You Will Be Careful as to the Second Article

The contradictory deductions of medical professors make wise men tremble, good men sad, and bad men bold...

A.S. Taylor, Poisoning by Strychnine, 1856

In 1848 Great Britain was nominally at peace, but it was a turbulent year. There was revolution in Berlin and at home the Chartist riots continued. The Irish famine was in full spate. Five thousand miles of railway lines had been built, a third of them already equipped with the electric telegraph. Powerful social changes were at work in the English shires; Britain was undergoing the massive changes that would make it the first country in the world to become more than half urban. Soap was taxed and most people did not wash very much. In rural southern counties such as Hampshire, the standard of living had not improved in a generation. Many families lived on a diet of bread, cheese and beer, and were dependent on the local parish rates to supplement their subsistence wages.

All of this may not have unduly worried Mrs. Sergison Smith of Romsey in that county, who was comfortable enough. According to the Hampshire Independent,1 she was "an amiable and beautiful lady in the prime of life" (she was about 35). An officer's wife and mother of five, she lived in an agreeable house, called Jermyn's, and employed several servants, one of whom, Caroline Hickson, was described as a "nurse and lady's maid."

On October 30, 1848, Mrs. Smith, who had recently suffered a miscarriage, felt unwell with "weakness" and the local pharmacist, Mr. Jones, sent in a prescription of nine grains of salicine (willow bark), a useful analgesic, mixed with orange-peel. This arrived at about six o'clock in the evening. The hypothesis that Mrs. Smith was not really ill is supported by the fact that she did not take any of it until seven o'clock the next morning, when Hickson saw her drink half a wineglassful. She said that it seemed to taste unlike previous prescriptions of the same medicine that she had been given by other druggists, but she thought that this may have been because she had also been taking laudanum to treat a pain in her face. The laudanum had given her bad dreams during the night, and she had been terrified by a vision of a madwoman.

Five or ten minutes later, she called for Hickson who found her still in bed but leaning on a chair at the bedside. Hickson thought she had fainted, and she appeared to be suffering from spasms. Hickson sent the coachman to fetch the surgeon, Mr. Francis Taylor, and when she got back she found Mrs. Smith lying on the bedroom floor surrounded by the other servants. She was screaming, very much, very loudly, Hickson said. Her legs were drawn up and contracted, and she begged to have them pulled straight, and to have water thrown over her. Hickson noted that her feet were turned inwards. She put a hot-water bottle on them, but it had no effect. The governess who was also present said that she had seen her mother affected in the same way, and Mrs. Smith said through clenched teeth, "Oh, you have, have you; do you think it is hysteria then?"

A little while later, Mrs. Smith said that she felt easier, and asked to be turned over. A few minutes later she died. She was conscious throughout, and recognised Hickson to the last. From the time she took the medicine to her death was about an hour and a quarter. Her teeth were clenched the whole time. At a later hearing Hickson was asked, "Was she the whole of the time from the fit coming on stiff?" "Yes," she replied, "she was only relieved a very few minutes before she died."

Taylor testified that he saw Mr. Jones, the pharmacist, come running up the drive in a state of great excitement. Jones's wife told the newspaper reporter that he "Did not feel so much the consequences to himself as the thought of having sent such a beautiful creature to another world, and such a good customer." Shortly afterwards a "very respectable" jury met at the house to view he body and consider the evidence. It heard that the salicine had been kept in a small bottle on a high shelf of the pharmacy, on which there was also a bottle of something else; strychnine hydrochloride. Jones had dispensed the prescription himself and had muddled the bottles. He was arraigned on a charge of manslaughter and committed suicide not long afterwards.

After death, Mrs. Smith's hands were tightly clenched and her feet twisted; her eyelids adherent to the eyeballs. The unnatural stiffness dissipated slowly after death, but after three days the hands and feet were still distorted.

Even social parasites deserve better than this.

Throughout the nineteenth century and beyond, the ready availability of strychnine-containing medicines was a constant danger, and the medical profession was by no means a certain bulwark against disaster. The case of poor Mrs. Sergison Smith was not unique. In the following year, 1849, Punch, in the form of a spoof letter from Paracelsus Pillcock, M.D., laid into doctors and pharmacists for illegible and incomprehensible prescriptions.2 Not long afterward, a young lady in London paid the price. She had been taking a nux vomica medicine for some time and in May 1853 her doctor wrote her a repeat prescription. It read:

Pulv. Strychnos Nucis vomicae ^ij Bismuth Nit. jss Pulv. Rhei. gr.viij

The young woman's father was pressed for time and took the prescription to an unfamiliar pharmacy. He unnecessarily told the assistant, "You will be careful as to the second article, the nux vomica, and let it be good." The inexperienced assistant assumed from this that the prescription was for both strychnine and nux vomica and put in 1% grains ^ij) of each. The prescription proved fatal in one hour and a half. A verdict of accidental death with censure of both the doctor and the druggist was returned. The Lancet3 opined that no single person was responsible for the mix-up. The word Strychnos was irrelevant; the term Pulv. Strychnos should not have been written on a separate line, and (as any Islington druggist's assistant should have known, the editors imply), Strychnos was not in the correct case (the genitive) to agree with Pulvis nucis vomicae. The assistant should have known that 1% grains of pure strychnine would be fatal and should have queried it. But they could not refrain from bemoaning the fact that if only the self-important father had refrained from putting his oar in, the mix-up might not have occurred: "If lay persons would not pretend to more technical knowledge than they really possess, nor presume to read prescriptions and give directions guided only by a slender acquaintance with such writings.." It did not occur to them to speculate that if doctors refrained from writing their prescriptions in mediaeval cabalistics, neither the father nor the assistant would have been confused.

The extent of nux vomica's use in traditional Indian medicine is uncertain. There are contradictory accounts. According to one nineteenth century source, it was seldom if ever used by Hindu physicians because of the dangers.4 However, if a modern compilation of traditional remedies is to be believed, it would probably be easier to list those afflictions for which it has not been recommended.5 Typically, in India the nuts were boiled in milk to soften them, then scraped into a paste which can be set aside and softened again when needed. They were also recommended as prophylactics against various diseases. It was commonplace to take nux vomica every day to protect against snake bites. In a paper read by Mr. Baker to the Medical and Physical Society of Calcutta in 1823, he related the case of a servant who, while carrying an umbrella for a British officer, suddenly fell down in a fit. He appeared stiff and lifeless, and when he stood up, rested on his heels, with his toes turned upwards, his eyes staring, and his teeth clenched so strongly that the company could not separate them. After a few minutes he recovered, vomited, and told Baker that he had been taking the Kuchila, or nux vomica, for four months to guard against rabies, starting with an eighth of a nut and gradually increasing the dose so that he was now on two a day, taken morning and evening. That morning he had taken it on an empty stomach.6 Baker reported that the nut was taken "either coarsely powdered, in its natural state, or half roasted on a hot iron, changing it from side to side till it swells out, which it does, in the course of one or two minutes." Two nuts would certainly contain a fatal dose of strychnine, although the roasting would decompose some of it. Later research would claim that although strychnine is not a cumulative poison, neither is it an habituating one; continually ingesting it leads to little or no tolerance, so the manservant was daily dicing with death.

Following Fouquier's work during the opening years of the nineteenth century, nux vomica, and very soon afterwards strychnine, showed a meteoric rise in popularity not only in France but throughout Europe, and before long in North America too. The use of nux vomica, together with that of other plant drugs, was described by Magendie in his influential Formulaire Pour la Préparation et L'Emploi de Plusieurs Nouveaux Medicaments (1821), and within a very short space of time the efficacy of nux vomica, and very shortly thereafter of strychnine, had become received opinion among French physicians.

By the later 1820s, a succession of snippets in The Lancet and elsewhere were reporting Continental physicians' claimed successes. At about this time, Pelletier and Caventou founded a laboratory in Paris for the commercial preparation of alkaloids, and their example was followed in London by Thomas Morson. In 1828 there appeared the first English-language recipe for the preparation of tinctures and pills of nux vomica and pure strychnine. This was based on Magendie's formulary, which had already gone through five editions in French, each translated into English.

In no time at all, a succession of British doctors had jumped on board the bandwagon. Deafness, headache, intestinal worms, prolapsed rectum, lead poisoning (or paralysies saturnines in French), rheumatism, diabetes, catatonia, strangulated hernia, even cholera; all these citadels and more were subjected to the cannonade of the new drug. M. Bernard at l'Hôpital de la Pitié

in Paris was operating on partially blind patients by injecting strychnine sulphate powder into the eyelid with "a small pen-shaped penetrating instrument."7 In a treatment that makes the eyes water even to think of it, urinary retention was treated by injecting a solution of strychnine up the urethra into the bladder using a probe.

Another influential publication popularizing the new drugs was the long-lived Treatise on Therapeutics by the wonderfully named duo of Trousseau and Pidoux.8 Armand Trousseau began his career as a teacher of rhetoric until he was persuaded to take up medicine by the physician Bretonneau. The first edition of his book with Pidoux was published in 1839 and the last, the ninth, containing additional sections on magnetism, electricity, acupuncture, massage, gymnastics and flagellation, almost forty years later. Throughout this period, the section describing the use of nux vomica and strychnine was virtually unaltered. Reading between the lines of the text makes it clear that the drugs' reputations had been founded from an early date on competing and dubious claims by various French physicians seeking to outflank Fouquier and gain credit for the claimed therapeutic successes which always persisted in being never quite clear-cut. Trousseau and Pidoux in their first edition say:

A more or less complete knowledge of the physiological action of this 'Heroique substance' led Fouquier to recommend it in paralysis; and although he himself was less successful, perhaps, than others have been, we must still award him the honour of the discovery Initially he used it against hemiplegia, but Bretonneau repeated his experiments and soon found that while it had little value in hemiplegia, it may be given with great profit in paraplegia, and in general in paralyses which depend on diseases of the cord, or of the nervous conductors only. After many trials [Bretonneau] formulated the cases in which it ought to be tried as follows; paraplegia symptomatic of concussion of the medulla, when the primary symptoms are past and paralysis alone remains; those which follow inflammation of the medulla or its membranes, when all the phenomena of local irritation have long disappeared; those which follow Pott's disease; the various paralyses caused by lead.9

Poor Fouquier! He introduces a nostrum which he thinks will work, gets equivocal results which he describes honestly, then has the credit taken away by less fastidious colleagues, such as Bretonneau (the man who got Trousseau his job, and to whom therefore he owes a favourable mention) who says that Fouquier would have succeeded if only he had used it against the right kind of paralysis.10 Bearing in mind the power of autosuggestion on patients given such a violent treatment and the fact that many neurological diseases are self-limiting or get better spontaneously, it was easy for any doctor to find a set of patients to support his account of successful cures. It is unlikely that any of them misreported their results mendaciously; it was easy enough to be persuaded unconsciously by the climate of general consensus that such a violent drug must do something useful.

The case could not have been put more clearly than by the pen of Trousseau himself. He is actually referring to the lack of hard evidence concerning strychnine's claimed efficacy against cholera, but in fact what he says gives the game away in respect of the entire strychnine saga:

.. .from these results, important as they perhaps are (unfortunately this is still very doubtful), how great is the distance to.that kind of infallibility which was at first attributed to the strychnia-treatment, an illusory infallibility, which soon disappeared before failures both numerous and marked.

By 1833, a minute but telling change in nomenclature had already surfaced. Dr. R. Rowland of Fenchurch Street, London, was using "The Strychnine" to treat neuralgia, period pains, amen-orrhoea and hysteria in women. Clearly strychnine had passed from being an interesting, if chancy, new remedy, to becoming a minor institution. Dr. Rowland had never seen any ill effect from its employment, nor did he believe that it required "such watching as is usual to inculcate." By 1835, at least two books had already been published in England on the miraculous properties of the new drug,11 and in 1836 it was included in the new London Pharmacopoeia, apparently against the wishes of some doctors.

Some physicians were administering stupendous amounts of nux vomica powder in a regimen of gradually increasing doses which would leave the life of the patient hanging on the question of how efficient his digestive system proved in absorbing the poison, how fine the powder was, and how much strychnine it contained. The situation was made even more hazardous by the widespread adulteration of drugs. Second-rate nux vomica powder adulterated with substances such as ground date-stones was often supplied to doctors, with lethal results. In France, strychnine was adulterated with chalk, magnesia, sugar or amidone: a criminal offence.12

Trousseau, now using strychnine rather than nux vomica (but in what degree of purity?) was recommending hair-raising doses. After giving the recipe for a syrup containing approximately 2 milligrams of strychnine per 5 millilitre teaspoonful, he describes how to administer it:

We give on the first day two or three teaspoonfuls of the syrup, according to the age, insisting on its being given at equal intervals during the day, at morning, noon and night, so that the effect may be watched and the aim not overshot. If the dose of three spoonfuls is well borne, it is continued at first for two days, then increased by one spoonful; then wait two days more, and thus attain the amount of six, always giving each at the proper intervals.

When this dose is reached, we substitute a dessert-spoonful (representing twice as much as the former) for one teaspoonful, and following the same rules, gradually reach six dessertspoonfuls per diem

The mind boggles. Six dessertspoonsful, or 24 milligrams per day, is nearly half the fatal dose, generally reckoned as one grain or 62 milligrams, and as little as half a grain taken all at once may have killed a 39-year-old man. But the real horror is yet to come:

.[thus] we at last give children of from five to ten years of age from 25 milligrams to 6 centigrammes [60 mg.] (0.41.0 grains).

So these are children's doses!

Beyond this age we begin with the dessert-spoonful, and gradually reach 10 centigrams (1Vi grains) of the active principle, for adolescents.It is the more essential, to watch over the treatment, as the remedy must be given in doses large enough to betray itself by physiological action. It is necessary, also, to let the person in charge know what may happen...

In a very few days, when we begin to increase the original dose, the patient feels at certain moments in the day, twenty or thirty minutes after the dose, a little stiffness of the jaw, headache, disturbance of vision, a little vertigo In some cases, there are also muscular shocks and often (if there is hysteria) spasms or convulsions. These shocks are produced especially when the patient is surprised, as when he receives a sudden order, and may throw him to the ground. The contractions are tetanic, painful, especially when there is an effort to resist and to remain upon the feet, but lying on the flat of the bed is sufficient to quiet the storm at once.

What better way for a doctor to retain complete control over a fractious patient; better than an electric fence, and all in the name of science too!

What is a poison? In his influential book A Treatise On Poisons (1829)13 Robert Christison, who had studied in Paris at the time of the isolation of strychnine, declined to give a definition and pitched straight into describing the various poisons and their effects. He contented himself with dividing them into two main classes: the irritant poisons, which destroy the tissues at the site of administration, and what he called "the nervines," poisons that act at a remote site in the body.

Had Christison wanted to come up with a good working definition, he could have done worse than go back to Paracelsus, who in 1538 wrote:

What is not a poison? All things are poisons, and nothing is without toxicity. Only the dose allows anything not to be poisonous. For example, every food and every drink is a poison if consumed in more than the usual amount, which proves the point. I admit that a poison is a poison; but that is no reason for condemning it outright.

In other words, "It's all a matter of the dose."14 Foods, drugs and poisons are all foreign chemicals taken into the body with varying results, however much this may offend believers in natural foods and remedies. Alcohol is a good example of a substance that clearly fulfills all three functions, depending on the dose; strychnine is certainly both a drug and a poison, although it has to be admitted that any role it plays as a food is hardly in evidence.

From the earliest days there had been accidental poisonings by nux vomica. Matthiolus in about 1550 told of an old lady killed by eating cheese made in a bowl in which it had been bruised. Later on, some drunken apothecaries in Germany bet one of their numbers that he would not be prepared to drink beer containing Cocculus indicus15 which they said would make him walk on his head. The man accepted the bet, but for a joke presumably, was given nux vomica instead. He went home and died fifteen minutes later.

Paradoxically, nux vomica powder, although less potent than pure strychnine, was the more dangerous. By the time they reached Europe, the extremely hard nuts could not be ground by hand, only filed. Physical factors—the fineness of division of the powder and its exposure to stomach acid—would strongly affect the degree of absorption of the strychnine, and were insufficiently taken into account by the early physicians. Fine powdering would later become possible with steam power and milling machinery.16 The spread of steam boiler technology in the first half of the nineteenth century allowed not only mechanical milling, but also the use of steam itself to soften the nuts so that they could be more easily powdered.

The problem was that when someone was given nux vomica powder, a high proportion of the alkaloids was retained in the nut tissue after it was swallowed, and leached out into the body only slowly. It was always possible to find unchanged powder in the stomach, from which a large amount of unchanged strychnine could be extracted.17 Thus, although it is usually stated that strychnine is not a cumulative poison, nux vomica certainly could be. One lady was given three grains of the powder three times a day for sixteen days. She began to suffer from purging and colic, so the treatment was stopped. Five days later, she complained of ringing in the ears, drowsiness, increased sensitivity to light and sound, numbness and deafness. On the ninth day after stopping the treatment, she became speechless and convulsions set in. The symptoms increased and she died, "apparently exhausted," four weeks after first being prescribed it, and a full twelve days after ceasing to take it. Nux vomica powder was therefore an extremely dangerous cumulative poison with wildly unpredictable effects; the most dangerous medicine that has ever been administered to human patients, despite some stiff competition.

From an early date, the more sensible doctors, including Fouquier, preferred an alcoholic extract of nux vomica, which was in theory at least more reliable and controllable than the powder, and then, as it became widely available, strychnine itself. But we have already seen how commercial samples of the alkaloid were very often contaminated with the less active brucine, and were also subject to adulteration, so the doctors had only very rough-and-ready ways of controlling the administration of such a perilous substance. Assaying, that is determining the effective strength of, such crude plant extracts so that the dose could be given accurately was a major problem to nineteenth-century physicians; or at least, to those that thought about it at all.

There are contradictory accounts concerning whether pure strychnine can act as a cumulative poison. This property is of signal importance when considering the medical evidence in the famous poisoning trials, such as the Castaing and Palmer cases. Whilst medical authorities are unanimous in saying that strychnine is not cumulative, its behavior in these cases was more unpredictable than their opinion would imply. The explanation is probably that when good scientific studies of strychnine metabolism were carried out and its fate in the body properly probed later in the century, the alkaloid was administered by injection or intravenously. But given by mouth, there is a complicating factor which I have not seen specifically referred to by any of its early enthusiasts. Strychnine is a nerve poison which interferes with muscle control and although these effects are most noticeable in the skeletal muscles of the limbs and chest, the nerves supplying the internal organs could also have been affected.18 This would have affected the functioning of the digestive tract, and is probably partly responsible for the intermittent nature of strychnine poisoning. Small doses were said to stimulate the intestines, but larger doses would have thrown them into spasm, thus interfering with the further absorption of the poison. The patient would partially recover as his digestive tract lost its power, then as it recovered a fresh surge of strychnine would be absorbed and the spasms would start again. So although strychnine given by injection is not a cumulative poison, strychnine given by mouth probably is. Whatever the reason, strychnine administered orally was an unpredictable tiger caught by the tail.

Trousseau and Pidoux, despite their blind attachment to administering the drug, did at least recognize this property:

When these effects appear we must not increase the dose any further, for strychnine, like all the preparations of nux vomica, is a remedy which, by virtue of its very peculiar long therapeutic range and a most remarkable accumulative action, is capable of causing unforeseen accidents, even though it has been given in moderate doses which up to a given point of time produced scarcely appreciable effects...tolerance of the remedy not only varies according to individuals but even in the same person, so that while the doses remain the same, we never can infer tomorrow's effect from that of yesterday; violent spasms may occur tomorrow immediately after the first dose, even when we are sure that the preparation remains the same.19

If given by mouth, a drug is potentially liable to chemical change as soon as it is swallowed, since it is subjected to the strong stomach acid, followed by the alkaline environment of the intestine. Assuming it is not affected by these and is absorbed into the bloodstream unchanged (or is given by injection), it may be metabolised by the tissues, especially the liver, before or after it has done its work. Some drugs (prodrugs) are not in the active form when they are administered; it is the metabolised form that is effective.

Some very powerful drugs, such as anticancer drugs, react chemically with their target, such as the nucleic acids of the cell. Penicillin reacts chemically with the cell walls of bacteria. But most drugs carry out their action without chemical change. They fit a receptor somewhere in the cell (the famous "lock-and-key" mechanism), cause their physiological change without themselves being altered, and are then released. This question of whether a drug can take effect without being chemically altered in doing so became of vital importance in the Palmer trial, as we shall see.

Strychnine is chemically stable and it is the unchanged alkaloid that is the active drug. It is however gradually metabolised by the liver, with a half-life of about 50 minutes; that is, half of a given dose disappears in each fifty-minute period after it reaches the bloodstream. So when it kills, it does so within an hour or two. The fatal dose of pure strychnine is generally given as V to 1 grain, or approximately 30 to 60 milligrams, but as little as 15 milligrams has killed. For comparison, a typical aspirin tablet contains 300 milligrams of active ingredient. So, strychnine is a highly dangerous poison and was especially hazardous in the nineteenth century when given in doses such as those described by Trousseau. His doses are so enormous that the strychnine with which he made up his syrup could not have been pure; even without conscious adulteration, it must have been a weaker (and variable!) mixture of strychnine and brucine.

Even from the first, there were sceptics. An 1822 review of Magendie's book20 says that it was easy to see how such an energetic substance could soon become a favourite treatment, and in Paris, its use had become as indiscriminate as Magendie could possibly have wished. But the reviewer had good reason to know that many of the patients relapsed as soon as they staggered out of the hospital gates. "Surely," he says, "when we possess so many pleasant, efficacious and innocent bitters, it is an effort of the blindest attachment to propose the substitution of so formidable and disagreeable a remedy." Thirteen years later, the anonymous reviewer of Mart's book21 preferred sarcasm:

Thirty-two more miracles performed by strychnine! Mr. Mart has come from H.M. Ship Raccoon and has discharged a very destructive broadside against hemiplegia, paraplegia, amaurosis, nervous indigestion, tic douloureux and neural-gia...the present work is not—Oh, fellow countrymen! a list of the killed and wounded. It resembles more a report of the Humane Society, and contains only a catalogue of the cured We ask Mr. Mart, and we shall continue to ask all the proclaimers of new medicines—"To how many patients did you administer your drugs without producing the least advantage from its employment?"

Mr. Hawkins of St. George's Hospital had not much faith in strychnine and believed it to be useful only in cases of temporary paralysis, and had never seen it to produce any better effect than spasmodic twitching of the limbs. He does not quite go so far as to query why it was necessary to use it at all, if it only affected temporary paralysis, but that is the implication. A Dr. Granville tried it out on an intimate friend of his, an eminent chemist, for a long period, but the treatment completely failed.22 Dr. Epps, using it in 1836, had noticed unfavourable effects such as convulsive movements of the legs, and as a result had transferred his patients to a much safer regime: arsenical liquor.

Others were more motivated by fears about its safety than doubts about its usefulness. Sigmond23 bemoaned the fact that there was so much variation in the strengths of nux vomica preparations and said that if this could be overcome, there would be no necessity to use strychnine, "which is the most ferocious poison we possess, and which, I think, should never be prescribed." Despite endorsements by Magendie and other famous physicians, it should be, in his opinion, "shunned by the practitioner." Others agreed, following a meeting of the Medico-botanical Society, that Strychnine's use was so dangerous that it should be confined to the most urgent and hopeless cases.

The history of strychnine, as it developed, reflected the different social structures of the two dominant European nations. France was (and remains) a highly centralized country, often with one set of received opinions about scientific questions. After the researches of Magendie, Fouquier and the others, this opinion was solidly behind strychnine and it is impossible to find a dissenting voice. Medical opinion in Britain was more difficult to corral. There were always those prepared to take a contrary view, and although there are no signs of overt anti-French xenophobia in the negative comments about strychnine, the fact that the new ideas came from over the Channel made it especially easy to be sardonic. But once a certain critical mass of medical opinion had fallen into line, the unrestricted capitalism of Victorian Britain came into play and the positions were reversed. When the dangers as well as the supposed benefits of strychnine were realised, the French climate of regulatory control ensured that its use was restricted to the medical elite, while in Britain, through the offices of the numerous unregulated drug wholesalers and apothecaries, before long anyone with twopence to spend could lay his hands on it.

There are early signs of hysterical overtones. Sigmond informs us that, "a curate, who had been in the habit of using strychnine," (he does not say what for), "presented a scarcely appreciable morsel to a denuded surface, and was instantly killed."24 The morass of confusion surrounding drugs, electricity, nervous phenomena and mesmerism persisted. Did not the limbs of a corpse twitch when electricity was passed through, and did not strychnine produce the same effects? It was widely thought that anyone touching a strychnine-poisoned human being or animal received an electric shock. A Mr. Moore from Mitcham wanted to destroy a dog and locked it up in a room with a saucer full of strychnine dissolved in milk. When he returned to the room some time later, the dog was dead despite not having drunk any of it.

But the bandwagon rolled on. Later claimed uses tell us much about Victorian obsessions. For urinary incontinence in children of both sexes, strychnine provided a useful alternative to cold baths, blistering and cupping of the loins. J.H. Houghton in 1856 is getting to grips with a really serious ailment. "In the daily round of practice there are few cases more annoying to the medical attendant, or less satisfactory in their general management, than habitual constipation," he writes. Medicines such as colocynth and ipecacuanha work at first, but gradually require greater and greater doses. A lady, age 55, corpulent, inactive and self-indulgent, had not gone a single night for eight or nine years without taking nux vomica, "except when she has been ill, and required other treatment." Another successful case had been of a patient whose life had been "dominated by colocynth, calomel and an enormous bottle of senna mixture and had become one of great misery, for the little comfort she got whilst her bowels were allowed to remain quiescent was destroyed by her fears of the next necessary resort to medicine." He does not report what form of words he used to persuade her not to be frightened of nux vomica.

A few years earlier, M. Duclos was treating another bogus but anxiety-causing nineteenth-century condition, spermatorrhoea.25 Nineteenth-century doctors found difficulty in distinguishing between sexual potency and fertility. Overuse of the sex organs, either deliberately or involuntarily, could result in loss of spermatozoa and thus infertility. On the other hand, complete abstinence in men, and especially women, had all sorts of undesirable side-effects including infertility and most notoriously hysteria, defined literally as disorder of the womb.

In the treatment of spermatorrhoea, patients were given nux vomica pills in gradually increasing numbers. The treatment could be supplemented with nux vomica ointment rubbed into the loins and the inside of the thighs. Duclos writes that the condition of incomplete impotence is as often found in those who have been excessively continent as in those who have abused their sexual organs. Self-pollution may occur either by night or day, the discharge being either a true or a pseudo-spermatorrhoea, whatever that is. Commenting on Duclos's work, the editor of The Lancet reveals that he has many times tried strychnine in these lamentable cases, but has never discovered any special benefit, and prefers cauterisation as the treatment.

As the century progressed, some formulation of either nux vomica or strychnine became a virtual obsession with some physicians. Strychnine pellets became so handy for one American doctor that "I can give them to a businessman to carry in his vest pocket to take one or two occasionally for indigestion or headache caused by the sluggish action of the liver, stomach or bow-els Railroad men, farmers etc. can carry them and use them in hot weather when they are inclined to drink so much water that it hurts them.children can take a few pellets to school in cases of bowel trouble when they are not sick enough to stay out of school." Victorian physicians can remind one of a motorist stuck far from a garage with a car that won't start. Their range of techniques is strictly limited. "Why don't you make sure the plug leads are all on properly?" a passer-by says. They try this, and occasionally it works. If this happens, they make sure never to set out on a journey without first hammering on the leads so tightly that sometimes they break. For some physicians, strychnine became the WD-40 of Victorian medicine.

In 1856 a cogent plea for the deletion of strychnine from the pharmacopoea appeared.26 J. Nichol FRCS pointed out that many highly poisonous medicines, arrested or guided by the hand of science were useful, but this was not the case with strychnine. In his opinion, not one of the effects that it had exhibited in its rapid career justified its use. "That it may, in very minute doses, in combination with other agents, produce some beneficial effect...may be possible, although I am inclined to doubt it; but these effects are equally obtainable from other medicines, and certainly do not afford an excuse for its use," he goes on to say. "The frightful disclosures being made in the courts and the careless manner in which this deadly poison passed from hand to hand make it a subject worthy of the attention of the medical profession and of the legislature."

Dr. Nichol, had he survived long enough, would have been dismayed by the number of accidental fatalities from strychnine poisoning and by the illicit uses to which it would continue to be put over the next few decades, often by doctors themselves. No doubt he would have been gratified to know that his wishes would eventually be fulfilled, in only a little over a century.

We will let a Scots physician have the last word. Sir James Mackenzie (1853-1925), in his time a well-known Harley Street cardiologist, tells us that he resolved to try its action for himself:

Strychnine had a great vogue, its effects being commented on by physicians and surgeons—the latter, indeed, often refusing to operate on a patient under an anaesthetic unless the patient had a preliminary dose of strychnine, while anaesthetists had often beside them a hypodermic syringe ready charged, lest the heart would fail. To my surprise I could get no result with strychnine whatever.. ..no effect could be found on the healthy heart, nor on people in a state of collapse. I read up the literature, and beyond assertions as to its value, there was not on record a single instance where there was given any evidence justifying the belief in its properties.27

This assessment, made in the early years of the twentieth century, probably puts Mackenzie among the earliest of those whose change of opinion contributed to the painfully slow decline in strychnine's medical reputation. But before that took place, a lot of nux vomica would flow under the bridge.

When all else had failed and the patient was on the way out, strychnine could be used to resolve things, one way or the other. "At one time few patients in Britain were allowed to die without being given strychnine injections."28 Not surprisingly, the biography sections of the nation's libraries can be scoured in vain for any specific mention of strychnine being used as this treatment of last resort.29 The physician was restrained by professional ethics; the friends and relations would not have known what the last injection contained, and as for the patient himself...

How many famous Victorians left this world with the words ringing in their ears, "there is just one other thing that I might try."?

Endnotes

1. Hampshire Independent, Nov. 4, 1848:5-6. The spelling of her name is as given in this newspaper report. Other spellings such as "Ser-jeantson Smyth" appear elsewhere.

2. Punch, 1849:37. "Pillcock" may have been a spoof on Dr. Locock, who achieved some fame as a marketer of Dr. Locock's Powders for All Disorders of Children (Stuart, 2004: 84). A Dr. Locock treated Helen Abercrombie when she was dying in 1830 (see Chapter 9).

4. Chevers, 1870:243.

5. Nadkarni, 1954:1175 et seq.

6. Sigmond, 1837.

7. This and subsequent similar descriptions of strychnine treatments are taken from the Lancet, circa 1830-1835.

8. Trousseau and Pidoux, 1839; Trousseau and Pidoux, 1875-1877.

10. Fouquier sounds like an engagingly modest man. "I have been so much credited with this discovery that I only made by chance," his obituarist records him as having said (Requin, 1852).

11. Bardsley, 1830; Mart, 1835.

12. Chevallier, 1850.

13. Christison, 1829.

14. Albert, 1987.

15. Indian cockle or fishberry is another Indian plant. It is a narcotic and used to stupefy fish so that they can be caught. It contains picrotoxin (not an alkaloid; it does not contain nitrogen).

16. As late as 1803, the Apothecaries Company installed horse-driven mills for grinding medicines at Apothecaries Hall in London. Strong heating partially decomposes strychnine and brucine, and reduces their concentration in nux vomica to a less dangerous level. In traditional Chinese medicine, the seeds are heated in dry sand or in very hot soya oil, then powdered (Boo-Chang Cai, 1990).

17. Taylor, 1859.

18. Although glycine receptors are commonest in the central nervous system, they also appear to exist in the autonomic nerves controlling the digestive tract.

19. Trousseau and Pidoux, 1876-1877 (transl. Lincoln), vol. II.

20. Edinburgh Medical and Surgical Journal, 1822, 18, p.15.

21. Lancet, 1835:112.

22. This was almost certainly Michael Faraday, a lifelong hypochondriac. Dr. Augustus Bozzi Granville (1783-1872) was one of the proposers for Faraday's membership of the Royal Society, and was a fellow-member of the newly founded Athenaeum club (James, 1991, vol. 1, 315 (footnote), 341).

23. Lancet, 1837:826.

25. Involuntary discharge of semen. A condition publicised by Claude François Lallemand (1790-1853), professor at Montpellier, who advocated circumcision as the cure. His ideas were taken up enthusiastically in Britain and the United States. One quack showed a patient with the aid of a microscope that his urine contained spermatozoa, and told him that he was condemned to death unless he handed over £50 for medicines and spent the next 28 weeks locked up in the dark (Acton, 1870). In the nineteenth century many cases of presumed "spermatorrhoea" would have been discharges caused by gonorrhoea. Believers in medical progress should, however, see how many Internet sites they can count today prescribing homeopathic cures for spermatorrhoea.

27. Wilson, 1926.

28. Pharmaceutical J., 1962:152. "A wise physician would know when to ease the administration of powerful stimulants like digitalis and strychnine" (Jalland, 1996; 92, citing a 1917 doctor).

29. The only explicit mention I have so far come across is in an account of a remarkable (and unsolved) twentieth century poisoning case. In 1928-1929, three members of the Sidney family were separately poisoned over a period of nearly a year with arsenic at an address in Croydon. The doctor found one of them in a state of collapse and gave him injections of digitalis and strychnine, without effect. Connoisseurs of the poisoner's art will be gratified by the additional fact that the third of the victims, Violet Sidney, was killed by someone putting arsenic into her bottle of Metatone, the strychnine-containing "tonic" (Symons, 1960: 163-171).

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