Now that the value of massage as a remedial agent is becoming more widely recognised, it is possible that some day English surgeons may be induced, far more generally than at present, to enlist its services in the after-treatment of abdominal operations. Few realise as yet how potent a remedy it is in the treatment of constipation, or how simple may be the manipulations that suffice to expel flatus. Half the discomfort that follows laparotomy is due to flatulent distension of the bowel, a discomfort that is magnified tenfold by the use of aperients. By the judicious use of massage it should be possible to avoid this cause of suffering entirely. Often all that is required is friction of the iliac colon, so that the hand need only touch the patient's skin over a small area some two inches to the "south-east" of the left anterior superior spine. This is a rare site for incision, so there should seldom be any cause to move bandage or dressing. Should this fail to secure the desired relief, kneading of the ascending and descending colon is possible through bandages, so that, in any case where a rectus incision has been made, a very good dose of massage treatment can be administered without in any way interfering with the surgical area.

After some operations, e.g., gastro-enterostomy or anastomosis of any kind, the surgeon relies on the formation of adhesions to secure his junction. After nearly all other intra-abdominal operations the formation of adhesions constitutes a sequel which should be avoided to the uttermost. In abdominal massage we have an agent that is well calculated to reduce the formation to a minimum. Moreover, in any case of gastro-enterostomy which has not proved as successful as had been anticipated, massage treatment may convert failure into success. The treatment should not start until four weeks at least after operation, as the union probably does not become organised till then. The technique corresponds to that recommended for atony of the stomach (see also pp. 401 et seq.).

Colitis is "a secretion neurosis of the colon" (Osier). It is almost always associated with some irregularity of the central nervous system, approximating in its nature to neurasthenia. The more we see of this extraordinary complaint the deeper seems the mystery of its pathology. This being so, it is evident that treatment must be largely empirical.

There are two main types of colitis - mucous and ulcerative. It is probable that the latter is an infective disease, and serum or vaccine treatment often alleviates, if it does not cure. It is usually associated with diarrhoea, blood occurring in the stools from time to time. All local massage treatment is of course contra-indicated. Massage may be prescribed in order to overcome insomnia or to maintain the nutrition of the limbs. Stroking and rhythmical kneading of the limbs and back are indicated for the latter, and surface stroking only (as for neurasthenia) for the former.

In the case of the mucous variety two facts only are outstanding, the first being that it is almost always possible on palpation to feel one or more pieces of bowel in spasm, or at least to note with what ease spasm can be produced in response to the trivial stimulus of gentle palpation. The second fact is that the victim instinctively seeks warmth for relief, and it is not uncommon to find that she - the patient is almost invariably a woman, though occasionally a man in an advanced state of neurasthenia may suffer thus - has acquired the habit of crouching before a fire with the bare back exposed to the warmth. This occurs when alleviation of the pain and discomfort becomes the one overwhelming necessity of existence.

All treatment has so far failed to cope with this very distressing complaint when it occurs as an isolated manifestation of central nervous disturbance. The Plombiere treatment meets with a varied amount of success. It consists of massage applied vigorously to the abdomen after the administration of a copious fluid injection. Spasm being one of the features of the disease, it is probable that the beneficial effect is largely due to actual stretching of the muscle fibres which have been accustomed to contract spasmodically, while the heavy massage is calculated to enhance the inhibitory action of the stretching. No one should ever undertake this highly specialised and drastic treatment unless qualified to do so by adequate training, and then only under strict medical supervision.

Treatment should be guided by these facts - first, that the disease is a neurosis; second, that the patient instinctively seeks for warmth over the spinal column (and often applies hot-water bottles to the abdomen as well); third, that inhibition gives relief.

As a neurosis, no form of "stimulating" treatment can be tolerated, and nothing but surface stroking should be administered. Any pressure exerted on the abdomen during massage -unless, as in the Plombiere treatment, very vigorous over a colon previously distended - is calculated to excite spasm The main area of the body that calls for attention is the back, this being the spot where the patient knows instinctively that the application of heat will give relief. The massage should consist, therefore, of back stroking only as advised for the treatment of neurasthenia. Every care should be taken to avoid chilling the patient, by keeping her adequately covered, and by paying due attention to the temperature of the room. If the patient is then conscious of any discomfort - if indeed she does not experience a most luxurious sense of ease and comfort - the technique is probably at fault, as the number of patients to whom this treatment is inapplicable is negligible. Surface stroking of the limbs may be added in any case where there are signs of general irritability. Later on, rhythmical kneading of the limbs may be added. In all cases which present any symptoms of insomnia, massage should be applied to the head and neck (see Chapter XXI (Massage Treatment In Neurasthenia).). Last, if inhibition brings relief, arguing from the relief of spasm that can be secured in voluntary muscles by surface stroking, an attempt should be made to inhibit the bowel spasm by firm surface stroking of the areas supplied by the intercostal nerves. The movement should begin near the mid-axillary line and pass downwards and forwards to the mid-line. For the sake of emphasis it is well to repeat that every effort should be made to avoid exerting any pressure which can possibly excite reflex response to mechanical stimulation.