A Text-book of Diseases of Women

by Charles B. Penrose

In the various plastic operations of gynecology disastrous results are, of course, not so likely to occur from imperfect asepsis as in those operations that involve opening the peritoneum. In some of these operations, such as closure of a vesico-vaginal or a recto-vaginal fistula, it is impossible to obtain perfect asepsis.

In minor gynecological operations, however, we may use antiseptic solutions which are inadmissible within the peritoneum; and the vascularity of the genital tract is so great that healing is usually rapid and perfect even with very imperfect asepsis. This fact, however, should never justify carelessness on the part of the physician. In every surgical procedure, however trivial, the strictest asepsis should always be observed. The practice avoids, at any rate, a minimum danger; it is a useful training for the physician; and it sets a valuable example to the assistants and nurses. No part of the technique should be “good enough.” It should be as good as it can be made.

The greatest factor in the success of modern gynecology has been asepsis. The doctrine has become so widely spread that the technique, and consequently the results, of careless operators of the present day are much better than those of the best operators before the days of Listerism.

This is not said to justify carelessness. No woman should at operation be exposed to any dangers not inseparable from her condition. The assistants and the nurses should be especially made to feel the responsibility of their positions. A careless nurse or assistant may introduce sepsis and cause death after the most skilfully performed operation. Unfortunately, there is not a distinct realization of this fact. An assistant, though conscious of some carelessness of his own, usually beguiles himself with the belief that death was due to some other cause. If there were a distinct realization of personal responsibility among all concerned at an operation, death from infection through carelessness would be avoided as are other kinds of manslaughter. Unless a surgeon knows that he can furnish the proper aseptic conditions, he has no right to advise a patient to submit to operation unless the disease is such that operation is demanded under any circumstances.

At the present day the gynecologist advises a woman to submit to a serious—potentially fatal—operation, like celiotomy, for the relief of many conditions which cause suffering, but which do not cause death. He does this conscientiously, because he knows that if the operation is properly performed the danger to life is very small. If he is not certain that the proper operative conditions will be at hand, he cannot conscientiously give this advice, and he had better follow some palliative treatment.

Operations are always better done in a well-equipped operating-room than in a private house. In the operating-room we have better asepsis, better light and mechanical appliances, better discipline of assistants and nurses, and greater opportunity of successfully dealing with unexpected complications.

In an operation which is performed in a private house something is always used which is more or less of a makeshift; and makeshifts should not be used in surgery, especially in abdominal surgery. If we hope to obtain perfect results, we must insist upon perfect surroundings and appliances. Continuous success is the result of scientific accuracy and attention to detail. I say continuous success, because this is the only test of good surgery. We should not be misled by occasional brilliant results obtained under imperfect conditions. In such circumstances the operator admits to himself that his patient was lucky. The element of luck should be entirely eliminated. Nothing should be trusted to luck.

Fortunately, most of the operations of gynecology are performed for conditions of such a character that there is no demand for instant operation. The woman can usually wait until suitable conditions are furnished. In cases of emergency the surgeon can only do his best under the existing circumstances, not his best under the best circumstances.

It cannot be denied that good results, as far as mortality is concerned, are obtained in abdominal operations in private houses. The mortality, however, for a long series of cases of all kinds is greater than that obtained in well-equipped hospitals by operators of equal ability. The number of incomplete and imperfectly performed operations is much greater in private houses than in the hospital, for the operator with imperfect surroundings fears to deal radically with some unexpected conditions which he meets, and is satisfied if the woman’s life is saved, though she be not perfectly cured.

It is not necessary to dwell upon the need of proper training of the operator himself in abdominal surgery. The minor gynecological operations may be performed by any one who is familiar with the ordinary principles of surgery and who understands the special technique of the operation. There is no fear of unexpected complications in such operations. Rapidity of work is not essential, as in abdominal surgery, and the operator may study the condition as he proceeds; moreover, errors arising from inexperience or ignorance are not attended by fatal results.