ByJW?#K?T?11 ' 'SS'H. or un ,f"tosv IN INDIA AND ITS TREATMENT: CHOPRA ?) March, 1935] DRUG ADDICTION 12V S?/j5? economic and health points of view. In this paper it is proposed to give a brief review of the work done by this inquiry. Original Articles The problem of drug addiction in India presents many features which are widely different from those met with in western AND DRUG ADDICTION IN INDIA ITS countries and about which a great deal of mis- TREATMENT apprehension exists in Europe and America. The habitual use of drugs of a stimulative and By R. N. CHOPRA, c.i.e., M.A., mj). (Cantab.) restorative character was prevalent in India LIEUTENANT-COLONEL, I.M.S. probably before they were used in any of the Professor of Pharmacology other countries of the modern world. The juice Research Fund ' (Drug Addiction, Inquiry, Indian of the soma plant' was a favourite drink of Association No. 21) Series the Aryan settlers and was regularly taken by them many centuries before the Christian era. Introduction ' What exactly the soma plant' was, is Although in India drug addiction has not known, though a number of plants, such as existed on a more extensive scale than in any Cannabis sativa, Ephedra Asclepias other vulgaris, country in the world with the exception acida, have been implicated. During the Hindu of China little known the or perhaps is regarding period, i.e., up to the 8th 9th century A.D., problem. Two were commissions appointed to alcoholic beverages were used by the people as go into the of matter at the end the last well as the preparations made from hemp drugs. century; a Royal Commission was appointed in These produced not only a sedative effect, but 1893 to enquire into the prevalence of the opium also brought about euphoria in the form of habit, and a commission to go into the question pleasant dreams, forgetfulness and, it would of was the Govern- hemp drugs appointed by also appear from the writings of that period, ment of India in 1895. Both these commissions voluptuous satisfaction. Opium and poppy collected important information regarding the were introduced on the west coast about the prevalence and effects of these drug habits in a 9th century A.D. by the advent of the general way, but unfortunately the medical and Mohammedan traders, and opiates soon came scientific were aspects of these addictions not into use. A study of records shows that during inquired into fully at that time. Nearly forty the period of the Moghul Empire, alcoholic years have elapsed since these commissions beverages, opiates and hemp drugs were freely did their work. Considerable changes have used. A decoction made from poppy capsules occurred and new come drug habits have into known as koknar was extensively used all over being, yet a perusal of the literature shows that India, and is used to the present day in parts very little work has been done on this important of the Punjab. A beverage containing wine, The even subject. information available with opium, Indian hemp and poppy capsules, known to regard the present-day incidence of the drug as chaharbargha (four-leaved), was drunk by addictions is meagre. The temperance and the well-to-do classes in the time of Akbar anti-opium societies have published some data, (155G to 1G05) and later. Opium on account out these are biased, and often inaccurate and of its stronger effects appears to have taken a Even such an misleading. important subject great hold of the people and poppy was exten- infantile as. administration of opium, which is sively cultivated all over the country during still so prevalent, is an enormous amount this and was in all classes. of doing period indulged by harm, and is probably a cause of the high infantile mortality in some communities, has Opium not been systematically investigated. Opium and author's is Opium, eating smoking.?The eating very prevalent in many parts and work in the field has shown that most of the opium is in in Assam smoking indulged freely raw opium sold in the country is used for and other areas. The are used to hemp drugs addiction purposes in one form or another. It an enormous extent. No work has systematic is generally consumed in the form of a pill or been done to determine the ill-effects produced solution in water. Opium smoking although hy these habits. Some the drug years ago not common is still practised in the lower Indian Research Fund Association the gave strata of society in many parts of the country. writer a small grant to the investigate drug It is common in Assam and in certain parts of addiction in this some country and interesting the Central Provinces and Berar. The data have been propor- collected. A list of papers tion of smokers to eaters in published in this opium opium connection is given at the end one- of Assam has been variously estimated from this memorandum. It is obvious that the third to half of the total addicts, but our recent inquiry has only touched the of this vast fringes enquiries show that the number has now come problem. The wide experience the writer has of down to a quarter. The Government of India the problem as it exists in different parts and all the governments have adopted to the conclusion that provincial ^eac^sJnm the the policy of checking opium smoking by subject is of vital importance?from the social, 122 THE INDIAN MEDICAL GAZETTE [March, 1935

of the diminishing the facilities for the practice per addict as compared with 20 grains worked out by habit through legislation. These measures have the Opium Commission of 1895. to in it succeeded to a great extent and as a result of Addiction opiates this country, although still does not in such^ this the habit has declined. very extensive, appear to exist greatly intense and pernicious form as it does in the west Although opium is habitually used by large sections with morphine and other alkaloids of opium. It may of the population at the present time, the indulgence be stated here that in the old days, when opium was is not so widely prevalent as might be imagined from cheap, addicts were undoubtedly met who took ISO some of the recent publications on the subject. The to 500 grains of the drug daily. The writer in recent Government of India have strictly adhered to their years has met with only a few individuals who took promise to the League of Nations and have progres- more than 50 grains daily; many of the old addicts, sively reduced both the production and consumption however, take more than 15 grains daily. The chief of opium. We have shown that, although if the reason for smaller dosage is that the price of opiu1? country is taken as a whole the consumption of opium has risen enormously. Whereas during the pre-British3 is low, in certain parts it is very high. For example, period, in the Punjab, opium used to sell at 2 to in Bengal presidency taken as a whole, the consump- annas (2 or 3 pence) per 'tola' (180 grains or 12 gm.)> tion per 10,000 of population is 8 seers per annum in 1901-02 it cost 8 annas for the same amount and instead of 6 seers required for the medical and scienti- in 1929-30 Re. 1-12-0 (half a crown). fic needs; in the town of Calcutta it is 58 seers, Hooghly district 21 seers, Howrah 16 seers and Administration of opium to infants.-" 15 seers. In the Madras 24-Parganas presidency Habitual administration of to infants at taken as a whole it is 8 but for East Godavari opium seers, certain of their and West Godavari it is 37 and 22 seers respectively. periods lives has been prevalent For the Punjab as a whole it is 12 seers, but for in India for many centuries. The habit appear? Ferozepore district 33 seers, Lahore 34 seers, Ludhiana to have been started because of the drug's 25 seers, Amritsar 30 seers. For the whole of Bombay power of allaying diarrhoea and vomiting* presidency it is 10.05 seers, but is considerably higher and in the towns of Bombay and Ahmedabad and in Broach relieving cough pain, and producing sleep- district. In the whole of the Central Provinces and The custom, although it is still met with in Berar it is 9.0 seers, but in Amraoti it is 40 seers, almost every part of has greatly declined Akola 50 seers and in 30 seers. For the India, Balaghat the last two or three decades. The United Provinces as a whole it is 4 seers but the during is still m incidence is high in a few districts, e.g., Cawnpore, drug, however, extensively employed Benares and Lucknow, where the consumption rate the Central Provinces and Berar and in the is 19, 21 and 17 seers respectively. In Assam as a industrial areas in all parts of India. whole it is 19 seers, but in Lakhimpore it is 70, Sibsagar 45, Nowgong 27, Darrang 22 and Kamrup In Berar it is stated that 75 per cent of the infants 8.9 seers. The highest consumption rate recorded in are doped with opium and that 25 per cent (i.e., 6,198-J the India is in the Sadiya frontier tract, being 94 seers. lbs.) of total_ opium consumed goes to infants- The high figures are due to smoking of the drug, The consumption is still higher in the cotton-growing areas where children account of the which necessitates a much higher consumption per for 40 per cent head. total consumption. The main reason for administering keep On the other hand, there are extensive areas in all opium is economic, the drug being given to so as provinces where consumption is very low, i.e., 1 to the children quiet to allow the mother to carrJ annum. out her whether in the or the field, 5 seers per 10,000 of population per Such areas work, _ factory are now on the increase. In and unhampered. The practice is begun during the firS Assam, Goalpara to are the In the few weeks of the infant's life, the earliest time Sylhet examples. Bombay presidency ?> (Kanara and Bijapore) and in the United Provinces commence being 3 weeks and the latest period is the many of the districts can be under this head. months. The drug usually discontinued when grouped n In the Punjab there are 20 out of the 29 districts where child attains the age of 2 or 3 years, that is when the consumption of opium is below the standard laid begins to play about and can live on ordinary food- The dose varies from a to three down by the League of Nations as being necessary one-eighth of grain for purely medical and scientific needs of the popula- grains daily. The drug affects the child's health hinders tion, i.e., 6 seers or 12 pounds per 10,000 of population adversely and growth. The children receiving have an per annum. opium emaciated, unhealthy and tox?B_nUc It will thus be seen that the habit is not widely appearance. They are more liable to catch infections disseminated among the population, its incidence and to attacks of epidemic diseases and the mortality them is among various is very irregular. The areas rate among comparatively high. Althoug'1 classes^ do with a high consumption rate are being investigated deaths from overdosage are not frequent, they with a view to determining the causes which have occur. Non-fatal overdosage is not uncommon. led to it, and steps are being taken to put down excessive use of the drug. A perusal of the following Addiction to Post (unlanced capsules of table will show that the consumption of opium in India Papaver somniferum).?The poppy capsules has fallen considerably during the last 20 years :? are known to have been used for their saporifie Consumption of opium in seers* properties by the ancient Egyptians, Greeks and India in British (excluding Romans. For many centuries have been Indian they Year States) used in the Chinese, Hindu and Mohammedan 1912-13 .. .. 506,664 medicines as a sedative in inflammatory diseases 1930-31 .. .. 241,211 of the alimentary and respiratory tract. 1931-32 .. .. 213,000 During the 16th, 17th and 18th centuries when * the 1 seer is approximately equal to 2 pounds. the Moghuls were in power in India, were used to a If 10 is taken as the average daily dose, then capsules extensively prepare grains which had and there are roughly 1 to li million persons in India who beverage soothing euphoric habitually take this drug. effects and which was almost universally The average dose taken in the writer's recent series indulged in. The habitual use ,of poppy of over a thousand cases was roughly 10 grains daily capsules for euphoric purposes has considerably J March, 1935] DRUG ADDICTION IN INDIA AND ITS TREATMENT : CHOPRA 123

The following table gives the total of decreased the last three decades quantities during but thehemp drugs supplied through licit sources used for addiction is still prevalent in certain districtshabitual consumption in India :? of the and in of Punjab, .. .. many parts Rajputana. 1912-13 990,783 seers The a .. present writer after study of over 500 1930-31 .. 547,030 addicts has come to the conclusion that habitual 1931-32 .. .. 511,307 ? use of poppy heads produces physical, mental Besides this there is little doubt that large quan- and moral as degeneration in the habitue; com- tities reach the people through illicit sources also. with a pared the opium habit its effects on the From close study of 1,500 cases, the average dose individual are much more pronounced. worked out in the case of charas and ganja is 5 -to 10 and of bliang a little more than double Addiction to alkaloids.?Habitual use grains daily opium this. There are approximately 1 to 2 million of has increased in morphine considerably India persons in India who habitually consume hemp in one' during recent years, the increase at present form or another. The consumption of hemp drugs is being confined to northern India, lliere highest in the United Provinces and then follow Sindh, Delhi, the Punjab and North-West Frontier appears to be grave danger of rapid extension of Provinces. this habit to other parts if steps are not taken The and mental effects these to check it. addiction physical produced by Morphine among Indians habits not to be so marked as is met drug appear opium, usually with in young persons between but they undoubtedly lead to mental and moral the ages of 20 and 25 years. The habit is not degeneration. When under the effect of these drugs, started for the sedative and analgesic effects of the addicts appear to lose all idea of correlation of time and their environment and the drug as in western but for its space. They forget countries, do not know what they are doing. Ganja and charas effects its euphoric and because of supposed are much more potent in this respect than bhang and aphrodisiac properties. Formerly the alkaloid their excessive consumption, especially of the latter, was taken almost the gives rise to insanity and leads to crime. This was exclusively by mouth, one of discussed but the method is into the points by the Hemp Drugs recently injection coming but no definite conclusions could be use. this Commission, By latter method, the effects produced arrived at. Some work has been done by the author by the drug on Indians are very similar to in this connection in the Ranchi Mental Hospital. those produced by cocaine. The habit produces Out of 1,000 patients examined in this hospital as as GOO a of a state of chronic toxjemia and many (35.5 per cent) gave history drug detrimentally addiction; in more than half of the latter, the history affects all tissues of the body, particularly the of hemp drugs (charas and ganja) addiction, and in nervous tissues. In morphine habitues physical, a third the history of alcohol could be distinctly mental and moral deterioration sets in much traced. Out of GOO cases discharged from the hospital as in 213 the cause of was addic- more rapidly than in addicts. cured, insanity drug opium tion. Out of 350 criminal insane patients, 114 or 38 Two kinds of poisons arc concerned ill producing per cent a of addiction to Hie toxremic gave history hemp drugs. state: (1) the exogenous poison, i.e., the These to show a distinct itself figures appear relationship drug which is rapidly absorbed after injection between drug addiction, insanity and crime, but to and circulates in the blood, and (2) the endogenous come to a definite conclusion more work is necessary. toxins which are formed by the action of the alkaloid on the general metabolic of the bio- processes body, Alcohol.?The use of distilled alcoholic chemical changes being thereby set up. Both these factors combined interfere with the normal functions liquors has extended during the early part cf of the organs giving rise to debility and malnutrition. this century but has decreased lately. In the General toxaemia and assimilation of food improper old days distilled liquors were used to a very products lead to wasting, sallow colour and anaimia, and limited wines were used. The finally a cachetic condition may supervene. extent; largely Addiction to other alkaloids of opium, e.g., codeine and aboriginal races of India made a beverage by heroine, is very rare in this country. fermenting rice?pachwai?and by fermenting Hemp palm juice?tari. Both these are extensively used in of India to the Indian hemp grows wild in the montane and many parts present The fluid that is drunk the submontane tracts over the whole of the north- day. habitually by of the Assam hills is a eastern nnd north-western parts of India and Xagas (Manipur State) weak zu. The three of its i.e., bhang (dried country beer called present preparations, writer has shown that the alcoholic content of leaves), charas (resinous exudate) and ganja the of the crude beers used in India (flowering tops) were in the largely used majority past is low and their nutritive value is by the poorer classes, on account of their very very high. Some of are rich in vitamin content low cost. Even to the day hemp drugs these beers present which is often in the of are the narcotics most extensively employed by poor general dietary the who drink them. The areas where the poorer classes throughout the country. Ex- people are arc free tensive work in the field has enabled the writer such beers consumed remarkably from diseases. Distilled to estimate approximately the prevalence of deficiency country are used the hemp drugs addiction in India and, taking the liquors and foreign liquors by to a lesser extent. country s a whole, the incidence of addiction richer classes comparatively in British India between 0.5 to 1.0 ranges per The drinking of youth and the social drinking in of thousand the population. In south India the endeavour to mitigate the wear and tear of life where the spontaneous growth of Cannabis and to get relief from its annoying factors, as it exists in the is not found among Indians. sativa does not occur, was and is still west, commonly hemp Extensive habitual use of alcohol is uncommon and cultivated tor use as a drug of addiction. 124 THE INDIAN MEDICAL GAZETTE [March, 1935 the harmful effects produced by it are rarely encoun- The tered. The problem of alcoholism has not up to the (0.5 to 1.0 gm.) has occurred to them. present time assumed a serious aspect in this country. drug is also sometimes mixed with tea and is It may however be out that the use of dis- pointed consumed some The tilled country liquors is rapidly increasing in certain habitually by people. areas and in many of India drunkenness is chloral habit has thus sprung up, though parts at being more frequently encountered among the masses. fortunately a very limited area is affected This is due to the fact that while restrictions are present. The drug is powerful and toxic, and on sale of and being imposed the opium hemp drugs several fatalities have been from and their has risen to the increase of excise reported price owing is & duty, in spite of the high excise duty a bottle of accidental overdoses. Chloral hydrate distilled liquor can still be purchased for a few annas. cheap product selling at about Re. 1-12-0 (halt in are the of Country liquors many parts taking place a crown) per and as there are no restric- and pound, opium hemp drugs. tions to its sale at the present time it can be Cocaine.?The present writer has shown that bought by anyone in any quantity from any more cocaine came into use quite accidentally about chemist's shop. Half to 1 gm. or a little 50 years ago. In spite of all the restrictions added to an alcoholic drink produces, symptoms imposed on the import, possession and sale of of intoxication followed by sleep. The habit the drug, the habit has spread from Calcutta is harmful and dangerous. It is much morr to large towns along the two main railway liable to produce pathological changes in the routes through the Central Provinces into the organs and immediately fatal results than any Punjab and the North-West Frontier Province. other drug of addiction in this country. The From Bombay it spread to some of the large mental, moral and physical effects produced by towns in that presidency. Cocaine is not this addiction are mo^e pronounced than in any manufactured in India but is smuggled into the other drug habit. The drug is cheap and is its country in large quantities. For some time easily procurable as there is no control over past the Far Eastern has driven the European sale. These factors are largely responsible f?r m and American manufactured product out of the the spread of its use among the population market. The drug is illicitly brought by crews certain localities. There is a danger of the use of ships running between Calcutta and the Far of chloral hydrate for adulteration of alcoholic East and is heavily adulterated before it is sold. beverages (toddy, rice-beer, etc.) being extended Cocaine is usually taken in the form of an and of the further spread of the chloral habit. or as a snuff in western injection countries, but Barbituric acid derivatives.?During recent at the method of present practically only years a number of the barbituric acid in India is the large taking the drug by mouth. It have been introduced into thera- is consumed it in compounds commonly by putting pan or peutics, including barbitone (veronal), sodium betel and for that reason addiction leaf, to barbitone (medinal), luminal, dial, allonab this alkaloid is among the 6e?eZ-leaf- prevalent veramon, of north-west neobutal, amytal, evipan, pyramidon, chewing population India, etc. Circulars from manufacturing firms the United Provinces and the Bengal, Bihar, the safe and sure action of these The habit not exists regarding Punjab. only among the drugs have been freely distributed which well-to-do but a number people large of the influence not only the medical artisan class in towns are also practitioners large addicted but the also. Wilcox and Purves- to it. lay public Stewart have described a series of cases of It has been calculated by competent authorities addiction to barbitol and allied drugs, and the that over 200,000 ounces of cocaine were smuggled Drug Addiction Inquiry has been alive to the 1929 that consumers into India in and the paid between of the formation of such habits m Rs. 270 lakhs and Rs. 648 lakhs to the possibility retailers for India. A number of from in" their doses of the drug. The symptoms and effects fatalities resulting produced by it were studied in 200 cases; the cocaine discriminate therapeutic use and self-medication habit is one of the most pernicious of the drug habits with these drugs have occurred and a few cases and the serious toxic effects produced by it on the of addiction have also been observed among Indian addicts have been shown by the present writer. the educated classes in India. The fact that, New drug habits.?During the last few years besides the toxic effects produced by massive chloral hydrate as a drug of addiction has also doses, the barbiturates also produce dangerous made its appearance in northern India. It has cumulative effects and a tendency to habit come into use since the price of spirituous formation has not been sufficiently appreciated drinks has gone up considerably on account of by the medical practitioners in this country- the increased excise duty. Most of those that A warning is therefore necessary. drink alcohol in India do not take habitually The drugs of this group have effective sedative and to obtain mild excitement or sedative it merely hypnotic properties, and, as they are analgesics also, effects, as is usually the case in the west, but they are largely used by the medical profession. In are to obtain intoxicating effects. Owing to increase Great Britain all the barbituric acid derivatives in Part II of the Poisons 1918, i-e". iii the of cannot afford to placed Schedule, price liquor they buy they cannot be dispensed without the prescription and are sufficient quantities for this purpose the a qualified medical man. In India, however, they ingenious idea of potentiating the effects by not classed as poisons and are therefore not included in of the schedules of the Act of 1919 adding small quantities of chloral hydrate any Poisons (amended in 1931). These drugs can thus be bought J IN INDIA AND ITS TREATMENT : March, 1935] DRUG ADDICTION CHOPRA 125

but to society. In India most of the common by any one and their use is The need for increasing. of addiction are taken the mouth and bringing the sale of barbituric acid derivatives as welldrugs by as crude never hypnotics like chloral hydrate, paraldehyde,being products produce such intense sulphonal, trional, tetronal, etc., under control iseffects as are observed in western countries. therefore very urgent. A large number of addicts from the lower Briefly then the principal lhabit-formingstrata of society are so poor that they have not the means to the of even the drugs used in India are :? carry indulgence crude and cheap drugs to excess; the upper 1. Opium is still extensively used buth byclasses are temperamentally more moderate. adults and infants. Post or koknar (unlanced Besides, India is pre-eminently an agricultural capsules of Palaver somniferum) were largelycountry, which makes it possible for the major- used at one time, but owing to restrictions in the ity of its inhabitants to lead a comparatively cultivation of the poppy their use is now free and easy existence. The strain and stress limited to a small area in northern India. The to use use of life which drive people the habitual of morphine, uncommon, is though graduallyof sedative drugs is not so great as in the west. increasing. It has been estimated that in In spite of all these factors the problem of British India alone out of a population of addiction is of very from millions at least 1 to million drug great importance twenty-seven i\ its extensiveness. The of the persons take in of all magnitude opiates habitually spite can be the fact whereas the efforts that are made to their problem judged by that, being stop in most of the countries in and America use. In the Indian States in Europe especially Raj- the addiction rate of the population is from 0.1 putana the incidence is much higher. to 0.2 per cent or even less, in many 2. Hemp drugs. (dried leaves), provinces Bhang of India the rate is 1 to 3 per cent or even more. charas (oleo-resinous exudation) and ganja These drug habits are responsible not only for (dried flowering tops coated with resin) are much economic loss but they also lead to extensively used all over the country in the physical and mental deterioration and arc of lower strata of society on account of their very very from the health of low cost. At a estimate at great importance point very modulate view. least 1 to 2 million of the of India population Another feature of addiction take hemp drugs noteworthy drug habitually. in India, insofar as opium and hemp 3. Alcohol. Pachwai (fermented rice) and especially tari drugs are concerned, is the religious and social (fermented palm juice) are largely used by the aspects of the problem. Indulgence in opium, poorer classes. Distilled country spirit and on account of usage and is imported liquors are used the richer classes. age-long custom, by sometimes on such occasions as 4. Cocaine was introduced 50 compulsory years ago; deaths and social its use is spreading in northern India. marriages, gatherings among certain classes. are considered to be 5. Chloral hydrate has been introduced Hemp drugs the food of the and are offered in during the last 10 Barbituric acid gods temples years. on festivals and ceremonial occasions. derivatives are the use of these religious being tried, Some sects take these under the drugs at present is but there is religious drugs limited; danger belief that the individual in of their extension for adulteration of alcoholic they help indulging beverages. them to free his mind from worldly attrac- tions and in this way to concentrate on the deity. Etiological factors.?It will be observed from This is the reason why in places of religious the foregoing that the first three groups of worship, like Benares, Mathura and Puri, there drugs, which are used in are commonly India, is an enormous of these drugs. raw and crude In cases consumption mostly products. many Such use of these they have to be the addict himself drugs is, however, rapidly prepared by decreasing. before use, which in itself limits their excessive The medical and semi-medical uses of Further crude opium consumption. by using products and is another factor. the addicts absorb smaller hemp drugs important comparatively In a vast like where the facilities quantities of the active which are country India, principles of medical relief are the of the responsible for the toxic effects. In poor, majority producing do not the benefit of western western countries almost all the used for population get drugs medical science. The sedative drugs such as addiction purposes are products highly purified opium and preparations are largely used such as morphine, heroine and cocaine. More- hemp over as household remedies and habits are often many of these drugs in the west are taken formed from such use. The doping of infants in the form of injections. This method brings with can be attributed to this. It about the action more and more opium partly quickly is still firmly believed by the ignorant At the same time the action is not intensely. masses that is a wonderful tonic to the so lasting as when the is taken the opium drug by it stimulates his growth and prevents the mouth. All these factors lead to a child, greater child sick. The writer has discussed desire or on the of the addict for getting craving part elsewhere the medical and semi-medical more frequent repetition of the dose and the fully uses of opium and the large variety of conditions habit is liable to be carried to excess and the for which it is used as a household remedy. addict to become a danger not only to himself 126 THE INDIAN MEDICAL GAZETTE [March, 1935

Almost all the diseases for the relief of which have taken small doses of opium or hemp drugs and are are opium hemp drugs used of minor or for 20 30 years without any apparent harm- character. Often the are taken to drugs dry As a matter of fact it would appear that the secretions from the and the conjunctiva respira- drug was doing them good as its stoppage made tory tract. suffer from toxaemias Many people them ill and prevented them from carrying out of focal sepsis, which causes of the rheu- pains their ordinary work. It stands to reason that, matic and mental neuralgic type, depression, when a person can lead an active and useful irritability and of the nervous hypersensitiveness life on fixed and unchanging there can system; these in small doses them doses, drugs give hardly be any mental or moral deterioration. relief and they form the drug habit. Treatment in this large group would appear to Opium is believed to stimulate physical be quite unnecessary. Some of this group, energy. Those who have to do with coolies in however, gradually increase their doses and the tea gardens and with labourers in rice and suffer from the toxic effects of the drug. In wheat fields in India realize the value of this such cases only, treatment is desirable and is' drug to those who have been exposed to cold wanted. and chill. The writer found that the use a of 2. The next and very large group consists opium increased during the harvest season in of those who owe their entry into the paths of many districts in the Punjab by 50 per cent. addiction to the association with and the example of other addicts, and to no other Treatment reason. Some of these are normal individuals who are to be The medical profession in this country is very anxious treated, and they respond ill-informed on the subject of drug habits and quite well to treatment. A proportion, however, their treatment. During the course of his in- start the habit from idle and vicious seeking vestigations in different parts of the country, the after new sensations; they take the drug for its writer had not come across many medical men pleasure-giving effects and for sexual stimula- who had any considerable knowledge regarding tion; these people are generally found in large the treatment of drug addictions or of the towns. Many oLthem have some defect in their character and mental to phenomena which accompany abstention. The make-up, and appear 1 in general impression appears to be once a drug be engrossed furthering their indulgence and the dose. a addict always a drug addict; he is incurable increasing They also have tendency and that is the end of him \ Ordinary hospitals to indulge in more than one drug at the same generally refuse to admit addicts; mental time; e.g., alcohol and opium, alcohol and hospitals are not suitable for many reasons. cocaine, alcohol, opium and hemp drugs. This class of vicious addict is There are no institutions established anywhere the most difficult from in India and the institutional treatment under the point of view of treatment. Fortunately expert guidance is unknown. It would certainly this type, which is more in evidence in western not be advantageous if a few specialized institutions countries, is commonly met with in India. of the type of abstinence sanatoria were estab- The few that exist belong generally to the rich lished in areas where the incidence of addiction and indolent classes. They do not seek treat- ment short of is very high so that treatment could be carried and nothing forced confinement out on scientific lines. There is no doubt that in a special institution, and prolonged training the public would take advantage of them. The and reconstruction of character, will restore writer's experience, so far as the treatment of them. addictions is concerned, is therefore limited to 3. There is the third smaller group of the non-institutional methods. habitues who have started using the drug in an attempt to tide over a period of special strain From the point of view of treatment, the drug or gross overwork and fatigue. This class of addicts in this country are divisible into three addict is the product of large towns and their main groups : percentage is not nearly so high in India as in a who use 1. There is large group opium or the west. This is the class who are anxious hemp drugs in small or very moderate quan- to get rid of the habit, are easily amenable to tities. The majority of these have started the treatment, and do very well even under non- drug after the middle period of their life, institutional treatment. generally for some minor disease or ailment. They usually start with a small dose and do not Prophylaxis by the medical man increase it. The narcotic and the euphoric The importance of prophylactic measures in effects of the drug have no attraction for them; preventing drug addiction is appreciated by the indeed they are not produced in this group at medical profession in India and most habit- all. The habitues thus have no temptation to producing drugs are used with great care. While in increase the dose, in fact they fully appreciate an analysis of the histories of drug addicts the evil effects which would result from it. western countries shows the medical man has Most of them are good and successful citizens been unwittingly responsible in starting addic- and carry on their daily work quite efficiently. tion in a large number of cases, in India the The writer has known numerous persons who writer has not come across many cases in IN INDIA AND ITS TREATMENT : CHOPRA 127 March, 1935] DRUG ADDICTION the treating physician, and they would become which or addiction to opiates hemp drugs coulddistrustful and hostile so that it would become be attributed to their use by the medical practi-difficult to establish friendly relations or to tioners in the first instance. With cocaine andinspire confidence in them. The writer has morphine addiction, however, this has occurredoften heard inveterate opium eaters remark that quite frequently. In India, where addiction tothey would rather endure hell than the abs- crude drugs is in vogue and the alkaloid addic-tinence symptoms. Experience in India is in tion so far as opium derivatives are concernedaccord with that of many authorities in the uncommon, the importance of prophylaxiswest who consider that the patients subjected js the by doctor does not play such an importantto harsher methods of treatment, such as lock- part as in western The countries. stringenting them up and letting them 'suffer it out', restrictions on imposed by the Government theare the very ones that are more likely to relapse distribution and sale of narcotic drugs (opiumand go back to the habit. The above remarks and its derivatives and cocaine and itsapply to the opium addicts only. In the case of derivatives) has to some extent safeguarded hemp drugs, cocaine, alcohol and chloral the of spread alkaloid addictions. Such drugs sudden withdrawal can be carried out are not hydrate, allowed to be sold except when pres- under non-institutional conditions without any cribed a by qualified medical practitioner; the great difficulty. dispensing chemist has to keep a careful account The writer has met with a great deal of of every of grain the drug sold, in books kept success with the slow or gradual withdrawal for the purpose which are frequently scrutinized method. There is no doubt that whether the by the authorities. or a process of withdrawal is gradual sudden, great deal of suffering has to be gone through Treatment of opium addicts by the patient. Administration of no amount of other will eliminate the distress- Sudden drugs completely and gradual withdrawal.?The with- of abstention. With the gradual drawal of ' ing symptoms the drug by the sudden method' the and discomfort of advocated method, however, pain by Bonhoeffer has been recognized actual withdrawal are reduced to a minimum. to be scientifically the best method of treat- If due attention is paid to the psychological ment in the success many countries. In spite of side of the treatment, the patient is made to with it achieved in Europe and America it has believe that the under- not been physician thoroughly possible to carry it out in India. The stands his trouble and is doing his best to writer has tried the method, but has met with relieve him of his sufferings, and the chances httle success. The reason that the conditions is of a permanent cure are greatly enhanced. under which the cases were were far treated The even carry not ideal. patient may unpleasant from There are no specially-equipped memories of his restoration period. Another institutions in this country where addicts under- advantage is that the post-withdrawal insomnia, going this form of treatment could be housed which is an extremely distressing condition, is ?ind could have all to them the facilities help much less frequent. Moreover, under conditions through the critical of abstention period existing in India, it appears to be the method The post-withdrawal insomnia and of with the^ymptoms. choice. If the withdrawal is affected digestive and other troubles are extremely reasonable celerity and with as little discomfort distressing and need efficient handling. Some to of the patient as possible, it will encourage the writer's cases treated in the had to be other sufferers to seek the treatment and those wards of an Some were ordinary hospital. who have relapsed may also return. While it treated in their own success homes where the cannot an of be said how long it would take Indian such a treatment was doubtful from the patient to be cured if he were to undergo treat- The writer's beginning. experience^ therefore, ment in an institution with the sudden with- with to the regard 'sudden withdrawal' method drawal the of is limited and method, experience many unsatisfactory from every point institutions is that at least three of view. European Although he has no personal experi- months' is The of ence of such stay necessary. adoption treatment in special such a ie institutions, treatment will, therefore, be very expen- has no hesitation in so far as saying that, sive for a like India. The writer's ndian addicts are country concerned, the sudden with- experience is that with the slow withdrawal drawal would a of imply period frightful method it takes three to six weeks to effect a physical and mental and trial suffering which cure in most of the Indian addicts who are ie of them unable to majority would be bear, going to be cured. The decrease in dosage is he shock of sudden withdrawal would be too carried out very gradually at first so that it is much for of the even many addicts and those a few it can be with imperceptible. After days strong will-power determined to get effected more rapidly, especially if some pill of the habit will stand it with |'dt difficulty, such as that containing nux vomica, gentian and would make the most and determined of willing black pepper is given as a substitute. The them lose confidence and would they end by substitution is started with the morning dose refusing to go through the treatment. Their at first, leaving the evening dose untouched, sufferings would make them lose their faith in 128 THE INDIAN MEDICAL GAZETTE [March, 1935 this procedure prevents insomnia. Minor The writer has shown that there is a pre~ symptoms such as and diarrhoea, epigastric pain dominant element in addiction nausea may be met alkaline psychic opium by giving ordinary and the of abstention mixtures. Usually in three to four weeks the production symptoms- He has come across cases of persons addicted drug can be entirely stopped. a to large doses of opium (20 to 100 grains It cannot be denied that in spite of all pre- day), who have been sent to a jail for some cautions a large number of failures result. In criminal offence and their supply was inevitably many cases when it was hoped that all was stopped; they did not however suffer from very going well, it was suddenly discovered that the marked symptoms of abstention. During _tne patient was secretly obtaining a supply of the treatment of addicts to rid them of opm10 drug. The ingenuity shown by the addicts in habit, the drug can be largely or totally re- im* this connection and the extraordinary way in placed by substances such as gentian or which they evade those on guard is amazing. vomica in pill form without the patients The chances of the treatment being prematurely realizing it. Further, if the patient is not aware ne suspended are also great. Even, by the slow that he is taking opium, the drug can lts method the withdrawal cannot be effected effectively given for weeks or months for except by exercising a good deal of compulsion. therapeutic effects, without producing addiction oe Most of the patients start with good resolutions or abstinence symptoms. A great deal can but give in about the second or third day when done by getting the co-operation of the patient' are side the symptoms very acute. To keep control and proper attention to the psychological over such patients under ordinary hospital or of the treatment ensures success in many cases- home conditions is difficult indeed. With very administration full of all these difficulties the Infantile oj opium.?The hab^ knowledge in infants and children is not difficult to break- gradual method has been tried under non- In the usual course of events the institutional conditions with a fair degree of parent3 continue to give the drug up to the age of success, especially in addictions of short dura- or three years and when the child can tion. Considerable care and attention has to be then, take care of it is Both tne exercised in the selection of cases. Before itself, stopped. gradual and sudden methods of withdrawal haVe starting the treatment the patient must be been tried with an equal degree of success? thoroughly examined and any physical condi- but it is better to adopt the sudden method- tions which may have led to addiction, e.g., The psychological element a very mino1" septic foci, must be treated. Duration of plays part in children and as a rule there is li^? addiction is an important factor; cases under discomfort. The withdrawal symptoms me 5 to 7 years taking 10 to 15 grains daily are with are looseness of bowels, diarrhoea, and generally amenable to treatment. In many 0 irritability of temper, and in severe cases loss persons over 20 for taking grains daily pro- nausea and abdominal als? longed circulatory disturbances appetite, pains periods, leading occur. Diarrhoea can be controlled by to collapse are likely to supervene if the easily drug powders containing sodium bicarbonate, bisrfldtn is suddenly withdrawn. Sudden withdrawal is carbonate and aromatic chalk. In severe cases successful and is recommended with addicts with mental a bromide mixture taking under five grains daily. irritability, with a few minims of tincture of belladonna The gradual withdrawal method is also suit- may help to quieten the patient. The child lS able for mass treatment of opium addicts. gets quite well in a few days and a cure The writer during the Great War in the East affected; no after-treatment is as a rule neceS' African campaign was in medical charge of a sary. Even the worst cases with marasmus Sikh company of sappers and miners, about and emaciation begin to put on weight soon 200 strong, from a state in northern India. after they are rid of the habit. Most of the Indian officers and men of this unit lS Opium smoking.?The experience in India were addicted to heavily opium, many taking that opium smoking is more difficult to cure as much as 100 and some over 200 grains daily than opium eating. Fortunately owing to very The unit in the a grains. beginning brought strict regulations the habit of smoking opiu111 certain of with it, but this was supply opium is now rapidly disappearing from many parts? soon exhausted and men had to fall back on it is still prevalent in Assam. The of 5 to 6 though the commissariat supply grains daily. writer's experience of its treatment is very With the of the officer the help commanding limited, but there appears to be little doubt the writer had no in company difficulty cutting that an opium smoker is much more attached the dose to a few a in a down grains day, to the drug than an opium eater. It would month's without of the men tne time, any showing appear that although smaller quantities of went 0? signs of distress. They gladly through alkaloids are absorbed (most of them must some the habit the cure and of them gave up destroyed by heat), the absorption is very rap*0 entirely. As there were no towns near, the from the large surface of the capillaries of tne local chances of anyone obtaining supplies lungs and the respiratory tract, and the effect3 were completely eliminated. are sudden and more intense resembling "J IN INDIA AND March, 1935] DRUG ADDICTION ITS TREATMENT : CHOPRA 129

he has injection of morphine. The treatment of in which learnt the habit and from opium associates in whose smoking has not been properly worked out in company he indulges in the to a India. Some authorities allow the patient the drug, preferably place where he cannot often effects a cure. drug by the mouth and gradually cut down get it, The writer knows of instances where the smoking. Once eating is successfully sub- many individuals from one of the went for a few months stituted for smoking, the addict becomes more part country to another where were amenable to treatment. part they unable to get the drug and where there were no associates; Post (unlanced capsules of P. somniferum). they were able to conquer the craving for many It is the common belief among the addicts that months at a time without difficulty. When, post does less harm than opium. Ihe writer's however, they returned to their old surroundings experience, however, is not in accord with this they again succumbed to the temptation. view. A person addicted to poppy heads Similar facts have been observed in addicts requires comparatively much larger doses of who have been kept confined in prisons. They opium to produce a similar effect; moreover the are able to give up the habit during confinement physical and mental effects produced by and go for years without the drug; but they ordinary doses of post are much more marked generally take it up again after discharge. The than with moderate doses of opium. I his in all writer is convinced that cocaine eating is com- probability is due to the potentiating effects paratively a much milder form of indulgence the constituent alkaloids of poppy capsules than cocaine injecting. have for one another. It is more difficult to and mental are get rid of this habit than of the opium habit. Psychotherapy training the of The sudden method is rarely practicable in important; psychological rearrangement the some innocent emo- these cases, the gradual method being the personality by finding only tional will often the habitue one which meets with success. The dose is compensation help to the habit. The must be with- gradually reduced by half a capsule till a fourth give up drug of drawn all at once and treatment the original dose is reached and then it is symptomatic stopped entirely. given for the withdrawal symptoms. Next to the opium habit, the cocaine habit is the most Hemp drugs.?The treatment of hemp drug difficult one to cure in India. habit is not at all difficult, though it is easier to cure the eating habit than the smoking habit. Auxiliary treatments.?Atropine and hyoscine have been tried in the earlier of with- Withdrawal symptoms as they are met with in stages the case drawal of and in the later of opium addicts are hardly ever seen, opium, strychnine indeed the with results. The belladonna- patients find no difficulty in giving stages good up the habit of their own accord. In northern hyoscyamus mixture recommended by Lambert India many people indulge in bhang drinking in is useful in that it lessens the shock, decreases the hot weather, on account of its cooling and diarrhoea, and relieves insomnia. Gastrogenous are not in the treatment of refreshing effects, and give it up in the winter phenomena marked quite suddenly. Hemp preparations when taken the opium habit, as they are with morphine, and habitually by the mouth can be suddenly with- alkaline and acid treatments are not necessary. drawn without any marked untoward symptoms. Adrenaline and ephedrine have been tried for Temporary loss of appetite, constipation lasting mitigating the withdrawal symptoms in a few for a few days and rarely palpitation and cases with good results. It is rarely necessary in this as restlessness may occur; all these can be easily country to use sedative drugs, such dealt with. codeine, narcosan, luminal, sodium amytal and pernocton, in the gradual withdrawal treatment Char as and ganja are stronger preparations of opium eaters and the writer has no as experi- and, they are generally indulged in by ence of the use of these drugs. smoking, their effects on the system and partic- Insulin treatment.?Insulin alone or with ularly on the nervous system are more pro- of late tried in nounced. The of the smoker is grape sugar has also been will-power used insulin alone in weakened and without the physician's help he Europe. Sakel (1930) is doses to 80 units in 24 hours to combat not able to give up the habit. Treatment up in special institutions with facilities for forcible withdrawal symptoms in cases where morphine was with results. withdrawal is to the best results. cut off abruptly, satisfactory likely give doses of the The psychological and mental treatment, and F. Braun administered bigger drug and in addiction like training and education of the addict are as employed soporifics luminal. The author has tried this method important in the case of hemp drug smokers as in with results. opium addicts, in spite of the fact that con- good siderable physical pain accompanying with- So far as opium eating is concerned he has drawal is absent. carefully tested the effects of the drug on the of both diabetics and normal Cocaine.?The habit of eating cocaine is blood sugar and moderate doses easier to cure than that of injecting cocaine. Indians. Small of opium Removal of the addict from the environment have little or no effect on the blood sugar of 130 THE INDIAN MEDICAL GAZETTE [March, 1935 individuals who are not from disturb- suffering effects a dose are and ances produced by unpleasant, in carbohydrate metabolism. In are persons heaviness of head, nausea, vomiting, etc., whose content is blood-sugar abnormally low, produced. A distaste for the drug is thus devel- may raise it. The blood in the opium sugar oped and as effects are not and mild euphoric produced early types of diabetes may be opium is not wanted. A control experiment actually reduced. It is in the severe forms only was also tried in the following manner. Some of the disease that the blood sugar is actually addicts were blistered in the usual way and the raised. In some does no more patients opium fluid from the blister was removed. Instead than raise the renal of threshold excretion. of the fluid from the blister being injected, in The writer's with to findings regard opium a number of cases injections of normal saline agree with those of Simenauer and and Pulfer, were given. It was found that the addicts who Anton who in human as found that beings, had normal saline did not in the same to little respond opposed animals, morphine produces way as those in whom actual serum was or no disturbance of the carbohydrate injected. In other mere did metabolism. words, blistering not do any good so long as the serum was not The of diuretics such as novasural and utility reabsorbed; nor were the effects due merely to in the slow withdrawal method euphyllin is the psychological effects of the injection. It is doubtful. The writer's observations show that at present difficult to say how long the sensitive- in addicts moderate and doses of taking large ness to the drug of addiction will last, but opium there is retention of fluid in the blood; investigations on this subject are carried in those small the being taking doses, however, output on. It must be however, that of urine is increased and the remembered, actually blood most of the addicts were prisoners under prison fluid is not altered. When the are kidneys discipline and living under conditions in which damaged and there is the adminis- albuminuria, temptations by way of easy access to opium tration of 1 to 9 of grains opium daily produces did not exist. In one of the jails the treat- an decrease in the of urine appreciable quantity ment was tried on two warders who were free passed and in none of the cases are there indica- to go about and could easily obtain opium if tions of added to the which damage kidneys, they so desired. In both cases the injections the drug is reputed to cause in such cases. of serum produced the same effects as in the Vesicatory serum therapy of Modinos in prisoners. addiction.?The method is opium, very simple, Whether the treatment will eventually pro- cantharides cerate to a size of 8 plaster square duce a permanent cure or not is difficult to say centimeters is to the patient's chest or so applied with any degree of certainty but the results and after 16 hours serum abdomen, varying far obtained are certainly striking. The from 2 to 8 c.cm. is taken and into reinjected patients gained in weight after the treatment, the of the arm or The upper part leg. operation the appetite returned and the general health is on the third or fourth and the repeated day, improved in a remarkable manner. The follow- third is 4 to 6 after the injection given days ing provisional conclusions can be drawn from second The dose of the narcotic is injection. the data so far obtained :? reduced and may be cut off rapidly completely That the treatment with vesicatory within 3 to 7 days. It is believed that anti- (1) serum is a valuable measure in the bodies are formed which create a distaste for the injections treatment of addicts. drug but this view is not universally accepted opium and distaste to the drug is attributed to the (2) That probably addicts who have any production of hypersensibility. Other author- will-power left will be completely and per- of the ities, like Noordhoek, say that the so-called manently cured habit through its agency- hypersensibility is not specific but is merely (3) That probably those who have no will- psychological and may be obtained by merely power left, although they may be temporarily injecting common salt solution. He further benefited, will relapse as soon as they have states that relapses after the treatment are as the opportunity. common as with other methods. It is believed that about 50 per cent of The writer's own experience with this form addicts could be cured by this method. the of treatment is limited, but method is being Lecithin treatment.?Lecithin treatment of of tried in the treatment opium addicts in addicts has been mentioned Ma the opium by Burma jails. Opinion among medical (1932) and is being tried in India by the author. the treatment is unanimous on officers trying From certain observations made on the physical that one or more one point, namely injections properties of the blood sera of such addicts a make the of the autoserum from blister addict where it has been found that the protein con- do sensitive to opium. The patients say they tent, specially the neuro-proteins, is lacking not because not wish to take opium any more, or deficient, particularly during the withdrawal they do not like it, but because the consump- period, the rationale of this treatment can even in does tion of the drug small quantities be understood. Ma (1932) from a cytopatho- not produce the pleasure or exhilaration that logical study of chronic morphinism in albino it used to produce before. On the contrary the rats found that the withdrawal of the drug in J March, 1935] SURGERY IN MALIGNANT DISEASE: SOMERVELL 131

the addicted animals led to severe patho- logical conditions of the Golgi apparatus in the cells of various organs. AV ithout treatment these conditions are overcome in 10 to 12 days. Feeding with lecithin, on the other hand, for a period of six days before and for some days after prevented the Golgi apparatus from becoming abnormally reduced; this was accompanied by a condition of general well-being of the animal which was absent in those receiving no lecithin. The treatment has been tried in China on 143 opium smokers. In addition to their ordinary diet the patients are given 6 to 9 eggs per day to enrich the diet in lecithin. The bouts of craving are overcome by administration of tincture of opium in small doses. The lecithin is given prepared from eggs and made into pills column) with glycyrrhiza powder. The usual dose (Continued from previous daily or factitions spirits. Indian Journ. Med. Res., Vol. XIV, is 4 to 6 grains. It has been found in most of p. 1005. the cases that lecithin, although it prevents Idem (1927). The deleteriousness of potable spirits most of on the untoward symptoms, is insufficient the Indian market. Indian Med. Gaz., Vol. LXII, to combat all the withdrawal alone. p. 195. symptoms, K. This method of Chopra, R. N., and Grewal, S. (1927). Opium treatment is now being tested Habit in An of 100 cases in India. analysis amongst the Indian addicts. Sikh population of Calcutta. Indian Journ. Med. After treatment.?The of Res., Vol. XV, p. 57. importance psycho- R. The logical aspects of the treatment of addicts Chopra, N. (192S). present position of the drug habit in India. Vol. 3S9. has been opium Ibid., XVI, p. already stressed. The responsibility Idem (1930). A note on addiction to of preliminary the physician does not end after the drug is 'Post' (unlanced capsules of Papaver samnijerum). withdrawn. The period following the with- Indian Med. Gaz., Vol. LXV, p. 3G1. R. K. J. and drawal is most critical and and un- Chopra, N., Grewal, S., Chowhan, S., dangerous G. S. (1930). Addiction to 'Post' (unlanced less care is Chopra, great taken relapses may occur. capsules of Papaver somnijerum) in India. Indian The whole of the nervous system has been Journ. Med. Res., Vol. XVII, p. 9S5. strained and a thorough reconstruction and Chopra, R. N., Mukherji, B., and Dikshit, B. B. rehabilitation of the and the (1930). Narcotine : its pharmacological action and personality therapeutic uses. Ibid., Vol. XVIII, p. 35. character of the addict if a is imperative per- Chopra, R. N., and Knowles, R. (1930). The action manent cure is desired. The physician can do of opium and narcotine in Malaria. Ibid., Vol. XVIII, much by way of encouraging the patient and p. 5. making him believe that by his will-power and Chopra, R. N., and Bose, J. P. (1931). Opium and he will Albuminuria. Indian Med. Gaz., Vol. LXVI, p. 299. firmness get rid of the habit. A common II. belief Chopra, N., and Chopra, G. S. (1931). Cocaine among Indian addicts is that elimination habit in India. Indian Journ. Med. Res., Vol. XVIII, of the drug habit will leave them sexually p. 1013. impotent. There is no basis for such a belief R. N., and Ghosh, N. N. (1931). Addiction to Chopra^,'Post' and the patient should be assured that (unlanced capsules of Papaver somnijerum). fully Part II. Ibid., Vol. 415. the loss of sexual XIX, p. desire which thdy observe Chopra, R. N., and J. P. (1931). after Bose, Psychological giving up the drug is a temporary pheno- aspects of opium addiction. Indian Med. Gaz., menon and is a part of the general loss of tone Vol. LXVI, p. 663. of R. and G. S. (1932). Chloral the organs. It passes off in 4 to 8 Chopra, N., Chopra, usually hydrate and as drugs of addiction. weeks, but it last for several paraldehyde rarely may Indian Med. Gaz., Vol. LXVII, p. 481. months. During the period following with- Chopra, R. N., Chopra, G. S., and Grewal, K. S. drawal a good tonic in the form of iron, arsenic (1932). Opium habit in the Punjab. Part I. Indian and Journ. Med. Vol. XX, p. 545. strychnine is very Res., helpful. Occupation Chopra, R. N., and Chopra, G. S. (1933). Morphine is also As soon as therapy very important. habit in India. Indian Med. Gaz., Vol. LXVIII, possible the patient should start doing some p. 368. work so that his attention is diverted in other Idem (1933). Some country beers of India. Ibid., Vol. 665. directions. He must lead a life and LXVIII, p. quiet Idem (1934). Administration of opium to infants avoid excesses of a or all kinds for year more in India. Vol. 489. after Ibid., LXIX, p. withdrawal has been successfully effected. Chopra, R. N., Mukherji, S. N., and Chopra, G. S. (1935). Studies on the protein fractions of blood sera. Selected mnLiocuAniY Part II. Indian Journ. Med. Res., Vol. XXII, Jan., Adams, E. W. (1932). Treatment of Drug Addic- No. 3. The tion?A Review. Parts I and II. Practitioner, Vol. Ma, W. C. (1932). effect of lecithin on opium Med. CXXIX, pp. 234 and 390. addicts. China Journ., Vol. XLVI, p. 806. . x M. Insulin of Chopra, R. N. (1927). Observations on the Sakel, (1930). in the Treatment of toxicity mature and immature genuine spirits and imitation Symptoms accompanying withdrawal of Morphine. Deutsche vied. Woch. Vol. LVI, p. 1777, (