If inertia uteri is present during labor, seeing that ergot is only allowa ble where the cervix is dilated, the presentation favorable, and the pelvis well-formed, it is much better to use the forceps. In presentation of the pelvic extremity, we much prefer pressure over the head after the method of Kristeller, and, if need be, the extraction of the foetus. During the third stage, least of all, should ergot be administered. The first thing to do in case of hemorrhage, is the uterus of the pla centa and the contained blood, and ergot, by causing retraction of the cervix, may oppose this. Therefore, again, never give ergot as long as the uterus contains anything. The rule is as absolute in case of hemor rhage due to inertia after delivery, but here we give ergot, but only after the uterus has been emptied of clots. Finally, there is a further instance where we allow ergot, and this is in case of secondary puerperal hemor rhage, the result of incomplete involution of the uterus.
We limit thus the use of ergot to the hemorrhages of the puerperium.
A number of accoucheurs, and we were once of this number, are accus tomed to give ergot to their patients after delivery, with the end in view of assuring permanent contraction, and to avoid hemorrhage. We have for long relinquished this practice as being more harmful than useful. As for the use of ergot in case of after-pains, we do not grant it. By in creasing uterine contractions, the after-pains are increased, and it is lau danum, in high dose, to which we resort. Finally, ergot has been recom mended as a prophylactic against the puerperal diseases. Jules Garin has advocated it, but we reject it for the reason that ergot may cause the retention of small clots.
{In the United States, it is safe to say that the great majority of ob stetricians, in particular the older ones, will not accept Charpentier's views in regard to ergot. They have been in the habit of administering ergot at any and all times, and have never been able to satisfy themselves that it has ever done any harm, for very much the same reason, we be lieve, that many of the same obstetricians will tell us that they have never seen a lacefated perineum in an extensive practice. Have they ever looked for the tear of the perineum? Have they ever stopped to consider if some difficulty in labor might not be traced to the ergot which they have given with unsparing hand ? It is our belief that the rules laid down for the administration of ergot are golden ones, and our own practice and teaching are fully in accordance therewith. We can conceive of abso lately no condition before the completion of the third stage of labor, where ergot could be of greater service to the mother cr child than other measures—massage, electricity, the forceps, version—which do not carry with them the risk that ergot unquestionably does. The real reason, we believe, why ergot is administered by many a practitioner is the hope of thereby saving personal time. Aside from the fact that this is a highly unworthy motive, we would Contend that if there is any indication from the side of the mother, or of the child, calling for the saving of time, there is always some procedure at our disposal which will act to better advantage and with greater certainty, without risking the life of the lat ter, and possibly also of the former. Ergot has been an instrument of greater harm than of good; and much as we prize it after the termination of the third stage, meaning thereby complete emptying of the uterus, and during the puerperium, we feel that rather than use it at other periods of labor, we would dispense with it altogether.
Elsewhere, in these volumes, we have stated the slight points wherein we would disagree with Charpentier's views in regard to the use of ergot in case of placenta prsevia, and during the puerperium (Vol. I.).
This work, however, would be incomplete without reference to the teaching and belief of many of the American accoucheurs who have ex pressed their views in regard to the value and the proper sphere of ergot. The literature of the subject is vast, and we must content ourselves with recording here the latest expressions of opinion on this subject. Engel mann, of S. Louis, and Johnson, of Washington, both claim that such has been and is the injudicious use of the drug, that it would be far bet ter for the woman and her child were it not resorted to at all, if it cannot be used rationally. The late Albert H. Smith, of Philadelphia, thus ex pressed his views in regard to ergot, in 1883: " I do not believe that it is ever needed under any circumstances, but that it is always capable of doing harm, and generally does harm. Its action is contrary to the ac tion of the law of nature. The more nearly we come to the natural pro cess, the more surely, effectually and safely shall we get our results. We know there is no law of nature more decided in the process of parturition, or more important for the safety of the mother and the child, than that which establishes the remarkable intermittent contraction of the uterine fibre. Ergot, on the other hand, produces a persistent tonic contraction of the uterus, and therefore every practitioner who gives ergot to aid in the expulsion of the child, outrages nature. In the first stage of labor it may be admissible, in extreme inertia and uterine relaxation with dila table os, if from previous experience we know positively that there is no obstruction to be met with within the pelvic canal, that there is no varia tion from a normal position or measurement of the foetus, and that its influence will be followed by immediate expulsion. But I maintain that it is very, very rarely, that we can know the presence of these conditions with sufficient positiveness to guarantee us against death to the child, and death or serious injury to the mother. In the second stage of labor we should never give ergot, because then we can use the forceps, an in strument which is absolutely safe, and with which the intermittent action of nature can be imitated. In the third stage of labor I have seen the very worst effects produced by ergot, viz.: a spasmodic contraction of the internal os, with obstinate incarceration of the placenta. In post-par tutu hemorrhage it is an utterly worthless agent." The above represents fairly well the views of those who are opposed to the use of ergot, except under the condition where it can do no harm, and this is after the uterus has been emptied. Most American authorities favor the drug during the puerperium, for the beneficial action it has on uterine involution. Others, where they know the patient thoroughly, from attendance at previous confinements, do not hesitate to administer ergot in small repeated doses during any of the stages of labor, some to aid the expulsion of the placenta (Campbell of Georgia, Wilson of Phila delphia, etc.), others place their reliance on it chiefly in case of post-par turn. hemorrhage. W. T. Howard, of Baltimore, believes that ergot di minishes to a certain extent the liability to some forms of puerperal fever, by preventing the retention of blood, etc., in the uterus; Reynolds, of Boston, claims that ergot is advantageously given, after delivery is com plete, to lessen the liability to after-pains by insuring prompt and thorough uterine contractions, even though these contractions are made, at first, more sharp under its use.