On rounds the following morning, twenty-four hours into the shift, the surgeon in charge explained to her son that the next few hours were critical: if her breathing did not improve, she would be unlikely to survive another night. Mrs. Labanovska’s pulse by that time was what they call “galloping”: a stampede toward oblivion. She still shrieked if she was moved, but had given up trying to escape her bed. Through the day I tried to visit her room, to talk to her expanding number of relatives, but it was midnight on the second day before I had the chance. She was peaceful then: though her breath came fitfully, she was less tormented by her struggle with both the pneumonia and with her broken hip.
During lunch the following day with my colleagues I was blurry-eyed with exhaustion when my beeper squealed once more. “It’s Mrs. Labanovska,” said the nurse on the end of the phone. “She’s dead. Do you want to certify her, or shall I get someone else to do it?”
“What was that?” asked the registrar as I put down the phone.
“Mrs. Labanovska’s dead. I’ve got to go down and certify her.”
“Don’t rush,” he said through a mouthful of food. “Let the poor woman get cold first.”
WHEN I ARRIVED at the ward her family was gathered outside the room. The nurses had laid her out neatly, and made the deathbed up with clean sheets. As I listened for a heartbeat that didn’t come, and shone a light into eyes that didn’t see, I glanced down at the shortened, rotated leg that had killed her.
If someone is to be cremated rather than buried, there are two forms to be filled in by the attending doctor: the death certificate, and the cremation form. The cremation form certifies that there were no suspicious features surrounding the death, and so incinerating the body won’t destroy evidence. The other function it serves is to reassure the undertakers that there are no pacemakers or radioactive implants in the body. Pacemakers can explode when subjected to the heat of a cremator, and radioactive implants, which are used in the control of some cancers, are dangerous to others if left among the ashes.
“She’s for cremation,” the nurse in charge said, handing me the form. I stood in the middle of the ward, with Mrs. Labanovska’s daughter and son standing beside me, and answered the bleak, bureaucratic questions while porters hurried by with other patients and phones rang unanswered on the desk. “Have you, so far as you are aware, any pecuniary interest in the death of the deceased?” NO. “Have you any reason to suspect that the death of the deceased was due to: a) Violence, b) Poison, c) Privation or neglect?” NO, NO, NO. “Have you any reason whatever to suppose a further examination of the body to be desirable?” NO. Then I had to sign the certificate “on soul and conscience”; the final words picked out in red, as if in letters of fire.
“Gosh!” said her daughter, suddenly. “What about the other hip?”
“Sorry?”
“Her left hip, the one they replaced. It’s made of metal. What’ll happen when it’s cremated?”
“Don’t worry about it,” I said, “the crematorium will sort it out for you.”
CREMATORIUMS ASK RELATIVES if they’d like the metal body parts of their loved ones returned to them, or sent on for recycling. Prosthetic hips, knees and shoulders contain some of the most high-performance alloys yet devised: combinations of titanium, chromium and cobalt that, after gifting mobility and independence to the elderly in their later years, are collected by the crematorium, melted down, and turned into precision parts for the engineering of satellites, wind turbines and airplane engines.
THERE’S AN ENDURING FASCINATION with Jacob’s struggle because he seems to be wrestling not just with an angel, but also with the frailty and resilience that as human beings we all embody. Some commentators have gone so far as to see in it all the hallmarks of a classic folk tale, in which an individual embarks on a perilous journey, takes on forces that seek to destroy him, is branded by that struggle, but ultimately triumphs. It’s a pattern that mirrors the convalescence stories going on in orthopedic and rehabilitation wards all over the world – journeys like the one Rachel Labanovska made when she fractured her left hip and had it successfully replaced, an experience by which she was marked but from which she recovered.
Some of the most enduring myths have several layers of possible interpretation and features that resonate across cultures. Some conclude naturally with the victory of the hero, but though they conform to patterns, not all of them have happy endings. In Genesis, Jacob makes it to a new homeland in Canaan, but is swept on by the narrative to Egypt. He dies there many years later, an old, troubled man. Genesis, chapter 49, sees him distribute blessings – some barbed, some bountiful – between his twelve sons. Then, “when Jacob had made an end of commanding his sons, he gathered up his feet into the bed, and yielded up the ghost” – he wasn’t transfigured, or transported to heaven. Rachel Labanovska had a more fitting, mythic end: some part of her lives on, and is even now whirling through the sky as a turbine, or orbiting high over the planet she once explored.
18
FEET & TOES: FOOTSTEPS IN THE BASEMENT
That’s one small step for a man, one giant leap for mankind.
Neil Armstrong
OCTOBER IN GRANADA: the old Arab quarter of the Albaysín turns its face south, toward the heat of Africa. The narrow streets and architecture still echo the glory of Moorish Spain. I’ve come to stay with a friend who lives there in a traditional house – a carmen granadino. The walls follow the contours of the hillside: we enter from a door at street level onto an upper floor at the head of the house, then descend by wooden staircases to a living area at its foot. The living room opens onto a south-facing garden.
At the end of the garden there is a shrine – nothing else to call it – built over the grave of a mummified little toe, buried in a tiny coffin. The owner of the house, Chemi, is also the owner of the toe. He lost it in a road traffic accident in 1994, and with the insurance settlement he was able to put down a deposit to buy the old house. He has officially renamed the house Carmen del Meñique – the House of the Little Toe.
Since losing his toe, every year in October Chemi holds a romería – a traditional mourning ceremony. The toe is unearthed and paraded through the streets of the city on a decorated platform more used to carrying images of Christ or the Virgin – proclaimed as an uncorrupted relic. There can be as many as two hundred devotees taking part, and as they process around the Albaysín they sing laments, making their way to a consecrated fountain, where they anoint the stump of Chemi’s foot then throw a riotous party. After a circuit of the Granadan streets the relic-toe is reinterred for the following year.
The foot is often overlooked by anatomists, relegated to the last pages of the textbooks and the last days of revision for students. But it’s said that the anatomical structure of the foot tells us something essential about humanity, about how as apes our ancestors came out of the forests and walked into our modern selves. There was something about the procession of the little toe that struck me too as quintessentially human: the ability to poke fun at a solemn ceremony, and transform pain and loss into a glorious celebration.
IN 1978 THE PALEOANTHROPOLOGIST Mary Leakey uncovered three sets of ancient footprints on the Laetoli plain of Tanzania. The prints extended for almost ninety feet and seemed those of a man, woman and child, walking together across some moist volcanic ash that had later solidified to rock. Part way across the span of footprints one figure paused for a moment as if in indecision, turned to the left, then carried on. More ash subsequently fell on the footprints and preserved them. It was raining as they walked: the ash had also preserved the imprint of raindrops.
The prints were made more than three and a half million years ago. They were not humans as we know them today but Australopithecus afarensis, one of the hominid roots of humanity’s family tree. Australopithecus had small, gorilla-like brains, did not yet know how to chip stone tools, but unlike gorillas they walked upright as we do. What did the figure stop to watch? It could have been a nearby volcan
o erupting, the source of the volcanic ash drifting over the plain. Perhaps the group was a family hurrying away from the eruption, from a foreboding, darkening sky. One of the sets of footprints had pressed deeper into the ash with the left foot, as if carrying a baby, a burden, or even struggling with a limp.
Experts in functional anatomy are able to gauge the weight, walking speed and species from these subtle footsteps in the ash: to the nonspecialist, the imprints are indistinguishable from our own human ones. Computer simulations based on fossil remains have estimated the group’s speed, gait and stride length. Like us, Australopithecus afarensis had big toes in line with the other toes, had arches to their feet, and they walked by striking the ground with the heel bone (calcaneum) first then pushing off with the toes. Before the Laetoli footprints were found, it was thought that an increase in brain size occurred before hominids began to walk upright, but Laetoli proved otherwise: that it was only by learning to walk upright that we freed our brains, and our hands, to manipulate abstract concepts and the raw materials of the world.
MEDICAL STUDENTS may learn the anatomy of the foot last and pay it little attention, but the foot is a marvel of engineering – when we run, around half of all the energy used in each step is stored in the elasticity of our Achilles tendons and sprung into the arches of the feet. The shape of our footprints is a reflection of three arches that bear our weight: two along each foot’s length, and one across its width. Parents worry about “fallen arches” in their children not just because they look odd, but because they can lead to pain and disfigurement. Like the arrangement of spans on a bridge, the arches of the foot are necessary for strength: without them the foot cannot adequately bear the weight of our bodies.
The arches of the foot are sustained in four ways. There are bones at the apex of each of the three arches that are shaped like keystones, with their wedged surfaces pointing groundward. There are ligaments joining each bone along its undersurface, like the staples running between each stone on the underside of a bridge. Tendons and tough, longer ligaments run from one side of the arch to another, like tie beams strapping the two ends of a span. Other tendons anchored in the leg hang the arches like the cables of a suspension bridge.
The neglect of the anatomy of the foot is undeserved. If we believe the evidence of the Laetoli footprints, it’s thanks to the arches of our feet that we stepped into our humanity.
Walking for too long, or burdened by too much weight, leads to stress fractures in the metatarsal bones just like cracks in the stone of an overstressed bridge (these are called “march fractures” because they were first recognized in soldiers on the march). Ligaments that strap the arch in place can become irritated and inflamed; this “plantar fasciitis” can be tormenting, and difficult to settle. Gout often attacks the joint at the ball of the foot, and Morton’s neuromas – painful swellings that develop on nerves – often develop in the web spaces between the toes. Children with flat feet need assessment for insteps or even special shoes, so that their bones can grow into a supportive arch. Even if scant attention is paid to feet at medical school, qualified doctors have little choice but to spend time thinking about their anatomy, and how to heal them when they go wrong.
ONE OF MY ANATOMY LECTURERS was Gordon Findlater: a straight-talking Aberdonian with quick hands and a silver beard. Before he became an anatomist, Gordon had worked as a telephone engineer. Perhaps he was a natural teacher, or perhaps his work fixing telephones had given him a talent for communication. He asked us, “Which is more specialized in terms of its function, and specific to human beings: the hand or the foot?”
“The hand!” we shouted. “Opposable thumbs!”
“Wrong,” he said, explaining that opposable thumbs are an easy modification, only subtly different from the hand of apes. “It’s the foot that is adapted to walking upright,” he said, “the foot is more specific to us humans.”
I used to work for Gordon preparing dissections of human anatomy as demonstrations for students. Up in the dissection room, high, drafty ceilings were supported by elaborate cast-iron beams, and for most of the year a cold, bleaching light fell in through its north-facing windows. Perched on a high stool, I worked on trays of body parts, or sometimes a full cadaver. It was restful, meditative work, equally occupying hands and mind. It was also revelatory: I found myself struck by a sense of wonder at the intricacy of our physical selves. There was satisfaction when a difficult anatomical arrangement was revealed: the brachial plexus, say, or the course of a pelvic artery. On dissecting out the pulley systems of tendons and nerves that control the fingers, I’d marvel that those same mechanisms were enabling my fingers to perform the work.
The dissections I prepared were often of individual body parts: hands, feet, legs, arms, faces or chests. Each part had a plastic tag identifying it – legislation ensures that a record is kept of all body parts dissected, and each was tagged so that the bodies could be reunited, after a fashion, for later cremation. The parts were wrapped in preservative-soaked rags and kept in large bins on wheels – a separate bin for each segment of the body. I’d sometimes go down to the basement and collect the appropriate bin for the day’s dissections.
The foot of the building was accessed by an old elevator. In dimensions the elevator was not deep, but it was wide enough to slide a coffin in sideways. Once you stepped inside, you had to pull across a black metal grill, of the same vintage as the ceiling beams, and slam it shut or the lock wouldn’t catch. If you were sharing the elevator with one of the cadavers, you’d have to hold your breath against the smell, and draw yourself into one corner to make space. Then, with the push of a button, you’d descend into darkness.
The base of the shaft opened into the embalming room: white-tiled walls, terracotta floors, the sharp smell of preserving fluids in the air. There were two embalming tables of mirrored stainless steel; each had two half-panels, which met in a “V”-shaped gutter. Alan the embalmer was kind-hearted and hard-drinking, with pickled skin and bottle-bottom glasses. He had been an undertaker once, but was glad to be rid of all the velvet curtains, hearses and flower arrangements that become necessary when you work not just with the dead, but with their relatives too. He’d been in the Army Reserves during the first Gulf War, and told me that it was the faces of Iraqi dead that haunted him, not the ones he embalmed. He kept a bottle of whisky on the high shelf of the mortuary office, and drank in a pub called “The Gravediggers.”
The cadavers were often of people who’d benefited from the local hospital and wanted to find a way to give something back. Soon after they arrived he’d lay them out on the embalming table and cut down to the femoral artery in the groin, or sometimes the carotid artery in the neck. After inserting a metal cannula he’d attach a rubber hose and strap the cannula in place with twine. A barrel of preservative solution was suspended from the ceiling – after connecting the barrel to the rubber hose, gravity would do the work of pumping preservatives through the blood vessels. As the fluid seeped into the body, blood would leak from the ears nose and mouth, and drain away into the steel gutters.
Just off the chiller room for the cadavers, where the bins for the body parts were kept, there was a descending ramp that ended at a thick, heavy door. One day, when I’d been working on the anatomy of the foot, I asked Gordon what was through that door. “Do you want to see for yourself?” he asked, pulling out his keys. “It’s in there that we keep all the stuff there’s no space for in the museum on the top floor.”
BEYOND IT THERE WAS DARKNESS. Vaulted arches of brick curved like ribs over narrow passageways. The ceilings were low, the air mineral, but at the same time I had the sense of being swallowed by something organic – drawn into the belly of a whale. Gordon found a switch and, after the buzz and crackle of old fluorescent tubes, the space filled with a dismal yellow light.
Catacomb corridors extended out of sight. They seemed to reach beyond the walls of the medical school, branching away within the earth toward the music school, the lecture ha
lls, and in the direction of the university’s grandest auditorium – the McEwan Hall. Racks of human skeletons were hanging along them, facing onto a pile of boxes labeled “Maori Remains – For Repatriation.”* Their eyeless sockets made me feel as if I were being watched. It was not just an ossuary; it was a menagerie too: a giraffe skeleton lay in crates beside parts of a hippopotamus. In a long polystyrene case I found two ivory narwhal horns, fissured like antique ceramic. Whale vertebrae lay along the edges of the corridor, as if pushed to one side of a plate. Dusty glass bottles lined the shelves, their labels written in copperplate calligraphy. In one corner an articulated skeleton of an orangutan was gazing toward the exit.
The University of Edinburgh has been particularly active in trying to repatriate remains that were insensitively “collected” in former centuries.
I stopped to open the topmost of another pile of boxes – they contained corpses dissected and lacquered by Alexander Monro Secundus over two hundred years earlier. Monro was an eighteenth-century professor at Edinburgh who revealed much of the anatomy of the brain. Beside them were torsos that his successors had injected with mercury in order to expose the lymphatic channels that are otherwise too fragile and lucent to see. The hearts, lungs and viscera of the bodies were shriveled and blackened, as if the corpses had been smoked over a fire. They had been sealed in polythene bags to preserve them: mummies dedicated not to eternal life, but to the dream of understanding the human body and its place in creation.
Adventures in Human Being Page 18
