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yet insufficiently employed for the express object, their effect in relieving the chest, when the bronchial cells and tubes are gorged with mucus, is scarcely less beneficial than their action in unloading the biliary system. They may justly be reckoned the most powerful expectorants we possess; speedy in effect, and often complete in relief. In bronchitis and other cases, where, from accumulation of mucus in the air passages, the breathing and pulmonary circulation are greatly oppressed, and the patient under much suffering, the change thus produced is sometimes surprising in degree, and such as we can obtain in no other Their value in way. croup well attested by the concurrence of all modern experience with that of the excellent physician who first enforced this
I have already commented on the apprehension of hæmorrhage, or pressure on the head, which checks one important application of emetics. In the case now before us, their use is often abandoned from the like fear of making undue pressure on the vessels or producing suffocation; an apprehension unwarranted by fact, and which the most common experience might correct. The converse of this is nearer the truth, and
forms, indeed, the especial value of the remedy in the instances alluded to. Even in cases of actual inflammation of the lungs I believe the risk of their use to be exaggerated, though undoubtedly more watchfulness is here required.
There is the greater cause for referring to this application of emetics, from our vague and imperfect views as to the whole class of expectorant remedies. Scarcely, indeed, is the term defined in its ordinary use in practice. It is left doubtful whether the expectorant is a medicine which promotes the secretion of mucus from the bronchial surfaces facilitates, after being formed, its removal from the chest — or combines both these effects in its single power. The natural
result is that of rendering practice almost equally vague on these points. And, though there is less liability to dangerous error here than in many other classes of remedies, yet it is obviously important to gain more distinct views than those currently received.
The emetic is probably the only agent which both promotes secretion and discharges it; the latter action being chiefly, if not altogether, a mechanical effect of the effort of vomiting induced. There is reason to believe that no one of the medicines termed expectorants can act in freeing the chest from mucus in the air passages, unless they be so given as to produce vomiting, or to bring on cough by irritating the membranes; or unless they increase or attenuate the actual secretion, so as in this manner to excite cough, and render it more effectual for expectoration. Their influence upon secretion is indeed the circumstance we must chiefly regard among medicines of this class; and here, again, their effects and relative value are very ill defined. It is probable that the expectorants, so termed, which act as emetics when given in larger doses, are principally of avail in augmenting the secretion when used so as to keep up a certain degree of nausea. This state has manifestly much influence in relaxing the exhalant and secreting vessels; and though I do not venture to affirm it, where proof is so difficult, I believe that it is chiefly in this way that the medicines in question come to be of any avail in practice.*
The question as to the proximate cause or seat of the sen
* The whole class of expectorants, however divided and defined, needs revision, as do so many other parts of the Materia Medica. The progress of medicine, as a science, requires that we should not bind ourselves too implicitly to old tables and formulæ, which have their origin in doubtful sources, and gain authority chiefly by long transmission from one book or lecture to another.
sation which we term nausea, and its relation to the act of vomiting, is indeed a curious and difficult one. If any thing like explanation is to be found, it will probably be through the results obtained by Magendie and others, to which I have already alluded.
Connected with this subject is the alleged effect of emetics as a remedy in the early stages of pulmonary consumption; an opinion held by many eminent physicians from an early period down to the present day; and which has gained rather than lost weight by recent inquiries on the subject. The researches of Dr. Carswell into the origin and seat of tuberculous deposits afford a more explicit notion how emetics may act, by removing or preventing the growth of tubercle on the membrane of the bronchial cells. It is easy to understand that any means which can promote the natural secretion into these cells, render their contents more liquid and easy of removal, and aid in actually procuring it, may be of singular advantage- especially in that earlier part of the disease, where the presumption exists that tuberculous deposits are only beginning to take place. The action of emetics reaches further towards these several objects than that of any other remedy; it is compatible with every other part of treatment required; — and under regulation of their use, and with due regard to any acute inflammatory states which may occur in the progress of the disease, I believe them to be the safest and most effectual means yet suggested for the relief of incipient phthisis.
Unfortunately this must still be stated more on speculation than on certain experience. A few Continental physicians have made systematic use of the remedy; but in England its employment with this object seems to have been very partial, though enforced by medical authorities which claim every respect. The difficulties, indeed, which oppose themselves
to the treatment, especially among the higher classes, are not easily overcome. The remedy, from various associations, is regarded as more formidable than is really the case; - the present habit of practice is adverse to it; and, further, the suggestion of the treatment comes at a time when fears may hardly yet be awakened, or when there is repugnance on the part of the patient and those around to admit what argues a dangerous disease at hand. The influence of these causes is well known to every physician.
The use of emetics in producing absorption of effused fluids, or of parts morbidly enlarged, seems sufficiently attested. But we have no reason to suppose that they have any effect on tubercles actually formed; and their employment therefore in phthisis, when we can obtain trial for them at all, is probably to be limited to the earliest stage of the disorder.
I need advert but slightly to the benefit derived from emetics in asthma; though here again it must be admitted that there is an insufficient use of the remedy, seeing the great good gained in many such cases by unloading the stomach and liver; and the equal advantage, though less obvious in explanation, from its influence on the actions of the circulation and nervous system. A single emetic may cut short a paroxysm for which opiates and antispasmodics have long been employed in vain.
The use of this remedy in the disorders of children is at present much less general than it ought to be. In very many cases emetics would beneficially supersede that employment of purgatives which often adds to the irritation it professes to remove. In the infantile fever, for example, which is a type of various disorders, an occasional dose of ipecacuanha, so as to excite vomiting (especially where there is much of the cough which attends this complaint, and large secretion from the mucous membranes), will be found more effectual than
any other means. It is to be noted, further, that the action of vomiting is for the most part singularly easy in children; more immediate, and generally less distressing, than that of purgative medicines.
In these remarks I have attended rather to the general effects of emetics, than to the several qualities and manner of action of the medicines so termed; it being my object only to draw attention to the fitness of their larger and more defined use in ordinary practice. The question of preference among different emetic substances is indeed of less moment, from their action in emptying the stomach of its contents. In the majority of cases, that may be deemed best which fulfils its purpose without actual pain, and with greatest certainty and speed. If ipecacuanha were invariably of good quality, which unfortunately it is not, it might be sufficient in almost every instance. Antimonials, from sustaining nausea longer, and producing more distinct sedative effect on the nervous and vascular systems, may be preferred where excitement of these exists. The emetic of simple mustard ought never to be lost sight of as an immediate resource, and one producing its effect with less previous nausea or distress than any other.
In considering, however, the effects of emetics, we must separate such as belong to the direct action of the medicine on the coats of the stomach, from those produced by the act of vomiting. The former may be more or less hurtful, as depending upon a peculiar irritation of the part; and here the action of emetic medicines must be assimilated to that of acrid or poisonous matters received into the stomach or generated there. But the mere effort of vomiting itself is much less injurious to this organ than might on first view appear likely. Without referring in proof to the "vomitus luxuriæ