at all times.  It is circular in shape.  Sometimes this grows larger, stiffer, or it acts spasmodically.  The opening is often so tight in some people that it is difficult to introduce even a finger, and it frequently produces a spasm of pain in the bowels, stomach and head to do so.  This kind will produce constipation or make it worse.  In such cases it should be stretched thoroughly but carefully so that the muscle will be able to close the opening and the bowel contents will not pass at any time unhindered.  There are two methods of stretching the muscle—­forcible or gradual.  The forcible method is generally done by inserting the two thumbs into the anus and stretching the muscle thoroughly in every direction until there is no resistance. (Dilators are made for this purpose, but unless they are very carefully used they will tear the muscle).  The forcible method should be done under an anesthetic.  Gradual stretching is done when an anesthetic cannot be used.  It is better to do too little than to do too much at the first sitting.  The muscle is very stubborn sometimes, and it requires careful handling or the irritability will be increased.  An instrument in the hands of a careful man is all right.  They can be stretched by the fingers or the Wales’ bougie, thus:  Patients should come to the office two or three times a week, the instrument (bougies) are introduced and allowed to remain within the bowel until the muscle resistance is overcome, and many times their withdrawal will soon be followed by a copious stool.  Forcible stretching is seldom required more than once, if a large sized instrument is used from time to time afterward, just as in gradual stretching; when thorough dilatation has been accomplished, the muscle instead of acting as an impassable barrier to the discharge of the feces, now offers only passive resistance, but sufficiently strong, however, to prevent any unpleasant accidents, yet not strong enough to resist the power of the expulsory muscles when the latter are brought into full play during stool.  Large quantities of feces do not now accumulate; consequently the pressure upon the mucous membrane and neighboring nerves is eliminated, and the bowel regains its normal sensibility and strength.  There are now sold dilators in sets for self use in almost every drug store.  These when used continuously do good and successful work.

[Digestive organs 141]

Abdominal Massage. (Kneading, Rubbing, etc.).—­This is an essential feature in the treatment.  It was practiced by Hippocrates hundreds of years ago.  Place the patient in the recumbent position upon a table which can be so manipulated that the head may be raised or lowered, the body rolled from side to side.  Gentle but firm pressure is then made with the palm of the hand and the ball of the thumb over the large intestine beginning in the lower right groin region.  Then go up to the ribs on the right side, then over the body to the same place on the left side