Nux Vomica.

Botanical name: 

Related entry: Strychnos ignatia

The dry, ripe seeds of Strychnos Nux vomica, Linné (Nat. Ord. Loganiacae). According to the U. S. P. it should contain at least 2.5 per cent of nux vomica alkaloids. India, along the Coromandel Coast, Ceylon, and other parts of the East Indies. Dose, 1/20 to 2 grains.
Common Names: Poison Nut, Dog Button, Quaker Buttons.

Principal Constituents.—The powerfully poisonous alkaloids strychnine (C21H22O2N2) and brucine (C23H26N2O4) in union with igasuric acid. Loganin, a glucoside, is inert.
Preparations.—1. Specific Medicine Nux Vomica. Dose, 1/30 to 5 drops. (Usual form of administration: Rx Specific Medicine Nux Vomica, 5-15 drops; Water, enough for 4 fluidounces. Mix. Sig.: One teaspoonful every 1 to 3 hours.)
2. Tinctura Nucis Vomicae, Tincture of Nux Vomica. Dose, 1 to 15 minims.

Specific Indications.—Atonic states; tongue pallid and expressionless, uncoated, or with a yellowish pasty coat; yellowness of conjunctivae; yellow or sallow countenance, and yellowish or sallow line around the mouth; fullness and dull pain in the right hypochondrium; pain in the right shoulder, with colicky pain, pointing toward the umbilicus; menstrual colic; constipation; diarrhoea of atony; functional forms of paralysis.

Action.—In small doses strychnine (and nux vomica) has but little apparent effect other than that of a powerful bitter and general tonic. Larger doses greatly stimulate and still further heighten bodily tone. Full medicinal doses increase reflex action, quicken the rate of respiration, and enlarge the capacity of the lungs, augment the force, rate, and volume of the pulse, raise arterial pressure, give increased sharpness to sight, hearing, and smell, and cause general irritation and excitement. It acts directly upon the heart-muscle and its ganglia, stimulating them, but its lethal doses depress. The arterial rise is due to vaso-motor stimulation. It is one of the most powerful of respiratory stimulants, acting through the centric center of respiration, and not only increases the rate and power of breathing, but enlarges the lung capacity. Its action upon the nervous system is chiefly upon the ganglionic cells of the motor tract of the spinal cord, and in poisonous doses causes such profound irritation or excitement as to render them extremely responsive to the slightest stimuli, resulting in tetanic convulsions. Most likely it also feebly stimulates the sensory tracts and slightly increases the power of nerve conduction. Upon the cerebrum it is almost without action, except possibly to stimulate to greater acuity the nerve centers of the special senses. Temperature is scarcely affected by ordinary doses of strychnine. While a portion of strychnine is oxidized in the body, the drug is excreted by the kidneys unchanged and as strychnic acid.

Strychnine, brucine, and nux vomica are all extremely energetic poisons, acting as such chiefly by excessive stimulation of the spinal cord and the medulla. Strychnine is the most powerful and quickest, brucine considerably less so, while nux vomica is slower than strychnine, but almost identical in action, and if the quantity be sufficient, equally certain to cause death.

The slightest observable effects from small doses of these drugs occasion slight twitching of the muscles of the arms and legs, especially during sleep. This is accompanied by restlessness, some anxiety, quickening of the pulse, and generally slight sweating. Sometimes the action of the bowels is increased, and there is a greater quantity of urine secreted, which is voided with more than ordinary frequency. The sexual passions may be excited. In larger doses, but not large enough to kill, a sense of weakness and heaviness is experienced, with depression of spirits, trembling of the limbs, and a slight rigidity or stiffness upon attempted movement. Inability to maintain the erect position is common, and a light tap upon the ham, given suddenly, will be followed at once by a slight spasm, and the patient will no longer be able to stand. These are toxic and near-lethal effects. Lethal doses bring on the most violent of spasms and death (see below).

The long-continued use of strychnine, in excessive amounts, tends to impair the digestive organs, and while small doses favor diuresis, large quantities impair that function by producing spasms of the bladder muscles.

Toxicology.—Lethal doses of nux vomica or strychnine produce at first marked uneasiness and restlessness, with more or less of a sense of impending suffocation. Tremors of the whole body are observed. Suddenly there is violent starting of the muscles, and the ensuing convulsions are of such great violence as to throw the patient off the bed, or to a considerable distance. Nearly all the muscles are affected at the same time; the exception being, perhaps, of those of the jaws, which become locked last. The risus sardonicus is present and gives to the countenance a fiendish expression. Opisthotonos to an extreme degree takes place, the body resting upon the head and heels, with the hands clenched and the feet inverted. The convulsion is distinctly tetanic and is followed by a brief period of rest, during which the patient suffers acutely from pain, weariness, and rending of the limbs. He is conscious at all stages of the poisoning except just preceding death. During the intervals of repose from the convulsions there is acute sensibility and dreadful alarm. Upon the renewal of attack the patient may cry out from the violence of the spasmodic grip upon the respiratory organs. The slightest sound, draught of air, or beam of light will at once renew the convulsions. The spasms succeed each other rapidly, death usually taking place after three or four convulsions. Death may occur during the interval from exhaustion, or paralytic asphyxia, or during the vise-like grip upon the respiratory muscles and the heart from cramp asphyxia. The body stiffens after death and this rigidity has been known to persist for months.

The smallest doses known to have produced death are 30 grains of nux vomica (equal to about 1 seed, or ⅓ grain of strychnine); 3 grains of the extract of nux vomica; and 1/16 grain (child) and ½ grain of strychnine (adult). Death usually occurs in about two hours, or may be delayed for six hours. If six hours have elapsed without death the patient is likely to recover.

In poisoning by strychnine (or nux vomica) the patient must be kept absolutely quiet. No noises should be permitted, nor even a draught of air be allowed to strike the body, nor a strong beam of light the eye. Emetics are only admissible very early before convulsions have occurred. If the patient is seen immediately after taking the poison the stomach should be repeatedly washed out with a solution of permanganate of potassium, or of tannin, or strong table tea. If an emetic is to be used, apomorphine is to be preferred. Lard, sweet oil, milk, or charcoal may be given with a view of enveloping the poison and retarding its absorption. Chloroform is the best agent to control the convulsions, but should be administered between spasms while the patient is able to inhale. No inhalation can take place during the convulsions. Amyl nitrite is also useful. Large doses of bromide of potassium (60 grains) and chloral hydrate (30 grains) may be given per rectum. King believed camphor antidotal to strychnine and cited its saving effects upon animals to prove his contention. Artificial respiration is useful, but if resorted to the body must be grasped firmly as it is then less likely to excite spasms than is light and superficial contact with the skin. If a very large dose of the poison has been swallowed death is almost inevitable as its action is usually in full force in fifteen minutes, and as a rule, long before medical aid can be procured. Circumstances, however, alter the rapidity of poisoning, as the manner of taking the drugs, the contents of the stomach, and the facility for absorption, hence every effort should be made to sustain life even in apparently hopeless cases. Nux vomica poisons more slowly than the strychnine salts.

Therapy.—As a rule nux vomica is more largely used in disorders of the gastro-hepatic tract than is strychnine; while strychnine is more generally preferred for nervous, sexual, and bladder disorders. For cardiac and respiratory dyspnea, shock, and other emergencies, strychnine, hypodermatically administered is by far the quicker and better procedure. In all the conditions named to be considered, either nux vomica or the alkaloidal salts may be used, with the almost complete preference for the nux vomica in the stomach and bowel disorders.

Nux vomica should not be given for long periods without intervals of rest, and strychnine should be reserved for an emergency remedy and never given, as it is, too frequently, for long periods as a nerve bracer. Remember, it is a powerful stimulant, but stimulates to exhaustion, causes prolonged erethism, and often invokes a low-running fever. The best dose of nux vomica for general purposes is the fractional, at most not to exceed one drop of the specific medicine.

Nux vomica is the most important remedy for atony and relaxation of the stomach and bowels and disorders dependent thereon. The condition is never one of irritation from offending food, or from active hyperemia, or ordinary congestion, and with rare exceptions of inflammation, even of subacute type. But there is very marked nervous irritability due to atony of the muscular coats, irresponsive glandular action, and depression of spinal and vagal innervation. The tongue is pale and expressionless, and may be pasty and have a yellow coating. There may or may not be nausea or vomiting, or both, there is a sallow or yellow border around the mouth, a general sallow complexion, and evident hepatic malfunction. Quite often the conjunctivae are yellowish, there is pain extending to beneath the right shoulder blade, and a colicky type of intestinal pain with flatulence, pointing from the gall-bladder to the umbilicus. With some, or the totality of these indications, it proves a remedy of great power in a variety of digestive and intestinal wrongs, among which may be named simple atonic indigestion, pyrosis, flatulent colic, nervous gastric debility, chronic diarrhea, cholera infantum, muco-enteritis, and chronic non-inflammatory diarrhea. In the three last named disorders, the child is weak, apathetic, and listless, the stools pass unnoticed and painlessly, or perhaps may be preceded by a slight umbilical colic. For colic, nux vomica is second only to colocynth, and preferable when the above indications are present.

Nux vomica is one of the best agents for so-called chronic gastritis of various types and origins, but all of an atonic character. With other bitter peptics, especially hydrastis, it is especially valued in chronic atonic dyspepsia. Rx Specific Medicine Nux Vomica, 10 drops; Glycerin, 2 fluidrachms; Phosphate of Hydrastin (or Specific Medicine Hydrastis, 1 fluidrachm) 10 grains; Water enough to make 4 fluidounces. Mix. Sig.: One teaspoonful every four hours. The pale tongue, bad taste and pallor about the mouth will guide to its selection. In rare cases in which the tongue is of normal redness it may be alternated with hydrochloric acid in minute doses. When the liver involvement is prominent—with yellow, pasty tongue, hepatic tenderness and icteric coloration of the eye, Specific Medicines Leptandra or Chionanthus may be substituted for the hydrastis preparations. Not alone does nux vomica overcome the irritability upon taking food, but it overcomes dilation of the organ from relaxed musculature and the associated flatulent distention. Drop doses of the specific medicine in a full glass of cold water taken upon an empty stomach upon arising in the morning, and insistence upon an absolutely rigid adherence to a regular time for attempting defecation, will aid marvelously toward a cure of obstinate habitual constipation. Drop doses several times a day is also good medication in the dyspepsia of inebriates, with loss of digestive power and relaxation, and either stubborn constipation or oft-recurring diarrhea. Nux vomica will sometimes relieve spasmodic conditions of the bowels when due to lack of peristalsis, with obstinate constipation, and it also occasionally relieves colic and costiveness caused by lead. But few doses of nux vomica, given in hot water, will be required to cut short an attack of infantile colic when due to torpid digestion; and the remedy is direct in relieving borborygmus in women with relaxed and weak abdominal walls and intestinal ptosis. It is sometimes of greater advantage when given in trituration with milk sugar, carbo-vegetabilis and asepsin, when fermentation of food with belching of gases is prominent.

In that form of so-called congestion of the hepato-splenic circuit due to weakness and sluggish portal circulation the drug is promptly effective. The congestion here is not active, but rather a stagnation due to atony and poor innervation. Nux vomica is the most commonly employed remedy to relieve that condition comprehended in the general and somewhat vague term "biliousness", a state best described by the totality of gastro-hepatic symptoms included in the specific indications at the head of this article. It should be borne in mind that in the stomach and bowel disorders requiring nux vomica or strychnine, there is always a feeble and sluggish circulation, capricious appetite, faulty digestion, irregular bowel action, and depressed spinal and sympathetic innervation. When these are present it is a most decidedly beneficial remedy. Glyconda or neutralizing cordial is a good vehicle for the administration of nux vomica to children when sugar is not contraindicated.

Nux vomica, and more particularly strychnine, are the leading remedies for amblyopia due to alcohol and tobacco; and both are valuable in eye strain, especially of the type of muscular asthenopia. Aggravations of eye and ear disorders, when due to general systemic atony, are nearly always mitigated by it. Foltz declared it the best remedy for purulent otitis media with general lack of tone, and advised it in chronic conjunctivitis and phlyctenular keratitis due to the same cause.

Both nux vomica and strychnine are very serviceable in the urinal incontinence of children, and of the aged, when due to a relaxed or paralyzed sphincter, with feeble circulation. Conversely both are remedies for paralytic retention of urine; and in catarrh of the bladder with marked muscular and nervous depression. Both stimulate the sexual organs and have, therefore, been given with varying success in impotence, spermatorrhea, and sexual frigidity of women. When coupled with abstention from sexual excesses good results are observed. When there is anemia, constipation, and general torpor, then these drugs, together with iron, sometimes rectify amenorrhea. With cramps, chilliness, and premature flow, and where there is great bodily weakness, they may be administered for the relief of dysmenorrhea and in menstrual colic, while for leucorrhea with heavy yellow discharges and marked nervous debility they greatly assist other specific measures in restoring a normal condition.

Nux vomica is a valuable auxiliary in the treatment of chronic alcoholism, especially in those of a robust constitution, but with great nervous excitability and disposition to indulge in periodical sprees. We have given the following with excellent results: Rx Specific Medicine Belladonna, 20 drops; Specific Medicine Nux Vomica, 30 drops; Specific Medicine Capsicum, 10 drops; Water enough for four fluidounces. Mix. Sig.: One teaspoonful every four hours.

The Eclectic Materia Medica, Pharmacology and Therapeutics, 1922, was written by Harvey Wickes Felter, M.D.