effleurage should be applied for from five to fifteen minutes, four to six times a day. Effleurage is the main element also in

Massage of the Neck,

which may be performed with the operator either in the front or in the rear of the child. In massaging the neck from behind, the operator may stand, the patient occupying the sitting position. The operator then sup ports the patient's head upon her chest, and employs both hands in the manipulation. In effleurage of the neck the operator's hands should encircle the neck, excluding the windpipe. The operator's thumbs will thus meet or cross at the spine, while the finger-tips will press closely into the depression at the

FIG. 6.-SECOND KNEADING MOTION.

side of the windpipe upon each side. The pressure should be firm, and the motion should be downward from the jaw to the chest. The object of effleurage of the neck is to hasten the current of the blood in the external and internal jugular veins. The external jugulars extend from the jaw downward, just beneath the skin, on each side of the neck, and can often be distinctly seen. The internal jugulars lie more deeply, near the trachea, upon each side. The external jugulars convey blood particularly from the scalp. The internal ones receive blood from the face, the mucous membranes of the

mouth, throat, nose and ear, also a large part of the return blood from the brain.

A second variety of neck massage is useful with children having long, delicate necks. In this motion the operator places herself opposite the child, joins the fingers of her hands behind the spine, and then with the thumbs performs stroking motions, the motions being at first slow and gentle, and afterwards more energetic. The thumbs are thus moved from the jaw to the collar-bone, stroking partly the region of the internal jugulars, and partly the lateral regions of the

the thumbs are lifted and carried back to neck. The collar-bone having been reached, their starting place without touching the

neck.

Sometimes this close pressure over the internal jugulars will cause cough. Το obviate this difficulty pass the thumbs or fingers alternately down one side and then the other. The windpipe will be thus simply displaced without compression.

Neck massage may be used in the treatment of headache from congestion, in a number of other brain affections, in tonsilitis, and in catarrhs of the nose, throat and ear. Under a physician's direction it may sometimes be used also for enlargement of the cervical glands. I speak thus hesitatingly in regard to these enlarged glands because in many instances it is undesirable to "scatter" these lumps, on account of more or less harmful matters which they may contain. Always, therefore, have a physician's advice in regard to them.

I have described the stroking motion or effleurage first, because it is the most important motion connected with massage, and also because it is the easiest to apply. No special skill is required to encircle the limb with your well-oiled fingers and carry your hand upward or downward between the extremity and the trunk. Simple repetition of this motion constitutes effleurage, and this is all that there is to it. The stroking motions of neck massage similarly present no difficulty. Any one with soft, warm hands can perform these motions.

We come now, however, to the kneading

motions of massage, or the motions of massage proper. To perform these motions will require special practice and skill.

The First Kneading Motion.

The first is a circular motion performed with the thumb or forefinger, the pressure being directly downward toward the bone. In this motion do not move the hands upon the skin, but move the finger with the skin upon the underlying part. This is very important. Friction is no part of this motion.

The Second Kneading Motion.

The second kneading motion is obtained by compressing the part between the thumb and the first two or three fingers. This motion is applied to muscles or the fleshy parts of the body. The motion itself is a squeeze. You squeeze the muscle precisely as the bulb of the Davidson's syringe is squeezed. It is customary to make three or four or a half-dozen of these motions; to vary this motion by effleurage from one joint to the next; then to shift the position of the hand a fraction of an inch, and repeat the series of kneading motions, repeat the effleurage, and so on.

This motion is used upon small parts, such as the forearm, and takes precedence over all other kneading motions upon the child's small limbs. The alternation with the stroking motion is essential to the best result, the order being, massage one, two, three, four; effleurage; massage, etc.

The combination of these two motions with effleurage gives us an effective form of massage for use in

Muscular Weakness or Club-foot.-Used for this purpose, it may be applied twice daily for fifteen minutes each time. Almond or sweet oil will be preferable to vaseline for a lubricant, as, being already fluid, further liquefaction abstracts less heat. Even adults will often complain that vaseline makes them feel cold.

The Third Kneading Motion.

A third kneading, motion is applied upon larger parts, such as the thigh or trunk. In this motion apply the hand as in Fig. 7,

being careful not to indent the flesh with the ends of the fingers. This motion is not a pinching, but also simply a squeezing or grasping maneuver, the hand embracing so far as possible all of the tissues down to the bone. This motion is applied to the treatment of constipation in young children, as shown in Fig. 8. In this treatment place the fingers under the back and carry the thumbs well up into the notch under the breastbone. With the hands in this position knead the abdomen with a firm but very gentle motion, giving to the application five minutes once or twice a day. Should diarrhoea result from the treatment, the manipulation of the abdomen the motions should be slow, has been unnecessarily harsh. In massage

FIG. 7.-THIRD KNEADING MOTION.

and care should be taken to avoid abruptness in the alternations. The pressure should gradually increase and then gradually diminish in force.

To Give General Massage to a Baby. Have the room very warm. A warm bath should have been first given quickly but with the utmost gentleness. Then cover the child with a blanket, and have within the blanket a flannel-covered, hot-water bag. These . special precautions are directed against the chilling which is apt to follow the use of oil. In these cases we almost invariably use cod

liver oil or almond oil, for its nutritive effect by absorption through the skin.

Having thus prepared the child, place at a convenient distance the saucer of oil. Apply it, however, sparingly; you gain nothing by deluging the child with oil; a little upon your fingers to make them slip easily will be all that will be absorbed. Then take out one little arm and gently manipulate every part, using as required the first and second kneading motions, and alternate both with effleurage. Rapidly pass in the same way over the four extremities, and last knead the muscles of the neck and back with the second kneading motion, finishing with a brisk fric

FIG. 8.-THIRD KNEADING MOTION.

tion over the spine. The application of massage to the abdomen in such a case would depend upon the condition of the bowels, and should always be made with extreme gentleness. Not more than ten or fifteen minutes should be occupied with the whole proceeding, and the utmost care must be used both at the time and subsequently to prevent chill.

Rubbing with alcohol will be suggested, or half alcohol or whisky and oil. I can

almost hear these suggestions; they are always made when the subject of massage comes up. If your object is to escape chilling, do not use alcohol in any form. Alcohol and whisky both evaporate rapidly and leave the skin cool. In a case where you need not use oil, or in which oil is not well borne, use talcum powder. With its use your hands will slip easily, your manipulations will not hurt the little invalid, while at the same time the chilling of the surface so common with oil will be avoided.

Systematic Applications of Massage to the Whole Body

are desirable in cases of general muscular weakness, to favor convalescence after acute illnesses, in rickets, and where, for any other reason, ordinary exercise is not taken. Massage is useful for babies where, after prolonged stomach or bowel trouble, recovery is slow. I will refer to the case of a little girl of one year who had been ill all summer with vomiting and diarrhoea, so that her weight was reduced to 11 pounds, and she would lie in one position all day, apparently unable to move. Massage commenced to be used daily with inunctions of cod-liver oil. The appetite increased, and gradually the limbs began to be moved, and after one month of the treatment the child could stand alone.

In another case, that of a little boy of one year, there had been diarrhoea lasting all summer, reducing the weight to thirteen pounds. Massage and oil inunctions were commenced, and within two months the weight had increased to seventeen pounds and the child could stand alone.

It is not our purpose to detail cases in this paper; we give these two instances simply as an illustration of the value of massage in marasmic conditions. This value, we think, can scarcely be overstated.

Rickets. In using massage for rickets, the peculiar tenderness of the body must be borne in mind. Very great improvement may, however, be obtained by gentle patience, even in these cases. The child will probably be larger than the one we have just described; he will lie upon a bed or couch. Do not undress this sensitive child altogether at

once, and keep all the parts except the one upon which you are working well covered. Employ the same motions as in the preceding case, varying them with

Passive Movements

at the joints. These are simply the natural motions of the part. The fingers are "worked "back and forth, the hands back and forth, etc. A half-hour should be sufficient to complete both the massage and the passive gymnastics in such a case. Once daily will be sufficient for the application, unless after it the child seem very much fatigued, when the lower extremities and abdomen may be manipulated in one part of the day, and the upper extremities and back

in another, fifteen minutes being given to each application.

The convalescent from fever or other conditions will be, perhaps, a still older child, and massage in this case will scarcely differ from that in the adult. More frequent use can be made of the third kneading motion, and a whole hour may not be too much for the application. Even in this case, however, extreme gentleness must still be used.

It is a great mistake to give pain by any of these manipulations. A little pain and fright is capable of thwarting your best-directed efforts. It is better to "play at massage" for a few times, until you have obtained the confidence of the little patient, rather than by precipitancy to forfeit any chance of benefit.

THE

The Remittent Form.

From intermittent fever remittent may be

often wanting, the child merely complains of feeling cold. The fever soon follows, becoming almost continuous with slight exacerbations in the latter part of the day. The pulse is rapid, 120 to 140 beats per minute; the cheeks are usually flushed, sometims a bright scarlet, and the temperature is high, from 102 to 104 or 105 degrees Fahr. The child, if old enough, complains of pains in the stomach, nausea, and often vomits more or less bilious matter; the tongue is coated and the breath is foul. The bowels are constipated, the urine scanty and high colored. There is great thirst, causing the child to drink large quantities of water, which is often regurgitated as soon as swallowed. Loss of appetite, and a dry, hacking cough, are common symptoms. In severe cases delirium is present, especially on waking. Gastric symptoms, such as nausea and vomiting, sometimes persist for several days. Relapses are common after the lapse of five to seven days.

The Congestive Form.

Congestive fever is a malignant, destructive type of malarial fever, which differs from the simple or ordinary variety only in degree. It may be either of the intermittent or remittent form. The attacks are of the tertian or

quotidian type. quotidian type. It is often preventable, and many lives are saved by prompt, efficient treatment. In many parts of the world it is the most dreaded of all diseases. The suddenness with which it overwhelms a patient gives it additional terrors. One paroxysm is almost certain to be followed by another, and unless relief be promptly given, the patient soon sinks and dies. Fortunately, this is a disease where medical skill avails if it be not deferred too long. Perhaps in no other disease of equal gravity are the results of prompt treatment more conspicuous.

Congestive fever is not so rare in infancy