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tents may be explained in a similar manner ; degener- ative changes are to be expected where life is prolonged to the nineteenth day from the beginning of the attack. * Cyclopaidia of Medicine, von Ziemssen, vol. v., p. 673. ■■'Buhl: Lungen Entziindung, Tuberkulose und Schwindfiichtig, p. 50. Mil chcn. 1873 October ii, 1884.] THE MEDICAL RECORD. 401 MORPHIA IN CARDIAC DISEASE. By benjamin EDSON, M.D., BROOKLYN, N. Y. The following case seems to have some bearing upon the use of morphia in one form of disease of the heart. C. R , fifty-si.x years of age, Scotchman, merchant, called at my office early in November, 1883, complain- ing of a troublesome cough and shortness of breath on exertion. He attributed his trouble to "catching cold " from exposure. As he was in great haste I prescribed a cough mixture without making thorough investigation. A few days later he called again. His cough was no better, and his respiration so much more difficult that he could not lie down to sleep. When I proposed an exami- nation, he slapped his hand upon his chest, saying : " There is nothing the matter with me here, sir : I'm as sound as a dollar." I found, however, that he had mi- tral regurgitation with marked dilatation of the heart. The cause of the cough and dyspntea was but too appar- ent. The kidneys were not affected, and as yet there was Buy Acillin no oedema. A few days later the legs began to swell. I advised him to keep strictly quiet, and at the same time put him upon such treatment as seemed best calculated to give relief. I found it difficult to convince him of the grave nature of his disease, and being of a nervous, active temperament, he considered it a great hardship not to be permitted to attend to his daily busi- ness in New York. Finally I persuaded him to consult Dr. Armor, who confirmed my diagnosis and approved the treatment, which " must be palliative and on general principles." For the next two or three weeks he continued fairly comfortable, the cedema moderate, but he was able to sleep only as he reclined in his chair. He was very irritable, and urgently called for something that would enable him to sleep /■« bed. I did not feel warranted in granting this request, but still he insisted that he must have some good sleep. Finally, Ampicillin 500 Mg through the persuasion of a relative, he was induced to call in a distinguished homceopathic physician, who acceded to his request and gave him sufficient morphia to enable him to sleep several hours in bed. But on waking and attempting to rise he was seized with dyspnoea that nearly terminated his life. By vigorous efforts on the part of his attendants he eventually rallied somewhat, but soon after he suddenly fell back and expired. I have considered that death in this case was due to the morphia used. It may have been only indirectly the cause, by permitting the patient fo assume the recumbent position, rising from which produced over-distention or overwhelming Ampicillin 500mg of the weakened heart-structure. Mori)hia may^have contributed to the paralysis. Kartholow (" Ma- teria Medica," 5th ed., p. 524) says of lethal doses of morphia, that " in some instances very sudden death en- sues from paralysis of the heart." How large the dose required to produce this untoward result obviously de- pends much upon the condition of the heart. What in health might be but a medicinal dose of morphia, in case of dilatation, with muscular walls greatly weakened and nerve-distribution disturbed, might readily prove Order Ampicillin to be a lethal or paralyzing dose. Thus in this case it is not improbable that both these factors conduced to the sud- den death of the patient. This man had never had rheumatism, and previous to this illness there had never been any suspicion of cardiac trouble. In looking back over this case theje arises a question Buy Ampicillin Online which leads to speculation, and which may not be wholly devoid of interest. In the summer of 1880, through some business complications, this man had a period ol very great mental depression. It took the form of marked pathophobia. He was fearful that he would drop down dead, and that his body would be unrecog- nized and sent to the morgue, so he was very particular to keep in every pocket papers bearing his name and address, with minute directions as to what should be done in case of the event he so much feared. Scores of times daily he took out these papers and examined them to reassure himself that, if he did drop dead, his body could be properly identified. On one occasion, being up-town in New York, the Ampicillin 500 " feeling " came over hirii that he never could get back to his store alive. His evil genius told him that he nuist not ride, and he had not the power to walk. In this dilemma it was finally revealed to him that he could perchance run back. This he did, bv short runs between lamp-posts and awning-posts, to each of which he would cling while screwing up courage to make a bold run for the next goal. In this way he finally reached his store, out of breath and reeking with perspiration. While narrating these and many other freaks of his malady equally ridiculous, he remarked, " You may laugh at them ; I do now ; but when the incubus is upon me I am a coward, a victim of my fancies." After a few weeks his business troubles passed away, and with them his morbid fear of death. There Online Ampicillin is a possibility — indeed, is there not a strong probability? — that at this time there was actual heart- trouble. If so, whether it stood in the relation of cause or of consequence is of course mere speculation. Is patho- phobia, with the kindred affections, agoraphobia, etc., simply a functional derangement — a neurosis — or may it not be associated with and possibly dependent upon actual pathological conditions ? §leports of hospitals. COOK. COUNTY HOSPITAL, CHICAGO, ILL. Case of Congenital Diaphragmatic Hernia. REroRTED BY M. L. HARRIS, M.D., House Physician. K. C , male, aged thirty-four, laborer, was received into the hospital November 15, 1883, under the care of Dr. F. Henrotin, attending physician. On admission the patient was much prostrated and suffered from intense dyspnoea ; hence no accurate ac- count of his history was elicited. He said that he had usually enjoyed good health, and that this was his first acute illness. The case was found to be one of acute croupous pneumonia affecting the lower lobe of the right lung and complicated with an acute pleurisy of the same side. November 17th the patient died suddenly and un- expectedly. The autopsy was held forty-eight hours after death by Dr. W. T. Belfield, pathologist to the hospital. Body of spare build, the abdomen markedly depressed. .Vfter the usual incision from chin to Cheap Ampicillin pubes and removal of the sternum, the appearance represented in Fig. . was exhibited. The heart was in about the usual posi- tion, the apex a trifie nearer the sternum than normal. The right pleural cavity contained some recently coagu- lated lymph. 'I'lie inferior and middle lobes of the right lung exhibited gray iie|>atization ; the lower portion of the upper lobe showeil reii hepatization ; the upper por- tion of this lobe was quite tedematous. The left pleural cavity contained, besides the left lung, the stomach, nearly all of the small intestine, part of the colon, and half of the pancreas. The lung, eight inches in length, one to two inches in thickness, and two to three inches in breadth, was crowded into the anterior and upper iiortion of the left chest, resting against the mediastinum. It appeared to consist chietly of the upper iobe, which, with the exceptii)n of a few cheesy nodules, in the apex and some sligiit ledema, was fairly normal, crepitating well and floating upon water. The inferior iobe was crowded into a small firm mass which contained, no air and sank in water. The abdominal cavity vas shallow, containing only 402 THE MEDICAL RECORD. [October ii, 1884. the liver, kidneys, spleen, a small portion of the ileum and ascending colon, and the descending colon. The liver was slighth' enlarged and fatty ; the anterior border of the right lobe extended downward four fingers'- breadth below the margin of the ribs, its deep position being due not to an increase in size but to a tipping for- ward and downward of the organ. The kidneys and spleen occupied their normal positions respectively and appeared healthv. Fig. I. — I, Left lung ; 2, convol 5, spleen ; 6, descending colon flexure : lo. bladder The diaphragm presented a single large opening occu- pying its central and posterior portion, through which the various organs — inferior vena cava, aorta, thoracic duct, portal vein, small and large intestine, pancreas, superior mesenteric artery, etc. — passed to or from the thorax. This foramen was large enough to permit the Fig. 2. — 1, CEsophagus ; 2, stomach ; 3, pylorus ; 4, cardia ; 5, duodenum (dotted line) ; 6, pancreas (dotted line; ; 7, spleen ; 8, arch of aorta ; 9, pulmonary artery ; 10, heart (drawn to right) ; 11. descending aorta ; 12, diaphragm ; 13, cut end of portal vein ; 14. kidney ; is. descending colon ; 16, ileum ; 17, coecum : tS, sigmoid flexure ; 19, bladder. passage of the closed fist. The left border of the right crus arched to the left, forming the free margin of the foramen ; this was round and smooth and attached to the head of the twelfth rib and to the base of the trans- verse process of the twelfth dorsal vertebra. There was no left crus. The course and relations of the alimentarv canal are shown in Fig. 2. Here the lungs and liver have been removed, the heart drawn to the right and the small intestine to the left, the ribs represented by the dotted lines. The oesophagus passed behind the arch of the aorta, along the anterior and right side of the descending aorta, until it reached the eighth dorsal vertebra, where it passed Purchase Ampicillin in front of the aorta, suddenly turned vertically upward, and after a course of about two inches entered the cardiac extremity of the stomach. The stomach it- Buy Ampicillin

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