120 



DISCOVERY 



surgical procedures, the growth being liable to much 

 retardation or distortion ; and for this reason all 

 types of bone-operation arc generally avoided up to 

 the age of about seventeen. 



The recent tendency has been to rescr%'e these 

 operative procedures for cases where reapposition of 

 fragments is very difficult to maintain in any other 

 way ; even the Liverpool school, which usually 

 attains reapposition by powerful traction, and reten- 

 tion by Thomas's splints and their adaptations, finds 

 scope for operative fixation where one fragment is 

 small and imcontroUable — in their striving after true 

 apfjosition and correct alignment. 



A recently-introduced method of obtaining small 

 muscle movements, suitable for maintaining a healthy 

 condition during enforced rest, as immediately after a 

 fracture, or again during the period of loss of power 

 from nerve injury, consists in " treatment by 

 Graduated Contractions." It is possible to obtain so 

 small a contraction that the tendon merely stands 

 out prominently without even producing a move- 

 ment of the joint ; and any required force of con- 

 traction may be provided with the greatest degree of 

 accuracy. Such a method is obviously of the utmost 

 value in maintaining muscles in good condition ; for 

 it is in active use that muscles find tfieir best restora- 

 tive ; and it can be applied when it is stiU undesirable 

 to allow of any joint movement, as in the early steps 

 of treatment of a fracture. Contractions obtained by 

 this method closely resemble ordinary voluntary 

 movements. By this method, however, a single 

 muscle can be made to contract, a feat which is 

 extremely difficult of performance, and without 

 practice almost impossible, under ordinary voluntary 

 power. Any weakened muscle can thus be singled 

 out for attention. A further advantage is that a 

 small contraction is obtainable when none at all can 

 be obtained by voluntary power ; it can therefore be 

 used to pave the way in a recovering muscle for move- 

 ments of a voluntary nature. 



It must be added that Graduated Contractions, 

 graduated as to force with a scientific accuracy by the 

 specially-trained masseuse, are greatly superior to 

 voluntary contractions which are of much less certain 

 force and amplitude, and are likely to do more harm 

 than good in a recently injured limb. 



It was by the recent elaboration after prolonged 

 experiment of a special faradic coil that such Graduated 

 Contractions have been made possible. The stimulus 

 from the ordinary faradic coil is painful, and the 

 patient inevitably resists. The coil which succeeds is 

 practically painless in that it provides a secondary 

 current of very low voltage, and that it has a perfectly 

 regular action of the interrupter. The intensity of 

 the stimulus is varied at will by pushing in or with- 



drawing the soft iron core which is found in the 

 primary coil here as in an ordinary induction coil.' 

 It may be noted»in passing that the electricity is not 

 employed for any general effect it may have on the 

 body, but entirely to obtain the graduated muscular 

 contraction which is the end in view. It is applied 

 at certain spots on the skin of the limb, known as 

 " motor points," of which there is approximately one 

 for each muscle. 



Slight cases of weakness in a muscle may be 

 remedied by exercising this special muscle against such 

 a resistance as a skilful masseuse can supply with her 

 hand ; and this method always becomes supplementary 

 to Graduated Contractions in the later stages of 

 muscle recovery ; obviously, however, it is not avail- 

 able with a paralysed muscle ; and, as mentioned 

 above, it is an undesirable method of maintaining 

 muscle tone when recent fractures or severe joint 

 injuries are present. 



The muscle-wasting which occurs in an immobiUsed 

 limb, and which occurs much more markedly when 

 the nerve or a neighbouring joint has been injured, 

 has been in the past extensively treated by massage. 

 Since, however, this does not in itself involve any 

 active contractions, it is a very inferior procedure for 

 the purpose in view. Massage acts directly on the 

 circulation of the part and refle.xly through the nervous 

 system ; it is suitable for quite another class of disorder. 

 Passive movements, i.e. movements performed by the 

 masseuse, who holds the limb, are also inferior in that 

 active contraction of the wasted muscles is not an 

 essential part of the procedure. 



How very important is the procedure of graduated 

 contractions will be realised when it is also recalled 

 that in every case of joint injury there is severe 

 muscle-wasting. Community of nerve-supply is re- 

 sponsible for a sort of " symbiosis," if we may 

 borrow the term, between joint and closely associated 

 muscles ; if, for example, the knee-joint is affected, 

 extreme wasting is liable to occur in the Vastus In- 

 ternus, the muscle which forms the swelling just above 

 the knee on the inner side. 



Champonniere aimed at avoiding muscle-wasting 

 and stiffness of the tissues during the treatment of 

 fractures by " active " means — movement and massage. 

 Now we are achieving, better than ever before, some 

 of the results at which he was aiming, with the great 

 advantages we now possess in delicate modern in- 

 struments for obtaining small muscle contractions, such 

 as the specially wound induction coil mentioned above. 

 That muscles require such minute care during the 

 treatment of a fracture is probably one of the chief 

 considerations which is leading to the transference of 

 such injuries to the orthopaedic surgeon. 



' See W. Rowley Bristow's book quoted at end of paper. 



