The symptoms which are produced by a lesion affecting the facial nerve in the Fallopian aqueduct are well seen in the following case : A little girl, aged sixteen mouths, was admitted into the East London Children's Hospital on March 24th. The mother stated that the child had been always healthy until two weeks previously, when she had begun to be feverish and to be irritable and thirsty. For the same time she had been losing flesh and had had some cough. The day before, while sitting up in her mother's arms, the child had suddenly fallen backwards in a fainting condition, and had seemed to lose consciousness. It was then noticed that her face was drawn to the right. On admission there was found complete paralysis of the left side of the face, and the left eye closed incompletely. The uvula was small and showed no distortion. A discharge escaped from the left ear, but the mother could not say how long this had been going on. On examination of the chest there was impaired resonance at each apex, and the breathing was high-pitched and bronchial, with a large bubbling rhonchus. Over 12oth sides of the chest dry and moist riles were heard. During the first fortnight of the child's residence in the hospital her temperature varied between 99° and She took her food fairly well, but seemed to swallow with difficulty, and occasionally fluids returned through the nose. The paralysis of the face continued, and the left eye became red and congested. The otorrhcea improved ; but the child's temperature became higher, and rose to in the evening. Then the left cornea sloughed, and the patient died suddenly on April 19th.
After death both lungs were found studded over with small cheesy masses. On examination of the left ear the tympanic membrane was de stroyed ; the a3sicles were carious and broken down ; the tympanum and mastoid cells were filled with pus ; the wall of the tympanum was carious, and a probe could be passed though it in the direction of the Fallopian canal. There was no inflammation of the brain or its membranes. The cranial sinuses were not examined.
The occurrence of the paralysis is not always attended with symptoms of shock, as in the above instance. Usually it is only discovered acci dentally by noticing a deviation in the child's face when it cries. The sloughing of the cornea in the case narrated was due to implication of the sensory branch of the fifth nerve.
In the parts supplied by the paralysed facial nerve the loss of power is usually complete ; and if the lesion affect the nerve after its passage through the internal auditory meatus—that is to say, if the facial nerve and no other be implicated, the motion of the tongue is unimpaired, the muscles of mastication act well, and there is no loss of power in the levator palpebrm or the muscles of the eyeball. In all but the mildest forms the paralysed muscles soon lose their irritability, and cease to respond to the electric current.
When the paralysis is due to caries of the petrous bone there is usually discharge from the meatus of a very offensive kind, and more or less im pairment of hearing. When the cause of the loss of power is inside the skull cavity, we get signs indicating the involvement of other nerves. There is squinting,, or deafness, or and hemiplegia may be pres ent. Occasionally it happens that paralysis of the sensory branch of the fifth nerve accompanies the facial paralysis. If this nerve be affected at a, point anterior to the Gasserian ganglion, where it lies on the petrous part, of the temporal bone, there result loss of sensibility of that side of the face, of the conjunctiva, and of the anterior portion of the tongue, also,. inflammation of the conjunctiva, and ulceration of the cornea. If the
be affected at a point posterior to the Gasserian ganglion, inflammation and ulceration of the cornea do not follow, although the sensibility of the face is still affected. If the portia Jura be diseased at its origin in the nucleus common to it and the sixth nerve, internal strabismus from paralysis of the external rectus muscle of the eyeball will accompany the facial palsy.
Diagnosis and Prognosis.—If the paralysis is noticed directly after birth in'a child who has been delivered with instruments, the cause of the in firmity is evident and the prognosis most favourable. In older babies and young children it is very important to discover the seat of the lesion. If it is due to caries of bone, and the nerve is consequently affected in the Fal lopian canal, there is an offensive discharge from the auditory meatus, and the sense of hearing is more or less blunted. Perhaps, also, we can detect a certain degree of flattening of the palatal arch on the affected side, with a little twisting of the uvula, but this sign in children whose uvula is small is often absent. The existence of impairment or perversion of the sense of taste is also impossible to ascertain in young children. In them old standing otorrhoea, or even a recent offensive discharge from the meatus, combined with facial paralysis, affords suspicion of the strongest kind that the facial nerve is affected in the Fallopian aqueduct. The prognosis in these cases is very unfavourable. In fact, death usually occurs sooner or later from extension of the inflammation to the dura plater and the brain. The form of facial palsy which is found in children under the age of three years is commonly due to this cause. In an older child, if the paralysis has not been preceded by any impairment of the sense of hearing, or by otorrhcea ; if his sense of taste is natural, his mouth perfectly moist, and his uvula straight, we may conclude that the nerve is affected in the third part of its course. If, as usually happens in such cases, there is history of to cold or of some slight injury to the face, the prognosis is favourable although recovery may take some tine.
Treatme•t.—Facial palsy from pressure of the forceps during delivery soon disappears, and little treatment is required beyond frequent frictions to the face. Paralysis from cold should be treated by steady frictions with stimulating liniments, and the affected side of the face should be wrapped up in cotton wool. Electricity is useful. Dr. Duclienne's plan was to em ploy first the constant current with frequent intermissions, and as the ir ritability of the muscles returned, to make the intermissions less frequent and the sittings shorter. He never used faradism until several weeks had elapsed after the beginning of the paralysis, although at the later stage he allowed its value. Under the use of these measures the tonicity of the muscles returns, and the face regains its symmetry some weeks before voluntary power is restored.
Besides electricity and passive exercise, Dr. NV. A. Hammond recom mends the early employment of strychnia in sufficient doses to bring the patient under the full influence of the drug. He also insists upon the im portance of supporting the affected side of the face by means of a little hook placed in the angle of the mouth and fastened to the ear. But me chanical supports of this kind, which depend for their usefulness upon the intelligent co-operation of the patient, are not well suited to young children.
In cases where the palsy is due to disease of bone, little can be done in the way of treatment. Our efforts must be then directed entirely to the cure of the otitis. •