THIS CASE IS PRESENTED to call attention to the sporadic use of hyoscyamine for the sensations derived therefrom, that, if unsuspected, might constitute a diagnostic problem. Such use is rare in our society, but is of long history and wide occurrence in other geographic areas and other cultures.

Case Report

Mr. B., an 18-year-old unemployed, unmarried man, was admitted to the psychiatric service via the emergency room. He had been observed to be staggering about in a confused state. Reported positive findings include dilated pupils, a temperature of 100.2, a pulse of 100, disorientation as to time, place, and person, lack of recent memory, and the appearance of hallucinating. The police officer who brought him to the emergency room reported that when they first saw him there was a fine brown powder at the corner of his mouth. His mental state cleared rapidly, and in 24 hours he was noted to be free of evidences of organic dysfunction. His speech and manner were an exaggeration of the beatnik stereotype. He had dropped out of school in the tenth grade and had since been wandering about the country, sporadically accepting employment. He freely admitted to taking peyote, amphetamines, barbiturates, glue-sniffing, and to ingesting Asthmador. He stated that he had taken one-and-a-half teaspoons of the latter prior to admission. He described his Asthmador experience as something like his reaction to peyote, but with Asthmador he was more confused, the hallucinations were more solid, and were generally of people, animals, and things, as opposed to the less structural transparent hallucinations of color and design induced by peyote. He had no memory for his experiences immediately antecedent to admission, but stated that he could recall the sensations he experienced with Asthmador on other occasions when he had taken a lesser dosage.

Comment

Asthmador, a physically fine powder, is a nonprescription mixture of belladonna and stramonium; the directions on the package state that the powder is to be burned and the smoke inhaled to relieve bronchial asthma. The mixture contains between .23 percent and .31 percent alkaloids. Hyoscyamine, the principal alkaloid in both belladonna and stramonium, is the levorotatory isomer, and atropine the racemic form of the same compound. The 1-isomer is reported to be about 12 times as strong as the d-isomer in mydriatic and cardiovascular effect. All forms are reported to have about the same effect on the central nervous system; there are reports that atropine is a more potent cerebral stimulant than hyoscyamine and reports that the d-isomer is more of a stimulant to the spinal cord of the frog than is the 1-isomer(2, 4, 5). The patient stated he took no particular care in measuring out one and one-half tea- spoons; he probably ingested between eight and 12 and perhaps as much as 20 mg of hyoscyamine. The description of atropine toxicity in this dosage range includes hyperpyrexia, accelerated pulse, mydriasis, confusion, delirium. hallucinations, exaltation, and bizarre neurological symptoms(2, 5). Datura stramonium (one of the ingredients of Asthmador), of which hyoscyamine is the principal alkaloid, was used in the Middle Ages in demonology, and to evoke hallucinations. It was smoked by the Arabs and Swahili of East Africa and in the Bengal legion of India in recent times. It has been ingested in the Darien and Choco regions of the Americas, by the Aztecs and by Indian tribes in the southeastern and western United States to evoke hallucinations and for religious and ceremonial purposes( 1, 3 ). A colleague has spoken of the suspected present-day use of Datura stramonium (Jimsonweed) in the southeastern mountain region of the United States. Vegetable products containing scopolamine have also been used many times and places for similar purposes. Hyoscyamus niger was used in ancient Greece to evoke prophecies and in the Middle Ages to conjure up demoms and give the gift of prophecy. Hyoscyamus albus was smoked in recent times in Egypt, Balucstan, and the Punjab. Datura arborea was ingested by many South American Indian groups and Duboisia hopwoodii was so used in Australia(3). Scopolamine has essential similar but perhaps a different ratio of peripheral effects than does hyoscyamine. When used in moderate dosage, scopolamine occasionally stimulates but usually depresses the central nervous system; hyoscyamine is usually a stimulant.

Mr. B. knew directly of two other individuals, and indirectly of at least four others who took Asthmador. Inquiries were made of several individuals who took marihuana, peyote, and LSD as to their knowledge of Asthmador. Most had not heard of it; those who had classed it with "glue sniffing." The pleasure derived from Asthmador is of a peculiar kind and would not appeal to many people, even to most of those who use marihuana and peyote. The patient did not speak of a state of well being, of insight (spurious or not), of character change, or of mystic understanding, but rather of disorganization, intoxication, and hallucinations that were not particularly attractive. There are undoubtedly many individuals (although a small percentage of the population even of drug users) who will use Asthmador or similar preparations as a hallucinogen and intoxicant. The nature of the full reaction is such that, if seen by others, they are likely to be brought to medical attention. Even when they take the drug in the company of a friend who is not using it, the nature of the reaction may be so distressing that the friend will bring them to medical attention. The presence of mydriasis, gross disorientation, confusion, and muscular incoordination, particularly when circumstances and appearances suggest that a drug is involved, justify consideration of hyoscyamine toxicity. The degree of mydriasis would, in most cases, exceed that which would be expected with the degree of alcohol intoxication compatible with the other signs. Peyote and LSD are also mydriatics; those individuals who would take Asthmador would also take these drugs. The degree of confusion and disorientation caused by hyoscyamine exceeds that of LSD or mescaline, and this should be useful in distinguishing the two conditions to those who have observed patients with LSD or mescaline toxicity.

Summary

An 18-year-old man with staggering gait, dilated pupils, a temperature of 100.2, and a pulse of 100, who was grossly confused, disoriented to time, place, and person, and who appeared to be hallucinating, was admitted to the hospital. These signs and symptoms were absent 24 hours later, at which time he gave a history of the periodic ingestion of Asthmador for the sensations derived therefrom. He stated that several of his acquaintances also used Asthmador for such purposes. Asthmador is a nonprescription mixture of belladonna and stramonium (hyoscyamine is the active agent in both) that is meant to be burned and the smoke inhaled to relieve bronchial asthma. The use of vegetable material containing hyoscyamine is of interest as similar preparations have been used as intoxicants and for mystic and religious purposes in many cultures and periods of the history of Western culture. The patient's clinical picture, that of hyoscyamine intoxication, is difficult to diagnose if not suspected.

REFERENCES

1. Avery, A., Satina, S., and Riestema, J.: Blakeslee: The Genus Datura. New York: The Ronald Press, 1959.
2. Goodman, L., and Gilman, A.: The Pharmacological Basis of Therapeutics. New York: The Macmillan Co., 1965.
3. Lewin, L.: Phantastica, Narcotic and Stimulating Drugs, Their Use and Abuse. New York: E. P. Dutton & Co., 1964.
4. Osol, A., and Farrar, G.: The Dispensatory of the United States of America. Philadelphia: J.B. Lippincott Co., 1955.
5. Sollman, T.: A Manual of Pharmacology. Philadelphia: W. B. Saunders Co., 1957.