 
its purgative force is a little increased and its astrin- 
gency diminished. As was claimed for aloes also, 
the addition of a bitter enhances the power, and in 
still greater degree union with an alkali,—the prin- 
ciple of action in the latter case having been pre- 
viously explained. Such is the scope of the Mist. 
R., Gentian et Sodii, to which Fothergill alludes as 
“Haustus Stomachicus, Mistura Mirabilis, a combination 
of world-wide fame.” But other properties than the 
purgative are assisted and secured by such a combi- 
nation ; and in particular the antacid and antiseptic: 
the familiar eccoprotic mixture which provides Rhu- 
barb and soda or magnesia and peppermint, is 
sufficient illustration. 
The tendency which Rhubarb has to cause griping 
pain, and which is quite prominent in some subjects, RHEUM. 
83 
may be diminished by union with the various car- 
minatives,—the mints, ginger or cardamom. When 
the indication is action brought to bear upon stom- 
ach, and also upon bowel by a gentle laxative, a 
combination of Rhubarb with oxalate of cerium, with 
or without a little ipecac., has a good effect.* But 
except as it is administered in frequent, subdivided 
dose, it must be borne in mind that Rhubarb, alone 
and in its simple combinations, is too bulky for 
cathartic effect. In the Compound Rhubarb pill, on 
the other hand, we have provided an agency much 
more compact, of action similar to that of the 
material which gives it its name, but of wider range ; 
and, in full dose, capable of procuring a cathartic 
operation more nearly approaching that of Castor oil 
than can easily be obtained by any other resource. 
* As in the following formula :— 
li. Pulv. rhei, 3 j 
Cerii oxalat., 3 iss 
Pulv. ipecac., gr. v. 
M. Cht. No. xx. fiant. 
Sig — One powder repeated p. r. n. 84 
EVACUANT MEDICATION. 
MANNA. 
History.—As known to medicine, Manna is a whi- 
tish, concrete, stalactiform sugar, derived from several 
species of the ash, chiefly from Fmxinus Ornus, of nat. 
ord. Oleacese, cultivated for this purpose in Sicily, 
Sardinia and elsewhere. It is also obtainable from 
other sources; Virgil and Ovid allude to a substance 
of this nature produced by the oak, and the fact was 
familiar to Arabian physicians. To this day, oak 
Manna is a product of some importance in certain 
parts of Armenia; the excrescence being found 
upon the leaf in early morning is shaken off 
and collected upon strips of cloth placed on the 
ground. There is in the Materia Medica cabinet of 
Dartmouth College a fine specimen of oak Manna, 
contributed by Dr. Parmelee, Missionary of the 
American Board in Turkey. It has a wholly differ- 
ent look from that of ash Manna, seems to be made 
up of fragments of leaf and sugar, incorporated 
together, and has the appearance of a resinous, dark- 
green, amorphous mass. F. & H. state that formerly 
ash Manna was also collected from the leaf, until, 
indeed, about the middle of the sixteenth century, 
when the present method of incisions in the trunk 
was substituted, by which a more liberal supply is 
obtained; but this mutilation of the tree was for a 
time strenuously opposed by legislative enactment. 
The Manna of commerce is variously known, 
according to its form, as flake, fatty, and the tears of 
Manna. It is a sweetish, gritty, aromatic tasting MANNA. 
85 
body, with composition chiefly of mannite or manna 
sugar, about 70 p. c., and residuum of common sugar 
and extractive. The greenish color of some speci- 
mens has been attributed to copper, but is really 
due to fraxin, a principle of the ash bark. Manna is 
soluble in 6.5 parts of water. It may be made arti- 
ficially by treating glucose with sodium-amalgam. 
The export of Manna from Messina in 1877 amounted 
to about 57,000 kilgr.* 
Use.—The special action of this purgative has 
never been much investigated. In this country it is 
now less used than formerly; but it is considerably 
used in Italy and largely employed in South America. 
It has the peculiarity of being slow in action, but 
its action is apt to be maintained for some time 
when once it has been set up. Manna has superior 
value, or rather it has superior convenience as the 
laxative for the infant at breast or at the bottle ; 
and has been too readily forgotten and superseded 
by certain other compounds which do not act so 
kindly either on stomach or bowels. By selection of 
the finer varieties of Manna, the infant’s food can be 
sweetened as with sugar, or it will be accepted as a 
tasteful confection. Indeed, the coarser kinds are 
never desirable, being gritty and of resinous taste. 
An old-time association of senna and Manna has 
been mostly abandoned ; when in use it was believed 
that senna thus combined was less drastic. 
* F. & II. describe varieties of Manna produced by tbe birch, 
willow, eucalyptus, tamarisk, cotoneaster, and at least two forms 
of animal origin. CHOLAGOGUES. 
In the chapter on cathartic medication, the reason 
is given why it was not thought best to distribute 
purgative materials among the various sub-classes of 
laxatives, etc., etc., as is done by many writers upon 
this department of therapeutics. But in a treatise 
meant to be preeminently practical, there seems to 
be good ground for departure from this general 
scheme in the present instance ; for there is no more 
frequent, no more important question presented to 
the mind of the physician, in the employment of 
purgatives, than that which concerns the selection of 
an agency which shall specifically affect the liver so 
as to promote the secretion of bile, as preliminary to 
its operation as a purgative. The term Cholagogue, 
Gr. yoh><: and ayw, i. e., bile-driver, is unfortunate; but 
it has been sanctioned by too long usage to be set 
aside. That is strictly a bile-driver or expeller 
which evacuates the duodenum and the bowel below 
with such speed and force as shall carry before it all 
the bile which the intestine already contains, and 
thus prevents its reabsorption and return to the liver. 
But the term Cholagogue, as usually applied, has a 
very different signification; reference being had to 
whatever material may have the function of so im- 
pressing the liver as to secure the secretion, and con- 
duct away from it, of new bile. 
The literature of this branch of medicine has been 
86 CHOLAGOGUES. 
87 
both enriched and obscured by many monographs 
written, many experiments performed and treatises 
based on experiments, all devoted to the general 
subject, during the last fifteen or twenty years. In 
1866, a committee of the Medico-Chirurgical Society, 
appointed for such investigation, gave its majority 
report, after long and arduous labor, in effect that 
mercury is not cholagogue in its purgative action; 
this in the face of an almost universal opinion to 
the contrary, held by many generations of medical 
men. It is true that eminent members of the 
committee dissented from this conclusion, and that 
the minority report questioned its validity, suggest- 
ing, prominently, the following sources of error :— 
(1) The subjects of experiment were animals, 
mostly dogs, and it is conceivable that upon such 
subjects mercury may have a different action than 
upon man. 
(2) The animals were in a state of health as con- 
cerns the liver ; and it is not assumed that, in man, 
mercury promotes the flow of bile from a healthy 
liver. 
(3) Many fibres of the sympathetic were mutilated 
or unavoidably sundered in the cutting operations 
incidental to insertion of the canula; and it is sur- 
mised, from analogy, that such mutilation might of 
itself modify the influence of so powerful an agent 
as mercury upon so important an organ as is the 
liver.* 
* The clinical argument has not been introduced in the text. 
In the discussion which followed the presentation of this famous 
report, Dr. Gamgee remarked that, as one of the committee, of 88 
EVACUANT MEDICATION. 
The researches of many other investigators 
are well deserving of record, blit it need only be 
added that, so lately as 1878, Professor Rutherford 
instituted careful enquiry into the actual influence 
over the bile-secreting function of many drugs 
which are commonly reputed to be cholagogue. 
His labors, in addition to affording many facts which 
will require to be quoted elsewhere, appear to justify 
the following general conclusions, viz.: (1) Contrary 
to expectation and previous opinion, it was quite 
conclusively proved that irritation or stimulation of 
the duodenal mucous membrane, although in the 
immediate neighborhood of the entrance of the com- 
mon biliary duct, has no actual influence over the 
liver as respects secretion of bile. 
(2) Repeated observations support the position that 
which Dr. Bennett was chairman, he begged to express his opinion 
that the experiments had not conclusively proven that mercury 
does not act upon the liver. That mercury does influence those 
functions of this organ which have for an end and purpose the 
production of bile, is a clinical observation constantly repeated 
for ages ; and it would be absurd to set up a few experiments 
made upon dogs against such constantly established experience. 
Professor Lister also bore testimony to the relief of especial symp- 
toms of deranged biliary function, such as the cleansing of the 
skin and urine often effected by calomel, phenomena familiar to 
every physician, however they maybe explained. Finally, in his 
inaugural address, as president, before the Association, in 1875, Sir 
Robert Christison used these words: “While deeply interested 
and much instructed by experiments performed by a committee of 
this Association, regarding the use of mercury, I remain as 
thoroughly convinced as ever, that this much-abused drug exerts 
a powerful action on a function of the liver, and is to be trusted 
as a most efficient remedy in the control of not a few of its disor- 
ders. ’ ’ CHOLAGOGUES. 
89 
those purgative agents which act most powerfully as 
glandular evacuants have the least power to evacuate 
bile from the liver, suggesting the formulation which 
has been previously employed, scil., that hydragogues 
are not cholagogues. This expression, however, may 
require slight modification as applied to actual 
practice; and in effect as follows: A diminished dose 
of a glandular cathartic, so operating as to cause a 
slight intestinal secretion, may also exert a slight 
influence over the liver. On the contrary, we are 
not warranted in believing that a drug which is 
mostly a peristaltic stimulant will therefore act upon 
the liver ; and we know' that senna, e. g., has little or 
no powrer over this organ. 
Finally, the second general conclusion suggests 
an effective agency, in a direction in w'hich the 
profession has but few and uncertain resources. 
There is no lack of materials calculated to promote 
the secretion of bile ; it but needs to recognize them 
and to know' how to apply them. There is no lack 
of materials capable of playing the role of literal 
bile-expellers; and by their free purgative evacuation 
they are readily brought to bear to drive the bile 
from the intestine which had previously been therein 
rendered. But how to depress bile-secretion or pro- 
duction, what remedies to apply to limit the liver in 
its fabrication, so to say, has been much more of 
a problem. It follow's, however, from the researches 
to which allusion has been made, that the hydra- 
gogue cathartic possesses somewhat of this inhibitory 
influence; probably by the effect it has to lowTer 
blood-pressure in the great organ within w'hich the 
bile is secreted. 90 
EVACUANT MEDICATION. 
PODOPHYLLIN. 
History, Materia Medica.—Podophyllin, or Resina 
Podophylli, a preparation from the root of Podo- 
phyllum Peltatum, of the Berberidacese. Is produced 
extensively throughout the eastern part of North 
America. In some sections it has received the pop- 
ular name of May apple, on account of a small, 
yellowish, subacid fruit which it bears, and which 
is sometimes eaten. This remedy was of familiar 
use in Indian medicine, and the plant was figured 
about 1730, by Catesby, who remarks that it is an 
excellent emetic, an illustration of confusion of emetic 
and purgative materials of which we have several 
instances. It was introduced into the United States 
Pharmacopoeia as long ago as 1820, but into the 
British not until 1864. The consideration that so 
active a purgative was indigenous, and exclusively 
so, to the United States, naturally awakened the in- 
terest of the American profession; moreover, it was 
early put forward as a preeminent cholagogue, and 
proposed as a substitute for mercury, at a time when 
all mercurials, on account of previous abuse, were 
passing into disfavor. Thus Podophyllin came to 
be known and employed as “the vegetable mercury 
(or) calomel.” 
Pharmacy.—Podophyllum, or the rhizome of Podo- 
phyllum, is of very variable strength, and so, of 
necessity, are all the preparations made from it. It 
contains berberine, peculiar to plants of the order to 
which it belongs, and an inconstant per cent, of PODOPHYLLIN. 
91 
resin, in which latter resides all medicinal proper- 
ties. Squibb finds the resin always the same in 
quality, from however poor a specimen of root it 
may be taken. This resin is almost universally re- 
cognized by the profession as podophyllin: F. & H. 
remark “ very incorrectly so-called,” but it is too 
late to urge this objection. There would seem to be 
a double reason why all other preparations than this 
should be set aside; the derivatives of Podoplryllum, 
as insisted, are of variable strength; besides, there is 
reason to fear confusion in the use of names so similar, 
as applied to materials of such different energy, 
Podophyllin being of concentrated power. As 
respects the abstract, of United States Pharmacopoeia 
(1880), Dr. Squibb well observes that “ this is simply 
surplusage.” The FI. Ext. of Podophyllum, however, 
may be retained as occasionally convenient in liquid 
mixtures, with subjects who cannot take a pill; but it 
has uncertain strength. The dose of Podophyllin, 
as an aperient cholagogue, is a fraction of a grain, 
seldom raised so high as one grain. 
Action and Uses.—Podophyllin is an active irritant 
and, applied to a mucous membrane or the abraded 
skin, is capable of causing an inflammation which, 
if allowed to proceed, may terminate in pustulation 
of bad character. This quality is inherent to the 
drug, and must be kept in mind when it is proposed 
to prescribe it internally. Notwithstanding this, 
Brunton asserts that Podophyllin will purge, brought 
in contact with a blistered surface or introduced 
hypodermically. Upon the bowels its operation has 
been compared to that of jalap; but it does not 92 
EVACUANT MEDICATION. 
evacuate so much serosity, while its influence in 
augmenting peristalsis is much more positive. 
It is a serviceable cholagogue, but its action is 
conditioned. In Rutherford's experiments, an actual 
purgative dose was observed to lessen bile-secretion, 
somewhat after analogy with the action of a purga- 
tive dose of jalap; a smaller quantity, but still within 
purgative measure, might slightly raise bile-secre- 
tion, but it quickly ceased as the purgative material 
passed down the intestine. On the other hand, with 
doses which may be termed aperient, a special action 
upon the liver was quite sure, and was apt to be 
prolonged. In considerable purgative quantity, it 
may operate as soon as within six hours, often occa- 
sioning violent colic; rashly administered, it has 
been followed by hypercatharsis and bloody stools ; 
in proper cholagogue dose, it may require ten to 
twelve hours in rendering its results. Podophyllin 
doubtless communicates somewhat of influence to 
the organs of the pelvis, and there would seem to be 
support for the prevalent professional opinion that it 
has emmenagogue properties; the more especially 
when given in combination. 
The chief indication for recourse to this material is 
afforded by whatever condition suggests the need of a 
cholagogue—i. e., by “ biliousness,” so called, whether 
as an attendant upon chronic constipation or as 
an accident of temporary digestive disturbance. 
This resin may be selected either because physician 
or patient wishes to avoid calomel, or because the 
condition presented requires continuous medication, 
and a continuous or repetitive employment of a PODOPHYLLIN. 
93 
mercurial is deemed precarious. Ringer, however, 
makes the following point in differential therapeusis; 
in effect that Podophyllin acts best when the stools 
are black and foetid, and calomel best in colorless 
or clay-colored stools. 
Universal rules are seldom safe in the application 
of remedies, but it would seem that the rule which 
follows is warranted alike by physiological study and 
by experience. Podophyllin should never he exhibited as 
a purgative. We have seen that purgative action defeats 
the purpose for which it is given,—i. e., so far as that 
purpose is to secure relief to the liver and evacuation 
from it; and where the intention is solely that of a 
cathartic, there are many other materials as sure, and 
far more safe and gentle, in operation. 
In small fractional dose, it is often admirably 
adapted to the subject of constitutional torpor of the 
bowels and of bilious temperament; who, if intelli- 
gent, can be entrusted with its occasional use, for 
brief periods, as it would not be safe to entrust the 
self-administration of mercury. Thus employed, 
Podophyllin has a quality which is believed to be 
strictly peculiar to itself: gr. ss, e. g., taken at inter- 
vals as far apart as twenty-four hours, will be found 
to act more powerfully upon the liver and the bowels 
in the second repetition than upon the first occasion, 
and upon the third still more strongly than on the 
second. Thus we will often find that the patient 
gets but slight effect in the morning from the pill 
taken the night before; the second pill gives the 
desired result, while the third, taken the third night, 
is so emphatic that the course is stopped forthwith. 94 
EVACUANT MEDICATION. 
Contra-indication.—(1) Podophyllin is contra-indi- 
cated as a purgative, in purgative dose ; the grounds 
of this statement require no farther discussion. 
(2) It must be avoided in any state of actual in- 
flammation in stomach or small intestine; to pre- 
scribe it in purgative dose in typhoid fever, e. g., 
ought to be adjudged malpractice. For the patient 
already suffering from nausea, some other material 
should be selected. 
Administration.—According to Waring, the con- 
joined use of sodium chloride increases the activity 
of the drug to an undesirable extent; whereas lactic 
acid and substances convertible into it tend to antag- 
onize its action. Like other resinous cathartics, its 
power is enhanced by the addition of an alkali; 
and a combination with potassium bitartrate is in 
favor with those who order Podophyllin with pur- 
gative purpose. In its use as a cholagogue, some 
individuals get considerable colic, even from the 
smaller doses, especially if often repeated; and this 
may be averted in a measure by union with hyos- 
cyamus or belladonna. When Podophyllin is in- 
troduced into a pill for chronic constipation, to 
be taken after each meal, the dose should not be 
larger than gr. £ to Ar- For emmenagogue effect, 
it may be combined with aloes, nux vomica, and 
perhaps ergotine. The following formulae may 
illustrate sufficiently:— 
1. R Podophyllin, gr. ij 
Ext. hyoscyami, gr. iv. 
M. Pil. No. iv. ft. 
Sig.—One pill after supper, etc. PODOPHYLLIN. 
95 
2. R Podophyllin, gr. iij 
Aloin, gr. iy 
Ext. nuc. vomic., gr. vij. 
M. Pil. No. xx. ft. 
SlG.—One pill after meals, as required. 
3. R Podophyllin, gr. ij 
Ext. nuc. yomic., gr. vij 
Ergotinse, J) j. 
M. Pil. No. xx. ft. 
Sig.—One pill after each meal. 96 
EVACUANT MEDICATION. 
EUONYMIN. 
An oleo-resinoid body, in appearance like a solid 
extract, and of intensely bitter taste, with somewhat 
of acridity. Derived from the bark of E. Atropurpu- 
reus, or Wahoo, of nat. ord. Celastracex. Euonymin 
is not, properly, an active principle, and its chemistry 
is not entirely declared. There are other preparations 
of this material, but they have no advantage, aside 
from an occasional convenience of the fluid extract. 
Euonymin is a purgative of degree largely in ratio 
with the quantity administered, but is chiefly 
valued for its property of promoting the flow of 
bile. It acts with about equal energy upon glandu- 
lar structure and muscular coat of the intestine. 
Its especial service in medicine is set forth in the 
next chapter. Usual dose two grains. 
Professor Rutherford’s study of cholagogues has 
been chiefly concerned in giving prominence to 
various substances, e. g., baptisin, leptandrin, sangui- 
narin, as well as Euonymin and iridin, the discus- 
sion of which would bring us into the domain of 
poly-pharmacy. The two latter are believed to be 
sufficiently representative of their class. LRIDIN. 
97 
IRIDIN. 
A substance of like character with the last, obtained 
from rhizome and rootlets of Iris Versicolor, of nat. 
ord. Iridacese. A black, bitter, rather acrid body, of 
undetermined chemical constitution. From the iris 
are also prepared a solid and a fluid extract; the 
former is simply “ surplusage,” but the latter is con- 
venient for some liquid preparations and for such 
patients as cannot take a pill. 
All these various remedies, often enumerated 
together, but the office of which is well enough 
performed by euonymin and Iridin, are chiefly pre- 
scribed to meet the condition discussed under podo- 
phyllin; a condition alike familiar to physician 
and patient as biliousness, and especially in its more 
chronic form. But podophyllin is not well adapted 
to continuous use, at least long at a time, on account 
of its irritant quality, and still more, of a kind of 
cumulative action. 
There is a variety of liver derangement of 
peculiarly obstinate character, from which some 
people suffer for weeks together during that long 
period, in the northern United States, when winter is 
passing into summer,—corresponding to the spring of 
more favored latitudes,—and which will not yield to 
any modification of diet or to the operation of ordi- 
nary purgatives. Here, euonymin and Iridin have 
often succeeded after other materials to 
give relief. The patient is to take a two-grain pill 
of euonymin, or a four-grain pill of Iridin, every 98 
EVACUANT MEDICATION. 
night after supper, for a considerable period, to be 
followed by a saline early the next morning if the 
pill has not already acted. Professor Rutherford 
calls attention to a distinction in the function of these 
remedies: euonymin suffices to remove a slight degree 
of biliousness, but Iridin is the more powerful of the 
two, in a more positive form of the affection where the 
tongue is decidedly yellow. Yet euonymin is the 
stronger purgative; there are many other illustra- 
tions of this principle, that the stronger purgative is 
the weaker cholagogue. 
Upon more than one occasion, Rutherford remarks, 
after giving four grains Iridin the night before, he 
has been surprised to find the next morning that 
the yellow tongue and the bilious sensations were 
entirely gone. The improved appetite and digestion, 
which have often been observed to follow the con- 
tinuous use of one material or the other, may be 
wholly due to a rectified function of the liver; but 
these cholagogues have a bitter principle which may, 
not unlikely, exert a favorable action on the stomach. 
The usual dose is gr. iv. MERCURY. 
99 
Materia Medica.—But Mercury, and most generally 
calomel or the mercurous chloride (as most con- 
venient of all the derivatives of Mercury), is par ex- 
cellence, the cholagogue. The many names which have 
been applied to this material, of which calomel, 
mild chloride, mercurial panacea, aquila alba are a 
few examples, give testimony to its wide diffusion 
and extended use in the past. Our conclusion that 
this substance is cholagogue,—and, indeed, as just 
said, the cholagogue, as being the mildest, the surest, 
and the most often applicable of any of its class,—is 
not, however, the result of physiological study; in- 
deed, even Rutherford finds himself obliged to endorse 
the negative decision of previous experimenters. 
It may be objected, it is true, that Rutherford’s 
conclusion concerned the action of calomel as given 
in purgative dose; and it may be that the same 
principle is involved in this relation, as appeared 
prominently in the operation of fractional and of 
actively purgative doses of podophyllin. Perhaps 
all who went before us were wrong in their use of 
five and ten-grain doses of calomel for the relief of 
symptoms referable to the liver; and the physiologists 
alone are right. We know that we are right in our 
observation of the every-day removal of the discom- 
forts of the bilious through the administration of 
Mercury, by the method now so commonly employed. 
Uses.—The symptoms which are usually presented 
by one requiring the intervention of calomel are a 
MERCURY. 100 
EVACUANT MEDICATION. 
foul tongue, dry skin, loaded bowels, loaded and 
dark-colored urine and a bitter taste in the mouth, 
especially in the morning. “ In such state, Mercury 
declares its value over every other cathartic agent.” 
The subjects requiring the remedy have been thus 
effectively introduced: “ Muddy complexions, unc- 
tuous skins, a disagreeable odor in the breath and, 
generally, constipated bowels. Such persons are all 
the better for a course of alteratives and purgatives 
from time to time, when out of sorts.” (Fothergill.) 
In more chronic conditions, the salines will sometimes 
continue and complete the work which Mercury has 
begun; or, after a positive attack with the latter 
remedy, to be renewed from time to time as occasion 
may require, the patient may be kept continuously 
under the influence of one of the vegetable chola- 
gogues previously discussed. 
Stools of a characteristic appearance should follow 
the operation of Mercury, and such are seldom absent 
when the best results are secured. These are made 
up, wholly or in considerable part, of matter which 
has been likened to chewed grass or spinach; it 
doubtless contains bile, and its presence may be 
accepted as evidence that the liver has been reached : 
it is true that the effort has been made to prove that 
the calomel stools owe their peculiar character to 
salts of Mercury; but that bile is the principal con- 
stituent, has been authoritatively determined by the 
analyses of Golding Bird and other chemists. 
Administration.—The best method of exhibition of 
Mercury—at least of calomel—is a modification of 
that first proposed by Dr. Law, of an Edinburgh MERCURY. 
101 
hospital, in 1838. Law’s method divided one grain 
calomel into twelve parts, and gave one such fraction 
every hour until salivation was reached; this in the 
treatment of syphilis. But in the present applica- 
tion, the fraction and the frequency of repetition may 
be varied according to indication. Frequently, the 
grain divided into six to eight parts, a sixth or an 
eighth to be given every two or three hours, will 
give the best results. In the frequent digestive and 
bilious derangements of children, a brief treatment 
pursued according to this plan will give relief, which 
is often as gentle as it is speedy and effectual.* 
A very positive impression, both purgative and 
cholagogue, and chiefly applicable to adults, can be 
obtained by dividing the grain into four parts, a 
portion to be taken every two or three hours. The 
attempt to carry the principle of subdivision still 
farther, which has been so extensively inaugurated 
by some of the large (little) pill manufacturers,—each 
pillule containing but or Ar gr. of calomel,—is, in 
our opinion, too much in the direction of minimizing, 
*We must not pass over so important a subject without a word 
farther. It would be hard to exaggerate the value of this resource 
or the frequency of its application, to a physician who knows how 
common is this derangement in young children, and who has seen 
the operation of calomel thus applied. Its action, rightly ordered, 
seems to be kindly and thorough, alike upon stomach, liver and 
bowels ; and this without danger at the time or unpleasant after- 
effect. But the remedy is one which the physician must keep 
strictly in his own hands ; it is never to be entrusted to the mother 
on occasion of the report which a mother so well knows how to 
bring,—that, “ It is the condition that you prescribed the little 
powders for, a month ago, which worked so well.’, 102 
EVACUANT MEDICATION. 
and calculated to bring reproach, or discredit, upon 
a medicine which has hitherto suffered from the 
abuse of extravagant use. 
Calomel, in whatever dose and for every purpose, 
is best employed unmixed with any other substance. 
It is, chemically, rather unstable, too ready to take 
to itself another equivalent of chlorine and pass into 
the corrosive chloride; and grave cases of poisoning 
are on record where the physician supposed he wras 
using pure calomel in moderate quantity. In order 
to provide security and also to prescribe it by the 
scheme as above proposed, it is essential that the 
practitioner should carry and dispense his own 
calomel; a little experience will enable him to sub- 
divide the grain according to varying indications, 
and the quantities are too small to be dispensed and 
sent out by a druggist. Calomel has been known 
to borrow corrosive potency from such improbable 
sources as sugar and alkaline earths ; and it is not 
certain that trituration with, and continued exposure 
to, the bicarbonate of soda might not cause chemical 
change. 
There are two other materials of like energy and 
application as calomel, viz., the blue mass and Mercury 
with chalk or with magnesia; but these mechanical 
mixtures have probably more variable power than 
that which is strictly chemical, and are not so well 
adapted to the continuous method of medication, 
while they have no advantage which calomel has 
not. Two Mercurials, however, remain for brief con- 
sideration, as having subordinate, and yet invaluable 
uses, viz., the iodide and the Mercuric chloride. MERCURY. 
103 
(1) Of the Iodide. The Mercurous iodide, or green 
iodide, is commonly employed,—in rare cases the red 
iodide also. The former has cholagogue power 
superior to that of calomel, and perhaps to that of 
every other preparation of the mineral. It is appli- 
cable to exceptionally obstinate forms of hepatic 
torpor, which do not yield to the mild mercurials. 
Also, in special degree, to the incipiency of cerebral 
inflammation in young children, and to symptoms 
which suggest this grave lesion. A brief course with 
this remedy will sometimes put a wdiolly different 
face upon a condition which had given rise to serious 
apprehensions. It is probably more likely to cause 
mercurial sore mouth than any other preparation of 
Mercury,—hence its power,—and its disposition to fly 
to the mouth must be closely watched. Usual dose, 
gr. i to J after meals, p. r. n. Here, as also in the 
use of calomel, there must be assurance of occasional 
relaxed action of the bowels ; attention must be given 
to this with view to the evacuation of the bile, not 
only, but to the elimination of the Mercury, in order 
that it may not be “ stored ” in the system.* 
(2) The Mercuric Chloride, often, but incorrectly, 
called the “ bichloride,” is the only preparation of the 
* Either a persistent constipation, which is not removed by the 
calomel or iodide, and which is unprovided for otherwise, or the 
contemporaneous use of salt in quantity, may contribute to bring 
about this result. The only case of mercurial sore mouth ever seen 
by the author in his own practice, in an experience of over twenty 
years, was produced in an infant of hardly more than one year 
set.—still fed at the bottle—from the exhibition of less than one 
gr. calomel in five or six powders. The child had learned to take 
habitually a large amount of salt with its food. 104 
EVACUANT MEDICATION. 
mineral suitable for the purposes of continued medi- 
cation, where the intention is to escape all traces of 
mercurial saturation and yet to maintain a positive 
therapeutic impression. It is adapted to this service 
because of its free solubility, its chemical stability 
and, as just intimated, its slight tendency to cumu- 
lative action. Even the physiologists, and Ruther- 
ford in particular, admit that this salt may act upon 
the liver. The dark, swarthy person, “ unctuous,” 
with dirty skin and melan-cholic complexion,—every- 
where recognized as the bilious subject,—who needs 
to have the purification which calomel has begun 
continued for two or three weeks, will often find in 
the Mercuric chloride a safe and effectual resource. 
Such people are especially apt to suffer the various 
penalties of a torpid liver in the early spring. The 
soluble chloride may be readily combined with a 
tonic, in a mixture which shall fix the dose at gr. | 
to -gh, according to circumstances , as, e. g.:— 
I£ Hydrarg. Chlorid. (Corros.), gr. j 
Tr. Cinchonae comp., Jjiiss. 
M. 
SiG.—One teaspoonful after each meal. 
Clinically, this mercurial has been found to affect 
the bowels very differently in different subjects. In 
some, the bile is carried off full tide from the begin- 
ning, and unless the dose prescribed be diminished 
or made less frequent, a troublesome diarrhoea is soon 
established. Again, very little influence is exerted 
this way, and the help of purgative salines must be 
superadded. Every patient about to take a course 
of this remedy should be instructed respecting such MERCURY. 
105 
variability, or kept under observation until the char- 
acter of individual response is ascertained. 
Finally, the liver may be reached by dermal 
medication; as may the chest in accumulations of 
water or in congestive bronchitis with pyrexia. 
Some practitioners report inunction of the right 
hypochondrium with oleate of Mercury (15 to 20 p. c.) 
with good results. But the occasions are so few in 
which Mercury in some form cannot be given by 
the mouth as to lessen the real value of this resource. 
Contra-indications.—As respects calomel. Perhaps it 
is too much to say that calomel is absolutely contra- 
indicated as purgative, although there may be rea- 
son to suspect that, so far as it is prescribed for the 
liver, a positively purgative operation defeats the 
intention. Calomel is less irritant than podophyl- 
lin, and yet it has so much of this quality as to 
require a cautious administration, in purgative dose, 
in inflammatory states of stomach and small in- 
testine. Here, fractional doses can be used without 
hesitation. But one condition forbids the use of this 
material in quantity,—viz., the same condition which 
forms the chief contra-indication to the selection of 
senna,—i. e., cumulative constipation with tendency 
to impaction. The most torturing colics have been 
produced, before the calomel finally accomplished 
the evacuation, in neglect of this precaution. 
It is to be hoped that the responsible physician no 
longer orders calomel solely for action upon the 
bowels and because it is convenient,—being of little 
bulk and tasteless. Prominent among the abuses in 
the past for which Mercury is still made to answer, 106 
EVACUANT MEDICATION. 
and by which its employment is still prejudiced, 
was the routine exhibition of calomel as a purgative ; 
and especially to children. The child was hard to 
find, however intractable to the offer of other 
remedies, that would not take the gray powder 
or the white powder in any quantity or with any 
frequency desired. Doubtless, an immeasurable 
mischief was done through this very facility 
of administration. We are better informed than 
were our fathers upon the scope of the physio- 
logical action of Mercury, upon the real purpose 
of its medicinal action, upon the possible atrocity 
of its toxic effects; we are better armed with 
purgative materials and combinations, of various 
power and intention; and there is no longer excuse 
for the exhibition of any mercurial upon the sole 
indication of an evacuation of the bowels. MINERAL CATHARTICS. 
A few materials remain for discussion, which are 
from a mineral source, chiefly such as are known as 
the saline 'purgatives, in addition to mercury, just con- 
sidered. Some writers, indeed, with a genius for 
classification, distribute cathartics among the three 
“ kingdoms,” although nothing farther than veal 
broth and similar liquids, medicated and otherwise, 
can be found to justify a third group. If an animal 
broth act as purgative, it must be, as Fonssagrives 
says of manna, because of its indigestibility. In the 
same spirit, oily purgatives have been made to stand 
together, even by writers of authority, although 
croton and castor and sweet almond oils were placed 
in the same sub-order; but this is to sacrifice thera- 
peutics to materia medica. 
Of the salines, a few representatives are in common 
use, and known to both profession and public; but 
many others, although of special application, are 
seldom applied in practice. They are referable to 
three classes, magnesian, potassic and sodic, and are 
salified by both mineral and vegetable acids. These 
facts are of interest sufficient for mention, but it is 
not proposed to follow a classification based upon 
them, since our concern is with the therapeutics of 
the subject. 
107 108 
EVACUANT MEDICATION. 
POTASSII BITARTRAS. 
Materia Medica.—Cream of Tartar (Cremor Tar- 
tar), or Acid Tartrate of Potass,—an acid salt very 
generally and largely adulterated and which, there- 
fore, must be got only from an accredited source of 
supply. It is obtained from crude tartar deposited in 
the cask during fermentation of wine; and is not 
inaptly discussed first of all since it is a connecting 
link, as it were, between purgatives derived from the 
vegetable and from the mineral kingdoms. Its 
physical characteristics are everywhere familiar and 
need not be described. The neutral tartrate of potass 
is also recommended by the Pharmacopoeia, but is 
mostly used as a diuretic and antilithic. The French 
have set aside the Bitartrate and substituted “ a 
soluble Cream of Tartar,” or the boro-tartrate. 
Pharmacy.—Cream of Tartar is scarcely directed 
by the U. S. P., unless by itself alone, except in the 
combination noticed under jalap—the comp, jalap 
powder. The English make considerable use of 
Potus imperialis, in which 1 to 1| dr. of the salt is 
infused, together with the rind of a half lemon, in a 
pint of sweetened boiling water. The laxative water 
of Corvisart* applies the energizing power of tartar- 
ized antimony, as in similar combination with 
Epsom salts; q.v. Dose of Cream of Tartar as pur- 
gative, 5ss-j. 
* L'eau lax. de Corvisart has 30 gram. P. B., 25 milligr. Tartar 
Emet. and 1000 gram, water. A small glass every two hours till 
operation. POTASSII BITARTRAS. 
109 
Action and Uses.—This material is refrigerant, 
diuretic and purgative, according to mode of admin- 
istration. It exerts so little influence upon the 
muscular coat of the bowel that some have denied 
that it arouses peristalsis at all. Indeed, Lauder 
Brunton ascribes its catharsis to an agency which 
does not pertain to any material previously consid- 
ered,—viz., to its power of retaining water and so of 
distending the bowel. Doubtless, one element of 
action is provided in this exceptional quality; but the 
bitartrate, while not an irritant, has still, as an acid 
salt, enough of stimulant property to bring into 
gentle activity the glandular structure and evoke 
secretion. Thus, in a twofold way, the bowel becomes 
distended with fluid, and, if its contractility had 
been previously enfeebled, there may be such paraly- 
sis of peristalsis from over-distention as to permit of 
this fluid being retained, and, later, being reabsorbed. 
Hence an occasional value of combination with 
jalap. Such quality of action on the part of Cream 
of Tartar, and the fact that its purgative influence 
is brought to bear upon the small intestine, render it 
least of all purgatives liable to disturb the organs of 
the pelvis. Its special uses may be enumerated as 
follows:— 
(1) In some cases of chronic constipation—and 
more particularly as combined with jalap—it will 
procure evacuations where more powerful cathartics 
have been tried in vain. There are patients whose 
prevailing fault is dry dejections—probably the dis- 
ability, in part, at least, consists in an osmotic flow 110 
EVACUANT MEDICATION. 
away from the intestine—and the bitartrate meets 
the indication by virtue of its mode of operation. 
(2) Cream of Tartar is adapted to cases requiring 
a gentle hydragogue, and which forbid the use of 
such as are violent; where a mild, continuous, 
diuretic-purgative intervention is desired to evacuate 
dropsical effusions. 
(3) This salt is valuable above any other purgative 
saline, in the latter months of pregnancy, to meet 
the condition known as “ bloating,” and which may 
mean serious implication of the kidneys and portend 
disaster later; and which, again, is innocent. Never- 
theless, in either case, the kidneys should be gently 
stimulated, the bowels kept open and the blood 
pressure maintained at normal standard ; and this 
threefold service has often been performed by a con- 
tinuous exhibition of the bitartrate. Directions may 
be made simple and not unpleasant, as follows : To 
be prepared every morning and drunk from at 
frequent intervals throughout the day, a full goblet 
of water, slightly sweetened, containing a heaping 
teaspoonful of the bitartrate, upon which may be 
floated a slice of lemon. On account of the imper- 
fect solubility of the salt, the tumbler must be stirred 
from the bottom every time the patient drinks from 
it. A still freer diuresis can be obtained by the 
conjoined use of digitalis, and the purgative power 
enhanced in various ways. 
(4) For the subjects of active inflammation of the 
uterus and yet requiring purgation, of metrorrhagia, 
of hemorrhoids with inflammation, the bitartrate 
answers a better purpose than any other purgative POTASSII ET SODII TARTRAS. 
111 
that could well be selected. In metrorrhagia espe- 
cially, the results of such intervention may be favor- 
able for the uterus, as tending to diminish hemor- 
rhage and sanguine pressure. Very little disturb- 
ance attends the cathartic action, and a positive 
lowering of arterial tension follows upon it. 
Tartrate of Potass and Soda; a double salt, in 
which one of the equivalents of acid of the bitar- 
trate has been devoted to combination with Soda. 
Known also as Rochelle salts, sel de Seignette, etc. 
Seldom used as purgative, more often as antacid. 
Rochelle salt, however, is an important ingredient of 
the Seidlitz powder, or Pulvis Effervescent Compositus, 
as prepared in the two packets or powders every- 
where familiar, one of which (white paper) contains 
5ij Rochelle and 3ij sodium bicarbonate; and the 
other (blue paper) thirty-five grains tartaric acid. 
The method of administration requires no descrip- 
tion. There are several proprietary imitations, where 
all the ingredients are placed together and chemical 
change and effervescence occur only upon addition 
of water, as in the “ Tarrant’s Aperient,” etc. 
These carbonated purgatives are palatable, gentle 
and, in sufficient dose, sure and rapid in operation ; 
action and uses are similar to those of the Cream of 
Tartar. 
The French also have a magnesian seignette or 
double salt of Potass and magnesia.* 
POTASSII ET SODII TARTRAS 
* Indeed, the Seidlitz Spa water contains Epsom Salts ; about 
thirty-three grains to the litre. 112 
EVACUANT MEDICATION. 
MAGNESII SULPHAS, 
Epsom Salts. “ The type of the purgative salines; 
it is also the most used of all; but it must be con- 
fessed that it is the most disagreeable.”* In the 
opinion of Mathew Hay, all the salines act in about 
the same way. They hardly irritate the alimentary 
canal or cause the secretion of digestive or biliary 
juices; they sweep the passage with the least possi- 
ble disturbance to the digestive function. Epsom 
Salts has a nauseous, bitter taste, very offensive to 
some subjects, and is pertinently known to the Ger- 
mans as bittersalz. Its action upon the bowels is 
similar to that of the salines just considered; but 
whether because it has somewhat more power as a 
peristaltic stimulant, or for other reasons, it is much 
more likely to work its way and not remain in the 
bowel to be reabsorbed; although reabsorption now 
and then occurs. Rutherford found that this salt, in 
full purgative dose, positively depresses bile-secretion. 
Pharmacy.—The United States Pharmacopoeia re- 
cognizes no other composite preparation than the 
Inf. Sennx Comp., or “ black draught,” a very physi- 
ological compound, doubtless, but one which it is 
pleasant to avoid. Epsom Salts is sometimes ener- 
gized, and given in subdivided dose, as follows:— 
R Magnes. sulph., j 
Antim. et potass, tart., gr. j 
M. Aq. purse, 
SiG.—Two teaspoonfuls every one to two hours. 
This salt is soluble in less than its own weight of 
water. 
* Fonssagrives. MAGNESII SULPHAS. 
113 
Uses.—Its chief uses may be stated in few words. 
To effect a rapid and considerable lowering of blood 
pressure in certain inflammatory affections. (2) To 
procure a gentle and yet thorough evacuation in 
accumulation of hardened faeces, and especially in 
impaction of the caecum, and in typhlitis where 
there is no complicating peritonitis. (3) As an agency 
of frequent resort with individuals of large appetite, 
generous feeders, of rapid assimilation and, conse- 
quently, with torpid or burdened liver. (4) Magne- 
sian Sulphate is also the cathartic commonly chosen 
for subjects of lead cachexia or other mineral poison- 
ing ; generally given in free solution with excess of 
sulph. acid. 
Epsom Salt, and the glauber, next to be considered, 
are the effective purgative agencies in such cathartic 
waters as the Hunyadi, the Friedrichshall and the 
Pullna, so extensively introduced in England and 
America within recent years; and found serviceable 
in the frequent demand, presented by modern con- 
ditions of life, as suggested in the third indication 
for sulphate of magnesia. 
Hunyadi.—The Hunyadi Janos * was first known 
as Ofner water, from a town in the neighborhood of 
* Professor Charteris gives this formula for artificial Hunyadi 
Janos :— 
R Sulph. magn., 519.92 gr. 
Sulph. sod., 513.54 gr. 
Sulph. pot., 2.76 gr. 
Chlor. sod., 39.15 gr. 
Bichlor. sod., 15.60 gr. 
Water, 16 oz. 
Costs hut a penny a quart. Dose, ij and upward. 114 
EVACUANT MEDICATION. 
Pesth, and near the spring. It was called by its 
present name by its proprietor, in order to commemo- 
rate a distinguished Hungarian orator. In this 
water, as also in the Bitterwasser or Friedrichshall, 
it is believed the combination of the Epsom with 
common salt helps to prevent the disturbing effects 
of the former upon digestion. Sir Hy. Thompson, 
Von Mering, et cet., have declared, by means of 
physiological experiments, that the sodium chloride 
renders the purgative operation milder and less ex- 
hausting. Mosler emphasizes the value of the 
Friedrichshall in habitual constipation, with liver 
affections. Scanzoni directs it for the constipation 
of pregnant women. Schroder and Veit, in uterine 
congestion and inflammation and, especially, in 
chronic metritis. Weber, in catarrh of the bladder, 
and Sir H. Thompson, once more, in calculous dis- 
ease and for the prophylactic treatment of gravel. 
The Hunyadi is a little the stronger. Dose of 
either, a wineglass to half a goblet before breakfast. 
SODII SULPHAS, 
Or Glauber Salt. Often said to be even less palat- 
able than Epsom; but some writers are emphatic in 
expressing a preference the other way. The physi- 
ologists accord considerable cholagogue energy to 
this salt. It is a fact, not often noted, that a free use 
of the magnesian sulphate, and of its potassic congener, 
has been known to be followed by fatal results. Thus, 
Christison reports the death of a child in ten minutes SODII SULPHAS. 
115 
after having taken two ounces of Epsom salts; and 
Taylor, the death of a drunkard who took a consid- 
erable quantity in beer. Pereira brings together 
three fatal cases from the use of sulphate of potass 
as a purgative—the old sal de duobus, so largely ap- 
propriated to the necessities of the parturient subject 
in an earlier practice. In this connection, the recent 
experiments of Dr. Hay are of interest, who finds 
magnesian sulphate powerfully toxic when injected 
into the blood, paralyzing the respiratory centres, the 
heart, etc.; whereas, a like injection of Sodium Sul- 
phate is innocuous. Fonssagrives suggests, respect- 
ing the reports of Taylor and Pereira, “ May it not 
be that our humors, being alkalmized by soda, the 
sudden irruption of a large quantity of magnesian 
or potassic salts into the blood may as suddenly 
change the chemical status of this fluid, and so there 
shall result a more or less grave perturbation.” * 
Uses.—Glauber Salt, then, alike from physiological 
investigation and the best clinical observation, is a 
more valuable purgative than the more familiar 
Epsom, and several reasons might be assigned why 
it is to be regretted that a prevalent medical fashion 
has given preference to the latter. In respect of 
action upon the liver, it may be remarked that more 
than one independent and sharp-sighted practitioner, 
in the days prior to physiological studies in thera- 
* A similar principle is involved in a preference of the sodic bro- 
mide to the other alkaline bromides where large quantities are 
being given continuously ; which the author has illustrated in a 
paper previously published. 116 
EVACUANT MEDICATION. 
peutics, had determined for himself its superior 
power as a cholagogue. 
According to Thompson, et cet., this salt has a spe- 
cial efficiency in preventing the cholesterine deposits 
known as gall-stones, as well as renal calculi; they 
also assert its efficacy in diabetes. The Glauber is 
the potent element in the Carlsbad water. The solid 
residue of Carlsbad Sprudel has more than half its 
weight of this salt, about one-fourth sodium carbon- 
ate and one-fifth sodium chloride. It is often pre- 
scribed in Germany, as Sal Thermarum Carolinense, 
one teasp. in q. s. warm water. This purgative is 
claimed to render especial service in tropical dysen- 
tery.* According to Rabuteau, constipation is espe- 
cially apt to follow the use of the Glauber. 
It may be said, in this connection, that none of 
the salines are well adapted to the purposes of con- 
tinuous subdivided medication, except, at least, as 
there is conjoined use of some purgative capable of 
providing peristalsis. In repeated small doses of any 
saline, the tendency is to absorption of the salt, and 
so to increase, rather than removal, of constipation. 
Now, if constipation is especially apt to follow the 
cathartic action of the Glauber, it is, probably, 
because this salt offers especial facilities for ab- 
sorption. 
* And in dysentery of temperate climates also. Fonssagrives 
says : “ The employment of sulphate of soda is, in a sense, classic 
in acute dysentery.” It first increases the number of stools, and 
then diminishes them ; and it is not rare to see it produce a kind 
of constipation. MAGNESII CITRAS. 
117 
SODII PHOSPHAS. 
Action and Uses.—A readily soluble, slightly alka- 
line, not unpleasant purgative, in dose somewhat 
raised above that of the two sulphates just consid- 
ered. Prof. Stevenson, of Aberdeen, has directed at- 
tention to it as the purgative for children, on account 
of its gentleness and unobjectionable taste. It may 
even be • added to soup without its presence being 
detected. It is an hepatic stimulant of decided 
power, according to Vignal and Rutherford, render- 
ing the bile more watery and increasing the amount 
of the secretion. Binz believes that, when it is in- 
troduced into the system in large quantity, it may 
possibly affect the constitution of the blood; but such 
casualty would have to be explained otherwise than 
in the case of disaster from the use of potassic and 
magnesian salines, and in the direction of the disen- 
gagement of phosphoric acid. Our forefathers even 
believed that phosphoric acid could be decomposed, 
and made to contribute phosphorus to the tissues, 
and sodium phosphate was a favorite remedy in ra- 
chitis. But chemical affinity,* in case of both acid 
and salt, is so strong as hardly to leave defensible 
the theory of Prof. Binz or the practice of an earlier 
day in rickets. Brunton asserts that doses much 
short of purgative effect may act on the liver, and 
orders 3 to 10 gr. for children. Purgative dose, §ss 
and upward. 
MAGNESII CITRAS 
Citrate of Magnesia: first proposed by a pharma- 
cist of Aisne, Rog6 Delabarre, in 1847, and favorably 118 
EVACUANT MEDICATION. 
reported upon by the French Academy of Medicine 
the same year. It had “ an enormous vogue ” from 
the first, says a French writer, on account of its 
agreeable taste. It has none of the nauseant bitter- 
ness of the Epsom, but its purgative action is less 
sure than that of the latter. In frequent, moderate 
quantity it exerts the properties of a temperant, anti- 
febrile, and, in less degree, of a diuretic. Must be 
given in quantity above half an ounce, and often 
repeated several times, if purgative operation is 
sought. Is especially liable to adulteration, and 
should not be trusted except with assurance of its 
source. Its best preparation in the market has the 
form of granules, as from the house of Morson. The 
heavy syrup of the citrate, so common a few years 
ago, should always be refused; such preparation 
offers every facility for adulteration, and its use 
oftentimes has no other effect than to disturb the 
stomach. 
Sulphovinate of Soda. In the attempt to intro- 
duce a palatable saline purgative, Rabuteau has 
been more successful than Delabarre—i. e., as re- 
spects the purgative and not its introduction. The 
statement which follows will show that this material 
has superior qualities, and that it deserves a more 
extended use.* 
It was in 1870 that Rabuteau called attention to 
this new salt, which was subsequently carefully 
SODII SULPHOVINAS. 
* Sulphovinic, or Ethylsulpliuric, acid results from reaction be- 
tween sulph. acid and alcohol. MAGNESIA AND MAGNESII CARBONAS. 
119 
studied by the pharmacist Limousin. “ Its cooling 
taste, a little sweetish and without bitterness; its 
extreme solubility in water of ordinary temperature 
(less than its weight), the energy of its purgative 
action, triple that of the sulphate of soda and of the 
citrate of magnesia, make it a useful purgative. 
Rabuteau attributes to it a gentle purgative action 
and one exempt from colics. The magnesian salts, 
from prolonged use, favor the formation of calculi of 
ammonio-magnesian phosphate ;* the Sulphovinate of 
Soda has its especial advantage when there must be 
frequent recourse to a saline purgative. It does not ap- 
pear to be followed by constipation.” (Fonssagrives.) 
Attention must be given to purity, lest this salt 
may contain barium; and if barium from a certain 
source, also arsenic. 
“ In a word,” says its author, “ it is the type of 
known dialytic purgatives. It does not produce ab- 
normal intestinal contractions, and therefore can be 
administered to the pregnant female without fear 
of provoking uterine contractions.” Its only weak 
point, according to Rabuteau, is that it is liable to 
change, and must be kept carefully, or it will pass 
into sulphate of soda and other products derived from 
alcohol. Dose, 5ij-5iij, freely diluted, preferably in an 
effervescent water. 
Calcined Magnesia and the Carbonate of Magne- 
sium ; two bodies of very similar appearance and 
MAGNESIA AND MAGNESII CARBONAS. 
* Italics our own. 120 
EVACUANT MEDICATION. 
properties. The former is also known as Magnesia 
Usta and is apt slowly to pass into the carbonate upon 
exposure to the air. For a long time the calcined 
magnesia, or something closely related to it, was in 
use and widely vaunted as a specific under the title 
of Count Palma’s Powder. In 1773, Mr. Henry 
proposed calcination, and the name Henry’s Magnesia 
is still familiar in commerce.* 
Special Action.—Both these magnesias, being insol- 
uble, can only act as they find acid in the stomach 
and upper intestine, except—and herein lies an ex- 
planation of the chief part of their cathartic opera- 
tion—as they act through specific gravity and such 
mild irritation as they occasion in their passage down 
the bowel. In a choice between these two materials, 
there is one modification of action which concerns 
both action and application. The Magnesia has 
more of irritant property, and should give place to 
the Carbonate in irritable states of stomach and in- 
testine ; whereas, the Carbonate should be avoided in 
conditions like flatulent dyspepsia, where the canal 
is already distended with gases. 
That the mode of action of the insoluble magne- 
sias has been rightly explained seems probable, if 
not sure, on consideration of the character of the 
stools following their use, which are not at all like 
those produced by the salines,—watery and hydra- 
gogue,—but feculent; and even in greater degree 
* There are in reality two varieties of calcined magnesia known 
to pharmacy : the French magnesia or the light, and the English 
or the heavy; or, respectively, the magnesia of Henry and of 
Howard. They vary in density as 2.6 and 3.14. MAGNESIA AND MAGNESII CARBONAS. 
121 
than those which result from senna or rhubarb.* 
There would appear to be a small class of purgatives 
answering in function to the irritant emetics, in that 
their rejection is brought about by irritation and 
their purpose accomplished through topical action 
and not through absorption. The magnesias now 
being discussed belong to this class, and their opera- 
tion is chiefly brought to bear through the mucous 
membrane upon the muscular coat and secured by 
energized peristalsis, together with just enough stimu- 
lation of glands and follicles to provide for the easy 
passage of the stools. 
There is also apparent that exceptional third 
element of action, which appears prominently in 
the action of rhubarb and concerns the mucous 
surfaces. In the case of Magnesia there is less as- 
tringency; but there is none the less exerted a favor- 
able modification upon morbid conditions of the 
intestinal membrane, with result of neutralization of 
acid and acrid secretions. Magnesia is slow in opera- 
* Some authorities take a different view. Thus, Rabuteau 
says that the Magnesia, to an extent, makes a soluble combination 
with the acid of the stomach ; the rest, passed along, finds acid in 
the large intestine, with which it unites,—except a residuum 
which remains inert and comes away in the stools. But if this 
explanation were right, the dejections ought to he such as are 
procured by other soluble Magnesian salts, and not solid and 
semi-solid. 
Rabuteau is, preeminently, a pharmacologist ; but it is remark- 
able that some of the most eminent writers in therapeutics, at 
present, in English and French, are so much in love with a chem- 
ical basis for their classification as to consider all Magnesian pur- 
gative salts in one chapter, as if calculated to exert the same action 
and to meet the same indications. 122 
EVACUANT MEDICATION. 
tion, and often requires ten to twelve hours.* Cath- 
artic dose, 3j to 5j. 
One remark of interest respecting the stools of this 
purgative, and also a fact sometimes associated with 
their rendering: Dorvault has demonstrated, in the 
use of calcined Magnesia, that a large portion of it, 
when evacuated, is in the form of the carbonate, the 
transformation taking place by contact, in the intes- 
tinal tube, with carbonic acid gas and the alkaline 
carbonates. He has proved this statement by the 
effervescence which the dejections give forth when 
sulphuric acid is poured upon them. Again, the 
same observer has remarked that the magnesian 
stools generally have but little odor, since the Mag- 
nesia absorbs the ammoniacal and sulphydric gases 
of the intestines. 
Trousseau, many years ago, called attention to a 
disability which sometimes attends the continued use 
of either Magnesia. Properly applied—as, e. g., in a 
case of diarrhoea—it at first arrests the flux; but if 
its use be kept up too long, the original disorder 
may return in still graver form. Still later, it sets 
up an irritation which is almost dysenteric. Other 
observers testify to an anal burning and tenesmus 
* “The purgative action (of Magnesia) makes the patient wait, 
hut it is more durable than with other evacuants. Trousseau says 
he has sometimes seen it manifested after 20, 24 and even 36 hours. 
The English physicians have not noticed, so far as I am informed, 
this slowness in the effects of calcined Magnesia. This divergence 
on the other side the channel holds, doubtless, to the custom of 
associating the Magnesia, as also the resinous purgatives, with the 
meals, by which are obtained effects more prompt, more sure and 
more gentle.”—Fonssagrives. MAGNESIA AND MAGNESII CARDONAS. 
123 
peculiar to a course with Magnesia, which, with 
most subjects, only attends defecation, but which, 
occasionally, continues for a considerable time after 
the act. 
Uses.—The applications of the Magnesias are more 
like those of rhubarb than of any other purgative. 
They are deservedly in favor with infants and young 
children, who are apt to suffer from constipation at- 
tended with acidity and fermentation. A similar 
condition of the intestinal tract, from different causes, 
is frequently presented by pregnant women. Indi- 
cations have been already given respecting selection 
between Magnesia calcined and carbonate. To this 
it may be added that, so far as there is marked acid- 
ity of the intestinal canal, a freshly-calcined Mag- 
nesia is to be chosen, as being prompt at chemical 
combination, and, so, capable of affording the double 
service of an antacid and purgative. 
Jules Simon prefers Magnesia to every other purg- 
ative for the nursing infant, as the dose is small and 
easily administered; it is sure, does not cause colic 
and can be left to the nurse. The only inconven- 
ience which can well attend this remedy concerns its 
too continued use, as already said, and there remains 
for mention a possible source of danger. There is 
somewhat of liability to the formation of concretions, 
particularly where an insoluble magnesia is admin- 
istered for some time in quantity short of purgative 
effect. 
This purgative (as represented by the two magne- 
sias) is one of the very few which hardly suggests 
a contra-indication; it may even be used, and 124 
EVACUANT MEDICATION. 
perform service, in conditions which forbid the use 
of rhubarb. 
Hydrate of Magnesia.—Calcined Magnesia will unite 
with water, as with carbonic acid, to make a salt. 
In this form it is chiefly used as an antacid and anti- 
fermentescent, except in the case of very young infants, 
who may also sometimes be purged by a moderate 
dose. The hydrate consists of about one-third water 
(31 per cent.), and is chiefly known under the name 
of the milk of Magnesia. It is made by various 
formulae, and is, mostly, a proprietary preparation. 
The following method is probably as good as any: 
One part of calcined Magnesia, three parts white 
sugar, seven or eight parts pure water; to be thor- 
oughly boiled together. Dose, as a corrective, 1 to 2 
teaspoonfuls. 
Dorvault gives the following facts respecting the 
differential therapeusis of three prominent Magne- 
sias—Calcined, Citrate and Sulphate: Relative to the 
number of evacuations: a mean of 2.83 with calcined, 
3.28 with citrate and 4 with sulphate. 
Relatively to duration of action: for calcined Mag- 
nesia, 18.83 hours; for citrate, 11 hours; for sul- 
phate, 8.60 hours. 
As to weight of dejections: respectively, 1 k. 017, 
1 k. 771, 2 k. 100. 
As to nature of stools: feculent, semi-serous and 
serous. 
As to effects produced on the stomach: nausea very 
marked with the sulphate, less with citrate, nil with 
calcined. SULPHUR. 
125 
SULPHUR. 
Materia Medica.—Sulphur is found in volcanic 
regions, and in a state of impurity from both mechan- 
ical and chemical admixture. It is not used in its 
native state. As known to pharmacy, it exists in 
three forms, results of as many methods of prepara- 
tion. 
(1) S. Sublimatum, or the flowers of Sulphur; apt 
to have traces of acid. 
(2) S. Latum, or washed Sulphur; treated with 
dilute ammonia, by which acid impurities are re- 
moved. 
(3) S. Precipitatum, Lac Sulphuris, or milk of Sul- 
phur ; the result of a complex chemical process by 
which the Sulphur is thrown down in a state of 
minute subdivision, from a liquid in which a prepa- 
ration of it had been held in solution. Is of milk- 
white color. Properly made, it is, according to 
Binz, of great purity, fineness of texture, minuteness 
of subdivision and hence of high activity. 
Pharmacy.—The U. S. P. recognizes but one com- 
pound Sulphur preparation, as bearing upon purgative 
medication, viz., The Comp. Liquorice Powder,— 
Pulvis Glycyrrhizse Comp.,—introduced from the Prus- 
sian Pharmacopoeia a few years ago, and already 
become a favorite laxative remedy, especially for 
children. It consists of senna, 18 parts; liquorice 
root, 16; fennel seed, 8; washed Sulphur, 8; white 
sugar, 50. Dose, one teaspoonful. The British 
Pharmacopoeia also directs a confection, chiefly a mix- 
ture of Sulphur and cream of tartar, which in varying 
ratios is also a favorite laxative in the United States. 126 
EVACUANT MEDICATION. 
Action and Uses.—The washed Sulphur is generally 
chosen for purgative purpose, as being free from acid 
and less likely to cause irritation. As with the in- 
soluble magnesias, a small part doubtless effects 
chemical combination in the course of the alimen- 
tary canal, and is absorbed; this is made evident, 
e. g., by the sulphurous smell which the body of one 
who is taking a course of Sulphur may emit, and by 
the blackening of silver coins carried in the pocket. 
Another small portion effects combination with 
result of sulphydric and like gases, which render the 
stools and flatus so foul-smelling as to oppose a consid- 
erable objection to the use of this remedy. The larger 
part, however, of the quantity ingested is carried 
along the bowel, exciting peristalsis and secretion in 
about equal degree, and provoking defecation by the 
stimulation of contact. The stools are soft, fre- 
quently not much changed in consistence or color— 
again blackened by alkaline sulphides—and are 
rendered in ten to twelve hours. 
Between popular acceptance and professional use, 
Sulphur has two prominent applications, to which its 
employment as a purgative is chiefly confined. It 
has a widespread reputation as a so-called “ spring- 
medicine,” perhaps to less extent now than formerly ; 
but there is still a prevalent impression or belief that 
a course of Sulphur, in the early spring months, 
serves a good purpose as a “ blood medicine.” Dick- 
ens has satirized the abuse of this custom in his 
account of the tyrannous system of Sulphur and 
treacle enforced upon the scholars of Dotheboy’s Hall. 
Again, this purgative has a deserved repute for SULPHUR. 
127 
constipation complicating hemorrhoids. Its continu- 
ous use, pretty surely, exerts somewhat of cholagogue 
action; it prevents fsecal accumulations in the ali- 
mentary canal, and it ensures stools of a soft, pasty 
character most favorable for any rectal complication. 
Here, it is often best to energize purgative action by re- 
sort to the confection of the B. P., although not always 
in the ratio of that combination. Such mixture, in 
this affection, was a favorite prescription of the late. 
Prof. Peaslee, and used by him for this purpose for 
many years. One part Sulphur and two of the 
bitartrate often best meet the indication, mixed with 
glycerine, syrup or honey, according to choice ; but 
with glycerine, when the patient wTill consent:—dose 
about one teaspoonful in the early morning. 
The very general introduction of the comp, liquor- 
ice powder, in the domestic treatment of children, is 
justified by the gentleness and sureness of its action, 
by the moderate size and unobjectionable taste of its 
dose, and the fact that its use is not followed by con- 
stipation ; it is a mild, safe and effective agency for 
frequent resort in the nursery. DIFFERENTIAL THERAPEUSIS. 
OLEUM TIGLII. 
Action.—Upon the upper portion of the intestinal 
canal, probably involving the whole of the small 
intestines. Affords an approach to equivalents of 
energy, in respect of the two agencies which procure 
catharsis, i. e., increased peristalsis and increased 
secretion; these activities operating with great force. 
Hydragogue stools, forcibly expelled, with attending 
colics. Should operate in one to two hours. 
Uses.—(1) In subjects disgusted with bulky medi- 
cines, and where the stomach will not receive, or 
the bowels will not respond to them ; and who still 
require an emphatic cathartic action. (2) In excep- 
tionally grave torpor of the bowels, as in lead ca- 
chexia. (3) In some cases of apoplexy, for revulsion 
and derivation. (4) As a part of the treatment for 
the expulsion of tapeworm. 
Inconveniences, Contra-indication.—Causes very se- 
vere colic in some subjects. Is uncertain in action, 
as respects dose, time required for operation, etc., 
in different individuals. 
An inflamed state of stomach or small intestine 
forbids its use; a past experience of idiosyncrasy, 
respecting colic and vomiting, should cause selection 
of another purgative. 
Poisoning.—(1) An abundance of milk or oily 
emulsion,, to envelop irritating particles. (2) Opium 
128 JALAPA. 
129 
to relieve colic and arrest diarrhoea, at proper stage. 
(3) Stimulants to overcome prostration. 
OLEUM RICINI. 
Action.—(Much like that of croton oil, with less 
energy.) Stimulates peristalsis and secretion in 
about equal degree. Involves entire alimentary 
tract. Operates in four to six hours; stools feculent 
and semi-solid. Purgative principle is secreted in 
the milk and affects the nursling. Diminishes bile- 
secretion. Its use is frequently followed by constipa- 
tion. 
Uses.—(General.) Wherever is required promptness 
and thoroughness of action, with a minimum of con- 
stitutional effect. (1) In the puerperal state. (2) In 
dysentery, to keep the upper bowel unloaded. (3) 
To meet purgative indication in rectal and abdomi- 
nal surgery. (4) In cumulative constipation and 
impaction. (5) For abortion or relief of sudden 
“ cold,” by its revulsive action. (6) Cure of chronic 
constipation, by Cullen’s method. 
No contra-indication. 
JALAPA. 
Action.—Chiefly on glandular and follicular struct- 
ure ; but involves peristalsis, frequently, to extent 
of severe colic. Upon the small intestine; and so 
high up as, sometimes, to involve the stomach and 
cause nausea. Is not secreted in milk, and so does 130 
EVACUANT MEDICATION. 
not affect the nursling. Does not reach the liver in 
its influence. Should operate in two to four hours ; 
stools watery. 
Uses.—(General.) In constipation with dry stools, 
suggesting defective secretion in intestinal tract. 
(1) As hydragogue, for evacuation of anasarcous 
fluid and accumulations in serous cavities. (2) As 
purgative, for subjects of disease of rectum or uterus. 
Contra-indication.—In inflamed states of stomach 
and upper bowel. Idiosyncrasy, previously ascer- 
tained, characterized by undue colic or undue nausea. 
Action.—Upon lower bowel, i. e., colon and below. 
Chiefly on muscular coat. Especially slow in opera- 
tion,—ten to twelve hours. Has considerable power 
as a cholagogue. Has a general tonic and stimulant 
influence. Cathartic action does not fatigue the 
bowels, is not followed by constipation; upon repe- 
tition, a larger dose is not required. Is secreted in 
the milk. Acts when placed in the rectum or upon 
the abraded skin. Action on involuntary muscle apt 
to be communicated to uterus. Stools feculent. 
Uses.—(1) In habitual constipation. (2) In amen- 
orrhoea of the anaemic. (3) In inflammatory con- 
ditions of head and chest. (4) The purgative of 
those often requiring a purgative; and of the feeble, 
the anaemic and the old. 
Contra-indication.—In active disease or lesion of rec- 
tum. In hypersemia, inflammation or hemorrhage 
of the womb. In threatened abortion. 
ALOE. COLOCYNTHIS. 
131 
Combinations.—With rhubarb and carminative. 
With nux vomica. With quinia or quassia. With 
iron. With ergot. With mastiche. 
CAMBOGIA. 
Action.—Upon upper part of intestinal tract, chiefly 
upon the glands and follicles. An active hydra- 
gogue; stools watery, rendered in two to four hours. 
Is non-cholagogue. A powerful stimulant to the 
kidneys. 
Uses.—In dropsy, from a fourfold advantage: 
easily administered; does not offend the stomach, in 
continual use; evacuates abundant serosity; pro- 
cures a free flow of urine. 
Contra-indication.—In inflamed states of stomach 
and neighboring intestine. Perhaps in pregnancy. 
COLOCYNTHIS. 
Action.—Similar to that of gamboge. Causes 
hydrocatharsis; probably has an influence upon 
large intestine, also, which gamboge has not. May 
operate by endermic application. 
Uses.—(1) In gonorrhoea. (2) In various combina- 
tions. N. B.—The Co. Ext. Colocynth. is a very dif- 
ferent material and with different applications. 
Contra-indication.—Same as with gamboge. 
Poisoning (and in that of gamboge).—Treatment 
similar to what is directed under ol. tiglii. 132 
EVACUANT MEDICATION. 
ELATERIUM. 
Action.—Causes rapid hydrocatharsis; acts upon 
glandular structure of small intestine, and often so 
high up as to implicate the stomach and occasion 
distressing nausea. Action upon peristalsis, subor- 
dinate, but may be so marked as to produce colic. 
Notwithstanding its depletory powers, Elaterium 
still has the properties of a stimulant cathartic. 
Uses (never appropriate to use as simple purgative). 
—(1) For withdrawal of dropsical effusions, relief 
of venous congestion, lowering of blood pressure. 
(2) For diversion from the kidneys, and to afford 
these organs a period of rest; as well as to secure 
the more speedy and an extended evacuation of 
toxic matter from the blood. (3) For revulsion and 
derivation from the head ; as procured by croton 
oil, also. 
Contra-indications.—Inflammation of stomach and 
just below. Marked cerebral anaemia. Idiosyncrasy 
—ascertained by previous use—indicating a com- 
plicating gastric distress, nausea and vomiting. 
SENNA. 
Action.—Chiefly addressed to muscular coat of 
small intestine; increasing peristalsis much as 
aloes increases that of the large bowel. Operates in 
four to six hours, stools feculent or semi-fluid. Is 
secreted in the milk, purging babe at breast. Organs 
of pelvis may be slightly implicated in the ener- 
gized contractility. But slight cholagogue power. 
Uses.—Serviceable in occasional constipation; MANNA. 
133 
adapted to habitual constipation with subjects who 
cannot take aloetics, and who can bear the interfer- 
ence with alimentation which Senna is liable to 
occasion. 
Combinations.—With a bitter, to increase purga- 
tive power. With carminative, to prevent colic, to 
which some subjects are exposed. With jalap, to 
provide a complete cathartic—i. e., one which shall 
act equally upon peristalsis and secretory function. 
Contra-indication.—In cumulative constipation, 
with impaction. 
CASCARA SAGRADA. 
Action and Uses.—Physiologically, has much resem- 
blance to senna, but is milder in operation. Again, 
it resembles castor oil, both in about equally ener- 
gizing peristalsis and secretion, and in making its 
impression upon the entire canal. A gently tonic 
and stimulant laxative; is probably secreted in the 
milk, and is a mild cholagogue. Six to eight hours 
in procuring operation. 
Adapted to infancy, to delicate females, and to 
many subjects of chronic constipation. 
Action and Uses.—Slow, uncertain as to time, but 
prolonged beyond that of drastics and salines. Use 
does not cause subsequent constipation. 
Eligible in infancy and early childhood, on ac- 
count of gentleness of action and convenience of use. 
MANNA. 134 
EVACUANT MEDICATION. 
RHEUM. 
Action.—Conditionally, a purgative, astringent, 
tonic, eupeptic, antiseptic agent. Three elements con- 
cerned in purgative action, viz.,—increased secretion, 
increased peristalsis and modified mucous surface. 
Yields pasty, yellow stools in four to six hours. Is 
secreted in the milk and is a mild cholagogue. Does 
not fatigue the bowels, but tends to subsequent con- 
stipation. (Purgative power is first to act and then 
the astringent.) 
Uses.—(1) In diarrhoea ab ingestis of children and 
corresponding condition of adults. (2) In acid, 
fermentative indigestion with constipation. (3) In 
neglected and cumulative constipation. (4) In diar- 
rhoea, from infarction of fseces. 
Contra-indication.—In inflamed states of stomach 
and small bowel. 
Combinations.—With aloes and carminative, in C. 
It. pill. With alkali (soda or magnesia), in ecco- 
protic mixture. With a bitter, to enhance both 
tonic and purgative properties. With jalap, in 
elixir salutis. 
From whatever source, and salified by whatever 
acid, act alike in this: that they exert a minimum 
of influence upon the muscular coat of the bowel, 
seldom irritate the mucous membrane, but chiefly 
act through their power to retain water and to evoke 
secretion from the glands and follicles of the intesti- 
nal tube. Are generally acceptable in irritable states 
THE SALINES, MAGNESII SULPHAS. 
135 
of stomach and bowel, and have the power to derive 
from and relieve the kidneys, and to diminish blood 
pressure. Are, mostly, non-cholagogue. Procure 
watery stools, and, generally, act rapidly. 
Action.—A diuretic purgative; a mild, refrigerant 
laxative, with so little influence upon peristalsis that 
its saline solution may linger in the canal until it is 
absorbed, and thus, continuing in the blood, fail of 
purgative effect. 
Uses.—(1) In constipation, with dry stools. (2) 
Dropsy, requiring a mild, gentle hydragogue and 
diuretic. (3) In the “ bloat ” of the last months of 
pregnancy. (4) As purgative in active inflammation 
of the uterus, of rectum, in metrorrhagia, etc. 
Combinations.—With jalap and with tartic emetic. 
POTASS. BITARTRAS. 
MAGNESII SULPHAS. 
Action.—Mild, sure, rapid, almost wholly on gland- 
ular apparatus. Depresses bile-secretion. 
Uses.—(1) To effect a rapid and considerable lower- 
ing of blood pressure, in some inflammations. (2) 
To thoroughly evacuate in accumulations of hardened 
faeces, in impaction, perityphlitis, etc. (3) For fre- 
quent use with subjects of large feeding, rapid assimi- 
lation, burdened liver. 
Combinations.—With senna, with tartar emetic. 136 
EVACUANT MEDICATION. 
The Hunyadi and Friedrichshall largely owe their 
properties to this saline. 
Action.—Similar to that of the Epsom. Has con- 
siderable cholagogue power. A more kindly influ- 
ence than Epsom, so far as it is absorbed into the 
blood. 
Uses.—Much the same as with the Epsom; with 
the following especial:— 
For prevention of cholesterine formations (gall- 
stones) and renal calculi. In dysentery. Supposed 
virtue in diabetes. 
SODII SULPHAS. 
SODII PHOSPHAS. 
Action.—Similar to that of the glauber, but has 
greater cholagogue power. 
Uses.—As purgative of children, on account of 
slight taste. For action upon liver, in small, fre- 
quent, non-purgative dose. 
SODII SULPHOVINAS. 
Action and Uses.—A gentle, palatable, cooling sa- 
line purgative; appropriate to delicate women and to 
children, on account of these qualities. Its con- 
tinued use is not open to the objection raised against 
the citrate of magnesia, of liability to the formation 
of calculi of ammonio-magnesian phosphate. A 
mild cholagogue. THE INSOLUBLE MAGNESIAS. 
137 
MAGNESII CITRAS. 
Action, Uses. — An elegant, palatable cathartic; 
possessing also refrigerant and slight diuretic proper- 
ties. Non-cholagogue. 
THE INSOLUBLE MAGNESIAS. 
Action.—Bring to bear, in modified form, the triple 
influence of rhubarb—i. e., action is exerted upon 
mucous membrane, glandular structure and muscu- 
lar coat, the first and third specifications being 
prominent. Slow in operation, ten to twelve hours, 
and even longer, and yield feculent stools. The 
material is not absorbed prior to purgative operation ; 
it is because it is not absorbed but produces local 
irritation that it acts cathartically. Use followed by 
subsequent constipation; non-cholagogue; not se- 
creted in the milk. 
Uses.—In constipation of infancy, of pregnancy, 
and of fermentative dyspepsia. 
Caution.—Continued use—and especially in non- 
purgative dose—may result in formation of concre- 
tions. Too persistent purgative use sometimes causes 
painful rectal tenesmus and a kind of dysenteric 
diarrhoea. 
Differential.—Carbonate better in irritable stomach; 
per contra, carbonate should be avoided where there 
are already gas accumulations; calcined preferable 
as antacid. 138 
EVACUANT MEDICATION. 
CHOLAGOGUES. 
PODOPHYLLIN. 
Action.—An irritant, drastic cathartic; depresses 
bile-secretion, in full purgative doses. In fractional 
doses, has considerable cholagogue power, especially 
upon repetition. Has peculiarity of acting with 
increased energy upon both liver and bowels, with 
each successive exhibition. A positive peristaltic 
excitant; enhanced contractility of bowel may be 
communicated to uterus; hence Podophyllin may 
be emmenagogue, especially in combination. Accord- 
ing to Waring, its activity is increased by conjoined 
use of sodium-chloride, and diminished by lactic 
acid or whatever is convertible into it. As with all 
resinous cathartics, an alkali augments its power ; as 
in combination of Podophyllin and potass, bitart. 
Uses.—Much the same as those of calomel; but 
influence is less sure and efficient. According to 
Ringer, dark and fetid stools especially indicate 
cholagogue intervention of this drug. Also as 
emmenagogue, alone, and particularly in combina- 
tion. 
Contra-indications.—As a purgative; too harsh and, 
thus given, defeats purpose of exhibition, so far as 
liver is concerned. In inflamed states of stomach 
and duodenum, and in nausea. 
EUONYMIN AND IRIDIN. 
Action.—As purgatives, these drugs nearly afford 
equivalents of augmented peristalsis and secretion. MERCURY. 
139 
Euonymin has less power as a cholagogue, but more 
as a purgative. 
Uses.—For occasional biliousness, as a substitute 
for mercury; in persistent torpor of the liver, as 
having considerations of convenience and safety of 
administration, which podophyllin and calomel have 
not. For continuous use, in the biliousness of 
swarthy subjects and others, especially in early 
spring. 
Differential.—Rutherford finds Euonymin suffi- 
cient for a light and transient form of bilious dis- 
turbance ; Iridin better adapted to such as is more 
grave or more obstinate. 
MERCURY. 
Action.—The preeminent cholagogue, if properly- 
used. Best exhibited in small and frequent doses ; 
either such as are not purgative or will be remotely 
so. (Best results are obtained where the Mercury is 
allowed to expend its action upon the liver ; and a 
purgative, given later, carries away both the mineral 
and the bile which its influence has solicited.) 
Characteristic dejections follow its operation. 
Uses.—Ringer says: Best adapted to persons whose 
stools are clay-colored or colorless; (V. Podophyllin, 
action.) Applicable to subjects of the dry and dirty 
skin, the foul tongue, foul breath, bitter taste in the 
mouth, especially in the morning, and the loaded 
and high-colored urine. 
Differential. — Calomel for occasional use. The 140 
EVACUANT MEDICATION. 
mercurous iodide for extreme conditions or obstinate 
states, which will not yield to calomel. The mercuric 
chloride in continuous use for persistent hepatic tor- 
por, in subjects of swarthy complexion, unctuous 
skin, and who present, in high type, the symptoms 
enumerated above. 
Contra-indication.—All mercurials are contra-indi- 
cated, if not forbidden, in purgative dose with purga- 
tive purpose. At all events, the mineral should never 
be prescribed for catharsis solely; and the liver is best, 
if not alone, reached by the method of small dose 
and continuous medication. CATHARTIC MEDICATION. 
Definition.—A Cathartic is an influence* or agent 
which, in variable degree according to selection, increases 
both intestinal movement and secretion; with the result 
of provoking preternaturally free and rapid evacuation 
of the bowels. 
The use of the terms cathartic and purgative has 
been traced back to that epoch in the history of 
medicine, when, under the controlling influence of 
the humeral doctrine, all attention was devoted to the 
elimination of the “ peccant humors,” the presence 
of which was thought to contribute to, or actually to 
constitute, disease. The word purgative had the 
double sense of that which evacuates and which 
purifies—not a bad definition, to-day—and cathartic 
(Gr. xaOdtpecv, to cleanse, to wash away) had a like 
significance. Some writers have attempted to make 
a slight distinction in the meaning of these terms, 
with view to difference of application; but such 
effort seems forced and unnecessary, and, for our 
purpose, purgative and cathartic are to be accepted as 
synonymous, and are employed indifferently. In a 
* An influence as well as an agent, as in other departments of 
therapeutics. Purgation may be procured, e. g., hy a modifica- 
tion of diet, hy the application of faradaic electricity, as it may be 
precipitated under the power of some controlling emotion, like 
fear or anxiety. 
141 142 
EVACUANT MEDICATION. 
former time, the use of evacuants was so universal 
that both to purge and to make vomit were expressed 
in the one word, medicamenter, or papudxsiv; so, also, 
the word physic, which has at present so indefinite 
and general a sense, had its origin in a former much 
more limited application. 
Certain distinctive terms calculated to define the 
degree and kind of cathartic action, e. g., laxative, 
drastic, hydragogue, have been long in use, and have 
a considerable convenience in a general discussion; 
but when the attempt is made, by such indications, 
to establish as many and corresponding sub-classes 
among which cathartic materials are to be dis- 
tributed, the result is arbitrary and such as may 
either mislead or confuse. As well might we accept 
the ancient valuation of purgative action in general, 
and say that that is not purgative which does not 
evacuate at least four pounds of liquid matter. The 
number, the quality, the rapidity of stools all vary 
for the same subject, with the same material, at dif- 
ferent times. Thus, Schwilgu6, in experiments upon 
this basis with glauber salt, never twice in succession 
attained the same number of stools. Such con- 
siderations as dose, a previous state of the bowels, 
combination with a non-purgative substance, inges- 
tion with food or upon an empty stomach, may 
render the same material, in the same patient, aperi- 
ent, drastic and even hydragogue. Repeated illus- 
trations of this principle appear in the discussions 
of cathartics. 
It seems best, however, to depart from the pro- 
posed rule of classification in one particular: the MECHANISM OF CATHARSIS. 
143 
function of the liver, in respect of secretion of bile, 
and the office of some purgatives as influencing 
this function, are of such importance in their bear- 
ing upon purgative medication, that cholagogues have 
been presented in a separate group. 
Mechanism of Catharsis.— Cathartic and purgative 
have been variously, often very inadequately, defined. 
In our attempt at definition, attention was had to the 
three conditions which ought always to govern in 
such case, and which should give a result at once 
concise, intelligible and comprehensive. No view of 
purgative action, physiological or therapeutic, can be 
correct or adequate which does not recognize the 
invariable presence of two forces in the influence 
exerted,—i. e., increased intestinal movement and 
secretion,—each essentially contributing to the result 
obtained. As concerns secretion in particular, the 
fact of its inevitable increase, under the operation of 
the mildest, least irritating materials, has been estab- 
lished by clinical observation in all time; and such 
testimony has been confirmed by certain physiologi- 
cal experiments, to which allusion may be made later. 
Thus far, then, the definition is justified; two ele- 
ments must always inhere to cathartic action, and 
the ratio of prominence of one and of the other varies 
greatly according to material used. These facts are 
constantly evident in the review of cathartic mate- 
rials; but it was also made evident that there are 
exceptional materials, rhubarb, e. g., which make an 
additional impression; and a few salines which, per- 
haps, act quite as much by retaining water in the 
canal, as by provoking its secretion ; and it would 144 
EVACUANT MEDICATION. 
be hardly feasible to construct a definition so spe- 
cific as to embrace these departures from the usual 
influence. 
The modus operandi of Catharsis, therefore, involves 
no such complexity of mechanism as is required to 
bring about the act of vomiting; and it obviously 
differs from the latter function also in that purga- 
tion is but the exaggeration of an habitual act, 
whereas vomiting implies reversal and departure 
from custom. Our more recent, intelligent physio- 
logical and clinical observation has served to correct 
many errors of theory, if not of practice, of the past; 
and among others the mechanical theory of Poiseu- 
ille, who believed he could demonstrate all the vital 
activities pertaining to purgation by means of his 
instrument, the endosmometer. It has been well 
said that if a saline cathartic, e. g., operates solely by 
virtue of osmosis, the Seidlitz water should act 
equally upon the living and the dead,—“ a crucial 
experiment which is still awaited with interest.” 
Again, that the water evacuated by a so-called 
hydragogue is not merely and directly drawn from 
the blood vessels (and without elaboration through 
the intestinal glands), is rendered probable by the 
fact that the serosity of the stools does not contain 
albumen coagulable by heat and acids, but an albu- 
minose which is acted upon only by mercuric chlor- 
ide. The fact of augmented peristalsis as incidental 
to cathartic action is obvious, and requires no discus- 
sion. 
Selection of a Cathartic.—Fonssagrives has well said: 
“ At the present day, aside from some distinctions SELECTION OF A CATHARTIC. 
145 
which are established by experience and tradition, 
it may be remarked that purgatives constitute a vast 
pele mele of medicaments, from which one draws by 
chance, guiding himself more by the facility of ad- 
ministration and exaggerated concession to the 
wishes of the patient than by any intention of adap- 
tation of the purgative chosen to the indications 
which determine its use.” To select the right cathar- 
tic is a far different and more difficult thing than it is 
to decide whether or not the patient should suffer 
cathartic interference; and it may be feared that the 
physician is most ready thus to interfere who has 
the least knowledge and skill in selection. 
Does the subject present constipation dependent 
chiefly upon atony of fibre, or upon deficient secre- 
tion ? Is the stomach already irritable, and thus op- 
posed to such material as acts upon the upper part 
of the canal, and which may implicate this organ? 
Or, again, can the patient afford the nutritive drain 
occasioned by an agent which will sweep the ali- 
mentive tract of elaborated chyme and chyle? Will 
a purgative which chiefly acts upon the lower portion 
of the canal best meet indications ? Or is it safe to 
select such material as may, at the same time, in- 
volve in its action certain neighboring organs ? Is 
colic imminent and, therefore, to be avoided, by the 
choice of an agent least likely to advance such con- 
dition? Must cathartic response be prompt, or is 
time a consideration of no importance in its opera- 
tion ? Is it desired to involve the nursling in the 
cathartic effect produced in the mother, or to act 
upon the mother alone ? 146 
EVACUANT MEDICATION. 
But such questions need not be multiplied, although 
they are almost without number; they are being 
constantly presented in variously modified form; too 
often they demand a present and not a deferred 
answer; and no physician, at the present day, should 
be entrusted with the use of this class of remedies 
who is not well acquainted with, at least, their promi- 
nent therapeutic characteristics, indications and con- 
tra-indications. 
Cathartic Effect on Nutrition, etc.—The expression, 
sweep the alimentive tract, etc., has just been used. 
There are some general facts respecting the influence 
of purgative medicines upon digestion, assimilation 
and nutrition which are of such importance as to 
demand brief attention. A cathartic may be em- 
ployed in such way as to arouse appetite, exert a 
tonic influence and assist digestion. A few cathartics 
have, associated with the purgative principle, a 
bitter which is obviously calculated to have this 
effect. Rhubarb or magnesia may be so directed as 
to aid gastric digestion; and if it be a dyspepsie par 
constipation, and not a dyspepsie avec constipation, 
merely, the purgative operation of rhubarb may 
directly promote nutrition. 
None the less, the usual cathartic operation im- 
plies interference with nutrition, inhibition or waste. 
If castor oil or a saline, e. g., be taken imme- 
diately before or soon after a meal, the result will 
be much the same as if less food had been re- 
ceived or the meal omitted altogether. It is much 
in this way that the Ilunyadi or Friedrichshall 
gives relief to the over-eating and over-burdened, INDICATIONS FOR CATHARSIS. 
147 
so frequently met with in society at present. The 
epicure of to-day follows the fashion and gratifies 
the palate, as did the Roman epicure whose ex- 
ploits are recorded by Seneca, only that the method 
of the former is less physiological. It is true that 
the mechanism of purgation is more in accord with 
physiological purpose than the method of emesis; 
but he who leaves the table to evacuate a distended 
stomach by means of a simple device, is less of 
a nutrition-despoiler than he who arouses the en- 
ergy of the' bowels to hurry away from the assimi- 
lative tract the food which has, wdiolly or in part, 
received the specific impregnation of the digestive 
juices and the elaboration of the digestive forces. 
The gourmand, who needs such drain, may avail 
himself of it; but that many cathartics have such 
influence upon nutrition—at least, unless carefully 
timed as to their exhibition—must not be forgotten 
in the case of the weak and ill-nourished. 
Indications of Catharsis.—The chief indications and 
results of cathartic medication may be thus pre- 
sented :— 
First Indication.—A purgative or purgative course 
may be required to relieve a condition of bilious- 
ness, occasional or chronic, where the liver is only 
secondarily at fault; or, to make the statement in 
physiological terms, the cathartic is indicated for 
the removal of stagnation and torpor of the duode- 
num. The office of the liver may be said to be a 
double one as respects a single function—i. e.,it both 
forms new bile out of the blood, and it eliminates 
from the blood the old bile brought back from the 148 
EVACUANT MEDICATION. 
duodenum. Whatever condition impairs local peri- 
stalsis, and so permits the bile to remain in that 
portion of the bowel where it was rendered by the 
common biliary duct, provides the conditions of its 
reabsorption and return to the liver ; and that such 
transference is rapid as well as sure has been 
variously shown. Indeed, it has been proved by 
physiological experiment that the return of a sub- 
stance from bowel to liver occupies about five min- 
utes. We have but to suppose a state of continuous 
duodenal torpor to present the status which Lusana 
has called the entero-hepatic circle, and which has often 
been figured in the text-books by means of a dia- 
gram. 
In the scope of such operation as shall reenergize 
duodenal peristalsis, prevent the stagnation and re- 
absorption of bile, and so break in upon this vicious 
circle, any purgative may be a true cholagogue, al- 
though not in the accepted sense of the term; i. e., so 
far as it shall sweep the bile along and procure its 
final evacuation. The state to which reference is 
had is often misinterpreted; the biliary distress or 
derangement is manifest enough, but the conclusion 
is reached that, therefore, the liver is at fault, and 
requires medication calculated to repress or modify 
its cholopoietic function. As already said, this in- 
direct hepatic disturbance may be occasional, and, 
again, it may be chronic or more or less habitual. 
So far as it is occasional, nothing could better serve 
for its removal than the old-time heroic powder of 
calomel and jalap, which will effectually drive the 
bile from the intestine, and so relieve the portal cir- INDICATIONS FOR CATHARSIS. 
149 
culation and the liver, and this without need of recog- 
nition of any direct action exerted upon the liver 
itself. 
But duodenal biliousness has its especial discom- 
forts for the patient when it exists in chronic form. 
It may obtain as a complication, as presented, e. g., 
in the disorder of the returned East Indian, so called, 
of him who has resided for many years in a tropical 
climate; and this element or phase of the affection 
must not be lost sight of, although in such subject 
the liver also is quite sure to be gravely at fault. 
The typical state, however, and that depending upon 
a continuous circulation of bile in the portal system, 
is manifest in the patient in whose case a careful ex- 
amination fails to establish any real and direct liver 
trouble,—a patient so often met with amid the con- 
ditions of modern life, and to whom Fothergill in par- 
ticular, among modern authors, has paid his respects. 
Persons of this constitution, he observes, can assimi- 
late more nutriment, and more thoroughly, also, if 
kept on liberal supplies of food combined with 
purgatives, than “ if they attempt to avoid bilious- 
ness by starvation.” “ There is a large amount of 
waste in their furnace,” continues this observer, “ no 
matter how small the quantity of fuel; and the only 
effectual plan is to keep the flues swept and, at the 
same time, be liberal with the fuel.” “ The great 
matters in the treatment of the bilious are the regu- 
lation of the amount and character of the food and 
the systematic use of alkaline saline purgatives. By 
such means the headache, the languor, the sense of 
misery, are all relieved. The person eats more, as- 150 
EVACUANT MEDICATION. 
similates more, and becomes a new person, by judi- 
cious, yet energetic, purgation, especially in the 
morning. Popular, as well as professional, experi- 
ence has pronounced its verdict as to the association 
existing between biliousness and the necessity for the 
use of purgatives.” 
The preliminary remarks upon the influence of 
catharsis upon nutrition, together with what has 
already been said under the present indication, must 
commend the justice of these observations of Fother- 
gill to every physician who has had experience 
among the class of the “ well-to-do,” who enjoy the 
privilege, and suffer the penalty, of life amid condi- 
tions of abundance and waste. Such are the indi- 
viduals who are never quite so well, never eat so 
freely, with so good appetite, and with so little dis- 
comfort, as during the yearly visit to the Spa, where 
nature has provided, and custom sanctions, the use 
of an unlimited supply of dilute purgative waters. 
The recent introduction of more concentrated waters 
also, such as the Hunyadi Janos and the Friedrichs- 
hall—so widely and gratuitously advertised by cer- 
tain medical authorities, who thus advertise them- 
selves—bears testimony in the same direction. 
The system pursued at Carlsbad, as set forth by 
Dr. Ringer in the eleventh edition of his Handbook, 
and which chiefly consists of a limited allowance of 
stale bread and weak vermicelli soup and an unlim- 
ited supply of warm Carlsbad, may be adapted to 
such as have passed several stages beyond the condi- 
tion at present contemplated, or, more likely, to those 
who have also a complicating liver disease. INDICATIONS FOR CATHARSIS. 
151 
Second Cathartic Indication.—A second use of purga- 
tives respects the elimination and evacuation of cer- 
tain mineral poisons, and, although of infrequent 
application, is conveniently introduced at this point. 
It is unquestionable that many of the heavier metals, 
as iron, copper, lead, mercury, are, in considerable 
part at least, eliminated by the liver and in the cur- 
rent of the bile.* Thus brought to the intestine, 
with natural purpose of egress from the system, the 
metal must be reabsorbed, together with the bile, if 
allowed to remain long at the place where it was 
rendered. This casualty will be especially liable if 
the mineral poison happen also to be a peristaltic 
paralyzer, as is lead in eminent degree. Thus an 
entero-hepatic circle is set up, in the current of which 
constantly circulate the vestiges of the metallic toxic, 
whatever solvent, as potassium iodide, and in what- 
ever quantity, may be prescribed for its elimination. 
There must, therefore, be selection of a cathartic 
course best qualified to overcome the paresis of the 
muscular coat of the intestines, and such influence 
must be exerted upon the whole extent of the canal, 
lest there should still be reabsorption lower down, 
and, so, an entero-systemic circle be established. 
* The following data, established by the experiments of Orfila, 
have a general interest. Arsenic, in continuous use, is completely 
eliminated twelve days after its exhibition. This elimination, for 
corrosive sublimate, is achieved in one month ; it takes four months 
at least for antimony, more than five months for silver, eight months 
for lead and copper ; and elimination having ceased, the organs 
may yet contain appreciable quantities of the poison.—Fonssag., 
Prin. de Th&rap. Gen., p. 107 et scq. 152 
EVACUANT MEDICATION. 
One point farther: a fact established by the re- 
searches of Dumarel, has interest in this connection. 
This physiologist has shown that iodine has the 
faculty of determining whatever metal may make 
combination with it toward the salivary glands. 
Fig. 1. 
Here iodine plays the part, in the language of Prof. 
Gubler, of a vector. Thus, iodide of iron, received 
into the stomach, may be brought back to the mouth. 
This physiological fact particularly concerns the fa- 
miliar use of an alkaline iodide for the solution and INDICATIONS FOR CATHARSIS. 
153 
final elimination of the stored particles of lead or 
mercury. It but needs a reference to facts already 
presented, and to the accompanying diagram, to see 
in what way, under such treatment, a gastro-salivary 
or an entero-salivary circle may be established. 
Unless farther provided for, the patient is worse off 
than before interference; for the imprisoned mineral 
has been released and started upon its travels through 
the system. There must, therefore, be a conjoined 
purgative course, calculated to remove the paresis of 
the intestinal tube and to procure such free and ex- 
tended peristalsis as shall sweep the bile, and the 
toxic mineral which it holds in solution, along the 
intestinal tube beyond any point of possible reab- 
sorption, and so ensure its expulsion from the body.* 
Lusana believed that the materies morbi of mala- 
rial poisoning may be retained in the system by a 
kind of vicious circle, like those already illustrated. 
Whatever may be said for this theory, the peculiar 
efficacy of a brisk cathartic sweep, in the treatment 
of poisoning by malaria, is familiar to every physi- 
cian with practical experience in this department of 
disease. The virtue of the quinine seems to be at a 
standstill until after cathartic intervention.! There 
* There is, obviously, an important difference always possible 
between the operation of the gastro-salivary and entero-systemic 
and of the entero-hepatic circles, in that the latter may be confined 
within the limits of the portal system, and never become involved 
with the general circulation ; although, practically, after a while, 
the over-burdened liver grows congested and the general circula- 
tion is impregnated with certain bile elements. 
f As apposite to this statement, Dr. H. W. Fuller gives an 
instance of an ague which had been treated for a fortnight in the 154 
EVACUANT MEDICATION. 
may also be mentioned in this section the advisa- 
bility of occasional catharsis, in certain conditions 
where the patient is receiving large quantities of 
some remedy by the method of continuous medica- 
tion. The wisdom of a frequent, if not a periodic, 
intervention by a purgative, in the bromide treat- 
ment of epilepsy, e. g., is recognized by many, if not 
by all neurologists. 
Third Indication.—A third indication for resort to 
the cathartic is apparent in the too obvious excuse, 
the plausible occasion and less often demand, afforded 
by constipation. It is, perhaps, to be expected that 
the uninstructed should, in such condition, inva- 
riably turn this way, and with no better selection 
than is suggested by convenience in taking and rela- 
tive pleasantness of taste; but the physician should 
follow a far different rule. The popular and profes- 
sional abuse of cathartics was probably never before 
so great as now, and there are many reasons why it 
should be so; but even Plutarch, in his day, con- 
demns a like expedient, “ to which the majority of 
men make too ready resort.” The constipation that 
is accidental and temporary may often best be re- 
lieved by medicine; here, the question of various 
measures of relief is comparatively unimportant. 
It is chronic constipation that presents a problem to 
the physician, often demands his serious considera- 
usual way without benefit ; but which was removed by a single 
resort to purgative medicine. Such experience more than sup- 
ports the position taken in the text,—viz., that a brisk cathartic 
may accomplish more in a few hours than had been accomplished 
for many days by medication otherwise. INDICATIONS FOR CATHARSIS. 
155 
tion, and not infrequently reveals the need which the 
subject of it has for instruction, as well as for medi- 
cation, at his hands. 
Chronic constipation is most often habitual consti- 
pation ; and such faulty habit implies, of course, the 
absence or loss of a normal physiological habit. It 
does not follow that every individual should have 
an evacuation from the bowels once every twenty- 
four hours, although nature surely intends that this 
rule should be enforced with most people; but there 
are those who must have a regular movement twice 
a day, and others whose bowels move naturally once 
every two or three days. What nature does require 
of all alike, in respect of this function, is strict regu- 
larity and periodicity.* In nothing connected with 
the training and education of the young, among the 
more intelligent classes, is there more grievous lack 
than in the inculcation of this fixed physiological 
* Sir Andrew Clark, in an article upon “Constipation,” com- 
municated to The Lancet in January of the present year (1887), 
emphasizes the essential importance of instructing the patient to 
make a daily effort at bowel evacuation at that hour of the day 
which most closely corresponds with the hour of a life-habit; 
insisting, farthermore, that a disposition to visit the closet at 
whatever other hour of the day should always be resisted and 
discouraged. 
As a medicinal help, he proposes an excellent pill, to be taken 
daily about supper time ; and proceeds to give curious illustration 
of the truth that one may justly stand prominent among medical 
celebrities and yet betray ignorance upon simple, every-day facts 
of therapeutics. Sir Andrew allows a half-grain of ipecac, to be 
added to his- pill, provided that (the italics are in the original 
paper) ‘‘''there be no especial weakness of the heart!” What can a 
half-grain of ipecac, do to a weak heart ? 156 
EVACUANT MEDICATION. 
principle, — and especially in respect of young 
women. 
The right habit may have been formed, but if 
there be a tendency to intestinal torpor, it will quite 
likely be found that the opportunity has been lost for 
the day, if the appointed hour has been let slip by. 
Others than Montaigue have learned the essential 
importance of “ le saut du litit is more than carpe 
diem, in this matter, rather is it, carpe punctum tem- 
poris! Nay, more, the individual may be unme- 
thodic in other things; still must he follow strict 
regularity in this daily function. Otherwise, the 
postponed office soon becomes perfunctory, and once 
perfunctory, a little later gets to be neglected now 
and then; so that all the advantage of a previous 
training and system may be lost in an incredibly 
short time. Instruction in this special department 
the physician, owes to his patient,—to the young 
who, too often, fail to receive it at home. 
As respect therapeusis, every case of chronic con- 
stipation must be studied by itself and treated upon 
individual principles. It was a maxim of the an- 
cients that acute disease is general (as pertaining to 
a genus), and chronic disease personal and especial; 
and few chronic affections are so peculiar to the sub- 
jects of them as is habitual constipation. Of 
the diet of the patient has an important bearing 
upon the action of the bowels ; but a change in diet, 
which even involves the setting aside of much that 
is particularly agreeable and the substitution of what 
the patient has little appetite for, will not, by itself 
alone, accomplish much toward the cure of consti- INDICATIONS FOR CATHARSIS. 
157 
pation. The relation of the liver to the intestinal 
tract must be considered in every case; the bowels 
cannot be right and regular, under any circumstances, 
long at a time, unless the biliary duct discharge the 
due amount and quality of bile into the duodenum. 
Sometimes it is a question of exercise that must 
be considered. Of course, a generous, invigorating 
exercise, of whatever kind, is favorable to regularity of 
the bowels; horseback riding may wisely be chosen, 
and yet undue devotion to this sport has been known 
to create a constipated habit.* Such caution applies 
still more positively to bicycle riding. Lauder Brun- 
ton has the pertinent remark that the exercise which 
encourages contraction on the part of the diaphragm 
is, thereby, calculated to secure a secretion of bile; 
and a brief, daily course of such character may do 
more for the patient than a long, idle and listless 
walk. 
Finally, the author has seen more than one case 
of prompt relief—and less often of cure—of a consti- 
pation which had baffled all previous treatment, 
however varied, through the simple drinking of 
hot water. This recent prescription has been ele- 
vated into a system, has had monographs written 
* Fonssagrives gives among his causes of constipation: “2d,— 
Habitual compression of the seat (du siege), by a too prolonged sit- 
ting position, as in equitation ; it is known that we may momen- 
tarily suppress expulsive solicitations of the intestine, in diarrhoea 
or under the influence of a purgative, by sitting down, or by firm 
pressure of the perineum ; one may, little by little, habituate the 
mucous membrane of the extremity of the large bowel to a con- 
tact which at first it does not well support, but which, finally, 
deadens its sensibility. ’ ’ 158 
EVACUANT MEDICATION. 
upon it, and, like many other tilings nowadays, has 
had its craze; but, none the less, it has its occasional 
wise application. The water must be hot, not warm 
(temperature 110° to 130° Fahr.), must not be made 
aromatic, and should be drunk slowly, by sipping, 
and in considerable quantities ; perhaps a pint before 
breakfast. A pint thus taken is sufficient for some ; 
with others it but begins the day. How the hot 
water performs its service, when effectual, is not 
quite plain ; a good deal has been said by its advo- 
cates about a power inherent in hot fluids of pro- 
moting peristalsis; Lauder Brunton observes “the 
secretion of bile is not only increased, but the 
pressure under which it is secreted is raised by sipping 
fluids,'”—and has a theory respecting a conjoined in- 
hibitory action of the vagus on the heart. 
In whatever way it may act, that it acts effectually 
in some subjects cannot be denied. It has occasion- 
ally solved the problem at its most difficult point; 
and the patient with whom all purgative combina- 
tions had failed—an aperient or laxative mixture 
being insufficient and an effective cathartic com- 
pound always drastic and irritating—has been 
enabled to reestablish regularity of habit under the 
“ hot water system.”* 
* The adaptation of the enema to habitual constipation is con- 
sidered later.—vide p. 179. The faradaic current also has its uses ; 
it may even be remedial, more often it is adjuvant. Its applica- 
tion is simple—one electrode placed upon the sternum, the other 
made to follow the course of the intestine, and especially that of 
the large bowel; but a discussion of such application cannot be 
entered upon here. Either a Hall or a Kidder “tip cell ” will 
provide a sufficient current. INDICATIONS FOR CATHARSIS. 
159 
When all, however, has been done that can be 
done, by the cooperation of physician and patient,— 
and the physician cannot cure otherwise than by co- 
operation,—there will still remain a certain number 
of persons who must have medicinal aid; and par- 
ticularly will this be true of those who approach, or 
who have somewhat passed, middle age, and who 
have long followed a sedentary habit in life. With 
such, more often than otherwise, the fault is not in 
the liver or in quantity or quality of secretion at any 
point of the intestinal canal, but consists in loss of 
contractile force, and is to be sought for in enfeebled 
peristalsis. For the benefit of such patients, as truly 
or more truly than for any other, practical pharmacy 
has made its recent advances; the gross pill or 
bolus or draught, never so offensive as when often 
repeated, need no longer be prescribed, and a 
minute parvule may even be found too active for the 
requirements of the case. As already said, each 
case of chronic constipation is a case by itself; so 
the regulative pill must be constructed and modi- 
fied for the individual patient.* The purgatives 
most appropriate to chronic constipation are senna, 
cascara, rhubarb and aloes; their office in this 
capacity was presented in the discussion of these 
* The elegant pills and parvules, made by approved manufac- 
turers, have a considerable value and convenience for the practi- 
tioner, and especially if he live at a distance from the large cities. 
But they have the disadvantage that they tempt to routine pre- 
scribing. No manufacturer could afford to make pills for the sub- 
ject of habitual constipation ; they must be made by the thirties 
and not by the gross. 160 
EVACUANT MEDICATION. 
materials, and their more limited indications and 
contra-indications are made obvious in the chart 
upon Differential Therapeusis. 
Fourth Indication.—Has to do with removal and 
cure of a certain form of diarrhoea, the constipation 
des selles diarrheiques of the French. The situation 
implies a paradox, and it is not strange that it is 
sometimes misinterpreted, even by the observant 
physician; but it is not seldom presented, and is of 
a character that will not yield except to treatment 
based upon a correct diagnosis. In the experiments 
of Brunton, directed to the determination of the 
mechanism of catharsis, it was observed that such 
slight irritation as is occasioned by the tickling of 
the interior of the bowel by a feather, would provoke 
an abundant secretion which, under favorable con- 
ditions, an increased peristalsis must pass downwards 
from the point where the irritant was applied. 
Such, and a much greater, irritation is occasioned by 
an accumulation of dry and hardened feeces, which, 
once that they have become imprisoned, by their 
very pressure and distention have partially para- 
lyzed the intestine at the point of contact. A state 
of hypersecretion is soon set up, and this, in turn, 
with the attendant and consequent perverted secre- 
tion, soon terminates in diarrhoea. But in this case, 
the so-called “ effort of nature ” at relief is abortive 
and a failure; for as the diarrhoea originates no 
higher up than the locus of irritation, the intestinal 
flux, however free, cannot dislodge and bring awTay 
the offending cause. 
Such a state of things is very sure to be misinter- INDICATIONS FOR CATHARSIS. 
161 
preted by the patient, and, as before said, there is 
some liability that the physician, too, will misread 
the case or misinterpret it through the patient’s read- 
ing ; and, particularly, if opportunity is not offered 
to examine the abdomen as the subject lies in bed. 
The patient had eaten nothing to bring on the 
diarrhoea,—such is the frequent report,—had tried 
various simple measures for its arrest before sending 
for the doctor, and is quite sure that, previous to the 
attack, the bowels had moved nearly every day. 
Close questioning just here would probably have 
elicited the information that the bowels had not been 
evacuated every day ; the office had recently been 
imperfectly performed ; quite likely more had been 
retained, daily, of what should have been discharged 
than was brought away. 
Let such a patient be treated by opiates and 
astringents, and the general distress and diarrhoea, 
temporarily palliated, must inevitably return in 
severer form. Now he takes to his bed, if not before, 
temperature rises, the bowels are distended and sore 
to the touch, there is anorexia, coated tongue, etc. ; 
and a diagnosis of typhoid fever is reached. This 
the writer has had experience of in consultation 
more than once, and such “ typhoid fever ” has been 
cured in twenty-four hours; a cautious, cumulative 
and thorough cathartic evacuated the alimentary 
canal, corrected the diagnosis and speedily restored 
the patient to his accustomed activities: “ Ourationes 
naturam morborum ostendunt.” 
But restoration is not always so complete and 
prompt; more care, more skill, more time are re- 162 
EVACUANT MEDICATION. 
quired; a more serious disorder is implied, something 
approaching to a grave mechanical stoppage,* and 
when at last a free passage for anything more than 
liquid stools has been accomplished, and the intesti- 
nal tube has been finally evacuated, both physician 
and patient may be left to wonder at its capacity and 
accumulated contents. 
The treatment in this complication must be varied, 
largely, according to the ability of the stomach to 
receive the remedies most appropriate to the case. 
If vomiting is already present, the difficulty is 
greatly increased; and if not present, it is more 
or less imminent, and must be avoided, if possible. 
Two facts in medication apply to all cases; the 
purgative is best given by the continuous method, 
and a relatively large dose, of whatever material may 
be chosen, will be required to move the bowels. In 
children, a syrup or sweet tincture of rhubarb some- 
times serves a good purpose; a half to a whole table- 
spoonful every hour, until the desired result is 
reached. In adults, the compound rhubarb pill is 
most often acceptable and serviceable; one pill every 
hour, p. r. n. The bowels are at last evacuated with- 
out previous nausea and without attendant pain, 
but quite likely not until after ten to fifteen pills 
have been taken in all. The adjuvant aid of poul- 
*Even peritonitis would be possible. Such complication has 
been known, in a few instances, to attend violent superpurgation, 
the irritation to which the mucous membrane was subjected, hav- 
ing been transmitted to the peritoneal investment ; and a not un- 
like liability is presented in the extreme case of the disorder now 
being discussed. INDICATIONS FOR CATHARSIS. 
163 
tices of senna or colocynth to the bowels, a supposi- 
tory of aloes, or of an abdominal hypodermic of 
strychnia may also be advisable. 
A similar pathology, and a not unlike but a 
simpler therapeusis apply to a frequent form of sum- 
mer diarrhoea in children and in adults. The small 
bowel is more or less occupied with the crudities of 
imperfectly-digested food, and with the products of 
fermentation and subacute inflammation. The di- 
arrhoeal flux brings them away, but so long as the 
condition of the mucous membrane, which gives 
rise to perverted secretions, continues in force, such 
irritant secretion must be reproduced. Too often the 
physician steps in with inhibitory medication, with 
purpose to stop the diarrhoea; and now the natural 
safeguard which the patient had before is gone, and 
the perverted secretions are “ locked up ” in the 
bowels. This disorder may indicate a mild opiate 
for present relief of pain and spasm, but only sub- 
ordinatfcly; the prime, essential indication is for such 
cathartic as shall do the double office of evacuation 
and of impressing a healthful modification upon the 
diseased mucous membrane. Rhubarb with an al- 
kali may avail, or if an active inflammation forbid 
rhubarb, then magnesia; again, castor oil and a 
little laudanum. 
Fifth Indication.—There are certain physiological 
facts—and corresponding applications—pertaining to 
the action of cathartic medication upon the blood, 
and, through the blood, upon distant organs, as well 
as upon the bowels themselves, which have a con- 
venience in being grouped about an indication. 164 
EVACUANT MEDICATION. 
Cathartics may do a good service, at the beginning 
of fever or inflammation, in sweeping the bowels of 
altered secretions, the continued presence of which 
would be calculated to increase the disturbance. 
The ruheolous, variolous and typhoid diarrhoeas, 
which sometimes attend the early stages of these 
diseases, indicate an effort of nature in the same 
direction. Brunton quotes Bouchard as saying that 
alkaloids form in the bowels, even of a healthy 
man, in the course of twenty-four hours, which 
would be sufficient to kill, if they were absorbed and 
not excreted.* Thorough catharsis, as by castor oil, 
at a proper remove from childbirth, often accom- 
plishes great good and averts various ills. 
Sir Chas. Bell, Heincken, et cet., report cases where 
neuralgic pains in different parts of the body were 
promptly removed by the intervention of a purga- 
tive. Accumulations in the colon give rise to pain 
in the loins, spermatic cord or groin. Pain at the 
lower angle of the scapula is referred by Sir Charles 
to disorder and distention of the duodenum. This 
is often accompanied by flatulence, and is described 
by patients as a “ pain in the pit of the stomach, 
shooting through between the blade-bones/’ and is 
not infrequently termed by them “ windy spasms.” 
It may be relieved at once by rhubarb and an alkali, 
* Brunton has also pointed out the languor and weakness which 
occur in many cases of indigestion, and emphasized the resem- 
blance of these symptoms to such as attend poisoning by curare— 
believing that the languor was due to the absorption of poisonous 
substances from the intestines. ‘ ‘ These I considered to be prob- 
ably peptones, but it is possible that they may be ptomaines.”— 
Practitioner, 2d vol. of ’80. INDICATIONS FOR CATHARSIS. 
165 
given before meals. Dr. Bell also reports a case of 
toothache, with neuralgia of jaw and temporal re- 
gions, which was supposed to depend upon a defect- 
ive tooth, but which readily yielded to a cathartic, 
by which irritating matter was removed from the 
bowels. The late Dr. Todd cites a case of hiccough 
which had persisted for a number of days, but which 
was at once arrested by the operation of a cathartic. 
Hancock obtained good results from the employment 
of drastics in sciatica, by which the injection of the 
neurilemma of the suffering nerve was abated. A 
lowered general blood pressure may bring relief to 
the pain of a local inflammation; not only is the 
arterial tension lessened by the operation of the 
purgative, but the blood current is urged forward 
with less force, and the congestion of the inflamed 
part and the painful throbbing, before felt with every 
pulsation, are abated or may disappear for a consid- 
erable time. 
Again, the principle of revulsion may be operative 
through cathartic action. Such was the purpose of 
Trousseau’s method with aloes for relief of cerebral 
and thoracic inflammation. Fonssagrives says, con- 
cerning the potency of sanguine derivation accom- 
plished by the.purgative, “ It is a Junod’s boot applied 
to the portal system.” Such is the scope of this 
medication when it awakens the person out of the 
somnolent state which follows blows upon the head 
and fracture of the cranium. Its revulsive efficacy 
is also shown in the speedy relief which it will bring 
in conditions of extreme congestion and inflamma- 
tion about the eye, so that, as in frequent instances, 166 
EVACUANT MEDICATION. 
the eye that was completely closed by the surround- 
ing oedema, and exquisitely painful, may he, in a 
few hours, open and free from pain, by virtue of a 
single brisk purge. Such was the basis of Teissier’s 
system of treatment for the cure of paraplegia.* 
The relation between the bowels and the skin—the 
internal and external membranous investment—is 
so close that a cathartic operation may be capable 
alike of great good and great evil. It is true, as 
already remarked, that a salutary diarrhoea may 
attend the early stages of certain eruptive diseases; 
hut the physician can hardly imitate such an agency 
in his practice. Nothing is likely to act more disas- 
trously in the epoch of development of the erup- 
tion of scarlatina, e. g., than derivation toward the 
bowels by means of catharsis. Remedies of this 
class, therefore, have an important bearing upon the 
treatment of skin diseases. Constant, in effect as 
follows, sums up his observations at Biett’s Clinique: 
Purgatives may be serviceable in chronic eruptions, 
or, at least, after the acute stage has passed: in giving 
them earlier, there is danger of aborting an effort of 
nature, “ which should be respected as the expres- 
sion of a besoin physiologique” 
But it is upon the blood, in especial, that purga- 
* Fonssagrives remarks upon the unquestionable fact that purga- 
tives may also produce paraplegia, as in Leroy’s System of purga- 
tion a, outrance of sixty years ago. “In this case the conges- 
tion provoked by the purgatives passed the limit within which 
its effects should have been confined, and the lower portion of the 
medulla participated in the effect. It is an example among a 
thousand of contrasted effects realized by the same means, accord- 
ing to the activity and the persistence of its use. ’ ’ INDICATIONS FOR CATHARSIS. 
167 
tion makes its capital impression. An energetic 
purge, says Fonssagrives, is “ une saignee blanche,” 
“ une saignee de la veine porte ! depletive, hypostheni- 
sant and derivative.” It is a serous bleeding, so to 
speak, but no less real than a hemorrhage. This 
fact has already received illustration, and still appears 
in certain later applications of hydragogue purga- 
tives. Some recent researches of Dr. Mathew Hay 
have, practically, afforded a new resource to the pro- 
fession. This observer calls attention to the power- 
ful depletory action of a concentrated solution of a 
saline purgative introduced into a comparatively 
empty bowel. The patient having previously ab- 
stained from food and liquid, it was found that 
twenty-one grams, sodium-sulphate in three ounces 
of water, would so evacuate the serum of the blood 
that in less than a half hour the red corpuscles would 
rise from 5,000,000 to 6,790,000 per millim. cube. 
Epsom salt, being soluble in a quantity of water less 
than its own weight, is especially adapted to this 
purpose. Sodium and potassium-phosphate are too 
little soluble. Such medication is especially indi- 
cated in anasarca, where the vitality of tissues is 
threatened by accumulations of serosity, and there is 
urgent demand for absorption. The Rochelle salt 
may be substituted for the Epsom. Brunton, in re- 
marking upon the extraordinary efficacy of Hay’s 
method in dropsy and like conditions, gives his 
opinion that dilute purgative salines owe such activity 
as they possess chiefly to their diuretic action. 
Once more, a cathartic course may be so ordered 
as materially to diminish polysarcia; observations 168 
EVACUANT MEDICATION. 
previously offered respecting the bearing of this 
medication upon nutrition, must make this fact 
apparent. Such a resource, however, must be adapted 
to the patient with great care, lest it weaken his 
forces and derange digestion more than it lessens his 
weight; and should never be followed unless under 
the close observation of a skilled physician.* 
Sixth Indication.—Chiefly concerns the kidneys. 
These organs have less close anatomical connection 
with the bowels than has the liver, the purgative, in 
their respect, can scarcely be called a Junod’s boot, 
but their physiological relation is quite as intimate. 
The kidney is one of the few essential organs of the 
body which is permitted no rest; in a state of health, 
it is fitted for unremitting work, but when it is dis- 
eased, a certain respite may be indispensable both to 
the resumption of its own functional operation and 
to the safety of the patient. This may be accom- 
plished by powerfully determining toward the skin, 
or by hydragogue purgation. Hydrocatharsis is 
particularly indicated in inflammation or congestion 
of the kidneys, with urine markedly albuminous, 
and in threatened suppression of urine. The opera- 
tion of elaterium has many times been observed to 
lessen or wholly remove albumen from the urine, 
render that excretion abundant,—without aid of 
diuretics or where diuretics had been previously in- 
* This treatment of obesity was familiar to the older physicians. 
Their purpose was to realize the attenuated cycle, within the limits 
of which the body should be drained of nutritive fluids, by means 
allied to saline purgatives, and gradually and imperfectly allowed 
the materials of reparation. INDICATIONS FOR CATHARSIS. 
169 
operative,—and so, for the time at least, rescue the 
patient from a grave situation. 
A close relation also between the liver and the 
kidneys may be made apparent, as in the not infre- 
quent experience where various diuretic measures 
have been without result, but, after a thorough 
solicitation with mercury, the diuretic performs its 
accustomed service. 
The salutary cathartic intervention in conditions 
approaching cumulative action of certain remedies, 
as the bromides or arsenic—to which allusion has 
previously been made—still farther illustrates the 
connection subsisting between the functional work- 
ing of the bowels and of the kidneys. 
It is an interesting fact that the milk treatment, 
which will be found so serviceable as applied to the 
cure of a form of chronic vomiting, was some years 
ago proposed as the ally of, or substitute for, a cath- 
artic course, in the treatment of one form of 
dropsy, viz., ascites. It would appear to be Chres- 
tien, of Montpellier, who, about 1830, rescued this 
method from a long oblivion and reestablished its 
utility, by the report of a considerable number of 
successful cases. He did not insist upon a milk 
regimen exclusively, but confined the patient to a 
vegetable diet and pure milk in good quantity. It is 
supposed that the ascites receives relief through a 
nearly equal influence exerted upon the bowels and 
the kidneys. 
Seventh Indication.—And final, is found in the later 
stages of grave heart disease, accompanied with pro- 170 
EVACUANT MEDICATION. 
nonneed serous congestion, with the consequences of 
serous effusion, dyspnoea and cyanosis. More benefit, 
more immediate and material relief is to be obtained 
from free catharsis than would be believed, by one 
not familiar with this resource; and the attending 
prostration is more than compensated for by the se- 
quential ease and comfort. Of course, the material 
to be chosen is one which will best evacuate serosity, 
e. g., Dr. Hay’s concentrated saline solution, the comp, 
jalap powder or elaterium. The possibility of syn- 
cope must be considered and provided for; but 
elaterium in particular is stimulant as well as de- 
pletory in action, and when the depression which 
attends its accidental irritation of the stomach is 
escaped, its stimulant properties may be quite ap- 
parent. In the case now contemplated, a careful 
physician will probably have provided a previous 
treatment with digitalis, and he will have at hand 
both alcoholic and ammoniacal stimulants at the time 
of the hydragogue operation; but Fothergill makes 
a fairly representative statement when he says that 
it has never been his fortune to see any evil conse- 
quences from this mode of treatment, adding—a 
saving clause of much significance—“ My patients 
all take iron and digitalis at the same time, a not 
unimportant matter.” Indeed, it is almost wonder- 
ful to see how well the cyanotic and the breathless 
will undergo hydragogue purgation; how each 
repetition will afford a new—though it be brief— 
lease of life, providing a respite which could not be 
gained from any other source. More detailed in- MODIFIED ACTION. 
171 
formation respecting this treatment is given in the 
discussion upon elaterium.* 
Modified Action.—Comparatively little attention has 
been paid by those who have written upon this de- 
partment of medication to modified action,—i. e., to 
the modifications introduced into the usual cathartic 
influence by such variable conditions as age, idiosyn- 
crasy, etc.; but there remains little to add to the 
observations which have appeared at frequent points 
in the previous discussions. Idiosyncrasy has less 
concern with cathartic remedies than with such as are 
more strictly neurotic in their operation and results; 
still, there may be departure from the usual and an- 
ticipated action of a purgative by irregularity intro- 
duced from this source; and such phenomenon is 
the more frequent and perplexing in the action of 
the stronger materials, as croton oil and elaterium. 
The physician, about to prescribe any one of what 
may be called the toxic purgatives, should always 
enquire of an intelligent patient respecting a pos- 
sible previous experience in its use. 
Age is generally supposed to modify in the direc- 
tion of a lessened dosage for the young; and tabula- 
tions are calculated upon this principle, as, e. g., of 
castor oil, dose for the adult, one-half oz.; for the 
child, one dr. But such rule can hardly be applied 
* The profession is more indebted to Fothergill than to any other 
writer for the treatment of the important subject presented in this 
indication. It is remarkable that so full and so philosophic an 
author as Fonssagrives has nothing to say respecting the relation 
of cathartic medication to heart disease, nor has Lauder Brunton, 
in his recent volume on Therapeutics. 172 
EVACUANT MEDICATION. 
except, at least, with the infant at the breast. The 
young can seldom, or never, require any of the class 
just denominated the toxic purgatives; the milder 
and gentler agencies should always be selected in 
their case; but of aloes, rhubarb, Epsom salt, e. g., 
the child passed five years, as well as the adolescent, 
will need about the same dose as the adult: in such 
subject a drachm of castor oil is likely to be wholly 
inadequate. 
But there are two periods of life which demand of 
the physician more consideration than they have 
been wont to receive. At the time of the menopause, 
the peristaltic cathartics must be given with great 
caution; a usually mild material is apt to be at- 
tended, in its operation, with painful colics. Again, 
a purgative should be selected and combined with a 
view to lessen, to remove, if possible, and certainly 
not to increase, the flatulency which is so prevalent 
at this epoch. 2d. With the aged, and whatever 
subjects present the lowered powers of calorification 
of the aged, cathartics which make a rapid drain 
upon the serosity of the blood are liable to act 
badly; “ cold remedies,” like the mineral laxatives, 
are too depressant in their influence; they are often 
found, with whatever patient, to lower the tempera- 
ture by half a degree, and this is uncomfortable to 
the old man or woman. Such medication, with 
added slight exposure, is even accused of having pre- 
cipitated into a pneumonia. The following remark 
of an able writer upon many medical subjects can- 
not be too seriously considered, at least by the young 
physician: “ It is attention to these comparatively trifling CONTRA-INDICATIONS FOR CATHARSIS. 
173 
matters that helps to make the successful practitioner quite 
as much as more solid attainments 
General Contra-indications and Cautions.—Nearly or 
quite all the more positive purgatives have their spe- 
cial contra-indications, as has been seen in the review 
of materials; but there are a few general contra-indi- 
cations and cautions which must be presented briefly. 
(1) A present peritonitis always forbids the use of any 
purgative whatever; a previous peritonitis demands 
caution. -(2) Fear of perforation contra-indicates; so 
does (3) a syncopal state, or marked tendency to 
algidity. Inflammation of stomach, of duodenum, 
or of colon, rectal lesions, pregnancy, uterine disease 
and hemorrhage simply make requisite a skilled 
selection of agencies,—based upon an exact differ- 
ential therapeusis in this department. In a concealed, 
but suspected, strangulated hernia, a purgative may 
be urged cautiously so long as diagnosis is uncertain; 
but the first appearance of stercoraceous vomiting 
indicates prompt arrest of such a course. 
The case of volvulus or invagination is one of still 
greater difficulty as respects early diagnosis, and grave 
difficulty as concerns treatment. In this desperate 
situation, what may be considered heroic or des- 
perate measures may afford the only hope of success 
in the attempt to save life. Fonssagrives observes 
of invagination in young children that it commonly 
has its seat in the large intestine, and, in the great ma- 
jority of instances, the intussusception is from above 
downward. “ For a long time, metallic mercury has 
been employed, and with especial success. The objec- 
tion which is made to this measure (by Pereira), e. g. 174 
EVACUANT MEDICATION. 
that the invagination, being almost always from 
above downward, is not suited to such means of relief, 
cannot hold before the empirical establishment of its 
success and of its harmlessness.” For the adult, 
Colson advises 300 to 400 gram, metallic mercury. 
Menard reports having used shot, “ often in a dose of 
half a pound to a pound, and with the same inno- 
cence and the same success.” Dr. Maydieu, reported 
by Fonssagrives, published in 1870 twelve illustrative 
cases of the use of “ No. 5 ” shot, in doses of 50-100 
gram, for the child, and 200 gram, for the adult. 
The lead was first washed, and then administered in 
60-120 gram, olive oil. Fonssagrives proposes sub- 
stitution of pearls of glass, which, however, it would 
seem would be of inferior value because of their 
light sp. gravity.* 
Dr. West advised insufflation in the case of in- 
fants, and has found it especially successful, as it 
should be if the lesion in these subjects is located 
low down in the colon. J. Wood, 1836, and Trastour, 
1873, also proposed distention, by air pumped into 
the bowel. Probably in extreme accumulations of gas, 
the measure so often and safely employed by veter- 
inarians, of puncture (or with an aspirator), would 
afford help, as a preliminary to this method. Gamier, 
* The lead, in some successful cases, remained five or six days 
in the bowel before working its passage. Fonssagrives suggests 
glass because he thinks the lead shot may be acted upon by the 
acid of the stomach and made angular and rough. It is surprising 
that writers of such repute as those quoted in the text should 
gravely discuss the question whether mercury or lead can be so 
changed chemically in the canal as to permit the absorption of a 
soluble salt and, so, cause poisoning. CONTRA-INDICATIONS FOR CATHARSIS. 
175 
Lyons, cites a desperate case, cured by discharge 
through the rectum of one quart carbonic acid gas 
from a bottle. Lavage of stomach, as first proposed by 
Kussmaul, was applied to one case of obstruction 
which had lasted eight days, and to another of nine 
days, with faecal vomiting ; there was a degree of re- 
lief almost at once, and both patients were saved. This 
method, which has also been endorsed by Senator 
et al, seems to favor the reduction of the twisted gut. 
Dr. Roux, in a patient in extremis, with faecal vom- 
iting, and in whom all previous measures had 
failed, applied alternately to the abdomen, by means 
of an ice-bag, very hot and very cold water; and 
after a considerable labor brought his patient 
through. Dr. Kormann, of Cobourg, reports a case 
advanced to the tenth day, where life was saved by 
an injection of two quarts of ice-water and conjoined 
manipulation of the abdomen. It has also been 
suggested that the two elements of an effervescent 
mixture might be injected as high up into the 
bowels as possible; one solution very soon after the 
other,—as by an application of the Seidlitz powder. 
Finally, Bettelheim, after an examination of a large 
number of cases and review of various methods, de- 
cides that “ metallic mercury is by no means a 
worthless remedy (dose 200 gram.).” 
It has seemed worth while thus to group together 
the various measures which have been used in a great 
emergency, and one which brings more of anxiety 
to the physician, and alarm and distress to the pa- 
tient and his friends, than any other condition— 
hardly without exception—that medical practice has 176 
EVACUANT MEDICATION. 
to contend with. If one extreme measure fail in 
such extreme situation, another may succeed. At all 
events, the treatment must be of that heroic charac- 
ter which was contemplated by the ancients when 
the familiap aphorism was reversed and made to 
read, “ Medicus magister naturae.” None other than a 
masterly hand can be expected to afford relief in 
such condition as this.* 
It but remains to discuss briefly the relation of an 
employment of purgatives to an epidemic of cholera; 
which prevailing disease, in various opinion, de- 
mands caution in, or forbids the use of these remedies 
to, such, of course, as still retain their health. Every 
one knows that an antecedent cholerine both 
threatens, and serves as a signal of, the much more 
dreaded cholera to follow; and it has, there- 
fore, been urged, that whatever relaxes the 
bowels may establish cholerine. Among others who 
* If all else fail, help may be afforded through surgery,—and 
even life saved. Indeed, such extraordinary advance has been 
made in the department of abdominal surgery within the last ten 
years, that it may now be regarded quite feasible to open the 
bowel for the resolution of a fixed mechanical stoppage of what- 
ever character. But while so radical a measure should not he de- 
layed too long, it is never to be applied until less heroic resources 
have been well considered ; and with all such resources as are avail- 
able the physician should he familiar. 
In this place, also, may be mentioned the extreme accumu- 
lation of imprisoned gas or flatus, which is calculated to render all 
ordinary measures for an evacuation of the bowels ineffective, and 
which, meantime, gives the patient great distress. This condition 
in horses, as I am informed by my friend Dr. J. R. McLaughlin, 
is often and safely removed by simple puncture ; an operation 
which might be extended to the human subject. ADMINISTRATION OF CATHARTICS. 
177 
have borne testimony upon this subject, Dr. Escall- 
den, in 1849, in the columns of l’Union Medicate, 
reports that, in the epidemic of cholera, he prescribed 
purgatives to such as required them, with only the 
best results. The reader is reminded that a purga- 
tive is not alone a stimulant to the functions of the 
bowels, but an alterative or modifier; and that, in 
infantile cholera, a timely purge is not infrequently 
found to do more for the patient than any other and 
every other form of treatment. To which it may be 
added, as every physician with experience of cholera 
well knows, that a precedent diarrhoea is often less 
to be dreaded than a precedent and neglected consti- 
pation ; the latter having put the subject of it in the 
worst possible condition for a sudden attack of the 
epidemic disease. It need hardly be insisted, that 
under such circumstances, the cathartic shall be 
chosen and urged with especial caution, and with 
close observation of its effects. 
Administration.—In addition to the usual method, 
a few cathartics are capable of exhibition by rectum 
and skin, as was observed from time to time in the 
review of cathartic materials. It is believed that the 
actual feasibility of hypodermic insertion has never 
been accepted by the profession, in respect of any 
material among the list, although especial claims 
have been occasionally asserted. Such as might be 
adapted by concentration and solubility are too 
irritant in their local action. But Dr. Shoemaker, of 
Philadelphia, identified with the introduction into 
practice of various oleates, has recently demonstrated 
the occasional advantage of the insertion in the 178 
EVACUANT MEDICATION. 
areolar tissue of both nutritive and purgative oils; 
so small a quantity as one to two drachms castor oil, 
thus exhibited, has been found capable of absorp- 
tion with but little pain, without subsequent local 
injury, and with quite assured purgative result. Of 
course, a modification of the usual syringe is required 
for this purpose. Such resource might prove of 
value in meeting certain conditions presented under 
the fourth indication. 
For the most part, and with the usual intention of 
a simple evacuation of the bowels, the purgative is 
best ordered at the time of the meal or directly after, 
unless, possibly, in the case of such salines as are 
taken with a large quantity of wrater. Fonssagrives 
says, respecting this point: “ It is the English method 
and it is good; ” and intimates that the French, 
accustomed to receive the cathartic upon an empty 
stomach, get less mild, less sure and less speedy action. 
The saline purgatives and the purgative waters are 
often well taken early in the morning, as soon as may 
be after rising; and, if there be prompt response, 
there need be but little interference with nutrition. 
The ancients in their use of purgatives made 
frequent account of a principle of combination which 
is too little regarded nowadays. Their prescriptions 
of this class were generally composite, and were 
pretty sure to contain some ingredient which was 
supposed to answer to a diffusible stimulant, and to 
which prominent place was given, such as anise, 
ginger and sage. With the aged, the anaemic, such 
as are in danger of being unduly prostrated and 
chilled by the purgative operation, great help may ENEMATA. 
179 
be had from a conjoined, if not combined, use of 
spirits of chloroform, of comp, cardamom, of laven- 
der, or of some alcoholic spirit. 
Enemata.—It but remains to devote a few words 
to the purgative enema. Such may contain purga- 
tive material, or it may be simply of water and act by 
mechanical distention and stimulation; and it may 
also have the double office of occasional use, and of 
habitual and systematic relief, as in chronic consti- 
pation. 
The medicated injection may be variously con- 
stituted, as was frequently seen in the discussion of 
cathartic materials. It is obvious, if it is to operate 
cathartically, that its volume must be small, and that 
it must be retained long enough to allow of absorp- 
tion and action through the blood. The enema of 
oil may perform a twofold service: it may be directed 
solely to distend and lubricate, and so prepare for 
and facilitate the passage of a considerable mass of 
hardened faeces, and it may be designed for absorp- 
tion and a later service, the same as if exhibited by 
stomach. There is much uncertainty respecting an 
actual cathartic operation in any given case, and it 
has often been denied that oil inserted in the rectum 
will give such result; but there is repeated clinical 
proof, none the less, that a purgative oil thus admin- 
istered will operate thoroughly and satisfactorily. 
The dose of castor oil must be three or four fold 
what would be given by stomach, and the patient 
instructed to retain it.* 
* The oil for this purpose is best emulsified, and by the follow- 
ing method : to be placed in a small howl with three or four 180 
EVACUANT MEDICATION. 
A medicated enema is now and then demanded 
for the evacuation of acrid secretions and products 
of fermentation located in the sigmoid flexure and 
above; and in its preparation it may be well to bear in 
mind that the natural reaction of this tract is acid. 
Carbolic acid may be used in proper quantity and 
strength, but only with caution and recollection of its 
toxic properties. A prescription which has been 
found widely applicable, and which can do no harm, 
is as follows: A pint or more of warm, strong spear- 
mint tea, with addition of a teaspoonful of sodium- 
bicarbonate. The tea should be made from the leaf 
as far as possible; but in default of this, the tincture 
may be substituted (5ss-j to the pint). Introduce 
slowly, have retained ten to fifteen minutes, if possi- 
ble ; this is always grateful to the patient, and may 
give great relief and do good service. 
In the use of a warm water enema for occasional 
removal of accumulation in the lower bowel, an in- 
telligent patient can need ho instruction; and we 
reserve remaining space for the discussion of this 
measure as applied to chronic constipation. It is 
remarkable how commonly the action of this simple 
means of relief is misapprehended. The patient 
who has long been practically familiar with multi- 
farious purgative pills and mixtures, on sale at his 
druggist’s or grocer’s, is very apt to regard the pump- 
ing of a little warm water into his rectum as an 
“ unnatural procedure; ” and too often his physician, 
times its quantity of strong and hot soap water, these to he passed 
through a Davidson syringe several times, and then at once ad- 
ministered . ENEMATA. 
181 
rather than otherwise, supports this prejudice, and 
has views of his own respecting various local mis- 
chief liable to follow if such interference should be 
resorted to too often. Even an author so invariably 
correct in his conclusions as Fonssagrives—and 
whom we have found it to our advantage so often 
to quote—is evidently opposed to the warm water 
enema, lest its frequent use should gradually remove 
normal sensibility and contractility. 
Now, the fact is that the habitual enema, properly 
restricted in its application, and properly controlled 
in its use, is capable of giving great comfort, of ac- 
complishing great good, and is not obnoxious to 
the charge of doing the patient harm. It can sel- 
dom be appropriate to any except to those who have 
reached middle life or have passed this period; with 
such, if the constipation has become habitual, and 
obstinately so, and is located in the large bowel, 
as it generally is, how much more feasible is it, how 
much more direct to solicit the removal of the accu- 
mulation by mild, mechanical means entered at the 
rectum, than to administer remedies by the mouth ! 
Dr. Brunton, somewhere in his writings, says he has 
personal knowledge of a man who has depended 
upon a dinner pill, daily, for twenty years, with 
uniform satisfaction, without injury and without 
increase of dose, meanwhile; and this is strong 
testimony to a fact which could easily be supported 
by other clinical evidence. So the author has known 
a patient who, for considerably over twenty years, 
has used the syringe—seldom needing any other help, 
but always requiring this—and who has employed 182 
EVACUANT MEDICATION. 
such instrument without any discoverable harm, 
still finding it as efficient to-day as it was when it 
had hardly been used a year. 
But for such service as this, as already said, there 
are restrictions, rules of the utmost importance, which 
should always be insisted upon. The injection must 
be taken at a regular time ; it must be received only from 
a fountain-syringe * (or appliance made on this prin- 
ciple), the water must not be taken in undue or increasing 
quantity, the enema must consist solely of water, and its 
temperature should closely approach that of the body. 
Thus conditioned in its application, and with right 
selection of patients, no agency for the relief of 
habitual constipation which the physician can en- 
dorse can be more physiological than the enema of 
warm water. The patient will, for the most part 
and most comfortably, retain the water five to ten 
minutes, until it shall have set up the peristalsis 
through which it accomplishes its purpose. 
It is equivalent to repeating what has already been 
said, but the fact is of such importance as to demand 
* Not alone because no other instrument can so well promote 
the comfort and ease of the patient (at least among all measures 
of self-help). Not to insist upon the uncomfortable posture which 
any pump-syringe necessitates, upon its irregular introduction of 
the water, frequently mingled with air, thus causing unnecessary 
discomfort, there is danger, in its habitual use, of the gradual 
formation of abrasions, or local callosities, which may, later, occa- 
sion serious trouble. Among all the instrumental agencies which 
have enriched therapeutics within the last twenty years, what 
other instrument is so simple, so direct in its purpose,—a purpose 
which serves an inexpressible comfort and convenience,—as the 
fountain-syringe ! ENEMATA. 
183 
emphatic assertion, that the contractility of the 
bowel need not be impaired by this method of relief 
—this has been variously proved—and that response 
to the mechanical stimulus may, and ought, to be 
found equally prompt and complete after many years. 
The subject is one to which the writer has long given 
attention, and he is prepared to affirm, farthermore, 
that there has been no tendency to distention or 
pouching of rectum or sigmoid flexure, even with 
those who have for many years been familiar with 
the warm water enema, and who yet have used 
proper care. 
The habitual enema or injection must have its 
regular time, as previously insisted, and just as 
strictly so as if the individual depended upon a pill, 
or upon a natural and unassisted habit. But it is 
believed that the majority of persons will find that 
an injection once in forty-eight hours is all that is 
required; and, still farther, that the function is better 
cared for in this way than if an attempt with the 
syringe were to be made every twenty-four hours. 
This, at least, has been the result of the author’s 
observation. 
Once more: Some who are accustomed to the 
periodic injection have found upon occasion of more 
than usual repletion, as from over-eating, or of ex- 
ceptional accumulation in the lower bowel, because 
the syringe, for once or twice, had not been so 
efficient as it should be, that it has been possible so 
to direct the enema as to obtain the results of a brisk 
and thorough cathartic of the entire intestinal 
tract. In order to do this, it but required to receive 184 
EVACUANT MEDICATION. 
a larger quantity of water than usual, and to retain 
it longer than usual,—perhaps by a quarter of an 
hour,—though at the cost of some discomfort. Here, 
doubtless, we have, in addition to what ordinarily 
obtains, an extension of the energized peristalsis to 
the small intestine: first comes an unloading of the 
large bowel and, after brief interval, a flux of liquid 
matter, which, if it be repeated, as it often is, will 
present unmistakable evidence of bile. GENERAL PRINCIPLES. 
1. Resinous cathartics,—e. g., senna, jalap, etc.,— 
being digested in the small intestine and by virtue 
of an alkaline reaction, are energized by the addition 
of an alkali. 
2. Peristaltic cathartics, aloes in particular, are 
energized by the addition of nux vomica. 
3. Cathartics which act chiefly through energized 
peristalsis—aloes, senna, etc.,—may be given habitu- 
ally in aperient dose without causing fatigue of 
bowels, subsequent constipation, or requiring in- 
crease of dose. 
4. Cathartics which act chiefly through augmented 
peristalsis of the small bowel—senna, calomel, etc., 
—must be avoided in cumulative constipation and 
impaction, especially of the small intestine. 
5. Cathartics which act chiefly through augmented 
peristalsis of the large bowel—aloes, in particular, 
and its combinations—are apt to extend an influence 
to the pelvic organs, and are variously contra-indi- 
cated in uterine and rectal disease. 
6. Cathartic materials which contain a bitter prin- 
ciple—as do, e. g., aloes, euonymin, colocynth, cas- 
cara—are also more or less active in capacity of 
tonic and stomachic, increasing the appetite. 
185 186 
EVACUANT MEDICATION. 
7. Resinous cathartics, and aloes in particular, re- 
ceive an increment of energy by the addition of a 
bitter, as quassia and quinia. (N. B.—A like claim 
is made for iron.) 
8. Materials which most stimulate the glandular 
and secretory structure of the canal are most likely 
to depress bile secretion. Hydragogues are not chola- 
gogues. 
9. Cathartics which in large dose and drastic 
action may depress bile secretion,—e. g., podophyllin, 
calomel,—in smaller dose, and with gentler action, 
will stimulate secretion of bile. 
10. Cathartics which procure hydragogue stools, 
and so rapidly deplete the blood, are ill adapted to 
the aged, the feeble and to the markedly anaemic. 
11. Materials which chiefly bring to bear either 
peristaltic or secretory influence in the alimentive 
tract—e. g., castor oil, senna, colocynth, the salines 
—are ill adapted, in frequent use, to the poorly 
nourished. 
12. Active cathartics are likely to increase fer- 
mentation and occasion colics at the time of the meno- 
pause ; at this epoch there should be careful selection, 
and combination with carminatives, with this fact in 
view. 
13. Cathartics which act highest up upon the 
canal, and so more or less involve the stomach in 
their action,—e. g., jalap, elaterium, podophyllin,— GENERAL PRINCIPLES. 
187 
must be avoided in inflamed stomach, existent 
nausea, threatened vomiting. 
14. Materials which chiefly act through increased 
secretion and power of retaining water—e. g., potas- 
sium bitartrate—are most appropriate to rectal and 
uterine hypersemia, and metrorrhagia. 
15. While all cathartics act by variable increments 
of augmented peristalsis and secretion, rhubarb and 
the insoluble magnesias bring to bear a third in- 
fluence,—viz., a modified mucous surface. 
16. The toxic purgatives—e. g., croton oil, colocynth, 
elaterium, gamboge—should never be prescribed 
where the sole intention is an evacuation of the 
bowels. 
17. All cathartics are forbidden in peritonitis, per- 
foration, strangulated hernia, in extreme algidity, 
and in a state of collapse. EVACUANTS.—N0. 2, EMETICS. 
Materia Medica, History.—Radix Ipecacuanhas, or 
Ipecac, tlie root of the Cephaelis I., of nat. ord. Rubia- 
cex (to which cinchona also belongs), and indigenous 
in Brazil. Three chief varieties are described. Maisch, 
in his Organic Materia Medica, figures the annulated, 
the striated and the undulated ;* but the former is al- 
most solely used in the United States. It has an ap- 
pearance strictly peculiar, and as if a series of firm 
ligatures had been placed, at close and regular inter- 
vals, about the growing root. In its natural habitat, it 
is chiefly found in the shade of great trees, in lowland 
or valley situations, is known locally as poaya ; and 
its collection, at all seasons of the year, forms the 
chief industry of the so-called poayeros. Its increas- 
ing expensiveness, and its extensive use in certain 
diseases of the British tropical possessions, have led 
to the attempted cultivation of the Ipecac plant in 
India; hut, hitherto, with only partial success. 
Chemically, this root chiefly consists of an active 
alkaloid, emetin, an acid, ipecacuanhic, and a small 
per cent, of a fetid volatile oil, which latter, although 
IPECACUANHA. 
* Corresponding respectively, as to their source, to Cephaelis I, 
Psychotria Emetica and ffichardsonia Brazilierms, according to Rabu- 
teauand other authorities, Rabuteau makes the farther statement 
that the barks of these roots contain emetin in ratios as 16 to 100, 
9 to 100 and 3 or 4 to 100, which appears to he an error as gross 
as it is unaccountable. 
188 IPECACUANHA. 
189 
present in minute proportion, may, perhaps, perform 
a special service in medication.* The yield of emetin 
is only one per cent, according to the best author- 
ities,f and is obtained almost absolutely from the 
bark of the root, the woody fibre of the interior 
being tasteless, and nearly inert. Accordingly, the 
powder of Ipecac is considerably stronger than 
the root in substance; since in the process of tritura- 
tion, the ligneous fibre, irreducible to powder, is re- 
jected. Various salts have been made from emetin, 
but it is mostly used as alkaloid. Ipecacuanhic acid 
has close relations with kinic and caffetannic acids, 
and is a glucoside. It is bitter, odorless and amor- 
phous. 
Various other plants have properties nearly allied 
to those of Ipecac ; such is the American Ipecac, or 
euphorbia spurge, and the polygala. It is a fact of 
much interest that the garden violet—viola odorata%— 
which has positive emetic properties, has been shown 
to contain emetin.§ Indeed, the Brazilians apply 
the word poaya to “ emetic roots of plants belonging 
to the orders Rubiacese, Violarix and Polygalese.” Eme- 
tin was first eliminated by Pelletier, in 1817. 
Ipecac is one of several invaluable medical mate- 
* Yide Emetic Medication, p. 244. 
t“Less than one per cent.,” say F. & H., who refer “nu- 
merous higher estimates ” to a product of impure emetin, or of 
defective analysis, 
X Sydenham could hardly have known Ipecac in his practice, 
but appears to have made constant use of the Viola. 
# In all parts of the plant: “the indigenous succedaneum of 
Ipecac.’’ (Fonssagrives.) 190 
EVACUANT MEDICATION. 
rials which tropical South America has contributed 
to the medical art. An indispensable emetic, it is, 
no less, a requisite specific in certain other applica- 
tions, if the term specific can ever properly be used in 
medicine. Its use is said to have been long known 
in Brazil, but the first mention of it appears in a 
history of that country, written lyy a Portuguese 
friar, about 1570, where it is termed Igpecaya. It 
was not until a century later—1672—that the trav- 
eler, Legras, brought a specimen of the root to Paris. 
It has been well said, by a recent writer, speaking 
upon this subject: “ It is one of those cardinal medi- 
caments of which the wise physician makes account 
in a wide range of cases; and posterity has shown 
itself singularly ungrateful, in being oblivious of 
the name of Legras, who, in bringing the Ipecac 
to Europe, rendered to humanity so signal a 
service.” 
It was as a remedy for “ the bloody flux ” that the 
Portuguese friar first extolled the properties of Ipecac. 
When Gamier, a merchant of Paris, about 1680, be- 
came possessed of one hundred and fifty pounds of 
the root, it was still against dysentery that the new 
remedy was directed. Ilelvetius made trial of it in 
this direction, and, according to the narrative, caused 
placards to be posted in the streets proclaiming his 
wonderful success. Upon investigation, the French 
Court accorded him the sole right of selling the 
drug; later, when several remarkable cures were be- 
lieved to have been wrought in the persons of those 
attached to the Court, the secret was purchased by 
royalty for the sum of 1000 louis d’or; and this secret, IPECACUANHA. 
191 
as concerned both material and method, was given to 
the public in 1688. 
Pharmaceutical Preparations :*— 
1. Pulv. Ipecac. ; emetic dose, 9j--5j- 
2. Pulv. Ipecac. Comp., Dover’s Powder (Pulv. Ipecac, and Pulv. 
Opii, a a gr. j ; sugar of milk, gr. viij : a gr. x powder). 
Dose gr. v-x. Better named as in the text than Pulv. 
Ipecac et Opii, as there is, now and then, an occasion where 
the presence of opium in the prescription is best undeclared 
to the patient, f 
3. Ft. Extract. Ipecac., TT\, j, corresponding to gr. j powdered root. 
4. Syrupus Ipecac., dose variable. 
5. Vinum Ipecac., dose variable. 
6. Pulv. Morphise Comp. (Tully’s powder) ; analogue of the 
Dover and with same dose : contains—Ipecac, morphia, 
liquorice, camphor and calcium carbonate. 
7. Emetin, Emetic dose, gr. Emetin is sometimes used, 
especially in hospitals and dispensaries, in the preparation 
of the syrup. Experiments in Yulpian’s laboratory are as- 
serted to have proved “that all the physiological, therapeu- 
tic and toxic properties which Ipecac possesses, are due 
to its alkaloid which seems equivalent to saying that the 
quality of action of both materials, in the wide scope of their 
influence, is the same. Both the syrup and the wine, although 
closely alike in strength and otherwise, have their especial 
conveniences in prescribing ; the syrup is more liable to 
change, through fermentation, hut it has been stated that 
the wine may diminish in strength if too long kept. 
Physiology.—Ipecac is primarily and always an 
irritant, whether in contact with a mucous mem- 
brane or the abraded skin; and such irritation may 
* Not necessarily only those which are recognized by the U. S. 
P.,—although respect is always had for such recognition,—hut the 
preparations which are used in practice. 
f There is also a liquid representative of the Dover’s powder, in 
which one minim answers to one grain. The powder is also ele- 
gantly prepared as a 5 gr. compressed pill by Wyeth & Bro. 192 
EVACUANT MEDICATION. 
even pass into a pustulation of character strictly 
peculiar to the agent used. Bretonneau proposed to 
apply it for counter-irritation, as tartar-emetic is some- 
times used, and found the severity of its action to 
be about midway between that of tartar-emetic and 
croton oil. In its operation as an emetic, doubtless, 
the irritation produced in the stomach is an agency 
of importance in the accomplishment of the result. 
But it is as modified by idiosyncrasy that the irritant 
influence of this drug affords the most notable 
phenomena. There are individuals, who, upon ex- 
posure to the slightest quantity of Ipecac dust, 
develop all the symptoms of a violent attack of hay- 
fever, as manifested by continuous sneezing, asthma, 
coryza, lachrymation, to be followed by a degree of 
febrile reaction, lasting for several hours: to the 
more local of these conditions, perhaps all people are 
susceptible in various degrees. 
The general physiological action is so largely 
modified, and indeed controlled, by quantity admin- 
istered and method of exhibition, that it is difficult 
to discuss the subject independently, and as this 
department of other materials is discussed; but, 
still holding this fact in view, some of the more gen- 
eral features of tendency and influence may be pre- 
sented.* Such tendency appears in a stimulation of 
all mucous membranes to increased secretion, and es- 
pecially the mucosa of the respiratory and intestinal 
* A good illustration of modification produced by method of ex- 
hibition is given by Fonssagrives in the experience that Ipecac 
“ en lavage,”—that is to say, suspended in a large quantity of water 
—will pass rapidly into the intestine and act as a purgative. IPECACUANHA. 
193 
tracts. It is probably in part by virtue of this 
property that Ipecac is found to energize the purga- 
tive action of jalap. It is true that increase of mu- 
cous secretion attends the impression of all nau- 
seant remedies; but, Ringer, et cet., are probably 
right in their conclusion that Ipecac excites secretory 
action independently of its influence as a nauseant. 
A like decision has been reached also respecting its 
diaphoretic action. 
Ipecac is believed to exert a strictly characteristic 
modification in the blood supply of the lungs. Stoll 
first taught that it caused ansemia of these organs, 
and Trousseau adopted this opinion. Pecholier 
shows that animals poisoned by Ipecac invariably 
present this condition,—a condition not due to 
nausea or vomiting, as antimony often causes an 
opposite state. Rutherford and Vignal find Ipecac 
a very sure cholagogue, in doses of one grain and 
upward. 
A continued ingestion of this drug in considerable 
quantity, and yet too small to ensure its rejection by 
vomiting, may bring about a state of great distress, 
and one attended with alarming symptoms, promi- 
nent among which are a universal prostration, and 
relaxation of extreme degree; nausea is constant, 
vomiting occasional, the entire body is suffused 
with perspiration, and the subject is in such abject 
misery, that death is both feared and desired. 
The emetic operation of Ipecac is signalized by 
little antecedent nausea and little subsequent de- 
pression; the drug acts slowly, mildly, but often 
with tendency to repetition. 194 
EVACUANT MEDICATION. 
Therapeutics.—Ipecac is a favorite subject with 
writers upon therapeutics, as admitting more modi- 
fication into its action, and especially in respect of 
the dose administered, than any other known 
material. Through the conjoined influence of dose 
and the varying state of the patient, it may be made 
to serve as emetic, anti-emetic, nauseant and depres- 
sant, tonic and stomachic, expectorant, diaphoretic, chola- 
gogue and purgative. In addition to all this, it has 
qualities which, in default of a better term, must be 
styled “specific.” There was once supposed to be a 
still farther modification, which may be said to have 
been brought about by the mutual reaction of cer- 
tain states of disease and a continuous, skilled ad- 
ministration of the remedy, to which the term 
“ Tolerance ” was applied, and to which earlier 
writers devoted much ingenious discussion; but there 
is a problem here, which, whatever solution may be 
rendered, has hardly any longer a practical aspect. 
Emetic Uses.—Quality of action in this capacity, as 
already characterized, helps to anticipate the applica- 
tion of the remedy. The emetic service of Ipecac is 
adapted to subjects requiring mildness and thorough- 
ness of operation, with a minimum of subsequent 
constitutional disturbance. It is, preeminently, the 
material to be chosen for the infant, the aged, 
the enfeebled patient of either sex and of whatever 
age. Still farther, the fact that its emetic influence 
occasions but little derangement of heart and circula- 
tion renders it eligible where cardiac depression is the 
danger to be chiefly avoided. Again, Ipecac is appro- 
priate to indigestion from repletion, to distress from IPECACUANHA. 
195 
suddenly arrested digestion ; to conditions requiring 
the exertion of a positive antispasmodic influence, 
like croup, laryngismus stridulus, etc.; and some- 
times for the dislodgement of foreign bodies, en- 
gaged deep in the throat. Still, where the indication 
points to action especially prompt and sure, some of 
the materials to be discussed later are more wisely 
chosen. To cases of poisoning, and particularly of 
narcotic poisoning, Ipecac is not adapted. 
Anti-Emetic.—Much difference of opinion prevails 
in the profession respecting the value of minute 
doses of Ipecac for the arrest of vomiting ; but it is 
probable that failure sometimes comes from non- 
recognition of the conditions of success.* Dr. Rin- 
ger, to whom we are indebted for many especial 
studies in therapeutics, gives much valuable infor- 
mation upon this subject. And (1) Ipecac is often a 
resource of value in the vomiting of pregnancy, both 
such as attacks the patient on first awaking, and 
that which is more or less continuous, or which es- 
pecially recurs upon taking food. (2) It is of service 
in flatulence coexisting with sickness; but if flatu- 
lence exist alone, anti-fermentive remedies are more 
availing, like charcoal and carbolic acid. (3) Ipecac 
gives relief in the misplaced nausea and vomiting 
which attend the suckling of the infant,—instead of 
appearing at an earlier period,—which sets in after 
the first two or three weeks and continues till the 
child is weaned. (4) It is often applicable to a simi- 
lar disturbance of the stomach, which is periodic 
*Even Dr. Einger orders the remedy in such way as is calcu- 
lated, many times, to ensure its failure. 196 
EVACUANT MEDICATION. 
and associated with menstruation. (5) Occasionally 
successful in the morning vomiting of drunkards. 
(6) Is appropriate to the “ morning vomiting which 
sometimes accompanies general weakness, and is met 
with in convalescents from acute diseases.” 
(7) Ipecac controls the vomiting of children from 
acute catarrh of the stomach; and Dr. Ringer be- 
lieves the remedy, generally, to be more effective in 
children than in adults. (8) It gives relief to the 
vomiting of whooping cough, which depends upon 
the violence of the cough, although the severity of 
the latter may be in no wise affected. Finally, (9) 
Ipecac often arrests the vomiting which, in whatever 
subject, sets in soon after meals, unaccompanied with 
distress or pain, and where the food is returned but 
little modified by digestion. On the other hand, it 
is a fact of the clinical experience of those who have 
had the most success with the remedy, that in each 
and all of the above conditions, Ipecac often and un- 
accountably fails. 
N. B.—There is a form of nausea not included in 
the first specification, which shows a tendency to in- 
crease through the day, and becomes most severe at 
evening; here, if Ipecac fail, Dr. Ringer has found 
nux vomica give relief. In the second specifica- 
tion, nux vomica and Ipecac may be given together, 
especially if the patient has a “ tongue coated with 
a creamy fur” and shows much acidity and heart- 
burn. Arsenic often succeeds better in the fifth and 
seventh applications, and especially in the fifth. Dr. 
Ringer credits Ipecac with a measure of relief in 
the vomiting of cancer of the stomach. IPECACUANHA. 
197 
Per contra, Ipecac proved valueless in the vomiting 
of infancy where hard, cheesy curds of milk were 
returned, often attended with an intense and penetra- 
ting acid smell; here, lime water, magnesia or sodium- 
bicarbonate is indicated, or there may have to be a 
change of diet; and in that peculiar form of vomit- 
ing occurring in infants of a few weeks or a few 
months old, where the milk is thrown up in volume 
and with violence, often but little changed, soon 
after feeding; in this state, minute and frequent 
doses of calomel accomplished the most. 
Tonic and Stomachic.—Ipecac has frequent use 
and various applications in this capacity; but, 
obviously under conditions of dosage too small 
to produce any degree of its peculiar depressant and 
nauseant influence. It is probable that its property 
to augment mucous secretion—shown even in the 
mouth by an increase of saliva—is closely concerned 
in the exertion of a eupeptic action. 
This scheme might be followed still farther, and 
the separate physiological properties of Ipecac, as 
previously enumerated, be illustrated; but, for the 
most part, such qualities are best shown in especial 
applications. One or two uses of the drug, where it 
exerts a kind of specific influence, must now be con- 
sidered. 
Dysentery.—It was as Radix Anti-dysenterica, and 
not as an emetic, that Ipecac was first introduced to 
civilized Europe, and it was in this capacity that it 
first, and for a considerable time, wrought its repeated 
triumphs. Its employment as an emetic was then 
but little considered, and was altogether an after- 198 
EVACUANT MEDICATION. 
thought. It was pretty surely for such supposed 
specific value that the French Court bought the high- 
priced secret from Helvetius. It was for such prop- 
erty that Pison pronounced his memorable eulogy: 
“Anchoram sacram, quia nullum prsestantius ac tutius 
* * * natura excogitavit remedium.” The response 
which Fonssagrives makes to this formula embodies 
the experience of many observers: “ If one use often 
in dysentery, and especially in colonial dysentery, he 
will find no exaggeration in the enthusiastic eulogia 
which were lavished upon it by Pison; it is an arm 
of marvelous efficacy, provided one is familiar with 
the method of use.” 
In India, as previously said, such success has at- 
tended the use of Ipecac in dysentery, that an • at- 
tempt has been made to acclimatize the plant. On the 
other hand, the value of this resource seems never to 
have greatly impressed the profession in this country. 
Dr. Woodward, U. S. A., admits its efficacy as used 
in India and China, but would restrict its use to the 
acute stage. And yet there can be little doubt that, 
in the dysentery of temperate climates—and espe- 
cially in epidemic dysentery—Ipecac is capable of 
performing an unequaled service. In its best action 
it literally jugulates the disease, aborts it, even as 
quinia may abort a malarial fever; and this no 
other remedy can do in dysentery.* 
* The office of this drug, as illustrated in the limited experience 
of the author, has been in effect as follows (to take a specimen 
case) : A young, vigorous girl, seen the first day of the attack— 
strong febrile reaction, frequent bloody discharges, with tenesmus 
and pain. A dose of 30 grs. of powder speedily evacuated the IPECACUANHA. 
199 
In Certain Forms of Chronic Diarrhoea.—In 1873, 
Dr. Bourdon, of Paris, published an elaborate clinical 
statement (which has received too little attention) 
respecting a special application of Ipecac in two 
forms of chronic diarrhoea, viz., in that which often 
attends the later stages of phthisis and in the chol- 
eriform diarrhoea of infancy. The treatment pro- 
posed directed the exhibition of the remedy per 
rectum, in order to avoid a probable emetic effect, and 
included the preparation of the root by a special 
process of decoction. The dose for the adult is 
equivalent to 20 grs. of the root, given twice daily, 
preferably night and morning, and always 2-3 hours 
away from the meals; the infant to receive by like 
method, but only the above quantity. It was 
first for an intractable form of infantile diarrhoea 
that this treatment was proposed, or for what may 
be termed chronic cholera infantum. 
Again, in some cases of diarrhoea of phthisis, and 
which had previously resisted approved remedies, 
Dr. Bourdon found this scheme of treatment espe- 
cially successful; nor was the stomach disturbed 
when the proper precautions were taken. But it has 
been the experience of the writer that the remedy 
should be suspended, provided that favorable re- 
sponse is not made within a few days. If successful, 
it will be required less often; if followed too long 
stomach ; a second dose, three hours later, was retained with hut 
little nausea. Several still smaller doses were given at intervals. 
There was hut slight discomfort from the dysentery after the second 
dose ; it was very soon evident that an impression had been made, 
and 24 hours later fever was gone and the flux cured. 200 
EVACUANT MEDICATION. 
continuously, the chronic poisoning may be suddenly 
set up, which was remarked upon in the section of 
physiology.* 
As respects an application of this remedy to chol- 
era infantum, its disability lies in its method of use. 
It is a very uncertain thing whether the infant, of 
two years and under, will retain the occasional—not 
to say the frequently-repeated—enema. But that 
Ipecac introduced into the rectum, with sufficient 
frequency and in sufficient dose, has power in cholera 
infantum, the author is assured out of his own expe- 
rience. There is a form of chronic cholera infantum 
which, once established, is pretty sure to hold on till 
frost—i. e., if it do not previously wear the patient out. 
In such variety, rectal Ipecac has often proved the 
only assured medicinal resource. In more than one 
instance favorable modification has thus been im- 
pressed upon the disease, when, all at once, the little 
patient has refused to retain the enema, and relapse 
supervened. An attempt to transfer the medication 
to the mouth, in effective dose, will almost surely 
occasion nausea, and, if persevered with, serious dis- 
turbance of the stomach. 
As Expectorant.—Nothing is more common in 
medicine than the prescribing of some preparation 
* Such complication is the more to be avoided on account of its 
possibly sudden and unlooked-for precipitation. In one case of 
partial success, in diarrhoea of phthisis, the injections had been 
repeated twice daily for considerably longer than a week, when, 
all at once, the patient passed into a state of universal and most 
alarming depression, from which she was rescued with great 
difficulty. IPECACUANHA. 
201 
of Ipecac as an expectorant; and too often the pur- 
pose is as vague as the dose is indeterminate. And 
yet, properly directed, the physiological properties of 
the drug, in impressing a relaxed state and a secre- 
tory activity upon the entire respiratory tract, are 
calculated to perform a service of considerable value. 
In larger dose also, and in graver conditions, the 
establishment and maintenance of a degree of per- 
spiration upon the entire surface of the body must, as 
a derivative agency, carry the advantage still farther. 
But acting in either capacity, it must not be lost sight 
of that Ipecac is adapted to such only as are kept in- 
doors and otherwise guarded; with the unprotected, 
the physiological influence is of a character to ren- 
der more susceptible to taking cold and to expose to 
fresh accessions of inflammation in the respiratory 
mucous membrane. Again, however kindly may be 
the remedial operation of the remedy, it has an un- 
fortunate tendency to depress the appetite and dis- 
turb the stomach where the expectorant dose is being 
constantly repeated; and this must be foreseen and 
allowed for. 
Asthma.—Ipecac is highly recommended by Hyde 
Salter, et cet., in asthma. In extreme conditions, its 
emetic action may suddenly arrest spasm and give 
breath to the patient; otherwise, it may be so di- 
rected as to keep up a gentle influence as relaxant 
and nauseant; given alone and in various combi- 
nations. 
“ Winter Cough”—Drs. Ringer and Murrell report 
a remarkable experience in the so-called “ Winter 
Cough” an affection characterized by dyspnoea, es- 202 
EVACUANT MEDICATION. 
pecially on exertion, and a dry, spasmodic cough, 
likely to last through the entire winter, and liable 
to frequent exacerbations through taking cold. The 
success of a secret remedy first called the attention 
of these observers to the efficacy of Ipecac wine, 
used by a simple atomizer. At first the preparation 
may prove harsh to the throat, and the wine require 
to be diluted. The spray should be thrown gener- 
ously, which the patient is instructed to reject from 
the mouth as much as possible, in order to avoid the 
nauseant effect of the Ipecac. The treatment gave 
relief in almost every case. It must be remembered, 
by the way, that perhaps no other surface is so 
prompt at absorption as the respiratory mucous 
membrane; this has been proved, as well as other- 
wise, by the speed with which mercurial saturation 
is established by an inhalation of the mercurial, 
and if the wine be pressed too far, the patient will 
be nauseated, although none of it be swallowed. 
Hoarseness.—According to the same authority, a 
frequent form of hoarseness depending upon conges- 
tion of the vocal cords will often yield to the spray; 
if it has lasted but a few days or a week or two, it 
may be cured very speedily; and the chronic variety 
of two or three months’ duration is generally relieved 
in good measure, although a degree of hoarseness 
may still remain. 
In Subordinate Conditions—Cholagogue.—Ipecac has 
more or less of value and repute in several states 
which may be presented without attempt at classifi- 
cation. It has come within recent years to be pre- 
scribed for cholagogue action, with quite as much of IPECACUANHA. 
203 
vagueness as has long characterized its use as expec- 
torant. It is worthy of note that the physiological 
observations upon which this application is based, 
were generally concerned with a dose of two grains 
and upwards; and it is far from sure that a fraction 
of a grain, in an aperient or alterative pill, or a few 
drops of wine or syrup, can ever reach the liver at 
all. A quantity of the drug, calculated to influence 
the secretion of bile, would, not infrequently, pro- 
duce disturbance of stomach. In this instance, as in 
certain conditions antecedent and which are to fol- 
low, we have illustrated a quality of the remedy 
which is often encountered elsewhere in therapeutics, 
and which demands skill and caution on the part of 
the physician (and often involves perplexity) in the 
effort to direct a medication, and yet control or 
escape some ascertained physiological property in 
the medicament.* 
Two or three applications which follow very well 
sustain this point; and herein also may be found 
partial explanation why they are held in much less 
consideration in present practice than formerly. 
Ipecac, in emetic dose, was believed to have efficacy 
* Indefinite illustration might he given of this principle. Ja- 
borandi is prominent as a case in point. Observe how often a 
beneficent action upon the skin in behalf of the kidneys must be 
interrupted because of a synchronous malign action upon the heart: 
here we have one physiological property arrayed against another. 
Again, in the therapeutic application of physostigma for relief of 
the spasm of tetanus, too often a physiological property involves 
both respiratory centre and heart in paralysis, and so kills the 
subject it had undertaken to save ; although hereby it substitutes 
a more merciful form of death. 204 
EYACUANT MEDICATION. 
in haemoptysis and pulmonary apoplexy, because of 
its observed physiological action upon the circu- 
lation of the lungs. Baglivi declared it to be in- 
fallible in “ fluxibus dysentericis aliisque hsemorrha- 
giis” Trousseau extolled its use, in large dose, in 
pneumonia, and also believed it had a remarkable 
adaptation to the puerperal state; that, in brief, its 
exhibition shortly after childbirth impressed a favor- 
able character upon every function of this eventful 
period, as respects the action of the liver, the estab- 
lishment of the locliial flow, of the secretion of milk, 
etc. 
Administration. — The irritant nature of Ipecac 
must not be lost sight of—at least when it is pro- 
posed to give it in any considerable quantity. An 
emetic dose of the powder, e. g., in quantity insuffi- 
cient to act promptly as emetic, may in part become 
engaged in the crypts of the mucous membrane of 
the stomach, and so give rise to a serious inflamma- 
tion. For emetic effect it is best taken with copious 
draughts of warm water—never hot or made aro- 
matic. If vomiting does not occur within 15-20 
minutes, a full dose should be repeated. Indeed, 
Ipecac is one of the few materials which can hardly 
be given in too large dose, and especially to the 
infant; whereas, there is danger of possible mischief 
—and never more so than with the infant—if the 
powder or syrup, which was designed to be speedily 
rejected, should be retained. The dose with present 
purpose has already been determined ; but the indi- 
vidual requirement is often found to vary greatly, 
and Dr. Ringer is, doubtless, right when he says of IPECACUANHA. 
205 
children, that they bear large doses, “and babies 
only a few months old may require ten to twenty 
grains of the powder.” The younger and more 
feeble the subject whom it is proposed to vomit with 
Ipecac, the more sure and complete should be the 
emetic action; and error is more likely to be on the 
side of an insufficient than of too large a dose. 
As anti-emetic, the wine has advantage of every 
other preparation—for reasons which should be ob- 
vious. One drop is the usual dose, not repeated 
“ three times a day,” as Ringer proposes, but much 
oftener—every half-hour or hour, for at least a part 
of the day. With purpose of cholagogue action, it is 
quite possible that one grain, if taken three times a 
day,—as a part of a tonic or aperient pill, ordered 
after each meal,—may have considerable influence 
upon the liver and yet not depress the appetite. For 
the influence of an expectorant, a mild antispasmodic 
and diaphoretic, it will often be found that a dose so 
small as to be inoperative at first, will soon prove 
effective if repeated every one to two hours, and this 
especially with children (five to ten drops wine or 
syrup). 
In rectal administration the fluid extract has been 
found convenient and to meet all the indications of 
Bourdon’s prescription. It is well to begin with 
smaller doses than he proposed, and advance tenta- 
tively. The experiments of Vulpian’s laboratory, 
by the way, have shown that Ipecac, given by the 
rectum, exerts the same action as when given by 
mouth; but Bourdon believes that absorption is 
slower, and thus the nauseant effect is escaped. 206 
EVACUANT MEDICATION. 
The pills of Legond, extensively used in the treat- 
ment of dysentery, especially in the French marine 
service and tropical possessions, are composed of 
Powd. Ipec., 40 centigr.; Calomel, 20 centigr.; Ext. 
of opium, 5 centigr. The method first vomits with 
Ipecac, and then purges with this pill. 
ANTIMONIUM. 
History, etc.—Antimonii et Potassii Tartras, Anti- 
mony or Tartar-emetic, a material which has played 
a very important role in the practice of the past. 
Probably there is no other agent, not excepting mer- 
cury, which, since its actual introduction, has been 
the object of so many and strong vacillations in 
opinion and action; and one who knows anything 
of recent medical history, and considers medical 
practice from its present aspect, will surely be im- 
pressed with this fact. Fifty years ago, here and in 
England, the practitioner was familiar with all anti- 
monials, and employed them more often and more 
widely than perhaps any other active remedy. To- 
,day, there is many a physician in constant practice 
who hardly prescribes tartar-emetic once in the course 
of the year. 
It is said on authority that this mineral was in use 
in remote antiquity as a cosmetic; it was the yuvauhov 
with which women blackened their eyebrows, and 
that Jezebel of Scripture history employed this 
device when she sought to make herself attractive 
to the angered Jehu. 
As a therapeutical agent, the Greek and Roman ANTIMONY. 
207 
writers make slight allusion to it, except to applica- 
tion for topical action, chiefly as an astringent; and 
the Arabs do not appear to have contributed to the 
medical art in respect of any researches made into 
the action and uses of Antimony. Indeed, as the 
names * of some of its compounds indicate, its first 
applications in medicine were made among the 
monks and alchemists toward the close of what is 
termed the Middle Ages. Probably Paracelsus, who 
flourished the first half of 1500, was more concerned 
than any one else in the active introduction of Anti- 
mony into therapeutics, although the honor of such 
exploit has been also shared by the supposititious 
monk, Basil Valentine. 
A vigorous opposition was soon aroused; Perreau 
published the Rabat-joie, in which first appeared the 
statement of the origin of the word antimony, as ex- 
pressed in the note. Guy-Patin declared that tartre 
stibie ought to read tartre stygie, “ since it conducted 
to the borders of the Styx all who had the misfor- 
tune to take it.” In a word, the mineral would seem 
to have been alternately vaunted as a panacea and 
proscribed as a poison. Its use is pronounced a penal 
offense in a decree of the French parliament; next, it 
is believed to be the agency which restored the young 
King Louis to health after a dangerous sickness, and 
again it starts upon full tide of popular favor. In 
1637 it was recognized by the Codex, but was intro- 
* Such as regula antimonii, crocus metallorum, verre d’ antimoine, 
currus triumphalis antimonii of Paracelsus. Indeed, the word anti- 
mony is said to have originated in the deadly work of this power- 
ful drug, as too freely used among the monks. 208 
EVACUANT MEDICATION. 
duced into the Pharmacopoeia as a purgative. Flasks 
of Antimony were constructed, into which water was 
poured over night and drunk off the next morning; 
small, round masses were in estimation as “perpetual 
pills ” and, in fact, were appropriately so called, be- 
cause, if reclaimed and cleansed, they were adapted 
to an indefinite service. 
Pharmacy.—The original basis of all antimonials 
used in medicine is- not metallic Antimony, or 
Stibium, but black antimony—a tersulphide, often 
incorrectly called metallic Antimony. This prep- 
aration is largely inert, and has been dropped from 
practice, although it was in frequent favor with 
Trousseau. Chemical combination throughout fol- 
lows the rule of union with three or with five equiva- 
lents of the base; this, at least, according to late 
authority. The antimonials of the United States 
Pharmacopoeia are as follows:— 
1. Antimouii Sulphidum Purificatum. 
2. Antimonii Oxidum. 
3. Antimonii Sulphnratum. 
4. Pil. A. Composita. 
5. Pulvis Antimonialis. 
6. Yinum Antimonii. 
7. Syrupns Scillse Compositus. 
8. A. et Potassii Tartras. 
The British Pharmacopoeia has also the “ Brown 
Mixture,” or Mist. Glycyrrhizx Comp., a valuable 
preparation for such as propose to use any antimo- 
nial in practice, on account of its effective combina- 
tion with other materials. It will be briefly discussed 
a little later. The same authority still retains Un- ANTIMONY. 
209 
guentumA. Tartarati (tartar-emetic ointment)*—wisely 
dropped from our own Pharmacopoeia, and, for the 
most part, from use,—also Liquor A. Chloridi and 
Pil. Hydrargyri Subchloridi Comp., the latter a close 
correspondent of No. 4 of the above officinal list. 
Certain other antiinonials, e. g., Kermes Mineral, or 
“ bi-antimoniate of potassa,” and the Powder of Alga- 
roth, or the “ oxychloride,” are often met with in older 
medical writings, but have only a historical interest. 
In the preceding table No. 4 represents the Plum- 
mer’s Pill, contains sulphurated Antimony, calomel 
and guaiac, and, as already said, corresponds to the 
English Comp. Calomel Pill, the former presenting 
Antimony in ratio of 1 to 4 and the latter in 1 to 5. 
No. 5 is James’ Powder, at one time in extensive use 
as an antipyretic and diaphoretic, and has one part 
oxide of Antimony to two parts phosphate of lime. 
From No. 8 are made preparations represented by 
No. 6 and No. 7, and the Brown Mixture. No. 6, the 
V Antimoniale of the British Pharmacopoeia, has 
about two grains tartar-emetic to the ounce of wine. 
No. 7 contains squill, senega and nearly three-fourths 
of a grain of tartar emetic to the ounce of syrup. 
The Brown Mixture chiefly consists of extract of 
liquorice, paregoric, nitrous ether, and of wine of 
Antimony, about six parts in one hundred. It was 
in great esteem not many years ago as a cough and 
expectorant mixture—with a usual dose of one tea- 
spoonful. 
* Strength, 1 to 5 ; the pomade of Autenrieth having a strength 
of 1 to 3. 210 
EVACUANT MEDICATION. 
And, indeed, No. 8—the potassio-tartrate of Anti- 
mony, or tartar-emetic—and its representatives meet 
all the demands of practical medicine at the present 
day, nearly every other curious mechanical and 
chemical combination of the past having been set 
aside. The discovery of this salt is credited to 
Mynsicht, in 1631—a discovery which seems to have 
given a new impetus to antimonial medication, if we 
may judge from such publications as “ antimony jus- 
tified ” and “ antimony triumphant,” which appeared 
within a few years after. Still, as observed by Ra- 
buteau, tartar-emetic might be said to have been in 
considerable use before it was discovered, it having 
been customary to expose the “ antimonial crocus ” 
to the action of such wines as were rich in tartar, 
Rhine wines, e. g., by which its energy was increased. 
Tartar-emetic has the form of transparent or whit- 
ish crystals, soluble in 20 parts of water. Vegetable 
astringents cause an immediate precipitation of an 
inert powder. Any liquid containing tannin—and 
tea especially, as always ready at hand—is best used 
as an antidote in case of poisoning by antimony. 
The dose of tartar-emetic ranges from one grain, the 
emetic dose, to the twelfth or sixteenth of a grain 
when used as expectorant or diaphoretic. 
Physiological Action.—Locally applied, Antimony 
is an irritant in direct degree with the extent of its 
solubility. When the pomade of Autenrieth,* or 
any other preparation of tartar-emetic, is left in con- 
tact with the skin, a warmth and burning ensue, 
* Pomade of Autenrieth—1 part T. E. and 3 parts lard. ANTIMONY. 
211 
soon to be followed by an inflammation of as specific 
character as that which pertains to Croton oil or to 
smallpox. It is not diffused, but distinct, papular, 
and finally pustular—closely resembling, indeed, the 
eruption of variola. The irritant appears to select 
points in the skin for its attack, and there is reason 
to believe that tartar-emetic will not act locally, either 
upon the surface of the body or in the stomach, ex- 
cept in the presence of acid, the point of selection, as 
respects the skin, being determined by the orifices 
of the sweat-ducts, which furnish an acid secretion. 
The chloride of Antimony,per contra, causes a diffused 
dermatitis, involving the entire skin in a process of 
destructive inflammation. 
Fifty years ago, when Antimony was in familiar 
use, the physician was taught to recognize a possible 
threefold modification in its action, according to 
method of exhibition. First, was the simple emetic 
effect, requiring no remark; second, what the French 
call emetic en lavage, where the same dose as before 
was given in a large quantity of water, with pre- 
liminary emetic effect quite likely, but with the ex- 
pectation of a subsequent purgative action, which 
was the purpose of the administration. The third 
method represented the subdivided dose and the 
continuous medication, as we are familiar with it in 
the use of certain other remedies at the present day; 
and such small and frequent subdivisions of the 
salt were known as Rasorian or contro-stimulant 
doses. Under this system, the primary emetic in- 
fluence was soon spent,—at least, such was the expec- 
tation ; a little later still the purgative action ceased, 212 
EVACUANT MEDICATION. 
and now the condition recognized as “ tolerance ” is 
about to be established. The subject of this experi- 
ment, if successful, may receive as much as one 
gramme of the salt in the course of the day, and 
still without injury, perhaps without much discom- 
fort. 
The resultant constitutional state was one strictly 
peculiar to the drug and the method, and was 
characterized by “ slowing of the pulse, lowering of 
temperature and a diminution of myotility; in one 
word, by a state called contro-stimulism.” Volumes 
have been written upon “ tolerance,” in the attempt 
to explain, to apply and to defend ; as well as to de- 
termine what modifications might be demanded in 
method and effected in condition by certain diseases, 
and especially by pneumonia. How many lives 
were sacrificed, how often health and constitution 
were permanently crippled by those who were accus- 
tomed to urge this theory and system—and especially 
by the more heroic and unskilled—it would be im- 
possible now to conjecture; but we may be sure that 
misadventure and disaster were much more frequent 
than was believed, in a generation familiar with the 
free and constant use of the strongest preparations of 
Antimony. 
The general physiological action of Antimony is 
illustrated by its frequent classification with materials 
which increase waste. It is an agent especially active 
in the province of metabolism; a powerful altera- 
tive, but with definition. There are alteratives 
possessed of strong reconstructive tendencies, such 
are iodine and arsenic; Antimony may be accepted ANTIMONY. 
213 
as the type of an alterative with positively destructive 
influence. It is rapidly absorbed, penetrates the 
entire system and is capable of universal elimina- 
tion ; moreover, like the metals generally, it may be 
partially eliminated in the bile and, unlike most 
metals, serve at the same time as an active ehola- 
gogue. Again, it is a potent and universal depress- 
ant and paralyzant; it is a direct cardiac depressant, 
a respiratory depressant, a muscular depressant, a 
paralyzant of the spinal cord and of both sensory 
and motor tracts. Its action in the latter particu- 
lars presents close analogy with that of aconite,* and, 
like aconite, it depresses blood pressure and the 
powers of calorification. Finally, in the words of 
Ringer, “ we are led to infer that probably tartar- 
emetic is a protoplasmic poison, destroying function 
in all nitrogenous tissues.” 
As an Emetic; Uses, etc.—The mechanism of vomit- 
ing by Antimony has been much discussed. Magen- 
die believed he had proved, by the experiment so 
often cited, that this drug procures vomiting solely 
by a direct impression upon the vomitive centre. 
Probably this is but one, although an important, 
element of its emetic influence; and in ordinary 
* The physiological and therapeutical analogy which exists be- 
tween these powerful drugs is the more remarkable when also the 
various strong points of contrast are considered. It need hut he 
recalled (to state it negatively) that aconite is not an alterative 
in any sense ; it does not increase waste, it is not an irritant, it is 
not emetic in action : whereas Antimony is not narcotic in any 
phase of its influence; it does not affect sensation in any degree, 
except remotely and as a sequel to a universal toxic impression. 214 
EVACUANT MEDICATION. 
operation, at least, we have superadded an irritant 
action exerted upon the gastric mucous membrane. 
It has been repeatedly observed that tartar-emetic, 
introduced directly into the stomach, will vomit 
more promptly than when injected into a vein. The 
emetic operation is scarcely more speedy than that 
of ipecac, although it has been claimed to be; it 
may even require twenty minutes before inception, 
but it is much more depressant, is apt to be repeti- 
tive and is preceded and followed by a distressing 
nausea which is often hardly at all relieved by the 
vomitive act. Lauder Brunton calls attention to the 
fact that the stage of nausea in the action of this 
drug is apt to be attended with a lowered tempera- 
ture in the extremities, because of a depressed car- 
diac impulse and sequential anaemia, and conse- 
quently, with a raised temperature in the trunk of 
the body. 
Medical practice of the present day, amid many 
causeless and unproductive vacillations, has both 
wisely and widely departed from the practice of the 
fathers in respect of the use of Antimony. In cer- 
tain of the conditions in which it was once believed 
to do good service, it is no longer applicable because 
we are provided with better means. It is no longer 
necessary to depress the entire muscular system with 
tartar-emetic in order to reduce a strangulated 
hernia or relax a rigid uterine orifice; an anaesthe- 
tic works more effectively and safely. Antimony is 
no better adapted than ipecac to the case of narcotic 
poisoning; both are far too slow in operation, and 
the former is far too depressant. Its especial danger ANTIMONY. 
215 
as an emetic agent in the young will be presented 
later; its especial danger in the weak and in the 
aged is obvious. 
In embarras gastrique, ipecac will accomplish as 
much as tartar-emetic and with greater safety. In 
croup it is not so safe as ipecac, and not so effective 
as turpeth mineral; and for the foreign body en- 
gaged deep in the throat, which it is proposed to re- 
move by vomiting, it is not so safe and effective as 
apomorphia. As an abortifacient of pneumonia 
and of certain local inflammations, as tonsillitis, 
mammitis, onychia, it is doubtful if tartar-emetic 
will accomplish as much as aconite (as by Sparks’ 
method and otherwise); and the accompanying 
malign physiological action of the former does much 
to complicate the case and endanger the patient. 
Still, there are occasional conditions in which 
Antimony is a valuable remedy, and in which its 
behavior does much to justify the esteem in which it 
was formerly held. Such, e. g., is asthma, in a strong 
subject and presenting an exceptionally intractable 
form of the disease. It is in experience that when 
other resources have failed, and the nausea and even 
vomiting of ipecac have afforded only temporary 
relief, a transfer to Antimony has more than justi- 
fied the change in treatment: tartar-emetic in “con- 
tro-stimulant ” dose and with result of establish- 
ment of a measure of “ tolerance,” forthwith proved 
a most effective anti-spasmodic and released the 
patient from the grip of his enemy for the time. 
The once well-recognized treatment of pneumonia 
with Antimony is another matter, but it is not wholly 216 
EVACUANT MEDICATION. 
to be condemned. We are fairly well satisfied with 
our present method and materials in the treatment 
of this disease, and with results. The treatment with 
kermes, or diaphoretic antimony, and bleeding would 
seem to be as nearly opposite as can well be con- 
ceived ; but when Laennec and Louis and Trousseau 
plied these antimonials in pneumonia, they did not 
originate ; they only revived a method, and gave it 
the sanction of their own authority, which had been 
held in former repute, but permitted to fall into ob- 
livion. Assuredly, they must often have produced 
an impression in speedy arrest or relief of pain and 
dyspnoea, in limitation of the inflammatory, and in 
early establishment of the healing process, which 
appeared to justify the medication. Such clinical 
observers could not always have been blinded by 
prejudice. 
Once more, when such a clinician as Dr. Graves de- 
clared that typhus might sometimes be “ summarily 
checked ” by an antimonial emetic given early in the 
disease; that a like “profound impression’’would break 
up an intermittent which refused to yield to quinia 
alone, there was, unquestionably, clinical support for 
the statement. Doubtless, this practitioner com- 
manded an influence in the wild delirium of typhus 
or typhoid, by conjoined exhibition of antimony and 
opium, which is not always secured nowadays by 
the use of opium alone. “ The combined influence 
of these remedies calms the excitement and induces 
refreshing sleep, out of which the patient wakes re- 
freshed and free from delusions. Judiciously em- 
ployed, these remedies may save an almost hopeless ANTIMONY. 
217 
life. Each drag appears to assist the action of the 
other, and the relative doses must be determined by 
the circumstances of the case. In furious delirium, 
the tartar-emetic must be given in full, and the opium 
in small, quantities, while, if wakefulness predomi- 
nate, with not very boisterous delirium, the dose of 
tartar-emetic must he reduced and the opium in- 
creased.”—(Dr. Ringer.) 
So much by way of apology. One side of the 
balance-sheet can be made to show good accom- 
plished, with more directness or with greater cer- 
tainty than could well have been secured by any 
other means. But Antimony is a drug with which 
the physician must have a large experience or which 
he st raid not use at all. Doubtless, the skilled 
phyoician, in the early years of this century, often 
learned to employ it with allowance for frequent idio- 
syncrasy, and with such adaptation to varying con- 
ditions as to procure the desired degree of physio- 
logical and therapeutic impression, and to escape 
toxic effects.* Doubtless, the “ well-nigh hopeless 
case,” and otherwise irremediable, was sometimes 
saved by Antimony. But it is equally beyond ques- 
tion that, even in skilled hands, this powerful toxic 
must have done terrible mischief. Tolerance was not 
always set up as expected, or as assumed, chronic 
* Probably, antimony would be, in especial degree, liable to the 
irregularities introduced by idiosyncrasy and other recognized 
modifying conditions. Thns, Dr. Thaly records bis observation 
respecting race, that negroes can take “enormous doses ” of tartar- 
emetic ; that one gramme in the twenty-four hours will cause no 
more trouble than five centigr. in the white subject. 218 
EVACUANT MEDICATION. 
poisoning supervened,—its symptoms, quite likely, 
so masked by those of the disease that the presence 
of this complication was never disclosed; the patient 
died of Antimony, and death was credited to pneu- 
monia or disease of the heart. 
Moreover, the patient and nurse often used reck- 
lessly a remedy more familiar than almost any other 
to the physician and to the sick, and cases of acute 
poisoning were not infrequent. Still again, tartar- 
emetic must have done a terrible work among the 
young; it is impossible to escape this conclusion, 
even as concerns its wise administration. The de- 
struction which the unskilled must have wrought 
with this drug—the charlatan, the enthusiast in 
contro-stimulism—is simply fearful to contemplate ! 
A long discussion, therefore, reaches a solely nega- 
tive conclusion. As an emetic, Antimony should not 
be used; substitution is always feasible, and we have 
no right to expose the patient to the discomfort or 
danger of its impression. Admitted that there are 
exceptional conditions of disease, both lesional and 
functional, in which the mineral used otherwise than 
as emetic might do a valuable service; but it is too 
potent and too variable in its action, as already said, 
to be prescribed by any physician except as he has a 
large experience in the observation of its use. The 
space given to the discussion must be justified by the 
interest of the material to medical history, by the 
large place which it has held in past practice; its 
physiological action throws important light upon 
general emetic medication; and, finally, there would 
be presumption in a proposal to set aside a remedy ANTIMONY. 
219 
of such history and potency without some attempt to 
defend the decision. 
Treatment of Poisoning.—An unjustifiable similarity 
in labels between such totally different compounds 
as “Ant. et Pot. Tart.” and “Sod. et Pot. Tart.” has, more 
than once, led to accident in dispensing and to se- 
rious poisoning. The principles of treatment in poi- 
soning by this mineral are obvious. There must be 
immediate and thorough evacuation of the stomach, 
and it is not always safe to trust to the emesis already 
produced by the Antimony. AVarm infusion of tea 
or solution of tannin should then be administered in 
copious quantity, both to wash out the stomach and 
to render inert any particles of the poison that may 
be still retained. Lavage of stomach is especially to 
be advised. Later, stimulants, ammoniacal and al- 
coholic, will be required, and opium to relieve pain; 
and if life be saved, the patient will, quite likely, 
after the immediate peril, suffer from a gastrointes- 
tinal inflammation which will demand careful con- 
sideration. 
Thus far, all the books. A different phase, a pos- 
sible sequel, of acute poisoning should always re- 
ceive the attention of the physician. Notwithstanding 
every effort to remove the Antimony and to render 
it inert, a considerable residuum may have been ab- 
sorbed. The subject of the accident should be kept 
under observation, even after he has got about again, 
with this possibility in view, and the urine be exam- 
ined at intervals for Antimony. The possible com- 
plication of sequential and chronic toxic action, 
which is now recognized and occasionally encoun- 220 
EVACUANT MEDICATION. 
tered after acute arsenical poisoning, is even more 
•■probable in poisoning by Antimony.* 
APOMORPHIA. 
Materia Medica, etc.—Apomorphia and Hydro- 
chlorate of Apomorphia, the former an artificial 
alkaloid, discovered by Arppe in 1845, he having 
obtained it as a result of reaction between sulphuric 
acid and morphia. For a number of years it re- 
mained nothing more than an object of chemical 
interest. It is now made by exposing morphia and 
hydrochloric acid in a closed glass tube, to a pro- 
longed temperature of about 140° to 150° C. In 
1869, two English physicians, Mathieson and Wright,f 
first declared its emetic properties and gave the 
material the name it has since borne ; in observation 
of the fact that the artificial is produced from the 
natural alkaloid by means of the abstraction of one 
molecule of water.! Both Apomorphia and its 
* These two minerals are too often compared with each other in 
therapeutical treatises, and sometimes to the confusion of the 
physician. They have close physical and chemical analogies : their 
physiological and medicinal actions are far remote. Accumulation is 
especially common in the use of Antimony; in the use of arsenic 
it is less probable than in that of any other toxic mineral. As 
stated in a previous note, arsenic is eliminated in twelve days ; 
Antimony requires more than four months. 
t Dr. Ringer differs from other authorities in the statement that 
‘ ‘ it was first tested experimentally by Dr. Gee, who discovered 
that it was a very prompt and certain emetic.” Indeed, his brief 
article, throughout, on Apomorphia (11th Ed.) is far from repre- 
senting the best work of this author. 
X“ Deux equivalents d’eau.”—(Trous. & Pid.) APOMORPHIA. 
221 
principal salt—in which latter form it is commonly 
used—are but little soluble in water; and yet suffi- 
ciently so for medicinal purposes. 
The salt is white, but becomes green and takes on 
a metallic lustre upon exposure to light, and in this 
change there is probably involved a degree of oxida- 
tion, as there is observed to be increase of weight. 
Such change is especially rapid and pronounced 
when the salt is prepared and allowed to stand in 
solution.* The solution for hypodermic use must 
be made extemporaneously, various expedients which 
have been proposed to prevent change in color, and 
presumably in properties, having failed of their pur- 
pose. It must be remembered, by the way, that this 
alkaloid originates in the abstraction of equivalents 
of water from the corresponding natural alkaloid, 
and that prolonged exposure in aqueous solution 
may be calculated to restore these equivalents, and so 
to change back to thebaic character a material which 
is administered with an entirely different intention. 
Blaser, of Leipzig, claims to have found in sugar an 
* There has been much discussion and difference of opinion re- 
specting the effects of this modification upon medicinal action. 
On this subject Fonssagrives says: “Mossier has expressed the 
opinion that this solution, thus changed in its aspect, loses its 
vomitive properties and becomes toxic. Kohler has invoked 
against this view his own experience, which has shown him that, 
even at the end of some weeks, and although the' solution were 
very green, its properties had not changed. Riegel, after more 
than seven hundred experiments with Apomorphia, is firm in his 
opinion that the solution is inalterable. I am of this view, 
having many times injected a solution which had been prepared 
more than a month, without observing sensible difference in its 
effects.” 222 
EVACUANT MEDICATION. 
assured preservative of Apomorphia, prepared as a 
thick syrup, to be diluted with water on occasion of 
use ; and the analogy of the inhibitory power which 
sugar has elsewhere in pharmacy prepares us to 
attach considerable importance to this expedient. 
Action and Uses.—If there is one emetic material 
which provokes vomiting solely by virtue of an im- 
pression upon the vomitive centre, we may expect 
to find it in Apomorphia. Like antimony, it vomits 
both when introduced into the stomach and when 
inserted under the skin ; but, unlike antimony, in- 
duces this action much more speedily and in smaller 
quantity when the latter method is employed. 
Again, the emetic influence of Apomorphia is differ- 
ent from that of all other agents of the class in im- 
portant particulars. When best exhibited and when 
it works the best, it serves as a direct and powerful 
emetic, evacuating the stomach with little precedent 
nausea and with little subsequent depression, some- 
times as rapidly as within five minutes of its intro- 
duction into the system. There may even be scarcely 
so much as consciousness of any physiological influ- 
ence, until, all at once, the result is accomplished, in 
the vomitive act, for which the remedy was applied. 
Once more, the force of the action appears to be 
concentrated upon the stomach, the contents of 
which organ alone are evacuated ; there is not, as 
with the emetics previously considered, the sequential 
influence upon the liver and bowels, as shown in 
vomiting of bile and in a purgative operation. More- 
over, a quite characteristic tendency to sleep or sleepi- 
ness follows the action of Apomorphia. APOMORPHIA. 
223 
But this emetic does not always act so benignly; 
a considerable difference of action in different in- 
dividuals, a considerable degree of variation, if not 
of inconsistency, in the reports of different medical 
observers, as well as a very various judgment as to 
dose required, have hitherto marked the clinical 
history of this material. It would be hard to find 
—at least, we are not acquainted with—any other 
authority who has endorsed the statement of Dr. 
Ringer, to the effect that a tenth of a grain, given 
hypodermically, will excite vomiting without nausea 
“ often in one or two minutes.” In fact, ten to fifteen 
minutes, and even twenty, may elapse before such 
result is secured. 
The more especially if the dose be rather inade- 
quate, but sometimes also with a sufficient dose, 
there may suddenly supervene, five or ten minutes 
after ingestion, a profound physiological impression, 
and such as is calculated to give alarm to one un- 
initiated in the peculiarities of the remedy. The 
face suddenly grows pale, the eye loses its brightness, 
the pulse falls perhaps from 72 to 48, and at the same 
time becomes weak and irregular, and the patient 
seems to be passing into a syncope. But after a few 
minutes this phase passes off, and the more surely 
and quickly if vomiting supervenes. 
It is far from sure that variation in the operation 
of this drug may not sometimes depend upon a 
modification in its constitution.* Perhaps it has 
* It should uot be understood by a previous statement, that we 
are at all sure that Apomorphia, in continuous aqueous solution, 
passes with morphia ; but we are not sure that it does not or may 224 
EVACUANT MEDICATION. 
been too hastily and too generally assumed to have 
properties wholly different from those of opium. It 
is well, at least, to remember its source; Fonssa- 
grives, e. g., classifies Apomorphia with thebaic eme- 
tics, and it is true that morphia also excites vomiting, 
only not so directly and invariably. It was left for 
the acumen of Professor Gubler to discover the co- 
incident, if it is nothing more, that the Sanguinaria 
Canadensis belongs to the same botanical family as 
the Papaver; and, again, that the alkaloid sanguina- 
rin “ appears to have a similar action, and a similar, 
if not an identical, constitution with that of Apo- 
morphia.” 
A few facts in general physiological influence re- 
main for mention. Some authorities—and Brunton 
in particular—assert that Apomorphia, in its early 
impression, is an excitant of the respiratory centre; 
but this is a matter of slight importance, for a fully- 
established influence makes for depression and pa- 
ralysis of both respiratory centre and heart, and 
medicinal action is in this direction rather than the 
other. Ringer cites authorities who assert that Apo- 
morphia is a muscle poison (perhaps with analogy to 
antimony). Other observers have found a similar 
anaesthetic action exerted upon the eye with that of 
cocaine ; but the application is painful, and absorp- 
tion brings vomiting and salivation. Its nauseant 
and vomitive action produces the free secretion of 
the respiratory mucous membrane characteristic of 
not. There should he no uncertainty upon this point if Apo- 
morphia is to be prescribed to the young. APOMORPHIA. 
225 
other emetics, and at times in a farther degree pecu- 
liar to itself. A fatal suffocation, caused by a sudden 
plugging of the bronchial passages with mucus, has 
several times been reported, especially in the young. 
Singular physiological effects have been observed 
in animals to which large doses were administered. 
The subjects of experiment at first executed a rota- 
tory movement; later, they showed diminution of 
reflex irritability and tendency to paralysis of the 
hinder extremities, with frequent dilatation* of pupil. 
Recovery took place after this considerable disturb- 
ance. Riegel and Chouppe assert experimentally 
that Apomorphia will cause vomiting after section 
of the vagi, in which respect it differs from emetin; 
but this conclusion has been disputed. 
Therapeutics.—As respects the therapeutical appli- 
cations of this material, it may be said, in a word, 
that the expectations of its early observers and ex- 
perimenters have been more often disappointed than 
realized. For this, two explanations are prominent: 
first, its use is apt to be attended with great varia- 
bility of response, as already said, perhaps on ac- 
count of idiosyncrasy in the patient (and the sub- 
stance from which it is an artificial product is 
peculiarly liable to this sort of disturbance), perhaps 
on account of the uncertainty of its own constitution. 
Second, it has certain malign physiological influ- 
ences in ambush—and our discussion makes this suf- 
ficiently evident without specification—which may 
* At least one natural alkaloid of opium produces dilatation of 
the pupils ; such, at least, was Harley’s experience with cryptopia. 226 
EVACUANT MEDICATION. 
strike down the subject at any time with alarming, 
if not with fatal, force. 
A priori, Apomorpliia is adapted to the indication 
demanding a prompt, sure, uncomplicated evacuation 
of the stomach in the incorrigible or the unconscious 
—in such as cannot or will not take an emetic by the 
mouth. And there are still prominent authorities 
who direct hypodermic Apomorphia in narcotic poi- 
soning and in apoplexy. But clinically, in such appli- 
cation, it has been found a source of danger or disap- 
pointment. Not to urge, still again, the possible 
impropriety of exhibiting, in opium poisoning, any 
derivative of opium whatever,—and particularly in 
the young,—it must be borne in mind that an agent 
which acts chiefly or altogether by stimulation of the 
vomitive centre, is likely to be inoperative in lethargy 
or paralysis of that portion of the nerve tract; and 
Apomorphia absorbed, and not eliminated by vomit- 
ing, will but dangerously increase the previous vital 
depression of the subject of narcotic poisoning or of 
apoplexy. 
In other poisoning than narcotic, and where as 
prompt evacuation of the stomach as possible is de- 
manded, Apomorphia is apt to be too slow in opera- 
tion, and its intervention is hardly to be preferred in 
any case to that of the irritant emetics, to be pre- 
sented later. If it would act, according to the asser- 
tion of Dr. Ringer, “ in a minute,” it would be the 
material of all others to be selected; but rather than 
this, it is more likely to require twenty minutes. 
Its application in overloaded stomach, as proposed 
by Bartholow, et cet., may be justifiable, where the APOMORPHIA. 
227 
sole indication is to empty this organ on account of 
repletion or arrested digestion; but its use is not to 
be extended to the more complicated, less transient 
condition so well expressed by the French term 
embcirras gastrique. “ It should not be thought for a 
moment to replace antimony and ipecac in embarras 
gastrique by Apomorphia.”—(T & P.) Here the 
action of the latter is too circumscribed, and there is 
loss of the extended action upon the liver and bowels, 
which the other emetics would exert. 
The peculiar cardiac lethargy, so to say, which 
sometimes appears in the physiological influence of 
Apomorphia a short space before the occurrence of 
vomiting, and which may continue for a minute or 
more, has suggested its hypodermic insertion in va- 
rious forms of hemorrhage, and especially in haemop- 
tysis. Here would seem to be a sound physiological 
basis for a clinical application, and T. & P. report 
a “ remarkable case of success ” in this use of the 
remedy. Hardly any other agency could lower 
blood pressure so quickly and safely and positively 
as hypodermic Apomorphia in its best operation.* 
Once more, this material has been advised for ser- 
vice as an expectorant, either by stomach or skin, in 
quantity short of emetic effect. It would seem to be 
* Mention may also be made of the proposed prevention of an 
epileptic seizure by Dr. Vallender, of Berlin. He injects ten to 
fifteen drops of a solution of one centigr., in ten grams, of water, 
instantly upon the aura, and expects ‘ ‘ success, if there he ten to fif- 
teen minutes' interval." Dr. Riegel, of Cologne, also claims to have 
prevented frequent and severe attacks by the insertion under the 
skin, at once upon the aura, of one-half centigr., and even less. 228 
EVACUANT MEDICATION. 
adapted to dry bronchitis with the sibilant r&le, and 
like states, because of its power to promote mucous 
secretion; but there are, up to the present, hardly 
sufficient data to warrant a clinical conclusion. It 
would not be strange, however, if variability of ac- 
tion here, also, should interfere with the effectiveness 
of the application. 
It would appear, therefore, that Apomorphia is 
appropriate to the exceptional case, and not to a 
class of cases, and to the exceptional case in the double 
sense of that which is of rare occurrence, and also of 
what is of frequent occurrence, but resists the usual 
remedy. The fact that it is the only emetic agent of 
convenient and of preferred exhibition by the skin 
carries with it a large part of its practical value. 
Thus employed, it may prove, e. g., the only effectual 
resource in a case of impaction of a foreign body 
deep in the throat.* Ringer’s suggestion of its value 
in some hysterical affections, and report of its success 
in persistent hiccough which had resisted other rem- 
edies, are also instances in illustration. Doubtless, a 
like trial with Apomorphia is to be made in a case 
of coma, where evacuation of the stomach is indi- 
cated and the patient cannot take the usual emetic 
in the usual way; but we cannot justify the conclu- 
sion, although sanctioned by such eminent authority 
as Trous. and Pid.—viz., that “ this medicament is 
particularly indicated in such as have been poisoned, 
* Thus, M. Verger reports a success in a child with plum stone 
lodged in the oesophagus ; ipecac had failed, but a second injection 
of Apomorphia secured its extrication. APOMORPHIA. 
229 
in children and in patients attacked with delirium or 
with coma * 
Administration.—Dose by the stomach, grain; 
by the skin, iV grain. This is Bartholow’s rule and 
is definite and safe; but the fractions are smaller 
than those ordered by many other writers and will 
sometimes prove inadequate. Whether infancy may 
show the same singular susceptibility to Apomorphia, 
that is shown to all natural thebaic preparations, has 
not been adequately determined; but great care 
should be taken in ordering this active neurotic 
remedy with the young. Kohler claims to have 
shown in his experiments, that a smaller dose will 
vomit, received per rectum, than as given by the 
mouth; solutions of the salt rubbed into the thighs 
and introduced into the vagina of dogs remained 
without effect. If the small fraction of a grain, 
required by the skin, be freely diluted, there will be 
little smarting and no subsequent irritation. The 
solution is seldom quite clear, and it has been pro- 
posed to clarify by adding a few drops of dilute 
hydrochloric acid; but this makes the vehicle more 
irritating and secures no advantage. The proposal 
to add glycerine is objectionable for the same rea- 
son. As already said, the solution for exhibition by 
either method must be freshly prepared, and the 
salt used must have been previously well kept.f 
* Italics our own. 
f Of other possible artificial alkaloids derivable from opium, 
apocodeine in particular has received attention. It is a much 
more stable body than Apomorphine,has the same emetic properties 
but less energetic, but has not been obtained in crystalline form. TOPICAL OR IRRITANT EMETICS. 
These are such as provoke vomiting solely by virtue 
of an irritation brought to bear upon the interior of 
the stomach. Obviously, they are not absorbed ; 
it is because they are too irritant to admit of absorp- 
tion that they perform this service; their emetic 
operation, therefore, is singularly prompt and limited 
in action. The materials usually applied to this 
purpose are, with one exception, of mineral origin. 
The most familiar are the sulphates of zinc and copper, 
the yellow sulphate of mercury, alum and mustard. 
Rabuteau has established the rule that salts of 
the metals which have an atomic weight inferior to 
that of zinc do not provoke vomiting when received 
into the stomach,—i. e., of course, with the exception 
of minerals like arsenic, which are essentially toxic. 
But it is otherwise with salts of metals having an 
equal and superior atomic weight; and the deriva- 
tives of copper and mercury are familiar illustrations. 
The salts of cadmium are emetic, and so are those of 
iron, unless diluted and used with care. 
ZINCI ET CUPRI SULPHAS. 
Known commercially as the White and the Blue 
Vitriol. The white or Zinc-Sulphate is less energetic; 
but its emetic action is less likely to be followed by in- 
flammation of the stomach. White vitriol was used 
by Paracelsus, and blue vitriol by Dioscorides, and 
230 HYDRARG. SULPH. FLAVA. 
231 
both these materials were relatively in much more 
common use, prior to the discovery of the emetic 
properties of soluble preparations of the toxic min- 
eral antimony and the introduction of ipecac into 
Europe. The emetic dose of the Zinc salt is twenty 
to thirty grains, and of the Copper salt, ten to 
fifteen grains, in two to three ounces of warm water; 
to be repeated in fifteen minutes if vomiting does 
not occur. Doubtless, as already suggested, the 
green vitriol, or iron-sulphate, might often be substi- 
tuted with advantage for the more poisonous vitriols. 
HYDRARG. SULPH. FLAVA, 
Or Turpeth mineral, the most convenient of all irri- 
tant emetics, on account of small dose and slight 
taste, is everywhere familiar—at least, to American 
physicians—through its suggested employment in 
croup. Dr. Barker, of New York, whose name is 
always associated with this application, has received 
both the thanks and the rebuke of the profession for 
such contribution to therapeutics. Mercury, like 
antimony, is an actively toxic mineral, and a con- 
siderable dose, given for prompt emetic effect, which 
should chance to be retained and, in part at least, 
absorbed, may do a serious harm. It should be the 
province of the physician alone to direct its action, 
and to guard against the latter result. It must be 
remembered, moreover, that the disease for which it 
is proposed is a most serious affection; that the 
patient is generally a child, and so a difficult subject 
for the exhibition of bulky and offensive remedies. 232 
EVACUANT MEDICATION. 
The timely dose of Turpeth mineral may save—as it 
doubtless has saved—from the graver necessity of 
tracheotomy, and even from death by suffocation. 
But it is far too energetic and uncertain a material 
to be prepared beforehand in form of “ croup pow- 
ders,'”—as some of the books have proposed,—and 
entrusted to the family for use at discretion. 
The usual dose is three to five grains, to be added 
to a little sugar and swallowed with water. It should 
vomit within fifteen minutes; if not, it must be re- 
peated. Action is almost sure to follow the second 
dose, if not the first; but in the rare case where it 
fails, emesis must be made sure by resort to some 
other material. Rightly applied, the value of this 
emetic in croup is unequaled, and danger is remote 
and improbable. 
ALUMEN. 
Powdered Alum ought to be erased from the list of 
topical emetics. Its comparative safety is its only 
recommendation. It must be taken in large bulk, is 
very offensive to the patient and is slow in operation, 
often requiring thirty minutes. It has had frequent 
application in croup, but the claim that this salt 
may exert some especial action in dissolution or 
detachment of the membrane is hardly any longer 
maintained. The usual dose is a full teaspoonful, 
made into a partial confection with syrup or honey.* 
* The author will never forget his effort to crowd this disgusting 
emetic down the throat of his own child ; nor the efforts of the 
little sufferer at resistance, frightened by the unprecedented harsh- 
ness of treatment, and in a frantic struggle for air at every breath. 
It was a final experience with an Alum emetic in children. SINAPIS. 
233 
SINAPIS. 
Mustard also is a harsh remedy, especially for the 
child; but it has the advantage of being everywhere 
available, in the emergency where time is of the ut- 
most importance, and delay, in sending for some 
other material, may be fatal. It is, therefore, espe- 
cially suited to the case of poisoning, narcotic and 
otherwise. There is probably force also in the claim 
of Bartholow that this emetic is appropriate in de- 
pressed states of the system, in feeble pulse and weak 
heart, as calculated to exert almost at once after inges- 
tion the influence of a diffusible stimulant. The 
dose must be large, a heaping teaspoonful or more, 
stirred in a teacup of warm water and drunk 
rapidly. Emetic action may both be farthered, and 
the stomach receive relief, by the drinking of tepid 
water at frequent intervals until vomiting has been 
secured. EMETIC MEDICATION. 
Definition.—An emetic is that, whether material or 
influence, which causes vomiting; and vomiting is the 
result of a complex physiological mechanism which pro- 
cures the evacuation of the upper part of the alimentary 
canal, and chiefly the stomach, through the oesophagus 
and mouth. 
Sir Henry Holland, in “Medical Notes and Reflec- 
tions,” remarks upon a wellnigli universal change 
which had taken place in medical practice within 
the period covered by his own observation. For- 
merly, the physician, by a sort of routine,—to which, 
in all ages, he has been too ready to yield,—when 
called to a case of acute disease or sudden functional 
disorder, would, almost invariably and first of all, 
take into consideration the propriety of an emetic; 
and his decision and action were seldom negative. 
Such was the prevalent practice up to the close of 
the last century and for many of the earlier years of 
the present. The change which Dr. Holland re- 
marks, and, to an extent, deprecates, has not only 
carried the profession to the other extreme, as respects 
the emetic, but has caused the substitution of another 
method of interference; and it is now the familiar 
and protean purgative that the doctor orders, and 
the patient takes without orders. 
Hippocrates appears to have had a very just con- 
ception of the province of the emetic, and of its more 
234 DEFINITION OF EMESIS. 
235 
important applications; and it should be said, by the 
way, that the term ‘purgation, in the Hippocratic 
writings, more often pertains to vomitive action 
than to cathartic. Sydenham, whose practice, in all 
particulars, illustrates the best part of the principles 
of Hippocrates, directed the emetic with excellent 
skill and judgment, and with results which, it is to 
be feared, are not always gained by the physician of 
the present, who is quite sure to follow a course of 
abstinence in this direction. Fonssagrives perti- 
nently observes that the singular vitality of the hu- 
meral theory, held, in various forms, through succes- 
sive centuries, has been calculated to conserve to 
emetics a dominant role in therapeutics. But 
these remedies suffered “ a complete eclipse ” for 
a time, as their use was totally inadmissible in the 
system of Broussais, and, indeed, continues our writer, 
“ It was an extraordinary thing to observe the noise 
that was made about the first dose of tartar-emetic 
which was given in the service of Andral—greatly 
to the alarm of the choice spirits, among whom was 
incessantly and gratuitously invoked the phantom 
of a gastritis produced by the treatment. There 
were published, just as if it were a clinical novelty 
of ineffable temerity, the six observations of embarras 
gastrique, of anginas, etc., etc., treated at la Pitie by 
tartar-emetic and ipecac.” 
The “complete eclipse” of Fonssagrives has been 
again realized, and in our own age and country. 
Many an active practitioner could be found to con- 
fess that he had never, in all his experience, prescribed 
an emetic, and the average patient has conceived a 236 
EVACUANT MEDICATION. 
horror of emetic remedies, and formed a conception 
concerning the harshness and severity of emetic 
action, which would greatly have surprised the pa- 
tient of a century ago. That the change from emetic 
to purgative does not always inure to the advantage 
and comfort of the patient, a consideration of ca- 
thartic and of emetic medication must make appa- 
rent. The purgative, to be sure, and as previously 
said, is the more physiological in the direction of its 
operation; but the emetic may be both more physio- 
logical and direct in purpose and results. It may 
be better and wiser, e. g., to seek to recover a recent 
undigested and an indigestible meal by means of a 
process of so-called “ reversed peristalsis ” than to 
force its passage onward, through many feet of intes- 
tine, by a method of purgation. 
And it is worthy of remark in this connection, 
what little harm comes to the stomach and other 
organs immediately concerned from the vomitive 
act, and how much of actual abuse may be suffered 
from this source without a sign of injury. Witness 
the long-continued, almost unbroken agony of nau- 
sea and vomiting which sea-sickness and pregnancy 
sometimes inflict, and the prompt and complete re- 
covery of stomach and nervous system when once the 
condition of disturbance has been withdrawn. His- 
tory has informed us of the custom of Roman epi- 
cures of promoting vomiting in an artificial way— 
either before the meal or between its courses—that 
they might eat the more bountifully, or after the 
meal was completed to bring escape from the distress 
of gluttony. “ They vomited that they might eat, MECHANISM OF EMESIS. 
237 
and they ate that they might vomit,” says Seneca. 
Occasional individuals have possessed the faculty— 
which, among the Romans, might have passed for a 
happy faculty—of ejecting the contents of the stomach 
at will, and in two instances it was turned to account 
for purposes of physiological study. Gosse, of Gen- 
eva, it is said, could bring back his food at any 
stage of digestion by a true process of vomiting, 
accomplished by swallowing successive volumes of 
air. In Montegre’s case, stomach evacuation was 
effected by a kind of eructation; without seeming 
effort or the aid of the muscular movements ordina- 
rily contributory to vomiting, the contents of the 
stomach could always be rendered into the mouth— 
apparently after the manner of ruminant animals. 
Mechanism of Emesis.—The physiological process 
which terminates in vomiting is so singularly com- 
plex that the fact of complexity seems to demand 
recognition in the attempt to define. This intricate 
organic act has, until lately, been imperfectly under- 
stood, but it has naturally received the especial 
study of physiologists, and it is hardly too much to 
claim that recent advances in this department have 
rendered it intelligible, both in its entirety and its 
various parts. To approach the study in detail, it 
may first be considered what is the function of the 
stomach in vomiting and its relation toward the 
genesis of the act. 
In this organ there would appear to be three essen- 
tial contributory conditions,—viz., an open cardia, a 
closed pylorus and vermicular contraction, or a kind 
of peristalsis in the muscular wall. It was once 238 
EVACUANT MEDICATION. 
supposed that the latter condition was enough of 
itself; whereas, Magendie believed that his experi- 
ments had proved that the stomach is wholly 
passive and non contributory in the production of 
the vomitive act. The following case—and similar 
observations obtained by experiments in animals 
—seemed to give support to this position : a man was 
gored by ahull and left with his stomach protruding 
from a tear in the abdominal walls. There was con- 
stant and intense nausea, and constant and repeated 
spasmodic effort at vomiting, which, however, were 
both ineffectual so long as the stomach was left pro- 
truding ; but, at once upon its being returned to its 
place in the cavity, vomiting took place. Moreover, 
Magendie was able to cause vomiting, by an injection 
of tartar-emetic, in animals from which he had re- 
moved the stomach and replaced it by a pig’s bladder. 
But the living stomach is a quite different viscus 
from the pig’s bladder, placed in the best possible 
relations for sustaining pressure, with view to evacu- 
ation upward; the position of the adult human 
stomach in particular, with respect of the oesopha- 
gus, and its shape, are obviously unfavorable for the 
production of vomiting ; moreover, the contraction 
which takes place in its muscular parietes is not of 
the sharp, expulsive character which pertains to 
voluntary muscle, but is slow, progressive, vermicu- 
lar, like that concerned in the peristalsis of the 
bowel. If, then, the stomach is passive as regards 
the final act of vomiting,—and it is far from certain 
that we have right to assume as much as this,— 
it assuredly performs an energetic office in prepara- MECHANISM OF EMESIS. 
239 
tion for the act. It is doubtful if emesis ever oc- 
curs without a preliminary contractile energy in this 
organ ;* indeed, this gastric contraction may be quite 
sensibly perceived by the subject of it a little time 
before vomiting takes place; and it is probable that 
such function is essentially concerned in the produc- 
tion of the two conditions,—viz., closed pylorus and 
open cardia,—in the absence of which the vomitive 
act would be impossible. Moreover, it may well be 
that this localized contraction has an effect, for the 
moment, favorably to modify the position and shape 
of the stomach in respect of vomiting; at all events, 
we cannot doubt that it aids in the evacuation of the 
organ, even as does a not unlike vermicular contrac- 
tion in other hollow viscera aid in defecation and 
micturition. 
(2) The diaphragm has an important part to per- 
form ; a strong and accurately timed contraction in 
its muscle being requisite to the accomplishment of 
the act of vomiting. It is true that Marshall Hall 
taught that this organ, constituting, as it does, the 
floor of the thorax, and a partition between two 
great cavities, remained in a relaxed and passive 
state; but the fallacy of this, as well as what is its 
real function, will soon appear. 
(3) Powerful contraction on the part of the thoracic 
and in still greater degree on the part of the abdomi- 
nal muscles, as said in the last section accurately 
timed, and, like all involuntary action in voluntary 
* In the adult human stomach ; not necessarily in the stomach 
of infancy or in that of certain animals. It is quite possible 
that the dog, e. g., can vomit at will. 240 
EVACUANT MEDICATION. 
muscles, especially emphatic, appears to be the 
mechanical force applied last of all, and which, as 
it were, precipitates the result. 
Postponing, then, for a minute, the fourth con- 
dition, the neurotic element, which may be said to 
set to work the mechanism of vomiting, we are pre- 
pared to discuss the modus operandi of the act in its 
completeness. Just prior to emesis, the stomach 
being in readiness as aforesaid, the lungs are filled by 
a strong, sharp, involuntary inspiration, the glottis 
is closed and the muscles of the chest and the dia- 
phragm are firmly fixed at what would have been 
the beginning of expiration; instantly upon this, 
the muscles of the abdomen contract and compress 
the stomach between the liver and other surround- 
ing organs and the unyielding thorax. It is easy to 
see that if at this critical moment, the diaphragm 
were to relax and give way, the point d'appui would 
be lost, and the vomitive act rendered incomplete, if 
not impossible. The stomach being thus grasped 
and surrounded, and itself being in a state of con- 
tractile activity, must be evacuated either into the 
duodenum or the oesophagus; but the pylorus is 
closed, and the duodenum, doubtless, to an extent, 
involved in the common pressure. There can be vent, 
therefore, only at the cardia which has been left open 
or relaxed, and the gastric contents are accordingly 
propelled with violence through the oesophagus into 
the mouth. 
A minor and non-essential detail in this intricate 
chain of conditions may be left unprovided for, and 
it is observed in sudden vomiting that there often MECHANISM OF EMESIS. 
241 
is passage first through the nose as well as the 
mouth; but this is prevented at a later stage by the 
drawing together of the posterior pillars of the 
fauces, so as to shut off the lower from the upper 
part of the pharynx, similarly as obtains in degluti- 
tion. 
Closure of the glottis affords a point d’appui above, 
just as a contracted diaphragm does below—a fact well 
brought out in a clinical observation by Dr. Broad- 
bent. A child recently operated upon by tracheotomy, 
was found to be in state bordering upon convulsions. 
“ Watching it sharply, I perceived that the general 
convulsive movements were preceded by violent con- 
traction of the abdominal muscles, with facial ex- 
pression suggestive of vomiting. The attempt to ex- 
pel the contents of the stomach, however, was defeated 
by the absence of appui, due to the opening in the 
trachea. Recognizing this, I closed the tube at the 
moment of each convulsive effort, whereupon free 
vomiting occurred, and convulsions at once ceased.” 
The fourth condition implied in the act of vomit- 
ing is the neurotic; and this, after all, is the source and 
the direction of the energy which sets the complex 
mechanism into operation. This department of the 
subject has been especially illuminated by the ex- 
periments and observation of d’Ornellas. The im- 
pression which in ordinary vomiting, or that of gas- 
tric origin, evokes the vomitive act, is made upon 
sensory nerve filaments spread out upon the mucous 
membrane of the stomach and its continuity for a 
distance above and below, and which, gathered up 
into a bundle and constituting a nerve-trunk, con- 242 
EVACUANT MEDICATION. 
vey the sensation to the brain. The influence which, 
in response to this excitation, calls forth vomiting, is 
then evolved from the brain along the course of cer- 
tain motor nerves which are distributed to the muscles 
concerned in the mechanism of the act. For this 
phenomenon, then, observes d’Ornellas, as for every 
other reflex act, “ we must admit a point of departure 
of the stimulus with transmission to the centre, and 
a centre of reflexion with propagation toward the 
periphery.” This centre is located in the floor of the 
fourth ventricle, very closely related to the respiratory 
centre. Some physiologists, prominent among whom 
is Lauder Brunton, insist upon a separate and dis- 
tinct nosud of nervous energy, which they call the vomi- 
tive centre: others believe that the control of the act of 
vomiting pertains functionally to the centre of respi- 
ration. Either position receives support in the close 
relation existing between the operation of the cor- 
responding functions: e. g., the synchronous relaxa- 
tion and secretion in stomach and respiratory pas- 
sages, as procured by the action of certain medicinal 
agents; the inevitable connection between the in- 
voluntary contraction of the respiratory muscles and 
an accomplishment of the act of vomiting; and the 
frequent inability to obtain vomiting, in case of nar- 
cotic poisoning, so long as the respiratory centre is 
paralyzed and life has to be maintained by artificial 
breathing. 
The stomach receives its innervation chiefly 
through the pneumogastric ;* also, to an extent, from 
* The par vagutn is the only pair of Cephalo-rachidian nerves that 
supplies the stomach ; the pharynx is supplied from the same MECHANISM OF EMESIS. 
243 
the great sympathetic. We were careful to say that 
the sensitive nerve filaments, which receive the vomi- 
tive impression, are distributed to the gastric mu- 
cous membrane and its continuity, for a distance above 
and below. The vomitive tract doubtless extends 
above to the oesophagus and the posterior pillars of 
the fauces, and below throughout a portion of the 
duodenum.* 
source. The par vagum is formed from two roots, together consti- 
tuting one rachidian nerve, of which the anterior root, or motor, is 
of spinal origin, and the posterior, or sensory, is the pneumogastric. 
The latter, although having an anterior motor root, is essentially 
a sensory nerve, whose office it is to transmit gastric sensations, e.g., 
nausea, hunger and thirst. The spinal anterior root controls the 
intrinsic movements of the stomach,—those necessary to chymifi- 
cation. The muscles which produce the extrinsic efforts at vomit- 
ing, and notably the expiratory, receive their nerve supply from 
the same root, and also from the fourth cervical pair and the first 
lumbar pair. 
* D’Ornellas proved repeatedly by experiments upon animals 
that section of both pneumogastrics at the neck was followed by 
an invariable attempt at vomiting. Such nerve mutilation had 
evidently served as a vomitive stimulant, and a like result ensued 
as when the irritant is applied at either pole of the circle,—i.e., the 
stomach or the vomitive centre. In these animals, after sufficient 
repose, an injection of emetin aroused a delayed and imperfect 
effort at emesis ; and this, although both avenues by which the 
impression should be conveyed had been interrupted. The physi- 
ologist thus meets the difficulty : “ We believe, with Bernard, that 
the organism is never limited to a single resource for the perform- 
ance of its more important physiological functions ; and that, in the 
present case, the sensitive fibres of the great sympathetic may be 
made to take the place of those of the pneumogastric, and so be- 
come the centripetal conductors of the emetic influence.” 
It is a significant fact that when only one nerve was cut vomit- 
ing was not excited by the operation ; nor was it less prompt and 
emphatic subsequently, upon use of an emetic. 244 
EYACUANT MEDICATION. 
Prof. Gubler makes the probable suggestion that 
an emetic agent possesses the more power as its ex- 
citant action is the more extended over the sensitive 
tract. In some materials of the class the direct 
emetic influence is due to a different constituent from 
that which exerts the nauseant influence. Thus, in 
ipecac, the nauseant action is referable to an odorous 
principle, separable by ether, and the vomitive action 
to an alkaloid, soluble in water and alcohol. These 
substances comport themselves as follows: Emetin 
acts directly upon the gastric mucous membrane, 
whereas the nauseous volatile oil acts upon fillets of 
special sensibility distributed higher up than the 
stomach,—derived from the glosso-pharyngeal and 
the olfactory,—and may provoke vomiting almost at 
the moment of ingestion, and in rare cases (through 
a previous association) before ingestion, and, so, inde- 
pendently of any local impression brought to bear 
upon the stomach. 
Notes. — The following observations have their 
practical interest, and also serve to shed a side light 
upon the mechanism of emesis. In convulsive cough 
the stomach may be violently compressed, and yet 
vomiting be prevented by contraction of the oesopha- 
gus; whereas, in actual vomiting the oesophagus is 
relaxed. If this contraction be at the lower end of 
the oesophagus, i. e., in the neighborhood of the 
cardiac sphincter, there will be retching instead of 
vomiting. 
It has been suggested that vomiting does not occur 
in the horse largely on account of the great length of MECHANISM OF EMESIS. 
245 
the oesophagus, lying between diaphragm and stom- 
ach, so that contraction of its longitudinal fibres causes 
it to fold upon itself and obstruct the cardiac orifice, 
instead of allowing it to remain open, as in other 
animals. 
An empty viscus will not respond to pressure. Accord- 
ingly, when the stomach is empty, prior to the vom- 
itive effort, air is swallowed involuntarily, as is also 
the saliva gulped down, which is secreted in greatly- 
increased quantity during nausea; and the latter 
statement is true, also, of the gastric mucus. 
Bernard and Blondlet found that gentle tickling 
of the interior of the stomach caused its membrane 
to assume a rosy hue and secrete tfiucus; but if such 
irritation were too long maintained, or too violent, 
the membrane became pale, a ropy mucus was se- 
creted and symptoms of vomiting appeared. Food 
and drink illustrate the same principle: that which 
is suitable promotes conditions favorable to diges- 
tion, whereas that which is too concentrated or too 
irritant causes distress, nausea, etc.* 
According to Budge, irritation in the right hemi- 
sphere will cause vomiting more readily than in 
the left, the explanation being that the right corpus 
striatum and optic thalamus are the cerebral centres 
for movements of the stomach—little or no influence 
proceeding from the left. 
* The settlement of the vexed question of the eupeptic and dis- 
turbing influence upon digestion of alcoholic stimulants rests upon 
the principle here apparent. The properly dilute and the pala- 
table acts like the “ gentle ticklingand both awakens a sense of 
hunger and provides the digestive secretion. 246 
EVACUANT MEDICATION. 
A tendency to vomiting is often increased by lying 
on the right side, probably because, as in the sitting 
posture also, the weight of the stomach causes a 
dragging toward the pylorus, which, both in health 
and disease, is more sensitive than the cardiac ex- 
tremity. 
From what source proceeds the irritation of the 
vomitive centre in sea sickness f This problem has 
elicited various attempts at solution. Brunton be- 
lieves it is frequently derived from the shaking or 
dragging of the abdominal viscera, caused by the 
motion of the ship, and that it may be restrained 
by a firm band applied externally. He also empha- 
sizes the fact that distention of the stomach by food 
sometimes gives relief. 
Production of Emesis, etc.—In the review of the few 
materials which are used to produce vomiting, it was 
insisted that a sufficiency of diluent should be given 
in every instance; and the reason for such addition 
was stated, while it was equally remarked that too 
great a quantity of water might convert emetic into 
purgative action. But this subject has other aspects 
besides the medicinal. Antecedent to the act of 
vomiting—by longer or shorter interval, and present 
in greater or less degree—is the peculiar condition 
known as nausea,—a word, probably, derived from 
the Gr. vau$, because a ship is a frequent provocative 
of this state,—“ a vague, indefinable malaise, which 
lays hold at the same time upon the respiratory and 
digestive functions; there is epigastric and respiratory 
anxiety, yawning and nausea ; the face grows pale, PRODUCTION OF EMESIS. 
247 
the sense of smell assumes an unwonted delicacy; a 
state of semi-syncope, with vertigo, dependent upon 
cerebral ischemia, invites to take a horizontal posi- 
tion ; the pulse slows, sometimes it becomes uneven; 
then incomplete contraction of the expiratory mus- 
cles open, in a sense, the expulsive scene.” 
The patient should have a reclining posture, and 
if it be a child, the head should be raised a little and 
turned to one side, lest a sudden evacuation of the 
stomach should cause a portion of the matters vom- 
ited to penetrate through the opening into the larynx. 
After the primary exoneration of stomach, in re- 
sponse to the emetic, farther vomiting should be 
rendered easy by drinking freely of warm water or 
of some herb infusion. Sydenham used whey as a 
means of facilitating vomiting which had been once 
initiated by antimonials. 
Vomiting which is slow to appear may be hastened 
by various means. The patient may be instructed 
to stand up, to walk across the room; the brain 
becomes anaemic, and vomiting supervenes at once. 
Formerly, when the emetic was so prominent a re- 
source in medication, various expedients were fa- 
miliar with the view to expedite its operation in the 
slow or dubious subject; such were the mustard pedi- 
luvium, and ligatures applied just above the knee— 
both acting to produce anaemia of the brain. In a 
ruder age it was proposed to present to sight or 
smell some fatty or malodorous object, in order to 
convert the qualms of nausea into the effectual 
spasm of emesis. The point has been well made 
that “ titillation of the palate should not be employed 248 
EVACUANT MEDICATION. 
except-when the vomitive act is imminent, for it 
causes a heaving of the stomach without opportunity 
for the production of the so important physiological 
processus which ought to precede the vomitive act.” 
—(Fonssagrives.) 
The quantity of water discharged in vomiting 
varies greatly, but much more because of a variable 
condition in the patient, than through a special 
action of the emetic agent. Darwin reports an ob- 
servation where an individual took with an emetic, 
about one quart of tea, and vomited over six quarts 
of liquid. Such an emetic operation is truly hydra- 
gogue, but it cannot be directed with any such degree 
of certainty as can a corresponding purgative inter- 
ference. It is doubtless true, however, that through- 
out the physiological process which precedes vomit- 
ing, the stomach is invariably the seat of a consid- 
erable circulatory and secretory activity. 
In therapeutic emesis, it may be expected that the 
vomiting will be repeated two or three times, with 
brief interval between the acts; and then leave the 
patient with little or no local discomfort, and, quite 
likely, with but slight constitutional depression. 
But vomiting of morbid type may be indefinitely 
repeated; and in this state, after several repetitions 
and primary evacuation of stomach, a backward 
flow of bile takes place, and this fluid, with a small 
quantity of ropy gastric mucus, is all that is rendered. 
The gall-bladder necessarily participates in the com- 
mon pressure and in superemesis, as it has been 
called, the bile expressed into the duodenum is con- 
veyed to the stomach, either by a process of inverted CLASSIFICATION OF EMETICS. 
249 
peristalsis or, more probably, because the pressure is 
exerted in an upward direction. Hence the color 
imparted to the vomited matter varies at different 
stages of vomiting; at first being yellow, and 
later, when there, is no longer acid in the stomach, 
green. 
Classification of Emetics.—Observation of the range 
of impressions which commonly provoke vomiting 
demands a subdivision into four classes,—viz., Topical 
or Irritant, Special, Direct, and Reflex or Diastaltic,* 
the two former of which chiefly concern materials, 
and the two latter, influences. 
(1) Topical emetics have already been enumerated, 
and their role, as well as their mode of action, have 
been discussed. 
(2) Especial emetics, an objectionable term, but 
convenient from long usage and a very general accep- 
tation. This class includes only such materials as 
are specifically vomitive, and as will produce vomit- 
ing however they may be introduced into the system. 
The conclusion seems deducible, both from clinical 
observation and that concerned with physiological 
* Professor Gubler has an ingenious physiological division of 
emetics into two classes: (1) Those that act primarily upon the 
gastric mucous membrane ; and, (2) Those that act upon the ner- 
vous centre. The first make vomit after the manner of Vembarras 
gastrique, and the second after that of meningitis. 
J. Grasset divides into three classes : (1) Peripheric vomitives, 
of which ipecac is type ; (2) Central vomitives, which directly 
excite the vomitive centre; (3) The mixed group, which act 
both upon the periphery of the pneumogastric and npon the 
nerve centre. 250 
EVACUANT MEDICATION. 
experiments, that a special emetic must alike be 
rendered in the stomach, and be absorbed from its 
surface, before it can exert its emetic influence. 
The emetic dose of ipecac, although a local irritant, 
does not procure vomiting as does a dose of either 
vitriol from topical impact; it must first be absorbed 
(and, indeed, it must probably be brought back in 
the circulation and secreted by the gastric mucous 
membrane) before it can declare the result for which 
it was administered. Various observations illustrate 
this principle. D’Ornellas found that hypodermic 
emetin required three times as long a period for its 
action as that ingested by stomach, and Bourdon 
believes, as said before, that rectal ipecac is largely 
non-vomitive, because of the delay in its transmis- 
sion to the stomach. 
(3) A direct or centric emetic influence, as the word 
implies, is that which operates by an impression 
made immediately upon the vomitive centre. Some 
authorities believe, as previously said, that it is thus 
that vomiting is procured in the use of apomorphia, 
and, at times, of antimony. An indisputable and 
familiar illustration of centric vomiting is seen in 
the emesis which accompanies inflammation of the 
base of the brain, tubercular meningitis, etc. Vomit- 
ing is an early symptom in these affections and, to an 
extent, pathognomonic, the floor of the fourth ventri- 
cle being actually implicated in the inflammation, 
or suffering from inflammation of closely surround- 
ing parts. Disease, pressure, injury of various parts 
of the encephalon, concussion of the brain, are apt to 
be promptly followed by emesis; but vomiting from CLASSIFICATION OF EMETICS. 
251 
such causes,—except as the cause be located at the 
base of the brain,—as well as that which is ideational 
and sensorial, although frequently defined as centric, 
should more properly be discussed with the condi- 
tions of the next group.* 
Before proceeding to the consideration of the last 
subdivision, and that which presents, of all others, 
the most varied and extended conditions and pheno- 
mena of emesis, the question may be asked : Does 
vomiting ever occur from an irritant applied at any 
other place than at either pole of the vomitive cir- 
cle ? The experiments of d’Ornellas would seem to 
indicate that pressure applied upon both trunks of 
the par vagum would occasion emesis, but that pres- 
sure from a unilateral tumor would have no such 
effect. „ 
The fourth group—that of reflected disturbances 
provocative of vomiting, or of emetic agency of reflex 
origin—is the most extensive of all in range, and va- 
ried in mode of solicitation. In this section should be 
included much that is often referred to the last; e. g., 
vomiting from irritation of any one of the special 
senses, as caused by a disgusting sight, a nauseating 
smell, or taste, etc. Such, also, in origin, is the nau- 
sea of sea-sickness, that caused by the whirl of a 
dance, the oscillations of a swing, or by riding with 
back to the horses;—the vomitive excitation in all 
such instances probably originating in some part of 
*It appears to be a fact of curious interest, that while brain 
irritation so often and directly produces vomiting, irritation and 
disease of the spinal cord rarely have any etiological relation to 
the act. 252 
EVACUANT MEDICATION. 
the sensorium. Such again is the nausea and vomit- 
ing complicating inflammation, pain, spasm, trau- 
matism, mechanical irritation of whatever por- 
tion of the body, as encountered in unnum- 
bered instances,—the vomiting of hernia,, of peri- 
tonitis, of passage of biliary and renal calculi; 
Cen tral afferent 
paths through 
which vomiting 
may be excited. 
Pharyngeal 
branches of the 
glosso-pharyn- 
geal nerve. 
[Nervous centre of 
I vomiting in the 
medulla oblongata. 
-Spinal cord. 
—Vagus nerve. 
Pulmonary bran- 
ches of vagus. 
Liver and gall blad- 
der, with nerves 
going to them. 
Splanchnics giving 
fibres to liver 
and intestines. 
Stomach and gas-1 
trie branches of 
the vagus. J 
--Gall duct. 
- Renal nerves. 
Kidney and ureter... 
Intestine 
’ Mesenteric nerves. 
Uterus ... 
( Uterine nerves. 
Bladder.. 
Vesical nerves... 
of colic, hepatic, renal and uterine. The mechanism 
of reflex nausea, as well as its range, is readily made 
intelligible by the accompanying diagram, adapted 
from one first proposed by Lauder Brunton. 
“ Reflex nausea ” from tickling the fauces may be 
similarly referred, although it is more properly ex- CLASSIFICATION OF EMETICS. 
253 
plained by an irritation of the extreme upper portion 
of the gastro-cesophageal vomitive tract.* This con- 
dition has practical connection with a continued 
bromide medication, especially in epilepsy. The pha- 
ryngeal line between reflex nausea and deglutition is 
strictly drawn; and the feather applied so as to pro- 
duce vomiting, if carried a little too far, will excite 
muscles which cause it to be swallowed into the 
stomach.f 
Modified Vomitive Action.—There is much variation 
in different individuals, not so much as respects the 
readiness of response to the action of emetic reme- 
dies,—although there is variation in this also,—as in 
the degree of ease and comfort, or of difficulty, with 
which the function is performed. There are people 
* Brunton states that in tickling the fauces, the irritation is re- 
ceived by sensitive fillets of the glosso-pharyngeal nerve, carried 
to the medulla without intervention of the brain ; so that “ tickling 
the fauces will produce vomiting in a man whose cerebral faculties 
are so besotted with alcohol that he hardly feels blows or bruises 
which would cause him severe pain when sober.” 
In another place, he observes that inflammation of this pharyn- 
geal tract in children will frequently give rise to a hard, ringing 
cough, attended with expulsive efforts on the part of the stomach, 
retching and even vomiting. He suggests that the nausea and 
vomiting sometimes peculiar to the cough of phthisis may depend 
upon an irritation of the pulmonary fibres of the pneumogastric, 
constituting a true reflex vomiting. 
f The vomiting which signalizes the invasion of certain zymo- 
tic diseases, and especially of scarlatina, as also of a severe attack 
of paludism, has been referred to the operation of a special emetic 
agency, pertaining to the second subdivision, upon the theory that 
the potent, immaterial poison which constitutes the materies morbi 
is carried to the stomach with natural intent of elimination by 
vomiting. 254 
EVACUANT MEDICATION. 
who vomit with such facility that they prefer to 
provoke the act rather than suffer from slight reple- 
tion or tolerate the presence of slightly-disturbing 
food; while with others, evacuation of stomach 
brings such strain and distress that they willingly 
submit to prolonged discomfort in the struggle to 
escape vomiting. An attempt to explain this great 
variability, familiar to every physician, involves, 
probably, peculiarities neurotic as well as anatomi- 
cal. An exceptional susceptibility to the office is 
largely the part of idiosyncrasy, and, in immediate 
excitation, may be ideational almost altogether, as 
where a remembered or a pictured object of special 
offense to sight or smell or taste occasions qualms of 
nausea. 
It is not known that race or sex or age has any 
constant relation to the facility with which the act 
of emesis is performed, with the exception of the 
period of early childhood, when modifications of 
importance are apparent. It is a physiological fact of 
much significance, that the very young evacuate the 
stomach more easily than the adult—perhaps wholly 
from anatomical considerations. As previously ex- 
plained, the act of vomiting chiefly depends upon a 
compression of the stomach between certain extrinsic 
muscles and surrounding organs; now, in the infant 
the contributory muscles are, relatively, very strong, 
and the organs—and especially the liver—are, rela- 
tively, very large. Then there is another fact of 
greater weight than this: in the adult the anatomi- 
cal form of the stomach might justify the conclusion 
that it was constructed with reference to almost any MODIFIED EMETIC ACTION. 
255 
other function than its evacuation through the 
oesophagus. It has already been suggested that the 
pre-vomitive contractile activity of the stomach may, 
as well as otherwise, be concerned with the produc- 
tion of a favorable modification of its shape; but 
help from this source can only be partial. In the 
more rudimentary organ of the infant, on the other 
hand, we have approach to wThat might be considered 
little else than a conical distention of that portion 
of the canal which lies between the oesophagus and 
duodenum, and to what is admirably adapted to 
yield to vomitive pressure. 
Some observations of Prof. Schultz respecting the 
comparative facility of vomiting in different ani- 
mals still farther illustrates the point under discus- 
sion. He remarks that the horse, rabbit, hare and 
guinea pig cannot be induced to vomit under any 
circumstances, whereas the dog and cat evacuate the 
stomach frequently and without apparent discom- 
fort. In the horse, etc., the doctor found, in an ex- 
aggerated degree, the condition which obtains in the 
adult human stomach: the oesophagus, instead of 
being inserted in the left upper extremity, enters in 
the middle between the left extremity and the py- 
lorus. There can be little doubt that the rudiment- 
ary form of the infantile organ wras designed by 
Providence to allow a prompt evacuation upon the 
first approach to repletion; and it is certainly true 
that infants which habitually return a portion of 
their food are at once most apt to be well nourished 
and to keep free from digestive disturbances. 
A fact still remains for consideration respecting 256 
EVACUANT MEDICATION. 
modified vomitive action, and which is of clinical 
and medicinal import. Antimonial emetics are both 
greatly more energetic and greatly more variable in 
action in the infant than in the adult. This subject 
is of such gravity that it cannot properly be passed 
by—notwithstanding all that has been previously 
said in criticism of the use of antimony in general; 
and the more so because the books give little or no 
attention to it. Dr. Armstrong, some years ago, at- 
tributed the greater mortality from whooping-cough 
in English country districts than in London to the 
freer use of antimony in rural practice. In respect 
of this drug, as applied in childhood, and more 
strikingly even than in that of opium, it is the great 
variability of action, rather than a disproportioned 
energy, that makes it dangerous. Dr. Beck reports 
a case where one-thirtieth grain tartar-emetic, given 
to a child in croup, produced such extreme and pro- 
tracted vomiting and alarming prostration that the 
aid of stimulants had to be called in to save life. 
Again, one-quarter grain, prescribed to a child pre- 
viously in no peril, caused vomiting which ended in 
death. Children have been fearfully prostrated or 
thrown into convulsions, and, again, have been actu- 
ally destroyed, by antimonial wine given for a cold. 
It is doubtful if any measure of skill or experience 
on the part of the physician can anticipate the prob- 
able degree of susceptibility of the untried child, or 
of the same child in different conditions and periods, 
so as always to avoid these terrible results. 
But very few out of the many authors who have 
written on this subject, and. who are accepted as MODIFIED EMETIC ACTION. 
257 
authority, seem to be awake to this danger. Fons- 
sagrives, wiser than many, fixes the age when it is 
safe to begin with tartar-emetic at ten years, and de- 
clares that ipecac should be the emetic for children, 
“ aside from cases of exceptional apathy to this med- 
icine.” Bouchut places the term as low as seven 
years. There is force in a suggestion of Pinel, that 
a small dose—twenty-five milligr.—may be safe with 
a child at the breast which might cause accidents 
with an older child, because the stomach of the infant 
is likely to discharge it before it enters the circula- 
tion. But the rule of Prof. Beck * is more physio- 
logical and safe than any other; and this directs, in 
effect, that an antimonial should never be given to 
the young child. Ipecac is always safe and gener- 
ally effective; in the rare case of “ apathy ” recourse 
can be had to a topical emetic. 
The physician, however, is much less often the 
offender in this direction than formerly; more often, 
nowadays, the danger comes from another source. 
By a singular fatality, the most frequent relict of a 
former antimonial barbarism—the compound syrup of 
squill—is to be found entrenched in the nursery. 
Nothing else could well be more specious and attract- 
ive than the “ Hive Syrupthe name suggests honey, 
and the taste goes far to warrant the name, for the 
mixture is very sure to prove palatable. Yet every 
ounce contains three-quarters of a grain of tartar- 
emetic. A strange perversity, as the author has more 
* In an admirable monograph on “ Infant Therapeutics,” now, 
unhappily, out of print. 258 
EVACUANT MEDICATION. 
than once had occasion to observe, and in intelligent 
families, has caused an impression to obtain that 
hive syrup can be dosed out at the discretion of the 
mother or nurse, where the use of ipecac demands 
advice from the doctor. The physician should see 
to it that, so far as his influence extends, no domestic 
medicine-closet shall be permitted to retain hive 
syrup on its shelves. 
INDICATIONS FOR EMETIC MEDICATION. 
First Indication.—For simple evacuation of the stom- 
ach, upon repletion and evidence presented that the 
food received will not be digested. It is obviously 
much better to procure its immediate return than to 
permit indigestible food to remain, to the farther dis- 
comfort of the patient, until it shall have passed 
into the bowel; there still to continue an occasion of 
offense and irritation up to the time of its being 
finally expelled, perhaps in a diarrhoea. It is worthy 
of note, however, that it is comparatively difficult to 
obtain vomiting when the stomach is distended with 
food or otherwise, perhaps because there is imperfect 
contact between the particles of the emetic agent 
and the internal gastric parietes. This condition, 
therefore, is' especially suited to hypodermic apo- 
morphia, or to lavage, or the stomach-pump may 
take the place of the emetic. 
Again, this first indication should include the case 
of poisoning; where the stomach has been made to 
receive any poisonous agent, narcotic or otherwise. 
Indeed, the first step in the treatment of such con- 
dition is evacuation of the stomach. INDICATIONS FOR EMETIC MEDICATION. 
259 
Second Indication.— To produce modification in the 
upper gastro-intestinal membrane, etc.: a department 
of therapeutics in which our predecessors used the 
emetic much more frequently than it is used in pre- 
sent practice, and, quite surely, got better results. 
Not alone is stomach and duodenum, but also the 
liver, the portal circulation, and the cholopoietic 
apparatus are directly amenable to the impression 
of an emetic and susceptible of great benefit, if it 
be wisely directed. The preceding discussion has 
made this sufficiently plain. A gastric catarrh, and 
especially a chronic catarrh and allied conditions, 
may receive more benefit from an occasional emetic 
than from all applications designed to be topical, 
from cathartic medication and even from lavage. 
Evacuation and washing out of the organ simply 
secure a temporary gain; its strong compression, its 
energized contractile activity, attendant upon the 
action of an emetic, and subsequently modified secre- 
tion may result in permanent improvement. In- 
deed, in such state, if extreme, and by such treat- 
ment, the truth of the Hippocratic aphorism may be 
realized, “ Vomitus vomitu curatur.” Cases are on 
record where vomiting, intractable under all other 
treatment, has been cured by the nausea and vomit- 
ing of a sea voyage. 
In this section also belongs the complication so 
often recognized by the older writers, by Hufeland 
and Cullen and Sydenham, where the normally 
absorbent and assimilative energy of the stomach, 
temporarily lost, is restored by the timely emetic. 
The quinia, which had been hitherto unproductive, 260 
EVACUANT MEDICATION. 
or which had acted as an irritant and toxic, after this 
interference exerts its due therapeutic force; and the 
delayed cure is.accomplished, or already well under 
way. Partly to this indication and partly to that 
just discussed, pertains what we may call the abor- 
tifacient emetic, which, administered in the early 
stages of a continued fever, as in the practice of Dr. 
Walsh and his contemporaries, occasionally arrested 
the disease altogether; perhaps oftener impressed 
upon it subsequently a more benign phase. 
That the liver in certain bilious states, etc., may be 
more directly reached and more powerfully impressed 
by an emetic than by a purgative medication is 
apparent, alike from physiological considerations and 
clinical testimony; but the practice of the present 
gives preference almost entirely to the latter resource. 
Third Indication.—That of secousse mecanique, me- 
chanical shock, has two or three practical applica- 
tions. Such is the application of an emetic with 
purpose of dislodgement of a body deep in the 
throat,—the relaxation of the oesophagus which at- 
tends vomiting and the powerful vis a tergo from the 
stomach, both being concerned in its release and 
extrication. Caution must be had that the foreign 
body is not too large and so too firmly engaged for 
this method, and that the emetic action aroused is 
not too violent, lest there be rupture of the oesopha- 
gus. But the emetic in croup is the most frequent 
instance of the value of secousse, the intention being 
the disengagement, and, if possible, the removal of 
false membrane from the air-passages. Here three 
forces cooperate, or should cooperate, for the best INDICATIONS FOR EMETIC MEDICATION. 
261 
result: a preliminary secretion in the respiratory 
tract, at the seat of the membrane, relaxation of the 
trachea and below, and a rapid rush of air through 
the trachea, as associated with the convulsive breath- 
ing of the vomitive act. Selection of emetic agents 
has already received attention; but it may be re- 
marked that it is wise, so far as possible, to secure a 
period of nausea prior to exhibition of the emetic, as 
by ordering ipecac in frequent, non-emetic dose, in 
order to obtain secretion in the respiratory passages. 
Once more, abscess of the tonsil has been adroitly 
lanced, so to say, by the operation of an emetic. The 
practical difficulty lies in timing its administration; 
but the force is quite apt to be wisely applied, as the 
pointing of the abscess is often turned toward the 
stomach, and away from possible inspection by the 
surgeon. 
Fourth Indication.— The heart and the circulatory 
system in general, are directly and ‘powerfully controlled 
by the emetic influence. Immediate effects are singu- 
larly like those that result from blood-letting; but 
blood-letting is spoliative, and therefore recovery 
from the former intervention is more speedy and 
complete. Every one has witnessed, if he has not 
experienced, the profound depression which nausea 
alone may exert on cardiac action; it may be 
doubted if the entire body has elsewhere organic 
sympathies so close and interdependent as those 
holding between the plexuses which control the 
innervation of the stomach and that of the heart. 
More remotely, but not less obviously, and largely 
because of this relation as affected by emesis, the 262 
EVACUANT MEDICATION. 
entire nervous system is involved in a disturbance, 
manifested by paleness, faintness, or tendency to syn- 
cope, smallness and threadiness of pulse, feebleness of 
respiratory murmur, coldness of extremities, relaxa- 
tion of the sphincters and, in fact, of all muscles, 
voluntary and involuntary. Probably no other 
agency than vomiting, which the physician can 
direct, physiological or medicinal, is capable of ac- 
complishing a sedative impression at once so prompt 
and emphatic and extended, and yet so transient 
and safe for the subject of it: a somewhat like con- 
dition, it is true, may be realized by application of 
cold ; but cold has its discomforts and dangers, and, 
moreover, is soon followed by a stage of reaction and 
stimulation. 
The occasion for resort to emetics, corresponding to 
the fourth indication, is not realized so often as 
formerly, as the physician nowadays reads his cases 
and applies his remedies; and especially as respects 
the power to be exerted over the heart and circula- 
tion. None the less, the subject demands attention 
because of its close relations to the general physi- 
ology of emetic medication ; and, moreover, there is 
the rare and grave emergency when such medica- 
tion may be turned to good account. The conjoined 
control exercised upon the muscular system sug- 
gests a more frequent application of emetic remedies. 
Some forms of muscular spasm, e. g., are peculiarly 
amenable to this mode of treatment; the spasmodic 
seizure being at once too violent and too strictly 
localized to permit either topical or general recourse 
to materials drawn from the class of narcotics. Such INDICATIONS FOR EMETIC MEDICATION. 
263 
is laryngismus stridulus, spasmodic croup, asthmatic 
seizure, hysterical convulsion. But even here, ap- 
plication has been limited by the introduction of 
anaesthesia; and in strangulated hernia or rigidity of 
the uterine os, the depressant emetic is wholly a 
thing of the past. 
In conclusion, it is worthy of note, that the extra- 
ordinary control which the emetic may bring to 
bear upon the heart involves no danger to life ; and 
no more does the sudden disturbance of circulation 
in the brain; except in the presence of certain contra- 
indications, to be discussed later. As previously 
said of the stomach alone, so now it may be re- 
marked that stomach, heart and brain may be sub- 
jected to a degree of strain or to a measure of con- 
tinuous and often repeated interference, in the opera- 
tion of the emetic,—and yet recovery thereafter be 
prompt and complete,—which would be incredible 
but for the results of assured clinical observation. 
Such, therefore, are the more prominent and use- 
ful, it may be added the more obvious, indications 
for the service of an emetic. Some writers distin- 
guish as many as eight or ten indications; such as 
that with antiphlogistic or with derivative purpose, 
or that based upon the known effects of the emetic 
upon the respiratory apparatus. But with the ex- 
ception of the latter, the corresponding applications 
are few and unimportant; although Trousseau, et cet., 
believed that diarrhoea might be cured by the revul- 
sive action of emetic medication, and were disposed 
thus largely to explain the efficacy of ipecac in dys- 
entery. The influence which the emetic extends to 264 
EVACUANT MEDICATION. 
the bronchial passages is so constant, that it may be 
assumed to be a part of such action; and, accord- 
ingly, much that pertains to the pulmonary service 
of this class of remedies has been disposed of 
already. So far as the emetic material is also the 
every-day expectorant, it is almost wholly when 
exhibited in dose short of emetic or nauseant 
action.* 
Contra-indications.—Emetics are forbidden in the 
aged when there is suspicion of degeneration of the 
heart or arteries, and also in the apoplectic. Certain 
other forms of heart disease, in whatever subject, 
render their use inconsistent with safety; such is 
marked neurotic feebleness, dilatation, aneurism, and, 
of course, degenerative lesion of every form. The 
existence of hernia is not a positive contra-indication, 
but demands caution and, generally, resort to other 
remedies. Active congestion or inflammation in the 
brain forbids their use. They are best avoided at 
the time of the menopause, and must be employed 
intelligently or not at all during the continuance of 
the menstrual period. The powerfully perturbative 
and derivative influence which the emetic exerts in 
another direction than the pelvis, affords explanation 
of the latter caution, and also partly explains the 
following exception: “ When the menstrual flux is 
painful or scanty, or, again, when a metrorrhagia 
supervenes under the influence of a bilious condition, 
*It will be remembered, in the discussion of the physiology of 
ipecac, that the position was taken that this drug has power to in- 
crease bronchial secretion, aside from any influence exerted upon 
the vomitive apparatus. ARREST OP VOMITING. 
265 
we may procure vomiting with great benefit to the 
patient.” 
Mode of Administration.—Nothing remains to be 
said, except to summarize and bring together state- 
ments previously made. Emetics are given by the 
stomach or else hypodermically—chiefly by the 
former method. If hypodermically, there should be 
complete and neutral solution ; a slightly acid reac- 
tion in the vehicle is not so likely to cause abscess as 
is the presence of undissolved particles. Ingested by 
stomach, the material should either be in form o’f solu- 
tion or, if insoluble, should be suspended in warm 
water. Two conditions are essential in the vehicle—it 
should be warm and provided in liberal quantity. 
A cold or hot or aromatic draught helps to defeat the 
purpose of the emetic. All emetics, whether mechani- 
cal or special, are more or less irritant, and the crypts 
of the mucous membrane of the stomach must be 
protected from contact with their particles; besides, a 
void stomach renders the vomitive act distressing 
and, it may be, ineffectual.* Still farther, if the 
emetic material prove slow in operation, draughts of 
warm water will shorten the preliminary nausea and 
make emesis more easy and complete. 
Arrest of Vomiting.—There is a state of supervom- 
ition, as there is of superpurgation; the former, how- 
ever, much oftener the result of certain morbid 
complications than of medication. Few conditions 
are so distressing as is the obstinate vomiting which 
* Probably in no other instance is this rule so often unconsidered 
as in the exhibition of Turpeth Mineral. 266 
EVACUANT MEDICATION. 
shows no disposition to stop, and which with each 
repetition leaves the patient, after brief interval, 
sicker than before and with less strength and reso- 
lution to make a stand against the prevalent and 
persistent nausea. Few other conditions so surely 
demand from the physician alike patience and de- 
termination and extensive material resources ; espe- 
cially, as it too often happens, if he be not called until 
after the patient is nearly exhausted, until various 
measures both wise and unwise have been applied, 
and until the repetitive vomiting has already acquired 
somewhat of the force of a habit. To this we must 
add that there are few conditions to which medical 
writers give so little attention, leaving the young 
physician to treat the case as best he may out of his 
general knowledge—notwithstanding that, as just said, 
few emergencies involve such distress and require 
such broad and exact measures of relief—or confining 
him to the little information he may have gained 
from discussion of a few anti-emetic remedies. 
Too often the subject of obstinate vomiting, even 
though intelligent, will be found to have labored under 
the delusion that the vomiting must be repeated with 
every call, and perhaps even the nausea be encour- 
aged, at least so long as the bitter and foul-looking 
matter is rendered by the stomach. The first fact, 
therefore, for the physician to grasp is this, viz.: TJie 
nausea has become continuous and the emesis peri- 
odic through the operation of a kind of vicious circle; 
the very effort which rids the stomach of a little 
irritating bile brings as much more bile into it, which 
must equally demand expulsion a few minutes later. ARREST OF VOMITING. 
267 
The first indication, then, in treatment is to break 
in upon this vicious circle forthwith, with resolve to 
discourage all farther vomiting. The second indi- 
cation, wherever applicable, secures the cooperation 
of the patient, and, by intelligible representation and 
persuasion, brings him to make as determined a 
stand as possible against the vomitive impulse. If 
his age, his confidence in his physician and his force 
of will are such as to afford this cofiperation, the 
battle is already more than half fought. The third 
and last indication ensures that the patient is provided 
with all possible resources to help him in his struggle; 
and this indication alone needs discussion—discus- 
sion alike exact and comprehensive. 
He is to lie quietly upon his back, with head little 
or not at all raised ;* to lie absolutely still, because 
if the case is a severe one it will often be found that 
the slightest muscular movement will be sufficient 
to induce vomiting. We have previously seen that 
the erect position and that motion favor vomiting, 
that the brain is anaemic during the performance of 
this function. Now instinct often either affords little 
guidance to the sufferer from constant vomiting, or 
else he has become so nervous and restless that he 
gives no attention to intimations from this source. 
* With the possible exception of young infants: Fonssagrives 
quotes Foville as having reported deaths in the very young from 
suffocation, the head being low during the vomitive act and chyme 
having entered through the trachea. Parrot has seen a fatal case 
in a child of two, and in another of eleven, months; in the latter, 
death supervened in three hours; coagulated milk had entered the 
bronchi and the ‘ ‘ lung parenchyma was, in some degree, digested 
by the gastric juice.” 268 
EVACUANT MEDICATION. 
He will often be found sitting erect in bed and, in 
great agitation, constantly changing position. Our 
previous study of the mechanism of reflex vomiting 
has shown that irritation at any part of the body 
may serve as an excitant of the act. In continuous 
vomiting there may not infrequently be developed 
a stage of weakness and excessive sensibility, where 
the entire organism seems to comport itself much as 
if it were a periphery of the vomitive centre; and 
the voluntary contraction of any muscle will speedily 
set into operation the complex and conjoined muscu- 
lar contractions which accomplish vomiting. The 
movement of an arm may be enough to fire the train. 
The patient must lie flat and must lie still, at whatever 
temporary cost of effort and discomfort! 
The bowl or cuspidor, which too often has 
stood by the head of the bed and near at hand, 
although half full of sour-smelling bile and mucus, 
is to be carried away once for all. All about the pa- 
tient should be clean and sweet. If he cannot always 
resist the impulse to vomit, he may use a handker- 
chief ; not rising in bed, however, but still prone 
and a little turned to one side. The strain and 
retching must be stopped as soon as possible after this 
bile has been thrown off. A light mustard paste— 
not a large and heavy poultice—applied to the 
epigastrium, will often give comfort and relief. 
Thirst may become extreme, but it cannot be grati- 
fied, although a single teaspoonful of ice water or a 
small pill of ice, swallowed at regular intervals of every 
ten or fifteen minutes, sometimes seems to do good and 
afford comfort. Under favorable circumstances and ARREST OF VOMITING. 
269 
with full control, a bad case may frequently be 
brought round with no farther treatment than this. 
With full control; for the weak confidence, the 
weak and vacillating will, the exhausted and hyster- 
ical nervous system oppose no slight obstacles to suc- 
cess and prompt recovery. Just here—and it can- 
not be made too emphatic—a great deal will depend 
upon the physician, upon his confidence in himself 
and in his resources, upon the confidence that he 
imparts to his patient, and upon the clearness and 
positiveness of his orders. 
The weak or undisciplined nervous system never 
appears to greater disadvantage than in the compli- 
cation under discussion; and such a subject, as well 
as the young and the ignorant, may require farther, 
and more strictly medicinal, resources. One law must 
obviously govern all intervention of this character: 
the remedy must be given in small, if not minute, 
bulk, and be of absolutely unirritating quality. First, 
may be mentioned a few materials which are always 
tentative, and which, in their best operation, exert a 
kind of specific action. We do not know how or why 
they give relief, but there is sufficient clinical evi- 
dence of their value. Prominent among these is 
ipecac, full particulars respecting the exhibition of 
which were given when this drug was under discus- 
sion. Again, arsenic sometimes affords satisfaction; 
one drop of Fowler’s solution in ice water or placed 
upon the tongue. Dr. T. T. Gaunt (U. S.) reports 
thirteen cases “ of the most varied character ” 
promptly arrested by drop doses of the comp, tinct. of 
iodine. Others have recommended iodide of potas- 270 
EVACUANT MEDICATION. 
slum * Calomel, also, is much used, is always safe 
and convenient, and is sometimes effective ; but the 
dose must be very small,—one-tenth to one-twentieth 
grain,—best placed upon the tongue at frequent inter- 
vals, dry and unmixed with any other substance. 
To just what condition calomel is most apposite is 
not very clear ; but it is naturally suggested in an 
acid state of the stomach and in markedly bilious 
complications. 
The remedies which remain may be mostly 
grouped about two prime indications. First, with the 
purpose to remove or diminish the extreme irritabil- 
ity of the vomitive centre and of the gastric fillets 
of the pneumogastric. The materials which have 
the greatest convenience and power in this function 
are opium, sodium-bromide, chloral-hydrate and hydro- 
cyanic acid. Frequently a minute quantity of mor- 
phia, wisely directed, will afford speedy relief; as a 
twentieth of a grain, given every five or ten minutes, 
until it has been repeated three or four times. In its 
introduction into the stomach, care must be had that 
but little of its bitterness is left in the mouth, as a 
bad taste at such a crisis will re-awaken or confirm 
nausea. A larger dose and more positive impression 
will be required to overpower the vomitive centre, 
and there are cases in which the vomiting will not 
cease until this result is reached; here the opium 
* No very exact directions have ever been attached to the anti- 
emetic use of these remedies. One drop of Fowler may be 
repeated every half hour till four to six drops have been received. 
The tincture of iodine must be given very carefully on account of 
its irritant properties. ARREST OF VOMITING. 
271 
should be given by enema or suppository. The 
hypodermic injection, although at times successful, 
is too much of a venture—as likely of itself to cause 
vomiting in many subjects. The liability to subse- 
quent nausea in the use of opium in considerable 
quantity must be kept in mind; none the less there 
are individuals who find it impossible to control the 
vomitive impulse until a strong thebaic impression 
has been produced. 
The sodic bromide should be invariably selected 
where a bromide is to be used, and to the exclusion 
of every other, as having full medicinal virtue, and 
giving less offense to palate, and causing less irrita- 
tion to the stomach than all other bromides. If the 
stomach can but be induced to retain fifteen or 
twenty grains of this salt for a few minutes, a favor- 
able and often curative influence is exerted; but the 
difficulty is to introduce it. This must be done 
slowly, and is perhaps best done by the following 
method: The salt is placed upon several lumps of 
ice, together of about the size of an egg, to which 
2-3 tablespoonfuls of cold water are added. In short 
space, the mixture will be sufficiently cold and dilute 
for the patient to take a sip of it, and this can be 
often repeated, according to ability, until the ice 
shall have melted and the entire dose been received. 
Here also, however, rectal medication is now and 
then best substituted, the patient taking thirty grains 
or more of either sodic or potassic bromide in warm 
and free dilution ; in states of weakness it is wisely 
conveyed in a solution of the peptonoids or in pep- 
tonized milk. 272 
EVACUANT MEDICATION. 
The value of chloral hydrate, as well as of the 
bromides, in sea-sickness perhaps suggested its use 
in chronic vomiting from whatever condition. This 
remedy must always be given by enema,—it is far 
too bulky and irritating to permit of its ingestion by 
the sick stomach. 
A recent writer has called attention to the fact 
that the finger will be benumbed if held for a few 
minutes over an unstoppered vial of hydrocyanic acid, 
and suggests the value of this acid in nausea and 
vomiting. It is easily taken, and doubtless exerts 
somewhat of the influence of a local anaesthetic 
upon the inner walls of the stomach as upon the 
finger in the experiment—the only remedy in this 
group, by the way, the action of which is brought to 
bear solely upon the peripheral expansion of the 
vomitive tract; and, so, of topical action alone. 
Chlorodyne, if genuine, as containing this acid, mor- 
phia, etc., sometimes has a very favorable effect upon 
the stomach—one or two drops at a time, rubbed up 
with a teaspoonful of ice water. 
(2) Vomiting is occasionally kept up by gastric 
acidity and fermentation; and here remedies are 
obvious and manifold. The chief problem is how 
to introduce them in sufficiently large quantity to 
have them retained and exert their due effect, as a 
grain or two of sodium-bicarbonate, e. g., can do but 
little in a stomach with morbidly acid reaction. 
Cerium-oxalate often gives better results than any 
other and all other materials, but must be taken in 
dose of five grains or upward. In conditions where 
fermentation is prominent, carbolic acid may be ARREST OF VOMITING. 
273 
advisable, one-third teaspoonful of the five per cent, 
solution in ice water, or two to three grain powders 
of salicylic acid;* but it is hard to get the sick 
stomach to retain these preparations. In acidity, 
again, bismuth and magnesia are obvious enough, but 
in the experience of the author they have not been 
so easy to retain or so satisfactory in result as the 
cerium. 
The locally anaesthetic properties of carbonic acid 
are universally acknowledged, and it has valuable 
uses in the affection now being considered. Indeed, 
carbonic acid may be said to hold a position midway 
between the medication and the support of the sub- 
ject of persistent vomiting. This is not the place for 
treatment of this accident when it depends upon ex- 
posure to a special and continuous disturbant, as 
that of pregnancy, of ulcer or of cancer of the 
stomach. But in a patient previously weak and 
reduced, continuous vomiting may, in short space, 
develop a state of such extreme prostration as shall 
of itself threaten to render all resources ineffectual; 
for if we accept the general physiological law—as 
we must—that “ weakness is sign and concomitant 
of irritability,”f the expression in the converse is 
equally true that irritability is sign and concomitant 
* It has been more than once stated upon authority in the text- 
books, that, while salicylic acid is an effective antifermentative 
remedy, its salts, like sodium salicylate, have no such power. 
This rejection of the salt, however, has not always been supported 
by good clinical observers, who insist that as direct effects are ob- 
tained in gastric fermentation from the latter as from the acid, and 
chemical considerations support this view. f Fothergill. 274 
EVACUANT MEDICATION. 
of weakness. Complete and continuous gastric in- 
continence will sometimes develop pretty rapidly in 
a nervous patient, although of good resources at 
first, and if the vomiting is not soon controlled, the 
weakness which it occasions, both general and local, 
will tend, as just said, to render ineffectual the usual 
remedies for its arrest, and have the physician at 
great disadvantage, and the patient in imminent 
danger. 
In such crisis as this, and alike as means of tem- 
porary support and for the partial relief of vomiting, 
the carbonated alcoholic liquors are often of most 
material service. Such is a good champagne, taken 
often, in small quantity and with ice; but it must 
be “ dry,” i. e., contain relatively little sugar, and be 
drawn by a spigot forced through the cork, which 
shall allow frequent draft and yet keep the liquor 
fresh and effervescent. It is not too much to say 
that in a few cases in the author’s experience, this 
expedient has seemingly availed to save life. Again, 
champagne disagrees, though of the best selection, 
the sugar is at fault, the wine “ sours upon the stom- 
ach ” from the first, and the patient soon refuses it. 
In this emergency the “ alcoholized seltzer ” has often 
proved a complete success, and is best constituted and 
given as follows: a teaspoonful of pure brandy, 
iced, upon which seltzer or “ soda water ” is to be 
turned, and the mixture drunk off during efferves- 
cence. Some other distilled spirit may do in special 
cases, but brandy is the best with the majority of 
patients; and it is, of course, essential that it should 
be pure and old and smooth. It must generally be ARREST OF VOMITING. 
275 
left to experiment to determine which subject will 
most kindly receive the champagne and which the 
carbonated brandy; but one or the other will, very 
surely, afford material aid, if it do not, indeed, effect 
a cure, provided it be introduced at the right time 
and in the right way. 
The value of ice and iced liquids has been empha- 
sized already; cold has somewhat of anaesthetic 
property, and is grateful to the fevered and irritable 
mucous membrane; while, at the same time, the 
quantity to be presented to the stomach is too small 
and the repetition is too frequent to allow the un- 
favorable reaction always liable to follow a more ex- 
tended application of this agent. Occasionally, an 
alternation of the hot and the cold is found very 
helpful to the patient, the hot potion being made as 
hot as can be swallowed without burning. To meet 
the latter indication, nothing else so often does good 
service as a genuine cafe noir; especially where there 
is evidence of progressive depression, or where the 
after-effects of opium, previously administered, begin 
to be felt. The decoction of coffee must be absolutely 
clear, that is free from grounds or sediment. 
Among external applications to the epigastrium, 
the most simple and often appropriate—the mustard 
paste—has been mentioned hitherto. In grave con- 
ditions, ether-irrigation to the pit of the stomach has 
been highly endorsed; the ether being thrown as 
spray from a simple atomizer. Mendez reports a case 
where he believes that life was saved by means of 
this expedient, as the last extreme of prostration had 
been reached and all other resources had been without 276 
EVACUANT MEDICATION. 
avail. But in the author’s experience, if there be 
any agency of final appeal, and such as is to be trusted 
to when all other measures have gone wrong, it is 
the spinal ice-bag; this simple instrument has doubt- 
less more than once 'saved life.* Directions may be 
given in a few words: Every physician should have 
a spinal bag of rubber, ten to twelve inches in 
length, provided with a band near the top, which 
having been drawn, once the bag has been packed 
and the small upper segment reversed, ensures against 
escape of liquid. This bag, for the present purpose, 
is to be loosely packed with alternate layers of ice in 
small pieces and of salt, until the band is reached, 
and then secured at the top as just said. This pro- 
vides a freezing mixture which, even in hot weather, 
will often cause an almost immediate deposit of frost 
upon the surface of the bag, and which must be used 
with care. 
There may be difference of opinion respecting the 
point of election in the spinal column at which the 
application of a refrigerant compound will most in- 
fluence the circulation of the brain; but there should 
* First impressions, a first experience, often continue to have the 
most force; and the writer will never forget his first experience 
with the spinal ice-bag. The patient, a neurotic female, had reached 
the last extreme of prostration from persistent vomiting, life was se- 
riously threatened, and it seemed as if all known remedial resources, 
internal and external, had already been tested. Prof. Edw. 
H. Clarke, called in consultation, could propose nothing farther 
than an experiment with the ice-bag. The effect was magical, the 
relief immediate, the patient very soon gave expression to her 
sense of comfort and satisfaction; and a single application, to all 
appearances, wrought the cure. ARREST OF VOMITING. 
277 
be no question where most effectively to apply the 
ice-bag for relief of vomiting. First, raise the patient 
from his previously horizontal position and support 
him upon pillows at about an angle of 45°; then 
introduce the bag under the clothing and place it 
against the naked back, between the patient and his 
support of pillows, as- nearly as possible opposite to 
the pit of the stomach. How long the application of 
such intense cold might be kept in place without 
freezing the integument may be uncertain, but re- 
peated experience has shown a ten minutes’ period 
to be sufficient for remedial purposes and always 
consistent with safety, and the author has never ex- 
ceeded this limit. The statement in the note may 
be regarded representative of usual observation, 
and the ice-bag applied to the patient who needs it, 
although very weak and exhausted, does not cause 
shock and pain, but rather an almost immediate feel- 
ing of ease and comfort. 
In its best operation, however severe the case, one 
application is sufficient; but sometimes relief is only 
partial, or, if complete, only temporary, and here the 
frequency of application must be calculated for each 
patient. The measure is one, simple as it may seem 
in detail, which, alike for safety and efficiency, may 
well engage the personal superintendence of the 
physician until the nurse has been instructed in the 
object lesson at all points. In one instance, a good 
nurse, entrusted with the application of the bag, ap- 
plied it upside down; the patient, long tortured by 
persistent vomiting in its worst form, experienced 
such speedy and material relief that she was sound 278 
EVACUANT MEDICATION. 
asleep in less than five minutes (a not uncommon 
experience), only to be aroused by the trickling of 
salted ice water down her back, her clothing being 
already saturated by it and herself on the verge of a 
chill. A long and painful illness was the penalty 
of this inattention, and, although many years since, 
impressed upon the physician and the writer the 
wisdom of the invariable superintendence of at least 
a first application of the spinal ice-bag by the prac- 
titioner in attendance. Here, as everywhere in prac- 
tice, it is the busiest physician who can best afford 
time to assure the safety and effectiveness of what- 
ever important measure he directs. 
So much for the treatment of what we may call 
acute persistent vomiting; there is also a variety of 
this distressing affection which assumes a more 
chronic form. There is the occasional patient, who 
presents no real evidence of gastric lesion, but with 
whom nausea is nearly constant, and emesis set up 
on the slightest provocation, as upon the entry of a 
little bland food into the stomach, whose comfort is 
destroyed and life threatened—a condition, in a word, 
which signifies life or death in the result, largely 
according to the interpretation placed upon it by the 
physician and the intelligence of his treatment. 
Such experience is well illustrated by a brief clinical 
report, published some years ago by Dr* Anstie. A 
middle-aged man had suffered from incessant vomit- 
ing for many weeks, until he had become reduced to 
an extreme state of emaciation. His case was such 
as to lead to the opinion that malignant disease of the 
stomach existed, and a fatal result seemed near at ARREST OF VOMITING. 
279 
hand through sheer inanition. After a number of 
remedies had been tried in vain, a half-grain of mor- 
phia was ordered to be taken in pill three times a 
day. This was retained, and its effect, says the re- 
cord, was “ almost miraculous.” The vomiting 
ceased, and the patient, on whose case so grave a 
diagnosis had been passed, and who seemed at the 
very verge of death, was restored so as to leave the 
hospital in about three weeks’ time. 
Every practitioner of experience can call to mind 
cases of which Anstie’s case may serve as type, but 
in which a baleful diagnosis was not corrected; 
and no treatment can much avail which follows 
upon a fatal diagnosis. With some physicians, in- 
deed, there would seem to be a readiness to diagnos- 
ticate malignant disease of the stomach, which savors 
of indifference or inertia. Gastric cancer is con- 
fessedly obscure except in the last stages; to pro- 
nounce such decision is equivalent to a sentence of 
death, and there can be no question that innumera- 
ble patients have been given over to die where a 
more conscientious study, a more acute insight, a 
more generous and ingenious therapeusis would have 
controlled the disease and saved life.* 
* Clinical reports might be appended in farther support of this 
statement, but they can avail comparatively little for instruction 
in an affection where so much is determined by circumstance and 
individuality. But the fact it is desired to impress cannot receive 
too much emphasis. 
In particular, let the young physician remember that a stomach 
may, for weeks together, present as absolute incontinence as if it 
were the seat of a fatal lesion ; it may be necessary to feed almost 
solely by rectum, and to keep the vomitive centre under the con- 280 
EVACUANT MEDICATION. 
Once more, there is the variety of gastric incon- 
tinence which is chronic in its phase as well as in 
course and duration; the patient is not confined to 
liis bed, as in the class suggested in the note; he 
keeps about more or less, but he is disabled from his 
usual pursuits, and is pronounced by his friends to 
be in a progressive “ decline.” The author has once 
or twice seen such a case where an obvious fault in 
the functional working of the liver suggested an ob- 
scure but rational responsibility for the disorder in 
the stomach, and a treatment which began with 
small and frequent doses of the mercurous iodide, 
continued for a week at a time, was rendered plain 
and prosperous thereafter. But this experience is 
unusual, and, moreover, has the misfortune to be 
represented by conditions so obscure, that it is far 
from sure that it will be recognized, and the right 
treatment be applied, when it does exist. 
We must not conclude this chapter without brief 
allusion to a case in farther illustration of this divi- 
sion of the subject, published some years ago by Dr. 
Wm. Hunter, under the title, “ The successful cure of 
a severe disorder of the stomach by milk taken in small 
quantities at once,” which has often since served as 
a basis of hopeful opinion and fruitful treatment. 
trol of narcotics ; nay, more, grave consultants may have been “led 
to the opinion that malignant disease of the stomach exists,” 
and yet there may be no actual structural disease ; the affection 
may be strictly a neurosis (and all the more if the patient be 
young and a female), and a hopeful diagnosis, an intelligent, a 
courageous and patient system of treatment will yet save life and 
restore to accustomed health. ARREST OF VOMITING. 
281 
The report which follows is largely in the doctor’s 
own words. A lad was brought to him by his father, 
who had so long suffered from repeated vomitings 
as to present an extreme degree of emaciation and 
weakness, and a suggestion of his having nearly 
reached the end of the miseries of life. Various 
physicians had been consulted, approved remedies 
had been tried, but nothing had given relief. Care- 
ful examination of the patient and reflection on the 
history of the case led the doctor, speaking aside to 
the father, to give an unfavorable prognosis; but he 
was careful to add, “ It may take a favorable turn ; 
we see such wonderful changes every day in the 
persons of young people, even in cases apparently 
the most desperate; in them the resources of nature 
are astonishing.” 
The scheme of treatment proposed was, in few 
words, as follows: The patient cannot live without 
nourishment, and he immediately rejects everything 
taken into the stomach. It is better that he should 
take very little, although it be inadequate, if he can be 
made to keep it. Again, the food selected should 
be of such quality as is least likely to offend a 
weak stomach, and such food is found in milk. 
Give, therefore, one teaspoonful of milk at a time, 
and, if retained for a certain period, repeat; if this 
succeeds, very cautiously increase the quantity. Later, 
other smooth liquid foods may be ventured upon. 
Details need not be given farther. In conclusion, Dr. 
Hunter says:— 
“ I heard nothing of the case till, I believe, 
between two and three months afterwards. His 282 
EVACUANT MEDICATION. 
father then came to me with a most joyful coun- 
tenance, and, with kind expressions of gratitude, told 
me that the plan had been pursued with scrupulous 
exactness and with astonishing success ; that his son 
had never vomited since I had seen him ; that he 
was daily gaining strength and color and spirits, and 
now grown importunate to have more solid food. I 
recommended that the change be made by degrees. 
His recovery was complete, and many years ago he 
was a healthy and very strong young man.” To this 
it may be added, that Mr. Hay, of Leeds, cites four 
instances in which Hunter’s plan was followed with 
like fortunate results, and Dr. Pavy has had the 
same experience with several individuals. 
It should, however, be observed that this method 
is more likely to succeed with children than with 
adults; the adult is farther removed from the natural 
food of the nursery, and the experience of the author 
has led him to suspect that, in chronic persistent 
vomiting, the stomach of the adult is more likely 
to present a strong acid reaction—a fatal objection 
with the milk diet—than is the stomach of the 
child. It is true that even here a mild alkali 
like lime-water or soda or magnesia, may make the 
milk acceptable; but if the stomach be positively 
acid, and if the milk be the sole diet, this resource 
will generally fail after a short time. But the milk 
diet has this advantage: commonly, it gives its 
decision speedily, as respects adaptedness, in the case 
under observation. In unfavorable adult cases, the 
writer has known one tablespoonful of pure milk, 
rendered antacid and introduced with the utmost ARREST OF VOMITING. 
283 
care, forthwith produce an agony of dyspepsia, which 
so wore upon the already exhausted patient, that 
the loss could hardly be made good by a pint of 
acceptable and assimilated nourishment. 
In this exigency, koumiss may avail,—a mild, car- 
bonated, alcoholic liquor, which would have been 
considered previously but for its proper allusion in 
this place. The same patient who cannot take a 
tablespoonful of milk, has been brought, after brief 
experience, to receive a quart bottle of koumiss in the 
twenty-four hours, with satisfaction and comfort, and 
to thrive upon it. It may be said without hesitation 
that it has been known to solve the problem at its 
most critical point, and, seemingly, to save a life. 
Here, in its best operation, it is all that champagne 
or carbonated brandy is, and it is more. “ Nothing 
succeeds like success,” where koumiss is successful. 
Unfortunately, it is not always acceptable and it 
is not always available. However it might have 
proved with the stomach, with some patients the 
taste is offended from the first and they cannot 
learn to take it kindly. An offended palate is a 
hopeless obstacle with any food in persistent vomit- 
ing. Again, notwithstanding the claims of manu- 
facturers, koumiss is a difficult material for the 
physician to obtain whose practice is located away 
from the cities, and a difficult material for any 
physician to direct in hot weather. At the best, it is 
liable to prove variable in quality and taste, espe- 
cially in the summer months ; and this is a great 
inconvenience, to say the least, in its present appli- 
cation. In short, it is an essential article of the 284 
EVACUANT MEDICATION. 
armamentarium, but, as respects the special case, is 
now indispensable, and, again, wholly without value.* 
* Suggestions respecting the treatment of vomiting due to cer- 
tain especial states may be found in the chapter on Ipecac. 
A word concerning rectal feeding, to which allusion has been made 
once or twice, and which may prove a material, if not an essen- 
tial, aid in support of the subject of continued stomachal incon- 
tinence. Dilute alcoholic liquors are doubtless absorbed from the 
rectum and lower bowel and appropriated ; in respect of food undi- 
gested and unaccompanied with a digestive ferment, we cannot be 
so sure. There is reason to believe that the more nutrient part 
of a milk punch or an egg-nog, given as enema, can perform no 
service at all; and the same applies to animal broths and teas. 
On the other hand, without quoting authorities and reports, there 
is both physiological and clinical evidence of the substantial value 
of digested fluids, such as peptonized milk, of the “beef pep- 
tonoids,” etc., and these are always available. INDEX 
PAGE 
ACID, cambogic 54 
carbolic, in vomiting 272 
carbonic “ 273 
cathartic 67 
hydrocyanic, in vomit- 
ing 270 
ricinoleic 26 
salicylic, in vomiting.. 273 
Aconitum, vs. antimony.... 213 
Aleurites triloba 26 
Aloe, as anthelmintic 46, 52 
as emmenagogue 49 
combination 48, 52 
contraindications 46 
dermal use 48 
differential therapeusis 130 
in bile 44 
in chronic constipa- 
tion 44, 45 
in gonorrhoea 53 
in haemorrhoids 46 
in leucorrhcea 53 
in pregnancy 47 
materia medica 40 
pharmacy 41 
vs. rectum 43 
special action 42 
special uses 44 
with iron 49 
with nux vomica 48 
with quinia 48 
with women 47 
Aloin 41 
Alumen, emetic uses 232 
Antimonium, vs. arsenic.... 220 
elimination 151 
emetic action 213 
history, etc 206 
in asthma 215 
in infancy 256 
in pneumonia 215 
in typhus, etc 216 
PAGE 
Antimonium, pharmacy.... 208 
physiology 210 
poisoning, treatment... 219 
vs. race 217 
tolerance 211 
Apocodeine 229 
Apomorphia,action and uses 222 
administration 229 
as emetic .. 222 
as expectorant 227 
in apoplexy 226 
in embar. gastrique 227 
in narcotic poisoning... 226 
materia medical 220 
vs. sanguinar. canad.... 224 
therapeutics 225 
Arsenicum, vs. antimony.... 220 
elimination 151 
in vomiting 269 
Biliousness, duodenal. 148 
Bismuth, in vomiting.. 273 
CALOMEL, in vomiting.. 270 
with jalap 37 
Cambogia, as hydragogue... 55 
differential therapeusis 131 
materia medica 54 
uses 55 
Carlsbad water 116 
Cascara sagrada, action and 
uses 73 
differential therapeusis 133 
in constipation 74 
in infancy 75 
pharmacy 73 
Cassia marilandiea 72 
Castor oil, vide ol. ricini 24 
Catharsis, at menopause.... 172 
vs. blood 163, 177 
vs. heart 169 
in aged.... 172 
285 286 
INDEX. 
PAGE 
Catharsis, indications 148 
in cholera 176 
in intussusception 173 
in obesity 168 
vs. kidneys 168 
vs. liver 169 
mechanism of 143 
Cathartic, effect on nutrition 146 
medication 141 
selection of 144 
Cathartics, administration. 177 
contraindications 173 
general principles...... 185 
mineral 107 
Cathartin 67 
Cerium oxalate, in vomiting 272 
Champagne, “ 274 
Chloral hydrate “ 270 
Chlorodyne, in vomiting... 272 
Cholagogue, ipecac 202 
Cholagogues 86,138 
Colocynthin 59 
Colocynthis, action and uses 59 
dermal use 60 
differential therapeusis 131 
in gonorrhoea 60 
in insanity 60 
materia medica 58 
pharmacy 58 
Comp, jalap powder, r.pulv. 
jalap co 36 
liquorice powder®, pul. 
glycyrr. co 125,127 
Constipation, chronic 74 
Corvisart, laxative water... 108 
Count Palma’s powder 120 
Croton oil, vide ol. tiglii.... 15 
seeds 15 
Cupri sulphas, as emetic... 230 
ELATERIUM, action and 
uses 63 
contraindications 66 
differential therapeusis 138 
in cerebral inflam., etc. 65 
in dropsy 64 
vs. kidneys 64 
materia medica 62 
pharmacy 63 
PAGE 
Emesis, in infancy 254 
mechanism of 237 
production of 246 
Emetic medication 249 
Emetics, action modified... 253 
administration 268 
centric 250 
classification 249 
contraindications 264 
especial 249 
vs. heart 261 
indications 255 
irritant 230 
reflex 251 
topical 230 
Emetin 189 
Enemata 179 
Epsom salt,®.magnes.sulph. 112 
Euonymin, action and uses. 46 
differential therapeusis 138 
Euphorhiacese 15, 24 
Euphorbia lathyris 31 
spurge 189 
Evacuant medication 13 
Flowers of sulphur 125 
Fountain syringe in 
chronic constipation. 182 
Friedrichshall 113 
Gamboge, v. cambogia.. 54 
Glauber salt,®.sodium 
sulph 114 
HENRY’S magnesia 120 
Howard’s magnesia... 120 
HunyadiJ&nos 113 
artificial 113 
Hydrargyrum, v. mercury.. 139 
sulph. flava 231 
IODINE, etc., in vomiting. 269 
Ipecac, administration.... 204 
American 189 
anti-emetic 195 
as cholagogue 202 
emetic uses 194 
expectorant 200 
history 189 INDEX. 
287 
PAGE 
Ipecac, in asthma 201 
in chronic diarrhoea.... 197 
in cholera infantum.... 197 
in dysentery 197 
in hemoptysis 204 
in hoarseness 202 
in pulmonary apoplexy 204 
in “winter cough”.... 201 
materia medica 188 
pharmacy 191 
physiology 191 
vs. polygala 189 
vs. viola 189 
tonic, stomachic 197 
Iridin, action and uses 97 
differential therapeusis 138 
Iron and aloes 49 
as emmenagogue 49 
JALAPA, action and uses. 34 
anthelmintic 36 
contraindications 36 
differential therapeusis 129 
in gonorrhoea 36 
in liver 35 
materia medica 33 
pharmacy... 33 
with calomel 37 
James’ powder 209 
KERMES mineral 209 
Koumiss, in vomiting. 283 
Lavage, in volvulus 174 
en lavage, antimony... 211 
Lead, elimination 151 
in volvulus 174 
Magnesia, special act’n 120 
carbonate, “ 120 
differential therapeusis 137 
Henry’s 120 
Howard’s 120 
hydrate 124 
in infancy 123 
in vomiting 273 
milk of. 124 
stools 122 
PAGE 
Magnesii citras, action and 
uses 117 
differential therapeusis 137 
Magnesii and common salt. 114 
differential therapeusis 135 
sulphas, pharmacy 112 
uses 113 
Manna, artificial 85 
differential therapeusis 133 
history, use, etc 84 
oak.., 84 
other varieties 85 
Medication, cathartic 141 
emetic 234 
evacuant 13 
Mercury, administration.... 100 
and common salt 103 
contraindications 107 
differential therapeusis 133 
elimination 151 
iodides 103 
in volvulus 174 
Law’s method 101 
vs. liver 87 
materia medica 99 
mercuric chloride 103 
oleate 105 
stools 100 
uses 99 
Milk of magnesia 124 
of sulphur 125 
Mineral cathartics 107 
OIL of spurge 31 
Oleum ricini, action 
and uses 25 
administration 29 
chronic constipation... 29 
differential therapeusis 129 
in colds 28 
in dysentery. 28 
in lactation 27 
in puerperal state 26 
materia medica 24 
Oleum tiglii,administration 19 
contraindications 18 
differential therapeusis 128 
external use 20 
inconveniences 17 288 
INDEX. 
PAGE 
Oleum tiglii, special action, 
uses 15, 16 
toxic action 18 
Opium, in vomiting 270 
PILL, Legond 206 
Podophyllin, action 
and uses 91 
administration 94 
as emmenagogue 92, 93 
as purgative 94 
combination 94 
contraindications 94 
differential therapeusis 138 
history, etc 90 
in biliousness 93 
in chronic constipation 94 
Pomade of Autenrieth 210 
Potass, bitartras,pharmacy, 
uses, etc 108 
differential therapeusis 135 
in constipation 110 
in uraemia Ill 
uterine diseases, etc 111 
Potass, et sod. tartras Ill 
Potus imperialis 108 
Powder of Algaroth 209 
Pullna water.... 113 
Pulv. efferves. co Ill 
glycyrr. co 125,127 
jalap co 36 
RHEUM, action, uses...78, 79 
administration 82 
combination 82 
composition 77 
contraindication 81 
differential therapeusis 134 
history, materia med- 
ica 76 
in haemorrhoids 82 
pharmacy 78 
Rhubarb, pill comp 83 
Rochelle powders, etc Ill 
Salines, the 134 
Sal de duobus 115 
Thermarum Caroli- 
nense 116 
PAGE 
Scammonium, pharmacy, 
uses 38, 39 
Sel de Seignette Ill 
Senna, contraindications.... 71 
differential therapeusis 132 
materia medica, phar- 
macy 67, 68 
special action, uses...69, 70 
Sinapis, as emetic 233 
Sodii bromid., in vomiting. 270 
bromid., vs. other bro- 
mides 115 
phosphas, with chil- 
dren 117 
salicylas, in vomiting.. 273 
sulphas, as a chola- 
gogue 116 
sulphas, differential 
therapeusis 136 
sulphas, in diabetes... 116 
sulphas, in dysentery.. 116 
sulphas, in gall-stones, 
etc 116 
Sulphur, action and uses... 126 
and cream of tartar 127 
in haemorrhoids. 126 
pharmacy, etc 125 
TARTAR emetic, vide 
antimonium 206 
Triplex pill 19 
Turpeth mineral, vide hy- 
drarg. sulph. flav 231 
VIOLA odorata, vs. ipecac 189 
Vomiting in croup 260 
in dog.. 239, 255 
in horse 244, 255 
treatment of, in infancy 254 
WAHOO, v. euonymin... 96 
Water, hot, sipping.. 157 
Winter cough 201 
sulphas, as emetic 230