by Barrett L. Dorko

There is a poem by William Stafford(1) entitled "Turn Over Your Hand" that begins:

Those lines on your palm,they can be read for a hidden part
of your life that only those links can say nobody's voice can find so tiny a message
as comes across your hand.

Manual care in physical therapy today has evolved into a complex variety of techniques and theories, often in marked opposition. For the many diagnoses for which it is said to be effective, the application of the hands to the skin ranges from heavy pressure with the knuckle to the gentlest possible touch with the finger pad. This is not an essay about what to do, but about what anyone touching others in hopes of being therapeutic might consider before they begin.

In his poem, Stafford takes an approach toward the palm of the hand that reveals his respect for its quality of shape. We know it to be unique and immediately accessible should we only take a moment to look. However, our habitual postures don't often expose the palm to our vision or the vision of others. In order to see it we need to consciously lift it open, as if opening the lid of a box. When we want to reveal ourselves to others we open our palms toward them, place our palms against theirs, or touch them in some fashion with the padded, more sensitive part of our hand's anterior aspect. On balance, it is the back of the hand that is used forcefully toward others, and that includes supposedly therapeutic techniques as well.

Stafford takes an approach to the lines of the palm that requires selfexamination. He does not suggest that anyone else can tell you what these lines mean, but that they speak of a hidden part of our life that only we ourselves can sense. I would paraphrase the line to read: "Nobody else's voice can give you so true a message as comes across your own hand."

In short, this poem begins with an invitation to reveal a part of your life you normally hide with pronation and flexion. The act of supination and extension evokes feelings of vulnerability, openness, and supplication that many find too revealing to commonly express. Stafford's admonition, "turn over your hand," is both an unusual act and a movement toward revelation.

The skin is normally thought of as a barrier between the therapist and the organs they hope to affect with the various pressures of technique. In fact, however, it begins embryologically in the same layer as the nervous system and can be accurately described as the exposed nervous tissue,(2) providing not a barrier but a bridge to the organ responsible for the sensation of comfort or pain. What the skin reveals in its temperature, and response to provocation may be interpreted as a reflection of much more deeply embedded and widespread processes. A tender spot on the surface is often the tip of the iceberg, and not necessarily a reliable representation of a specific lesion or a good place to apply treatment.(3)

The skin is our surface. Here we reveal what we may or may not want to, and here we often hide what we want most desperately to express. Similar to a river, its surface is fractally shaped,(4) meaning that its intricate geometry is selfsimilar across scale like a variety of waves produced by turbulence, weather, span, rate of flow, and untold other influences.

Anything fractally shaped has been produced by chaotic forces and its response to provocation is simply not predictable. Although some fractals are far more stable or imbued with negative feedback than others (a rocky coast line, for instance), human skin is notoriously fickle in its ability to mediate underlying changes because of its connection to our mind. Consider the scope of reaction we may have when touched by the people we know (or don't know) in this world, even if the pressure and location of that touch were always identical.

When our skin is touched two reactions always occur: mechanical and reflexive. The former is a function of the amount of pressure brought to bear and it grows directly in proportion to that pressure.

Reflexive reaction is dependent upon the anatomical relations of the nervous tissue stimulated, and grows in inverse relation to the force of the pressure. It follows that gentle pressure is more likely to evoke widespread nervous reaction as well as a diminishing protective response.(5)
Gentle touch reveals the body's "watery" nature and heavy pressure its rocky coastline.

Stafford continues:

Forbidden to complain, you have tried to be like somebody else, and only this fine record you examine sometimes like this can remember where you were going before that long silent evasion that your life became.

If the skin in its most intimate shape can be used as a metaphor for our true selves, and as an expression of that self through gesture toward and contact with others, it is also a reminder of the ways we aren't in the world. This is the "silent evasion" that Stafford suggests might be evident during thoughtful inspection of our own palms.

When we touch another we enter a place where we may or may not be welcomed, and this is not entirely dependent upon our approach or intent. Others have their own agenda, and may not find something in us with which they can resonate.

Bodily processes are often chaotic and this means that a tiny provocation can have a large effect, or, conversely, a strong provocation may produce very little lasting change. Predicting how anyone else will react when we touch them is, to put it mildly, a tricky business.

It would seem that gentle contact with the palmer aspect of a soft and pliant hand would most likely lead to an expression of selfhood that is authentic and therapeutic on several levels. There is no reason that the reaction mediated through the hand of the therapist shouldn't have a similar effect on the caregiver.(6) Perhaps those of us who choose to provide manual care should begin with the premise that we ourselves will be changed each time we treat another. It might make us think more carefully about our choice of technique.

In one sense, when we touch another, two rivers meet. We cannot manage them with force and coercion. We cannot account for every swirl and eddy, while at the same time we ignore them at our peril.

When we choose the simple modality of touch we influence directly an organ that both protects and reveals other organs, processes, thoughts and feelings in ways both subtle and obvious, predictably and unpredictably. As William Stafford suggests poetically, the skin itself carries in its peculiar way the story of human possibility and the ways we might be if given permission. Perhaps the permission needed to move toward health can come from a caregiver who understands the potential power of simple touch.


1. Stafford W. Stories That Could Be True. 1977.

2. Montague A. Touching The Human Significance of the Skin. Harper.

3. Cyriax. Textbook of Orthopaedic Medicine. Vol 1. Williams & Wilkins: 73.

"The least reliable way to diagnose in soft tissue lesions is to palpate immediately for tenderness in the area outlined by the patient." Increasingly "trigger points" are understood to be transient physiologic processes and not visible anatomic lesions. Subsequently, techniques that seek to alter physiology through corrective movement, breathing, and expression are more likely to produce lasting results. Tender areas are at times useful as "doorways" into the sensorium by virtue of the membranous tension within the epithelium.

See "The Intimate Sense: Understanding the Mechanics of Touch" by Frederick Sachs in The Sciences Jan/Feb 1988. Also, "Simple Contact and Distant Change" by Barrett L. Dorko. Unpublished copies available from the author.

4. Goldberger, Rigney, West. Chaos and fractals in human physiology. Scientific American. 1990;Feb.

The skin is specifically identified as fractal in "Chaos: To See a World in a Grain of Sand and Heaven in a Wild Flower" by Goldsmith. (Archives of Dermatology, September, 1990.) See also "The Shapes Within" by Barrett L. Dorko.

5. Dorland's Medical Dictionary. Arndt Schulz Law: "weak stimuli increase physiologic activity, and very strong stimuli inhibit or abolish activity." Also applicable here is Weber Frechner's Law dictating that thresholds of sensitivity decrease in the presence of low excitation, thus enhancing interoception and the possibility of learning with gentle technique.

6. Dorko BL. Changing.