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such size would likely be overlooked. Of course the thickness through the abdomen Viagra 100mg Dose as well as the thick- ness and density of the abdominal wall will in- fluence the clearness of the picture very much. Pyloric stenosis. In pyloric stenosis one is apt to find the peristaltic Viagra 100mg Dose waves unusually deep and fre- quent, while they last. They may then cease en- tirely for an indefinite period. They may at times be excited again by external manipulation of the abdomen, by mere pressure against the screen, or by deep inspiration. Reversed peristalsis ma_\- at times be observed in cases of pyloric obstruction. Jonas' and Holz- knecht" were the first to call attention to the re- versed peristalsis. I have observed it in several cases. In a case examined Viagra 100mg Dose recently I saw Viagra 100mg Dose three deep waves at once apparently stand still for a short time, as if hesitating, and then move in the reversed direction. When these reversed peristaltic waves are present they are likely to extend nearer to the upper pole than the junction of the middle and lower third of the stomach, and the direct peristaltic waves begin higher. Reversed peristalsis is char- acteristic of pyloric obstruction. The study of the peristaltic wave as applied to carcinoma of the stomach cannot be dismissed without recognition of other conditions which have Viagra 100mg Dose a similar influence. Gastric ulcer will at times cause tetanic or spas- modic contractions which may last an indefinite time. I have observed one case in which it lasted at least an hour, and produced a decided hourglass contraction. In such cases, of course, the peristaltic wave is interrupted. I have seen these spasmodic contractions, too, in connection with movable kid- ney. Generally such spasmodic contractions may be seen to relax, then a complete wave will pass, to be followed again by the spasmodic contraction. Of course, an indurated gastric ulcer will give the same appearance as an early carciinnna, and it is to be hoped that more of these early cases can be exam- ined in the future. A differentiation between ulcer and early carcinoma is as superfluous as it is im- possible. Gastric adhesions, secondary to gastric or duo- denal ulcers, or secondary to a cholecystitis, will also interfere with the peristaltic wave. These in- volve also most often the lesser curvature. They inay even cause considerable distortion of the stom- ach. Adhesions may involve a considerable extent of the stomach wall, and may cause displacement ^Deutsche tn^disintsclie IVochcuscttrift, 1906, No. 23. *Radioloeische Diagnostik der intra Viagra 100mg Dose und gxira ventricularen Tu- wren, Wien, 1908. 882 GOLDMAN: TEST BREAKFAST VERSUS FASTING STOMACH CONTENTS. of the stomach without Viagra 100mg Dose interfering much with the Viagra 100mg Dose lumen, while a carcinoma of such extent will ob- literate much of the lumen, and prevent complete filling by the bismuth mixture. I Viagra 100mg Dose must repeat that at no time would I attempt a diagnosis upon the study of this wave alone. All other x ray and clini- cal evidence and the history must Viagra 100mg Dose be given due con- sideration. 'Gastric atony, whether associated with neuras- thenia, gastroptosis, or gastric ptosis secondary to pyloric obstruction, may give general absence of the peristaltic wave, or one may have to excite tlie wave by external manipulation. In these cases, very strong waves are likely to occur at long intervals. Therefore, when they can be observed they are of special diagnostic value. I have noticed that peristaltic waves may at times be excited by giving the patient some appetizing food after the bismuth mixture. This hasty review of the observations regarding the peristaltic wave is given because comparatively little fluoroscopic work has been done upon the stomach in America, and it may serve as a basis, at least, for corrections and additions. Fluoroscopy has very properly been regarded b}' us as too dangerous. I think I have eliminated the danger from direct radiation, but not the danger from secondary rays. We are only beginning to realize the importance Viagra 100mg Dose of these secondary rays from the air and objects in the neighborhood of an excited tube, and later we may learn that they too are dangerous. CONCLUSIONS. 1. Cinematographic reproduction of the peris- taltic wave of the stomach is at present possible by reducing and repeating separate exposures at com- paratively long intervals. 2. Biorontgenography is at present of great value in demonstrating to an audience both normal and pathological movements of the stomach. 3. In the near future we may hope to record cin- ematographically (ten or Viagra 100mg Dose more exposures in a sec- ond) special phases during the study of a stomach upon the fluorescent screen. Viagra 100mg Dose This may then make it of additional value in diagnosis, since the photo- graphic plate is more sensitive than the eye. 4. A careful study of the peristaltic wave will give the earliest evidence obtainable of carcinoma of the stomach. 1 82 1 Spruce Street. TEST BKE.'VKFAST I'ERSUS FASTING STOMACH CONTENTS. By .Alexander Goldman, M. D., New York. in cases of digestive disturbance, of what value is the test breakfast? Do we learn from it Viagra 100mg Dose more than from simply pumping a fasting stomach, and of what value is the pumping Viagra 100mg Dose of a fasting stomach for diagnostic purposes? Before proceeding to dis- cuss this c[uestion we must first make up our mind