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Neuropsychology
 Neuropsychology
A Review of Science and Practice, III

Edited by
Sandra Koffler
Independent Practice
Philadelphia, Pennsylvania

E. Mark Mahone
Kennedy Krieger Institute
Johns Hopkins University School of Medicine
Baltimore, Maryland

Bernice A. Marcopulos
James Madison University
Harrisonburg, Virginia
University of Virginia
Charlottesville, Virginia

Douglas Johnson-​Greene
Miller School of Medicine
University of Miami
Miami, Florida

Glenn Smith
Clinical and Health Psychology
University of Florida
Gainesville, Florida

1
 1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

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© Oxford University Press 2019

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Library of Congress Cataloging-in-Publication Data

Names: Koffler, Sandra, editor. | Mahone, E. (E. Mark), editor. | Marcopulos, Bernice A., editor. |
Johnson-Greene, Douglas Eric, 1962– editor. | Smith, Glenn E., editor.
Title: Neuropsychology : a review of science and practice, volume III / edited by Sandra Koffler, E. Mark
Mahone, Bernice A. Marcopulos, Douglas Johnson-Greene, Glenn Smith.
Description: New York, NY : Oxford University Press, [2019] | Includes bibliographic references.
Identifiers: LCCN 2018035009 | ISBN 9780190652555
Subjects: LCSH: Clinical neuropsychology. | Neuropsychiatry.
Classification: LCC RC341 .N43558 2019 | DDC 616.8—dc23
LC record available at https://lccn.loc.gov/2018035009

1 3 5 7 9 8 6 4 2

Printed by WebCom, Inc., Canada

 Contents

Preface to Volume III vii

Contributors ix

1. Studies in Cannabis Use: Year in Review 1

Ileana Pacheco-​Colón, Jacqueline C. Duperrouzel, and Raul Gonzalez

2. Hypertension and Cognitive Impairment in Older Adults: Review and

Update 22
Richard F. Kaplan and Lauren Strainge

3. Technologically Enhanced Neuropsychological Assessments:

Review and Update 59
Thomas D. Parsons and Robert Kane

4. Cross-​Cultural Tests in Neuropsychology: A Review of Recent Studies and

a Modest Proposal 93
Alberto Luis Fernández and Bernice A. Marcopulos

5. Interventions for Functional Impairments 129

Alyssa Weakley and Maureen Schmitter-​Edgecombe

6. Recent Research Trends in the Neuropsychology of HIV Disease 171

David P. Sheppard, Savanna T. Tierney, Kelli L. Sullivan, Victoria M. Kordovski,
Gunes Avci, and Steven Paul Woods

7. Parkinson’s Disease: Recent Strides 211

Alexander I. Tröster

8. Pediatric Epilepsy Update 243

Madison M. Berl

Index 277

v
 PREFACE TO VOLUME III

This, the third volume of the series Neuropsychology: A Review of Science and Practice,
will provide the reader with timely and comprehensive reviews of the literature rel-
evant to clinical neuropsychology and related professions. Unique to this series, the
practitioner, investigator, and student will find that the chapters in Volume III con-
tribute to practice in its most broad definition: in the office, the laboratory, and the
classroom. The reviews in this volume provide resources for furthering ongoing re-
search, providing incentives for new studies and enhancing our value and service to
patients. Following is a brief summary of the chapters.
In Chapter 1, on cannabis and neurocognition, Pacheco-​Colón, Duperrouzel, and
Gonzalez report their review of 30 neurobehavioral and neuroimaging studies. They
found that the non-​acute effects of cannabis use are heterogeneous, but earlier onset
and heavier use are associated with memory and executive functioning deficits in
adults. The effects on adolescents are mixed. The authors conclude that in order to
further understand the long-​term effects of cannabis use, confounding variables such
as cannabis composition and potency must be considered.
In Chapter 2, literature on arteriosclerosis, the small vessel disease of the brain,
is reviewed by Kaplan and Strainge for its association with age-​related cognitive de-
cline, dementia, and possible late-​life depression. The association of hypertension and
aging as risk factors for small vessel disease is reviewed, as well as the significant di-
agnostic studies that identify the associated brain lesions. Studies on the moderating
factor of cognitive reserve and the implications for clinical practice are presented.
Drs. Parsons and Kane, in Chapter 3, provide a state-​of-​t he-​art technology review
of technology-​enhanced assessment for the field of neuropsychology. The authors
consider advances in technology-​enhanced assessment of specific conditions such
as attention deficit disorder, concussion, and cognitive aging. They discuss the dif-
ferent platforms (e.g., web-​based vs. tablet-​based) for administering more classic as-
sessment paradigms. Parsons and Kane explore how neuropsychology practitioners
may engage in telemedicine to expand access to clinical services. They further ex-
plore how technology can be deployed to enhance ecologically valid assessments.
This chapter is a primer on how ubiquitous technology is changing the status quo.
Chapter 4, on cross-​cultural tests, reviews recent literature on cross-​cultural neu-
ropsychological assessment with a focus on adults. Three methods for addressing this
issue are evaluated by Fernández and Marcopulos: (1) adapting existing tests through
language translation and norm development; (2) developing new tests specific to the
culture of interest; and (3) developing universal tests that can be adapted and used
with any language and culture.

vii
 viii preface to volume iii

In Chapter 5, on interventions for functional impairments, Weakley and Schmitter-​

Edgecombe observe that many neurological conditions result in functional deficits
with an inability to perform occupational tasks and activities of daily living that are
necessary for a person to remain living independently. Neuropsychological tests en-
able us to understand the relationship between cognitive and functional impairments
and provide evidenced-​based interventions. This chapter highlights cognitive inter-
vention approaches, compensatory strategies, and assistive technology, such as vir-
tual reality, aimed at improving and promoting functional independence and quality
of life for persons with functional impairments.
Chapter 6, on the neuropsychological effects of HIV, summarizes an extensive
literature pertaining to cognition and HIV, including the latest findings on HIV-​
associated neurocognitive disorders (HAND) and the influence of clinical, demo-
graphic, and other moderating factors. Sheppard, Tierney, Sullivan, Kordovski, Avci,
and Woods review the latest data on prevalence and screening and the impact of
HAND on functioning, as well as its treatment with pharmacological interventions
and cognitive rehabilitation.
The cognitive findings in patients with Parkinson’s disease are reviewed by Tröster
in Chapter 7, with emphasis on the role of clinical neuropsychology in documenting
the changes that may take place. Included are studies evaluating individuals at risk
for Parkinson’s disease, the Parkinson’s associated risk Syndrome (PARS), and per-
sons who are genetically at risk. Mild cognitive impairment is reviewed with respect
to different presentations (subtypes) and their implication for further cognitive de-
cline. The validity of differences in screening instruments is discussed.
Epilepsy is a common neurological disorder among children but is not unitary;
rather, epilepsy is a complex set of disorders that often co-​occur with several other
neurodevelopmental disorders. In Chapter 8, on pediatric epilepsy, Berl provides an
opportunity for neuropsychologists to update their practice and contributes to our
understanding of the field, reporting advances in neurosurgery, genetics, pharmaco-
logical treatment, neuroimaging, and big data analysis.
 CONTRIBUTORS

Gunes Avci Victoria M. Kordovski

Department of Psychology Department of Psychology
University of Houston University of Houston
Houston, Texas Houston, Texas

Madison M. Berl Bernice A. Marcopulos

Division of Neuropsychology Department of Graduate Psychology
Children’s National Health System James Madison University
Washington, DC Harrisonburg, Virginia
Department of Psychiatry and
Jacqueline C. Duperrouzel
Neurobehavioral Sciences
Center for Children and Families
University of Virginia
Department of Psychology
Charlottesville, Virginia
Florida International University
Miami, Florida Ileana Pacheco-​Colón
Center for Children and Families
Alberto Luis Fernández
Department of Psychology
Department of Psychology
Florida International University
Universidad Católica de Córdoba
Miami, Florida
Universidad Nacional Córdoba
Cordoba, Argentina Thomas D. Parsons
Computational Neuropsychology and
Raul Gonzalez
Simulation Laboratory
Center for Children and Families
NetDragon Digital Research Center
Department of Psychology
Department of Learning Technologies
Florida International University
University of North Texas
Miami, Florida
Denton, Texas
Robert Kane
Maureen Schmitter-​Edgecombe
Cognitive Consults and
Department of Psychology
Technology, LLC
Washington State University
Washington, DC
Pullman, Washington
Richard F. Kaplan
David P. Sheppard
Departments of Psychiatry and
Department of Psychology
Neurology
University of Houston
University of Connecticut Health
Houston, Texas
Farmington, Connecticut

ix
 x contributors
Lauren Strainge
Department of Psychological Sciences
University of Connecticut
Stores, Connecticut
Kelli L. Sullivan
Department of Psychology
University of Houston
Houston, Texas
Savanna T. Tierney
Department of Psychology
University of Houston
Houston, Texas
Alexander I. Tröster
Department of Clinical
Neuropsychology and Center for
Neuromodulation
Barrow Neurological Institute
Phoenix, Arizona
Alyssa Weakley
Department of Psychology
Washington State University
Pullman, Washington
Steven Paul Woods
Department of Psychology
University of Houston
Houston, Texas
 1
Studies in Cannabis Use
Year in Review

Ileana Pacheco-​Colón, Jacqueline C. Duperrouzel,

and Raul Gonzalez

INTRODUCTION
Many patients presenting for neuropsychological assessments, in either the clinic or
the laboratory, have used cannabis at some point in their lives. During 2015, 44%
of Americans over 12 years of age reported ever having used the drug and 8.3%
endorsed past-​month use (Center for Behavioral Health Statistics and Quality, 2016).
Among 12th graders, 45% have used cannabis and 23% have used in the past month
(Johnston, Miech, O’Malley, Bachman, & Schulenberg, 2016). Annual prevalence of
use rose from 24% during 1991 to 36% during 2016 among 12th graders. Concurrently,
public opinion toward legalization of cannabis has become more permissive. When
the Pew Research Center began surveying, in 1969, public opinion toward cannabis
legalization, 12% supported legalization, whereas 84% did not (Pew Research Center,
2016). A reversal occurred more recently, with 57% of Americans supporting and
37% opposing cannabis legalization during 2016. Consistent with these trends, 28
U.S. states have passed medical marijuana laws and 8 have legalized recreational use
for adults over the age of 21. These trends can also be observed around the world. For
instance, Uruguay legalized recreational use, while other countries such as Germany,
Canada, Argentina, Czech Republic, Italy, and Mexico have passed medical mari-
juana legislation. Also, in countries like the Netherlands and Spain, cannabis use is
decriminalized and largely tolerated.
Cannabis and its constituents are also the subject of research efforts focused on
medical applications. Results from studies examining the effectiveness of cannabis
as medicine suggest that it may be effective for treating nausea among patients with
cancer, anorexia among those with cancer or HIV, pain among patients with HIV or
multiple sclerosis (MS), and urinary dysfunction in those with MS (Borgelt, Franson,
Nussbaum, & Wang, 2013; Koppel et al., 2014). A recent meta-​analysis examined
79 clinical trials and concluded that cannabinoids may be beneficial for nausea and
vomiting, pain reduction, and reduced spasticity (Whiting et al., 2015). If the trend for
medical cannabis continues to grow, one can expect additional patients presenting for
1
 2 neuropsychology: a review of science and pr actice, iii

neuropsychological assessment with cannabis included in their list of medications,

particularly considering that many of the medical applications to date have focused
on disorders that affect the central nervous system (e.g., MS, epilepsy, HIV). Thus, it
could be argued that it is now more important than ever for neuropsychologists to be
aware of the effects of cannabis on neurobehavioral functioning in order to consider
its impact on observed test results and inform diagnostic decision-​making.
The effects of cannabis on the central nervous system occur primarily through ac-
tivity at cannabinoid receptor type 1 (CB1) (Pertwee, 2006, 2008). CB1 receptors are
located throughout the cortex and densely concentrated in numerous brain regions
important for cognition and psychomotor functioning (Glass, Faull, & Dragunow,
1997). Thus, it is not surprising that cannabis use (particularly when use is regular)
has an impact on neurobehavioral functioning. Two meta-​analyses synthesized
results from studies examining associations between cannabis use and neuropsy-
chological functioning. Both focused on non-​acute effects (i.e., when participants
were not acutely intoxicated) and included only studies that attempted to control
for critical confounds that would otherwise hamper interpretation of findings. The
meta-​analysis by Grant, Gonzalez, Carey, Natarajan, and Wolfson (2003) included
15 studies, resulting in data from 704 cannabis users and 484 non-​using controls.
Levels of cannabis use varied widely across and within study samples, ranging from
one to seven times per week to at least 22 days out of the previous 30 days. Overall,
evidence emerged for a “residual cannabis effect” that was statistically significant
but small in magnitude (effect size [ES] = −.15, 99% confidence interval [CI] [−.29,
−.02]), suggesting that cannabis users’ neuropsychological performance was about
one-​sixth of a standard deviation (SD) worse than that of controls. For individual
neuropsychological domains, the only statistically significant effects were observed
for learning (ES = −.21, 99% CI [−.39, −.02]) and forgetting (ES = −.27, 99% CI [−.49,
−.04]). A more recent meta-​analysis by Schreiner and Dunn (2012) used guidelines
for study inclusion and grouping of neurocognitive domains that were similar to
those used by Grant et al. (2003) but included only studies published since 2000,
to minimize overlap. Their analyses included 33 studies, yielding 1,010 cannabis
users and 839 controls. An overall negative association between cannabis use and
neuropsychological functioning was also observed (ES = −.29, 95% CI [−.46, −.12]).
Significant detrimental effects of cannabis use were observed for learning (ES = −.35,
CI 95% [−.55, −.15]) and forgetting/​retrieval (ES = −.25, CI 95% [−.47, −.02]), abstrac-
tion/​executive functions (ES = −.21, CI 95% [−.38, −.05]), attention (ES = −.36, CI 95%
[ES = −.56, −.16]), motor skills (ES = −.34, CI 95% [−.57, −.11]), and verbal/​language
(ES = −.23, CI 95% [−.47, −.001]). Thus, both meta-​analyses suggest that cannabis
use is associated with poorer neuropsychological functioning, with the magnitude of
these effects hovering around one-​t hird of a standard deviation.
This chapter reviews key studies published mainly in 2016 focusing on can-
nabis and neurobehavioral functioning, as well as those focusing on neuroimaging
outcomes. With the exception of a few studies, we focused on studies examining
effects of cannabis when individuals were not acutely intoxicated (as would be the
usual case in the clinic or laboratory). Our review is organized such that new review
 3 Studies in Cannabis Use: Year in Review

articles and meta-​ analyses are discussed first, followed by new cross-​ sectional
studies, and finally a review of new longitudinal studies. Cross-​sectional studies con-
tinue to yield valuable insights into the effects of cannabis and have been valuable
in advancing research in this area. Yet, they have an important limitation: they pre-
clude making strong causal inferences between use of cannabis and declines in neu-
ropsychological functioning. They do not answer the question, “Does cannabis use
cause declines in neuropsychological functioning?” Studies that assess how changes
in cannabis use prospectively influence changes in neuropsychological functioning,
compare neuropsychological performance before and after onset of cannabis use, or
make use of co-​t win designs are more apt for inferring causation. Thus, we review
these studies separately. Although such studies have been rare in the past, they are
now rapidly emerging. Each section is further subdivided into neurobehavioral and
neuroimaging studies. Finally, we briefly summarize some notable studies that do
not fall neatly into the aforementioned categories but that we thought would still be
of interest to readers. We then offer a summary and conclusion.

REVIEWS AND META-​A NALYSES

Neurobehavioral Studies
Several reviews examining the links between cannabis use and neurocognition were
published in 2016. Ganzer, Bröning, Kraft, Sack, and Thomasius (2016) conducted
a systematic review of 38 studies between 2004 and 2015 examining the residual
neurocognitive effects of cannabis use in adolescents and adults after a prolonged
period of abstinence. Overall, the findings regarding neurocognition were hetero-
geneous. Most studies reported some deficits in attention or concentration in absti-
nent cannabis users, as well as in different aspects of memory. There were, however,
mixed findings in the domains of inhibition, impulsivity, visuospatial functioning,
and decision-​making. Although not many studies examined motor function, most of
those that did reported worse performance in abstinent users relative to non-​using
controls even after prolonged abstinence. Furthermore, results suggested that neu-
ropsychological functioning in individuals who initiated cannabis use at an earlier
age was not significantly different from that of individuals with a later age of onset
(Ganzer et al., 2016).
On the other hand, a review by Curran et al. (2016) identified episodic memory
impairments as the most consistently reported long-​term effects of cannabis use, while
findings for working memory, attention, and impulsivity were mixed. Somewhat
similarly, Broyd, van Hell, Beale, Yücel, and Solowij (2016) identified verbal learning
and memory as the neurocognitive domain most consistently impaired by acute and
long-​term cannabis use. This review suggested that impairments in working memory,
attention, and psychomotor performance are observed with acute cannabis intoxica-
tion, and may persist with chronic cannabis exposure, but are often resolved with
long periods of abstinence (Broyd et al., 2016). Different subdomains of executive
functioning also appear to be differentially affected by acute and chronic cannabis
 4 neuropsychology: a review of science and pr actice, iii

exposure. Specifically, there are clear acute impairments in inhibition, but the effects
on planning, problem solving, reasoning, and interference control are mixed (Broyd
et al., 2016).
Overall, findings on the effects of cannabis use on neurocognition appear heter-
ogeneous. As a possible explanation for this heterogeneity, Volkow et al. (2016) pos-
ited that the magnitude of neurocognitive impairment and the persistence of this
impairment after abstinence may depend on factors such as frequency and duration
of cannabis use, age of onset, and the length of the abstinence period. Furthermore,
the aforementioned reviews identify gaps in our knowledge and suggest areas for
future investigation, such as the neurocognitive effects of varying levels of cannabis
use at different stages of neural development (such as during adolescence), as well as
elucidating the effects of different types of cannabis (high vs. low potency; different
ratios of tetrahydrocannabinol [THC] to cannabidiol [CBD]) on neurocognition
(Broyd et al., 2016; Curran et al., 2016; Ganzer et al., 2016; Volkow et al., 2016).
Finally, Schoeler, Kambeitz, Behlke, Murray, and Bhattacharyya (2016) conducted
a meta-​analysis investigating the effects of cannabis on memory performance in
healthy individuals and patients with psychosis. Across 88 studies comprising 7,697
healthy participants and 3,261 patients with psychosis, results revealed moderate ef-
fect sizes suggesting that cannabis use in healthy individuals was associated with sig-
nificantly impaired prospective memory, and small effect sizes for impaired global,
verbal immediate and delayed recall, and visual recognition. In those with psychosis,
however, there were small to moderate effect sizes suggesting that cannabis use was
associated with better global memory, visual immediate recall, and recognition rel-
ative to healthy cannabis users. Healthy cannabis users had higher depression scores
than age-​matched non-​users, and cannabis-​using patients had lower depression levels
and were of a younger age than non-​using patients. Thus, while cannabis appears to
have differential effects on memory for users with and without psychotic disorders,
these differences may have been due to the confounding influences of variables like
depression and age. Specifically, the lower level of depression and younger age of the
cannabis-​using patients with psychosis may have attenuated the adverse effects of
cannabis on memory. Furthermore, longer duration of abstinence reduced cannabis
effects on memory across groups.

Neuroimaging Studies
Lorenzetti et al. (2016) conducted a review of 13 functional magnetic resonance im-
aging (fMRI) studies that involved tasks assessing working memory (e.g., N-​back),
inhibition (e.g., go/​no-​go), and reward processing (e.g., monetary incentive delay
[MID]) in adolescents. All studies reviewed cross-​sectionally compared healthy non-​
using controls to cannabis user groups, with most samples smoking a mean of 400
lifetime occasions. Results suggested altered brain function in the frontal-​parietal
network, a network thought to mediate cognitive control, particularly among heavier
users. Abnormalities reported across studies were heterogeneous across tasks, yet
hyperactivity in the posterior parietal region and medial prefrontal cortices was
 5 Studies in Cannabis Use: Year in Review

consistently cited relative to non-​cannabis-​using controls. Hyper-​and hypoactivity of

anterior cingulate cortex, superior frontal regions, and cerebellum were also reported
in abstinent users compared to controls. However, despite observed differences in
brain activation, there were no significant differences in behavioral task performance
between adolescent cannabis users and controls. The study samples reviewed were
relatively small (n = 7–​28) and consisted of mostly male participants with an average
age of 18, which may limit the generalizability of these findings to other adolescent
cannabis users. Furthermore, few of these studies controlled for the influence of po-
tential confounds, such as other substance use and mental health problems.
Another review of 31 structural neuroimaging studies examined associations be-
tween levels of cannabis use and neuroanatomical alterations among adolescents
and adults (Lorenzetti, Solowij, & Yücel, 2016). Brain regions most consistently re-
ported as altered relative to non-​using controls were the hippocampus (reductions in
volume and shape), amygdala, striatum, cerebellum, and orbitofrontal, parietal, and
insular cortices. Unsurprisingly, these regions, which are dense in CB1 receptors,
are thought to be most vulnerable to the neurotoxic properties of high levels and
exposure to THC during adolescence. The authors noted that CBD, a potentially
therapeutic compound found in cannabis, may provide neuroprotection to these re-
gions. Of note, recent changes in cannabis composition and potency may contribute
to these neural alterations, as low levels of CBD and high levels of THC are common
in recreational cannabis. Despite these findings, the wide array of measurements of
cannabis use and cannabinoid levels (i.e., dose, frequency, duration, age of onset) re-
ported across studies continues to be a limitation.
Similarly, a review by Weinstein, Livny, and Weizman (2016) of 103 structural and
functional studies suggested differences in gray matter and white matter volumes,
blood oxygenation level–​dependent (BOLD) response, and neurotransmitter re-
lease between cannabis users (i.e., regular and recreational users) and non-​users.
Definitions of regular cannabis use varied across studies. The authors concluded
that regular cannabis use was associated with no global structural changes, although
alterations were consistently reported in the hippocampus and parahippocampus,
as well as frontal and cerebellar regions. Additionally, alterations in BOLD re-
sponse in structures implicated in executive functioning, decision-​making, atten-
tion, memory, inhibitory control, and emotional processing were identified among
users when compared to non-​users during functional and resting-​state neuroim-
aging. Structures with such alterations included the anterior cingulate, dorsolateral
prefrontal cortex, orbitofrontal cortex, amygdala, ventral tegmental area, thalamus,
and striatum. Reduced BOLD activity in limbic regions (i.e., amygdala and anterior
cingulate) was also consistently reported in cannabis users across multiple studies,
suggesting a disruption in emotional processing. Consistent findings of increased
striatal dopamine release (i.e., via [11C]-​racloprid binding measurement in positron
emission tomography [PET] imaging) in cannabis users and healthy volunteers
under acute THC administration were also reviewed, highlighting cannabis effects
on dopamine transmission and its influence as a possible rewarding and motivating
mechanism for continued use. Furthermore, the pharmacological studies examined
 6 neuropsychology: a review of science and pr actice, iii

suggested opposing effects of CBD and THC, with THC often inducing psychotic
symptoms and CBD acting as an antipsychotic and anxiolytic agent.

CROSS- ​S ECTIONAL STUDIES

Neurobehavioral Studies
Several cross-​sectional studies published in 2016 examined the impact of age of
onset of cannabis use on adult neurocognitive performance. For instance, Schuster,
Hoeppner, Evins, and Gilman (2016) examined the association between age of
onset and learning impairments in a sample of 48 young adults who reported using
cannabis at least once a week, as compared to 48 age-​and sex-​matched non-​users.
Users were classified according to age of first use, with early use defined as use at
or before age 16, and late use defined as use after age 16. Cannabis users with early
onset showed lower overall learning and worse delayed recall performance on the
California Verbal Learning Test–​II (CVLT-​II) than late-​onset users and controls.
However, once delayed recall was adjusted based on the learning phase of the CVLT-​
II, there were no significant between-​group differences in delayed recall. Early-​onset
users also evidenced significantly less semantic clustering than controls, though this
difference in learning strategy use did not mediate the association between onset of
cannabis use and delayed recall. Thus, these results suggest that the poor memory
performance typically associated with cannabis use may be explained by factors such
as age of onset and learning inefficiencies.
Similarly, Dahlgren, Sagar, Racine, Dreman, and Gruber (2016) assessed the im-
pact of different patterns of cannabis use on executive functioning, as measured by
the Stroop Color and Word Test and the Wisconsin Card Sorting Task (WCST).
Participants were 44 adult chronic, heavy cannabis users (used at least five times per
week) and 32 non-​users. Users were subdivided into early onset (regular use before
age 16) and late onset (regular use at or after age 16), with “regular use” broadly de-
fined as cannabis use on a routine, expected, and consistent basis. Cannabis users
showed poorer performance on both the Stroop and WCST relative to non-​users.
These differences, however, were driven by the performance of the early-​onset can-
nabis users; late-​onset users’ performance was similar to that of non-​users. The as-
sociation between early onset and poorer performance on WCST was still present
after accounting for frequency and amount of weekly cannabis use, suggesting that
age of onset of regular cannabis use uniquely contributed to executive functioning
impairments. Though these findings are compelling, they are based on a sample
of heavy cannabis users and thus may not be generalizable to more occasional
cannabis users.
Taken together, these cross-​sectional studies suggest that poor neurocognitive
performance by cannabis users may be explained, at least in part, by age of onset.
However, different definitions of “age of onset” make these findings harder to
interpret. While Schuster et al. (2016) classified users based on age of first use,
Dahlgren et al. (2016) classified them based on age of onset of “regular” cannabis
 7 Studies in Cannabis Use: Year in Review

use (i.e., age at which they began using cannabis on a routine and consistent basis).
Even though both studies found that age of onset was important, future research
should examine whether age of first use or age of onset of regular use has a greater
impact on later outcomes and should be consistent in defining “regular” use in
order to facilitate better interpretation of findings (Crane, Schuster, Mermelstein,
& Gonzalez, 2015). Furthermore, although both studies used age 16 years as a
cutoff point between early and late onset, one classified age 16 onset as early and
the other as late onset.
Another set of cross-​sectional studies from 2016 examined the effects of can-
nabis on various domains of neurocognition. For instance, Hirst, Young, Sodos,
Wickham, and Earleywine (2017) sought to explore whether the commonly reported
neurocognitive impairments in cannabis users could be due to a lack of effort put
forth during testing. They examined effort as a potential mediator of the association
between cannabis use and learning/​memory performance in a sample of 62 young-​
adult chronic cannabis users, defined as those using at least 4 days a week over the
past year. Participants completed a neurocognitive battery, which included tests
such as the CVLT-​II and the Rey Complex Figure Test, as well as the Word Memory
Test, which assesses effort. Hirst et al. (2017) found that frequent cannabis users had
higher scores on the CVLT-​II, thus failing to replicate previous research. However,
frequent cannabis use was associated with decreased effort, underscoring the impor-
tance of assessing effort with this population.
In order to examine the combined effects of cannabis and tobacco use on
neurocognition, Schuster, Mermelstein, and Hedeker (2016) employed an ecolog-
ical momentary assessment protocol in a sample of 287 community young adults.
The protocol involved a 7-​d ay data-​monitoring period in which participants used
handheld computers to complete assessments in real time. The devices provided
random prompts to the participants multiple times a day. Participants were also
instructed to initiate assessments immediately after smoking tobacco. During
both random and participant-​initiated prompts, participants indicated whether
they had used cannabis or alcohol in the past hour. During these prompts,
participants also completed a brief spatial working memory task. Using a within-​
subjects design, results indicated that working memory was poorer with cannabis
use (as well as alcohol use), but better with tobacco use. There was no interaction
between cannabis and tobacco use. Thus, tobacco use may compensate for the
adverse effects on working memory among young-​adult cannabis users, as previ-
ously suggested in the context of episodic memory (Schuster, Crane, Mermelstein,
& Gonzalez, 2015).

Neuroimaging Studies
Jakabek, Yücel, Lorenzetti, and Solowij (2016) conducted a cross-​sectional study
using diffusion tensor imaging (DTI) examining differences in white matter
structure in a sample of 56 regular cannabis users compared to 20 non-​u sers.
White matter integrity was assessed by deriving fractional anisotropy (FA),
 8 neuropsychology: a review of science and pr actice, iii

axial diffusivity, and radial diffusivity maps from diffusion-​weighted images.

Correlational analyses examined associations between the diffusion measures and
factors such as age of onset, as well as duration, frequency, and dose of current
cannabis use. Results revealed lower FA for cannabis users in the forceps minor
tract. Younger users also showed predominantly reduced axial diffusivity, while
older users showed higher radial diffusivity in widespread tracts. Duration of can-
nabis use was also associated with higher axial diffusivity in the cingulum angular
bundle. These findings suggest that cannabis use may alter normal brain matura-
tion, and this effect may be age related.
A cross-​sectional study conducted by Orr, Paschall, and Banich (2016) used DTI,
voxel-​based morphometry, and shape analyses to examine the white matter integ-
rity and subcortical morphometry in a subset of adult recreational cannabis users
(n = 466) from the Human Connectome Project (HCP) consortium, a large data-
base of neuroimaging data from a community sample. Participants completed the
Semi-​Structured Assessment for the Genetics of Alcoholism, a self-​report measure
used to quantify the number of times used and age of first use of cannabis on a 5-​
point ordinal scale. Similar to Jakabek et al.’s (2016) study, white matter integrity
was measured by deriving FA, axial diffusivity, radial diffusivity, and mean diffu-
sivity maps from diffusion-​weighted images. Also, analyses of voxelwise gray matter
morphometry were conducted to examine the effects of cannabis on cortical and
subcortical volumes, as well as cortical thickness across several regions of interest
(ROIs). Finally, shape analyses of subcortical ROIs (hippocampus, amygdala, nucleus
accumbens) were conducted. All analyses included age, sex, years of education, and
use of alcohol and tobacco as covariates. Results revealed that earlier age of onset
of cannabis use was associated with lower white matter coherence, as evidenced by
lower FA and higher radial diffusivity in long-​range tracts, suggesting that adoles-
cent cannabis use may impact the development of white matter tracts. Although
there were no associations between cannabis use and cortical volume, earlier age of
onset was associated with abnormalities in nucleus accumbens shape, while number
of lifetime uses was linked to differences in the shape of the amygdala and hippo-
campus. Thus, these findings suggest that earlier onset of cannabis use is associated
with subtle structural changes in subcortical regions that are consistently implicated
in the process of addiction.
Additionally, Rigucci et al. (2016) used DTI to examine the effects of cannabis
potency on the microstructure of the corpus callosum in a sample of 56 first-​episode
psychosis patients (37 of whom were cannabis users) and 43 healthy adults (22 of
whom were cannabis users), using similar metrics to those in the studies discussed
earlier. Frequent users of high-​potency (i.e., high levels of THC and low levels of CBD;
“skunk-​like”) cannabis had higher mean and axial diffusivity in the corpus callosum
than users of low-​potency cannabis (i.e., hash-​like) and non-​users, with no effect in
the psychosis group, suggesting that corpus callosum integrity may be highly sensi-
tive to high levels of THC. These findings highlight the importance of examining the
effects of varying potencies, especially as use of high-​potency cannabis is becoming
increasingly prevalent.
 9 Studies in Cannabis Use: Year in Review

LONGITUDINAL STUDIES
Neurobehavioral Studies
In a prospective cohort study, Mokrysz et al. (2016) examined the association be-
tween adolescent cannabis use and IQ and educational outcomes in a sample of
2,235 adolescents from the Avon Longitudinal Study of Parents and Children. IQ
was assessed at ages 8 and 15, and educational performance data were collected at
ages 10–​11 and 16. Users were categorized into five levels based on their cumulative
cannabis use frequency. Results indicated that cannabis users who had used can-
nabis at least 50 times by age 15 had lower IQ and poorer educational performance
at age 15 than those who had never used cannabis. However, after accounting for a
variety of potentially confounding variables, including pre-​exposure IQ and educa-
tional performance, maternal and early life factors, childhood behavioral problems,
mental health, and adolescent use of other drugs, these associations were no longer
significant. Of these factors, cigarette use was the most influential in predicting edu-
cational outcome. These findings highlight the importance of accounting for poten-
tially confounding factors when examining the associations between cannabis use
and various outcomes. Of note, because the levels of cannabis use reported in this
sample were modest, it is possible that associations between cannabis use and IQ and
educational outcomes may manifest at higher levels of use.
Another longitudinal study, by Fishbein et al. (2016), examined the neurocognitive
characteristics associated with early onset of cannabis use. They followed a sample of
465 substance-​naïve adolescents from a high-​risk community from ages 10–​12 at base-
line to ages 12–​15. Participants underwent testing spanning multiple neurocognitive
domains, including IQ, memory, attention, decision-​making, emotional perception,
and other executive functions. Results from a stepwise regression model revealed
significant associations between initiation of cannabis use and baseline performance
on neurocognitive tests, particularly on an Emotional Stroop Task, a task in which
children are asked to state the color that an emotional word (positive or negative)
is written in while disregarding the content of the word and which assesses cog-
nitive processing interference generated by emotional stimuli, as well as the Facial
Recognition Task (FACES). Specifically, misattribution of sad faces on the FACES
task and greater interference for positive than for neutral words on the Emotional
Stroop Task best predicted initiation of cannabis use. However, after controlling for
age, sex, and caregiver education, misattribution of sad faces on the FACES task was
the only significant predictor of initiation. The authors concluded that deficits in per-
ception of emotions may be a risk factor associated with early-​onset cannabis use. It
is important to note, however, that this study focused on initiation of cannabis use;
more research is needed to understand the neurocognitive effects associated with
escalation in cannabis use.
Notably, Jackson et al. (2016) employed a co-​t win design examining associations
between cannabis use and neurocognition using a sample of 3,066 twins from two
longitudinal cohorts. Twins from the Risk Factors for Antisocial Behavior (RFAB)
study underwent IQ testing at ages 9–​10 and then again at 19–​20, while those from
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The Project Gutenberg eBook of Through
deserts and oases of central Asia
 This ebook is for the use of anyone anywhere in the United
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Title: Through deserts and oases of central Asia

Author: Ella Sykes

Sir Percy Sykes

Release date: February 9, 2024 [eBook #72916]

Language: English

Original publication: London: Macmillan, 1920

Credits: Alan, Peter Becker and the Online Distributed

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*** START OF THE PROJECT GUTENBERG EBOOK THROUGH

DESERTS AND OASES OF CENTRAL ASIA ***
THROUGH DESERTS AND OASES
OF CENTRAL ASIA

Strike me dead, the track has vanished.

Well, what now? We’ve lost the way,
Demons have bewitched our horses,
Led us in the wilds astray.
Pushkin.
A YA-YIEH OR YAMEN RUNNER.
Frontispiece.
 THROUGH DESERTS AND
OASES OF CENTRAL ASIA

BY

Miss ELLA SYKES

F.R.G.S.
AUTHOR OF
“THROUGH PERSIA ON A SIDE-SADDLE” AND “A HOME HELP IN CANADA”

AND

Brigadier-General Sir PERCY SYKES

K.C.I.E., C.B., C.M.G.
GOLD MEDALLIST OF THE ROYAL GEOGRAPHICAL SOCIETY
AUTHOR OF
“A HISTORY OF PERSIA” AND “THE GLORY OF THE SHIA WORLD”

MACMILLAN AND CO., LIMITED

ST. MARTIN’S STREET, LONDON
1920
 MACMILLAN AND CO., Limited
LONDON · BOMBAY · CALCUTTA · MADRAS
MELBOURNE
THE MACMILLAN COMPANY
NEW YORK · BOSTON · CHICAGO
DALLAS · SAN FRANCISCO
THE MACMILLAN CO. OF CANADA, Ltd.
TORONTO

COPYRIGHT
 PREFACE
Few works dealing with Chinese Turkestan and the Pamirs have
been published of late years, although the Heart of Asia, where the
empires of Great Britain, Russia and China meet, can never fail to
excite our interest. Furthermore, the great trade route which ran from
China to the Roman Empire lay across Chinese Turkestan, from
which remote land silk was introduced into Europe.
The present book has been written in two parts. The chapters
composing Part I., which describe the nine months’ journey in
deserts and oases, in mountains and plains, have been written by
my sister, while I am responsible for those dealing with the
geography, history, customs and other subjects.
We are indebted to Mr. Bohlin of the Swedish Mission in Chinese
Turkestan, and to Khan Sahib, Iftikhar Ahmad of the British
Consulate-General, Kashgar, for much assistance; and also to Dr. F.
W. Thomas, of the India Office, who has read through the historical
sketch.
A good deal of new material will be found in the various chapters,
and as far as possible the subjects so ably and exhaustively dealt
with by Sir Aurel Stein have been avoided.
To my sister belongs the honour of being the first Englishwoman to
cross the dangerous passes leading to and from the Pamirs and,
with the exception of Mrs. Littledale, to visit Khotan.
We greatly enjoyed the nine months we spent in Chinese Turkestan
and on the “Roof of the World,” and if we succeed in arousing the
interest of our readers in this old-world backwater of Asia, and at the
same time convey something of its distinctive charm, our ambitions
will be fulfilled.
P. M. SYKES.
 CONTENTS
PART I
CHAPTER I
PAGE

Across the Russian Empire in War Time 3

CHAPTER II
Beyond the Tian Shan to Kashgar 18

CHAPTER III
Life at Kashgar 39

CHAPTER IV
Round about Kashgar 66

CHAPTER V
Olla Podrida 86

CHAPTER VI
On the Way to the Russian Pamirs 103

CHAPTER VII
The Roof of the World 129

CHAPTER VIII
The Aryans of Sarikol 148

CHAPTER IX
The Ancient City of Yarkand 175

CHAPTER X
Through the Desert to Khotan 191
 CHAPTER XI
Khotan the Kingdom of Jade 209

PART II
CHAPTER XII
The Geography, Government and Commerce of Chinese
Turkestan 235

CHAPTER XIII
An Historical Sketch of Chinese Turkestan: The Early
Period 248

CHAPTER XIV
An Historical Sketch of Chinese Turkestan: The
Mediaeval and Later Periods 263

CHAPTER XV
An Historical Sketch of Chinese Turkestan: The
Modern Period 275

CHAPTER XVI
A Kashgar Farmer 300

CHAPTER XVII
Manners and Customs in Chinese Turkestan 308

CHAPTER XVIII
Stalking the Great Sheep of Marco Polo 324

INDEX 333
 ILLUSTRATIONS
Note.—The illustrations, with one exception, are from reproductions of
photographs taken by the authors.

FACE PAGE

A Ya-Yieh or Yamen Runner Frontispiece

Cart used in the Osh District 26
Daoud and Sattur 41
Watering Horses in the Tuman Su 56
Kashgar Women and Children 58
Water-Carriers at Kashgar 60
Shoeing in the Kashgar Bazar 62
A Kashgar Grandmother 64
Priest at the Temple of Pan Chao 67
Kashgar City (showing the city wall and Tuman
68
Su)
Women at the Shrine of Hazrat Apak 69
Chinese Soldiers at the Kashgar Yamen 74
Jafar Bai displaying the Visiting Card 77
Study of Kashgar Women 82
Ruins of the Buddhist Tim, Kashgar 85
The Shrine of Bibi Anna 93
Fording the Gez River 109
Kirghiz Women in Gala Dress 118
Loading up the Yaks 124
Bringing in an Ovis Poli (Nadir with rifle) 146
(a) The Game of Baigu—the Mêlée 150
(b) The Game of Baigu—the Pick-up 150
(c) The Game of Baigu—the Victor 150
Nasir Ali Khan, a Muki of Sarikol 156
Sarikoli Dancers 158
Muztagh Ata—The Snout of a Glacier 162
A Kirghiz and his Daughter 164
Kashgar Musicians 170
Our Arabas on the Yarkand Road 176
A Hunting Eagle 182
Ferry on the Yarkand River 192
The Pigeon Shrine 206
Beggars at the Gate 212
A Dulani Shaykh 222
Dulani Musicians 224
A Dulani Woman and her Son 226
The Tian Shan or Celestial Mountains 236
The Tungani Commander of the Troops at
Khotan 242
Tamerlane 268
A Load of Clover from Isa Haji’s Farm 302
The Sons of Isa Haji ploughing 304
A Magician and his Disciple 314
A Kashgar School 316
A Woman throwing Mud to effect a Cure 320
Ovis Poli—the 51-inch head 328
Hunting-Dogs with Kirghiz owner 330

MAPS
Supplementary Sketch Map showing Country to
the East of Route Map 275
Map to illustrate Authors’ Routes (In pocket at end
of volume)

ERRATUM
Page 134, line 22, for “there was no sign of a division” read
“it was broken up into islands.”
PART I
 CHAPTER I
ACROSS THE RUSSIAN EMPIRE IN WAR TIME
The cities are called Taskent[1] and Caskayre,[1] and the people that warre
against Taskent are called Cassaks[1] of the law of Mahomet, and they
which warre with the said countrey of Caskayre are called Kirghiz,
Gentiles and idolaters.—Anthony Jenkinson.

On March 5, 1915, my brother and I started off on our long journey

to Kashgar, the capital of Chinese Turkestan, where he was to act for
Sir George Macartney, the well-known Consul-General, who was
taking leave.
Owing to the War, we were obliged, as the first stage of our journey,
to travel to Petrograd by the circuitous route through Norway,
Sweden and Finland. The small Norwegian steamer, the Iris, in
which we embarked at Newcastle, made its way up the coast of
Scotland to a point opposite Peterhead in order to avoid mines and
submarines, after which it crossed to Bergen. We passed two
choppy nights in stuffy cabins with the portholes tightly screwed up,
and I was too prostrate with sea-sickness to care when the engines
of our steamer stopped dead during the first afternoon. My brother
rushed up on deck to see if we were held up by a German
submarine, which might mean the unpleasant experience of
internment for him, but after a couple of hours we went on again, and
no explanation of the delay was given us.
Some three months later this same vessel was attacked in reality,
two torpedoes being fired at her, and only the zigzag course skilfully
pursued by the captain saved her from destruction. Amundsen, the
discoverer of the South Pole, was on board, and wrote to the papers
describing the incident, and strongly reprobated Germany’s policy
towards neutral shipping, which, he declared, had converted him to
the side of the Allies.
To return to our journey, we finally steamed in safety up a long fiord,
and Bergen stood up picturesquely against its background of snow-
covered hills. We thought that the pleasant-mannered Norwegians
were decidedly Scotch in appearance, and a sturdy youth, quite of
the type of a Highland gillie, soon guided us to the Hospidset Hotel,
which had originally belonged to the Hanseatic League in Bergen. In
old days the apprentices lived in this house, being locked up safely
at night, and though the building has undergone considerable
restoration, it is still a characteristic piece of architecture.
Next morning we tramped round Bergen in our snow-boots, finding
the steep roads very slippery with frozen snow, even the inhabitants
falling headlong now and again. Here and there children were merrily
tobogganing, dashing recklessly across the main street through
which the trams were running, and hurling themselves down steep
inclines on the other side in a way that made me shudder. They were
all sensibly clad in woollen garments, their rosy faces peering out
from fur caps or fur-trimmed hoods, and it did one good to see them.
A graver note was struck as a funeral passed by, with all the
mourners on foot; and the pastor, in a stiff ruff with muslin frills at his
wrists, seemed to have returned from the sixteenth century, and
might have posed for a portrait of Calvin. Sleighs were everywhere,
drawn by sturdy little ponies that raced along at a great pace with
jingling bells and kept their feet wonderfully.
We left by the night train for the twenty-seven hours’ run to
Stockholm, changing at Christiania, and next day were speeding
through a land of snow and pine inhabited by a hardy-looking, fur-
clad race. Fish seemed a staple article of food, and we were offered
salted prawns, herring-salad, raw sardines and anchovies; veal, ham
and tongue, with pickles or cold fried bacon, forming the meat
course. There were no sweets or fruit, but for compensation we had
delicious coffee and cream. In the restaurant car the bread and rolls
were fastened up in grease-proof paper, sugar in tiny packets, and
biscuits in sealed bags, in order to prevent unnecessary handling.
It was night when we steamed into the “Venice of the North,” a city
which must be lovely in the summer, as it rises from its waters; but at
the time of our visit the river was covered with floating blocks of grey
ice, and all the world was skating or ski-ing.
The people were not unfriendly to us, but from more than one source
we learnt that, owing to their hereditary fear of Russia, the Swedes
were generally partisans of Germany, in contradistinction to the
Norwegians, who, as a nation, were warmly in favour of the Allies.
We had a five o’clock dinner (three to five o’clock being the usual
time, reminding one of early Victorian customs), and then settled
ourselves into the comfortable sleeping coupés which we were to
inhabit for two nights as far as Karungi, the direct route across the
Gulf of Bothnia being inadvisable for obvious reasons. There were
four racks for light luggage in each compartment, a convenient
washing apparatus and a table, and we could open our windows,
whereas in Russia we found the windows screwed up until the
spring.
But there was one thing in which the Russian trains, with their three
bells rung for departure, compared favourably with those of
Scandinavia, and that was that the latter gave no real warning when
they were about to start. The engine whistled and moved off
immediately, with the result that I was always nervous about walking
up and down the platform, for the iron steps leading up to the
carriages were so slippery with frozen ice that I feared to risk a fall if
I scaled them in a hurry.
A Russian girl travelling in the carriage next to ours had given her
ticket to the care of a French lady, a complete stranger to her, and,
strolling along the platform with a fur collar round her neck but no fur
coat, was unluckily left behind. The railway officials sent her ticket
back to her and took care of her belongings, and I trust that some
good Samaritan aided her, but she must have had a most
unpleasant experience. I asked a Swede who talked to me why the
trains gave practically no signal when they started, and he said that
there was some reason which he had forgotten.
The country lay deeper in snow the farther north we advanced, and
on either side, as far as eye could reach, the undulating ground was
covered with vast forests of fir and pine. At intervals we passed little
towns and villages, the small wooden houses, painted in many
colours, giving the impression of toy-dwellings. The brightly clad fur-
capped little girls with long fair plaits of hair seemed as if they had
come to life from the fairy books of my childhood, and one could
almost credit the existence of gnomes and trolls in those limitless
uninhabited tracts of pine. Soldiers in blue-grey or navy-blue
uniforms, with white sheepskin caps or picturesque three-cornered
cloth hats, stood about on the platforms up and down which we
tramped in our snow-boots whenever the train halted. As there was
no restaurant car we obtained our meals at the station buffets, halts
of about half an hour being made at 10 a.m., 3 p.m. and 10 p.m. In the
absence of waiters the hungry crowd of passengers helped
themselves, selecting from a tray laid out with different kinds of fish,
cheese, pickles, etc., or piling their plates with hot pork or veal. I
made invariably for the big cauldron of excellent soup with
vegetables, and there was always coffee and milk, bread and cakes
in abundance, and no pushing or hustling on the part of those
travelling.
At last we reached Karungi, the frontier between Sweden and
Russia, and scores of sleighs were in waiting at the station to convey
the passengers the short distance to the Russian Karungi. The fine-
looking Russian Consul, clad in a splendid fur coat and cap to
match, was most obliging, and cheered us greatly with the news—
alas, quite inaccurate, as we found out later—that the Allied fleets
had silenced all the forts in the Dardanelles! My brother went off to
pass our heavy luggage through the Swedish Customs, and I had
some difficulty in collecting our small possessions on to one sleigh,
because half a dozen men and boys, clad in nondescript garments of
fur and leather, hurled themselves upon hold-alls and dressing-cases
and bore them off in all directions, utterly regardless of my
remonstrances. The only thing I could do was to follow the most
responsible-looking of my self-constituted porters, and when he
deposited his burden on a sleigh I induced him to accompany me in
a hunt among the lines of shaggy little ponies, finding the tea-basket
in one place, a hat-box or a bundle of sticks and umbrellas mixed up
with another passenger’s luggage, and so on. The Consul told me to
come and drink coffee in the buffet, exclaiming reassuringly, “You
can leave everything safely, for in this part of the world the people do
not know how to steal.”
At last we drove off in the keen air across a level waste of snow,
traversing a frozen river which forms the actual boundary, and in half
an hour, with many a bump and jolt, we reached a gate through
which, after we had shown our passports, we were admitted into
Finland.
We had now a wait of some six hours, which we spent in walking on
the crisp snow or sitting in the little station buffet, where I observed
that coffee had given way to tea, the Russian national beverage,
drunk in glasses with a slice of lemon and much sugar. From now
onwards the pièce de résistance of our chief meals was sturgeon. I
liked it fairly well when stewed or fried, but it was usually tough when
served cold. Some of these enormous fish are said to weigh two or
three tons.
When the train made a tardy appearance it could not accommodate
all the passengers, and many were perforce left behind to follow the
next day. The first halt was at Tornea, to which point travellers used
to drive until the extension of the line to Karungi after the outbreak of
the War, and, though we were in the Arctic Circle and it was early in
March, the air seemed quite mild as we rushed across Finland, our
wood-fed engine belching forth immense whorls of smoke. At Vyborg
we entered Russia, and at midnight of the second day reached
Petrograd.
In the Astoria Hotel it was remarkable to see every one drinking
kvass, a somewhat mawkish beverage made from bread or from
cranberries, in lieu of wine or spirits. In Finland alcoholic
refreshments were obtainable in the restaurant car, but now we
found ourselves in a country which the will of an autocrat had made
so strictly teetotal that we were unable even to purchase methylated
spirit for our tea-basket!
Some of our Russian acquaintances spoke with enthusiasm of the
beneficial effect of the Tsar’s edict, one competent observer pointing
out that the Russian women were just beginning to take to drink,
which would have meant the ruin of many thousands of homes. On