Clinical neurology in ancient art

Fig. 1

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In 2011, the French Neurologist Jean-Louise Devoize proposed that this roman terracotta (1st century CE) [Fig. 1], discovered in Smirne (Turkey) displayed at the Dutch National Museum of Antiquities in Leiden, represents hemifacial spasm or “the other Babinski sign”. The first description of this terracotta was made by historian of medicine Mirko Drazen Grmerk (1924-2000) who considered it to be a representation of a facial palsy because of the asymmetric distortion of the face. Devoize’s explanation is based on the raising of the eyebrow which occurs in conjunction with eyelid closing. The simultaneous contraction of the orbicularis and frontalis muscles of the same side in the hemifacial spasm was described in detail by the French Neurologist Joseph Babinski (1857-1927). At the Société Neurologique de Paris on 06 April 1905, Babinski reported for the first time paradoxical syncinesis in hemifacial spasm in a lecture given with this description: “The most singular is the following: when orbicularis oculi contracts and the eye closes, the internal part of the frontalis contracts at the same time… the eyebrow rises during eye occlusion… this set occurrences is impossible to reproduce by will…”. From this observation, Babinski concluded that hemifacial spasm is neither the result of a psychological nor of a cortical lesion, but is a consequence of a lesion that affects the facial nerve.

In 2007, William Stamey and Joseph Jankovic reported that although this sign has only 25% sensitivity for hemifacial spasm, it has 100% specificity in differentiating hemifacial spasm from blepharospasm. These authors proposed that the “other Babinski sign” is renamed “the brow-lift sign”. Hemifacial spasm is a movement disorder characterized by irregular, clonic or tonic contraction of the muscle of the face innervated by the same side of the seventh cranial nerve. Twitching commonly begins in the orbicularis oculi, but usually spread involving muscles of the upper and lower face, including platysma, and rarely involves the whole face. Hemifacial spasm is idiopathic or sporadic, usually due to compression of the facial nerve at the root entry zone by an aberrant artery while blepharospasms has a cortical origin. The “other Babinski sign” is an under recognized and useful physical sign that may be present in hemifacial spasm and it is helpful to distinguish it from blepharospasm. Although the origin of the “other Babibski sign” in hemifacial spasms is not clear, this sign is not seen in blepharospasm, because the motor neuron pools for orbicularis oculi and frontal muscle have different patterns of cortical innervations. In hemifacial spasm, the co-contraction of these muscles presumably reflects a peripheral co-activation.

In 2009, Andrea Stenner and colleagues demonstrated an electromyographical differentiation between hemifacial spasms and blepharospasm that can lead to a safe diagnosis and an accurate injection scheme for the use of botulinum therapy. They proposed a new eponym for hemifacial spasm: “Babinski 2-phenomen”.

References

• Babinski J. Hémispasme facial périphérique. Nouvelle iconographie de la Salpetriere 18: 418-23, 1905
• Devoize JL “The other” Babinski sign: paradoxical raising of the eyebrow in hemifacial spasm. J Neurol Neurosurg Psychiatry 70: 516, 2001
• Devoize JL Hemifacial spasm in antique sculpture: interest in the ‘other Babinski sign’. J Neurol Neurosurg Psychiatry 82: 26, 2011
• Grmek M, Gourevith D Les maladies dans l’art antique. Paris, Fayard, p. 240-1, 1998
• Mitchell A Disparate bodies in ancient artefacts: the function of caricature and pathological grotesques among Roman terracotta figurines. In C. Laes, (ed.). Disparate Bodies "A Capite ad Calcem" in Ancient Rome. Leiden: Brill; 2013, pg. 275-297
• Reichel G, Stenner A, Hermann W “Babinski 2: sign” – A new and old test for the differentiation of hemifacial spasm and blepharospasm. Akt Neurol 36: 1-2, 2009
• Stamey W, Jankovic J The other Babinski sign in hemifacial spasm. Neurology 69: 402-4, 2007