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Journal of the History of the Neurosciences: Basic and Clinical Perspectives Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/njhn20
Early Observations on Facial Palsy a
J. M. S. Pearce a
Department of Neurology, Hull Royal Infirmary, East Yorks, England Published online: 16 Dec 2014.
Click for updates To cite this article: J. M. S. Pearce (2014): Early Observations on Facial Palsy, Journal of the History of the Neurosciences: Basic and Clinical Perspectives, DOI: 10.1080/0964704X.2014.956923 To link to this article: http://dx.doi.org/10.1080/0964704X.2014.956923
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of the History of the Neurosciences, 00:1–7, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0964-704X print / 1744-5213 online DOI: 10.1080/0964704X.2014.956923
Early Observations on Facial Palsy J. M. S. PEARCE
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Department of Neurology, Hull Royal Infirmary, East Yorks, England Before Charles Bell’s eponymous account of facial palsy, physicians of the Graeco-Roman era had chronicled the condition. The later neglected accounts of the Persian physicians Abu al-Hasan Ali ibn Sahl Rabban al-Tabari and Abu Bakr Muhammad ibn Zakar¯ıya R¯azi (“Rhazes”) and Avicenna in the first millennium are presented here as major descriptive works preceding the later description by Stalpart van der Wiel in the seventeenth century and those of Friedreich and Bell at the end of the eighteenth and the beginning of the nineteenth centuries. Keywords facial palsy, history, Bell, Ali ibn Sahl Rabban al-Tabari, Abu Bakr Muhammad ibn Zakariy¯a R¯az¯ı (“Rhazes”), Avicenna
The importance of observation and careful examination is seen in ancient writings and relates directly to modern practice. Long before Charles Bell’s (1774–1842; Pearce 1993) famous, eponymous account of facial palsy (Pearce, 1999) and its anatomical basis (Bell, 1821, 1829), Aulus Cornelius Celsus (1st century AD) and Aretaeus of Cappadocia (c. 2nd century AD), physicians of the Graeco-Roman era (Spencer, 1971) had chronicled facial paralysis. Aretaeus recorded: “Wherefore, the parts are sometimes paralyzed singly, as one eye-brow, or finger” (Pearce, 2013). He described facial distortion in cynic spasm, a condition of unilateral facial muscle spasms reminiscent of hemifacial spasm (Pearce, 2013). However, the clinical patterns and significance remain unclear. Galen (131–201 AD) described how separate nerves or branches innervated different parts of the face and identified the facial nerve as the fifth pair; it passed through “the blind or one-eyed canal [stylomastoid foramen] close by the auditory meatus” (Pearce, 2013). When Persia was defeated by the Arab conquest in 651 AD, the patronage of the new rulers supported efforts to translate the ancient Greek and Roman texts into the Arabic languages. The translators were Nestorian Christians initially, such as Hunayn b. Ishaq, the great translator of Galen. We have no evidence in medicine of non-Arab Muslim or Jewish translators. Abu al-Hasan Ali ibn Sahl Rabban al-Tabari (c.810–c.861 AD; see Figure 1) was a Persian physician known as Tabari who converted from Christianity to Islam (Khan, 1990). His father was a respected physician from Tabaristan in Persia (Ibn Rabban Tabari, 2008 as cited by Sajadi, Sajadi, & Tabatabaie, 2011; Shoja et al., 2009). Tabari’s ninth century work Firdaws al-hikma [Paradise of Wisdom] was a seven-volume textbook (Khan, 1990) first edited in the twentieth century by M. Z. Siddiqui. It contains a section on paralysis and tremors in which Tabari amplifies Galen’s account: Address correspondence to J. M. S. Pearce, 304 Beverley Road Anlaby, East Yorks, HU10 7BG, England. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/njhn.
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Figure 1. Abu al-Hasan Ali ibn Sahl Rabban al-Tabari. Posted by “vickysoomro” on June 5, 2011. Retrieved from http://thepage4u.wordpress.com/2011/06/05/ali-ibn-rabban-al-tabari.
If half of the face becomes paralyzed, it will be drawn to the healthy side, because the muscles that are healthy are strong, and will pull the paralyzed muscles toward itself. (Sajadi et al., 2011) Facial paralysis was treated as a disorder separate from facial “cynic” spasm and from the combined paralysis of both face and limbs. Tabari thus appears to have given an accurate description of isolated facial palsy. Avicenna (980–1037) also described spastic, atonic, and convulsive types of facial palsy (Gruner, 1930), corresponding to current nomenclature of upper motor neurone, lower motor neurone, and probably hemifacial spasm. Avicenna reported: [A] disease in which the face is pulled unnaturally, its normal shape is distorted and the natural ability of both lips meeting is prevented. Tabari’s standing however, was eclipsed by his more famous pupil, Abu Bakr Muhammad ibn Zakar¯ıya R¯azi (“Rhazes”; see Figure 2), a Persian physician known as Razi (c. 865– c. 925 AD), who was born in the city of Rey (near Tehran) and practiced there and in Baghdad. Razi was esteemed for his practice and scholarship (Elgood, 1951; Mohaghegh, 1992). Such was his fame that Caliph al Moktafi asked him to build the largest hospital in Baghdad. In his work, Kitab al-hawi, is a chapter entitled “Facial Distortion, Spasm and Paralysis,” cited by Shelley (2013). Al-Hawi was written for the ruler Man u¯ r ibn Is aq and became known in the West after Gerard of Cremona’s twelfth-century Latin translation. Razi ascribed the description of facial palsy to Galen and referred to Archigenes, Celsus, and other contemporaries. Like Tabari, he recognized facial paralysis as distinct from hemiplegic patients in whom both face and limbs were affected. Razi distinguished
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Figure 2. Drawing of Muhammad Zakariya Razi (see Koushan, 2012).
facial spasm from paralysis: “It is important, based on their special signs and symptoms to separate the two” (Razi, 1990, as cited by Sajadi et al., 2011). He said that with spasm the uvula was involved and that the muscles of the temples, cheeks, and forehead were hardened with tremors. In a different section, he wrote: According to my observations, I have found out that the wrinkles on the forehead of the affected side disappear and the skin in that area is pulled strongly. The source of facial distortion is either spasm or paralysis, and these two can be differentiated by pain, as the paralytic type is without pain. (Ibid.) Here, Razi described a clinical method for distinguishing spasm and paralysis. However, Razi omits mention of Tabari but quotes the observation of his contemporary Bolus (physician to the ninth-century Abbasid Caliph Al– Mu’tasim): “paralysis is not seen on the distorted side of the face; rather, it is on the opposite side” (Sajadi et al., 2011). He also cites Ibn Batrigh (known as Eutychius, 877–940 AD): [T]he patient’s face while smiling is crooked, and the eye on the affected side is sunken in, small, and always has tears running down it. The patient chews food on the unaffected side, they speak softly, and mood is depressed. (Sajadi et al., 2011)
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J. M. S. Pearce Razi also describes bilateral facial palsy: I have seen a man who was affected by a type of facial distortion in which his face was not crooked, but one of his eyes he could barely close and his other not at all, and when drinking, water would flow from his mouth. The lack of his crooked appearance was because both sides were affected by the disease. (Ibid.)
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Differentiating central from peripheral lesions and prognostic factors Razi noted the preservation of sight, hearing, and sensation in peripheral palsy; he reported central facial palsy: Some patients, following facial distortion, suffer from a stroke, some die, and some develop paralysis. Thus, pay attention and if the facial distortion is attended by confusion and difficulty in moving the body or limbs, then immediate treatment is needed. (Ibid.) In the modern era, doctors still sometimes struggle to differentiate a lower from an upper motor neuron palsy; these historical perspectives show this to be an old problem in which the elicitation of physical signs relates to modern practices. Razi’s treatments included rest in a warm room, vigorous massage, warming oils, ointments, and compresses, inhaled medicines to induce sneezing, oral medications, laxatives, special diets, phlebotomy, and application of a bandage to the distorted area to counteract the unbridled pull of the muscles. He recognized that the condition could be self-limiting. Treatment could last up to a month, but “if six months passes after the start of the facial distortion, and it is unchanged, it is unlikely to resolve” (Ibid.). Shoja et al. (2009) recently provided a translation of an abridged version (not the primary text) of al-Hawi (Razi, 1990) on facial palsy, where they identified inconsistencies (Sajadi et al., 2011, pp. 117–128). Other early accounts of facial palsy, cited here, describe the condition, but Razi’s was one of the earliest detailed descriptions. Aggarawal records Muhammad Akbar Arz¯an¯ı, (d. 1722), another influential practitioner of Islamic medicine, whose The M¯ız¯an-e Tibb described facial palsy before modern Western accounts. In the first chapter (third section), entitled “On Diseases of the Head” (b¯ım¯ar¯ı-h¯a-e sar) Arz¯an¯ı described the symptoms and treatments of facial paralysis: The signs of flaccidity are dimness (kud¯urat) of the senses, loss of taste, and the hanging down (firo hishtan) of the bottom eyelid and mouth. And the signs of paralysis are stretching (tamaddud) of the skin of the forehead and paucity of the water of the mouth. (Aggarawal, 2013) He advocated Chinese mirror therapy permitting the patient to view his face during therapy. Not until 1683 did Cornelis Stalpart van der Wiel (1620–1702) elaborate lower motor neurone facial palsy; he also credited Avicenna (980–1037) with describing it before him (Gruner, 1930). Avicenna had much earlier described spastic, atonic, and convulsive types of facial palsy. Bell in a letter to Professor Descot referred to the French neurologist, Roux, who described his own facial nerve paralysis (Bell, 1827) with hyperacusis and altered taste. Earlier still was a sketchy account of James Douglas in 1704 (Bird, 1979). However, it was Nikolaus Anton Friedreich (1761–1836), who comprehensively reported three cases of peripheral facial paralysis in 1798 (Friedreich, 1798, as cited by Bird, 1979; Pearce 1999).
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He was probably the grandfather of Nikolaus Friedreich of Würzburg and Heidelberg who elucidated hereditary ataxia:
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A man of forty-six years . . . exposed the left side to a stream of cold air from a window. . . . In the morning after a very restless night a very painful swelling, of the size of a hazel nut, appeared in the neighbourhood of the left mastoid process . . . the malady was recognized to be rheumatic . . . On the morning of the fifth day, our author found the muscles of the left side of the face paralyzed, and the mouth and the nose drawn towards the right side . . . the integrity of all the senses, and of all the other muscles of the body, he could not view the evil as apoplectic, but as being local and proceeding from the rheumatism. (Friedreich, 1798, as cited by Bird, 1979; Pearce, 1999) Various local treatments (aconite, guiac, antimonials, and blisters, etc.) were applied by Friedreich “for seven weeks without any amendment”: He employed: weak and few electric shocks, but gradually stronger and more numerous . . . directed them variously through the left side of the face from that place where the nerve comes through the stylomastoid foramen . . . At last their voluntary action returned by degrees and after electricity had been used for a month, volition had regained its full energy, and the face its natural appearance. (Friedreich, 1798, as cited by Bird, 1979; Pearce, 1999) The report in 1704 of James Douglas F. R. S. (1675–1742), a Scottish anatomist and Physician Extraordinary to Queen Caroline (Shelley, 2013) and the Dutch physician, Cornelis Stalpart van der Wiel also preceded Bell (van de Graaf and Nicolai, 2005). In 1804/1805 Evert Jan Thomassen à Thuessink (1762–1832) published an extensive study on idiopathic peripheral facial paralysis (Thomassen à Thuessink, 1804) that he related to trigeminal neuralgia and attributed to rheumatism.
Discussion Undoubtedly, these physicians would have been intrigued by the current use of steroids and antiviral drugs (Sullivan et al., 2007; Engstrom et al., 2008). The Cochrane report concluded that the evidence robustly supports the treatment of Bell’s palsy with oral prednisolone and shows that antivirals alone or in addition to steroids provide no additional benefit (Salinas et al., 2010). Charles Bell’s much-cited paper (Bell, 1821) to the Royal Society of 1821 gave a brief but unmistakable account of facial paralysis of lower motor neuron type: the “respiratory nerve of the face.” Bell deserves full credit for his account of facial palsy. His paper records a Mr. Daniel Quick, gored by an ox, and several other, mostly traumatic causes, although the idiopathic condition we now call Bell’s palsy was not really part of his description. The variable involvement of the nerve to stapedius causing transient hyperacusis and of the chorda tympani producing impairment of taste were elaborated at a later date, and well described, inter alia by Todd, Gowers, and Wilson. Bell clearly separated it from the palsy of upper motor neuron lesions, although this terminology was not then in use. His important lecture to the Royal Society in 1826, graphically showing the upturning of the globe (Bell’s
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sign), received more attention from Gowers and later Kinnier Wilson than his account of facial palsy. Bell provided a subsequent and more detailed report in 1829. The symptoms described by past generations can plainly be recognized as evolving into modern accounts of the clinical features that have been enhanced by improved knowledge of facial nerve anatomy. Both transcranial magnetic stimulation tests performed within seven days (Hur et al., 2013) and electrophysiological tests of amplitude and latency of muscle-evoked potentials and R1 monosynaptic blink reflex response after 14 days, though seldom clinically necessary, may facilitate prognosis (Djordjevi´c & Djuri´c, 2005).
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References Aggarwal NK (2013): Mirror therapy for facial paralysis in traditional South Asian Islamic medicine. Journal of the History of the Neurosciences 22: 1–5. Bell C (1821): On the nerves: Giving an account of some experiments on their structure and functions, which lead to a new arrangement of the system. Philosophical Transactions of the Royal Society of London 111: 398–424. Bell C (1827): Case of paralysis of the face. In: M. le Professeur Roux, of Paris; communicated by himself to M. Descot. Appendix to the papers on the nerves. London, Longman, Hurst, Rees, Orme, Brown & Green, pp. 68–72. Bell C (1829): On the nerves of the face, being a second paper on that subject. Philosophical Transactions of the Royal Society of London 119: 317–330. Reprinted in Medical Classics. Williams & Wilkens, USA, 1936; 1: 155–167. Bird TD (1979): Nicolaus A. Friedreich’s description of peripheral facial nerve paralysis in 1798. Journal of Neurology, Neurosurgery & Psychiatry 42: 56–58. Djordjevi´c G, Djuri´c S (2005): Early prognostic value of electrophysiological tests in Bell’s palsy. Medicine and Biology 12: 47–54. Elgood C (1951): A Medical History of Persia and the Eastern Caliphate. Cambridge, UK, University Press. Engström M, Berg T, Stjernquist-Desatnik A, Axelsson S, Pitkäranta A, Hultcrantz M, . . . Jonsson L (2008): Prednisolone and valaciclovir Bell’s palsy: A randomized, double-blind, placebocontrolled mulicentre trial. Lancet Neurology 7: 993–1000. Friedreich NA (1798): De paralysis musculorum faciei rheumatica. Journal der Erfindungen (Gotha) 8(25). Quoted in English in Annals of Medicine (Edinburgh) 1800; 5: 214–226. Cited by Bird TD. Gruner OC (1930): A Treatise on the Canon of Medicine of Avicenna Incorporating a Translation of the First Book. London, Luzac. Retrieved from http://archive.org/stream/ AvicennasCanonOfMedicine/9670940-Canon-of-Medicine_djvu.txt Hur DM, Kim SH, Lee YH, Kim SH, Park JM, Kim JH, . . . Oh KJ (2013): Comparison of transcranial magnetic stimulation and electroneuronography between Bell’s palsy and Ramsay Hunt Syndrome in their acute stages. Annals of Rehabilitation Medicine 37(1): 103–109. Ibn Rabban Tabari. (2008): Minavi Kheradya Ferdos Hekmat Dar Teb [The Paradise of Wisdom], trans. Madani SA, Boroujerdi A. Tehran, Mehr Amin Press. Khan MS (1990): Ali ibn Rabban at-Tabari, a ninth century Arab physician, on the Ayurveda. Indian Journal of History of Science 25: 1–4. Koushan J (2012): Drawing of Muhammad Zakariya Razi. Retrieved from http://commons. wikimedia.org/wiki/File:Zakariya_Razi_001.JPG Mohaghegh M (1992): The “Kitab al- Shukuk’alas Jalinus” of Muhammad ibn Zachariya al-Razi. Medical Journals of the Islamic Republic of Iran 6(3): 47–51. Pearce JMS (1993): Sir Charles Bell (1774–1842). Journal of the Royal Society of Medicine 86: 353–354. Pearce JMS (1999): Bell’s or Friedreich’s palsy. Journal of Neurology, Neurosurgery & Psychiatry 67: 732.
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Pearce JMS (2013): The neurology of Aretaeus: Radix Pedis Neurologia. European Neurology 70(1–2): 106–112. Razi (1990): Al–Hawi al–Kabirfi al–Tib [Continens Liber]: Hyderabad version (1955), trans. Tabatabaie SM. Tehran, al–Hawi Pharmaceutical Company. Sajadi MM, Sajadi MR, Tabatabaie SM (2011): The history of facial palsy and spasm: Hippocrates to Razi. Neurology 77(2): 174–178. Salinas RA, Alvarez G, Daly F, Ferreira J (2010): Corticosteroids for Bell’s palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews 17(3). doi:10.1002/14651858.CD001942. Shelley BP (2013): Historical perspectives of facial palsy: Before and after Sir Charles Bell to facial emotional expression. Archives of Medicine and Health Sciences 1: 85–88. Shoja MM, Tubbs RS, Loukas M, Shokouhi G, Ardalan MR (2009): Facial palsy and its management in the Kitab al–Hawi of Rhazes. Neurosurgery 64(6): 1188–1190. Spencer WG (1971): Celsus AC. De Medicina, an English translation. Cambridge, MA, Harvard University Press. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, Davenport RJ, Vale LD, Clarkson JE, Hammersley V, Hayavi S, McAteer A, Stewart K, Daly F (2007): Early treatment with prednisolone or acyclovir in Bell’s Palsy. The New England Journal of Medicine 357: 1598–1607. Thomassen à Thuessink EJ (1804): Verhandeling over de paralysis rheumatica musculorum faciei [Report on rheumatic paralysis of the facial muscles]. Het Medisch Magazijn Leijden 3: 91–99. van de Graaf RC, Nicolai JP (2005): Bell’s palsy before Bell: Cornelis Stalpart van der Wiel’s observation of Bell’s palsy in 1683. Ontology & Neurotology 26: 1235–1238.
Journal of the History of the Neurosciences: Basic and Clinical Perspectives Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/njhn20
Early Observations on Facial Palsy a
J. M. S. Pearce a
Department of Neurology, Hull Royal Infirmary, East Yorks, England Published online: 16 Dec 2014.
Click for updates To cite this article: J. M. S. Pearce (2014): Early Observations on Facial Palsy, Journal of the History of the Neurosciences: Basic and Clinical Perspectives, DOI: 10.1080/0964704X.2014.956923 To link to this article: http://dx.doi.org/10.1080/0964704X.2014.956923
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of the History of the Neurosciences, 00:1–7, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0964-704X print / 1744-5213 online DOI: 10.1080/0964704X.2014.956923
Early Observations on Facial Palsy J. M. S. PEARCE
Downloaded by [Colorado College] at 16:57 08 April 2015
Department of Neurology, Hull Royal Infirmary, East Yorks, England Before Charles Bell’s eponymous account of facial palsy, physicians of the Graeco-Roman era had chronicled the condition. The later neglected accounts of the Persian physicians Abu al-Hasan Ali ibn Sahl Rabban al-Tabari and Abu Bakr Muhammad ibn Zakar¯ıya R¯azi (“Rhazes”) and Avicenna in the first millennium are presented here as major descriptive works preceding the later description by Stalpart van der Wiel in the seventeenth century and those of Friedreich and Bell at the end of the eighteenth and the beginning of the nineteenth centuries. Keywords facial palsy, history, Bell, Ali ibn Sahl Rabban al-Tabari, Abu Bakr Muhammad ibn Zakariy¯a R¯az¯ı (“Rhazes”), Avicenna
The importance of observation and careful examination is seen in ancient writings and relates directly to modern practice. Long before Charles Bell’s (1774–1842; Pearce 1993) famous, eponymous account of facial palsy (Pearce, 1999) and its anatomical basis (Bell, 1821, 1829), Aulus Cornelius Celsus (1st century AD) and Aretaeus of Cappadocia (c. 2nd century AD), physicians of the Graeco-Roman era (Spencer, 1971) had chronicled facial paralysis. Aretaeus recorded: “Wherefore, the parts are sometimes paralyzed singly, as one eye-brow, or finger” (Pearce, 2013). He described facial distortion in cynic spasm, a condition of unilateral facial muscle spasms reminiscent of hemifacial spasm (Pearce, 2013). However, the clinical patterns and significance remain unclear. Galen (131–201 AD) described how separate nerves or branches innervated different parts of the face and identified the facial nerve as the fifth pair; it passed through “the blind or one-eyed canal [stylomastoid foramen] close by the auditory meatus” (Pearce, 2013). When Persia was defeated by the Arab conquest in 651 AD, the patronage of the new rulers supported efforts to translate the ancient Greek and Roman texts into the Arabic languages. The translators were Nestorian Christians initially, such as Hunayn b. Ishaq, the great translator of Galen. We have no evidence in medicine of non-Arab Muslim or Jewish translators. Abu al-Hasan Ali ibn Sahl Rabban al-Tabari (c.810–c.861 AD; see Figure 1) was a Persian physician known as Tabari who converted from Christianity to Islam (Khan, 1990). His father was a respected physician from Tabaristan in Persia (Ibn Rabban Tabari, 2008 as cited by Sajadi, Sajadi, & Tabatabaie, 2011; Shoja et al., 2009). Tabari’s ninth century work Firdaws al-hikma [Paradise of Wisdom] was a seven-volume textbook (Khan, 1990) first edited in the twentieth century by M. Z. Siddiqui. It contains a section on paralysis and tremors in which Tabari amplifies Galen’s account: Address correspondence to J. M. S. Pearce, 304 Beverley Road Anlaby, East Yorks, HU10 7BG, England. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/njhn.
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Figure 1. Abu al-Hasan Ali ibn Sahl Rabban al-Tabari. Posted by “vickysoomro” on June 5, 2011. Retrieved from http://thepage4u.wordpress.com/2011/06/05/ali-ibn-rabban-al-tabari.
If half of the face becomes paralyzed, it will be drawn to the healthy side, because the muscles that are healthy are strong, and will pull the paralyzed muscles toward itself. (Sajadi et al., 2011) Facial paralysis was treated as a disorder separate from facial “cynic” spasm and from the combined paralysis of both face and limbs. Tabari thus appears to have given an accurate description of isolated facial palsy. Avicenna (980–1037) also described spastic, atonic, and convulsive types of facial palsy (Gruner, 1930), corresponding to current nomenclature of upper motor neurone, lower motor neurone, and probably hemifacial spasm. Avicenna reported: [A] disease in which the face is pulled unnaturally, its normal shape is distorted and the natural ability of both lips meeting is prevented. Tabari’s standing however, was eclipsed by his more famous pupil, Abu Bakr Muhammad ibn Zakar¯ıya R¯azi (“Rhazes”; see Figure 2), a Persian physician known as Razi (c. 865– c. 925 AD), who was born in the city of Rey (near Tehran) and practiced there and in Baghdad. Razi was esteemed for his practice and scholarship (Elgood, 1951; Mohaghegh, 1992). Such was his fame that Caliph al Moktafi asked him to build the largest hospital in Baghdad. In his work, Kitab al-hawi, is a chapter entitled “Facial Distortion, Spasm and Paralysis,” cited by Shelley (2013). Al-Hawi was written for the ruler Man u¯ r ibn Is aq and became known in the West after Gerard of Cremona’s twelfth-century Latin translation. Razi ascribed the description of facial palsy to Galen and referred to Archigenes, Celsus, and other contemporaries. Like Tabari, he recognized facial paralysis as distinct from hemiplegic patients in whom both face and limbs were affected. Razi distinguished
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Figure 2. Drawing of Muhammad Zakariya Razi (see Koushan, 2012).
facial spasm from paralysis: “It is important, based on their special signs and symptoms to separate the two” (Razi, 1990, as cited by Sajadi et al., 2011). He said that with spasm the uvula was involved and that the muscles of the temples, cheeks, and forehead were hardened with tremors. In a different section, he wrote: According to my observations, I have found out that the wrinkles on the forehead of the affected side disappear and the skin in that area is pulled strongly. The source of facial distortion is either spasm or paralysis, and these two can be differentiated by pain, as the paralytic type is without pain. (Ibid.) Here, Razi described a clinical method for distinguishing spasm and paralysis. However, Razi omits mention of Tabari but quotes the observation of his contemporary Bolus (physician to the ninth-century Abbasid Caliph Al– Mu’tasim): “paralysis is not seen on the distorted side of the face; rather, it is on the opposite side” (Sajadi et al., 2011). He also cites Ibn Batrigh (known as Eutychius, 877–940 AD): [T]he patient’s face while smiling is crooked, and the eye on the affected side is sunken in, small, and always has tears running down it. The patient chews food on the unaffected side, they speak softly, and mood is depressed. (Sajadi et al., 2011)
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J. M. S. Pearce Razi also describes bilateral facial palsy: I have seen a man who was affected by a type of facial distortion in which his face was not crooked, but one of his eyes he could barely close and his other not at all, and when drinking, water would flow from his mouth. The lack of his crooked appearance was because both sides were affected by the disease. (Ibid.)
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Differentiating central from peripheral lesions and prognostic factors Razi noted the preservation of sight, hearing, and sensation in peripheral palsy; he reported central facial palsy: Some patients, following facial distortion, suffer from a stroke, some die, and some develop paralysis. Thus, pay attention and if the facial distortion is attended by confusion and difficulty in moving the body or limbs, then immediate treatment is needed. (Ibid.) In the modern era, doctors still sometimes struggle to differentiate a lower from an upper motor neuron palsy; these historical perspectives show this to be an old problem in which the elicitation of physical signs relates to modern practices. Razi’s treatments included rest in a warm room, vigorous massage, warming oils, ointments, and compresses, inhaled medicines to induce sneezing, oral medications, laxatives, special diets, phlebotomy, and application of a bandage to the distorted area to counteract the unbridled pull of the muscles. He recognized that the condition could be self-limiting. Treatment could last up to a month, but “if six months passes after the start of the facial distortion, and it is unchanged, it is unlikely to resolve” (Ibid.). Shoja et al. (2009) recently provided a translation of an abridged version (not the primary text) of al-Hawi (Razi, 1990) on facial palsy, where they identified inconsistencies (Sajadi et al., 2011, pp. 117–128). Other early accounts of facial palsy, cited here, describe the condition, but Razi’s was one of the earliest detailed descriptions. Aggarawal records Muhammad Akbar Arz¯an¯ı, (d. 1722), another influential practitioner of Islamic medicine, whose The M¯ız¯an-e Tibb described facial palsy before modern Western accounts. In the first chapter (third section), entitled “On Diseases of the Head” (b¯ım¯ar¯ı-h¯a-e sar) Arz¯an¯ı described the symptoms and treatments of facial paralysis: The signs of flaccidity are dimness (kud¯urat) of the senses, loss of taste, and the hanging down (firo hishtan) of the bottom eyelid and mouth. And the signs of paralysis are stretching (tamaddud) of the skin of the forehead and paucity of the water of the mouth. (Aggarawal, 2013) He advocated Chinese mirror therapy permitting the patient to view his face during therapy. Not until 1683 did Cornelis Stalpart van der Wiel (1620–1702) elaborate lower motor neurone facial palsy; he also credited Avicenna (980–1037) with describing it before him (Gruner, 1930). Avicenna had much earlier described spastic, atonic, and convulsive types of facial palsy. Bell in a letter to Professor Descot referred to the French neurologist, Roux, who described his own facial nerve paralysis (Bell, 1827) with hyperacusis and altered taste. Earlier still was a sketchy account of James Douglas in 1704 (Bird, 1979). However, it was Nikolaus Anton Friedreich (1761–1836), who comprehensively reported three cases of peripheral facial paralysis in 1798 (Friedreich, 1798, as cited by Bird, 1979; Pearce 1999).
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He was probably the grandfather of Nikolaus Friedreich of Würzburg and Heidelberg who elucidated hereditary ataxia:
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A man of forty-six years . . . exposed the left side to a stream of cold air from a window. . . . In the morning after a very restless night a very painful swelling, of the size of a hazel nut, appeared in the neighbourhood of the left mastoid process . . . the malady was recognized to be rheumatic . . . On the morning of the fifth day, our author found the muscles of the left side of the face paralyzed, and the mouth and the nose drawn towards the right side . . . the integrity of all the senses, and of all the other muscles of the body, he could not view the evil as apoplectic, but as being local and proceeding from the rheumatism. (Friedreich, 1798, as cited by Bird, 1979; Pearce, 1999) Various local treatments (aconite, guiac, antimonials, and blisters, etc.) were applied by Friedreich “for seven weeks without any amendment”: He employed: weak and few electric shocks, but gradually stronger and more numerous . . . directed them variously through the left side of the face from that place where the nerve comes through the stylomastoid foramen . . . At last their voluntary action returned by degrees and after electricity had been used for a month, volition had regained its full energy, and the face its natural appearance. (Friedreich, 1798, as cited by Bird, 1979; Pearce, 1999) The report in 1704 of James Douglas F. R. S. (1675–1742), a Scottish anatomist and Physician Extraordinary to Queen Caroline (Shelley, 2013) and the Dutch physician, Cornelis Stalpart van der Wiel also preceded Bell (van de Graaf and Nicolai, 2005). In 1804/1805 Evert Jan Thomassen à Thuessink (1762–1832) published an extensive study on idiopathic peripheral facial paralysis (Thomassen à Thuessink, 1804) that he related to trigeminal neuralgia and attributed to rheumatism.
Discussion Undoubtedly, these physicians would have been intrigued by the current use of steroids and antiviral drugs (Sullivan et al., 2007; Engstrom et al., 2008). The Cochrane report concluded that the evidence robustly supports the treatment of Bell’s palsy with oral prednisolone and shows that antivirals alone or in addition to steroids provide no additional benefit (Salinas et al., 2010). Charles Bell’s much-cited paper (Bell, 1821) to the Royal Society of 1821 gave a brief but unmistakable account of facial paralysis of lower motor neuron type: the “respiratory nerve of the face.” Bell deserves full credit for his account of facial palsy. His paper records a Mr. Daniel Quick, gored by an ox, and several other, mostly traumatic causes, although the idiopathic condition we now call Bell’s palsy was not really part of his description. The variable involvement of the nerve to stapedius causing transient hyperacusis and of the chorda tympani producing impairment of taste were elaborated at a later date, and well described, inter alia by Todd, Gowers, and Wilson. Bell clearly separated it from the palsy of upper motor neuron lesions, although this terminology was not then in use. His important lecture to the Royal Society in 1826, graphically showing the upturning of the globe (Bell’s
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sign), received more attention from Gowers and later Kinnier Wilson than his account of facial palsy. Bell provided a subsequent and more detailed report in 1829. The symptoms described by past generations can plainly be recognized as evolving into modern accounts of the clinical features that have been enhanced by improved knowledge of facial nerve anatomy. Both transcranial magnetic stimulation tests performed within seven days (Hur et al., 2013) and electrophysiological tests of amplitude and latency of muscle-evoked potentials and R1 monosynaptic blink reflex response after 14 days, though seldom clinically necessary, may facilitate prognosis (Djordjevi´c & Djuri´c, 2005).
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