The laws which govern the direction in which manipulation is to be given are, of course, identical in the two cases. Only one word is necessary. When applying tension the greatest care should be taken not to let the grasp slip. The grip, in other words, must be very firm. The manipulation must be performed smoothly and with even pressure; there must be no aimless waggling to and fro and no spasmodic jerking. The pressure must be released as smoothly and gradually as it was applied.

In order that the patient may be in the most favourable attitude to contract his antagonists, the position in which he is placed in the massage-room as a preliminary to the administration of forced movement is not always identical with that chosen when the manipulation is to be performed under a general anaesthetic.

Thus, for instance, flexion of the knee is often best performed with the patient on his face, and the foot is often manipulated to best advantage while the leg rests on the masseur's lap.1 Shoulder and elbow are best treated absolutely recumbent.

The after-treatment of cases which have been treated by mobilisation under an anaesthetic varies with the condition found. Restoration of function being the objective, active movement must be prescribed at the earliest possible moment. This should be within a few hours of the manipulation, and if possible within a few minutes. But all manipulations must be regarded in the light of the infliction of injury. If pathological tissue has been broken down - the picture is far different if it has been severely stretched only - the injury as a rule is trivial, and we can proceed apace. If pathological or normal structures have been stretched, reaction varies with the amount of damage done. It may only be very slight. On the other hand, if manipulation has been too vigorous, or if it has been unskilfully performed, then the structures around the joint - ligaments and tendons - and the muscles that control the movements of the joint have suffered injury which may amount only to slight strain, to sprains of all degrees of severity, until finally we come to the by no means unknown catastrophes, torn muscles, tendons or ligaments, or even dislocation and fracture. Obviously treatment must vary with the extent of the damage done, and this can only be gauged by reaction. To expect a masseur to put a joint through its full range of movement merely because this has been done under anaesthesia is utterly preposterous, unless, indeed, we have the certainty that no strain has been placed on any non-pathological tissue. So rarely, however, is this the case that the full range of movement is rarely attainable for two or three days unless there was little or no previous limitation. Each case must be treated individually, and the laws which govern all treatment of recent injury must be respected.

1 See Fig. 34, p. 76; and Figs. 32 and 33, pp. 74 and 75.