Psychotria ipecacuanha. N.O. Rubiaceae.
LOCALLY, ipecacuanha produces dermatitis, going on to pustulation. It is an uncertain antiseptic, destroying, for instance, anthrax bacilli but not the spores. Internally administered in appropriate doses it is a powerful but not a rapidly acting emetic and an expectorant.
Most of the pathogenic effects of ipecacuanha are doubtless due to its chief alkaloid (or “active principle”) emetine, which has come of late years to supersede, in some spheres, the use of the powder and the wine. They will be considered together, special reference being made later to some of the uses of emetine. Administered by the mouth salivation quickly occurs and is followed by nausea and vomiting. The usual feelings of weakness, muscular relaxation,faintness, with quickened pulse, increased secretion of the mucous glands of mouth and pharynx, and waves of hot perspiration accompany the nausea and lead up to the act of vomiting.
In the case of ipecacuanha the emetic effect is due to its irritant action on the gastric mucous lining. This is shown by the fact that a much larger dose (of emetine) injected subcutaneously is required to cause vomiting than would be required by the mouth. Large doses so injected, in addition to causing vomiting, induce diarrhoea with blood in the stools and, in the case of experimental animals, produce fatal collapse. Massive doses injected may cause convulsive movements and rapid collapse without vomiting occurring.
These facts indicate a specific influence on the digestive tract, for the vomiting and diarrhoea occur after injection if the dose is regulated so as to give time for excretion, via this route, before collapse and death occur. The mucous membrane is congested, swollen and sometimes ecchymosed, muco-purulent discharge covering the surface. In dogs and in some cases of poisoning in the human subject ulceration is found.
Another digestive tract effect is the increased secretion of bile-and not merely a more complete evacuation from the gall- bladder-causing the drug to rank as a direct cholagogue.
Whether inhaled or administered by the mouth ipecacuanha produces hyperaemia of the respiratory mucosae-bronchial and pulmonary, the secretion of mucus being increased and cough resulting. In some sensitive subjects acute asthma is produced by quantities too small to be mechanical irritants.
There are a few other effects which will be referred to more fully in the provings record; they are: (a) A general tendency to bleeding from mucous surfaces; (b) rigidity, spasms and convulsive movements of various muscular groups; (c) diminished urinary secretion with dark red or bloody urine, and (d) fever without thirst during the heat, worse after 4 p.m. The provings add some details and qualifications to these general statements.
Generalities.-The chief of these are relief in the open air, and sensitive to either extreme of heat and cold. Exertion of any kind aggravates the dyspnoea and the colic.
Mind.-The ipecacuanha patient is irritable and impatient, but not violent or rowdy. If the patient be a child it shows its irritability by constant screaming. Ipecacuanha patients are sensitive to noise, including loud music.
Head.-Shooting pains (vertex) and bruised pain throughout the head from skull to root of tongue, with pain in the occiput and nape are induced.
Eyes.-Redness of the eyes, with lachrymation and shooting pains through the eyes, and mucus in the outer corners are recorded.
Nose.-Paroxysmal sneezing in severe attacks is noticed, with thin mucous discharge, cough and expectoration. Epistaxis is frequent.
Face.-The face is pale, especially during an asthmatic paroxysm, with blue areas under the eyes, and there may be twitchings of the lips and other facial muscles. With pyrexial conditions the face may be bright red, or bluish red, and the lips blue during spasmodic attacks. Soreness and ulceration may be found around the mouth.
Mouth.-Salivation is one of the earliest and most persistent symptoms, causing frequent swallowing. The tongue is fairly clean as a rule, or it may have a thin yellowish coat; there may be a sweetish taste due to oozing of blood from gums or elsewhere.
Stomach.-The outstanding symptom is NAUSEA, which, though located in the stomach, is a true “general”; it is present whether digestive or respiratory symptoms predominate, and whether the former be chiefly gastric or intestinal. Vomiting,of course, may be present, true gastric vomiting, though intravenous injection of emetine may cause it to come on via the medullary centre; there is a good deal of retching. This and vomiting are aggravated by cold drinks and by smoking. The ejecta may be of food (if recently taken), of bile or greenish mucus. Blood may be mixed with them. A dragging feeling in the abdomen suggests that the stomach is too full and heavy, and is “hanging down.” A sharp, cutting pain in paroxysms, so severe that the patient dare not move, is located in the stomach region, above the umbilicus. It passes from left to right. Absence of appetite, loathing of food, is part of the nausea complex; sweets are particularly objected to. Absence of thirst is a definite feature of ipecacuanha (except during the hot stage of intermittents).
Abdomen.-There is cutting, colicky pain in the abdomen, chiefly round the umbilicus. It may be likened to a hand clawing the belly, each finger, as it were, being felt to clutch or grip the bowels. The pains cause shivering, and are worse on movement.
Stools.-There is always diarrhoea if large doses have been administered, even if not given by the mouth, and a frothy, fermented appearance of the stools is frequently present. The evacuations may be (at first) thin faecal matter, or faeces coated with blood-stained mucus; later of white or greenish mucus. Straining may be present, but is not so conspicuous as with some other poisons; smarting and burning in the rectum and anus accompany it.
Genito-urinary system.-The urine is scanty and dark red, and sometimes contains blood. Ineffectual efforts to pass water may be made. Menstruation comes on prematurely, and is profuse, bright and clotted, and associated with a pressing down pain.
Respiratory Tract.-Paroxysmal sneezing with discharge of thin mucus is noticed, especially from irritation by the powder, as in sensitive subjects who have to dispense it. Indeed, this sensitiveness may be so great that sneezing, cough and asthma may come on when ipecacuanha is being handled in another room. The constrictive effect on the bronchial tubes,with tickling in them, causes great dyspnoea and a suffocative cough. It is worse from cold and walking about, but is rather relieved in the open if not very cold, and worse in the house. Loud wheezing, anxiety and oppression felt round the heart or in the epigastrium are present, the anxiety being due to shortness of breath and the annoyance of the wheezing. Any exertion renders the difficulty of breathing worse. Cough at first is dry and spasmodic, but later loose and rattling.
Limbs and Back.-Here the nervo-muscular element is prominent in the shape of spasms in the dorsal muscles, making them hard and bending the spinal column backwards; jerking in the legs and cramps in the thighs. There may also be pains in the bones and joints, variously described as bruised, torn, &c., or numb.
Skin.-Violent itching occurs, without rash, not relieved by scratching, until spots appear.
Fever.-The chilly stage of febrile conditions is followed about 4 p.m. by heat without thirst. One side or one hand is hot, while the other may be cold.
Haemorrhage.-Bleeding from nose, bowel, uterus, &c., are recorded in poisonings and provings, but clinical experience has extended this. Any haemorrhages of bright blood which clots readily may bring up ipecacuanha for consideration.
For many years it has been acknowledged that for some cases of vomiting minute doses of an avowed emetic-ipecacuanha-formed a useful remedy. Followers of Hahnemann naturally advanced this as a striking instance of homoeopathy. Opponents answered that the results were due to the “tonic” action of the drug. Against this, evidence was supplied to show that the benefit accrued from doses far too small to be described as “tonic,” and that tartar emetic acted similarly, though no stretch of imagination could describe this as a tonic, unless on the homoeopathic principle. An emetic in a large dose, a stomachic tonic in a small one! Depressants or irritants in large doses, and tonics or sedatives in small ones! It is “the dual action of drugs”-that convenient formula for evading the acknowledgment of homoeopathy.
Digestion.-Taking the therapeutic spheres of ipecacuanha in the order already followed, we begin with the digestive tract. Gastric catarrh, subacute or chronic,is perhaps the commonest of the complaints for which this remedy is required. The cause may vary from alcoholism to cancer, including pregnancy, lactation, acute fevers, whooping-cough, and menstruation. Fats, pastry, &c., may act as exciting causes. The symptoms are less severe than in arsenical cases, and they extend to the intestines; persistent nausea is the most striking concomitant; vomiting may or may not be present. The dysentery-like actions are often found in children, from unsuitable feeding; the stools are as already described;ipecac. will quickly benefit. Cholera infantum, cholerine and entero-colitis are terms applied to such conditions. It is also one of the standard remedies for dysentery, its use being indicated by similarity of symptoms, not by the name of the causative parasites, though the drug is more suited to amoebic cases than to bacterial. The large doses used in orthodox medicine are unnecessary if only those cases with appropriate indications are treated by the drug. Tenesmus is not a striking feature, but griping and bloody mucus are. In the early stage of some cholera cases it has been used with success, i.e., where nausea and vomiting are the chief features.
Haemorrhages.-Passing from the bleeding of dysentery to that of other conditions it is only necessary to mention the following: Menstruation, regular and irregular, post-partum haemorrhage, haematemesis, melaen, haemoptysis, epistaxis. In them all the prime qualitative indication is that the blood, whether flowing actively or passively, is bright red and quickly clotting; it may be profuse in some cases. In post-partum bleeding, unless kept up by mechanical means, haemorrhage as described, coming in gushes, accompanied with nausea and faintness, ipecac. may be relied on to act quickly. Ipecac. of course does not rank as a local haemostatic such as tannin or perchloride of iron, or like adrenalin, pituitrin or ergot by contracting the bleeding vessels. The rest of the patient’s symptoms must correspond with those of the drug if success is to be guaranteed. In cases where deeper conditions underlie the bleeding (such as tuberculosis or cancer) the remedy may be only palliative. In enteritis cases it may be curative, and the same is true of some cases of menorrhagia, epistaxis, haematemesis and pertussis. Menorrhagia or metrorrhagia from chill or shock and having ipecac. concomitants will be rapidly controlled.
Respiratory Diseases.-Ipecacuanha is useful in this sphere when catarrhal and spasmodic conditions, as indicated by the symptoms of the case, are combined. In coryza it is not of much use unless paroxysms of sneezing accompany the “cold”; in laryngeal or tracheal catarrh with spasmodic suffocating cough, dry at first, and with mucous discharge later, it is useful, especially if nausea be persistent. In the “croupy” cough early in measles it is sometimes indicated. In bronchial catarrh, acute or chronic, with a suffocating cough and dyspnoea, worse from the slightest exertion, ipecac. is invaluable, whether it has the specific pertussis element or not. In whooping-cough where epistaxis is present ipecac. will probably be required. Bronchial asthma is benefited, not only by palliation of the asthmatic attack, but also curatively. At the extremes of life for acute bronchitis ipecacuanha deserves consideration; for capillary bronchitis with patches of broncho-pneumonia in children, an in old people for emphysema with bronchitis an asthma. Where these cases are complicated by digestive derangements, with nausea, colic and frothy stools ipecacuanha would be additionally indicated. One author quotes a case where strings of tough mucous were brought up on coughing after an asthmatic paroxysm which resembled casts of the bronchi. A feeling of oppression and distress about the cardiac region is another indication.
Nervous Diseases.-The only named disease in this sphere for which ipecacuanha has been recommended is cerebro-spinal meningitis; in an epidemic “at Avignon in 1846-47″(Hughes, op. cit. p. 569), it was adopted as a specific with considerable success. In neuralgia of the eyes and head it has been used, but chiefly when the pain was part of a wider spread condition, such as conjunctivitis, lachrymation, sneezing, &c.
As complicating other maladies, stiffness amounting to slight opisthotonos, retraction of head, rigidity of muscular groups, even convulsive movements in acute diseases of children with red face, may be confirmatory symptoms. Tetanus is said to call for ipecac. at times.
Indolence and mental depression are the chief mental characteristics. Restlessness with spells of prostration with rank as a “general” symptom.
Pyrexia.-Without its possessing any very striking indications in the pathogenesy ipecac. has acquired reputation in the homoeopathic treatment of recurrent malaria. It is most useful where the type is irregular, where the characteristic nausea and salivation are well marked, where the hot stage is marked by an absence of thirst and by flushes of heat, sometimes limited to one coldness is worse from a warm room. The sweat is sour-smelling and is mostly on the upper part of the body. Movement, stooping and sweating all aggravate the patient. The attacks often being in the evening or early night. The use of this remedy in intermittents is not confined to homoeopathic ranks, though it is now out of fashion. It counteracts the abuse of quinine in intermittents.
Further, it was recommended by Hahnemann as an antidote to chronic opium poisoning.
The headaches of ipecac. are rheumatic or gastric, with the features already described.
(1) The one striking red thread running through the string of ipecacuanha symptoms is PERSISTENT NAUSEA, unrelieved by vomiting.
(2) Retching with empty stomach.
(4) Abdominal pains shooting left to right.
(5) Stools: (a) dysenteric; cholera infantum.
(6) Haemorrhage from many parts; bright, clotting, and possibly in gushes (uterine).
(7) Respiratory mucosal catarrhs with spasmodic breathing, suffocative cough, &c.; bronchial asthma.
(8) Intermittent fevers-irregular, hot stage without thirst.
GENERAL AGGRAVATION: Movement, stooping, sweating, evening or early night, warm room. Oversensitiveness to both extremes of temperature, dry, cold weather.
EMETINE.-The Brazilian ipecacuanha contains a considerable proportion of emetine, more than that from New Grenada (the Uragoya granatentis). It deserves mention here because of its use in amoebic dysentery, thought it cannot be described as a direct anti-amoebic, for it does not affect the Entamoeba histolytica, in vitro. It may therefore be assumed to act by increasing the resistance of the blood-serum or the tissues against this amoeba, and it is not be specially noted that if given too long or in too large doses it causes intractable dysenteric diarrhoea with weak pulse, prostration and even collapse. It appears to cause a dermatitis with desquamation in fine flakes. If we regard the prescription of emetine or ipecacuanha as unconscious or unconfessed homoeopathy, it must at the same time be confessed that the results of treatment show that infinitesimal doses are not always necessary. It is given as hydrochloride by injection, in doses of 1 gr. daily for about ten days. This is usually followed by emetine-bismuth-iodide by the mouth in cachets, of which 3 gr. daily are given for about a fortnight. These doses may cause vomiting or diarrhoea, and opium is necessary in sensitive subjects to enable the course to be continued. The patient is kept in bed and on a light diet, chiefly milk. Repeated examination for cysts in the stools should be made before declaring a chronic case or a carrier cured-a second course, after an interval, may be needed. There is some incompletely understood relationship of a specific nature emetine and the Entamoeba histolytica which does not exist between the drug and other amoebae. The influence of the drug reaches even to the amoebae of a liver abscess. “In amoebic liver abscess Rogers removes the pus by aspiration and then injects into the cavity a grain of emetine dissolved in 1 to 2 oz. of sterile saline solution to destroy the amoebae” (Cushny, “Pharmacology,” p. 481).
Emetine hydrochloride has also been used by local injection (into the sore) in cutaneous leishmaniasis (oriental sore)with some results. Similarly it has been given intramuscularly or intravenously for urinary schistosomiasis (bilharziasis), 1 gr. in water 2 c.c.