CHAPTER II.

SYMPTOMATOLOGY—PHYSICAL EXPLORATION—DIAGNOSIS—PROGNOSIS.

SYMPTOMS.—The symptoms of fistula are not easily overlooked. Occasionally there is considerable pain present, but more frequently only a feeling of uneasiness about the anus is experienced. When a fistula originates, as I believe it most commonly does, from a preëxisting abscess, there is a sensation of weight about the anus, with swelling of the integument, considerable tenderness upon pressure, pain in defecation, and a constitutional disturbance associated with rigors. These symptoms are relieved after the matter is discharged. The exploring needle (Fig. 20) is often useful in determining the presence of pus in such abscesses in which it is impossible to obtain fluctuation. In complete fistula in ano, and in the incomplete internal variety, the evacuations are streaked or covered with pus and mucus, perhaps also slightly tinged with blood.

The chief discomfort to a patient with fistula is the discharge, in greater or less quantity, of purulent or muco-purulent matter which is kept up from the sinus so long as it remains unhealed, soiling the linen and making it wet and uncomfortable, and producing an excoriation of the nates. The discharge is not of itself sufficient to be a source of great exhaustion, and does not interfere with ordinary occupations, so that many patients have had fistula for a considerable length of time without being conscious of any serious ailment. The escape of flatus and mucus from the bowel in complete fistula will often prove a source of annoyance, as will also the passage of feculent matter which will be expelled through the sinus should the fistulous channel be very free.

An attack of secondary suppuration is always liable to complicate the presence of a fistula, and is usually due to a stoppage of the track by small particles of feces or by exuberant growth of the granulations. Such a sequela, of course, is attended with pain, until a new opening forms or one is made by the surgeon. In some cases the original fistulous track becomes reëstablished. Fistula in some persons, particularly those of a nervous temperament, produces an impression of physical imperfection and weakness in their organization, which renders them miserable. As in other affections of the rectum, various reflex or sympathetic pains are experienced in cases of fistula; they are referred to the back, to the loins, and to the bottom of the abdomen. When such pains extend down the leg and to the foot, they are likely to be attributed to sciatica unless the history of the case is carefully studied and a critical examination made.

OCULAR AND DIGITAL EXAMINATION.—Immediately before an examination is made in cases of fistula, as well as in all other investigations connected with the diagnosis of rectal diseases, the bowels should be emptied by an enema. This procedure not only renders the exploration of the parts easier and cleaner, but also, in women especially, serves to quiet the patient's fears of any untoward accident occurring, and therefore facilitates the thoroughness of the surgeon's examination by securing the coöperation of the patient, as in extruding the parts, etc.

In order to examine a patient with supposed fistula, he should be placed in a recumbent position on a table or an examining-chair, preferably on the side on which the external opening is situated, with the legs well drawn up toward the abdomen, and the buttocks brought to the edge of the couch.

The anus and the surrounding parts should be carefully examined to detect any apparent lesion. If the external orifice of the sinus is prominent, or if there is a sentinel granulation present, the outlet of the fistula will be obvious; but when it is small and located between folds of the skin, its situation may be demonstrated by making pressure with the top of the finger in the suspected locality, which will usually cause a little drop of matter to exude. The site of a fistula may often be detected by feeling gently all around the anus with the forefinger and finding an induration which feels like a pipe-stem beneath the skin. A flexible silver probe (Fig. 21) should now be passed along the fistulous track. In doing this, considerable care is requisite, and the utmost gentleness should be observed, bearing in mind that the probe is to be directed by its own weight through the sinus, and not by force applied by the hand of the surgeon. If it does not pass easily, bend it and see if it cannot be coaxed along the channel. In many cases it will pass directly into the bowel. When the probe has been passed as far as it will go without the use of any force, introduce the finger gently into the rectum. This should be subsequent to the passage of the probe, as otherwise the introduction of the finger into the bowel will set up a spasm of the sphincter muscles, which will greatly interfere with the passage of the probe. When the finger is in the bowel it will frequently come in contact with the probe, which fact demonstrates the presence of a complete fistulous track; in other cases the mucous membrane is felt to intervene between the digit and the probe. In such cases the internal opening generally exists, but is difficult to discover,—sometimes because the examiner searches for it too high in the bowel. Palpation with the sensitive tip of the finger will often render the presence of the inner orifice obvious, by coming in contact with an indurated mass of tissue. If such a spot be felt, the finger should be placed upon it and the probe passed toward the finger. Make sure that the fistula is a complete one, by feeling the probe touch the finger. There may not be an internal opening; if not, see how near the probe comes to the surface of the bowel.

If a doubt still exists as to the completeness of the track, one of a variety of specula (Figs. 22, 23, 24) may be introduced into the rectum, and the outer orifice of the sinus injected with either milk or a solution of iodine, when if there be an internal opening the appearance of the colored fluid within the bowel will set the question at rest.

If the inner opening be not discovered by these methods, the case must be looked upon as one of external rectal fistula.

According to Ball,[44] in cases where the probe passes away from the rectum and is directed along the anal fascia to the upper portion of the ischio-rectal fossa, or where the entire substance of the rectal wall separates the finger and the probe, the case is one either of external rectal sinus, or of fistula originating in the superior pelvi-rectal space. In such cases, Mr. Ball states, "we must go farther and try and find the cause, such as diseased bone, etc.; and in the female a vaginal examination may show us a uterine or ovarian origin. Where there are numerous external openings it is necessary to carefully probe all of them, so as to determine whether they are all connected, and the direction which they take. The upper limit of the separation of the mucous membrane should also be made out, and search should be made for the presence of more than one internal orifice, if such is likely to be present."

The presence of incomplete internal rectal fistula is more difficult to determine than the other varieties of this lesion which have just been considered. It is the most painful form, but, fortunately, it is of infrequent occurrence. Its orifice may be located anywhere in the rectum, but is generally found between the internal and external sphincters. According to Allingham,[45] the circumference of this opening is often as large as an English threepenny piece, its edges being sometimes indurated, at other times undermined. The feces, when liquid, pass into the sinus and create great suffering—a burning pain often lasting all day after the bowels have acted.

In this variety of fistula the feces are coated more or less with pus or blood, and a boggy swelling is noted at some portion of the circumference of the anus. A peculiar feature of this swelling is often noted—viz., its presence one day and its disappearance in a day or two, followed by an increased discharge of pus from the bowel. This fact is explainable by the closure of the outlet of the fistula, caused either by a plug of feces or as a result of inflammatory swelling, which allows the collection of a quantity of pus and the consequent formation of a boggy tumor. The swelling disappears upon the reëstablishment of the communication between the bowel and the sinus, and is attended by the profuse discharge of matter previously mentioned. This phenomenon is repeated over and over again, and indicates the nature of the disease.

In other cases of blind internal fistula, if the orifice can be felt, or if it can be seen through a speculum, a bent probe may be introduced into it and made to protrude near to the cutaneous surface of the body, where its point can be felt.

DIAGNOSIS.—The method of diagnosing fistula has already been sufficiently detailed. A few words, however, as to differential diagnosis may prove useful. Fistulæ frequently coexist with other rectal diseases; it is therefore important that an examination should be carefully made, so as to exclude such lesions—for instance, the presence of stricture, malignant disease, hemorrhoids and other tumors, etc. A thorough physical examination of the chest should also be made, to ascertain the presence or absence of phthisis, which so frequently complicates fistula in ano. Serious kidney disease should be excluded before recommending operation, for obvious reasons. In cases of caries of the vertebræ, of the sacrum, or of the pelvis, fistulous tracks may form and simulate anal fistula. In such instances a careful investigation will reveal the true origin of the trouble, and will show that the case is not one of ordinary fistula in ano.

COURSE AND PROGNOSIS.—This disease untreated has a tendency to increase. The longer its duration the more tortuous and complicated does it become. Hence the earlier the patient submits to treatment the more favorable will be the prognosis, and the time and extent of the treatment necessary to effect a permanent cure will be correspondingly diminished.

Footnote 44:

_Op. cit._, p. 77.

Footnote 45:

_Op. cit._, p. 21.