The masseur is born, not made. As the pocket-knife is unsuitable for surgery, so some hands are unsuitable for massage, and no training or teaching can make them otherwise. Given the hands, the training, and the teaching, constant practice is essential to the maintenance of an efficient technique: without it the masseur "rusts" no less surely than the pianist.

Much has been written on the personal attributes to be desired in those who undertake massage work: perhaps the first is that they should have suffered illness or injury themselves, and have undergone a course of treatment. It is impossible for a person in health to realise the torture that can be inflicted by inefficient massage, and its extraordinary power of irritation, though being practised on by one's fellow-pupils during training is supposed to fill the deficiency. It does not, and massage with faulty technique must be endured after severe illness for its possibilities to be believed. The experience - referred to as hideous, torture, maddening, exhausting and so forth - is invaluable.

No great power or muscular development is required in the masseur: knack can effect more than force, and skill replaces physical strength, except when treating complaints such as obesity and fascial thickenings. For the treatment of these and similar maladies medical gymnasts should always be endowed with good physical strength. Patience is essential, and that not of the Kismet type, but of the ever-hopeful and optimistic. Sometimes it is necessary to perform our work week after week - even, it may be, year after year - with the certain knowledge that all we can hope to accomplish is to retard to the uttermost the downward path of the patient. Here optimism that refuses to acknowledge the gradual defeat may help the patient as much as, if not more than, the treatment. More and more it is becoming recognised in general medical work that the psychical side of existence must be acknowledged, and that its influence on recovery is great. In massage work this is more obvious than in most of the other branches of medical treatment; and it is impossible, in selecting a masseur for a particular case, to ignore the personal factor. It is part of the masseur's duty to inspire the hope of getting well; it may be, even to instil the desire to do so. Fear of disappointing the masseur has often been the sole incentive to the perseverance which has ended in recovery; and desire to prove to a masseuse that her efforts are being successful frequently hastens recovery.

Self-assurance that is not aggressive is a valuable asset, just as timidity and lack of firmness may be the reverse.

Though introspection in a patient is never beneficial if it consists of a study of symptoms, it may be of great help if it begins and ends with attempts to note their decreasing severity and the gradual restoration of function. It is for this reason that no treatment can remain unchanged if it is to be beneficial: it must be steadily progressive, no matter how slight the progress may be, unless, indeed, the task is set merely to retard the inevitable downward passage.

Though obvious, it is well to emphasise that the masseur should never arrive at work over-heated or out of breath, and the hands, if cold, must be warmed before commencing treatment. The masseur must never be in a hurry.

The care of the hands is one of the first duties of all physicotherapists, and the lotion used at St. Thomas' Hospital is of great service. The prescription is: -

Glycerini . . .

Pulv. Tragacanth. Ol. Lavandul.

Aq. Dest. .... M. ft. Lot.

Sig. For the hands.

Cold cream of the "vanishing" type is a good substitute for some skins. A fatty cream should be used at night if necessary.

In all treatments, even of the most vigorous type, the massage at the beginning and the end should be of the gentlest and most soothing nature, rising in crescendo and passing off in diminuendo.

Each masseur has his own favourite lubricant. The best is the simplest, namely, French chalk. This may be improved very cheaply by adding ten minims of the oil of Bergamot, or of any other volatile oil, to each pound of chalk.

Soap and water has its obvious attractions in hospital outpatient practice and is delightful to work with. In all cases of injury the patient will appreciate its use at the earliest possible moment.

Oil has its uses, particularly in softening a hard or scaly epidermis. Some masseurs seem to secure better results with oil than with powder, but it is a personal factor in most instances. The improvement in appearance after using oil is sometimes very marked, and it may add greatly to the patient's comfort. It is an undoubted fact that some oil is absorbed, but a very wide area must be treated for any real benefit to ensue. Inunctions, e.g., with mercurial ointment, cannot be considered as a part of massage, and the use of thyoscyamine preparations as an adjunct to massage is, so far as my experience goes, disappointing.

To shave a part as a preliminary to massage is usually a confession of lack of skill: it should never be necessary, as even massage of a scalp well clothed with hair presents no difficulty to the skilled masseur.

The personal comfort of the patient throughout treatment is worthy of the closest study; only less so is that of the masseur. It is impossible to perform massage efficiently while cramped or in discomfort from any other cause.

As will be seen later, human life, its functions and actions, are subdued to a natural rhythm. Our object in massage being to restore function, it is obvious that we must maintain, and may perhaps assist in the restoration of, rhythm. Let us see to it, then, that our movements are rhythmical.

The responsibility for the treatment of a patient rests entirely on the medical man. The only responsibility of the masseur is to see that orders are carried out implicitly, and, if dissatisfied with the progress made as the result of the faithful performance of these orders, to report accordingly. It is a fatal mistake for the masseur to assume a responsibility which belongs solely to the person who recommended him as a fit and proper person to carry out his instructions. If the masseur has any suggestions to make as to alteration of treatment, or if asked by the patient to make them, the matter must always be referred to the medical man. If treatment fails, the masseur is then blameless: had the alteration been made, he would assuredly become the scape-goat. The plea "I thought you would not mind my trying so-and-so" is unavailing; and "Oh, the patient asked me to do it!" is no excuse.

Were it not for the frequency with which it is said, it would seem almost superfluous to add that the "I wonder if you have tried so-and-so" of masseur to patient is the acme of disloyalty. Also, it is no part of the masseur's duty to advise on the choice of stimulant or aperient; or to recommend remedies for headache, indigestion, flatulence, and so forth. It is disheartening to discover the frequency with which these crimes are committed. If only the masseur, who has done these things, would think of the responsibility entailed, he would, for purely selfish reasons, never do them again, putting aside all ethical considerations as to loyalty.

Massage work in this country is so largely in the hands of female workers that a mere man offers with diffidence a few further suggestions. His only excuse is that he has been particularly requested to do so.

In conversation with patients it is highly desirable to avoid professional "shop," and the masseur must always be ready with some substitute for those patients who may be talkative. A good general education is therefore a most valuable asset, but it must be backed by strenuous endeavour to keep abreast with current topics. Otherwise "shop" becomes inevitable, and indiscretions almost equally so. Education will also help to render the masseur adaptable to the surroundings as well as to the individuality of the patient, and savoir faire may cover a multitude of errors in other directions.

"A smiling face oft masks a breaking heart" in the masseur, but, if it does so, the patient should never be conscious of it. It is essential to be consistently the same in manner and behaviour to each individual, as nothing could be more distracting to a patient than to be the victim of moods or petty irritations. Also boasts of past feats are of no interest to the patient. If success attends the treatment there is no need to boast; if it fails the boaster is stamped as a liar for all time. The necessary confidence is instilled into the patient by general demeanour and deportment rather than by the spoken word, and is dependent on the self-confidence of the masseur, which, however, must not be blatant. The disbeliever will be converted by the progress made, and not by promises.

Cheerfulness is essential, but it must be adapted to the needs of the patient. It may jar most horribly to be approached by a person with a beaming smile and a flow of chatter the day after a limb has been broken; whereas a fortnight later these may afford the only break in the tedium of a long and wearisome day. Inquisitiveness should be kept under strict control, and all sentimentality should be banished completely from the sympathy that may be felt for the patient.

Though on dangerous soil, it may be said without offence that the dress should be inconspicuous, and preferably of some washing material. Failing this, an over-all should be worn. Bangles, rings, and bracelets should of course be barred, except perhaps a well-fitting watch-bracelet. A little stand for the watch, so that it can be stood up beside the patient's bed, is more business-like and quite inoffensive.

Training should have instilled order and system till both are ingrained and natural. Untidiness, hesitancy, or lack of system are all inimical to success. Punctuality is a virtue that should be cultivated.

Observation and the power to draw correct deductions from the observations made are all-important, and the eyes and hands should be constantly on the alert to detect every change, physical and, if possible, psychical, in the patient. To utilise aright the deductions made by constant observation, a certain amount of authority must be exercised by the masseur. Every care must be taken not to be dictatorial, but equally all trace of familiarity must be avoided. Self-respect and self-contro are essential, and any departure therefrom invites lack of them on the part of the patient. Any suggestion of slackness in movement or posture tends to degrade the professional worker in a sick-room.

But before all comes loyalty - loyalty to the medical man and loyalty to the patient. If these should prove to be irreconcilable, it is better to throw up the case. There are few medical men who would fail to appreciate the sacrifice of a good case for adequate reason; there are fewer still who would forgive continuation of work if such reason existed.