The Joint of Strength and Mortality

A doctor looks at Jacob’s hip. /

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 greatest 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.

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, Ya’akov, 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 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 explains 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 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.

One of the first patients I ever admitted to hospital was on a 52-hour shift covering orthopedics as a newly qualified doctor. She was Rachel Labanovska, a “fractured neck of femur” according to my new, technical language, but in human terms an 84-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 primary care physician had 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 18 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 arm 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, sedated 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 and a mask giving high-flow oxygen (which, in her confusion, she kept pulling off), and arranged for a physiotherapist to help her cough mucus from her lungs in order to improve her breathing.

I’ve seen death come as meekly as an expiring candle, or as terribly and all-consuming as a black hole. 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, and 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 her 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, 24 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 the expanding number of visiting 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 her broken hip.

During lunch with my colleagues the following day, my beeper squealed once more. “It’s Mrs. Labanovska,” said the nurse on the other end of the line. “She’s dead. Do you want to certify her, or shall I get someone else to do it?”

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, 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?”


“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.

In Genesis, Jacob makes it to a new homeland in Canaan, but is swept on to Egypt by the narrative. He dies there many years later, an old, troubled man. Genesis 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” (v. 33, KJV). Rachel Labanovska had a more 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.

Gavin Francis is a Scottish physician and author. Last year, The Behemoth excerpted a section on emperor penguins from his book Empire Antarctica. This article is excerpted with the publisher’s permission from Adventures in Human Being: A Grand Tour from the Cranium to the Calcaneum, by Gavin Francis (Basic Books, 2015).

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Also in this Issue

Issue 34 / October 29, 2015
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  3. Deeper than Deep Space

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  4. Whale Fall

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  5. Wonder on the Web

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