Although the manipulation of joints under anaesthesia does not in any sense come under the heading of "massage," yet I have been tempted to include the present chapter here. It is an article which I wrote for the Lancet and which was published on February 7th, 1920. The whole subject of the treatment of the after-effects of injury is interwoven with that of the administration of forced movement, and this in turn is intimately connected with the art of what is commonly known as "bone-setting." The principles which underlie the administration of forced movement in the massage-room are very similar to those that should control forced movement under an anaesthetic. I am constantly asked to expound the principles of "bone-setting," to explain as far as I may why the quack "bone-setter" is able to flourish so exceedingly, and to compare the results of "bone-setting" with those of orthodox practice.

The first reflection is that the material on which the "bone-setter" thrives should never exist. This does not mean that the formation of adhesions can always be wholly prevented, but it should be, and may be, very greatly eliminated; and, whenever this is impossible, the adhesions should be broken down at the earliest possible moment.

Speaking generally, it may be said that the "bone-setter" flourishes not because people suffer injury, but on account of the treatment they receive. The doctrine of fixation, rest and splintage is his great ally; his enemy is the treatment of recent injury by mobilisation. Until the time has come when the old teaching of absolute and prolonged rest after injury shall have been supplanted by Lucas-Championniere's doctrine of the scientific combination of rest with mobilisation, the type of disability which fills the "bone-setter's" rooms will never decrease.

But, do what we may, no amount of skill in treatment will always prevent the formation of adhesions after injury, especially in the presence of sepsis; and, if they form, it is essential that we should know how to deal with them, and carry out our treatment as early as possible.

It has fallen to me to encounter many of the failures of the "bone-setter," and from them much may be learnt. I have also had the most valuable and, I believe, uncommon experience of witnessing the results of mobilisation under anaesthesia as practised by a very large number of different surgeons - some, as I believe, too conservative, some too drastic. I have also discussed this subject very widely with surgeons on both sides of the Atlantic, and have been able to form conclusions as the result of these varied experiences. In my own practice, I know only too well how often I have withheld my hand when movement under anaesthesia would have saved prolonged treatment, pain, and tedious convalescence. I know, too, why I have been so often tempted thus in the past, and the reason may be summed up in one word - failure. It was only when I realised the cause of failure that I again began to practise manipulation under anaesthesia and formulated the principles which, I believe, should govern the art. Now this method of treatment is a mainstay on which I frequently rely not only to hasten convalescence, but very often to render possible cure of disability.

The cause of my failure in earlier days was dual in origin: first, I did not know what the natural movements of joints were, and, second, I tended to do too much. Because a patient is unconscious he cannot feel pain, but this is no excuse for mobilising a joint indiscriminately. During conscious life, reflex contraction of the muscles that oppose a movement invariably takes place, so as to limit the movement before undue strain is placed upon normal structures. Under anaesthesia this protective reflex is lacking; and so it behoves us, if we would avoid inflicting injury, to exercise even more care when we approach the limit of movement than we should use were the patient conscious.

Then comes a consideration which I believe to be very generally overlooked, but clinical experience has convinced me of its accuracy. This is that adaptive shortening takes place in the body with astounding rapidity, and particularly in the presence of pathological change, even though this change is only reflex wasting of muscle. Each muscle fibre and group of fibres is surrounded by a connective tissue sheath, and this sheath is endowed with the property of elasticity. Deprived of its function of shortening and lengthening, the sheath seems to lose its capacity very rapidly and, for the time being, becomes comparatively inextensible. The whole muscle mass, in other words, has undergone adaptive shortening. Restoration of function alone restores the elasticity. If, then, we imagine that the movement, say of extension of the elbow, has been limited by adhesions in or round the joint for some weeks, it follows that the flexors throughout that time have never been fully stretched. The elasticity of the fibrous tissue which goes to the make-up of the anatomical muscular mass has, therefore, never been utilised to the full extent since the day when adhesions which limit extension first began to form. The result is that the elasticity remains unimpaired only through the range of movement allowed by the adhesions. Beyond this range the elasticity is impaired, or, if the lesion is of long standing, may be almost non-existent. When the patient has been anaesthetised and movement has been performed through sufficient amplitude to rupture the adhesions, all further attempt at movement will tend to place undue strain upon the fibrous tissue, which, as we have seen, has suffered impairment of its extensible properties owing to disuse. Forced movement through the full anatomical range may thus inflict severe injury on the fibrous tissue that has lost the elasticity which is essential for the natural performance of the movement.

The first golden rule in manipulation under anaesthesia should therefore be that no further attempt at movement is to be made in any direction when once a definite adhesion has been felt to give way. If this rule is ignored injury will inevitably be inflicted on the fibrous tissue which forms a large bulk of the muscles which oppose the movement. Movement in other directions may, however, be continued. Two criticisms then arise. First, full range of movement may not have been restored by one manipulation; and, second, we do not know that, because one adhesion has been broken, there may not be others which still limit movement. The answer to the first criticism is this. Rupture of a pathological band is practically painless, and the local reaction is mild and transitory when compared with the considerable reaction that follows undue stretching, i.e., spraining, of physiological tissue. There should be, therefore, no interference with function and the voluntary use of the limb after skilled mobilisation, except that due to inelasticity of the fibrous tissue within the muscles, and perhaps a mental incapacity to realise that movement or use, which has hitherto been impossible, is restored. Functional use of the limb will rapidly restore the elasticity either up to the anatomical limit or up to the limit allowed by other adhesions should these exist. If, on the other hand, we have forced movement to the anatomical limit, and have thereby overstretched the temporarily inelastic fibrous tissue, we have inflicted a more or less severe sprain, since normal movement may be excessive for structures which have undergone adaptive shortening. Thus we inflict a fresh injury which may be no less difficult to cure than that which the patient originally sustained.