CASES OF DISEASES OF THE HEART.

72 it is

merely meant that no ulterior or permanent mischief has cussion. The dullness of the prsocordial region is not increased. arisen; but it would be difficult to satisfy the patient that there is Auscultation: The impulse is more powerful than natural, and no harm in unnecessary and removable pain, and I apprehend rather irregular and unequal; at the apex, the first sound was unthat any long persistence in the practice of allowing such pain to accompanied by any bruit for the first three or four beats of the continue, would sooner or later elicit cases in which it gave rise to heart; but, without increased impulse, a loud bruit de souflet then became audible, and lasted during its whole period, being less actual disease. Again: I very much doubt whether opium, in moderate doses, intense as you ascended towards the aortic valves. Second sound, has any power to check those contractions of the uterus which are normal: between the cartilages of the second and third ribs, and needful to clear it of its contents, to diminish the calibre of its near the sternum, another bruit is audible, accompanying the first bloodvessels, and to restore it to its natural dimensions. sound, and transmitted up the carotids. His aspect is anxious; In the interesti g memoir of Dr. Marshall Hall, on the condi- face, lips, and tongue pale, the latter slightly furred; no headache, tion of muscular irritability in paralysed limbs, it is shewn that dizziness, oedema, or enlargement of the liver. The palpitation is while the spinal marrow is exclusively the source of the irritabi- increased by exercise and mental affections; much diminished lity of the muscular fibre, the cerehram, on the contrary, is an after going to bed. exhaustor of that property. Long before the appearance of that Diagnosis.-Nervous palpitation. The reasons for this arememoir I had often remarked the following circumstances :cr, the aspect indicates a nervous and not organic affection; C, no 1. That when, in the earliest stage of labour, with the view of obstruction is observable in the lungs, or elsewhere; y, the dullquieting tedious pains, which appeared to be useless, and hardly ness on percuting the praecordial region is not increased; , the indeed to warrant the idea that labour had actually begun, I gave mitral bruit was not heard at first; E, the aortic bruit is direct; a moderate dose of opium, (as from twenty-five to forty minims and lastly, he is a nervous person, troubled with dyspepsia. of the tincture,) and thereby produced drowsiness, or even a short Diet.-Meat and bread; no vegetables or beer; a little spirit sleep, instead of any considerable intermission of the pains occur- and water. 1. Simple infusion of gentian, one ounce; tincture of ring, their character has rapidly improved, and labour has thence- sesquichloride of iron, fifteen drops; and tincture of capsicum, five forth gone on steadily. drops; three times a day. 2. That though in almost all cases I administered opium sub16th.-Better. Palpitation continues, though lessened; mitral sequently to childbirth, after-pains were rarely absent, and were bruit nearly disappeared; aspect, spirits, and dyspepsia, much imin general sufficiently violent to be much complained of. proved. Bi. Simple infusion of gentian, one ounce; tincture of 3. That in a very large proportion of my midwifery cases the foxglove, ten drops; tincture of sesquichloride of iron, fifteen drops; uterine action commenced during sleep, as shewn by its being to be taken twice a day. Under this treatment he speedily refirst perceived on waking. This fact is evidently analogous to the covered ; the mitral bruit entirely disappeared; the aortic bruit and the palpitation very much diminished; and he ceased taking frequent invasion of convulsions, and of apoplexy in the night. Upon the principle announced as above by Dr. Marshall Hall, medicine on the 29th, and was advised to be careful in regard to these circumstances are easily explained. The administration of exercise and diet. - Remaps.—This case illustrates well the importance of auscultaan opiate in the early stage of labour, by abating the activity of the brain, occasions an increased irritability of the excito-motory tion, as by antiphlogistic treatment, or even low diet continued for system, and thus augments the expulsive action of the uterus. any length of time, dilatation of the heart would have been proGiven after delivery, at a time when the sensorium has been duced ; but by an opposite method, he speedily recovered. These highly excited by anxiety and suffering, an opiate, by tranquil- cases most commonly happen to persons of an irritable or hyslizing the mind and feelings, empowers the uterus to complete its terical disposition, and therefore chiefly occur in females, especially work efficiently, by contracting upon its residual contents, and those who are ansemic, or in whom the uterine functions are disgradually restoring its vessels and general substance to their due ordered. Dyspepsia, sedentary occupations, an ill-regulated diet, dimensions. In the same manner, natural sleep, at about the full &e., are the most common causes. But we may have palpitation term of pregnancy, leads frequently to such an exaltation of the without organic disease, in plethoric, in stout individuals, in whom excito-motory power as to occasion the commencement of labour. the heart has to propel an unusually large amount of blood; these What are the practical principles to which the above consider- cases, of course, require a mode of treatment directly opposed to ations lead? that adopted here. 1. That opiates, in moderate doses, rather increase than dimiThere is one point about this case which is well worthy of nish uterine action, either during or after childbirth. remark-viz., the mitral murmur. This is usually stated to 2. That they ought generally to be given after delivery, not depend only on organic disease; but the facts that here three or merely to soothe the sensorial system, but to augment the excito- four beats of the heart occurred without any mitral murmur, and that after tonic treatment the murmur entirely disappeared, withmotory power of the uterus. 3. That they are often advisable in the early stage of labour, to out any mercurial preparations being administered, or counterquiet that mental anxiety which, besides being most distressing irritants used, seem to prove that we may have a mitral murmur to the patient, tends to exhaust or paralyze the power of the accompanying the first sound, without organic disease. I have uterus.

another similar case, but have lost or mislaid the notes of it; but in regard to this point, we must not forget that mitral murmurs not unfrequently disappear under mercurial treatment. The diagnosis of these cases is not always easily made, as they sometimes very closely imitate organic disease. I remember a man named J. Hamilton, aged 39, a painter, who had symptoms which apparently indicated hypertrophy of the left ventricle with obstruction of the aortic orifice, and which was so diagnosed by a physician of acknowledged skill as an auscultator, and was also treated in the London Hospital for such; and yet, on a post mortem seen

The chief contraindications to the employment of an opiate in either case are, the existence of costiveness and that of plethora. The first objection might be easily overcome by a dose of castor oil, the quickest of purgatives, or (if the stomach is irritable) by an enema. The second is more serious. I have seen a single grain of opium, administered after childbirth to a full-blooded patient, followed in less than half an hour by coma and hemiplegia, requiring the immediate and vigorous use of the lancet. It will be observed that I speak of opium only as to moderate doses. Larger quantities may no doubt overcome the involuntary But such doses are obviously as well as the sensorial powers. poisonous, and ought in no case to be ventured on. Brentford, 1844.

CASES OF DISEASES OF THE HEART. By JOHN W. TRIPE, London. FUNCTIONAL

DERANGEMENT.

CASE I.-1Oth May. 1844. Mr. I-, aged twenty-six, a eigarmaker by trade, and of a nervous temperament, states, that for the last two years he has been very subject to cough, pain of the thoracic parieties, and palpitation of the heart. In addition to these, he complains of loss of appetite, flatus, pain after taking food, irregularity of the bowels, and great depression of spirits. In consequence of the palpitation being unusually troublesome of late, and a slight cough supervening, he asked to have his heart and

ungs examined. On local examination-Of the lungs: They are healthy, with the exception of a slight bronchial inflammation. Of the heart: Per,

examination

being made, no organic lesion was appreciable. PERICARDITIS.

CASE 2.-March 28th, 1843. Alice C-,aged twenty, of leucophlegmatic appearance, is subject to rheumatism and palpitation of the heart, though never sufficient to be very unpleasant. Three days since she was attacked with acute rheumatism of the feet, and which affected all the limbs. To-day she has the constitutional symptoms usually attending acute rheumatism, the shoulders being the parts most painful; pulse 90, full, and rather hard; heart’s action regular, and unaccompanied by any abnormal sound. Ten ounces of blood from the arm; and let her take tincture of meadow saffron seeds, thirty drops; carbonate of magnesia, five grains ; tincture of opium, ten drops in one ounce and a half of water; every four hours. About six the following morning she felt great palpitation of the heart and dyspnoea, with occasional sharp pains in the praecordial region. When seen at ten A.M., her condition was as follows:-Position on her back, and disinclined to change; the face anxious and dusky, and mind much alarmed. Complains of constant pain of the heart, of a burning character, with occasional lancinating pains, which extend

73 to the shoulder and partly down the arm, the constant pain being most acute near the junction, of the cartilage of the third rib with the sternum. Percussion: Pressure between the cartilages of her

died in the London

Hospital with granular kidney, and whose comparatively sudden death could not be accounted for, as he did not complain of any pain, palpitation, or dyspnoea, and yet, on a ribs, and in the epigastric region much increase in the pain, the post-mortem examination being made, his heart was found covered latter causing a feeling of faintness. Dyspncea. a deep-drawn with recent lymph, and the pericardial cavity nearly filled with breath causes a feeling of suffocation; skin clammy ; tongue fluid. I have noticed several cases of serous inflammation in furred, with a red centre; pulse 125, small, soft, and without irre- persons affected with morbus Brightii," in all of which the gularity, though fluttering; the impulse of the heart abrupt and complaint of pain has been far less than when they occurred labouring, as if congested, the sounds unattended by any bruit de after ordinary predisposing causes. of the third rib, and near the sternum, a loud friction sound is audible, accompanies both sounds of the heart, and during part of the interval between the second and first (the period of repose) is superficial, circumscribed, and very similar to the creaking of a new saddle, mixed with a duller sound, resembling the rubbing together of pieces of

souflet; but just below the

cartilage

The friction sound

which,

when present,

we

may consider

pathognomonic of the disease, is considered by many to be audible only previously to the effusion of fluid; but I think the case related, and the two following, shew that it may be heard even when a large quantity of fluid is present. CASE 3.-June 6th, 1844. E. S-, aged sixteen, has had pericarditis for four days. On percuting the thorax, there is persoft leather. Diagnosis.-Pericarditis. The indications being the peculiar fect dullness extending from the side of the sternum to a line pain, the dyspnoea, palpitation, and alarm; the great pain on pres- drawn from above downwards, through the nipple, and from the sing between the cartilages of the ribs and on the epigastrium; lower ridge of the fourth rib to that of the seventh. No impulse; sounds scarcely audible below the fourth rib, but are plainly heard the friction sound, and the absence of abnormal valvular sounds. Let eighteen leeches be applied between the cartilage of the first and second ribs near the sternum, .D:’e&—Sago, barley-water, &c. to the region of the heart, and let her take hydrochlorate of mor- up the large arteries, and without any bruit de souflet; above the phia, one-sixth of a grain; calomel, half a grain, every second cartilage of the fourth rib, and extending to that of the second, hour; and tartar emetic, one-eighth of a grain in one ounce of is a loud friction sound. CASE 4.-1842. Joseph S-, in-patient of the London Hoswater, every fourth hour. Seven P.M.—The symptoms are not at all abated; the pain is pital, has had pericarditis fourteen days. Dullness on percussion, increased. Let ten leeches be applied to the chest. from the lower edge of the cartilage of the second rib to that of 30th.-Better. The pain, dyspncea, and palpitation, are less; the seventh, from the centre of the sternum for the same distance, the countenance less anxious; bowels open; the friction sound less to a line drawn perpendicularly on the left side of the nipple. intense; the impulse lessened, but more unequal; and the pulse cor- No impulse; sound of the heart inaudible lower than the third

But when the man no abnormal, aortic, or friction sounds. moved from his recumbent to a sitting posture, and bent forwards, the normal sounds of the heart became audible near the only every third hour. 31st.-Decidedly improved. The countenance clear; the pain fourth rib, accompanied by a friction sound, and which lasted is relieved, yet still slightly existing; friction sound less intense; during part of the (so-called) period of repose. This was tried’ action of the heart and pulse as yesterday. Salivated. Diet: Milk, ’, several times, and with the same result. The chief medicinal agent on which we depend for cure, is Let the calomel be given every fourth hour, and con- ’, sago, &c. tinue with the tartar emetic. mercury, given so as to produce speedy ptyalism, which appears April 1st.—Not so well. All the symptoms aggravated, espe- to be most rapidly effected by half-grain doses of calomel every the pain. Let one grain of calomel, and one-fourth of a half-hour, or one-grain doses every hour, by which plan the desired effect has frequently been obtained by six grains of the grain of hydrochlorate of morphia, be given every second hour. 2nd.-Better. The pain relieved; also the palpitation and mineral, and in the case of E. S-, by five grains in five hours. dyspnoea; sounds of the heart rather indistinct; friction sound as The ptyalism should be kept up for some time, taking care that before. Much salivated. Give of tartar emetic, one-eighth of a it does not proceed too far, as then the specific effect of mercury, grain; hydrochlorate of morphia, one-slxth, in one ounce of water, in preventing the deposition, and causing the absorption of lymph, every fourth hour; and calomel, one grain; hydrochlorate of appears lost or diminished, as I have seen two cases of fatal perimorphia, quarter of a grain; at bed-time. carditis occur in persons profusely salivated; the post-mortem 4th.-Much better. Countenance smiling; pulse 90 ; pain and examinations shewed the effusion of lymph, and neither had any dyspnaea gone, except on motion; friction sound audible, but not general, and one of them no local symptoms of the disease preso intense; sounds of the heart muffled, and dullness in percussion viously to the ptyalism occurring. One of them happened in the of the praecordial region increased; rheumatism gone. Beef-tea. London Hospital. In regard to bleeding and low diet, they do not seem to be of much service after the first few days, and Let the mercury be omitted. 6th.-Friction sound inaudible; impulse of the heart diminished; should not be persevered in to an inordinate extent, or dilatation of the heart will result. pulse 85. Let all the medicines be continued. ENDOCARDITIS. 7th.-Not so well; the rheumatism of the limbs returned; pulse CASE 5.-June 15th, 1843, 8 P.M. E. B., aged seventeen, has 105, rather full and soft, though irregular; the friction sound has again appeared, though the signs of effusion are present-viz., in- enjoyed good health until about four days ago, when, after greatly diminished impulse, flutter- exposure to cold, she was attacked with pains in her feet, which creased dullness on percussion, irregular action, and muffled sounds. Omit the beef-tea, apply extended to her other limbs, and yesterday attacked the shoulders. six leeches, and give one grain of calomel, with one-fourth of a She is now suffering from acute rheumatism, and complains of grain of hydrochlorate of morphia every second hour. Suffice a sense of weight, and great uneasiness about the praecordial to say, that after another relapse she entirely recovered, the region, with palpitation of a rather violent character, but withtreatment adopted being calomel and morphia when the first out any pain attending it. The countenance is anxious and attack supervened, and a blister to the thorax; at the same time slightly flushed, respiration slightly accelerated, and the pulse 90, the strength of the patient was supported by beef-tea during the full, strong, and regular. On a local examination: percussion; the dullness of the prsecarintervals, and, towards the termination of the case, by the exhibition of iron, with very small doses of digitalis. The recovery dial region does not exceed the normal extent. Auscultation: was complete, for, on ceasing attendance, no remains of the the impulse of the heart is violent, abrupt, and regular; the cardiac disease could be traced, beyond occasional palpitation, sounds accompanied by a bruit de souflet, which, at the apex on and pains of a tensive kind, when exercise was taken. the left side, is loud, lasts throughout the whole of the first sound, May 5th, 1844.-Complains of palpitation, but not more than and diminishes as you ascend the ventricle; but between the carshe was accustomed to, previously to the attack last year, and tilages of the second and third ribs, near the sternum, two bruits looks much out of condition. On a local examination, no organic are audible ; one during the first sound, which is very intense in disease is appreciable; the increased action being caused ap- the upper part of the sternum, and less so, though plainly heard up the carotids ; the other during the second sound, a period of parently only from dyspepsia and nervous causes. - Remark.—We do not, in all cases, have the symptoms so well repose, and which, although obscuring, does not smother the marked as in this, as pericarditis may occur (especially the second sound. chronic form) without any pain or friction sound, causing merely Diagnosis. - Endocarditis; the mitral and aortic semilunar palpitation, more or less dyspnoea, a sense of oppression of the valves being affected. The endocarditis is shewn by the prsecorthorax, increase of fever, and, perhaps, a stronger pulse, which dial uneasiness and weight, the anxious countenance and palpitalatter, however, alters as the disease progresses. Hope states, tion, the violent, abrupt, and regular impulse, and the abnormal " If in rheumatism we have a strong jerking pulse, with great in- bruits. Of the particular valves, the mitral from the tricuspid by the crease of fever and anxiety, we may consider the disease to have bruit being most audible on the left side ; of the aortic, from the supervened." As an example of the insidious form in which this pulmonic by the bruit being heard up the carotids ; and that the disease occasionally occurs, I may mention the case of a man who pulmonic semilunar are not affected, by the second sound being

responds. Let all the medicines be continued. Quarter to seven P.M.—Slightly salivated. Give the

cially

ing

rib;

calomel

was

74 the mitral from the aortic, by the sound I see the motions of the foetus through the abdominal parieties. I the apex, and diminishing as you ascend the felt now convinced that it was a case of extra-uterine gestation, ventricle, and that it is regurgitant by accompanying the first an opinion which was further CGiinrmed by an examination. sound. through the vagina, when the uterus was found perfectly naBleeding to ten ounces. Let her take of calomel one grain, tural, with its neck long and loose, and not larger than when unand hydrochlorate of morphia, a quarter of a grain, every hour, impregnated. After waiting two or three weeks, I called in Mr. and of tartar emetic one-eighth of a grain every four hours. Walker, of Walpole, an old practitioner of sixty years’ standing, 16th.-Countenance more anxious, greater uneasiness of the who, on applying his hand to the abdomen, soon felt the motion prsecordial region, increased dyspncea and palpitation. On aus- of the fcetus, but could not speak positively as to the nature of the cultation, the impulse less forcible and abrupt, and rather irre- case, but advised her to be carefully watched, and to await pagular, and the abnormal sounds scarcely so intense. Pulse corre- tiently the natural termination of her pregnancy, advice in which sponds with the heart’s action. Not salivated. Twelve leeches to I fully concurred. About the middle of December, I was called the thorax, and repeat the calomel and morphia. up in the night by the nurse, who informed me that Mrs. Roberts 17.-Not so well: greater anxiety, general uneasiness, and was in labour : upon my arrival, I found she had been for two or dyspnoea. The impulse of the heart lessened, more irregular, three hours suffering from severe pains, which came on at regular unequal, and intermittent; the heart being apparently congested, intervals ; she had also a slight discharge of mucus tinged with the sounds not so clear, and the bruits less marked. Pulse 120, blood; the uterus had undergone little or no change since my small, irregular, unequal, and intermittent. Slightly salivated, and last examination, with the exception of a slight dilatation of its rheumatism nearly well. Repeat the calomel and morphia every mouth, but that not to a sufficient extent to admit the end of six hours, and give three grains of the carbonate of ammonia the finger. After waiting with her an hour, I gave her an anoevery three hours. dyne, and left, with a request to be called as soon as any circuml8th.-R,ather improved. Less dyspncea and anxiety of counte- stances arose requiring my attendance. On the following mornnance ; impulse slightly increased and more regular; pulse corre- ing I found her nearly free from pain; she had slept for two sponds, and the bruits louder. Calomel, one grain, and hydro- hours; and soon after I left, passed, per vaginam, a membranous chlorate of morphia, a quarter of a grain, at bed-time. Repeat the substance, which, on examination, appeared to resemble the memcarbonate of ammonia. From this time she gradually recovered, brana decidua: the os uteri was now closed, and the discharge the rheumatism left, the irregular action of the heart ceased, but very thin, but of a fresh colour. In about three or four days she the bruits remained, and on the 30th her condition was as follows: complained of a great weight in the lower part of the abdomen, Aspect pale; skin cool and moist; appetite moderate ; and on which rolled about whenever she altered her position in bed, and auscultating the lungs, they were found healthy, except a little also a sensation of coldness in the back; these feelings were protedema posteriorly. Of the heart, dullness on percuting; the bably attributable to the death of the fcetus. Nothing worthy of prsscordial region not increased ; the impulse rather increased, notice occurred for a month from this time, when the catamenia but regular, but the abnormal bruits persist. re-appeared, indicating the healthy state of the uterus, and its Dec. 20th.-Complains of constant palpitation and dyspncea, return to its natural functions. After this time, she was seen by increased in walking, and not ceasing in bed; in fact, with all the many of the most eminent medical men in this and the adjoining signs, both local and general, of slight enlargement of the left county, by whom various opinions were formed as to the nature side of the heart, which by rest, digitalis, and iron, and occasional of the case, some believing it to be extra-uterine pregnancy, while others regarded it as ovarian disease. I quite lost sight of purgatives, were considerably lessened. Remarks.-Most of the observations on pericarditis are applic- her till May, 1843, when she returned to Halesworth much able here; but we must not forget that this is a more dangerous emaciated, and suffering severe lancinating pains in the right affection, as it commonly leads to organic disease, whereas peri- iliac fossa, which was swollen, inflamed, and very tender on prescarditis is frequently cured, no disease remaining after the sub- sure : the bones of a fcetus could at this period readily be felt, and sidence of the inflammatory stage. There is one feature remark- it was supposed that suppuration would take place in this situaable about the case-viz., the length of time which elapsed before tion, and that they would be discharged externally. She, however, the system became affected with the mercury, forty doses having partially recovered, and again left Halesworth, so that I did not been given before ptyalism occurred. see her till March, 1844, just three years from the commence(To be continued.) ment of her pregnancy. Her appearance at this time was one of great suffering, and she was evidently fast sinking. She had

still

most

perceptible; intense

being

near

diarrhoea, during which a great quantity of mucus and blood passed away, mixed with offensive matter. She complained of something pricking her when the bowels were relieved. Upon examination through the rectum nothing could be detected ; she ON the nineteenth of Nov. 1841, I was requested to visit Mary continued in this state for two months, when she experienced Anne Roberts, aged thirty-eight, and found, upon inquiry, that great pain in passing her urine, which was highly offensive, and she considered herself about eight months advanced in pregnancy; contained a considerable quantity of purulent matter. On the that during the last month she had been suffering from spasmodic 2nd of August I found her in great pain about the neck of the pains in the abdomen, which were at times very severe, and were bladder, and, upon examination, discovered some foreign body in enly relieved by large doses of laudanum, which she had been that situation, which I proposed removing by dilatation of the taking under the direction of a druggist, who had hitherto attended urethra; but during the night she passed, while voiding urine, a her, under the belief that she was pregnant; that now thinking foetal tibia, encrusted on its upper half with calcareous deposit, himself and the woman mistaken as to the nature of the case, I the lower portion of the bone having evidently been detained was called in. She had not been pregnant for sixteen years, within a cyst, while the upper portion was pushed into the having only one child, a daughter of that age. In April, the bladder, and exposed to the action of the urine. From this time catamenia did not, as usual, make their appearance; she had morn- she became rapidly worse, and expired on the 18th of August. ing sickness, and all the usual symptoms of pregnancy, which left Having expressed a desire that her body should be examined, a About post-mortem inspection took place on the 20th of August, thirtyno doubt in her own mind of her being in that situation. the sixteenth week, while gleaning in the harvest field, she ex- six hours after death, in the presence of Dr. Turrell, Mr. Beales, perienced, for the first time, the motion of the child, which con- W. E. Crowfoot, J. Wase, and myself, when the following aptinued up to the time of my seeing her. My first attention was pearances presented themselves :directed to the breasts, which were fuller, their areola larger and Externally, body well proportioned, but much emaciated, with darker than usual, and milk was also passing from them. On general anasarca, more especially of the lower extremities; an examining the abdomen, which was much enlarged, a hard apparent tumour of the abdomen, but pressure in the hypogastric tumour was discovered in the epigastric region, immediately under region, immediately above and to the right side of the symphisis the ensiform cartilage; it appeared to be about the size of an pubis, communicated a grating sensation, as of the crushing of orange, and perfectly moveable. I was at once convinced of the numerous small bones beneath the fingers. Upon dividing the existence of a child, but did not mention my fears as to the nature abdominal parieties, no effusion of any kind was found within the of the case till I had the opportunity of making a further ex- cavity of the abdomen, and the peritoneum and abdominal viscera amination. The following morning I again visited her, the tu- were perfectly healthy, and free from any marks of inflammation, mour was distinctly to be felt in the same situation as on the preexcept in the hypogastric region, where the lower edge of the vious day; by applying pressure, it receded, and upon keeping the omentum was found firmly connected by adhesions of long standhand on it for some time, I felt what I believed the foetus give a ing to the peritoneal covering of the anterior parietes of the abcomplete turn in the abdomen, the head passing from under my domen. Upon dividing the upper part of the omentum from its hand into the right iliac region, and the extremities rising into attachment to the transverse arch of the colon, and reflecting it the situation which the head had previously occupied; byexpos- downwards, some purulent and offensive matter was observed to ing the body for some minutes, both myself and the nurse couldl flow from under it, and a large cyst was laid open with very thin constant

CASE OF EXTRA-UTERINE GESTATION. By MR. F. HEMARD, Surgeon, Halesworth.