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and Obsts., Nov., 14. Holzknecht: "Die normale Peristaltik des Colon," Miinchener nied. Wochenschr., 1909. Clairmont and Haudeck: Aus der Chirurerischen Klinik Frer. viagra after eating von Eiselsberg; Magenradiologie fiJr die Chirurgie, Jena Verlag Gustav Fisher. 1911. A. E. Barclav: Positive viagra after eating diagnosis. Duodenal Ulcer Archives Roentgen Ray, 15 XIX, 282. I. S. Hirsch:'N. 1'. Medical Journal, July 5, 1913. 234 Central Park W'est. 646 MEDICAL RECORD. [Oct. 16, 1915 THE EXCISION OF THE FISTULOUS TRACT IN THE TREATMENT OF FISTULA IN ANO. By carlo SAVINI, M.D., .. ' . NEW TORK. An observation, even superficial, of the structure of the fistula in ano is sufficient to convince one that the best way of treating this disease is by the extirpation of the fistulous tract. The viagra after eating total excision is superior to all the various procedures advocated for the treatment of this condition for many rea- sons, and whenever it is possible it should be con- sidered as the method of choice. It is a viagra after eating rational operation; it valium and viagra permits a plastic suture of the sphincters, and so reduces to a mini- mum the dangers of incontinence, and by removing all the pathological structures produces a radical cure in the shorte.st period of time. The fistulous tract is in reality a tumor, and as such should be totally removed. The fistula is Pig. 1.- -Transverse section of the fistulous t-anui . tissue : b, granulations. a, fibrous essentially formed of a tube of hard fibrous tissue lined with granulations. The limits of this tube are very well defined, and its adhesions to the sur- rounding muscular fibers of the sphincters can be easily separated and dissected. On the microscopical examination of a cross-sec- tion of the specimen we find that the fistula consists mainly of a tube of fibrous tissue perforated by a great quantity of blood-vessels passing from the external to the internal part of the tube. In the inside of the viagra after eating tube these vessels form capillary loops and pedunculated tufts like hemorrhoidal nodes. The abundance of blood-vessels and the fibrous tissue are the main features of the structure. The skin around the opening of the fistula is also viagra after eating affected, and should be removed with the fistula. If the specimen is cut lengthwise we find that at the level of the external opening of the fistula the rete mucosum or Malpighian stratum of the skin is thickened and shows proliferation of the epithelial cells into the derma. Some sections give the appear- ance of a squamous epithelioma, and we find also the concentric globes or pearls which in the past were considered characteristic of squamous epithelioma. In my opinion the introflexion of the ... ...:/ Fig. 2. — Longitudinal section of a fistula ; a, fibrous tissue ; h, granulations ; c, Rete mucosum of the skin ; d, pearls ; e, vascular tissue in the internal part of the fistula. valium and viagra epithelium and the pearls are the remnants of the cicatrization of old fistulous openings now