most useful articles for constipation are abundant water, coarse brown or bran bread, oatmeal, butter, fresh green vegetables (lettuce, spinach, rhubarb, etc.), prunes, figs, apples (cooked or raw), peaches, berries, buttermilk, apple cider, honey, English walnuts.

Persons suffering from habitual constipation do well to give up the following articles: Eggs, milk, sweets, pastry, puddings made of simple amylaceous substances, such as rice, sago, etc., fried foods, rich gravies, sauces, curry, strong condiments, pickles, cheese, tea, sour or red wines.

HYDROTHERAPY.

Careful observation has convinced me that the addition of some form of hydrotherapy enhances the value of medical gymnastics and dietetic measures, and often succeeds after the latter alone have failed. The hip bath, as recommended by Fleiner, of two to five minutes, temperature of 50° to 68° F., once or twice daily, and an abdominal compress of 50° F. at bedtime, have given excellent results. A form of abdominal douche, or hydrotherapeutic massage, from a one-eighth inch nozzle, slowly played over the region of the colon, either at 45° or 110° F., has often furnished satisfactory results. This form of massage can be continued from five to fifteen minutes, if done slowly, and repeated once a day before the usual time for evacuation. This form is highly recommended by Nothnagel and Hackel.

In constipation occurring in gouty, anemic or otherwise depreciated patients, a thorough intestinal irrigation with salt solution, administered every day, removes ptomains. If followed by the rapid introduction and outflow of eight ounces of water at 40° F., the reflex stimulation is aroused. It is not advisable to use the enormous colonic irrigation, because of the overdistention and conse

quent enfeeblement of the bowels. In all cases of constipation tonic hydriatic procedures are of as great value as is muscular exercise, which it may often substitute temporarily in feeble patients.

OLIVE OIL INJECTIONS.

This is a very satisfactory measure, and is highly recommended by Kussmaul. Inject from three to ten ounces of warm olive oil in the rectum at bedtime. This is retained during the night, and usually results in an evacuation after breakfast on the following day. If the oil is introduced slowly, at a low pressure by the force of gravity, the patient should have no difficulty in retaining it for the night. The following is described by Dr. Hershel as the best apparatus to be used in giving oil injections:

"A glass funnel of a large relative capacity to its height, provided with a loop by which it can be suspended at a convenient height above the patient, is fitted with about 28 inches of rubber tube of 3/8-inch caliber, and terminates in a nozzle. I have found the colon tube of equal efficiency. The outflow of the oil is controlled by a spring clip. The injections can be made by the patient without assistance. The oil is first heated by placing the bottle containing it in a basin of hot water. The funnel is hung on a nail above the bed. The patient lies on his back directly under it with the hips on a pillow, introduces the tube and waits until the funnel is empty. It is best to commence with five or six ounces and to reduce the dose daily until the smallest amount which will produce an action of the bowels is found. In a few days it will probably be found that a few ounces of oil at bedtime will produce a daily evacuation. The effect may then be tried of using the oil on alternating nights, and as the case

progresses the action of the oil will extend over a longer period and will be followed by several daily stools. When this period arrives the injection should be ordered to be taken only on the evening of the day on which the action has not taken place.

MASSAGE.

The most common and important use of abdominal massage is to relieve chronic intestinal inactivity. The various manipulations are complex, and when rightly performed require the skill and experience of thoroughly trained operators. The general causes of constipation, as regards conditions of the bowel which may be relieved by massage, are the following:

1. Relaxed abdominal muscles, resulting in prolapse of the bowel and other viscera, and constant stasis of the intestinal contents, with resulting dilatation of the colon. The dilatation may exist either in the cecum or the sigmoid flexure, or the entire colon may be affected. In consequence of delay to evacuate the bowel the fecal contents often form hard masses, as the result of the excessive absorption of fluid due to their prolonged sojourn in the colon.

2. Deficient production of bile, due to an inactive state of the liver, either as a result of inactivity in the portal circulation or some local functional derangement. This condition, commonly spoken of as "torpidity," or "biliousness," is one in which the liver fails to perform its work effectively in destroying ptomains which are received in the blood or are formed in the alimentary canal, or to convert into less toxic forms the leucomains, or tissue poisons, normally developed in the system and prepared by the liver for elimination by the kidneys.

3. Deficient activity in the nerve elements supplying

the intestines and controlling the reflexes by which peristalsis is maintained, the contents of the bowels moved along the intestine, and the normal diurnal rhythm maintained whereby the residue reaching the lower part of the colon is regularly discharged from the body.

The immediate indications in relation to the removal of these causes, so far as massage is effective to accomplish it, may be enumerated as follows:

1. Increase of glandular activity by an increase of the activity of the blood current in the portal vein, and stimulation of the abdominal sympathetic ganglia, the nerve mechanisms which control the motor, vascular and secretory functions of the intestines.

2. Increase of peristaltic activity through a stimulation of the nervous reflexes by which this activity is maintained, and by an increased outflow of bile from the liver, the natural laxative by which rhythmical peristaltic activity is promoted.

3. Relief of passive congestion of the portal system, and of the viscera under the influence of this branch of the circulatory system, especially the liver, spleen, stomach and intestines, thus aiding the return of these structures to a normal state and a consequent restoration of their functions.

4. Mechanical dislodgment of the contents of the colon. 5. Development of the abdominal muscles, thereby increasing intra-abdominal tension, which favors expulsion of the intestinal contents.

6. Replacement of displaced viscera. The procedures offered by massage, by which these indications are best met, are the following:

1. To stimulate the nervous reflexes, and hence the peristaltic, glandular and vascular activities, under control of the abdominal sympathetic.

(1) Reflex Stroking.-With the ends of the fingers make very light strokes in a circular or semicircular direction about the umbilicus. Also make vertical strokes along the sides in the mammary line, and parallel with the rectus muscle. Strokes may also be made over the fourth, fifth and sixth ribs at the sides of the chest. The profound reflex effect produced in patients who are very sensitive is evidence of the strong influence of this procedure upon nervous activity.

(2) Vibration.-Strong vibration applied to the abdominal contents has been shown to be one of the most powerful means of stimulating the nervous reflexes, circulation, glandular activity, and peristalsis, which can be employed for this part of the body. I am now using the electrical vibrator in place of hand vibration, as I was taught.

(3) Percussion.-This is unquestionably the most powerful of all the stimulating means which can be applied to the viscera through the abdominal wall. All the different modes of percussion, viz., tapping, spatting, clapping, hacking, and beating, may be usefully employed.

2. To produce mechanical effects by means of which stasis of the intestinal contents may be overcome and accumulated fecal matter dislodged, at the same time that the circulatory and glandular activities are stimulated.

For this purpose deep kneading is especially to be recommended. This may be accomplished by a number of different procedures: (1) Digital kneading. (2)

Kneading with the closed fists.

(3) Kneading with the

thumbs. (4) Mass kneading. (5) Palm kneading. (6) Rolling. (7) Massage of the gall bladder.

3. To strengthen the abdominal muscles.

Massage alone is not sufficient as a means of develop