Chronic colitis with diarrhoea can also be treated by massage exactly similar to that which I have described with regard to chronic constipation. Similarly massage in these cases is best as an accessory to the other treatment. Of late years, however, I have employed the ordinary large, warm astringent washing out of the colon daily (e.g., with 4 to 5 grains of tannin to 1 or 1 1/2 litres warm water), and after a few weeks have performed or ordered abdominal kneading over the accessible parts of the colon, and have not seldom seen unmistakable effects from it, especially in obstinate cases, where astringent washing out of the colon combined with treatment with tannigen internally (which often alone brings about recovery) has not been entirely satisfactory.*

Perityphlitic or Appendicitic Exudations can be treated by massage like other exudations, of which they are a type, which arise in or near the abdomen after the inflammatory process is over. It assists reabsorption and thus often relieves the constipation which is frequently present, removes the feeling of pressure or weight, or even of pain, due to the presence of inflammatory products, and diminishes also, by producing a complete reabsorption, the danger of repeated acute inflammatory processes.

* In many cases of chronic diarrhoea there is no better remedy than to eat daily a large quantity of dried bilberries. It is the slow progress through the entire alimentary canal of these undigested fruit-skins, rich in tannin, which is of value. In the case of an Anglo-Indian official, who had for a long time been under treatment by various physicians, this simple method had the desired effect.

The technique is also in these cases very simple. One presses into the abdominal wall with the upper phalanges of the three middle fingers over the exudation, and with infinitely gentle, even pressure performs the small manipulations, resembling frictions spoken of above, at the beginning for short, later for longer, periods, during which the patient takes the same position as for ordinary abdominal kneading.

In spite of the fact that massage lessens the danger of new inflammation by promoting complete absorption, this danger is undoubtedly increased during the actual treatment by the mechanical effect of massage. The shorter the time which has passed since the inflammatory process came to an end, the less completely has it entirely ceased, and the more tender to pressure the region attacked, so much the greater is the danger of producing relapse. The first rule of all in these cases, therefore, is to postpone massage treatment until some time (a few months) has passed since the perityphlitis, and even then only to perform it with the greatest possible care, and at the least warning, such as increased tenderness to pressure and spontaneous localised pains, to cease immediately. We must not forget that there is a perpetual risk which we cannot clearly estimate, since we never understand in detail the preceding process, its cause, and its connection with the vermiform appendix, the peritoneum, etc. All this is a riddle for us, since we have no other guide than palpation and subjective symptoms.

Finally, for many, apart from the old rule, excellent in practice, to avoid above all doing harm, and thus generally rather be passive than interfere, when such interference may easily be harmful, the consideration carries weight that if perityphlitis or appendicitis, which are particularly apt to recur, should do so whilst under massage treatment the patient and his friends will seldom fail to blame massage for the relapse.

From the above it is clear that in many cases it is immaterial whether the remains of exudation present after such processes are massaged or not. For my part, I have treated a number of cases in this way without any mishap, some with very good, some with tolerably good, results. The experience of my colleagues who in similar cases have had less success has, however, made me little inclined to take over these cases for massage until a considerable time has passed since the inflammation.

After extensive peritonitis peristalsis is often hindered by adhesions, and the patient is also troubled by severe pains on movement. Abdominal massage has in such cases often speedy and excellent results. The earlier it begins after the cessation of the peritonitis the more easily are the adhesions and newly-formed membranes absorbed or rendered thinner and easily stretched, but the greater the danger of producing new inflammatory processes. I dread much more, however, those cases which come to me after perityphlitis, or, to use a modern term, appendicitis, than after other peritoneal processes. If one waits a few months before beginning massage, and if, especially at the beginning of the treatment, one goes to work with careful friction with a small kneading movement, one can without danger produce results astonishing both to patient and doctor.