  For oriented manifolds of dimension at least 4 that are simply connected at
infinity, it is known that end summing is a uniquely defined operation. Calcut
and Haggerty showed that more complicated fundamental group behavior at
infinity can lead to nonuniqueness. The present paper examines how and when
uniqueness fails. Examples are given, in the categories TOP, PL and DIFF, of
nonuniqueness that cannot be detected in a weaker category (including the
homotopy category). In contrast, uniqueness is proved for Mittag-Leffler ends,
and generalized to allow slides and cancellation of (possibly infinite)
collections of 0- and 1-handles at infinity. Various applications are
presented, including an analysis of how the monoid of smooth manifolds
homeomorphic to R^4 acts on the smoothings of any noncompact 4-manifold.
