The answer to the second criticism is that it is better to break down any second adhesion under a second anaesthetic and inflict no further injury, than to break down both at once and inflict an injury which is a potent predisposing agency to the formation of new adhesions. Essentially is the old adage "More haste, less speed" applicable to forced movement under anaesthesia.

The criterion of success after the manipulation should be that the patient has increased function; loss of function speaks of an error in technique. Unfortunately this is not generally realised; and many surgeons labour under the delusion that, should the necessity of giving a second anaesthetic arise, they made an error in not doing sufficient on the first occasion. The "bone-setter" suffers from no such delusion, and frequently arranges from the outset to perform a series of manipulations, when proposing to loosen a joint in which there has been gross limitation of movement for a considerable time. His practice is sound; and we should undoubtedly accept this lesson he teaches. More active harm is done by excessive movement under anaesthesia than passive harm by neglect to use this most valuable remedial agency.

The question as to when forcible manipulation should be performed is not an easy one to answer. If the injury has been uncomplicated by sepsis it is probably unwise to proceed until six weeks have elapsed since the receipt of injury. I have fixed this limit for the simple reason that it is by no means certain till at least this time has elapsed that the exercise of the voluntary function of the limb will not restore the movement which is lacking. If sepsis has been present, and if this has obviously played some part in causing the limitation of movement, it is probably unwise to manipulate the part forcibly for several months, three to six, according to the severity of the sepsis. The same applies to cases in which loss of function is due to osteoarthritis and similar causes. I make it a rule also to hold my hand for three months at least in all cases where injury has resulted in the outpouring of an excessive callus formation.

It is not uncommon for attempts to be made to break down adhesions without the aid of an anaesthetic. Provided the limitation of movement is small and the original injury to the joint in question is probably slight, this is quite justifiable. For instance, it is often a simple matter to rupture adhesions in the inferior radio-ulnar joint after a Colles' fracture without an anaesthetic. On the other hand, an attempt to flex rigid meta-carpo-phalangeal joints in similar manner is opposed by the full strength of the long extensors in the forearm, and the movement cannot be performed without severely straining and thus injuring them. It should be a guiding rule, therefore, always to administer an anaesthetic whenever we are liable to encounter severe muscular resistance to our manipulations.

The choice of anaesthetic depends chiefly on the skill of the anaesthetist. Nitrous oxide gas suffices if adequate skill in administration is forthcoming, and if the manipulator knows exactly what to do and how to do it. Very few seconds should suffice for the manipulation of most joints, and a skilled anaesthetist can almost always ensure this much at least of complete relaxation with nitrous oxide gas. For manipulation of the hip or back it is wise to use some other anaesthetic, as more time is required for these manipulations than in most other joints.

The grip employed during manipulation is important. Our aim being to rupture an offending band and no more, it is usually wise to use as short a leverage as possible. Then, too, we want to reduce subsequent pain and disability to a minimum; and experience shows that this end is attained better if the adhesions are broken by a single sharp movement than by a slow gradual tearing. Rapidity of movement should be combined as far as is compatible with complete control which checks the movement the moment the objective, i.e., the rupture of the adhesion, has been attained. On the other hand, nothing could possibly represent a greater error in technique than to give a succession of ineffective tugs on the offending band. Once its resistance is encountered, it must be overcome forthwith; once overcome, the movement must instantly cease.

Hutton's statement that force in pulling or pushing is valueless, but that "the twist is the thing," gives the key to manipulations of most joints. The whole art is the knowledge of what precise "twist" to administer to each individual joint.

The first thing to ascertain definitely is what movement or movements are limited or give rise to pain, and it is usually wise to compare the mobility of the sound limb with that which we are about to manipulate. Then, directly the patient is relaxed under the anaesthetic, every movement which the patient can perform freely and voluntarily is carried out rapidly. If any resistance is encountered we know the patient is not relaxed, and await a more propitious moment for breaking the adhesions. Once relaxation is assured, the joint is moved firmly and steadily past the obstruction. If movement has not been limited, but only painful, full movement through the anatomical limits should be performed in all directions. If movement has been limited, only those movements which have previously been free and painless may be performed to the full. As we pass the limit set by adhesions, one of two things will be noticed: either there will be a sharp crack or click or a dull tearing, often felt rather than heard. Instantly manipulation becomes more guarded, and is carried on only sufficiently to feel that free movement is now possible past the point to which it was formerly limited. The manipulation then ceases in the direction chosen and the process is repeated in any other direction in which movement had previously been limited, Nothing whatever is to be gained by repetition of movements in any direction, if those already performed have been carried through with necessary exactitude. To repeat a movement is a confession of doubt as to the skill with which our performance has been carried out.