Aconitum Napellus.
The dried tuberous root of Aconitum Napellus, Linné (Nat. Ord. Ranunculaceae). Mountains of Europe and Asia, and northwestern North America. Dose (maximum), 1 grain.
Common Names: Aconite, Monkshood, Wolfsbane.
Principal Constituents.—Aconitine (C34H47O11N) one of the most poisonous of known alkaloids, occurring as permanent colorless or white crystals, without odor. A drop of solution of one part of aconitine in 100,000 of water will produce the characteristic tingling and benumbing sensation of aconite. The alkaloid itself must never be tasted, and the solution only when extremely diluted, and then with the greatest of caution. Aconitine is soluble in alcohol, ether, and benzene; very slightly in water. Other constituents of Aconite are aconine and benzaconine, both alkaloids; the former of little activity; the latter a strong heart depressant.
Commercial Aconitine is a more or less impure mixture of aconite alkaloids.
Preparations.—1. Specific Medicine Aconite. An exceedingly poisonous and representative preparation. Dose, 1/30 to ½ drop. (Usual form of administration: Rx Specific Medicine Aconite 1-10 drops: Water 4 fluidounces. Mix. Sig. One teaspoonful every one-half (½) to two (2) hours.)
2. Tinctura Aconiti, Tincture of Aconite (10 per cent aconite). Dose, 1 to 8 minims.
Note.—Fleming's Tincture of Aconite is many times stronger than the preceding, with which it should not be confounded. It should have no place in modern therapeutics.
Specific Indications.—The small and frequent pulse, whether corded or compressible, with either elevated or depressed temperature and not due to sepsis, is the most direct indication. Irritation of mucous membranes with vascular excitation and determination of blood; hyperemia; chilly sensations; skin hot and dry, with small, frequent pulse. Early stage of fevers with or without restlessness. When septic processes prevail it is only relatively indicated.
Action.—The effects of aconite, considered from the so-called physiological action, are expressed in local and general irritation followed by tingling, numbness, and peripheral sensory paralysis, primarily reduced force and frequency of the heart action, due to vagal stimulation, and subsequent rapid pulse, due to vagal depression. The heart muscle is also thought to be paralyzed by it. The action upon the vaso-motor system is not well understood, though the lowered arterial pressure is explained by some as due to depression of the vaso-motor center. In small doses aconite quiets hurried breathing, but large doses may cause death through respiratory paralysis. Temperature is lowered by aconite, probably by increase of heat-dissipation and possibly through the action of the thermo-genetic system. This action is most pronounced during fevers. Except of the skin and kidneys, the glands of the body seem to be but little, if at all, affected by aconite. The kidney function is slightly increased, while that of the skin is markedly influenced according to the quantity administered. The motor nervous system is not noticeably affected except when poisonous doses are given, but the sensory nerves, especially at the periphery, are notably impressed by even so-called therapeutic doses. It is quite clear that aconite does not act strongly upon the cerebrum, except that poisonous doses somewhat depress the perceptive faculty. Upon the skin and mucous surfaces it acts first as an irritant, then as an anaesthetic. The mode of elimination of aconite is not yet well determined, but it is thought that it is largely oxidized, thus accounting for the short duration of its action. Indeed, the systemic effects of aconite seldom last over three hours, though the therapeutic result may be permanent. When aconite kills it does so usually by paralyzing the heart, arresting that organ in diastole.
Locally, aconite and its alkaloid, aconitine, act as irritants, producing a tingling, pricking sensation and numbness, followed by peripheral sensory impairment, resulting in anaesthesia of the part. The latter is due to paralysis of the sensory nerve terminals. Usually no redness nor inflammation follows, but in rarely susceptible cases vesicular or pustular eruptions take place, or intense cutaneous itching. Both are extremely irritating to the nasal and ocular membranes, and when inhaled may give rise to a peculiar local sense of icy-coldness.
Administered internally in small doses aconite occasions a tingling or prickling sensation, felt first in the mouth, tongue, and fauces, and quickly extending to the stomach. This is rapidly followed by more or less numbness. Gastric warmth and a general glow of the surface follow non-lethal doses. Slight perspiration may be induced, but sweating to any great degree does not take place except from large doses. Then it is an almost constant symptom. Temperature is reduced, but the more readily during pyrexia, when the pulse is frequent and small, if the dose administered be fractional.
In maximum doses (by some called full therapeutic doses) aconite causes gastric heat. A sense of warmth throughout the system follows, and occasionally the thrilling or tingling sensation will be more generally experienced, with perhaps some numbness. There may be dizziness most marked upon assuming the upright posture, pain in the head, acute body pain, excessive depression, with feeble circulation and diminished respiration. The pulse may fall to 30 or 40 beats per minute and muscular weakness become extreme. Eclectic teaching has long protested against giving aconite in doses sufficient to produce these effects, which some, with extreme boldness, declare to be therapeutic results.
Toxicology.—In poisonous amounts the symptoms given are exaggerated and the effects extremely rapid. Tingling and numbness increase and are felt all over the body, the thrilling and creeping coldness approaching from the extremities to the body. Excessive sweating comes on, rapidly lowering the body temperature, dimness of vision, loss of hearing and touch, and general peripheral paralysis extending from the extremities to the trunk. The victim is conscious of danger, feels cold and is extremely anxious and prostrated. Muscular weakness is pronounced, tremors occur, and rarely convulsions. The power of standing is lost early. The face is extremely pale, the sclerotics pearly, eyes sunken, the countenance one of extreme anxiety, and there is a tendency to fainting. There may be gastric pain and vomiting. If the recumbent position is not maintained, or even if slight exertion be attempted, sudden death may occur from syncope. Unless consciousness be lost through syncope, the intellect remains unimpaired until just before death, showing that aconite probably does not greatly impress the cerebrum.
The one diagnostic symptom of aconite poisoning is the characteristic aconite tingling. If confession (in case of attempted suicide) is not forthcoming or the patient is unable to reveal the fact that poison has been taken, this of course cannot be known. In the absence of this knowledge, and when absolute muscular and other prostration, fainting and other forms of collapse, shallow dyspnoeic breathing, merely trickling or barely perceptible pulse, with no vomiting, no purging, or no alteration of pupils, nor characteristic symptoms of other poisons, poisoning by aconite should be suspected. The action of a lethal dose of aconite is rapid, symptoms coming on within a few minutes. Death may occur in from one half hour to six hours, the average time being a little over three hours.
The treatment of poisoning by aconite should be prompt and quietly administered. The victim must at all hazards be kept in the recumbent position, with the feet slightly elevated. If seen early, tannic acid or strong infusion of common store tea (to occlude the poison) should be administered. External heat should be applied and artificial respiration resorted to as soon as respiratory embarrassment takes place. In the earlier stage emetics may be tried, but will probably fail to act if the stomach has been anaesthetized by the poison. The stomach-pump, or siphon, is to be preferred. Besides, emetics may be inadvisable for fear of the muscular contraction producing heart-failure. Whatever method be followed the stomach contents should be received upon a towel, the patient under no circumstances to be raised from the prostrate position. The chief hope lies in stimulation. Ammonia or alcohol, or Hoffman's anodyne, may be given by mouth, and ether, alcohol, and digitalis hypodermatically. Digitalis is the nearest to a physiological antidote to aconite, but acts very slowly, whereas the action of aconite is rapid. The more diffusible stimulants, therefore, are to be given first, and closely followed by the digitalis. Atropine may stimulate respiration, and caffeine (or hot coffee) sustain the heart. Nitrite of amyl may be used cautiously, allowing but a whiff or two, lest the stimulant action be passed and dangerous depression induced. A full dose of strychnine sulphate or nitrate (1/20 to 1/10 grain) should be given subcutaneously to sustain the heart-action. Of the newer biologic products, possibly adrenalin chloride (1 to 1000) or pituitrin, hypodermatically administered, might aid in preventing circulatory collapse.
Therapy.—External.—As a topical agent, aconite, in tincture or as an ingredient of anodyne liniments, may be applied to relieve pain, allay itching and reduce inflammation. Its use, however, must be guarded as it is readily absorbed. A well-diluted spray gives relief in the early stage of tonsillitis and when quinsy occurs, and it relieves the distress and shortens the duration of faucitis, pharyngitis, and some cases of laryngitis. If used in local inflammations it should be in the earlier stages. Locally applied above the orbits it may give relief in sinusitis; used over the mastoid bone it mitigates the pain of otitis media and modifies external inflammation of the ear. Its obtunding power gives temporary relief in facial and other forms of neuralgia (when hyperaemia is present), the neuralgia preceding zoster, pleurodynia, myalgia, rheumatic gout (rheumatoid arthritis), peridental inflammation, and so-called chronic rheumatism. It also allays the pain and itching of chilblains, and the discomfort of papular eczema, pruritus ani, and other forms of pruritus.
Internal.—Aconite is a most useful internal medicine. The weight of evidence from those who use aconite most frequently shows that it is a safe agent when used in the minute dose and according to specific indications, and is proportionately dangerous as the dose approaches that which produces its physiological action. It is capable of great good in the hands of the cautious and careful therapeutist, and is capable of great harm if carelessly or thoughtlessly employed.
Aconite is the remedy where there is a dilatation from want of tone in the capillary vessels. It moderates the force and frequency of the heart's action, increasing its power, and is, therefore, useful in functional asthenia; it also lessens pain and nervous irritation. Aconite cases are those showing a frequent but free circulation; where there is super-active capillary movement; and in enfeeblement of the circulation, functional in character and not due to structural degeneration or sepsis, and manifested by a frequent small pulse, a hard and wiry pulse, a frequent, open and easily compressed pulse, a rebounding pulse, or an irregular pulse. It lessens determination of blood (hyperaemia), quiets irritation, checks the rapid circulation in the capillaries when it is too active, and increases the circulation when it is sluggish. We account for this by believing that it gives the right innervation to the vascular system. Scudder (Diseases of Children, 42) says of it: "I have been in the habit of saying that aconite is a stimulant to the heart, arteries, and capillaries, because whilst it lessens the frequency, it increases the power of the apparatus engaged in the circulation." It should be stated that our term sedative differs in fact from that accepted by other schools. An agent such as aconite, which in full doses would depress but in minute doses will stimulate the vascular system to normal activity and thereby reduce febrile states by correcting or regulating innervation, is classed in Eclectic therapy as a "special," "vascular," or "arterial sedative."
Aconite is a remedy for irritation of the mucous membranes. It matters little whether it be of the nares preceding an attack of coryza, of the larynx, of the bronchi, or of the gastro-intestinal tube, liable to lead to inflammation of those tracts, aconite may be used to control the morbid process. In simple gastric irritation with or without vomiting, in the irritative forms of diarrhoea—whether simple or of the more complicated forms of enteric inflammation, of cholera infantum, or of dysentery—it is equally important and usually specifically indicated. In the diarrhoea of dentition it often controls the nervous symptoms and the discharges. Of course one must take into consideration the role played by food toxemia. In such cases modification or complete change of food must be resorted to, and frequently a simple purge given to cleanse the gastro-intestinal tract. Then if irritation persists, or there is fever, aconite usually acts promptly. The form of cholera infantum best treated by it is that showing increased bodily heat. If dentition is accompanied by irritation and fever, it may be given alone or with matricaria. In many of the stomach and bowel disorders, particularly gastric irritation with diarrhoea, and gastro-enteritis, it acts well with ipecac, or rhus. For aphthous ulcerations with fever, aconite and phytolacca internally with infusion of coptis locally have not been excelled. In simple dysentery, aconite, ipecac and magnesium sulphate is a most effective combination, seldom failing to control the disease in a few hours.
Aconite allays fever and inflammation, and it's the most commonly used agent for such conditions. When specifically selected it proves useful in glandular fever (with phytolacca) and in acute gastritis and gastric fever, with yellow-coated tongue and diarrhoea. In simple febricula it is diagnostic, if, as Locke has well stated, the patient is not well or markedly improved in twelve hours, he has more than a case of simple fever. In intermittent or malarial fevers it prepares the way for the successful exhibition of antiperiodics. As quinine, the best antagonist of the malarial parasite, acts most kindly when the skin is moist, the tongue soft and clean, and nervous system calm, aconite is signally useful as it establishes those very conditions. In septic fevers, or those depending upon sepsis, the presence of pus, etc., its value is limited, though it may assist other measures. It is especially of value in the fevers of irritation of childhood—such as arise from overloading the stomach, from colds, and from dentition. Most febricula subside quickly, but they do so more quickly and kindly when assisted by the small dose of aconite. So valuable has aconite become in fevers, that by some writers it has been christened the "vegetable lancet;" by Webster, the "pulsatilla of the febrile state;" and by Scudder, the "child's sedative."
In all febrile states in which aconite is indicated there is sudden onset and rapid evolution; moreover, the remedy is seldom needed, nor indeed is it admissible except in the first few days of the invasion. Very rarely is it to be used in the protracted fevers, except at the very outset, and then it must be strongly indicated. It is much better to omit it than to advise its employment in continued fevers of an adynamic type, lest some carelessly or perhaps boldly push it in too large doses or for too long a period to the detriment of the patient. In typhoid or enteric fever there are usually conditions to face which make aconite an ill-advised medicine, except in rare instances in which distinct indications for it may be present. These are so rare, however, as to be pronounced exceptions. The blood disintegration, the toxic impression of the secretions and the nervous system, the defective excretion and the progressive weakening of the heart and circulation, make aconite all but contraindicated in this devitalizing disease. If used at all we question the expediency of employing aconite or any other febrifuge for a prolonged period in typhoid or other adynamic fevers.
In urethral fever, due to catheterization, and in the febrile stage of acute gonorrhoeal urethritis, its action is prompt and effective. It may be used as an auxiliary agent in visceral inflammations of the abdominal and pelvic cavities, when simple in character. In such grave disorders as puerperal fever, because of its highly septic character, it is of questionable utility. The same is true of peritonitis of septic origin.
In the acute infectious diseases (including the infectious fevers already mentioned, but respecting the limitations in typhoid states) aconite is of very great value when used at the onset of the invasion. It is among the best agents in acute tonsillitis and quinsy before pus forms, in the initial stage of la grippe, in acute colds, acute coryza, lobar, and broncho-pneumonia, pleurisy, and allied infections. Here it controls temperature, retards hyperaemia, establishes secretion, prevents effusion when threatened, and gives the nervous system rest. When it alleviates pain it does so chiefly by allaying inflammation. In pleurisy, aconite associated with bryonia is an admirable remedy until effusion takes place, then it no longer is serviceable. To reduce high temperature it is temporarily useful in phthisis when invasion of new portions of the lungs takes place. Aconite may be used in cerebro-spinal meningitis until effusion takes place; after which it should be discarded.
Other disorders of the respiratory tract are benefited by its action as far as irritation, hyperaemia, and inflammation prevail—acute nasal and faucial catarrh, acute pharyngitis, acute bronchitis, acute laryngitis and acute tracheitis. For spasmodic and mucous croup it is the best single remedy, often checking the disease in an hour's time. Aconite was at one time freely used in diphtheria, and is still valued by some, but its use should be carefully guarded for the same reasons stated under typhoid fever. The most it can do is to aid in controlling temperature; and if carelessly employed it may invite paralysis of the heart in a disease itself prone to paralysis through its own toxicity. Aconite should not be omitted in the treatment of erysipelas with high temperature.
Aconite and belladonna are indispensable in the exanthemata, and are the drugs most often indicated. It is to be used when the skin is hot, dry, and burning and the temperature high. By its timely use the eruption is facilitated, the temperature lowered, the secretory organs protected, spasms averted, and damage to the kidneys and the over-wrought nervous system forestalled. It is, therefore, indicated in the initial stages of varicella, measles, scarlatina, and sometimes in variola.
While by no means an antirheumatic, aconite is of marked benefit in acute inflammatory rheumatism, when high fever and great restlessness prevail. Besides it protects the heart by lessening the probability of endocarditis and possible heart failure. The dose, however, must be small lest we induce the very calamity we aim to avoid. Locke regarded it almost a specific in uncomplicated rheumatism; but while it greatly aids in reducing fever, inflammation and pain, it needs the assistance of the more direct antirheumatics and their allies, as sodium salicylate, bryonia and macrotys. More slowly, but less certainly, it sometimes alleviates simple acute neuritis.
Mumps is well treated by aconite, asclepias and phytolacca, while for mastitis aconite, bryonia, and phytolacca are our most effective agents. With careful nursing, emptying of the breasts, and sometimes judicious strapping and supporting of the glands the formation of pus may be averted. Should it form, the bistoury is the only rational medium of relief.
As a remedy for the disorders of the female reproductive organs, aconite is very valuable. It is particularly valuable in recent amenorrhea, due to cold, if the circulation and temperature are increased; and in menorrhagia, with excited circulation and hot, dry skin. Dover's powder or the diaphoretic powder adds to its efficiency. Some rely on it to relieve the nausea and vomiting of pregnancy.
Neuralgic pain is somewhat relieved by aconite, used both locally and internally. The varieties best treated are facial, dental, visceral, and rectal neuralgia, and that preceding herpes zoster. Though most efficient when fever accompanies, it is held to be useful also when the temperature is not exalted. King found aconite a remedy of marked worth in that anomalous condition best described as non-febrile spinal irritation.
Purely functional palpitation of the heart, due to indigestion, has been relieved by small doses of aconite. One of the instances in which large or physiological doses of aconite are permissible is in simple cardiac hypertrophy, but even then veratrum is to be preferred. In very minute doses aconite has been advised by Scudder in the algid stage of Asiatic cholera, and in the cold stage of fevers.
