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June 2016 AMERICAN OSLER SOCIETY Volume 17 Issue 1 The Oslerian A Message from the President HERO #1 PAUL BRAND: RESTORER OF HANDS By Joseph VanderVeer, Jr. I suspect that all of us in this Socie- to their claw hands by a special tendon President’s Message ty have heroes, persons that have inspired transplant operation. It was the best lecture Pages 1-3 us or after whom we have sought to pattern I have ever heard, before or since, and at a our lives. No doubt for us, Osler is one, reception afterward, I met him and asked if AOS Meeting Highlights witnessed by our joining the AOS. In my I might visit him in India. He said he’d be Pages 4-5 professional life I’ve had several other phy- glad to have me come, and so the next sum- sician and surgeon heroes. In a series of mer, it happened. Oslerians and Their Views messages this coming year, I will describe I chose to visit Dr. Brand by attach- Pages 6-7 those heroes and their influence on my own ing that trip to a summer I spent on the Ex- History of Medicine and career. periment in International Living in which I Medical Humanities Sir Charles Bell wrote, “It is in the had 1-2 week home-stays with five Indian Pages 8-9 human hand that we have the con- families across the subcontinent. I visited summation of all perfection as an in- Dr. Brand for three days in his hospital at Opinion - Obituaries strument.” Second only to the brain, the the Christian Medical Col- Pages 10-11 hand is the most significant adaptation we lege in Vellore in South In- humans have due to evolution. Our ancient dia, where I stayed with him Looking Back/Ahead fore-bears doubtless counted on their fin- and his wife Margaret. The Page 12 gers, a habit that I suspect led to the adop- entire summer, getting to tion of the decimal system. Consider the know the culture and several versatility of those fifty-four bones and families in India was a mar- some seventy odd muscles that comprise velous, eye-opening experi- our hands: An experienced mountaineer can ence, and the highlight was grip a fissure at a pressure of eighty pounds getting to know the Brands. Paul Brand 1961 per square inch, and an accomplished con- Paul Brand was one at time of my visit. cert pianist can strike the ivory keys at a of several men in my life for rate of twenty key-strokes per second. You whom I took an instant liking and with and I can lift a brick weighing a kilogram whom I felt a bond. That’s maybe a bold between our thumb and index finger, but statement – for I was a medical student we can also modify our grip to grasp and who’d not achieved anything much to date. lift an egg without crushing it. But as he told of his life – which included During the fall of my first year of serving an apprenticeship as a builder be- medical school in Rochester, NY, my study fore he decided on medicine as a career – I of anatomy was enhanced by hearing a spe- began to feel a kinship, for I’d been a car- cial lecture sponsored by the Christian penter’s apprentice during my college sum- Medical Society by Dr. Paul Brand, a mis- mers, and I was also a Christian. President sionary on furlough from India. His talk, to Paul Wilson Brand was born in Joseph VanderVeer, Jr. a packed audience in the Whipple Auditori- India, of missionary parents, went for th um, was about his work with patients who schooling to England, and attended medical 47 AOS President had Hansen’s disease – leprosy – and in school in London in 1940 during the Blitz. installed at the 2016 particular about his work restoring function After training as a general surgeon, he re- meeting at Minneapolis Please turn to next page The Oslerian Volume 17 Issue 1 June 2016 Page 2 President’s Message (Continued from page 1) turned to India to the Christian Medical College at Vellore hand, connecting them to the flexor carpi radialis brevis, an in the Indian State of Tamil Nadu. In his lecture, Brand told intact muscle in the forearm. In theory, this would restore of being shown around the grounds of the Christian Medi- extension to each finger. (That muscle flexes the wrist. Its cal College by the director, who was also a physician. They function is covered by another muscle, the flexor carpi ra- came upon a man who was trying to fasten his sandal, a dialis longus, so in using the brevis muscle, wrist function leprosy patient with a claw-like hand – one of the evidenc- was not lost.) At the end of the operation, Brand put the es of the disease, caused by paralysis of the extensors of the patient in a forearm plaster cast for three weeks. fingers. Brand bent down and tied the sandal thong for him, When the patient returned and the cast was re- assuming the man’s hand was paralyzed. The director intro- moved, Brand asked the patient to open his hand. He could duced them, and as they went to shake hands, Brand briefly not. Brand thought the operation was a failure until one of examined the man’s hand. As we often do in medicine, he the medical students piped up, saying that the muscle that asked the fellow to “squeeze my fingers." To Brand’s sur- was now connected to the former lumbrical tendons was prise, the man squeezed with such force that his long fin- actually the one the patient previously used to flex his gernails dug into Brand’s hand and almost drew blood. The wrist. So Brand, on himself, showed the patient how to flex patient was indeed paralyzed, but only partly. The exten- the wrist, and asked him to do likewise. As the patient re- sors of the fingers, innervated by the lumbrical muscles in peated the motion shown by the doctor, VOILA! The claw the hand, were paralyzed (and led to the claw-like appear- hand opened! This operation became the key to restoring ance of the hand), but the flexors – acting through tendons function to the useless claw hands of leprosy patients. But, from the strong muscles of the forearm – were intact and Brand said, repairing the hand was just the beginning of the strong. Because leprosy caused a loss of sensation and pro- restorative care these patients needed. Parenthetically, how prioception, as well as a selective paralysis, the patient had Paul Brand cared for his patients, giving them total care, no idea how much force he was applying in squeezing not just restoring their hand function, was one trait that Brand’s hand. made him a hero for me. Throughout history and over the Brand related this was the first of several myths of world, lepers have been outcasts. India was no exception. leprosy that got dispelled when he began taking care of pa- Dr. A. B. MacDonald, Scottish missionary and tients. The second myth was even more dramatic, namely founder of the Itu leper colony in Nigeria, wrote this about the common belief that leprosy caused fingers and toes to the time I visited Paul Brand: “The leper is sick in mind as drop off. “I went all over South India looking for fingers well as body. For some reason there is an attitude to lepro- that were dropping off, but never found one,” he said. What sy differing from the attitude to any other disfiguring dis- he did find was that because patients with leprosy devel- ease. It is associated with shame and horror, and carries, in oped anesthesia of their hands and feet, they often injured some mysterious way, a sense of guilt, although innocently them-selves unknowingly. They could even, if not watch- acquired like most contagious troubles. Shunned and des- ful, amputate a finger as they worked with sharp imple- pised, frequently do lepers consider taking their own lives ments. Moreover because of the insensitivity and lack of and some do.” (Parenthetically, I noticed similar attitudes pain in their hands and feet, they got infections from minor toward AIDS patients and toward alcoholic American Indi- injuries such as cuts or puncture wounds. They’d develop ans as my own clinical experience unfolded.) osteomyelitis of the bones of the hand or foot from such Brand knew that if he was to prevent the leprosy puncture wounds; with the painless infection the bone patients from going back to a life of begging, he had to would absorb and the finger would shorten. Or, even more teach them a useful trade, and that’s where his building gruesome, an anesthetic finger that was draining pus might skills came in. As part of the New Life Center erected on get bitten off by a rat as the patient slept at night. the hospital grounds, he set up a workshop where patients In his lecture at Rochester, Brand told the story of could build simple toys or make cutout puzzles, as part of the first patient on whom he did a tendon transplant, and it their rehabilitation. In doing so, Brand took special precau- so happened during my visit, that first patient came back to tions to make sure the tools were safe by extending the han- the clinic for his ten-year follow-up visit. I heard the story dles on saws and planes to keep fingers out of the way.

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