FLACCID PARALYSES The flaccid paralyses and pareses always indicate a lowering of energy of the muscle and are the result of a disturbance which has attacked either the muscle itself or its connection with its nerve-centre. Thus a partial interference with the conduction will cause a paresis, a complete one, however, a total paralysis in the muscles supplied.
Etiology and Prognosis of flaccid paralysis varies considerably in importance according to its etiology. The connection between the end-apparatus of the nerve and the muscle may be dis turbed by poisons or degenerative agents (neuritides, muscular dystro phies). Mechanical injuries may affect the peripheral nerve-conduction (fractures, injuries, compression from hemorrhages). The nerves which lie close to the bone or which run through bony canals often have to suffer from pressure or from fixation to their rigid neighborhood from scars (paralyses of the radial nerve in fractures of the humerus, paresis of the facial nerve in otitic processes).
The nearer the site of injury is to the centre the greater will be the paralyzed field, because this will then correspond to the injury of col lective circuits (plexus paralyses). In flaccid paralyses of a central origin in children the scat will be usually found in the spinal cord (polio myelitis, spinal meningitis, Landry's paralysis, progressive muscular atrophies of unknown etiology); tubercular and tumorous processes in the spinal canal and the brain are rarer causes of flaccid paralyses.
Before treating flaccid paralyses, we have to analyze most care fully their etiology and pathologic anatomy, because this will determine the prognosis.
Postdiphtheritic and neuritic flaccid paralyses give a favorable prognosis and we can determine their nature from the history and their clinical course. In these cases surgical interference would be a mistake, even treatment with apparatus is not absolutely necessary, and we must wait at least a sufficient time for spontaneous recovery. Improvement is possible even after years; the slight voluntary fibrillations which we were frequently able to observe from the beginning often increase from reconstruction of the muscular material to entire recovery of their power.
Prognostically opposite are the severe destructions and degenera tions of a progressive character, though these are fortunately rarer (Landry's paralysis, progressive atrophy and dystrophies of the muscles). The rapid course will here render all surgical aid superfluous, but even in the more lingering extensive progressive muscular atrophies we must abstain from all radical surgical operations, and we shall only enable the child to move around as long as possible by supplying it with some sensible apparatus or chair to walk with, and thus make its existence bearable until either a sure cessation has set in or until an attack upon the higher centres frustrates our efforts.
In poliomyelitic paralysis (Ileine-Mcdin's disease) again things are different. Here we have to deal with an infectious inflammatory process in the anterior horns of the spinal cord, though we do not yet know the infecting agent which appears in epidemics. Reactive processes /1101.1 the focus take place here the same as in infections in other organs; through the spreading of the infection, through collateral edema, the function of the nerves will be disturbed over a large area (considerable peripheric spreading of the primary paralysis). The reactive and regenerative action of the protective apparatus of the body will wall in the infection, and either surmount it entirely at times or a focus of destruction will remain which is finally absorbed and replaced by a scar. In the course of 60111e months the peripheral paralysis will either dis appear entirely or the part corresponding to the scar will be finally paralyzed, though slight improvement may be observed even after years.
From this we will see that the time which has elapsed since the attack, as well as the condition of the affected muscle, will determine our further action.