CoTrhplzjrhents of tTte AoutKov. 
Ergot : The Use and Abuse of 
this Dangerous Drug. 
GEOEGE J. ENGELMANN, M. D., 
BY 
St. Louis. 
(ffijnccoloflical 
REPRINT PROM TOEUME Till ERGOT; THE USE AND ABUSE OF THIS DAN- 
GEROUS DRUG. 
GEOEGE J. ENGELMANN, M. D., 
St. Louis. 
Much is said in condemnation of meddlesome midwifery, 
as applied to early or injudicious operative interference, and 
especially to the use of the obstetric forceps; but meddle- 
some midwifery of a far more insidious and dangerous kind, 
because it is less evident and more common, has almost en- 
tirely escaped criticism. 
It is the abuse of ergot in obstetric practice to which I 
would impute a great, if not the greater, part of the suffering 
to which women who have home children are condemned. 
In labor and in abortion ergot is a universal and perpetual 
remedy in the hands of physician and midwife; it is the all- 
powerful and the only agent in use in the obstetric practice 
of too many. The injury done by this powerful drug is so 
great that I would condemn its use altogether; parturient 
women would be less prone to injury if ergot were stricken 
from the pharmacopoeia. It is never absolutely necessary or 
irreplaceable, and, where it might prove really useful, can not 
be relied upon for immediate action, so that in these cases 
other means must, of necessity, be resorted to. 
In obstetric practice it does good service, if given after 
the contents of the uterus have been expelled, to stimulate 
contraction when labor is completed, especially after the phy- 
sician has left his patient. 
In extreme cases, where it is urgently necessary that uter- 
ine contractions be excited, this drug, with which so much ERGOT. 
damage is done, which is thought to he a necessity to the 
obstetrician, is powerless; other means must be resorted to. 
Why, then, permit parturient women to be endangered 
in milder cases, and why toy with them in the more severe ? 
Why not ostracize this dangerous drug, and at once resort 
to safe and reliable means—to such as are harmless and 
effective in all cases ? 
It has been my custom, when engaged to attend an ob- 
stetric case, to see that the patient is betimes supplied with 
what I supposed, and was taught by teachers and text-books, 
to be the necessary remedies—such as I could not do without 
in case of trouble. In my early practice, ergot, freshly pow- 
dered, as fluid extract, or as the aqueous extract for hypo- 
dermic injection, was always prominent among these; yet 
this proved to be the remedy I least used; if I gave it at all, 
it was always given after labor was completed, merely as a 
safeguard against hemorrhage. 
Sad evidences of the popularity of the drug are the traces 
of its use which are every where found. When called upon 
to remedy a lacerated cervix or a ruptured perineum, the 
history is often that of a labor hastened by ergot; when 
summoned to deliver, by forceps or version, a child with, 
at best, feebly pulsating heart, from the iron grasp of a 
firmly contracted womb, you need but stop on your way 
at the family drug-store, and you will not fail to find that 
one medicine has been repeatedly called for—the fluid ex- 
tract of ergot! In case of post-partum hemorrhage the most 
precious moments are wasted in awaiting the effect of this 
drug, which fails where most needed. 
Results sadder still are scored to its use : rupture of the 
uterus, one of the most rare and dangerous of all the acci- 
dents attending parturition, is its most terrible sequent. 
I myself have seen two such cases, where young, well- 
built women with healthy tissues and roomy pelvis, thus, 
together with the unborn child, fell victims to a dangerous 
practice. 
Both had before borne children with ease; nor did the GEORGE J. ENGERMANE. 
3 
post-mortem examination reveal abnormal conditions of pel- 
vic wall or uterine muscle. In one the vertex presented, 
in the other the shoulder. In both, ergot was given by the 
impatient practitioner to hasten labor—given until the uter- 
ine fiber was strung in tonic contraction to its utmost, finally 
beyond endurance, and two lives were sacrificed at one 
stroke. 
Such is the experience which has forced me to the posi- 
tion I now take. It is my firm conviction that the abuse of 
this dangerous drug must be checked—a powerful drug and 
valuable in its place, but worse than poison to women in 
labor, because so often at the time apparently useful, whilst 
the injuries consequent are masked and but slowly appear; 
because cause and effect are indistinct, unperceived by the 
sufferer, and it maims oftener than it kills. From this 
Society must issue the fiat; hence let us inquire into the 
abuse—the present use of ergot—and its action. What are 
its dangers, and where is its proper place ? Last, but not 
least, how can we, with safety and certainty, attain what is 
supposed to be accomplished by ergot ? 
The uses of ergot to which I would call attention are in 
obstetric practice, in labor and abortion. 
In labor, ergot is used in the earlier stages to hasten par- 
turition—to increase the frequency and force of labor-pains 
—partially with the sincere wish of affording the best possible 
attention to the patient and giving more speedy relief, as 
often to relieve the impatience of the practitioner himself. 
Should the pains lessen in force or frequency, or cease 
altogether for a time, ergot is given to bring them on again; 
it is given if labor progresses too slowly, if the os does not 
dilate, or the ovum descend with sufficient rapidity; later, 
in the second stage, if the head is slow in making its way 
through the utero-vaginal canal, or in sweeping the perineum, 
regardless of proper rotation or relaxation of the parts. 
It is frequently given a short time before the expected 
delivery of the head ; in the third stage, to further uterine 
action and the expulsion of the placenta; after delivery 4 
ERGOT. 
is completed, to prevent too profuse a flow and secure proper 
contraction. 
Should post-partum hemorrhage occur, ergot is always 
the first remedy resorted to—in almost every case the fluid 
extract per os, rarely by hypodermic injection—and much 
valuable time is lost in awaiting the effect which this magio 
drug is thought in duty bound to produce. 
In abortion, it is given at all times in the beginning, 
when hemorrhage is profuse ; or, should this not be the case, 
whatever the dilatation of the os may be, to expel the con- 
tents of the womb, whatever they may be. Ergot is at all 
times used, apparently without strict indications, and, unfor- 
tunately in this class-of cases, when the physician is rarely 
called, by nurse or midwife. 
That we may thoroughly appreciate the consequences to 
which this abuse must lead, I will briefly outline the action 
of ergot upon the uterus and its contents. The evil effects 
which I shall point out to you as resulting are not the de- 
ductions of scientific reasoning; unfortunately, not mere 
theoretical suppositions, but sad realities—facts—cause and 
effect. 
In the first place, let us consider the physiological action 
of the drug upon the uterus and its contents. 
In the main, it is a powerful stimulant to uterine contrac- 
tion, and acts, during the continuance of the effect, persist- 
ently and uninterruptedly upon the involuntary non-striated 
muscular fiber of the womb; its effect upon the organ in 
labor—the continuous tonic contraction due to the drug plus 
the intermittent contractions of labor-pains —is to perma- 
nently increase the tension of the muscular fiber, to con- 
tinuously augment the intra-uterine pressure; as the dose is 
repeated or increased, the contrast between labor-pains and 
the intervening period of relaxation is lessened more and 
more, the intervals are shortened, and, though the pains are 
more frequent, they are less marked; the powerfully acting 
muscle is artificially stimulated, until the intermittent con- 
tractions of natural labor become blended with the continu- GEORGE J. ENGELMANK 
5 
ous effect of ergot, and a tonic contraction results. Although 
ergot at first apparently serves to increase labor-pains, the 
tendency is toward tonic contraction, to diminish that inter- 
val of rest between the pains which is so important in the 
entire process of parturition, especially for the safety of 
mother and child. With the lessening in this alternation 
between relaxation and contraction the dilatability of the 
os is impaired, and, as the state of tonic contraction is ap- 
proached, the outlet from this vise—the mouth of the womb 
—does not enlarge correspondingly, but becomes more firm 
and unyielding. 
Another danger arising from the use of this drug is in 
the relaxation which it not infrequently produces. Whether 
this is an idiosyncrasy, or due to peculiar conditions, I am 
not prepared to say. I have seen it repeatedly when ergot 
was given to check menorrhagia or hemorrhage; perhaps 
profuse menstruation due to fibroids, and also when given in 
post-partum hemorrhge. In the latter case it has been 
ascribed to a relaxation of the system resulting from nausea 
or weakness of the stomach, due to the irritation from quan- 
tities of the unabsorbed material in the inactive stomach. 
What, then, are the dangers which we may theoretically 
expect to arise from such a remedy % 
Most evident is the injury which must result to the child : 
during a healthy, normal labor-pain the nutrition of the ovum 
is momentarily impaired, the beats of the fetal heart are en- 
feebled and diminished in number; to the auscultating ear 
they become weak and slow, almost inaudible at times; in the 
interval between the pains restoration rapidly takes place. 
Under the influence of ergot the permanent pressure is in- 
creased, and the effect upon the child during the pain is 
more severe, continuing, though in a less degree, in the in- 
terval ; perfect restitution is prevented; as the pressure is 
increased, or the intervals diminished, asphyxia and death 
must inevitably result. The child may also suffer from be- 
ing rapidly forced through unprepared parts. 
The mother can not escape injury. The uterine muscle 6 
ERGOT. 
is unduly exerted, labor is precipitated, and expulsion of the 
child through unprepared, unyielding parts must lead to rup- 
tures of the utero-vaginal canal—first of all, rupture of the 
perineum ; probably with almost equal frequency, laceration 
of the cervix, which may be due to the rigidity caused by 
ergot, as well as to hastened labor. Should this not occur, 
should the fibers of the os not yield and those of the fundus 
be drawn more firmly in tonic contraction, like bands of 
steel, about the ovum, already compressed to its utmost, they 
must burst, and rupture of the uterus result. 
Such are the dangers to which the use of ergot exposes : 
laceration of the cervix, rupture of the perineum (more rarely, 
vesico- and recto-vaginal fistulse), rupture of the uterus, death 
or asphyxia of the child. To prove this with positive cer- 
tainty is almost impossible. The patient herself is entirely in 
the dark as to cause and effect, and the physician is equally 
innocent, or he would shrink from the use of this dangerous 
poison. As I have myself twice seen rupture of the uterus 
and the death of mother and child thus caused, I am con- 
vinced that the lesser injuries are but too numerous. 
If given, as advocated by some, during or immediately 
before the passage of the head, at a time when the funis is 
so exposed to pressure, evil consequences may still ensue, 
especially asphyxia of the child—as it is not always possible 
to say just how long this state will last—the idea being that 
the drug should not take effect until after expulsion. 
How often is ergot, however, given in the early stages, 
before a correct diagnosis is made, to hasten labor, in presenta- 
tion of the breech or the shoulder, when the ovum will not 
descend and labor does not progress with sufficient rapidity ! 
In breech presentations, where the first stage should be, if 
anything, retarded, the death of the child will result; should 
the shoulder present, version will become difficult or impos- 
sible, and rupture of the uterus may ensue. 
In the third stage of labor, after delivery of the child, 
the efforts of nature are in every way aided by the action of 
ergot; contraction is furthered, the separation of the after- GEORGE J. ENGELMANN. 
7 
birth is hastened, as well as its expulsion ; the sinuses are con- 
tracted and closed, yet there is one objection—the possibility 
of an incarceration of the placenta. Labor completed, the 
uterus emptied, the giving of ergot insures permanent con- 
traction, and relieves the physician of continued attendance. 
The idiosyncrasy alone is to be guarded against. 
In post-partum hemorrhage, the internal administration 
of ergot should be avoided, as it is powerless ; it is not even 
absorbed, and may seriously annoy the stomach, which should 
be carefully guarded. After the flow has been controlled, it 
may be used, best hypodermically, to prevent recurrence, 
and in aid of other more reliable measures. 
In miscarriage and abortion, the danger is in tonic con- 
traction of the uterus, by which hemorrhage is indeed checked, 
but the separation of the ovum retarded and incarceration 
made probable. The expulsion is often checked and delayed, 
but abortion is not prevented. 
Of the lesser evils which result from the use of ergot we 
are rarely, if ever, informed, but they are many; they are 
not reported, not even recognized, so that the evil remains 
unabated. Extreme cases, even, are perhaps more frequent 
than generally supposed, as they are neither recognized nor 
published; rupture of the uterus alone, the most dangerous 
and fatal of the evils consequent upon the use of this drug, 
may occasionally be traced with certainty to its proper cause. 
In view of these facts, the only possible conclusion is that 
the use of this popular, powerful, and dangerous drug should 
be strictly prohibited in obstetric practice proper, and re- 
stricted to the non-jpregnant womb ! 
The obstetrician can give it with safety only after the 
placenta has been expelled, bearing in mind its injurious 
effects, and the fact that in all those cases where this insidi- 
ous poison is given, and thought to be necessary, we have 
other milder, more harmless, and more effective means to ac- 
complish with safety the purposes which ergot is thought by so 
many to serve; these are external manipulations, massage and 
expression; hot antiseptic injections, vaginal and intra-uterine. 8 
ERGOT. 
Such, are the remedies by which we can, with certainty 
and without danger, secure uterine activity and contraction 
under all those conditions in which ergot might possibly be 
used, and even in all such as are usually supposed to indicate 
a resort to that drug. 
Having these means, which are in their action more safe 
and certain, more rapid and precise, covering every indica- 
tion which is met by ergot, and, in addition, useful in a much 
wider field, why discuss the possible merits of ergot, and 
mark out with care the utmost limits to its use ? 
Let us see how, by massage and expression, by injections, 
by external and internal manipulations, the desired result 
which ergot is supposed to further may actually be accom- 
plished and the object attained without risk to the patient. 
As we have seen, ergot is often given needlessly by the 
impatient attendant to hasten labor; or, more injudiciously 
still, in the early stages of breech and shoulder presentations 
—in both instances with most unfortunate result—and with- 
out the slightest reason or benefit, often under conditions 
where no interference whatsoever is indicated, certainly not 
of such a kind. All the injuries resulting from this very 
frequent manner of its abuse would be completely avoided 
by condemning the use of ergot in the gravid womb; no 
substitute is necessary. 
When it seems desirable to regulate labor-pains, opium or 
quinine is to be recommended; to stimulate and excite the 
uterine muscle to action, a judicious massage, friction of the 
fundus, is harmless and successful; hot carbolized vaginal 
injections serve the same end, and are especially useful if 
labor is delayed by rigidity of the os ; to aid in the expulsion 
of head or breech, massage and expression can not be too 
highly recommended. 
Better by far than ergot, and without possible evil result, 
for the purpose of securing separation of the placenta, its ex- 
pulsion, and contraction of the uterus in the third stage, are 
external manipulations, the following down of the fundus 
uteri with the hand—friction and kneading of the globe— GEORGE J. ENGELMANN. 
9 
massage; to secure permanent contraction after expulsion of 
the placenta, the same manipulations should he resorted to, 
and these will be admirably furthered by the hot vaginaj 
douche, in more severe cases by intra-uterine injections, to 
which a disinfectant should be added, such as carbolic acid or 
corrosive sublimate ; this cleanses and disinfects, leaves the 
patient comfortable and safe; by removing clots and shreds 
it may even, if repeated, alleviate after-pains. 
In case of bleeding or profuse hemorrhage, nothing can 
compare to this method; and, if safe and reliable in severe 
cases, why not resort to it in the more simple, where ergot is 
now supposed to be alone useful, even indispensable ? 
In abortion, the proper indications for the administration 
of ergot are so difficult to formulate, its use is so restricted, its 
injurious effects so frequent, that the foregoing axiom—that 
the gravid womb contra-indicates the use of ergot—need meet 
with no exception. Such remedies as meet immediate indica- 
tions must, of course, be adopted, and beyond these the hand, 
the douche, and the scoop, sharp and dull, will answer all 
purposes. Massage and expression are not so simple and 
direct as in labor at term, but the uterus can be thoroughly 
and safely manipulated, as Schroeder suggests—the ovum 
even expressed—by supporting the organ by two fingers of 
one hand placed to the sides of the cervix, or in the anterior 
and posterior culs-de-sac, while pressure is made upon the 
fundus with the other hand. 
Conclusion.—So much injury is done, so much suffering 
caused, by the indiscriminate and injudicious use of ergot, 
that it should be entirely abolished in labor, premature and 
at term. External manipulation, friction of the surface, 
massage and expression, and internal manipulations, by the 
hand, the scoop, and the douche, accomplish with safety and 
certainty the objects which it was supposed to serve, so that 
they will soon become popular, and ergot will only be given 
by the obstetrician for its one legitimate purpose—to insure 
contraction when labor is completed, and to act as a guard 
upon the treacherous fibers of the uterine muscle. To avoid 10 
ERGOT. 
the danger arising from idiosyncrasies, he should observe its 
effect before leaving his patient, giving ergot after the expul- 
sion of the placenta, after he has resorted to other means to 
stimulate uterine activity; and then, if satisfactory, the rem- 
edy should be left in the hands of the nurse—to be given 
occasionally during the first twenty-four hours —to guard 
against the possibility of relaxation and hemorrhage, to secure 
thorough, firm, and permanent contraction, to hasten involu- 
tion. 
This is the one condition under which ergot should be 
used. Later, in case of sepsis, it may be again given, to 
prevent absorption of putrid matter by contraction of the 
vessels, and to further the expulsion of such matter from the 
cavity. 
I will add that the drug might be given during the third 
stage of labor, when, barring the danger of incarceration of 
the placenta, it thoroughly fulfills the existing indications. 
But let us not enter into possibilities. Let us adhere to the 
maxim that ergot should only he given in the non-gravid 
uterus. This is demanded by the exigencies of the case. 
We must deal with facts, not theories. We must decide what 
it is best to do, not under what conditions ergot might be 
used, or how far we may push this use. 
Let its dangers be clearly demonstrated; let it be under- 
stood that ergot is nowhere indispensable ; that we have more 
safe and direct means of attaining those ends for which it 
has been so indiscriminately administered; but that it may 
be given, as an additional guarantee of safety, to secure uter- 
ine contraction and guard against hemorrhage after the ter- 
mination of labor. 
The advantages of massage and expression, of posture, 
and the disinfectant douche will soon be appreciated, and it 
will no longer be necessary to insist on the axiom that the 
use of ergot must be confined to the non-gravid womb.