All too infrequently the aid of massage is invoked for the treatment of constipation, as it affords one of the few chances of curing this very distressing complaint. As a rule constipation is an acquired evil, and often is attributable to errors in the physiological life of the individual rather than to pathological changes. In seeking to cure, we must bear in mind the proverb that "habit is second nature," and aim solely at securing a regular habit. The reason why aperients fail to cure is that the irritation they produce becomes an essential part of the "habit" - no irritants or stimulus, no action.

Massage, of course, is unable to cure when the physiological error is continued, but there are some pathological causes which can be remedied. Amongst the causes of the latter type most frequently encountered is dilatation of stomach or of caecum. For either trouble massage alone offers a prospect of cure. Suitable anastomosis by surgery may effect a cure, but the result is always a matter of profound speculation, whereas massage treatment, though often slow, is almost always certain. At least it can do no harm if skilfully performed, which is more than can be said of surgical interference in these cases.

For massage to be a success, the physiology of the case must be studied and all errors - dietetic and hygienic - must be corrected. For this reason, if for no other, the masseur should never risk a reputation by undertaking to treat a patient for constipation until the whole situation has been thoroughly investigated by a medical man. The danger becomes more obvious still when we remember that the sudden onset of constipation in an elderly patient is frequently the first symptom of malignant disease. It is plain, therefore, that ethical considerations and the interests of the masseur go hand in hand.

But, to be of full service to patient and doctor alike, a knowledge of the causes of constipation is essential; as it often happens that the masseur can extort information from the patient, in conversation or by observation, that might be missed during the ordinary professional visit of the medical man.

First and foremost is the question of habit. Many people owe the origin of this complaint to lack of supervision during the early days of life. In others the habit begins with the lack of provision of adequate time between breakfast and the start for morning school. In later life similar causes operate, and in quite a short space of time, the habit of a lifetime can be broken. There is an undoubted natural tendency in some individuals to be constipated, and these fall the easier victims.

Second in importance as a cause of constipation errors of dietary must be considered. In this country - and particularly amongst women - lack of fluid is an error responsible for much evil. To maintain a physiological balance at least three pints of fluid should be taken into the system daily. It is not at all uncommon to find that a female victim of constipation has been in the habit of taking no more than a half, a third, or even less, of this minimum. We might well follow the example of our American cousins in water-drinking.

Over-feeding entails over-loading of the bowel, but the presence of bulky excreta should not of itself cause constipation. Indeed, the reverse is true, for the more work we give a muscle to do the more its strength will develop. Hence the cures effected by agar and its preparations. But over-feeding combined with sedentary habits must be reckoned as a cause, and this fact indicates the line of treatment. When exercise is cut off there is always a tendency to constipation, chiefly on account of the lack of the natural "massage" of the abdominal viscera, which is inseparable from every movement of diaphragm and abdominal wall. Flaccidity of the abdominal wall must then of necessity be classed as another distinct cause.

The possibility of poisoning from drugs and such things as paint (plumbism) must be kept in mind when searching for the cause of constipation; and it is not infrequent to find it concurrent with inflammatory conditions in various parts of the bowel, e.g., colitis, chronic appendicitis, and chronic gastritis. After nearly all abdominal operations there is a marked tendency to constipation, which is directly proportional to the severity of the handling to which the bowel has been subjected. The injury done to the musculature of the abdominal wall renders muscular contraction a painful process. The pain or discomfort exerts an inhibitory effect and, unless steps are taken to prevent it, the effect is liable to become more or less permanent in a fair proportion of cases.

In cirrhosis constipation is common, and pressure on any point, or narrowing of the intestine, will obviously impede the passage of the intestinal contents. Under this heading the possibility of "kinking" or of the presence of adhesions must be considered. The former is a not uncommon cause in all cases of general visceroptosis. Muscular spasm alone may suffice, as in colitis. Muscular atony of any part of the bowel must of necessity impede the onward flow of the contents of the bowel, and atony of the caecum is doubtless responsible, when appendicectomy fails to effect the cure that has been anticipated.

Last we may place as a not uncommon cause of constipation the lack of efficient innervation which follows any serious disease, particularly if there has been sepsis and neurasthenia. It may be a purely hysterical phenomenon, and is particularly common amongst the insane.

Considering the variety of the causes of constipation, it is no matter for surprise if, in the absence of information as to the cause, treatment should fail, or even, it may be, inflict injury. For instance, sacral beating may prove a most efficacious remedy for the plethoric patient who owes his trouble to over-eating and too little exercise, while it will inevitably aggravate the trouble if the patient is suffering from the faulty innervation of neurasthenia.