As soon as it can, the crayfish slinks toward a rock or some other protection. Its body, once clad in lacquered chitin, now has the consistency of wet paper. During the next few weeks, the crayfish does all its growing for a year. It may add as much as an inch to its length before the new shell hardens into the shape and size of the new exoskeleton.
I have undergone a related process of faith molting. I started in a close-knit group that held rigid ideas of which Christians were worthy of fellowship. I tended to view the Body as an exclusive set of people like me encased in a shell. Inside, all was warm and comfortable; outside, the shell protected us from “the world.” As I traveled and gained breadth of experience, I realized that not all Christians shared my assumptions about behavior, worship style, and doctrine. So I grew a new shell until the next experience came along.
In contrast, Jesus avoided language that might describe an exoskeleton. He kept pointing to higher, more lofty demands, using words such as love and joy and fullness of life—internal words. When someone came to him for a specific interpretation of a traditional law, he would point instead to the principle behind it. As he said to the Pharisees who criticized him for breaking Sabbath rules, “The Sabbath was made for man, not man for the Sabbath” (Mark 2:27). Jesus understood that the rules governing behavior are meant to free movement and promote growth as a vertebrate skeleton does, not to inhibit growth as an exoskeleton does.
A troubling phenomenon occurs among young Christians reared in solid homes and sound churches. After living their early years as models of faith, many become spiritual dropouts—as many as 50 percent, according to some surveys. Crayfish-like, did they develop a hard exterior that resembled everyone else’s, only to find it restrictive and inadequate? When practiced mainly as an external exercise, faith can be cast aside in the manner of a crayfish flinging off its shell.
An outside shell may seem safe and attractive, and certainly it has advantages over no skeleton at all. God desires for us a more advanced type of skeleton, one that grows and adapts even as it remains hidden.
Blasts and Clasts
I must turn to the microscope to see the living activity of bone. With enough magnification I can identify two types of active cells in bone. We have already met one type: the osteoblasts, pothole-filling repair cells that attach themselves to fracture sites and lay down bone crystal. The blast cells do not simply wait around for accidents. Billions of them patrol inside me on maintenance duty. In my youth the bustling blasts replaced 100 percent of the bone in my body each year. My jawbone as a four-year-old did not contain a single remnant of my three-year-old jaw bone; the shape stayed the same, only larger.
Bone does not surrender territory easily. It must be dynamited and vacuumed out, and for this job the body calls on a demolition team of oversized cells known as osteoclasts. The reckless clast cell leads a kamikaze life, boring through mineral with such verve that it burns out after forty-eight hours and is itself escorted away as waste.
Blasts adapt their design to the body’s needs. If I break my foot and the pain causes me to adjust my walk so that I take shorter steps, the blasts will make alterations in my heel bone. If I take up weight-lifting, my bones will become thicker and develop extra struts. In fact, stress stimulates bone growth. Walking, lifting, flexing—any activity sends electrical currents through bone to generate growth.
Blasts predominate during the first half of a person’s life, laying down new bone in the orderly scheme of growth. As I have aged, less than 20 percent of my bone gets replaced each year. Eventually, the demolition clasts will outstrip the weary restoration cells. With old age, teeth sockets decrease in size, the chin protrudes, the jaw angles in, and the elderly are often left with more severe, pointed faces. A common fracture may debilitate the elderly, for their blasts can barely manage the rigors of routine repair.
The skeleton of rules governing behavior in a spiritual Body must also adapt as it encounters new stresses. The basic principles, such as those set forth in the Ten Commandments and the Sermon on the Mount, do not change, but their specific application certainly changes, for many of the laws and observances of the Bible were geared to a society and culture alien to our own.
Consider the following list of direct instructions, all given to Christians in New Testament times. Some are still subscribed to by most Christians, while others are practiced only by members of a few denominations. I know of no community that obeys all of these instructions, which I’ve adapted from a list by the author Mont Smith:
1. Greet one another with a holy kiss (Romans 16:16).
2. Abstain from food sacrificed to idols (Acts 15:29).
3. Be baptized (Acts 2:38).
4. A woman ought to have a veil on her head (1 Corinthians 11:10).
5. Wash one another’s feet (John 13:14).
6. It is disgraceful for a woman to speak in the church (1 Corinthians 14:35).
7. Sing psalms, hymns, and spiritual songs (Colossians 3:16).
8. Abstain from eating blood (Acts 15:29).
9. Observe the Lord’s Supper (1 Corinthians 11:24).
10. Remember the poor (Galatians 2:10).
11. Anoint the sick with oil (James 5:14).
12. Permit no woman to teach men (1 Timothy 2:12).
13. Preach two by two (Mark 6:7).
14. Eat whatever is put before you without raising questions of conscience (1 Corinthians 10:27).
15. Prohibit women from wearing braided hair, gold, pearls, or expensive clothes (1 Timothy 2:9).
16. Abstain from sexual immorality (Acts 15:29).
17. Do not look for a wife (1 Corinthians 7:27).
18. Refrain from public prayer (Matthew 6:5-6).
19. Speak in tongues privately and prophesy publicly (1 Corinthians 14:5).
20. Lead a quiet life and work with your hands (1 Thessalonians 4:11).
21. Lift up holy hands in prayer (1 Timothy 2:8).
22. Give to those who beg from you (Matthew 5:42).
23. Only enroll (for aid) widows who are over sixty, have been faithful to their husbands, and are well-known for good deeds (1 Timothy 5:9-10).
24. Wives, submit to your husbands (Colossians 3:18).
25. Show no partiality toward the rich (James 2:1-7).
26. Owe no one anything (Romans 13:8).
27. Abstain from the meat of animals killed by strangulation (Acts 15:29).
28. If a man will not work, he shall not eat (2 Thessalonians 3:10).
29. Set aside money for the poor on the first day of every week (1 Corinthians 16:1-2).
30. If you owe taxes, pay taxes (Romans 13:7).
Biblical scholars can explain why the writer applied an underlying principle in just that particular way. For example, the apostle Paul gave instructions on eating meat that had passed through heathen ceremonies, hardly a problem in most nations today. And in a place like ancient Corinth, women were judged by powerful social customs: if a woman spoke out in a public meeting, the group would naturally assume her to be a prostitute or pagan priestess.
Paul recognized the need to adapt lines of stress depending on the circumstances and the group. He refused to let Jewish Christians force Gentiles to be circumcised, yet he underwent purification rites in the Jerusalem temple (Acts 21) to win the trust of Jewish Christians.
Today we are facing new stress lines. As the population has multiplied and technology has increased, we need to place new emphasis on our responsibility to care for the planet. In a culture that objectifies sex, how can we reaffirm sex as a bond of intimacy and commitment and not as a haphazard expression of lust? My medical profession needs careful wisdom on new ethical issues. Today, we can prolong life almost indefinitely, even when the person has no consciousness or hope of recovery. Gene editing poses many new ethical questions by allowing us to manipulate genetic traits.
Although such issues do not call for sweeping revisions of creeds and beliefs, they do
show the need for Christian leaders to reflect, study the Bible, and pray, and then help apply the will of God to their own generation. These teachers serve as living bone cells in Christ’s Body, laying down the inorganic minerals that support our frame. They should possess humility and a commitment to preserve the basic principles of the faith, balanced by concern that the principles be relevant and give strength just where it is needed.
In 1892 Julius Wolff first noticed intersecting lines of stress in the cellular arrangement of the human skeleton, leading to Wolff’s Law, which every medical student learns. Caught up in his enthusiasm, Wolff declared that bones were in a state of great flux, adapting readily to changes in environment and function. Actually, when I visit a museum, or a Copenhagen attic, and compare skeletons throughout the centuries, I am chiefly impressed by their uniformity. Adaptations to stress are minor knobs and slight ridges along bones that have maintained a consistent length and shape. The bone endures; the body adapts to new stresses.
Chapter Twelve
BLOOD
Life’s Source
MY CAREER IN MEDICINE traces back to one dreary night at Connaught Hospital in East London.
Although my family had tried to influence me toward medicine, for a long time I stubbornly resisted all pressures to enter medical school. In truth, I was repulsed by the sight of blood and pus. Growing up in India, I shared in everything my parents did. Sometimes a patient came for treatment of an abscess, and when Dad dressed the wound, my sister and I held the bandages. My father had no anesthetics, so the patient would cling to a relative during the incision and drainage, and try not to cry out. Because of my vivid memories of those scenes and the sticky cleanup that followed, I dismissed any prospect of a career dealing with blood and pus.
Instead, I learned the building trade, apprenticing as a carpenter, a mason, a painter, and a bricklayer. I loved working with my hands and couldn’t wait to return to India to practice my trade. In rural India, though, some knowledge of tropical medicine can prove vital, so the mission advised me to enroll in the same introductory course that my father had taken. I reported to Connaught Hospital to learn basic principles of diagnosis and treatment.
One evening during my stint there, my whole view of medicine—and of blood—permanently shifted. That night, hospital orderlies wheeled a young accident victim into my ward. Loss of blood had given her skin an unearthly paleness, and her brownish hair seemed jet-black in contrast. Oxygen starvation had shut down her brain into a state of unconsciousness.
The hospital staff lurched into their controlled-panic response to a trauma patient. A nurse dashed down a corridor for a bottle of blood while a doctor fumbled with the transfusion apparatus. Another doctor, glancing at my white coat, thrust a blood pressure cuff at me. Fortunately, I had already learned to read pulse and blood pressure. I could not detect the faintest flicker of a pulse on the woman’s cold, damp wrist. She did not seem to be breathing, and I felt sure she was dead.
In the glare of the hospital lights she looked like a waxwork Madonna or an alabaster saint from a cathedral. Even her lips were pallid, and as the doctor searched her chest with his stethoscope I noticed the blanched nipples on her small breasts. Only a few freckles stood out against the pallor.
The nurse arrived with a bottle of blood and buckled it into a metal stand as the doctor punctured the woman’s vein with a large needle. They fastened the bottle high, using an extra-long tube, so that the increased pressure would push the blood into her body faster. “Keep watch!” the staff ordered as they scurried off for more blood.
Nothing in my memory can compare to the excitement of what happened next. The details of that scene come to me even now with a start. As the others all left, I nervously held the woman’s wrist. Suddenly I could feel the faintest press of a pulse. Or was it my own finger’s pulse? I searched again—it was there, a barely perceptible tremor. The next pint of blood arrived and the staff quickly replaced the empty bottle. A spot of pink appeared like a drop of watercolor on the patient’s cheek and began to spread into a lovely flush. Her lips darkened pink, then red, and her body quivered with a kind of sighing breath.
Then her eyelids fluttered lightly and parted. She squinted at first, and her pupils contracted, reacting to the bright lights. At last she looked directly at me. To my enormous surprise, she spoke. “Water,” she said in a breathy voice.
That young woman entered my life for only an hour or so, and the experience left me utterly changed. The memory of shed blood had kept me out of medicine; the power of shared blood ultimately led me to apply to medical school. I had seen a miracle, a corpse resurrected. If medicine, if blood could do this . . .
Vital Pipeline
Typically, blood gets our attention when we begin to lose it; the sight of it in tinted urine, a nosebleed, or a weeping wound provokes alarm. We miss the dramatic display of blood’s power that I saw in the Connaught patient, the power that sustains our lives at every moment.
“What does my blood do all day?” I once heard a child ask, peering dubiously at his scraped knee. I turn to a technological metaphor to illustrate the answer. Imagine an enormous tube snaking southward from Canada through the Amazon delta, plunging into oceans only to surface at every continent—a pipeline so global and pervasive that it links every person worldwide. Inside that tube a plenitude of treasures floats along on rafts: produce from every continent, smartphones and other electronics, gems and minerals, all styles and sizes of clothing, the contents of entire shopping malls. Seven billion people have access: at a moment of need or want, they simply reach into the tube and take whatever product suits them. Somewhere far down the pipeline, a replacement is manufactured and inserted.
Such a pipeline exists inside each of us, servicing not seven billion but forty trillion cells in the human body. A renewable supply of oxygen, amino acids, salts and minerals, sugars, lipids, cholesterols, and hormones surges past our cells, carried on rafts of blood cells. In addition, that same pipeline ferries away refuse, exhaust gases, and worn-out chemicals. Five or six quarts of this all-purpose fluid suffice for all the body’s cells.
Sixty thousand miles of blood vessels link every living cell. Highways narrow down to one-lane roads, then bike paths, then footpaths, until finally the red cell must bend sideways and edge through a capillary one-tenth the diameter of a human hair. In such narrow confines the cells are stripped of food and oxygen and loaded down with carbon dioxide and urea. From there, red cells rush to the kidneys for a thorough scrubbing, then back to the lungs for a refill. The express journey, even to the extremity of the big toe, lasts a mere thirty seconds.
A simple experiment reveals the composite nature of blood. Pour a quantity of red blood into any clear glass and wait. Horizontal bands of color will appear as various cells settle by weight until the final result resembles an exotic cocktail. The deepest reds, comprising clumps of red cells, sink to the bottom; plasma, a thin yellow fluid, fills the top part of the flask; white cells and platelets congregate in a pale gray band in between.
The body’s survival depends on each of these cells. Platelets, for example—which have a delicate floral shape—play a crucial role in clotting. When a blood vessel is cut, the fluid that sustains life begins to leak away. In response, tiny platelets melt, like snowflakes, spinning out a gossamer web of fibrinogen. Red blood cells collect in this web, and soon the tenuous wall of red cells thickens enough to stanch the flow of blood. Platelets have a small margin of error. A clot too thick may block the flow of blood through the vein or artery and perhaps lead to a stroke. On the other hand, people whose blood has poor clotting ability live in constant peril: even a tooth extraction may prove fatal. A healthy body expertly gauges when a clot is large enough to stop the loss of blood yet not so large as to impede the flow within the vessel itself.
If any part of the network breaks down—the heart takes an unscheduled rest, a clot overgrows and blocks an artery, a defect diminishes the red cells’ oxygen capacity—l
ife ebbs away. The brain, CEO of the body, can survive intact only five minutes without replenishment.
Blood once repulsed me. Now, however, I feel like assembling all my blood cells and singing them a hymn of praise. The drama of resurrection enacted before my eyes in Connaught Hospital takes place without fanfare in each heartbeat of a healthy human being. Every cell in every body lives at the mercy of blood.
Life in Peril
To those of us who practice medicine, blood symbolizes life; that quality overshadows all other aspects. Every time I pick up a scalpel I have an almost reverent sense of the vital nature of blood.
In surgery I must control bleeding, for each quiver of the scalpel leaves a thin wake of blood. Most often it comes from a few of the millions of tiny capillaries, and I disregard them, knowing they will seal up of their own accord. Every minute or two a spurt of bright blood warns me of a nicked artery, which I must either clamp or sear with a cautery. The slow ooze of darker blood indicates a punctured vein, and I pay even closer attention. Having less muscle in its wall than an artery, a cut vein cannot easily close itself off. To avoid these problems, I try to locate each significant vessel before I make a cut, then I clamp it in two places and do my surgical work in the area between the clamps.
Despite all precautions, a different level of bleeding may occur—the surgeon’s worst nightmare. Sometimes, through an error of judgment or loss of manual dexterity, a really large vessel gets cut or tears open and the wound gushes with blood. Welling up in the abdomen or the chest cavity, blood totally obscures the rip in the vessel from which it pours. The surgeon, as he fumbles in the sump of blood up to his wrists, shouts for suction and gauze sponges—and inevitably this is when the suction nozzle gets blocked or the lights go out. Few surgeons go through a career without such an incident.
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