The type of fissure which corresponds to the authors third-degree lesion is in reality a true ulcer as shown by endoscopic examination. For this reason the term “anal ulcer” is preferred by us. As the essayist has indicated, this lesion is usually found posteriorly. However, in our experience, anterior anal ulcer occurs much more frequently in the female that it does in the male.
The anatomico-physiologic aspect of anal ulcer is important to the proper understanding of the lesion. The anal canal bounded above by the anorectal or dentate line and below by the anus is lined by modified skin, i.e., stratified squamous epithelium nd not by mucous membrane. The innervation of this anal lining is somatic, just as it is for skin elsewhere. This is in marked physiologic contract to the rectal mucous membrane with its visceral nerve supply. An anal lesion, such as ulcer or thrombotic external haemorrhoid, is decidedly painful because ordinary pain fibers are stimulated.
In the case of anal ulcer the concomitant anal spasm resulting from contraction of the irritated anal muscles adds insult to injury. Anal ulcer, which is after all a relatively insignificant lesion pathologically, causes severe symptoms. A short distance above the anorectal line, i.e., on the rectal side, a malignant lesion may develop and grow for some time unaccompanied by warning symptoms, principally because the gut has a visceral innervation which can be stimulated only by crushing or by overdistention.
The author has included in his paper the confusing subject of pectenosis. Miles states that the pecten band does not exist in a health individual. Hence the term implies inflammation although it does not passes the usual “itis” ending. Since infection if the underlying cause of most anal affections, it seems logical to us that such conditions as cryptitis, papillitis, etc., may account for the pathologic condition which the essayist and others choose to call pectenosis.
We thoroughly agree with the author in his attitude toward divulsion but in this connection we should like to know just what he means by deep massage.
Except in those cases of simple traumatic fissure we believe in the radical correction of all anorectal pathology. It is agreed that the removal of normal of healthy tissue elsewhere. We do not suture these wounds because of our profound belief in the value of proper surgical drainage.
In closing , the discussed wound like to ask the essayist what he means by the normal function of a crypt (it has never been explained surgeons does he thank are fully aware of the significance of cryptitis.
Dr. Von Bopnnewitz, (closing): The discussors inquiry regarding the classification of anal fissures I believe was clearly was clearly set forth in the paper and was for the benefit of my staff in carrying out the treatment after operation.
I cannot agree that “Pectenosis” is a confusing subject, since it is well recognized in all the rectal clinics of Europe and man articles have appeared in magazines in this country, such as the excellent treatise by Dr. J.W. Morgan appearing in the journal of Surgery, Gynecology and Obstetrics, November, 1934, and a very lucid discussion in the May issue of Clinical Medicine and Surgery, by Dr. W.A.Hinckele.
The crypts of Morgagni placed about the anal canal is for the purpose of lubricating the passage with a bland fluid, which materially assists the passage of a hard, dry stool. I fully agree with Dr. Schofield that the general surgeon does not recognize the importance of diseased crypts in anorectal surgery.
