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.
[Illustration: Fig. 20—Small Trocar and Acupuncture or Exploring
Needle (for testing the character of ambiguous swellings or fluid
collections about the rectum).]
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.
[Illustration: Fig. 21—Silver Probe attached to handle.]
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.
[Illustration: Fig. 22—Pratt's Speculum.]
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.
[Illustration: Fig. 23—O'Neil's Speculum.]
[Illustration: Fig. 24—Kelsey's Rectal Retractor.]
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.
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Footnote 44:
_Op. cit._, p. 77.
Footnote 45:
_Op. cit._, p. 21.