HYPODERMIC INJECTIONS

IN THE TREATMENT OF

NEURALGIA AND OTHER DISEASES OF THE NERVOUS SYSTEM.

BY A. RUPPANER, M.D.

OF BOSTON.

THE subject of hypodermic injections in the treatment of neuralgia and other disorders of the nervous system, has of late greatly engaged the attention of medical men, both in Europe and America. Brought before the medical world a few years ago by Dr. Alexander Wood, of Edinburgh, in a small treatise, entitled, "On a new Method of treating Neuralgia by the direct Application of Opiates to the painful Points," and in a communication to the British Medical Journal (August 28th, 1858, p. 721), the subject has grown in importance in proportion to the testimony in its favor, by reliable medical men, who have given it a fair and impartial trial. "In Edinburgh," says Dr. Wood, "the use of this instrument has become nearly universal (in the treatment of neuralgia), and the efficacy of the process is well known. I could narrate a vast number of cases in which it has proved eminently successful." Dr. Fuller, Physician to St. George's Hospital, London, speaking of this new method of treatment in his late work on Rheumatism, Rheumatic Gout and

*

* Braithwate's Retrospect, Part 38.

Sciatica*, remarks: "I have seen it produce effects as satisfactory as they were astounding. The agonized sufferer, who for many days and nights in succession has been unable to close his eyes, or obtain a moment's repose, notwithstanding the internal administration of morphia in large doses, has fallen into a calm sleep within a few minutes after the injection has been commenced." Drs. Hunter and Page, of London, Drs. Béhier and Becquerel, of France, and many others, are strongly in favor of this therapeutic agent. In foreign and American medical journals, successful cases are repeatedly reported.

Before considering, however, the subject proper, may I be permitted to allude briefly to the claim of priority of this operation. Whether or not the introduction of narcotics into the system, by means of subcutaneous injection, be a new one, or whether this modus operandi has been long known to the profession, certain it is, that to Dr. Alexander Wood, of Edinburgh, are we indebted for directing our attention to this agent. Next, we will notice the improvement in the construction of the instruments, so that we are enabled to calculate and divide the fluid to be injected, even to the extent of half a minim. Nor was I aware, till within a short time, of any one having disputed with Dr. Wood, or rather claimed the credit of priority of this treatment.

Mr. F. Rynd, Surgeon to the Meath Hospital, &c., Dublin, however, in the Dublin Quarterly Journal of Medical Sciences for August, 1861, after describing an instrument of his own construction for the operation, further remarks: "The subcutaneous introduction of fluids for the relief of neuralgia, was first practised in this country by me, in the Meath Hospital, in the month of May, 1844. The cases were published in the Dublin Medical Press of March 12th, 1845." Rynd evidently limits the expression "in this country," to

* London, John Churchill, 1859, 3d Ed.

Mr.

Ireland; and his cases were published already in March, 1845, whilst Dr. Wood's first case occurred at the end of November, 1843, in Edinburgh. His first papers on the subject were published in the same city, in 1855, and in the British Medical Journal of August 28th, 1858. None, however, will deny the valuable labors of Dr. W., the Edinburgh Professor, in this direction. No man has done more than he to enlist the attention of physicians in this subject. But whilst Dr. Wood confined himself solely to cases of neuralgia, Dr. Hunter, of St. George's Hospital, London, and Dr. Béhier, of France, did not rest there, but demonstrated, by experiments, the applicability of hypodermic injections to many other disorders of the nervous system; so that we are able to record not only cases of neuralgia successfully treated, but also cases of paralysis, tetanus, delirium tremens, chorea, mania, continued wakefulness, &c.

Having premised thus much, I shall now consider First, The requisites for obtaining satisfactory and safe results.

Secondly, The history of 210 cases reported by 18 physicians and surgeons.

Thirdly, The advantages obtained by this treatment.

Fourthly, The disadvantages arising from this treatment.

First, The requisites for obtaining satisfactory and safe results. They are briefly :

(a) That the case be a proper one for treatment.

(b) That a proper instrument be employed.

(c) That a concentrated solution of the narcotic or sedative be used.

(d) That the dose or quantity of fluid to be injected be duly considered and exactly known.

(e) That the proper place be chosen for the operation, and the injection be not repeated at short intervals at the same point.

(a) That the case be a proper one for treatment.

Here we must distinguish between neuralgia proper, and those disorders of the nervous system, such as paralysis, delirium tremens, tetanus, chorea, mania, &c., to which the field of application of this agent has of late been extended. In the latter diseases, the diagnosis is generally easily arrived at; in the former, the disease occurring in all the most possible forms, and in subjects of all ages, habits and occupations, the difficulty is often increased from our inability to decide whether the case under consideration be one of a purely neuralgic character, unconnected with local organic lesion and irritation in distant parts of the body. If the patient be subject to rheumatism or gout, or infected with a syphilitic taint, or suffering from gastric and intestinal irritation, or exhibiting symptoms of disease of the brain, or if we suspect pressure upon the nerve itself, caused either by a tumor or by thickening of the bony canal through which a branch of a nerve passes, we cannot expect much success from subcutaneous injections-except temporarilyunless we use, at the same time, constitutional remedies appropriate to the case. In so far as this can be done, subcutaneous injection, with judicious constitutional treatment, will seldom disappoint the practitioner. Nor should we overlook the action of the heart and the age of the patient. The effect of the operation is so decided and manifests it self so quickly, that no physician would ever think to venture upon its use in a case of neuralgia complicated by heart disease, or great debility, or old age.

As a general rule, it will be found that the curative effect of the operation is most manifest in uncomplicated cases of recent standing, and in those which are most benefited by morphia applied to the blistered surface. Hence to test the value of the present proposed method of relieving the pain, it is essential that the application in neuralgia be limited to purely neuralgic affections-where the pain is ac

tually seated in the course of the nerve; and it must, moreover, be remembered, that agreeably to the laws by which nervous action is propagated, the irritation, that is, the pain, may be seated directly on, or reflected indirectly on the nerve, at any point between its extreme peripheral distribution and the point at which it joins the brain.

(b) That a proper instrument be employed.

The instrument employed may be either that of Travoy, used for the injection of perchloride of iron, or that recommended by Ferguson for injecting a nævus, or the simple instrument constructed by Young, of Edinburgh, or Tiemann, of New York. It consists of a barrel made either of glass or caoutchouc, containing a piston, which may or may not be regulated by a screw rod, so that at each half turn a drop of the fluid is expelled from the needle which is screwed to the barrel. The syringe we generally employ is that manufactured by Tiemann, of New York, holding half a drachm of fluid. It answers very well when the quantity to be injected is quite large, and the number of drops need not definitely to be known. As the exact knowledge of the number of drops to be injected is, however, the great desideratum, and the most important element, a screwsyringe, giving the exact number of minims, is to be preferred. To the body of the syringe are attached hollow needles of various lengths. The point of the needle is sharp, and perforated on one side by an oblique opening, through which the narcotic is expelled. Undoubtedly, the finer the needle the better, as the chances of loss of blood are diminished; the fluid is less apt to ooze out, and the wound is next to nothing, Mr. Hunter uses needles made of silver, with a hardened gold point; one of tempered steel, however, answers every purpose.

In all cases, the use of a lancet to make the required incision, and the insertion of the nozzle of a small glass syringe under the skin, for the purpose of injecting the nar