Beneath the surfaceBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f380 (Published 21 January 2013) Cite this as: BMJ 2013;346:f380
- Robin Ferner, director, West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham B18 7QH, UK
The three and three quarter miles from Bishop’s Road, Paddington to Farringdon Street in the City of London mark out the route of the world’s first underground railway, opened 150 years ago this month. The Times saw it as “the great engineering triumph of the day,” that afforded “a direct and expeditious means of conveyance for the enormous traffic between the east and west ends of London.”1 It had the great advantage that it avoided the increasingly tangled street traffic above, although it also had disadvantages. The trains were hauled by steam engines, and the “sulphureous gas” they emitted made it “most unpleasant to the officials, and . . . in a less degree, to the passengers themselves.”2 Indeed, two porters had been carried away from the Gower Street [Euston Square] station “in a very weak and sinking state.”3
The year 1863 also saw the publication of Charles Hunter’s “Practical remarks on the hypodermical treatment of disease” in the Lancet, a review whose main purpose was to claim credit for introducing treatment of nervous disorders by hypodermic injection of atropine, and to confirm to Hunter’s satisfaction “the superiority this method has over all others in checking disease.”4
There is debate about who invented the hollow needle and syringe,5 but it was clearly not Hunter. His review made no mention of Alexander Wood of Edinburgh, who in 1855 reported that he had injected morphine solution around painful nerves in eight cases, some successful, in the belief that the morphine would have a local effect.6 We now know that the effects of morphine are predominantly at opioid receptors in the central nervous system, and that morphine is not active locally.
Dr Wood gives admirably clear descriptions of the systemic effects. Within ten minutes of injection, his first patient “began to complain of giddiness and confusion of ideas.” Although in half an hour her pain had subsided, she was fast asleep over 12 hours later, when “she was roused with difficulty.” Several of the patients vomited. He deduced “that the effects of narcotics [locally] applied are not confined to their local action, but that they reach the brain through the venous circulation, and there produce remote effects”; and that “in all probability what is true in regard to narcotics would be found to be equally true in regard to other classes of remedies.”6 Events have proved Wood correct: the current British National Formulary lists around 200 drugs for subcutaneous injection or infusion.
By 1885, hypodermic injection of morphine was being advocated as an alternative to hanging. “The advantages of this method are its certainty, its painlessness, the freedom from the chance of horrible displays, the reduction of the dramatic element to a minimum, and its inexpensiveness.”7 Cost effectiveness is, no doubt, important, but these arguments seem rather to miss the point. The hypodermic syringe also “unquestionably proved a source of the morphine habit in many instances, the victims being enabled to carry out this practice surreptitiously for themselves in their limbs and other covered parts of the body.”8 Indeed, Sherlock Holmes’s forearm was “all dotted and scarred with innumerable puncture-marks” from where he injected himself with morphine or cocaine.9
“Skin popping”—that is, subcutaneous injection of heroin, doesn’t just leave scars: several injecting drug users in Germany and in the UK over the last year have developed anthrax; but they have presented with local necrotising fasciitis or abscesses, meningitis, or systemic sepsis, rather than the classic black eschar.10 So, if you see a subcutaneous heroin injector with a painful arm, consider what might be beneath the surface.
Cite this as: BMJ 2013;346:f380