The mechanical measures serve to strengthen the bowel and in this way promote a better action, or they directly effect a stronger intestinal peristalsis. The mechanical measures comprise massage, exercise, electricity, hydrotherapy, and lastly injections into the bowel.

(a) Massage. The general principles of massage have been described above (page 80). Its action consists principally in producing more efficient peristalsis of the large bowel. It should therefore never be used in conditions in which spasmodic contractions of the bowel may be assumed to exist. Its most useful field lies in cases of atony of the bowel.

Massage should be applied at first either by the physician himself or under his strict supervision. It should never be applied with much force and it should never cause pain. According to Illoway,1 the duration of massage treatment should be from five to fifteen minutes for a grown person and from three to five minutes for children. The massage should be employed every other day with great regularity for a period of about six weeks at least. Illoway suggests that the massage sittings may be performed less frequently as soon as there is a decided improvement in the condition of the bowels. It is, however, never advisable to stop the massage treatment suddenly, but it should rather be kept up for a long period of time, although later at longer intervals. Massage is best applied early in the morning in the fasting condition of the patient. During its employment no other remedy for constipation should be administered unless the latter has lasted several days and gives rise to various symptoms.

Auto-massage may also be of benefit. This may be carried out by the patient himself, kneading his abdomen principally over the course of the large bowel with his right hand or by means of some instrument adapted for this purpose. Sahli was the first to recommend the use of a cannon-ball, weighing about three to five pounds. These balls may be wrapped in flannel and rolled over the abdomen for about five to ten minutes. This procedure is best performed early in the morning in bed in the fasting condition of the patient. The ball is best rolled over the abdomen in a spiral direction, principally along the course of the colon. But the other parts of the abdomen should also be subjected to this procedure. The flannel covering the ball may be left off if desired. Dr. A. Rose,2 of New York, has practised this method quite extensively and warmly recommends its use. Dr. Arthur Kahn,1 also of New York, has invented an apparatus for auto-massage which may also be used for this purpose. Rosenheim 2 suggests using auto-massage in the following manner: The patient in an upright posture makes short palpating strokes with the fingers of his right hand inclined somewhat inwardly over his abdomen for several minutes.

In this procedure also the course of the colon is especially to be considered.

1 Illoway: "Constipation in Adults and Children. " New York, 1897.

2 A. Rose: New Yorker medizinische Monatsschrift, January, 1893.

(b) Gymnastic exercises. Exercises which bring into play especially the muscles of the abdomen are of great benefit. Exercises on the horizontal bar, horseback riding, mountain climbing, skating, rowing, bicycle riding, are all beneficial, provided these sports are not kept up for too long a time, and do not cause a superabundant loss of water by extensive perspiration.

Indoor gymnastic exercises may also be used. Bending of the body', rotations of the trunk, especially in a siting posture, quickly drawing up the knees toward the thorax in the recumbent position, also alternate squatting and rising are of special benefit. The passive, so-called Swedish movements may also be employed either in a Zander Institute or manually by a nurse. Massage and these exercises are best applied in conjunction.

(c) Electricity. Percutaneous electrization (principally faradization) of the abdomen has been recommended by some writers as a cure for constipation. Recently direct electrization of the intestine, applying one electrode to the rectum and the other over the abdominal wall, has been used. Boudet's rectal electrode is best adapted for this purpose, especially when galvanization is employed. The insertion of one electrode in the stomach and the other in the rectum, as suggested by Kussmaul and Leubuscher,1 has not come into use to any extent.

1 A. Kahn: Centralblatt fur Chirurgie und orthopadische Mechanik, Berlin. 1889, Bd. v., p. 4. 2 Th. Rosenheim: " Krankheiten des Darms, "1893, p. 513.

Electricity seems to act favorably on the intestinal peristalsis and it is especially indicated in the treatment of constipation in conjunction with massage, particularly in atony of the bowel. Doumer2 has very recently recommended the use of static electricity. He applies localized franklinization in the form of sparks or "souffles elec-triques " for about five to twelve minutes in the iliac fossae, principally the left. By the employment of this method of treatment every other day for a period of two to three weeks Doumer reports having cured the most obstinate cases of chronic constipation.

(d) Hydrotherapeutic means. Hydrotherapeutic measures may be applied either alone or in conjunction with the above-named mechanical means. Hackel3 gives the following rules: In constipation due to atony of the bowels use a jet of water of about the thickness of the small finger with the force of two atmospheres, first over the epigastrium. The hose of the mobile douche is then placed over the region of the colon. Charcot's douche is best adapted for this purpose, as it allows a sudden change of temperature. When using the latter apparatus the temperature can be readily changed to any degree desired during its application. The alternations in temperature should be considerable, often from 102° F. to 120° F. Thus both mechanical and thermic effects come into play. After using the douche over the abdomen, it is applied over the chest and back, throwing a fan-shaped jet, the temperature being kept constant.

1 Leubuscher: Centralbl. f. klin. Medicin, 1887, No. 25.

2 E. Doumer et Musin: Annates d'Electro-Biologie. 1898, p. 722.

3 Jeannot Hackel: Deutsche med. Wochenschrift, Jan. 5, 1899.

In constipation due to spastic contractions of the bowels Hackel applies water under a pressure of two and a half kilograms, letting it flow in the form of a fine spray. It falls like a fine rain on the abdomen. The temperature of the water should not be lower than 95° F. and not higher than 102° F. and should not be changed. The duration of the douche is from two to two and a half minutes. The hose is directed along the course of the colon while the water constantly runs over the epigastrium. Ninety-six such circuits over the intestines may be made. Afterward the lower extremities, chest and back, are douched. The skin of the abdomen must not-be subjected to vigorous friction after the douche; the extremities, however, should be well rubbed. After the douche the patient should lie in bed for about five to ten minutes, being warmly covered, and then may walk for about a quarter of an hour.

Cold sitz baths (12° C.) for about five minutes are also of benefit, as well as a Priessnitz compress or Neptune's girdle over the abdomen over night.