Adventures in Human Being

by Gavin Francis

  Some Indonesian peoples held that because the placenta and its membranes seem to have come from the sea, it must be returned to it: after being placed in a pot it would be thrown into the river to float back to the ocean. This was done to prevent the placenta falling into malign hands (the idea that the placenta is part of the child, and is in some way identical with it, is a persistent one). Other Southeast Asian peoples prepared a funerary bier for the placenta, surrounding it with oil lamps, fruit and flowers, before floating it downriver.

  For some cultures it has not been the affinity of afterbirth with the sea that has been celebrated, but its resemblance to a tree: the way that the spiral trunk of the cord seems rooted into the earth of the womb. I’ve been told that during the delivery of a baby – the second stage of labor – the pain women experience is that of relentless waves of pressure combined with the knife-and-fire stretching of the perineum. Passing the afterbirth is quite different; a deep sense of an uprooting, of something long buried being tugged free. In The Golden Bough, James Frazer’s magisterial work of cultural anthropology, several cultures are described as burying the placenta beneath a sacred or significant tree, which then retains its connection to the child throughout the life of both. The tree is renamed for the child, and becomes the center of its world just as the Omphalos in Delphi was the center of the Greeks’ world.

  FOR MOST OF us, the landscape of our childhood retains a special power; it’s a common experience for its influence to be formative, and extend into adult life. In the West we don’t usually sanctify that landscape by burying placentas in it, or by dedicating the afterbirth to a local fertility goddess, but it can carry a sense of the sacred all the same. In the late 1970s Seamus Heaney read an essay on BBC Radio, “Mossbawm,” in which he described the yard of the farmhouse where he grew up in those terms. He called the opening sequence “Omphalos,” and described in it how the water pump behind his back door was the center of his world as a child. American military were conducting maneuvers across County Derry, bombers flew low into a nearby airbase, but the rhythms of home remained undisturbed by great historical events. The drone of the bombers was distant; closer at hand was the sound of water falling into buckets, repeating omphalos, omphalos, omphalos, as women pumped water for five households from a single pump. The omphalos was the still point at the center of his life – still but flowing with the water of life, and sustaining the lives of all who lived around it. Heaney was anchored by the water pump, just as the umbilical cord anchors a baby through its nine months in the womb.

  In his radio broadcast Heaney wasn’t content to meditate just on the pump – his circuit of the sacred landscape of his childhood widened, taking in a field of peas (“a green web, a caul of veined light”), and then a hedge, the fork of a beech, a hay byre, and the hollow trunk of an old willow. The willow was his favorite: he’d lay his forehead against the bark and feel the crown of the tree swaying above him, both embraced by the wood and shouldering it the way Atlas shouldered the world. Then, in a sudden midsentence switch of mythology, he recalled the antlered branches rising from his head as if he were Cerunnos, one of the gods of the Celtic pantheon. The landscape was sacred, omphalos and caul, and it was irrelevant whether Christian, Greek or Celtic traditions were used to express that sanctity.

  WE CAN EAT IT, burn it, float it on a raft or inter it under a tree. We can call a priest to help us bury it under the house. We can sell it to the highest bidder, drop it into a hole at high tide or secrete it away from bad spirits. In wealthy, modern health care systems, a new possibility has arisen: to have it cryogenically preserved.

  Buried in the jelly of the umbilical cord are cells that are genetically identical to the baby, but that have not differentiated into any particular tissue type. These “undifferentiated” cells are a type of “stem cell” because, just as it’s possible to regrow a tree from a single cutting, they are stems from which other body parts can theoretically grow. The cells within the cord blood have the potential to develop into tissues such as bone marrow, while the cells within the jelly of the cord are related to the structural components of the body: bone, muscle, cartilage and fat.

  The leaflets advertising umbilical cryogenics have two types of pictures on them: cute and smiling children at play, or radiation-suited scientists engaged in some challenging laboratory task. There are no images representing multiple sclerosis, Parkinson’s disease or leukemia, despite the companies’ claim that storing stem cells might be an insurance policy against these illnesses in later life. You can donate stem cells to a public bank, for use by anyone, or you can pay a private company to store your baby’s cord and stem cells for the sole use of your family.

  Some cultures maintain that a baby’s visceral connection to its umbilical cord is an association that lasts a lifetime, and for that reason the cord must always be handled with respect. These cryogenics companies agree: if you want a private cord bank to store your baby’s umbilical cord, you can arrange for a lab scientist to be on standby for the birth of your child in order to extract the stem cells within the critical time period in which they’re still viable. Your baby’s lifetime association with the cord can be maintained through regular payments from a credit card. Many developed countries have developed a cord-blood storage service, preserving stem cells for research, and investigating their use in bone marrow transplants for whoever might need them. Within a decade we’ve gone from throwing afterbirth out with the trash, to reinvesting it with a depth of significance that had almost been forgotten.

  There’s some debate as to whether the private banks can ever supply enough stem cells to treat an adult, and so it remains controversial whether the high costs of preserving a child’s cord for its own use are justified. While the East African might feel tied to his umbilical tree, rooting him to a particular patch of the earth, you’re unlikely to draw strength and a sense of belonging from regular visits to a cryogenics lab. The laboratories themselves share specimens, and your cord may end up being stored in another country altogether, inaccessible to you or your child. But at least it will be out of reach of ants, swine, dogs and magpies.

  LOWER LIMB

  17

  HIP: JACOB & THE ANGEL

  His hips were titanium-vanadium,

  where the angel touched.

  Iain Bamforth, “Unsystematic Anatomy”

  THE HIP IS A STRONG JOINT: a bossed knuckle of bone clasped deep into a hollow of the pelvic skeleton. It’s buried beneath layers of the thickest and most powerful muscles in the body. There are four main groups of these, and all of them are active when walking: two groups have their greatest actions on the hip and two groups have their greater actions on the knee. The process of taking a step involves countless adjustments, each muscle continuously testing itself against the strength of all the others. Each movement must take into account uneven terrain, movements of the trunk, and the balance and kinetics of the other leg.

  There’s a novel by Italian writer Italo Svevo in which the protagonist, a hypochondriac businessman called Zeno (after the Greek philosopher of paradox), meets an old school friend whom he hasn’t seen for years. The friend is afflicted with debilitating arthritis, and Zeno is surprised to see him walking with a crutch. “He had studied the anatomy of the leg and the foot,” says Zeno, “and laughingly told me that when you walk quickly, the time taken to make each step is less than half a second, and within that half-second no less than fifty-four muscles are in motion.” Zeno is horrified by this “monstrous machinery” in his leg, and he at once turns his awareness inward, hoping to sense each one of the fifty-four moving parts. The deeper consciousness he obtains doesn’t help him to a greater understanding of his body; instead, he becomes baffled by his own complexity. “Walking became a difficult labor, and also painful,” Svevo wrote. “Even today, while I write, if someone watches me in motion, the fifty-four movements become too much, and I’m at risk of falling over.” The hip and its movements become so fundamental to Zeno’s sense of hims
elf that all he has to do is think of them and he’s immobilized.

  Hips cause all sorts of problems, and seemingly minor issues in childhood can cause a permanent limp if they’re not addressed. As fetuses in the womb, we fit best if we tuck our legs up cross-legged; if hips aren’t flexed in this way, they grow with roughened and shallow sockets (“developmental dysplasia”). Once the baby begins to stand up, the development of walking will be painful and slow. I check every newborn baby I see for this problem: grasping the baby’s legs I fit each knee snugly into the palm of my hands, and place my fingertips over his or her hips. Pushing down on the knees, and splaying the thighs out and in, occasionally reveals a subtle and ominous click. The cure is straightforward if demanding both for the baby and the parents: both legs must be spread widely and immobilized in a harness for the first few months of life.

  After a year or two another problem may occur in the growing hip: toddlers suffering from viral infections can develop an isolated build-up of fluid within the joint. They start to limp and fall over; these “irritable hips” settle down without treatment over the course of a few weeks. By the time children are five or six yet another problem may develop: a disruption of blood flow causes a softening and distortion of the bossed head of the femur. This is “osteochondritis,” four times commoner in boys than in girls, and surgery is often required to restore the shape of the bone within the hip.

  Once the danger years of osteochondritis are past, and children reach adolescence, they may develop a fourth hip problem: between the ball of the hip joint and the femur itself there’s a growth plate within the bone that allows for lengthening of the thigh. This can sometimes detach and slip – a “slipped upper femoral epiphysis” – and if not fixed by surgery, the teenager can be left with a permanent limp.

  One of my anatomy tutors used to say that the best evidence for evolution over creationism is how many failings we have – the human body could be far better designed. Much of the misery our hips inflict is a result of their meager blood supply. There are plenty of places in the body with a blood supply greater than that which is actually needed – you can block off an artery to the stomach, hand, scalp or knee with little consequence. But the hip is far more vulnerable: in common with the eye, brain and heart it has a blood supply that is easily obstructed. Blockage of blood to the brain results in a stroke, to the eye results in blindness, to the heart results in a heart attack. Loss of blood to the hip can be just as catastrophic – even fatal.

  If someone over the age of seventy-five falls heavily onto the hip, they’ve about a one in ten chance of breaking the bone. A crack in the hip often cuts off the blood supply to the ball of the joint, and the bone within that ball dies off. These fractures can’t be repaired; the only solution is to cut out the joint and replace it with an artificial one. Debilitated elderly men and women, already so weak they’ve begun to fall over, frequently struggle to recuperate from such a major operation. Around 40 percent of them will end up in a nursing home because of the fall, and 20 percent will never walk again. Between 5 and 8 percent will die within three months of the fall.

  THE HIP CAN REPRESENT the life that as human beings we carry within us. Tibetan Buddhists make trumpets from the bone in order to remind themselves of death, and in the Book of Genesis the joint is taken as one of the principal sources of human life. Jacob, grandson of Abraham, fools his brother Esau into forfeiting his inheritance. The two are twins and this isn’t their first fight: earlier in Genesis we’re told that Jacob was born grasping at his brother’s heel (his name Yaakov is related to the Hebrew akev, meaning “heel”).

  At the outset of the story Jacob has prepared hundreds of animals as an appeasement gift for Esau. Before he can offer them to his brother he is set upon by an angelic figure who wrestles him to the ground. The Zohar, a mystical, Kabbalistic commentary on the first books of the Bible, describes the assailant as representative of humanity’s darker side, and Jacob’s fight with him as an allegory of the struggle to live a morally upright life. The two fight “until the break of day,” with Jacob trying to extract a blessing from the figure. When the angel realizes that he cannot match Jacob fairly, he forcibly ends the fight by dislocating Jacob’s hip, leaving him with a permanent limp as a reminder of the night when he took on an angel and almost won. The chapter closes with the newly named Israel’s proclamation that he has seen “the face of God,” and explaining that the “sinews” over the animal hip are henceforth a forbidden food for Jews: “because he touched the socket of Jacob’s hip on the sinew.”

  Rabbis and Hebrew scholars can’t agree on the exact significance of the story. One perspective is that the hip and thigh were, for the ancient Semitic culture of Abraham and Jacob, storehouses of sexual and creative energy. The word in the text, yarech, could refer to the inner curve of the thigh where it folds onto the scrotum in men, and the vulva in women – a Hebrew scholar told me that it is probably better translated as “groin.” The same word is used in the Book of Jonah to describe the inner hollow of a boat, and in Genesis, chapter 24, Abraham asks his servant to swear an oath by touching him in the hollow of the thigh – a reference to the ancient custom of swearing by the testes (hence, “testify”). From this perspective, by touching Jacob’s groin and hip the angel imparted the strength and authority to father a whole nation.

  There’s a rival theological position that claims Jacob’s subsequent limp to be the most important factor in the parable: his injury is a reminder that the Jews should not try to stand alone. Jacob tried to fight an angel and, because he was human, he failed. His limp branded him as vulnerable and mortal, as we all are. From this perspective the strength and progress of the Jewish people depends on an acknowledgment that God decides whether we fail or prevail, live or die.

  THE FIRST ON-CALL I ever worked in a hospital was a fifty-four-hour shift covering orthopedics. Before that shift I’d never gone even twenty-four hours without sleep, and my recollection of those hours is hazy and hallucinatory; a delirium of sleep deprivation and panic. At my graduation from medical school a couple of weeks earlier I’d been awarded a gold medal, and handed a certificate awarding me “MBChB with Honors.” Gold medal or not, it was immediately apparent just how much I still had to learn.

  People quickly became their diagnoses. I admitted broken ankles, snapped wrists, dislocated shoulders and crushed spines – each individual had to have paperwork filled in, their X-rays and blood tests arranged, and if they needed an operation, then I was to explain the risks of surgery and have them sign a disclaimer that they accepted those risks. At the same time, there were two wards full of patients who needed to be checked and attended to, hundreds of drugs and intravenous fluids to prescribe, and my boss to assist in the operating room.

  One of the first patients I ever admitted was Rachel Labanovska, a “fractured neck of femur” according to my new, technical language, but in human terms an eighty-four-year-old lady who ordinarily lived comfortably and alone, managing all her own affairs, though she required the help of a metal walking frame. Some years before she’d fallen and fractured her left hip: it had been replaced by a metal alloy one that had succeeded in helping her maintain some liberty and independence. A few days before I met her she developed a chest infection – her daughter had noticed a cough – and her family doctor prescribed some antibiotics. The antibiotics didn’t work well enough and she became feverish and delirious, falling over her metal frame and breaking her other hip. She lay on the kitchen floor for eighteen hours before her daughter found her; by the time I met her she was hypothermic and close to death.

  She lay on a gurney hallucinating, her limbs stick-thin, waving her fingers in the air as if each were a magic wand. Her right leg was shorter than it should have been, and her knee was facing out to one side: “shortened and externally rotated,” as the textbooks put it. When I attempted to take blood from her arms the dreaminess vanished: she dug her fingernails into my skin and shrieked as if being disemboweled. I had to hold her
down to take blood and, because her temperature was still dangerously low, sedate her so that she’d stay put beneath the hot air blanket we’d set up to warm her.

  Mrs. Labanovska was trapped in a terrible paradox: without surgery to replace her hip she’d be killed by her pneumonia, but because of the infection in her lungs she was too weak to survive surgery. I took her daughter to one side to explain. Hope, fear and anxiety moved across her face like cloud shadows. “So what now?” she asked me. “My mother is a feisty lady – she’s traveled all over the world. She couldn’t cope with being dependent on others, living in a nursing home.”

  “We’ll take her upstairs and give her strong antibiotics,” I said. “You say she’s a fighter – she may recover enough for the operation.”

  She was taken to a side room on the orthopedic ward where I set up intravenous antibiotics, a mask giving high-flow oxygen (which, in her confusion, she kept pulling off), and arranged for a physiotherapist to help her to cough mucus from her lungs in order to improve her breathing.

  I’ve seen death come as meekly as an expiring candle, or terrible and all-consuming – a black star. Mrs. Labanovska was tiny and wizened, but her life had been daring and expansive, and her death was equal to its drama. For the first few hours she was quiescent, only muttering if she was disturbed by me, the nurses or the physiotherapists. Then the delirium caused by her infection took greater hold: confusion laden with fury began to thicken in her mind. She tried again and again to leave her bed, but howled with agony whenever she tried to move her broken hip. She was unable to stand. At some point in the middle of the first night her daughter went home to rest and was replaced by a son, who sat by her bed while she writhed and moaned. I gave morphine for her pain, but too much would hasten her death, and there was still the chance that she might survive and be able to undergo surgery.