Veratrum Viride.

Botanical name: 

Related entry: Veratrum album

The dried rhizome and roots of Veratrum viride, Aiton (Nat. Ord. Liliaceae). An indigenous plant of swamps, low grounds, and moist meadows. Dose, 1 grain.
Common Names: American Hellebore, Swamp Hellebore, Green Hellebore, Indian Poke.

Principal Constituents.—A powerfully toxic alkaloid veratrine (C32H49NO9), or cevadine, ocurring in both crystalline and amorphous forms; protoveratrine (C32H51NO11), also extremely poisonous; jervine, vertroidine, pseudojervine, rubijervine (sternutatory) and resin.
Preparation.—Specific Medicine Veratrum. Dose, 1/20 to 5 drops.

Specific Indications.—Pulse full, frequent, and bounding; pulse full, rapid, corded or wiry; pulse full, strong, and intense, with throbbing of the carotids; pulse rapid and beating so forcibly that sleep is prevented; tissues full, not shrunken, and surface flushed with blood; increased arterial tension, with bloodshot eyes; erysipelas resembling an ordinary inflammation; cerebral hyperaemia; sthenic fevers and inflammations; irritation of nerve centers due to an excited circulation; convulsions, with great vascular excitement, full pulse, and cerebral hyperaemia; puerperal eclampsia; red stripe down center of the tongue; weight in the epigastrium, with forcible circulatory pulsations.

Action and Toxicology.—Veratrum is a powerful circulatory depressant. The exact action of the individual alkaloidal constituents is yet undetermined, as well as the effect each produces in the sum total of the effects of the root. According to Wood, the drug is a spinal and arterial depressant having no direct action upon the spinal centers; the direct action of jervine upon the heart-muscle, and the stimulation of the inhibitory nerves by veratroidine lower the pulse-rate; the force of the heart-beat is lowered by the direct action of jervine upon the heart-muscle, while the same constituent, according to dose, produces a more or less complete vaso-motor paralysis. The depression of the spinal motor centers is attributed to jervine. The emetic action of veratrum is said to be due to the combined action of veratroidine and the resin. All vaso-motor depressants and all agents which diminish the vital force, favor the action of veratrum. Nausea is always the signal for suspension of the administration of the drug. Death from veratrum is caused by asphyxia.

Veratrine and cevadine are identical. The veratrine of commerce, however, is variable in composition, but its action is probably mostly due to the amount of true cevadine present. Late investigations show that most of the action of veratrine is that of cevadine, though veratrum does not furnish the veratrine of commerce (see Veratrina). One of the peculiar effects of veratrine is that of muscular contracture produced when in contact with the heart and the voluntary muscles. It is exhibited in a prolongation of relaxation following the contraction of the muscle, appearing almost like a tetanic effect, but it is free from any rigidity or spasmodic quality—in reality a prolonged contraction in which there is a long and gradual relaxation several times longer in duration than that occurring in the unpoisoned muscle.

American hellebore exerts an influence upon the system quite similar to that of White Hellebore (Veratrum album). Veratrine does not represent the action of this plant, which contains but a small proportion of this body. Applied to the skin, veratrum is rubefacient; and to the nose, excites sneezing. Small doses of veratrum appear at first not to affect the frequency of the pulse, but to lower its force; it afterwards slows the pulse, it becoming moderately full and soft, and remaining so, unless the patient, during this stage of depression, attempts to rise or make any exertion, when the pulse becomes very rapid, small, thready, and sometimes almost imperceptible. During the stage of depression there is marked muscular weakness and relaxation, and nausea and vomiting take place, the contents of the stomach being evacuated first, and then those of the gall-bladder. Occasionally a watery diarrhea is caused by veratrum, sometimes amounting to hypercatharsis, but as a rule purging is not produced. The nausea produced by veratrum is intense, and the vomiting severe and often persistent, making it, therefore, an unsafe emetic. The most characteristic action of veratrum is its effects upon the movements of the heart and upon vascular tonus. The pulse-rate has been lowered to thirty-five beats -a minute with this agent, a corresponding depression of force accompanying this action. When such depression is reached, it is seldom that emesis can. be prevented. In large doses it is a very dangerous agent, yet, singularly, fatalities from its use are rare. Toxic doses produce an exceedingly weak heart-action, almost indistinguishable, running pulse, reduced temperature, cold, clammy sweat, extreme retching and incessant vomiting, dizziness, faintness, failure of sight, pupillary dilatation, complete muscular prostration, slow, shallow breathing, sleepiness, coma, and unconsciousness, with sometimes stertorous breathing. The prompt emesis induced by this agent undoubtedly prevents lethal effects.

In poisoning by veratrum, withdrawal of the drug and free stimulation will quickly overcome the depression. Large draughts of warm water may be given to encourage and assist emesis until the stomach has been thoroughly washed out. This should be followed by undiluted whiskey or brandy to check the vomiting. Opium or morphine may be given by mouth or otherwise, ammonia and alcoholics may be used by enema or hypodermatically, and strychnine or digitalis may be given by the latter method. External heat, sinapisms, friction, etc., must be utilized, and under no circumstances must the patient be allowed to rise from the recumbent position, not even to raise the head to vomit.

Therapy.—External. Painted upon boils, felons, carbuncles, abscesses, inflamed acne, cellulitis, and other local inflammations, veratrum will frequently ease pain and facilitate resolution, or hasten suppuration. For erysipelas showing much tumefaction and redness, and appearing much like an ordinary inflammation, veratrum is one of the best topical applications. It should be given internally at the same time. Similarly used, it sometimes relieves herpes labialis and herpes zoster. It is one of the local medicines that occasionally relieves the dermatitis of rhus poisoning. Used by means of a spray it may abort acute tonsillitis and modify it after it is established. But small quantities should be used.

Internal. Veratrum is a remedy of great value and power, though quite transient in its effects. Small doses do good work when indicated, but they must follow each other at short intervals, so that a continuous action may be kept up. Owing to its tendency to induce gastric irritability, with nausea, large doses are not tolerated, and small doses are contraindicated when the tongue becomes long and pointed and reddened at the tip, and nausea and other unpleasant gastric phenomena are present. Veratrum increases secretion from the lungs, kidneys, and liver, but depresses the circulatory system. It is not adapted to asthenic troubles, but proves an admirable remedy in sthenic conditions, with the full, bounding pulse.

Therapeutically veratrum is one of the chief special or arterial sedatives. The so-called sedative action of this group of remedies, so important in specific medication, is in reality that of gentle stimulation of the nerves controlling the heart and circulation, and depends wholly upon the manner of using them. In the smallest medicinal doses they are arterial or special sedatives; in the large doses they are cardiac and circulatory depressants, and are then dangerous remedies. To this group belong the trinity—veratrum, aconite, and gelsemium. Each has its own special field, and no one of them will exactly duplicate the effects of the others. Aconite and veratrum have been said to act similarly. In a measure only is this true, and there are many properties peculiar to each. To do the kindly therapeutic work that veratrum accomplishes in small and safe doses would require a dangerous dose of aconite. Full doses of aconite will bring down the full, strong pulse in sthenic disorders, but it does so only in a dose which imperils the patient. So long as aconite is reserved for use in small doses for the small frequent pulse, without capillary resistance one need have no cause to fear its action in the least. But one must hesitate at the large dose required to reduce a full, vigorous pulse, for there he is taking an unsafe risk; besides, we have in veratrum a drug that will meet the condition better and do it without the least danger to the patient's health or life. A long experience has convinced us fully of the confirmation of the truth that the great specific indication for veratrum is the full, bounding pulse with or without inflammation or elevation of temperature.

Veratrum is a remedy for sthenic conditions, whether it be a fever of any of the commoner types, an inflammation, iodiopathic or traumatic, or puerperal septicemia, or puerperal convulsions. The prime indication is the full, bounding, rapid pulse, hard and rope-like in character, with or without fever or inflammation. It is the remedy where there is free action of the heart, with active capillary circulation; serous inflammation with hard and full pulse, or full and bounding pulse; or even with wiry or corded pulse. It should not be administered freely when there is gastric irritability, but fortunately, as a rule, when veratrum is indicated this irritability is not often present. The effects of veratrum are of short duration; therefore, it should be frequently administered in small doses for its continuous effects.

The winter season is particularly a time when veratrum is likely to be needed most. The majority of cases of acute infectious pneumonia, which prevail most largely during the cold months, come on suddenly with the full, bounding pulse. Veratrum wonderfully controls the circulatory and febrile conditions and aids in checking the inflammatory ravages of the disease. It should be given in the early stages only and in the cases markedly sthenic. The dose should be small and frequently repeated until the temperature and circulation respond, when the pain will be found to have been lessened, nervous excitation allayed, secretion reestablished, and cough controlled. It is probably oftener indicated in acute pneumonia than any other agent except bryonia. In pleurisy, veratrum sometimes acts like magic, and in la grippe (epidemic influenza) it is, perhaps, the safest of all the circulatory sedatives and the most frequently indicated. At the onset of tonsillitis the conditions are usually sthenic and indications prominent for veratrum.

Painting veratrum upon the tonsils, or using it diluted by means of a spray, is often a great aid in controlling the inflammation, allaying pain and aborting abscess (quinsy). In all acute sthenic sore throats it is a most valuable agent. The facility with which veratrum controls the situation in acute respiratory disorders of a sthenic type, is a striking confirmation of the truth of specific medication—the pulse slows and softens, the temperature comes down without shock, expectoration is facilitated, pain is allayed, cough is lessened, and the nervous unrest gives way to peace and comfort, and in curable cases the battle is half won at the beginning. In chronic lung disorders we occasionally find veratrum of use when acute exacerbations occur and the circulation is augumented and temperature heightened. But as a remedy for other purposes, except occasionally to control nervous unrest, we have not found it so valuable in chronic pulmonary troubles as others have reported it to be. Veratrum should not be overlooked in hemoptysis, when there is great excitement of the circulation, the pulse being full and bounding. Here it justifies the claims made for it.

Veratrum is a most important agent in acute inflammatory disorders. Acute articular rheumatism of a sthenic type is well treated when veratrum forms a part of the medication, and if endocardial or myocardial inflammation accompanies or follows, we have never known it to do harm, but rather to be of benefit. In hypertrophy of the heart, accompanied or not with fever or inflammation, it is an ideal and safe agent. Erysipelas of the violent type, with full, bounding pulse and vivid redness, will find in veratrum one of the best medicines, using it both internally and locally. In peritoneal inflammation, due to blows upon the abdomen, veratrum is the best remedy known, and in septic peritonitis it assists greatly in controlling the circulatory excitement and inflammatory process, and contributes as much as any medicine can to a favorable termination of the disease. In any visceral inflammation, particularly pelvic, it is often indicated to control the blood current and modify the inflammatory action. Occasionally it proves valuable in gonorrhea and to prevent or alleviate mastitis, orchitis, and ovaritis.

We have used veratrum with great satisfaction in individuals whose lives have been such as to task the circulation to its utmost, and who have before them the probability of a future chronic nephritis and arteriosclerosis. In these prenephritics, we will call them, a correction of vicious habits and the judicious use of small doses of veratrum will often avert disaster. If arteriosclerosis has not already obtained it may be warded off, the integrity of the kidneys maintained, and the life current guided past the point of danger. Small doses of specific medicine veratrum should be given for a prolonged period.

A remarkable instance of the therapeutic power of veratrum in high blood pressure was in that of a man bleeding from the gums. The patient, a blacksmith of middle age, indulged in occasional sprees and drank more or less all the time. The pulse was hard and full as a rope and whipping along vigorously and fast, nervous agitation was extreme, and blood was oozing from the spongy gums around every tooth in his head. The carotids were pulsating strongly, the eyes bulging and injected, and the head felt and looked as if it would burst. Veratrum, in the ordinary dose, completely relieved this man in less than two hours, with no return of the trouble—though the patient still continued his devotions at the shrine of Bacchus. Veratrum may be employed in small doses for the relief of a certain form of nervousness. The patient has a full circulation, throbs, feels the beating of the heart, the abdominal aorta and the carotids. When retiring to rest, sleep is prevented by the throbbing pulsations in the head and ears, so distressing that sleep is prevented or delayed. Small doses of veratrum do wonders for these badly-shaken patients.

In the treatment of the common fevers, except the febricula, we have not found veratrum of much service; in fact, not often indicated. In our experience it has rarely been needed in typhoid fever, but occasionally is indicated in acute malarial intermittents. In the threatened attacks of sunstroke (not in heat exhaustion with pallor, cool skin, and weak pulse, but in the robust, full blooded, overheated individual, with bounding pulse and rope-like circulation), a few small doses of veratrum should be given at intervals of ten or fifteen minutes.

We are among those who believe that veratrum has some virtues outside of its power over the circulation, for it has alterative powers of great value. Just how it acts is not known; possibly its circulatory control aids also lymphatic elimination. While not prepared to go as far as did Howe in claiming it the only alterative in tubercular conditions, we believe it could be profitably restudied for its power of eliminating morbid products in many chronic ailments depending upon faulty elimination. Some have valued it in chronic bronchitis and so-called chronic pneumonia. As an alterative in chronic broncho-pulmonary disorders small doses of veratrum may be given for several days; and then omitted for a few days; or it may be administered every other day, syrup of lactophosphate of calcium being given on the days when the veratrum is omitted.

When convulsive disorders depend upon an excited circulation, veratrum may prove a useful anticonvulsive. It is sometimes of value in spinal irritation, with spasms, and in acute mania and cerebro-spinal meningitis, all with violent circulatory excitement. If accompanied by fever and there is hyperaemia, it may relieve neuralgic headache; otherwise it fails. When the pulse is full and bounding, the eyes bloodshot and suffused, and with a state bordering upon inflammation, it may restore quiet and allow sleep in delirium tremens.

Veratrum is our most important agent to control puerperal convulsions. We have injected a half drachm of specific medicine veratrum every half hour for three hours in a case of post-partum eclampsia, with puerperal mania, with the result of being complete master of the situation. In this disorder the full pulse must be subdued and kept subdued until the convulsions cease. It is the one instance in which the large or extreme physiologic (near toxic) dose of veratrum is absolutely demanded.

For the purposes above named, except where otherwise directed, veratrum should be given to control indications as revealed by the pulse, and then its administration should be stopped; and the fractional dose (15 to 20 drops in four ounces of water; dose, a teaspoonful every fifteen, thirty, or sixty minutes, as required) is much more satisfactory than large doses at long intervals. Veratrum will slow the pulse down to a very few beats. Usually, however, emesis will then take place. This is why veratrum seldom or never poisons. Only in exceptional cases are the large doses permissible, as in puerperal eclampsia, in which, singularly, it seldom occasions vomiting.

"Veratrum is less valuable than aconite in simple cardiac hypertrophy, though it quiets palpitation when blood pressure is high and the trouble is not due to valvular incompetency. It sometimes relieves the irritable heart of excessive tobacco users, especially when the heart action is strong and erratic. By retarding the velocity of the blood current and reducing vaso-motor tonus it does some good in aneurism. In all heart and circulatory disorders, especially in hypertrophy, it does good when the pulse is full, strong, and intense, the carotids beat forcibly, the eyes are bloodshot, and there is cough, headache, and weight in the upper epigastrium, while the heart may beat so violently as to shake the bed, and sleep is entirely prevented. It relieves the excitement, the heart-action approaches the normal, the cough is allayed, and the patient is in every way better." (Locke.)

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