A Brief History of Facial Paralysis: From Bell's Palsy to Hunt's Syndrome

The main function of the facial nerve is to innervate the facial expression muscles, so if the conduction pathway of the facial nerve is damaged, the facial expression muscles will be paralyzed, which is called "facial paralysis"
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Facial palsy is so common in neurology that it has been observed and documented very early
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Author: Huang Bo This article is published by the author authorized by the author, please do not reprint without authorization
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The description of facial paralysis can be traced back to the father of Western medicine - Hippocrates of ancient Greece
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In his writings Hippocrates wrote: "Facial distortions of spontaneous or iatrogenic origin, without other disorders of the body"
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A later Aretius described it in more detail: "The muscles of the eyebrows, cheeks, mouth, and jaw are distorted to the opposite side"
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When it comes to the history of Western medicine, Galen is an inescapable name.
He is the master of ancient Roman medicine
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Galen's description of facial paralysis is: "muscle spasms of the lips, eyebrows, forehead, cheeks, and the base of the tongue
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" He went a step further on the basis of his predecessors and tried to explore the pathogenesis through the vivisection of monkeys, cows and other animals
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He said: "If the muscles of the right lip are paralyzed, the lip will be crooked to the left
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" Not only in the West, but also in the classics of traditional Chinese medicine, related records have been left for a long time.
It is considered that facial paralysis is a kind of "meridian tendon disease" - "draining the basin and cheeks, leaving the mouth secluded .

In urgent
cases, the eyes will not close
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If the heat is hot, the tendons will be longitudinal, and the eyes will not open
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When there is heat, the tendons will relax and become unbearable, so they are secluded
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"Simply translated, it is probably to say: "Suddenly the corners of the mouth are askew, and the eyelids cannot be closed
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When the cheek tendons are cold, the cheeks will be pulled and the mouth cannot be closed; when the cheek tendons are hot, the tendons will be slack and weak, so the eyelids cannot be opened, and the corners of the mouth are skewed.
” The
recorded
treatment method is also very interesting.
, and drink fine wine and savour beautifully roasted meat", use "horse paste" (horse fat) to iron the affected side, then drink alcohol, eat barbecue, and massage
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When the onset of the disease is slow, the mulberry branch is used to hook the corner of the mouth, and then the mulberry branch is burned into charcoal
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And also proposed "burning acupuncture and robbing"
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Although these strange methods have been rarely tried, but today Chinese medicine is still using acupuncture and moxibustion.
Facial paralysis, does this come from the "Huangdi Neijing"? For a long time, the scientific development of the Islamic world has been ignored by the public, in fact, Islamic medical scientists have also made important contributions to the study of the facial nerve
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For
example, al-Hasan Ali ibn Sahl Rabban al-Tabari) and Razi (Abu Bakr Muhammad ibn Zakariya Razi)
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 Razi is examining the open-mouthed pediatric patient, author: Hossein Behzad Razi is a famous Persian medical scientist.
al-Hawi, الحاويفي الطب) conducted a detailed study of facial paralysis, and on the basis of Galen, Tabari and other predecessors, his understanding has greatly improved
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For example, based on his own observations of cases, he proposed two methods for the first time.
The symptoms of facial paralysis are different, and it is pointed out that the forehead lines are the key to distinguish the two
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The difference between central facial paralysis and peripheral facial paralysis is the most basic knowledge today, so I won't go into details
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Today, neurologists often speculate on the location and etiology of the lesions by observing whether there are symptoms of upper facial muscle involvement such as “inability to frown, disappear forehead lines, and inability to close eyelids”, which originated from Lacy’s discovery
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 Schematic diagram of the conduction of the facial nerve, author: Patrick J.
Lynch Lacy's observation of patients with facial paralysis is very detailed.
He is not limited to the general "facial muscle skewness" described by previous scholars, but tries to subdivide the type based on symptoms
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In addition to accurately proposing the distinction of "frontal lines", he also proposed that facial paralysis does not affect facial sensation.
Some patients with facial paralysis will be accompanied by symptoms of brain involvement, such as altered state of consciousness, visual/hearing loss, limb paralysis, etc.
No.

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In addition to this, Lacy also described patients with bilateral facial paralysis, among others
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In terms of treatment, he listed ointment hot compress, massage, bloodletting and so on
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It is worth noting that Lacy emphasized that patients need to avoid light and rest in a dark room, which is very similar to today's treatment principles, because if the orbicularis oculi muscle is paralyzed, the eyes cannot be closed for a long time, and if the lacrimal gland secretion is blocked, it will be affected.
Causes the cornea of ​​the eye to be exposed and dry, making it susceptible to infection
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Therefore, eye drops are often given to patients in clinical practice today, or it is recommended to wear eye shields for protection
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Lacy's "Medicine Synthesis" was later translated into Latin and spread widely in Europe, becoming a classic in medical history, influencing generations of doctors
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Although Lacy's contribution is very important, it has to be admitted that his research is still at the superficial level of observation, and the most important question is still unsolved - without the basis of neuroanatomy, it is impossible to really understand the pathogenesis
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That historic mission fell to an artist-doctor in Scotland, Sir Charles Bell
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 Portrait of Sir Charles Bell, 1839 Bell was born in 1774 into an elite family in Edinburgh, Scotland.
His father was a priest and his three brothers were outstanding, either a law professor or a famous doctor.
Bell was the youngest brother, and the eldest brother was much older than him.
17 years old
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Although his father died when he was 5 years old, his family was well-off and his high social status remained unchanged
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Bell was sent by his mother to study with famous painters at that time, and cultivated outstanding artistic talents.
Later, his painting and sculpture skills benefited from this
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He easily entered the University of Edinburgh from a selective high school at the age of 18, following his second brother John Bell (John Bell) to study medicine
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Later, he entered the Royal Hospital Affiliated to the University of Edinburgh as an assistant to John
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Using his artistic talent, he drew many medical anatomy drawings and made wax figures of cases of interest
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But the good times did not last long.
In 1804, John had a violent personnel conflict with the then chairman of the Royal Hospital and was forced to leave
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Bell was implicated in trying to donate 100 guineas and his own Anatomy Museum collections to the University of Edinburgh just to observe and describe the hospital's operations
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100 guineas at the time was roughly equivalent to 25 ounces of gold, which was a lot of money
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A few years later, the Duke of Wellington led the British Expeditionary Force to compete with Napoleon for Spain, and his military expenditure was only 80,000 guineas
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However, even so, he was ruthlessly rejected
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Bell's career fell into a low ebb, he left Edinburgh sadly and went to practice in London
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Bell began teaching anatomy and surgery in London in 1805
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However, not only was his paper rejected, but he also failed to seek a teaching position at the Royal Society many times [2].
He was also appraised by the president of the society as "insufficient in temperament, modesty, and lack of judgment"
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Throughout history, outstanding people often have to go through the troughs of life before they have the opportunity to think thoroughly, face their truest self, and rise up in the troughs
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Over the next few years, Bell's interests turned to the nervous system, where he volunteered to provide medical care to soldiers wounded in the Napoleonic Wars
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He even went to Waterloo himself in 1815, and on the battlefield he had the opportunity to come into contact with many nerve-damaged soldiers and to make detailed medical records
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It is especially worthy of respect that Bell was a doctor who truly followed the Hippocratic oath.
He not only treated the British soldiers, but also operated on the wounded French soldiers for three consecutive days and nights
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At that time, Joseph Lister's aseptic technique had not yet been proposed, let alone Alexander Fleming's penicillin, so the mortality rate of the operation was very high
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However, the progress of medical knowledge is not only due to the cured cases, but also the death cases have brought profound lessons to doctors, thus promoting the medical community to constantly reflect and research, and constantly improve the next diagnosis and treatment
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During this period, Bell completed a series of important work.
He proposed that the nerve conduction bundles connected to different parts of the brain must undertake different functions
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He discovered for the first time that the anterior horn of the spinal cord divides movement and the posterior horn divides sensation, which is the so-called "Bell-Magendie law"
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This great discovery is still in use today and has become common knowledge that every doctor must know
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But it was not accepted by peers at that time, and the paper was rejected again
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Bell can only be featured in self-published pamphlets
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After the war, Bell continued to work on anatomy and surgery, and his most famous study was published in 1821, and it has been a blockbuster ever since
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The seventh pair of cranial nerves was thought to be related to breathing at the time, and Bell found through clinical and animal experiments that this nerve innervates the muscles of facial expression
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He wrote: "Severing the 'respiratory nerve' on one side of the monkey prevented expression on that side, the movement of the eyelids and eyebrows disappeared, the eyes could not blink, and the lips were slanted to the opposite side.
" When laughing, the lip is visibly tilted to the opposite side, unable to whistle, and when trying to sniff or sneeze, the facial muscles on the damaged side remain motionless
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”  From neuroanatomy, animal experiments to detailed clinical data, Bell's research has formed a strict logical chain and has drawn reliable conclusions .
For the first time in history, he demonstrated that the seventh pair of cranial nerves that innervate facial expression muscles, should be called the "facial nerve", and that damage to this nerve directly leads to facial paralysis .
With the development of more than two thousand years, generations of doctors and scholars have continuously deepened the understanding of human facial nerve .
Gathering the knowledge of the sages, and Bell's own persevering efforts to explore, finally ushered in this critical moment .
Bell's work is important not only for its demonstration of the role of the seventh pair of cranial nerves, and for its use in guiding clinical diagnosis and treatment .
Not only did it inspire later Charles Robert Darwin to think about the origin of human emotions












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Its significance lies in creating a research method that combines the basic scientific research of neuroanatomy with clinical practice, which is called translational medicine today, and Bell was one of the first doctors to do so
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In today's neurology books, idiopathic facial nerve palsy, also known as "Bell palsy"; and due to paralysis of the orbicularis oculi muscle, the eyeball can be seen turning outward and upward when the eye is closed, exposing the white sclera.
This phenomenon is called the "Bell sign"; in addition, the long thoracic nerve that innervates the serratus anterior is also called the "Bell nerve"
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After the war, Bell co-founded University College London and Middlesex University School of Medicine, serving as a surgeon and professor
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He then entered the Royal Society of London, where he was knighted with honors for his outstanding research and work
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Some of his paintings and more than 3,000 wax blocks are still displayed in university museums in London and Edinburgh
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 Anatomical diagram of the brain Author: Charles Bell now in the University of Chicago Museum Anatomy diagram of the facial nerve Author: Charles Bell 1829 [4] James Ramsay Hunt [5] The history of the facial nerve does not end there
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Thirty-two years after Bell's death, in 1874, another luminary, James Ramsay Hunt, was born in Philadelphia, USA
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Hunter is very talkative, intelligent and humorous, and it is easy to get along with his peers [6]
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During his studies at the University of Pennsylvania, Hunter was recognized by the dean of the School of Medicine, Silas Weir Mitchell, a well-known neurologist at the time, who founded the American Academy of Neurology (AAN), which is widely known today, and as chairman
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Mitchell gave young Hunter an unexpected job — working as a personal doctor for a wealthy patient and traveling the world with him
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Hunter took this opportunity to study abroad for several years in continental Europe, before returning to the United States to practice law at Cornell University
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In 1904, Hunter saw a strange patient, a 66-year-old woman.
Two days after she got cold, she experienced tingling pain in the left face, occiput, and neck, followed by an outbreak of herpes, which appeared a few days later.
The left side of the face is paralyzed, the corners of the mouth are slanted, and the salivation is drooling
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In the same year, another 48-year-old worker developed tingling and burning sensations in the right occiput and neck at the onset of the disease, followed by a herpes outbreak.
A few days after the rash appeared, he developed facial paralysis of the same flank.
The course of the disease was very similar to that of the previous patient.

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This time aroused great interest in Hunter, the patient died of pneumonia a month later, so Hunter conducted an autopsy, especially observing the edema and inflammation of the facial nerve
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Through the study of two cases, he also referred to other similar cases reported, and found that this postherpetic facial paralysis is often accompanied by other symptoms, such as tinnitus, deafness and other auditory symptoms
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Hunter summed up the characteristics of this type of syndrome, and then speculated that the facial nerve does not simply innervate the facial muscles as previously thought, but a mixture of nerve fibers with more extensive functions
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This was an important discovery at the time
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Today, neurologists all know that the facial nerve includes: 1.
Motor fibers, which innervate the muscles of facial expression, occipital muscles, platysma, etc.
; 2.
Sensory fibers, including the tympanic cord that conducts taste in the anterior 2/3 of the tongue, and the external auditory canal and tympanic membrane.
3.
Parasympathetic fibers, which control the lacrimal, nasal, sublingual, and submandibular glands, and secrete tears and saliva
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Therefore, when facial paralysis, not only muscle paralysis, but also prone to earache, hyperacusis, dry mouth and dry eyes and other symptoms
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The specific symptoms will depend on the location of the lesion
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Schematic diagram of facial nerve anatomy and paralysis, source: Knight Atlas of Nervous System Diseases For example, lesions in front of the facial nerve canal tend to affect the function of all nerves below the lesion
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Facial nerve palsy caused by herpesvirus infection of the geniculate ganglion, often in addition to peripheral facial paralysis, patients are often accompanied by impaired tear secretion (involvement of the greater petrosal nerve), hyperacusis (involvement of the stapedius nerve), and loss of taste in the anterior 2/3 of the tongue , salivary secretion disorder (involvement of the cord drum), severe pain behind the ear, herpes in the external auditory canal (involvement of the posterior auricular nerve)
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Today the disorder is called Hunt syndrome, named after its earliest discoverers
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Hunter started from two strange patients he received in 1904, diligently thinking, digging deeply, from careful observation and induction of clinical symptoms, to neuroanatomy and staining, persevering in tracing the cause, and finally found and summarized the disease.

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Today, for each patient with facial paralysis, neurologists must inquire and examine the accompanying symptoms in detail, determine the location of the lesions, and take corresponding diagnosis and treatment
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For example, for those diagnosed with Hunt syndrome, antiviral drugs such as acyclovir are often used
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From Hippocrates to Galen, from Lacy to Bell and Hunter, the stars are shining, and there are many doctors and scholars who have not been mentioned or even left their names in history.
Geography spans several continents, time Over two thousand years, their efforts have brought together what we know about the facial nerve today
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The knowledge that the sages once painstakingly sought out, has now flown into the homes of ordinary people and has become the basic common sense that every neurologist must master
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Looking back at the historical volumes, from today's perspective, they stumbled step by step so clumsily, the theory is not only superficial, but also often full of errors and omissions
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However, medical progress is like this.
The lives and efforts of predecessors are condensed into words, tables, and pictures in books and documents, which will save more people's lives and improve the lives of more people in the future
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It was so before, and it is still so today
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  References: [1].
Sajadi, MM, M.
Sajadi and SM Tabatabaie, The history of facial palsy and spasm: Hippocrates to Razi.
Neurology, 2011.
77(2): p.
174-178.
[2].
Grzybowski , A.
and MH Kaufman, Sir Charles Bell (1774−1842): contributions to neuro-ophthalmology.
Acta Ophthalmologica Scandinavica, 2010.
85(8): p.
897-901.
[3].
Reich, SG, Bell's Palsy.
CONTINUUM Lifelong Learning in Neurology, 2017.
23(2, Selected Topics in Outpatient Neurology): p.
447-466.
[4].
Brendan, et al.
, The nervous system and the anatomy of expression: Sir Charles Bell's anatomical watercolors.
Progress in Brain Research, 2018.
[5].
Louis, et al.
, A Biography of James Ramsay Hunt (1874-1937).
Journal of the History of the Neurosciences, 2003.
[6].
Louis, ED, James Ramsay Hunt (1874-1937).
J Neurol, 2004.
251(2): p.
240-1.
[7].
William, J.
and Hunt,On Herpetic Inflammations of the Geniculate Ganglion.
a New Syndrome and Its Complications.
Journal of Nervous and Mental Disease, 1907.
34.
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