morphine was injected, which the patient reported at the next visit was of no benefit whatever, stating that it was, he knew, a very small amount nothing like what he had been used to getting. The dose of morphine was very carefully increased to 1-2 grain without any effect, and finally, at the earnest solicitation of the patient and his assurances that he could stand the morphine, the dose was increased to one grain. This injection bore out his statements as to his previous experiences and "just about steadied him," without producing anything but a very short sleep. His subsequent periodic sprees were treated along the same lines, from 3-4 to one grain being used at an injection. It became so much a matter of course to inject this patient, and see no untoward effects whatsoever that there was no hesitation on the part of the speaker about giving him a grain of morphine two or three times a day, according to the exigencies of the occasion. Between the sprees the man, who was of more than average intelligence, not only abstained from alcohol, but did not have the slightest desire for morphine or any other drug. The treatment detailed above was carried out until the last spree, about a month ago. On this occasion he presented himself, intoxicated, but retaining all his faculties, and begged for an injection of morphine, saying that he would only be put "on the ragged edge" as he expressed it, if he received the usual dose. He stated that he had taken as many as 3 grains of morphine without any bad effects, but this statement he afterwards denied. He had a very important meeting for the next day, and therefore was desirous of securing a good night's rest. One and one-half grains of morphine sulphate were injected into his left arm. In about half an hour the speaker was called to him hurriedly, and found him in a much stupefied condition. This was about 8 P. M.; a small dose of cocaine was injected and the speaker left, returning about 9 o'clock, when the patient was breathing slowly, about 5 or 6 a minute. He was walked up and down until about II o'clock, at which time his respirations had diminished to one in two minutes. Up to this time there had been injected hypodermatically 3-5 of a grain of cocaine, 4-150 of atropine sulphate, 4-30 of strychnine and 4-100 of nitroglycer ine. He had also been given about a quart of strong, black coffee. The situation being desperate, at the request of the man's family 1-12 of apomorphine sulphate was injected as an emetic and was effectual in about one-half a minute. The patient went steadily into a deep coma, became very blue and was apparently dying. Artificial respiration and the administration of oxygen were then resorted to and the tongue pulled forward with artery forceps. At 1:30 P. M. he began breathing at the rate of about 4 a minute. About a quart of black coffee was given as an enema, and at about 3 A. M. he was breathing about 10 times a minute and was conscious. The oxygen and artificial respiration, together with the cocaine, probably saved the man's life. Two lessons should be learned from this case: (1) not to be importuned into giving any patient a large dose of morphine, even though he is used to it; and, (2) not to abandon hope or relax one's efforts, even when the patient is apparently beyond hope, as this case shows that even in apparently fatal cases life may be saved. Dr. R. H. M. Dawbarn opened the discussion of this case which, he said, recalled to his mind a case of morphine poisoning which occurred when he was interne at the Nursery and Child's Hospital. He placed the patient on his back and administered atropine (the first dose of which dilated the tubes) until, from morphine poisoning the patient developed a case of atropine poisoning. Life was saved by artificial respiration, which was kept up for 8 hours by the speaker and his assistant each taking two-minute turns. Walking the patient up and down was tried, but the exertion seemed only to make the heart weaker. If he were to criticize the treatment of the case under discussion, it would be the giving of depressing narcotics, as after vomiting from an overdose of morphine the patient usually collapses. Dr. Maurice Packard said that in a series of experiments in which he had been interested, which were being conducted by Doctors Bodine and Jeffries, they were trying to find out from guinea pigs how much morphine would act as an antidote for a given injection of cocaine, acting upon the principle that cocaine is a physiological antidote for morphine. Previously atropine had been used for this purpose, but atropine and morphine acted similarly, in that both had a tendency to depress the smooth muscle fibers as well as secretion, while, on the other hand, cocaine stimulates the smooth muscle fibres, and increases secretion, as is shown by the drooling at the mouth and the frequency of urination. The best possible treatment, he thought, was the stomach tube. After using it once, however, it must be used every half hour, for the mucous membrane of the stomach will repeatedly secrete morphine. With the stomach tube and the proper use of cocaine, most of these cases will end in recovery. The paper of the evening was read by Dr. E. L. Keyes, Jr., and was entitled: RENAL COLIC. He said, in part: Renal colic is usually considered a symptom of kidney stone, but it is not absolutely pathognomic of stone, nor are the position and character of the colic pains always an infallible index of the position of the stone. Indeed, so misleading is renal colic in a certain few cases, and yet so rarely is it a symptom of anything but stone, that I think it by no means waste of energy to study attentively some of the cases which have come under my observation and in which renal colic has been a misleading and often a confusing symptom. The late Dr. Bryson once formulated in a tentative way the theory that stone in the pelvis of the kidney causes pain in the loin radiating down the ureter, while stone at the lower end of the ureter causes frequent and painful urination and pain in the pelvis. This distinction holds true in the great majority of cases; yet I have seen one case that was a striking exception to this rule, in that the only pain suffered was from frequent and painful urination, although he had but one stone, and that lay in the pelvis of his kidney. The first patient, a lean, asthmatic man, 63 years old, complained of frequent urination. Sixteen years ago he applied for insurance; was refused on account of albuminuria. He consulted a surgeon, who stated that he had a surgical inflammation of the kidney. Except for the passage of two calculi from the right kidney, eight and five years ago respectively, and except that he had to rise once or twice at night to empty his bladder, there were no symptoms until about a year ago, when his urination became more frequent and he consulted an eminent urologist who began and has since continued treating him for chronic cystitis attributed to prostatic hypertrophy. His symptoms have grown gradually worse. Examination showed the right kidney to be readily palpable, somewhat large and tender; the left kidney could just be felt, but was not tender. The urine was hazy with pus; specific gravity 1016; albumin 1 per cent. by weight; various casts of many kinds; many red blood cells; a total excretion of from 25 to 30 ounces; the bladder capacity was 8 1-2 ounces. The prostate was not enlarged; there was no residual urine. X-ray examination revealed a shadow in the region of the right kidney pelvis, but for various reasons the operation was postponed for 18 months, when the patient's condition was so unsatisfactory that it became imperative. Upon opening the right kidney, an oxalate stone was found fitting in the upper end of the ureter and was removed through an incision in the kidney pelvis. The kidney itself was considerably dilated and covered with small cysts which contained serous, bloody, and sero-purulent fluid. It was suspected, because of the nature of the symptoms, that there was a stone in the ureter, but careful search failed to reveal one. After operation, instead of passing urine constantly as he had done heretofore, he had to be catheterized until the second day, when he began to urinate at intervals of from 2 to 4 hours. The secretion of urine remained low, and, finally, at the end of three and a half weeks, the patient died from asthenia and failure of kidney function. It is noteworthy that in this case we were able to arrive at a diagnosis with the aid of an X-ray photograph, while the practitioner who had previously treated it had failed to make the diagnosis because he had not employed this expedient. In contrast to the above case, in which a patient with stone suffered from a pain that did not resemble renal colic, the second case shows the brilliant contrast of a patient with renal colic, but without stone. The patient, 58 years of age, complained of repeated attacks of renal colic. He never passed blood, never had any anuria or bladder symptoms, although since the first attack he had urinated twice at night and every three hours a day. No lumbar tenderness could be evoked by palpation, nor was it possible to feel either kidney. X-ray photographs showed small sclerotic kidneys, but no shadow suggestive of stone. Examination of urine showed many pus cells, but no bacteria. Macroscopically there was no pus and very few blood cells. He was given an alkaline mixture, advised to drink freely of water and to exercise to the limit of toleration; and I believe that in January, 1906, he had no further renal colic. A detailed history was presented of a patient who suffered from most violent attacks of renal colic brought on by digestive causes. A carefully restricted diet, much exercise and water and the administration of beta-naphthol, bismuth, and salol caused a cessation of these attacks. In further contrast to this case was Case V, in which the colic caused by digestive disturbance was intestinal and not renal, although the pain was precisely that of renal colic. The last history presented by the speaker was an example of a class of cases which he considered very important. They are relatively infrequent, and cause objective symptoms absolutely characteristic of renal stone; yet a careful examination will reve 1 the fact that they suffer from nothing more than seminal visiculit ́s. Correspondence. QUININE IN PNEUMONIA. SAN DIEGO, CAL., March 21, 1906. DEAR DOCTOR ROBERTS: Some little time since I read your article on use of quinine in Pneumonia, and have been reading the ex |