Systematic manipulation is of great value both as a means of preserving health and as a scientific method of treating certain diseases in children.

Mere rubbing or friction of the surface cannot be included under massage in its literal sense; still, it is a useful form of manipulation, and needs no special instruction, being possible to any intelligent, soft-handed mother or nurse.

Massage, on the contrary, is an art, and, like every other art, requires study and patient preparation for its successful practice. It is a powerful remedy, too, and, like other agents of its class, as potent for evil as for good in unskilled hands. Therefore, to insure good results, a trained masseuse is necessary, and she must act under the direction of the physician.

Massage includes several processes of manipulation. Those given by Murrell, from whose excellent little work* I have taken much of the description of the different "movements," are effleurage, petrissage, friction, and tapotement.

* "Massage as a Mode of Treatment." W. Murrell.

Effleurage is a stroking movement made with the palm of the hand passing with more or less force over the surface of the body centripetally. The movements are made to follow as nearly as possible the direction of the muscle fibers, and for deep-seated tissues the knuckles can be used instead of the palm. This method is of minor value in itself, but of great use when combined, as is the rule, with the procedures to be described.

Petrissage consists essentially in picking up a portion of muscle or other tissue with both hands or the fingers of one hand, and subjecting it to firm pressure, at the same time rolling it between the fingers and the subjacent tissues. The hands must move simultaneously and in opposite directions, the skin must move with the hands to avoid giving pain, and the thumb and fingers must be kept wide apart in order to grasp a bulk of tissue, a whole muscle belly, for instance. The manipulation must be uniform, in a direction from the extremities toward the centre of the body, bearing in mind the arrangement of groups of superficial muscles and keeping well in the spaces between them.

Friction, or massage a frictions, is performed with the tips of the fingers. It is a pressure movement rather than a rubbing. It is always associated with effleurage, and, to be of any use, must be performed quickly and readily.

Tapotement is a percussion which may be made with the tips of the fingers, their palmar surfaces, the palm of the hand, the back of the half-closed hand, one or other border of the hand, or with the hand partly closed, so as to contain, when brought in contact with the surface of the body, a cushion of air.

The hand of the masseuse must be perfectly clean and soft, and the finger-nails short and smooth. The length and frequency of the sittings must vary with the individual case. Most authorities are in favor of short and frequent seances, and except in special cases recommend dry massage, that is, without the use of oil, liniments or ointments; vaseline especially is to be avoided.

Clinical experience shows that massage increases the activity of the circulation, reddens the skin, and elevates the temperature in the part manipulated. It also increases the electrical contractility of muscular tissue, and stimulates the flow of lymph in the lymphatic vessels. Muscular stiffness and fatigue are relieved, nervous irritability is calmed, and restless and wakeful patients are soothed by it into refreshing sleep.

With these facts at hand, it is not difficult to see what a useful agency we possess in skilfully employed massage. By its application we have the power to prevent the wasting of muscles and to augment muscle strength, to build up such tissues as fat and blood, to improve nerve force, both directly by producing a better blood supply and indirectly by relieving irritability and giving rest and sleep; and finally, to hasten the absorption of waste tissue and of morbid effusions. At the same time it must always be remembered that massage is a powerful remedy. A short seance with gentle movements may do good in infantile palsy, for example, but it does not follow that by doubling the time or force, twice as much benefit will be derived. In fact, the reverse of the proposition is true; short, gentle massage maintains the size and strength of the muscles, while long, forcible manipulation causes them to waste quickly. The same truth runs through the whole question and must be observed.

Before entering upon the therapeutic application of massage proper, it will be well to revert to the process of simple rubbing, already mentioned. This is of much value as a general hygienic measure. Each day, after the bath, the skin having been thoroughly dried by a soft, warm towel, the whole surface should be gently rubbed with the palm of the hand, the process occupying about five minutes. This increases the circulation in the minute blood-vessels, encouraging thorough reaction, aids nutrition and adds vigor to the frame. Weakly children especially thrive under it. In older children, friction with a soft towel may be substituted for hand-rubbing, but this change should not be made before the fifth or sixth year.

Sometimes it is well to rub certain portions of the body more thoroughly than others. Thus in rickets the spine should receive special attention, in indigestion and constipation, the abdomen; in weak ankles, the feet and legs, etc.; although even in these cases the general surface must receive a share.

Massage may be employed with advantage in the following diseases of childhood:

(a) Long-standing stomach or intestinal indigestion (chronic gastro-intestinal catarrh). In this condition the skin is harsh, and often so dry that a shower of dead scales, falls from the surface on the removal of the underclothing; the muscle tone is faulty; general nutrition is impaired, and there is a determination of blood from the surface toward the mucous membranes. To get the skin active, and in this way balance the circulation, is an important step in the reestablishment of normal digestion, secretion and excretion, the essentials of perfect nutrition. To accomplish this, a full, warm bath is administered every evening, just before bedtime, the patient remaining in the water for five minutes. Then the surface is thoroughly dried, and half an ounce of olive oil is gently rubbed into the skin (inunction), the child enveloped in a light blanket and put to bed. After a little time sweating begins. As soon as the sweating is free the skin is again dried and the night-dress put on in preparation for sleep. Next morning, at some convenient time after breakfast, the child is subjected to twenty minutes' massage. The inunctions are continued until the skin becomes soft and active, and massage is employed daily until there is a decided improvement in the amount of flesh and general strength - a period generally of two or three weeks. Afterward, "movements" every third day will be sufficient to complete the cure.