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Since 1955 nearly three-fourths of the known cases of tetanus in New York City have occurred in narcotic addicts. Tetanus in addicts gives the impression of being a new and different disease because of its unusual age, sex, residential and seasonal distribution and because of its severity (Cherubin, 1967). The age distribution, the increased case fatality and the absence of a summer peak of incidence can be explained: first, by the age distribution of addicts in this city; second, by the more severe nature of tetanus arising from puncture wounds; and last, by an absence of a summer increase in occupational exposure that exists for the nonaddict population. Left unexplained are the preponderance of cases in women and the unusual focus of the disease in the area of Harlem. Differences in protection by humoral antibodies are inadequate to explain these findings (Cherubin and Millian, report to be published). An

Heroin Addiction. Presented by C. Heaton, MD; R. Bennett, MD; and J. Decherd, MD. The patient's history revealed rheumatic fever at age 7, eclampsia, partial hysterectomy cholelithiasis, adult onset diabetes, and hepatitis. The patient has been a heroin addict since 1968 and admitted to "skin popping" recently as her veins have "run out." Multiple ulcers over both arms and a few ulcers on her legs are in several stages of healing. Results of laboratory studies showed electrolytes, blood urea nitrogen, and glucose levels within normal limits; the rapid plasma reagent card test was nonreactive; the hemoglobin level was 11.2 gm/100 ml; the white blood cell count was 6.6/cu mm, with 3% band cells, 68% segments, 23% lymphocytes, 4% monocytes, and 2% eosinophils. The automated multiple analysis system was within normal limits except for total proteins of 9.9. Culture of abscesses yielded a coagulase-positive staphylococcus and a β-streptococcus group A. Urinalysis

Three heroin addicts developed cutaneous necrotizing lesions at the sites of "skin popping." Investigation of the injected substances revealed that a quinine substitute which was being used to cut the heroin prior to street sale would produce similar lesions in the addicts when injected intracutaneously. Similar lesions were produced in mice after the first injection of this substance. The quinine substitute caused a nonspecific precipitate when combined with an addict's serum and the serum samples of three nonaddicted controls. These findings are compatible with the cutaneous lesions resulting from a direct toxic effect or primary irritant reaction of the quinine substitute in the skin. Black market methamphetamine hydrochloride did not produce similar lesions. Local and systemic reactions due to adulterants can be expected to be seen more frequently with the increasing heroin abuse.

To the Editor.— I agree with the main points presented inThe Journal'seditorial (226:660,1973). However, the authors made an error of their own in interpretation of addict terms used in scientific journals. In my three years of experience with the heroin addict and as a director of a methadone maintenance program, "skin popping" is not injecting intradermally, but is the subcutaneous or intramuscular injection of a compound—usually heroin—and usually into the deltoid or buttock area. Intradermal injection of "street heroin" with its various diluents would certainly cause necrosis of the dermis in many instances. "Skin popping" is normally done at two different stages of opiate use; either at the beginning, when the technique of intravenous injection has not been mastered and the "heroin rush" is not desired, or after the person (usually a long-time addict) has destroyed all of his veins, and "skin popping" is the only available route

To the Editor:.— In reference to the article by Dr. Henry Brown, relative to the clinical management of "Tetanus" ( 204 :614, 1968), the author omitted to mention the cause of many cases of tetanus seen in large metropolitan areas, namely chronic drug (especially heroin) addiction. This appears to be quite frequent in addicts of long standing, with an unusually high percentage of women affected, who have used the subcutaneous route for administration ("skin popping"). It is a much more lethal illness under these circumstances, frequently provoking much more severe respiratory difficulties than are usually seen. It may also be of interest to note that the so-called minor tranquilizers (chlordiazepoxide hydrochloride [Librium], diazepam, etc) have been used by other authors with good results, although no controlled studies are available as yet. It would seem reasonable to use these drugs in preference to those which depress respiration.