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chart indicates, is a very definite period.

51 ^



NUMBER OF MONTHS — »-
Chart III. Showing duration of menopause in months.

The average duration of the menopause was 11.46 months.
An interesting feature brought out by this chart is that among
such a large proportion of the cases, 68 per cent., the menopause
lasted between ten and twelve months and that in but 5 per cent,
of the cases did the menopause last more than sixteen months.
The drop between sixty-two cases in which the menopause lasted



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212 norms: the menopause.

twelve months and nine cases in which the duration was thirteen
months is most noticeable, and can only be accounted for by a
coincidence and perhaps because a patient is more apt to re-
member a period as one year than as thirteen months.

The clinical lesson to be learned from this chart would seem
to be that the menopause lasting more than one year is unusual,
and that if this period be extended to fourteen months is so rare
among normal women that a thorough physical and pelvic
examination is indicated.

TYPE OF THE MENOPAUSE.

(a) Sudden or almost immediate cessation of the flow, the
entire menopause lasting two or three months.
(6) Gradual but slow cessation of menstruation.

(c) Marked irregularities but becoming progressively less.

(d) Prolonged irregularities lasting over a period of more than
eighteen months.

The first type is extremely rare and occurs in but 2 per cent,
of my cases. A combination of the second and third types is
by far the more frequent, being present in over 95 per cent,
of the cases. The usual history is of a gradual cessation for
three to six months followed by irregularities lasting over a like
period. The menopause is normally established without an
increased loss of blood; as the period of actual cessation of the
menopause approaches, the flow is less in amount and the time
occupied by the flow is decreased. Aft^r the first month or
two of *the onset of the menopause, the menstrual blood becomes
thinner, it decomposes rapidly and, unless great care is exercised
by the patient, gives rise to a peculiar, stale, sour odor. The
number of patients in whom the menopause extends over a
period lasting more than eighteen months is extremely small,
1 . 5 per cent, in my series.

Although a literal translation of the word menopause means
a cessation of menstruation (wvc?, menses; iraww, cessation),
the actual bleeding in the normal woman is but a very secondary
consideration; as has been pointed out in menstruation, the
uterus is simply the active agent, the chief factor being the
metabolic activity of the ovaries, so at the menopause the
important feature is the entire changes in the nervous system
of the patient. At this time various neuroses may become
manifest. A wide variation in the variety and degree of the
symptoms depending upon the temperament and general con-



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norms: the menopause. 213

dition of the patient may be present. These symptoms fre-
quently antedate any disturbance in the menstrual function and
may persist for six to eighteen months after the final cessation
of bleeding. It is almost impossible to obtain accurate statis-
tics as to the duration of this class of symptoms, and in this
paper when the word menopause is used it refers to the cessation
of uterine bleeding. Although the neuroses are not infrequently
the most distressing symptoms from which the patient suffers,
the actual bleeding may be regarded as the barometer of health
for if a general disease become aggravated or a malignant
neoplasm makes its appearance in the uterus the presence of such
a lesion is usually at once indicated by an increase or irregularity
in the flow.

The frequency of carcinoma of the uterus is well known. The
fact that the earliest and most frequent symptom of carcinoma
of the uterus is irregular bleeding at or near the menopause is
also well recognized together with the necessity of early diagnosis.
The sum and substance of the study of the menopause from a
practical standpoint is to, if possible, define what constitutes a
normal menopause; what constitutes excessive hemorrhage,
and what constitutes suspicious hemorrhage, and can the symp-
toms of the normal menopause be differentiated from those
of early malignant disease.

We know that in the cases of early cancer, the only cases in
which a hope of cure can be offered, hemorrhage is the chief if
not the only symptom. It is easy to state that the typical
hemorrhage of cervical cancer is the spotting, or the slight flow
of blood following trauma. There is no doubt as to the treat-
ment of cases giving this symptom, but in a very definite pro-
portion of cases this symptom cannot be obtained and in the
majority of cases of cancer of the body of the uterus no such
history is present. We know that a very decided proportion
of normal women give a history of irregiJar bleeding at the
menopause. What then shall be the treatment of these cases?
Shall all women who give a history of irregular bleeding at the
menopause be subjected to a gynecological examination?
From a study of this series of cases certain definite bounds can
be laid down as to what constitutes a normal and what con-
stitutes an abnormal menopause.

I. A menopause which has lasted over twelve months should
be viewed with suspicion, and a gynecological examination
in the case of a multipara is, in the author's opinion, indicated.



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214 NORRIS: THE MENOPAUSE.

By far the greater proportion of these cases will be found normal.
In 13 per cent, of my cases, the menopause lasted over twelve
months. But it should be bom in mind that these statistics
refer to normal women only. Among the general run of cases
the per cent, would probably be at least doubled.

2. Any menopause which has lasted over fourteen months in
either a multipara or nullipara is such a rare occurrence, 8 per
cent, in my cases, that a gynecological examination is indicated.

3. Any increase in the amount of blood lost is indicative of
a pathological lesion and does not ordinarily occur during the
normal menopause.

4. The menopause is a period in which pathological lesions
are extremely likely to make their appearance ; and this, together
with the nervous phenomena which are so frequent, make it
extremely desirable that all women should at this time be under
the observations of a physician.

CONCLUSIONS.

1. That menstruation being dependent upon an ovarian
secretion, it is fair to assume that the menopause is due to a
change in the ovary. That this theory is born out by clinical
facts, histological studies and animal experimentations.

2. That the generally accepted statement that the menopause
is established at forty-two to forty-five is incorrect, and that
forty-six to forty-nine is nearer the actual age in the Eastern
United States.

3. That among normal women the age at which the menopause
appears varies within wide limits, being influenced by many
factors.

4. That the following conditions prolong the menstrual
functions: child-bearing, marital relations, good nutrition and
hygiene, city life, and education, while converse conditions tend
to an earlier menopause.

5. That climate and race undoubtedly play a definite part
in the age at which the menopause occurs but are probably of a
secondary importance in the United States.

6. That hereditary influence is in many cases a potent factor,
in some families the menopause occurs early, in others late.

7. That in the majority of cases, the chief feature of the
menopause is not the cessation or diminution of bleeding but the
neuroses. These frequently antedate any change in the men-



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Mcdonald: the forceps operation. 215

struation and may continue for six to eighteen months after the
final cessation of bleeding.

8. That the actual bleeding is, however, the barometer of
health.

9. That, normally, the menopause is established without an
increased loss of blood. When menorrhagia occurs an exami-
nation is indicated. Metrorrhagia should always be viewed with
suspicion.

10. That in about 90 per cent, of absolutely healthy women
the menopause occurs normally, but that among average women
fully 30 per cent, present symptoms which call for a careful
physical and gynecological examination.

11. All women at the menopause should be under the obser-
vation of a physician. Care of the cases at this time will result
in the menopause being established with less discomfort to
the patient, and many malignant neoplasms of the uterus will
be diagnosed earlier than would otherwise have been the case.

BIBLIOGRAPHY.

1. Hitschmann and Adler. Monat. Geb. u, Gyn., i, xxii., 1908.

2. Leopold and Mironoflf. Arch, Gyn,, xlv., 506-538, 1894.

3. Engelmann, G. J. Am, Gynecology, 2, 238, 1903.
1503 Locust Street.



THE FORCEPS OPERATION.
With Report of Methods and an Improved Instrument.

BY

ELLiCE Mcdonald, m. d.,

New York City.
(With fifteen illustrations.)

Improper knowledge and teaching of the technic of the
forceps operation in obstetrics is due mainly to the lack of
opportunity for demonstration of the operation to the students
in their course. The operation is one which is more or less of an
emergency operation, and is done most frequently outside of the
hospital and under circumstances when it is difficult to dwell
upon the procedure of the operation and to properly analyze
the steps of its execution. When students attend obstetrical
hospitals they see a few forceps operations and those mainly
done in the operating room of the hospital where circumstances
are much different and the procedure more complicated than



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216 Mcdonald: the forceps operation.

when the operation is done in a house. In the hospital, con-
ditions are abnormal; a metal operating table is at hand with
iron leg-holders, a large sterilized outfit is convenient, and there
are assistants and nurses who obscure to the student the sim-
plicity of the operation.

Hospital conditions are by no means the most advantageous
for the forceps operation. A metal operating table with iron
stirrups is about the worst possible position in which to place
the patient for the forceps operation in so far as the operator is
concerned. The reason for this is that the stirrups hold the feet
in the way of the operator, the buttocks do not project to the
end of the table, the patient slips down easily when tractions
are made, and the table itself is as a rule too high for convenient
execution of the maneuver. The table, being usually on castors,
moves with the tractions. It would seem wise that in hospitals
conditions of the private house, particularly those of the better
class, should be copied in the operating room in order that the
student should learn to cope with the conditions which he will
most probably meet in practice, and learn the technic of the
operation under these circumstances. This can be done without
a loss of aseptic technic and with a gain of success in the per-
formance of the operation, as no table is better on which to do
the forceps operation than the ordinary kitchen table with a
blanket added, and covered with a sterile cloth and a Kelly pad;
and no position of the patient is better for the execution of the
operation than that with the Robb leg-holders which hold the
legs well up in position and allow the buttocks to project over the
edge of the table. For these reasons, it has been thought useful
to incorporate some of the modifications and simplifications
of forceps technic into a compact article by which the practitioner
may be able to obtain a correct view of the simplicity and ease
of doing the forceps operation with perfect asepsis and no evil
results to the patient or her child. The operation, as taught
in the various text-books, lacks definite detail and uniformity
of execution.

Indications for the Operation. — A common indication for
forceps is delay of advance of the head over a certain period of
time ; as, for example, two hours delay when the head is above the
perineum and one hour when the head is upon the perineum.
This is, of course, modified to some extent by the condition of
the mother and child, but as an arbitrary rule, and inexact as
most arbitrary rules are, it is a pretty fair one. However, with



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Mcdonald: the forceps operation. 217

more experience in the care of labor, and a power of estimation
or prognosis of the proper duration of that particular labor,
forceps may often be applied when such time has not elapsed
after the delay in the advance of the fetal head; forceps may be
even correctly indicated when the head does not advance for a
shorter time than that mentioned and with failing pains. And
so considerable time may sometimes be gained in the total
progress of the labor; thus, if the head rests upon the rigid
perineum and if good pains are beginning to diminish and weaker
ones result, it is often advisable to apply forceps sooner than
when they are advised in the text-books. This is, however, a
matter of the personal capability of estimating the probable
duration of the labor and the power of expulsive force.

Preparation for the Operation. — The requisites of a good
forceps operation in a house are an ordinary kitchen table
padded with a blanket and covered with a sheet, a Kelly pad,
a pail, a chair, and a footstool.

The proper dressing of the patient is a matter of some impor-
tance in the maintenance of rigid asepsis. The necessities are a
number of sterile towels, some adhesive plaster, and a strong
elastic band. In addition, if the obstetrical bag provides a
pair of leggings or cotton stockings, these are of some advantage.
These cotton leggings are best made in the form of simple oblong
open-ended bags 15 inches wide and 36 inches long. These bags
are more convenient than those leggings which are shaped with
feet, as they may be pulled on in any way and cover everything
as well as the more elaborate ones. At the upper end, the
seam should be left open for 15 inches, so that the ends may
project over the abdomen.

Another useful aid to insure asepsis and to prevent contami-
nation by discharges from the rectum is the use of a strong
elastic band which passes across over one buttock to the other
and is attached to two ordinary harness clips such as are used
upon driving reins and which hold the towel in position below
the vagina and above the anus. These snaps are held in position
by two long pieces of adhesive plaster which pass around the
thigh and which may be applied while the patient is in bed and
before she is placed upon the table. The large rubber band is
boiled with the forceps and may be readily placed in position
by the nurse or attendant while the towel is held in front of the
field of operation, and allowed to fall over after the band is
attached. This can be done after the vulva and vagina have
3



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218 Mcdonald: the forceps operation.

been washed, and can readily be done without contamination
of the towel. Instead of the towel a large piece of sterilized
rubber dam or sheeting may be used and is very convenient for
this purpose.

This elastic band has certain definite advantages over the
common method of passing the bits of adhesive plaster across
the buttocks to hold the towel in this position. When the
adhesive plaster strip alone is used it must be applied after the
patient is in position, on the table, which in itself is a matter



Fig. I.

of a little diflftculty, and which being done by the nurse or
attendant unaccustomed to it, under the direction of the oper-
ator, is seldom done well. And also when the tractions are
made and the perineum bulges with the descending head, the
adhesive plaster is torn away from the perineum and from its
attachments so that a cup is formed between the buttocks and
perineum and the towel which collects the discharges is a
source of inconvenience and may be a point of infection. With
the elastic band, however, the towel is kept approximated to the
perineum, all discharges flow over its surface, and, should it



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Mcdonald: the forceps operation. 219

become soiled or soaked, the towel may be grasped and pulled
away from the buttocks and a clean one dropped inside and
held in position equally well, so that there is no fear of infection.
The method of applying these towels may best be seen from the
illustrations i to 5.

In the placing of the other towels it is well to put two side
towels in position before the upper or top towel. In this way
they do not slip down as they are held from doing so by the
towel on top.



Fig. 2.

Patient is washed with ordinary soap and water and the
vulvar hairs clipped before any attempt at dressing the patient
is made. I usually do this myself with gloves on, washing the
external vulvar parts very well with water into which a little
green soap has been poured. I then wash the gloves in an
antiseptic solution, slip then off and proceed to the operation
without gloves.

The forceps should be placed conveniently at hand on a table
or chair, and it is usually better to allow them to rest in an
antiseptic solution. I use for this purpose a solution of 1-500



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220 Mcdonald: the forceps operation.

izal which is nontoxic and nonirritating and of strong antiseptic
powers. They may rest in this solution as long as required
before the time for operation. It is also necessary to have
at hand before the. operation is begun a hot douche which is
also better made of an antiseptic solution. I use the same
solution as that which covers the forceps for this purpose, a
solution of izal 1-500. This antiseptic is nontoxic and said
to be many times more powerful than carbolic acid; it does not
coagulate albumin and is very useful for obstetrical purposes.



Fig. 3.

It has been used a great deal in Great Britain, and very good
reports of its use in puerperal infection have come from Knyvett
Gordon (Jour, of OhsU and Gyn. for the British Empire, 1907
and 1908, vol. xiv, No. 14), and Wilson {Intercolonial Medical
Journal, 1909, May 25).

In making an examination before a forceps operation it is well
that the labia should be held widely apart while the examining
fingers are thrust in so that the fingers do not touch the outside
of the labial surfaces, for it has been proved that the outer labial
surfaces are more difficult of cleansing and contain many more



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Mcdonald: the forceps operation. 221

microorganisms than do the inner surfaces. It is also useful in
making these examinations to employ a lubricant as the trau-
matism of thrusting in the dry hand may often in itself wound
the mucous membrane. A useful lubricant for this purpose
may be made from Irish moss, by boiling in water. Three
ounces of Irish moss should be taken and washed in running
water for a half hour. It should then be placed in two pints of
water in a sauce pan and allowed to boil over a rather slow fire
while constantly stirred. If it is not stirred it had better be put



Fig. 4.



in a double boiler otherwise it will stick to the bottom of the
sauce pan. After this has boiled for ten minutes it should be
taken off and passed through a fine wire strainer such as is used
in kitchens. If it does not flow readily through the strainer it
may be expressed by means of rubbing a large spoon against
the meshes of the wire. This strained jelly is again put upon
the stove and sterilized by boiling for one-half hour with sufl5cient
water added to make it of the consistency of jelly. After one-
half hour of boiling the jelly is taken from the stove and poured



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222 Mcdonald: the forceps operation.

into lead paint tubes* which have been previously boiled
with their stoppers in another vessel. Before the jelly is poured
into the tubes it is my custom to add to it the antiseptic, izal,
in the proportion of i to 500 in order that the lubricant should
have some antiseptic power, f

In making vaginal examinations before a forceps operation
it is often useful, at the same time and even while the patient



Fig. 5.

is going under her chloroform, to attempt to dilate the vaginal
orifice. This may be done by means of thrusting the entire
hand into the vagina, or better by pressing down upon the
perineum with the first and second fingers of the hand and

* These collapsible tubes may be obtained from the National Can Company
of Detroit, and cost for the 1x6 inch size about three dollars per gross, or two
cents apiece. The jelly costs about five cents a quart when finished.

t This lubricating jelly may be used for vaginal examinations in the oflfice, or
for lubricating catheters, etc. If it is required for this purpose, it is better in place
of the izal to use some of the milder aromatic antiseptics such as thymol, gomenol
2%, etc., as a preservative. If it is desired to make the jelly clear and transparent
it is better to add a large quantity of water and filter through muslin ana later
evaporate to the requisite jelly-like consistency. However, there is little advantage
in going to this trouble in order to get a clear product as all that is required is
lubrication and antisepsis.



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Mcdonald: the forceps operation. 223

massaging them from side to side. This will add considerably
to the ease of delivery and at the same time when done with
lubricant causes but little traumatism to the mucous membrane.
Chloroform is by all means the best anesthetic at present.
Pregnant women bear it well, much better than the nonpreg-
nant, and come out of it easily. Chloroform should be given
carefully to keep the patient under very lightly until forceps are
applied, then the anesthesia should be a little deeper and when
the head is upon the perineum and being delivered ; the anesthe-
sia is practically that required for minor operations. If there
is any sudden loss of blood during the operation the nurse should
be instructed to watch the pulse of the patient until the cir-
culatory equilibrium has been restored. Ether is contra-
indicated in the forceps operation because pregnant women



Fig. 6.

bear ether badly and suffer from respiratory irritation causing
excess of mucus and stertorous breathing. The fetus is also
affected by ether as is often observed in Cesarean operations
where ether is used, and the fetus delivered under the influence
of the anesthetic is difficult of resuscitation with an odor of ether
upon its breath. Applegate of Philadelphia has reported to me
in a personal communication that he had used spinal anesthesia
with good effect, but in the present knowledge of this form of
anesthesia it would seem wiser to wait for more complete reports
before using it unless specially indicated. My experience with
this form of anesthesia in other conditions would lead me to
believe it the ideal anesthetic were its dangers removed.



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224 Mcdonald: the forceps operation.

Choice of Instrument, — ^The great factor in the success of the
operation is the choice of the proper instrument. Very few
students come from college with any knowledge of the advan-
tages of the various types of forceps. First, the forceps should
not be too long in the blades as are the forceps of the Simpson
type. In forceps of this type when tractions are made on the
head so that the head comes upon the perineum, and the tractions
are then made in an upward direction, the blades which grasp
the head over the parietal process pivot upon these processes
and the tip of the blades projecting beyond the head impinge
upon the pelvic floor and cause traumatism, often wounding
the vaginal mucous membrane to cause the beginning of a peri-
neal tear. This has been shown in a study of perineal injuries
(McDonald, Lacerations of the Perineum, Surgery, Gyn, and
Obst., Jan., 1908) where a number of vaginal tears were
begun in this way, and where it was noted that, as soon as
the continuity of the mucous membrane was impaired, the
stretching by the descending head caused small lacerations to
increase in extent just as a small tear in a piece of cotton will
readily extend. The muscle also in these cases often splits along
the lines of cleavage to such a degree that, in one case reported
in that paper, there was a separation of planes of the muscle
down to the skin in the sacro-iliac fossa. For this reason it is
well to have the blades of the forceps as short as consistent with
a firm grip of the head

Another disadvantage of forceps of the Simpson type is the



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 23 of 109)