On Looking: Eleven Walks With Expert Eyes (21 page)

Doyle was stunned when Bell was able to identify a man’s profession after a glance—by noticing a hobble and a worn area on the inside knee of his trousers (where a cobbler typically held a smooth, heavy lapstone for hammering leather). Sherlock Holmes was bequeathed this genius for minutiae—a genius for observation more than one of learning. I wondered if this practice would persist among doctors today, well schooled in hospitals typically well equipped. I have been a patient in a few hospital rooms where the heart-rate monitor by my bed was given more studious attention than my own heart in my chest. Are there still practicing doctors who attempt to interpret their patients’ conditions through observation—of the seeming trifles that reveal things about ourselves—as much as through instruments? According to Doyle, Bell often spoke of the particular importance of the “infinitely little” detail: the visible traces on ourselves and others that we don’t bother to notice. I set out to find a Sherlock Holmes of my own.

I found Dr. Bennett Lorber. He agreed to walk with me in his hometown of Philadelphia, a city I knew but had quit after college. Lorber is a professor at Temple University School of Medicine and, at the time, was the president-elect of the College of Physicians of Philadelphia, the country’s oldest medical organization; we were to meet in its dark-paneled lobby. The college is home to the Mütter Museum, an astonishing repository of medical history ephemera. As I waited, I browsed through the museum display cases, one of which held the recently arrived slices of Einstein’s
brain. I considered whether being donated to a museum of medical grotesques was enviable or dreadful.

Lorber is also a practicing doctor. On our walk, I was asking him to, essentially, diagnose on the fly. Simply by being outside on the street, people are inadvertently revealing their life histories in their bodies, in their steps, in the hunch of their shoulders or set of their jaw.

Waiting for Lorber, I couldn’t help but feel a little trepidation: What characteristic tic would I display? What would the flush of my cheeks disclose? What was I revealing with my pupils, my teeth, or the grip of my handshake that I may not know myself? I thought of Sherlock Holmes gently chiding his assistant Watson for his pitiful skill at noticing obvious details: “I can never bring you to realize the importance of sleeves, the suggestiveness of thumb-nails, or the great issues that may hang from a boot-lace.” I tugged at my sleeve, straightening it, and peered down at my shoes: laceless. Whew. Glancing at my own thumbnail, I noticed it was ridged somewhat. Each thumb’s nail had a tiny downturn, a kind of keratin pothole. My brow furrowed: What could this mean? Low iron? Liver disease? Imminent collapse? With my thumbs, I Googled “nail abnormalities” on my iPhone. Thousands of hits. Among the first, this news: “Superficial nail problems are caused by proximal matrix disruption, while deeper nail abnormalities are caused by distal matrix disruption.” Uh-oh—a disrupted matrix? I felt wary of any medical news that used not one but two words I did not understand.

The appearance of a slender, be-suited man at the front desk in the lobby distracted me: that must be Lorber. Feeling proud of my detective work (he was the best-dressed man in the room, and it was the precise time we were to meet), I quickly forgot about my bumpy thumbnails and approached him.

Lorber greeted me with a gentle smile and a look of calm
exhaustion. He seemed to exhale deeply as he turned toward me and shook my hand (without commenting on my grip). He had just been lecturing on microbiology and art, the convergence of his professional and personal interests. We sat down on one of the dark wooden benches in the lobby for a few moments of repose before we began our walk. Lorber specializes in diagnosing and studying anaerobic infections, but I had come to walk with him because of his side interest in the physical exam. Like many professors, Lorber serves as preceptor to medical students who are learning clinical techniques. He demonstrates how to take a history and how to do a physical exam—and he clearly delights in it, for it gives him the opportunity to undo some of the damage done by years of pre-med memorization, and teach the students to see the patient in front of them again.

He described being influenced by his father, a metalworker who was also an artisan and draftsman, and who bequeathed to his children the visual awareness he had: “We’d go someplace, and when we would leave, [his father] would ask us to draw a floor plan—where was the piano, where was the window.
He
knew. Once we did that a few times we started really paying attention.”

Years later, as an adult, Lorber turned these early visual lessons into a similar test he devised for his medical students. Leading a group of students into a patient’s room, he allows them introductions and a look, and then he says,
Everybody turn around and look at the wall.

“And then I’ll say to one of them, ‘Tell me
one
thing about Mrs. Johnson that you learned. A single thing. Anything.’ And they usually say, ‘She has an IV.’ That’s the most consistent answer. And I’ll say ‘Right, she does. Where is it? Is it in her arm? Her right arm? Her left arm? Is it in her neck?’ And they very often can’t tell you that. And then I turn to the second person—and they always say, ‘I was going to say she has an IV.’ ”

Then Lorber proceeds to rattle off the details he has noted: the patient has a bible on her nightstand and one on her lap; there are photographs on the wall and chair and notes beginning “Dear Granny,” and so forth. So he knows she is a religious woman, has lots of adoring grandchildren . . . and suddenly a picture of this patient starts emerging from behind the IV. The next time Lorber’s students enter a patient’s room, he reported, they look intently at the patient and all around her—and they start seeing things they otherwise would have missed.

We had seated ourselves to give him a breather, but Lorber was clearly not a man who rests for long. Before I knew it we were up and he was giving me a tour behind the velvet ropes of the college building. Between the grand classroom spaces, ancient medical libraries, artwork, and medical paraphernalia, there were various examples of a kind of art reality. For here was a Thomas Eakins portrait of an ophthalmologist, one Dr. William Thomson—and in front of the oil painting lay the ophthalmoscope that the subject holds in the portrait. Up a grand staircase, between us and a large photograph of a late-nineteenth-century surgeon performing a dissection before a large audience of eager students, was his very dissection table, a huge marble slab with a large webbed drain in its belly.

We, too, were about to be artwork embodied, springing forth out of this building, which stands as a kind of museum to medical investigation, and doing our own medical investigating on the street. While we would not be palpating anyone’s thyroid or percussing their spleens, those simply walking toward us would be presenting themselves for brief inspection. Moving through space, we reveal the ways we are functioning poorly: stiffness in a gait; an asymmetry to the swinging of our arms; a tendency to look overly closely when listening; a lugubriousness in carriage and expression.

Indeed, we were not yet ten yards out of the building before we
saw a couple of men approaching. The investigation had begun. I took a quick survey of our surroundings. December already, it was late in the season to be as warm as it was. It had been raining. Philadelphia is already the color of rain, and she wore the damp comfortably. Yellow gingko leaves decorated stone-slab stairs and sidewalk squares. While talking, Lorber and I stole looks at the men approaching us. I began my discovery: What could be wrong?
Coats?
Check.
Raingear?
Nope—but it was not raining this moment.
Um. Hmm. Have all their body parts?
Seems so.

I had come to the end of my diagnostic tether: I had nothing. Lorber, though: “That gentleman needs his hip replaced.”

That’s all Lorber said, but as soon as he said it, I saw the limp on the fellow on our right. As my vision awakened, the limp seemed to get more pronounced by the step. A huge limp! All I had noticed was a puffy jacket.

Gait is like the poker player’s tell: revealing of all faults. We can think of walking as a kind of controlled falling, accelerating toward the center of a circle with our legs as radii and the journey of our hipbones drawing an arc on the circle that is ours alone.
¹
Despite the large range of body types among members of the species
Homo sapiens,
it is as easy as identifying features on a face to identify a normal gait. Researchers have quantified the order, duration, and phases of what are called “interactions between two multi-segmented lower limbs and the total body mass”—i.e., between your legs and you.

This is how it goes. You are standing. (Congratulations on that, by the way. Bipedalism is fairly rare among animals, and causes all sorts of organizational and balance issues for our bodies, which we spend our lives fine-tuning. Infants might take a
full year from their birth to be upright without support, recapitulating in that year what it took our species millions of years to do. By fourteen months old, toddlers are taking approximately two thousand steps an hour. They are also falling—
ka-boom!
—about fifteen times an hour.) To begin walking, you lurch forward, nose first. You are aloft! One foot has begun to lift and swing, your weight shifts to the other leg, and you are already off-balance, both from front to back and from side to side. Your lightening foot rises from the knee, which itself requires the hip to lift. Your pelvis pivots back. If your abdominal muscles do not kick in right there, you begin to feel it in the muscles that are stronger: your lower back, your rear end. The toes of your raised foot are pointed down, but must lift, too, climbing above the plane of the foot and raising high, so as to send their blunt friend the heel toward the ground. Already the toes of the other foot are feeling the pressure of the motion, of holding your body’s weight, and begin to clench to encourage that foot’s readiness. Your heel strikes the ground, the rest of the foot slapping down after it, your knee flexed to absorb the shock. You rock from the outer edge of your foot forward and toward the inward edge, knee wobbling over the center line of the foot. And you are in what orthopedists will call a
stance,
with a foot on the ground. Actually, two feet. During walking, of course, we are no horses: we never have both feet off the ground. That is “running.” During walking, the stride time with a foot in the air is
shorter
than the stride time with both feet on the ground. No wonder we don’t get anywhere fast while walking: we’re half standing still.
²

One foot swung, the other races to keep up. Ideally, the second does the exact same thing as the first.

But that exact same thing almost never happens, and this is why gait analysis is such a ripe place to see an internal disorder manifest externally. Gait can go wrong in many characteristic ways. An asymmetric gait can reveal a spiraling host of one-sided troubles. The whole gait pattern—one “step”—is diagnostic, too. Someone who seems to waddle might do so because of a muscular disease: unable to stabilize his pelvic muscles, a person will tilt his entire pelvis with each step. Some hyperkinetic gaits, legs twitchy and restless, can indicate a problem in the basal ganglia of the brain. A hurried gait, along with shaking or tremors, might be a symptom of Parkinson’s disease. If, on taking a step, the toes drag or the knee is lifted overly high to avoid dragging the toes, damage to the peroneal nerve could be indicated.

This last one I knew myself. Much to my chagrin, midway through taking these walks I incurred a back accident. Hoisting my young son into the backpack carrier we used when we needed to get someplace farther than a toddler’s walking endurance, I felt a tweak. A few days later, I learned that “tweak” wasn’t a bad description of what had happened: the disk between two vertebrae (L5/S1, for those of you with back injuries who collect the alphanumeric jargon) had herniated. My sciatic nerve was pinched, and with that, pain shot spastically and electrically through my left leg. A week, various steroids, and even more various narcotics mitigated the pain. But I was left with a compressed nerve, which takes weeks, months, maybe years to recover. In the meantime, various muscles, including those of my left foot and my left glute were not being innervated: they were numb and nearly useless. I spent a lot of time gazing at my foot, willing the toes to flex. They looked like perfectly good toes. They would bend if I pushed them manually, but they were cold to the touch: the muscles were deeply asleep, covered in pillows, blinds drawn and earplugs in.

Walking was an awkward, slow affair. The muscles assigned
to lift the toes and push the foot—and thus the body they carry—over and forward were not working. Nor was the muscle responsible for lifting the leg. So, using muscles in my back, I essentially threw my leg forward each step, then pivoted over it.

My gait had become, in the parlance of physical therapists, “disorderly.” I learned about the other disorderly gaits after I had my own. Eventually, I had surgery on my back to relieve the compression on the nerve; six weeks later, I found myself barefoot and in shorts, walking down a long hallway in a physical therapist’s office. At the end of the hallway was Evan Johnson. He sat with perfect posture on a low stool and studied me walking. The “gait test,” a classic, simple test of function, is widely used among physical therapists, and is surprisingly good at revealing disorder. It is also refreshingly low-key: you walk off, then you turn around and walk back.

Having looked at the innards of my spinal cord, excising a slice of my wayward disk, and sewing me up, my neurosurgeon (to whom I am forever thankful for doing those three things so well) had given me this diagnosis: “You could get full recovery” of the use of my leg, he said. “Or not. I can’t tell.”
Really? My neurosurgeon can’t tell?
This was incredible and depressing news.

I was coming to accept that the prognosis for recovery from a nerve root injury is decidedly uncertain. But after seeing me walk off-and-back, Johnson popped up from his stool. “You’ll be running again,” he told me. “With time,” he added.