The following summary includes only the more important points relating to the method of procedure, and is of course in no sense exhaustive; but the points referred to are, so far as my experience goes, those which are most worthy of note.

1. Although not invariably necessary, an anaesthetic should be given in all cases. The anaesthesia should be profound, and the behaviour of the muscles of the affected part should be observed whilst the patient passes under the influence of the anaesthetic. The more these muscles twitch and contract during this period, the better as a rule is the prospect of the treatment. In neurotic cases free spontaneous movement of the stiff joint frequently occurs at this time.

2. All attempts at the breaking down of stiff joints should, unless circumstances make it impracticable, be preceded by a methodical course of massage and passive movement. This is especially indicated when the muscles are rigid and apparently adherent. The effect of a course of massage in such cases is most marked in loosening the rigidity of the muscles, which frequently leads to considerable diminution in the stiffness of the joint. Joints treated in this way often become easily manageable by breaking down after the massage, although they may have previously appeared almost hopeless.

3. The first forcible movement made in attempts at breaking down a joint should be flexion. Extension should never be employed as the first movement.

4. The opposing force across which the joint is bent should be placed exactly in the line of the articulation, and not upon the bone immediately above that point. When possible the whole length of the proximal bone, when it is a long bone, should be applied to a flat surface, a table for example, the end of which, with a thick blanket laid over it, should be exactly in the line of the articulation. The proximal portion of the limb should be kept firmly applied to the flat surface by the hands of an assistant whilst the manipulator manages the distal part. In the case of the elbow and similar joints, the opposing force (the hand of the manipulator, or a padded bar) should be carefully placed in the flexure of the joint exactly in the line of the articulation.

5. The attempt at flexion should be made by means of steady intermittent movements, not by one sweeping motion. Extension should be made by one continuous pull or push, the same precautions being taken about the position of the opposing medium as has been indicated in speaking before of its use in flexion.

6. It is of importance that no attempt at extension should be made until after the greatest possible amount of flexion has been effected. In other words, the breaking-down process should be considered primarily to consist of two stages which are quite distinct, first flexion and then extension, the first being complete before the second is commenced - abduction and adduction, circumduction forming a third distinct stage in dealing with joints in which such movements are normally present.