The Moment of Truth - 4



The tensions produced by visible deformities are bad enough but the tensions produced by deformity of the genitals can have a shattering effect on the patient and the parents. One such condition, which is not very rare, is congenital absence of the vagina. In such a condition, more often than not, the uterus is also absent. The patients are otherwise well-developed and often attractive females. Following the reconstruction many of my patients have been happily married. All of them have kept their promise to me to reveal their disability before betrothal, as I believe, honesty is the best foundation for a lasting relationship.

But let me begin at the beginning. First just the consultation can pose problems. They do not want to be examined. Those who have been examined by other doctors under anaesthesia ask to be examined under anaesthesia. Their tensions, shyness and natural reluctance need to be overcome by gentle words of reassurance and not by anaesthesia. Rarely do gentle words fail. In which case I make it clear to them that they might as well go home as it would not be possible for me to do anything for them. I tell them that I have to examine and do dressing etc. many times after the operation and that if they cannot give me their trust, I will have to do all procedures under anaesthesia which I will not.

Such frank talk has always worked. I am pleased to say that no one had ever to be given anaesthesia for examination or dressing. Those who had been anaesthetised on previous occasions would admit that their fears were unfounded. This establishes a rapport between doctor and patient ensuring unquestioning compliance, so necessary in the post-operative period.

The post-operative period is very important after this reconstruction. The patients have to be taught new skills to look after themselves, thus avoiding embarrassing visits to yet another doctor.

There is another tense moment in the consultation when the patients are told that the operation can make them fit for normal marital physical relations but that they have no prospect of having 'periods' or conception. That is the moment of truth. This changes an eager and attentive expression into a pained and distraught one. Often a few tears roll down the cheeks. But it is better that those tears are shed before an operation than after, lured by false hopes.

I cite the following story to illustrate this point.

An early middle-aged woman came to a busy OPD of a public hospital, with a meek-looking man in tow (her husband). She (a nurse) had undergone reconstruction of vagina by a lady gynaecologist, in Karnataka two years earlier, followed by an uncomfortable post-operative period. Six or seven months after the operation, she got married as she was advised that everything will "settle down" after marriage. (I am always impressed by the abiding faith some doctors have in the institution of marriage considering it a panacea to overcome all problems arising after vaginal reconstruction!).

This couple was not happy and so they had come to Bombay. I examined the patient; she was born without a vagina or uterus and there was no trace of the reconstruction effort except scarring. I told her required reconstruction of the vagina, using her skin graft (skin not used before), followed by about 1'/2 months post-operative care my supervision after which she could return home. She can have intercourse some 21/2 months after the operation. I added, almost as an afterthought: "Of course, you already know this-you will not have periods or conception”. Tears welled up in her eyes and she flared up angrily: "Then what's the use of the operation?” I was taken aback. I asked whether the lady gynaecologist had not informed her of this. Her reply astounded me. She said: "She told me by and by everything will be all right". I could only ask: "When? A hundred years later?"

I explained to her the facts as I knew them. I told her: "I am sorry to have disappointed you by destroying the hopes you have been nurturing these last two years. The small benefit offered by my operation is capable of bringing lasting happiness to your married life". But she refused to be operated upon. I encouraged her to reconsider for the sake of her husband. But she left and never came back. I was not sorry for missing out on one more operation. However, I was sorry to see her shedding tears. Which is more painful: to help a patient understand the bitter truth before the operation or to let her build up false hopes only to have them shattered after the event?

A congenital abnormality in male children which is more common than the preceding deformity-hypospadias-also comes to a plastic surgeon as reconstruction is involved. Urine comes from a proximally placed opening, the missing portion of the tube needs to be reconstructed. It is usually ti mother who is tense and full of questions. Cradling the infant in her as she often asks: "Why can't the operation be done now?” Convincing mother of the advisability of delaying the operation till the child is a older is difficult. When she is convinced, further questions on delicate matters are asked till satisfactory answers are obtained.

With any congenital abnormality, comments by other superstitious ladies create guilt feelings in the mind of the mother. Deformity is looked upon as punishment for a wrong deed. Babies with cleft of or cleft of the palate have a problem of getting adequate nourishment obvious deformity invites many comments which creates guilt teen the mind of the already-worried mother. This reduces her breast milk and worsens existing problems. The situation is at its worst when it is the first born which is deformed. I have to convince the sorrowing mother that what has happened is not due to Divine Wrath or the sins committed either by her or her husband, nor related to the conjunction of stars etc. It is only then that one notices a momentary spark of happiness in the mother’s eyes. This is a good start for the treatment.

Compilation of professional reminiscences of specialists - edited by M.V.Kamath and Dr.Rekha Karmarkar