Again, in the severe acute pain of serous inflammations, especially pleurisy, may usually be afforded all the relief which formerly was sought through the employment of the lancet or of leeches, by the hypodermic injection of 1/16 to 1/4 grain of acetate of morphia. One or two such injections daily, during the early stages, will usually suffice to keep the patient free from any considerable suffering.

Indeed I may probably go further, and assert that in all febrile diseases (fevers, acute inflammation, pyaemia, etc.), if it be necessary to use opium for any purpose, it is highly advisable to employ hypodermic morphia. The reason is that morphia, given in the manner referred to, produces much less disturbing effect on the stomach than any opiate administered by the mouth, provided it be not given in excessive doses; and it need hardly be said that, in acute diseases, it is often of the greatest importance not to interfere with the power of digesting food. The hypnotic power of hypodermic morphia is not materially different (except as regards the dose employed, and the rapidity with which the brain is influenced) from that of morphia swallowed; but, for the reason just mentioned, it is often highly expedient to adopt the former method of administration.

1 Transactions, vol. li.

Much difference of opinion exists in regard to the relief of localized pains; viz., as to whether the injection should be made near to the painful part or in an indifferent situation. In favor of the former plan we may cite the authority of Wood, Eulenburg, Behier, Lawson, etc.; and in favor of the latter, Hunter, Anstie, the committee of the Medico-Chirur-gical Society, and others. Probably it is only in a minority of cases that the local injection presents any advantage over injection into a convenient indifferent part; and, in fact, absorption takes place, under ordinary circumstances, so rapidly, that the drug must reach the general circulation before it can act upon the site of pain.

Of precautions against sudden fatal accidents from hypodermic injection of morphia it is unnecessary to speak at length. It would seem that the only serious danger of such an occurrence lies in the possibility of injecting by mishap directly into a vein. It becomes, therefore, the duty of the injector always to avoid such localities as are evidently or probably supplied with large superficial veins.

Therapeutic Actions of Codeia. - As a hypnotic, codeia has received a great deal of commendation from trustworthy authorities, though Garrod and some others somewhat unaccountably depreciate its powers. Berthe and Aran specially recommend it for procuring sleep in cases of tormenting cough, of gouty pains, and of pains from cancer; and Krebel praised it highly, more especially in cases of nervous insomnia, and sleeplessness from rheumatic pains. The latter authority particularly states that the sleep it causes is light and refreshing, and not followed by the disagreeable after-effects of opiates. Reissner employed codeia subcutane-ously, and found it analogous to morphia both in its beneficial and in its inconvenient effects. In France, codeia is largely employed, more especially as a hypnotic, and Claude Bernard placed it (along with morphia and narceia) in the soporific group of opium-alkaloids; nor can it be supposed to be much weaker than morphia in this respect, since the highest dose employed by Krebel was about one grain; and he recommended only the 1/15 or 1/10 grain for sensitive subjects. The nitrate of codeia, which was recommended by Magendie because of its solubility, must on that account be given in somewhat smaller doses than the alkaloid itself.

As a remedy for pain, codeia on the whole is doubtless greatly inferior to morphia. Erlenmeyer employed it subcutaneously for neuralgia, but without any effect; and for the relief of any very severe pain it is probably, according to English experience, nugatory. Yet it has been recommended warmly by Berthe, Aran, Krebel, and others, in abdominal neuralgias, and Krebel also recommended it in rheumatic sciatica; but assuredly it cannot compete with hypodermic morphia in this or in any other capacity.

In irritation and hypersecretion of the bronchial mucous membrane, there is reason to think that codeia may often play a valuable part when morphia or other opiates are not well borne. It was strongly recommended for this purpose by Vigla and Aran; and Dr. Anstie informs me that he has employed it with satisfactory results in such cases in the dose of 1/6 grain every three to six hours.

Therapeutic Action of Narceia. - Here again we meet with great conflict of opinion among authorities, the various views ranging from absolute denial of any medicinal virtues in narceia, to the statement that it is the best promoter of sleep and soother of pain that exists. There can be little doubt that each of these extreme views is quite incorrect. The substantial agreement of all the best French authorities (Claude Bernard, Behier, Delpech, Bouchardat, fils) with two of the best German experimenters, Erlenmeyer and Eulenburg, completely disposes of the idea that narceia is an inert or nearly inert substance,; on the contrary, it is plainly a hypnotic of considerable power, though it fails to affect some individuals, and is comparatively free from the tendency of opiates to produce after-headache. It is probably an exceedingly good remedy in irritative cough, and especially in phthisis, for which Behier has particularly recommended it.1 Unfortunately the alkaloid itself cannot be conveniently injected under the skin, since it causes violent local irritation. This seems to depend in part on its high insolubility, and may possibly be hereafter remedied, as Husemann suggests, by the use of the very soluble lactate. The dose, as a hypnotic, given in powder or pill, is half a grain to a grain. To me it seems sudorific as well as hypnotic and anodyne.

Therapeutic Actions of Papaverine. - This alkaloid has also been the subject of the most conflicting statements; but the conjoint weight of the clinical researches of Baxt and those of Leidesdorf has probably convinced most persons who are impartial that the powers of genuine papaverine are very real. Baxt and Sander reckon it equal in strength to morphia, but this seems doubtful; on the other hand, the trials of Hof-mann and of Reissner, which gave quite negative results, must surely have been made with bad specimens of the alkaloid. On the whole, it seems probable that for cases of insomnia with nervous excitement, papaverine is an effective hypnotic in doses of about a grain. The phosphate is not adapted for subcutaneous injection on account of its irritating properties. The muriate was successfully employed in this way by Leidesdorf, but does not appear to be more effective when injected than when swallowed.