The diagnosis of art: facial nerve palsy in ancient Rome

In the first century BCE, sculptors in Rome broke with the classical Greek tradition of idealized but bland and anonymous sculptured faces and produced individualized portraits from which the subjects could be recognized. These sculpture portraits were stern, brutally realistic and often unbecoming, but they projected the personalities of the subjects and the virtues valued in the Republican period: strength of character, honesty, frugality, hard work and devotion to country. Ugly or unusual features of face or head were not only recorded but highlighted. These sculptures were of imported Greek marble,1 and the sculptors are thought to have been of Greek origin,2 but the exaggerated realism, or verism, was a distinctly Roman innovation and is considered by many art historians to have been one of the Romans' more significant artistic contributions. It has been suggested that the deliberate ugliness of some of these faces may have resulted from the contempt held by Greek sculptors for their Roman sitters.3 Still, the Romans must have liked the portraits, for they commissioned many of them. One of the Roman Republican portraits in the Metropolitan Museum of Art ( Figure 1) shows the signs of right-sided seventh nerve palsy. As a result of weakness of the muscles of expression on the right, the levator anguli oris, zygomaticum, orbicularis oculi and frontalis, the face is asymmetrical. The right corner of the mouth sags, and there is atrophy of the right zygomatic musculature. The right eye is wider than the left, and the furrows of the forehead come to an abrupt end over the right eye with a flattening of the right forehead. Figure 1 Marble portrait of a man. Late 1st century BCE. Metropolitan Museum (21.88.14) The weakness of both lower and upper facial muscles indicates a lesion at the level of the facial nerve or the pons, making a stroke unlikely. We do not know the prevalence of Bell's palsy in Roman times, but today it accounts for 65–70% of all unilateral facial palsy.4 Charles Bell (1774–1842) originally described the condition ‘in a man who developed suppuration anterior to the ear’.5 This may have been an infection of the parotid gland, through which the facial nerve passes. Over the years, however, Bell's palsy has come to refer more specifically to the rather common facial palsy of abrupt onset and limited duration associated in most cases with the herpes simplex virus.4 Recovery is usually complete or nearly complete. The severe and longstanding atrophy of facial musculature in this Roman sculpture weighs against Bell's palsy. There are, of course, many less common causes of unilateral, peripheral facial nerve deficit.6–8 On the right side of the head, above the level of the ear and anterior to it, there appears to be a cutaneous scar ( Figure 2). This man had apparently suffered some sort of head trauma. The scar is above the level of the temporal bone, but it could have been associated with a blow to the head that fractured the right temporal bone. The facial nerve passes through its petrous portion and can be permanently injured by a horizontal fracture of that bone.9 This Roman lived in violent times. Many male citizens did military service and often engaged in hand-to-hand fighting, as they enlarged and defended their vast frontier. There must have been many blows to the head, with more than a few temporal bone fractures, seventh nerve injuries and permanent facial palsies. Figure 2 Detail of Figure 1, showing an apparent scar above and anterior to the right ear The haunting realism of the Roman Republican sculpture portraits allows us some insight into the mindset that created one of the world's largest, most efficient, and longest-lasting empires. It also allows us to speculate about a clinical diagnosis.