The proposed functions of the interstitial cells of Cajal (ICC) are to 1) pace the slow waves and regulate their propagation, 2) mediate enteric neuronal signals to smooth muscle cells, and 3) act as mechanosensors. In addition, impairments of ICC have been implicated in diverse motility disorders. This review critically examines the available evidence for these roles and offers alternate explanations. This review suggests the following: 1) The ICC may not pace the slow waves or help in their propagation. Instead, they may help in maintaining the gradient of resting membrane potential (RMP) through the thickness of the circular muscle layer, which stabilizes the slow waves and enhances their propagation. The impairment of ICC destabilizes the slow waves, resulting in attenuation of their amplitude and impaired propagation.2) The one-way communication between the enteric neuronal varicosities and the smooth muscle cells occurs by volume transmission, rather than by wired transmission via the ICC. 3) There are fundamental limitations for the ICC to act as mechanosensors.4) The ICC impair in numerous motility disorders. However, a cause-and-effect relationship between ICC impairment and motility dysfunction is not established. The ICC impair readily and transform to other cell types in response to alterations in their microenvironment, which have limited effects on motility function. Concurrent investigations of the alterations in slow-wave characteristics, excitationcontraction and excitation-inhibition couplings in smooth muscle cells, neurotransmitter synthesis and release in enteric neurons, and the impairment of the ICC are required to understand the etiologies of clinical motility disorders. smooth muscle; slow waves; enteric neurons; excitation-contraction coupling; peristaltic reflex; motility disorders; volume transmission; synaptic transmission, ICC THE INTERSTITIAL CELLS WERE characterized originally by Raymond V. Cajal (20,21). These cells got his attention and that of others because they are intercalated between the autonomic nerves and the effector cells. On the basis of the understanding of the interneuronal communication in the central nervous system (CNS) at that time, Cajal proposed that the intercalating cells [later called the interstitial cells of Cajal (ICC)] mediate the transmission of signals from the autonomic neurons to the smooth muscle cells. A few years later, Keith (84) observed a collar of similar cells in the myenteric plexus of the rat ileocecal junction. He was looking for a pacemaker of the gut smooth muscle electrical activity because a few years earlier he had identified such a pacemaker in the sinoatrial node of the heart. He hypothesized that those interstitial cells were the pacemaker cells in the gut. In the late 1960s and early 1970s, several investigators described a plexus of the ICC within the myenteric and submucosal plexi of the small and large intestines. They also identified close connections between the enteric axonal varicosities and ICC processes on one side and g...