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Year : 2013  |  Volume : 1  |  Issue : 1  |  Page : 85-88

Historical perspectives of facial palsy: Before and after Sir Charles Bell to facial emotional expression

Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka, India

Date of Web Publication21-Jun-2013

Correspondence Address:
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore - 575 018, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4848.113590

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How to cite this article:
Shelley BP. Historical perspectives of facial palsy: Before and after Sir Charles Bell to facial emotional expression. Arch Med Health Sci 2013;1:85-8

How to cite this URL:
Shelley BP. Historical perspectives of facial palsy: Before and after Sir Charles Bell to facial emotional expression. Arch Med Health Sci [serial online] 2013 [cited 2023 Mar 31];1:85-8. Available from: https://www.amhsjournal.org/text.asp?2013/1/1/85/113590

Sir Charles Bell (1774-1842), Scottish surgeon anatomist, and First Professor of Anatomy and Surgery at the Royal College of Surgeons, London has long been considered to be the first to describe idiopathic facial paralysis in the early 19 th century. Bell's most important works are in the fields of research on the brain and the nerves. [1],[2],[3] His book, "An Idea of a New Anatomy of the Brain" (1811), has been called the "Magna Carta of Neurology."

Sir Charles Bell was one of the chief practicing surgeons at the Middlesex Hospital in London. In 1814, he accepted a position as a surgeon at the Middlesex Hospital and was instrumental in the founding of the Middlesex Hospital and Medical School in London in 1828. Charles Bell joined the British army as a surgeon and had a unique opportunity to study facial gunshot injuries during the Napoleonic wars, most notably in the Battle of Waterloo. It was the battlefield experiences along with animal experiments done in his laboratory that led to his conclusion that the seventh cranial nerve controlled facial expression. In 1821, Sir Charles Bell described the anatomy of the facial nerve and its association with the unilateral facial palsy that bears his name.

He later described a syndrome of complete facial paralysis in a lecture 'On the nerves: giving an account of some experiments on their structure and functions, which lead to a new arrangement of the nervous system' to the Royal Society of London in 1821. His seminal paper published in Phil. Trans. R. Soc. Lond. 1821 dwelt on the intricacy of nerves, both structure and function, principles of arrangement (anatomical details), with experiments in animals and clinical observations; went on to describe a section on the facial nerve, which then he referred to as 'exterior respiratory nerve of the face' (Bell's nerve). His 1821 paper did provide a brief but unmistakable description of facial paralysis of lower motor neuron type. He clearly separated it from the palsy of upper motor neuron lesions, although this terminology was not then in use. His account of the upturning of the globe (Bell's phenomenon) was graphic and important, and received more attention from Gowers and later Kinnier Wilson than his account of facial palsy. His second paper published in Phil. Trans. R. Soc. Lond. 1829 titled 'On the Nerves of the Face; Being a second paper on that subject' is an exposition of the anatomy of the fifth and seventh cranial nerves where he demonstrated that the cranial nerve V was sensory to the face and motor to mastication, whereas cranial nerve VII controlled muscles of expression.

It is interesting to note the existence of several controversies in the historical perspectives of Bell's palsy. One such controversy is whether Sir Charles Bell himself did have right facial palsy. [4],[5],[6] Literature gives evidence of Bell having right facial palsy based on the documentation by Jongkees and further affirmed by studying the photography of Sir Charles Bell [Figure 1]a. However, there is a historical conundrum between the accounts of Dr. S. F. S. Korteweg (Netherlands) versus the late Professor Leonard Barend Willem Jongkees (Amsterdam) on this issue of Sir Charles Bell having right facial palsy. [7] Original Bell's publications demonstrate that Bell never describes that he was suffering himself of a facial palsy and no ex­isting portraits confirm this hypothesis. 'The jury is out' in this matter, the overall consensus is to accept that Charles Bell was not af­fected by peripheral facial palsy himself. At this point, it is important to emphasize that historians need to ensemble accurate data based on valid primary sources and original documents, otherwise theoretical reflection and secondary references will contribute to inaccuracies, paradoxes and debates in the annals of history of medicine. [8]
Figure 1: (a) The right facial palsy of Sir Charles Bell: Absence of wrinkles on the right forehead; the right eyebrow is abnormal and asymmetric; wider palpebral fissure on the right side; depressed left angle of mouth; left nasolabial fold is more shallow with deviation to the left side (Ref: Resende LAL, Weber SAT. Arq Neuropsiquiatr 2009; 67(3-A):783-784) (b) Ref: Volitional and Emotional Supranuclear Facial Weakness. (Ref: R.T. Ross, M.D., and Robert Mathiesen; N Engl J Med 1998; 338:1515) (c) The Mona Lisa Smile

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A re-appraisal and verification of the historical accounts of peripheral facial nerve palsy and facial distortion does give evidence of its earlier description to the Greek (Hippocrates, Galen), Roman, Egypt, and Persian physicians in the history of Neurology. [8],[9] Sir Charles Bell himself was, therefore, long remembered for his description of facial paralysis but certainly not the first to describe Bell's palsy. Peripheral facial paralysis was described by earlier physicians such as Sydenham, Stalpart van der Wiel, Douglas, Friedreich, and Thomassen a' Thuessink. [10],[11]

The earliest comprehensive treatise on facial paralysis was in the 9 th century by the Persian physician Razi in his sixth book of al-Hawi in a chapter titled "Facial distortion, spasm and paralysis." His work differentiated peripheral facial palsy from central seventh nerve palsy, Bell's phenomenon, the significance of absence of forehead wrinkling, described bilateral facial palsy, and eluded to clinical methods to distinguish facial paralysis from hemifacial spasm. Razi's al-Hawi was first translated into Latin in 1279, coming into print in Europe in 1468. It was only after three quarters of a millennium did Sir Charles Bell describe the anatomic basis of facial nerve palsy. [12]

The first medical study of the disease is attributed to Avicenna (Abu-Ali al Husayn ibn Abdalla Ibn Sina, 979-1037 A.D.) who described the etiology, treatment, and prognosis of peripheral facial paralysis. Avicenna had much earlier described spastic, atonic, and convulsive types of facial palsy. [13]

Before Sir Charles Bell's work, James Douglas (1675-1742) in the 18 th century also described facial paralysis. However, the chronology has now to be revised because Cornelis Stalpart van der Wiel from The Netherlands clearly observed and recorded a case of Bell's palsy in 1683. Therefore, Stalpart van der Wiel has the priority of being the first to describe Bell's palsy. [11]

It was Nikolaus Anton Friedreich (1761-1836), who comprehensively reported three middle-aged adults with a similar history of acute or sub-acute onset of unilateral facial paralysis that slowly improved over a period of weeks to months. He was a professor in the faculty of medicine at Wurzburg in the eighteenth century and was presumably the grandfather of the famous Nicolaus Friedreich of Heidelberg who described the chronic familial 'Friedreich Ataxia.' Friedreich used electrical stimulation "to where the nerve comes through the stylomastoid foramen." in the first without recovery but early electrical stimulation in his second patient caused full recovery within three weeks. The English review of Friedreich's paper was published in the Annals of Medicine in 1800 in Edinburgh "Paralysis musculorum rheumatica". [14],[15]

It is possible that paper published in the Annals of Medicine was read by Charles Bell who was studying medicine in Edinburgh at that time. Bell later studied the function of the facial nerve in experimental animals, and also described several patients with facial nerve paralysis. Bell's first report of facial nerve paralysis in a patient was published in 1821. He mentioned briefly a man whose facial nerve was injured by a "suppuration which took place anterior to the ear and through which the nerve passed in its course to the face." Thus, Nikolaus Anton Friedreich's detailed description of this syndrome had demonstrated careful clinical observations, accurate deductive reasoning about the nervous system, provided useful speculation about pathophysiology, practical attempts at treatment, and documentation of recovery of normal function. His description, therefore, preceded those of Charles Bell by 23 years, and one would wonder whether history should have called it as 'Friedreich's palsy.' [16]

Through the history of art, many artists in their works have portrayed different signs of pathologies. Within the numerous works of art that have attracted medical interest, there is none comparable to the most famous and enigmatic portrait painted by Leonardo da Vinci, the Mona Lisa. The painting Mona Lisa, del Giocondo or "Mona Lisa del Giocondo" is a 16 th century portrait done by Leonardo Da Vinci during the Italian Renaissance and considered the most famous painting in the history of art in the world. Mona Lisa's smile, has perplexed both art historians and researchers [Figure 1]c. Some postulated that the smile of the portrait's model was due to Leonardo da Vinci's anatomically precise representation of a new mother affected by Bell's palsy subsequent to her recent pregnancy due to facial muscle contracture developing after facial nerve partial wallerian degeneration and has regenerated. The accompanying synkinesis would explain many of the known facts surrounding the painting and is a classic example of Leonardo da Vinci as the compulsive anatomist who combined art and science. Bell's palsy is more prevalent in women who are either pregnant or who have recently given birth. [17],[18] At a meeting of the facial nerve in Zurich, Adour and Jongkees concluded that the "Gioconda" had right peripheral facial paralysis. [19]

[Additional file 1]

  Volitional and Emotional Facial Palsies Top

Facial movements are undoubtedly under the powerful influence of the cerebral cortex and are essential for the appropriate execution of many important functions such as mastication, swallowing, and social interaction, including speech and non-verbal communication. It has long been known that dissociation between voluntary and emotional innervation exists in central facial paresis. Whilst in most of the modern textbooks one fails to find this dissociation mentioned, Gowers, in his" Manual of Diseases of the Nervous System," vol. ii describes how facial palsy accompanying hemiplegia, the smile may be equal on both sides, although voluntary movement is lost on one side; however, he gives no explanations for this dissociation. Gower's description provides an early description for a clinical dissociation between voluntary and emotionally driven facial expressions. [20]

In contrast to the well-described peripheral voliotional facial palsy (VFP) is the inverse condition, referred to as emotional facial paralysis (EFP) otherwise referred to as 'mimetic,' 'involuntary,' 'emotional facial palsy,' or 'amimia.' Emotional facial paresis (EFP) or mimic paresis is a rare condition that refers to weakness of emotionally evoked facial movements such as smiling or weeping, with normal volitional activation. Emotional facial paresis is characterized by impaired activation of face muscles with emotion but normal voluntary activation. Conversely, volitional facial paresis (VFP) refers to a weakness of facial muscles on voluntary effort while emotional movements are preserved (Hopf et al.,1992) [21] [Figure 1]b.

Emotional facial paralysis has been reported to occur in patients with lesions of the, frontal sub-cortical structures, operculum, midline cortex-cingulate motor cortex and supplementary motor area (SMA), mesial temporal lobe, insula, striatocapsular region, thalamus, or dorsolateral pontine tegmentum. This suggests the presence of separate neural systems or alternative frontothalamopontine pathway to the seventh nerve nucleus, which is distinct from the facial contingent of the corticonuclear tract, controlling emotional movements of the face.

From a description of peripheral and central facial paralysis alluded to earlier in this article, the clinical dissociation between voluntary and emotionally driven facial expressions would illustrate the organizational complexity of human facial emotional expression and control. The components being the complexities of central cortical facial representation in the primary motor area, SMA, cingulate cortex; facial representations interconnected through topographically organized corticocortical connections, corticobulbar projections to the facial motor nucleus. Insights from neuroscience does not support the classic teaching that suggested motor neurons in the upper half of the facial nucleus to give rise to axons that innervate the lower facial muscles, whereas neurons in the lower half of the facial nucleus give rise to axons supplying the upper facial muscles instead suggests that there is evidence for a musculotopic organization of the facial nucleus. [22],[23] It is the combined and complex contributions of each component of a large-scale distributed neural network that impose a greater and harmonious effect on motor neurons forming the facial motor nucleus. [24] Distinct from a fairly simplistic Bell's palsy, the human facial emotional expression is more complex and is the end result of the interactive and summative synaptic architecture of such a large-scale neural network, much like a symphonic orchestra.

  References Top

1.May M, Schaitkin BM. History of facial nerve surgery. Facial Plast Surg 2000;16:301-7.  Back to cited text no. 1
2.Jay V. A portrait in history: Sir Charles Bell-Artist extraordinaire. Arch Pathol Lab Med 1999;123:463-5.  Back to cited text no. 2
3.Pearce JM. Sir Charles Bell 1774-1842. J Neurol Neurosurg Psy 1993;56:913-6.  Back to cited text no. 3
4.Jongkees LB. Notes on the history of facial nerve surgery. HNO 1979;27:325-33.  Back to cited text no. 4
5.Zulch, K. J. Idiopathic facial paresis. In Handbook of Clinical Neurology, Vol. 8, part II. Edited by P. J. Vinken and G. W. Bruyn. Diseases of Nerves. North-Holland Publishing: Amsterdam.1970 p.241-49.  Back to cited text no. 5
6.Korteweg SF, Van de Graaf RC, Werker PM. About the right facial palsy of Charles Bell. Was Sir Charles Bell himself really affected by facial paralysis? - Comment on 'Peripheral Facial Palsy in the Past. Contributions from Avicenna, Nicolaus Friedreich and Charles Bell'. Arq Neuropsiquiatr 2009;67:783-4.  Back to cited text no. 6
7.Korteweg SF, Van de Graaf RC, Werker PM. Sir Charles Bell was not affected by facial paralysis himself!. Arq Neuropsiquiatr 2010;68:321-2.  Back to cited text no. 7
8.Mudry A, Ruben R, Pirsig W. Inaccuracies and useless debates associated with the use of secondary references. Arq Neuropsiquiatr 2011;69:268-70.  Back to cited text no. 8
9.Resende LA, Weber S. Peripheral facial palsy in the past: Con­tributions from Avicenna, Nicolaus Friedreich and Charles Bell. Arq Neuropsiquiatr 2008;66:765-9.   Back to cited text no. 9
10.van de Graaf RC, Ijpma FF, Nicolai JP, Werker PM. Bell's palsy before Bell: Evert Jan Thomassen a' Thuessink and idiopathic peripheral facial paralysis. J Laryngol Otol 2009;123:1193-8.  Back to cited text no. 10
11.van de Graaf RC, Nicolai JP. Bell's palsy before Bell: Cornelis Stalpart van der Wiel's observation of Bell's palsy in 1683. Otol Neurotol 2005;26:1235-8.  Back to cited text no. 11
12.Sajadi MM, Sajadi MR, Tabatabaie SM. The history of facial palsy and spasm: Hippocrates to Razi. Neurology 2011;77:174-8.  Back to cited text no. 12
13.Gruner OC. A treatise on the canon of medicine of Avicenna incorporating a translation of the first book. London: Luzac; 1930.  Back to cited text no. 13
14.Bird TD. Nicolaus A. Friedreich's description of peripheral facial nerve paralysis in 1798. J Neurol Neurosurg Psychiatry 1979;42:56-8.  Back to cited text no. 14
15.Friedreich NA. De paralysis musculorum faciei rheumatica. J der Erfindungen (Gotha) 1798;8:25. Quoted in English by Bird TD in: Annals of Medicine (Edinburgh) 1800;5:214-26.  Back to cited text no. 15
16.Pearce JM. Bell's or Friedreich's palsy. J Neurol Neurosurg Psychiatry 1999;67:732.  Back to cited text no. 16
17.Adour KK. Mona Lisa syndrome: Solving the enigma of the Gioconda smile. Ann Otol Rhinol Laryngol 1989;98:196-9.  Back to cited text no. 17
18.Borkowski JE. Mona Lisa: The enigma of the smile. J Forensic Sci 1992;37:1706-11.   Back to cited text no. 18
19.Walker M. Sir Charles Bell, his Palsy and Mona Lisa. Nepal J Neurosci 2004;1:123-5.  Back to cited text no. 19
20.Privatdozentin BW, Rodden FA, Rapp A, Erb M, Grodd W, Ruch W. Humor and smiling: Cortical regions selective for cognitive, affective, and volitional components. Neurology 2006;66:887-9.  Back to cited text no. 20
21.Hopf HC, M¨uller-Forell W, Hopf NJ. Localization of emotional and volitional facial paresis. Neurology 1992;42:1918-23.  Back to cited text no. 21
22.Szentagothai J. The representation of facial and scalp muscles in the facial nucleus. J Comp Neurol 1948;88:207-20.  Back to cited text no. 22
23.Crosby EC, DeJonge BR. Experimental and clinical studies of the central connections and central relations of the facial nerve. Ann Otol Rhinol Laryngol 1963;72:735-55.  Back to cited text no. 23
24.Morecraft RJ, Stilwell-Morecraft KS, Rossing WR. The motor cortex and facial expression: New insights from neuroscience. Neurologist 2004;10:235-49.  Back to cited text no. 24


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