Surgery on the Narcotic Addict *

B. EISEMAN, M/I.D., R. C. LAMI, M.D., BENJANIIN RUSH, M.D.

From the Surgical Service, U. S. Public Health Service Hospital and the Departmentof Surgery, University of Kentucky School of Mledicine, Lexington, Kentucky

ALTHOUGH there are 45,00024 known nar-cotic addicts in the United States, no onepracticing surgeon normally has more thana superficial experience with problems oftheir surgical diagnosis and care. The pur-pose of this paper is to summarize the sur-gical experience of the U. S. Public HealthService Hospital in Lexington, Kentuckywhere 85 per cent of the patients are nar-cotic addicts. The surgeon who occasion-ally deals with this difficult type of patientmay thus benefit from the accumulated ex-perience of this hospital.

Clinical Facilities

The U. S. Public Health Service Hospitalin Lexington is a 1,042 bed institution forthe care of narcotic addicts. Twenty to 25per cent of the patients are prisoners whohave violated the narcotic act. The other75 to 80 per cent are voluntary admissions,40 per cent of whom sign out against advicewithin two weeks after admission. Com-plete medical, sturgical and psychiatric fa-cilities are used for the care and study ofthe patients.During the 27 years since the commis-

sioning of this hospital, there have been anaverage of 1,100 annual admissions. In re-cent years, the rate has been approximately3,000. The majority of the admissions are

* Presented before the Southerin Surgical Asso-

ciation, Hot Springs, Virginia, December 10-12,1963.

Supported by The Fred Rankin Surgical Fundand a Grant from the USPHS.

repeaters. A full-time surgical staff and con-sultants perform 120 major sturgical proce-dures annually.The drugs utilized by these addicts are:

heroin accounting for about 90%r of theadmissions), morphine, demerol, dilaudid,paregoric or barbiturates. Cocaine addic-tion is now a rarity. When brought into thehospital, the patients are admitted to a with-drawal ward where they are appropriatelysedated and weaned from their drug.Thereafter, the patient enters a psychiatrichospital ward routine for the remainder ofhis stay. Addiction is 300 times higheramong physicians, dentists, nurses andparamedical personnel than in the generalpopulation! 24

Table 1 is a summary of the operationsperformed in this institution during thepast five years. In general, the patientsthemselves do not differ radically from theroutine in other institution hospitals notcaring primarily for addicts. The frequencyof plastic procedures and circumcisions isnot unusual in an institution population.

General Comments

MIany addicts notoriously will brook nophysical or moral restraint in their effortto obtain a narcotic and wvill fabricate end-lessly and ingeniously in order to earn adose of narcotic. The scarred abdomen ofsome of the patients is often mute testi-mony to previouis success in convincingsuirgeons that laparotomy is necessary. Themore experienced the surgeon, however,the less likely he is to operate upon an

748

Volume 159 SURGERY ON THENumber 5

addict patient on subjective complaintsalone. The lore of this hospital is filled withtales of inmates who try to con the newlyarrived physician into operating upon themin an effort to obtain a shot, only to giveup immediately upon encountering the ex-perienced and wholesomely skeptical sur-geon who they know will recognize theirdeceit.

Since drug withdrawal produces manysigns and symptoms 17-19 that complicatesurgical evaluation of a patient it is im-portant to appreciate the clinical manifes-tations of this state for it is a period inwhich the addict may stoop to any meansto obtain relief. During withdrawal theaddict is nervous, hyperactive and alter-

NARCOTIC ADDICT 749nately may have profuse sweating or chillsand goose flesh. Frequently he complainsbitterly of leg cramps and has fine general-ized muscle twitching.

Intestinal symptoms may be very acuteduring withdrawal. Vomiting, hyperperi-stalsis, abdominal cramping pain of a se-vere nature, gastric hypersecretion and pro-fuse diarrhea may predominate. Occasion-ally signs of intestinal obstruction are morenoticeable with abdominal distention anda typical distended small bowel pattern onx-ray examination. It is our clinical impres-sion that the picture of gastro-intestinalobstruction is more common in the opiumaddict seen in the Orient than in ourexperience in Kentucky.

TABLE 1. Summary of Operations Performed at the USPHS Narcotic Hospital 1957-1961

No. Operations During YearTypes Performed 1957 1958 1959 1960 1961

Skin, subcutaneous areolar tissues,including tatto, scar revision andgrafts

Breast

Musculo-skeletal system

Respiratory system excluding (5)below

Lungs and pleuraVascular systemLymph nodesDigestive system excluding

(9) (10) (11) (12) belowStomach and intestinesAnus and rectum

Biliary tract

Abdomen, peritoneum andomentum including hernias

Urinary systemMale genital system including

circumcisionFemale genital system

Thyroid glandBrain, spinal cord and nerve roots

EyesEars

1877

61

14

4

16

4

75

69

3

54

49

115410

2

2

0

194 1532 5

48 60

8

5

143

71

554

3621

78390

1

1

0

6

2

127

6

3

42

10

42

15

44

31

60

70

216

8

54

14

2

22

6

8

8

3717

49

15

2059

47

8

5

172

4

10

3518

48

43

3449

60

73

33724

377

750 EISENIAN, LANI AND RUSH

.W;M. .

FIG. 1. Persistent spasm of lesser curvature ofstomach simulating gastric carcinoma in an opiumsmoker.

Gastro-intestinal ObstructionThe most common and perplexing surgi-

cal differential diagnostic problem in thenarcotic addict is that of intestinal obstruc-tion. Addiction and withdrawal both pro-

duce important changes in intestinal mo-

tility which confuse the picture. Morphineand its derivatives cause spasm of intestinalsmooth muscle 22 which result in crampy

pain and constipation, indistinguishablefrom that seen in mechanical obstruction.The problem is further complicated by thedesire of the addict to obtain a narcotic.This desire will lead him to magnify symp-

toms and to produce as many signs as pos-

sible of obstruction. The amusing yet tragicliterature of Munchausen's syndrome 2,9 re-

cords the ends to which these addicts willgo in swallowing air and in other ways pro-

ducing the clinical pictture of obstruction.Since many addicts halve had numerous

previous laparotomies, establishing the di-agnosis is further complicated by differen-

Annals of SurgeryNMay 1964

tiating gastro-intestinal symptoms second-ary to withdrawal from those due toobstruction. The more the number of pre-vious operations, the more concerned thesurgeon becomes as to the likelihood ofsuch organic obstruction. It takes greatsurgical restraint to refuse operation underthese circumstances. In a 45-year-old pa-tient seen in this hospital in 1953, therewere 49 previous laparotomies for intestinalobstruction! It is significant that despiteher pleas, laparotomy was not requiredonce she was admitted to the narcotic hos-pital, and she recovered from every ab-dominal crisis.

Differentiation between mechanical ob-struction and simulated obstruction in theaddict is a clinical art but certain pointsare worthy of mention. The addict simu-lating obstruction often will swallow largeamounts of air prior to examination, pro-ducing a grossly distended abdomen.

Constipation and diminished intestinalmotility may allow much swallowed air toremain in the gut. To help in differentiatingsimulated from true obstruction, it is wiseto insert a large bore indwelling gastrictube and institute immediate suction toprevent further accumulation. It is also wellto keep the patient under careful observa-tion to make certain that the tube is notpurposely occluded by the patient andmore air subsequently swallowed.

In most instances gastric suction andlarge bore rectal tube will decompress suchaerophagics in a matter of a few hours. Ontwo occasions massive spontaneous decom-pression per rectum occurred as anesthesiawas being induced in the operating roomthus obviating laparotomy for what wasthought to be intestinal obstruction.The objectivity of laboratory data is of

prime importance in differentiating organicbowel obstruction fromn the aeroplhagic dis-tention of the addict. Hemoconcentrationand a leukocytosis are the only laboratoryfindings that are occasionally of help in

SURGERY ON THE NARCOTIC ADDICT

suggesting organic disease. Radiologic ex-

amination may reveal dilated loops of smalland large bowel in the classic pattern ofobstruction but there is no cut-off of thegas pattern and there will usually be gas inthe large bowel.

Segmental areas of spasm occasionallyoccur in the narcotic addict, which, if per-

sistent, give radiologic patterns that simu-late carcinoma. In an opium smoker inSoutheast Asia, a consistent annular con-

striction was noted in the transverse colonon three separate barium examinations.Exploration was required to rule out an

organic lesion. In another instance a similar

....

FIG. 2. Multiple cuta-

neous scars in narcotic

addicts at sites of un-

sterile injections.

area of persistent spasm appeared on thelesser curvature of the stomach and simu-lated gastric cancer on two barium x-ray

studies (Fig. 1). Operative exploration was

only avoided when a third examinationthree weeks later demonstrated no spasm or

filling defect.

Abscess and Infection

Most addicts sooner or later resort tointravenous administration of drug to attainthe sudden and total impact of the nar-

cotics. This is due both to increased toler-ance to the drug and to diluted narcoticwhich characteristically is pushed by illegal

Volume 159Number 5 751

EISEMAN, LAM AND RUSH Annals of SurgeryMay 1964

FIG. 3. Scar contrac-tLtres of fingers of addictsfollowing infected injec-tion sites into digitalveins. Note superficial re-

semblance to Dupuytren'scontracture.

salesmen and which requires an increaseddosage to produce the desired effect. Mostaddicts neglect even the most rudimentaryhygienic precautions in intravenous injec-tions and wound infections and venous

thromboses ensue.

As accessible veins become fewer andmore difficult to puncture, the addict seeksmore distal vessels. Occasionally in des-peration he will scarify himself and rubpowdered narcotic into the wound to attainvenous absorption. These unsterile prac-

tices understandably result in wound infec-tion and subsequent scarring over accessi-ble portions of the body. One of the hall-marks of the narcotic addict is a multitudeof small scars scattered anywhere over ac-

cessible portions of the body (Fig. 2). Theseusually first are made on the arms butlater on the legs, thighs, trunks and even

on the penis as every conceivable venous

channel is punctured.Barbiturate addicts are particularly prone

to multiple abscess and scarring due to theirritative nature of the high molecularweight alcohol in which the barbituratesare usually dispensed. Interstitial extravasa-tion of this diluent produces marked tissuedestruction and contractures.A unique lesion occasionally seen in ad-

dicts is an infection medial to the firstinterphalangeal joint where a tiny vein is

visible through the thin skin in this area.

Utilizing this small vein for unsterile injec-tion, the addict may produce a scar (Fig.3) that superficially resembles Dupuytren'scontracture. Excision and closure of thesecontractures necessitated cross-finger flapsfrom the palm of the hand to restore fingermotion. Six such operations have been per-

formed during the past five years,* butonly in two was full finger motion restored.Fusion of the joint in the position of func-tion has been required in the others.

In one patient, repeated unsterile injec-tions of barbiturates into the deltoid mus-

cles produced such contractures that thepatient carried his arms frozen in 35 de-grees abduction. He was a dancing instruc-tor who found this winged position pro-

fessionally awkward. It was necessary to

bisect what was left of the deltoid and itssurrounding scar to allow normal position-ing of the arms (Fig. 4).Although tetanus has been described fre-

quently in narcotic addicts 20, 21 this diag-nosis has not been made in the USPHSNarcotic Hospital. In all likelihood suchpatients have been treated in local cityhospitals before coming to this institution.

Subacute bacterial endocarditis occasion-

* These plastic procedures were performed byDr. Andrew Moore of Lexington.

752

SURGERY ON THE NARCOTIC ADDICT

ally occurs as a result of repeated unsterileintravenous injections, 0 l)ut iapparently istreate(l at t local hospital, for I(o Such case

Jiuts been ( liagwosed in the Nar-cotic Ilos-

pital dturing(y the patst five years.

Hepatitis

If fully interrogated, mnany addicts givea history of previous hepatitis or jaundicedue to the unhygienic means employed forintravenous narcotic injections. Commonlya group of addicts will share an unsterilizedneedle and syringe.1 3 4, 5. 1::, 20 Table 2documents the occurrence of actute hepa-titis and hepatic cirrhosis in the hospitalpopulation during the past five years. Therelatively low incidence of alcoholic cir-rhosis reflects the surprising rarity ofchronic alcoholism in narcotic addicts.4'10, 12 The frequency of hepatitis is of im-

portance both in evaluating the etiologyof jaundice in the narcotic addict and in

FIG. 4. Scar contracture of deltoid due to un-

sterile injections by an addict. Operative excisionof contracture on patient's left has restored normalposition. A similar procedure was later performedon the right.

TAIBLE 2. Occuirrence of Aclive IIepatilis and CirrhosisDuring he Pceriod 1957-1961

1957 1()58 1959 1960 1961

1 IcpaltitisCirrhosis (all t !')cs)

7 13 7 15 73 3 4 8 4

evaluating his status as a surgical risk. Inthis regard it is safe to assume that any

confirmed addict has had hepatitis.

Asthma

The high incidence of asthma in the nar-

cotic addict 14 1- commonly complicatessurgical management under a variety ofpostoperative conditions. It is problematicas to wvhether the co-existence of the dis-ease is due to the asthmatic seeking reliefby the use of narcotics or whether narcoticsactually produce bronchial spasm by re-

leasing histamine.

Myths About the Addict

Both pancreatitis and Buerger's Diseaseallegedly are more common in the addictthan in the normal population. In the ab-sence of an elevated serum amylase it isextremely difficult to make an exact diag-nosis of pancreatitis in an emotionally un-

stable person complaining of upper ab-dominal pain. The problem is compoundedin an addict who recognizes the doctor'sdilemma and uses the knowledge of thissyndrome to obtain narcotics.During the last five years, there have

been but two patients diagnosed as havingpancreatitis at the Narcotics Hospital andreview of their charts left doubt as to theaccuracy of the diagnosis in both. On thebasis of this experience it is believed thatco-existence of the two diseases is not com-

mon and that many addicts are given nar-

cotics improperly because of this incorrectdiagnosis.

The probable source of this inaccuracyis the eventual addiction that commonly

Volume 159Number 5 753

754 EISEMAN, LAM AND RUSH

befalls so many patients with the unrelent-ing abdominal pain of pancreatitis, sincemorphine and other narcotics are known tocause spasm of the sphincter of Oddi. Thisestablishes a neat explanation for pancre-atic reflux and obstruction through a com-mon channel. Despite these theories thereis, however, no evidence that narcotic ad-diction produces a high incidence of pan-creatitis.

Origin of the belief that narcotic addictscommonly have Buerger's disease is difficultto document but may be due to the multi-ple venous thromboses which are, of course,not due to inherent vascular disease butto multiple venipunctures. During the fiveyears of this study a diagnosis of Buerger'sdisease has been made on six patients butin none was the diagnosis microscopicallyconfirmed.

Preoperative Medications

The addict's increased tolerance andemotional dependence on narcotics createsa difficult problem for pre-anesthetic seda-tion. The mechanism of tolerance is notcompletely understood even though its ex-istence is incontrovertible.2' The addict willtolerate circulating blood drug levels thatwould be lethal for a normal patient."Liver slices from drug-tolerant animals me-tabolize no greater a proportion of the drugload than do normals. Because of the enor-mous blood levels of narcotics, addictsactually inactivate drug at an increasedrate.'8 29 This does not suggest an adaptiveenzyme response of the liver but a de-creased sensitivity to drug effect.'6Whatever the pharmacologic explanation,

addicts may require huge doses of narcoticto produce somnolence while respondingnormally as far as pupil size and respiratorydepression is concerned. Tolerance de-creases toward normal as the drug is with-drawn. Those who sign out against adviceand go back to addiction consistently tellof finding their tolerance decreased after

Annals of SurgeryAMay 1964

being off narcotics for several weeks. When-ever possible the oral route of administra-tion is utilized in addicted patients wlhenadministering preoperative sedation. Thepreoperative rouitine fouind most uiseftul forthe addict who has been recently with-drawn from his drug has been: 1) Pento-barbital 100 mg. the night prior to opera-tion; 2) Promazine HCI (Sparine) 25 mg.intramuscularly 11,-3 hours prior to opera-tion; and 3) One hour prior to operation:Demerol 50 mg., Scopolamine 0.4 mg., intra-muscularly.During withdrawal or while the patient

remains addicted much greater amounts ofdrugs may be required. Despite such seda-tion, patients characteristically come to theoperating room wide awake and talking.Though obviously not deeply sedated theymay demonstrate the usual pupil constric-tion expected from the medication.For reasons we cannot explain these pa-

tients characteristically come to the operat-ing room with profound hypotension. Ayoung addict with no cardiovascular ab-normality may have a recorded blood pres-sure of 50/20 immediately prior to opera-tion! In a survey of 280 consecutive addictpatients who were normotensive on theward, it was found that mean systolic pres-sure immediately pre-induction was 56 mm.Hg.!To determine which preoperative agent

might be responsible for this hypotension,50 patients have been sedated as describedabove except for omission of promazine(Sparine). There was no significant altera-tion in blood pressure from the controls.Substitution of atropine for scopolaminesimilarly did not alter the hypotension.A vasopressor Methoxamine HC1 (Vas-

oxyl), 10 mg., given 30 minutes prior tooperation and repeated as necessary there-after often is utilized in the elderly narcoticwhere cerebrovascular or cardiac abnor-malities are feared with such degrees ofhypotension. These patients seem to toler-

Volume 159 SURGERY ON THENumber 5

ate mild hypotension well and do not re-quire inordinate or unexpected amounts ofblood replacement. Previous studies in thishospital have shown a decreased blood vol-ume and blood cell mass in addicts.16, 27Further investigation of such preoperativehypotension is under study.

Anesthesia

Characteristically, the addict by repeatedself injections has thrombosed all readilyavailable veins prior to operation. Fortu-nately, all but the most desperate spare theexternal jugular veins which are commonlythus utilized by the anesthetist for adminis-tration of pentothal and subsequent fluids.In major operations, cutdown on a deepvein in the lower extremity may be neces-sary either for blood transfusions or post-operative intravenous therapy.Because of the high incidence of hypo-

tension, cyclopropane, rather than ether,has been utilized for inhalation anesthesia.Otherwise, intravenous sodium pentothal isby far the most common agent employed.

It is difficult to quantitate the amount ofanesthetic agent required by these patientsbut it is our clinical impression that toler-ance is extremely high. As an example, itis not unusual for an addict of mediumbody size to require 40 to 60 ml. of a 2.5per cent solution of sodium pentothal fora 20-minute dilatation and curettage. Evenwith this or comparably large doses ofother anesthetic agents the patients areusually wide awake and talking shortlyafter leaving the operating room. Anesthesi-ologists believe that pupil size is an un-reliable index of depth of anesthesia inthese patients.A volume of agent sufficient to produce

deep anesthesia in a normal patient andresulting in eye signs that would signalsuch narcosis may be found insufficient toovercome unacceptable muscle straining.Muscle relaxants are a necessity in the an-esthetic management of these patients.

NARCOTIC ADDICT 755

Postoperative Care

Postoperative care in the addict is com-plicated. The most immediate difficulty isfinding suitable veins for intravenous ther-apy. It has been found that fellow-patientsacting as orderlies, aids or laboratory tech-nicians are extremely expert at puncturingobscure veins even after staff physicianshave failed. The jugular vein, deep veincutdowns and subcutaneous clysis are allutilized.The problem of medication for pain ob-

viously is complex in these patients whosevery addiction has caused their hospitaliza-tion. Narcotics of all kinds must be usedsparingly and discontinued promptly de-spite vehement protests of the patient.These addicts will stoop to every form ofpersonal threat, plea and vilification tomaintain their narcotic schedule and a hardheart and a deaf ear are required to servetheir best interests.

Occasionally the addict will induce in-fection in his postoperative wound in orderto obtain more drugs of various kinds.Operative sites on the upper extremitiessuch as those following tattoo removalsmay purposely be licked, or the suturesbitten in order to sponsor infection. On theabdomen or lower extremities a commonpractice is to pick at the wound with a pen,pencil, match, comb or fingernail. The sur-geon must, therefore, be alert to suchsources of postoperative wound infection innarcotic addicts attempting to prolong drugtherapy.

Although the exact medication, narcoticand sedation schedule must be tailored tomeet the addict, his operation and his per-sonality, it has been customary to utilizemethadon, morphine or coreine for painand promazine (Sparine) for sedation.Oral administration of drugs is alwayspreferred.

It is our clinical impression that aspiringiven simultaneously with the necessary

756 EISEMAN, LAM AND RUSH Annals of Surgery

narcotic often greatly potentiates the effectof the latter and minimizes the need forrepeating or increasing the narcotic.Of paramount importance is for the sur-

geon to maintain control of the patient-doctor relationship in a positive mannerfrom the beginning. Preoperatively neshould tell the patient about what to expectof discomfort and pain and indicate ap-proximately what type of medication willbe utilized. Having thus explained theproblem he must stick by his plan and notgive in to pleas unless he sees objectivesigns of a complication. Such a positive atti-tude by the surgeon toward postoperativenarcotic needs requires maturity of judg-ment and firm attitude which is recognizedby the narcotic patient as stemming fromexperience.

Constipation is always a problem in theaddict due to derangement of intestinal mo-tility but in the postoperative period canbe particularly bothersome. Early ambula-tion, early feeding, and the usual technicsof enemas, mineral oil and laxatives areoften required.

SummaryIn order to delineate some surgical prob-

lems peculiar to the narcotic addict, thesurgical experience of the USPHS NarcoticHospital in Lexington, Kentucky has beenreviewed for a five-year period.The frequency of gastro-intestinal symp-

toms in the narcotic addict is emphasizedand the plea made to avoid laparotomy forobstruction under almost any circumstancein these patients.

Pre- and postoperative problems of careare described with emphasis on difficultiesin finding unthrombosed veins for intrave-nous therapy. Use of the jugular veins isadvocated.A reasonable routine for pre and post-

operative sedation is described utilizingwith great restraint methedon, promazine(Sparine) and barbiturates.Conditions of surgical significance such

as hepatitis and asthma commonly asso-ciated with addiction are described. Therehas not been a high incidence of pancrea-titis or Buerger's disease in this experience.Hypotension of a marked degree followingeven mild sedation has seemed to be char-acteristic of many of these patients.

References1. Appelbaum, E. and M. Kalkstein: Artificial

Transmission of Viral Hepatitis Among Intra-venous Diacetylmorphine Addicts. J.A.M.A.,147:222, 1951.

2. Asher, R.: Munchausen's Syndrome. Lancet,260:339, 1951.

3. Batonbacal, V. I. and A. Slipyan: Transmissionof Serum Hepatitis in Heroin Addicts. NewYork J. Med., 59:320, 1959.

4. Bloomquist, E. R.: Addiction, Addicting Drugsand the Anesthesiologist. J.A.'M.A., 171:518,1959.

5. Cardon, P. V. and E. NI. Beck: The RecentOccurrence of Hepatitis Among Drug Ad-dicts of New York City. New York State J.Med., 52:1037, 1952.

6. Chessick, R. D., D. H. Looff and H. G. Price:The Alcoholic-Narcotic Addict. Quart. J.Study Alc., 22:261, 1961.

7. Feldberg, W. and W. D. M. Paton: Releaseof Histamine from Skin and Muscle in theCat by Opium Akaloids and Other Hista-mine Liberators. J. Physiol., 114:490, 1951.

8. Friedman, A. H. and W. R. Martin: Hista-mine and Its Release. The Modern Hospital,85:108, 1955.

9. Gatenby, P. B. B.: A Case of Munchausen'sSyndrome. J. Irish Med., Assoc., 30:102,1952.

10. Gerard, D. L.: Intoxication and Addiction,Psychiatric Observation on Alcoholism andOpiate Drug Addiction. Quart. J. Study Alc.,16:681, 1955.

11. Goodman, L. S. and A. Gilman: The Pharma-cological Basis of Therapeutics. 2nd Ed.MacMillan, 1960.

12. Gregory, I.: Alcoholism and Drug Addiction.Minn. Med., 44:445, 1961.

13. Havens, W. P.: Viral Hepatitis, Multiple At-tacks in Narcotic Addict. Ann. Int. Med.,44:199, 1956.

14. Henriksen, E.: Mlorphine and Asthma. Uge-skrift for Laeger, 113:1158, 1951.

15. Herschfus, J. A., A. Salomon and NI. S. Segal:The Use of Demoral in Patients with Bron-chial Asthma. Ann. Int. Med., 50:506, 1954.

Volume 159 SURGERY ON THE NARCOTIC ADDICT 7575'u,mhpr 5

16. Isbell, H.: The Effect of Morphine Addictionon Blood Plasma and Extracellular FluidVolumes in Man. Public Health Reports, 62:1499, 1947.

17. Isbell, H.: Manifestations and Treatment ofAddiction to Narcotic Drugs and Barbitu-rates. Med. Cl. No. Amer., 34:425, 1950.

18. Isbell, H.: Medical Aspects of Opiate Addic-tion. Bull. N. Y. Acad. Med., 31:886, 1955.

19. Isbell, H. and W. M. White: Clinical Charac-teristics of Addictions. Amer. J. Med., 14:558, 1953.

20. Kushner, D. S. and P. B. Szanto: Heart Fail-ure, Fever and Splenomegaly in a MorphineAddict. J.A.M.A., 166:2162, 1958.

21. Levinson, A., R. L. Marke and M. K. Shein:Tetanus in Heroin Addicts. J.A.M.A., 157:658, 1955.

22. Salter, W. T.: A Textbook of Pharmacology.Philadelphia, W. B. Saunders Co., 1953,p. 74.

23. Seevers, M. H. and L. A. Woods: The Phe-nomena of Tolerance. Am. J. Med., 14:546,1953.

24. Treasury, U. S. Department of, Bureau ofNarcotics: Prevention and Control of Nar-cotic Addiction, 1960.

25. Vogel, V. H., H. Isbell and K. W. Chapman:Present Status of Narcotic Addiction.J.A.M.A,. 138:1019, 1948.

26. Way, E. L. and T. K. Adler: The Pharmaco-logic Implications of the Fate of Morphineand Its Surrogates. Pharmacological Reviews,12:383, 1960.

27. Williams, E. G. and F. W. Oberst: A Cycle ofMorphine Addictions, I: Biological Investi-gations. Public Health Reports, 61:1, 1946.

28. Woods, L. A.: Distribution and Rate of Mor-phine in Non-Tolerant and Tolerant Dogsand Rats. J. Pharmacology and Exp. Thera-peutics, 112:158, 1954.

29. Zauder, H. L.: The Effect of Prolonged Mor-phine Administration on the In Vivo andIn Vitro Conjugation of Morphine by Rats.J. Pharmacology & Exp. Therapeutics, 104:11, 1952.

DISCUSSIONDR. BEN RUSH (closing): These patients, as

you already have gathered, are quite an interestinggroup to study. We have continued, as Dr. Eise-man has indicated, to evaluate their peculiarlylabile pressure. I might say, by way of an aside,that in studying these patients it is interestingwhat a clinical attitude they can bring to yourattempts to intubate their arteries and veins. Sincetheir personal experience in this matter is so vastthey can be quite critical of one's technic.

Occasionally in these studies we must givenarcotics. There is no doubt in their minds whenthe needle is in and the dose delivered. Theircomment at this point is usually, "Dad, you'vegot a hit!"

Very briefly, there have been three areas towhich we have turned our attention as far asblood pressure is concerned. One has been thequestion of plasma volume. We found that com-pared to the ideal, the group did have a lowerblood volume. However, when compared withsimilar patients, prisoners in the same institutionwho were not narcotic addicts, these blood vol-umes showed no significant difference.

A second area that engaged our interest forsome time was the question of vascular responseand vascular reflexes as described very recently bySharpie-Schaefer, who noted that barbiturate ad-dicts had a definite impairment of their vascularreflexes. Using his methods we found abnormalresponses in only one of 27 patients as theseslides illustrate.

The third area and one that we are currentlystudying is the question of circulating catechol-amines. Recent studies have indicated that inaddicted animals that have been subjected towithdrawal, catechol-amines in the tissues aresubstantially lowered. We have now studiedcatechol-amines through the help of Dr. JerryRosenberg and his excellent laboratory and havefound in a small group of patients that there isa significant lowering in serum catechol-aminesin patients undergoing narcotic withdrawal, andthat, in addition, the patients' catechol-amine levelsfail to respond to a stimulus which consist ofcarbon dioxide 10 per cent breathed over a periodof ten minutes.

We hope that these early results may point theway to the difficulty that these patients have.