ACCIDENTS INCIDENT TO THE SUBCUTANEOUS INJECTION OF MORPHIA.
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.”
[Illustration: RESULT OF SUBCUTANEOUS INJECTION (see p. 71).]
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:—
Sulphate of morphia, 256 grains
Salicylic acid, 8 grains
Distilled water, 16 fluid ounces.
“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:—
Symptoms. Skin. Mouth.
Absorption 5 min. 110 min.
Pulse increased 8 beats. None.
Pulse lowered 12 ” 10 beats.
Headache 36 hours. 10 hours.
Nausea 46 ” 3 ”
Pulse, its nat. standard 22 ” 8 ”
Incapacity to work 7 ” None.
Total duration of symptoms 46 ” 11 hours.
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.
[Illustration: _a_, Commencement of the Cephalic Vein; _b_, Main Trunk of
the Cephalic Vein; _c_, Anterior Branch of Basilic Vein; _d_, Posterior
Branch of Basilic Vein; _e_, Basilic Vein; _f_, Median Vein; _g_, Median
Basilic Vein; _h_, Median Cephalic Vein; _i_, Biceps Muscle; _j_,
Tourniquet.
(_Agnew._)]
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).