Little need be added on the subject of breaking down adhesions that are due to trauma of muscles or of tendon sheaths. The chief thing to remember is that no harm is done by doing too little; severe injury is always inflicted if we do too much. Repetition of the manipulation is also frequently advisable.

One word remains to be said concerning the so-called "traumatic lumbago." The victim is not a malingerer, though often he is dubbed as such. The disability is very severe; if the origin is due to adhesions following rupture of a few muscle fibres, the treatment fortunately is easy and usually satisfactory. The patient is given a general anaesthetic, and is placed fully recumbent. The hip of the less painful side is fully flexed into the abdomen and is again placed by its fellow. The process is repeated on the opposite side. Then both hips are flexed together on to the abdomen, flexion of the knee in each instance coinciding with the flexion of the hip. When the anterior surfaces of the two thighs are as far as possible in contact with the abdomen, the sacrum is raised well away from the couch. The pelvis is then waved freely from side to side as the extreme flexion is slowly relaxed and rotation of the spine is performed. When lateral movement is no longer possible without dragging the sacrum from side to side on the couch the patient is placed fully recumbent once more, and the hands are passed round the trunk till they meet in the mid-line behind. Then firm traction is exerted forwards as if attempting to raise the whole weight of the body. A considerable arching of the back is thus secured, and lateralisation is administered as the traction is relaxed and the recumbent position is slowly restored. "Traumatic lumbago" is frequently due to a slight tilting of one ilium on the sacrum. The pain can be relieved almost spontaneously by treating the patient prone. One hand is placed over the region of the posterior superior spine and exerts downward pressure, while the other forcibly pulls the thigh backwards. The cervical region is sometimes affected in similar manner, or symptoms (neuralgic pains in the back of the head and neck and even brachial neuritis) may be described in the absence of a history of definite injury. There is no call for anaesthesia for the performance of the manipulations. The patient is placed recumbent with the head and neck projecting freely over the end of the couch. The head rests on the manipulator's hands, and the main point that calls for attention is that tension should be given by securing a firm grip either of occiput and mastoid on each side with one hand, or of occiput with one hand and chin with the other - a grip corresponding to that of the collar in ordinary head suspension - before the movements of flexion, extension, lateralisation and rotation are performed.

At the other end of the spine we meet with that troublesome and often intractable complaint, coccidynia. Sometimes this can be relieved by manipulation, and sometimes it fails. The forefinger must be passed into the rectum, and each joint is then manipulated in turn. In addition to the pure flexion and extension a slight twisting movement should be added. Care must be taken not to be too severe in carrying out the manipulation.

There is no "mystery" in the art of "bone-setting." Certain details require attention and nothing more. We must know what the natural movement of the joint is, we must realise its limits, we must avoid laying any strain whatever on any normal structure - under anaesthesia there is no protective reflex to save it from harm - and all will be well. But under anaesthesia nothing is more simple than to damage normal structures, and then we have to face the unpleasant necessity of dealing with a sprain of our own creation. It is often an easy matter when administering forced movement without an anaesthetic to strain severely any muscle which is thrown into reflex protective spasm during the manipulation.

If our object is to relieve pain or secure increased mobility, we have failed if either of these two objects fall short of attainment. In mobilisation under anaesthesia we have very often an excellent example of the fact that in many cases we do not cure, but depend on the patient's voluntary co-operation before the end is achieved. Manipulation will often suffice to cure pain alone, but it is rarely enough to restore movement. After mobilisation the patient must be taught how to improve his mobility as the result of voluntary effort, and without skilled teaching and cordial co-operation the whole procedure may be rendered void and of no effect, for the adhesions will quickly re-form. It is for this reason that severe pain after manipulation should be regarded as an indication of failure. The pain inhibits voluntary action, and without this recovery is well-nigh hopeless. Unless the patient owns up to greater comfort or more freedom within an hour or so of the manipulation, too much has probably been done.

The application of the principles already laid down to manipu-lation in the massage-room is simple.

In the first place, the anaesthesia of forcible manipulation has as its object relaxation of the antagonists which oppose the movement we wish to perform. In massage this place is taken by "active relaxation." As soon as pain is felt this relaxation is supplanted by reflex spasm of the antagonists, which can only be abolished by calling upon the muscles which control the movement to contract. This, of necessity, causes reflex relaxation of the antagonists. In the massage-room, therefore, forced movement should always partake of the nature of assistive movement. Far better is it to assist the action of a muscle than to attempt to stretch or tire out its antagonists. There should be no excuse for confounding forced movement with passive movement. The latter can only be administered when the muscles are in a condition of complete voluntary relaxation, and when there is no perceptible obstacle to movement.