"It's Like Pulling 'leedl" by Phil StephensPage IConstance PhillipsIt'sLikePullingTeeth:ACase StudyinPhysiologyPhil StephensBiology DepartmentVillanova University,Villanova, PAPart1-The HospitalAt last the day had come, Mr. Thompson was having his wisdom teeth removed. He was tired of the aches and pains and the sight of his puffy face in the mirror every morning. He felt helpless, lying on the gurney watching the ceiling lights whiz by as he was being wheeled to surgery.Mr. Thompson had selected this particular oral surgeon because of the sign outside his practice that read: "We cater to cowards." But the surgeon still hadn't seemed to understand Mr. Thompson's fear of dental procedures; he had wanted to use a local anesthetic. Fortunately, the anesthesiologist was sympathetic to his request for a general anesthetic.As the mask came over Mr. '.ll10mpson's face, he felt so alone. It reminded him of how he felt asa boy, in the orphanage. '.ll1en the halothane started to take effect and he went under.As surgery was about to begin, Mr. Thompson started twitching. The anesthesiologist saw Mr.'Thompson's heart rate increase, his muscle contractions become strong and widespread throughout his body, and the patient began to sweat profusely. As Mr. Thompson's temperature quickly increased, the anesthesiologist injected a solution into the IV drip. Then Mr.
The last time anyone saw my smile was the night of February 1, 2002. I’d been out for Korean barbecue with old friends, and had been complaining about a headache that I’d had for five days. I’d likened it to a spike driven through the top of my head and down to the back of my throat. “We’ll send you heavy-duty pliers,” someone joked as we said good night.
When I woke up the next morning, my face felt slack; I thought I’d slept too long in one position. Then I looked in the bathroom mirror. There were no creases on the left side of my forehead, and the laugh fold to the left of my nose had almost disappeared. I could raise the right eyebrow but not the left. The right eye blinked; the other was frozen open. I couldn’t pucker or retract my lips. My head was still throbbing.
At the emergency room, the doctor was unimpressed. “It’s Bell’s palsy,” she said, as if describing a case of flu. She told me that it was a common, temporary paralysis brought on by the inflammation of the seventh cranial nerve, which activates the facial muscles. The condition is named for the Scottish physician Charles Bell, who called it by its then familiar name, “blight,” in cranial-nerve studies that he conducted in the eighteen-twenties. (Bell also considered the problem “not formidable.”) Bell’s palsy afflicts about one in sixty-five people at some point in their lifetime; most recuperate within three weeks, but about fifteen per cent never recover fully. The exact cause is unknown.
That was Saturday. I was sent home with a prescription for a strong pain reliever for the headache and an eye patch to protect my cornea until I could blink again. By Monday, I couldn’t keep food or water down; I returned to the hospital and was told that my kidneys had failed. By Tuesday, I was constantly dizzy, even while lying in bed. The inflammation had disturbed the eighth cranial nerve, which regulates the inner ear. It and the seventh cranial nerve pass through a pair of tiny canals, one on each side of the skull. The nerves had likely been squeezed up against the ragged internal walls of the left canal and damaged.
After several days, my kidneys started working again. (Their failure turned out to have been a side effect of the pain medication; my headache dissipated on its own during the following week.) Six months of physical therapy restored my sense of balance. The eighth cranial nerve didn’t heal, but with effort the eyes can be trained to take over the work of the inner ear, providing information about balance to the brain. The seventh cranial nerve was able to heal, but only in part. Like a utility trunk line, it is a bundle of thin strands that attach to an array of facial muscles. When the strands are “insulted,” as my doctor put it, the ones leading to the upper face often heal first and best; those serving the lower face can take longer and sometimes reattach sloppily to the wrong neuronal partners.
And so I regained the ability to blink and wink on both sides, to frown, and to look absorbed. But the nerve that once connected to my left zygomaticus major, the muscle that traverses the cheek and pulls it up for a smile, had attached itself to my left platysma, the muscle that extends into the neck and pulls down the mouth and chin. Doctors call this condition synkinesis. For the past thirteen years, my smile has been an incoherent tug-of-war between a grin on one side and a frown on the other: an expression of joy spliced to an expression of horror.
Smiles are our most important form of nonverbal communication. They express warmth and familiarity; they signal receptiveness, openness, alliance, approval, arousal, mirth, and pleasure. They’re also pleas for attention; tools of ingratiation, seduction, appeasement; flags of disapproval, contempt, embarrassment. Some people wield them parsimoniously; others dole them out willy-nilly. The spontaneously joyful smile is the facial expression most easily recognized from a distance—as far as a hundred metres, researchers say.
If a stranger approaches me smiling and I try to return the greeting, I watch the person’s face fade into apprehension and wariness. I teach theatre at Hunter College, and, when I first enter the classroom each semester, new students have no idea what to make of me, because my face doesn’t corroborate my claim of being accessible and eager to work with them. A confusing message is the last thing I want to send, so I try to produce the most normal-looking expression possible, which in my case is usually a flat, tight-lipped half smile that comes off as ungenerous, patronizing, or insincere. If something tickles or pleases me, I try to smile, and my left cheek is yanked down as if by a rubber band.
I have a photograph in my office of Bill Clinton and me, taken about ten years ago, when he visited campus. Clinton, the old pro, is beaming. The camera has caught me leaning slightly away, trying to show pleasure with my eyes while holding my mouth flat to avoid looking deformed. Most people who see the photo chuckle and assume that I couldn’t stand Clinton. Actually, I have always rather liked him and am sorry the record seems to show otherwise.
The scientist who first explained the separate actions and effects of the human facial muscles was an eccentric nineteenth-century Frenchman named G. B. Duchenne de Boulogne. His 1862 compendium, “The Mechanism of Human Facial Expression,” established the “orthography” of humanity’s “language of the emotions,” which Duchenne presumed to be “universal and immutable.” (Charles Darwin, Paul Ekman, and others later provided evidence for the claim of universality.) Duchenne’s was the first scientific work to illustrate its findings with photographs. The book contains more than a hundred remarkable plates, some as misshapen as anything a Bell’s-palsy patient is likely to see in the mirror.
Duchenne cast aside the pseudoscientific literature on physiognomy—reading character and morality in people’s faces—that had been piling up since the seventeenth century. Using an apparatus he’d invented, Duchenne stimulated volunteers’ facial nerves at the points where the nerves entered each facial muscle. He then photographed the resulting contractions, compiling a catalogue of discrete muscle actions that correspond to particular emotions.
Among the experimental subjects were a mustachioed young actor with the rare ability to move many of his facial muscles independently; an attractive, nearly blind young woman; and a prematurely wizened middle-aged man so “stupefied by the abuse of alcohol” that he died of the D.T.s ten days after being photographed. I found my own condition in photo No. 58. One of the regular subjects, a toothless old man with nerve damage so severe that he could not feel the electrodes, is having his left platysma muscle “electrized.” His neck is grotesquely strained on the left, and his lower lip is drawn sharply down and sideways. He looks irritated, baffled, and attentive all at once. Duchenne called the platysma “the muscle of fright.”
Duchenne was the first to observe that a spontaneously joyful smile cannot be faked, because it results from the simultaneous contraction of two muscles, only one of which is ordinarily under conscious control. Most people can voluntarily lift the corners of the mouth, but authentic joy lives in the eyes. It requires contractions of the orbicularis oculi, the sphincter muscle surrounding the eye socket, which, Duchenne wrote, “is only put in play by the sweet emotions of the soul.” The effect of this muscle is unmistakable: it subtly lifts the lower eyelids and pushes the skin around the eyes inward, and the eyes seem to sparkle.
Certain people, it turns out, do have the ability to activate this muscle voluntarily. Method actors, for instance, can produce radiant smiles by force of imagination, just as they produce hot tears, shrieks of terror, gusts of indignation, and blasts of rage. Watch Meryl Streep laughing in “The Bridges of Madison County”; she later told Oprah Winfrey that she was able to do so convincingly by thinking about the times that Clint Eastwood forgot his lines. In general, the presence or absence of these eye-muscle contractions makes all the difference between a real smile and a forced one—an observation that social scientists today consider to be so fundamental that they refer to the smile of spontaneous joy as the “Duchenne smile.”
About three years after the onset of my Bell’s palsy, I started trying to recover something of my old smile. I realized that, to avoid prompting puzzled double takes and averted eyes when I met people for the first time, I’d begun suppressing facial expression altogether, holding my face impassive and emotionless. I had decided against corrective neurosurgery after hearing that it sometimes worsens the condition. But my son, Sam, inspired me to get creative. One day when he was eight, he was sitting across from me on the floor holding a camera, and I happened to lean my weak cheek against my knuckles. “Hey, look—you just smiled!” he said, and snapped my picture. Sure enough, the lifting action of my hand had produced a tolerable facsimile of a smile in the photo. Improvements soon followed. My wife, Julie, pointed out that even better photos resulted when I pressed close to her and used her right cheek to hold up my left.
The first step in my recovery program was to explain a mystery: often, and in all sincerity, my friends say that they see nothing wrong with my smile. Reading Duchenne, I figured out why. He described a phenomenon that contemporary scientists call “holistic processing,” in which a facial expression that is formed by a single muscle seems to involve movement of the entire face. For instance, doubt can be expressed by the knitted brow alone, but studies show that viewers often think that the expression enlists other muscles as well, such as those controlling the upper lip. In my case, thankfully, because the nerves of my upper face have healed, the orbicularis-oculi muscles around my eyes contract when I’m happy or amused. My friends overlook the outlandish appearance of my cheeks and mouth because they see the smiling in my eyes and project it onto the rest of my face.
Studies done in the past ten years have shown that people prefer mates who have symmetrical faces, associating them with health and fertility, and that the brain computes whether a face is attractive or threatening before processing whom it belongs to. The assessment, made in milliseconds, is strongly influenced by abnormal features such as scars, blotches, or conspicuous asymmetry. My main social challenge, as I saw it, was to figure out how to postpone this assessment until I could provide a new acquaintance with more information. I couldn’t escape the reaction to my deformity, but I could delay its recognition.
The most useful tactic I’ve developed was inspired by watching stutterers, who, when they start to say something and fail to get the words out, often settle for an alternative statement. Some stutterers, however, go to work on their mistakes, gradually correcting whatever misunderstandings may have arisen and eventually returning to their original points. Misunderstood facial expressions, I’ve found, can be “worked” in the same way.
At a small gathering in my home a few years ago, a guest brought up the charged subject of the new bicycle lanes proliferating throughout New York City. The mother of one of my son’s friends said, heatedly, “I just hate them. The whole thing’s gone way too far.” I launched into a careful defense. “I like them,” I said, keeping my tone cheerful while squeezing my face into the friendliest smile I could manage. “I wonder if it isn’t possible to share a little bit.”
“There’s no need to be sarcastic,” the woman said.
“No, that’s not . . . I’m not . . . I understand what you’re saying.” I then embarked on an appeasement campaign, using words to do the work that my face couldn’t. At some point in the deluge, the woman noticed my eyes. My smile was absurdly crooked, but my eyes triggered a whole-face illusion that didn’t convey antagonism, and she immediately turned convivial.
Sometimes more elaborate stratagems are required. One of them is the “pick play.” In sports, a pick is a blocking move in which the player with the ball uses a stationary teammate as an obstruction, freeing up the player to pass or shoot. In my variation, my wife or an agreeable friend stays on my left as I move about or stand in a group. The idea came to me one evening at a dinner party. Old friends happened to be seated on my left, and people I’d just met were on my right. Toward the end of the meal, I noticed that I hadn’t needed to resort to my stutterer strategy. No quizzical looks had come my way. The new acquaintances had seen only my good side, while my understanding friends on the left had fielded most of my distortions.
I first tried out my strategy at a cast party for a new production that had opened Off Broadway. I was eager to talk to one particular actor. I waited for an opening, introduced myself, smiled—and absorbed his perplexed reaction. I said I’d be back in a moment, and returned with my wife, whom I planted on my left so that the actor, on my right, faced her directly and me in profile. “We saw your Hamlet—did Jonathan tell you?” Julie said. “We went to a matinée and then talked about it the entire night afterward.” I saw the actor glance at me as I looked at my wife; I could now plausibly continue the three-way conversation without turning to face him directly. Within minutes, I was asking him questions about his working relationship with the actress playing Gertrude, who was known to be intimidating, and he looked me in the eyes and tracked my emotions. He seemed not to notice that I’d shown him only my profile before, and from then on it didn’t matter.
I have developed two shortcuts to the “whole-face illusion.” One is the “Clark Gable.” If I’m walking toward someone from a distance—the host at a restaurant, say, or an acquaintance on a subway platform—I start a smile with my head tilted down, staring along my brows. Using the pressure of my chin to keep my mouth immobile, I’m able to raise the right side of my mouth without allowing the left side to droop. As I approach, I gradually lift my head, slowly release my mouth and cheeks, and add an amiable raised brow at the last second. The rolling action tends to keep attention focussed high and allow my smile, such as it is, to function as a kindly greeting.
A variation is the “Jack MacGowran,” named for Samuel Beckett’s favorite Irish actor, who concluded his silent performance as the philandering title character in Beckett’s first television play, “Eh Joe,” with a smile made of twitches and cheek flutters. Like many Bell’s-palsy veterans, I get occasional facial twitches, which make me squint on the left side, and this in turn calls attention to my twitching eye. But if this happens at just the right moment I can use the fluttery squint, along with a few voluntary brow and forehead movements on the other side, to make me look as if I were about to say something fascinating.
My case of Bell’s palsy is by some measures a lucky one. In the waiting room of my neurologist, I saw a few patients who had recovered almost no facial movement, even years after their injuries. Their cheeks hung slack, their eyelids drooped, and their mouths sagged to the side as if perpetually reaching for a straw. In some of these cases, surgeons sew tiny gold weights into the paralyzed eyelids to help them close.
My paralysis is moderate enough to allow me to pass. But my tricks are only partial compensation. The worst effect of my damaged smile is that it can dampen my experience of joy. Scientists have long been aware that emotions are the product of a collaboration between the mind and the body. Happiness, we know, results in smiling, but the converse is also true: the act of smiling can create feelings of happiness. “Thus the sovereign voluntary path to cheerfulness, if our spontaneous cheerfulness be lost, is to sit up cheerfully, to look round cheerfully, and to act and speak as if cheerfulness were already there,” the psychologist William James wrote in 1892.
James’s theory has been understood by actors (to say nothing of wise aunts and uncles) since ancient times. Clowns have always known that mimicking expressions and gestures can induce corresponding emotions. Modern experiments have charted the underlying biochemistry, bolstering what has become a widely accepted idea: emotions aren’t intangible phenomena traceable to an abstraction called the mind; rather, they are responses rooted in physiology. As the neuroscientist Antonio Damasio wrote in his 1994 book, “Descartes’ Error,” our minds have no meaningful existence apart from the organism that they evolved to serve: “The mind had to be first about the body, or it could not have been.”
The trouble is, my brain doesn’t receive the same feedback messages that normal people receive from their smiles, which reinforce their happy feelings as well as relaying them. I’ve been devastated by the loss. When I make an extended effort to smile, my initial pleasure is extinguished, first by the squinting of my left eye, which distorts my vision, and then by a concatenation of distracting thoughts, emotions, and mental images. I’m bombarded with arbitrary and discordant sensations, as though at the edge of sleep. I feel viscerally distressed, and the distress makes me woozy.
For a long time, I despaired of ever again feeling happy in this way, until a year ago, when I read Angus Trumble’s “A Brief History of the Smile.” Trumble chronicles many therapeutic uses of laughter, including Norman Cousins’s legendary claim to have laughed off heart disease and arthritis, Japanese studies showing that laughter alleviates allergies, and yogalike clinics in India that offer “laughter therapy” for stress reduction. I wondered if laughter could be a therapy for me. I had read that a laughing face doesn’t necessarily require the zygomaticus major to contract; perhaps a work-around was possible. Could I find a way to laugh without smiling?
Almost all laughs begin as expansions of a smile, but everyone laughs differently. Snickerers and snorters keep their mouths closed, titterers and grunters pulse through parted teeth, wailers and barkers yawp through gaping mouths and throats. My old laugh was an open-mouthed guffaw that raised my brow a bit and formed a dimple. Lately, through trial and error, I’ve adjusted this expression, finding a slightly different muscle position—my mouth more O-shaped, my lips pulled into a sort of half pucker—that accommodates my laugh reasonably well and asks little of my zygomaticus major. As long as I don’t let my cheek slip in a way that awakens that killjoy platysma muscle, I don’t feel any discomfort.
My face coöperates well on second or third laughs. First ones are trickier. It seems to take at least one tug of the platysma to remind my muscle memory of its self-improvement program. I also have the problem that laughter sometimes brings on yawning. And during long, amusing stories I’ve noticed a danger zone between laughs, when my face tries to settle into a smile. At such times, I lean my head back and let my jaw hang slack, which encourages expostulations like “ha-ha” and “ho ho.”
I received an early dose of therapeutic laughter in 2002, during one of my first ventures out of the house after my attack of Bell’s palsy. I’d been asked to interview Steve Martin for the Times, and though I could still barely walk, I accepted the assignment, partly because I wanted to meet him and partly to assure myself that I was on the mend. I expected to speak to him at the rehearsal hall (he had adapted a ninety-year-old German farce called “The Underpants”), but he suggested lunch, and made me laugh unself-consciously for an hour and a half. He told me that he had known several people with Bell’s palsy, including a movie star. I’m pretty sure he knew how hard it was for my weakened lips to hold food in my mouth, but he didn’t let on, and we methodically picked over the old German comedy.
The spirit of that conversation has some relation to what I’m trying to do now—to forget vanity, calculation, other people’s reactions. Martin, in a famous rant from “Planes, Trains, and Automobiles,” said, “You can start by wiping that fucking dumb-ass smile off your rosy, fucking cheeks.” To which I would respond, “I’m trying! I’m trying!” ♦