Ipecacuanha. The root of Cephaëlis ipecacuanha A. Richard (Nat. Ord. Rubiaceae). (U. S. P.) Racine d'ipécacuanha, Fr.; Brechwurzel, Ger.

Extractum, Ipecacuanhae Fluidum

Fluid extract of ipecacuanha. Dose, τηij— 3 j.

Syrupus Ipecacuanhae

Sirup of ipecacuanha (fluid extract, 70 c. c.; sirup to 1,000 c. c). Dose, 3 j—oz ss.

Tinctura Ipecacuanhae et Opii

(Deodorized tincture of opium and fluid extract of ipecac.) Dose, τη v—τη xv. A liquid equivalent of Dover's powder.

Trochisci Ipecacuanhae

Troches of ipecacuanha (ipecac, traga-canth, arrow-root, sugar, and sirup of orange-peel). Dose, one or more. Each troche contains one fourth of a grain of ipecacuanha.

Trochisci Morphinae et Ipecacuanhae

Troches of morphine and ipecacuanha (each troche contains one fortieth of a grain of morphine and one twelfth of a grain of ipecac).

Vinium Ipecacuanhae

Wine of ipecacuanha (fluid extract of ipecac, 100 c. c.; alcohol, 100 c. c.; white wine to 1,000 c. c). Dose,

τηj-3j.

Pulvis Ipecacuanhae et Opii

Compound powder of ipecacuanha. Dover's powder. Ten grains contain one grain each of ipecac and opium, and eight grains of sugar of milk. This preparation has already been discussed in the article on opium.

Composition

Since the time of Magendie emetine combined with ipecacuanhic acid has been held to be the active principle. The diverse opinions entertained regarding the physiological properties of this alkaloid have been explained by the discovery recently, by Paul and Cownley, that emetine is composed of two distinct alkaloids, which they have named cephaeline and emetine, the latter being the same as the emetine described by Glenard. Ipecacuanhic acid is a glucoside, and is chemically related to kinic and caffetannic acids

Antagonists and Incompatibles

The salts of lead and mercury, the vegetable acids, and astringent infusions, are incompatible. The tannate of emetine is extremely insoluble. Bismuth, carbolic acid, hydrocyanic acid, and narcotics generally, hinder its emetic action.

Synergists

The emetics—those by local action and the systemic —favor the vomitive action of ipecac. Its effects on the skin and bronchial mucous membrane are promoted by opium, warm diluents, etc.

Physiological Actions

Inunctions of ipecacuanha excite very considerable irritation of the skin: at first, small, isolated pustules appear, and these are followed by large pustules and ulceration (Duckworth). When applied to the mucous membrane of the nares, it produces a sensation of heat, and causes sneezing. Some persons are so susceptible to its action that the smallest quantity inhaled will induce an asthmatic paroxysm.

Administered by the stomach in small doses (from one eighth to one quarter of a grain), ipecacuanha acts as a stomachic tonic, and probably increases the gastric secretions. In larger doses (from five grains to a scruple), it is nauseant and emetic; but the sickness which it causes is not severe, and the vomiting is not accompanied nor followed by much depression. Its action as an emetic is rather slow, from twenty minutes to a half-hour being required, and is not persistent. Repetition of large doses will, in most cases, but not invariably, produce a condition of tolerance, when vomiting does not occur, but a cathartic action is induced, the stools having a peculiar bilious character, appropriately designated "ipecacuanha-stools." Both vomiting and purging are sometimes produced by an emetic of ipecacuanha.

Like other nauseants and emetics, ipecac increases the secretions of the broncho-pulmonary mucous membrane, and is, therefore, held to possess expectorant properties. More than any other agent of the class, it relaxes the skin, and promotes cutaneous transpiration.

Ipecacuanha exerts but little influence over the circulation. In animals, lethal doses of emetine cause death by paralysis of the muscles of respiration, the heart continuing in action after the cessation of the respiratory movements (D'Ornellas). The temperature of the surface falls, but the internal temperature remains the same, or rises somewhat, owing, it is said (D'Ornellas), to the irritant action of the agent on the intestinal mucous membrane.

In the post-mortem, examination of animals killed by emetine, very considerable gastro-intestinal irritation is found. The lungs are sometimes seen to be hyperaemic and presenting patches of hepatization, and sometimes exsanguine, but the former condition is more frequently observed. As the most common state of the lungs, caused by lethal doses of ipecac, is similar to that which is induced by section of the vagi, it is a reasonable conjecture that it has a special action on these nerves—according to Chouppe, on the terminal filaments of the vagi.

The elimination of emetine takes place in large part by the gastrointestinal mucous membrane, and it is found in the secretions.

The physiological actions of the alkaloids of ipecacuanha have been reported on by Wild, and his conclusions are represented in the following summary: Both cephaeline and emetine possess a powerful emetic action, but the dose required to produce emesis was twice greater for emetine, but the nausea preceding vomiting was twice greater with cephaeline. Both lower the arterial tension, but more depression was caused by emetine. Both cause contraction of the blood-vessels, but emetine is the more active. Both cause slowing and weakening of the heart's action in about the same degree. Both act as muscle poisons, but cephaeline has the greater effect, and also acts on the motor nerve endings, causing muscular contraction. Salivation was caused by both, and a flow of nasal mucus by emetine. Both apparently increased peristalsis, and gave rise to loose motions without any distinct purgative action. No effect was observed on the skin or kidneys by either alkaloid.

Wild concludes that cephaeline may prove useful as an emetic, without depressing effects, in doses of from one twelfth to one sixth of a grain. It is too slow in action, however, for cases of poisoning. As an expectorant in catarrhal and febrile conditions, emetine would seem to be indicated in doses of from one sixth to one third of a grain. The effect it has in causing contraction of the vessel explains the utility of ipecacuanha in haemorrhage, and indicates the special value of emetine for this purpose.

Therapy

As both the alkaloids of ipecacuanha have a decided emetic property, they may be utilized under the same conditions and with the same limitations as the powder of the root. As they can be used subcutaneously, they present obvious advantages in many stomachal and other diseases. Although emetine is slower in action, it causes less nausea and systemic disturbance than cephaeline. As these alkaloids increase secretion, nasal and intestinal, and also promote peristalsis, they can be prescribed instead of ipecacuanha in torpor of the liver, constipation from insufficient secretion of the intestinal glands, etc. Just as ipecacuanha is now prescribed as an expectorant in cases of broncho-pulmonary catarrh, ordinary coughs, asthma, and similar affections, emetine may now be substituted. As a remedy in pulmonary haemorrhage, in menorrhagia, purpura, and similar morbid states, emetine will no doubt prove efficient. It is probable that in uterine haemorrhage, under the conditions named in the paragraph on that subject, emetine subcutaneously may. prove an efficient substitute for the crude drug. Until, however, more facts are accumulated and the true powers of the alkaloids are determined by clinical trials, it is probable that the crude drug, or its preparations, will continue to be preferred. For therapeutic purposes, the most efficient preparation is the fluid extract. The dose of this is so small and its efficiency so decided, that on the score of convenience as well as power it has many advantages as compared with the powder.

For ordinary purposes no emetic is more safe and efficient than ipecacuanha. As it causes but little depression, and is free from irritant effects in ordinary doses, it may be given in conditions of the system in which tartar-emetic and the other mineral emetics are inadmissible. When the stomach is to be relieved of undigested aliment, ipecacuanha is the most suitable emetic. Attacks of acute indigestion, migraine, and the so-called bilious sick-headache, may not infrequently be cut short by an ipecac-vomit. The good effects of the vomitive treatment are not infrequently most strikingly exhibited in the beginning of contitiued fevers, the eruptive fevers, erysipelas, and periodical fevers. It has been alleged that fevers are sometimes "aborted" in this way. In denying the possibility of such results, it must be admitted that clinical experience has shown the good effects of the practice on the subsequent course of the malady. Formerly an ipecacuanha-emetic was much more frequently employed at the outset of fevers than is the fashion at present, and the author is convinced that this mode of treatment should be resorted to now in suitable cases. The indications for the use of emetic doses of ipecacuanha, in the fevers above named, are these: a heavily coated tongue, much nausea and ineffectual efforts to vomit, a strong sense of epigastric oppression, icterus or an icterode hue of the surface, a hot and dry skin, acid and turbid urine. When these symptoms are present in cases of malarial fever, the antiperiodic remedies will be much more effective in their action if their administration has been preceded by an ipecacuanha-emetic.

In all the cases in which emetics are employed for mechanical effects, as in membranous croup, capillary bronchitis, foreign bodies lodged, etc., ipecacuanha may be used. In croup it is not so effective as the yellow subsulphate of mercury; in capillary bronchitis, as tartar-emetic; but, as respects the latter disease, ipecacuanha is to be preferred in the very young or very old, and in those debilitated by any cause. In the domestic treatment of laryngismus stridulus an emetic dose of the sirup of ipecac is the most usual remedy.

As an emetic, twenty grains of the powder of ipecacuanha may be diffused in a cup of warm water, and a table-spoonful of the mixture exhibited every fifteen minutes until emesis occurs. Two grains may cause vomiting; and four grains will usually act efficiently; hence a good method of proceeding, when an emetic effect is desired, is to exhibit a powder of four grains in a table-spoonful of warm water every fifteen minutes until vomiting occurs. The action will be facilitated by drinking freely of warm water; but, if the systemic impression of the ipecacuanha is desired, the patient should retain the recumbent posture, and all fluids should be withheld. If the cathartic as well as the emetic action is sought for, some weak animal broth should be given when the stomach is emptied of its contents. If free action of the skin is to be promoted, as soon as the vomiting has ceased, warm aromatic infusions should be administered, and the patient should be covered with blankets.

It has long been known that ipecacuanha, in small doses, has the power to arrest certain kinds of vomiting. Attention has recently been recalled to this curious fact. It is in nervous vomiting more especially that this remedy is useful: for example, in the vomiting of pregnancy, vomiting of drunkards, vomiting of migraine, etc. A minim of the vinum ipecacuanhae, given every half-hour or hour in a little water, will sometimes relieve these cases in a very remarkable manner. It fails much more often than it succeeds, and the author has never yet seen an instance of its successful use in this way. The belief in this action is largely traditional—even apocryphal.

It is a singular fact, showing the remarkable phases through which professional opinion passes, that ipecacuanha, which was introduced at the close of the seventeenth century as a remedy for dysentery, after a time ceased to be employed in this disease, but has again been restored to the estimation in which it was originally held. Epidemic dysentery, especially of malarious and tropical countries, is the form of the disease to the cure of which ipecacuanha seems best adapted. The author has used it with much success in acute dysentery, as it occurs in the interior valley of this continent. When the characteristic ipecacuanha-stools are produced, the tormina and tenesmus cease, and the dejections soon become fecal; the skin, previously dry and hot, becomes moist and cool, and a refreshing calm is experienced. Large doses of ipecacuanha are required in the treatment of acute dysentery. In the severe attacks of tropical regions, from twenty to sixty grains are given for the initial dose, and the quantity subsequently administered depends on the effect —usually about twenty grains every four, six, or eight hours. It is important to establish tolerance of the remedy as speedily as possible. If the first dose be rejected, subsequent ones may be retained. Various expedients may be resorted to in order to secure the retention of these large doses. The ipecacuanha may be combined with some opium and aromatic powder: Rx Ipecacuanhae, 3 ss; opium, gr. j ; pulv. aromat., grs. v. M., ft. pulv. no. j. After the dose of ipecacuanha is administered, a sinapism may be applied to the epigastrium, and an enema of laudanum and starch, or the subcutaneous injection of morphine, may be practiced. Milk is an excellent vehicle for the administration of ipecacuanha. In the cases of dysentery treated on this plan by the author, he has found that doses of fifteen grains, given in milk, were generally pretty well borne. It not infrequently happens, however, that tolerance can not be established, and the remedy must then be abandoned. Some patients so object to the nausea produced by it as to be reluctant to take it, and others, after one trial, decline to continue the treatment Notwithstanding these drawbacks, it must be conceded that ipecacuanha is a most valuable remedy in epidemic and sporadic dysentery. It has been shown that in India, before the introduction of this method of treatment, the mortality from dysentery was about 7·96 per one thousand of cases; but, since the use of ipecacuanha has been generalized, the mortality has fallen to 20·15 per one thousand of cases.

Ipecacuanha has also been used with success in chronic dysentery, but, in the author's experience, it is by no means so beneficial as in the acute. It succeeds best in those cases which are the outgrowth of acute attacks, and in which the intestinal ulcerations are not far advanced. The rules for its administration are the same in chronic as in acute dysentery. In the summer dysentery and diarrhoea of teething children ipecacuanha is often extremely serviceable. The special indication for its use is the occurrence of greenish stools, containing mucus and sometimes blood. These stools are usually voided with much pain and straining. At the same time the skin is harsh and dry, the tongue rather dry and pasty, or glazed, and there is great thirst, although the fever may not be high. Ipecacuanha changes the character of the stools, induces perspiration, and allays the thirst and dryness of the mouth. From two to five grains every two hours may be given in these cases, or it may be administered with pepsin, oxide of zinc, bismuth, or other remedies. Rx Ipecacuanhae, grs. xij; bismuthi subcarb., 3 j; pepsinae sacch., 3 ss. M., ft., pulv. no. xij. Sig.: One in milk every two hours.

The evidence is conclusive that ipecacuanha possesses very valuable antihaemorrhagic powers. It has been successful in haemoptysis, epis-taxis, menorrhagia, post-partum haemorrhage, etc. As Peter has observed, "the vomitive medication" (ipecacuanha) "arrests not only haemoptysis but all kinds of haemorrhage, and is, therefore, a general antihaemorrhagic medication." In haemorrhages the ipecacuanha should be given in frequently-repeated doses until vomiting ensues; usually, when this effect is produced the haemorrhage ceases. Other antihaemorrhagic agents may be combined with ipecacuanha. Rx Ext. ipecac. fluidi, 3 ij: ext. ergotae fluidi, 3 iv; ext. digitalis fluidi, 3 ij. M. Sig.: Thirty minims to a tea-spoonful at a dose, as required. The author has witnessed excellent results from this combination in haemoptysis and menorrhagia. In the treatment of post-partum haemorrhage, the most suitable combination is fluid extract of ipecacuanha and fluid extract of ergot. Trousseau strongly urges the employment of ipecacuanha in post-partum haemorrhage, and, indeed, in the various accidents which occur in the puerperal state, and, above all others, as respects the utility of the treatment—puerperal dysentery—in which the author has verified Trousseau's statements. "He has not observed the least ill-result from this practice; on the contrary, in the most of these cases, he has obtained either a cure or a notable amendment."

Certain acute affections of the broncho-pulmonary mucous membrane are much benefited by non-emetic doses of ipecacuanha; for example, acute catarrh of the nasal and bronchial mucous membrane, hay-asthma, capillary bronchitis. An emetic dose will cut short an attack of laryngismus stridulus. An occasional emetic gives great relief in whooping-cough, when there is profuse bronchial secretion. Non-emetic doses of the fluid extract (τη j—τη iij) diminish the violence of the spasms in this disease. Nauseating and emetic doses are serviceable in the attacks of spasmodic asthma, but the good effects of the remedy are lost by repetition. Ordinary colds, especially in children, are benefited by doses sufficient to produce slight nausea but not vomiting. A troublesome cough at night, which prevents sleep, may not infrequently be arrested by a dose at bed-hour of some one of the ipecacuanha preparations. For these various purposes the wine or the fluid extract may be used, but the latter preparation is much more trustworthy and effective than the former, if genuine.

Authorities referred to:

Chouppe, M. Archives de Physiologie, No. 1, 1875, p. 101.

D'Ornellas, Dr. Antonio-Evaristo. Du Vomissement, etc. Bulletin Gén. de Thérap., vol. lxxxiv, pp. 193, 244, 295, 348.

Duckworth, Dr. Dyce. St. Bartholomew's Hospital Reports, vol. v, p. 287, 1869.

Fluckiger and Hanbury. Pharmacographia, article Ipecacuanha.

Fuller, C. C. London Lancet, December 4, 1869. On the Action of Ipecacuanha.

Husemann, Dr. Theodor. Handbuch der gesammten Arzneimittellehre, zweiter Band, p. 608, et seq.

Peter, M. Michel. A propos des Hémoptysies et de leur Traitement par la Medication Vomitive. Bulletin Gen. Thérap., vol. lxxvii.

Phillips, Dr. C. D. F. On the Actions and Uses of Ipecacuanha. The Practitioner, vol. iii, p. 276, et seq.

Ibid. Materia Medica and Therapeutics, article Ipecacuanha.

Ringer, Dr. Sydney. Handbook of Therapeutics.

Trousseau et Pidoux. Traité de Thérapeutique et Mat. Méd., huitiéme edition, vol. i, p. 733, et seq.