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severity for the first two hours, and then continue with vigor for from six to ten hours, gradually becoming less until they cease entirely. Some patients suffer so much from these pains as to refuse to proceed in the treatment, while others bear them without much inconvenience. We do not always observe these painful effects even when the drug operates very beneficially. Sometimes the hemorrhages are controlled, as it were, insensibly, and the tumor slowly decreases in size without the patient experiencing any considerable discomfort. It seems highly probable, from the statements made by my correspondents, and especially Dr. Wey, as well as my own observations, that the benefits of the remedy are produced with more rapidity in the early part of the treatment.
The preparation used internally more frequently than any other is the fluid extract, either alone or in combination with belladona. Each minim of Squibb's Fluid Extract is equal to one grain of ergot. Some recommend that it be given in doses of thirty drops three or four times a day. Others believe that it should be given in larger doses less frequently repeated, as for example one drachm once or twice in twenty-four hours. It is efficacious given in either way, but probably more so in the larger and less frequent doses. This preparation is so offensive, and causes so much nausea in exceptional instances, that it cannot be borne.
Dr. Squibb claims that his solid extract does not offend the stomach so frequently as the fluid extract. This extract may be used in pills coated with gelatine. A pill of five grains is equal to twenty grains of the crude ergot, and may be administered twice or three times daily. From observation of the effects of the different preparations, I am satisfied that this is altogether the most efficient and agreeable for internal administration.
A suppository for the rectum, which in Dr. White's practice acted satisfactorily, may be composed of fifteen grains of the solid extract, and enough gelatine to give it size and form. I have no doubt of the great usefulness of this method of administering ergot.
I think it is also quite certain that the addition of belladonna in some cases increases the curative effects of ergot; how much I am not quite sure. Dr. Goodrich, who reached such splendid results, gave the fluid extract of ergot and belladonna together throughout the entire treatment of his case.
From what has been said it may be inferred that hypodermic injection, if the most efficacious, is also the most objectionable
method of using the ergot, and that in many cases the exhibition of it in this way is rendered entirely impracticable because intolerable to the patients. The profession is much indebted to Dr. E. R. Squibb for his most eligible and efficient preparations of the drug, both for hypodermic injection and internal administration.
May we not hope for great improvement still in the pharmacy of ergot? Ergot produces many good effects besides reducing the size of the tumors and relief of hemorrhage. I have seen, and some of my correspondents mention, great functional improvement in the more important organs. · Some patients are relieved by it of obstinate constipation ; the appetite is improved, and the general health restored. This remarkable salutary effect is obvi. ously due to its action on the ganglionic nervous system. In ex ceptional instances, ergot has very disagreeable effects. Dr. Goodrich mentions inflammation of the uterus as one, and my patients often complain of great heat and tenderness in the uterine region. Hildebrandt speaks of one case in which, after the sixth injection, the patient complained of vertigo, imperfect control of her lower extremities, and slight spasms of the flexor muscles of the forearm. Dr. Wey observed severe general nervous perturbation to follow its use in one instance. And Dr. Morris's patient discontinued treatment because of the terrible and tumultuous effects upon
the uterus. Dr. E. P. Allen, of Athens, Pennsylvania, sends me the report of a very interesting case of fibrous tumor treated by hypodermic injection of ergot, in which phlebitis supervened. A condition of one limb was produced precisely similar to phlegmasia alba dolens, and ran its protracted course to a favorable termination. Prior to the accident the tumor had very much decreased in size, but after the treatment was suspended and during the course of the phlegmasia, it rapidly increased again, and the hemorrhages which had been controlled returned. After trying other methods of treatment without any good results, he and his patient in despair were driven to the use of ergot again. It was tried internally with some good effects, but as the remedy thus administered disagreed with the stomach, it was again injected hypodermically with rapid improvement. The injections were used on the side of the abdomen, opposite to that formerly affected with phlebitis. After a number of injections, signs of inflammation of the veins were again observed, and the sound leg passed through all the stages of phlegmasia that had been observed in the first. From
the intelligent observation of Dr. Wey and others, we may fairly conclude that it is not improper to continue the use of ergot during the menstrual flow. I can also add my testimony as to the entire harmlessness when given during that periodical flow.
With the exception of Drs. Goodrich and Howard, all the writers and correspondents quoted, have depended exclusively on ergot for the removal of fibrous tumors of the uterus; in fact, the treatment has been experimental, and had for its object the solution of the question suggested by the publication of Hildebrandt's articles on the use of ergot; viz., will ergot cure fibrous tumors of the uterus? The course pursued was well calculated to, and I think did, test Hildebrandt's treatment pretty thoroughly, but it is doubtful whether this exclusiveness is the best practice. The well-known alterative and sorbefacient medicines bave, in rare instances, been credited with the cure of these tumors without the aid of ergot, and it is not difficult to understand that absorption may be promoted with more certainty by the alkaline bromides and iodides, where the vitality of the tumor is first impaired by the action of ergot on its vessels and the muscular fibres surrounding it. Dr. Goodrich seems to have held this view of the alterative treatment, as he prescribed iodide of potassium and bichloride of mercury with ergot. Dr. Howard also employed alteratives in the same way. Both of these gentlemen combined belladonna with ergot. The efficiency of this combination, as represented by their reports, justifies us in believing that the alteratives employed by them were auxiliary in a high degree. How much may be effected by judicious alterative and other auxiliary treatment will doubtless be determined by future observation.
CORRECTIVE TREATMENT. By this I mean treatment that will prevent or ameliorate the disagreeable effects of ergot in certain exceptional instances. The distressing pain caused by it may sometimes be made more tolerable by the administration of hydrate of chloral, without very materially influencing its other effects. Indigestion, constipation, hydræmia, and nervous debility may be corrected by tonics, alteratives, laxatives, and stimulants given simultaneously with ergot. In short, the general condition of the patient should be cared for in the same rational manner as if ergot was not being administered.
The fibrous tumor of the uterus may be affected by, ergot in three ways
1. It may be gradually disintegrated and absorbed. In this way it disappears without any violent or disagreeable symptoms.
2. Its nutrition may be so interrupted as to produce a rapid destruction of its vitality ; thus, decomposition may occur within the capsule, and a semiputrid mass be expelled a little later. This process is accompanied with evidences of inflammation of the uterus, and toxæmia more or less grave, according to the size of the tumor, the length of time between the commencement of decomposition and the expulsion of the tumor, and the vital resistance of the patient.
3. The tumor, inclosed in its capsule, may be totally or partially expelled from the cavity of the uterus, attended with a greater or less degree of inversion of the organ. In this condition it becomes amenable to surgical process for completing its removal.
When these tumors disappear in the manner first mentioned, no evil consequences to the patient are experienced, but grave and even fatal effects are likely to arise during their gangrenous dis. integration within the uterine tissues. Even when the tumor is small, great suffering and peril to the patient supervene, and when large it is pretty certainly disastrous. I have not been so unfortunate as to witness fatal consequences from the effects of ergot, but I have seen the overwhelming results of gangrenous disintegration of large fibrous tumors arising from other causes. In the case of a large tumor now under treatment, I was upon one occasion forcibly reminded of what might happen by the violent and prolonged contractions of the uterus, brought about by large doses of ergot. Very dangerous symptoms of inflammation were excited in this case.
Ergot is not always immediately, or even soon, followed by contraction of the uterine fibres. Its effects are in certain cases cumulative; hence its steady administration for a length of time may be followed by extremely violent and prolonged action when it does occur. In the case above referred to, its effects were not observed until the patient had taken the medicine for two months; then with explosive suddenness the patient was attacked with terrific uterine contractions, which did not subside under the use of opium and chloral until the fifth day. The patient took the
fuid extract internally. This effect should be regarded as possible in all cases where the patient appears to resist the influence for several weeks, and when the tumor is large we should be cautious to avoid, and prompt to counteract, such consequences by appropriate means.
The violent action of ergot may also be brought about some. what suddenly by increasing the quantity beyond a moderate amount.
From a review of the cases it will be seen that the gradual disappearance of the tumor takes place under doses too small to cause the violent action here referred to. Dr. Hildebrandt administered hypodermic injections containing what was equivalent to fifteen or twenty grains of crude ergot once a day or every second day. Dr. Dean's treatment proved to be sufficient, although the amount was not greater than Hildebrandt's, and was administered but once a week.
Our opportunities for observation have been too limited to enable us to arrive at accuracy of detail in the use of ergot for the cure of fibrous tumors of the uterus. I think, however, we are warranted in saying that moderate doses of ergot, say half-drachm doses of the fluid extract twice or three times a day given internally, or five grains of the solid extract once a day hypodermically persistently used, is generally sufficient when we wish to cause a gradual disappearance of the tumor, and that this quantity should not be exceeded in the treatment of large multinuclear tumors. When, however, we desire to cause the expulsion or gangrenous disintegration of a tumor, it is necessary to give much larger quantities and persevere until it produces the violent action necessary for such effects.
I conclude my address with the cautionary observation that ergot, in the treatment of fibrous tumors of the uterus, is a prompt and very powerful agent, which cannot be recklessly used without great danger; and that much careful observation is still necessary to enable us to determine the circumstances under which its ad. ministration will be both safe and effective.