It is an important and infallible rule in cases of chronic constipation that hygienic as well as dietetic treatment should supersede the use of medicine. It is very necessary to establish a uniform hour for going to stool each day, and all efforts at straining should be avoided. Exercise in moderation should be insisted upon, such as walking at least an hour or two twice a day, but of exercise in the open air, horseback riding is by far the most beneficial. One or two rides a week are much better than none. Many persons find improvement from bicycling. Tight lacing and constriction of the abdomen by tight belts should be avoided, and also sitting long in positions compressing the abdomen. Much good may be accomplished by elementary instruction in calisthenics, in which special attention is paid to deep respiratory movements of the diaphragm and abdominal muscles.

Regularity should be observed in habits of life, in hours of sleep, and of meals. Many business men whose daily routine of early rising, exact hours, and evening dinners is disturbed on Sundays by late breakfast and a noon dinner, find that the regular habit of the bowels is interrupted at the first of the week, and in consequence may suffer for a day or two from headache and " biliousness".

Massage

Massage is the process of manipulating the muscles and subcutaneous cellular tissue. The aim of the treatment is to mechanically compress and stimulate the structures beneath the skin, and it is to be distinguished from the effects of merely rubbing the surface of the body, which acts through excitation of the cutaneous nerves and circulation.

Massage promotes the movement of the blood through the veins and of the lymph in the lymph spaces and capillaries, and favours the removal of waste products from the tissues compressed, and the increase of healthy metabolism in the muscles. It also stimulates the latter in a slight degree to contraction. It aids the functional activity of the liver, stomach, and bowels. The various manipulations are complex, and when rightly performed require the skill and experience of thoroughly trained operators. The chief manipulations are classed as -

1. Percussion by short quick blows of the fingers or small rubber hammers.

2. Rolling the muscles and subcutaneous tissues beneath the extremities of the fingers.

3. Kneading with the fingers and palms of both hands, placed one above the other, on the patient's arm or leg.

Massage of the abdominal muscles is most useful for constipation, and both percussion or mechanical vibration and kneading are to be used. It should be performed in the "direction of the colon, commencing low down on the right side of the abdomen, ascending to the ribs, crossing to the left, and descending upon the left side to the sigmoid flexure. This mechanical movement not only pushes along the intestinal contents, if the abdominal wall be not too fat or rigid, but it stimulates peristalsis by reflex action. If possible, it should be given in the morning before rising, and at first daily, for fifteen or twenty minutes, but later every other day. The treatment should be continued for a month or more. Obstinate cases have been cured in this manner, and the method is especially serviceable for very obese patients.

Some persons derive aid from manipulating the abdominal wall for themselves while lying in bed in the morning. A large wooden ball like a croquet ball or a heavy metal ball weighing four to six pounds may be rolled over the abdomen for five or ten minutes every morning, pressing it in deeply in the direction of the colon. This sometimes, in thin subjects, promotes the movement of the intestinal contents.