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 German-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 inwards, 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 labour, 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 himself that all he has to do is think of them, and he’s immobilised.
Hips cause all sorts of problems, and seemingly minor issues in childhood can cause a permanent limp if they’re not addressed. As foetuses 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 immobilised in a plaster cast 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 which 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 meagre 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 which 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 per cent of them will end up in a nursing home because of the fall, and 20 per cent will never walk again. Between 5 and 8 per cent 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 realises 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 that 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 acknowledgement 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 orthopaedics. 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 Honours’. 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 checked and attended to, hundreds of drugs and intravenous fluids to prescribe, and my boss to assist in the operating theatre.
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 which 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 was 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 disembowelled. 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 travelled 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 orthopaedic 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.
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 towards 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 bleeper 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 were 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, answering 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 aeroplane 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 orthopaedic and rehabilitation wards all over the world – journeys like the one that 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.