Kinesiologo

30 September 1967

MEDICAL JOURNAL

BRmyI

815

Papers and Originals
Facial Paralysis*
HENRY MILLERt M.D., F.R.C.P.
Brit. med.
J.,

1967, 3, 815-819

At first sight facial paralysis seems a banal and even uninteresting subject. After all it is a common condition, often of no great clinical importance, and we deal with most of our cases by rule of thumb. In fact, it poses a numberof intriguing and unanswered questions in the fields of anatomy, neurophysiology, and pathology. Its systematic consideration covers a wide range of general medicine, and it affords a promising field for research by the subtle techniques of the applied neurophysiologist, as well as by the simpler methods of the clinician. If there is one particular lesson to be learnt from a review of this subjectit concerns the extent to which therapeutic practice depends on personal impression and uncontrolled observation, rather than on any scientific or rational basis. Nowhere is this more evident than in the case of Bell's palsy, which is bound to occupy a good deal of any discussion devoted to the problem of facial paralysis. An extensive review of the world literature has yielded no single shred ofscientifically valid evidence that surgical treatment exerts a favourable influence on the course of this disorder, yet there are surgeons all over the world who profess an almost religious conviction of its efficacy, and who apparently perform an operation of one kind or another on practically every case referred to them. Some such enthusiasm may of course be a spontaneous manifestation of thatinnate physical energy and joie de vivre that so often distinguishes the surgeon from his more debilitated medical colleagues. On the other hand, I do not find it easy to dissociate the repeated and urgent pleas that reverberate through the American literature describing Bell's palsy as a surgical emergency and begging the physician to refer it at once to the nearest otolaryngologist from thespecial economic conditions of practice in the United States. I am reminded of a revealing comment of that great medical historian Henry Sigerist, of Johns Hopkins University, 30 years
ago. He observed that the treatment of chronic rheumatism in the United States comprised a prolonged series of expensive injections carried out in the physician's office; in the Soviet Union it consisted of aprotracted and expensive course of physiotherapy carried out in a trade union nursing-home on the shores of the Black Sea. We have no evidence to show which of these was the more effective routine, or indeed whether either procedure influenced the course of the patient's disease for better or for worse. What this contrast certainly did reveal was the potent influence of social and economic considerationson medical practice in general and our therapeutic habits in particular. Perhaps the slight hint of therapeutic nihilism that our Continental visitors detect in the British approach to the treatment of facial palsy may not be entirely unconnected with the fact that we work in a professional environment where it is necessary neither to ensure the patients gratitude nor to impress him with thedynamism of our therapeutic approach.

Clinico-anatomical Considerations
The diagrammatic anatomy of the medical neurologist is of far cry from the flesh-and-blood anatomy of the surgeon. It is true also that there are many aspects of the finer structure and function of the facial nerve about which we remain woefully ignorant. However, we know enough to allow us to localize anatomical lesions of thisparticular nerve on the basis of simple clinical examination, an exercise always pleasurable to the neurologist. Here we will first discuss some of the commoner types of facial palsy as they arise from lesions at various sites on the motor pathway.
course a

Supranuclear Lesions
In the first place it must always be remembered that facial paralysis or weakness may be due to a lesion above...