Adventures in Human Being

by Gavin Francis

  Slashing at your wrists is a way of lashing out at life: through the pulse, the wrist is emblematic of life, testifying to the strength and vitality within. It’s a common way of giving release to feelings of tension: up to 4 percent of the population admits to self-cutting (what is known as “deliberate self-harm,” or DSH), and though the wrist is the most popular, forearms, legs and hips are also common. Teenagers admit to much higher proportions, around 15 percent, with girls more likely to come forward for help than boys. Cutting is often precipitated by feelings of extreme anxiety or distress, temporarily relieved by the act of drawing blood. As one self-harmer explained: “As the blood flows down the sink, so does the anger and anguish.” An anthropologist who has studied self-harming behavior called it “a strategy of withdrawal or self-abasement used to show those one must both love and obey that one is hurt by them.”

  The self-harmers I see are often teenage girls who are placed in impossible situations: pulled between the expectations of their parents, the demands of their peers, and an anguish that’s partly about grieving their childhood, and partly about finding an adult identity. Cutting conveys the depth of conflict they feel, showing their families and friends just how appalling they feel inside. “Communication of emotional pain to others may result in validation of that pain,” wrote one group of DSH researchers, “and demonstration of the severity of problems may elicit help, or maintain a valuable relationship.” From this perspective, to cut yourself is a rational decision.*

  One strategy to reduce the scarring of DSH is to encourage those who do it to hold ice cubes against the skin until it hurts instead, or sting their skin by stretching and releasing an elastic band placed around the wrist.

  For the most part, the teenage girls I see haven’t suffered systematic, tormenting abuse at the hands of those who were supposed to look after them, but childhood abuse is often the precursor of such cutting: having been abused as a child quadruples your chances of self-harming as an adult. When I meet people who self-harm in clinic, I try to elicit whether they have been, or are being, abused, but how likely they are to admit that to me, I don’t know.

  IN THE EMERGENCY DEPARTMENT there’s a “psych cubicle”: a room with more privacy than the usual cloth-curtained spaces, and stripped of anything that could be turned into a weapon. It’s telling that the room in which we assess patients who are mentally ill is the same room as that reserved for prisoners. It has two doors, so that a patient can’t get between you and your exit, and both of them are lockable.

  Melissa wore cheap plastic tennis shoes, stained pink jogging bottoms, and a shapeless pink pullover with “Gorgeous” written across it. Her hair was unwashed, bourbon-brown, and her eyes were liquid with panic. I’d picked up her file on the wall outside – it had her name, date of birth and the address of some nearby supported accommodation: a place where those with severe mental health problems can live quasi-independently, helped by trained staff and social workers. Across the top of her file the triage nurse had written just “DSH.”

  She sat in the psych cubicle looking at the floor, checking and rechecking the dressings on her forearms. The sleeves of her top were pushed up to the elbows to make the dressings more visible. She had five or six adhesive dressings on each forearm, and spreading out from their margins I could see old scars: the skin surface was ridged and fissured as unpolished marble.

  “It’s because I was abused,” was the first thing she said. I nodded.

  “That’s awful,” I said. At times it’s the only thing to say.

  “It was my grandpa – he’s dead now – got what he deserved.”

  She had been cutting herself only half an hour before and the blood was still spreading through the dressings.

  “I didn’t stop it. I should have stopped it. I’m so stupid.”

  I sighed, and shook my head. “How old were you when it started?”

  She shrugged. “Two? Three?”

  “So you were just a tiny girl, how could you have stopped it? It wasn’t your fault.” We sat in silence for a few moments together. Outside I could hear the clatter of gurneys and the arrival of ambulance sirens. “What meds are you on?”

  “I don’t want any meds.”

  “Are you sleeping?”

  “Not for three days.”

  “Well, I could give you something to sleep at least, and let you rest.”

  She nodded her head.

  “Will you let me take a look at your cuts?”

  She nodded, and held out both forearms. I began peeling off the dressings: the cuts were just shallow grazes, not deep enough even to need paper butterfly stitches, much less needle and suture. Slowly I began washing the cuts, and covering them with fresh dressings.

  “You got down here to the hospital on your own, that was well done,” I said. “You knew when you needed to get help.”

  With teenage girls, sometimes just having their cutting acknowledged by those around them is enough – the habit stops when the family around change their own attitudes, or the girl grows old enough that the tensions of adolescence begin to resolve. Melissa’s anguish had far more sinister origins; I felt utterly powerless to help.

  ANOTHER WEEKEND NIGHT, so busy the patients are lining up outside the waiting room and along the corridor. There’s a six-hour wait to be seen. At the nurses’ station there’s a radio tuned into the ambulance system; the police and the paramedics use it to alert the department when multiple, or very serious, casualties are on their way. It rings: a sound like a klaxon that makes even the most experienced staff jump.

  “Major RTA on the city bypass,” says a voice in the radio, and requests an ambulance fitted out to carry two doctors to the accident scene. The ambulance staff don’t request it often because it takes two doctors from the emergency room floor, but if there are casualties trapped in a vehicle, then calling it out can save lives.

  I won’t be going; I’m allocated to the minor injuries area for the night. But with only five doctors on the floor instead of seven the waiting time is going to get even longer. Braced for the fury that is about to break over me, I stand at the doorway of the waiting room to tell the patients.

  “At the moment it’s six hours to be seen,” I shout out, “but two doctors have just been called away to deal with another emergency, so it will take longer. If you think you can go home for the night and be seen tomorrow, please come forward.”

  The waiting room goes silent; everyone sits tight and glowers at me. In the front row I can see a girl with a bag of frozen peas on her ankle, a man holding a cloth over his eye, an old lady with a graze on her forehead – but each has been waiting some hours already, and no one wants to get up first. After a few moments a man at the back wearing a boiler suit and work boots gets up. He’s young – in his early thirties – with long sideburns and a splendid keel of a nose. His hand is wrapped in an old beach towel. “I can probably come back tomorrow,” he says. As he speaks, his Adam’s apple bobs up and down like a float.

  I take him into the adjacent cubicle. He tells me his name is Francis, and as I unwrap the towel I jump back: there’s a nail through his palm.

  “There’s a nail through your palm,” I say, pointlessly.

  “I know.”

  “What happened?”

  “I was working late on the house, was getting tired … and fired the nail gun by mistake.” The nail is clean, about four inches long; the puncture wounds on each side are neat with a halo of dried blood. He laughs: “I was lucky it didn’t fire right into wood,” he laughed, “or I might still be there, pinned to a beam like Jesus.”

  WITHIN THE PALM of the hand are four bones – the metacarpals – one for each finger. A fifth supports the base of the thumb. Between each bone are the delicate nerves that supply sensitivity to the fingers, some blood vessels, and also the muscles that splay the fingers or bring them tightly together (the muscles that bend or straighten the fingers lie in the forearm, not the hand). The metacarpal bases are bound to the bones of th
e wrist by tough ligaments, but further out, toward the fingers themselves, they are held fairly loosely. It’s quite possible to fire a nail through the palm of your hand without causing any major damage: the nerves are narrow and run close to the bone, and the main blood vessels run in a broad arch from the heel of the hand to the base of the thumb, away from the palm itself. Firing a nail through the wrist is a different matter: the wrist has a tight, seed-like intricacy of nerves, blood vessels and interlocking bones.

  Francis might have joked about crucifixion, but if you wanted to nail someone to a piece of wood, you wouldn’t do it through the palm of the hand. The same anatomical features that allow a nail to pass through without causing serious damage mean that the structures of the hand aren’t strong enough to support the body’s weight. The tissues would rip and your hand would come free – mutilated and useless, but free.

  Francis’s fingers were all flexing normally and his sensation was undamaged: none of his nerves or tendons were hit by the nail. The blood flowed to his fingers as it should. The X-ray of his hand showed the nail passing beautifully between the metacarpal bones, as if shot through the bars of a cage.

  After cleaning up his wounds I sent him to the plastic surgeon. They would pull out the nail in an operating room, in order to have a proper look into the hole and make sure that no fragments had been left behind. No matter how neatly they closed up the wound, he’d be left with stigmata on both sides of his hand, a lifelong reminder of the night he was almost nailed to a beam.

  IN THE 1930S a zealous French surgeon called Pierre Barbet became passionately fascinated by the details of crucifixion. To test whether the hand could support the body’s weight he experimented by nailing cadavers to a wooden cross. Making a guess at Jesus’s weight and the position of the arms with respect to the torso during Roman crucifixion, he calculated that the nails must have been hammered through the small bones of the wrist rather than the palm. Those wrist bones – the “carpus” – are held together very tightly by ligaments; Barbet found that if he nailed his corpses by the wrists rather than the palms, they didn’t tear out.

  Pierre Barbet published his experiments on the nailing of a human body in the 1930s, but in 1968, in a burial cave near Jerusalem, a skeleton was found of a young man who’d been crucified during the Roman period. A nail about eleven centimeters long had been driven into the outside aspect of his right heel bone – the calcaneum – and traces of coarse olive wood, presumably used in the vertical stake of the crucifixion, were found under the head of the nail.

  Dramatic claims were made after the find – the first direct evidence of Roman crucifixion – and the professor of anatomy at the Hebrew University suggested that a single nail had been put through both feet, that the forearms had been nailed, and that the victim’s legs had been broken while still alive, in a coup de grâce. Fifteen years later two skeptical colleagues – Joseph Zias and Eliezer Sekeles – re-examined the remains and came to different conclusions: the nail had been passed through only one heel – the right (the other heel bone had been lost) and the arms showed no trace that they’d been nailed. They concluded that crucifixion, as practiced by the Romans, involved tying the arms to a T-shaped cross-beam with rope, and nailing each heel to a vertical stave. Olive trees usually generate straight beams for only two to three meters at the most, and so victims would not have been hoisted very high.

  That Roman crucifixion occurred through the palms is such a commonplace in Western culture that “stigmata,” the development of bleeding wounds over the points of the body where Jesus was said to have been nailed, have surfaced throughout the last millennium. I’ve read of them on palms, wrists, the flank (where Jesus was said to have been stabbed), and even on the tops of the feet. I haven’t heard of them happening on the side of the heel, and I’m yet to see someone fire a nail gun through their calcaneum.

  ABDOMEN

  11

  KIDNEY: THE ULTIMATE GIFT

  Nowadays it is possible to say that lives are connected,

  by transplant, across the thresholds of life and death.

  Alec Finlay, Taigh – A Wilding Garden

  IN THE INDIAN FOOTHILLS of the Himalayas there’s a Tibetan hospital that serves the community around the home of the Dalai Lama. Between training in emergency medicine and beginning in general practice I worked there for a few months, managing the leprosy, dog bites, tuberculosis, dysentery and injuries of the local Tibetan population. It was a general hospital that turned no one away, and the job involved delivering a lot of babies and looking after two wards full of patients, as well as outpatient clinics twice a week. Through translators I’d labor to understand fifty or sixty newly arrived refugees, most of whom were suffering from stress headaches, indigestion, homesickness or diarrhea. Occasionally there’d be a forlorn westerner in the line, pale and emaciated with dysentery they’d picked up by drinking unfiltered water. “I want to live like the locals,” they’d say; I’d inform them the locals got dysentery too.

  There was an alternative to the hospital: just down the road was the Tibetan Medical and Astrological Institute. Traditional Tibetan medicine is an ancient system involving the manipulation of five elements and three humors – practices resonant with Vedic and Hippocratic perspectives on the body. Those patients with vague aches, and unusual constellations of symptoms that we couldn’t make sense of, often did well with the traditional Tibetan physicians. I often wish I had a comparable clinic down the hill from my office in Scotland.

  Out of curiosity I visited the Institute, a grand whitewashed building set among pine trees, on the spine of a ridge coming down from the Himalayas. Great charts of the human body were hung on the walls inside, overlain with meridians and lattices of lines, like the contours and grid squares on a map. Sometimes I understood the rationale for a particular Tibetan treatment, but for the most part it was a mystery – my understanding of the body didn’t concord with theirs at all. If the kidneys weren’t working, for example, the traditional practitioners thought that it was because the organs were too cold. The diagnosis “cold kidney” was an illness all to itself, called “k’eldrang.” Treatment of k’eldrang involved the avoidance of cold or wet seats, strains to the back, and certain foods thought dangerous for their cooling properties. In severe cases “moxibustion” was recommended: an ancient practice with its roots in Chinese medicine that uses burning herbs to heat the skin over particular meridians.

  Tibetan customs of pilgrimage include carrying stones from place to place over the landscape. It’s a practice I recognized from Scotland, where walkers often leave stones on the high ground of a particularly difficult or exhilarating climb. Once, when visiting a Tibetan monastery’s prayer rooms, I saw an old monk touching a pilgrim on the head and back with a special stone – it was smooth, dark and shaped like a kidney. I asked what was being done. The stones can heal, I was told; being touched by them can rebalance the flow of energy within the body.

  Traditional Tibetan medicine seemed to have some success, but I was doubtful that sacred stones could be successful against kidney disease or renal failure.

  THE WESTERN UNDERSTANDING of the kidney was slow in coming. Kidneys strain urine from blood, even Aristotle knew that, but as late as the fifteenth century one of the great Renaissance anatomists, Gabriele de Zerbis, still thought that the upper half of the kidney gathers blood, then strains it through a membrane strung across the middle of the organ. Anatomists like him had cut through human kidneys and can’t have seen any such membrane, because it isn’t there. Perhaps they wanted to believe in the existence of one so much that they saw it.

  De Zerbis was a professor at Padua in northeast Italy, and wrote one of the first treatises on the medicine of old age – Gerentocomia – in the late fifteenth century. To retard the advance of old age he advised living somewhere with an easterly exposure (northeast Italy perhaps?) and plenty of fresh air, and to eat a combination of viper meat, a distillate of human blood, and a concoction of ground-up gold with
precious stones. Esteemed throughout the eastern Mediterranean as a specialist in medical care of the elderly, de Zerbis was called to Constantinople in 1505 to treat a member of the Ottoman elite. The old Ottoman died, and so de Zerbis was caught, tortured and sawn in half, just like one of his dissected kidneys.

  De Zerbis’s successor at Padua was Vesalius, a Dutchman who effected a revolution in anatomy and medicine (in those days there was little distinction between the two). Vesalius took the innovative step of describing what he saw, rather than what the textbooks, some of them dating back to Roman times, told him he should see. He cut kidneys in half and saw no membrane. He still thought that kidneys filter blood in some way; he just admitted he didn’t know how they did it.

  No one would come closer to the true mechanism until microscopes became commonplace 150 years later, following advances in lens and prism technology. In the 1660s lenses were achieving transformations in the understanding of both inner and outer space: near Cambridge, Isaac Newton, in quarantine from the plague, used his time to demonstrate how sunlight can be broken into colors by a prism, and formulated his laws of gravity. In London, Robert Hooke published his Micrographia, which showed the astonishing intricacy of tiny, everyday structures, such as body lice, pieces of cork, and flies’ eyes. (He coined the word “cell” as the basic unit of life, because under the microscope they resembled a series of monks’ cells.) Around the same time, the professor of medicine at Pisa, Marcello Malpighi, used the microscope to demonstrate how blood and air did not mix freely in the lungs, but were merely brought closely together. He also revealed how capillaries in the kidney formed tiny sieve-like structures. He saw that the pale, central portion of the kidney was composed of masses of tubules; when squeezed these tubules produced a liquid that tasted just like urine. (Before biochemistry labs, the analysis of substances was often left to the tongue.)