964
fraught with difficulty and danger, with leakage-rates reaching 75% as the depth of the suture line in the pelvis increases. As with deep venous thrombosis, it was a special technique-in this instance a gentle water-soluble
FÆCAL INCONTINENCE F aeCAL incontinence is miserable for the sufferer and not very inviting to the surgeon, who does not find it automatically responds to treatment. Part of its origin lies
enema-which revealed the true incidence. Some surgeons will argue that the subclinical leaks are unimportant; but such leaks are sometimes the precursors of clinical disaster, and any controllable surgical inadequacy should be controlled. Now the Leeds academic surgeons have pursued this work on colonic anastomosis by comparing the standard technique of two-layer suture with one-layer apposition, in this case using an "all coats" interrupted suture.2 Though there is much experimental evidence in favour of one-layer anastomosis, they have been unable to show any significant difference between the two techniques. The technical leak-rate remained high (30% for high and 40% for low anastomoses in the pelvis), though it must be re-emphasised that these leaks were identified almost entirely by water-soluble contrast enemas and careful digital examination. Most patients had a smooth
in a rectum and anus that cannot sense properly what is going on/ and part in a pelvic floor and sphincters which cannot contract to enough purpose or at the right time. Hence faecal incontinence is a well-recognised event in manifestly neural disorders such as damage to the cauda equina.2 But in most patients neural disorder is not obvious. However, their treatment by open operation has recently made it possible to do biopsies on the external sphincter and pelvic-floor musculature. When Parks and his co-workers3 examined such biopsy specimens, they found evidence of chronic neural damage, the musculature being partly denervated and the small nerves fibrosed. In some cases the denervation is attributed to old age, with loss of spinal-cord neurons. But old age is not in itself a wholly satisfying explanation. Parks et al. did not examine control material from normal patients more than 64 years old, although nearly half their incontinent patients were older than this; if they had done, they might have found cases with evidence of denervation, but no incontinence. Secondly, it may well be possible for muscle partly denervated by increasing age to retain its whole strength by enlarging motor-unit sizefewer neurons, more muscle fibres per neuron.4 Thirdly, to assume that in every part of the nervous system neurons are steadily vanishing as we age may be unjustified ; some do not.5S Another explanation for the denervation that leads to faecal incontinence is that the nerve fibres are destroyed by repeated stretching. The explanation is plausible. Incontinence is then likely to follow rectal prolapse, and it does. Again, incontinence is seen after haemorrhoidectomy. Repeated straining to defaecate might overstretch the nerves and lead to incontinence, and straining is likely after hxmorrhoidectomy; adequate the lumen may be, but it is not the same as it was before htmorrhoidectomy, though its owner may be loth to tell his surgeon and risk (so he supposes) another operation. We now know that in faecal incontinence innervation of relevant striated muscle is likely to be faulty. Information about the innervation of smooth muscle at the lower end of the alimentary canal would also be helpful. Absent ganglion cells underlie Hirschsprung’s diseasej6 the muscle does not relax properly, although some fluid material can pass. Such a defect developing at the very end of the canal might exacerbate straining at defecttion and thus predispose to incontinence. Fxcal incontinence is very much more commonly reported by women. Men may have it and hide it, but why should they do so more than women? Stretching and squeezing of nerves certainly happen during parturition ; they make the perineum briefly numb afterwards, and kindly obstetricians know the advantage of repairing the perineum very promptly. But recovery is fast, and some nerves have a remarkable capacity to stand
contrast
postoperative
course
and
life-threatening complications
were rare.
,
This continued high rate of leakage in both techniques is disappointing because theoretical arguments support the one-layer method for its lack of tissue necrosis and smaller amount of suture material. The Leeds workers admit that their experience differs from that of Everett3 for high anastomosis and from what they rightly describe as the remarkable results of Matheson and Irving,4 whose leak-rate was 5% and 7% for high and low colorectal anastomoses. We can only speculate on the cause of the differences. Suture material may have something to do with it--Goligher used silk and Matheson used braided polyamide (nylon). This matter remains confused except that absorbable sutures on their own are inadequate,5 perhaps because of the remarkable lytic activity (particularly collagenolytic) in relation to colonic anastomoses.6Furthermore, we do not even know for certain whether lack of irritant provocation by a suture is good or bad. Robbs has cast doubt on our conventional views and even supports the use of a comparatively irritant material such as silk if the objective is an ultimately strong anastomosis. Details of technique may also be important: through-andthrough sutures (the Leeds choice) leave a foreign-body directly in the lumen whereas extramucosal techniques (used by Everett and by Matheson) do not. Here are some possibilities which open the way for further study both in the operating-theatre and in the laboratory.9 Meanwhile, the work carried out by enthusiastic and analytic surgeons on colo-rectal anastomosis is in the best traditions of clinical science and has identified and partly solved a problem which many would have said did not exist. 2.
Goligher, J. C., Lee, P.
W.
G., Simkins,
K.
C., Lintott, D. J. ibid. 1977, 64,
609.
Everett, W. G. ibid. 1975, 62, 135. Matheson, N. A., Irving, A. D. ibid. p. 239. Everett, W. G. Progr. Surg. 1970, 8, 14. Cronin, K., Jackson, D. S., Dunphy, J. E. Surgery Gynec. Obstet. 1968, 126, 747. 7. Hawley, P. R., Faulk, W. P., Hunt, T. K., Dunphy, J. E. Br. J. Surg. 1970,
3. 4. 5. 6.
57, 846. 8. Robb, J. V. Surgery Gynec. Obstet. 1977, 145, 235. 9. Van Winkle, W. in Wound Healing (edited by T. Gibson and
Meulen); p. 255. Montreux, 1975.
J. C.
van
der
Duthie, H. L. in Modern Trends in Surgery-3; p. 91. London, 1971. Butler, E.C B Proc. R. Soc. Med. 1954, 47, 521. 3. Parks, A. G., Swash, M., Urich, H. Gut, 1977, 18, 656. 4. Brown, W. F. J. neurol. Neurosurg. Psychiat. 1972, 35, 845. 5 Konigsmark, B. W., Murphy, E. A. J. Neuropath. exp. Neurol. 1972, 31, 1. 2.
304. 6.
Bodian, M., Carter, C. O., Ward, B. C. H. Lancet, 1951, i, 302.
965 Part of the secret is that axons follow a zigin unstretched nerve trunks, so that as the zag trunk stretches the axons merely straighten; part is that nerve trunks themselves may run sinuously in unstretched tissue, weaving to and fro; and part is that axons can stand some stretching.7 So the tip of the tongue and the tip of the penis do not generally become permanently denervated; it is not obvious why the female pelvic floor musculature should sometimes do so. Denervation underlies faecal incontinence much more often than is clinically obvious. The news is not immediately helpful; it means that electrical stimulation of the relevant muscles is no panacea, since denervated and disordered muscle cannot be expected to respond effi-
stretching.
course
ciently. SUDDEN DEAFNESS SUDDEN deafness in adults is mostly unilateral. In a busy surgery the usual practice is to rule out wax as a cause and then to offer a nasal spray. At follow-up many patients will have recovered their hearing, thus apparently confirming the optimistic diagnosis of "catarrh". In those whose hearing has not returned the otolaryngologist will diagnose sudden sensorineural hearing lossbut this switch of labels does not imply an understanding of the disease process. The suggested causes tend to be based more on clinical fancies than on solid facts. Almost everyone attributes some cases to viruses but, except in herpes zoster and mumps parotitis, the clinical diagnosis has seldom been confirmed by serology or isolation of the virus. The clinical behaviour of this viral group is by no means uniform. Some "sudden" cases are described as rapidly progressive, and what little audiometric information is available fails to link the infection with a consistent pattern of hearing loss or subsequent clinical course. Histologically, eight ears which had lost their hearing more or less abruptly showed changes similar to those in verified mumps and measles.l°2 The most consistent changes were atrophy of the organ of Corti and tectorial membrane; the stria vascularis showed mild to moderate atrophic changes; and the neuronal population seemed unaffected. But a case-report from Japan’ records very different findings-namely, degeneration of the cochlear nerve with a well-preserved organ of Corti. Viral infection doubtless causes sudden deafness in some patients but the types of virus responsible and the pathophysiology of the damage remain unclear. The abruptness of the hearing loss is suggestive of a vascular accident, and the condition used to be called cochlear apoplexy. The modern term is sudden sensorineural hearing loss of thromboembolic origin. The cochlea is known to be intolerant of ischamlia and, experimentally, function is irreversibly lost after sixty seconds of anoxia. However, most patients with sudden deafness do not have atherosclerotic disease, blood dyscrasias, diabetes, or hypertension, nor are they of the age-group in which these diseases are common. Simmons4 suggested that sudden perceptive deafness may result from intracochlear membrane breaks. Goodhill et
1972, ii, 523. 1 Schuknecht, H. Laryngoscope, 1962, 72, 1142. 2 Schuknecht, H., et al.Actaotolar. 1973, 76, 75. 3 Ishn, T. Toriyama, M. Ann. Otol. 1977, 86, 541. 4 Summons, F. B. Archs Otolar. 1968, 88, 67.
one of these ruptures in the form of perifistula was amenable to surgical treatment. lymphatic other membrane breaks also occur, involving Probably various structures within the labyrinth. Healing of the membrane could re-establish normal anatomy and metabolism, with return of hearing. Little has been written about the natural history of sudden deafness. The spontaneous-recovery rate has not been defined, making the assessment of treatment impossible. The confused state of knowledge of the nature of the condition underlines the description "idiopathic" and any drug treatment is based on pure speculation. Mattox and Simmons6 report the result of a prospective study in a university and its associated community. Several otolaryngologists cooperated in the assessment and management of sudden sensorineural hearing loss over five years. Out of 166 patients 88 patients (eightynine ears) satisfied the diagnostic criteria. Two-thirds recovered their hearing completely, spontaneously, and irrespective of any type of medical treatment. Most did so within fourteen days and many within the first few days. Some patients had abnormal vestibular tests, and those few whose caloric tests were hypoactive tended not to recover completely. There was no correlation with age (except extreme old age) or with hypertension, diabetes, and other chronic diseases. The incidence of recent respiratory infections corresponded to that in the population at large. There was a fundamental prognostic difference between the apical and basal cochlear hearing losses. The severe high-tone basal loss was commonly associated with a raised sedimentation-rate and often some degree of vertigo. These patients probably have widespread damage through most of the cochlea, and recovery, when it occurs, is slow and incomplete. This type is most compatible with a virus or other infection. The commonest type was that with a severe flat or upwardsloping audiogram, and recovery was always better, in this predominantly low-tone deafness involving the apex of the cochlea, than in the high-tone group. Vertigo had no significance here. The hearing loss in this group was often stable for a week or two, then hearing returned rapidly even from profound losses. This feature of delay followed by complete recovery is difficult to explain on a vascular or viral basis. A mechanical explanationbreaks or tears of an inner-ear membrane, followed by spontaneous repair-fits better. The prospective survey has failed to pinpoint a single cause for a symptom which is clearly a final result of several disease processes. Careful investigation is important if the truly idiopathic sudden deafness is to be identified, and the results of any treatment must at least exceed the spontaneous-recovery
al. showed that
rate.
POSTOPERATIVE ATELECTASIS POSTOPERATIVE pulmonary complications are more after upper-abdominal than after lower-abdominal surgery; they are rare after operations on the limbs and trunk (except in the elderly debilitated patient operated on for fractured neck of femur, whose troubles have more to do with immobilisation); they are more apt to arise in patients with pre-existing bronchial infection; and they are more frequent in smokers than in noncommon
5. 6
Goodhill, V., et al. Ann. Otol. 1973, 82, 2. Mattox, D. E., Simmons, F. B. ibid. 1977, 86, 563.
fraught with difficulty and danger, with leakage-rates reaching 75% as the depth of the suture line in the pelvis increases. As with deep venous thrombosis, it was a special technique-in this instance a gentle water-soluble
FÆCAL INCONTINENCE F aeCAL incontinence is miserable for the sufferer and not very inviting to the surgeon, who does not find it automatically responds to treatment. Part of its origin lies
enema-which revealed the true incidence. Some surgeons will argue that the subclinical leaks are unimportant; but such leaks are sometimes the precursors of clinical disaster, and any controllable surgical inadequacy should be controlled. Now the Leeds academic surgeons have pursued this work on colonic anastomosis by comparing the standard technique of two-layer suture with one-layer apposition, in this case using an "all coats" interrupted suture.2 Though there is much experimental evidence in favour of one-layer anastomosis, they have been unable to show any significant difference between the two techniques. The technical leak-rate remained high (30% for high and 40% for low anastomoses in the pelvis), though it must be re-emphasised that these leaks were identified almost entirely by water-soluble contrast enemas and careful digital examination. Most patients had a smooth
in a rectum and anus that cannot sense properly what is going on/ and part in a pelvic floor and sphincters which cannot contract to enough purpose or at the right time. Hence faecal incontinence is a well-recognised event in manifestly neural disorders such as damage to the cauda equina.2 But in most patients neural disorder is not obvious. However, their treatment by open operation has recently made it possible to do biopsies on the external sphincter and pelvic-floor musculature. When Parks and his co-workers3 examined such biopsy specimens, they found evidence of chronic neural damage, the musculature being partly denervated and the small nerves fibrosed. In some cases the denervation is attributed to old age, with loss of spinal-cord neurons. But old age is not in itself a wholly satisfying explanation. Parks et al. did not examine control material from normal patients more than 64 years old, although nearly half their incontinent patients were older than this; if they had done, they might have found cases with evidence of denervation, but no incontinence. Secondly, it may well be possible for muscle partly denervated by increasing age to retain its whole strength by enlarging motor-unit sizefewer neurons, more muscle fibres per neuron.4 Thirdly, to assume that in every part of the nervous system neurons are steadily vanishing as we age may be unjustified ; some do not.5S Another explanation for the denervation that leads to faecal incontinence is that the nerve fibres are destroyed by repeated stretching. The explanation is plausible. Incontinence is then likely to follow rectal prolapse, and it does. Again, incontinence is seen after haemorrhoidectomy. Repeated straining to defaecate might overstretch the nerves and lead to incontinence, and straining is likely after hxmorrhoidectomy; adequate the lumen may be, but it is not the same as it was before htmorrhoidectomy, though its owner may be loth to tell his surgeon and risk (so he supposes) another operation. We now know that in faecal incontinence innervation of relevant striated muscle is likely to be faulty. Information about the innervation of smooth muscle at the lower end of the alimentary canal would also be helpful. Absent ganglion cells underlie Hirschsprung’s diseasej6 the muscle does not relax properly, although some fluid material can pass. Such a defect developing at the very end of the canal might exacerbate straining at defecttion and thus predispose to incontinence. Fxcal incontinence is very much more commonly reported by women. Men may have it and hide it, but why should they do so more than women? Stretching and squeezing of nerves certainly happen during parturition ; they make the perineum briefly numb afterwards, and kindly obstetricians know the advantage of repairing the perineum very promptly. But recovery is fast, and some nerves have a remarkable capacity to stand
contrast
postoperative
course
and
life-threatening complications
were rare.
,
This continued high rate of leakage in both techniques is disappointing because theoretical arguments support the one-layer method for its lack of tissue necrosis and smaller amount of suture material. The Leeds workers admit that their experience differs from that of Everett3 for high anastomosis and from what they rightly describe as the remarkable results of Matheson and Irving,4 whose leak-rate was 5% and 7% for high and low colorectal anastomoses. We can only speculate on the cause of the differences. Suture material may have something to do with it--Goligher used silk and Matheson used braided polyamide (nylon). This matter remains confused except that absorbable sutures on their own are inadequate,5 perhaps because of the remarkable lytic activity (particularly collagenolytic) in relation to colonic anastomoses.6Furthermore, we do not even know for certain whether lack of irritant provocation by a suture is good or bad. Robbs has cast doubt on our conventional views and even supports the use of a comparatively irritant material such as silk if the objective is an ultimately strong anastomosis. Details of technique may also be important: through-andthrough sutures (the Leeds choice) leave a foreign-body directly in the lumen whereas extramucosal techniques (used by Everett and by Matheson) do not. Here are some possibilities which open the way for further study both in the operating-theatre and in the laboratory.9 Meanwhile, the work carried out by enthusiastic and analytic surgeons on colo-rectal anastomosis is in the best traditions of clinical science and has identified and partly solved a problem which many would have said did not exist. 2.
Goligher, J. C., Lee, P.
W.
G., Simkins,
K.
C., Lintott, D. J. ibid. 1977, 64,
609.
Everett, W. G. ibid. 1975, 62, 135. Matheson, N. A., Irving, A. D. ibid. p. 239. Everett, W. G. Progr. Surg. 1970, 8, 14. Cronin, K., Jackson, D. S., Dunphy, J. E. Surgery Gynec. Obstet. 1968, 126, 747. 7. Hawley, P. R., Faulk, W. P., Hunt, T. K., Dunphy, J. E. Br. J. Surg. 1970,
3. 4. 5. 6.
57, 846. 8. Robb, J. V. Surgery Gynec. Obstet. 1977, 145, 235. 9. Van Winkle, W. in Wound Healing (edited by T. Gibson and
Meulen); p. 255. Montreux, 1975.
J. C.
van
der
Duthie, H. L. in Modern Trends in Surgery-3; p. 91. London, 1971. Butler, E.C B Proc. R. Soc. Med. 1954, 47, 521. 3. Parks, A. G., Swash, M., Urich, H. Gut, 1977, 18, 656. 4. Brown, W. F. J. neurol. Neurosurg. Psychiat. 1972, 35, 845. 5 Konigsmark, B. W., Murphy, E. A. J. Neuropath. exp. Neurol. 1972, 31, 1. 2.
304. 6.
Bodian, M., Carter, C. O., Ward, B. C. H. Lancet, 1951, i, 302.
965 Part of the secret is that axons follow a zigin unstretched nerve trunks, so that as the zag trunk stretches the axons merely straighten; part is that nerve trunks themselves may run sinuously in unstretched tissue, weaving to and fro; and part is that axons can stand some stretching.7 So the tip of the tongue and the tip of the penis do not generally become permanently denervated; it is not obvious why the female pelvic floor musculature should sometimes do so. Denervation underlies faecal incontinence much more often than is clinically obvious. The news is not immediately helpful; it means that electrical stimulation of the relevant muscles is no panacea, since denervated and disordered muscle cannot be expected to respond effi-
stretching.
course
ciently. SUDDEN DEAFNESS SUDDEN deafness in adults is mostly unilateral. In a busy surgery the usual practice is to rule out wax as a cause and then to offer a nasal spray. At follow-up many patients will have recovered their hearing, thus apparently confirming the optimistic diagnosis of "catarrh". In those whose hearing has not returned the otolaryngologist will diagnose sudden sensorineural hearing lossbut this switch of labels does not imply an understanding of the disease process. The suggested causes tend to be based more on clinical fancies than on solid facts. Almost everyone attributes some cases to viruses but, except in herpes zoster and mumps parotitis, the clinical diagnosis has seldom been confirmed by serology or isolation of the virus. The clinical behaviour of this viral group is by no means uniform. Some "sudden" cases are described as rapidly progressive, and what little audiometric information is available fails to link the infection with a consistent pattern of hearing loss or subsequent clinical course. Histologically, eight ears which had lost their hearing more or less abruptly showed changes similar to those in verified mumps and measles.l°2 The most consistent changes were atrophy of the organ of Corti and tectorial membrane; the stria vascularis showed mild to moderate atrophic changes; and the neuronal population seemed unaffected. But a case-report from Japan’ records very different findings-namely, degeneration of the cochlear nerve with a well-preserved organ of Corti. Viral infection doubtless causes sudden deafness in some patients but the types of virus responsible and the pathophysiology of the damage remain unclear. The abruptness of the hearing loss is suggestive of a vascular accident, and the condition used to be called cochlear apoplexy. The modern term is sudden sensorineural hearing loss of thromboembolic origin. The cochlea is known to be intolerant of ischamlia and, experimentally, function is irreversibly lost after sixty seconds of anoxia. However, most patients with sudden deafness do not have atherosclerotic disease, blood dyscrasias, diabetes, or hypertension, nor are they of the age-group in which these diseases are common. Simmons4 suggested that sudden perceptive deafness may result from intracochlear membrane breaks. Goodhill et
1972, ii, 523. 1 Schuknecht, H. Laryngoscope, 1962, 72, 1142. 2 Schuknecht, H., et al.Actaotolar. 1973, 76, 75. 3 Ishn, T. Toriyama, M. Ann. Otol. 1977, 86, 541. 4 Summons, F. B. Archs Otolar. 1968, 88, 67.
one of these ruptures in the form of perifistula was amenable to surgical treatment. lymphatic other membrane breaks also occur, involving Probably various structures within the labyrinth. Healing of the membrane could re-establish normal anatomy and metabolism, with return of hearing. Little has been written about the natural history of sudden deafness. The spontaneous-recovery rate has not been defined, making the assessment of treatment impossible. The confused state of knowledge of the nature of the condition underlines the description "idiopathic" and any drug treatment is based on pure speculation. Mattox and Simmons6 report the result of a prospective study in a university and its associated community. Several otolaryngologists cooperated in the assessment and management of sudden sensorineural hearing loss over five years. Out of 166 patients 88 patients (eightynine ears) satisfied the diagnostic criteria. Two-thirds recovered their hearing completely, spontaneously, and irrespective of any type of medical treatment. Most did so within fourteen days and many within the first few days. Some patients had abnormal vestibular tests, and those few whose caloric tests were hypoactive tended not to recover completely. There was no correlation with age (except extreme old age) or with hypertension, diabetes, and other chronic diseases. The incidence of recent respiratory infections corresponded to that in the population at large. There was a fundamental prognostic difference between the apical and basal cochlear hearing losses. The severe high-tone basal loss was commonly associated with a raised sedimentation-rate and often some degree of vertigo. These patients probably have widespread damage through most of the cochlea, and recovery, when it occurs, is slow and incomplete. This type is most compatible with a virus or other infection. The commonest type was that with a severe flat or upwardsloping audiogram, and recovery was always better, in this predominantly low-tone deafness involving the apex of the cochlea, than in the high-tone group. Vertigo had no significance here. The hearing loss in this group was often stable for a week or two, then hearing returned rapidly even from profound losses. This feature of delay followed by complete recovery is difficult to explain on a vascular or viral basis. A mechanical explanationbreaks or tears of an inner-ear membrane, followed by spontaneous repair-fits better. The prospective survey has failed to pinpoint a single cause for a symptom which is clearly a final result of several disease processes. Careful investigation is important if the truly idiopathic sudden deafness is to be identified, and the results of any treatment must at least exceed the spontaneous-recovery
al. showed that
rate.
POSTOPERATIVE ATELECTASIS POSTOPERATIVE pulmonary complications are more after upper-abdominal than after lower-abdominal surgery; they are rare after operations on the limbs and trunk (except in the elderly debilitated patient operated on for fractured neck of femur, whose troubles have more to do with immobilisation); they are more apt to arise in patients with pre-existing bronchial infection; and they are more frequent in smokers than in noncommon
5. 6
Goodhill, V., et al. Ann. Otol. 1973, 82, 2. Mattox, D. E., Simmons, F. B. ibid. 1977, 86, 563.
