Types of permanent total flaccid paralysis is the indication of the death of the muscle. Absolute rest in the muscle, caused by the interruption of nervous conduction, condemns the muscle to atrophy from inactivity. It is gradually absorbed and turned into a shell of connective tissue from which there is no return. But as long as there is only the slightest trace of conduction in the nerve or trans mission of electrical irritation through it or as long as the muscular fibres are stimulated through the muscle itself, so long will the sensitive end organs in the muscle remain active even after years of paralysis (Erb, Bardenheuer).
They can resume their activity as soon as we are able to remove the interruption in the nerve-current, either in the centre or at the periph ery, and produce the necessary tension in the muscle or provide a new supply of nervous energy through operation. The muscle will re-form from the nuclei in the sareolemma, the same as it does after neuritic paralyses and also normally under increased demand by hyper trophic growth.
We must, therefore, in cases of flaccid paralysis never desist from our stimulating treatment before either the muscle has re-formed spon taneously or we have finally decided to use other measures.
These measures consist in operations on the nerves and tendons. When should these be performed? It is surely a mistake to stop the treatment with electricity and massage after six months and to sit back and wait to sec what Nature will do for our patient. A slight improvement will usually return even after years, especially in those muscles which were still reacting, if only with the so-called "vermiform" fibrillations. But if these should not show the least improvement in the course of some months, or the reac tion to stimulation decrease, or if increasing number of amperes be required to produce a minimal contraction, then we should not wait any longer before joining the diseased area to a healthy nerve supply provided we intend to do any nerve operation. The chances will only get less, especially if we stop stimulation of the ends of the nerves and the muscles and sacrifice them to entire involution.
On the other hand, should we decide on a tendon operation then it will be better to wait for one and a half or two years. By this time the body of the child will have adapted itself to existing conditions and it will try to get along with what it has (motilite supplee, according to Letievant). From this we should take our rue for the plan of our opera
tion. But we must always be careful to avoid the production of secondary deformities (contractions, overstretching of paretic muscles, pathologic dislocations). These we can avoid by posture, by simple splints made of plaster or celluloid, or by applying hinged braces, the paralyzed mus cles being replaced by elastic traction. We counteract the overstretching by putting on weights or by the use of braces, thus preventing secondary deformities until our operation, or when the paralysis is extensive and operation impossible we give the patient a certain though limited use of his paralyzed limb.
Which paralyses are suited for nerve-grafting? Those in which one nerve-muscle area is involved either alone or nearly so while other sur rounding nerves are either intact or only slightly affected. The nuclei for the different muscles in the spinal cord lie in different segments, hut the centres for those muscles which are supplied by one common periph eral nerve-trunk are close together in the cord as well, and we therefore freqently observe separation of the paralyzed regions according to nerve areas.
When the whole of such an area is paralyzed, then nerve-grafting will he preferable to tendon-grafting, because we thus attack the paral ysis nearer its centre and because we are able to restore the function of the whole of such an area, and this is especially important in the com plicated motions of the upper limb, which could not be done successfully by the combined operation on different tendons (Spitzy, Bardenheuer, Stoffel).
Tendon-grafting is preferable in disseminated paralyses, in paral yses of single muscles of different groups, and it gives specially good results in paralyses in the lower limb, the type of motion in which is simple. It also offers more hope of success in paralyses of long stand ing which no longer show any sign of contractHity in the muscles than would nerve-grafting, because we thus supplant dead material by a healthy one, and because we have hardly any right to expect a revival of the muscle which is dead and entirely degenerated. But even in some of these cases nerve-grafting will give remarkable results, so it ran only be tried tentatively, and in case of failure tendon-grafting will be justi fied, because we are not permitted to sacrifice any of the healthy nerve fibres by nerve operation in such doubtful cases.