there is con siderable pain, but more frequently only a feeling of uneasiness about the anus. When a fistula originates, as it most commonly does, from a pre-existing ab scess, there is a sensation of weight about the anus, with swelling of the integu ment, considerable tenderness upon pressure, pain in defecation, and more or less constitutional disturbance associated with rigors.
The chief discomfort is the discharge, which varies in quantity and may be purulent or muco-purulent. This dis charge occurs from the sinus so long as it remains unhealed, soiling the linen and making it wet and uncomfortable. It often produces an excoriation of the nates. The discharge is not of itself suf ficient 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 cases of 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 sec ondary suppuration is always liable to complicate a fistula, and is usually due to a stoppage of the track by small par ticles of fees or by exuberant growth of the granulation. Such a sequel, of course, is attended with pain, until a new opening forms or one is made by the sur geon. In some cases the original fis tulous track becomes re-established. Pa tients of neurotic habit often suffer men tally and from general weakness. As in other affections of the rectum, various reflex pains are experienced, which may be referred to the back, to the loins, and to the lower portion of the abdomen. When such pains extend down the leg and to the foot, they are liable to be attributed to sciatica, unless the history of the case is carefully studied and a critical examination is made.
Diagnosis.—Prior to the examination of the rectum the bowels should be emp tied 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's occur ring; and therefore facilitates the thor oughness of the surgeon's examination by securing the co-operation of the pa tient, as in extruding the parts, etc.
The patient should be placed in a re cumbent position on a table or an ex amining chair, with the legs well drawn up toward the abdomen, and the buttocks brought to the edge of the couch. If
the external orifice of the sinus is promi nent, or if there is a sentinel granulation, 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 tip of the finger in the suspected lo cality, 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 fore finger and finding an induration sug gesting a pipe-stem beneath the skin. A flexible silver probe should now be passed along the fistulous track. In do ing this considerable care is requisite and the utmost gentleness should be observed, the probe being directed by its own weight through the sinus and not for cibly. If it does not pass easily, it may be bent, and "coaxed" along the chan nel. In the majority of instances it will pass directly into the bowel. When the probe has passed as far as it will go with out the use of any force, the finger is in troduced into the rectum. When it comes in contact with the free end of the probe it demonstrates the presence of a complete fistulous track. In other cases the mucous membrane is felt to inter vene between the finger and the probe; in such cases the internal opening gen erally exists, but it is difficult to dis cover,—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. There may not be an internal opening; if not, the operator should ascertain how near the probe comes to the surface of the bowel. If a doubt still exists as to the completeness of the track, any one of a variety of specula may be introduced into the rec tum, and the outer orifice of the sinus in jected with a solution of iodine, creolin, or of peroxide of hydrogen, when, if there be an internal opening, the appear ance of the fluid within the bowel will set the question at rest. If the inner opening be not discovered by these meth ods, the case must be looked upon as one of external rectal fistula.