- Email: [email protected]
Folklore surrounding facial deformity and the origins of facial prejudice
ooO7-1226/81/0155-0237 $02.00
British Journal
ofPlastic Surgery (1981) 34, 237-246 0 1981 The Trustees of British Association of Plastic Surgeons
Folklore surrounding of facial prejudice
facial deformity
and the origins
W. C. SHAW Department of Orthodontics,
Dental School, Welsh National School of Medicine, Heath, Cardiff
results of an interview survey of present folklore and “old wives” tales concerning facial deformity are reported.
Introduction In the pioneer study by MacGregor et al. (1953) extended interviews with facially deformed patients revealed the serious psycho-social difficulties that could be encountered in everyday life. This view was elaborated by Goffman (1963) who held that facial deformity was one of several conditions that could stigmatise individuals, making them less acceptable to the rest of society. The desire to overcome social prejudice is certainly an important motive for patients who seek corrective surgery (Jensen, 1978). Hostility towards the facially deformed is no longer as extreme as in 1708 when Frederick V. of Denmark ruled that no individual with a facial deformity might show himself to a pregnant woman (Weiser, 1963). Yet in some parts of the world, open prejudices still persist: among some African tribes a deformed man is prohibited from elevation to chieftaincy (Babalola, 1978) while among rural communities in the Indian subcontinent, the family which begets a deformed child is held in low esteem until certain purifying rituals have been performed (Dehragoda, 1978). Even in modern society, feelings of aversion are still aroused by deformities of the face, particularly the more severe, though the modifying effect of other emotions such as sympathy and curiosity are poorly understood (Shaw et al., 1980~). In the less inhibited society of childhood, disapproval of deviant physical features is openly voiced (Shaw et al., 1980b) and in interviews held recently at out-patient clinics for children with deformities such as cleft lip and facial .burns, most of the children were reported to be victims of frequent teasing and harassment (Jones et al., 1979). In the first part of this paper, possible reasons why facial deformities may evoke an unfavourable social response are examined. In the second part,. primitive beliefs about the genesis of deformity in general, then more specific facial deformities, are reviewed. Finally, the
Part 1 Reaction to Facial Deformity There may be several reasons for unfavourable reactions towards deformities of the face:
Instinctive Rejection Sexual Aversion Modern man undoubtedly retains a legacy of instinctive behaviour handed down from a time when natural selection shaped behavioural as well as physical attributes (Wilson, 1975) and instincts which limited procreation by imperfect would have been desirable in partners evolutionary terms (Dawkins, 1976). As facial deformities may be a visible indication of more profound mental or physical disorder (Gorlin et al., 1976) some degree of instinctive aversion could be expected. This instinct, however, is somewhat indiscriminate, operating within the sexes as well as between them and against acquired facial deformities which cannot be genetically transmitted. Fear Wright (1960) suggested that a normal person’s unconscious body-image could be threatened by the appearance of an individual with a deformity, in as much as he identifies to some extent with that person. The truly instinctive nature of fear arousal is suggested by the observation of Hebb (1946) that spontaneous fear of mutilated bodies experienced by man and chimpanzee alike is due to neurophysiological conflict and there is some evidence that initial reactions to deformed faces are autonomic in character (Aamot, 1978). 231
238
BRITISH JOURNAL
OF PLASTIC SURGERY
Conjtision
considered attractive, desirable social qualities
The visual pattern of a normal face is learned early in life (Kagan et al., 1966) and another component of instinctive rejection may be the confusion and unease experienced when witnessing anything strange or inconsistent. Facial deformity may be particularly stigmatising because of the unique importance of the various functions of the face. It is not only the primary means of personal identification but the facial expression (at rest and in action) is an enormously rich source of non-verbal information (Ekman, 1978). According to Morris (1967) ke face provides a highly important focus of erotic interest in sexual encounters and there is a primitive and profound association in the mind between the whole integrated pattern of the face and the pattern of the torso. Deformities of the face may interfere with the normal transmission of social information in several ways. Certain defects such as ptosis or Bell’s palsy clearly interfere with the transmission of a vast range of non-verbal messages and for the individual with a tight repaired cleft lip, a broad engaging smile may be unattainable. Finally, transient expressions characteristic of mood may be permanently imitated by morphological features. For example, the intention bite (Grant, 1969) may be noted in an individual with mandibular prognathism and lower incisor display and give him an “aggressive look”.
such as intelligence, honesty and friendliness are repeatedly attributed to those so endowed (Adams, 1977). The evolutionary origins of this behaviour remain obscure. Is it an over extension of the instinct designed to limit procreation by genetically substandard members of the species, or inspired purely from an intuitive pleasure at beholding any object which is aesthetically appealing in its own right? Whatever the genesis of the response, sexual attractiveness appears to be of no less importance today in mate selection (Adams, 1977) and consequently the genetic constitution of future generations.
Stereotyping While there is no sound evidence that personality can be accurately read from individual physiognomic cues (Ekman, 1978), first impressions of a face can produce an extraordinary consensus of opinion concerning the subject’s personal characteristics (Secord, 1958). Although part of this process, such as the effect of pupil size, may have a physiological basis (Hess, 1975) much facial stereotyping remains unexplained. Perhaps the most potent facial cue is the aggregate quality of attractiveness. Experimental studies show that a surprisingly high level of agreement on an individual’s facial attractiveness can be reached by different judges (Berscheid and Walster, 1974) and that while there is no apparent intrinsic merit in inheriting the combination of genes which produces a face
Social Conditioning
and Reinforcement
ConjbrmitJ As Darwin (1871) pointed out, one cultural group’s concept of a pleasing appearance may vary from another’s, but within the group there is pressure to conform to a socially defined norm, even if this involves expense, discomfort or physical trauma (Jenny, 1975). Distortions and elaborations which include neck elongation, head moulding, scarring and the wearing of lipdiscs have been reported among primitive peoples, but modern civilisation is also replete with examples of cosmetic ritual. How else should we regard the use of cosmetics, the control and cultivation of facial hair and the grooming of scalp hair? Sadly, the commercial exploitation by the advertising media of the desire to be beautiful, merely serves to perpetuate myths about the quality of the individual behind the face. Popular Images of Horror and Amusement It requires little imagination to see how much the various prejudices and instincts already considered are compounded by popular imagery. Distortions of the human form associated with evil and terror were part of oral and written tradition long before the arrival of horror films, while the comic face has long attracted amusement in circus, theatre, caricature and cartoon. Folklore and Superstition Finally it is likely that through the ages, attitudes to those with facial deformities have been strongly influenced by popular understanding of
FOLKLORE
SURROUNDING
FACIAL
DEFORMITY
the cause and significance of such conditions. Thus, sinister beliefs that facial deformity represented a form of curse or supernatural retribution could only add to the stigma associated with the condition and the prejudices which the possessor would confront. Attempt to account for such phenomena were, of course, limited by contemporary understanding of the Universe and prevailing religious doctrines, while eventual explanations may have been tailored in such a way as to rationalise more profound instincts to which human beings are already subject. Part 2 Folklore Surrounding the Genesis of Facial Deformity Congenital
Dejbrmities
Throughout the history of man, the birth of a child with a congenital deformity must have stimulated speculation as to the cause. The beliefs held since primitive times have been many and varied and attitudes to the deformed child, at times his very survival, have depended upon them. The monumental review of the subject by the Scottish obstetrician, Ballantyne (1904) supplemented in more recent years by Warkany (1977), provide a brief resumi: of the past theories of teratology. The Gods According to Ballantyne, the Greek historian Euhemerus (316 BC), considered that so-called monstrous infants were incarnations of the gods themselves or their progeny. It was suggested that the cyclops’ foetus inspired the image of the god Polyphemus: the sympodeal foetus becoming a siren: Atlas, a case of occipital encephalocele: the god Ptah of the Egyptians, an example of achondroplasia. The more popular view, however, was that the gods were creators of monstrous infants, either for their amusement or to warn, admonish or threaten mankind. The power of this latter belief undoubtedly contributed to the common practice of sacrificing such offspring (and often the mother) in Roman times, and even later during the Middle Ages in Europe in attempts to placate the gods. In Mesopotamia, congenital deformities were considered to herald future events and Ballantyne describes one tablet dating to 2000 years BC
239 which carried a list of divinations relating to 62 teratological conditions. These include the forecast that when a woman gives birth to an infant “that has no tongue, the house of the man will be ruined; that has an upper lip which overrides the lower, the people of the world will rejoice; whose teeth are already cut, the days of the King will be prolonged”. Eail Spirits Belief that evil influences had teratogenic powers were also widespread: a satanic origin commonly being suggested for any infant bearing supposedly demonic features such as hairy naevi, ichthyosis, club feet and syndactyly. Haffter (1968) has investigated the history of such attitudes in European folklore, where physically deformed or mentally retarded children were regarded as the offspring of fairies, elves or other sub-human beings. The idea that the so-called “changeling” had been surreptitiously substituted for the real child is a pre-Christian superstition of CeltoGermanic origin and it had important implications for the way in which parents might attempt to reverse the change. In some parts, the changeling was considered to bring good luck and should be well treated, but more widespread was the advice that the child should be treated so cruelly that the elves would be coerced to return the stolen child. The later Christianised form of the superstition supposed that the devil himself had performed the exchange and this was especially significant for the parents. Blame, originally projected to wicked spirits, became regarded as retribution for sins of the parents, evidence of witchcraft or collusion with the devil.
The influence of the position of the heavenly bodies entered into the beliefs of the ancient races and the astrology of the Babylonians survives in the popular mind to this day. Not every child could be “born under a lucky star” and the position of Venus or the moon in particular, had a supposedly potent effect in determining whether the infant was to be normal or deformed. Hybridit In the Middle Ages, foetal abnormalities which had some perceived animal resemblance, were considered to be the issue of human and animal union and it has been suggested that traces of
240 these beliefs might have been reflected in such mythological images as the Centaur and Minotaur. The birth of an animal or human foetus with some perceived hybrid characteristic could lead to the execution of an innocent human being, such practices being recorded as late as the seventeenth century. Maternal Impressions
A notion of great antiquity is that a pregnant woman can produce a deformity in her child by sighting deformed individuals, being frightened by animals or by witnessing disturbing events. Belief in such psychogenic effects are represented in Roman, Hebrew and early Christian writings and have also been shown to exist in India, China, Asia, Africa, Europe and among the Eskimos. The supremacy which this theory gained over suspicions of satanic or bestial intercourse in the sixteenth and seventeenth centuries had at least the beneficial effect of rendering the arrival of a deformed child a misfortune but no longer a crime. Many scientific men objected to this theory in favour of more realistic biological explanations. One of the most effective and scientific refutations was supplied by William Hunter who, in the eighteenth century, made a prospective study asking mothers before their confinement, about psychic traumas during pregnancy. In no case did he find any correlation between the woman’s answer and a congenital anomaly in the child. Yet, as late as the nineteenth century, reports of the alleged influence of maternal imagination appeared in the medical literature. Seminal and Menstrual Causes
The beliefs of some early Greek writers reflected their somewhat erroneous views of reproduction. Empedocles considered that congenital deformities were due to deficiencies or alterations in the semen, while the notion that children conceived during menses would be deformed was widely held, being related to Hebrew legislation on coitus during the menstrual period. Aristotle, however, was more accurate in his belief that monstrosities arose from the conjoint action of perverted strains of both sperm and germ. Mechanical Causes It is clear in the writings of Hippocrates,
that he believed that antenatal deformities might be due
BRITISH
JOURNAL
OF PLASTIC
SURGERY
to direct injury to the foetus or to intra-uterine moulding and one popular variation of the theory, still receiving much attention in the nineteenth century, was the injurious effect of tight corsets. Ballantyne considered that the significance of mechanical effects had been pushed to absurd lengths when medical men suggested that cleft lip might be induced by the foetus lacerating its upper lip with its nails, and when it was suggested that cleft palate might be due to intrauterine thumb sucking or to the pressure of the tongue tip. Cleft Lip
In the case of this deformity, a belief which recurs commonly in the folk history of many European countries is that the defect arises when the mother sees a hare during pregnancy. A variation of this tale is that the mother need only step over a hare’s lair to induce the deformity, but that she can break the spell by tearing her petticoat or dress in a prescribed manner (Bruford, 1978). One vivid account recorded in the North of Scotland in 1893 was as follows: “An unmarried woman in Kingussie became pregnant. She was shearing in the harvest field, and came upon a hare’s lair. Her companions suspected her condition, and said she ought to take a snip from the border of her petticoat. To conceal her shame, she, so far from taking the advice of her companions, put her foot in the lair, stepped over it, and then back. The child had a double harelip”. Such beliefs were shared elsewhere in the British Isles (Hole, 1961; Evans, 1972; Briody, 1978; Sanderson, 1978) and in Denmark (FoghAndersen, 1942), Sweden (Nyman, 1978; Schon, 1978) and Norway (Christiansen, 1978), where indeed, an old Norwegian law for the protection of pregnant women forbade butchers from displaying hares in public (Reed, 1956). This curious association between cleft lip and the hare is represented by the terminology of the condition in many languages (Table 1) and the true antiquity of the association is revealed in the writings of Galen in the second century by usage of the term “lagocheilos” (Weiser, 1963). The natural form of the hare’s upper lip lends itself appropriately to description of untreated cleft lip in man, but the same is true for the snout of many other mammals (Bateman, 1977) and there appear to be additional reasons for the hare-cleft lip association. Together with the cat,
FOLKLORE
SURROUNDING
FACIAL
DEFORMITY
241
Table 1 Implied association between cleft lip and the hare in several languages
Table 2 Implied causal inference from the etymology of “birthmark” in several languages
Language
“Harelip”
Translation
Language
“Birthmark”
Translation
Dutch German
hazenlip hasenlippe hasenscharte
Dutch
moedervlek
German
Danish French Swedish Spanish Italian Irish Old English Old Frisian
hareskarr bet de Kvre harmynthet labio leporino labbro leporino bearna haersceard hasskerde
harelip harelip scharte: crack, fissure. gap, notch hare cut hare’s mouth hare lipped hare lip hare lip slash (in dress), gap, chasm hare cleft hare lipped
Danish
geburtmal muttermal modermaerke
French Spanish
envie estigma
Italian
voglia e.g. voglia de fragola
moeder: mother vlek: spot, stain, mark, mole mutter: mother mal: mole, mark, spot moder : mother maerke: mark, sign desire, longing birthmark, mother’s mark. stigma, slur wish, desire, craving, longing, strawberry birthmark
Norwegian
branflekk
Czech
materskeznameni
the hare in folklore is regarded as a common witche?? familiar, or form assumed by a witch, in order to avoid detection during the execution of some malevolent act. Tales of such witch-hares are abundant in various parts of the British Isles (McPherson, 1929; Gwyndaf, 1977; Smith, 1978). Looking further into the past, most folklore surrounding the hare supports its connection with an ancient religion (the worship of Diana, goddess of childhood and the moon) and a universal complex of moon-hare myths can be traced (Evans, 1972). The hare was associated with the moon in ancient Egypt and among the North American Indians, while Indian and Chinese children are still told bedtime stories about the hare and the moon, rather than the man in the moon. In African mythology, it is believed that the moon in anger actually split the hare’s lip and similar tales are recounted in Tibet (Layard, 1944). These interwoven beliefs are also revealed in the pre-Columbian culture of Mexico, where to the present day, lunar eclipse, rather than the hare is considered responsible for cleft lip (Ortiz-Monasterio and Serrano, 1971). Thus the folklore surrounding the aetiology of cleft lip appears to represent a fusion of several of the primitive beliefs reviewed by Ballantyne; supernatural influences, lunar influence, hybridity and maternal impressions. Birth Marks
In several modern languages the equivalent word for birth mark again implies a supposed causal inference between experiences of the mother and the anomaly (Table 2). Various maternal impressions have been implicated such as the witnessing
of a conflagration
or the slaughter
of
brann: tire flekk: mark matersky: mother’s znameni: mark
animals, especially when the woman is unwise enough to simultaneously touch her own face. Even more common is the belief that birth marks are produced when a mother craves for or eats vividly coloured food such as strawberries. Indeed dietary cravings or indiscretions of this kind are represented in the pregnancy taboos of every corner of the world (Ferrera, 1969). Not surprisingly, many such tales have been transported by North American immigrants where “marking theories” have been comprehensively recorded (Fife, 1976; Hand, 1979). Here, an additional recurring belief was that deformity of the child was induced by the mother previously mocking someone similarly afflicted, implying therefore, a form of punishment. Part 3 A Survey of Present Day Beliefs
In order to examine current beliefs and knowledge relating to facial defomities, 200 women in the age range 20-69 years were privately interviewed, either at their place of work (schools and factories), or in their own homes. They were shown colour photographs of 6 individuals who demonstrated a distinct type of facial deformity (Fig. 1). These deformities were a repaired bilateral cleft lip; portwine stain; mandibular protrusion; mandibular retrusion;
242 mandibular asymmetry and acromegaly. The women were asked to give a description of each deformity, their beliefs as to its cause and any other causes which they may have heard of. In addition, they were asked to comment on the
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
kind of personality which they thought the photographed individual might have and whether they knew anyone with such a condition. Responses to each question were recorded verbatim and, to assist the analysis, subsequently categorised (Table 3). Frequency counts were calculated and in order to see whether the replies were influenced by the age of the subject or prior acquaintance with someone with the deformity demonstrated, cross tabulation and Chi-square analysis were performed (Nie et al., 1975).
Description
of Facial Deformity
(Table 3a)
Precise or reasonably accurate descriptions were given for all demonstrated conditions with the exception of acromegaly. Of the respondents 7.5 % simply regarded this condition as a manifestation of subnormality while 15.5 % used such bizarre descriptions as “boxer, rugby player, mongol, spastic, pre-historic man”.
Causes of Facial Deformity
(Tables 3bhd
c)
Quasi-Medical Explanations While many respondents were unable to suggest a cause for the various conditions, a reasonable proportion tendered various medical or quasimedical explanations. Included under the heading “Genetic” are various replies such as “hereditary, just born like that, or fault at conception”. Intrauterine pressure was considered a potential cause for all the conditions, more specifically thumb sucking (in the case of cleft lip) and according to one respondent, tight corsets during pregnancy (for mandibular retrusion). Attempted abortion was mentioned by a minority as a cause of cleft lip, mandibular asymmetry and acromegaly and for this last condition, excessive of alcohol in and consumption smoking pregnancy.
Fig. 1 Facial photographs of 6 individuals, originally in colour, who demonstrate a facial deformity. A. Bilateral cleft lip; B. Port-wine stain; C. Mandibular protusion; D. Mandibular retrusion; E. Mandibular asymmetry: F. Acromegaly.
Maternal Impressions Relatively few respondents considered maternal impressions to be an important cause of the deformity, except in the case of portwine stain. This condition was frequently reported to be due to the mother’s consumption of strawberries or red cabbage, or to an unsatisfied craving for such foods. Less often it was considered to be due to the mother being frightened by an animal, her contact with blood during pregnancy or some
FOLKLORE
Summary
SURROUNDING
FACIAL
of200 inteniiew
(Responses
expressed
Table 3a
Description
as percentage) of Facial Deformity Portwinr .sturn
Mrrndrhulat protrusion
MundihuLaf r’rtrll.\rrm
Mundihulor ir.\~Ynmetr\
87 10 1.5 0.5
87.5 11.5
I .o
.._
46.5 48 2.5 1.5 1.5
71.5 JO.0 3.5 0.5 4.5
54 39 2 2.5 2.5
Portwinr stain
Mandihular protru.sion
Mandihulut rrtrusion
Mandibular aspnmrtr~
50 34.5 6 3.5
42.5 21.5 7.5 5.0
49 33 1.0 3
42 34
45 14 6.5 7.5
39 20.5 3.0 5.0
3.0
3.0 -_ 9.0 11.0 0.5
7.5 5.5
7 14
23.0 2.5 0.5
26.0 5.0 1.5
Cleft lip
Precise Reasonable Bizarre Don’t know Subnormal
Table 3b
1.0
Don’t know Genetic Intrauterine Birth trauma Later trauma illness Environmental Psychogenic Craving: Others
Table 3c
lip
I 1
or
2.5 0.5
Other Reported
Ckji
None Genetic Intrauterine Birth trauma Later trauma illness Environment Psychogemc Cravings Others
5 64 15.5 8.0 7.5
Cause of Facial Deformity
Ckfi
Table 3d
243
DEFORMITY
I
_.
I 1.0
Causes
Irp
80.0 1.5 3.0 1.5
Portwine stuin
Mundibular protrusion
Mandihulut wtrurion
Mandibular usymmetry
,4cromrgal,v
43.0 1.0 2.5
94.0 0.5
76.5 3.5 1.0
86 1.5 1.5 2.0
86 3.0 1.0 0.5
1.5
2.0 3.0 0.5
3.5 13.0 2.5
5.0 2.5 1.0 0.5
4.0 2.0 1.5
or
12.5 0.5 1.6
Treatment
_
2.0
of Facial Deformity
Ckft
Don’t know None possible Surgery Medical Dental/orthodontic Psychiatric Emotional support Cosmetics Unorthodox Physiotherapy
25.5 26.5
9.0 4.5 82.0 0.5 t.5 0.5 0.5 1.0 0.5
lip
Portwine stain
protrusion
Mandibular
8.0 17.5 58.5
18.5 14.5 42.0
1.0
1.5 13.0 0.5
16.0 2.0 1.5 0.5 4.0 1.0
Mandihulas retrusion
10.0 2.0 x.5 0.5 76.0 1.5 1.5
Mundibular
as)mmrtrv
Acromegalj
19.5 12.5 49.5 1.5 4.5
21.5
2.5 3.0 5.0 2.0
37.5 28.0 4.5 1.5 4.0 1.5 1.0 0.5
244 Table 3e
BRITISH JOURNAL OF PLASTIC SURGERY Prior Acquaintance Clef lip
Portwine stain
Mandibular protrusion
Mandibular retrusion
Mandibular asymmetry
Acromegaly
NO
69.5
71.0
92
96
30.5
29.0
89.0 11.0
64
YES
36
8
4
Portwine stain
Mandibular protrusion
Mandibular retrusion
Mandibular asymmetry
Acromegaly
13.0 49.5 35.0
13.5 23.5 39.0 2.5 6.0 15.5
9.5 32.0 37.5 8.0 3.0 10.0
14.0 28.0 36.0 3.0 3.5 15.5
12.5 20.5 15.0 22.5 18.5 11.0
Table 3f
Attributed Personality Clef lip
Don’t know Normal Self-conscious/shy Subnormal Aggressive Odd/disturbed
‘9.5 28.5 44.0 3.0 6.5 8.5
2.5
injury. extra-abdominal Few respondents admitted personal conviction that maternal impressions caused cleft lip, though many more were familiar with the old tales. Only a few women believed that the mother had been frightened by a hare or rabbit and only one respondent blamed the mother’s failure to observe the spell-breaking ritual of tearing her dress. Treatment (Table 3d) Popular faith in the efficacy of surgical treatment was revealed for all conditions and in the case of mandibular retrusion orthodontic or dental treatment. Medical solutions included the use of tablets, or for acromegaly, hormone treatment. Provision of psychiatric therapy or emotional underlines expectations support of mental subnormality (vide infraj and, not surpriscosmetic disguise of portwine stain ingly, was suggested. A minority of respondents recommended physiotherapy or rather unorthodox approaches such as prayer or a change of environment. It was interesting to note that about one quarter of respondents considered that the repaired cleft lip represented the, as yet, untreated condition.
Personality
(Table 3f)
The present approach, which adopted interviews based on photographs, clearly fails to incorporate a wide range of methodological controls. These are considered more fully elsewhere (Shaw et al., 1980a). Nevertheless, the replies seemed to reveal common preconceptions of the personality of individuals with deformed faces. Of course, many respondents felt it impossible to predict personality from a photograph and others reported that the individual would be unaffected (these responses were included under “Don’t know” and “Normal”), while it was widely anticipated that the deformed individuals would be self-conscious or shy. Personality assessments of a more discrediting kind were however reported by the remainder of the sample; the individuals displaying acromegaly and mandibular retrusion were regarded as being subnormal by 22% and 8 y0 of respondents respectively. The acromegalic and to a lesser degree the other deformed individuals were considered by some to be aggressive and a minority substantial anticipated that the individuals photographed would have personalities which were in some other way odd or disturbed. Effects of Age of Respondent
Prior Acquaintance Table 3e shows the percentage of respondents who were acquainted with individuals who possessed the various facial anomalies.
No consistent associations between age of respondent and the various replies on description, treatment and personality emerged. However, for portwine stain, psychogenic or
FOLKLORE
SURROUNDING
FACIAL
245
DEFORMITY
dietary causes were reported more frequently by individuals over 39 years of age (25.2 9, v 10.9 Y;, p < 0.05), than those under 39 years.
Effects of Prior Acquaintance Only to a slight degree did prior acquaintance with a deformed individual lead to more informed replies. Personality characteristics were judged to be normal by a higher proportion of respondents who were acquainted with persons having mandibular prognathism (41”;; v 21 Y:, p ~0.05) and acromegaly (SO”,, v 199,, p
Conclusions The results suggest that many misconceptions about facial deformity persist, even when there is prior knowledge of the deformity. Almost all the various ancient and medieval explanations reviewed by Ballantyne (1904) were mentioned by one or other respondent and notably the role of maternal impressions in producing facial birth marks was more commonly believed by the older women. Folklore beliefs would however, appear to be dying out, being repiaced instead by sometimes accurate, sometimes inaccurate, quasi-medical explanations. On the other hand, unfavourable preconceptions about the personality of individuals with facial deformities are still prevalent.
Discussion Attitudes to facially deformed individuals appear to arise from a complex of deep seated psychological instincts and cultural pressures. In addition. a legacy of confused folk belief persists so that to
the present day, understanding of the nature and causes of facial deformity remains imprecise. Certainly, parents of children with a congenital or acquired deformity of the face, and subsequently the child himself, deserve a clear and sympathetic explanation of the cause and treatment of the condition, not least in order to appease any feelings of guilt which may be experienced (Cracker and Cracker. 1969). In this respect it is unfortunate that medical understanding of the aetiology of many deformities remains incomplete. An account of morphogenesis does not answer the question, “Why our child?‘. apparent prejudice Society’s towards the disfigured and the unjustified value placed on attractiveness physical significant represent problems. Undoubtedly the broadening scope of corrective treatment offers immeasurable benefit to a growing number of patients. Paradoxically however, the application of refined techniques to subjects with negligible deviations from the norm, add credence to the unfortunate view that the cover is more important than the book. As the dramatic progress in cosmetic surgery seen in recent decades now reaches a plateau, a search for better means of helping the disfigured individual come to terms with his condition and more comfortably integrate with society. would seem appropriate.
References Aamot, S. (1978). Reactions to facial deformities: autonomtc and social psychological. Europeun Journal qf’ Sociul Psychology. 8, 315. Adams, G. R. (1977). Physical attractiveness research. Toward a developmental social psychology of beauty. Humun deuelopmenf 20 (4), 217. Babalola, A. (1978). Personal communication from the Department of African Languages and Literatures. University of Lagos, Nigeria. Ballantyne, J. W. (1904). Manual of Antenatal Pathology and Hygiene. The Embryo. Edinburgh. William Green and Sons. Bateman. G. (1977). Zoology Department, National Museum of Wales, personal communication. Berscbeid, E. and Walster, E. (1974). Physical attractiveness. In: “Advances in Experimental Social Psychology”. Vol. 7. Ed. L. Berkowitz, New York. Academic Press. Briody, M. (1978). Personal communication on the archives of the Department of Irish Folklore, Dublin. Bruford. A. (1978). Personal communication on the archives of the School for Scottish Studies, Edinburgh. Christiansen, I. (1978). Personal communicatton from the Institute of Folklore. Oslo.
246
BRITISH
Cracker, E. C. and Cracker, C. (1970). Some implications of superstitions and folk beliefs for counselling parents of children with cleft lip and palate. Clefi Palate Jour&, 7, 124. Darwin, C. (1871). The Descent of Man, and Selection in Relation to Sex, Vol. 2, London. John Murray. Dawkins, R. (1976). The Selfish Gene, Oxford. Oxford University Press. Dehragoda, R. (1978). Personal communication. Ekman, P. (1978). Facial signs: facts, fantasies and possibilities. In: Sight, Sound, and Sense, Ed. Sebeok, T. A.. Bloomington. Indiana University Press. Evans, G. E. (1972). The Leaping Hare, London. Faber and Faber. Ferrera, A. (1969). Prenatal Environment. American Lecture Series, Springfield, Illinois. C. C. Thomas. Fife, A. E. (1976). The marking of children and psychic imprinting. In: American Folk Medicine: A Symposium, Ed. Hand, W. D., Los Angeles. University of California Press. Fogh-Andersen, P. (1942). Inheritance of Harelip and Cleft Palate, Copenhagen. Nyt Nordisk Forlag. Goffman, E. (1963). Stigma: notes on the management of spoiled identity. Englewood Cliffs, N.J. Prentice-Hall, Inc. Gorlin, R. J., Pindborg, J. J. and Cohen, M. M., Jr. (1976). Syndromes of the Head and Neck, New York, McGrawHill. Grant, E. C. (1969). Human facial expression, Man, 4, 525. Gwyndaf, R. (1977). Personal communication on the archives of the Welsh Folk Museum, Cardiff. Haffter, C. (1968). The changeling: history and psychodynamics of attitudes to handicapped children in European folklore. Journal of the History oj’ Behmioural Sciences, 4, 55. Hand, W. D. (1979). Personal communication of unpublished files of The Dictionary of American Popular Beliefs and Superstititions, University of California. Hebb, D. 0. (1946). On the nature of fear. Psychological Reciew, 53. 259. Hess, E. H. (1975). The role of pupil size in communication. Scienti$c American, November. 110. Hole, C. (1961). Encyclopaedia of Superstitions, London. Book Club Associates. Jenny, J. (1975). A social perspective on need and demand for orthodontic treatment. International Dental Journal, 25, 148.
JOURNAL
OF
PLASTIC
SURGERY
Layard, J. (1944). The Lady of the Hare, London. Faber and Faber. Macgregor, F., Abel, T., Lauer, E. and Weissmann, S. (1953). Facial deformities and plastic surgery. A psychosocial study. New York. C. C. Thomas. McPherson, J. M. (1929). Primitive beliefs in the North-East of Scotland. London. Longmans Green and Company. Morris, D. (1967). The Naked Ape. London. Corgi. Nie, N. H., Hull, C. H., Jenkins, J. G., Steinbrenner, K., Bent, D. H. (1975). Statistical package for the social sciences, 2nd ed. New York. McGraw-Hill. Nyman, A. (1978). Personal communication on the archives of the Instiut for Undersokning av Svenska Dialekter Och Folkminnen. Ortiz-Monasterio, F. and Serrano, R. A. (1971). Cultural aspects of cleft lip and palate treatment. In: Cleft Lip and Palate, Eds. Grabb, W. C., Rosenstein, S. W. and Bzoch, K. R. Boston. Little Brown and Company. Reed, S. C. (1956). Counselling in Medical Cenetlcs. Philadelphia. W. B. Saunders Company. Sanderson, S. F. (1978). Personal communication on the archives of the Institute of Dialect and Folk Life Studies. Leeds. Schijn, E. (1978). Personal communication on the archives of the Nordiska Museet. Stockholm. Secord, P. F. (1958). Facial features and interpersonal perception. In: Person Perception and Interpersonal Behaviour, Eds. Taguiri, R. and Petrullo, L., Stanford. Stanford University Press. Shaw, W. C., Humphreys, S., McLaughlin, J. M. and Shimmin, P. C. (1980a). The effect of facial deformity on petitioning. Human Relations 33, 659. Shaw, W. C., Meek, S. C. and Jones, D. S. (1980b). Nicknames, teasing, harassment and the salience of dental features among schoolchildren. British Journtr2 of Orthodontics,
7, 14.
Smith, L. (1978). Personal communication on the archives of the Ulster Folk and Transport Museum, Holywood. Warkany. J. (1977). In: Handbook of Teratology. Eds. Wilson, J. G. and Fraser, F. C. New York. Plenum Press. Weisser. Aall, L. (1963). Om haren i norsk overievering. Norueg, 10, 55. Wilson, E. 0. (1975). Sociobiology: The New Synthesis, Cambridge, Massachusetts. Harvard University Press. Wright, B. A. (1960). Physical disability. A psychological approach. New York. Harper and Row.
Jensen, S. H. (1978). The psychological dimensions of oral and maxillofacial surgery: a critical review of the literature. Journal
of Oral Surgery,
36, 447.
Jones, B. M., Gahe, M. J. and Shaw, W. C. (1979). Unpublished student elective project. Dental School, Cardiff. Kagan, J., Henker, B. A., Hen-Tov, A., Levine, J. and Lewis, M. (1966). Infants differential reactions to familiar and distorted faces. Child Development, 3, 519
The Author W. C. Shaw, PhD, MScD, FDS, DOrth, DDO, Senior Lecturer, Department of Orthodontics, Dental School, Welsh National School of Medicine, Heath. Cardiff CF4 4XY.
British Journal
ofPlastic Surgery (1981) 34, 237-246 0 1981 The Trustees of British Association of Plastic Surgeons
Folklore surrounding of facial prejudice
facial deformity
and the origins
W. C. SHAW Department of Orthodontics,
Dental School, Welsh National School of Medicine, Heath, Cardiff
results of an interview survey of present folklore and “old wives” tales concerning facial deformity are reported.
Introduction In the pioneer study by MacGregor et al. (1953) extended interviews with facially deformed patients revealed the serious psycho-social difficulties that could be encountered in everyday life. This view was elaborated by Goffman (1963) who held that facial deformity was one of several conditions that could stigmatise individuals, making them less acceptable to the rest of society. The desire to overcome social prejudice is certainly an important motive for patients who seek corrective surgery (Jensen, 1978). Hostility towards the facially deformed is no longer as extreme as in 1708 when Frederick V. of Denmark ruled that no individual with a facial deformity might show himself to a pregnant woman (Weiser, 1963). Yet in some parts of the world, open prejudices still persist: among some African tribes a deformed man is prohibited from elevation to chieftaincy (Babalola, 1978) while among rural communities in the Indian subcontinent, the family which begets a deformed child is held in low esteem until certain purifying rituals have been performed (Dehragoda, 1978). Even in modern society, feelings of aversion are still aroused by deformities of the face, particularly the more severe, though the modifying effect of other emotions such as sympathy and curiosity are poorly understood (Shaw et al., 1980~). In the less inhibited society of childhood, disapproval of deviant physical features is openly voiced (Shaw et al., 1980b) and in interviews held recently at out-patient clinics for children with deformities such as cleft lip and facial .burns, most of the children were reported to be victims of frequent teasing and harassment (Jones et al., 1979). In the first part of this paper, possible reasons why facial deformities may evoke an unfavourable social response are examined. In the second part,. primitive beliefs about the genesis of deformity in general, then more specific facial deformities, are reviewed. Finally, the
Part 1 Reaction to Facial Deformity There may be several reasons for unfavourable reactions towards deformities of the face:
Instinctive Rejection Sexual Aversion Modern man undoubtedly retains a legacy of instinctive behaviour handed down from a time when natural selection shaped behavioural as well as physical attributes (Wilson, 1975) and instincts which limited procreation by imperfect would have been desirable in partners evolutionary terms (Dawkins, 1976). As facial deformities may be a visible indication of more profound mental or physical disorder (Gorlin et al., 1976) some degree of instinctive aversion could be expected. This instinct, however, is somewhat indiscriminate, operating within the sexes as well as between them and against acquired facial deformities which cannot be genetically transmitted. Fear Wright (1960) suggested that a normal person’s unconscious body-image could be threatened by the appearance of an individual with a deformity, in as much as he identifies to some extent with that person. The truly instinctive nature of fear arousal is suggested by the observation of Hebb (1946) that spontaneous fear of mutilated bodies experienced by man and chimpanzee alike is due to neurophysiological conflict and there is some evidence that initial reactions to deformed faces are autonomic in character (Aamot, 1978). 231
238
BRITISH JOURNAL
OF PLASTIC SURGERY
Conjtision
considered attractive, desirable social qualities
The visual pattern of a normal face is learned early in life (Kagan et al., 1966) and another component of instinctive rejection may be the confusion and unease experienced when witnessing anything strange or inconsistent. Facial deformity may be particularly stigmatising because of the unique importance of the various functions of the face. It is not only the primary means of personal identification but the facial expression (at rest and in action) is an enormously rich source of non-verbal information (Ekman, 1978). According to Morris (1967) ke face provides a highly important focus of erotic interest in sexual encounters and there is a primitive and profound association in the mind between the whole integrated pattern of the face and the pattern of the torso. Deformities of the face may interfere with the normal transmission of social information in several ways. Certain defects such as ptosis or Bell’s palsy clearly interfere with the transmission of a vast range of non-verbal messages and for the individual with a tight repaired cleft lip, a broad engaging smile may be unattainable. Finally, transient expressions characteristic of mood may be permanently imitated by morphological features. For example, the intention bite (Grant, 1969) may be noted in an individual with mandibular prognathism and lower incisor display and give him an “aggressive look”.
such as intelligence, honesty and friendliness are repeatedly attributed to those so endowed (Adams, 1977). The evolutionary origins of this behaviour remain obscure. Is it an over extension of the instinct designed to limit procreation by genetically substandard members of the species, or inspired purely from an intuitive pleasure at beholding any object which is aesthetically appealing in its own right? Whatever the genesis of the response, sexual attractiveness appears to be of no less importance today in mate selection (Adams, 1977) and consequently the genetic constitution of future generations.
Stereotyping While there is no sound evidence that personality can be accurately read from individual physiognomic cues (Ekman, 1978), first impressions of a face can produce an extraordinary consensus of opinion concerning the subject’s personal characteristics (Secord, 1958). Although part of this process, such as the effect of pupil size, may have a physiological basis (Hess, 1975) much facial stereotyping remains unexplained. Perhaps the most potent facial cue is the aggregate quality of attractiveness. Experimental studies show that a surprisingly high level of agreement on an individual’s facial attractiveness can be reached by different judges (Berscheid and Walster, 1974) and that while there is no apparent intrinsic merit in inheriting the combination of genes which produces a face
Social Conditioning
and Reinforcement
ConjbrmitJ As Darwin (1871) pointed out, one cultural group’s concept of a pleasing appearance may vary from another’s, but within the group there is pressure to conform to a socially defined norm, even if this involves expense, discomfort or physical trauma (Jenny, 1975). Distortions and elaborations which include neck elongation, head moulding, scarring and the wearing of lipdiscs have been reported among primitive peoples, but modern civilisation is also replete with examples of cosmetic ritual. How else should we regard the use of cosmetics, the control and cultivation of facial hair and the grooming of scalp hair? Sadly, the commercial exploitation by the advertising media of the desire to be beautiful, merely serves to perpetuate myths about the quality of the individual behind the face. Popular Images of Horror and Amusement It requires little imagination to see how much the various prejudices and instincts already considered are compounded by popular imagery. Distortions of the human form associated with evil and terror were part of oral and written tradition long before the arrival of horror films, while the comic face has long attracted amusement in circus, theatre, caricature and cartoon. Folklore and Superstition Finally it is likely that through the ages, attitudes to those with facial deformities have been strongly influenced by popular understanding of
FOLKLORE
SURROUNDING
FACIAL
DEFORMITY
the cause and significance of such conditions. Thus, sinister beliefs that facial deformity represented a form of curse or supernatural retribution could only add to the stigma associated with the condition and the prejudices which the possessor would confront. Attempt to account for such phenomena were, of course, limited by contemporary understanding of the Universe and prevailing religious doctrines, while eventual explanations may have been tailored in such a way as to rationalise more profound instincts to which human beings are already subject. Part 2 Folklore Surrounding the Genesis of Facial Deformity Congenital
Dejbrmities
Throughout the history of man, the birth of a child with a congenital deformity must have stimulated speculation as to the cause. The beliefs held since primitive times have been many and varied and attitudes to the deformed child, at times his very survival, have depended upon them. The monumental review of the subject by the Scottish obstetrician, Ballantyne (1904) supplemented in more recent years by Warkany (1977), provide a brief resumi: of the past theories of teratology. The Gods According to Ballantyne, the Greek historian Euhemerus (316 BC), considered that so-called monstrous infants were incarnations of the gods themselves or their progeny. It was suggested that the cyclops’ foetus inspired the image of the god Polyphemus: the sympodeal foetus becoming a siren: Atlas, a case of occipital encephalocele: the god Ptah of the Egyptians, an example of achondroplasia. The more popular view, however, was that the gods were creators of monstrous infants, either for their amusement or to warn, admonish or threaten mankind. The power of this latter belief undoubtedly contributed to the common practice of sacrificing such offspring (and often the mother) in Roman times, and even later during the Middle Ages in Europe in attempts to placate the gods. In Mesopotamia, congenital deformities were considered to herald future events and Ballantyne describes one tablet dating to 2000 years BC
239 which carried a list of divinations relating to 62 teratological conditions. These include the forecast that when a woman gives birth to an infant “that has no tongue, the house of the man will be ruined; that has an upper lip which overrides the lower, the people of the world will rejoice; whose teeth are already cut, the days of the King will be prolonged”. Eail Spirits Belief that evil influences had teratogenic powers were also widespread: a satanic origin commonly being suggested for any infant bearing supposedly demonic features such as hairy naevi, ichthyosis, club feet and syndactyly. Haffter (1968) has investigated the history of such attitudes in European folklore, where physically deformed or mentally retarded children were regarded as the offspring of fairies, elves or other sub-human beings. The idea that the so-called “changeling” had been surreptitiously substituted for the real child is a pre-Christian superstition of CeltoGermanic origin and it had important implications for the way in which parents might attempt to reverse the change. In some parts, the changeling was considered to bring good luck and should be well treated, but more widespread was the advice that the child should be treated so cruelly that the elves would be coerced to return the stolen child. The later Christianised form of the superstition supposed that the devil himself had performed the exchange and this was especially significant for the parents. Blame, originally projected to wicked spirits, became regarded as retribution for sins of the parents, evidence of witchcraft or collusion with the devil.
The influence of the position of the heavenly bodies entered into the beliefs of the ancient races and the astrology of the Babylonians survives in the popular mind to this day. Not every child could be “born under a lucky star” and the position of Venus or the moon in particular, had a supposedly potent effect in determining whether the infant was to be normal or deformed. Hybridit In the Middle Ages, foetal abnormalities which had some perceived animal resemblance, were considered to be the issue of human and animal union and it has been suggested that traces of
240 these beliefs might have been reflected in such mythological images as the Centaur and Minotaur. The birth of an animal or human foetus with some perceived hybrid characteristic could lead to the execution of an innocent human being, such practices being recorded as late as the seventeenth century. Maternal Impressions
A notion of great antiquity is that a pregnant woman can produce a deformity in her child by sighting deformed individuals, being frightened by animals or by witnessing disturbing events. Belief in such psychogenic effects are represented in Roman, Hebrew and early Christian writings and have also been shown to exist in India, China, Asia, Africa, Europe and among the Eskimos. The supremacy which this theory gained over suspicions of satanic or bestial intercourse in the sixteenth and seventeenth centuries had at least the beneficial effect of rendering the arrival of a deformed child a misfortune but no longer a crime. Many scientific men objected to this theory in favour of more realistic biological explanations. One of the most effective and scientific refutations was supplied by William Hunter who, in the eighteenth century, made a prospective study asking mothers before their confinement, about psychic traumas during pregnancy. In no case did he find any correlation between the woman’s answer and a congenital anomaly in the child. Yet, as late as the nineteenth century, reports of the alleged influence of maternal imagination appeared in the medical literature. Seminal and Menstrual Causes
The beliefs of some early Greek writers reflected their somewhat erroneous views of reproduction. Empedocles considered that congenital deformities were due to deficiencies or alterations in the semen, while the notion that children conceived during menses would be deformed was widely held, being related to Hebrew legislation on coitus during the menstrual period. Aristotle, however, was more accurate in his belief that monstrosities arose from the conjoint action of perverted strains of both sperm and germ. Mechanical Causes It is clear in the writings of Hippocrates,
that he believed that antenatal deformities might be due
BRITISH
JOURNAL
OF PLASTIC
SURGERY
to direct injury to the foetus or to intra-uterine moulding and one popular variation of the theory, still receiving much attention in the nineteenth century, was the injurious effect of tight corsets. Ballantyne considered that the significance of mechanical effects had been pushed to absurd lengths when medical men suggested that cleft lip might be induced by the foetus lacerating its upper lip with its nails, and when it was suggested that cleft palate might be due to intrauterine thumb sucking or to the pressure of the tongue tip. Cleft Lip
In the case of this deformity, a belief which recurs commonly in the folk history of many European countries is that the defect arises when the mother sees a hare during pregnancy. A variation of this tale is that the mother need only step over a hare’s lair to induce the deformity, but that she can break the spell by tearing her petticoat or dress in a prescribed manner (Bruford, 1978). One vivid account recorded in the North of Scotland in 1893 was as follows: “An unmarried woman in Kingussie became pregnant. She was shearing in the harvest field, and came upon a hare’s lair. Her companions suspected her condition, and said she ought to take a snip from the border of her petticoat. To conceal her shame, she, so far from taking the advice of her companions, put her foot in the lair, stepped over it, and then back. The child had a double harelip”. Such beliefs were shared elsewhere in the British Isles (Hole, 1961; Evans, 1972; Briody, 1978; Sanderson, 1978) and in Denmark (FoghAndersen, 1942), Sweden (Nyman, 1978; Schon, 1978) and Norway (Christiansen, 1978), where indeed, an old Norwegian law for the protection of pregnant women forbade butchers from displaying hares in public (Reed, 1956). This curious association between cleft lip and the hare is represented by the terminology of the condition in many languages (Table 1) and the true antiquity of the association is revealed in the writings of Galen in the second century by usage of the term “lagocheilos” (Weiser, 1963). The natural form of the hare’s upper lip lends itself appropriately to description of untreated cleft lip in man, but the same is true for the snout of many other mammals (Bateman, 1977) and there appear to be additional reasons for the hare-cleft lip association. Together with the cat,
FOLKLORE
SURROUNDING
FACIAL
DEFORMITY
241
Table 1 Implied association between cleft lip and the hare in several languages
Table 2 Implied causal inference from the etymology of “birthmark” in several languages
Language
“Harelip”
Translation
Language
“Birthmark”
Translation
Dutch German
hazenlip hasenlippe hasenscharte
Dutch
moedervlek
German
Danish French Swedish Spanish Italian Irish Old English Old Frisian
hareskarr bet de Kvre harmynthet labio leporino labbro leporino bearna haersceard hasskerde
harelip harelip scharte: crack, fissure. gap, notch hare cut hare’s mouth hare lipped hare lip hare lip slash (in dress), gap, chasm hare cleft hare lipped
Danish
geburtmal muttermal modermaerke
French Spanish
envie estigma
Italian
voglia e.g. voglia de fragola
moeder: mother vlek: spot, stain, mark, mole mutter: mother mal: mole, mark, spot moder : mother maerke: mark, sign desire, longing birthmark, mother’s mark. stigma, slur wish, desire, craving, longing, strawberry birthmark
Norwegian
branflekk
Czech
materskeznameni
the hare in folklore is regarded as a common witche?? familiar, or form assumed by a witch, in order to avoid detection during the execution of some malevolent act. Tales of such witch-hares are abundant in various parts of the British Isles (McPherson, 1929; Gwyndaf, 1977; Smith, 1978). Looking further into the past, most folklore surrounding the hare supports its connection with an ancient religion (the worship of Diana, goddess of childhood and the moon) and a universal complex of moon-hare myths can be traced (Evans, 1972). The hare was associated with the moon in ancient Egypt and among the North American Indians, while Indian and Chinese children are still told bedtime stories about the hare and the moon, rather than the man in the moon. In African mythology, it is believed that the moon in anger actually split the hare’s lip and similar tales are recounted in Tibet (Layard, 1944). These interwoven beliefs are also revealed in the pre-Columbian culture of Mexico, where to the present day, lunar eclipse, rather than the hare is considered responsible for cleft lip (Ortiz-Monasterio and Serrano, 1971). Thus the folklore surrounding the aetiology of cleft lip appears to represent a fusion of several of the primitive beliefs reviewed by Ballantyne; supernatural influences, lunar influence, hybridity and maternal impressions. Birth Marks
In several modern languages the equivalent word for birth mark again implies a supposed causal inference between experiences of the mother and the anomaly (Table 2). Various maternal impressions have been implicated such as the witnessing
of a conflagration
or the slaughter
of
brann: tire flekk: mark matersky: mother’s znameni: mark
animals, especially when the woman is unwise enough to simultaneously touch her own face. Even more common is the belief that birth marks are produced when a mother craves for or eats vividly coloured food such as strawberries. Indeed dietary cravings or indiscretions of this kind are represented in the pregnancy taboos of every corner of the world (Ferrera, 1969). Not surprisingly, many such tales have been transported by North American immigrants where “marking theories” have been comprehensively recorded (Fife, 1976; Hand, 1979). Here, an additional recurring belief was that deformity of the child was induced by the mother previously mocking someone similarly afflicted, implying therefore, a form of punishment. Part 3 A Survey of Present Day Beliefs
In order to examine current beliefs and knowledge relating to facial defomities, 200 women in the age range 20-69 years were privately interviewed, either at their place of work (schools and factories), or in their own homes. They were shown colour photographs of 6 individuals who demonstrated a distinct type of facial deformity (Fig. 1). These deformities were a repaired bilateral cleft lip; portwine stain; mandibular protrusion; mandibular retrusion;
242 mandibular asymmetry and acromegaly. The women were asked to give a description of each deformity, their beliefs as to its cause and any other causes which they may have heard of. In addition, they were asked to comment on the
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
kind of personality which they thought the photographed individual might have and whether they knew anyone with such a condition. Responses to each question were recorded verbatim and, to assist the analysis, subsequently categorised (Table 3). Frequency counts were calculated and in order to see whether the replies were influenced by the age of the subject or prior acquaintance with someone with the deformity demonstrated, cross tabulation and Chi-square analysis were performed (Nie et al., 1975).
Description
of Facial Deformity
(Table 3a)
Precise or reasonably accurate descriptions were given for all demonstrated conditions with the exception of acromegaly. Of the respondents 7.5 % simply regarded this condition as a manifestation of subnormality while 15.5 % used such bizarre descriptions as “boxer, rugby player, mongol, spastic, pre-historic man”.
Causes of Facial Deformity
(Tables 3bhd
c)
Quasi-Medical Explanations While many respondents were unable to suggest a cause for the various conditions, a reasonable proportion tendered various medical or quasimedical explanations. Included under the heading “Genetic” are various replies such as “hereditary, just born like that, or fault at conception”. Intrauterine pressure was considered a potential cause for all the conditions, more specifically thumb sucking (in the case of cleft lip) and according to one respondent, tight corsets during pregnancy (for mandibular retrusion). Attempted abortion was mentioned by a minority as a cause of cleft lip, mandibular asymmetry and acromegaly and for this last condition, excessive of alcohol in and consumption smoking pregnancy.
Fig. 1 Facial photographs of 6 individuals, originally in colour, who demonstrate a facial deformity. A. Bilateral cleft lip; B. Port-wine stain; C. Mandibular protusion; D. Mandibular retrusion; E. Mandibular asymmetry: F. Acromegaly.
Maternal Impressions Relatively few respondents considered maternal impressions to be an important cause of the deformity, except in the case of portwine stain. This condition was frequently reported to be due to the mother’s consumption of strawberries or red cabbage, or to an unsatisfied craving for such foods. Less often it was considered to be due to the mother being frightened by an animal, her contact with blood during pregnancy or some
FOLKLORE
Summary
SURROUNDING
FACIAL
of200 inteniiew
(Responses
expressed
Table 3a
Description
as percentage) of Facial Deformity Portwinr .sturn
Mrrndrhulat protrusion
MundihuLaf r’rtrll.\rrm
Mundihulor ir.\~Ynmetr\
87 10 1.5 0.5
87.5 11.5
I .o
.._
46.5 48 2.5 1.5 1.5
71.5 JO.0 3.5 0.5 4.5
54 39 2 2.5 2.5
Portwinr stain
Mandihular protru.sion
Mandihulut rrtrusion
Mandibular aspnmrtr~
50 34.5 6 3.5
42.5 21.5 7.5 5.0
49 33 1.0 3
42 34
45 14 6.5 7.5
39 20.5 3.0 5.0
3.0
3.0 -_ 9.0 11.0 0.5
7.5 5.5
7 14
23.0 2.5 0.5
26.0 5.0 1.5
Cleft lip
Precise Reasonable Bizarre Don’t know Subnormal
Table 3b
1.0
Don’t know Genetic Intrauterine Birth trauma Later trauma illness Environmental Psychogenic Craving: Others
Table 3c
lip
I 1
or
2.5 0.5
Other Reported
Ckji
None Genetic Intrauterine Birth trauma Later trauma illness Environment Psychogemc Cravings Others
5 64 15.5 8.0 7.5
Cause of Facial Deformity
Ckfi
Table 3d
243
DEFORMITY
I
_.
I 1.0
Causes
Irp
80.0 1.5 3.0 1.5
Portwine stuin
Mundibular protrusion
Mandihulut wtrurion
Mandibular usymmetry
,4cromrgal,v
43.0 1.0 2.5
94.0 0.5
76.5 3.5 1.0
86 1.5 1.5 2.0
86 3.0 1.0 0.5
1.5
2.0 3.0 0.5
3.5 13.0 2.5
5.0 2.5 1.0 0.5
4.0 2.0 1.5
or
12.5 0.5 1.6
Treatment
_
2.0
of Facial Deformity
Ckft
Don’t know None possible Surgery Medical Dental/orthodontic Psychiatric Emotional support Cosmetics Unorthodox Physiotherapy
25.5 26.5
9.0 4.5 82.0 0.5 t.5 0.5 0.5 1.0 0.5
lip
Portwine stain
protrusion
Mandibular
8.0 17.5 58.5
18.5 14.5 42.0
1.0
1.5 13.0 0.5
16.0 2.0 1.5 0.5 4.0 1.0
Mandihulas retrusion
10.0 2.0 x.5 0.5 76.0 1.5 1.5
Mundibular
as)mmrtrv
Acromegalj
19.5 12.5 49.5 1.5 4.5
21.5
2.5 3.0 5.0 2.0
37.5 28.0 4.5 1.5 4.0 1.5 1.0 0.5
244 Table 3e
BRITISH JOURNAL OF PLASTIC SURGERY Prior Acquaintance Clef lip
Portwine stain
Mandibular protrusion
Mandibular retrusion
Mandibular asymmetry
Acromegaly
NO
69.5
71.0
92
96
30.5
29.0
89.0 11.0
64
YES
36
8
4
Portwine stain
Mandibular protrusion
Mandibular retrusion
Mandibular asymmetry
Acromegaly
13.0 49.5 35.0
13.5 23.5 39.0 2.5 6.0 15.5
9.5 32.0 37.5 8.0 3.0 10.0
14.0 28.0 36.0 3.0 3.5 15.5
12.5 20.5 15.0 22.5 18.5 11.0
Table 3f
Attributed Personality Clef lip
Don’t know Normal Self-conscious/shy Subnormal Aggressive Odd/disturbed
‘9.5 28.5 44.0 3.0 6.5 8.5
2.5
injury. extra-abdominal Few respondents admitted personal conviction that maternal impressions caused cleft lip, though many more were familiar with the old tales. Only a few women believed that the mother had been frightened by a hare or rabbit and only one respondent blamed the mother’s failure to observe the spell-breaking ritual of tearing her dress. Treatment (Table 3d) Popular faith in the efficacy of surgical treatment was revealed for all conditions and in the case of mandibular retrusion orthodontic or dental treatment. Medical solutions included the use of tablets, or for acromegaly, hormone treatment. Provision of psychiatric therapy or emotional underlines expectations support of mental subnormality (vide infraj and, not surpriscosmetic disguise of portwine stain ingly, was suggested. A minority of respondents recommended physiotherapy or rather unorthodox approaches such as prayer or a change of environment. It was interesting to note that about one quarter of respondents considered that the repaired cleft lip represented the, as yet, untreated condition.
Personality
(Table 3f)
The present approach, which adopted interviews based on photographs, clearly fails to incorporate a wide range of methodological controls. These are considered more fully elsewhere (Shaw et al., 1980a). Nevertheless, the replies seemed to reveal common preconceptions of the personality of individuals with deformed faces. Of course, many respondents felt it impossible to predict personality from a photograph and others reported that the individual would be unaffected (these responses were included under “Don’t know” and “Normal”), while it was widely anticipated that the deformed individuals would be self-conscious or shy. Personality assessments of a more discrediting kind were however reported by the remainder of the sample; the individuals displaying acromegaly and mandibular retrusion were regarded as being subnormal by 22% and 8 y0 of respondents respectively. The acromegalic and to a lesser degree the other deformed individuals were considered by some to be aggressive and a minority substantial anticipated that the individuals photographed would have personalities which were in some other way odd or disturbed. Effects of Age of Respondent
Prior Acquaintance Table 3e shows the percentage of respondents who were acquainted with individuals who possessed the various facial anomalies.
No consistent associations between age of respondent and the various replies on description, treatment and personality emerged. However, for portwine stain, psychogenic or
FOLKLORE
SURROUNDING
FACIAL
245
DEFORMITY
dietary causes were reported more frequently by individuals over 39 years of age (25.2 9, v 10.9 Y;, p < 0.05), than those under 39 years.
Effects of Prior Acquaintance Only to a slight degree did prior acquaintance with a deformed individual lead to more informed replies. Personality characteristics were judged to be normal by a higher proportion of respondents who were acquainted with persons having mandibular prognathism (41”;; v 21 Y:, p ~0.05) and acromegaly (SO”,, v 199,, p
Conclusions The results suggest that many misconceptions about facial deformity persist, even when there is prior knowledge of the deformity. Almost all the various ancient and medieval explanations reviewed by Ballantyne (1904) were mentioned by one or other respondent and notably the role of maternal impressions in producing facial birth marks was more commonly believed by the older women. Folklore beliefs would however, appear to be dying out, being repiaced instead by sometimes accurate, sometimes inaccurate, quasi-medical explanations. On the other hand, unfavourable preconceptions about the personality of individuals with facial deformities are still prevalent.
Discussion Attitudes to facially deformed individuals appear to arise from a complex of deep seated psychological instincts and cultural pressures. In addition. a legacy of confused folk belief persists so that to
the present day, understanding of the nature and causes of facial deformity remains imprecise. Certainly, parents of children with a congenital or acquired deformity of the face, and subsequently the child himself, deserve a clear and sympathetic explanation of the cause and treatment of the condition, not least in order to appease any feelings of guilt which may be experienced (Cracker and Cracker. 1969). In this respect it is unfortunate that medical understanding of the aetiology of many deformities remains incomplete. An account of morphogenesis does not answer the question, “Why our child?‘. apparent prejudice Society’s towards the disfigured and the unjustified value placed on attractiveness physical significant represent problems. Undoubtedly the broadening scope of corrective treatment offers immeasurable benefit to a growing number of patients. Paradoxically however, the application of refined techniques to subjects with negligible deviations from the norm, add credence to the unfortunate view that the cover is more important than the book. As the dramatic progress in cosmetic surgery seen in recent decades now reaches a plateau, a search for better means of helping the disfigured individual come to terms with his condition and more comfortably integrate with society. would seem appropriate.
References Aamot, S. (1978). Reactions to facial deformities: autonomtc and social psychological. Europeun Journal qf’ Sociul Psychology. 8, 315. Adams, G. R. (1977). Physical attractiveness research. Toward a developmental social psychology of beauty. Humun deuelopmenf 20 (4), 217. Babalola, A. (1978). Personal communication from the Department of African Languages and Literatures. University of Lagos, Nigeria. Ballantyne, J. W. (1904). Manual of Antenatal Pathology and Hygiene. The Embryo. Edinburgh. William Green and Sons. Bateman. G. (1977). Zoology Department, National Museum of Wales, personal communication. Berscbeid, E. and Walster, E. (1974). Physical attractiveness. In: “Advances in Experimental Social Psychology”. Vol. 7. Ed. L. Berkowitz, New York. Academic Press. Briody, M. (1978). Personal communication on the archives of the Department of Irish Folklore, Dublin. Bruford. A. (1978). Personal communication on the archives of the School for Scottish Studies, Edinburgh. Christiansen, I. (1978). Personal communicatton from the Institute of Folklore. Oslo.
246
BRITISH
Cracker, E. C. and Cracker, C. (1970). Some implications of superstitions and folk beliefs for counselling parents of children with cleft lip and palate. Clefi Palate Jour&, 7, 124. Darwin, C. (1871). The Descent of Man, and Selection in Relation to Sex, Vol. 2, London. John Murray. Dawkins, R. (1976). The Selfish Gene, Oxford. Oxford University Press. Dehragoda, R. (1978). Personal communication. Ekman, P. (1978). Facial signs: facts, fantasies and possibilities. In: Sight, Sound, and Sense, Ed. Sebeok, T. A.. Bloomington. Indiana University Press. Evans, G. E. (1972). The Leaping Hare, London. Faber and Faber. Ferrera, A. (1969). Prenatal Environment. American Lecture Series, Springfield, Illinois. C. C. Thomas. Fife, A. E. (1976). The marking of children and psychic imprinting. In: American Folk Medicine: A Symposium, Ed. Hand, W. D., Los Angeles. University of California Press. Fogh-Andersen, P. (1942). Inheritance of Harelip and Cleft Palate, Copenhagen. Nyt Nordisk Forlag. Goffman, E. (1963). Stigma: notes on the management of spoiled identity. Englewood Cliffs, N.J. Prentice-Hall, Inc. Gorlin, R. J., Pindborg, J. J. and Cohen, M. M., Jr. (1976). Syndromes of the Head and Neck, New York, McGrawHill. Grant, E. C. (1969). Human facial expression, Man, 4, 525. Gwyndaf, R. (1977). Personal communication on the archives of the Welsh Folk Museum, Cardiff. Haffter, C. (1968). The changeling: history and psychodynamics of attitudes to handicapped children in European folklore. Journal of the History oj’ Behmioural Sciences, 4, 55. Hand, W. D. (1979). Personal communication of unpublished files of The Dictionary of American Popular Beliefs and Superstititions, University of California. Hebb, D. 0. (1946). On the nature of fear. Psychological Reciew, 53. 259. Hess, E. H. (1975). The role of pupil size in communication. Scienti$c American, November. 110. Hole, C. (1961). Encyclopaedia of Superstitions, London. Book Club Associates. Jenny, J. (1975). A social perspective on need and demand for orthodontic treatment. International Dental Journal, 25, 148.
JOURNAL
OF
PLASTIC
SURGERY
Layard, J. (1944). The Lady of the Hare, London. Faber and Faber. Macgregor, F., Abel, T., Lauer, E. and Weissmann, S. (1953). Facial deformities and plastic surgery. A psychosocial study. New York. C. C. Thomas. McPherson, J. M. (1929). Primitive beliefs in the North-East of Scotland. London. Longmans Green and Company. Morris, D. (1967). The Naked Ape. London. Corgi. Nie, N. H., Hull, C. H., Jenkins, J. G., Steinbrenner, K., Bent, D. H. (1975). Statistical package for the social sciences, 2nd ed. New York. McGraw-Hill. Nyman, A. (1978). Personal communication on the archives of the Instiut for Undersokning av Svenska Dialekter Och Folkminnen. Ortiz-Monasterio, F. and Serrano, R. A. (1971). Cultural aspects of cleft lip and palate treatment. In: Cleft Lip and Palate, Eds. Grabb, W. C., Rosenstein, S. W. and Bzoch, K. R. Boston. Little Brown and Company. Reed, S. C. (1956). Counselling in Medical Cenetlcs. Philadelphia. W. B. Saunders Company. Sanderson, S. F. (1978). Personal communication on the archives of the Institute of Dialect and Folk Life Studies. Leeds. Schijn, E. (1978). Personal communication on the archives of the Nordiska Museet. Stockholm. Secord, P. F. (1958). Facial features and interpersonal perception. In: Person Perception and Interpersonal Behaviour, Eds. Taguiri, R. and Petrullo, L., Stanford. Stanford University Press. Shaw, W. C., Humphreys, S., McLaughlin, J. M. and Shimmin, P. C. (1980a). The effect of facial deformity on petitioning. Human Relations 33, 659. Shaw, W. C., Meek, S. C. and Jones, D. S. (1980b). Nicknames, teasing, harassment and the salience of dental features among schoolchildren. British Journtr2 of Orthodontics,
7, 14.
Smith, L. (1978). Personal communication on the archives of the Ulster Folk and Transport Museum, Holywood. Warkany. J. (1977). In: Handbook of Teratology. Eds. Wilson, J. G. and Fraser, F. C. New York. Plenum Press. Weisser. Aall, L. (1963). Om haren i norsk overievering. Norueg, 10, 55. Wilson, E. 0. (1975). Sociobiology: The New Synthesis, Cambridge, Massachusetts. Harvard University Press. Wright, B. A. (1960). Physical disability. A psychological approach. New York. Harper and Row.
Jensen, S. H. (1978). The psychological dimensions of oral and maxillofacial surgery: a critical review of the literature. Journal
of Oral Surgery,
36, 447.
Jones, B. M., Gahe, M. J. and Shaw, W. C. (1979). Unpublished student elective project. Dental School, Cardiff. Kagan, J., Henker, B. A., Hen-Tov, A., Levine, J. and Lewis, M. (1966). Infants differential reactions to familiar and distorted faces. Child Development, 3, 519
The Author W. C. Shaw, PhD, MScD, FDS, DOrth, DDO, Senior Lecturer, Department of Orthodontics, Dental School, Welsh National School of Medicine, Heath. Cardiff CF4 4XY.