The cocaine problem in India
Author: I. C. Chopra, Sir R. N. Chopra
Pages: 12 to 24
Creation Date: 1958/01/01
Director, Drug Research Laboratory, Jammu and Kashmir (India) Sir R. N. Chopra
Member of the Expert Advisory Panel on Addiction-producing Drugs of the World Health Organization
The use of coca leaf for euphoric purposes was started centuries ago by the natives of certain parts of South America. Its various aspects and the attitude of the governments involved and of the international community have been dealt with in several articles published in the Bulletin on Narcotics.*
The active principle of the coca leaves, the alkaloid cocaine, was discovered in 1859-60, but it was only after 1884 that the importance of the plant from the medicinal point of view extended rapidly. Export of dry leaves from South America started from that time. About 1890, factories were opened in Peru to extract cocaine in crude form for export with a view to saving the cost of transport of the whole leaf. It was in this way that the alkaloid replaced the leaves, and knowledge of the effect produced by it spread to other parts of the world. In 1890, 1,730 kg of crude cocaine were exported, increasing to 10,600 kg by 1901. Between 1890 and 1910, cocaine began to be fairly largely used in the United States of America for euphoric purposes. Negroes particularly used this drug in the form of snuff, and cases of ulceration of the septum of the nose were not infrequently seen among them.
The knowledge of the remarkable effect produced by cocaine gradually spread to Europe, India and China. It was thought at that time that administration of cocaine in cases of opium and morphine addiction and in alcoholism helped to break these habits. Unfortunately, instead of curing morphinism it produced morphino-cocainism. During the First World War, there was so much increase of habitual use of cocaine in Europe that vigorous measures were taken by the authorities to put an end to this practice.
*See especially Vol. I; Vol. II, No. 1; Vol. II, No. 4; Vol. IV, No. 2; Vol. IV, No. 3; Vol. IV, No. 4; Vol. V, No. 4;
The successful use of cocaine for producing local anaesthesia began to be increasingly appreciated in the early parts of the twentieth century, and it was considered worthwhile to produce it by synthesis. Extraction from the leaf, however, was easier and cheaper and plantations were started in Java and elsewhere. The leaf from Java was sent to factories in Europe, America and Japan for processing, and the South American product was practically driven from the market. In 1922, 1 ? million kg of leaves were exported from Java with a cocaine content of 1.5%.
Species Erythroxylum in India. Erythroxylum coca is not indigenous to India. No reference is to be found in the ancient Sanskrit literature about this shrub or the use of its leaves or the properties possessed by them. The only references in medical literature that exist are of very recent origin, and concern the use of the alkaloid cocaine, and not the leaf itself. The variety Erythroxylon monogynum is said to be indigenous to India (Madras), but it does not contain cocaine or any of the related alkaloids. This variety has smaller leaves than E. coca and can stand higher temperatures; and it is thought that if cultivated under proper conditions it might produce cocaine. Two other varieties of Erythroxylonare believed to grow indigenously in Bombay State, but if they grow at all they must be extremely rare. One of them yields a mere trace of cocaine, the other does not yield any alkaloid at all. The habit of chewing coca leaves consequently never existed in India.
In 1870 E. coca was brought to Ceylon from the botanical gardens at Kew, London, and in 1883 it was brought over to India. When carefully cultivated under suitable conditions, the leaves have been found to be rich in cocaine, the yield increasing with the age of the plant. In India, it was observed that the best results were obtained from plants grown on the uplands of the Nilgiri hills; those planted in the hot low plains did not thrive, and eventually died out.
E. coca has never been cultivated in this country on a large scale. Some time ago (1926) an account of the prevalence of the habitual use of cocaine appeared in the English daily press in India. It was suggested that cocaine bearing Erythoxylon coca was growing wild all over the country, that people were learning the habit of chewing the coca leaf, and that there might be secret factories for the manufacture of cocaine. It was argued that large quantities of the drug coming from an unknown source were seized on railways, and that the cocaine habit was spreading rapidly. The alleged cultivation of the coca plant was also referred to at a meeting of the Advisory Committee of the League of Nations on Traffic in Opium and other Dangerous Drugs in 1925. Careful inquiries were made by the Government of India, and it was established that neither Erythroxylon coca nor any other plant from which cocaine could be produced was culativated in India. E. coca, far from growing wild all over the country, is not known to grow in a state of nature anywhere in India. A few plants were found in some of the Nilgiris estates, which were in all probability relics of the experiment made in 1885, but even these contained little or no cocaine. The manufacture of cocaine is a highly technical process, and there is no ground whatever for the belief that cocaine was ever secretly manufactured in India.
II. HABITUAL USE OF COCAINE IN INDIA
Near the end of the nineteenth century, it was realized that cocaine was being used in certain parts of the States of Bengal and Bihar for its euphoric effects. The earliest record of its use came from a small town named Bhagalpur in Bihar State. The story is related of a rich land-owner who contracted the habit accidentally after using cocaine to relieve dental pain. So extraordinary were the effects produced that not only did he become habituated to its use, but he passed on the habit to many others. In course of time, it was observed that cocaine was being secretly sold by certain agencies to people who were taking it in prepared betel leaf (pan). A class of pedlars had sprung up who were selling the drug not only to grown-up people but also to teen-age schoolboys. It was usually sold in packets or "lifafas" (envelopes) of a half grain each.
In this way the habit spread to large towns such as Calcutta and others. The habit appears to have spread along two main rail routes to northern India. It worked its way up to towns like Benares, Lucknow, Rampur, Saharanpur and Ambala on the one side, and through Allahabad, Kanpur, Agra, Muthra and Delhi on the other. We were informed that in Delhi the habit existed on a fairly large scale in the early part of this century. There, it is said to have spread through the agency of a medical practitioner who prescribed it in large quantities as a stimulant and as a tonic. Trained midwives are said to have been responsible for its introduction among the womenfolk of certain towns. Shawl merchants and dried-fruit traders from the north, who were in constant communication with Calcutta, took the drug to Amritsar, Lahore and Peshawar. An excise officer of the North-West Frontier Province (now in Pakistan) said that people from Peshawar were in a great measure responsible for the traffic in cocaine in the country. Large quantities of "charas" (resin of Cannabis sativa manufactured in central Asia) were smuggled through the frontier area at a low price. This was carried by them to big centres such as Bombay and Calcutta, where it was sold at high profit to traffickers. The proceeds of these sales were utilized to smuggle cocaine back from the seaport towns to different large towns of the country.
Control over the Import and Sale of Cocaine
When the habitual use of cocaine began at the end of the nineteenth century and the beginning of the twentieth century, restrictions on the import, sale and use of this drug were not strictly enforced. The excise authorities soon realized the seriousness of the situation, and regulations were brought into force to ensure strict control of the import and sale of cocaine. The sale of the alkaloid to the general public was forbidden, and even the sale by licensed druggists and chemists to medical practitioners and dentists was strictly controlled. No one was allowed to possess coca leaf, alkaloids of coca, or any preparations made from them, or preparations containing ecgonin or any substance chemically allied to cocaine or having similar physiological effects, except under a special licence. The possession of these drugs under licence was also strictly controlled. In spite of this, Chuni Lal Bose, Chemical Examiner to the Bengal Government, writing in the British Medical Journal, 1913, said, "Despite the vigilance of the excise authorities and notwithstanding the stringent measures adopted by the Government against the possession and sale of this substance by unlicensed persons, there is reason to believe that the cocaine habit has much increased and is rapidly spreading."
The excise authorities, of course, had knowledge of the individuals who were responsible for the cocaine traffic in various parts of the country. In fact, lists of such persons had been prepared and circulated. They were, however, powerless to put an end to their activities because of the great difficulty of proving the offence in courts of law. Besides, many of the persons dealing in this traffic were dangerous individuals, and people were afraid to come forward and give evidence against them. More often than not the cases against them failed.
Extent of the Habit during the Period between the Two World Wars
It is not possible to say with any degree of accuracy to what extent the habitual use of cocaine existed in India at that time. Luke (1914) said that the habit of taking cocaine was by no means confined to the poor and uneducated classes. Information gathered from investigations in various states of India showed that at first only members of the medical profession knew about the euphoric properties of cocaine, and that it was from them that the lay people in towns learnt about its stimulating and pleasure-giving properties. At the outset, when the restrictions regarding the possession and sale of cocaine were not strict, the habit quickly spread from one town to another on account of the transport facilities afforded by railways, which were developing in the country at that time. The stimulant effects produced by the drug were a great attraction to the type of individual who was ignorant of the evil effects it produced on the body. Moreover, the enormous financial gain which the dealers in this nefarious traffic obtained soon induced them to employ agents to push on their trade by advocating and popularizing the use of the drug. It thus came about, that even when restrictions were imposed, the use of this drug was not significantly curtailed for some time. On the contrary, it increased, and cocaine became a well-known commodity to many of the inhabitants of large towns in India.
It was popularly believed to be a sexual stimulant, and many started taking in to increase their virility. The other attraction for its use was that it had a most extraordinary, though temporary, effect in rapidly overcoming physical fatigue and mental depression. For these reasons, its use rapidly spread among the upper and educated sections of society in towns. The drug was smuggled into Bombay from abroad, and its use spread from one town to another in the State of Bombay and to other states. The remarkable fact was that although the large towns along the main railway lines were affected, those along the branch lines generally remained untouched. The only part of India in which the habit did not spread to any great extent was south India, particularly Madras State.
It was very difficult to form any accurate estimate of the incidence of the cocaine habit in different parts of the country because the habit was considered to be so disgraceful that no self-respecting individual would own up to it. Besides this, the sale as well as the possession of cocaine had been declared illegal, and the possessor of the drug as well as the dealers were liable to prosecution and punishment under the Dangerous Drugs Act. Inquiries were therefore very difficult and delicate and sometimes even dangerous. Only after several years of patient investigations could some idea be formed of the incidence of the habitual use of cocaine among the people in different states. In this work the collaboration and help of the excise authorities were invaluable. It was surprising to find that the habit was spreading among the educated classes and well-to-do people in towns. The lower strata of society were also taking the drug. Even women of high-class families were taking the drug, particularly in Uttar Pradesh State. The drug was invariably taken in betel leaf, which they were in the habit of chewing all day long. The dealers in this drug fully realised that unless they got hold of wealthy families who could afford to pay a high price it would not be worth their while to carry on this nefarious and rather hazardous trade. They therefore tried to introduce the drug into the homes of rich people, chiefly through the agency of betel sellers and servants.
As the popular way of taking the drug in this country was and still is to add it to betel leaf, it was quite an easy matter for a designing person to put the drug in a "pan" (prepared betel leaf) and introduce it into the household of unsuspecting individuals. The immediate effects of the drug were so striking and the sensations produced were so refreshing, stimulating and extraordinary, that not infrequently the habit was acquired without the victim realizing its dangers. It was for this reason that the habitual use of the drug was more prevalent among the section of population which was in the habit of chewing betel leaf. Some idea of its incidence could be formed by careful inquiries in towns where the habit was known to exist. The difficulties, however, in forming even an approximate estimation were great.
The incidence of the habitual use of cocaine during the period between the two world wars may be summed up briefly as follows: The areas which were most affected were the towns in Uttar Pradesh and southern Punjab, but the habit existed in the States of Bengal, Bombay, Bihar and Orissa. These could be put roughly under four categories: (1) large towns which were badly affected and in which the incidence of the habit was 5 to 10 per thousand of the population (e.g., Lucknow, Benares, Kanpur, Saharanpur and others); (2) large towns in which incidence was 2.5 to 5 per thousand (Mathura, Ghaziabad, Mirzapur and others); (3) smaller towns in which the habit existed to a small extent (e.g., towns of 20,000 to 40,000 where there would be 10 to 20 addicts); (4) those in which the habit had recently been introduced, and in which there were only a few addicts here and there.
The town of Delhi was about the worst affected, the incidence of the habit there being roughly 5 to 20 per thousand of the population during that period. A certain amount of addiction existed in towns in the neighbourhood of Delhi, chiefly among the artisan class in places such as Rohtak, Karnal, Panipat and Hissar. This could be attributed to rapid road communication brought in by the introduction of motor transport.
Investigation in the field in most of the states showed that in smaller towns and rural areas addiction to cocaine was almost unknown. Certain small townships and even villages in the neighbourhood of big commercial centres were sometimes affected, but not extensively.
III. COCAINE TRAFFIC AND MODES OF SMUGGLING
For bona fide medicinal purposes, cocaine was imported into India from European countries, particularly from Germany, and later supplies were also received from America.
When restrictions on the sale and use of this drug were brought into force, a certain amount of the alkaloid began to be illicitly imported at first from the same sources. Later, the Far East drove the European and American manufactured article out of the Indian market. Japan, which manufactured the alkaloid, became the main source of supply for some time. Illicit cocaine was brought from Japan to Calcutta either direct or via Amoy by steamers of various lines. The conveyors were mainly Chinese, and to some extent Indian crew members, though acting independently of one another. Imports were managed through individual conveyors among the crew and not jointly.
China itself manufactured no cocaine, but imported it from Japan and Europe, and illicit traffic was carried on from its seaports through the ports of Hong Kong and Singapore, making use of various fictitious brands and labels.
The drug was hidden in inaccessible places in ships. On account of its small bulk, the landing of the drug did not present much difficulty. It was often not brought into the port at all in the ordinary way, but was thrown overboard in watertight packets into the sea or into the river from where it was picked up by organized gangs of smugglers. In this way, large quantities of the drug found their way into seaport towns such as Calcutta, Bombay and others.
The amount seized by the Calcutta customs authorities in 1930 was 7,200 ounces. Experienced excise officers placed the seizures at between 2 to 5 per cent of the quantity which actually got through. This meant that somewhere between 200,000 to 250,000 ounces of cocaine were successfully smuggled into the country every year. It was estimated by competent authorities at that time that consumers in India paid between 27 million and 65 million rupees to the retailers for their doses during 1929. This is an enormous sum of money, and from this some idea of the total number of persons addicted to the drug could be formed. Taking an average dose as 2 to 3 grains daily per individual, there must have been between 250,000 and 500,000 individuals who were taking cocaine habitually in India for its euphoric effects. This figure was very much on the conservative side, as a large amount of cocaine smuggled into the country was heavily adulterated by the dealers before it actually got to the consumers.
It is not necessary here to go into details of the devices which were employed by the smugglers. These have been dealt with by Mr. A. T. Bhargava of the Criminal Investigation Department in a pamphlet published by the Oriental Press of Allahabad in 1916, and can be added to indefinitely. It will suffice to say here that many extraordinary methods were used which enabled large quantities of the drug to be smuggled through into the hands of organized gangs in centres such as Calcutta. There was in existence a very elaborate system of distribution of the drug from the seaport to even the remotest towns in India. Depots had been established by the traffickers in towns where there was demand and which the retailers knew as a source of supply. Ordinary people in the guise of menials, such as grass-cutters, cobblers or labourers whom nobody would even suspect, were usually employed for transporting the drug. Sometimes purdah women in a "burka "* acted as carriers. Even respectable-looking Anglo-Indians and Europeans travelling first and second class in the railways were found in possession of large quantities of cocaine.
The distribution to the addicts was done chiefly through the agency of betel-leaf sellers, and also through itinerant pedlars. The police and excise authorities made a large number of arrests, causing the traffickers to become more careful. It being unlawful to possess or to sell cocaine, the traffickers did not carry it on their person, but placed the packets in some unfrequented place and indicated its location to the addict after they had received the price. The wholesale and retail dealers who kept stocks of cocaine were to be found in different towns and in many cases were known to the police. Actual arrest and prosecution were, however, very difficult, because the traffickers were clever in evading the law. They had effective methods of clearing away the drug at a moment's notice when their places were raided. The favourite method was to keep some water handy, and as soon as a police raid was anticipated the drug was thrown into water and the solution poured down the nearest drain, thus hiding from the police any trace of the drug. Carriers of cocaine were very rarely caught by the excise authorities. They carried only small quantities which could be easily concealed on the person. When bringing cocaine from big centres, these people often did not disembark from the train at big stations where they were likely to meet the excise agents. They frequently got out in small suburban or wayside railway stations and conveyed the cocaine by road to large towns. Even if some of them were arrested, they were paid well enough to go to jail and not give the chief culprits away. Very often, after doing a few months' hard labour, they came out and resumed their trade. Thus, the real persons who managed the business of smuggling not only escaped, but grew rich.
Betel-leaf sellers and women of low morals, such as prostitutes, played an important part in the spread of the habit to their clients. They were also sometimes the medium through which the drug was sold, and they induced their customers to buy and take the drug. A number of the addicts attributed the beginning of the habit to their association with these women.
It has been stated that the drug smuggled into the country was often already adulterated. The retail dealers further adulterated it with cheaper similar-looking products such as phenozone, acetyl salicylate, potassium nitrate, etc., the last-named because it imparts a sense of coolness to the tongue somewhat like cocaine. One consignment confiscated in Delhi consisted of pure phenozone. The drug was then put into small packets or" lifafas "containing 1/2 to 3 grains (30 to 200 mg) each which were then handed over to the pedlars who were personally in touch with the addicts.
*The burka is an ample garment covering the body from head to foot (with a small aperture to allow the woman to see) under which even large packages can be carried unbeknown.
The Present Extent of the Habitual Use of Cocaine
It is not possible to form any idea of the incidence of the habitual use of cocaine in India at the present time. We have studied the figures of imports of cocaine from 1934 to 1957 very kindly supplied to us by the Central Board of Revenue. These do not show excessive import of this drug. The quantities imported are likely to be required for bona fide medicinal purposes in the country. Even if some of it was diverted illicitly for euphoric purposes, this quantity could not be large in view of the strict control exercised on its sale to the public.
We have also obtained figures of seizures of illicit cocaine from 1950 to 1957, the only figures available. Here also the quantities seized are very small. Granting that those seizures represent only 2 to 5 per cent of the cocaine actually smuggled in, as is estimated by excise authorities, the number of persons who use cocaine habitually for euphoric purposes could not be so large as to be alarming. There is no doubt, however, that the use of cocaine for such purposes does exist in India at the present time, small though it may be.
It is said that some cocaine is now being smuggled into the country from India's north-western frontiers, and if action is not taken this may become a menace. The opinion we have been able to form from our investigations is that eating of cocaine has not become extinct in India. The situation will have to be carefully watched by the authorities, as the remarkable and fascinating effects which the drug produces and the large financial gains it brings to smugglers may start illicit import on a large scale, and its habitual use may increase again.
IV. ANALYTICAL STUDY OF 200 CASES OF COCAINE EATERS
Two hundred cases of habitual cocaine eaters studied were collected not by selection from any particular area, but as they came during the course of work in the field. They were thoroughly examined and the histories, symptoms and physical and mental changes were recorded. The majority of this series, however, came from Delhi, and others from northern towns of the Uttar Pradesh and southern towns of the Punjab. The addicts were not seen just once, but with many of them - especially those from Delhi -it was possible to maintain contact for months, so that a more detailed and thorough study could be made. However, all of them were from the lower strata of society- that is, the artisan and menial classes. For obvious reasons it was not possible to get any of the wealthier class of people who indulged in the drug to come forward for examination. A number of them were of course seen, but detailed examinations and follow-ups were not possible, Even so, it was our impression that the better hygienic conditions, good food, etc., enjoyed by this class did not significantly mitigate the evil effects produced by the drug. On the contrary, we found that wealthier people who could afford to buy larger quantities of the drug deteriorated more rapidly. In them the process of physical, mental and moral degeneration was more rapid.
Race and Religion
The following is the division of the cases according to race and religion:
It will be seen that the majority of our cases were Mohammedans (62.5%), followed by Hindus (34%).
The commonest age of contracting the habit in this series was between 15 to 30 years. The fact was obvious that the cocaine habit in India was chiefly the habit of the second and third decades of life, when the sexual functions were at their highest and sexual instinct dominated in the individual. In a small minority only was the habit started at a later period of life. There were a few cases in which the habit was formed as early as 15 or 16 years of age, showing that the drug was being conveyed to the teenagers in schools by pedlars. Between the ages of 16 and 40 years, the incidence was 79.6%; between 40 and 50 years a few cases only were examined. It will thus be seen that in over 90% of cases habit formation occurred between the ages of 16 and 50 years. Cocaine eating in India would thus appear to occur mostly in the young. It begins with adolescence, reaches its maximum between the ages of 21 and 49 and declines rapidly as age advances. It is thus confined mainly to the period of life at which sex impulses are predominant-i.e., the sexually active or romantic period of life.
It was also obvious that prolonged and heavy indulgence in the drug adversely affected the longevity of the addicts, and many of them did not live much beyond the age of 40.
The majority of addicts in our series were of the artisan class: shopkeepers, taxi drivers, tradesmen and the like who made a modest living. The rest came from practically all classes, but chiefly the menial classes. They spent most of their earnings on the drug. More than 60% of the addicts were unmarried. This, in a country like India, is a high percentage. The series was not large enough to permit any conclusions to be drawn as to the effect of the drug on fecundity.
Only seven of this series were females. This, however, does not reflect the true sex incidence, as most of the women who take the drug would naturally not come up for examination in this country. In the Uttar Pradesh area at least, many women were known to be taking the drug at that time.
In more than 45% of the cases the dose did not exceed 1 to 2 grains daily, in 21% between 3 to 4 grains, and in 24% between 5 to 10 grains daily.
V. AETIOLOGY OF COCAINE ADDICTION
(1) In India, the use of cocaine was to some extent confined to the class of individuals who were more or less addicted to other narcotic drugs such as opium and "ganja", or to alcohol; but it was also met with in people who were not using any of the other narcotic drugs. The chief cause of the habit was association with cocaine eaters or people who were taking other narcotic drugs. It is a curious fact that people addicted to euphoric drugs always attempt to persuade their friends and acquaintances to try the drug of their choice. We have known cases where betel leaf with cocaine was given to individuals without their knowledge, and resulted in their becoming habituated to it. Many of the older addicts said that their first introduction to the drug was by traffickers who told them of its remarkable effects. They were given the first few doses gratis and when they had enjoyed the effect and were attracted by the drug, they ended up by spending all their money in buying it.
(2) Others try the drug out of sheer curiosity. A small number underwent such severe reactions after taking the first dose that the experiment was not repeated. Others, however - generally the class of individuals whose mental equilibrium was not stable - obtained such pleasurable effects, temporary though these were, that they almost invariably bought the drug, repeated the dose, and in this way became victims to the habit. Inexperienced youngsters fell into the habit of taking the drug, and their whole life was ruined. Cases are known of boys who contracted the habit through the agency of their household servants or some designing person, with disastrous results.
For its Pleasure-giving Effects and as a Luxury
Cocaine eating in India was more or less confined to people with licentious and vicious habits. Sexual vice and dissipation being very prevalent in these circles, they were always anxious to find new avenues of pleasure-giving sensation. Those belonging to the indolent rich classes took the drug because their sense of appreciating the ordinary pleasures of life had become dulled or exhausted, and they wanted some sort of stimulant so as to be able to enjoy again the pleasurable sensations to which they had become insensitive through long and excessive indulgence. This type of individual was not rare in large towns even among the artisan classes. The surroundings in which these people worked were dull and unhygienic, and they took to narcotic drugs for want of healthy recreative occupations. There was also the idle rich class already referred to who, having no occupation, started taking euphoric drugs for the sake of "having a kick out of life" or "to make it worth living ".
(3) For Sexual Gratification
Cocaine is one of those drugs which was frequently used by the women of the underworld and prostitutes in India not only for their own pleasure, but also for stimulating the sexual appetite of the licentious people who visited them. The pleasurable sensations produced by the drug stimulatedtheir sexual desires. The temporary stimulation of the psychic areas probably produced mental excitement resulting in a semblance of aphrodisiac effects in some individuals. This was certainly the case with the female sex.
(4) To alleviate Fatigue, Worry and Strain
Since cocaine removes for a while the feeling of fatigue and hunger and gives a feeling of self-satisfaction and forgetfulness, it was sometimes taken by some working-class people towards the evening after the day's work. As the effect of one dose lasts for only a short time, the desire to repeat it at frequent intervals became irresistible in some of them.
This was a very rare cause for contracting the habit in India; in our series of 200 cases there were only two addicts who started the drug because it relieved attacks of asthma from which they were suffering and for which they first took the drug.
(6) City Life and Cocaine Addiction
Cocaine eating in India was chiefly confined to dwellers in towns and cities. Insanitary conditions, overcrowding, want of hygienic and healthful recreation, the strain and stress of life in large towns, all predispose to addiction to euphoric drugs. The cocaine habit was practically unknown in the rural areas not only because of the non-availability of the drug but because people's time was fully occupied with work. The economic condition of these people did not allow them to spend their hard-earned money on such an expensive drug. Besides, there was the fear that in a small community such a habit would soon be known to others.
(7) Nervous and Psychological Factors
The cocaine habit, like other narcotic drug habits, is chiefly confined to individuals whose psychic condition is in an unstable state of equilibrium. Most of the addicts examined could be put in two classes: (a) Weak-minded, phlegmatic and mentally dull and deficient individuals; there might have been a family history of insanity, alcoholism or neurosis in such cases. These individuals were unable to stand the daily stress of life and often resorted to drugs to enable them to carry on their daily routine of work. Such individuals did not resort to cocaine for sexual or vicious purposes, but merely for its stimulating and euphoric effects. In our experience with opium addicts, this was a common cause of contracting the habit, and we have no doubt that this factor also played an important part in habitual use of cocaine in India. After a dose of cocaine, persons who were irritable and depressed became self-confident and cheerful and were able to face the World with fortitude. Unfortunately, the effects were temporary. (b) Irritable, nervous and hypersensitive temperaments. Such individuals formed a smaller group. They became easily upset and irritated by small worries of life of which normal persons would take no notice. They wanted some sort of sedative or narcotic to give them a sense of mental balance.
Methods of taking Cocaine
The method almost universally employed in India is by putting the drug in "pan" (prepared betel leaf). This was the reason why addiction to cocaine was more prevalent amongst people who indulged in "pan" chewing. As is well known, the betel leaf is taken by mixing it with small quantities of catechu and slaked lime; a little betel nut or sometimes spices such as cinnamon, cardamon, ginger, etc., are also added. Cocaine is either mixed with the spices and then wrapped in the betel leaf, or some of the eaters place the alkaloid on the tongue and then chew a "pan" immediately afterwards. Habitual cocaine eaters who have been indulging in the drug for a long time generally put the cocaine on the tongue and merely take a little lime and catechu afterwards, dispensing with the betel leaf altogether. It is said that by doing this the action of the drug is enhanced and the effects produced are stronger. Rarely, the drug has been taken in the form of a solution, obtained on a doctor's prescription, the addict sipping the solution at intervals and following it each time with a betel leaf. The method of rubbing the drug into the gums or taking it as a snuff is up to the present time unknown in this country, and we did not meet anyone who used it this way. A method occasionally employed - particularly by prostitutes - is that of injecting a solution of cocaine into the vagina by means of a douche. This give the individual a sense of local constriction and general effects appear almost immediately. The sexual act is said to be prolonged if the drug is administered in this way.
VI. SYMPTOMATOLOGY OF COCAINE ADDICTION
From a careful study of 200 cocaine eaters it has been possible to form some idea of the symptoms and effects produced by the drug in Indian addicts. A description of the symptoms produced was obtained first-hand from the cocaine eaters themselves and is reproduced below.
Immediately after taking the drug there is a slight smarting or tingling sensation in the tongue; the lips feel swollen, dry and thick. There is irritation in the fauces and a sensation of constriction in the throat. Soon there is a complete loss of sensation in the oral cavity, tongue and lips. There is a feeling that the tongue is missing from the mouth. Following these preliminary sensations, which last less than ten minutes, the drug begins to gain entrance into the circulation, and the stimulant stage begins. There is a slight feeling of dizziness or heaviness in the head, a throbbing sensation in the arteries of the neck and palpitation of the heart. The unpleasant sensation of confinement and air hunger, which sometimes occurs after subcutaneous injections of cocaine, is rarely met with when the drug is taken by the mouth, unless the saliva is swallowed or enters the stomach by trickling through the oesophagus. There is a very pleasant sensation, a feeling of warmth all over the body, and sensation that something is being drawn away from the limbs towards the head and the mouth. A peculiar, delicious feeling is perceptible in the region of the tongue. The ears become hot and red, the cheeks become pale, the tip of the nose becomes cold, and the patient begins to perspire on the forehead and over the neck. These symptoms are more common in the early stages of the habit, but are hardly perceptible in confirmed cocaine eaters of long standing, unless they take an overdose.
By this time a peculiar sensation of excitement is felt by the individual; he feels cheerful and experiences a sensation of comfort both in mind and body. He feels capable of undertaking anything, however difficult,whether it may involve physical or mental effort. During this period the cocaine eater looks very keen and excited, his eyes are bright and he talks coherently. Complicated intellectual work may be done without mistakes. The increased sensitiveness of the sensory nerves is perceptible all over the body. The eater gets agreeable hallucinations, he imagines himself to be a wealthy man such as a rajah or a nawab. During this stage he may walk along the streets continuously for hours without feeling fatigued. His eyes may be glued to the ground and he imagines he is looking for gold and treasures; instead he picks up rubbish, stones and other articles from the ground thinking them to be riches and articles of value. These he carries on his person till he recovers from the effects of the dose and finds them to be useless. During this time he is afraid of being robbed and fears everyone he meets. Fear of excise authorities or the police are prominent among the hallucinations occurring among the poorer class of addicts in India. The indication of the maximum amount of exhilaration is marked by coldness of finger-ends, and mydriasis.
When chewing the betel leaf, cocaine eaters as a rule have marked objection to talking. As the leaf is chewed the mouth becomes full of saliva, and there is a pleasant sensation as if the whole cavity were full of butter which spoken words might dissipate. The addicts as a' rule do not swallow the saliva but retain it in the mouth and give it time for absorption from the buccal cavity. The reason for this appears to be that if some of the saliva containing cocaine gets into the oesophagus and from there into the stomach, it gives rise to a feeling of constriction and discomfort in the throat and chest. Besides this, the drug is more quickly absorbed from the stomach and produces a more intense action which in the uninitiated may be so severe as to produce symptoms of great discomfort all over the body and even a mild collapse. Ordinarily these symptoms consist of a sense of confinement in space, lack of air, feeling of severe oppression in the chest, dizziness and heaviness in the head. The saliva is not swallowed, in order to escape from the concentrated effects of the drug. In order to avoid its trickling into the gullet and stomach the addicts firmly close their lips and avoid talking to friends when they are chewing the betel leaf containing cocaine. Confirmed and experienced cocaine eaters, however, do not hesitate to swallow the saliva to get stronger effects from the dose. Those who are new to the drug and are afraid of its strong effect expectorate the saliva when chewing the betel leaf.
The stage of excitement after cocaine lasts from forty-five minutes to about two hours. There was a good deal of difference of opinion among cocaine eaters regarding the duration of the stimulant stage, undoubtedly due to the fact that mostof the drugs supplied was adulterated to a greater or lesser extent. The addicts who had been taking cocaine for long periods were sure that the pure drug which they formerly obtained had a much stronger and lasting action than the adulterated commodity they obtained later. The effects, they emphatically stated, certainly lasted for one hour to about two hours or even longer. They also said that in six months the pure alkaloid reduced the eater to a state of a physical and mental wreckage when large doses were taken. He became pale and thin "like a straw ", as many of them described the condition. The intoxication effect of the heavily adulterated drug (according to the majority of them) did not last for more than an hour or two.
During the stage of excitement, the cocaine eaters like the company of other eaters, and they mutually persuade each other to indulge more and more in the drug, thus leading to long cocaine debauches. The advanced hours of the night do not induce them to retire to sleep, as during cocaine intoxication the sensation of fatigue and drowsiness is entirely absent. In this respect cocaine differs from other euphoric substances such as opium, cannabis preparations or alcohol which sooner or later produce drowsiness and sleep. Many cocaine eaters related how, when indulging in cocaine, they sometimes did not sleep or even close their eyes for two or three nights. When, however, the debauch was finished and the effects of the drug had passed off, they experienced the results of their vigil in the form of an acute feeling of physical and mental fatigue, headache and extreme misery, till they dropped into natural sleep from sheer exhaustion. If a fresh dose of the drug is taken, even at this stage, it has a wonderfully reviving effect, the eater feeling more or less normal for the time being and capable of doing any kind of work. The resultant depression is much greater, because there is an irresistible desire to repeat the dose again and again in order to get over the loathsome depression which follows. When the drug is available, such doses may be repeated many times, and deaths have been recorded from cocaine poisoning on account of over-dosage. If another dose cannot be obtained, the cocaine eater feels absolutely lifeless and dejected and prefers to be left alone. He has a sensation of impending death.
During the stage of depression the eater experiences a strange fear of unpleasanthappenings, and persuades himself to take a fresh dose to get over this. The depression of spirits, however, seems to be more imaginary than real, for there is no fall of temperature, no effect on the pulse, heart or respiration. The tongue and lips become moist again, the perspiration on the forehead and neck stops altogether. During this period, the cocaine eater, avoids the company of his friends and associates, and has a feeling of hiding himself away from them and people in general. He may lie down in a quiet, dark corner refusing to speak to or even to face his friends. During, this stage also the cocaine eater may sometimes suffer from maniacal symptoms such as hallucinations, chiefly taking the form of persecution by the police or excise authorities. He imagines that the police are coming in search of him, and any noise or sound of footsteps startles him.
A large number of cocaine eaters are subject to paraesthetic sensations such as formication and crawling of insects or snakes or lice on the body or under the skin. Others get intense itching all over the body. A number of cases of insanity have followed a prolonged period of cocaine eating. While the individual is under the influence of cocaine, there is complete loss of appetite. There is no desire for food at all, and a cocaine eater will reject the daintiest dishes offered to him during this period. Often a very intense feeling of thirst is experienced.
Cocaine eaters suffer from a very obstinate type of dyspepsia which is believed by them not to yield to any other form of treatment except another dose of cocaine. On account of its stimulating effect on the ganglia of Auerbach's plexus, a dose of the drug in many eaters produces rapid evacuation of the bowels immediately after it is taken. This symptom was particularly noticeable in cocaine eaters of the Delhi area. Soon after taking the dose they had to run to the latrine, where they remained seated for a considerable time absorbed in their delusions. Constipation, however, is more common, and it is the most distressing sympton occurring in cocaine eaters. It was given by many as the reason for the repetition of the dose. It was said that the bowels were confined, and there was a very unpleasant sensation of fullness in the abdomen- the feeling being described as if the inside was full of stones. This was readily relieved by a dose of the alkaloid, the effect being so strong that a rush had to be made to the lavatory immediately after the drug was taken. Some cocaine eaters of old standing, however, were not worried much by either the constipation or other gastro-intestinal symptoms.
Another distressing sympton noticed in cocaine eaters was insomnia. They kept awake all night desiring a fresh dose of the drug. They simply could not sleep although they tried very hard. The ordinary hypnotic drugs appeared to produce little or no effect in producing sleep. Most of the cocaine eaters complained of insomnia, and it was very often for this reason that they consulted a doctor. In a few of the addicts who took fairly large doses, insomnia did not occur. Delusions and hallucinations greatly disturb the mental equilibrium of cocaine eaters and gradually make them very miserable. The prolonged use of the alkaloid is also said to bring about deafness, and confirmed cocaine eaters are said to be often slightly deaf. This was observed in a number of subjects studied by us.
In the case of stronger intoxication, whether through bigger doses or abnormal sensitiveness of the individual, hallucinatory symptoms quickly appear. These hallucinations (as already stated) are of the nature of persecution and paraesthesia of the skin. Sometimes, especially after larger doses have been taken, there is a feeling of sickness, nausea, vomiting and cramps in the muscles. If toxic doses of cocaine are taken, the eater may become semi-conscious and may suffer twitchings of the muscles of the face. General tremors of the body may occur, followed by convulsions. The body temperature shows a considerable tendency to rise. Convulsions can be easily controlled by sedatives and, if severe, inhalations of a general anaesthetic may benecessary. Very often they pass off, the patient gaining consciousness but feeling utterly exhausted and miserable. A dose of cocaine in this condition revives the victim almost immediately. Paralytic symptoms may appear if very large doses of the drug have been taken. This may be followed by coma and death from stoppage of respiration. These, of course, are extreme cases of intoxication, and are very rarely seen.
The foremost of these is a strong desire or a craving of the cocaine eaters to repeat the dose. After the effect of one dose is over, the desire for the next dose is almost irresistible. The one idea in the addict's head is to get another dose, and he will do anything to satisfy this craving. There is such a strong desire in some individuals for the drug that the eater will commit any kind of crime, and a woman will even sell her honour to get the drug. The eater feels restless, irritable, unable to concentrate, and quarrelsome. There is a great disinclination for mental and physical exertion, and he feels dull, drowsy and lazy. In fact, he is in a condition of complete lethargy and inertia; the gastro-intestinal functions are depressed; sometimes the symptoms of constipation, cramps and sensation of formication, etc., are delayed, not appearing for three to four days after the debauch. Rarely patients get so depressed that they feel they are going to die; they may become prostrated and may collapse. Such symptoms are met with much less frequently in the case of cocaine than with opium and morphine. A number of addicts, especially those taking large doses, lose all interest in their life and surroundings and develop suicidal and morbid tendencies. All these symptoms disappear for a while if a dose of the drug is taken.
Time of taking the Drug, and Dosage
Cocaine is generally taken by the eaters in India late in the evening or in the early hours of the night. Persons engaged in dissipation, who are confirmed and inveterate eaters, take it during all hours of the day in betel leaf. It was noticed that many of the artisans and workmen in Delhi did not take the drug except once during the evenings when they had finished their day's work. Others took it twice a day and no more. They generally took one or two doses of the drug or as much as they could afford, and then went home to rest. They said the effect of one dose lasted them for six to eight hours, and if they could get it they were able to carry on their daily vocation without any difficulty. Occasionally, however, some went on taking small doses of the drug all night, especially when they were in the company of prostitutes.
Dosage. The daily dosage consumed showed wide variations. The drug was very expensive and difficult to get; besides, it was often very heavily adulterated. The tendency to increase the dose was strong, and in the short space of a few weeks the dose was sometimes increased to 20 or 30 grains a day. Rich people as a rule were apt to take much larger doses than people with smaller means. The majority of the eaters took doses ranging from a half grain to 15 grains, the latter being the maximum limit among the ordinary type of eater. There were, however, exceptional cases where individuals were known to have taken as much as 60 grains in the course of a single night.
Cocaine addiction is a disease like other addictions, artificially produced by the individual himself. It has already been stated that neuropathic diatheses, neuroses, worry, exhaustion and mental instability or deficiency all act as predisposing factors to this drug habit. The addicts were in the majority of cases individuals with an initially unstable mental equilibrium. Cocaine being a general protoplasmic poison, it acts detrimentally on all the tissues of the body, particularly the nervous tissues. The habit undoubtedly leads to a state of chronic toxaemia. There are two types of poison concerned in producing a toxaemic state in cocaine eaters. These are:
(a)The exogenous poison - that, is the drug itself - which is absorbed from the mucous membranes of the mouth and pharynx and then circulates in the blood.
(b)The endogenous toxins which are formed by the action of the alkaloid on the general metabolic processes of the body and the biochemical changes thereby set up.
Both these factors combined interfere with the normal functions of the organs, giving rise to debility and anaemia. General toxaemia and improper assimilation of food lead to general wasting, sallow colour, anaemia and finally a cachectic condition.
General Appearance of Cocaine Eaters
The general appearance of cocaine eaters is very pitiable. It is not difficult to recognize them when one has seen a few. They are as a rule emaciated, sickly and flabby-looking individuals with a dull facial expression. They have no regard for personal appearance or cleanliness of body or clothes. They are pale and anaemic, have a sallow complexion, sunken eyes, dilated pupils, prominent cheeks, and look as if they are suffering from severe toxaemia.
When not under the influence of the drug, the cocaine eater looks a picture of misery. In the vast majority of eaters there is a blackish-red deposit on the teeth. This is said to be a very important sign in cocaine eaters in India and by some is regarded to be pathognomic. The usual colour of" pan" in the mouth is red on account of the catechu contained in it; the colour of the teeth and tongue of cocaine eaters is, however, dark brown or chocolate. The teeth appear stained with a dark reddish or black coloured deposit, and the tongue is also coated with dirty, dark coloured fur. Both these conditions are attributed to the fact that cocaine eaters do not pay any regard to the cleanliness of the mouth and teeth; the tongue therefore becomes very dirty. It is also possible that owing to the anaesthetic effect of the drug on the mucous membrane of the tongue, the cocaine eaters use much more lime in the "pan" than if the mucous membranes were sensitive. Many of the addicts have cracked lips, due probably to the irritating effects of the lime and the devitalizing action of the alcaloid on the various parts of the oral cavity. The parts become insensitive and, therefore, any mechanical or chemical injury is not readily felt and is aggravated. The coloration of the tongue and the teeth does not disappear even a month after the eating of the drug has been given up. The black deposit is more marked on the lower teeth, particularly on their posterior surfaces. It is more in evidence on the central incisors and canines, but not infrequently it extends to the last molar teeth. There is no doubt that this deposit is due to chemical changes taking place between lime, catechu and the alkaloid in the alkaline medium of the saliva. Those who wash out their mouth immediately after they have taken the "pan" with the drug as a rule do not have these deposits to the same extent. This dark red colour of the teeth and tongue is one of the signs by which cocaine addicts can be recognized in India. Some people, however, use a preparation called "missi" which gives a black colour to the teeth very similar to that of cocaine.
Cocaine undoubtedly has a well-marked toxic action on the digestive system. It has already been pointed out that habitual cocaine eaters suffer from persistent loss of appetite due to the dulling of the sensibility of the mucous membrane of the stomach. They take very little by way of food and drink, and can do without any nourishment for days when they are taking the drug. This naturally interferes with the nutrition of the body, and produces emaciation and wrinkling of the skin. It was observed that individuals who were strong, robust and handsome became pale, emaciated and dark, and looked physical wrecks in the course of time. Some of them were reduced to mere skeletons. Sometimes, but rarely, cocaine eaters have a craving for eating earth. Owing to the stimulant action of the drug on the sympathetic system, cocaine eaters generally suffer from relaxed condition of the tone of the intestinal musculature. It is this which produces the obstinate constipation and stasis of the gut contents leading to toxaemia, which has been described above (p. 19).
Circulatory and Haemopoictic Systems
Stimulation of the sympathetic nerves and ganglia in the heart gives rise to palpitation and acceleration of the pulse rate. The pulse becomes full and its frequency does not, as a rule, exceed 115 per minute. After the dose, the blood pressure usually rises and there is a throbbing sensation in the arteries of the neck and the blood vessels look full. When the stimulant effect of the close is over, the pulse generally shows some slowing. Auscultation of the heart immediately after a dose reveals increased frequency and force of the heart beats. In anaemic persons, murmurs may be heard. Besides this the alkaloid, especially in large doses, has a toxic action on the myocardium, and in old-standing addicts and those taking large doses the pulse is weak and the blood pressure low. Even after moderate doses there is stimulation of the sympathetic nerves and depression of the vagus, but after the stimulation there is generally a paralytic condition of the sympathetic system.
As regards the effect of cocaine on the haemopoictic system, there is little doubt that the drug has a direct action on the blood-forming organs, especially when taken in large doses. It also produces an indirect action by producing intestinal stasis and toxaemia and through the malnutrition it brings about.
Soon after taking the dose the respiration is quickened. When large doses are taken there is marked quickening at first, the respiration becoming deeper and more frequent. This effect is undoubtedly produced by the stimulation of the respiratory centre. With toxic doses there is a slowing down, and the respiration may assume the Cheyne-Stokes type.
The amount of urine in cocaine eaters is said to be diminished, but we have not been able to carry out any observations on that point. Probably this is due to a smaller intake of both food and drink. The urine of a number of eaters in this series did not show any abnormal constituents; the quantity of the alkaloid, if it is excreted by the kidneys, is probably too small to be detected by the ordinary alkaloid-precipitating reagents. None of the addicts complained of passing abnormally small quantities of urine, but tenesmus of the bladder was observed, especially after large doses. Women taking cocaine habitually suffer from backache, leucorrhoea and often from amenorrhoea and dysmenorrhoea.
Nervous System and Sensory Organs
The central nervous system is the greatest sufferer from cocaine eating, the highly developed nerve cells of the grey matter suffering most of all. These cells are at first violently stimulated, and the stimulation is followed by a reactionary depression. The effects, such as delusions, hallucinations, impairment of character and low state of mental efficiency and sometimes a sort of chronic insanity called "cocaine paranoia ", can all be thus explained.
We found that prolonged use and excessive indulgence lead to great mental impairment, and a drift towards insanity. We observed a few cases of epilepsy, the fits having started after the commencement of the habitual use of the drug. Some addicts suffered from suicidal and homicidal impulses, the former being more common. All these effects are no doubt brought about by the persistent use of the drug resulting in structural changes in the nervous tissue. The most distressing of all symptoms was insomnia of a very obstinate nature.
There may be widening of the palpebral fissure and the cornea may have a glassy appearance. The eyeballs also pro-trude, owing to sympathetic irritation. In two of our cases at least there was impairment of vision and hearing was generally impaired. The deafness occurring among cocaine eaters was probably due to the paralysing effects of the alka- loid on the auditory nerve endings. The superficial and deep reflexes were not affected. The skin was pale, there was loss of subcutaneous fat, and in some cases a peculiar rash was observed. Paraesthesias were frequently met with (in 30% to 40% of addicts in this series). The paraesthesias appeared and disappeared.
Cocaine has the reputation in India of being perhaps the most important euphoric drug to be associated with the stimulation of sexual functions. For this reason it is closely associated with sexual vice and prostitution. Quite a large number of this series started the drug for its alleged stimulating effect on the sexual faculties. On careful questioning, however, none of the cocaine eaters could say definitely that the drug possessed any marked stimulant effect on the sexual faculties and appetite. During the general stimulation of the higher parts of the brain which follows indulgence in this drug, there is undoubtedly sharpening of all the senses and faculties and this may produce a semblance of sexual stimulation. Even in this state the alkaloid has no specific exciting effect on the sex organs either in the male or in the female. It has been stated that the period leading up to ejaculation is greatly extended in man, but most cocaine eaters said that the sexual act was not in any way strengthened or prolonged; as a matter of fact, most of them said that it was distinctly weakened. When deeply under the effect of the drug, cocaine eaters said it was impossible to perform the sexual act. It was during the depression period that, according to some of them, the act was considerably strengthened and the ejaculation time markedly extended.
As regards the effect of the drug on the female sex, data in this respect have been very limited, being confined only to a few prostitutes. In his able memoire on cocaine addiction, Professor Hans W. Maier (1926) stated that owing to the stimulation of the psychic areas, bodily erotic attractions increase in those who are inclined that way. Habitual use of cocaine in such individuals generally has a sexual origin, and the users show all possible perverse symptoms and loss of moral control. Homosexuality is not uncommon amongst those indulging in the drug, and this was actually observed in some cocaine eaters of Uttar Pradesh. Sexual depravity is undoubtedly due to loss of control of the higher centres which is present under normal conditions and is absent in cocaine eaters. Hetero-sexuality may change to homosexuality during intoxication. It was definitely stated that the sexual desire certainly increased among the female cocaine eaters.
A number of cocaine eaters stated that cocaine has a distinct depressant action on sexual functions in all stages. A few said that in the beginning the sexual act was somewhat prolonged but a distinct weakening effect was produced later on in the course of its habitual use. Others stated that they felt no sexual desire while under its influence, but the desire returned after its effect had passed off and then he or she experienced voluptuous feelings. Still others definitely stated that they did not get erections while under the effect of the drug, their only desire at that time being for a fresh dose. These people felt sexually fit only when the intoxication produced by the drug had entirely passed off.
It would be interesting to note here that not a few of the cocaine eaters, especially those who had taken the drug for a long time, complained of sexual neurasthenia and complete loss of sexual desire and disinclination for the company of the opposite sex.
Social and Moral Effects
Cocaine eaters are generally despised in India. The cocaine eater, contemptuously called "cocaine baz" (one indulging in cocaine) is intensely disliked by those round him. It was noticed that almost all cocaine eaters were persons of low morals and that they were habitual liars and pilferers. No one would trust them in business matters, and their evidence in court was not relied upon. Their company was considered to be objectionable by their neighbours and relations. They had lost all sense of self-respect and would resort to anything, however despicable or criminal, to secure their daily dose when it was not forthcoming by fair means. Some of them said that they would simply take the dose from another by force if they could not obtain it by other means. It has been stated that the reason why cocaine among all other narcotic drugs deserves the fullest attention is first, the easy way of its application (i.e., by eating in "pan "); secondly, because the drug is not indulged in isolation by the addict like some of the other narcotics- it is taken in company and its use spreads like a contagious disease; lastly, its disintegrating and demoralizing effect on the character of the individual paves the way to prostitution and crime.
The cocaine eater in India, so far as it can be judged from this small series, is more dangerous to himself than to other members of the society from a criminal point of view. Many cocaine eaters of the artisan class observed by us carried out their daily vocations and indulged in the drug only in the evening for an hour or two, afterwards returning to their homes or spending the night in the company of some women. They took the drug, they said, just to experience the exquisite feeling produced by it. When asked to describe what sensation they felt, they said that they could not describe it in words, just as they could not describe the sensation of pleasure obtained during the sexual act. They all said that the sensation was so wonderful and fascinating that they were prepared to face all consequences to obtain it even for a short space of time.
A number of cocaine eaters said that they repeated the dose of the drug because of the severe constipation from which they suffered, and because of the most distressing feeling in the abdomen, which could not be relieved except by a dose of cocaine. They all loathed the habit and wished to be rid of it. They begged us to find something which would help them to conquer the craving. They all remembered their first introduction to the drug and cursed the person who was responsible for introducing them to the habit.
Strength of the Habit
The cocaine habit once formed is very difficult to give up, although it is believed by some to be not more difficult to abandon than the opium habit. Prolonged use leads to mental deterioration and weakness of will power, so that the individual seldom has the strength to give it up. The withdrawal symptoms already described, especially insomnia, cramps in the muscles, constipation, disturbance in the abdomen, etc., make it all the more difficult. Proper guidance, complete removal from the environment and improvement of the physical condition and vitality of the patient may help him to resist.
VII. DIAGNOSIS AND TREATMENT
In India it is not difficult to diagnose cases of cocaine addiction after one has seen a few eaters. The following are the chief points which help in diagnosing a cocaine eater.
The general appearance of the addict: he is generally young, emaciated, with sallow complexion, sunken eyes, wrinkled face and dilated pupils.
The dark, chocolate-coloured deposit on the teeth and the tongue. (This deposit is more marked on the incisors and canines, particularly on their posterior face.)
Such symptoms as hallucination, delusions of a persecutory nature, moral and mental degeneration.
The treatment is general. The most important points to be remembered are:
(1) Removal of the cocaine eater from the environment in which he indulges in the habit, and from the associates in whose company he takes the drug, preferably to a place where he cannot get the drug. This is very important. We have known instances where individuals went from Delhi or Saharanpur for a few months to the Punjab where they were unable to get the drug and where they had no associates. They conquered the craving for months without much difficulty. When, however, they returned to their old surroundings (where they were able to obtain a supply of the drug) they again succumbed to the temptation. Similar facts have been observed in cases of cocaine eaters who were sent to prison. The habitual use of the drug was given up in goal without difficulty for years, but immediately on release the use of the drug was started again.
(2) Psychotherapy, mental training and impressing upon addicts the gravity of continuance of the cocaine habit are very important.
(3) The drug must be withdrawn all at once.
(4) The rest of the treatment is simple and symptomatic.
Cramps and insomnia should be treated by simple means such as massage, exercises, hydrotherapy (warm baths). If there is need for a sedative, bromides should be given; chloral and paraldehyde should be used with caution, while hypnotics such as opium and morphia are absolutely contraindicated.General tonics such as iron and strychnine and vitamins should be given. Quinine, strychnine, iron and arsenic in pill form are very useful. Constipation should be treated by simple means such as warm soap enema or saline purgatives. Drastic purgatives are not recommended.
Diet should be simple, easily digestible and nutritious, such as milk, soups, vegetables (minced and well cooked), and fruit juices. Farinaceous vegetables and fats should as a rule be avoided in the early stages of treatment.
(1) Erythroxylon coca has never been cultivated in India on a large scale. So far as is known, no other varieties of Erythroxylon, which bear cocaine, grow wild in India or are cultivated. The leaves of E. coca have never been used in India for euphoric purposes.
(2) The use of cocaine for euphoric purposes is of comparatively recent origin in India, the earliest records of its use being less than a hundred years old.
(3) During the period between the two world wars habitual use of cocaine in" pan" (prepared betel leaf) became a serious menace in the towns of certain states of India. The evil effects produced came to the notice of the medical profession and the authorities. Severe restrictions were at once placed on the import, sale, possession, transport and use of the alkaloid and the preparations in which it was contained and ecgonine from which it can be manufactured. In spite of this, the habit spread from Calcutta to large towns along the two main railway routes through the Uttar Pradesh into the Punjab and the North-West Frontier. From Bombay it spread to some of the large towns in that state.
(4) Cocaine was smuggled into India in large quantities from the Far East through seaports, particularly Calcutta. It was illicitly brought by crews of various lines of mercantile marine from the Far East, especially Japan, where it was manufactured. It was distributed to different parts of the country by smuggling organizations, through a network of pedlars. Smuggled cocaine was generally very heavily adulterated, the chief adulterants used being phenozone, phenacetine, caffeine citrate, acetyl salicylate and potassium nitrate.
(5) The habit of cocaine eating was chiefly prevalent among the betel leaf chewing population of the north western region of India (including the States of Bengal, Bihar, Uttar Pradesh and, to a lesser extent, the Punjab). It was estimated that about half a million cocaine eaters belonging to different strata of society existed during the period between the two world wars. The habit was foremost among the artisan class in large towns.
(6) With regard to the present extent of cocaine eating in India, it is not possible to form any idea. The legal imports of cocaine from 1934 to 1957 as well as the seizures of illicit imports indicate that the use of cocaine for euphoric purposes is not large, but there is no doubt that it does exist.
(7) Two hundred cocaine eaters were examined and studied. Analytical data are given regarding the causes leading to cocaine addiction; its duration; the occupation of the addict; the dosage; the sex incidence; its effects on sexual functions; its association with other drug habits, etc.
(8) The main causes leading to cocaine addiction were association with other eaters (66% of cases in this series); luxury and pleasure (21%); fatigue, worry and strain (6.5%); curiosity and fancy (4.5%) and disease (2%). The habit is chiefly confined to individuals whose psychic condition is in an unstable state of equilibrium.
(9) The most common method of taking cocaine in India is by putting it in a "pan ". The drug is either mixed with spices, which are usually put in "pan ", or some of the addicts place the alkaloid on the tongue and then chew the betel leaf afterwards. Addicts of long standign generally put cocaine on the tongue and follow it up by a little lime and catechu, diespensing with the betel leaf. This is believed to enhance the action of the drug. The method of taking the drug by injection or taking it in the form of snuff is unknown in India.
(10) The symptoms produced in cocaine eaters as observed in the small series of 200 cases are described in detail. The deleterious effects of the habit on the physical, mental and moral condition of the addict are discussed.
(11) The diagnosis of cocaine addiction and its treatment are described.
BOSE, K. C. : Indian Medical Gazette , 1902, p. 85002
TUKE, A. W. : Ibid., 1914, p. 254003
MAIER, Hans W.: Der Kokainismus , Georg Thieme Verlag Leipzig, 1926004
CHOPRA, R. N. & CHOPRA, G. S. : Indian Journal Medical Research , 1931, 18:3005
LEWEN, L. : Phantastica, London, 1931006
CHOPRA, R. N. : Indian Medical Gazette, 1935, 70: 3, 121