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              THE  NEW  YORK




JOURNAL  OF  MEDICINE.


             FOR  SEPTEMBER, 18 46*'°'


             •   ----------■  i:£H7


On  the Effects of Emetics in the young subject. By John B. Beck,
  M.D., Professor of Materia Medica and Medical Jurisprudence in the
  College of Physicians and Surgeons of New York.

With the exception of cathartics, there is no class of remedies more
generally resorted to in the management of the diseases of children,
than emetics ; and in a large number of cases, there is  certainly none
more useful.  They are active agents, however, and like all agents of
this description are capable of doing good or evil, according to the man-
ner in which they are given.  In the use of them, therefore, it is all
important to ascertain whether  there is anything in  the young subject
which modifies their operation.   Unless this is done, it is impossible, of
course, to prescribe them with any degree of precision, or even safety.
The subject is one of interest as well as of practical importance, al-
though it does not appear to have attracted the attention to which it is
so justly entitled. In a previous paper,* I endeavored to point out how
the effects of opium were modified in the infant subject.  On the pre-
sent occasion, I propose to pursue a similar  investigation in relation to
Emetics.
  As it regards the mere mechanical act of vomiting, young children per-
form it more easily than adults.   This is a fact which has long been ob-
served by practical men, and about which there can be no  question.
It is no doubt a wise provision of the Creator to enable the child to re-
lieve itself from the effects of an overloaded stomach, to which it is so
constantly liable in the early period of its existence.  Although the fact
has thus been long known, and the intention of it is obvious, yet the rea-
sons have not been so well understood. They appear to be the two
following.
  In the first place, from the experiments of Majendie, in relation to the
manner in which vomiting is performed, it would seem that in that pro-
* Journal <rf Medicine and the Collateral Sciences, for January, 1844, p. 1. 
2               J. B. Beck on the Effects of Emetics.          [Sept.

cess, the stomach is in a great measure passive, and that a certain de-
gree of pressure upon it from  the surrounding organs  is absolutely ne-
cessary, before vomiting can be accomplished.   This pressure is made
by the contraction of  the  diaphragm  from above and  of the abdominal
muscles from below, upon the viscera surrounding the stomach.  As a
matter of course,  the pressure  thus exerted will be greater or  less, ac-
cording to the volume of the viscera.   Now it is well known that in the
early periods of life, the abdominal viscera have a much larger propor-
tional size than they have in  the adalt.   This is particularly the case
with the liver.*  In early life, therefore, during the  act of vomiting, the
pressure made upon the  stomach by  the  surrounding organs must ne-
cessarily be greater than it is in  the  adult, and in consequence of this,
the greater the ease with which the organ is evacuated.
   In the second  place, the shape of the stomach in the infant is more
favorable to the easy evacuation of its contents.  That the stomach un-
dergoes successive changes in its shape, from birth  onwards, is a fact,
which although but recently investigated,  is, I believe, well established,
and for its elucidation we are indebted to the  labors of  Prof. Shultz of
Germany.   His attention seems  to have  been called ^to it from the pe-
culiarities which  he  noticed in the shape of the stomach of those ani-
mals which vomit easily, and  those which cannot be made to vomit  at
all. Thus for example, the horse, rabbit, hare, and guinea pig, cannot be
made to vomit even by the most powerful  emetics, while the dog and
the cat throw up very readily—and he found that the shape of the sto-
mach  in the  two sets of animals  was entirely  different, and that the
same  difference exists between  the  stomach of the child and the sto-
mach of the adult.  The  former is more of a conical form, drawn out
lengthwise, and gradually narrowing towards the two extremities.  The
oesophagus is inserted into the fundus at the  left  extremity, and at a
distance from the  pylorus, leaving the two curvatures of the stomach
running almost parallel to each other.   In  short  the  stomach of the
child resembles that of the carnivorous animals generally.  The  latter,
i. e. the stomach of the adult, is very different; it is more circular in  its
form, and the oesophagus, instead of being inserted into the left extremity,
is  in  the middle, between  the  left  extremity  and the pylorus.  The
pylorus, too, is drawn back towards the cardia, so that the  small curva-
ture  is very  short, while the large curvature is  greatly  extended.  The
consequence of all this is, that the stomach of  the adult has  a rounder
shape, resembling that of herbivorous animals generally.   Now, accord-
ing to Prof. Shultz, the stomach  which  approaches  nearest to  the
cylindrical  shape, must have its contents evacuated with the greatest
ease ;f and this  would appear  to be the  case, as a matter of course,
whatever theory  of vomiting may be adopted ; whether performed, as
some suppose, by the simple antiperistaltic action of the stomach itself;
or according to Majendie, by the contractions of the diaphragm and  ab-
dominal muscles alone ; or according to others, by the combined action of
all these organs.
   The foregoing considerations would seem to account very satisfacto-
rily, both physiologically and  anatomically, for  the fact with which we

   * According to Meckel the proportion between the weight of the liver and that
of the whole body, is as 1: 18 or as 1 : 20, in the full grown foetus ; while in the adult
it is as 1: 35 or as 1 : 36.  Meckel's Anatomy by Doane, vol. iii  p 309
  t British and Foreign Medical Review, vol. ii., p. 537.       '' 
1846.]
J. B. Beck on the Effects of Emetics.
3
started, that the mechanical act of vomiting is  performed with greater
ease in the child than in the adult.   If vomiting, then, be induced in  a
child by mild agents, the whole process is performed with greater facili-
ty than by the adult.   This, then, is the first peculiarity in the effects of
Emetics in children.
   If, on the other hand, Emetics of an active and debilitativg character,
and which produce much nausea, be used, the effects are more uncertain and
energetic than  in the adult.  The articles to  which  I allude, are the
antimonial emetics, and these accordingly are  frequently hazardous to
young children, and that, too, when used in  doses not peculiarly large.
The immortal Sydenham seems  to have  been  fully aware of this fact.
In speaking of the continued fever of 1661, 2, 3, and 4, he says, " it has
often been a difficulty with me, when called to infants and children  in a
fever, and observing an emetic indicated, whereby they might have been
preserved from danger, that I durst not give them this infusion (crocus me-
lallorum), for fear of a bad consequence."*   It will  be recollected, that
at this time the Ipecacuanha had  not yet been  discovered.  Dr. Clarke
of London states that " a quarter of  a grain  of  Tartrate of Antimony in
solution, has been known to excite a vomiting which  has ended  in the
death of a young child, which before was  in  no danger."!  Dr. Arm-
strong observes that he " has seen again and again, delirium produced by
antimonial preparations, given so as  to excite  the mucous membrane of
the stomach and intestinal canal in very young children."J   Dr. Ham-
ilton advises,  that" Tartar Emetic  should never  be given to infants,
for alarming convulsions have followed  its use."§   By  Mr. Noble of
Manchester, a case is  related, in which the  death of a  child,  eleven
months old, was owing to the effect  of antimonial wine given as an
emetic. (|   Mr. Wilton (surgeon  to  the  Gloucester Infirmary) has also
reported two cases of children, one a year old and the other four years
old, which  were manifestly destroyed by the  use  of antimonial wine
given for ordinary colds.  Slight convulsions—vomiting—diarrhoea—sud-
den prostration and death took place, notwithstanding the use of cordials
and stimulants. TT  I have known a case  occurring  in this city in which
the one  thirtieth part of a grain of Tartar Emetic given to a, child a
year old, laboring under croup,  produced  such  severe  and protracted
vomiting, together with general  prostration, as to require stimulants to
save life.  Some  years  since I was called  to  see a  child, about three
years  old, who had been attacked  with  scarlet fever.   The symptoms
at first were mild, and no danger was apprehended  in the case, when  it
was suddenly taken with such alarming symptoms of prostration as to
call for a consultation.   On inquiry, I found that the attending physician
had been  prescribing small doses of Tartar Emetic.  Notwithstanding
the use of stimulants, the child died  in an hour or two after I saw it.   I
then suspected, and  have since been confirmed in  the  correctness  of
the suspicion,  that  the medicine  had no little  agency in bringing about
  * The Works of Thomas Sydenham, M.D., with notes by Benj Rush.M.D., p. 18.
  t Commentaries on some of the most important Diseases of Children.  By John
Clarke, M.D., &c, p. 33.
  J Lectures by the late John Armstrong, M.D.,p. 248.
  § A Treatise on the management of Female Complaints, and of Children in early
infancy. By Alex. Hamilton, M.D., p. 353.
  II Provincial Medical and Surgical Journal. By Robert J. N. Streeten, M.D., 1844,
p. 47.                      T Ibid, p. 204. 
4                J. B. Beck on the Effects of Emetics.           [Sept.

the fatal result.   The  child was naturally delicate, and there certainly
was nothing in the symptoms of the case to account for such a termi-
nation.
  The foregoing facts would seem  sufficient to show the uncertainty
as well as energy with which Tartar Emetic operates on the young sub-
ject, and the causes are obvious.
  In the first place, Tartar Emetic is a powerful sedative, and it is well
known, that in early life, the system cannot bear so well the operation of
this class of agents, as it can in the adult.  A striking illustration of this
we  have in  blood-letting, when carried to the extent of producing syn-
cope.  Adults, as a general  rule, recover very readily from this state ;
children, on the contrary,  recover  very slowly, and there is  always
more  or less danger to life  either from  convulsions or general prostra-
tion, and the same thing holds good  in relation to Tartar Emetic.  Be-
sides this, Tartar Emetic frequently acts as a local  irritant.  From the
delicacy of  the  mucous  tissue in early life,  it is of course more apt  to
act as such at  that period, than it  is in advanced years.   In both these
ways, it is evident that Tartar Emetic must necessarily prove more ener-
getic in  its action on the young subject.
  In the  second place, there is scarcely any medicine, whose action is
more decidedly modified by the  existing  condition of the system than
Tartar Emetic.   In the ordinary state  of the  system, it  acts as a  seda-
tive to the circulation, but at the same time causes, even  in very mode-
rate doses, nausea, vomiting, sometimes  free purging and  diaphoresis.
On  the other hand,  in certain states of  the system characterized by high
inflammatory action, very large doses and frequently repeated too, may
be given without any other effect than that of lessening excitement, and
curing the disease.   Again, as soon as this  state of excitement is sub-
dued under the use of the remedy, all the ordinary physiological effects
of it are reproduced.  Under these circumstances the article can no lon-
ger be  tolerated, and the use of it must be relinquished.   All  these
interesting peculiarities are  abundantly  illustrated  in the treatment of
pneumonia,  as first  practised by Rasori  in  Italy, then by Laennec  in
France, and afterwards by numerous English and American physicians.
Now, if Tartar Emetic is  thus  modified in  the adult by the existing
state of the system, how much more readily must all this  take place  in
the young subject.   In the successive changes taking place  in the child
in the different states  of disease, from irritation to  inflammation, it  is
hardly possible to estimate the degree  of uncertainty  attending the ope-
ration of this article.
  Again, vomiting, we know, depends very much  upon the existing
condition of the nervous system.   In certain conditions of the brain and
nerves, it  takes place very readily, while in others it is  almost  impos-
sible to excite it, even by the  most powerful means.   For examp'e,
when the system is under the influence of some narcotic, such as opium,
everybody is aware how difficult it is  to bring on vomiting ; and the
same thing occurs in the other morbid states of the nervous system,-ouch
as apoplexy,  &c.  Notwithstanding this, it has been observed, that if
under these circumstances, large  quantities of Tartar Emedc be given,
or if the use of it be too often repeated,  although vomiting may not  be
induced, yet there may remain sensibility enough in the system to ena-
ble  it to operate as a poison.   An interesting case illustrative of this is
related by Cloquet, of a person laboring  under' apoplexy, who received 
1846.]          J. B. Beck on the Effects of Emetics.                5

into his stomach upwards of forty grains of Tartar Emetic, without pro-
ducing either nausea or vomiting.  On  dissection,  besides the morbid
state of the brain, extensive lesions were found in the alimentary canal,
which were attributed to the action of  the Tartar  Emetic retained in
the stomach.*   Dr. Christison quotes a case from the Edinburgh Medi-
cal and SurgicalJournal (vol. vii., p. 305), in  which a scruple of Tartar
Emetic was given to  a person poisoned  by opium, without producing
any effect as  an emetic; sulphate of zinc was afterwards  given and
with  success.   As he recovered from the effects of the opium, he was
seized with pains in the stomach and bowels, and with tenesmus, which
lasted several days."|"   Now, it must be evident that in the young sub-
ject, all these results are much more likely to  occur, than in the adult.
   While Tartar Emetic operates in this way on the  young subject, Ipe-
cacuanha is never known to be followed by any injurious consequences.
To the youngest infant it may be  given not only  with  impunity, but
frequently with the greatest benefit. Why this is  so, must be manifest,
if we reflect  for a moment upon the peculiar  properties of the  two arti-
cles.   Although both are emetics, yet they differ widely from each  other
in many important respects.   The one is a mild  article  and limited in
its operation  to the stomach, upon which it never produces  anything
like local irritation, even when given in large doses.  The other, be-
sides   acting  as a  powerful emetic, is  a direct sedative,  capable  of
producing  general  prostration, and in some  cases acting as  a  local
irritant to the stomach and bowels, showing  itself in excessive vomit-
ing and  diarrhoea.
   With  regard to the manner in which  Tartar Emetic proves so dan-
gerous to infants, it is probably more by its action as a sedative, than
as a local irritant.  This may be inferred  from the symptoms attending
those  cases,  as  well  as from the appearances on  dissection* J*In the
two cases recorded by Mr. Wilton already alluded to, the main symp-
toms  were those of collapse, and on dissection  no appearances of inflam-
mation could  be detected either in the stomach or intestinal canal.   In
the case, however, related  by Mr.  Noble, on dissection, evidences  of
local   inflammation  were  found  in  the mucous  membrane of the
ileum.J
   The foregoing, then, appear to  be the important peculiarities in the
effects of Emetics on the young subject.  While vomiting, induced by
ipecacuanha and other mild means, is performed with greater ease than
by the adult  and does  not injuriously affect the  system, the  vomiting
induced  by Tartar Emetic is frequently followed  by severe  symptoms,
and sometimes proves  fatal.
   Now the due understanding of  these peculiarities is evidently of the
highest importance in the use of Emetics in children, and upon  the mind
of the student and young practitioner especially, they cannot be too
deepty,impressed.  From the manner in which medicines are treated of
in c'asows, in most of the books of Materia Medica, and in the lectures on
that subject, the student is insensibly led  into  the belief of a greater re-
semblance between them than really exists in nature, and it is only after
he  has nad tsome experience of  his own, that the error is corrected.

  * Paris and Fonblanque, Medical Jurisprudence, vol. ii., p. 280.
  t Elements of Medical Jurisprudence.  By T. R.  Beck,  M.D.,and J. B.  Beck,
M.D.,  vol. ii., p. 586.
  $ Provincial Journal for 1844, p. ^8. 
6                J. B. Beck on the Effects of Emetics.            Sept.

He cannot, therefore, too early in his career, learn that all classifications
are artificial—not founded  in  nature—that medicines are arranged  in
classes, merely for the sake of convenience, not because the articles un-
der each class are precisely alike, but because they resemble each other in
some one or more important feature, while in other respects they differ
greatly. No two medicines, even in the same class, are precisely similar,
and in acquiring a knowledge of them, the study of the points of difference
is  even more  important than  those  in which  they  resemble  each
other.
   From the foregoing considerations, it appears  to me that some infer-
ences of practical value, to the young  practitioner at least, may be de-
duced.
   1. As a  general rule we need not be afraid of vomiting the youngest
child, provided the means used be mild—such as ipecacuanha, &c.  The
mere act of vomiting  is attended with  no danger, while  the remedial
agency of an emetic is one of great power and value.  Besides acting on
the stomach, it extends its influence to the mucuous membrane  lining
the pulmonary organs, promoting secretion in the first place, and then
aiding in dislodging and ejecting  morbid accumulations ; accordingly,  in
pulmonary affections, there is nothing so efficacious.
   2. The vomiting induced by  the preparations of antimony ought  to
be resorted to  with great caution in very young children, and should
never be used except in those cases where a sedative effect is required,
and can be borne with safety.  Inflammatory excitement ought then al-
ways to be present to justify its use in  a young  child.  Where the
object  is simply to evacuate, the  stomach, it ought never to be thought
of.  In such cases as croup and pneumonic inflammation,  it may be
justifiably and  beneficially used.   In those cases it will be  found, that
the sj^tMi can  bear the sedative influence of the article much better
than it can in the ordinary conditions of the system.  Even here, how-
ever, care should be taken not to  push the article too far, as dangerous
collapse has been known sometimes to be the result.
   3. The  continued use of Tartar Emetic in young subjects cannot be
too specially guarded against.   It is in this way, probably,  that it is  so
apt  to  prove  injurious.  A single dose, even though it vomits very
freely, may be  borne with comparative impunity, while the  repetition of
it  may keep up nausea and intestinal irritation, so as to cause injurious
prostration.  This is very likely to happen in cases of a chronic charac-
ter, like hooping-cough.   Although mild emetics  are among  our best
remedies in this disease, and where the  subject is old enouo-h, a single
emetic  of antimony is frequently exceedingly beneficial, yet the repeat-
ed use of antimonial emetics,  as is too often the  case, appears to me to
be a great error in practice.   It is not  indicated by the nature of the
symptoms, and violates a great  rule which ought always to be observed
in the  management of chronic cases,  and that is, not to break down un-
necessarily the strength of the patient.*  Again, in ordinary catarrhal
affections in children, a good deal of mischief is frequently  done by the
continued  use  of expectorant mixtures  containing this  active article.
The Hive Syrup of Dr. Coxe, which is  now in  every family,  and is
  * Dr. Armstrong says that" it is a most notorious  fact, that the hooping-cough
is far more fatal in London than in the country ; and  I believe," he adds, " that thig
arises from the very free use of antimonials in London."  Lectures, p. 248. 
1846.]           J. B. Beck on the Effects of Emetics.                7

given on  the slightest occasions  to  infants, without even  consulting a
physician, has, I am convinced, done a great deal of harm.   I say this
without wishing to undervalue  this preparation.   In proper cases it  is
really a useful article, but persons out of the profession ought to know
that its  principal efficacy is owing to the quantity of Tartar Emetic
which it contains, and that the indiscriminate use of it  in  cases where
mild articles are required, must be injurious.*
   4.  As the effect of Tartar Emetic on the system cannot  always be
measured by its emetic operation, even in the adult, this fact ought to
serve  as  a caution against the too common practice of giving repeated
doses  of  it to  produce vomiting in children, when they happen to be
narcotized.  While it fails to vomit, it may still operate as a poison to
the system.   In all cases of  this kind, the  proper method of treatment
is, not to push the emetic, but to endeavor to restore the sensibility of the
patient, and then sometimes vomiting comes on at once.
   5.  In using Tartar Emetic in children, especial regard should be had
to their constitutions.   In those naturally delicate, and especially  where
the scrofulous diathesis exists, it should never be used if it can be  avoid-
ed.   Prostration is much more  apt to ensue in them, and where the ar-
ticle is persisted in for any length of time,  is sure to do harm.  It is  in
such constitutions, when  laboring under hooping-cough, and where the
use of this article has been too long continued, that the baneful  effects
 of it  are  most  strikingly observed.
   6. It is perhaps hardly necessary to say that if Tartar Emetic be  an
 article of such  danger, the younger the subject to whom it is given, the
more likel^Ss it to do  harm.  In children under a year, I should say, as
a general rule,  it ought never to be used.   During that period, the pow-
ers of life are too  feeble to bear so active a remedy, at th
 that all the beneficial effects of  an emetic may be gained ft
 of ipecacuanha, or even milder means.

   * Every ounce of Coxe's  Hive Syrup contains one grain of Tartar Emeti#.-
 My friend, Dr. McCready, has communicated to  me  the particulars of a  case  in^
 which a  child between  four and five years of age, laboring under hooping-cougk, „
 manifestly sunk  under the  too frequent use of this article.  The exhibition of it
 had been continued about eight days, when symptoms of intestinal  irritation came
 on, accompanied with great general prostration,  which in a few days ended  the
 child's existence.
e same time
og^A&use