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Strychnine alkaloid can be found naturally in Strychnos nux-vomica, a tree native to tropical Asia and North Australia, and in Strychnos ignatii and Strychnos tiente, trees native to South Asia. The alkaloid was first isolated in 1818 by Pelletier and Caventou.5,17 It is an odorless and colorless crystalline powder that has a bitter taste when dissolved in water. Besides strychnine, the dried seeds of S. nux-vomica contain brucine, a structurally similar, although less potent, alkaloid.89 In addition to the naturally occurring alkaloidal form, strychnine is available from commercial sources in its salt form, usually as nitrate, sulfate, or phosphate. In the past, strychnine poisoning was responsible for significant mortality, especially in children. Meticulous, supportive care remains the most important component of the management of the strychnine-poisoned patient.

Strychnine was first introduced as a rodenticide in 1540, and in subsequent centuries was used medically as a cardiac, respiratory, and digestive stimulant,49 as an analeptic,93 and as an antidote to barbiturate92 and opioid overdoses.60 Nonketotic hyperglycemia,9,39,81 sleep apnea,77 and snake bites17 were also once considered indications for strychnine use. In 1982, at least 172 commercial products were found to contain strychnine, including 77 rodenticides, 25 veterinary products, and 41 products made for human use.84 Currently, strychnine is used mainly as a pesticide and rodenticide (for moles, gophers, and pigeons),84 and a research tool for the study of glycine receptors. Most commercially available strychnine-containing products contain about 0.25% to 0.5% strychnine by weight.84

Between 1926 and 1928, strychnine killed more than three Americans every week.5,30 In 1932, it was the most common cause of lethal poisoning in children,5,84,99 and one-third of the unintentional poison-related deaths in children younger than 5 years were attributed to strychnine.61 Currently, strychnine poisoning is rare and continues to decrease in the United States, although deaths are still reported. The Toxic Exposure Surveillance System (TESS) and National Poison Data System (NPDS) data of the American Association of Poison Control Centers (AAPCC) reports 1309 strychnine exposures during the past 10 years with only nine deaths (Chap. 135).

Strychnine poisoning has resulted from deliberate exposure with suicidal and homicidal intent,12,30 from unintentional poisoning by a Chinese herbal medicine (Maqianzi),18 a Cambodian traditional remedy (slang nut),52,54,87 and adulteration of street drugs.14 Maqianzi is used to treat limb paralysis, severe rheumatism, and inflammatory disease, whereas slang nut is used to treat gastrointestinal illness. The bitter taste and lethality of strychnine allow it to be substituted for heroin46 and cocaine.14,25,65 There are also reports of strychnine poisoning from adulterated amphetamines,25 ecstasy (3,4-methylenedioxymethamphetamine [MDMA]),28 Spanish fly,13 and from the ingestion of gopher bait.55

Standard references list the lethal dose of strychnine as approximately 50 to 100 mg...

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