result: a preliminary secretion in the respiratory tract, at the seat of the membrane, relaxation of the trachea and below, and a rapid rush of air through the trachea, as associated with the convulsive breathing of the vomitive act. Selection of emetic agents has already received attention; but it may be remarked that it is wise, so far as possible, to secure a period of nausea prior to exhibition of the emetic, as by ordering ipecac in frequent, non-emetic dose, in order to obtain secretion in the respiratory passages.

Once more, abscess of the tonsil has been adroitly lanced, so to say, by the operation of an emetic. The practical difficulty lies in timing its administration; but the force is quite apt to be wisely applied, as the pointing of the abscess is often turned toward the stomach, and away from possible inspection by the

surgeon.

Fourth Indication. The heart and the circulatory system in general, are directly and powerfully controlled by the emetic influence. Immediate effects are singularly like those that result from blood-letting; but blood-letting is spoliative, and therefore recovery from the former intervention is more speedy and complete. Every one has witnessed, if he has not experienced, the profound depression which nausea alone may exert on cardiac action; it may be doubted if the entire body has elsewhere organic sympathies so close and interdependent as those holding between the plexuses which control the innervation of the stomach and that of the heart. More remotely, but not less obviously, and largely because of this relation as affected by emesis, the

entire nervous system is involved in a disturbance, manifested by paleness, faintness, or tendency to syncope, smallness and threadiness of pulse, feebleness of respiratory murmur, coldness of extremities, relaxation of the sphincters and, in fact, of all muscles, voluntary and involuntary. Probably no other agency than vomiting, which the physician can direct, physiological or medicinal, is capable of accomplishing a sedative impression at once so prompt and emphatic and extended, and yet so transient and safe for the subject of it: a somewhat like condition, it is true, may be realized by application of cold; but cold has its discomforts and dangers, and, moreover, is soon followed by a stage of reaction and stimulation.

The occasion for resort to emetics, corresponding to the fourth indication, is not realized so often as formerly, as the physician nowadays reads his cases and applies his remedies; and especially as respects the power to be exerted over the heart and circulation. None the less, the subject demands attention because of its close relations to the general physiology of emetic medication; and, moreover, there is the rare and grave emergency when such medication may be turned to good account. The conjoined control exercised upon the muscular system suggests a more frequent application of emetic remedies. Some forms of muscular spasm, e. g., are peculiarly amenable to this mode of treatment; the spasmodic seizure being at once too violent and too strictly localized to permit either topical or general recourse to materials drawn from the class of narcotics. Such

is laryngismus stridulus, spasmodic croup, asthmatic seizure, hysterical convulsion. But even here, application has been limited by the introduction of anæsthesia; and in strangulated hernia or rigidity of the uterine os, the depressant emetic is wholly a thing of the past.

In conclusion, it is worthy of note, that the extraordinary control which the emetic may bring to bear upon the heart involves no danger to life; and no more does the sudden disturbance of circulation in the brain; except in the presence of certain contraindications, to be discussed later. As previously said of the stomach alone, so now it may be remarked that stomach, heart and brain may be subjected to a degree of strain or to a measure of continuous and often repeated interference, in the operation of the emetic,-and yet recovery thereafter be prompt and complete,-which would be incredible but for the results of assured clinical observation.

Such, therefore, are the more prominent and useful, it may be added the more obvious, indications for the service of an emetic. Some writers distinguish as many as eight or ten indications; such as that with antiphlogistic or with derivative purpose, or that based upon the known effects of the emetic upon the respiratory apparatus. But with the exception of the latter, the corresponding applications are few and unimportant; although Trousseau, et cet., believed that diarrhoea might be cured by the revulsive action of emetic medication, and were disposed thus largely to explain the efficacy of ipecac in dysentery. The influence which the emetic extends to

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the bronchial passages is so constant, that it may be assumed to be a part of such action; and, accordingly, much that pertains to the pulmonary service of this class of remedies has been disposed of already. So far as the emetic material is also the every-day expectorant, it is almost wholly when exhibited in dose short of emetic or nauseant action.*

Contra-indications.-Emetics are forbidden in the aged when there is suspicion of degeneration of the heart or arteries, and also in the apoplectic. Certain other forms of heart disease, in whatever subject, render their use inconsistent with safety; such is marked neurotic feebleness, dilatation, aneurism, and, of course, degenerative lesion of every form. The existence of hernia is not a positive contra-indication, but demands caution and, generally, resort to other remedies. Active congestion or inflammation in the brain forbids their use. They are best avoided at the time of the menopause, and must be employed intelligently or not at all during the continuance of the menstrual period. The powerfully perturbative and derivative influence which the emetic exerts in another direction than the pelvis, affords explanation of the latter caution, and also partly explains the following exception: "When the menstrual flux is painful or scanty, or, again, when a metrorrhagia supervenes under the influence of a bilious condition,

* It will be remembered, in the discussion of the physiology of ipecac, that the position was taken that this drug has power to increase bronchial secretion, aside from any influence exerted upon the vomitive apparatus.

we may procure vomiting with great benefit to the patient."

Mode of Administration.-Nothing remains to be said, except to summarize and bring together statements previously made. Emetics are given by the stomach or else hypodermically-chiefly by the former method. If hypodermically, there should be complete and neutral solution; a slightly acid reaction in the vehicle is not so likely to cause abscess as is the presence of undissolved particles. Ingested by stomach, the material should either be in form of solution or, if insoluble, should be suspended in warm water. Two conditions are essential in the vehicle-it should be warm and provided in liberal quantity. A cold or hot or aromatic draught helps to defeat the purpose of the emetic. All emetics, whether mechanical or special, are more or less irritant, and the crypts of the mucous membrane of the stomach must be protected from contact with their particles; besides, a void stomach renders the vomitive act distressing and, it may be, ineffectual.* Still farther, if the emetic material prove slow in operation, draughts of warm water will shorten the preliminary nausea and make emesis more easy and complete.

Arrest of Vomiting.-There is a state of supervomition, as there is of superpurgation; the former, however, much oftener the result of certain morbid complications than of medication. Few conditions are so distressing as is the obstinate vomiting which

* Probably in no other instance is this rule so often unconsidered as in the exhibition of Turpeth Mineral.