There are certain dangers attending the temporary or continued use of morphia by the hypodermic syringe that deserve careful attention, in order that, if possible, they may be remedied. The first is the production of abscess and inflammation.

The majority of those who use morphia in this way are badly scarred. The skin is thickened, reddened and covered with bluish and reddish discolorations. Abscesses just forming, formed, or commencing to heal, are found here and there. Ulcers and sloughs are sometimes seen. Cysts are occasionally met with. Isolated patches of erysipelatous inflammation and gangrene are found in some instances. In the accompanying cut (p. 73) is shown the condition of the skin in a male nurse at Bellevue Hospital, who was an habituè. The photograph from which the cut was made was taken but a short time before death. I have now other patients who are quite as badly scarred. In the case of a young married lady, the skin, everywhere that the dress covered the body in front, and the limbs all over, was scarred, contracted and discolored, as though she had been badly burned and then pricked all over with India ink.

Dujardin Beaumetz (quoted by Bartholow[11]) relates a case where these injuries resulted in death.

These abscesses are due, in the majority of instances, to (a) carelessness in injecting, (b) unclean needles or syringe, (c) a dirty or over-acid solution, and (d) a low condition of the general system, predisposing to inflammation and suppuration on slight irritation.

I have never seen but one habituè who had a clear solution of morphia, and he made it up fresh each day. Abundant testimony as to the production of inflammation and abscess from the above mentioned causes can be found in my little work on “Morphia Hypodermically.”

Those patients who exercise great care in regard to cleanliness and manner of injecting are rarely troubled with abscess. Thus one patient of mine had used morphia subcutaneously in large amount, for over six years, injecting every time, and that several times daily, into a spot upon one thigh, that could be covered by a small tea-saucer, and has never yet had either inflammation or abscess.

Indeed, some persons who exercise no care whatever to keep syringe or solution clean, are free from this troublesome complication. Such a case is related by Dr. Roberts Bartholow, as follows: “One of the most inveterate subjects I have ever encountered was a man living in the wilds of Texas, who used a glass hypodermic syringe, that had been broken many times, and mended with successive deposits of sealing wax, until only the rusty old needle remained in view, and yet he escaped all accidents.”

Magendie’s solution is that most commonly used. It is of the strength of sixteen grains of sulphate of morphia to the ounce of water, a few drops of acid being added to dissolve the drug. The solution made after the plan of Dr. H. M. Keyes is excellent. It will keep for a long time unchanged. He writes as follows: “Some years ago, while attached to the Roosevelt Hospital, in New York city, after repeated experiments with various tests and anti-ferments, I became convinced of the practicability of making a solution of the sulphate of morphia, of the strength of Magendie’s, without the aid of acid, except salicylic, and that not as a solvent, but as a preventive of decomposition, making a solution that, when properly prepared, gave perfect satisfaction after years of use, never causing abscesses, as is frequently the case when the mineral acids are used, and when carried in the pocket for months being in as perfect condition for use as when freshly prepared.

“The following directions, if followed, will give the desired result:—

“Heat the water in a porcelain capsule, over a spirit lamp, until the boiling point is reached; add the powders and stir with a glass rod, until they are dissolved. Filter through coarse filtering paper, while hot, and keep in a glass-stoppered bottle of green glass.”

Some physicians use carbolic acid, some chloral hydrate, some benzoic acid, and some chloroform, as preservative agents. Any of these substances, present in sufficient amount to prevent decomposition and clouding of the solution with minute vegetable growths, are apt to be irritating. In my first work on morphia, a full list of the solutions used in this and other countries will be found.

Erysipelas sometimes results from the subcutaneous use of morphia.

The syringe needles are sometimes broken off in the flesh. This is, however, a rare occurrence.

The method of making an injection, undoubtedly, has something to do with the occurrence of abscess. The usual plan is to pinch up a fold of skin and pushing the needle in quickly, inject the solution slowly, beneath it. Some persons prefer to plunge the needle deep into the muscular tissue. It is claimed for this plan that abscess seldom occurs, and there is certainly less liability of wounding a vein.

The following is taken from my book on “Morphia Hypodermically,” and illustrates very fully another danger sometimes attending the use of the drug in this way:—

Articles have, from time to time, appeared in various medical journals, at home and abroad, detailing certain alarming symptoms following immediately upon the injection, subcutaneously, of moderate doses of morphia. Such accidents have been ascribed by most authors, to the entrance of a needle into a vein, with the consequent sudden passage of the drug into the circulation; by some, to the injection of a bubble of air into the vein; by others, to fright attendant upon the dread of the operation and the prick of the needle; and by still others to the rapid absorption of the remedy when a vein is not punctured. Which of these hypotheses is the correct one it is at present difficult to decide; perhaps each may have proved a factor at certain times or in certain cases. The weight of opinion would seem to favor the idea of sudden entrance of the drug into the circulation by puncture of a vein. By a careful study of some of these cases we may be able to come to a definite conclusion.

Dr. M. E. Woodling, of North Branch, Minn., writes:—“My first case in which the hypodermic injection of morphia was tried, resulted as follows: Patient large, strong and robust-looking man. Complained of pain in the course of the sciatic nerve, and of lumbago. Injection given back of the trochanter major, patient sitting; given slowly. I turned to lay the syringe on the table, when the patient appeared unsteady, straightened rather rapidly and persistently, and slipped from the chair, falling full length, supine, upon the floor, pale and with absent respiration. He was now perfectly limp. No response to shaking or questions. Spoke the word ‘breathe,’ loudly, in his ear. This he obeyed. Repeated this for about a minute, and in another he was able to sit up, but was very sleepy and unsteady, requiring assistance. In about five minutes he was able to stand, and I took him out on the street and walked around with him for an hour. I then took him home, still sleepy, but improving. The next morning he was all right, but the pain was only partially relieved. Other injections were given, with no bad consequences.”

Dr. A. Atkinson, Professor Materia Medica, College of Physicians and Surgeons, Baltimore, in reply to my fifth query, writes: “Never had death to result, and but one accident, and that was apparent suspension of animation for about fifteen minutes, in a young lady, very anæmic, in whose case I injected one-eighth of a grain of the sulphate of morphia (the regular Magendie’s solution) into the rectus muscle of the abdomen, at the repeated and urgent entreaties of the patient, to relieve an obstinate uterine neuralgia. She recovered from the neuralgia and from the effects of the morphia in three-quarters of an hour. I had, a year before, injected one-fourth of a grain into the arm of this same patient, for cardiac neuralgia, with complete relief of the pain in one hour, and with no bad effects.”

Dr. E. Jones, of Cincinnati, has kindly written me and inclosed an article[12] of his, bearing directly upon this subject. In it he says: “Did the needle enter an abdominal vein? Several times. The first time I became somewhat alarmed; the patient at once threw up her arms, complained of suffocation, giddiness, excessive fatigue, a severe tingling sensation following the course of the circulation. The countenance was at first livid, then flushed; the eyes became unusually brilliant; slight muscular twitchings, profuse sweating, with cold extremities, and in a few moments complete relaxation was followed by deep sleep, which lasted only four hours, when she awakened, feeling, as she expressed it, ‘ever so much better.’

“The same accident occurred three times, the symptoms much milder, with the exception of a burning sensation of both eyelids of either eye and both lips, which at one time became painfully intense. The above symptoms were produced by an injection of five grains of sulphate of morphia into an abdominal vein.

“Being unable to see her for a day or two, I requested my friend, Dr. Geo. E. Walton, who had watched the case with a good deal of interest, to call and give her an injection of two grains, when she put both hands to her head and gave a cry of excruciating agony. A sharp pain darted through her head, which lasted ten or fifteen minutes; also complained of an intense itching of nose and lips, finally passing off, leaving no deleterious effects. The same accident occurred to myself, only in a less degree. These injections were also made in the abdomen.”

The patient was a German woman, aged thirty-seven, and weighing about 135 lbs. The case was presumably one of fecal accumulation in the colon, with severe abdominal pains.

Dr. W. A. Neal, of Dayton, Michigan, writes in this connection as follows: “No deaths; the only accidents were where a vein was punctured. This produced dyspnœa, great distress, and was usually followed by a chill and the reaction by fever; but in every instance there has been but one chill, and fever once, lasting three or four hours.”

Edward T. Wilson, M.B., Oxon., F.R.C.P., Lond., who has a valuable and interesting article on the subcutaneous injection of morphine, in the St. George’s Hospital Reports, for 1869, writes me as follows: “Never either death or accident. Nothing beyond a temporary feeling of faintness, and on two occasions a temporary outburst of urticaria, which soon passed away.” I hardly think these phenomena were due to injection into a vein; indeed, the writer does not endeavor to account for them on this ground. They partake more of the nature of rapid absorption with some idiosyncrasy. Dr. E. C. Seguin makes mention, in the New York Medical Record, of a lady thus affected (urticaria) by any preparation of opium taken by the mouth.

Arthur R. Graham, M.D., etc., of Weybridge, England, sends me the following interesting and conclusive case: “No deaths; but one alarming accident worth recording: I had injected a large dose (probably three-quarters of a grain) into the right forearm of a woman whom I was in the habit of injecting daily. Almost immediately she started up, and holding up her left hand and looking at it, exclaimed, ‘O, how funny my fingers feel!’ and fell back in a dead faint, with blanched lips. I immediately bound a tape tightly around the arm, above the puncture, and then gave brandy and asafœtida injections, but she remained unconscious, I think, for more than half an hour. After she was sufficiently recovered to talk rationally I loosened the tape, when she immediately fainted again. Of course, I at once tightened the ligature and kept it so for some hours. The second swoon was less alarming than the first. In the first no pulse could be felt, nor could the heart sounds be heard, excepting with great difficulty. My impression at that time was that, had I not applied the ligature at once I should have had a fatal result to chronicle. It was the impulse of the moment to tie on the tape, and had I had time to reason I should have rejected the idea as an entirely useless one; but in any similar emergency I should now recommend any one to try it.”

Dr. E. Fletcher Ingalls[13], who has devoted much attention to the hypodermic injection of morphia, reports the following case: “I have often used hypodermic injections of morphia, and always with good results, until a few weeks since, when I obtained alarming results from the administration, by this method, of one-fourth of a grain of morphia.

“The patient, in consequence of continuous watching with sick children, had become debilitated, and, as a result, suffered at times from severe pains of a neuralgic character. I was called in the night to see her in one of these attacks. The pain had commenced about twelve hours previously, and with frequent exacerbations, had steadily increased in severity until it had become unbearable.

“I dissolved one-fourth of a grain of morphia in pure water, and administered it under the integument on the outer side of the arm. Within a few seconds the breathing became stertorous, the pulse failed, the lips and countenance became livid, and the eyes were set; respiration ceased, the radial and cardiac pulsations were lost, and the heart sounds could not be distinguished. The woman was to all appearances dead. How long this condition continued I cannot tell; it seemed an age, but was probably only ten or fifteen seconds, for by prompt means I succeeded in resuscitating my patient.

“After a few minutes she expressed herself as much relieved. I remained with her some time, and then left careful directions with the husband in case any other unfavorable symptoms should occur. During the next few hours the patient fainted twice, but she was restored by dashes of cold water in the face.”

Dr. H. L. Harrington, of Little York, Ill., refers me to the report of a case[14] of his, which reads as follows: “Was called a short time since to treat W. S., male, aged sixty-two, for acute dyspepsia (bilious attack) accompanied by very severe pain. Administered hypodermically, in the hypogastric region, morphiæ sulph. 0.02 gram. Before the syringe was emptied alarming syncope supervened, and occurred twice, at intervals of ten or fifteen minutes. Stimulants administered freely, artificial respiration and the use of electricity were successful in reviving the patient. Neither narcotism nor coma were in any degree present. Is it possible to attribute the syncope to the effects of the drug? Not over fifteen seconds were occupied in the operation.” I think this an excellent example of the puncture of a vein with entrance of the drug directly into the circulation.

Dr. Aug. M. Tupper, of Rockport, Mass., published the following interesting case:[15]

“On the morning of the 22d ult. I was called to see Mr. G., who was stopping at one of our hotels. I found a healthy-looking young man, about thirty years old, suffering from lumbago, confined to his bed, and in considerable pain, aggravated very much by movement. Applications of mustard and an anodyne liniment were prescribed. In the evening I called again, and as the relief was slight, decided to inject some morphia directly over the seat of pain, a method I have found very efficacious in similar cases. Accordingly I injected nine drops of a solution of sulphate of morphia, one grain to a drachm of water, into a spot midway between the spine and crest of the ilium. As is my custom, the solution contained one drop of carbolic acid, which I added in order to keep it. In five minutes he expressed himself as feeling relieved, and sat up in bed to show us the improvement. I told him to lie down and keep still awhile, and he did so. We chatted pleasantly for perhaps five minutes longer, when, turning toward his wife, he said, ‘I think I am going to vomit,’ and turned to the side of the bed. I noticed that he looked a little pale, and before Mrs. G., could get the basin, he grew deadly pale, his eyes rolled up in his head so that only the whites were visible, the jaws were clenched, the head was drawn back, and the whole body stiffened, respiration ceasing also. I immediately went to him, dashed cold water in his face, and took the wrist to feel his pulse, which, to my horror, was not to be felt. He was in this state for perhaps a minute. I then raised him up, and looking into his eyes, which were staring wide open, saw that the pupils were widely dilated. Very soon the color began to return to his face, he was drenched with perspiration, and recovered consciousness. I laid him back on the bed, and he looked up, smiled, and said, ‘I’m all right now.’ The pulse was quite full at sixty, but inclined to be irregular. I gave him brandy freely, and he had no further trouble, but the pulse remained at sixty for the next twenty-four hours; he said it was usually about eighty. I cannot verify that, for he left town the following day.

“That was certainly a very unusual effect from such a dose, a little over one-eighth of a grain. The question arose in my mind whether the acid could have had anything to do with it; but I have given the same mixture a great many times without the slightest trouble. I may add that the solution was prepared that morning, and I injected the same dose into the same part of the body, for neuralgia, in a female patient, that very same day, previous to using it on this patient. I should not care to repeat this operation on Mr. G., and advised him never to have it done again. I would also state that it relieved his lumbago, for the next afternoon he was dressed and down at his meals.”

After seeing the report of this case I wrote Dr. Tupper, who has courteously furnished me with the following additional facts: “My patient, I should say, was of a phlegmatic temperament. He had taken no medicines by the mouth before I saw him, nor while under my care. He had never taken any narcotic in his life, he says. The pupils were natural very soon after the effects of the dose ceased. He writes me that his pulse remained at sixty for a week, but that he felt first rate. Pulse rate since then has been seventy-six. It seems to me that it must have been a peculiar susceptibility to this drug in his case, else it would not have had such a lasting effect upon the pulse. I do not think it was due to the mode of administration. He related to me afterward, that a cousin (I think that was the relation) had very peculiar and even dangerous symptoms from a dose of Dover’s powder, some time ago, and that the physician in attendance was detained all night in consequence. This would go to show an idiosyncrasy in the family.”

I think that the doctor is right with reference to idiosyncrasy, but I think, also, that the method of administering the drug had much to do with it. As I have said before, where an idiosyncrasy, be it to narcotism or any other peculiar manifestation, exists, the sudden entrance of the drug into the system is certain to aggravate those symptoms; may, indeed, call forth an idiosyncrasy that the drug given by the stomach would, possibly, never have revealed. The fact that some ten minutes elapsed between the time of the injection and the first appearance of the alarming symptoms seems to preclude the idea of the needle having entered a vein. The symptoms are, however, exactly those that are seen when a vein is punctured. As will be seen from the results of experiments soon to be recorded, and from the conclusions arrived at by the Committee of the Medico-Chirurgical Society[16] of England, five minutes is abundant time for enough of the drug to be absorbed to produce its characteristic, and, therefore, its unusual effects, where idiosyncrasy exists.

Prof. H. C. Wood,[17] states that he has seen deep coma produced in three minutes by a hypodermic injection of morphia. This may have been due to unusual rapidity of absorption from the cellular tissue, or to direct injection into a vein.

Here is a somewhat similar case[18]: A lady, aged twenty-four, who has been a sufferer from neuralgia every day for months, was given a hypodermic injection of one-fourth of a grain of the hydrochlorate of morphia in the subcutaneous tissue of the leg. Alarming syncope and extreme prostration came on within five minutes after the injection was made. The patient was not out of danger for four hours after, and was too ill to leave her bed for two weeks. The neuralgia did not return for some months.

Dr. Francis H. Miller, of East New York, formerly House Surgeon of St. Peter’s Hospital, Brooklyn, writes me: “Several times, when I suppose my fluid entered some small vein, the patients complained of sudden weakness, faintness and dizziness, and almost syncope.”

Dr. Samuel W. Francis, of Newport, R. I., writes me: “I have heard of two or three cases where extreme syncope set in, the patients being restored only with great difficulty.”

Dr. J. S. Jewell, Professor of Nervous and Mental Diseases, Chicago Medical College, writes me: “I have never had any serious consequences follow morphia injection, but have seen temporary unpleasant symptoms (vaso-motor disturbances), vertigo, mental confusion, etc., a few times.”

Dr. Geo. R. Fowler,[19] of Brooklyn, states that he has twice had alarming symptoms from puncturing a vein. He believes that this may be avoided by making the skin of the part to be punctured tense, and introducing the needle at a right angle to the axis of the limb.

Prof. Nussbaum,[20] of Munich, has published an interesting account of an accident that happened to himself. He had made use of the hypodermic method of giving morphine to himself, as often as 2000 times, using sometimes as much as five grains of morphia at an injection. One day he accidentally injected two grains of the acetate of morphia into a vein, and did not recover from the dangerous effects for two hours. He has seen the same symptoms, in a less degree, in two of his patients. He advises slow injecting, and withdrawal of the piston if a vein is punctured.

The following interesting remarks are clipped from an English journal,[21] and bear directly on the question in hand:—

“‘Observer’ remarks that ‘Spectator,’ in the Journal, of April 12th, very accurately described what always happened when a vein has been pierced and morphia injected into it, although he might have added (as no doubt it occurred) that the person injected also experienced a strong taste of morphia; and probably, also, an unusually large quantity of blood flowed from the puncture. It is a very serious accident to inject morphia into a vein, but it need never happen, if the operator, thrusting the instrument under the skin, will draw up the piston, when, if the point be in a vein, blood will be drawn into the syringe. ‘Observer’ knows a gentleman who for years has been in the habit of injecting himself with morphia, three and four times a day, to whom the accident has frequently occurred, accompanied by the symptoms described by ‘Spectator.’ He is much alarmed at the time, and is afterward careful to draw up his piston, but in three or four months he begins to be less cautious, until he gets another reminder. As to the necessity of drawing up the piston, there cannot be two opinions; for besides the symptoms certain to follow the introduction of morphia directly into a vein, there is the danger of air entering as well, should care not be taken to prevent it. ‘Observer’ has known an habitual morphia taker by injection to contract albuminuria. The albumen would greatly diminish on the daily quantity of the injection being lessened, and entirely disappear in forty-eight hours, when the morphia was wholly discontinued.

“‘Injector’ was, until very lately, for nearly two years, one of the victims of morphia, and during that time he five times thoroughly, and twice partially, experienced more or less of the horrible symptoms sketched by ‘Spectator’ in the Journal of April 12th. The sensations were as follows: 1. A dull, gnawing pain in some decayed teeth, accompanied by a metallic taste in the mouth. 2. A pricking and tingling of the forehead and cheeks, somewhat like prickly heat; but this soon increased, spreading to the ears, neck, arms and chest (but not below the waist, although the morphia was injected into the calf of the leg). This pain soon became almost unbearable, but it was entirely eclipsed by what ‘Spectator’ calls ‘throbbing,’ but which ‘Injector’ says would be better represented by imagining twenty blacksmiths confined in his head, with each an India-rubber-headed sledge hammer, and each trying to make the best of his way out. Imagine, at the same time, that you are suffering from the first mentioned broiled feeling; that your skin feels as if about to burst; your eyes as if already started from their sockets; your lips as if they did not belong to you—then you may have a faint idea of what ‘Spectator’ wishes to describe, and what I, who have five times felt it, yet feel powerless to lay before you as I ought.” He had always thought that this condition was caused by: 1, too rapid injection; 2, too much at once; 3, the solution being too strong; and 4, by its being injected directly into a tolerably large vein. When the symptoms have occurred, he has always noticed that injection has taken place at one of two spots—probably into the same vein each time in each leg—one on each leg. Again, it only occurred when he had to inject a large quantity in a short time; and he always used a very strong solution of acetate of morphia (forty grains to the half-ounce of water). He advises that when one feels any of the symptoms coming, he should walk about as rapidly as he can. He has relieved his worst attacks in this way, and has warded off others by violent exercise in his room, as soon as he felt the pain in his teeth, or the metallic taste or the “prickly heat.” He thinks that corroboration of his belief as to the cause of the symptoms is afforded by Dr. Pepper’s description of the results of injecting milk into the veins of anæmic patients.

The case referred to by ‘Observer’ reads as follows:[22] “Scarcely has the fluid left the syringe when the most intense feeling of irritation and pricking is felt in the skin, spreading from the puncture rapidly all over the body. At the same time the skin becomes suffused with a bright blush. The heart’s action then becomes greatly quickened, and there is a throbbing, rushing feeling through the head. The hands are somewhat swollen and the lips get a glazed appearance. In one case that I had, the patient became suddenly unconscious, as if knocked down by the sudden shock; and in all the cases where these symptoms have appeared the general disturbance has been very great and the attack of a severe character. The symptoms generally subside gradually, leaving behind great pain in the head.”

This gentleman gives these as the main symptoms of several such accidents that have occurred in his practice, and characterizes their occurrence as something novel and important.

Dr. J. A. Houtz,[23] of Logansville, Pa., who is a staunch advocate of the hypodermic method, says: “The greatest danger is in injecting into a vein sufficiently large to carry the whole dose at once into the circulation. That can be avoided by selecting a place where the large veins are least numerous, and by injecting, say a third of a dose, and then waiting eight or ten seconds, when, if in a vein, the symptoms will show themselves. The first symptoms are a feeling of great fullness of the head and intense flushing of the face, coming on within a few seconds after the operation. Such, at least, was the case in a patient of mine.”

A case of syncope and prostration is reported by Dr. E. Wenger, of Gilman, Ill. The amount of morphia used is not stated.

F. Woodhouse Braine, F.R.C.S., etc., publishes the following case:[24] “Mrs. H. C., aged thirty-five, in good health otherwise, had been kept awake seventy-two hours by intense neuralgic pain on left side of head, face and neck, arising from a carious molar tooth on the left side of lower jaw. She was injected with one-third of a grain of acetate of morphia. At 1 A.M., on June 28th last, the morphia, dissolved in about four drops of water, was introduced under the skin of the left arm, just over the insertion of the deltoid. No blood appeared at the puncture. In about fifteen seconds tightness of the chest and difficulty in breathing was complained of, and the patient asked to be raised, saying she felt as if she was dying. Her face and lips now became pale; speech became indistinct (not inaudible); pulse irregular; some spasm of the facial muscles took place, and she fell, to all appearance, dead. Cold water was freely dashed over her face and chest, and as she was unable to swallow, her tongue was rubbed over with sal volatile, and ammonia applied to her nose, artificial respiration being kept up at the same time. During this time her face was blanched, pulse not to be felt, and respiration not to be perceived. Insensibility continued for about three minutes; then, happily, one or two feeble beats of the pulse, and a shallow inspiration or two, showed returning animation. She then became conscious; pulse feeble but regular; respiration slow; fingers remained numb and both thumbs were firmly drawn into the palms of the hands. This passed off in about six minutes, leaving her feeling very ill, but free from the neuralgic pain, which did not return. There was no feeling of nausea, and no attempt at vomiting during any part of the time.”

Mr. Arthur Roberts[25] publishes the following cases:—

“Sir:—The case described by Mr. Braine, in your last week’s journal, of an unusual effect of subcutaneous injection, is what I have seen in two instances, but nothing like to such an alarming extent. One was in a gentleman whom I had injected several times previously, the other in a lady. I have also partly noticed it when I have injected myself. In the first case, a few minutes after the operation, the face became intensely flushed; this was followed by vomiting, and then a dead faint and struggling for breath, the pulse scarcely perceptible. These cases, and the effect on myself, taught me, when injecting a patient for the first time, never to give more than the sixth of a grain—wait a quarter of an hour longer, and then give the remainder of the dose, after ascertaining how the first injection was taking effect. Women, I have found, are generally bad subjects for subcutaneous treatment; for they get frightened and nervous—in fact, one woman told me that though the morphia taken by the skin did her more good than by the mouth, yet she preferred the latter, for the instrument frightened her. I have used my needle over three hundred times, and I have always noticed one fact, that if the wound bleeds after the operation the morphine enters the system much more powerfully and rapidly; and I always know when it is going to bleed, by the operation giving a good deal of pain. When this is the case I withdraw the instrument, to see if the puncture bleeds; if it does, I try a fresh place.”

Bartholow,[26] in his useful and able little work, calls attention to this danger in these words: “In practicing the hypodermic injection it is important to avoid puncturing a vein. Serious depression of the powers of life, fainting and sudden and profound narcotism have been produced by injecting a solution of morphia directly into a vein. Fatal collapse might be induced by injecting air into a large vein, along with the solution.”

Syncope, etc., as we have seen, from this cause, is common; narcotism rare, the drug seeming to exhaust itself in its initial action, or to produce a condition of the system in which narcotism is wholly or partially impossible.

Dr. Corona[27] (Giornale di Medicina Militaire), summing up the results of his experiments on animals, says: “The injection of the two poisons (morphia and atropia) into the veins showed that a much smaller dose was sufficient to produce rapid and grave poisoning, but even then the morphia produced its action instantaneously, and its action always superseded that of atropia.”

J. Pennock Sleightholme, L.R.C.P., Lond.,[28] reports the following case: “A young man of sound constitution and good health, who had never before taken morphia hypodermically, partly as an experiment and partly with the hope of relieving some slight restlessness, injected himself, at about 3 A.M., with one-sixth of a grain of morphia. Immediately after the injection he fell down on the floor in a state of syncope, and had slight convulsive movements on one side of the body; consciousness did not entirely leave him, and after lying still for about ten minutes he was sufficiently recovered to be able to go to the next room and help himself to a couple of glasses of sherry. After this the feeling of faintness gradually passed off, and he slept for about two hours, but on rising, at eight o’clock in the morning, the same feeling of faintness returned, accompanied with great pallor. These symptoms were relieved by a dose of brandy, but did not entirely cease until noon the same day.”

A physician in the South, who is a slave to this habit, writes me: “Several times I have been unfortunate enough to puncture a vein, and to introduce some of the solution directly into it. Immediately I feel a peculiar tingling all over me, from the tips of my fingers to the ends of my toes. The skin of my head feels as if a myriad of pins were penetrating it. This feeling passes off in from three to five seconds. Sometimes it has been followed by a turgescence of the vessels of the brain, causing a great fullness and throbbing, with slight headache following.”

In a most interesting and instructive letter from Dr. Wm. W. Cable, of Pittsburg, Pa., I find the following: “I have spoken of minor accidents which sometimes occurred. In all that I have seen they were caused by the injection of the morphia directly into a vein. A series of phenomena instantly take place. The patient describes the first sensations as the stinging of bees all over the body, with difficulty of respiration, and intense congestion and swelling of the face and body. In one case that I saw the face was so swollen that in five minutes all traces of the natural features were lost. This condition of affairs calls for prompt action. If possible, the patient must be kept in motion and applications of cold water be made to the face and spine. If the patient falls the limbs must be raised, and all methods used to keep the heart acting, for if you can bridge over ten or twelve minutes the patient is safe. To prevent being ‘struck,’ as he calls it, one patient of mine carries a cord, which he throws over the arm, and if an unfavorable symptom occurs, he uses it as a tourniquet, and in a moment the result is apparent in the extravasation of the blood and the morphia from the wounded vessel. This is a safe condition, as afterward no rapid absorption can occur.”

This is a companion case to that reported by Graham, where ligation of the limb proved to be of great practical importance.

An interesting series of experiments, bearing directly upon the use of the ligature in such cases, were made by Mr. Georges,[29] at the Paris Society of Practical Medicine, some of which were conducted for this gentleman by M. Claude Bernard. These experiments consisted in “injecting poisonous substances into the cellular tissue, with the view of showing the far greater safety and certainty of the hypodermic method as a means of administering, medicinally, highly-poisonous substances. He injected quantities of codeine, atropine and especially strychnine, which would surely cause death in the absence of precautions for preventing the too rapid introduction of the poisons. These injections were practiced without danger in the dog’s paw, the passage of the poison into the veins being checked by the forcible application of a ligature around the paw. To render the experiment still more striking, he resolved to employ injections of the most dangerous of poisons—curare—and M. Claude Bernard conducted them for him. A solution containing about five centigrams of curare (sufficient to kill more than fifty dogs of the size of the one operated upon), was injected into the paw, and in twenty minutes the animal fell on its side. The paw was now firmly tied, and at the end of about twenty minutes the animal arose. Whenever the ligature was loosened he again fell down, sometimes at the end of ten minutes, and sometimes in a shorter period,[30] and in this way it became possible to dose with complete certainty, according to the effect desired to be produced, the quantity of poison to be absorbed. The next day the dog was found on his three paws, only suffering from the swelling caused in the fourth by the injections. The ligature was removed and he was soon all right.

“The same experiment performed on another dog was followed by the same results, the animal being caused to fall or rise at the end of five, ten, or fifteen minutes, accordingly as the paw was tied or untied. This dog, however, next morning, on the removal of the ligature, fell down again, all the poison not having had time to become eliminated by the urine, so that it was necessary to reapply the ligature. M. Georges points out the superiority of the endermic method, when we have to administer powerful substances, as we may apportion the dose with an exactitude, according to the tolerance of the disease and idiosyncrasy of the patient, quite unattainable when administered internally.”

Dr. Alonzo Clark, Professor of Theory and Practice of Medicine and Clinical Medicine in the College of Physicians and Surgeons, New York, kindly gives me the details of the following case: “There was brought into Bellevue Hospital, some years ago, during his term of service, a young woman, aged about twenty-five, suffering from trismus. The jaws were so firmly locked that it was necessary to break out a tooth, in order to administer food and medicine. All ordinary medicine failing, on the evening of the second day the house physician determined to treat the case with hypodermic injections of morphia. He gave three injections of fifteen minims of Magendie’s solution, with two hours’ interval between the doses, and finding that no effects of the morphia were apparent at 2 A.M., he gave an injection of twenty minims. When he returned to the ward, at 4 A.M., the patient was dead. The nurse, on being questioned, stated that the patient was “asleep” before the doctor left the ward. The arm in which the puncture had been made was examined by Dr. Clark and others, and over the point of the last puncture a little discoloration, as from extravasated blood, was apparent, and which, on careful dissection, was found to mark the track of the needle, which had opened directly into a vein.”

In this case the patient probably died almost immediately, the action of the morphia being shock-like, and its effect the more intense as one grain and a half had already entered the system by the skin.

Prof. Wm. T. Lusk, of this city, writes me of a case of syncope following immediately upon the injection. No blood appeared at the point of puncture.

Another case of death from injection into a vein is reported to me by Professor Willard Parker. An injection of morphia, to relieve the severe pain of neuralgia, was made into the temporal region of an apparently healthy young man. Death was almost immediate. The case was in the hands of a physician in Connecticut. I have repeatedly written, asking for full particulars, but cannot get them. It is a strange fact that all the cases where injection into the temporal or infra-orbital region is mentioned by correspondents and by some authors, have been attended by either intense narcotism or death. This is, of course, not a uniform occurrence, but it has happened sufficiently often to call our attention to it, and urge caution in its use in this situation.

In this connection, and in point of history, the following quaintly worded extract from a diary, which appears in Pepy’s Journal,[31] of May 16th, 1664, is of interest. “With Mr. Pierce, the surgeon, to see the experiment of killing a dog by letting opium into its hind leg. He and Dr. Clark did fail mightily in hitting the vein, and in effect did not do the business after many trials; but with the little they got in, the dog did presently fall asleep and so lay till we cut him up.”

The different effects produced by the same accident on different persons seems to be due to some peculiarity of constitution with reference to morphine. The drug is thrown so rapidly into the circulation that it carries everything before it, seeming to instantly overwhelm the vital powers. The brunt of its action seems to be exerted on the heart, and the key to proper treatment is thereby afforded. To whatever cause due, the effect is essentially the same, the difference being only one of degree. That syncope and vaso-motor disturbances are ever due to the injection of air into a vein with the solution, I very much doubt. In the first place the morphia itself is quite sufficient to produce the symptoms, and in the second place not more than a bubble of air is ever left, by carelessness, in a syringe, and this is not sufficient to produce these symptoms. To settle this matter, I purposely injected into the median cephalic vein of my own arm twice as much air as this, with a solution of warm water, and without any bad effects; in fact, no effect whatever. My arm, above the point of puncture, was protected by a ligature that could have been drawn tight at a moment’s notice, had there been any untoward symptoms. The following day I injected one-sixteenth of a grain of the sulphate of morphia into another vein, with the effect of producing sudden dizziness, a feeling as if the head would burst, pricking and tingling of the nose, suffusion of the face and eyeballs, dilatation of the pupils, faintness and nausea. The pulse was first greatly accelerated, and then fell to about 65, and remained so all that day. My pulse in health is 74. This was done at 10.30 A.M., and I did not fully recover until about 3 P.M. It may be well to state that morphia, either by the mouth or skin, always has a very unpleasant effect on me, while opium has not. Instead of causing sleep and soothing irritation, the former makes me nervous, “twitchy” and somewhat light-headed. In both cases the needle entered the vein, as it was made prominent by the ligature, and blood appeared at the point of puncture. As soon as the injection was made the ligature was loosened, I being ready to pull it tight at a moment’s notice.

M. Calvet[32] presents a physiological research of the action of morphine upon the various functions of the organism. A clinical study of morphine as a therapeutical agent, especially in the relations of acute to chronic morphinism. In the first he observes that both intravenous as well as subcutaneous injection of the hydrochlorate of morphine accelerates respiratory movements, succeeded by a period of retardation, and produces sometimes a momentary arrest or respiratory syncope. The same relative effects occur with the cardiac movements; at first accelerated, followed by retarded pulsations; sometimes even by cardiac syncope. During this time animal heat exhibits analogous phenomena, namely, the elevated is followed by lowered temperature. In fact, the absorption of morphine, whether by intravenous or subcutaneous injection, produces a very marked influence upon the reflex actions. In certain cases the period of exaltation does not occur, but the temperature becomes lowered, and the respiratory and cardiac movements are slower. Though he has not finally completed his researches, M. Calvet advances the opinion “that the above phenomena are the dyspnœa, dizziness, etc., sometimes seen during the operation of intravenous injection of milk.” A study of these cases[33] (milk injections) shows us that these phenomena rarely if ever present themselves until a large bulk of fluid (from two to six ounces) has been added to the blood, and that, therefore, the argument does not hold good.

An interesting and novel series of careful experiments on man and animals, made by Dr. Gaspar Griswold,[34] then house physician in Bellevue Hospital, this city, although not made with that end in view, seem to demonstrate very clearly that a powerful and possibly irritant medicine (aq. ammonia dil.) when injected into a vein in quantity does not produce any untoward symptoms, but, on the contrary, were always found to have the happiest, and sometimes a most marvelous effect.

Another question arises here: Is it possible for such phenomena as have been ascribed to the injection of morphia into a vein to take place without such puncture? I think so. Some of the cases reported would seem to prove it; notably that by Dr. Tupper, where the symptoms did not appear until ten minutes after the injection was made. Every insertion of a hypodermic needle, of necessity, cuts across or opens a number of capillary vessels, to which is undoubtedly due, to a certain extent, the rapidity of absorption when drugs are given in this manner. The Committee of the Medico-Chirurgical Society[35] came to the conclusion, from experiments on men and animals, that absorption of a sufficient amount of the remedy to produce decided symptoms took place in from four to ten minutes.

“Experiments on a healthy man, aged thirty-two. One-sixth of a grain of acetate of morphia was employed:—

I have found that some drugs, notably jaborandi, when used hypodermically, manifest their peculiar symptoms in so short a time as one minute, no vein of any size being punctured. It is to be supposed that one drug is absorbed from the subcutaneous cellular tissue with about the same rapidity as another, but that each drug manifests its presence in the circulation with a difference in point of time, according to its peculiar action, or to some idiosyncrasy of the patient. Thus, while morphia may be absorbed as rapidly as pilocarpine or jaborandi, it does not, save in certain persons or at certain times, give evidence of its presence by recognizable symptoms so early or so decidedly as the latter, unless the patient manifests some idiosyncrasy.

From this it would appear possible, in certain cases, for a very rapid absorption to take place, and sudden overwhelming of the heart by the drug to occur without the puncture of a vein. As the needle does not go deeper than the subcutaneous cellular tissues, in a large majority of the cases the immediate treatment would be as effective in one case as in the other.

At a recent meeting of the New York Pathological Society,[36] Dr. Amidon presented some microscopic specimens exemplifying the pathology of hypodermic medication. He said that although hypodermic medication had been in vogue twenty-five years, or according to the claims of some, forty years, he was not aware of any accurate investigation of the relations between the hypodermically injected mass and the skin. He had injected Prussian blue (a weak solution) into the skin of moribund subjects, and a portion of skin was excised after death. The hypodermic injection was given in what he considered the best manner, namely, the pinching up a fold of skin and introducing the needle horizontally. The hypodermic injection was found to occupy a space three and a half centimetres in diameter and one millimetre in thickness, tapering in shape. The location of the hypodermic injection varied according to the amount of adipose tissues in the subject. In those who had but little adipose tissue the hypodermic injection remained immediately below the skin, while in those who had much, the injection diffused itself. It would be seen in the specimens presented that the hypodermically injected mass lay close to the arteries and veins; sometimes it completely surrounded an artery or vein. This, together with some other experiments, proved that it was by the blood vessels and not by the lymphatics that absorption took place.