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the effect of massage or inanipulation of the stom- ach through the abdominal wall. At times, these waves begin to pass iminediately after food enters the stomach : at other times, they become strong only after ten or fifteen minutes ; and at others they seem to wait for an external stimulus, such as pressure of the screen, palpation by the liand, etc. These varying conditions make it alinost impossible to get at the real facts in many patho- logical conditions, except by a rather prolonged ■^tudy fluoroscopically. We may, in the future, be able to make such studies fluoroscopically and, at chosen intervals, make cinematographic records. Judged by any- thing that I have yet seen, I believe that no actual diagnostic evidence is obtained that cannot be ob- tained fluoroscopically. I speak enthusiastically of fluoroscopy, realizing fully that it is a dangerous procedure, and I think it should not be used e.Kcept in such conditions which demand a study of motion or rapidly chang- ing relations. In other words, I confine its use to the study of the stomach, bowels, heart, and dia- phragm, and I always make a number of plates at intervals during my investigations. N0RM.\L GASTRIC PERISTALSIS. The normal peristalsis begins at the upper pole, as a series of slight indentations, but they become ^At a regular meetinsr of the Philadelphia Ronlgen Society. March 24, 1911. PFAHLER: GASTRIC PERISTALSIS IN Where To Buy Generic Viagra In Canada STOMACH CARCINOMA. 88i deep enough to be of practical importance only at the junction of the middle and lower third of the stomach. At this location, a slight indentation can be seen on both the lesser and the greater curva- ture. These move forward and increase progressive- ly in depth as they approach the pylorus. .At about three fingers' breadth from the pylorus they reach their maximum depth, and nearly bisect the stom- ach. This appearance led Holzknecht^ to look upon this contraction as a special sphincter which separates the contents of the body of the stomach from Where To Buy Generic Viagra In Canada what he regarded as the pyloric antrum. This view is not accepted at present, and the deep inden- tations are simply regarded as a part of the regular course of the peristaltic wave, there being therefore no true pyloric antrum. The wave seen on the lesser curvature is usually deeper than the opposite side and moves and termi- nates slightly in advance of the one on the greater curvature. In my experience, the waves of the nor- ma! stomach and in some pathological conditions are deepest and most easily seen when the stomach is Where To Buy Generic Viagra In Canada only partially filled. In the normal stomach there are usually two or three peristaltic waves visible at one time, following each other in regular succession. It requires ap- proximately twenty-two seconds for a wave to pass from its origin to the pylorus. Each wave seems to carry a considerable jx)rtion of the stomach con- tents up to the pylorus, but, on account of the re- sistance of the pylorus, most of this mass is forced back through the constriction caused by the wave. EVIDEXCE OE DISEASE SHOWN BY DISTURB.AXCE IN THE G.^STRIC PERIST.\LSIS. In describing the evidence of disease as is shown in disturbance of the peristaltic wave, I would not be understood to mean that a diagnosis should ever be based upon this symptom alone, nor that any other evidence should be neglected. I have confined myself to this one symptom for the sake of brevity only, and to conform to the subject under study. Carcinoma naturally first suggests itself as likely to cause disturbance in the peristalsis. As is well known, the most frequent seat of carcinoma is at the pyloric end and since the peristaltic waves are strongest Where To Buy Generic Viagra In Canada at this point any induration of the stom- ach wall is bound to influence this wave. Unfortunately most of the cases which we have an opportunity to examine are already so far ad- vanced that the entire pyloric end is involved, and in addition is commonly adherent. This may all be true. even when no tumor is palpable.* In these advanced cases the peristaltic wave stops completely at the site of the tumor. One has also the obliterations of much or all of the lumen of this portion of the stomach, associated with the rather characteristic, irregular, serrated margins. At times, however, only a portion of the pyloric end is involved. In my experience such localization more or less affects Where To Buy Generic Viagra In Canada the lesser curvature. When the disease is localized in one curvature, the wave can "Die Peristallik am Antrum Pylori dcs Menschcn, Mittcilungen aus dem Institute fur radiotogische Diagnostik und Therapie, von Dr. G. Holzknecht in Wien, i. No. i. *In a recent contribution read before the Medical Where To Buy Generic Viagra In Canada Section of the College of Physicians, March 2^, 191 Where To Buy Generic Viagra In Canada 1, I called attention to the means of recognizing such adhesions, so that I v.i\\ not dwell upon that phase here. be followed to the tumor, then becomes obliterated, while that on the opposite side may be seen to move smoothly to the pylorus. The most characteristic evidence is obtained when the wave can be followed to the carcinoma, becomes obliterated, and then be- gins again on the opposite side. When only one curvature of the stomach is involved the wave on the opposite side is apt to be deeper than normal — apparently a compensatory effect. I believe that in cases in which the peristaltic waves are otherwise good, an induration an inch in diameter or less should be recognized, providing it occupies the lesser or greater curvature. If it oc- cupies the posterior or anterior surface, a tumor of