The reflex effect of correct massage in stimulating the activity of unstriped muscle has already been considered, but it is also possible to secure a definite mechanical effect in the treatment of the viscera by massage.

It has been mentioned that the dilated stomach can be made to contract by reflex in response to stimulation, but it will be found that the contraction of the stretched and therefore weakened muscles may by itself be inadequate to empty the organ of its contents. The movement of these contents by mechanical methods, copying as far as may be the natural movement, undoubtedly assists their passage through the pylorus; though even here reflex action must still play its part, as all the mechanical persuasion which we can exert with our massage will not induce the sphincter to relax.

As we have already seen, attempts to secure the passage of its contents along the small bowel by mechanical means would seem to be doomed to failure. It is impossible for us to know the direction of the passage of the contents in any particular coil under our hand, and, for all we know, any pressure we may exert tends merely to force them "against the stream."

In the large bowel, on the other hand, there is a possibility of our being able to afford valuable assistance, though the instances where we can do so must be comparatively few when compared with the many in which we can help by securing reflex contraction. None the less it is undoubtedly possible to assist to some extent the passage of the contents downwards in the descending colon and upwards in the caecum and ascending colon. The transverse colon is not so easy to manipulate, as its position is so variable. In rare cases, however, it is possible to note the presence of scybala or gas, and then our assistance to their onward passage may be most valuable.

The most common use of mechanical means for assisting the passage of the contents of a hollow viscus is, of course, in securing expulsion of the placenta; but this hardly comes within the scope of massage.

Massage is also employed for the treatment of the solid viscera, and even the pancreas has been mentioned in this respect. It is possible that this organ can be influenced reflexly, but it would seem probable that it is only by the indirect effect produced by improving the general vascular tone. We may also be able to excite it to activity as the result of the passage of the contents of the stomach, which, without our assistance, might have been delayed.

The effect of massage on the spleen has already been considered (p. 10).

Whether the action of the kidneys can be effected by massage is extremely problematical. During a cystoscopy, urine may be seen to pass from the mouth of the ureter into the bladder in response to kneading of the kidney. Whether this result can be made use of for clinical purposes is more than doubtful, as a prolonged pummelling - sufficient to lead to the elimination of an appreciable quantity of urine - would, it is easy to imagine, be attended by serious risk of inflicting damage on so delicate an organ. Changes in the amount and proportion of the solids excreted in the urine as the result of general massage, and particularly of abdominal massage, have been demonstrated by many observers.

Much the same may be said of treatment administered to the liver. There is a common idea that anything that "shakes up the liver" is beneficial. The massage usually administered as a routine part of a "general abdominal treatment" should certainly achieve this end; but what the physiological result of this "shaking" may be it is not easy to judge. Certainly in the post-mortem room it is difficult to see in what respects "shaking up" would be beneficial, and examination of the liver cells under the microscope seems to increase the difficulty. The assistance given to the portal circulation by our general abdominal massage may, and indeed must, have some effect on the circulation within the liver; and were it possible to knead the organ thoroughly we could doubtless aid the circulation within it still more. By assisting the circulation we can assist all the functions of the organ; and not only so, but we can probably reduce the viscosity of the bile and so render its excretion more easy. But that this effect, or indeed any other beneficial result, can follow as a direct result of percussion of the ribs seems more than doubtful. If it is attainable it is probably due to reflex via the intercostal nerves and the sympathetic system.

I was particularly interested to read in Dobbie's translation of Kleen's Massage that "abdominal massage is an extremely valuable form of massage. It is, however, much less valuable for its effect upon the glands of the digestive apparatus and on the circulation than for its powerful influence upon the musculature of the alimentary canal."

The gall-bladder, being a hollow organ, is amenable to the mechanical effects of massage. The very shaking up of the bile within it may have a beneficial effect, and doubtless its muscular fibres - though none too numerous - can be toned up and exercised. It is possible to imagine that we could actually aid the passage of the bile past the spiral valve in the neck of the bladder by our manipulations.

Of the organs within the thorax the lungs are, of course, amenable to mechanical treatment, as in the compression that forms part of artificial respiration. Though this is outside the realm of massage proper, much benefit may be derived by rendering mechanical assistance to respiration. The effect of massage on the heart is probably not a mechanical effect at all, but merely reflex, - the response of unstriped muscle to mechanical stimulation if treatment is applied directly to the organ. Otherwise any effect of massage on the heart is by reflex through the central nervous system.

Massage is applied to the prostate for mechanical effect. By its means we endeavour to squeeze out undesirable debris in the ducts.

Massage of the ears can assist in allaying retraction of the drums.