1 To most of my readers I hope that these remarks will appear to be unnecessary. Unfortunately this is not invariably so. I have cause to remember a medical man expressing to me his distrust of masseurs in general. On inquiry it transpired that his masseur had been prescribing a patent charcoal biscuit for his patient, and he had taken this exceptional behaviour as typical of what he might expect from masseurs as a whole. Again, soon after, I saw a lady suffering from sub-acute obstruction due to intra-abdominal adhesions. A fully-qualified Swedish masseuse had been giving abdominal massage for ten days. The patient's condition was steadily deteriorating, and my advice was asked by the doctor in charge as to whether it was wise to continue the treatment. The technique was good (though somewhat too vigorous). Something else was obviously at the root of the trouble. Investigation proved that the masseuse had advised a strong purgative pill, and one had been taken each night since treatment commenced. I had never heard of this masseuse before, but could not help thinking that it would have been impossible to imagine a more humiliating situation than mine would have been, had I been responsible for the recommendation of a masseuse who could be guilty of such an error.

The atony may be the primary cause of other troubles, and then local treatment by massage holds out the best chance of recovery that the patient possesses. Chronic dyspepsia, from whatever cause, may lead to the atonic type. The chronic dyspeptic who over-eats, or drinks much beer or other fluid, affords the typical picture. In this country, where so many of us (and women in particular) drink too little to maintain the physiological balance within the body, the over-eating is probably the chief cause. The same applies to the French; while in America iced drinks and (until recently) "cocktails," and in Germany beer-drinking, are probably the usual causes. Last, the atony may be due to structural defect caused by chronic over-stretching. This is not infrequently a symptom of visceroptosis, and always follows pyloric obstruction.

Be the cause what it may, the symptoms do not vary very greatly. There is always a feeling of oppression in the stomach, which may or may not amount to actual pain at intervals, usually after food. The patient may have a furred tongue and little appetite, but the "oppressed" feeling is often mistaken for actual hunger, and appetite may be voracious and thirst great. Acid eructations are common and flatulence is almost invariable.

Emptying the stomach regularly of its contents constitutes the cure, unless mechanical impediment is present. This alone can allay the inflammation of the mucous membrane, and thus enable the stomach to regain its powers of excretion. Moreover, when empty, the over-stretched muscle fibres are left at liberty to contract down to normal length, and thus regain their tone.

Any form of dyspepsia may be a forerunner of the atonic variety. To prevent this sequence of events every effort should be made to empty the stomach. Thus, for the treatment of dyspepsia, whatever the cause, local treatment is always the same. As usual, massage may be employed for either reflex or mechanical result.

The stomach reflex area lies from the tip of the tenth costal cartilage on the left side to the sternum and then down the right costal margin. The technique is thus described by Dr. Douglas Graham, of Boston, Mass., in his text-book: "With the patient supine, place the phonendoscope or stethoscope on the right of the umbilicus. Place your right hand on the patient's abdomen with the tips of the fingers at the costal margins; then find the tip of the tenth rib, and with the tips of the first, second, and third fingers glide very gently with a trembling motion over the skin. It is the delicate, light touch which is efficient. After a few seconds or minutes, action will be heard beginning in the stomach. The first to leave is always the gas. Cease the stimulation until the contraction has stopped. Then begin again and continue till the stomach is empty, when a blowing, sighing sound will be heard. These treatments should be given daily, five hours after a meal, and last from twenty to thirty minutes, and should be continued for a while after recovery, to prevent relapse. Constipation usually accompanies this condition, and at the end of the first week the bowels move normally in most cases. It is necessary to continue the daily treatments until at 6 p.m., after an ordinary meal [i.e., at one o'clock], there is no sign of splashing, distension or retention of food."

Nothing more need be added as to treatment, which aims solely at securing contraction by reflex. When there is no great dilatation this means will prove all-sufficient, but if the greater curvature can be shown by percussion - it may even be visible - more than two fingers' breadth below the costal margin, other means should be used as adjuvants. We rely now on two things: first, the reflex contraction of unstriped muscle in response to mechanical stimulation, and, second, the mechanical assistance we can give, to ensure that the fluid contents of the stomach pass outwards when the pylorus relaxes.

If we notice the rate of passage of a peristaltic wave across the abdomen, it is seen to be very slow. A wave is started in response to mechanical stimulus at the left side and passes slowly across, relaxation following contraction. If a second stimulus is administered before the relaxation is complete, there is great danger of producing spasm, and all wave-like motion ceases. Add to this undesirable result the fact that undue stimulation is liable to paralyse the unstriped muscle fibres, and we see at once that there are two essential laws of treatment - the movements must be slow and gentle. The rate should be about twelve movements a minute and the pressure only sufficient to dent the abdominal wall. Any pressure submitted to the surface will be transmitted through the hollow viscera, almost as if the whole contents of the abdomen were a fluid mass and subject to the laws of hydrostatics - provided, of course, that the abdominal wall is sufficiently relaxed to allow of the transmission of pressure at all. The justification for considering the hollow viscera to be comparable to a fluid mass is seen whenever an abdomen is opened in the Trendelenburg position, when all the hollow viscera are found to have gravitated into the upper part of the abdomen, save only those portions that are bound down by the peritoneum to the posterior abdominal wall.