A medical man practising massage in the United States wrote to tell me that he even made use of the reflex action of massage as a means of confirming diagnosis. Thus, if a patient were the subject of persistent headache or neuralgia, he relied on massage to show whether or no the patient should be subjected to operation. He appears to believe that, if the pain can be relieved by massage, all idea of organic disease can be dismissed; if the pain is not relieved, its persistence is in itself sufficient evidence of organic trouble to justify operation. This claim would seem to be extravagant, but it is none the less worthy of record, as showing how profound is the faith in the reflex action of his massage on the part of a competent, if enthusiastic, worker. Incidentally it should encourage us to hold out massage as a hope of relief to those sufferers from facial neuralgia and headache who owe their affliction to no cause that can be discovered. Assuredly the amount of relief that can be given is often great. It is particularly effective if the pain is due to fatigue, provided, of course, that the massage movement selected is suitable. Otherwise failure is certain, and it is possible that the trouble may be greatly aggravated (see Chapters XXI. and XXIV.).

C. In Abdominal Massage. - If the abdomen of a pithed frog is opened, the lightest tap on the exposed bowel is capable of producing a dual effect. The portion of gut tapped passes instantly into spasm, and cardiac inhibition takes place simultaneously - surely a deleterious reflex. This reflex inhibition should always be kept in mind while performing abdominal massage.

Yet abdominal massage, as taught and performed in many schools, would appear to have only a mechanical effect in view, so heavy are the movements and so great the pressure exerted. Why students should be left with the impression that treatment of the abdomen should entail the expenditure of much force is not quite clear, but so it is. The root of the evil may lie in the hurry that is inseparable from the attempt to accomplish too much in a limited time, or in a lack of comprehension of what it is that they wish to attain. If we regard our massage merely as a means to an end and consider how we wish to achieve that end, we shall rarely indeed apply heavy massage to the abdomen. Much has been written concerning the effect of abdominal massage on the activity of the glands which produce the various digestive juices, and doubtless this has had its effect on technique. Kleen, after an exhaustive summary, expresses his conclusions thus: "On the whole the most experienced experimenters have formed the opinion that mechanical stimulation does not produce, or at least is a long way behind chemical stimulation in producing, secretion of active digestive juices."1

It is possible that by mechanical means we can help empty a dilated stomach, and we can certainly assist in the softening and moulding of scybala, in those very exceptional cases where they are palpable, and therefore amenable to manipulation. In this event we can also assist their passage along the bowel.

The undilated stomach is completely hidden by the ribs, except for a minute area below the ensiform cartilage, and the only portions of the bowel which lie in fixed relationship to the abdominal wall, and in which we can be certain of the direction of the passage of the contents at any given moment, are the duodenum, the ascending and descending portions of the colon, and the iliac colon. In the transverse colon we know that the passage is from right to left, but we can never be certain of its position unless some pathological sign provides an indication. How is it possible then that we can hope to effect very much by massage of the abdomen unless it is by reflex effect?

Anyone, who has examined the abdomen of a patient who is suffering from sub-acute obstruction, must have been struck with the readiness with which a portion of the bowel will pass into spasm under the hand, in response to the gentlest of taps or the lightest of palpation. It is thus that we are able sometimes to assist in forming a diagnosis when, in response to the slightest stimulation, we witness the sign of visible peristalsis. Here then we have direct evidence of the reflex contraction of the unstriped muscle of the bowel in response to mechanical stimulation, and we see also one way in which we can assist the propulsion of the fluid contents of the bowel, viz., by stimulating peristalsis.

1 See Kleen's Massage, p. 58. Translated by Dr. Mina Dobbie. All further references to Kleen's work are taken from this book.

On the other hand, let those who hope to attain the same end by mechanical means witness the early stages of an operation for gastro-enterostomy. The surgeon draws up a portion of the jejunum, and, with the bowel actually in his hands, it is often a matter of difficulty to arrange for the passage of its contents so that he may have an empty piece of bowel on which to work. How much greater then must be the difficulty, if we can only handle that piece of bowel imperfectly through the abdominal wall! Moreover, if a patient is placed in the Trendelenburg position, the whole of the bowel (in response to the force exerted by gravity) flows into the upper part of the abdomen as if it were a fluid mass, save for the duodenum, the fixed portions of the colon, and the rectum. Surely then any pressure we may exert through the abdominal parietes will have a corresponding effect. The actual portion of bowel touched by the indented abdominal wall will contract before gliding away from the part pressed upon. How then can we by our massage exert a mechanical influence upon any given portion of the bowel if it is free to move? And, were we able to do so, how can we tell in what direction we wish to exert this influence, unless we are dealing with those very limited portions of bowel which remain permanently in a fixed position? In the other parts may we not be forcing the contents "against the stream" while endeavouring to assist?

It will be seen, then, that during general abdominal massage we must rely in the main on the reflex response to mechanical stimulation of the unstriped muscle if we wish to hasten the onflow of the contents of the bowel. But there are other ways in which we can secure reflex response to stimulation, on the part of the hollow viscera at least. Thus certain stimulation of the skin over the abdomen can be shown to originate peristaltic movement in the stomach; while stimulation of the skin round the spine of the fifth thoracic vertebra causes the pyloric sphincter to relax. It is probable that similar stimulation round the seventh cervical spine has the opposite effect, and doubtless each portion of the bowel can be directly influenced by skin reflex. The only other instance of reflex response which has, I believe, been definitely proved is the reflex contraction of the muscle in the rectum in response to sacral beating and to hacking over the left sciatic nerve where it emerges from the cover of the great sacro-sciatic notch. The whole of this subject, however, calls for definite investigation and research.

It is possible that other abdominal organs can be influenced by reflex, e.g., the unstriped muscle of the spleen may contract in response to mechanical stimulation transmitted from the ribs, or applied to the organ itself if it is enlarged. The function of the muscular tissue in the organ being to contract and relax, there is no doubt that stimulation to activity may be beneficial, but the physiological explanation of the benefit would be involved.

Professor Wide, of Stockholm, has shown by means of a blood-count, before and after treatment, that the number of red corpuscles in the blood is increased by abdominal massage. This, together with the general toning up of the vascular system, must re-act indirectly on all the abdominal organs.

The direct effect of massage on kidneys and liver will be dealt with when considering the mechanical effect of massage (P. 25).

The uterus is the abdominal organ to which massage treatment is very frequently applied. The reflex response to mechanical stimulation of the unstriped uterine muscle is a well-known aid to parturition.

The use of massage for stimulation of the heart is recognised in surgery, and it is performed in emergency by the "abdominal route." Some surgeons advise that the hand should be inserted into the upper part of the abdominal cavity, and the heart then compressed between the diaphragm and the ribs. A more effective method of dealing with cardiac failure during operation is to incise the diaphragm, whenever this is possible from the surgical nature of the case, and to pass the hand into the thorax so that the heart can be grasped near the base of the ventricles. Reflex response by contraction to mechanical stimulation is thus more readily assured. The vigour with which the manipulation is usually performed would encourage the supposition that purely mechanical action was anticipated, namely, that of pumping the blood from the heart into the great vessels. It may be necessary to render this assistance, but the effect of the massage would probably be no less gratifying were the pressure sufficient merely to render a mechanical stimulus to the unstriped muscle. If it is possible to stimulate into activity a heart that has actually stopped beating, it must be possible in the case of a heart that is already beating to enhance its activity by mechanical stimulation. The danger of flogging an overtired horse must, however, be kept in mind.

I know but little from personal experience or investigation of the direct action of the ordinary movements of massage on the heart's action. It has been claimed that tapotement over the chest has the effect of lowering the rate of the heart-beat. This presumably is due to reflex action on the vagus. A general review of the literature available leads to the conviction that the claim is "not proven." Indeed the difficulty of investigation must of necessity leave a vastly "wide margin for error" in observation, as witness the experiments of Dr. Abrams (quoted by Graham), who found that "any (sharp) cutaneous stimulant . . . will produce a diminution in the size of the heart," and it is common knowledge how variable may be the pulse-rate of a patient with an "irritable" heart.

Whenever massage treatment is ordered it is necessary to take the age of the patient into consideration, and more particularly when we are aiming solely to secure a reflex action. The reflex arc in the child is highly sensitive, and the fullest effect is thus secured rapidly. In the aged it is possible to cause fatigue with equal rapidity, and treatment then produces an irritative effect. In the young, therefore, and in the aged the duration of massage treatment should be curtailed.