In order to still further test the matter, he had injected muriate of pilocarpine into the ankle and into the supraclavicular region. The physiological effects of the drug (diaphoresis, salivation, etc.) were produced in both cases in about the same time, varying in different subjects from one and a half to four minutes; there was no appreciable difference. If the absorption had been by means of the lymphatics, the injection in the supraclavicular region would have produced its effects much more rapidly than that injected into the ankle. In one of the slides the section had fortunately been in the line of the puncture of the needle, and showed that considerable injury had been done to the tissues.

I am firmly convinced that no physician should be held free from blame in case of accident where he has not had a ligature or tape loosely encircling the arm above the point of puncture. At the first intimation of danger this should be pulled tight and kept so for several hours, being loosened gradually, thus permitting but a gradual entrance of the drug into the general circulation. With this precaution it will be seldom necessary to treat such alarming symptoms as are here recorded. A tourniquet for this purpose is here shown. It consists of a strap or heavy tape, at one end of which is sewed a “patent buckle,” that will catch and hold at any point. In the absence of this or a skate strap with such a buckle, any cord or tape, so arranged as to be pulled tight at a moment’s warning, may be used. The treatment of such condition when already established, is summed up in one word—stimulation. Whiskey and ammonia hypodermically, cold affusion, electricity, when there is a battery at hand, and hot bottles to the præcordia.

In some instances tetanus has followed the use of rusty needles, in one case resulting in the death of the victim, an habituè.[37]

At Southsea, recently, an inquest was held upon the body of Mrs. Frampton, wife of a lieutenant and adjutant in the Royal Marine Light Infantry.

The husband of deceased deposed that his wife was twenty-five years old, and that in 1871, previous to giving birth to a child, she suffered greatly from sickness. A surgeon, to alleviate this, used morphia by the hypodermic method, always injecting the solution himself. Some time since deceased assured him she had entirely given up the use of morphia.

On the previous Thursday he found the deceased suffering from convulsions. She grew worse and died the following morning. Since her death several bottles had been found in her wardrobe, tied up in a parcel and secreted, together with five or six small cases, each containing a hypodermic syringe.

Mr. Cruise, pharmaceutical chemist, said that at first he refused to serve the solution, but on reference to his junior assistant he was informed that Mrs. Frampton had been frequently supplied with the solution. In August, September and October, he supplied nine bottles each month, the last being on the 30th ult.

Dr. Norman described the state he found deceased in, and stated that when Mr. Norman and Dr. Jackson were called in they discovered on the upper part of both arms a large number of old scars, which they were informed were the result of hypodermic injections five years ago. There were no recent marks about the arms, but upon both thighs there were a large number of similar marks, and also several marks of recent punctures. Around some of these latter there was a redness of the skin in different stages, and one particularly had the appearance of having been made within twenty-four hours. He was of opinion that Mrs. Frampton died from tetanus, caused by the punctures made in the thighs for the purpose of injecting a solution of morphia. He had been shown three syringes, all of which were in a dirty condition, apparently not having been wiped dry after using. The steel needles were in a very rusty state, which would be likely to set up inflammation.

The jury returned a verdict to the effect, “That the deceased died from tetanus, or lockjaw, caused by inflammation arising from punctures made by the deceased herself, for the purpose of subcutaneous injection of a solution of morphia.”[38]

The newspaper report of the following case has been kindly sent me by F. W. Barkitt, L.R.C.P., etc., Dublin, Ireland. The extract is from the Irish Times newspaper, October 23d, 1870, giving an account of the coroner’s inquest:—

The patient was a governess, single, aged 56, and addicted to the morphine habit, using the drug hypodermically.

Dr. Austin Meldon deposed he was called to see the deceased on the morning of the 16th instant. He found her in the spasm of lockjaw. She was actually in the spasm when he entered the room, her body being bent forward. Witness was of opinion the disease commenced late on Sunday night. From examination and inquiry, witness had made up his mind that the disease was caused by a slight wound, inflicted by the needle of a subcutaneous injection syringe. There were numbers of marks over her body, where she had been in the habit of making these injections. The slight wound to which he had referred was made on the previous Friday. He found she had been in the habit of using these injections for years. That morning she told him she had used twelve grains of morphia in one injection, and showed him the papers which had contained the four powders. That was an enormous quantity, a quarter grain being a full dose. The immense quantity she used that morning showed she had been using it for years. She told him that she was in the habit of using, when affected with neuralgia, twenty grains in twenty-four hours. There was no case on record of so much being used.[39]

Witness asked her why she had adopted that mode of taking morphia. She said, in order to avoid the temptation of taking more of the drug. There was a case of poisoning from morphia in the same way in London, last year, but the quantity was considerably smaller—the dose taken being only one grain four times a day. After witness saw her, he continued the injections during her spasms, and they relieved her pain, but, of course, the doses he gave were very small, and as the suffering became less, so did the quantity in the injection he administered. He would account for the lockjaw which caused her death by the particular puncture in the skin, as a nerve might have been injured by the entrance of the needle. It was a very hazardous thing for an unprofessional person to use one of those needles. He knew of two cases of lockjaw caused by it. In one of these cases, the patient was very nearly poisoned, for he used when he had no pain a dose which had been ordered him by a medical man when he was in great pain.

Witness made a careful post-mortem examination. He had never seen a lady of that age whose organs were in a more healthy condition. The reason she used it, I may say, was to relieve facial neuralgia, in the first instance, and the habit grew on her. I found the surface of the body punctured in innumerable places with the needle. She seemed as if she had been tattooed.

“Coroner. Is there anything else you think it well to tell us? Are you certain she died from traumatic tetanus? ‘I am clearly of that opinion, both from the history and condition of the case.’

“Coroner. There is one point which I would wish to have cleared up. Several medical men have mentioned to me that it is quite possible she might have obtained, either by mistake or otherwise, strychnia in place of morphia. You are satisfied that is not the case? ‘I am perfectly satisfied. I should say that the symptoms of tetanus and strychnine poisoning are the same while the spasms are on. After the spasms pass away, the patient becomes quite well in strychnine poisoning, but the muscles remain contracted in lockjaw.’”

I have written Dr. Meldon, asking for histories of the two cases of tetanus referred to, but as yet have not had a reply. The British Medical Journal, in commenting on this case, says that it has no knowledge of the case referred to by Dr. Meldon as occurring in London, but refers to three cases of death from traumatic tetanus after the hypodermic injection of the sulphate of quinine (Lancet, July 6, 1867), and a case of tetanus after the use of morphia, due, probably, to the use of rusty needles (Lancet, December, 1876, p. 873).