Ergot, therefore, is a powerful hemostatic, and should not, hence, be rejected in the treatment of miscarriage.
(b.) The applied—see in this connection the section on obstetrical operations—it certainly will stop the hemorrhage, and, if it fail, it is because it is imperfectly applied. The tampon opposes the external appearance of blood, and thus favors coagulation in the uterine cavity, and the pressure which it exerts on the cervix, bladder, and rectum, tends to increase uterine contractions, and thua accelerates dilatation, the separation of the ovum, and its expulsion. The sole objection to it is the pain caused by pressure, and the inter ference with the functions of the rectum and the bladder. The danger of converting external into internal hemorrhage is slight, owing to the small size of the uterine cavity at four months; and if, at a later period of gestation, we ought to watch the tampon more readily on this account, we still believe that it is to it we should resort under conditions of which we will speak later. (See Placenta previa. V ol. III.) We believe, however, that there is a better method than the use of either ergot or the tampon alone, and this is the combination of the two.
(c.) Tampon and Ergot A tampon is first applied, and left in situ, not a few hours, as is the custom of Barnes and the Ger mans, but for 24 to 36 hours according to the case, and we administer to our patients thirty grains of ergot, in eight divided doses, at first every ten minutes, and then, after an interval, every hour. We prefer ergot in powder form, to the subcutaneous injection of ergot, and we only resort to the latter when the former disagrees.
[With us a reliable fluid extract of ergot, administered in drachm doses every three hours, will be preferred to the powdered drug. Better still, than either, is the aqueous extract of ergot by suppository, for thus no risk is run of causing digestive troubles. An excellent combination is the aqueous extract of ergot (gr. v.) and the alcoholic extract of Cannabis Indica gr.), repeated every four hours. Cannabis Indica, when pure. has marked hemostatic powers, but its administration should be carefully watched, since certain patients are peculiarly susceptible to it.—Ed.] We thus obtain together the effects of both ergot and the tampon. Frequently, in removing the tampon, the ovum is found more or less engaged in the cervix. If then the hemorrhage be slight, and the con tractions energetic, the tampon need not be reinserted, but the case may be left to nature. If, however, the contractions are feeble, if the hem
orrhage is again intense, a new tampon should be inserted, and ergot again administered. In certain cases, where the ovum is engaged, we may simply give the ergot, since retraction of the cervix is no longer to be feared, for the ovum in its canal acts partially as a tampon, and partially from its irritating effect on the cervix determines uterine con tractility. But, and this is a point of prime importance, we must be careful not to interfere with this engaged ovum: it must be allowed it self to escape from the external os, and it must never be extracted until it is in the vagina. Otherwise only a portion would be removed, which would mean recontraction of the cervix, and retention of a portion of the ovum, and its consequences.
Unfortunately, however, matters do not always progress after the above fashion, and in many instances to the hemorrhage are joined the complications entailed by the prolonged retention of the placenta, rem nants of the membranes. and of the decidua, in the uterine cavity. If, at times, the retention of the placenta means only more profuse hem orrhages, the eases are far more frequent where the placenta putrefies, and determines in the woman phenomena which may prove fatal. And therefore it is why every writer has taken great interest in this subject of retention of the afterbirth.
At the outset, one capital point should be remembered: In many cases the prolonged retention of the placenta is admirably supported by the woman. It continues to live in the utexine cavity, without altera tion, and, at the end of a longer or a shorter time, it is expelled perfectly fresh, without other accident than more or less hemorrhage. Nothing is more variable than the time during which this retention may obtain, and to endeavor, as Gueniot has done, to fix the limit of what lie calls normal retention, seems to us rather the result of visionary theory tfian of clinical experience. We protest, therefore, against this view. Our col league forgets that misc,arriage is constituted not by the expulsion of the embryo, but by that of the placenta. Miscarriage is simply delivery, and to endeavor to set precise limits, is to contradict a fact of experi ence. Nothing is more irregular than miscarriage, and the time requisite for its full completion may vary from hours to days, and this without further accident to the woman than hemorrhage, which we can control by ergot and the tampon.