The Foot Savior

This weekend I am speaking at the dedication of a research center on the campus of Barry University named in honor of Drs. Paul and Margaret Brand.  I wrote three books with Paul Brand in the 1980s (Fearfully and Wonderfully Made, In His Image, and The Gift of Pain) and no one has influenced me more.  Paul Brand died in 2003 but Margaret, now in her nineties, spryly carries on an active life of violin-playing, lecturing, and great-grandmothering.

For a time Dr. Paul Brand was the only orthopedic surgeon working with 12 million leprosy patients in the world.  Christian history includes episodes that rightly cause shame and embarrassment, but the treatment of leprosy makes a very proud balancing chapter.  In the Middle Ages, as leprosy ravaged Europe, an odd rumor spread that Jesus must have had the disease, due to the prophetic description in Isaiah 52-53 of a Servant "disfigured beyond that of any man."  Leprosy became known as the Holy Disease, and Christians in Europe sought out sufferers as representatives of Jesus, who had said in Matthew 25, "whatever you do for one of the least of these brothers of mine, you do for me."

The devout, defying society's stigma as well as their own fears, looked past the unsightly symptoms of leprosy and began treating its victims as they would treat Jesus.  Orders of nuns devoted to Lazarus (the beggar in Jesus' parable who became the patron saint of leprosy) established homes for patients—2000 such homes in France alone.  These courageous women could do little but bind wounds and change dressings, but the homes themselves, called lazarettos, may have helped break the hold of the disease in Europe, by isolating leprosy patients and improving their living conditions.  In the nineteenth and twentieth centuries, Christian missionaries who spread across the globe established many colonies for leprosy patients, and as a result many of the major advances in understanding and treating leprosy came from missionaries.

As I have recounted in my books with Dr. Brand, his research in India led to the discovery that leprosy was not a flesh-eating disease, as long thought, but rather a disease of the nerves.  Virtually all the damage that occurred came about because of painlessness.  Leprosy patients literally destroyed themselves because they lacked the warning system of pain.  Such ordinary acts as wearing tight shoes or using splintered tools can cause permanent damage to someone unaware of damage to tissue.  Dr. Margaret Brand learned of a common way in which painlessness can lead to blindness: once the tiny pain sensor that causes a healthy eye to blink is silenced, the eye dries out.

Later, in the U.S., quite by accident Dr. Paul Brand stumbled across a new practical application for what he had learned about pain.  Although only a few thousand leprosy patients live in the United States, more than ten million diabetics live here, and his team found that his discoveries about pain had direct relevance to diabetics as well.  Dr. Brand tells the story as condensed from The Gift of Pain:

Late one evening as I was scanning a medical journal I noticed the phrase "diabetic osteopathy."  It struck me as odd: since when did diabetes, a disease of glucose metabolism, affect bones?  Turning the page, I saw X-ray reproductions which looked exactly like X-rays of the bone changes in the feet of my insensitive leprosy patients.  I wrote the authors, two doctors in Texas, who graciously invited me to visit them and discuss the topic.

A few months later I found myself in their Houston offices involved in a good-natured contest of "dueling X-rays." They would place an X-ray of deteriorating bone on a light table, and I would rummage around in my briefcase until I found a matching X-ray of bone absorption in a leprosy patient.  We compared X-rays of all the bones of the foot, and almost without exception I could duplicate each osteopathic problem they presented.  The demonstration made a great impression on the doctors and interns assembled, for most of them had no experience with leprosy patients and thought they had described a syndrome peculiar to diabetes.

Next, the Texas doctors invited me to speak to the Southern Sugar Club [I love this name!], a genteel group of diabetes specialists from Southern states.  I addressed the subject of feet, challenging their assumption that the common problem with diabetic feet (ulceration so severe that it frequently leads to amputation) was caused primarily by diabetes itself.  My own observations had convinced me that the wounds were, like those of leprosy, caused by the loss of pain sensation.

In a vicious cycle, nerves die off because of diabetes, the patients injure themselves because of the lack of pain, and the resulting wounds do not easily heal because the patient continues to walk on them.  I recounted for the Sugar Club our long history of tracking similar injuries among leprosy patients in India.  "I have examined the X-rays of diabetics," I told them, "and frankly I think most of the foot injuries you see are preventable.  They're caused by mechanical stress that goes unnoticed because the patient has lost pain sensation.  Walking on wounded feet drives the infection deeper so that it involves the bones and joints, and with continued walking the bones get absorbed and the joints dislocate."

I was astonished to learn that diabetics were undergoing 100,000 amputations each year, accounting for half of all amputations in the U.S.  A patient over sixty-five had nearly a one in ten chance of foot amputation.  If our theories were correct, tens of thousands of people were losing their limbs needlessly.  But how could I, with a background in the rather obscure field of leprosy, get the attention of experts in another specialty?

A physician in Atlanta, Georgia, provided the solution.  Dr. John Davidson, a renowned expert on diabetes, had attended the Southern Sugar Club, and I remember well our conversation after my speech.  "Dr. Brand, I run the diabetic clinic at Grady Hospital, a charity hospital that treats over 10,000 diabetics a year," he said.  "I must tell you, I'm skeptical about what you say.  I haven't seen nearly the number of foot injuries you say I should.  And I doubt seriously whether the damage that I do see results from the loss of pain.  But I want to be open-minded and so I'll check out your theories."

Back at his clinic in Atlanta, Davidson hired a podiatrist and instituted a simple rule: all patients had to take off their shoes and socks each time they came for a diabetic checkup.  The podiatrist examined every foot, even if the patient had no complaints about feet.  A few months later, Davidson called me, and this time I heard enthusiasm, not skepticism, in his voice.  "You won't believe what I found out," he began.  "I discovered that 150 of our patients had amputations last year, most of which we didn't even know about!"

"It works like this," he explained.  "They come into my office for a routine checkup, walking on an ulcer, and don't bother to mention it.  Patients see me for regulation of insulin, urine tests, weight monitoring and the like.  When they get a foot injury, they visit a surgeon instead.  The problem is, most of these patients don't report ulcers or ingrown toenails in the early stages because they don't feel any pain.  By the time they visit the surgeon, the foot sore is in bad shape.  And that accounts for all the amputations.  The surgeon checks their charts, finds out they're diabetic, and says, 'Oh, we'd better amputate right away, or that leg will grow gangrenous.'  All this time, I don't even know my patient has a foot problem!  The next time I see them for a checkup, they're walking on an artificial leg, and don't bother to mention that either."

With a podiatrist now on staff, Davidson's clinic was able to interrupt the sequence.  Detecting foot problems at an earlier stage, he could treat the sores and prevent serious infection from setting in.  By the simple measure of requiring patients to take off their shoes and socks for a visual inspection, the clinic soon managed to cut its patients' amputation rate in half.

We also found that sores on diabetic feet, like those on leprosy feet, are preventable.  Soaking the feet daily in a basin of water and using moisturizing cream does much to inhibit deep keratin cracks in the skin.  And when we outfit diabetics in specialty footwear and teach them proper foot care, the ulcers tend not to recur.  For a time the government considered issuing free shoes to needy diabetics, but, like other proposals that focus on prevention and not cure, that project never got approved.  As a rule, I have found it is easier in the United States to obtain good artificial limbs than good shoes.

Former Surgeon General C. Everett Koop told me that as a result of Dr. Brand's research into pain, some 50,000 amputations per year may be prevented in the United States alone.  That statistic takes on personal significance to me, for I have an uncle who lost a foot to diabetes and another who lost a leg below the knee.  And now a podiatric school in Miami is dedicating a multi-million dollar facility to further the research program begun by the Brands in a leprosarium in India.  Early on April 29, 2011, more than a billion people will tune in to watch a lavish royal wedding in London.  Later that same day a much smaller crowd will gather to honor two humble missionary doctors who worked with some of the most neglected people on the planet, yet whose work led to treatments that have improved the lives of millions.  The legacy of two great missionary doctors lives on.