Adventures in Human Being Page 5

  When I later became a demonstrator of anatomy, one of my jobs was to reveal these muscles in order to help students understand the way that stroke or palsy can affect the face, as well as give a grounding to those who’d one day perform Botox injections, facelifts or facial reconstructive surgery. All in all I’ve probably dissected between twenty and thirty human faces, but never lost the sense of privilege it afforded. Exposing each layer of the face was a process of gradual revelation, journeying from the skin, so reminiscent of life, down to the skull, so emblematic of death. The very fragility of the facial muscles enforced a level of tenderness and respect.

  LATE IN THE FIFTEENTH CENTURY, Leonardo da Vinci, the bastard son of a Florentine lawyer, was living in Milan and thinking about facial expression more closely than perhaps anyone had before him, and few have done since. His drawings of the muscles of the face wouldn’t be bettered for centuries. As a painter and draftsman, he believed in accuracy of representation, and had realized that to excel as a portraitist he had to understand those muscles intimately. He also believed that muscles were in direct communication with the soul, and that the motions of the soul could be understood through an appreciation of the body: “The joint of the bones obeys the nerve, and the nerve the muscle, and the muscle the tendon, and the tendon the Common Sense. And the Common Sense is the seat of the soul.”

  In about 1489 he was making sketches for a monumental statue of his patron’s father, Francesco Sforza,* as well as some notes for an anatomical treatise. His ambition was as unwieldy as it was magnificent, and his notes offer a glimpse of a mind churning with creative and intellectual energy, possessed by a will to comprehend every aspect of human being. He intended his treatise to explain conception, pregnancy, normal and premature birth, the growth of children, the normal constitution and physiognomy of adult men and women, as well as provide a complete exposition of the veins, nerves, muscles and bones. Then he outlined how the changing expressions of the face would be the key to understanding the human condition: “Then in four drawings you will depict the four universal conditions of man, that is: joy, with different ways of laughing, and draw the cause of the laughter; weeping in different ways, with their cause; fighting, with the different movements of killing; flight, fear, ferocity, boldness, murder …” For da Vinci, to tabulate the actions of muscles expressing these emotions was to come close to understanding the divine source of emotions themselves. He was not interested in portraying bland representations of beauty: he wanted to capture faces as they are, as they move, whether ugly or beautiful, and if those expressions were extreme – all the better. To anatomize was to come closer to God: “And you, man, who witnesses in this labor of mine the marvellous works of nature … if this his composition appears to you a marvellous piece of work, you should regard this as nothing compared to the soul that dwells within that architecture.”

  Sforza was one of Italy’s most renowned condottieri, a kind of warlord with a private army of the sort that regularly overran Italy’s city-states at that time.

  Later works like the Mona Lisa (1503–4) show just how sensitive da Vinci was to subtlety of facial expression. In the early 1490s his studio for exploring these ideas was the refectory wall of a Milanese convent on which he was painting an impression of The Last Supper. Other Renaissance Last Suppers had been rather staid, showing the apostles expressionlessly eating their dinner. To demonstrate the way in which emotion animates expression, da Vinci chose the moment of the Passover meal when Christ is said to have announced “one of you will betray me.”

  His apostles are caught in the commotion that followed – a drama of twelve expressions to set at play: four groups of three apostles each.* Da Vinci aimed to convey a vast range of facial expression, but notable among the thirteen figures is Bartholomew, furthest to the viewer’s left, who has leapt to his feet, palms on the table, and seems to glower with disbelief, furrowing his eyebrows in anger. St. Andrew is third from the left: his raised palms protest his innocence and his eyebrows seem to lift in dismay.

  Da Vinci’s Cenacolo was painted on a damp wall, and was already in a desperate state of disrepair by the mid-sixteenth century. Scholars have an idea of the power of the original from written descriptions, as well as the celebrated copy made around 1520 by Giampietrino, said by contemporaries to be the most accurate produced.

  Immediately to Jesus’s left, Thomas looks bewildered, pulling the corners of his mouth down to a frown with depressor anguli oris, and pointing at the ceiling with the finger that, a few days later, will be probing the resurrected Jesus’s wounds in doubt. A cataclysm of emotion has broken over James the Greater who sits next to Christ; he has thrown out his arms in a fury that has darkened his eyes and creased his eyebrows to barbs.

  It’s said that the models for the painting were members of the contemporary Milanese elite, but it’s not for its fidelity to the gospel story or for its series of commemorative portraits that the painting has been appreciated, but the way it uses facial expression as a means of giving insights into a storm of human emotion. Giorgio Vasari, biographer and contemporary of da Vinci, said that da Vinci would roam the streets, following men with particularly ugly, contorted or unusual faces in the hope of glimpsing them at moments of extreme expression. Sometimes he’d follow a particularly interesting face all the way out to the outskirts of town.

  Da Vinci was in Milan during a time of political turmoil; by 1499 he had to leave to escape the invading French. He trailed his sponsors to Mantua, Venice, Florence and Rome, but by the winter of 1510–11 he was back in the north, at the university and medical school of Pavia just south of Milan. Twenty years after he’d first outlined his treatise on anatomy he began in earnest the work he’d imagined so ambitiously. In the days before artificial refrigeration dissection was conducted only in winter – summer heat would putrefy corpses too quickly – and in Pavia da Vinci had a ready supply of cadavers from the hospital as well as a willing patron: Marcantonio della Torre, Pavia’s professor of anatomy. Many of the anatomical sketches completed in Pavia have been lost, but from the small portion that have survived it’s clear that da Vinci brought vision, imagination and astounding ability, both as an anatomist and as a draftsman, to the task. He studied anatomy to appreciate the body as it really is rather than how it has been idealized. From his perspective the human body was the supreme culmination of God’s creation.

  One of the leaves from his notes shows the muscles of facial expression in precise detail, drawn more than fifteen years after he’d reproduced their effects in The Last Supper. Frontalis, which he’d shown wrinkling St. Andrew’s forehead, is marked as “the muscle of fear.” He’d painted the nose and brow of Bartholomew, Peter and James the Greater snarling with rage, and here the muscle responsible for that expression, levator labii superioris alaeque nasi, is marked as “the muscle of anger.” In the notes between the sketches he has written: “Depict all causes of movement made by the skin, flesh and muscles of the face, and if these muscles have their movement from the nerves that come from the brain or not.” He perceived that there are two groups of muscles in the face: those we use for chewing, which are thick, strong and moved by the fifth nerve to issue directly from the brain, and those we use for facial expression, which are subtler, weaker and are moved by the seventh nerve from the brain.*

  These are the “cranial” nerves that issue from holes in the skull or cranium, rather than “spinal” nerves, which come out between vertebrae.

  The seventh nerve is aligned to the nerve of hearing and balance; it tunnels through the skull case behind the ear and issues just under the lobe. After passing through the largest salivary gland, just behind the angle of the jaw, it splits into five branches and radiates across the face into the muscles of facial expression. The five branches are immortalized in every medical student’s memory as Two Zombies Buggered My Cat (Temporal, Zygomatic, Buccal, Mandibular and Cervical). Remembering the locations of the nerve branches is helpful if someone sustains a facial injur
y, but is also useful in understanding the way palsy affects the ability to express emotions in the face.

  I MET EMILY PARKINSON in my emergency clinic; she’d telephoned just half an hour earlier from her city-center office. An accountant with two young children and a busy professional life, she had woken that morning to find that the left side of her face wasn’t working properly. After rising she had gone into the bathroom and caught a glimpse of herself in the mirror: her left lower eyelid was sagging slightly, and when she tried to smile the left side of her face was slacker than the right. She wondered if she’d slept awkwardly on it in the night, and went downstairs to prepare breakfast. “Look at this,” she’d said to her husband, “half my face has gone to sleep.”

  “Maybe you’ve caught a nerve,” he said, and shrugged.

  On the way to work she glanced in the car mirror and realized the problem hadn’t gone away; in fact it was getting worse. By the time she got to work she was anxious – more so when her secretary met her with a gasp. “What’s happened to your face?” she had cried out. “You look like you’ve had a stroke.”

  Emily had managed to finish her make-up that morning, but a persistent tear at the corner of her left eye had smeared her mascara. On her right she had a deep fold between her nose and the corner of her mouth – the result of happily active zygomaticus muscles pulling on her skin for forty years – but the fold on the left was almost gone. Before, her dimples had been like parentheses, bracketing everything she said. Having a dimple on only one side gave her a partially finished, ungrammatical look.

  I asked her to show me her teeth, and watched how the right side of her mouth pulled up and out, deepening her smile lines, but on the left her face hardly moved. Her wrinkles on the left had largely disappeared, but that side was lifeless. She was unable to screw up her left eye. The final test was to ask her to raise her eyebrows: the right eyebrow leapt obligingly, but on the left there was just a flicker.

  The frontalis muscle is unusual: most muscles in the body are controlled by the opposite side of the brain, so that the right arm, for example, is moved by the left cerebral hemisphere. Frontalis is the exception: both sides of the brain can operate the nerve on each side. If a stroke knocks out the function of one hemisphere, victims continue to be able to raise both eyebrows, but if a nerve on one side stops working, then the muscle becomes paralyzed. That Emily’s left frontalis had stopped moving meant she had not suffered a stroke.

  “So, if I haven’t had a stroke, what’s wrong with me?”she asked.

  “Bell’s palsy,” I said, “a disturbance in the nerve that gives expression to your face. It’s almost certainly going to get better over the next few weeks.” I paused a moment, hoping to reassure her. “No one is entirely sure why Bell’s palsy occurs, but the nerve that controls the muscles of your face passes through a very narrow tunnel of the skull near your ear. Even slight inflammation at that site puts enough pressure on to stop it working properly.”

  “What can you do about it?”

  “I’m going to give you steroid tablets to take for the next ten days, to dampen any swelling around the nerve, and we should patch up your left eye to protect it.”

  “What do you want to patch my eye for?”

  “If the palsy progresses much more,” I told her, “you won’t be able to blink.”

  THE GREEK PHILOSOPHER ANAXAGORAS, on being asked why he believed he had been born, replied, “in order to behold the heaven and the stars.” It was a common Renaissance view that humanity was special because of the way in which our faces are directed upward.* Hairlines frame and exaggerate our naked human faces, making expressions more visible at a distance than they would have been for our hairy-faced ancestors. The whites of our eyes have expanded in comparison with other animals to make the subtlest changes in gaze and eyelid position more obvious to others. When faces are available, we pay more attention to them than to any other part of the visual world. Descriptions of the face are among some of the most lyrical and expressive in literature, from Shakespeare’s “when forty winters shall besiege thy brow / and dig deep trenches in thy beauty’s field” to Iain Sinclair’s description of a character’s face “creased like a haemorrhoid cushion left too long in the bath.” Given the importance of faces to human communication, having Bell’s palsy can be more than embarrassing – for some it is socially devastating.

  Sir Thomas Browne notably pointed out that this is nonsense – the lowly flatfish has eyes directed even more piously heavenward than those of human beings.

  The palsy takes its name from Charles Bell, a surgeon and anatomist of the early nineteenth century who tracked the route of the seventh nerve. Bell came from a distinguished Edinburgh family: his father had been a clergyman, two of his brothers became professors of law and another brother – John Bell – was in his day the most famous surgeon in the city. Charles hated school but loved to paint, and his mother engaged a private tutor who taught the boy to imitate the finest classical and Renaissance artists.

  In 1792, when Charles was eighteen, he was apprenticed to his brother John. The anatomical illustrations of their contemporaries were for the most part clumsy; Bell wrote disparagingly of the bones drawn like fence posts and muscles like rags. Charles and John worked together on illustrations for a new “system of dissections,” infusing the work with tribute to the Renaissance masters whom he had learned to imitate.

  In 1809, at the height of the Napoleonic Wars, Bell was working as a surgeon and anatomical illustrator in London when the British army, with five thousand wounded men, returned to England from Corunna in Spain. He traveled down to Portsmouth to help the survivors, spending days amputating limbs, picking out shrapnel, cutting dead tissue from wounds. When he wasn’t operating he was sketching, and his dispassionately accurate notebooks show figures writhing in the agonies of tetanus, gored in the abdomen, as well as gunshot wounds of the arm, chest and scrotum.

  Six years later, news of the Battle of Waterloo reached London and Bell traveled to Brussels to assist. “It is impossible to convey to you the picture of human misery continually before my eyes,” he wrote from Brussels. The sketches he made this time are more detailed and involved, as if he had become more emotionally affected by the conflict; the soldiers’ portraits are furnished with names and more elaborate explanations are given. Of the forty-five drawings that survive there are two notable pictures of faces, individuals whom Bell must have examined carefully for nerve damage to the face, and whose expressiveness would have suffered as a result of their wounds. One shows a soldier who had been shot through the temples by a musket ball, shattering both eye sockets and destroying the tissue behind the bridge of his nose. The other shows a man with a bullet wound in the left cheek. Without careful surgical attention both would be mortal wounds, and even despite it, the men would carry stigmata of disfigurement for the rest of their lives.

  I REFERRED EMILY to the ear, nose and throat specialists, who confirmed that, for the moment, steroid tablets were the only treatment they could offer. A week later her palsy had worsened, and she was feeling more self-conscious. “It’s so embarrassing,” she said, when I called in to see how she was coping. Her fingers flickered around her face and continually brushed her hair forward as she talked. “I haven’t been back to work, and my left eye is constantly crying. It’s like I’m weeping for the loss of my face.”

  Two weeks later there was no further deterioration, but neither had things improved – she was still unable to return to work. “I couldn’t bear it,” she explained, “everyone would stare at me.” At six weeks she thought a trembling motion had come back into the corner of her mouth. “I’m definitely dribbling less,” she told me, “but the tears are still coming.”

  “Give it time,” I said. “Nearly everyone with Bell’s palsy makes a full recovery.”

  At three months that recovery seemed to have stalled, and at six months we conceded that her palsy was unlikely to improve. She had not returned to work, and seldom went out
. She had also styled her hair to hang in a curtain permanently over the left side of her face. “I can’t stand it,” she told me, “my face scares children.”

  “I’ll speak to the plastic surgeons,” I said. “They may be able to tighten up some of those slacker muscles in your affected side, and – you mentioned Botox – sometimes they use that to smooth out the good side.”

  “So to treat my paralysis, they’re going to paralyze my face?”

  I wasn’t sure they would be able to treat Emily’s paralysis – it’s difficult to get a damaged nerve to start working again. But in terms of normalizing appearance, the most effective treatment is often to use Botox to partly paralyze the good side. “Yes,” I said, “I know it sounds odd, but they’ll use it to make your face more symmetrical.”

  BELL WAS AMBITIOUS to make his name as a surgeon – his anatomies of the nervous system were unparalleled in his day – but it was the perfection of his art that preoccupied him. Long before Waterloo, while making drawings for the System of Dissections, he began a prolonged study of human expression – a project similar to Leonardo da Vinci’s three centuries earlier. The work was later published as Essays on the anatomy of the expression in painting. The book was worked and reworked throughout his life, the essays added to as Bell gained experience as a surgeon and as an artist. The final edition was enriched with his reflections from a long sabbatical in Italy, where he admired in particular da Vinci’s depictions of the face. Da Vinci had been forced to walk the streets looking for unusual or striking faces to paint; Bell had it easier: he had only to wait in his clinic and those faces came to him.

  Thirty years after Charles Bell’s death, another former Edinburgh medical student, Charles Darwin, was sufficiently inspired by Bell’s work to take up the subject where he had left off. In The Expression of the Emotions in Man and Animals Darwin wrote, “[Bell] may with justice be said not only to have laid the foundations of the subject as a branch of science, but to have built up a noble structure.” Darwin was a careful observer of the cultural as well as the natural world, and was less taken than Bell with the masterworks of Western art, particularly when it came to the study of expression. “I had hoped to derive much aid from the great masters of painting and sculpture, who are such close observers,” he wrote in his introduction, “but, with a few exceptions, have not thus profited. The reason, no doubt, is that in works of art beauty is the chief object; and strongly contracted facial muscles destroy beauty.” He had stumbled on a paradox: we need facial muscles to express ourselves, but have traditionally idealized symmetrical, expressionless faces.