If gymnastics are infinitely more important than massage in regard to the internal organs of the thorax, heart, and lungs, quite the opposite conditions obtain in the case of the digestive organs with the exception of the liver.

In the first part of the book I have set forth the most important physiological effects of abdominal kneading. From these it is evident that this form of massage for anatomical reasons has widespread effects, which, however, are not yet fully understood. It influences the circulation as a whole, the secretion of digestive juices, the appetite, digestion and power of assimilation, peristalsis and the onward movement of the contents of the stomach and intestines, the metabolism of the digestive canal, and last, but not least, the nutritive condition of the musculature.

The effect of abdominal massage (= kneading) on chronic "atonic" constipation constitutes it one of our most important forms of massage.

Its effect on atony and on dilatation of the stomach is of secondary importance.

Massage may also be used to aid reabsorption of exudations within the abdomen, as elsewhere, and has often been used with good results both for perityphltic and peritoneal exudations. I deal with this point later more in detail, and with the risks which often have to be considered in this, for the most part beneficial, treatment.

In many other abdominal diseases we are at present unable to estimate the value of abdominal massage, partly on account of our still defective knowledge of these diseases themselves, partly on account of our equally incomplete knowledge of the effect of mechanical stimulation on the activity of the nerves and glands. With regard to the effect of massage upon the different forms of dyspepsia and the various stomach neuroses, we shall do best to express ourselves with caution.

In this general survey of abdominal massage I remind my readers of the contra-indications referred to above. In advanced pregnancy, large ovarian cysts and new growths in the abdomen, in hydro-nephrosis, in haemorrhage from the walls of the urinary tract -with stone in the kidney, in echinococcus in the liver or elsewhere in the abdomen, in acute inflammations and catarrhs, in strangulated hernia, in ulcers in the alimentary canal, especially gastric ulcer, we do not use abdominal massage, neither should it be attempted in aneurysm of the abdominal aorta, and it is also out of the question where increase of blood pressure may cause danger* In simple hernia, gall-stones, and in floating kidney or spleen it should be undertaken with careful attention to these conditions. Even with stone in the bladder, abdominal massage should be carefully administered and the region of the bladder avoided. I know a case in which an ignorant and daring masseur caused a violent haemorrhage by abdominal kneading.

With regard to the technique of abdominal massage I refer to what has been said on pp. 35 - 38.

One can arrange the treatments almost at any time, but must avoid giving them too soon after meals; the best time is just before. The seances in obstinate cases should be given twice daily, and preferably for half an hour each time.

One ought previously to warn the patient that the abdominal wall will be tender after the first few days of massage, but that this will soon pass off.

The position of the patient during abdominal massage is important : the head raised, the knees flexed and somewhat abducted. He should breathe freely, and ought to control the contraction of the abdominal muscles, so easily produced by reflex action, which does away with the effect of the massage.

Abdominal massage in dilatation of the stomach and in ordinary chronic constipation may be undertaken by non-medical workers, if only they observe carefully the laws of technique. If there is a question of inflammatory residua in the abdomen, the massage should be performed by a doctor. The patient cannot himself carry it out in the form described here.+

* To what has been said on pp. 60 - 61 as to the effect of abdominal massage on the circulation I must add the following concerning Dr. T. Romano's observations (see "Effets dynamogeniques cardio-vasculaires du massage abdominale," These : Paris, 1895) : - During abdominal massage of a woman he noticed a contraction of the capillaries of the fingers, which was followed after massage was over by a considerable dilatation. In the frog he saw the vessels in the web of the back feet contract similarly, so that circulation almost stopped; after massage the opposite occurred. The effect upon the pulse was variable, but in seventy frogs he found the same as I have found in the human being - in ninety-three cases an acceleration of the heart-beat, in eleven cases negative or doubtful results. In some animals Romano found abdominal massage produce the same effect as the Goltz tapotement on the abdomen - the heart standing still in diastole. In dogs, guinea-pigs, and rabbits abdominal massage often caused the heart to stand still in systole ("le eoeur est reserre, tetanise, presque arrete"). Romano's and Colombo's researches seem to prove that gentle and short abdominal massage causes increase of pressure and slows the pulse, and that vigorous and continued abdominal massage causes diminished pressure and quickens the pulse.

+ H. Sahli, of Berne, recommended letting the patient, in lying position, himself roll a cannon-ball of 3 to 5 lb. weight over his colon. In spite of the indignation such a course would awaken among those who attempt to surround the technique of massage with a nimbus of purely mystic difficulty, I agree with Dr. Sahli's statement that the effect of Chronic constipation may have various causes, and it does not do to treat all cases by abdominal massage.

In those cases where constipation is caused by constriction of the alimentary canal, either by internal or external obstructions (tumours, stricture, hard faecal concretions, pregnant uterus, peritoneal adhesions, etc.), we cannot, as long as these obstructions are present, expect any lasting benefit from abdominal massage.

If the diet is unsuitable this must first of all be altered.

In chronic poisoning (opium, lead, etc.) we must also in the first case look for the cause.

When the effects of nervous disturbances from the brain or spinal cord are making themselves felt in this way, we cannot expect relief from abdominal kneading.

But in the ordinary so-called atonic constipation, due to weak musculature and weak peristalsis, abdominal massage offers us the best and hitherto the only means of permanent relief without carrying with it any of the evil effects which to a greater or less extent are attached to all internal purgatives without exception.

If massage is performed correctly and for a sufficiently long period every day, eventual recovery is only a question of time, i.e., months.

Even after appendicitis, where there is rigidity in a portion of the intestine on account of products of inflammation, massage, though not without danger in these cases, has usually excellent results.

Constipation commonly follows confinement, because the intestines tend to become distended by gases in order to fill the enlarged abdominal space, and so peristalsis becomes defective. Even these cases, which may be fairly obstinate, usually run a satisfactory course under treatment by abdominal massage.

For my part in a great many cases of chronic constipation which I have treated with massage, or handed on for others to treat, I have used no other means than simple dietetic instructions (hard bread or Graham's bread, raw or cooked fruit, etc.) and sufficient daily exercise. Special exercises to strengthen the abdominal muscles are unnecessary; chronic constipation is certainly only in very few cases caused by weakness in these.

Usually daily evacuation begins a few days after massage, often after the first treatment. In severe cases it may sometimes happen that daily evacuation begins first after weeks. In all cases one must previously inform the patient that the treatment, nevertheless, must be continued for some time, often two to three or sometimes four months, before the result becomes permanent, otherthis process in many cases is excellent. I do not know how this method arose, but heard of it as far back as 1884 from a patient who every morning rolled a smaller cannon-ball (covered with leather) round the abdomen, and who found it most effective.

wise the patient goes back gradually, more or less completely, to his former condition. In more severe cases massage should only stop when movement of the bowels has been uninterruptedly regular for a couple of months; after that for some time one may allow the patient to be treated only every other day. The outlook is naturally better for thin patients with thin abdominal walls; the treatment of obese patients is a thankless task, and it is well before one begins treatment by massage to submit them to a "reducing process."

When the constipation ceases, the patient's condition alters, as is well known, for the better, appetite is increased, dyspeptic symptoms lessen or disappear, flatulence, often so troublesome, is diminished, the whole nutrition is improved; especially there is an improvement in the markedly lowered psychic condition so often present in severe cases.