THE PROPER USE OF ERGOT IN OBSTETRICS BY JOSEPH TABER JOHNSON, M. D. REPRINTED FROM VOLUME VII. <«5pnecological 1883 THE PROPER USE OF ERGOT IN OBSTETRICS BY JOSEPH TABER JOHNSON, M. D. REPRINTED FROM VOLUME VII. <ran£act:ong 1883 THE PROPER USE OF ERGOT IN OBSTETRICS. BY JOSEPH TABER JOHNSON, M. D., Washington, D. C. The proper use of ergot in the practice of obstetrics has long been a subject of controversy, and the following con- tribution is modestly offered, to aid in a settlement of this important though hackneyed question. I have nothing new in the line of discovery to offer, but shall hope to bring the knowledge we do possess into such shape as to show the powers of this drug for good and evil, and shall suggest rules for our guidance in its administration to women in labor. With its other varied uses in the general practice of medicine this short paper will not attempt to deal. The. history of its early use details the varied experiences of obstetricians of great skill and wide reputation. It was declared by some, after repeated trials, to be without result. Others said it acted only through the imagination. An ef- fect was claimed for which the patient was prepared, and soon after its administration the tired organ would renew its efforts with a vigor which was attributed to the medicine. While still others declared that it was chiefly valuable on account of its inability to do harm. We know now, with the great number of cases of recorded accidents attributed to its abuse, that it is not incapable of doing harm. The failure to produce results in the hands of those declaring it ineffective must have been owing to the employment of impure or spoiled preparations. It is certainly in evidence that the specimens have to be selected with care, and are difficult to retain in their purity after the most skillful man- ufacture, especially when given in the powder or infusion, as is still the habit of many practicing in the country. 4 JOSEPH TABER JOHNSON That schools differ in teaching the indications for its use, text-books in their instructions, and obstetricians in their practice, none familiar with the subject will deny. Some au- thors advise its exhibition to hasten slow pains in the first and second stages of labor, others say it should never be given in these cases. Some try to overcome uterine iner- tia with it; others say it is little short of murder to give it, when the child is viable, to any woman in labor. Some advise its use to expel a retained placenta, and always give it immediately after the birth of the child's head, and as a prophylactic against hemorrhage ; others say it does harm in these cases. Some claim it to be the remedy in threat- ened and actual abortion, and especially valuable in causing the expulsion of the fetal membranes, while others say these are the cases in which ergot is positively contra-indicated. Some recommend its use in placenta previa and accidental hemorrhage, while others declare that it seriously damages the chances of the child in its race for life, and prevents the safe and successful manipulation necessary for version and extraction, should they become necessary. With all of these contradictory statements before us con- cerning the action of and indications for the use of this remedy in obstetrical practice there would seem to be no apology necessary for bringing to the attention of the So- ciety the subject of the use and abuse of ergot in the lying- in chamber, and to appeal for such a discussion of this highly important topic as would authoritatively settle dis- puted points in practice. In the beginning it would be desirable, if possible, to as- certain what is the real effect of this drug upon the muscu- lar fibres of the uterus and upon the child within its cavity. Recent text-books upon materia medica and obstetrics agree in the statement that ergot produces in a uterus already in labor a persistent tonic contraction, which, if sufficient be given, finally becomes tetanic in character; also that the kind of contraction produced is diametrically opposite to the in- termittent rhythmical contractions of the normal parturient uterus. 77ZA PROPER USE OF ERGOT IN OBSTETRICS. 5 When naturally acting, expulsion of the fetus is produced by the repeated shortening or contraction of the longitudi- nal uterine muscular fibres, while at the same time the cir- cular ones are retracted over the presenting part as the cer- vix and os become dilated. The phenomena of the labor pains constantly succeed each other in increasing power and rapidity until the organ is finally completely emptied of its contents. " When these pains lose their rhythmical quality and become continuous they cease to belong to the domain of physiology." Lusk remarks, that " whenever the alterna- ting relaxation ceases, and the uterus passes into a condi- tion of tonic contraction, no work is accomplished, and the pains are ineffective." In the persistent tonic contraction produced by ergot, all the muscular fibres of that organ act equally upon its contents, which are held as in a vise, in- stead of expelled as above described. In most cases this effect is produced, but in some instances the child has been suddenly expelled after its use. In these exceptional cases, the uterine forces must have acted energetically before the force of the contracting wave had reached the lower ute- rine segment, causing it also to contract, thus closing in- stead of dilating and retracting. In normal contractions the child and placenta are both compressed with considerable force, but they have time to recover fully during the interval between the pains. The placental circulation,' interfered with for a time, goes on naturally as soon as the contraction ceases. The temporary acceleration of the fetal circulation under the effect of ute- rine contraction is familiar to all who have studied the sub- ject or carefully observed the clinical progress of a normal labor. Not so with the ergot contractions. They, once thoroughly induced, may last for hours. The child, being equally compressed on all sides, cannot advance. The ex- change of gases is prevented in the placenta; its circulation is gradually suppressed, and the child is as certainly as- phyxiated as an adult when hung by the neck with a rope. If there were no interference with the fetal circulation by the persistent contraction of the placental site, the long con- 6 JOSEPH TABER JOHNSON. tinned compression of the chest and brain of the child might alone so interfere with the operations of vital func- tions as to produce its death. Instances of injurious and fatal crushing, under these circumstances, have been re- corded. Intermittent uterine contractions, together with the soft- ening, lubricating, and dilating processes natural to the par- turient act, gradually prepare the cervix, vagina, and peri- neum for the safe passage of the fetus and its final emer- gence. In the alternating relaxation of these tissues and the re- cession of the presenting part, thus relieving the agony of pressure and distention, does the safety of the process con- sist. No one has shown so satisfactorily and emphatically as our distinguished President, Dr. Emmet, the great danger of continued pressure ////relieved by the recession of the child's head in lingering or delayed labor. Necrosis of the soft parts from interference with the circulation takes place, and their more or less complete destruction follows in pro- portion to the amount and length of time the pressure is kept up. Whether vaginitis, pelvic cellulitis, or sphacelus occur will be determined by the length of time these tissues have been compressed and their nutrition has been inter- fered with. We may have so slight a fistula occurring as to be found with difficulty, or the greater portion of the an- terior vaginal wall together with neighboring parts may be- come gangrenous and. slough away. Ergot has frequently been substituted as the proper alternative for the forceps in these cases of delay or uterine inertia. Dr. Barker contrib- uted a paper to this subject a number of years ago. A dis- cussion of the danger of its abuse in these cases alone might occupy all the time allotted to my paper, if there were not a number of other points to briefly consider. While the action of ergot, we have seen, is to produce a continued tonic contraction of the uterus, suspending its al- ternate relaxation, undoubtedly cases do occur where, from abundant use, such powerful pains have taken place as to propel its contents suddenly through the unprepared soft THE PROPER USE OF ERGOT IN OBSTETRICS. 7 parts with such force and rapidity as to produce any or all of the lacerations combined, in a single case, from rupture of the uterus to complete laceration of the perineum. I will not stop to quote cases or authorities upon these points. So many accidents have taken place, and have been so fre- quently attributed to the abuse of ergot, that I cannot be far wrong if I take it for granted that proof by the quotation of authentic cases on record is unnecessary. Its uncertainty of action is one of the principal dangers of its use. It may act upon the entire organ, or upon only a portion of its fibres about the cervix, internal os, lower uterine segment, middle portion (constricting it in the centre like an hour- glass), upon the fundus, or one cornu. Upon its reintro- duction into obstetric practice in this country, the same fashion or craze seemed to control its use as has controlled the use of many other remedial agents before and since. There seemed to have been a general acceptance as a fact by the profession at large that ergot would originate and intensify uterine contractions, and therefore was the remedy to administer in cases of uterine inertia before and after delivery. In some quarters warning notes were sent out that ergot was the cause of many still-births and accidents during labor. Cases were reported where it was given to hasten slow pains, and the children were still-born after a labor sometimes not particularly hastened. The text-books have of late taught the correct use of this drug, but still many use it in the first and second stages of la- bor. Upon inquiry among physicians practicing in different parts of the country within the past few years, I have become convinced that the teachings of these authors, if read, are constantly disregarded ; and that it is as true now as when Meigs wrote, in 1867, " that multitudes of unborn children are being destroyed " by the unwise, unscientific, and per- haps I ought to say criminal use of this medicine. There is no lack, within my own knowledge, of cases where its ad- ministration might be made the basis of a charge of mal- practice, and the well-known opinions and practice of men 8 JOSEPH TABER JOHNSON. within the sound of my voice could be quoted as first-class evidence against the offenders. I know teachers who lec- ture their classes upon the criminality of the use of ergot be- fore the birth of the child. I know physicians in charge of the lying-in wards of maternity and other hospitals who positively forbid its administration by their internes and nurses until after the birth of the placenta. On the other hand, I so firmly believe the opposite of this custom prevails to an alarming extent throughout the country, that I have ventured to write this paper as an additional warning to those already in existence. My attention was drawn emphatically to this subject by a sad case occurring in the first years of my own practice, the chief points of which are as follows : The lady was a stout German who had previously been delivered of four children safely. The labor had been progressing well for some hours. The parts all seemed dilatable, and the child about to be born, when the pains began to be less effective, and seemed about to stop altogether. A condition of in- ertia was impending. I gave to this patient a teaspoonful of the fluid extract of ergot. Not much effect was noticed, and I gave more. She took in all about half an ounce. No real pains were produced, but the uterus from being soft be- came hard, and continued hard. She was in pain all the time, but occasionally it was intensified. It never, however, relaxed, or went off as in natural abor. I knew, and the mother knew, that the child was alive before she took the ergot. It seemed when given that a few more good pains would expel the child, but this tetanic action of the uterus came on, and the fetus was gradually squeezed to death or asphyxiated. I had finally to send for my forceps, but only then to extract a dead child. Had delivery been accom- plished with it at the time the fatal dose was administered, I believe the child would have been saved. Manual com- pression, or a large dose of quinine, would probably have produced the same result. I subjoin the history of two cases in illustration of this point, kindly furnished me by Dr. A. C. Adams of this city. THE PROPER USE OF ERGOT IM OBSTETRICS. 9 Case I. - Mrs. S., primipara, blonde, aged twenty-three, height five feet three inches, weight 105 pounds, general health good, was awakened with labor pains early on the morning of March 10, 1881. Medical service was summoned at 12 m. Upon examina- tion, the cervix was found dilated to the size of a twenty-five cent coin, and dilatable. 4 p. m. Cervix was dilated to the size of a silver dollar and somewhat attenuated during pains, which were now increasing in strength and duration. 8 p. m. Cervix dilated one half ; bag protruding, but not making firm pressure upon the cervix during the pains. 10 p. m. Pains apparently sufficient, but lacking duration ; pressure upon the cervix almost zzzZ, and cervix remaining soft during pains; bag artificially ruptured ; small quantity of liquor amnii escaped. 12 p. m. Character of pains unaltered ; degree of dilatation the same; ext. ergot® fl. admin- istered in half-drachm doses at intervals of half an hour. Pains became more continuous and attended with a sense of bearing down. March n, 5 a. m. Head tightly embraced by the cervix, but not descending. Patient wearied but strength preserved. By manipulation, internally, efforts were made to increase the dilata- tion of the cervix, and externally, by downward pressure to assist in expelling the fetus. 10 a. m. Head passed the cervix, and half an hour later escaped the vulva, when labor was speedily com- pleted, with a still-birth. Efforts to resuscitate failed. A bright- red band half an inch wide marked the entire circumference of the child's head. The mother made the usual recovery. Case II. - Mrs. S., primipara, black, aged thirty. Height five feet seven inches; weight 130 pounds; general health excellent. Labor pains commenced 6 a. m., August 8, 1882. Medical service called at 3 p. m. Upon examination, the vulva and vagina easily admitted the whole hand; the cervix was found dilated to the size of a silver dollar, and dilatable ; bag protruding with pains. 5 P. M. An extremity (an arm) was felt descending inside the amniotic bag, and the head not easily reached. Efforts to replace the arm were made during the intervals of pains, after which the head de- scended into the pelvic excavation. 7 p. m. Pains recurred regu- larly, but deficient in duration ; bag protruded, but the pressure upon the cervix was not in proportion to either the strength of the pains or the duration of labor. 10 p. m. Pains complained of for the most part in the back. Cervix dilated one half, soft and thick ; bag protruding during pains ; was artificially ruptured; liquor amnii dribbling away. Ext. ergot® fl. was administered 10 JOSEPH TABER JOHNSON. in teaspoonful doses every hour, one ounce being consumed. 12 p. m. Pains in back more continuous and annoying. Cervix not dilating ; thick and soft. Uterus not contracting. Movements of fetus not felt since 6 p. m. August 8, 2 a. m. Dilatation aided by digital movements. Head engaged in pelvis ; elongating and deficient in tone and resistance; not descending with pains. 3 a. m. By forced efforts at digital dilatation and external abdom- inal pressure the head was made to pass the thick cervix, and, owing to the size of the external soft parts, the child was imme- diately expelled dead. The mother made a rapid recovery. In the cases of these patients, one small, the other large in stature, both in the enjoyment of perfect health, there was, in the first place, a failure on the part of the cervix to complete dilata- tion. Second, all efforts to increase the dilatation failed to evoke the action of the longitudinal fibres. Third, after full dilatation was reached, inertia of the uterus was complete. Now, sixteen and twenty hours elapsed before resort was had to ergot with the view to excite uterine contractions, in which it not only totally failed, but, per contra, its entire influence was concentrated upon the circular fibres of the lower segment of the uterus, as was evinced both by the band around the head of one child and the death of both. If the ergot, which undoubtedly was destructive, was employed too soon in the delivery, could instrumental inter- ference have accomplished more, considering the failure of the cervix to dilate completely, and the inertia of the uterus ? As far back as 1845, Dr. Joseph A. Eve, one of our honor- ary members, wrote a long and exhaustive paper " On the Proper Use of Ergot in Obstetrics" for the "Southern Medical and Surgical Journal " which was published in June of that year, in which he warned the profession against its too frequent and indiscriminate use, and alleged that many fetal deaths were produced by it. He took the same ground that Beatty, of Dublin, did a few years before, that the fetus might be poisoned, even when no visible effect upon the uterus resulted, by the absorption of the essential oil into its blood, or might die soon after birth, in spasms, from its effects. Hardy, in Dublin, reported 48 cases in which he had given it to hasten lingering labors, and out of this number 34 ended THE PROPER USE OF ERGOT IN OBSTETRICS. 11 in still-birth. McClintock reported 30 cases with 20 still- births. Busche, 175 cases in which the fetus was known to be alive when ergot was given, and of this number 25 were still-born. West reported 64 cases with 9 still-births. Meigs declared in papers and also in his work on Ob- stetrics that " multitudes of children were dead born from this cause, by the imprudent exhibition of a medicine which as certainly excites spasm of the womb as nux vomica does in other muscles of the body." As far back as 1850 the Academy of Medicine of Paris di- rected a commission to investigate the influence of ergot on the life of the child, which reported " its life endangered both by compression and narcotism." In 1853 the Academy form- ally adopted the conclusions of M. Depaul, that " except in miscarriage, in certain labors attended with hemorrhage, and occasionally at the conclusion of natural labor, parturient women would be the gainers by the complete disuse of ergot." I cannot help referring to the very full and learned paper of Prof. E. N. Chapman, of the Long Island College Hospital, published in the " Medical and Surgical Reporter " of Phila- delphia, in January, 1861, vol. v., p. 415. He refers to Dr. Stearns who reintroduced this remedy into notice, and who used it more cautiously than many do at the present day, lost his practice from a strange mortality amongst the chil- dren, and from childbed fever which followed him like an evil genius from door to door. He declares that " there can scarcely be any doubt that one hour's ergot pain would be fatal to one half the children born, for they are literally smothered, since they are effectually shut out from the very source whence their blood can be supplied with oxygen." Beatty placed it at two hours. Chapman said in 1861 that " we should never use ergot as an expulsive agent, never where the pains have been and are vigorous, never to over- come impediments such as a narrow pelvis or rigid peri- neum, and never in a primipara under any circumstances." No arguments are necessary to prove the correctness of the teachings of our text-books in reference to the danger of its use in cases of mechanical obstruction from tumors, deformed pelvis, and rigidity of soft parts. 12 JOSEPH TABER JOHNSON. I have taken some pains to run over the literature of this subject, which is much more extensive than I had any con- ception of, and I find many instances reported, chiefly in journals, of the administration of this drug in cases of un- dilated cervix, delay in the pelvic cavity from unyielding soft parts, and rigid perineum. It seems therefore to be yet the practice of some to give ergot freely to produce dilata- tion of the os, drive the child more rapidly through the un- prepared cervix, vagina, and perineum of primiparas even, and I hope to attract the attention of this Society to the great harm which is being done in these cases. Among the poor who do not employ physicians in natural confinements, the midwives use this remedy largely. The health officer of our city informs me that the midwives re- port to his office a great majority of the still-births which appear in his monthly reports, and that upon inquiry he believes that their free use of ergot is the cause of many of their fetal deaths. It has been my misfortune to be called to a number of cases where a little delay had induced them to take from their capacious pockets their ergot bottle, which they all carry, and to quicken the pains by a few doses. No progress being made a physician would be sent for, and I have several times extracted a dead child with the forceps, after relaxing the soft parts as well as I could with chloro- form and the warm douche. I am convinced that this subject is not thoroughly under- stood, or, if understood, not fully appreciated. We have seen above that ergot acts in such a manner as not to be relied upon for aid in the class of cases just referred to. We should cause dilatation or relaxation of the soft parts by other means, and not attempt to make an exhausted uterus expel its contents by calling into requisition the powers of an agent which actually causes it to tighten its grip and re- fuse to open its door and let the fetus go. By the time the ergot pain relaxes the child has too often been asphyxiated. Can we hope to benefit a patient by its use in cases of threatened or actual abortion and retained placenta or mem- branes ? I think not. THE PROPER USE OF ERGOT IN OBSTETRICS. 13 When we consider its physiological action upon uterine muscular fibre we must be convinced that, instead of expel- ling the ovum or secundines, we run the risk of securely shutting them up inside the uterus, thus preventing, for a time at least, the use of safer means which should have been employed instead of the ergot. In cases of retained membranes after an abortion I am positive that the labor of their extraction has been made tenfold more difficult, and to that extent dangerous, by giv- ing ergot with the expectation of causing their immediate expulsion. Before its exhibition the examining finger could distinctly feel the retained mass through the partially di- lated cervix. It could be felt, but could not be grasped for removal. Whereas after its effect had been produced I could not even reach or feel it, the fibres of the lower uterine segment and internal os being in a state of firm, tonic, unyielding contraction. If an exact dose could be prescribed which would reproduce suspended pains resem- bling normal intermittent uterine contractions, this remedy would, in such dose, be an unalloyed blessing, but such, un- fortunately, is not the case. In these cases the risk of doing harm is so great that it would be much safer to rely upon other well-known means for extraction, or, if there be hemorrhage, to tampon the vagina securely and await the action of nature, watching meanwhile for any symptoms of danger. As a prophylactic against post-partum hemorrhage it is quite the custom of many to give it as routine practice, but we cannot rely upon it. In the fifteen or twenty minutes which it takes to act the patient might be lost even if her stomach were in a condition to absorb it. Unfortunately for its reputation it frequently produces vomiting, and thus adds to the exhaustion and danger of the patient. If she be much weakened by loss of blood it will not be absorbed, and the golden moments are lost which might have been profitably spent in the use of better means. Authors who recommend it for this accident advise that no dependence be placed on its controlling the flow, but that, while waiting 14 JOSEPH TABER JOHNSON for its action, we proceed as though it had not been given. The hypodermic use of ergotine acts more quickly, and with the advantage that it cannot be vomited or lie unabsorbed in the stomach. In desperate cases this advantage would outweigh any damage which it might do. The risks of the intra-uterine injection of Monsel's solution with its attend- ant evils are to be welcomed rather than speedy death by hemorrhage. In the floodings of pregnancy, namely, threatened abortion, placenta previa, and accidental hemorrhage, I do not see that ergot is indicated. When this drug is prescribed it should be with a full knowledge of its powers, and not with a simple belief that it quickens and intensifies uterine contractions, and is there- fore to be used in all cases where it is desired to accomplish these results. So far as my own opinion is concerned, I am free to say that I think the human race would be better off if ergot should be utterly abolished from the lying-in room. I be- lieve that as at present employed it does vastly more harm than good to parturient women and their unborn children. It certainly should never be given to a primipara. It would be safer to give it to no woman in labor ; but in care- ful hands, when its powers are fully known and its dangers appreciated, it might perhaps be administered in the second stage with advantage, to overcome uterine inertia, but only then in cases where the soft parts are relaxed, and we are quite certain both from present appearances and the his- tory of former labors that the child will be born in half or three quarters of an hour. Even then for the full protec- tion of the child frequent auscultation should be practiced, and upon its heart becoming slowed or enfeebled it should at once be extracted with the forceps. Similar advice is substantially given in the later text- books, but my advice would be, under such circumstances, to deliver with the forceps without subjecting the mother and child to the dangers of ergot. In the dilated and re- laxed conditions of the soft parts in which these authors ad- THE PROPER USE OF ERGOT IN OBSTETRICS. 15 vise the use of this oxytocic the forceps could be employed easily and safely. In cases, however, where patients fear or refuse to have it applied, ergot could first be employed with the understanding that if the child were not born in half or three quarters of an hour, or exhibited symptoms of as- phyxia, it should be extracted at once. In my case above referred to reliance was placed upon speedy delivery. A few good pains only seemed necessary for its birth, but the uterus was thrown into violent spas- modic action whereby the child's expulsion was prevented and its only supply of oxygen effectually cut off. When the danger was fully appreciated and the forceps applied, a dead child was extracted. It may be claimed that this is not always the case, and that good results have followed the use of ergot. I am free to admit this, but when we can accomplish the same result by safer means, I hold it to be our duty not to jeopardize the life of the fetus, and the parts of the mother, by resort- ing to a treacherous and, according to abundant testimony, a dangerous remedy. Professor Penrose, in an able lecture on this subject, some time ago, reported two fatal cases of ruptured uterus, in which he attributed the rupture solely to the use of ergot. Many reports of similar and other lacerations could be quoted did time permit and the occasion require, but enough has been said on this topic to prove the danger of ergot in the second stage of labor. It should never be used in threatened abortion so long as there is any probability of saving the conception, and its energy should be invoked only when the fetus is dead, and the safety of the mother becomes our first duty. In cases where the fetus has been expelled and the membranes remain imprisoned within the uterine cavity it has been largely relied upon to cause their expulsion. But in this class of cases I am persuaded that we do harm by its exhibition. The tampon, and the subsequent complete evac- uation of the uterus by mechanical means, accomplishes the desired end in a safer and better way. After the uterus is empty and bleeding continues from atony of its walls, the 16 JOSEPH TABER JOHNSON. unyielding tetanic contraction which ergot produces acts beneficially by occluding the orifices of the bleeding vessels. Lusk advises that " it should be withheld until after the ex- pulsion of the placenta or membranes lest the uniform ute- rine contractions lead to their prolonged retention or inter- fere with manual efforts for their extraction." The use of ergot is contra-indicated in retained placenta. It keeps up a state of painful contraction after natural labor, annoys and exhausts the patient needlessly, interferes with the normal discharge of the lochia, and perhaps aids in the causation of septicemia. Atony of the uterine walls, which is overcome by ergot in certain cases of abortion, may exist to an exaggerated degree after an otherwise natural labor, and in these cases ergot is an invaluable remedy, when great exhaustion is not present or collapse from loss of blood imminent. It would then make matters worse. Chap- man directs in most emphatic terms that it should not be used until reaction is brought about by opium and stimu- lants, as its sedative tendency would prevent reaction and directly and positively augment the prostration. In placenta previa and accidental hemorrhage ergot is not indicated if the child is viable or the possibility of prevent- ing its birth exists. As the principal indication in all cases of uterine hemorrhage from relaxed muscular fibre is to make the uterus contract and stay contracted, ergot will long re- tain a prominent place in our list of remedies ; but in these very cases the woman's safety consists in an empty and firmly contracted uterus. The action of ergot previous to the complete evacuation of the uterus would interfere with, if it would not for a time prevent, the manual efforts nec- essary for the turning and extraction of the fetus and pla- centa. Should bleeding continue subsequently, ergot is in- dicated. Midwives should be taught in some manner, by legislation if necessary, the dangers of indiscriminate use of this drug. A few convictions for infanticide by a coroner's jury would have a very salutary effect, if they could be reached in no other way. Its sale might be regulated by law, so that it could be obtained only upon a physician's prescription. THE PROPER USE OF ERGOT IN OBSTETRICS. 17 DISCUSSION. Dr. John P. Reynolds, of Boston. - In common, I am sure, with all the members of the Society, I express my obligations to Dr. Johnson for calling attention to the abuses of ergot. Every physician can bear witness to the existence of the facts which have been so carefully stated, and to their importance. I most cor- dially assent to the general teaching of the paper, that ergot ought not to be employed in labor until the uterus has been wholly emptied; but while I do this, I cannot help admitting that cases at times occur in which small doses of this drug, cau- tiously repeated, fulfill, even during labor, a valuable indication. If it is certain that no disproportion or deformity of child or pelvis exists, if especially male children have been previously safely delivered, if the soft parts are thoroughly prepared, and if important delay is, in the judgment of a competent attendant, due only to want of uterine action, as small a dose as ten drops of the fluid extract of ergot, repeated at intervals of ten minutes, will now and then render signal service. Careful watching of the case will soon show whether the remedy promises good results. It cannot be too strongly urged that instances of this kind form excessively rare exceptions, and that they by no means weaken the force of that general rule which the reader of the paper has so impressively laid down. It has seemed to me that in this immediate neighborhood re- sort to the hypodermic use of ergotin as a chief reliance for the control of post-partum hemorrhage has not been as general as its recognized value deserves. I shall be glad to learn, from gentlemen who often employ it, the details of its administration in their hands. The value of ergot, in cases where portions of an early ovum are retained in the uterus, is generally conceded. Theoretically, a judicious resort to opiates would seem as reasonable. If in these accidents due attention is paid to the early use of simple means of restraining loss of blood, the routine of manual interference, which is now so commonly enjoined, will in a large proportion of cases be found unnecessary. Ergot is advantageously given after delivery is complete to lessen the liability to after-pains by insuring prompt and thorough uterine contraction. In common with many of my 18 DISCUSSION. colleagues, I believe this to be good practice, even though these contractions be made, at first, more sharp under its use. Com- mon prejudice especially authorizes this procedure when the long administration of anesthetics has been demanded. I have been glad to follow this habit, though I have seen no reason for think- ing that ether, if suitably used in labor, predisposes to post-partum hemorrhage. Dr. Fordyce Barker, of New York. - I will not take up the time of the Society by any protracted remarks, because the subject is so broad, and affords opportunity for the discussion of so many points, that it will be utterly impossible to enter into any complete discussion of it at this time. All will agree that it is most desirable that we should have formulated if possible, and perfectly fixed, certain rules which will govern us in our practice. This should be the case with reference to all measures to be used in that class of cases in which we are re- quired to act promptly and most decidedly; but at the same time there is difficulty in laying down positive rules which may not have exceptions that are most important. I suppose it is agreed that ergot should never be administered in advanced parturition under certain circumstances; that it should never be used to in- duce uterine contraction in the first stage of labor ; that it should never be used except in vertex presentations ; that it should never be used where there is the slightest disproportion between the fetus and the passages of the mother ; that it should never be used unless the soft parts are perfectly prepared for dilatation ; that it should never be used unless all mechanical conditions are such that if sufficient uterine forces are present the fetus will be expelled rapidly, say within half an hour. All these principles are fixed, at the present day, among obstetricians. But when I hear it said, and laid down as an absolute rule, that ergot should never be given for purposes of exciting uterine contraction in labor, I think it is going a little farther than I should deem wise. It is exceedingly rare that I give ergot for the purpose of expelling the fetus, and yet there are some exceptions where, as I think, it can be administered with great advantage. All of us meet with patients in whom labor is retarded by morbid sensitiveness to pain, and often, under the moderate use of anesthetics, labor is assisted by calling into play all the accessory muscles which are under the control of the voluntary powers of the patient. But now and then we have patients who are so sensitive to pain that they re- THE PROPER USE OF ERGOT IN OBSTETRICS. 19 sist, by the voluntary action of their muscles, the progress of labor to a very great degree, and instead of bringing the voluntary muscles to the aid of labor so soon as pain approaches, they shrink from it; and, occasionally, after a certain time has elapsed, and a very great degree of suffering has been endured - perhaps they have been in labor some hours without accomplish- ing anything - the labor ceases, not on account of lack of uterine power, or muscular efforts, but because the nerve forces of the woman have become exhausted. Now, in these cases, I have found ergot, whenever this point has been reached, and there is no mechanical obstruction, or improper condition of the soft parts, to be a drug of very great service. I then put the patient under the influence of an anesthetic, giving chloroform in very minute doses until I overcome the morbid sensibility to suffer- ing, and then I give free doses of ergot to stimulate the uterus to action, and all the accessory muscles soon come into play, and the labor is usually quickly and successfully terminated. If, however, there is any delay, then I apply the forceps, because the conditions implied in the statement which has already been made show that there is no danger in the use of the instrument. Cer- tainly, therefore, I should hesitate about laying down positive rules concerning the use of ergot in the second stage of labor. Now, while I am almost in perfect accord with the paper which Dr. Johnson has read, yet there are certain points in which I feel I must disagree with the author, and upon these I will offer a few words, based upon my own experience in the use of the drug. Dr. Johnson has expressed the opinion that the use of ergot favors after-pains, and contributes greatly to the suffering of the patient. Upon this point I will say that I habitually give ergot after the birth of the child, but it is not chiefly for the purpose of preventing hemorrhage, for, if the danger of this be imminent, we cannot wait for the action of ergot. I give it to secure per- manent contraction of the uterus, and aid its effects by pressure, etc. I therefore give ergot, not expecting that it will prevent hemorrhage, but it is for the purpose of the subsequent effect produced by the drug. It is extremely rare now that I have patients suffer from after-pains sufficiently severe to prevent them from sleeping, and I have ascribed the effect to the attempt at securing fixed contraction of the uterus, and for this purpose ergot assists in preventing relaxation. The fixed contracted con- 20 DISCUSS/ON. dition of the uterus, therefore, which I aim to procure, is due partly to the ergot and partly to the other means employed; and when these effects are completely obtained, any effusion of blood into the cavity of the uterus is prevented, and in that way the occurrence of after-pairf is avoided. Aside from these points I agree entirely with the author of the paper. I will now refer to one point not mentioned in the paper. In my own estimation, an immediate and valuable result from the use of ergot in parturition is its promoting rapid and speedy in- volution ; and, also, the effect which this drug has in combination with other drugs, such as iron and nux vomica, in cases in which involution has been retarded on account of post-partum hemor- rhages, or from local causes. I think one of the most valuable effects which the drug can produce is the aid which it gives in causing involution, and I almost invariably administer it in the treatment of the pue peral woman during the first few days after labor in those cases in which the woman is feeble and has a slow getting up, as it is called ; and I have found ergot, com- bined with stimulants, iron, and strychnia, especially valuable. The President. - I would suggest that in the course of the discussion some of the members should consider the influence which the anesthetic has upon the action of ergot, such, for exam- ple, as is sometimes seen in connection with the use of opium. I throw out this suggestion because opium sometimes remains in the stomach apparently inactive, and, then, when the anesthetic is administered, the full effect of the opium will be produced, and at the same time the opium will increase the action of the anes- thetic. Have similar results been observed with reference to ergot ? Dr. Barker. - That v ts just one of the points, Mr. President, that I had intended to speak of, but it accidentally slipped from my memory, and upon it I will add only a few words. I see it constantly stated in various periodicals, etc., that the use of anesthetics greatly increases the dangers of post-partum hemor- rhages. Now, I wish to say that for thirty-four years I have rarely delivered a woman without the use of anesthetics, never where there has been any considerable pain; yet, I say boldly that I have never had a post-partum hemorrhage in my own prac- tice - and I have certainly used anesthetics in several thousand cases - except in one case in which no anesthetic was used; but it occurred just at the time of the expulsion of the child, the THE PROPER USE OF ERGOT IN OBSTETRICS. 21 labor being very short, less than one hour. I always, however, exercise the utmost care to prevent the occurrence of post-partum hemorrhage by following up the uterus by manual pressure, and its non-occurrence may be also partly clue to the fact that I use ergot immediately after the expulsion of the placenta for the pur- pose of securing firm contraction of the uterus. I believe that instead of the anesthetic being the cause of post-partum hemor- rhage it is, in a large proportion of cases, the best of all meas- ures for preventing it. What is the cause of post-partum hemor- rhage? In many cases it is due to exhaustion of nerve power, and this loss of nerve power is prevented by the use of the anes- thetic. I have attended patients who, in previous labors, had had their lives very much endangered by post-partum hemorrhages, and who had been placed under my care for this very reason. All these patients I have watched with the greatest anxiety, and endeavored to see that they were in such conditions as best resisted the occurrence of post-partum hemorrhage when the time for labor had arrived. I questioned many of them, or some of their intimate friends, and found that their former de- liveries had almost invariably been followed by extreme prostra- tion, and that, when labor was completed, they were in an ex- ceedingly feeble condition; that so feeble was their condition throughout the course of the labor the physicians had not dared to give chloroform on account of the peculiar idiosyncrasy and the tendency to the occurrence of hemorrhage - the very reason for which it should be given. In such cases these patients have invariably remarked to me, as soon as they have come from under the influence of the anesthetic, How different I am from what I ever was before after confinement." They take nourishment, and express themselves as feeling comparatively in good spirits ; so that instead of considering the danger of the occurrence of post-partum hemorrhage as being increased by the use of anes- thetics, I consider anesthetics as one of our aids in preventing it. I ha\ c taken the liberty of making these remarks because of the so frequent expressions which I have heard that anesthetics in- crease the tendency to post-partum hemorrhage. I may add that chloroform is the anesthetic which I always make use of in ob- stetric practice. The President. - The point I would like to have brought out in the discussion is the effect of anesthetics in those cases in which ergot has been administered and failed; and the question 22 DISCUSSION. was, whether the ergot which had failed had been aroused to action by the anesthetic administered subsequently ? Dr. W. T. Howard, of Baltimore. - I have always been greatly influenced by the instructions of my old teacher, the late Prof. Charles D. Meigs, with reference to most questions in obstetrics ; and I can say that I have never, in a single in- stance, used ergot for the purpose of increasing the expulsive powers of the uterus. It has always been my practice, when- ever I desired to supplement the expulsive forces, to employ the forceps, and I do so because the action of ergot, when it is established, never ceases. In all those cases in which ergot has been given where there has been an impediment to the exit of the child, it has been, if not criminal, the most hazardous prac- tice which could be adopted. Soon after anesthetics were intro- duced into obstetric practice I attended a lady in her first con- finement. It was the second case in which I had used anesthetics. She had excessive post-partum hemorrhage ; and, upon this point, I am entirely convinced that in cases where chloroform is used it does increase the liability to the occurrence of this accident by relaxation of the uterus in common with that of the other muscles of the body. In all cases, therefore, I have ergot present; so that if it becomes necessary to use chloroform, this drug can be promptly administered. If I know that the woman is predisposed to post-partum hemorrhage I begin with the hypo- dermic administration of Squibb's solid extract, five grains to eight or ten minims of water, as the head passes the vulva. And over and over again I have administered it; and yet hemorrhage has threatened, or has occurred to a certain extent. I do not be- lieve that the patient is entirely free from the liability to post- partum hemorrhage when under the influence of the anesthetic, and I very frequently give ergot hypodermically when urgently needed, because it will enter the circulation much more promptly than when administered by the mouth. Usually, when I use chlo- roform, I give, just as the head passes through the vulva, a full dose of ergot at once, a drachm of the fluid extract, for the pur- pose of securing prompt uterine contraction. Some obstetricians prefer hydrate of chloral to chloroform in cases of rigid, undi- latable cervix; but in a number of cases I have seen relaxation rapidly occur under the influence of that drug, even when ergot had been administered to counteract its effects. There is another point to which I would direct attention, and it is that the use of ergot diminishes to a certain extent the lia- bility to some forms of puerperal fever, and it does so by pre- venting the tendency, which exists in some cases, to the retention of blood and putrefactive substances in the cavity of the uterus. In certain cases, when I desire to increase the contractile powers of the uterus, I have often seen good effects follow the use of the sulphate of quinine in ten to fifteen grain doses. I would say, then, that ergot should rarely be given for increasing the expulsive powers of the uterus; but in all cases in which chloroform is administered, it is safe to give it in full doses immediately on the completion of the labor. Dr. J. D. Trask, of Astoria, New York. - It has been my practice of late years uniformly to resort to the forceps as an adjuvant to uterine pains in preference to ergot. In the early years of my professional life I was in the habit of using ergot for this purpose, but it is so uncertain in its effects, and its re- sults are often so unpleasant, that I have given it up altogether. There is a practical point which I may mention, and it is this : I have been in the habit, during the last few years, of giving a drachm of the fluid extract of ergot immediately upon the expul- sion of the head of the child, not to aid the expulsion of the placenta, for, if I had not confidence in the expulsive power of the uterus to eject the placenta before the action of the ergot could be secured, I should be unwilling to administer the ergot, fearing that it might prove a source of embarrassment rather than a help. It has occurred to me in cases of multipart, and I presume the same thing has occurred to others, to have a satis- factory expulsion of the child and of the placenta, and, as I sup- posed, a sufficient contraction of the uterus; and yet, in the course of three quarters of an hour, possibly, after leaving the house, I have been called back to find my patient suffering from severe but irregular pains in the abdomen, with all the symptoms of serious loss of blood, and, upon examination, found the vagina filled with blood, and the uterus with a hardened mass of coagula, the result of alternate relaxation and contraction. Now, since I have resorted to the practice of administering immediately upon the expulsion of the head a drachm of the fluid extract of ergot, I have not encountered a single instance of this kind. I am greatly surprised at Dr. Barker's experience in the use of anesthetics. With me there has been a growing mistrust for years concerning the use of chloroform in obstetric practice. I scarcely THE PROPER USE OF ERGOT IN OBSTETRICS. 23 24 DISCUSSION. ever administer it without being made aware of the inefficiency of uterine contraction, and I have made up my mind that I will not employ it any more in cases of normal labor. It was only last winter that I was in attendance in a case in which I administered chloroform little by little, because the effects all seemed to be of the most favorable character; but after a short time uterine inertia supervened, which finally compelled me to resort to the forceps. I administered a drachm of the fluid ex- tract of ergot immediately after the expulsion of the head, and, although the patient was a primipara, there was a profuse uterine hemorrhage which I could not help attributing largely to the in- fluence of the chloroform. These remarks do not apply to the use of sulphuric ether. Dr. G. J. Engelmann, of St. Louis. - There is one point which may be mentioned, and which has not yet been referred to. Dr. Johnson's paper treats especially of the great dangers of the use of ergot in the hands of unskilled persons, and sec- ondly of its use in the hands of skilled obstetricians. In the first place he has well spoken of the great danger which arises from the use of the drug in the hands of midwives. Now, I think, with reference to the abuse of ergot by midwives, it would be better, instead of preaching concerning its dangers, to give in- formation with reference to some more harmless remedy, such as the sulphate of quinine, or ipecac, or Dover's powder, which will, in many cases, answer the same purposes as ergot, and be attended with very much less danger. For the guidance of skilled practi- tioners it is difficult to lay down general rules concerning the ad- ministration of ergot. There are a few general principles which have been established and accepted. I have always carried it with me, but I have rarely used it; and whenever I have done so, I have doubted whether any great benefit has followed its ad- ministration. In cases of subinvolution I have also used it, and in those I believe we have equally efficient remedies in external manipula- tions, hot-water injections, etc. ; and hot water with disinfectants will do much to prevent the dangers which follow incomplete contraction of the uterus after removal of the placenta. I believe that hot water with carbolic acid, or salicylic acid, will answer a better purpose than ergot, and will at the same time prevent any danger which may arise from infection. Dr. Johnson. - I have but a word to say, in closing the dis- THE PROPER USE OF ERGOT IN OBSTETRICS. 25 cussion, referring to a remark by Dr. Engelmann. It was not my intention, Mr. President, to formulate rules for the guidance of members of this Society, but it was my purpose to draw attention to the great danger of the use of ergot in the hands of less skill- ful men who do not fully appreciate its dangers. For skillful men it would be impertinent to lay down further rules than we now have. With regard to the effect of chloroform upon the action of ergot - the point referred to by the President - I have had no experience. I have had little experience in the produc- tion of post-partum hemorrhage by the administration of chloro- form, although I give it very frequently to women in the last part of the second stage of labor. Upon general principles, however, it would seem that chloroform might produce relaxation of the uterine walls, and I have given ergot, as a rule, for the preven- tion of such hemorrhage. With reference to subinvolution - the point mentioned by Dr. Barker - it was a most excellent one, but it was not the intention of the paper to consider the use of ergot in connection with that class of cases. I only desired to draw attention to the use and abuse of the drug in the lying-in chamber. In the treatment of subinvolution it is certainly a most excellent remedy, as has al- ready been mentioned by Dr. Barker. In conclusion, I would return my thanks to the Society for the kind reception which it has given my paper.