"Diseases of the Rectum and Anus," second edition, London, 1890, p. 185. CHAPTER II. SYMPTOMATOLOGY—PHYSICAL EXPLORATION—DIAGNOSIS—PROGNOSIS. SYMPTOMS.—The symptoms in the early stage of this disease are not usually severe, and are generally experienced during defecation, when at some point or other there will be an uneasy sensation, consisting of an itching, pricking, slight smarting, or a feeling of heat about the circumference of the anus. As the disease progresses, the discomfort attending the movements of the bowel is greatly augmented, and at a variable period of time gives place to a severe pain, of a burning or lancinating character, which is followed by throbbing and excruciating aching, attended by violent spasmodic contraction of the sphincter muscles, continuing from half an hour to several hours. From reflex irritation, pains are often experienced in other parts, simulating sciatica or rheumatism; the urinary organs, as has already been mentioned, are liable to be sympathetically deranged, causing attention to be diverted from the real seat of the disease. The ulcer being fully established, the suffering usually comes on with intensity shortly after the actual passage of the motion, and frequently it lasts for many hours, completely incapacitating the patient for work while it continues. I have known persons affected with this malady who for hours were obliged to maintain one position, or to assume the recumbent posture, for fear that the slightest movement would aggravate the pain. After an indefinite period the pain subsides or entirely disappears, the patient feeling fairly comfortable, or even perfectly well, and to all outward appearance he would continue so were it not for the knowledge that the subsequent passage of fecal matter will bring with it a recurrence of agony. In consequence of this dread, the act of defecation is postponed as long as possible, with the result that when the evacuation does take place the pain is greatly increased. The feces, when solid, will be passed streaked with purulent matter,—possibly also with blood,—and when more soft will be figured and of small size; sometimes they are flattened and tape-like, due to the incomplete relaxation of the sphincters during defecation. Not infrequently the appearance of such a stool leads the inexperienced to make a diagnosis of stricture of the rectum. In this connection it may be well to state that a fissure is sometimes found associated with a stricture, which latter is due to a congenital contracted state of the anus. Serremone, quoted by Ball,[15] believes that the stricture is the cause and not the result of the fissure, the narrow outlet being more liable to injury from over-stretching.