Adventures in Human Being

by Gavin Francis

  One of the few artists Darwin singled out for praise was da Vinci, for his evident belief that beauty lay also in extremes of expression, not just in neutrality. Darwin devotes a passage of The Expression of the Emotions to the gestures portrayed in The Last Supper, meditating in particular on the attitude of the apostle Andrew. One of da Vinci’s maxims was that great art was arrived at through a demonstration of contrasts: “Your painting will prove more pleasing by having the ugly set by the beautiful, the old by the young, the strong by the weak.” What would da Vinci have made of a face with Bell’s palsy, when weakness and strength, ugliness and beauty, youth and age, are set side by side?

  EMILY HAD HEALTH INSURANCE through her employers. The plastic surgery clinic to which I sent her was expensively carpeted, with leather couches in the waiting room and society magazines on the table. On the wall was one of the clinic’s advertisements, styled as the cover of Vogue or Cosmopolitan: “Boob Jobs” and “Tummy Tucks” took the place of the cover’s splash features.

  “The office was beautiful,” she laughed when she came to tell me about it. “It was bigger than your waiting room!”

  The surgeon laid her on an examining couch, and cleaned the corners of her eyes, cheeks and angle of her mouth with a swab of alcohol. Then he drew up a small syringe from a vial of solution. “He told me it would be almost painless, and it was,” Emily said, “the needle was tiny.” He injected the solution at several points down the right side of her face, focusing on paralyzing parts of her zygomaticus and orbicularis oculi, as well as da Vinci’s muscles of fear and anger. “The paralysis from these injections will be effective for four or five months,” he had said. “And then, if you find it useful, you can come back for more.”

  “So was it useful?” I asked her.

  “See for yourself.” She pulled up the curtain of hair on her left side and gazed straight at me. The asymmetry was still there, but far less obvious. “When I smile now the right side doesn’t pull up and away so much” – she obliged by trying to give me a grin – “so my face stays more neutral. It’s taken years off me.”

  “And do you still scare the children?”

  “No, none of that,” she laughed. “I’m delighted – even been back to work.”

  AS A STUDENT AND TUTOR I’d examined the faces of the men and women I dissected with care, looking for clues about their past lives. Now the scrutiny I’d applied to those cadavers I turned more attentively on my patients in clinic. When I met people who’d developed frown lines too young, I began to question more about why that might be the case. I tried to distinguish those who were angry or distrustful from those who were simply afraid or feeling vulnerable, those who were anxious from those who were anguished. On meeting someone with an open, delighted face, I began asking about the secret of their happiness. And I realized that when my own expression showed irritation or impatience, relaxing my face made me feel and consult better.

  In his work on facial expression, Darwin wrote: “He who gives way to violent gestures will increase his rage; he who does not control the signs of fear will experience fear in a greater degree.” This idea, that adopting angry or fearful facial expressions can actually induce feelings of anger and fear, has been borne out by psychological research. Simply by contracting da Vinci’s “muscle of anger” or his “muscle of fear,” we may become more angry or more fearful. I suspected that the reverse could well be true, that preventing expressions of fear or anger could actually diminish the experience of those emotions.

  A few months later Emily came to the clinic again, but this time about an injury to her knee rather than anything to do with her face. I noticed that the obviousness of her palsy was back: she must have decided against having more Botox. When I’d finished examining her knee, I asked her why.

  “So you noticed,” she said, pulling back her fringe to show me her face. The deep furrow of her smile lines was back on the right, as were the crow’s feet around the angle of one eye, and the furrows across one half of her brow.

  “Did you get fed up with the injections?”

  “Not just that, but – my feelings are more real when I can show them,” she said. “I don’t want to go through life wearing a mask.”

  5

  INNER EAR: VOODOO & VERTIGO

  For the vortex disintegrates the heavy and the light when

  they should be together … Stooping causes dizziness for the

  same reason, for it separates the heavy and the light.

  Theophrastus, On Dizziness

  DRIVING A MOTORCYCLE is in a category apart from driving a car or even a bicycle. I’m a slow, careful rider, hesitant at speeds over sixty miles per hour, but even so there’s a pleasure not just in the unaccustomed speed of motion, the ease with which a motorcycle banks into and emerges from corners, but in the blending of so much sensory information, spatial as well as visual. You become one with a motorbike in a way that’s impossible in a car, and unnecessary on a bicycle.

  Once, I was riding a country lane on a motorcycle, late for a meeting. A forest flanked the road, its branches forming a dark canopy overhead. I wasn’t so much driving as soaring through a tunnel of green, music playing through headphones in the helmet, the road unspooling ahead of me. The air felt liquid as I leaned left and right into the corners, appreciating in my sense of balance, and in the shifting weight across my muscles and joints, how my body and the bike worked the road.

  Through an aperture in the trees ahead I glimpsed the stone parapet of a bridge: the road was about to take a sharp turn. I slowed the bike for the turn, noting a glaze of surface green – moss on the tarmac – where the road emerged into sunlight. Abruptly the whole world shifted sideways: the back wheel had hit the moss and gone into a skid.

  I was bearing down on the stone parapet at forty miles per hour, out of control. Braking hard would worsen the skid, but the stone wall was thirty yards away, then twenty, fifteen, and I slipped off the road’s camber and bumped along on rubble. I was trying to keep my eye fixed on the road edge rather than on the river and its boulders below when the back wheel found purchase and, with a wobble and a swerve, I pulled up and caught the tarmac, then swerved over the bridge.

  “The whole world shifted sideways” is how it felt: a momentary skid, over in a second, barely worth remarking on. But if it wasn’t for the efficiency and accuracy of my sense of balance, I would have been killed.

  Driving down that country road, as the back wheel of my motorcycle began its lateral slide, two events had occurred within the skull behind my ear. The bike sliding away inclined me toward the ground, tilting my head in the subtlest of angular rotations – a movement picked up by the spin of fluid through the semicircular canals within my inner ears. At the same time the jerk sideways was sensed by a related part at the base of the canal, the “utricle,” where sensitive hair cells, wired to the brain, are embedded in a jelly studded with particles of chalky material. The chalk gives the jelly mass and inertia, so as my skull made a skidding acceleration sideways, the jelly tugged on the hairs. The utricle transmits acceleration in the horizontal plane: sideways, or forward/backward. Another part of the inner ear, the “saccule,” senses acceleration in the vertical plane.*

  Since 2010 many smartphones have incorporated a gyroscope and an accelerometer, built with nanotechnology. Modeled on the inner ear, they orient our phones in space.

  Just as a mammal’s need for amniotic fluid in the womb is an echo of a time when all beings gave birth in the sea, the fluids within the inner ear are a reminder that once, our ancestors’ balance organs were simply tubes open to seawater.* As they rolled and pitched through the three dimensions, the free flow of seawater through those tubes conveyed their motion to the brain. Though it’s excluded from the usual roll call of five, balance is one of our most ancient senses: a portable sea anchor that moors us in the world.

  Some fish can’t generate their own chalky material for this purpose, but as their inner ears are still open to the sea, t
hey use pieces of sand that drift in from the outside.

  The word “vertigo” is often used to describe a fear of heights, but to doctors, vertigo is the sensation of nauseating dizziness that occurs when your balance organs and your eyes give conflicting messages about your state of motion. It’s related to seasickness, another result of conflicting sensory information. When you’re deep in the hull of a boat in a storm, your inner ear says you’re moving, but your eyes maintain that you’re not. The sensation of vertigo can be just as nauseating, caused either by a diseased inner ear insisting you’re stock-still when your eyes testify otherwise, or the obverse: your eyes insisting you’re still while the inner ear tells your brain that you’re turning.

  Of all the miseries our bodies inflict on us, nausea can be the hardest to bear, and one of the most difficult to treat with drugs. As a sensation it arises in a very primitive part of the brain, close to the spinal cord, suggesting that it could be a very ancient way of alerting the body to toxicity. That vertigo causes nausea probably means the brain interprets balance dysfunction as poisoning. It can be caused by infections in the inner ear, by tumors, even by washing the eardrum with warm water. It makes us retch in order to be rid of a poison, but vertigo and seasickness can’t be vomited up.

  JOHN WIRVELL was in his late fifties. He had a gray moustache like old rabbit fur, nicotine-stained, and his forehead was pleated by worry. Gold and silver hairs straggled from his eyebrows and gave him a startled expression. From his notes I saw that he was a taxi driver, divorcee, father of two grown-up children, and an intermittent heavy drinker. We’d met only once and he struck me as a bit of a stoic, a proud and independent man who treated doctors with caution. “No offense,” he’d told me in the consulting room, “but I don’t really go to doctors.”

  “Glad to hear it,” I’d said. “If there’s nothing wrong, why should you?”

  So it was unexpected when a year or so later he requested a visit at home, because, so the receptionist said, he’d been struck by attacks of nausea and vertigo. The attacks were so bad he was frightened to leave the house. I wondered if he’d had a stroke and called him before visiting to see if I should send an ambulance. “Arms and legs are still working, Doctor,” he said to me on the phone. “I just can’t turn my head.”

  When I arrived he was lying on his sofa, perfectly still. “A hundred times a day the room spins, I feel like puking my guts up, and I can hardly move,” he said. “It’s been hitting me for a couple of days – when it comes I just have to lie here, praying for it to pass.”

  I squatted down beside him. “What brings it on?”

  “It can be anything. Sometimes just turning to look over my shoulder sets it off. Sometimes all I need to do is roll over in bed. Bending over can do it.”

  Episodes of low blood pressure can sometimes cause dizziness, but Wirvell’s was slightly high. Alcohol can cause vertigo, but he’d been laying off the drink. I asked about other triggers, but he’d had no head injuries, recent infections, and had started no new medications.

  “Is it always when you turn in the same direction?” I asked him.

  “Yes,” he looked up at me. “It gets worse if I look down, and to the right.”

  When vertigo comes on only in certain positions it’s defined, helpfully, as “positional.” When it arrives in sudden and overwhelming bouts it’s called “paroxysmal.” The final distinction an ear specialist wants to make is between disease due to something malignant and progressive or disease caused by something benign and ultimately self-limiting. John’s illness was almost certainly the latter, so he had, in the mealy-mouthed but faultlessly descriptive jargon of otolaryngology, “benign paroxysmal positional vertigo,” or BPPV. Though the syndrome is an ancient one,* it wasn’t described until 1921 when a Viennese physician called Robert Bárány finally defined “episodic vertigo” as a syndrome.

  Hippocrates said that it was the fault of a southerly wind: Aphorisms 3:17.

  It used to be thought that in BPPV the chalky grains of the utricle and saccule became attached to the wrong membrane: the “cupula” that stretches across the base of the balance canals. The grains themselves were believed to distort the cupula’s shape, sending confusing messages to the brain about the head’s direction of movement. Treatment focused on repetition of the nausea-triggering movements until the patient became numbed to them, which could sometimes work. In severe, recurrent cases, the skull would be opened and part of the nerve that leads to the inner ear would be severed, risking deafness. It sounds drastic, but patients affected by recurrent waves of nausea and disorientation were often thankful for it.

  In the 1980s another theory was proposed, formulated by an American otolaryngologist called John Epley.* Epley believed that BPPV was caused not by chalky particles adhering to the wrong membranes, but by particles breaking free and rolling around the semicircular canals, stirring up eddies that the brain perceived as movement. Fashioning a model inner ear out of bits of hosepipe in his garage, he rolled it through different sequences, hoping to find a way to dislodge the particles and guide them out of the canals into a less sensitive part of the organ. Using this rudimentary technology, he worked out a series of simple movements that could be performed on his office couch. When he started experimenting on real patients he found that he could cure even those who had been suffering BPPV for years. When the sequence didn’t work he tried holding a vibrator to the skull behind the patient’s ears just before the maneuver, to help dislodge any adherent chalky grains, and found that this further improved his cure rates.

  In the 1960s Epley had been involved in trialing the very first cochlear implants.

  Surgeons whose livelihoods were bound up with recommending expensive procedures for BPPV were skeptical, and the fact that Epley had been holding vibrators to patients’ heads allowed them to label him a crank. He was laughed at in conferences, accused by some as unfit to practice. His maneuvers were perfected in the early 1980s, but it took a decade until his harmless, effective, medication- and surgery-free treatment for positional vertigo was published in a journal respected by his peers. It took another few years to percolate into general medical clinics around the globe.

  Anyone can do an Epley maneuver; you can download the sequence from the Internet and try it at home, even on yourself, though people with neck problems or poor circulation should be cautious. It was more than a decade after Epley published his findings that I first heard of the sequence and gave it a try. Epley reported a 90 percent cure rate in his Oregon clinic: the results could be just as astonishing when I began to use it in Scotland.

  I LED JOHN WIRVELL through to his bedroom, and asked him to sit toward the foot of his bed the wrong way round, legs extended toward the pillows. I noticed that he had small, oddly intricate ears, as convoluted as nautilus shells. I put one hand on each of them and then dropped him straight back so that his head fell past the horizontal off the end of the bed, his chin turned toward his left shoulder. This is a position that orients the head in a certain way with respect to gravity, calculated by Epley to allow chalky grains on the left side to begin to drift down through the semicircular canals. We waited a few seconds.

  “Nothing’s happening,” he said, creasing his forehead. “Is this supposed to make the dizziness go away?”

  The next time I dropped him back, turning his chin toward his right shoulder, his whole body tensed and his eyes began to jerk like beads of light on an oscilloscope – attempts by his eyes to follow the illusory motion sensed in the labyrinth. “That’s it!” he muttered, gritting his teeth, “You’re making it worse!”

  In the 1950s it had been figured out that when the canals on the right side were affected by BPPV, lying back with the chin toward the right was the movement most likely to bring on an attack. After thirty seconds holding that position, the jerking of his eyes began to settle. I turned his head slowly through ninety degrees, still hanging off the end of the bed, so that now his chin pointed toward his left shoulder. His v
ertigo came on again, but this time less so. After another thirty seconds, I rolled him onto his left side while maintaining his chin’s position, so that the position of his neck now turned his gaze to the carpet. His body relaxed, he ungritted his teeth – his symptoms were already settling. Thirty more seconds and I sat him up, asking him to slowly raise his chin and look toward the headboard of the bed.

  “How do you feel now?” I asked him.

  He paused a moment, then tentatively turned to look over his right shoulder. “OK so far,” he said, swinging his legs off the side of the bed.

  “Try bending over.”

  He stood up, then bent his head and looked over his right shoulder – the movement that had previously set off his vertigo. “It’s like magic … voodoo medicine!”

  WHY DID A TREATMENT so simple, risk-free and effective take ten years to be reported in the medical press? It’s wrong to assume that doctors are rationalists, that the medical gaze is as emptied of bias and as open to new ideas as the best science aspires to be. Physicians are just as prone to prejudice and protectionism as professionals in any other sphere of life – it’s just that we rightly hold them to higher standards.