From: exchangesupplies.org
The origins of injecting probably lie in the weapons such as blowpipes and poison tipped darts that have been used for thousands of years to introduce substances into the body - albeit involuntarily for most of the recipients.
At its most basic, a syringe is a type of simple pump and it is likely that syringe-type devices were produced by many people. The earliest and most common syringe type device was called a ‘clyster’ a device for giving enemas.
It is impossible to be precise about when this developed, and when injecting as we know it began - the origins of the hypodermic syringe are clouded in uncertainty because there were numerous parallel processes of evolution and experimentation that led to the development of devices to inject drugs and medicines.
Because of this various people have been credited with the 'invention' of the syringe including Christopher Wren, Robert Boyle and Pascal, and intravenous injection is recorded as early as the 17th century.
The Fergusson syringe of 1853 became the forerunner of the modern syringe when Alexander Wood used it for the subcutaneous injection of opiates for the relief of pain.
The first injections
Wren is the first person recorded to have employed intravenous injecting in Britain.
In 1656 he experimented by injecting dogs with opium and other substances (Macht 1916). Wren’s ‘syringe’ was a crude device, consisting of a quill attached to a small bladder. In order to gain access to a vein, an incision first had to be made in the skin. High risk injecting with crude injecting devices still persist today in places such as prisons where access to modern sterile equipment is often absent or limited.
Wren also attempted intravenous injection in humans. To do this he used “the delinquent servant of a foreign ambassador but it didn't go well:
“…the victim either really or craftily fell into a swoon and the experiment had to be discontinued” (Macht 1915)
it was at least another 100 years before a syringe with an attached needle intended for puncturing the skin was produced.
In 1807 the Edinburgh Medical and Surgical Dictionary defined a syringe as:
“A well known instrument, serving to imbibe or suck in a quantity of fluid and afterwards expel the same with violence. A syringe is used for transmitting injections into cavities or canals.”
Interestingly, the above source also describes injections as being employed almost solely for injecting substances into the blood vessels of corpses for the purpose of enhancing anatomical study. Various developments and refinements towards the modern syringe were made as a result of the study and teaching of anatomy in the 17th and 18th centuries.
In the 17th century, De Graaf made a device that closely resembled the modern syringe, with a metal barrel to which the needle was directly attached. Its purpose was to trace the blood vessels of corpses.
Deliberate subcutaneous injection (under the skin) did not begin until the mid to late 19th century, probably as an extension of the then new practice of inoculation against disease.
Early experiments
Experiments with intravenous injecting continued and techniques were further developed in the 17th century. Numerous drugs were used to attempt to treat various conditions, particularly epilepsy and syphilis.
Opium was one of the first drugs to be injected in this way, but difficulties in reliably accessing veins, the use of substances unsuitable for intravenous injection (such as cinnamon, oil of sulphur and arsenic) gave poor results - which were incorrectly attributed to the route of administration - and probably limited the development of intravenous injecting as a common method of drug delivery.
Absorption of drugs through the skin
The beginning of the 19th century saw an increase in interest in attempts to introduce drugs into the body via the skin itself. Initially, this usually took the form of causing blistering to an area, removing the outer layer of skin and placing a poultice or plaster containing the drug onto it. In 1836, Lafargue further developed this idea by dipping a vaccination lancet in morphine, and pushing it under the skin.
By the middle of the century Lafargue had developed a technique of placing solid morphine based pellets under the skin. Initially this was achieved by simply making a hole with a large needle and pushing the pellet into the hole. Over time and instrument was developed to aid this procedure which Lafargue called the ‘seringue seche’ or dry syringe.
Other variations of this method included that of Crombie, who in 1873 used a technique of coating silk thread with morphia and then drawing the impregnated thread under the skin. Crombie developed this method because he felt that the recently developed hypodermic syringe was expensive and easily damaged.
Subcutaneous injecting
Through the 19th and into the early 20th century, subcutaneous injecting was generally seen as a more valuable route of administration than intravenous injection. This may have been because of the earlier interest in the absorption of drugs through the skin, as well as a lack of realisation of the potentially increased potency of intravenous injections.
In 1880, H.H Kane described intravenous injection as mainly being an unwanted consequence of subcutaneous injection and gave ways to avoid its occurrence. Writing as late as 1916, Macht said:
“however useful intravenous medication may be in special cases, its field of application is certainly more limited than that of hypodermic (subcutaneous) injection…”
The discovery of systemic action
It seems odd now, but early physicians did not realise that substances that were injected would have a systemic effect i.e travel around the whole body, thinking the action of things they injected would be local.
Early understandings of the pain relieving effects of opiates centred on the belief that most of the drug stayed at the site at which it was injected. In fact, drugs administered by any route of injection will eventually permeate throughout the body. Intravenous injection is the fastest route for injected drugs to reach the brain in concentrated form and subcutaneous injection is the slowest injected route.
Alexander Wood, although recognising some systemic action, believed that the action of opiates admistered by subcutaneous injection was mainly localised. The use of the syringe rather than previous methods was thought to allow greater accuracy in administering the drug in close proximity to a nerve, hence it was thought, facilitating better pain relief.
This belief in localised action influenced many doctors at the time. Dr Francis Anstie, editor of The Practitioner, wrote in 1869 that there was no danger associated with the hypodermic injection of remedies, and later:
“it is certainly the case that there is far less tendency with hypodermic than with gastric medication to rapid and large increase of the dose when morphia is used for a long time together”
Charles Hunter, a house surgeon at St George’s Hospital, made the connection that opiates administered by injection exert a systemic action, when he was forced to move away from the original site of injection as a result of abscess formation. He found that the patient still experienced similar relief from pain. This as Berridge and Edwards have noted, “led to a period of sustained and acrimomious debate between Wood and Hunter” about the existence or otherwise of systemic action.
Subcutaneous injecting with a syringe was initially described and popularised by Wood. It has been suggested that the fundamental misunderstanding that dependence could not occur through injected medication was partly responsible for the creation of a large number of patients dependent on morphine, described in the 19th century as ‘morphinists’. This was because the effect of the injected drug was thought to be local, rather than systemic and partly because dependence was thought to be centred on the stomach – so the theory went, avoiding ingestion through the stomach would avoid dependence.
Common problems with early injections
19th century injecting was by no means without incident or problems. The following late 19th century account of the problems associated with medical injections has powerful echoes for street injectors in the UK and other parts of the world today who continue to need to add acids to the base forms of brown street heroin and crack cocaine in order to render them soluble for injection.
“The active agent to be injected subcutaneously must be in perfect solution. The solution itself should be neutral (i.e. neither acid nor alkaline), clear and free of foreign matter, and not too concentrated. The difficulty of fulfilling all of these conditions has in the past very materially hindered the more general use of this method of treatment. But comparatively a few years ago many of the alkaloids were only to be had as bases. They were more or less insoluble without the addition of some acid and the slightest excess of the latter caused intense local irritation.” (Sharpe & Dhome 1898)
19th century descriptions of frequent subcutaneous injectors can sound similar to the appearance of some frequent injectors of street drugs in the 21st century, particularly those who are having difficulties in accessing veins.
“An extraordinary spectacle was revealed on examination. The entire surface of the abdomen and lower extremities was covered with discolored blotches, resembling small vibices, the marks of the injections. He was spotted as a leopard. For four years he had averaged three or four a day – an aggregate of between 5 and 6 thousand blissful punctures! The right leg was red and swollen, and I discovered a subcutaneous abscess extending from the knee to the ankle and occupying half the circumference of the limb.” (Gibbons 1870)
The growth of the medical use of opiates
A powerful influence on the development of widespread and repeated use of opiates by injection, would have been the obvious and immediately beneficial effects of injected morphine, particularly to those experiencing chronic pain. Doctors at the time, with few truly effective treatments available, would have had difficulty in resisting the impulse to treat pain with something as powerful, fast and effective as injected morphine. Courtwright, when discussing 19th century opiate addiction in North America, has said:
“The administration of opium and morphine by physicians was the leading cause of opiate addiction in the nineteenth century…case histories, clinical notes and remarks in the medical literature support the view that although opium and morphine were ultimately given for such unlikely disorders as masturbation, photophobia, nymphomania and ‘violent hiccough’ it was principally in those suffering from chronic ailments that the use of these drugs led to chronic addiction.” (Courtwright 1982)
The combination of the development and spread of injecting, alongside the widespread availability of opiates and opiate-based patent medicines probably contributed significantly to the increase in numbers of injectors of opiates in this period.
Injecting in the 20th century - the growth of intravenous injecting
Throughout the 19th and early 20th centuries, the most common injected route amongst both medical and ‘non-medical’ injectors was by subcutaneous injection.
Interestingly, early accounts of intravenous injection describe it as something unpleasant and to be avoided, although this is probably as a result of using too large a dose. The preference for the intravenous route of drug administration seems to have become particularly prevalent with illicit users during the 1920’s.
Richard Pates reviewed the literature on the spread of illicit intravenous injecting (Pates 2005) and concluded that early intravenous injectors probably discovered the route accidentally, and learned to use smaller doses than would have been needed for subcutaneous injection. Before 1925 intravenous injection amongst illicit users was relatively rare, by 1945 it had become the norm:
“…in the early 20th century addicts were taking doses that were enormous by today's standards and mostly had overdose experiences when they accidentally hit a vein. But when narcotics started to become more difficult to obtain and the doses became smaller, communication in the drug subculture facilitated the diffusion of the intravenous technique. The fact that (intravenous) injecting is more economical and the enjoyable rapid effect, or 'rush', contributed to the quick diffusion.” (Pates et al 2005)
However, it is very important to understand that medicine was beginning to favour the intravenous route for particular medications in the first decade of the 20th Century, particularly a drug called Salvarsan, a treatment for syphilis. The most effective alkaline form of Salvarsan could only be delivered intravenously. As Patricia Rosales says:
“In order for alkaline Salvarsan to maintain its non-toxicity, it had to be administered intravenously. It therefore required what in 1911 was considered a surgical procedure; a process much more difficult to achieve than today’s shot in the arm.” (Rosales 1997)
Rosales suggests that improvements and standardisation in the design and manufacture of syringes, needles, ampoules and the formulation of drugs, were largely driven by the precision required in the new need to give intravenous injections. It is therefore very likely that medical advances played a crucial part in the diffusion of the intravenous route.
The non-medical intravenous injection of heroin was first described in 1925 (Kolb 1925). five years previously, B.S. Wyatt had written the following about the intravenous treatment of malaria:
“From the subcutaneous injection to the intramuscular injection was a logical evolution. From the intramuscular injection to the intravenous injection was inevitable. It had to come. It is here to stay. There is every argument for no argument against intravenous therapy. Once admitted that the blood is the medium in which medicine is carried to every organ, tissue and cell of the body…” (Wyatt 1920)
The switch to disposable needles and syringes
Patents for glass disposable syringes were being taken out as early as 1903, but they were probably ideas before their time, and do not seem to have entered production.
The first truly disposable ‘syringes’ to be produced in large quantities were originally designed by James T Greeley around 1912. These were collapsible tin tubes (a bit like a modern tube of superglue) that had an attached needle and contained a contained a specific amount of morphine for subcutaneous injection on the battlefield. These were used in the 1st World War and were further developed during the 1920’s and 30’s to become the morphine Syrette manufactured by Squibb.
Syrettes were a standard part of the 1st aid kit carried by U.S. medical orderlies in World War 2. Used Syrettes were pinned to the collar of a casualty in effort to avoid inadvertent overdosing.
Greeley described the reasons for the development of his disposable device in 1912, talking of the problems with existing syringes he said:
“Asepsis is uncertain, the making of the solution is time-consuming and impossible where water is not available; the joints often leak; the piston occasionally sticks, and the needle becomes dull and rusty from boiling.”
Throughout the 20th century , the production of precision-made glass syringes was gradually refined. The first major advance came with the manufacture of syringes and needles with interchangeable parts made to exact specifications, rather than as ‘one-off’ items, as has been said above, the impetus for this standardisation was driven by the need to inject the anti-syphilitic drug Salvarsan intravenously.
Until the1960’s the majority of needles and syringes used outside of warfare, were re-useable and were supplied unsterilised. They had to be sterilised before each use.
The development of plastic disposable syringes
There are several competing claims to the design of the first disposable plastic syringe, but the most plausible is that of the Monoject syringe developed in the USA by Roehr products in 1955. The development of the Monoject syringe spurred Becton Dickinson into the development of similar plastic syringes (they had previously been developing glass disposables) and BD introduced their own Plastipack syringe in 1961.
Fears about the transmission of hepatitis B (and the resulting lawsuits) by doctors using inadequately sterilised re-useable syringes led to the takeover of the market by plastic disposables. A 1998 article in the San Francisco Chronicle on healthcare needle stick injuries, quotes a BD executive Joseph Welch as saying in 1990 of hepatitis B:
“It was probably the reason Becton Dickinson is a $2 billion company today,''
Becton Dickinson produced the first one-piece insulin syringe with integral needle in 1970.
Difficult to re-use syringes
There are many types of difficult to re-use syringes, each with a different mechanism to prevent a syringe being used more than once. They were developed for hospitals and other health care settings where they can prevent the inadvertent re-use of syringes.
Although it might seem that supplying these syringes to illicit drug users would reduce needle and syringe sharing, it is widely believed that their introduction would lead to those syringes already in circulation being kept, re-used and shared more frequently - leading to an increase in hepatitis C and HIV transmission. The United Kingdom Harm Reduction Alliance and the National Needle Exchange Forum have both warned of the potential dangers of these types of syringe.
We have written a separate article on this issue, to read it CLICK HERE
Accidental sharing and the development of the Nevershare syringe
A video study of injecting risk in Glasgow by Avril Taylor from Paisley University highlighted the prevelance of 'accidental sharing' in which injecting drug users had difficulty in avoiding sharing because all their syringes looked the same.
Exchange Supplies made a documentary film with the researchers to disseminate their findings, to see it, CLICK HERE
One of the key recommendations of the study was that much of the risk of sharing could be removed if injectors (who are well aware of the risks) were more able to tell their syringes apart.
After several years of lobbying syringe manufacturers to ask them to act on these findings, it became clear that they weren't going to do so of their own volition so Exchange Supplies embarked on it's biggest ever product development project, resulting in the launch of the 1ml insulin type nevershare syringe with plungers in 5 different colours to reduce accidental sharing in May 2007.
The Nevershare was the world's first syringe developed specifically for injecting drug users and in addition to plungers in a range of colours, it has markings in millilitres rather than insulin units, a barrel clear of print so injectors can see the solution, and a 30 gauge needle to reduce vein damage.
In September 2011, we added a 2ml detatchable needle type nevershare syringe to the range so that injecting drug users who require a different needle size to the 'traditional' insulin type syringe can also have access to coloured plungers so they can tell their syringes apart.
References
Macht D I (1916) The history of intravenous and subcutaneous injecting of drugs. The Journal of the American Medical association. LXVI
Morris R and Kendrick J (1807) The Edinburgh Medical and Surgical Dictionary.
Kane H H (1880) The Hypodermic Injection of Morphia. Its History Advantages and Dangers. Chas L Bermingham and Co, New York.
Anstie F E (1871) On the effects of prolonged use of morphia by subcutaneous injection. Practitioner 6: 148-57
Berridge V and Edwards G(1987) Opium and the people. Opiate Use in Nineteenth Century England, pp. 139-40. Yale University press, USA.
Sharp & Dhome (1898), A brief summary of hypodermic medication, 6th edition pp.8-9. Sharp & Dhome, Baltimore. Quoted in Rosales P, A history of the hypodermic syringe 1850’s – 1920’s. Harvard University Thesis, December 1997
Gibbons H (1870). Letheomania: the result of the hypodermic injection of morphia. Pacific medical and surgical journal 12: 481-495. Quoted in Rosales P, A history of the hypodermic syringe 1850’s – 1920’s. Harvard University Thesis, December 1997
Courtwright D (1982) Dark Paradise; Opiate Addiction in America before 1940, p.42 Harvard university Press, USA
Pates R, Mcbride A, Arnold K (Eds) Injecting Illicit Drugs Blackwell Publishing 2005
Rosales P, A history of the hypodermic syringe 1850’s – 1920’s. Harvard University Thesis, December 1997
Kolb L, Pleasure and Deterioration from Narcotic Addiction," Mental Hygiene, 9 1925
Wyatt B. S. (1920) The intravenous treatment of malaria, New York Medical Journal 112: 366-369
Editor. (1876) Tetanus after hypodermic injection of morphia. Lancet 2: 873-6
Bartholow R. (1891) A manual of hypodermic medication: The treatment of disease by the hypodermatic or subcutaneous method, 5th Edition, J B Lippincott Company p 38. Philadelphia USA.
