Fearfully and Wonderfully

  These exhaustive methods yielded a few basic measurements. At what point does it start hurting (pain threshold)? Do you ever grow accustomed to the heat or pressure (adaptation to pain)? Where does it hurt (distribution of pain)? At what point can’t you endure it any more (pain tolerance)? Subjects also had to describe each pain verbally and distinguish degrees of pain (as many as twenty-one were reported).

  We students came away with slight lesions, blisters, and pinpricks, as well as a diploma that exempted us from further victimization. The professors came away with graphs mapping out sensitivities on every square centimeter of the body. Such experiments have proceeded unabated for more than a century for one reason: the nervous system is incredibly complex. Each tiny swatch of the body has a different perception of pain.

  I need not reproduce the charts here, for instinctively everyone knows the principles of pain distribution. A single speck of dust flies into your eye. You react immediately: your eye tears up, and you squint it shut and dab at the eyelid to remove the speck. Such a speck can immobilize even a superbly conditioned athlete like a baseball pitcher; the pain is so great that he cannot continue pitching until the speck is removed. The same speck on the pitcher’s arm would go wholly unnoticed. Indeed, thousands of dirt particles will accumulate there in the course of the game. Why the disparity in sensitivity?

  The eye has certain rigid requirements of structure. Unlike the ear, its well-guarded sensory neighbor, the eye must lie exposed on the surface, in a direct line with light waves. The eye must also be transparent, which severely limits a blood supply, for opaque blood vessels would block vision. Any intrusion represents danger since the blood-starved eye cannot easily repair itself. Therefore a well-designed pain system makes the eye extraordinarily sensitive to the slightest pressure or pain, and its hair-trigger response trips the blink reflex.

  Every bodily part has a unique sensitivity to both pain and pressure, determined by function. The face, especially in the area of the lips and nose, is acutely sensitive to both. Feet, subject to a day’s stomping, are better protected by tough skin and thus mercifully insensitive. Fingertips present an unusual case. Constant use requires them to be sensitive to pressure and temperature but relatively pain resistant: carpenters would be rare if the gripping fingers fired off pain signals to the brain at every stroke of a hammer. In the body’s torso, protecting vital organs becomes the main concern. Thus a light tap on the foot goes unnoticed, on the groin is felt as painful, and on the eye causes agony.

  As I study pain in the human body, I marvel again at the Creator’s wisdom. I might prefer that the lining of the trachea were even more sensitive to irritants, causing more pain and coughing and so making lung-destroying tobacco smoke intolerable. But could humans even endure a hypersensitive trachea in a dust storm or in our modern polluted environment?

  I think again of the eye and its split-second response. Wearers of contact lenses might wish for less sensitivity in the eye, but the sensitivity benefits the great majority of people and their need to preserve vision. Each part of the body responds to the appropriate danger that might interfere with it and thus affect the whole body.

  When I began to see patients, I encountered the phenomenon of referred pain. The economical body assigns pain sensors to alert us to the most common threats. The intestine warns of distention, though not cutting or burning; the secluded brain has few pain receptors. If a part of the body faces an unexpected danger, the body borrows pain sensations from other regions. An injured spleen may seek help from faraway pain receptors in the tip of the left shoulder, and a kidney stone may be felt anywhere along a band from the groin to the lower back.

  Referred pain makes proper diagnosis of a heart attack a tricky problem for a young doctor. “It’s a burning sensation in my neck,” one patient reports. “No, it feels like my arm is being squeezed,” says another. In a sense, the spinal cord is playing a trick on the brain. A warning system located in the spinal cord or lower brain detects a cardiac problem and instructs unrelated skin and muscle cells to act as if they are in serious jeopardy, as a favor to their wordless neighbor. Remarkably, the borrowed area—say, the left arm—may even feel tender to the touch. The left arm puts on an acting performance in order to seize the attention of a victim who would otherwise not attend to a vulnerable heart.

  I learned to see pain as a kind of language, the most effective language in mobilizing the body’s response to potential harm.

  Ongoing Conversation

  Daily, pain contributes to our quality of life, even in such a common activity as walking. A leprosy patient, with perfectly normal skin tissue on the soles of his feet, may return from a walk with foot ulcers. A healthy person who takes exactly the same walk will develop no blisters or ulcers. Why? A file cabinet in my office contains a box of photographic slides that illustrate the reason. The stress of walking causes an increase in blood supply and mild inflammation, which we can measure through a thermograph machine that displays heat in various colors.

  The slides of color-coded feet show that the way a healthy person puts feet to the ground changes radically from the first mile to the fifth mile. Perhaps at the beginning your great toe absorbs most of the stress; by the end of the walk your lateral toes and the lateral border of your foot will take over. Later the toe and heel will come down together. When you begin a really long hike, you will start off heel-toe, heel-toe. But when you return, you’ll be lifting your foot and setting it down as one unit—all these adjustments having been made subconsciously.

  You do not make those shifts because of muscular fatigue. Rather, pain cells in your toes, heels, arches, and lateral bones have intermittently informed the brain, “Ease up a little. I need some rest.” You stride along oblivious since your brain assigns these functions to a subliminal control system that constantly monitors pain and pressure in every part of your body. A leprosy patient, having lost this incessant hum of intercellular conversation, will walk five miles without changing gait or shifting weight. The same pressure strikes the same cells with unrelenting force. In the slides of my patients, the favored portions of the foot show a white-hot color, a visual warning of potential ulcers.

  As I sit and write these words, the pain cells in my hips and legs are periodically asking me to shift my weight a bit, and I reflexively obey by changing position and crossing and uncrossing my legs. Pain employs a tonal range of conversation. It whispers to us in the early stages of risk; subconsciously, we feel a slight discomfort and toss and turn in bed. (A paraplegic person lives in constant fear of bedsores because he or she can no longer hear those whispers.) It speaks to us as hazard increases: a hand grows tender and sore after a long stint at raking leaves. And pain shouts at us when the danger becomes severe: blisters, ulcers, and tissue damage force us to pay attention.

  A limp amplifies the body’s response to pain. Out of orthopedic habit, I tend to stare impolitely at people who limp. What they may view as an embarrassing malfunction, I view as a wonderful adaptation. A limper’s body is compensating for damage to one leg by redirecting weight and pressure to the other, healthy leg. Every normal person limps occasionally. Sadly, leprosy patients do not limp, and their injured legs never get the rest needed for healing.

  When the body’s pain-monitoring system breaks down, the inability to sense pain can cause permanent damage. Perhaps you step on a loose stone or curb. As your ankle begins to twist, the lateral ligaments of the ankle endure a terrific strain. Detecting the strain, nerve cells order the body to take all weight off the damaged leg, and its thigh and calf muscles will become momentarily flaccid. If your other, undamaged leg has lifted off the ground to take a step, you will now have no support and will lurch to the ground. (A step, says the anatomist, is a stumble caught in time.) Your body opts for falling rather than forcing the ankle to take on weight in its twisted position. You get up feeling a fool and hoping no one was watching, but in reality you have just achieved a beautifully coordinated maneuver that saved you from
a badly sprained ankle or worse.

  I cannot erase from my mind the memory of watching a leprosy patient sprain his ankle without falling. He stepped on a loose stone, turned his ankle completely over so that the sole of his foot pointed inward, and walked on without a limp. Lacking the protection of pain, he did not even glance at the foot he had just irreparably damaged by rupturing the left lateral ligament! Despite his therapist’s warnings, in subsequent days he kept turning his ankle again and again until eventually, due to more complications, he had to have that leg amputated.

  Pain, so often viewed as an enemy, is actually the sensation most dedicated to keeping us healthy. If I had the power to choose one gift for my leprosy patients, I would choose the gift of pain.

  Chapter Seventeen

  THE UNIFIER

  WHEN I REFLECT ON PAIN, I prefer not to think in a detached, academic way. Instead, I focus on one individual, and at such moments my mind flashes back to the refined features of Sadagopan, whom we called Sadan. He personified the soft-spoken, gentle Indian spirit.

  When Sadan arrived at Vellore, his feet had worn away from injury to half their normal length and his fingers were shortened and paralyzed. It took two years of tireless effort to halt the pattern of destruction in his feet. Meanwhile, we began reconstructing his hands, one finger at a time, attaching the most useful tendons to the most useful digits and retraining his mind to adjust to the rewired connections. In all, Sadan spent four years in rehabilitation from the many surgeries. Together, we wept at our failures and rejoiced at the gradual successes. I came to love Sadan as a dear friend.

  At last Sadan decided he should return home to his family in Madras for a trial weekend. He had come to us badly marred by the disease, which made him an outcast. Now his hands were more flexible, and with a customized rocker-type shoe he could walk without damage. “I want to go back to where I was rejected before,” he said proudly, referring to the cafés that had turned him away and the buses that had denied him service. “Now that I am not so deformed I want to try my way in the great city of Madras.”

  Before Sadan left, we reviewed together the hazards he might encounter. Since he had no warning system of pain, any sharp or hot object could harm him. Having learned to care for himself in our hospital and workshop, he felt confident as he boarded the train to Madras.

  That first night, after an exuberant reunion dinner with his family, Sadan retired to his old bedroom, where he had not slept for four years. He lay down on the woven pallet on the floor and drifted off to sleep, peaceful and contented. At last he was home, fully accepted once again.

  The next morning when Sadan awoke and examined himself, as we had trained him to do, he recoiled in horror. The back of his left index finger was mangled. Instantly he knew the reason because he had seen such injuries on other patients. The evidence was clear: prints in the dust, telltale drops of blood, and of course, the decimated clump of tendon and flesh that had been so carefully reconstructed some months before. A rat had visited him during the night and gnawed his finger. Made insensitive by leprosy, he had felt nothing.

  What will Dr. Brand say? he thought. All that day he agonized. Should he return to Vellore early? He decided he must keep his promise to stay the weekend. He looked for a rat trap to protect him that last night at home, only to find the shops closed for a festival. I must stay awake all night, he decided, in order to guard against further injury.

  The next night Sadan sat cross-legged on his pallet, his back against the wall, studying an accounting book by the light of a kerosene lantern. Around four o’clock in the morning the subject grew dull, his eyes felt heavy, and he could no longer fight off sleep. The book fell forward onto his knees, and his hand slid over to one side against the hot glass of the hurricane lamp.

  When Sadan awoke the next morning, he saw to his dismay that a large patch of skin had burned off the back of his right hand. He sat up, trembling, overcome with despair, and stared at his two hands—one gnawed by a rat, the other melted down to the tendons. He knew well the dangers and difficulties of leprosy, and in fact had taught them to others. Now he was devastated by the sight of his two damaged hands. Again he thought, How can I face the doctors and therapists who worked so hard on these hands?

  Sadan returned to Vellore that day with both hands swathed in bandages. When he met me and I began to unroll the bandages, we both wept. As he poured out his misery to me, he said, “I feel as if I’ve lost all my freedom.” And then, a question that has stayed with me, “How can I ever be free without pain?”

  Self-Unity

  Sadan’s plight is shared by millions of people who suffer from leprosy and other numbing diseases: diabetes, for instance, can have a similar effect on the extremities. Insensitivity offers a stark lesson about the value of pain. At its most basic level pain serves as a warning signal, like a smoke alarm that goes off with a loud noise when it senses fire. Sadan nearly lost his hands because he lacked that signal.

  Pain makes another related contribution that often gets overlooked: it unifies the body. In truth, Sadan suffered because the rest of his body had lost contact with his hands. A body possesses unity to the degree that it feels pain. An infected toenail reminds me that the toe belongs to me, an integral part of my body’s health. Hair—yes, that matters, but mainly as a decoration. We can bleach, shape, iron, and even shave it off without pain. What is indispensably me, pain defines.

  Nothing distresses me more than watching my patients in the Louisiana hospital lose contact with their own hands and feet. As pain fades away they begin viewing their own limbs as stuck-on appendages. You and I speak metaphorically of a hand or foot going “dead” when we sleep on it in an awkward position. Leprosy patients seem to regard their hands and feet as truly dead.

  The most common injury at Carville, the “kissing wound,” occurs when a cigarette burns unnoticed down to the nub and brands matching scars into the skin between the two fingers. Leprosy patients think of their hands as accessories, not unlike a plastic cigarette holder. One such patient, who was carelessly destroying his hands, said to me, “You know, my hands are not really hands—they’re things, just like wooden attachments. And I always have the feeling they can be replaced because they are not me.”

  I have to keep reminding leprosy patients to attend to painless parts of their bodies they may otherwise disregard. Although I try desperately to awaken in them a sense of their bodies’ unity, overcoming their detachment seems impossible apart from pain. Just as pain unifies the body, its loss irreversibly destroys that unity.

  In India I had one group of teenage patients nicknamed “the naughty boys” because they tested the limits of our medical longsuffering. These rascals competed to shock others with their displays of painlessness. They would thrust a thorn all the way through a finger or palm, pulling it out the other side like a sewing needle. They juggled hot coals or passed their hands over a flame. When quizzed about a wound on hands or feet, they grinned mischievously and said, “Oh, it must have come by itself.”

  Eventually, after taxing all our skill in education and motivational therapy, most of the “naughty boys” gained a respect for their bodies and learned to redirect their ingenuity to the goal of preserving their hands and feet. Throughout the rehabilitation process I felt as if I was introducing the boys to their limbs, urging them to reclaim these numbed parts.

  Years later when I began working with laboratory animals, I learned that they had even more estrangement from deadened parts of their bodies. If I denervated rats for an experiment, I had to keep them well fed; otherwise, the next morning I would find these animals with shortened feet and legs. I am told that a wolf or coyote, losing sensation through frostbite or a trap injury, will gnaw through its leg and limp away unperturbed. That image captures for me the worst curse of painlessness: the painless person, or animal, loses a fundamental sense of self-unity.

  Roots of Compassion

  An amoeba, one-celled, perceives any threat as a danger to the
whole. Bodies consisting of many cells need something more, and pain provides that crucial unifying link. Individual cells must suffer with one another for multicellular organisms to survive; the head must feel the needs of the tail. In the human nervous system, one slender nerve cell connecting the toe to the spinal column may span four feet—no other cell in the human body approaches that length.

  As I turn from the network of pain in biology to its analogy in a spiritual Body, again I am struck by the importance of such a communication system. Pain serves the same vital role in uniting a corporate membership as it does in guarding the cells of my own body. A healthy body feels the pain of its weakest part.

  Naturally, there are differences between the unity attainable in a physical body of linked cells and in a Body composed of autonomous members. No tangible axons stretch from person to person in, say, the global church. Nevertheless, a healthy spiritual Body shares the pain of all its members. When wounded, living tissues cry out, and the whole body hears the cry. And we in Christ’s Body—loving our neighbors as ourselves—are called to a similar level of identification: “If one part suffers, every part suffers with it,” says the apostle Paul (1 Corinthians 12:26).

  Deep emotional connections link human beings as surely as neurons (nerve cells) link the parts of our bodies, as shown even in sporting events. Watch the face of a wife sitting in the stands at Wimbledon as her husband plays in the championship tennis match. The action on the court can be read on the wife’s face. She winces at every missed shot and smiles at each minor triumph. What affects him affects her.