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ing the abdominal muscles, as is the case with all muscular structure. They must be brought into voluntary action by proper gymnastics. Kneading is the most effective procedure afforded by massage for stimulating development of the abdominal muscles. Both superficial kneading and deep kneading may be employed.


In most cases gymnastics is sufficient alone, and is what the patients generally wish, because it is less troublesome and cheaper. To be effectual, gymnastic movements must be used perseveringly; they should be gone through every day at least three times. It is important to impress upon the patient that the treatment should not stop as soon as improvement begins, but it should be continued even a few months after, if constant good health is to be gained. Every patient treated this way should be advised to rub his abdomen himself, for a relapse can easily occur, but can also easily be avoided, if the patient sacrifices ten to fifteen minutes daily on an abdominal kneading.

Gymnastic exercises for constipation :

1. Stretch stride standing, bending forward.

2. Stretch stride standing, bending obliquely outward, with flexion and extension.

3. Stretch stride standing, bending forward, swing arms down-back (wood-clapper).


4. Sitting trunk extension and flexion.

5. Back lying hip balancing, knee flexion and extension,


Numerous instruments have been devised to imitate the action of the hands, but as yet no device has been found quite to equal the human hand for

the administration of kneading movements.

One of

the most useful of all the several forms of mechanical

massage is mechanical vibration. Under this heading may be appropriately mentioned the "Cannon-ball massage." A cannon-ball covered with leather is a valuable mechanical accessory in the application of abdominal massage. It should weigh from four to six pounds, and should be rolled upon the abdomen, following the course of the colon from right to left. It should be used for fifteen minutes morning and evening, on an empty stomach.

Dr. H. Beer (Klinisch-therapeutische Wochenshrift) describes a mechanical laxative for infants. He uses the bulbous end of an ordinary rectal thermometer covered with vaseline, and inserted per rectum as in taking the temperature. It is then gently pressed against the sphincter ani and keeping it in the axis of the rectum, it is made to describe smaller and larger circles, as in dilating the sphincter. After two or three turns the sphincter is felt to relax, the rectum contracts, the anus opens and the act of defecation takes place reflexly. The effect is very prompt when the rectum is filled, and is absolutely harmless to the child.

In conclusion, I wish to say that I have not touched upon all the physiological remedies, but suffice to say that if the physician studies the remedies mentioned, and the patient, overdrugging would soon be a thing of the past. One thing should not be forgotten in treating obstinate cases of constipation, namely, to insist on regular habits, particularly in the young, whether the desire is present to have an evacuation or not, regularity of habit must be insisted upon.



It is not the purpose of this paper to present an exhaustive discussion of this affection; but to remind the members of this association that they are apt to meet with it any day, to set forth the symptoms that will enable an early diagnosis to be made, and to differentiate it, so that the patient can be given the best chance of relief by an early operation. These observations are based upon the study of about 1,300 cases of intussusception occurring in infants and children gathered from the literature, and a few in my own experience. Of these Hess, of Chicago, has collected 1,028, Cole and Clubbe, of Australia, 210, Wallace 20 and 24 which I have collected from the literature and my own records, the names of the authors being given in the bibliography. Early diagnosis is so essential that I have sought to discover from this large number of cases some means that will enable us to recognize the condition before the picture is too clear to be of use.

Any man who is practicing among children must bear constantly in mind the possibility of this very dangerous affection. When this point is gained, more than half of the battle is won. Clubbe states that the hospital internes in Melbourne rarely fail to "spot" these cases, so well drilled have they been as to its possibility.

Always suspecting it, the diagnosis would be very easy if the cases always presented the classical symptoms. How

easy would be the diagnosis of any disease if the patients would be so accommodating as always to present the syndrome of a typical case! A previously healthy child is seized suddenly with violent pain in the abdomen, which is paroxysmal. The child soon begins to vomit, and continues to do so, especially when given anything by mouth. It has a good deal of tenesmus, and after a few hours passes bloody stools but no feces. Its skin is cool, and rectal temperature low, but pulse and respiration are rapid.

It soon passes into a state of collapse, and all efforts at obtaining an evacuation of the bowels are futile. An examination of the abdomen shows a sausage-shaped tumor usually in the left iliac region, and it can also be felt per rectum.

No one could fail of a diagnosis with such a symptom complex. The difficulty, practically, lies in the fact that any one or more of these symptoms may be entirely absent, delayed or subdued.

Huber has reported a case in which the only symptom was pain occurring in paroxysms, until the fourth day of the disease, when a tumor was discovered in the subcostal space on the right side, resembling a floating kidney, after the patient had been anesthetized for operation.

In one of my cases the only symptoms were shock, nausea and constipation. In another the only symptom to be found was a peculiar character of respiration to which I shall call attention later. Upon this I made the diagnosis, which was confirmed by operation.

Because the symptoms are not always typical is the raison d'etre of this paper.

Let us consider these separately.

Pain: Pain is a very constant symptom. It usually occurs suddenly in a previously healthy child, is paroxys

mal and exceedingly violent. At first it is intermittent, and later becomes more or less continuous. It is at first referred to the umbilicus, later there is pain and tenderness over the whole abdomen. In the cases studied this symptom was almost universal, being noted as being present in every case but one, where it was absent. This was in one of my own cases, an infant a year old, and if present, was so slight as not to cause the infant any discomfort.


Nausea: Nausea and vomiting occurred in 90 per cent. of these cases. In the large majority it began early, and was more or less constant. The vomitus consists first of the contents of the stomach, and then of bile stained mucus. Very rarely in infants is it fecal. The vomiting is more violent the more complete is the obstruction. is not projectile. More often there is a great deal of gagging, with a little mucus finally expelled. In a great many cases vomiting is not a marked feature unless something is given by mouth. Whatever this may be, it is rejected very soon.

Constipation: This is one of the most misleading symptoms in the whole condition. It is impossible to say how many times physicians are thrown off their guard by the presence of stools. A child begins vomiting and has colicky pains; if the bowels did not move some obstruction would be suspected immediately; but the fact that there are a few stools, sometimes diarrheal in character, becoming bloody and mucus, leads to an error in diagnosis, cholera morbus, or some other digestive disturbance being supposed to be present. Aside from the error in diagnosis, it leads to the administration of cathartics, which aggravate the real condition. It is the rule, rather than the exception, for the bowels to move. The evacuations are fecal at first, representing the contents of the bowel

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