No abstract

Summary Ninety‐five patients complaining of urinary incontinence, 58 of whom had been subjected to previous unsuccessful surgery, were investigated by means of flow studies and voiding cine‐urethrocystography with simultaneous pressure recordings. Patients suffering from neurological lesions or fistulae were excluded from this study. It was found that urinary stress incontinence could result from weakness of the internal urethral sphincter, detrusor instability, urethral narrowing, or any combination of these three. Clinical symptoms and signs alone did not provide an accurate diagnosis. A rational plan of treatment, based on full investigation is outlined and attention is especially drawn to the treatment by internal urethrotomy ofincontinence due to urethral narrowing which may occur as a sequel to gynaecological surgery.

AND SummaryA series of 129 cases of adenocarcinoma of the uterus treated by Wertheim's hysterectomy and lymphadenectomy is reported. Preoperative radium was given together with postoperative irradiation when pelvic lymph nodes were involved in metastatic cancer. The five-year survival was 71 -5 per cent. This figure rose to 74 per cent when the growth did not involve the cervix. The incidence of lymph node involvement was 13-2 per cent, or 11.2 per cent when the cervix was free from growth. The incidence of node involvement was related to the degree of differentiation of the tumour and the depth of myometrial invasion. Thirty-six per cent of patients with positive nodes survived 5 years when lymphadenectomy was combined with external radiation. When death occurred the metastatic deposits were usually outside the pelvis. It is concluded that lymphadenectomy need be performed only in patients with poorly differentiated and deeply invasive growth. Postoperative external irradiation is indicated if the nodes contain cancer.

AND SummaryA series of 129 cases of adenocarcinoma of the uterus treated by Wertheim's hysterectomy and lymphadenectomy is reported. Preoperative radium was given together with postoperative irradiation when pelvic lymph nodes were involved in metastatic cancer. The five-year survival was 71 -5 per cent. This figure rose to 74 per cent when the growth did not involve the cervix. The incidence of lymph node involvement was 13-2 per cent, or 11.2 per cent when the cervix was free from growth. The incidence of node involvement was related to the degree of differentiation of the tumour and the depth of myometrial invasion. Thirty-six per cent of patients with positive nodes survived 5 years when lymphadenectomy was combined with external radiation. When death occurred the metastatic deposits were usually outside the pelvis. It is concluded that lymphadenectomy need be performed only in patients with poorly differentiated and deeply invasive growth. Postoperative external irradiation is indicated if the nodes contain cancer.

leucocyte ascorbic acid level within the normal range; after operation 66% achieved normal status. This improvement in ascorbic acid nutrition, however, did not correlate well with the improvement in dietary intake, and only when one considered those in whom both dietary and leucocyte ascorbic acid levels were subnormal before operation did this correlation achieve significance (Fig. 2). This paradox may be explained on the grounds that, whereas the leucocyte ascorbic acid estimations were accurate, the dietary ascorbic acid levels were of necessity only approximations, which lessened the likelihood of good statistical correlation.An alternative explanation, however, is that another factor is involved-an alteration in the absorption or utilization of ascorbic acid after vagotomy. It is striking that, in spite of the return to a full normal diet, the improvement in nutritional status is small, and that even those whose leucocyte ascorbic acid levels were converted to normal remain at the lower limit of normality. The absorption of ascorbic acid is known to be impaired by achlorhydria (Alt, Chinn, and Farmer, 1939), and it has been suggested that the therapeutic hypochlorhydria induced by vagotomy might result in malabsorption of ascorbic acid (Cohen and Duncan, 1967). In this study the reduction in peak half-hour output of acid was taken as an index of reduced gastric acidity, and there was a good negative correlation between this and the postoperative levels of leucocyte ascorbic acid. This finding lends weight to the argument that the hypochlorhydria induced by vagotomy was responsible for the failure of the ascorbic acid nutritional status to improve as much as might have been expected.Animal experiments have shown that ascorbic acid is essential for the formation of mature collagen in healing wounds (Robertson and Schwartz, 1953), and there is a high incidence of poor ascorbic acid nutrition in patients suffering from wound dehiscence (Crandon et al., 1958). It is evident, then, that poor ascorbic acid nutrition represents a hazard to patients undergoing surgery.From our findings one might postulate that the accepted minimum intake of 30 mg/day for normal subjects is insufficient for patients suffering from peptic ulcer, even after surgical treatment. It would seem to be a wise precaution routinely to administer ascorbic acid supplements not only to peptic ulcer patients before operation but to any patient undergoing surgery on whom a vagotomy has previously been performed. JOHN STALLWORTHY British Medical3Journal, 1972, 2, 740-742 Summary In the absence of a recurring indication for caesarean section vaginal delivery in subsequent pregnancy is a "trial of scar," with potentially serious implications for mother and baby. Labour under caudal analgesia was carefully supervised for 75 women with a surgically scarred uterus-due to lower segment section in 72, abdominal hysterotomy in one, and transcavity myomectomy in two. Every caesarean scar was assessed digitally during labour and every uterus was examin...