A System of Midwifery Part 28

As the attack approaches, the patient frequently complains of a peculiar dragging pain and sense of oppression about the praecordia, which comes on and again abates at short intervals, and is attended with much restlessness and anxiety: this is followed by intense pain, which usually attacks the back of the head, and upon the accession of which the praecordial affection apparently ceases; the pulse now becomes smaller and more contracted. If the convulsions do not make their appearance by this time, and the headach continues one or more hours, a slight degree of coma supervenes, the patient loses her consciousness more and more, and wanders now and then; after a time she becomes restless and evidently uneasy, the eye becomes fixed and staring, the countenance changes, and the outbreak of convulsive movements follows.

Sometimes the premonitory symptoms are much less marked; indeed, in some cases, there is scarcely a sign to warn us of the impending danger; in the midst of a conversation the patient becomes suddenly silent, and, on looking to see the cause, we find the expression altered, the muscles of the face are twitching, the features beginning to be distorted, and the next moment she falls down in general convulsions.

Wigand (_Geburt des Menschen_, vol. i. -- 102,) considers that the two symptoms which usher in the attack are, the frightful staring followed by rolling of the eyes, with sudden starts from right to left, and twisting of the head to the same side by the same sudden movements; as soon as the convulsions have commenced, the head generally returns to its former position, or rather is pulled more or less backwards; "the eyes are wide open, staring, and very prominent, the eyelids twitch violently, the iris is rapidly convulsed with alternate contractions and dilatations; the face begins to swell and grow purple, the mouth is open and distorted, through which the tongue is protruded, brown, and covered with froth; the lips swell and become purple: in fact, it is the complete picture of one who is strangled." (_Op. cit._)

These convulsions, as in common epilepsy under other circ.u.mstances, usually if not always commence about the head and face, gradually pa.s.sing down to the chest and abdomen, and then attacking the extremities. After the above-mentioned changes, they pa.s.s into the throat and neck, by which a state of trismus is produced, and the protruded tongue is not unfrequently caught between the teeth and severely wounded. The neck is violently pulled on one side, and from the pressure to which the trachea is subjected, severe dyspnoea is produced. The respiration is nearly suspended, and from the violent rushing of the air as it is forced through the contracted rima glottidis, the breathing is performed with a peculiar hissing sound. The muscles of the chest now become affected, and the thorax is convulsively heaved and depressed with great vehemence; those of the abdomen succeed, and the convulsive efforts are here, if possible, still more violent: such are the contractions of the abdominal muscles, and so powerfully do they compress the contents of the abdomen, that a person who had not previously seen the patient would scarcely believe she was pregnant; the next moment the abdomen is as much protruded as it was before compressed. From the same cause, the contents of the r.e.c.t.u.m and bladder are expelled unconsciously, the extremities become violently convulsed, and the patient is bedewed with a cold clammy sweat. The duration of such a fit is variable; it seldom lasts more than five minutes, and frequently not more than two, and then a gradual subsidence of the convulsions and other symptoms follow; the swollen and livid face returns to its natural size and colour, the eyes become less prominent, the lips less turgid, the breathing is easier and more calm, the viscid saliva ceases to be blown into foam from the mouth, and the patient is left in a state of comatose insensibility or deep stertorous sleep, from which, in the course of a quarter of an hour or twenty minutes, she suddenly awakes, quite unconscious of what has been the matter; she stares about with a vacant expression of surprise; she feels stiff and sore as if she were bruised: this will be especially the case if it has been attempted to hold her during the fit. The convulsive efforts of the muscles of the body and extremities are not easily resisted, and thus it is that we hear of a delicate woman under these circ.u.mstances requiring several strong men to hold her: the result of such treatment is, that her muscles and joints are severely strained, and continue painful for some time after. Patients, on recovering their senses, frequently complain of pain and soreness in the mouth, arising from the tongue having been bitten; in some cases where the tongue has been much protruded, the injury is very severe, the tongue being bitten completely across, and hanging only by a small portion.

The woman may suffer but one attack, and have no return of the fit, or in half an hour, an hour, or longer, the convulsions again appear as at first. If this happens several times, she does not recover her consciousness during the intervals, but remains in a continued state of coma from one fit to another. Although it rarely happens, that the patient dies during a fit, still nevertheless, one fit will in some cases be sufficient to throw her into a state of coma from which she does not recover; in others, the patient may lie for even twenty-four hours in strong convulsions and yet recover.

The character of these attacks appears to vary a good deal with the cause; thus, where plethora has been the predisposing cause, and the fits frequently repeated, they take on more or less of an apoplectic character, the coma is more profound and of longer duration, and is frequently attended with paralysis; the cerebral affection is more severe, the patient does not recover her senses even where the intervals between the attacks have been of considerable duration; and when the fits have ceased and the coma abated, she is occasionally left in a state of imbecility and blindness, which lasts for several hours or even days.

Where it is connected with constipation or deranged bowels, we think that we have seen it more frequently attended with delirium or even temporary mania; the fits are numerous, the convulsions as severe, but the cerebral congestion is not so intense, the coma less profound; instead of being left in a state of torpid stupor, the patient is very restless and at times unmanageable, and when we consider the ident.i.ty of the causes which produce these convulsions and one form of purerperal mania, it will be easily understood why the symptoms should a.s.sume this character. The degree also of determination to the head, will in no slight measure influence the character of the symptoms which attend these attacks. "One circ.u.mstance," says Dr. Parry, "of increased impetus deserves to be noticed. The delirium is preceded by a pain in the head, but as the delirium comes on, the pain ceases, though the impetus remains as before, or perhaps increases. Diminish in a slight degree the impetus, and you remove the delirium and renew the pain; diminish the impetus in a greater degree, and the frown on the forehead is relaxed, the features seem to open, and the pain entirely ceases." (_Posthumous Medical Writings_, vol.

i. p. 263.)

By far the majority of cases of eclampsia parturientium occur in primiparae: thus in thirty cases which occurred to Dr. Collins, during his mastership at the Dublin Lying-in Hospital, "twenty-nine were in women with their first children, and the other single case was a second pregnancy, but in a woman who had suffered a similar attack with her first child." In two instances, under our own notice, where the disease occurred in multiparae, the fits did not appear until _after_ delivery; the patients were plethoric, and in one especially, the bowels were excessively deranged; in the other, the attack had much of the apoplectic character, and the coma did not at once abate until the fatal termination.

Convulsions usually make their appearance towards evening; and if pains are coming on, they return with every uterine contraction. The patient's danger will, in great measure, depend upon the severity, frequency, and duration of the fits; and although they must ever be looked upon as a disease of the most dangerous character, yet we are justified in saying that in the majority of instances the patient recovers: thus, of the forty-eight cases recorded by Dr. Merriman, thirty-seven recovered; and of the thirty by Dr. Collins, only five died, "three of which were complicated with laceration of the v.a.g.i.n.a, one with twins, and one with peritoneal inflammation. It is thus evident that the fatal result in these cases, with the exception of the twin birth, was not immediately connected with the convulsions; and the danger in all twin deliveries, _no matter what the attack may be_, is in every instance greatly increased."

(_Practical Treatise_, p. 210.)

Although puerperal convulsions usually occur at the commencement of labour, it not unfrequently happens that they do not come on until after the child is born; whereas, in other cases they occur several months before the full period: these varieties depend entirely upon the circ.u.mstances under which the attack has appeared. "With respect to their occurrence in the last month of gestation, although the paroxysm mostly appears during the actual dilatation of the os uteri, or on the first approach of labour, still when we recollect that in the last week or two of pregnancy the neck of the uterus is fully developed, the subsequent changes being confined to the os internum (the most sensitive part of the organ,) it cannot be surprising that, in very irritable persons, a serious impression should be made upon the brain at those periods."

(Ingleby, _op. cit._ p. 11.)

Dr. Merriman has called it _dystocia epileptica_: there is, in fact, no difference between this disease and common epilepsy, beyond that, under ordinary circ.u.mstances, epilepsy is a chronic affection, and, generally speaking, not attended with much danger, whereas, in the present case, it is an acute attack, and of a highly dangerous character.

Many phenomena connected with uterine irritation, both in the unimpregnated state and during pregnancy, prove the intimate nature of the consent existing between the brain and uterus. Thus it is well known that menstrual irritation is accompanied with a great variety of nervous and hysterical symptoms, which are merely a part of the same series of results to which epilepsy itself belongs: it is occasionally attended with delirium, spasms, and even coma, and preceded by the oppression at the pit of the stomach and pain of head, which we have already noticed among the immediate precursors of puerperal epilepsy; on the other hand, as Dr.

Parry has well remarked, "the beginning and end of each epileptic fit, before total insensibility begins and after it ceases, is often delirium, screaming, false impressions, attempt to annoy others under these impressions," &c. (_Op. cit._ vol. i. p. 396. &c.) Thus also during labour, either at the termination of the first stage, when the os uteri has attained its full degree of dilatation, or immediately after the birth of the child, the patient is frequently seized with a sudden convulsive rigour so violent as to make her teeth chatter and agitate the whole bed, and which is nothing more than a harmless modification of convulsive action arising from uterine irritation; the surface is perfectly warm, and the patient frequently expresses her surprise to find herself shivering thus violently and yet not feel cold.

It has been a common opinion that epileptic puerperal convulsions are almost certainly fatal to the child, especially if they continue for any length of time: experience, however, proves the contrary, as cases continually occur where the mother has laid for many hours in a constant succession of severe convulsions, and yet has been ultimately delivered of a living child. Still, however, it must be owned, that barely an equal number of the children are born alive under these circ.u.mstances. Thus, in Dr. Merriman's 48 cases, as already mentioned, only 17 children were born alive (including the 6 born before the mothers were attacked with convulsions;) in the 30 cases recorded by Dr. Collins, 18 of the 32 children (two of the women having had twins) were born dead; of these, however, it must be observed, that 8 were delivered with the perforator, and two were born putrid.

_Tetanic species._ There is one modification of eclampsia parturientium, which, from the spastic rigidity of the uterus which accompanies it, is peculiarly dangerous to the child's life: it has been called the tetanic form: the convulsions are incessant, without any apparent interval, and the uterus actively partic.i.p.ates in the state of general spasms: under such circ.u.mstances, the pressure which it exerts upon the body of the foetus will seriously obstruct the abdominal circulation, and produce the same effects as pressure on the cord.

In most cases, however, the convulsions have no effect upon the process of labour, which continues its course uninterrupted; so that, where there has been no return of consciousness during the intervals between the fits, and the patient has laid in a continued state of coma for some time, the child may actually be born before there has even been a suspicion that labour was present. It is, therefore, of great importance that the pract.i.tioner should be on the watch to detect any symptoms of its coming on, not only for the purpose of giving her the necessary support at the moment of expulsion, but also such a.s.sistance as may tend to shorten that process.

"By attentively observing what pa.s.ses in cases of convulsions, we remark that they do not always interrupt the course of the labour pains, whether they had excited those pains, or the pains had preceded them. All authors relate examples of women who have been delivered without help after several fits of strong convulsions; and others while they were actually convulsed, whether there were lucid intervals between, or that the loss of understanding was permanent. The progress of labour in most of these cases seems even more rapid than in others, since we have often found the child between its mother's thighs, though an instant before we could discover no disposition for delivery." (_Baudelocque_, trans. by Heath, -- 1109.)

_Diagnosis of labour during convulsions._ Where the patient is in a state of insensibility, we may infer the presence of labour by a variety of symptoms; every now and then, from a state of torpor, she becomes restless, and evidently uneasy; she pushes the bed-clothes from the abdomen, and gropes about it as if trying to remove something that is heavy or uncomfortable; she writhes her body, and moans as if in pain; after awhile, she again relapses into her former state of coma. A little attention will soon show us that these exacerbations of restlessness are periodical; and if we examine the abdomen at the moment, we feel the uterus evidently contracting; the os uteri also will be found tense and more or less dilated: if the head has already advanced into the v.a.g.i.n.a, these contractions will be accompanied by a distinct effort to strain.

It is rare to find convulsions complicated with malposition of the child; indeed, so uncommon is the occurrence of it under these circ.u.mstances, that we may feel almost certain, on being summoned to a case of convulsions, that there will be little chance of this additional difficulty being superadded. "There was but one case," says Dr. Collins, "of convulsions during my residence in the hospital, where the child presented preternaturally; there was not one case with a preternatural presentation during Dr. Clarke's residence; and Dr. Labatt has stated the same fact in his lectures while master of the hospital. In these three different periods there were 48,379 women delivered, so that from this we may infer, where the presentation is preternatural, there is little cause to dread the attack." (_Practical Treatise_, p. 200.)

_Prophylactic treatment._ Under no circ.u.mstances is the old saying of "Prevention is better than the cure," so well ill.u.s.trated as in the prophylactic treatment of puerperal epilepsy: it is only by carefully watching for and recognising those symptoms which we have already enumerated as threatening an attack, that we are able to adopt such measures as shall either keep it off entirely, or at any rate considerably diminish its violence.

The treatment which we have recommended during the last weeks of pregnancy, is particularly valuable in keeping off any disposition to these attacks: regular, and for her condition even tolerably active, exercise and strict attention to the bowels, should be required, especially in primiparae. If any distinct symptoms of cerebral congestion make their appearance, such as flushed face, headach, or slight wandering; if, moreover, the pulse be slow and labouring, we must at once relieve the circulation by bleeding; and by an active dose of calomel and James's powder at night with a warm pediluvium, and a brisk laxative the next morning, endeavour to ward off the dreaded attack. Not unfrequently, however, we have no warning of the danger until the fits burst out, and are thus debarred the opportunity of preparing against them.

_Treatment._ During the fit itself little can be done beyond placing the patient in such a situation that she should not injure herself by her exertions. If she happens to be upon a chair when the attack begins, it will be as well to let her sink gently upon the floor, and lie there until the fit is over; if she is in bed when it comes on, we have merely to watch that she does not roll off during her struggles; her movements should be restrained as little as possible, and by so doing we shall spare her the suffering after the fit from strained muscles and half-wrenched joints, which is so severe where the a.s.sistants, from mistaken kindness, have endeavoured to hold her.

It has been recommended by Dr. Denman to have the patient's face frequently dashed with cold water during the fit, a remedy which, as Dr.

Merriman observes, is very effectual in ordinary hysterical paroxysms, and which possibly may have a slight effect in moderating the violence of the epileptic convulsions; but from what we have seen we are not inclined to consider it of much use.

_Bleeding._ As soon as the fit is sufficiently over to render the operation possible, the patient ought to be placed in a half-sitting posture, and bled from a large orifice in the arm; the quant.i.ty of blood abstracted must be determined by the appearance of the patient, the severity of the cerebral symptoms, and the condition of the pulse; this latter will usually be found labouring, and even small, but will rise considerably in fulness and volume as we gradually relieve the circulation. Syncope is an effect which, under these circ.u.mstances, it would neither be easy nor safe to produce; but at the same time it will be highly desirable to produce a powerful effect upon the circulation by so large and speedy an abstraction of blood as shall be certain of alleviating the cerebral congestion: this is not often attained until after a loss of twenty, or five and twenty ounces. She should be supported in the half-sitting posture by means of a chair turned against the head of the bed, so that its back forms an inclined plane, which should be covered with pillows for her to lean upon.

_Purgatives._ An active dose of purgative medicine should be given the moment the patient is able to swallow; for in case of the fit returning, it will be sometimes very difficult to make her take any thing. Eight or ten grains of calomel, with fifteen or twenty of jalap, should be mixed into a paste with a little thin gruel and laid upon the back of the tongue, and a few spoonfuls more of gruel, &c. given to carry it down. If this cannot be taken, a few drops of croton oil will seldom fail to produce the necessary effect.

It is of the greatest importance to do this as early as possible, not only for the reason we have just a.s.signed, but also because we find that purgative medicines frequently take a longer time to operate in these cases than they do under ordinary circ.u.mstances, and require the repet.i.tion of even a powerful dose before the bowels can be made to act.

Where the convulsions appear to depend in great measure upon the deranged state of the bowels, the indications for the immediate employment of purgatives become still more urgent, for although we may control the cerebral congestion by means of the lancet, we shall not remove the source of irritation; but when once the bowels have been freely evacuated, the chain of morbid actions is broken, and the disease ceases: hence, in some cases, we observe much more striking relief produced by purgatives than even by bleeding. In order, therefore, to ensure a certain and speedy effect upon the bowels, she should take, about two hours after the powder, repeated doses of salts and senna, and if necessary, have their action still farther a.s.sisted by a purgative injection.

In the mean time, the hair must be closely shaven from the crown and back of the head, leaving the front bands, that she may be disfigured as little as possible, and a large bullock's bladder half filled with pounded ice, applied to the bare scalp; in lieu of which, an evaporating lotion of vinegar spirit and water, may be applied until the ice is procured.

Sinapisms to the calves of the legs and soles of the feet will also be required, so that, on coming into a room where a patient is lying in puerperal convulsions, the pract.i.tioner may quickly find employment for the numerous friends or a.s.sistants, who generally crowd round her on such occasions, and convert their officiousness into real utility. The air of the room must be kept as fresh as possible, and no more people allowed to remain in it than are absolutely necessary.

If she be tolerably conscious during the interval, a hot foot bath, rendered still more stimulating by some mustard flour, will be of great service; flannels wrung out of a hot decoction of mustard, and wrapped round the feet and legs, are also useful, and tend still farther to diminish the cerebral congestion.

In all cases of convulsions, especially if the patient be near her full time, it will be necessary to ascertain the state of the bladder; for the pressure of the head frequently produces much difficulty in evacuating it, and sometimes causes so much distention and irritation as to be itself quite capable of exciting the convulsions. Lamotte has given two instances where the fits had been evidently brought on by retention of urine, and where relief was immediately given by evacuating the bladder.

Where the patient has still some time to go, and no appearance of uterine action has been excited, the probability is, that the above-mentioned treatment, will be sufficient to prevent a return of the attack; and, if we have succeeded in calming the circulation, we may combine a little henbane with her medicine to allay irritability. But if she be near her full time, and labour has distinctly commenced, there will be little chance of the convulsions permanently ceasing until she is delivered, as the contractions of the uterus frequently appear to excite a return of them.

The practice in former times of dilating the os uteri, introducing the hand and turning the child, has been long since justly discarded, for the irritation produced by such improper violence would run great risk of aggravating the convulsions to a fatal degree.

"No cases require more prudence, attention, and sagacity, than the accident of convulsions in women, with their first children especially.

The state of the os uteri is of immense importance, and when it will admit of your delivering the woman without violence, trouble, or irritation, no doubt it ought to be performed with all prudent expedition, as you never can be sure of her being restored without delivery." (M'Kenzie's _Lectures_, MS. 1764, quoted by Dr. Merriman.)

Where we are called to a patient, who has been some little time in convulsions, and where bleeding and other necessary measures have been already had recourse to, we may, with a tolerable degree of certainty, expect to find the os uteri fully dilated, and the head in a favourable state for the application of the forceps. The pract.i.tioner should be able to apply the forceps whether the patient be lying upon her back or her side, as it is not always possible to choose her position; the former, will generally be the safest, as she will not only lie more quietly upon her back, but can be kept with most facility in this posture. Generally speaking the fits subside immediately after the child is delivered, although not unfrequently they recur during the first twelve or sixteen hours after labour, coming on at increasing intervals.

If, however, the state of the os uteri forbids our interfering with art, we must be content to follow out that plan of antiphlogistic treatment which has been just laid down, bearing in mind, that in proportion as we reduce the power of the circulation we increase the disposition of the os uteri to dilate, and, as Baudelocque justly observes, "while we wait the favourable moment for operating, we should only employ those means which we could use after delivery, if the convulsions should continue." (_Op.

cit._ -- 1110.)

By the time that the medicine has begun to operate, a considerable change will usually be observed in all the symptoms--the violence of the convulsions abates, the coma is less profound, and if the child be not yet born, the process of labour much more speedy and favourable; but if we find that the convulsions a.s.sume a tetanic character, and that the uterus actively partic.i.p.ates in this state of spasmodic rigidity, we must not expect any very favourable change until delivery is effected; and there will be little chance for the child of its being born alive for reasons already mentioned. Under such circ.u.mstances, which are fortunately of rare occurrence, it will be our duty to perforate rather than run the risk of losing the mother as well as her child; but before proceeding to this extremity we must satisfy our minds that the state of the os uteri forbids the forceps, and that, from the tetanic action of the uterus, there is little chance of its farther dilatation.

"It does not always happen that the convulsions cease upon the termination of the labour; on the contrary, they often continue after the birth of the child, and sometimes increase in violence, and at length produce death.

If, however, the intervals between the fits become longer, a more favourable prognosis may be formed, but it will be expedient to continue our exertions in relieving the symptoms." (Merriman's _Synopsis_.)

The after treatment will be little more than a continuation of that which has been described during the attack, only in a much milder form: the head must be kept cool by a proper lotion, and the bowels sufficiently open by gentle laxatives; a little gruel, with or without milk, may be given occasionally; and if the child be alive, it should by all means be applied early to the breast, in order to establish a flow of milk as soon as possible. Where the b.r.e.a.s.t.s have been very flaccid, and there were little or no signs of milk, we have now and then applied a sinapism over them with very good effect, for the mammary excitement thus produced has been attended with a copious lochial discharge, which has evidently produced much relief.

_Apoplectic species._ Dr. Dewees has described a species of convulsions by the term "apoplectic," but it is perhaps questionable how far he is correct in calling them "puerperal convulsions;" for, from the cases which have come under our own notice, the disease has been nothing else than genuine apoplexy occurring in the pregnant, parturient, or puerperal state: he justly observes, that "it may be brought on by causes independent of pregnancy, though this process may with propriety be regarded as an exciting cause; for it sometimes takes place when this process is at its height, but is no otherwise accessary to this end, than increasing by its efforts the determination of blood to the head." (_Op.

cit._ -- 1238.)

The treatment will in no respect differ from that of the genuine puerperal convulsions, except that, as the danger is still greater, so, if possible, must the treatment be more prompt; indeed, it can scarcely be said that there is a convulsion, for there is merely loss of motion with insensibility. It is fortunately of rare occurrence, as the patient seldom recovers.

_Anaemic convulsions._ The next form of epiplectic puerperal convulsions is the anaemic form, where, in consequence of serious loss of blood or debility otherwise induced, the due balance of the nervous system has been disturbed, and irregular and convulsive actions have been the result.

We have already shown that cerebral congestion is favourable to that state of irritability, which, by the help of any exciting cause, may easily pa.s.s into a state of epilepsy; an opposite condition, viz. that of exhaustion, is capable of acting in a similar way, and thus confirms Dr. Cullen's a.s.sertion, "that there are certain powers of collapse, which, in effect, prove stimulants and produce epilepsy."

"That there are such powers which may be termed indirect stimulants, I conclude from hence, that several of the causes of epilepsy are such as frequently produce syncope, which, we suppose, always to depend upon causes weakening the energy of the brain." "The first to be mentioned, which I suppose to be of this kind, is haemorrhage, whether spontaneous or artificial. That the same haemorrhage which produces syncope, often at the same time produces epilepsy, is well known; and from many experiments and observations it appears, that haemorrhages occurring to such a degree as to prove mortal, seldom do so without first producing epilepsy." (_Op.

cit._) It is a well-known fact, that when once a state of exhaustion or collapse has been carried beyond a certain point, the irritability of the nervous system increases in proportion: the due balance of its various actions becomes more and more unsteady; their equilibrium is disturbed by the slightest impressions, and losing the state of well-adjusted repose which belongs to health, they continually vibrate between the extremes of excitement or collapse, which seldom fail to produce some serious derangement.

"The symptoms of reaction from loss of blood," says Dr. Marshall Hall, "accurately resemble those of power in the system, and of morbidly increased action of the encephalon; and, from these causes, the case is very apt to be mistaken and mistreated by the farther abstraction of blood. The result of this treatment is, in itself, again apt farther to mislead us; for all the previous symptoms are promptly and completely relieved, and this relief, in its turn, again suggests the renewed use of the lancet. In this manner the last blood-letting may prove suddenly and unexpectedly fatal."

_Symptoms._ A very little attention, however, will discover the real features of the disease; the pale face, the glazy eye, the shrunken features and colourless lip, the cold moist skin, the heaving chest, the quick, weak, small, and irritable pulse, all betoken a condition of exhaustion and collapse. The history of the case will also show that the patient has suffered from profuse haemorrhage, or some other debilitating evacuation; and the intense pain on the summit of the head, verging into actual delirium, the rambling thoughts and confused mental a.s.sociations, the restlessness or absolute insomnia, the tinnitus aurium, disposition to strabismus or other derangements of vision, indicate the defective condition of the cerebral circulation.

We have already mentioned, in the congestive form of epilepsy, that where the irritation from gastric derangement is conjoined to a state of body already predisposed to the disease, that this is frequently sufficient to excite it into action; still more will this be the case where the system is rendered irritable by exhaustion; and it will occur under more formidable circ.u.mstances, from our means of treatment being confined within still narrower limits. Dr. M. Hall justly observes, that "exhaustion is sooner induced under circ.u.mstances of intestinal irritation:" and again, "paralysis has occurred in a state of exhaustion from other causes, as undue lactation; and in various circ.u.mstances of debility, as in cases of disorder of the general health, with sallowness and pallor, and a loaded tongue and breath."