THE 
USB OF ASCENDING DOSES OF NUX VOMICA, 
AS AN AID IN THE TREATMENT OF 
INSUFFICIENCIES OF THE 
OCULAR MUSCLES. 
BY 
G. E. DE SCHYVEINITZ, M.D., 
OPHTHALMIC SURGI-.ON TO THE PHILADELPHIA ANl) TO THE CHILDREN’S 
HOSPITALS; OPHTHALMOLOGIST TO THE INFIRMARY FOR 
NERVOUS DISEASES. 
FROM 
T11 F. MEDICAL NEWS, 
November 2, i88q. [Reprinted from THE MEDICAL News, November 2, 1889 ] 
THE USE OF ASCENDING DOSES OF NUX 
VOMICA. AS AN AID IN THE TREATMENT OF 
INSUFFI CIENCIES OF THE OCULAR MUSCLES. 
By G. E. uk SCHWEINITZ, M l) , 
OPHTHALMIC SURGEON TO THE PHILADELPHIA AND TO THE CHILDREN'S 
HOSPITALS ; OPHTHALMOLOGIST TO THE INFIRMARY FOR 
NERVOUS DISEASES. 
In recent years unusual care has been bestowed 
upon the study of the ocular muscles, and their rela- 
tion to the production of headache, asthenopia, and- 
reflex nervous disturbances has afforded the subject 
of many researches. The older tests for the detec- 
tion of muscular troubles have been believed to 
be imperfect, and we have for use the ophthalmo- 
dynamometer of Landolt, the useful modification of 
this instrument by Alleman, the phorometer of 
Stevens, the method of Holden, the obtuse-angled 
prism of Maddox advocated by Randall, and the 
ingenious adaptation of Cretes’s revolving prism by 
Risley for measurement of the degree of discovered 
deviation. After lack of equilibrium in the ocular 
muscles has been demonstrated by any or all of 
these means, the important problem for solution 
consists in the proper method for the restoration of 
the disturbed balance. 
Here, again, we have a variety of measures at 2 
DE SCHWEINITZ, 
hand, depending upon the degree and character of 
the defect—decentration of the correcting lenses, 
the use of prisms, tenotomy, combined or uncom- 
bined with advancement, and the method of “ grad- 
uated ” or “ partial tenotomies ” revived and advo- 
cated by Stevens, Ranney, Webster, Standish, and 
other surgeons. Perfectly aware of the fact that 
where high degrees of insufficiencies, especially of in- 
sufficiency of convergence, exist, surgical treatment 
is the only one which is efficacious, and also fully 
alive to the fact that, especially owing to the work 
of American colleagues, the correction of minor 
degrees of heterophoria by means of partial tenoto- 
mies has become more and more a satisfactory oper- 
ative procedure, there are none the less a class of 
cases in which operation is either impossible, from 
lack of consent, or inadmissible owing to compli- 
cating circumstances. It is, perhaps, only necessary 
to refer to the instances of so-called neurasthenic 
asthenopia associated with great reduction in the 
amplitude of convergence, cases in which Landolt 
has so well shown that surgical treatment, without 
perhaps being entirely excluded, must be associated 
with general invigorating methods. It is in those 
cases, then, of muscular troubles in which an opera- 
tion cannot be performed, or, having been per- 
formed, has proved insufficient, and in which the 
use of correcting lenses combined with prisms has 
failed to relieve the symptoms, that I wish to call 
attention to the relief that is afforded by the use of 
ascending doses of nux vomica. 
Ophthalmic surgeons have long been accustomed INSUFFICIENCIES OF OCULAR MUSCLES. 
3 
to employ nux vomica or strychnia in the treatment 
of various forms of ocular disturbance. Since Nagel, 
in 1871, called attention to the value of strychnia in 
the treatment of nerve atrophy, it has been largely 
employed with varying degrees of success in the treat- 
ment of atrophy of the optic nerve. Nux vomica has 
been much used in forms of functional disturbance 
of the retina, associated with a lack of general bodily 
tone, in which at once a bitter tonic and stimulant 
to the trophic centres and a vaso-motor excitant 
were indicated. Naturally, weakness of the external 
eye muscles has called for its use, exactly as lack of 
tone in the general muscular system has always been 
one of its most important indications. It is not the 
purpose, therefore, of the cases which follow to show 
any new use for the drug, but only to describe a 
method of administration which has proved suc- 
cessful in my hands. 
Cask I.—Private patient, female, aet. twenty-one. 
Painful eyes ; supra-orbital neuralgia ; violent frontal 
and occipital headache ; general health good ; no 
lesion of the fundus; refraction error a compound 
hypermetropic astigmatism ; insufficiency of the in- 
ternal recti of seventeen degrees in the act of accom- 
modation, and five degrees at five metres. Correc- 
tion of the refraction error afforded partial relief, 
but the headaches returned when any close applica- 
tion with the eyes was practised. Ascending doses 
of the tincture of nux vomica were begun as follows: 
Ten drops three times a day, to be increased on 
succeeding days by one drop at each dose until some 
physiological action of the drug was manifest. 
When the dose had reached twenty-five drops, 4 
DE SCHYVEINITZ, 
three times a day, eye-tire had greatly lessened. At 
thirty-five drops three times a day the headaches had 
ceased, although the occupation of the patient was 
that of a school-teacher. The remedy was pushed 
until forty drops were taken three times a day, then 
gradually decreased to twenty-five drops, and finally 
discontinued, with the direction to renew the remedy 
should headaches reappear under the stress of work. 
The amount of insufficiency varied ; the lowest that 
it reached was ten degrees. Prisms were never 
used. 
Case II.—Private patient, male, aet. twenty-two. 
Exceedingly nervous, and the subject of occasional 
attacks of hepatic congestion ; marked asthenopia ; 
pain in the eyeball; frontal and occipital headache ; 
in the fundus; of each eye slight retinal haze, other- 
wise no changes; myopia of one dioptry; insuffi- 
ciency of the internal recti of eighteen degrees in 
accommodation and eleven degrees at twenty feet. 
Adduction three degrees; abduction eleven degrees. 
Nux vomica, in the method already described, was 
employed, and under its influence a severe winter of 
work was successfully undertaken, during which the 
patient was practically free from headaches, using at 
the same time three-degree prisms with their bases 
toward the nose. The prisms alone failed to give 
relief, but the prisms with the nux vomica were suc- 
cessful. 
Case III.—Private patient, female, set. nineteen. 
In good general health, but somewhat mentally de- 
pressed owing to domestic troubles ; blurred vision 
during reading ; eyes easily tired; severe frontal 
headache aggravated by all near work. The refrac- 
tion a simple hypermetropia ; insufficiency of the 
external recti of eight degrees. Correction of the 
refraction error produced almost entire relief for a INSUFFICIENCIES OF OCULAR MUSCLES. 
5 
number of months, then the headaches returned and 
were stubbornly present for a long time. Under 
the use of nux vomica they speedily improved. The 
maximum dose was thirty five drops three times a 
day. The insufficiency through the correcting lenses 
became as low as three degrees. 
Case IV.—Private patient, female, ait. thirty-four. 
In poor general health; of gouty ancestry; had 
recently recovered or partially recovered from pelvic 
peritonitis; was the subject of the most atrocious 
occipital headaches occasioned by any use of the 
eyes. The refraction a compound hypermetropic 
astigmatism. Insufficiency of the internal recti of 
twelve degrees. The use of the correcting lenses, 
together with prisms, afforded some relief, but eye- 
work instantly brought on the headache. During a 
period when it became absolutely necessary for the 
patient to use her eyes at sewing and similar work, 
ascending doses of nux vomica, while they failed to 
give the relief recorded in the previous cases, lent 
sufficient aid to enable the work to be performed. 
During a similar necessary period of eye-work on 
another occasion, without the use of nux vomica, 
the patient had a complete eye-breakdown. 
Case V.—Private patient, male, aet. thirty. In 
good general health ; occasional attacks of blurred 
vision ; some asthenopia, and now and then severe 
orbital neuralgia. Refraction error a simple astig- 
matism. Insufficiency of the internal recti from 
eight to ten degrees. During certain seasons of the 
year this patient is obliged to perform much night- 
work, during which time the supra-orbital neuralgia 
has usually been much aggravated in spite of the use 
of prisms. Ascending doses of nux vomica have 
never failed to give marked relief, so much so that 
it is with difficulty that he is persuaded during the 6 
DE SCHWEINITZ, 
administration of the drug to make use of any optical 
therapeutics. The maximum dose has on a number 
of occasions been fifty drops. The usual dose is 
thirty-five drops. 
Case VI.—Private patient, female, aet. twenty- 
three. A slender woman in delicate health, a 
school-teacher by profession ; aggravated a theno- 
pia; occipital headache; occasional attacks of mi- 
graine. Refraction error a compound hyperme- 
tropic astigmatism; no disease of the fundus; slight 
haze of the retinas. Insufficiency of the internal 
recti of ten degrees. The usual treatment with nux 
vomica has been productive of much relief, enabling 
the patient to perform long periods of eye-work with 
comparative comfort. The maximum dose was 
twenty-five drops; beyond this point there was 
production of disturbance of the alimentary canal 
and wakefulness at night. Although the comfort of 
the patient was increased by the u-e of the drug, no 
lessening in the amount of the insufficiency was 
observed, nor was the relief from headache perfect. 
Case VII.—Private patient, female, set. forty. A 
florid woman, but with flabby muscles; easily tired; 
much headache; eye-pain and inability to perform 
any lengthy work requiring tension on the accom- 
modation. The refraction a simple hypermetropia 
of one dioptry. No disease of the fundus except a 
slight patch of old choroiditis in the nasal half of 
the left retina. Insufficiency of the internal recti of 
eight degrees. Ascending doses of nux vomica, the 
maximum dose being twenty-five drops, beyond 
which amount the drug produced great restlessness 
and some nausea, greatly increased the eye-comfort 
and improved a very troublesome symptom, namely, 
an appearance as if the lines on a printed page were 
broken. INSUFFICIENCIES OF OCULAR MUSCLES. 
7 
Case VIII. — Private patient, female, aet. nine- 
teen. Of large frame and fine proportions, but in- 
tensely nervous, at times hysterical, and subject to 
intervals of great mental depression ; much head- 
ache, chiefly in the morning and usually in the oc- 
ciput, sometimes above the brow. Inability to read 
for more than a few minutes at a time without great 
aggravation of the symptoms just detailed. Re- 
fraction error a slight compound hypermetropic as- 
tigmatism. Insufficiency of the external recti of six 
degrees; the fundus of each eye reasonably healthy. 
Her symptoms were practically unrelieved by the use 
of correcting lenses and prisms. All manner of gen- 
eral treatment was tried with but indifferent success. 
Finally the use of nux vomica, in ascending doses, 
was followed by surprising improvement. No les- 
sening in the degree of the insufficiency was de- 
tected, but the relief to the eyes was evident and 
gratifying. The maximum dose was forty drops, 
without the development of any unpleasant symp- 
toms. 
These eight examples will suffice to show the class 
of t ases in which this remedy thus applied has proved 
useful. I could quote many others with similar re- 
sults. I could also quote instances which, under ap- 
parently exactly similar circumstances, have not been 
benefited by the drug. The method of using nux 
vomica in this manner was suggested to me by the 
paper of Dr. John H. Musser.1 In his experiments, 
in which he desired to demonstrate the influence of 
age on the dosage of nux vomica, he came to the 
conclusion that the effect of the drug was in inverse 
1 Therapeutic Gazette, vol. ii., 1886, p. 9. 8 
DE SCHWEINITZ, 
proportion to the age of the patient; the suscepti- 
bility increased with the age. The manner in which 
Muster administered the drug was to give ten drops 
three times a day, and increase three to five drops 
every second day until some physiological effect was 
produced. That very full amounts of the remedy 
can be safely employed in this way is attested by the 
fact that one of his patients took 200 drops three 
times a day, and between the ages of fifteen and 
forty forty-five drops were well borne. It may with 
perfect reason be asked, What is the use of giving 
large doses of an exceedingly bitter tincture, when 
the equivalent amount of its active principle could 
be gained by the administration of a small granule 
of strychnia, five minims of a good tincture being 
equal to grain of strychnia? I have often em- 
ployed strychnia in precisely similar cases, and it has 
not seemed to me that the same satisfactory results 
were obtained. The nux vomica in] this class of 
cases, in the form of the tincture, seems to act some- 
what analogously to the use of Fowler’s solution in 
ascending doses in chorea and anaemia. At all 
events, the clinical fact remains that under this 
method of administration, distinct improvement in 
asthenopia and headache occasioned by ocular insuf- 
ficiency, especially in neurasthenic cases, is distinctly 
manifest, precisely as it improves the general tone 
of the muscular system, aids digestion, and corrects 
the action of the alimentary canal. One very curious 
fact which I have observed, is that it never seems to 
do good if the insufficiency exists in the vertical INSUFFICIENCIES OF OCULAR MUSCLES. 
9 
muscles. As an example of this I may quote the 
following case : 
Private patient, female, aet. twenty-nine. A highly 
nervous woman, a school-teacher by profession ; 
the subject of menstrual disorders and atonic dys- 
pepsia. The two latter difficulties were grea’ly im- 
proved after a course of regulated diet, tonics, and 
dilatation of the cervix of an anteverted uterus. She 
was the subject of the most aggravated asthenopia. 
All manner of glasses had been prescribed without 
avail. Occipital headache was constant; reading, 
sewing, and similar occupations had become impos- 
sible. The refraction was a low compound hy- 
permetropic astigmatism. There was an insuf- 
ficiency of the superior recti of three degrees—right 
hyperphoria of Stevens’s cla sification. Decentra- 
tion of the lenses, and prisms were productive of no 
benefit (operation was declined). The persistent 
use of nux vomica signally failed to give relief. 
This is not a single example on which I base my 
opinion that the use of this drug will not be found 
to be of value in the treatment of the various forms 
of hyperphoria. I have tried it in a number of 
cases, and it never had one particle of effect, 
unless, perhaps, the good of a bitter tonic upon the 
stomach. 
Another point of interest in the administration of 
nux vomica and of strychnia, for this and for similar 
purposes in disturbances of the eyes, is the condition 
of the retina. It is a well-known fact that irritations 
of the nerves contraindicate the use of full doses of 
nux vomica or its alkaloid. It is a therapeutic law 
which must not be broken, that this drug should not 10 
DE SCHWEINITZ, 
be administered in paralyses from cerebral hemor- 
rhage until all irritation produced by the clot has 
passed away. On precisely the same principle, nux 
vomica and strychnia are contraindicated in ocular 
insufficiencies associated with headaches, if at the 
same time there is much retinal irritability, char- 
acterized by dread of light, manifest haze and thick- 
ening of the fibre layer, and the presence of numerous 
lymph reflexes throughout the eye-ground. I have 
more than once not only not seen the drug relieve 
the patient, but distinctly aggravate the headache. 
This was beautifully illustrated by the following 
case : 
Private patient, female, set. ten; very anaemic; 
of rapid growth ; much headache, worse during 
school hours. The refraction was a simple hyperme- 
tropia. There was a slight insufficiency of the in- 
ternal recti, and marked retinal irritation sufficient 
to produce decided photophobia. This somewhat 
subsided under the prolonged use of atropine and 
afterward of the correcting lenses, but still re- 
mained, and the headaches failed to disappear. The 
child had long been taking a tonic from her family 
physician. Upon investigation this was found to con- 
tain very full doses of strychnia, the exact amount 
of which I am unable to state. When this was dis- 
continued and simply iron substituted, the headaches 
rapidly disappeared, and, so far as I am aware, they 
have never returned. 
This is not a mere coincidence, for-I have over 
and over again tried the experiment in patients who 
had markedly irritable retinas, and have always suc- INSUFFICIENCIES OF OCULAR MUSCLES. 
11 
ceeded, when I pushed nux vomica, in aggravating 
their pain.' 
In conclusion, I would say that in those cases of 
ocular insufficiencies affecting the lateral muscles, 
where surgical interference is either impossible or 
contraindicated, where the use of correcting lenses 
and prisms has not been sufficient, and where the 
retina is quiet and dread of light is absent, as- 
cending doses of a good tincture of nux vomica 
will afford, in most cases, marked relief. If the 
method be tried, the drug must, however, be pushed 
up to its full physiological effect, and, according to 
the experiments of Musser, between the ages of 
fifteen and forty, a dose of forty-five drops will 
readily be borne. In fact, very much larger doses, 
if watched, may be administered without hesitation. 
1 I have heard my colleague, Dr. B. Alexander Randall, bring 
out this point with much force in a discussion in the Neurological 
Society some years ago, during the presentation of the subject of 
Tobacco Amblyopia, contrasting the remarkable facts that on the 
one hand irritations of the optic nerve and retina were usually 
aggravated by the use of strychnia, while on the other, when 
tobacco was the poison which had produced an axial neuritis, this 
was speedily and often remarkably relieved by the administration 
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