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obliterated. .^^ i\- -1 yl - ■ -ia."-.: Via. 3. — Enlarged view of the preparation of figure 2 ; e, genuine pfizer viagra 100mg vas- cular tissue in the internal part of the fistula. The epithelium of the skin ends abruptly at the level of the opening of the fistula. No epithelial lining is found in the internal part of the fistula. Oct. 16, 1915] MEDICAL RECORD. 647 It is impossible to understand how this structure could be cured by simple incision and curetting. As for the danger of incontinence of genuine pfizer viagra 100mg the sphinc- ters following the operation for fistula in ano it is necessary to recall some anatomical details of the rectum. The internal and external sphincters sur- round the last portion of the rectum, the pars analis recti ; but while the internal sphincter covers this pars analis in all its extent, the external sphincter occupies only a small part of it. The rela- tive extent of soft viagra vs viagra the two muscles is very important, and it is well demonstrated by Fig. 4, which shows semi- schematically the disposition of the muscular coats of the rectum, according to the researches of Roux. It is clear in this figure that the circular fibers of the internal sphincter are a continuation of the circular muscular fibers of the intestine, and com- pletely encircle the pars analis in its entire length, and the external sphincter covers only the most ex- ternal portion of the pars analis. . lon^itw/ina/ fibres Circu/rir f'/ins Mrjcofd t''.y^M.sphinch'r afii //ikr. '--^-^^M.spMilckr a/// erf. Pars an(//is S) C-^ -^ Fig. 4. — Schematic section of the rectum. The fistula usually affects only a small part of the sphincters, so that, even if the part of the sphincters intervening between the fistulous tract and the mucosa is cut and not repaired, we have always genuine pfizer viagra 100mg enough sphincter left to keep the anus con- tinent. The incontinence following the operations for fistula in ano is not due to the incision of the sphincters, but it is more the consequence of the divulsion of the anus preceding the operation. When the stretching is not carefully done, or when it is done too roughly, it may cause rupture of the mus- cular fibers, interstitial hemorrhages, and conse- quent atrophy of the sphincters and incontinence. The Operation. — The day before the operation the patient is given a cathartic and enemas to empty the bowels entirely. The perineum is shaved. The soft viagra vs viagra patient is put under general anesthesia and placed on the table in the lithotomy position. The operation consists of three steps : First. The stretching of the genuine pfizer viagra 100mg sphincter.^. This must not be attempted until the patient is under complete and deep anesthesia, and must be very gently done with patience and time, and using only the two index fingers. To use force is absolutely I/m ofijicision Anus