The first thing requisite for the student is to grasp the theory of massage ; a knowledge of mere rubbing is not sufficient. Therefore not only must the structures of the body be understood, but also the effects of the movements on the various structures. We have skin, fascia, muscles, bloodvessels, lymph vessels, and nerves to consider. A movement suitable for the skin and superficial fascia would be quite useless for muscles ; deep kneading necessary for muscles would do little good in matting of superficial tissues. A hot, dry skin can be cooled and made moist by gentle effleurage ; kneading of muscles produces heat. Light percussion on a nerve for a short time stimulates it ; the same movement done more vigorously and for a longer time benumbs a nerve, and so on. The point is to know how and when to apply these varieties of movements. In the Weir-Mitchell treatment massage takes the place of exercise. The work is more or less routine ; the muscles are directly acted on, and the circulation and tissue activity promoted by stroking, deep kneading, percussion, and movements of joints. It is plain, straightforward work, not calling for much thought or knowledge of anatomy. But it is quite different in a host of other cases. In dropsy, oedema, and obesity superficial kneading is suitable. Fractures, synovitis, etc., call for still different work, and it is in such cases theory is so important. There is no rule-of-thumb work. The worker must keep before her what she wants to do, and the results she wishes to produce. She must not become a rubbing machine, working automatically.

Deep breathing should always be added to massage, that the internal blood and lymph vessels may be acted on, and internal massage produced.

As the term ' friction ' is used by some writers to denote effleurage, it will save confusion to say that in this book it is applied only to the movement in which the tissues are moved on each other by the cushions of the thumb or fingers or with the flat hand. The word 'massage' is derived from a Greek word signifying to knead, and an Arabic word meaning to press ; it comes to us through the French, which accounts for the use of the terms effleurage, etc. ; these, having been widely adopted, must serve the purpose of description till simpler terms are substituted. It is the scientific manipulation of the soft tissues of the body.

The skin and muscles are stroked, kneaded, squeezed, rolled and tapped, with the result that

(a)   The functions of the skin are improved ;

(b)   The flow of blood and lymph is quickened ,

(c)   Blood is attracted to the surface from internal parts ;

(d)   Nerves are stimulated or soothed as the case may be ; (e) Effete matter is got rid of ;

(f) Adhesions of soft parts are broken down ;

(g) Swelling and thickening of tissues are reduced ;

(h) Nutrition is increased. In. giving general massage, if the patients are received at the house of the operator, a suitable couch should be provided, say 2 feet wide, comfortably padded, and about 26 inches high ; the room should be kept at a proper temperature, between 650 and 700.

In visiting the patient at her house, she would probably be in bed, which might be of an inconvenient height, and the room of a temperature preferred by the patient rather than approved by the masseuse. In such a case the latter would have to fit herself into the circumstances. The patient's comfort and benefit must always be the first consideration, but the masseuse should also make herself as comfortable as possible, so that she may do her best work. The nightdress need not be removed ; it is well to have an extra blanket or sheet laid crossways on the bed under the lower limbs, that each leg may be wrapped up separately ; this protects the leg which is not being worked on from draught and cold. Some patients like to wear a flannel dressing-gown, in which case the extra covering is not required, as the legs may be separately wrapped in the gown. Others like a massage suit ; there is no reason why their tastes should not be gratified ; the point is to keep them warm and well covered, no part exposed except that which is being manipulated. It is well to have a small soft shawl to throw over parts which might otherwise not be sufficiently covered. Hot-water cans are not a necessity, and should not be introduced if the patient has not been accustomed to them ; if she has been, they must be continued, as it is not well to make changes, otherwise massage should be depended upon to give warmth. If the feet are habitually cold, it is a good plan to put on bed-socks after the feet have been manipulated, to keep up the heat generated by the massage. In heart cases hot-water tins are used, not only to the feet but about the body, and it is important that they should be replaced as each part is finished.

When the lower limbs have been manipulated, they are wrapped up and the bedclothes folded back to the hips, the nightdress being raised to get at the abdomen. The chest comes next, to get at which the hands can be slipped under the nightdress.

In doing the arms, one sleeve is taken off at a time, and replaced.

The patient is then turned and the séance completed by massage of the back. This order need not always be followed; the arms may be left till last, or the first movements may be on the abdomen.

In massage of the abdomen only, the nightdress is turned up above the region of the liver and the bedclothes are turned down to the hips.

For the back only, a jacket is worn, with the opening at the back, thus covering the arms and chest.

Scarcely too much stress can be laid on the manner of doing massage. As a rule the operator faces the patient, and should stand or sit at a comfortable distance, so as to be neither cramped nor strained ; in most movements the elbows are kept close to the sides, but not stiffly, the fingers held close together and straight ; unnecessary stooping is to be avoided. The body should not be swayed nor the head moved up and down, keeping time, as it were, to the movements. No part of the operator's body (or the patient's) should be rigid.

It is imperative that there should be no jerking ; the hands should not be lifted suddenly from the patient's body ; the operator should not lose contact unnecessarily with the patient, but glide almost imperceptibly from one movement to another.

All this is not as simple as it sounds, for pupils often have difficulty in overcoming these little things. It is only by attention to details and constant practice that the expertness and rhythm so necessary to pleasant and successful massage is acquired.

The eye and hand must be trained to at once notice everything about a patient—the condition of the skin, muscles, joints, etc. ; no remark need be made, but mental notes taken which may be useful later on, or even at the moment, as the character of the work is influenced by the condition of the tissues : roughness of skin, matting and hardness of fascia and muscles, fulness of veins, grating of joints, would each call for special work.

During a course of massage the masseuse should immediately be struck, on touching the patient, by increased heat of the skin, and for her own satisfaction take the temperature. The normal temperature of the body is 98.4° F. ; a trifling variation need cause no alarm, but a rise to 99.4° or 100° would indicate that massage should be suspended till the doctor had seen the patient.

It is not necessary to enforce silence during the séance, nor must the masseuse suppose it is her business to talk to and amuse the patient ; she should answer all questions cheerfully (and wisely), and be ready to give any information she can. It is unnecessary to say to intelligent workers that gossip and the details of the illness and treatment of other patients should be avoided.

Care should be taken to get the hands of the masseuse into proper working order, and to keep them nice. Pupils cannot do better than to mass their own hands ; it will make them soft and supple ; every joint must be manipulated and the muscles of the palm well worked up. It is most important to train the left hand ; most persons are, unfortunately, very right-handed ; in massage both hands are needed, and it takes much practice to make the left hand as expert as the right.

Lubricants are not necessary except under special circumstances. Some persons cannot mass without some greasy substance, because their hands are damp or coarse, or they are clumsy in the use of them ; but given dry, soft hands, and the knowledge of how to use them, no fear need be entertained of causing rashes or abrasions. It is only in the stroking movements that the hands are required to glide ; greasy fingers are a decided disadvantage in kneading movements, where it is necessary to grip the muscles.

A lubricant is desirable (a) when a limb has been in splints, as it prevents showers of tiny particles of skin from flying about ; (b) over lately healed wounds ; (c) when the patient is very emaciated or aged, or very young ; (d) when the skin of the patient or the hands of the operator are damp.

Under these conditions, pure olive-oil, neat's foot oil, cocoa butter, or lanoline cream may be used. Children are sometimes rubbed with a cream made of lanoline and cod-oil.

No medicated oil or ointment should ever be used, except by a doctor's direction. Patients are always grateful to find the masseuse uses neither oil nor powder.

Inunction is good and useful, especially for young and delicate children, but it is not massage, and they must not be confused.

Quotations from well-known writers on massage will show there is good authority for ' dry rubbing.'

Dr. W. Murrell says : ' I am sure it is a mistake to use lubricants of any kind. Dry rubbing is to be preferred for the following reasons : You get better contraction of muscle and consequently a greater flow of lymph ; electrical currents are more readily developed in the tissues ; there is a greater elevation of temperature in the part.'1

1 ' Massotherapeutics. '

Dr. Stretch Dowse says : ' Some skins are very coarse and naturally greasy, and when this is the case I recommend the part to be well washed with a solution of eau de Cologne and ammonia ; I maintain that no form of unguent, fat or vaseline should be used during the massage process, with two exceptions, namely, to the abdomen and to the joints. After massage it is well to anoint these parts with some unctuous material, because it causes the heat and increased activity to be maintained.' In remarking on the anointing of children, he says : ' Apply your massage first ; your own skin should come into direct contact with that of your patient ; then you may work in cod or any other oil you like. Experience proves that oil rubbed into the skin of young children of a weakly and delicate constitution allays irritability and promotes nutrition.' Dr. Dowse advises equal parts of castor-oil and chloroform to be used to deaden pain in stiff joints, and in his primer for beginners says oil should be used from ' first to last ' in abdominal massage.

Dr. Douglas Graham, an American writer, says : ' Various greasy substances have been employed, so that ignorant and would-be masseurs may rub without injuring the skin ; when the skin is cold and dry, or cold and moist, and the tissues in general are insufficiently nourished, as well as in certain fevers and other morbid conditions, there can be no doubt of the value of inunction ; but no special skill is required to do this work, and there is no need of calling it massage. The multitude of modern bruisers and greasers who are supposed to do massage might profit by a hint from Galen as to the best time for applying unctuous material.' 1 Dr. Benjamin Lee, also an American, writes that ' in long-continued firm work on sprains, lubricants are undoubtedly advisable,' but adds : ' In general massage, where large regions of the body are gone over, this can never be necessary.' Again : ' When we are applying massage in surgical affections, the use of an unguent is appropriate, but when we are treating general or medical disorders, it is not called for ; of course the intervention of such an agent would be a frequent obstacle to the stimulation of the surface circulation.' 2

Dr. Emil Kleen writes that lubricants are ' often necessary, especially where vigorous effleurage is called for, otherwise pain would be caused by traction on the hairs of the skin.' 3

1 Lectures on Massage.

2 Tracts on Massage.

3 Handbook on Massage.

Dr. Weir Mitchell says that traction of the hairs ' may be avoided by using cocoa-oil or vaseline,' and adds, ' These, however, make the work less efficient and more difficult, and I do not order them unless it is considered desirable to rub in some oleaginous material.'1

Beginners will find it easier at first to work with a lubricant; but when they have learnt how to use their hands, it should be no longer used, except under the circumstances named above.

Traction on hairs may be avoided by omitting effleurage on hairy parts, and using only such movements as move the skin with the hands.

There are four principal terms used in massage ; they are :

Effleurage,                        Friction,

Pétrissage,                       Tapotement.

Several other terms are used, but all movements may be classified under three heads, thus :

All stroking movements under the head of Effleurage. All pressure movements under the head of Pétrissage. All percussion movements under the head of Tapotement. There is a movement which does not, strictly speaking, belong to any of these ; it is vibration.