When examining above the internal sphincter, especially posteriorly, where the bottom or floor of the rectum forms a cul-de-sac, direct the patient to strain down a little; this effort will throw the mucous membrane out into the speculum, at the same time spreads out and smooths its surface. In looking through a speculum this cul-de-sac of the rectum sometimes appears as a vacancy behind the internal sphincter, and has been mistaken and treated as an ulcer cavity. It often contains a liberal supply of mucous.
FISTULA.
Fistula in the recto anal region so far exceeds that in any other locality, that its overwhelming predominence here almost entitles it to the exclusive right of the term; while, to those who have given this part of the physical organism special study, the word itself, calls to mind a local condition of disease that is anything but an easy one to manage.
In point of frequency fistula is next akin to hemorrhoids, but a much less desirable complaint to treat. Allingham states that the number of cases occurring in hospital practice is greater. That two-thirds of all the cases operated upon of the in patients at St. Mark’s Hospital, London, were fistula. The most frequent cause assigned being abscess. A failure of the abscess to heal, leaving a sinus or sinuses, is explained by the presence of loose areolar tissue and fat, excessive mobility of the parts by the action of the sphincters, respiration, coughing and sneezing, and a strumous diathesis.
In consequence of an occasional failure of the muscles to regain their power after division by the knife, elastic ligature or galvano-cautery wire in the treatment of fistula, leaving the subject in a pitiable state of incontinence of feces, which has resulted in several well authenticated cases in suicide, new and rational methods have been devised for the relief of this very troublesome and unpleasant affection.
Kelsey says: “A permanent incontinence of feces is always considered by the patient a very poor exchange for fistula, which was causing comparatively little suffering and annoyance.”
The fact that such a deplorable condition does sometimes follow complete section of the sphincters, and that we have no means of knowing previously when it may or may not occur, I submit the question to all thinking, conscientious and painstaking physicians: Should we not seek the adoption of any efficient means of treatment, whereby such risk is wholly avoided?
About the first of March, 1890, Daniel Mc., aged 35, who a few months before had been operated upon by a reputable surgeon for a simple, uncomplicated fistula, sought my acquaintance, exhibited his condition and related his experiences.