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the colon. Operation verified the viagra online with paypal diagnosis. A hypotonic stomach is not unusually associated with ulcer; it is displaced to the left and dowm. A scar formation may occur on the lesser curvature near the pylorus and cause the stomach to bend on itself like a snail, hence Haudeck's snail form of stomach notorious in gastric literature. Delayed opening of the pylorus, in contradis- tinction to the rapid emptying of duodenal disease, is almost invariably seen in ulcer of the stomach following the administration of the bismuth water. Later pyloric spasm may also be associated reflexly with duodenal, gall-bladder, and cecal disease. A residue after six hours is very often associated with ulcer, but it may be absent. It has occurred, according to most authorities, in about 75 per cent, of cases; it varies from a viagra generico en farmacia small portion to one-half or one-fourth of the meal, and according to the amount of disease involvement. Most authors claim the residue is due to the spasm of the pylorus retarding the evacuation of the stomach. The writer has frequently seen a viagra generico en farmacia residue with nothing but an atonic condition of the stomach walls; that is to say, congenital visceroptosis may cause a resi- due with absolutely no pathological findings. A localized pain pressure-point over the gastric area is not a positive sign, as many persons are sensitive over the epigastric region. Unless the parietal peritoneum has been punctured as in a penetrating or perforating ulcer, the conditions are rarely acutely painful, but if a pain-point is defi- nitely localized it is of much importance in the final summing up of the diagnosis. Notwithstand- ing the many signs, both positive and suggestive of ulcer of the stomach, there is a small number of cases in which signs are absent, especially such cases as the florid type of ulcer in the pars pylorica and the stomach wall. In these cases the clinical evidence will help to clear up the diagnosis. The radiological signs of duodenal ulcer are not so clean cut and definite as those of gastric ulcer. They are, however, of sufficient importance, from a fluoroscopic as v^'ell as a radiographic standpoint, that a positive diagnosis can be made in nearly all cases. The signs may be classified as those that are static and those that are viagra generico en farmacia functional. A diagnosis of duodenal ulcer, I belive, is largely made on the functional signs. The symptom complex of duodenal ulcer is as follows : Quick emptying of the stomach ; hyper- motility, or the advance of the bismuth meal into the transverse colon in viagra online with paypal six hours; hypertonic or orthotonic stomach; late pyloric spasm; incisura Fig. 10 — Upper arrow points to obscure gastrointestinal disease discovered by palpation under the fluorescent screen. Patient examined recumbent. Adhesions of the hepatic flexure of viagra online with paypal the colon and adjoining region. Prolaps'e of the transverse portion of the colon on the ascending colon with possible adhesions. Lower arrow points to high cecum and clearly visible appendix which has emptied some of its con- tents. Diagnosis, old gall-bladder disease, adhesions of the colon in that region, viagra online with paypal and colonic stasis, due to mechanical stricture. or spastic indrawing of the greater curvature; marked antral activity of the pyloric antrum ; pain- point over the duodenal area; defect in the cap; a small residue in the duodenum or stomach; in the stomach the residue is due to a late pyloric Oct. 16, 1915] MKDICAI. RECORD. 645 spasm, a refle.x symptom of duodenal irritation; distended bulbus duodeni indicative of constric- tion viagra online with paypal of the duodenum in its descending portion. In duodenal conditions it is frequently necessary to take a number of plates, especially if the patient is large viagra generico en farmacia and muscular. I contend it is not always necessarj- to have a defective cap to diagnose a duodenal ulcer. An ulcer of the florid type may exist and absolutely no defect in the bulbus duodeni be visible. These ulcers may also be serious from a hemorrhagic standpoint. An ulcer of the florid type can be diagnosed only from its functional and radiological signs and not from any deformity. A defect in the duodenal bulb is frequently due to old gall-bladder adhesions or periduodenitis. A scar of an old healed ulcer often gives less annoy- ance than an acute ulcer of the florid type, and it is certainly less dangerous. Quick emptying of the stomach, hypermotility, deformity of the bulbus, late pyloric spasm, and marked antral activity are the cardinal signs of duodenal irritation. As suggestive signs we may consider: Pain-point over the duodenal area ; hypertonic stomach ; the incisura viagra online with paypal or spastic indrawing of the greater curvature; diminished peristaltic activity of the stomach (gastric ulcer has increased peristal- sis). Peristalsis of the duodenum is increased,