Chapter Seven

SKIN

The Organ of Sensitivity

AS AN INTERN IN LONDON I had the great privilege of training under Dr. Gwynne Williams, a surgeon who emphasized the human side of medicine. He strolled through the halls of our poorly heated hospital with his right arm Napoleonically tucked inside his coat, which, unknown to his patients, concealed a hot water bottle.

“You can’t rely on what patients tell you about their intestines,” Dr. Williams would admonish us interns. “Let their intestines talk to you.” The hot water bottle made his hand a better listener. He taught us to kneel by a patient’s bedside and gently slip a warm hand under the sheets onto the person’s belly. “If you stand,” he explained, “you’ll tend to feel only with the downward-pointing fingertips. If you kneel, your full hand rests flat against the abdomen. Don’t start moving it immediately. Just let it rest there.”

We learned to anticipate a sudden tightening of the patient’s abdominal muscles, a protective reflex. A cold hand guaranteed that those muscles would remain taut, whereas a warm, comforting hand coaxed them to relax. We gently caressed the abdomen, earning tactile trust. Once the muscles had slackened, we could sense the organs’ movement in response to the simple act of breathing.

Dr. Williams was right. A trained hand exploring the abdomen can detect inflammation and the shape of tumors that more complicated procedures merely confirm. Touch is my most precious diagnostic tool.

Later, in India, I was asked on several occasions to examine female patients in Hindu or Muslim households that observed strict purdah. A woman would put her arm though a curtain and allow me to take her pulse; otherwise I could not see or touch any part of her body. From my four fingers resting on her wrist alone, I was expected to make a diagnosis. I felt handicapped, unable to listen directly to internal organs through my fingertips.

Ever-Adapting Skin

Every small patch of skin has a different degree of sensitivity, and scientists have mapped the nerves as meticulously as Google has mapped the world. The physiologist Maximilian von Frey measured the threshold of touch, the amount of weight it takes for a person to sense that an object has come in contact with the skin. The soles of the feet, thickened for a daily regimen of abuse, do not report in until a weight of 250 milligrams is applied. The back of the forearm is triggered by 33 mg of pressure, the back of the hand by 12 mg. The really sensitive areas are the fingertips (3 mg) and the tip of the tongue (2 mg).

A wise mosquito will land on the forearm, not the sensitive hand, to go undetected. And only a foolhardy insect would attempt a stealth landing on soft lips.

The degree of sensitivity fits the function of that body part. Our fingertips, tongues, and lips are the portions of the body used in activities that require the most sensitivity. However, all touch sensors seem sluggish compared to those in the cornea of the eye, transparent, deprived of blood and thus extremely vulnerable. The cornea fires off a response if just two-tenths of a milligram of pressure is applied.

Moreover, the perception of touch changes constantly, based on context. A researcher lowers a 100 mg weight onto my forearm. Blindfolded, I realize that something is touching me. The sensation remains for four seconds, then fades. My brain now ignores the messages coming from nerve endings on my forearm, having decided there is no evident danger and no need to clog the circuits with useless information. I lose any awareness of the weight—that is, until the weight is removed, at which time my brain will draw attention to the change. Apart from this volume switch through which sensations pass, I could not wear wool or other coarse clothing; my body would incessantly remind me of its scratchy presence, and I could hardly concentrate on anything else.

I experience skin’s adaptation whenever I lower myself into a hot bathtub. I run the water so hot that I can barely stand it and gradually lower my body, feeling at first as though I am easing myself into a bed of stinging nettles. Within ten seconds my skin adjusts, and the same water feels soothing and comfortable. I can continue raising the temperature of the water, and my body will adapt—up to a maximum point of 115°F, beyond which I will feel constant, nonadapting pain.

Bioengineers use the word compliancy to describe a material’s capacity to mold to the shape of another surface, and skin exhibits this quality remarkably well. While trying to design shoes and tools for the insensitive feet and hands of leprosy patients, I have spent hundreds of hours studying the anatomy of living skin. Underneath the skin in the palm of the hand lie globules of fat with the look and consistency of tapioca pudding. So soft as to be almost fluid, fat globules cannot hold their own shape, and so they are surrounded by interwoven fibrils of collagen, like balloons caught in a rope net. The cheeks and the buttocks have more fat and less collagen, as anyone who has struggled with a double chin or sagging figure knows. In areas of stress, such as on the palm of the hand, fat is tightly sheathed by fibrous tissue in a design resembling fine Belgian lace.

I grasp a hammer in the palm of my hand. Each cluster of fat cells changes its shape in response to the pressure. It yields, yet cannot be pushed aside because of the firm collagen fibers around it. The resulting tissue, constantly shifting and quivering, becomes compliant, fitting its shape and its stress points to the precise shape of the handle of the hammer. Engineers nearly shout in awe when they analyze this amazing property, for they cannot design a material that so perfectly balances strength and pliability.

If my skin tissue were tougher, I might insensitively crush a goblet of fine crystal as I hold it in my hand; if softer, it would not allow a firm grip. When my hand surrounds an object—a ripe tomato, a hiking pole, a kitten, another hand—the fat and collagen redistribute themselves and assume a shape to comply with the object being grasped. This response spreads the area of contact, which prevents localized spots of high pressure.

In contrast, I have taken the hand of a human skeleton and wrapped it around a hammer. Against such a hard surface, the hammer handle will contact only about four pressure points. Without my compliant skin and its supporting tissues, those four pressure points would inflame and ulcerate after a few hammer blows. Because of compliancy, my entire skin-covered hand will absorb the impact.

Compliancy, a word with special meaning to my engineering colleagues, is a meaningful word for both the physical body and the spiritual Body. Compliant tissues covering my bones assume the shape—awkward or smooth—of whatever I am grasping. I do not demand that the object fit the shape of my hand; my hand adapts, distributing the pressure. The art of Christian living, I believe, can be glimpsed in this concept of compliancy. As my shape moves into contact with other, foreign shapes, how does my skin respond? Whose personality adapts? Do I, as does my grasping hand, become square to those things that are square, round to those things that are round?

It troubles me that Christians sometimes have a reputation for being divisive and exclusive. Though we live among others who may not share our beliefs and values, we have the clear example of Jesus, who found acceptance among physical and moral outcasts as well as despised minorities and Roman officers. Somehow he moved compliantly among diverse groups without compromising his good-news message of love and forgiveness.

The apostle Paul completes the analogy for us in 1 Corinthians 9, as paraphrased in The Message:

Even though I am free of the demands and expectations of everyone, I have voluntarily become a servant to any and all in order to reach a wide range of people: religious, nonreligious, meticulous moralists, loose-living immoralists, the defeated, the demoralized—whoever. I didn’t take on their way of life. I kept my bearings in Christ—but I entered their world and tried to experience things from their point of view.

The Need for Touch

Dr. Harry F. Harlow loved to stand in his University of Wisconsin laboratory and watch the baby monkeys. He noticed that the monkeys showed a kind of emotional attachment to cloth pads lying in their cages. Intrigued, he watched as they caressed the cloths, cuddled next to them, and bonded to them much as a child bonds to a teddy bear. In fact, the monkeys raised in cages with cloth pads seemed healthier and less agitated than the monkeys raised in cages with wire-mesh floors. Was the softness, the touchability of the cloth making the difference?

Harlow constructed a surrogate mother out of terry cloth, with a light bulb behind it to radiate heat. His ingenious cloth mother featured a rubber nipple attached to a milk supply from which the babies could feed. They adopted her with great enthusiasm. Why not? She was always available and, unlike real mothers, never roughed them up or bit them or pushed them aside.

After demonstrating that babies could be “raised” by inanimate, surrogate mothers, Harlow next sought to measure the importance of the mother’s touch. He put eight baby monkeys in a large cage that contained the terry-cloth mother plus a new mother, this one fashioned entirely from wire mesh. Harlow’s assistants, controlling the milk flow, trained four of the babies to nurse from the terry-cloth mother and four from the wire-mesh mother. Each baby could get milk only from its designated mother.

A clear trend developed almost immediately. All eight babies spent their waking time huddled next to the terry-cloth mother. They hugged her, patted her, and perched on her. Monkeys assigned to the wire-mesh mother went to her only for feeding, then scooted back to the comfort and protection of the terry-cloth mother. When frightened, all eight would seek solace by clinging to the terry-cloth mother. A famous photo in introductory psychology books shows one of Harlow’s baby monkeys clinging to the cloth mother with its hind legs while stretching mightily to feed from the tube on the wire mother.

Harlow concluded that young mammals need what he called contact comfort and will seek out whatever feels most like a real mother.

We were not surprised to discover that contact comfort was an important basic affectional or love variable, but we did not expect it to overshadow so completely the variable of nursing; indeed the disparity is so great as to suggest that the primary function of nursing is that of insuring frequent and intimate body contact of the infant with the mother. Certainly, man cannot live by milk alone.

Anthropologist Ashley Montagu reported on these and many similar experiments in his elegant and seminal book Touching. He discovered that young animals require close physical contact with a mother for normal development. Except for humans, all mammals—think of dogs and cats—spend time licking their young. Animals will often die if they are not licked after birth; they never learn to eliminate waste, as one consequence. Montagu concluded that the licking provides essential tactile stimulation.

As pet owners know, animals do not outgrow the urge to be touched. A cat arches its back and brushes against its owner’s leg. A dog wriggles on the carpet, begging for a belly rub. A monkey spends hours grooming and combing the hair on its fellow tribe members.

Montagu even suggested that human babies may need the tactile stimulations of labor. Only the human species goes through such a long, arduous birth process. Montagu believed the fourteen hours or so of uterine contractions, which have been described from the mother’s viewpoint but never from the fetus’s, may provide important stimuli to complete the maturation of certain bodily functions. Could this explain, he wondered, why babies delivered by Caesarean section have a higher mortality rate and a greater incidence of hyaline membrane disease?

Although the role of tactile stimulation during birth remains speculative, the need for touching after birth has been proved, decisively. As late as 1920, the death rate among infants in some foundling hospitals in the United States approached 100 percent, until Dr. Fritz Talbot of Boston introduced from Germany the unscientific-sounding concept of “tender loving care.” While visiting the Children’s Clinic in Düsseldorf, Talbot had noticed an old woman wandering through the hospital, always balancing a sickly baby on her hip. “That,” said his guide, “is Old Anna. When we have done everything we can medically for a baby and it still is not doing well, we turn it over to Old Anna, and she cures it.”

When Talbot proposed this novel idea to American institutions, administrators derided the notion that something as quaint as simple touching could improve their care. At that time, behaviorists were advising parents not to cuddle or coddle their babies; they proposed baby farms, where children could be raised by “scientific methods” away from their parents. The facts soon changed their minds. After Bellevue Hospital in New York adopted a policy that all babies must be picked up, carried around, and “mothered” several times a day, their infant mortality rate dropped from 35 percent to less than 10 percent. More recently, studies of children raised without touch in Romanian orphanages have shown a high incidence of stunted development, both physical and mental.

Despite these findings, even now touching is devalued and seldom viewed as essential for a baby’s development. In general, the higher the social strata, the less frequently parents touch their infants. One study showed that fathers in the United States spend an average of thirty seconds per day in tactile contact with their children. Among some severely disturbed children, touching may represent the only hope for a cure. Autistic children in particular need persistent touching to coax them out of self-hugging isolation.

Montagu concluded that the skin ranks highest among the sense organs, higher even than eyes or ears. In addition to conveying information about the outside world, skin also perceives basic emotions. Am I loved and accepted? Is the world secure or hostile? The skin osmotically absorbs that primal assurance.

Touch words have edged into our vocabulary as expressions of how we relate to others. We rub people the wrong way, or conversely we give them strokes. One person represents a soft touch; another, we handle with kid gloves. We are thin-skinned, thick-skinned; we get under each other’s skins. We relate tactfully or tactlessly.

Touching involves risk. It can evoke the cold, armor-like resistance of a hurt spouse refusing to be comforted or the lonely shrug of a child who insists, “Leave me alone!” Yet it can also conduct the electric tingling of love-making, the symbiosis of touching and being touched simultaneously. A kiss, a slap on the cheek—both are forms of touch, and both communicate. Skin cells offer a direct path into the deep reservoir of emotion we metaphorically call “the human heart.”

Love’s Medium

The skin of a spiritual Body too is an organ of communication: our medium of expressing love. I reflect back on how Jesus acted on earth. His hands reached out to touch the eyes of the blind, the skin of the person with leprosy, and the legs of the lame. When a woman pressed against him in a crowd to tap into his healing energy, he felt the drain of that energy, halting the crowd to ask, “Who touched me?” His touch transmitted power.

I have sometimes wondered why Jesus so frequently touched the people he healed, many of whom must have been unattractive, obviously diseased, unsanitary, smelly. He could have waved a magic wand, which would have affected more people than he could personally touch. He could have divided the crowd into affinity groups and organized his miracles—paralyzed people over there, feverish people here, people with leprosy there—raising his hands to heal each group efficiently, en masse. Instead, he chose a different style.

Jesus’ mission was not chiefly a crusade against disease (if so, why did he leave so many unhealed in the world and tell followers to hush up details of his miracles?) but rather a ministry to individual people, some of whom happened to have a disease. He wanted those people, one by one, to feel his love and compassion. Jesus knew he could not readily demonstrate love to a crowd, for love usually involves touching.

I have mentioned the need for us as Jesus’ followers to share resources such as food and medicine with those in need. Having participated in such activity overseas, I am convinced that we best express such love person to person, through touch. The further we remove ourselves from personal contact with the needy, the further we stray from the ministry Jesus modeled for us.

In India, when I would treat a serious case and prescribe a treatment, sometimes the relatives of the patient would go and purchase the medicine, then bring it back and ask me to give it to the patient “with my good hands.” They believed medicine had more power to help the patient if it came from the hands of a physician. And in the United States, recent studies on touch show that a doctor’s comforting touch can leave patients with the impression that a visit lasted much longer.

When I left India, I moved to the grounds of the only leprosarium in the continental United States. Carville has a poignant history. The hospital began in the 1890s when an order of Catholic nuns, the Daughters of Charity of St. Vincent DePaul, felt a specific calling to serve leprosy patients. Because no one wanted to live near a leprosarium, they purchased a remote plot of swampland on the Mississippi River under the guise of establishing an ostrich farm. The first patients, blackened and hiding under tarpaulins, were smuggled in at night on coal barges.

News of the leprosarium soon leaked, however, and the construction workers slipped away. Misconceptions of the disease struck such fear that no one would risk exposure to it. Undeterred, the nuns pursued their calling. Under the direction of a stout and courageous Mother Superior, they took up the hoes and shovels themselves, digging canals to drain the swamp. With no prior construction experience, teams of sisters in starched, sweltering habits dug foundations and erected buildings. Only they cared enough to touch and treat the disfigured patients who came to them in the dark of night.

Nearly a century later, I find myself treating leprosy patients at that same hospital. Many of them, their nerve cells destroyed, cannot distinguish what they touch: furniture, fabric, grass, asphalt—it all feels the same. When they put their hands on a hot stove because it feels no different from a cool one, I must treat their damaged hands.

I hate leprosy. Untreated, the disease slowly silences nerve sensors on the hands and feet until the afflicted lose the ability to sense human contact. Many cannot even sense when another person holds their hands or caresses them. Because of ignorance and superstition, this disease destroys social contact between patients and their friends, employers, and neighbors. Leprosy is a devastatingly lonely disease.

As at Carville, many of the great advances in leprosy research and treatment have come about because of Christian action, especially by The Leprosy Mission (British) and its counterpart, American Leprosy Missions. I have sometimes wondered why leprosy merits its own task force; I know of no Malaria Mission or Cholera Mission. Perhaps the reason traces back to the leprosy patients’ starvation for human touch. Theirs is a unique and terrible privation, and Christian love and sensitivity meet it best.

Medical teams can offer great assistance to leprosy patients. Physicians treat the raw ulcers and painstakingly reconstruct feet and hands through tendon transfers and plastic surgery. We transplant new eyebrows to replace missing ones, repair useless eyelids, and sometimes even restore sight. By training patients in constructive jobs, occupational therapists give them new life. Yet of all the gifts we can give to leprosy patients, the one they value most is the gift of being touched. We don’t shrink away. We love them skin to skin.

When I first began working with leprosy, I did so with trepidation. A missionary physiotherapist, Ruth Thomas, helped me overcome my latent fear. Ruth set up a physiotherapy area in our clinic, equipping it for hot paraffin treatment and electrical stimulation of muscles. She also believed that vigorous hand-to-hand massage would help prevent hands from stiffening. Every day she sat in the corner stroking the hands of leprosy patients. “Ruth, this is intimate skin-to-skin contact!” I warned her. “You really should be wearing gloves.” She would smile, nod, and keep on stroking. Ruth Thomas achieved remarkable success with her simple therapy, success that I credit as much to her gift of human touch as to any massage technique.

A few months after we opened the unit, I was examining the hands of a bright young man, trying to explain to him in my broken Tamil that we could halt the progress of the disease, and perhaps restore some movement to his hand, though we could do little about his facial deformities. I joked a bit, laying my hand on his shoulder. “Your face is not so bad,” I said with a wink, “and it shouldn’t get any worse if you take the medication. After all, we men don’t worry so much about faces. It’s the women who fret over every bump and wrinkle.” I expected him to smile in response, but instead he began to shake with muffled sobs.

“Have I said something wrong?” I asked my assistant in English. “Did he misunderstand me?” She quizzed him in a spurt of Tamil and reported, “No, doctor. He says he is crying because you put your hand around his shoulder. Until he came here no one had touched him for many years.”