J. Chassar Moir

THE GAUZE-HAMMOCK OPERATION

STRFSS incontinence of urine continues to be a challenge to the gynaecologist. The number of operations devised for the treatment of this distressing condition testifies to the uncertainty of each; and it is common knowledge that cases occur where one operation after another has been tried with little or no benefit. It is not the purpose of this paper to discuss the mechanical principles underlying the control of bladder function or to compare in detail the merits of the rival operative procedures. I would simply state that until recent years my own preference has been for a fascial sling operation; this I started to use in 1912 soon after the publication of Aldridge’s paper (1942) describing his modification of the procedures previously employed by Goebell (1911), Stoeckel (1917) and other German surgeons. Before going further it is necessary to point out that operations of this type do no more (although no less) than support the bladder neck and vesico-urethral junction and so prevent the undue descent of these parts when the woman strains or coughs. In selecting a patient for this procedure one must, therefore, make sure that she does in fact suffer from true stress incontinence of urine, and that the disability is of sufficient severity to justify interference. She must also show on examination the characteristic descent of the urethra and bladder neck on straining-a feature that is best described as a “wheeling” of the lower anterior vaginal wall under the symphysis pubis. The operation is useless if, on the contrary, there is a fixation of these parts from previous injury, or if the patient’s real symptom is bladder irritability with precipitancy, or urgency, of micturition. To use a sling operation in such circumstances is wrong, and may well aggravate the symptoms. To revert now to the Aldridge operation, I can testify to many cures, or near cures, effected by it in seemingly hopeless cases. But despite its undoubted value it is open to criticism on several scores. ( I ) It is not always easy to obtain an adequate strip of fascia from the abdominal wall, nor is the alternative of using a free graft from the fascia lata of the thigh always possible. (2) The necessity of uniting two strips of fascia under the bladder neck (or upper urethra) is a distinct disadvantage for there is then an overlapping of the strips and the need for stout sutures in an area that is vulnerable to sepsis. (3) More important still is the fact that the sling is little more than a narrow cord which, if pulled on, will constrict the vesico-urethral junction making normal micturition impossible. Prolonged use of an indwelling catheter is then needed: and cases are known where an overtight sling has cut through the urethra and created a urethro-vaginal fistula.

VESICO‐VAGINAL FISTULAE AS SEEN IN BRITAIN

THE literature contains many accounts of the vesico-vaginal fistula and its treatment. Most of them come from countries where the obstetrical services are underdeveloped or absent; and representative among these are the classical paper by Mahfouz (1938) and the more recent exposition by Lawson (Lawson and Stewart, 1967). The work now in progress in Addis Ababa is of special interest for in that centre the Hamlins (personal communication) have now treated a record number of 2000 cases with remarkable success. By contrast, however, there is a surprising scarcity of information regarding vesicovaginal fistulae as encountered in better developed countries, and the present analysis of personal cases is aimed at restoring some balance. In Britain vesico-vaginal fistula is rare, and usually results from surgical misadventure and not from obstetrical neglect. Because of my interest in this class of work many patients have been referred to me over the years, and these now number more than 450. When from this total are deleted those cases in which the operation was undertaken in Africa, India and other tropical countries, 431 remain, and these concern patients resident in the British Isles or referred to this country for treatment. Fistulae caused by active malignant growth or extensive radium necrosis are not included.

A COMPARISON OF THE OXYTOCIC EFFECTS OF SYNTHETIC VASOPRESSIN AND OXYTOCIN

WHEN, many years ago, the two principles of the posterior lobe of the pituitary gland were separated, the terms “vasopressin” and “oxytocin” were introduced to indicate the essential action of each. It therefore came as a surprise to find that in one respect the names were misleading, for vasopressin had, on the intact human non-pregnant and early pregnant uterus, an oxytocic action greater than that of oxytocin (Moir, 1934, 1944). Other more recent workers, for example Schild et al. (1951), have corroborated this finding. Although the evidence in favour of this paradoxical effect seemed convincing, there has been, hitherto, a lingering suspicion that the observed actions might be explained by an incomplete separation of the two pituitary fractions. With the advent of pure synthetic preparations of both posterior lobe hormones we have now put this possibility to the test and compared the effects of synthetic oxytocin and synthetic arginine-vasopressin on the human non-pregnant and pregnant uterus. Records of uterine contractility were obtained by the conventional means of inserting a small rubber bag in the uterus and recording the variations of intrauterine pressure on a kymograph. In early pregnancy, the observations were made when a therapeutic abortion was deemed necessary, and the recordings obtained either immediately before, or immediately after, the operation. Before going further it is necessary to digress in order to explain an elementary matter with regard to the standardization of the two principles. In brief, an oxytocic unit relates to a specific effect, under standard conditions, of the test substance on the isolated rat uterus; a vasopressor unit relates to a specific effect, under stated conditions, on the blood pressure of the rat. There is no relationship between the two different units; hence it would be meaningless to claim that one substance has less or more action on the uterus than the other, when the measurement of dosage in one case is oxytocic and in the other vasopressor. One can, however, compare the two substances with regard to their uterine action when the dose chosen is one which would be reasonably used in clinical work and which would fall short of producing undesirable side effects. It is in this sense that the two products are now compared.

RECONSTRUCTION OF THE URETHRA.

IN a series of more than 300 cases of vesicovaginal fistula referred because of unusual features or failure of previous surgical treatment, I have been specially impressed by one particular group. In this, the vaginal side of the urethra has been destroyed wholly or in greater part (Plate I ; Figs. 1, 2 and 3). These injuries are, anatomically, quite distinct from the more usual type of vesico-vaginal fistula, where the damage is to the bladder trigone or to the tissues of the vesico-urethral junction. There were 47 cases in the specified group (14 per cent of the whole series). The cause of the injury is shown in the accompanying table.

MEASURING THE OBSTETRIC VALUE OF THE PELVIS

IN a previous contribution (Moir, 1946) a system of radiographic pelvimetry and cephalometry was described in which an effort had been made to reduce the examination to as simple a procedure as possible, consistent with the degree of accuracy necessary for clinical work. The methods described were evolved from those associated with the names (amongst others) of Herbert Thoms and Chassard and Lepine . In the second section of that contribution (Moir, 1947) a new method of assessing the obstetric value of a pelvis was presented. By it, the significance of any set of pelvic measurements, relative to the foetal head measurement, could be quickly determined and the course of labour (in its mechanical sense) predicted with a new feeling of confidence. Experience gained since that date has strengthened the opinion that this method has considerable clinical value. Judgment of the obstetric radiographs is placed on a firmer basis than is possible by use of ‘‘ impressionistic ” methods of interpretation; moreover, the method has the advantage that it can be applied quickly, and the results presented in a form easily understood by the clinician. The purpose of the present paper is to record certain simplifications of the radiographic technique previously described ; to restate the methods by which certain “ difficult ” measurements can be obtained from the radiographs; and to present examples of cases in which the method has been found helpful in deciding the conduct of labour.

INVERSION OF THE BLADDER AS A COMPLICATION OF LARGE VESICO‐VAGINAL FISTULAE

A REMARKABLE complication of a vesico-vaginal fistula of large size is an eversion of the bladder through the fistula. In its lesser degrees a protrusion is not uncommon, and it presents as a soft, red, velvety mass plugging the fistula or pushing its way through the fistula into the vagina. It is of course the anterior bladder wall which first everts, and in most cases the process is limited to that wall. In extreme cases however the whole organ turns inside out (inverts) and fills the vagina, or even bulges far beyond the vulva. In a series of more than 175 cases of vesico-vaginal fistula (Moir, 1954, 1956) referred to the Nuf€ield Department of Obstetrics and Gynaecology for treatment, there have been some 8 or 10 instances of pronounced bladder eversion, and 2 of complete inversion. With the patient in the lithotomy position and the perineum depressed by a Sims’s speculum, the protruding bladder with its exposed mucosal surface can be clearly seen; and the tumour can be made to increase still more in size by asking the patient to strain. When, however, the patient is placed in the knee-chest position the local appearance is conspicuously changed. Because of gravity the everted bladder is now withdrawn; air rushes in, and both the vagina and bladder become widely distended making the anatomical limits of the fistula much more clearly defined (Fig. 1). This was, of course, the finding that so impressed J. Marion Sims more than 100 years ago, and which induced him to attempt the operative cure of vesico-vaginal fistulae; the influence that Sims’s work was to have on the subsequent development of gynaecolog~ is well known (Moir, 1940). When a vesico-vaginal fistula is associated with bladder inversion it usually follows that the ureters are situated at or close to the vaginal edge. The exact position of the orifices must be clearly identified before operative treatment is undertaken. In some cases the tell-tale spurts of urine. rhythmically ejected, make identification easy; in others it is only by careful search with the probe that the orifices can be found. The pressure from the inverted bladder, if long sustained, may cause one or both ureters to become grossly dilated. In the second of the cases to be described this change was so great that a medium-sized rubber catheter, passed into the bladder by way of a preliminary investigation, disappeared ’ entirely from sight and touch; only after a long search was the mystery solved by finding that the catheter had passed into a grossly dilated ureter, where it occupied a position far behind and to the side of the bladder. In this connexion, the importance of a preliminary intravenous pyelography examination to detect any possible ureteric or kidney abnormality is obvious.

ERGOT AND THE NON‐PREGNANT UTERUS

THE efficacy of ergot in arresting haemorrhage after delivery is undoubted and, by analogy, ergot has been thought to hold a place in the treatment of haemorrhage in gynaecological disease. For years Martindale’s Extra Pharmacopoeia supported two conflicting views when it described ergometrine as a palliative measure in menorrhagia, and crude ergot as an emmenagogue (Martindale, 1941). Thirty years ago Howard Kelly was in no doubt when he wrote of the treatment of menorrhagia, “Ergot, ingested in the past by thousands of tons, is useless” (Kelly, 1928). Today the British Obstetric and Gynaecological Practice recommends ergot in acute episodes of serious haemorrhage from metropathia but adds that this use is traditional rather than efficacious (Jeffcoate, 1955). The present paper reports a study of the effects of a crude ergot preparation and two ergot alkaloids on the contractility of the intact non-pregnant uterus. This is not straightforward like similar studies on the pregnant and puerperal uterus as the type of spontaneous activity in non-pregnant uteri varies with the phase of the menstrual cycle. In the first half of the cycle the characteristic pattern is one of rapid, feeble contractions or A waves, whereas later in the cycle (or during menstruation after ovulation) slower and many times more powerful contractions, or B waves, are the dominant feature (Moir, 1944). The several ergot preparations have been tried at all stages of the menstrual cycle and in a few anovulatory cycles. METHOD Records of uterine activity were obtained from 33 volunteer patients by the intra-uterine balloon method (Moir, 1934). Only cases giving a normal menstrual history were included in the series. Where curettage was indicated on medical grounds, endometrial biopsy was obtained to give more objective information concerning the endocrine conditions prevailing at the time of the study. With the usual antiseptic precautions the cervix was exposed and a small, collapsed, sterile balloon mounted on a hollow uterine sound was passed into the cavity of the uterus under direct vision and without anaesthesia. When in place the balloon was filled with water to 15 mm. of mercury initial distending pressure. As the maximum capacity of the balloon was designed not to exceed 2 ml., this initial distending pressure was “balanced” by the elasticity of the balloon walls. The balloon was then connected by water-filled pressure-tubing to a very fine tambour or, in appropriate cases, to a mercury manometer recording on smoked paper. After a suitable control period of recording, the ergot preparation was given and the effect noted.

RUPTURE OF AN INTRACRINIAL ANEURAYSM DURING PRAGNANCY

Impaction of the faecal masses in the rectum can cause serious obstruction to the progress of labour. Etzel et al. (1954) reported a case of dystocia caused by impacted faecal masses. The obstructing masses were removed with considerable difficulty but the labour then progressed very quickly. Grasby and Higgins (1955) reported a case in which dystocia caused by impacted faeces in the rectum and pelvic colon was relieved by manual removal of the impacted masses. In the present case, the impacted faecal mass, whose presence was not suspected, caused some delay in labour. It was expelled spontaneously but in the process caused a tear of the rectum although the exact mode of rupture of the rectum in this case is rather obscure.