Throughout treatment, whether aiming for reflex or mechanical effect, the patient should be in a position to allow the fluid contents of the stomach to impinge upon the pylorus whenever this happens to relax. There is a double objective - first, to cause contraction and thereby to exercise the muscle fibres (thus increasing their tone), and, second, to enable them to rest to the uttermost after their contraction, which can only be accomplished if the stomach is empty. The fullest contraction of the elongated fibres cannot empty the stomach unless everything is done, by arranging the patient's posture, to ensure that the fluid escapes into the duodenum whenever opportunity affords. Thus a pillow should be placed under the left side of chest and abdomen, the whole trunk should be flexed as far as is comfortable, the thighs flexed, and the knees flexed and supported on a pillow (see Fig. 130). When aiming for mechanical effect, the little finger of the stroking right hand should follow the outline of the greater curvature, and there should be a distinct attempt, as it were, to push the stomach upwards against the diaphragm.

As already stated, constipation is frequently present, and no seance can be regarded as complete that fails to deal with this complication. Absorption is faulty, and therefore everything should be done to assist the portal circulation; and, as it is more than probable that a general toxaemia is present in greater or less degree, a short time should be spent in general massage of the whole body.

As usual, full benefit cannot be bestowed by any external agency, and the patient should be instructed to use nature's own method of administering massage to the stomach, by practising deep breathing exercises, and a series of exercises should be designed of gradually-increasing severity for the abdominal muscles. Diaphragmatic exercises should always be utilised.

Surface stroking with surface vibration and deep stroking, with a vibratory movement incorporated in the stroke, are the only forms of massage that are permissible.

There are many neuroses of the stomach classified by Osier thus: -

Motor Neuroses.

Supermobility. Peristaltic unrest. Nervous eructations. Nervous vomiting. Rumination. Spasm of the cardia. Pyloric spasm. Atony of the stomach. Insufficiency of pylorus.

Secretory Neuroses.

Hyperacidity. Supersecretion. Nervous sub-acidity.

Sensory Neuroses. Hyperaesthesia. Gastralgia. Anomalies of the sense of hunger and repletion. Absence of sense of satiety. Anorexia nervosa.

An interesting comment may be made when reviewing this formidable list. Paul Dubois states that "ninety per cent. of dyspeptics are psychoneurotics," while Geo. Herschell puts the figure only less high. He says: "More than two-thirds of all the cases of this complaint met with in general practice [are] part of a general neurasthenia." 1

Most of the motor neuroses not already mentioned can be benefited by massage, by restoration either of tone or of rhythm. They are chiefly nothing more than symptoms either of psychasthenia, hysteria, or neurasthenia, and tend to disappear or to remain according to the progress of the general disease.

Hyperacidity and supersecretion can both be remedied to a certain extent by massage. In the former a long drink when digestion is at its height, - say two or three hours after a meal, according to the food taken, - followed by massage, tends to rid the stomach of all irritating material, and may avert the sequel of chronic dyspepsia. In supersecretion it should be possible so to hasten the onflow of the gastric contents by massage as to minimise the risk of dilatation. Restoration of general strength and stability is the only method of cure. In sub-acidity cases the latter is the only course open to us, as the mobility of the stomach remains unchanged, and no irritating material is present which requires removal.

The sensory neuroses are all symptomatic of irritability of the central nervous system, and therefore call for treatment as outlined for neurasthenia. Local stomach treatment will probably be found useful from the psychical aspect.

It is usual to administer massage to the coils of small intestine, whenever general abdominal treatment is undertaken. The raison d'etre of the practice is not clear. In the first place, during X-ray examination for obstruction, etc., it is the rarest thing possible, unless mechanical obstruction is present, for delay in the small bowel to be detected after the bismuth meal. Only if the caecum is at fault or if a "kink" is present is delay noticed in the last few inches of the ileum, unless again there is organic obstruction. The aid of massage should then be invoked only in exceptional cases, and probably with a view to stretching adhesions under an old scar. Next, unless visible peristalsis is present, it is impossible to judge in what direction the contents of the bowel under the hand are moving. Thus it may easily happen that we attempt to force the contents of the bowel "against the stream."

1 See "Problem of Nervous Breakdown," by Dr. Edwin Ash, p. 127.

Poisonous products do not tend to collect in the small intestine as sometimes in stomach or colon; when present, they lead to diarrhoea. For this condition massage may be of service, though it may seem bold to claim that one agent should be invoked to assist the cure of both constipation and diarrhoea. Yet so it is with calomel in therapeutics.

Most of us know the sense of comfort produced by a hot bottle or a vigorous rub over the abdomen when suffering from the "colicky" pains which accompany diarrhoea when the small intestines are affected. Moreover, a long railway journey is frequently beneficial in chronic diarrhoea. There must be some pathological explanation, and the most likely is that the heat relaxes spasm reflexly, while the rubbing and the railway journey act much as vibration in neuralgia, namely, by breaking the rhythm of the peristalsis, so causing relief of the spasm through the starting of another wave in a portion of bowel already relaxed. But the small intestine can, as a rule, be trusted to take care of itself, and certainly massage in diarrhoea should be administered with caution. The fear would be that absorption through the inflamed mucous membrane would be rendered more easy by manipulation, whereas there can be no call to increase the activity of the bowel, which is already doing all it can to hasten the passage of its contents. As delay in other conditions is quite exceptional, massage intentionally applied directly to the coils of the small intestine can only be required to stimulate peristalsis in exceptional cases.