It is important both from the diagnostic and prognostic viewpoint to determine the seat of the lesion in the peripheral portion of the facial nerve. If the lesion is at the base of the brain, there will be involvement of other nerves (auditory) and symptoms of cerebral disease. If the nerve is diseased in the region of the geniculate ganglion, there may (possibly) be a disturbance of lachrymation and (less certainly) paralysis of the soft palate. A disturbance within the ear produces characteris tic symptotns because the corda tytnpani is given off in that situation. There is impairment of the sense of taste in the anterior portion of the tongue and the secretion of saliva is decreased. In (rheumatic or traumatic) lesions situated at the stylomastoid there is muscular palsy without secretory or gustatory disturbances. The diagnosis between central and peripheral facial palsy rests on the fact that in the former the superior branch usually escapes, on the preservation of electric irri tability, and on paralysis of the extretnities, which is usually present also.
The treatment of facial palsy is chiefly concerned with the cause of the condition. Unfortunately even the complete cure of aural disease by a radical operation is not always followed by recovery from the facial palsy. In fact, the latter not infrequently first makes its ap pearance after an operation on the ear. In other forms of facial palsy potassium iodide or one of the salicylates (aspirin), depending on the cause, may be administered with doubtful chances of success, and elec tric treatment resorted to early. Local bleeding behind the ear and hot applications are also emyloyed. If there is lagophthalmus, the eye should be covered with moist dressings during sleep in order to prevent excessive drying of the conjunctiva.
2. Palsies of Other Cranial Nerves Other cranial nerve palsies, as paralysis of the spinal accessory, trifacial and hypoglossus, occur only in association with certain affec tions of the brain and medulla, so that it seems superfluous to discuss them at this place.
Isolated palsies of the ocular muscles may occur and have already been described as congenital, as muscular disturbances, and as the re sults of hereditary syphilis.
Periodic oculomotor palsy is a term used to describe a disease oc curring in children and characterized by paroxysmal, total and partial paralysis of one oculomotor nerve accompanied by migraine. During the intervals between the attacks the muscular function of the affected eye is either normal or but slightly impaired. The individual attacks last only a few days, or, in rare cases, weeks or months. With the ex ception of neuropathic symptonis that are occasionally present, the patients are otherwise free from nervous disease.
The nature of periodic oculomotor palsy is still in doubt, and opinions are divided in regard to its exact nosologic definition. In the limited number of cases in which autopsy could be performed, neoplasms or inflammations of the oculomotor were found. It is possible, how ever, that the condition begins as a vasomot or disturbance, which later forms the starting point of more serious lesions. To what extent periodic oculomotor palsy may be classified under the head of migraine is still undecided (Mobius). The prognosis as to recovery is doubtful, and not
altogether favorable with regard to the general health on account of the possibility of a neoplasm developing. The treatment is the same as that of migraine.
3. SerraIns Magnus Paralysis Paralysis of the serratus magnus or, in other words, an isolated paralysis of the long thoracic (posterior thoracic ? Morris) nerve has been observed after injuries, diphtheria, influenza, etc. Possibly it may also be eong,enital. The most striking symptom is the wing-like projection of the shoulder blade when the arm is raised and brought forward. During rest the shoulder blade is higher than its fellow and the distance between the angle and the vertebral column is diminished. This approximation of the scapula to the tnedian line becomes more distinct when the arm is raised to the horizontal position. The patients are unable to carry the arm beyond that plane.
I. Palsies in the Distribution of the Cervical Brachial Plexus Palsies in the distribution of the cervical plexus are of great impor tance in childhood; they result from birth injuries (see diseases of the newborn).
The sensory- and motor disturbances which result from pressure of cervical ribs on the nerves of the arm usually manifest themselves after the age of childhood.
A disease which is peculiar to childhood, although it is still a matter of dispute whether it should be included among the peripheral nervous diseases, is known as paralysie doulourense Chassaignae or painful paralysis of the arms in small children. It is observed in children be tween the ages of one and four years and is caused by a sudden pull on the arm as, for instance, in saving the child from a fall, or by some other forced movement of the arm. It is doubtful whether this form of palsy ever occurs without a preceding traumatism; in such eases there must always remain a suspicion that the nurse has probably concealed the cause. The injury is followed immediately by evidences of acute pain and the arm drops to the side as though paralyzed. The physician, who is usually sent for at once by the frightened attendants, finds on examination complete loss of movement in the arm, which is in prona tion, but no other disturbances. Passive movements elicit intense pain and resistance on the part of the child, but can be carried ottt without difficulty in all the joints of the body. No injury is found in the bones or joints, the muscles react normally to the electric current and the deep reflexes are not altered. Examination of the injured arm is ren dered difficult on account of the great pain, which is most marked during attempts at supination and pronation; but there are no regular, recur rent painful spots or pressure points. It is difficult to decide whether there is really abnormal sensitiveness to pain in the skin or whether the child cries out when one attempts to touch it because it is afraid of being hurt. The whole contlition, which at first is so alarming, rapitlly subsides without leaving any permanent damage. In from one to two days motion returns; in from four to five days, sometimes earlier, the normal conditions are entirely restored.