Some masseurs make use in other forms of massage of small wooden wheels, straps, brushes, gloves, sponges; the latter or metal wheels are used at times to give electric treatment along with massage. Most doctors who give massage themselves make use of their hands only, except in the case of instruments for vibration.

The strength of the manipulation is, of course, a very important factor, and varies widely with the different therapeutic aims and the different morbid anatomy underlying the special case. For instance, if one is dealing with a fresh sprain, and massage has chiefly an antiphlogistic aim, one sets to work, especially in the beginning of the treatment, with quite light effleurage; if one has before one an extensive hard oedema with a plastic tendency, effleurage as well as friction is firm; if the question is to get rid of already partially organised exudations round a joint after a joint inflammation, one must use hard friction; again, if it is perityphlic ("appendicitis ") or parametric exudation, one must exercise unceasing care, remembering the proximity of the peritoneum and the danger of a new inflammatory process, etc.; all matters which we shall deal with later more in detail, but which in individual cases must be left to the good sense of the masseur. With beginners the commonest fault is to be too hard-handed, but professional masseurs * often tend, on the contrary, to be too superficial. I would especially call attention to the erroneous statement of certain authors that massage should never be done hard enough to produce marks of discoloration of the skin, and that every such mark is the "fault" of the masseur. This may be true of general massage and some other cases, but very many of the cases for which massage is suitable (e.g., many chronic joint affections) need such strong massage that marks are necessarily caused. They are of little or no importance and soon disappear.

The length of the massage seance is also important, but there can be no general rule. Several points must be considered in deciding what is enough, and, in the first place, the nature of the lesion. Often in this, as in the strength of the manipulation, one must be guided by the patient's general condition, since nervous, sensitive patients can stand neither a long seance nor hard massage. In these cases one must begin the treatment gently and with a short seance, gradually increasing the strength of the massage and its duration. For local massage generally a quarter of an hour is suitable. General massage (which is usually done by some one other than a doctor) takes at least half an hour, often more.

In certain acute cases, and especially when used as an antiphlogistic (by means of effleurage), as, for example, in a recent sprain of the ankle, massage should be performed several times a day; in other cases at least twice, never less than once a day.

The masseur should from the beginning accustom himself to use both hands and divide the work fairly equally between them. While he is still new to the work, like other mechanical workers, he squanders his strength and becomes easily tired, but he quickly learns to obtain the greatest possible effect, and can do much more work than seemed at first possible.

The masseur should never make use of narcotics to prevent or remove pain which he must occasionally cause. The pain is seldom great, and there are other means of counteracting it. Latterly hypnotism and hypnotic suggestion have begun to play a part, in many cases with wonderful success; but I can offer no opinion on the subject, as I have never attempted it.

* Busy masseurs are under constant temptation to make their stances shorter and less vigorous than is really consistent with the patient's interest, the result of a simple calculation which we leave to the perspicacity of the reader, the consequence being that their work yields quick returns only in an economic sense.

Massage is almost always given directly on the skin, since in giving it over clothing, as is done by some masseurs in certain cases, one loses technical accuracy. Regard for modesty in a doctor's consulting room can be carried too far, to the detriment of more important considerations, and also to the extent of producing the painful self-consciousness it aims at avoiding. One takes care, especially with women patients, not to uncover more than need be uncovered, and not to uncover at one time more than the part about to be massaged.

Most masseurs make use of some lubricant to make the patient's skin soft and smooth. This is often a necessity, especially for firm effleurage, as otherwise one causes pain by dragging the hairs of the skin, and may irritate the glands of the skin and so cause acne or boils. Different skin lubricants may be used : glycerine, vaseline, lanoline, lard, "cold cream," olive oil, cocoa butter, etc. Glycerine I definitely condemn, since its strongly hygroscopic properties make it irritating to the skin; vaseline irritates somewhat. Liquid oils are troublesome to handle. Solid cocoa butter is better, but it has a fairly strong smell. On the whole it seems to me that lard should have the preference.

Some masseurs use only talc or other powders. In general massage this often seems to me most comfortable for the patient. If, however, the masseur has the good fortune to possess really dry hands he can give general massage without either powder or lubricant.

For deep effleurage, especially over the forearms or legs, it is sometimes necessary to shave the part once or twice a week, otherwise "pimples" may arise.

The masseur's hands must be carefully washed immediately before and after each seance; the nails should not be too long, and no rings should be worn.

The whole material outfit* needed by a masseur (besides the above-mentioned lubricant) consists of a couch of suitable length and breadth, and about 60 cm. high, accessible from all sides, a so-called plinth, preferably with one end which can be raised or massage.

* Even this bench is not at all necessary, and of late years I have myself used an ordinary couch. Plinths of different kinds are used in my Institute. During all the many years in which I have used massage in my practice I have used no instrument but my hands and a vibrator. This last should be in the possession of every one who makes much use of lowered according to need. When massage is given to any part of the back, buttocks, chest, abdomen, pelvis or legs, sometimes even to the shoulder joint, the patient lies on the plinth and the masseur stands or sits beside it. When massage is given to the lower part of the arm up to and including the elbow joint, the patient and the masseur sit directly opposite each other, one on either side of the plinth (upon which the patient rests his forearm). For massage of front or back of neck the patient sits on the plinth, and the masseur stands in front in the first case, behind or beside in the second. The suitable position for the patient is in most cases obvious. Where this is not the case we shall return to the subject in the special chapters.