Another adjuvant to the treatment is massage of the large intestine, particularly of the sigmoid flexure. It is well known that many physicians who have had much experience in the treatment of diseases of the intestine expressly warn against massage in spastic forms of constipation and advise massage only in cases of atonic constipation. We agree unequivocally that massage should be avoided in spastic constipation if the patients are given a diet that leaves a small residue (see Fleiner, 1. c., pag. 61). As soon, however, as our method of feeding with a voluminous diet that leaves a large residue is instituted the conditions are changed at once and massage of the lower portion of the large intestine is not only well tolerated but is decidedly beneficial to patients suffering from colica mucosa. In the first eight to ten days of the treatment massage of the bowel is well-nigh indispensable, particularly in cases in which the nervous system is greatly disturbed, as soon as the bowel becomes filled and distended; later in the treatment massage is no longer required.

In the meantime it has become common in general practice to treat patients with colica mucosa by giving them a diet leaving a large residue. Boas, Einhorn, Hemmeter, all agree on this point; they merely state that in their opinion the suggestion made by von Noorden to immediately change from a diet containing little residual material to a diet rich in residue is not practical; Boas says that he himself has had no experience in this matter but that he prefers the gradual transition from one diet to the other on theoretical grounds. Only Westphalen agrees with von Noorden, inasmuch as he advocates the immediate change of diet, without reservation; he also agrees with von Noorden in stating that much less trouble is experienced if the bland diet is at once replaced by the coarse diet than if the old diet is only gradually replaced by the new one. We have paid particular attention to this question, especially as authoritative voices have been raised against it; after a growing experience with the matter we still maintain that it is better to change rapidly from one diet to the other than to make the change slowly. We do not wish to maintain, however, that this method of proced ure is necessarily a matter of principle, for good results are also obtained if the transition from one diet to the other is gradual. The external conditions existing in each individual case will have to decide which plan is to be adopted. Our own experience with rapid changes of diet was almost all gained from observation of clinical cases (sanatorium, private practice, hospital). It is clear that in this class of cases the treatment can be more brusque, and the results of such energetic treatment can be better supervised and controlled than in cases that are treated at home. We will therefore concede that those who advocate a gradual transition from a mild to a coarse diet are right as far as cases are concerned that are not under clinical observation; in other words we agree that this treatment would better be reserved for the latter class of cases. Where external circumstances do not forbid the adoption of our plan it is clear that it is by far the best method of procedure. For in the beginning of the treatment a great variety of disturbances almost invariably appear, as for instance, nausea, a feeling of tension and fulness in the abdomen, rolling noises in the bowels, and occasionally even pain - whether we proceed rapidly or slowly. If the change in the diet is rapid, these disturbances rarely persist for more than two to four days, and after this period the patients feel perfectly well. If the change in diet is made slowly these disturbances and symptoms of distress in the abdomen persist for a much longer time, so that the patients, who are nervous and irritable and as a rule very anxious, easily become discouraged.

We usually allow the patients to remain on a coarse diet that leaves a large residue for from three to five weeks; we particularly encourage the use of much Graham bread; in order to aid the action of the bowels sugar of milk, honey, fruit juices, marmalade, dried prunes, leguminous plants, and boiled or baked potatoes are given. We never give purgatives. We do not consider a glass of Homburg or Kissingen water, that is frequently although not always given in the morning on an empty stomach, to be a laxative, for the reason that these waters when taken in the doses that we recommend (about 250CC. a day) do not possess any laxative virtues whatever; their only effect is stomachic. As soon as the action of the bowels has become uniform and regular on a diet of this character, we very gradually return to the ordinary mode of life. It is very important to determine whether the patient has not acquired certain bad habits prior to the beginning of the cure. Such bad dietary habits must of course be corrected, whether they consist of extreme dietetic restrictions or excesses. Unless this is done relapses are unavoidable.