It is not unusual to teach that general kneading and vibration over the small intestine stimulates glandular secretion. I was always sceptical as to the truth of this assertion, and I was delighted to read in Kleen's text-book, on p. 56, the following emphatic statement: "Abdominal massage ... is, however, much less valuable for its effects upon the glands of the digestive apparatus and on the circulation than for its powerful influence upon the musculature of the alimentary canal." When we consider the large part played by chemical action in the production of the digestive juices, this conclusion would seem to receive confirmation. When a patient suffers from general atony, the "toning up" of the musculature of the small intestine by the reflex response to mechanical stimulation will doubtless aid it the better to perform its functions.

It must be remembered that the veins of the abdominal viscera nave no valves, and that the venous flow is therefore dependent on external forces. Hence the necessity for massage over the central portion of the abdomen, whenever we wish to assist the portal circulation. But massage performed with this objective differs materially in technique from that which aims at assisting peristalsis. In either case the patient should be recumbent with the knees and thighs flexed by placing a pillow beneath the former. When dealing with the portal circulation only, the head and shoulders should be kept as low as possible, while, when administering treatment to the bowel itself, the shoulders and head may be raised. Again, when assisting the portal circulation there is no call for the use of vibration in any shape or form; deep stroking and kneading constitute all that is permissible. The pressure should be exerted from below upwards and towards the middle line, should be quite gentle- though, when the abdominal wall is properly relaxed, the hand will sink in deeply - and adequate time should always be allowed to elapse for the veins to refill before pressure on any spot is renewed. It is important, moreover, owing to the absence of valves in the veins, not to render the pressure intermittent as the hand passes upwards. In stroking the pressure is always even, but it is necessary slightly to alter the technique of kneading. The hand is placed flat on the abdomen and the maximum amount of pressure is exerted at once. A rotatory movement is then imparted while the hand glides slowly over the surface. It is possible to compare the effect of the movements on the blood in the veins with two forms of waves. When stroking we can imagine the onflow of the blood to resemble the Atlantic roller sweeping on; while, when kneading, the wave would resemble the ripples on the surface of a swift-running river. It is often wise to work with both hands in unison, so as to act as uniformly as possible on the whole venous system of the abdomen.

Intussusception is one of the common causes of acute intestinal obstruction. As a rule the ileo-caecal valve in-vaginates, as it were, the wall of caecum and colon; the latter then embraces it and attempts to pass it on as if it were a foreign body. Other parts of the bowel may be affected. The result is somewhat similar to that reported when two snakes tried to eat the same rabbit. The stronger represents the colon and the weaker the ileum, while the rabbit corresponds to the ileo-caecal valve. After arriving at the point of junction the stronger proceeds to swallow successive portions of the weaker. Nothing should be more simple in the early stages than for the surgeon, by the use of massage, to evaginate the small intestine from the large. Graham reports many cases where this treatment has succeeded. There is no need to emphasise the fact that only in recent cases should massage be applied, for, if a few hours have elapsed, the bowel wall will have suffered to such an extent that it would perforate later, even if left to itself, and massage in this case must be exceedingly dangerous. None the less, it should be quite possible to relieve a very recent case by massage, and the technique should consist of applying massage in an upward direction to the ascending colon on the rectal side of the tumour, much in the same manner as friction is applied to the iliac colon. The enlarged mass should not be handled directly at all. The stroking begins close to it on the distal side and passes along the adjacent bowel. At the same time stroking in the opposite direction should be performed over the bowel on the proximal side. The chief difficulty would be to secure adequate relaxation of the abdominal wall. The delay of operation could not exceed fifteen to twenty minutes, as, unless success has been attained by that time, no amount of perseverance would be calculated to succeed.

Graham also reports several cases of acute intestinal obstruction that have been completely and rapidly relieved by massage. These must be chiefly cases of obstruction by bands. Without experience it is impossible to say what percentage of cases could be treated with success. It is certain that no attempt should be made if more than twelve hours have elapsed since the onset of the attack. Thirty years ago it would have been desirable to extend to massage a free trial in cases of this nature, but the improvement of surgical technique has rendered the danger of operation so slight, and its success so sure, that few will be found to advocate even the preliminary trial of massage in any case of acute abdominal trouble. Where a surgeon's help cannot be secured quickly, or the circumstances of operation are very difficult, the patient should be given the only chance available.

At the present time no reputable advocate could be found for massage in appendicitis while the appendix remains within the abdomen. It is a lamentable fact that this mode of treatment was ever suggested; and it is not uncommon, even now, to see it alluded to as a possible alternative to operation. When once the appendix has been removed, however, massage frequently finds its metier. Operation is by no means the end-all of an attack of appendicitis; and, although acute danger is averted by the removal of the appendix, there frequently remains much ill-health and suffering. This is due to the typhlitis or perityphlitis which has probably been coexistent. The very fact of the appendix having been diseased is evidence of possible faulty action of the caecum, as witnessed by the number of patients who give a more or less definite history of constipation prior to the attack which ends in surgical interference. This loss in tone of the caecum (with the inevitable dilatation) is a disaster which the removal of the appendix does little or nothing to rectify. Thus a neurasthenic - so-called - of seven years' standing made a complete recovery when the caecum had been emptied and its activity restored by massage. Countless patients have submitted to operation in the sure expectation of relief, but have met with disappointment. This could be avoided almost entirely by the subsequent use of massage. The technique will be considered when dealing with constipation (see p. 400).