On Looking: Eleven Walks With Expert Eyes (23 page)

Lorber himself likes to shake a patient’s hand. He was hesitant to say just what it was that a handshake told him, but I got the impression that it was simply a way to open a conversation with touch, something both professional and personal. I made a note to shake his hand with conviction at our walk’s end.

Nor were we close enough to the people walking by to really experience their bodies. Now, this may seem like a fine thing indeed, as to be close to a person is to smell that person, and often the smell of strangers’ bodies can be repugnant. The smell of (quite a lot of) perfume used to cover the smell of bodies can be even more execrable. But by not getting close, we miss a fair amount of information. Lorber talked with a nostalgia usually reserved for childhood pancake Sundays and Aunt Léonie’s madeleine cookies about how doctors used to smell a sample of suspect skin cells with their eyes closed, something few do anymore. When Lorber sees a patient who has had diseased tissue aspirated by another doctor, he always phones that doctor and asks them how the tissue
smelled
. What we might call bad breath is itself revealing of systemic or specific illness. There might be fishy, ammonia-like, musty, or bloody notes in bad breath—each indicating a different diagnosis. Lorber has written about a trio of his patients for whom their “putrid” breath—before pain in breathing, a cough, or fever
appeared—was the only or first sign that they were harboring an anaerobic lung infection.

I clamped my mouth shut involuntarily.

Bodies do not only smell; they hum and whirr when everything is running smoothly, and especially when it is not. The nineteenth-century French physician René Laënnec made a catalog of the sounds one might hear in a person’s body, were one permitted to lean in close enough. Laënnec curled a piece of paper upon itself to listen to his female patients’ bodies, as to bend over a woman could be impracticable, if she was buxom, and was in any event indecorous. His simple paper cylinder later evolved into the stethoscope. Simply the muffled thuds of the heart’s valves snapping shut and the rhythmic wash of blood rushing away from the heart speak volumes about a person’s health. There is plenty of literature about how the
lub
(closing of the mitrial/tricuspid valves from atria to ventricles) or the
dub
(closing of the aortic and pulmonary valves as the heart pushes blood out) can vary with health. When you slip on a blood pressure cuff in addition, someone listening through a stethoscope can hear the difference between the pressure of the flow of blood through your arteries when the heart is contracting and when it is relaxing. One imagines that with another simple tool, doctors may be able to hear the hoofsteps of our mortality approaching.

Laënnec was especially interested in the sounds of disease. The list of sounds he heard through his paper tube reads like poetry. Of the various rattles from the bronchi, he heard pneumonia coming on as the sound of raw salt being gently heated in a pan. A pulmonary catarrh was so exactly like a pigeon’s cooing that he might check under the bed for uninvited avian guests. With an obstructed bronchi, he heard “the chirp of a small bird and the slick squeal made when layers of oiled marble slabs were pulled brusquely apart.” A cough like “a fly buzzing in a porcelain vase”
might indicate lung disease. Other unfortunate illnesses made their presence known sonorously, through “sighing of the wind through a keyhole,” “the murmur” from a toneless bellows, a pin “striking a porcelain cup,” the sound of a spun top. Lorber and I stood under an awning, listening to the rain. Thinking about such purring, cooing, whistling, sawing, hissing, and crackling happening within me made me feel oddly musical as I sneezed.

As Lorber and I surveyed the street scene, each person who approached us became a demonstration of something new. The game of finding out what, exactly, they were presenting was a great one. My own version of the game was less medically informed, of course, and was instead imbued with the bravado of someone too new to a field to realize how little she knows. I was less able to identify specific problems than to locate potential subjects of interest. Bus stops were minefields for this kind of medical lens on the passersby. We saw an older woman standing just apart from the other people waiting and wearing layers of ragged clothes with brand-new shoes. I am not sure what her health was like, but I could take a pretty good stab at the rest of her circumstance.

A young man waiting near her caught my eye. He was pacing, his head bent under a sweatshirt hood; his left hand held a phone to the side of his head. His gait was odd. It was as if his torso and hip were rigid as he moved, not fluidly rotating as they do in a comfortable stride. His toes were pointed outward. I pointed out my find to Lorber, who gently informed me that I had diagnosed a fashion statement. The fellow had his pants pulled down excessively, in the manner of lots of young men about his age—leading to a stiff swagger necessary to keep the pants from dropping to his ankles.

I looked for someone else whose gait might be based on their actual biology. There was a middle-aged man delicately crossing the street. Lorber was on it.

“I would guess that he has a disorder in his back, a spinal stenosis, which restricts the movement of his legs, and there is some atrophying of the muscles.”

Sure enough, looking more closely as the man crept across the street, that seemed to be precisely the case: the man’s trunk was solid, but his legs looked like they were dangling. He was not striding, but shuffling.

“It looks like he’s not actually using his legs,” I offered.

“Yes. He’s not
propelling
himself . . . he’s pushing his center of mass from side to side, using his legs as leverage.”

 • • • 

Across the street the pedestrian traffic was suddenly heavier—to D levels. A bus stop up ahead might have disgorged its commuters. A tall raincoat hurried a small raincoat along, all but their connected hands hidden under waterproof clothing. I thought about what it was like to be a young person dragged through an adult’s days. Walking with my son had already made me less likely to drag him anyplace, and instead to follow his lead (read: we have become experienced sidewalk loiterers).

Perhaps to have true empathy for one’s patients, one must know how to
become
a child, or a middle-aged woman, or a man with spinal stenosis and an anaerobic lung infection.

There is a likely neural explanation for the empathy those practitioners of medicine like Lorber and Johnson have, and it has just recently been discovered. In the early 1990s, an Italian researcher named Giacomo Rizzolatti and his colleagues were looking at monkey brains. In particular, they were recording, using single-neuron microelectrodes of brain activity of awake and alert macaque monkeys, which neurons in an area of premotor cortex called F5 fired when the monkey reached for a peanut. They were able to find particular neurons that were active for the reaching
and nut-grasping. One day, Rizzolatti noticed something unusual. The brainwave recorder was turned on as an experimenter set up the apparatus, placing a nut in front of the monkey. The machine captured evidence of those same neurons firing even as the monkey was sitting still, watching the preliminaries to the trial. The neurons were active just as the
experimenter
reached for the peanut; the monkey’s arm was by his side, unmoved. In other words, the monkey’s neurons fired both when
doing
an act and when
seeing it done
by others.

This was remarkable: the individual neurons had been implicated in specific behaviors
and
the neurons fired at two very particular times. Let us reflect again on the scene. Macaque monkeys are beautiful, small-faced creatures with overhanging brows that give them extra expression. On that day, one monkey, forced to sit in a small chamber with his head immobilized and his skull cut open to record from his brain, watched a human in a lab coat come into his room and mess with some peanuts on a platform. The monkey’s brain, whatever else was going on, also registered two things: that that person was another
individual
—and that he was doing just what the monkey himself would soon be doing.

This result has since been replicated and refined, and we now know that these “mirror neurons”—cells that fire at doing something and seeing it done—are found in various areas of the brain, in humans as well as monkeys. Two such areas are the insula and the amygdala, a part of the limbic system involved in feeling emotion and perceiving emotion in others’ faces, tone, and words. These mirror neurons may be part of our ability to match our behavior to others’—and, indeed, to cringe when we see someone twist his ankle and fall in pain; to be infected by a smile or laugh of a friend; or to feel real fear when in a darkened room watching actors play out a contrived horror scene on a film screen. These cells may be part of our ability to learn, as infants, how to toss a ball, tie a shoe,
or turn a doorknob by merely watching someone else do it. And they may be what allows for the empathy that, for most people, comes along with seeing others’ behavior and emotions.

Without the benefit of seeing inside their brains, I can make a pretty good guess that Lorber and Johnson’s mirror neuron systems are heightened to notice even more aspects of others’ physique and movement that map to their own bodies, because of their experience with the variety of ailments typical to their professions. In one research study looking at brain activity of expert dancers, ballerinas were asked to watch ballet dancers perform. Their mirror neuron systems went wild: they could feel all the moves the dancers were enacting. When nondancers watched, their brains showed evidence of mirror neuron activity, but it was much more modest. When capoeiristas, whose dance forms overlap in many ways with ballet, watched the ballet, their mirror neuron systems also fired wildly, though somewhat less than in the ballerinas themselves. Likewise, ballerinas watching capoeira had less activity than the experts in that dance, but both had more than the nondancers. Expertise matters, but it builds on something we all share: a propensity to feel others’ movements in our own bodies.

Lorber and I had toured around a long square block and were headed back to the college. Fewer people passed by, and for a moment we fell into the silence of those who have finished their dinners and are gazing at their cleaned plates admiringly. Then Lorber brightened.

“Like that?”

“Yes!”

I was pleased. I knew just what he meant: a woman with the Philadelphia Look had passed us. Just as he was sharpening my attention, I had tickled his awake. I cannot tell you exactly what Lorber saw, but somehow he extrapolated from a few examples
and came to identify an instance of what I was beginning to think was an imaginary category. Those who study facial proportions might tell us that we could map this look. “Anthropometric” research uses facial landmarks to measure distances and altitudes and angles, then compares the proportions of one measurement to another. Instead of the eyes, nose, and mouth, there are less obvious markers: the lowest browline point, the bridge and tip-top of the nose, the outer edge of the eye, the place where a jowl would hang if you had jowls, the outer edge of the mouth, the most concave point of the chin, and so forth. Researchers use this to get an average measurement—the “average” face—and to mark divergence from it in anomalous faces. Perhaps different “looks” might differ from the average look in similar ways. The typical six-year-old has an eye opening about one third as tall as it is wide, a mandible height half its width. To us he just
looks
six—but his look can be measured.

As we reached the college, I shook Lorber’s hand—strongly, I hoped, though I feared my hand was just cold and clammy. Certainly my thumbnails did not catch his attention . . . or did they? A smile flickered on Lorber’s face and he turned and jogged up the steps.

On walking back to my hotel I found that I was looking much more deliberately at passersby—as though they were still presenting themselves for inspection. In short order, I found that this encouraged people to look that way back at me (or simply look at my looking). Ack! Had I already forgotten the lesson from my son, staring too hard? I ceded to the rules of human interaction and looked away.

Some of what both Lorber and Johnson had seen was hardly visible to me, but none of it was invisible. While I had a vague sense of
Hmm, something’s amiss . . . ,
they could diagnose. It is not only the diagnosis that I valued; it is the way that knowledge orients
their looking—an ability to “see what they see,” as it were. I felt I had looked behind the curtain—and there, instead of a small man pretending to be a great wizard, I found a great wizard, expert at simply using his eyes.

¹
Speedwalkers define a much less hilly arc: their acceleration is directed more toward going forward and less toward falling down.

²
According to those who have spent preposterously long periods looking at gaits, the number is actually more than half: each step is divided into 62 percent stance (contact with ground) and only 38 percent swing (no contact with ground).

“Look, with all your eyes, look!”

(Jules Verne)

“A breeze lured me from down the street and I reflexively pursued it.”

Begin taking a series of walks around the block and, if ironic twists tend to befall you, soon enough you may find yourself unable to walk. This was what happened to this walker. A few weeks after herniating the disk in my back, I found that I could not push myself forward with my left leg. That is how it felt: I could use my leg
at all,
but I was not using it
at all well
.

My sciatic nerve was not on speaking terms with my left foot. I was frustrated that I could not run (a minor obsession) or pick up my son (a necessity), but I was alarmed to have a temporary disability: I could not walk normally. I was lucky: I could still walk, in an “ish” sort of way. Walking was an awkward, slow affair. Even after I had back surgery, I was still not walking well: my foot was paralyzed and I was forced to swing my leg around to the side instead of propelling it forward.