The idea that inducing vomiting was an effective way of purging the body of poisons has a long history
Attitudes to emetics have changed over the years, with current practices focusing on a less-is-more approach
When I was a kid my mum had a bottle of syrup of ipecac in the cupboard. It was there just in case my ever-curious self ingested something I shouldn’t have.
“ … a little ipecac on hand in the home, ready for instant use … is incomparably superior to sticking a finger down a child’s throat and trying to induce vomiting”1.
That was 1966 when syrup of ipecac was actively endorsed for use in children for accidental home poisoning. The American Academy of Paediatrics, the American Association of Poison Control Centres, the American Medical Association, and the Food and Drug Administration were all on board, and their endorsement enabled syrup of ipecac to become an over-the-counter medication.
Having a bottle in every home was considered a must-have for the safety-conscious parent. Australia enthusiastically promoted the same message.
The idea that inducing vomiting was an effective way of purging the body of poisons has a long history.
It’s a first-principles concept, which rapidly caught on. But my mum’s bottle ‘just in case’ ipecac was a classic example of a well-intentioned, but misguided, one-size-fits-all approach to medicine.
THE STORY OF IPECAC
Ipecac is short for ipecacuanha, the dried rhizome and root of either of two tropical American plants, Cephaelis acuminata and C. ipecacuanha.
Its literal meaning is sick-making plant.
Ipecac has two main pharmacologically active components: the alkaloids emetine (methylcephaeline) and cephaeline. These alkaloids represent at least 90% of the alkaloids present in ipecac; a 30ml dose of ipecac syrup contains approximately 24mg of emetine and 31mg of cephaeline.
Ipecac induces vomiting through both peripheral and central mechanisms. The emetic alkaloids stimulate gastric mucosa sensory receptors, which activate the area postrema in the brain, the medullary structure that controls vomiting. They also directly stimulate the chemoreceptor trigger zone in this area.
Ipecac fluid extract and ipecac tincture are both toxic, so it’s the syrup that has been used in over-the-counter preparations.
In homeopathy, ipecacuanha is used to prevent vomiting by preparing it as a 30x potency dilute solution.
This decimal potency means that one part of ipecac has been mixed with nine parts of alcohol or water, and 30x means that this decimal dilution has been repeated 30 times.
After the rapid uptake of home-use syrup of ipecac, warnings started to appear. In 1997, the American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists released a position paper that questioned its use2. Two subsequent reviews in 2004 and 2013 confirmed the initial concerns, stating that: “There is no evidence from clinical studies that ipecac improves the outcome of poisoned patients, and its routine use in the emergency department should be abandoned.”3
Not only did using ipecac not guarantee complete emptying of the stomach, it also had a number of potentially serious side-effects. These included persistent vomiting, diarrhoea, lethargy, and aspiration. Chief among the morbidities associated with ipecac abuse were myocarditis with arrhythmias, myositis, gastro-oesophageal pathology, including Mallory Weiss tears, and metabolic abnormalities from both vomiting and diarrhoea, including alkalosis, hypokaloemia and dehydration.
Today, syrup of ipecac has been all-but relegated to the history books. Despite this, products for children containing ipecacuanha can still be bought over-the-counter in both the US and Australia.
HISTORICAL EMETICS
The use of emetics has a long history. Older remedies included water with large amounts of salt or mustard added, copper sulphate, and hydrogen peroxide. The last of these is still used in veterinary practice. But the oldest of all has a fascinating and macabre history.
From the 12th to the 17th century the substance of choice for producing emesis – amongst other alleged health giving benefits – was called mummia. Considered a major part of medieval pharmacopeia, mummia was no less than the powdered flesh of mummified bodies. So popular was this remedy that in the 16th century, there was a shortage of Egyptian mummies from which to extract the needed flesh. This saw a flourishing trade develop in desiccated bodies – any that could be found – being dug up, ground and then sold as mummia.
Ironically, it was probably the resin used to embalm the bodies that was the active ingredient. This resin resembled bitumen, and naturally occurring bitumen from the Dead Sea had long been prescribed to treat a wide range of ailments, from cataracts, to leprosy, gout, dysentery, and rheumatoid arthritis.
The confusion likely arose because the Persian word for wax, mummia, was often used to describe bitumen, the same word from which mummy is derived.
Mummia was used in the embalming of mummies but had nothing to do with bitumen. When apothecaries were not able to obtain naturally occurring bitumen, they sometimes turned to this false bitumen. Initially, this was obtained from the shrouds of mummies. Eventually, it came to be believed that it was the mummy itself, not the substance used in its embalming, that contained the medicinal qualities. Mummia and mummy became synonymous.
CURRENT APPROACHES
Despite this colourful history, the benefits of emptying a stomach after ingestion of a poison through the use of an emetic have been re-examined.
Current guidelines on treatment for oral ingestion of a poison do not advocate the induction of vomiting, partly because there is little evidence for the efficacy of stomach-emptying via emetics, and also because of the considerable risks associated with this practice. Activated charcoal is an exception, but it has a very small window of time and range of use, and only in fully conscious adults. More recent research is even questioning this practice.
The bottom line is when a human, especially a child, has been suspected of ingesting a poison, it’s best to call the Poisons Information service and get to an emergency department. Kids are allowed to bring their mummy.
Dr Ursula King is Medical Editor, The Medical Republic
REFERENCES
- Galton. Lawrence(1966-0l-09). “New Lifesaver For Your Medicine Chest”. Parade.
- AmericanAcademyof/ inico/Toxicolog y. European Association of Poisons Centres and Clinical ·toxicologists. Position paper: ipecac syrup. J Toxicol Clin Toxicol. 1997. 35:699-709.
- Hojer, J .. Troutman. WG .. Hoppu, K. et al. Position paper update: ipecac syrup for gastrointestinal decontamination. ical Toxicology. 2013, 51: 134-139.
- Silber, TJ. Ipecac syrup abuse, morbiclity, and mortality: Isn’t it time to repeal it’s over-the-counter status?. J Adolesc Health. 2005, Sep: 37(3): 256-60.
