1. Clinical Toxicology (2013), 51, 128–129
Copyright © 2013 Informa Healthcare USA, Inc.
ISSN: 1556-3650 print / 1556-9519 online
DOI: 10.3109/15563650.2013.771741
COMMENTARY
Ancient Therapies
Invited Editorial
MILTON TENENBEIN
Bloodletting1 and trepanation2 (drilling of holes into the
skull) are ancient therapies long since abandoned. They
were intended to remove excess humors, toxins, or other
disease-causing agents from the body. Similarly, the intent of
ipecac-induced emesis and gastric lavage, the so-called “gastric decontamination” or “gastric emptying” procedures, is to
remove poisons from the stomach to prevent poisoning.
The origins of ipecac-induced emesis and gastric lavage
as interventions for the overdose patient date back greater
than one-half and two centuries, respectively. They became
first-line therapies and standard of care for the overdose
patient in the middle of the twentieth century. However, literature questioning efficacy began to appear in the 1980s.3,4
The landmark original position statements of the American
Academy of Clinical Toxicology (AACT) and the European
Association of Poisons Centres and Clinical Toxicologists
(EAPCCT) published in 19975,6 marked the “beginning of
the end” of these therapies as standard of care; however,
their use was already declining (Fig. 1). This is a reflection
of the impact of the literature published during the previous
15 years questioning the efficacy of these interventions. The
2003 statement of the American Academy of Pediatrics was
the death knell for the use of ipecac in the home.7 In this
issue of the Journal the AACT and the EAPCCT reaffirm
their 1997 position statements.
Preventing poisoning by removing it from the stomach
before it can be absorbed into the bloodstream is intuitive.
Indeed the suggestive generic terms “gastric emptying”
and “gastric decontamination” imply such outcomes and
likely contributed to their use. However the original position statements clearly showed that these procedures do not
remove significant amounts of ingested substances.5,6
We do not have absolute evidence, the revered randomized
clinical trial proving the lack of efficacy of ipecac-induced
emesis and gastric lavage. This prompts the evidence-based
medicine acolytes to remind us that lack of evidence does
not mean lack of efficacy. Indeed, this refrain is reiterated in
the last paragraph of the gastric lavage position statement.
Winston Churchill characterized the cold war era Russia as
“a riddle wrapped up in a mystery inside an enigma.” This
Churchillism can be applied to the clinical study of gastric
decontamination. There are too many factors to review in
this space as to why the production of RCT demonstrating
lack of efficacy is an unobtainable goal. In general, it is
always difficult to demonstrate the lack of efficacy. This is
the Chicken Little issue. It is virtually impossible to convince that hapless fowl of a nonoccurrence – the sky is not
falling. In the context of scientific design of clinical trials
this is the power issue. It requires an enormous number of
subjects to demonstrate lack of efficacy.
Power issues aside, there is a unique reason why we will
not have “absolute evidence” of lack of efficacy and this is
the uncertainty of the primary inclusion criterion, the ingestion of a dose sufficient to cause poisoning. In the clinical
arena, we routinely see patients who have ingested an overdose, but there is no a priori objective criterion to assure that
the patient has indeed consumed a poisonous dose. Clinical
experience demonstrates that most patients have not done
so. Thus all clinical studies will be diluted with a significant
proportion of “non-disease patients” in both the experimental and control groups.
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Address correspondence to Milton Tenenbein, MD, Professor of
Pediatrics, Pharmacology, Medicine and Community Health Sciences,
University of Manitoba, Children’s Hospital, 840 Sherbrook Street,
Winnipeg, Manitoba R3A1S1, Canada. Tel: ϩ(204) 787-2445. E-mail:
mtenenbein@hsc.mb.ca
7
20
10
20
0
04
20
8
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95
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89
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Received 23 January 2013; accepted 26 January 2013.
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Clinical Toxicology Downloaded from informahealthcare.com by 142.233.200.22 on 03/11/13
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Pediatrics, Medicine and Community Health Sciences, University of Manitoba, Children’s Hospital, Winnipeg,
Manitoba, Canada
Fig. 1. Percentage of patients treated with syrup of ipecac (diamonds)
and gastric lavage (squares) versus year. Data extracted from American
Association of Poison Control Centers annual reports (1983–2011).
Year refers to year of report.
128

2. Ancient therapies 129
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The American Association of Poison Control Centers
reports virtually no use of these interventions over the
past decade (Fig. 1) and some might debate whether it
is still necessary to reaffirm these position statements. It
would seem that a future reaffirmation would be unnecessary, particularly so for ipecac, which as noted in the
current position statement is no longer being produced.
This latest rendition of the position statements as well as
the 2004 reaffirmations8,9 cite no new evidence regarding
ipecac-induced emesis and gastric lavage. This reflects a
preponderance of opinion that these are indeed pointless
interventions not worthy of study.
All that remains is the speculation of how many decades
must pass before ipecac-induced emesis and gastric lavage
can be relegated to the museum of medical antiquities along
with bloodletting and trepanation.
Declaration of interest
The author report no conflicts of interest. The author alone
is responsible for the content and writing of the paper.
Copyright © Informa Healthcare USA, Inc. 2013
References
1. Munshi Y, Ara I, Rafique H, Ahmad Z. Leeching in the history – a
review. Pak J Biol Sci 2008; 11:1650–1653.
2. Missios S. Hippocrates, Galen and the uses of trepanation in the ancient
classical world. Neurosurg Focus 2007; 23:1–9.
3. Kulig K, Bar-Or D, Cantrill SV, Rosen P, Rumack BH. Management of
acutely poisoned patients without gastric emptying. Ann Emerg Med
1985; 14:562–567.
4. Tenenbein M, Cohen S, Sitar DS. Efficacy of ipecac-induced emesis,
orogastric lavage, and activated charcoal for acute drug overdose. Ann
Emerg Med 1987; 16:838–841.
5. American Academy of Clinical Toxicology and European Association
of Poisons Centres and Clinical Toxicologists. Position Statement:
Ipecac Syrup. J Toxicol Clin Toxicol 1997; 35:699–709.
6. American Academy of Clinical Toxicology and European Association
of Poisons Centres and Clinical Toxicologists. Position Statement:
Gastric Lavage. J Toxicol Clin Toxicol 1997; 35:711–719.
7. Bull MJ, Agran P, Dowd D, Garcia VF, Gardner HG, Smith GA, et al.
Poison treatment in the home. Pediatrics 2003; 112:1182–1185.
8. American Academy of Clinical Toxicology and European Association
of Poisons Centres and Clinical Toxicologists. Position Paper: Ipecac
Syrup. J Toxicol Clin Toxicol 2004; 42:133–143.
9. American Academy of Clinical Toxicology and European Association
of Poisons Centres and Clinical Toxicologists. Position Paper: Gastric
Lavage. J Toxicol Clin Toxicol 2004; 42:933–943.