were reached for each injection. She gave it up without difficulty, and with no inconvenience after the first day. It is, I suppose, a recognized fact that the drunkard takes to excess of alcohol just as he does everything else that is foolish and wrong-in other words, that drunkenness is one symptom of an abnormal mind.

No one had a more extensive experience as an inspector under the Inebriates Act than Dr. Braithwaite: he is doubtful whether habitual inebriety is ever acquired, and thinks that these people start life handicapped by an abnormal brain. Sir Frederick Mott, at the Glasgow meeting of the Association, expressed similar views. The drug addict is a product of modern civilization, and addiction is a symptom of a diseased mind. For many hundreds of years Christian nations regarded the insane as people possessed of the devil; they were tortured, burned and subjected to every indignity, and yet insanity continued. Almost the same condition is coming about now with drug addicts. I read that in July, 1921, the New York City Board of Health permitted the incarceration of drug addicts. The police imprisoned several, and the sudden withdrawal of the drug caused the death of one and collapse of several others.

I propose now to mention the substances more commonly used for addiction. Opium or one of its derivatives is the commonest addiction drug; it may be eaten, smoked, or injected. Eating opium or drinking laudanum is rare amongst Europeans, possibly on account of the constipation, the delayed absorption, and the difficulty in obtaining the large supplies necessary. It is, however, not uncommon in India, and its general use led to the Commission of 1895, which reported that moderate indulgence led to no injurious effect and did not shorten life, but that, on the contrary, it tended to ward off sickness and lessened the discomfort consequent on poor food and on malaria and other diseases. Opium is still taken in the fen district of England as a remedy to ward off the ague, a disease which has long ceased to be endemic. In India the opium habit appears to be comparable rather with our smoking than with the morphinist; it is a habit of middle life and advancing years, whilst modern statistics show that 70 per cent. of the European and American morphinists are under thirty.

Opium smoking is also mainly an Eastern habit, although it obtained a distinct vogue in the United States of America

until it was superseded by the infinitely more objectionable method of injection. The amount of alkaloid absorbed in the smoke is very small, both because the amount of opium used in the pipe is small, and because most of the alkaloid in the opium is destroyed. Absorption is rapid and an immediate effect is produced. Whether this is really due to the morphine I am not prepared to say, since even by smoking all day it would be difficult, if not impossible, to absorb half a grain. The morphine in ten pipes only contains about half a grain, and 99 per cent. of this is destroyed in combustion. After the first few whiffs there is a feeling of elation, followed in the habitué by delightfully languid ease, an exalted sense of superiority, and later by dreamy sleep. The smoker becomes a slave to the habit, and the evil is enhanced-at all events in the West-because the devotee must indulge in his vice in the worst possible surroundings. Opium smoking is the least objectionable form of the vice, because the amount of alkaloid taken is so small, because a strong craving is not formed, and because "cure" is relatively easy, since here we are dealing with a group indulgence, not a secret vice like that practised by the true morphinist. Withdrawal symptoms are never observed.

In Europe and America the alkaloid is usually injected: this is the most pernicious form of taking the drug, and to obtain the requisite relief the devotee must be continually increasing the dose. The amount of morphine injected daily varies greatly; 15 grains is an ordinary quantity for a morphinist to use in the twenty-four hours, though he will double this in the case of any trifling trouble.

Heroin has been used as a substitute for morphine and as an addiction drug since about 1913. This proprietary remedy was easily obtained and was even exported to the East as a cure for opium smoking. The addict often prefers heroin to morphine, since it is less constipating. The average morphine addict has perhaps one or two stools weekly, whereas the bowels of the heroin addict act almost normally. Heroin has no advantages over codeine or morphine, and its use might be forbidden without harming a single genuine patient.

EXTENT OF DRUG HABIT.

Reliable statistics are almost impossible to obtain, and such information as we have comes principally from America. Thus the report of the Special Committee of Investigation

appointed by the Secretary of the Treasury in the United States in 1918 gives the following consumption per head per annum in 1910:

Ninety per cent. of this American traffic is probably used for other than medical purposes. The Commission of the Treasury, U.S.A., in 1921, estimated that the country contained at least one million addicts. From all parts of America we find the same tale. In December, 1914, the Harrison Narcotic Law came into existence; it had the support both of the public and the medical profession. In effect this law dictates the manner of practising medicine, and involves many irksome details and much clerical work for the doctor. It includes an army of officials-Federal, State, county, and city—and every grain of narcotic must be accounted for. It has now been actively enforced for seven years, and it is the universal opinion of those best able to judge that it has signally failed in its purpose. The number of addicts and the amount of narcotic consumed is as great or greater than in 1915. I believe the main reason for this is to be found in the fact that the law takes no account of the causes of addiction: the drugger is regarded as a criminal just as were the insane in medieval times. Everything can be obtained if the price offered is appropriate to the risk, with the result that smuggling is rampant on the Pacific and Atlantic coasts, from Canada and from Mexico. Distribution is organized by underground channels by means of the so-called dope pedlars. In other words, the law has not altered the supply, but only the distribution of the supply.

Our own less stringent law came into force in September, 1921, and it is too early yet to appreciate its effects. But such drastic laws should make us extremely anxious; they may easily increase the very vice they aim at arresting, for they put a high premium on smuggling, and once the illicit drug dealer obtains a hold on the community an evil is produced infinitely greater than before, when the drugs could be obtained at a fair price through recognized channels.

Much of the increase in drug addiction has without doubt been started in ignorance; opium smoking was regarded as a

harmless pastime to be relinquished as desired; the employment of the "white snuff" cocaine served as a stimulant and pick-me-up; and heroin was used as a substitute for morphine with the idea that it was not an opium derivative. There is much evidence that the difficulty in getting alcohol leads people to try any substance which may have a "stimulant effect." But such people are neurotics, their mentality compelling them to search for any remedy to relieve their mental distress. To this normal man opium smoking or cocaine sniffing started in ignorance or in the spirit of adventure or bravado produces little or no pleasurable effect; and although from time to time the process may be repeated I do not believe true addiction ever occurs. The addict always finds it to his advantage to cooperate with the distributor of his drug, and almost never will he give information leading to disclosure of the source of the supply.

The chief characteristics of the drug addicts are plausibility and disorderliness; they are essentially creatures of impulse. They have little regard for time; appointments are not kept; rules of ethics are scarcely regarded and the conventions are allowed to lapse. When under the influence of their drug the attention can be concentrated for a time and they can write and work, though in a slovenly fashion. The fresh injection gives them a feeling of energy and well-being.

WITHDRAWAL.

Addicts are held in addiction largely through fear. Prolonged indulgence often fails to give them pleasurable sensations; still they must go on in order to avert the crisis of withdrawal. Their horror of pain, both mental and physical, is an obsession, and contact with the responsibilities of the world they feel is not to be borne.

The symptoms of withdrawal correspond almost exactly with stimulation of those tissues which morphine in medicinal doses depresses. The yawning, sneezing, nausea, vomiting, and mucous secretion result from stimulation of the medulla; the abdominal pains and diarrhoea from stimulation of Auerbach's plexus; the twitchings, cramps, circulatory troubles (rapid pulse, arrhythmia), and sometimes even convulsions, and collapse hardly distinguishable from surgical shock, are due to excessive stimulation of the cortical cells. Perhaps one of the first and most characteristic effects of withdrawal is a rise in blood pressure from excessive activity of the medulla; this is

followed later, at all events in severe cases, by a marked fall in the pressure associated with the collapse. A patient seen with these symptoms, even when in a state of collapse, on receiving an injection of his drug exhibits a transformation almost miraculous; he becomes in a few minutes a relatively normal person. Nitrites in cases of early withdrawal produce much the same effect as morphine on the blood pressure, but do not relieve the mental condition.

Sudden cessation of alcoholic beverages in those who have inbibed too freely for a long period may also lead to withdrawal symptoms, which we term delirium tremens.

The explanation I suggest to account for these withdrawal symptoms is that nerve cells, after prolonged narcosis, on reawakening become hyperexcitable. The contrary effect is an everyday axiom, that stimulation is followed by depression. Another explanation has been suggested by the fact that morphine and cocaine maniacs must be continually increasing the dose to get the necessary effect. This acquired tolerance

is at least partly explained by the enhanced power of the tissues to destroy the alkaloid. On this we have decisive evidence. But it is also suggested that this acquired tolerance, this inability of cocaine, morphine, and other drugs to produce their normal action on the brain, is due to some substance which neutralizes the effects of the poison.

Valenti rendered dogs tolerant to morphine, and found that on suddenly stopping the drug the animal showed typical withdrawal symptoms. He alleges that injection of the serum from these dogs into normal dogs caused similar symptoms. This view is.now completely disproved. No antibody formation ever occurs in animal or man from the injection of such relatively simple substances as the alkaloids.

COCAINE.

It has long been known that the Indians in the west of South America, especially in Bolivia and Peru, used coca leaves to chew as a stimulant and narcotic. The Indian uses coca as we use tea and coffee as a stimulant in mental and physical fatigue. Travellers assert that by chewing this leaf they are able to perform long and rapid journeys with less fatigue and without feeling the pangs of hunger and thirst. Experiments in the laboratory, using the urgograph, suggest that these effects are due to cocaine, but experiments by Europeans in the Alps have not been very successful.