By now it was October, the end of the hot season on the plains, and time for Margaret to move down to Vellore. It was a wonderful day for Paul when he was able to escort his wife and children down from the mountains and back to Vellore. The family would continue staying with the Carmans while Margaret adjusted to living in Vellore and managing a household in India, and then they would move into a place of their own.
Paul could not have been happier. For the first time the Brand family was living in one place. It made coming home from work after a long day a joy. In the evenings he could relax and sit and talk with Margaret. One of the things he talked with her about was his determination to find out more about the way leprosy affected people’s hands. Margaret was very supportive of his efforts, and Paul was glad he had married a fellow doctor who could understand his passion for this medical mystery.
It was good that Margaret supported him in his quest, because Paul spent many of his off-hours studying the problem. He decided that the best way to proceed would be to study a small group of leprosy patients and possibly operate on their hands. Vellore seemed the perfect spot to do this, since it was right in the middle of the highest density of leprosy in the world. Three out of every one hundred people in the Madras area were afflicted with the disease.
Paul asked Dr. Norman Macpherson, the medical superintendent of the hospital, whether he could have a few beds for leprosy patients. The conversation did not go well. Dr. Macpherson was kind but firm in his response: No leprosy patients had been or would be allowed in the hospital. Chingleput, not a “regular” hospital like the one in Vellore, was the place for leprosy patients. Leprosy patients simply did not belong in the general hospital population, because that would cause fear, even panic, among the other patients and staff. Paul found Dr. Macpherson’s second reason the most maddening: leprosy patients, he said, had “bad flesh” and it was pointless to operate on a patient who would not recover properly. Such thinking infuriated Paul. The reason there was no hope for leprosy patients was that they were always isolated in colonies and had no access to the specialists who might be able to help them.
Paul did not let Dr. Macpherson’s rejection of his plan stop his quest. If the leprosy patients could not come to him, he would go to them. He talked the situation over with Margaret, who agreed that he should go to the Lady Willingdon Leprosy Sanatorium in Chingleput each weekend to begin a scientific survey of the patients there. Paul spoke so enthusiastically about the idea that several others at Vellore pledged to help him in any way they could. Dr. Ida Scudder, namesake and niece of the hospital’s founder, was the head of the radiology department, and she put her staff and facilities at Paul’s disposal. Members of the pathology and dermatology departments also offered to do what they could.
But where to start? Paul knew his first task was to survey the patients at Chingleput to determine the type of condition of each person’s hands. He repeatedly examined the hands of every leprosy patient available, testing the patient’s sensation, first with a pin, then with a feather. He measured the movement of each person’s fingers and thumbs and determined which muscles were paralyzed, which nerves had thickened, and which fingers were missing.
As the weeks passed, Paul became excited with his results. It was obvious to him that the paralysis caused by leprosy followed a distinct, uniform pattern. Some patients with the disease might progress through the stages on the way to paralysis faster than others, but all leprosy patients went through the same stages. Soon Paul knew which muscles the disease would paralyze and which muscles would be unaffected. Paul now knew that perfectly good muscles were in place that he could surgically manipulate to take over from the paralyzed ones. There was hope of giving leprosy patients back some limited use of their hands.
The next thing Paul had to do was find out whether the flesh of leprosy patients was really “bad”—meaning that the flesh of the leprosy sufferer was infected with the disease and therefore would never heal. What good was doing surgery if the incisions would never heal? Paul did not believe this was the case, but because he did not know for sure, he took many flesh samples from the hands of leprosy patients and sent them to the pathology laboratory at the hospital in Vellore for testing. The result from all the samples was the same: there was no disease in the tissue, and under the microscope the sample appeared normal except for a smaller number of blood vessels and the absence of nerve endings. As far as the pathology reports were concerned, leprosy patients had “good” flesh, not “bad” flesh—flesh that could be coaxed to heal after an operation.
The one thing Paul had not yet discovered was what happened to the fingers of leprosy sufferers. How did they fall off? And with so many missing fingers, why weren’t fingers lying around like fallen leaves? Paul carefully drew outlines of patients’ hands over time to compare what was happening to the fingers. Yes, often parts of a patient’s finger or fingers would disappear, but more often than not the patients were unaware of the loss. And when this was pointed out to them, they had no idea of how, when, or where it had happened.
Paul was pleased with what he had learned, but he knew that he had a long way to go. The problem in helping leprosy patients recover some use of their hands was twofold. First was understanding the clawing aspect of the fingers. Paul was reasonably sure that given enough time he could figure out how to take good muscles in the hands and reassign them to finger movement, so that a muscle that had previously worked the little finger could bend the thumb. The second issue was helping patients understand what was happening to their fingers and how to prevent finger loss. This would happen not with a surgeon’s scalpel but by continuing the thousands of tiny measurements and observations that Paul was making and recording each week. Paul knew that over time some kind of pattern would emerge. He just had to stick to the task long enough to find out what was happening.
At the beginning of 1948, Paul felt that he had done enough research on the first part of the problem to try surgery on the paralyzed hand of a leprosy patient. He approached Dr. Cochrane and asked him to refer one leprosy patient to him who had nothing to lose, someone whose hands had been completely destroyed by the disease. Soon Paul was face-to-face with a new patient—Krishnamurthy—a young Hindu man who had recently arrived at the leprosy sanatorium at Chingleput.
“You can’t possibly make him any worse,” Dr. Cochrane had told Paul, who, as soon as he examined Krishnamurthy’s hands, had to agree. The only muscle the young man had any control over was his thumb, and even that was weak. There was no way that he could pick up anything, dress himself, feed himself, or take care of his own toilet needs. His feet, Paul noted grimly, were in worse condition than his hands. They ran with open ulcers. Paul did not have to wonder what living with leprosy had done to the young man; he could see it clearly in his eyes, which were filled with despair and hopelessness.
As Paul questioned Krishnamurthy, the young man had no expectation that any operation would help him in the slightest. He just looked forward to being fed regularly and having somewhere soft to sleep. He did not see himself as a pioneer, nor did he derive any excitement at the thought of being the first leprosy patient in history to have his hands operated on. At first Paul thought Krishnamurthy might not be intelligent enough to grasp the potential significance of the operation. After talking with him several times, however, Paul had to revise his opinion.
Krishnamurthy was a very intelligent young man from a prominent family. He spoke several languages and had a good job—that is, until he discovered a blemish on his skin, which soon became numb. He knew immediately what it was, the worst curse of all. Within weeks he had lost his job, his family, and his home and was wandering through the streets like a beggar. This swift change had made Krishnamurthy despondent, and hunger had eventually overcome pride, bringing him to the gates of the Lady Willingdon Leprosy Sanatorium.
Although Paul was mostly interested in Krishnamurthy’s hands, he decided that the man’s twisted feet were a more urgent concern. As a result of the paralysis in his feet from leprosy, Krishnamurthy tended to walk on the outer edges. Paul wondered whether it was possible to perform tenodesis on his feet. Tenodesis had been used on some polio sufferers who developed a similar foot deformity as a result of their disease. Tenodesis required the moving of tendons and reattaching them to the bone in such a way that they would pull the foot straight. Paul decided to give it a try. Much to his delight, the operation was a complete success. Soon Krishnamurthy was walking on feet that were straight. The soles of his feet were landing squarely on the ground, avoiding the infected ulcers that had resulted from walking incorrectly.
With Krishnamurthy’s feet correctly aligned and the ulcers healed, Paul decided it was time to do what he really wanted to do—operate on the young man’s hands. Through his research, Paul understood why the hands of leprosy patients assumed a clawlike position. He had worked out which of the seventy muscles controlling the movement of the hands were responsible. The ulnar nerve was one of the nerves destroyed by the leprosy bacilli (bacteria), and since this nerve controlled the intrinsic muscles of the hand, its deterioration effectively paralyzed those muscles. As a result, the flexor muscles in the forearm, which did not become paralyzed, pulled on the fingers and caused them to bend toward the palm of the hand in a clawlike way.
With this knowledge Paul decided to try a surgical technique known as Bunnell’s operation, which had been developed during World War I to correct hand disabilities from war injuries. Like the foot surgery, this operation had been employed to help polio patients regain use of their hands. The procedure involved repurposing the flexor sublimis digitorum muscles that controlled the bending of the second joint of the fingers to take over for the paralyzed intrinsic muscles.
Paul and his surgical assistant went to work on the delicate operation that involved detaching the muscles, splitting the tendons in two, rethreading the tendons through the palm of the hand, and reattaching the tendons to the top of the fingers.
During the first surgery, Paul performed Bunnell’s operation on only two of Krishnamurthy’s fingers. In a subsequent surgery he repeated the operation on all of his fingers. Of course, a lot of physical therapy followed, as the flexor sublimis digitorum muscles had to be trained to work the fingers differently from how they had been intended to work. In the end the operation was a success, and Krishnamurthy regained some use of his paralyzed hands.
Even though Paul tried to downplay the operation he had carried out on Krishnamurthy, word began to spread that something astonishing had happened. Words like breakthrough and new hope were being bandied about. Even though Paul was happy with the outcome of the surgeries, he cautioned people that many more steps had to be taken before they could reach any definitive conclusions about the effectiveness of the procedure.
Paul was delighted when he learned that Krishnamurthy had reached a conclusion of his own. Once he regained some use of his hands, he was again able to feed himself and hold a book. It was as if he had awakened from a bad dream. He asked questions and joked with the staff. But most of all, Krishnamurthy wanted to know what motivated Paul and the nursing staff who now tended him to work with such diligence and compassion. Person after person explained to the young Hindu man that they were following the teachings of Jesus. Eventually Krishnamurthy decided that he, too, wanted to follow Jesus. Paul attended the young man’s baptism, where he chose the new name of John.
