General anaesthesia for a morphine addict.

The patient, an unmarried woman, aged 54 years, was admitted to hospital on 11.4.54. She gave a long history of abdominal trouble with seven previous abdominal operations between 1926 and 1951. The original complaint was low right-sided abdominal pain. In 1926 a colopexy was performed and in the next few years two laparotomies were carried out because of continued pain. Then in 1946, an attempt to undo the colopexy resulted in an external ileal fistula which closed spontaneously. Since then she has had another three operations to relieve intestinal obstruction due to adhesions. At the last of these the jejunum and transverse colon were anastomosed but this was performed so high in the small intestine that the patient has since suffered from severe colic and diarrhoea. The patient had been taking morphine by injection since 1942, and the symptoms produced by the jejunocolic anastomosis aggravated the addiction. When admitted on 11.4.54, for closure of the anastomosis, the patient's average daily consumption of morphine was 7 grains (450 mg.) in 1-grain (64-mg.) doses. Her maximum had been 12 grains (768 mg.) in 24 hours and she had often taken single doses of 2 grains (128 mg.). Even with this dosage she was able to work in her home and her garden and to drive her car. On admission, the patient's general condition was fairly good. Mentally, she was very alert, taking a keen interest in affairs. A tall woman, she was thin, but not markedly so, and had lost 42 lb. (19.1 kg.) in the previous three years. The pupils were in a position of mid-dilatation, reacting to light, and she complained of no symptoms due to morphine. The blood pressure was 130/90; haemoglobin 11.3 g. per cent For many years, in addition, she had been taking a sedative at night and required a different drug every few months as she rapidly acquired a tolerance towards each in turn. Most of these had been of the barbiturate series. No record is available of her previous anaesthetics as these were administered in other hospitals. 178 ANAESTHETIC TECHNIQUE