The art of surgery: life drawing and leprosy

‘Life drawing”, “still life” and “life class” are all fairly mundane terms I thought only applied to nude figures or fruit bowls in an art studio. However, in November, I stood and drew in the corner of a plastic surgeon’s theatre in Lalgadh hospital, near Janakpur in Nepal. The theatre was set up to operate on the paralysed hands of leprosy patients. “Life drawing” became very appropriate very quickly.

Like many infectious diseases that predominantly affect those in poverty, leprosy is alive and well; there were more than 200,000 new cases were reported in 2015. The sad fact is that the disease is difficult to contract and relatively straightforward to treat. Many patients present late, when paralysis sets in. Although medication can make patients non-infective, the paralysis requires surgery to correct.

A patient being cleaned with iodine before his operation.

Each year, Working Hands – a Bristol-based charity run by hand surgeon Donald Sammut – spends two weeks, pro bono, operating on the backlog of patients in Lalgadh, training staff and providing hundreds of kilos of medical equipment and consumables. The work is highly skilled, but in many cases the objective is simple: to generate enough movement and power in a hand for the patient to go back to work, or to eat, or to look after themselves in a society where stigma is attached to those with the disease. Most of these patients are illiterate farmers whose only means of support depends on how much they can dig, or carry.

Raj undergoing an opponensplasty to give more strength and movement to his right thumb.

As I was drawing Raj, a 60-year-old man having an opponensplasty (an operation to restore strength and movement to a paralysed thumb), it occurred to me that there have been many crossovers between surgery and art. Leonardo da Vinci and Henry Tonks were two of them, both using drawing as a way of comprehending the human body.

The team amputating a lower limb under local anaesthetic.

Watching Sammut, I could see why surgeons often make great artists. The value of being bold, with highly tuned hand-eye coordination, an obsessive understanding of what looks beautiful and a consideration for symmetry were all tips from the drawing books. But it doesn’t end there. Surgery is also performed under great time pressure; these procedures are all done under local anaesthetic, including the amputations, with a tourniquet to stem blood flow. The shorter the tourniquet time, the less damage to the tissue.

Gulshan, a 21-year-old, was having the gangrenous and mummified fingers removed from both of her hands – a procedure done under local anaesthetic.

Before each surgery, Sammut spends several minutes drawing the patient’s hand; scar tissue shown with cross-hatching, deformity by weight of line, cut lines with dotted lines. “Those few minutes of examining and drawing the hand are invaluable,” he says. “While drawing, one is obliged to examine every millimetre, the texture and suppleness of the tissues one is about to rearrange. And it also gives one a few moments to plan the surgery, running it through one’s head like choreography steps.” The drawing is the beginning of a relationship built on trust, and a life-changing procedure.

Surgery notes for a 45-year-old male carpenter needing Lasso correction and opponensplasty. Drawing by Donald Sammut, Working Hands charity.

Leprosy patients here are treated at Lalgadh hospital for free, supported by the 400 paying outpatients the hospital treats each day.

An entire family collecting hay, typical of the sort of agricultural society that many of the leprosy patients work in.

Two patients waiting in line for physiotherapy after corrective surgery on their hands.

A Hindu funeral pyre for 55-year-old Krishna Bikram Chauhan on the bed of the river Sundari near Janatpur. The names of those watching the pyre are taken and they are invited to a celebration 10 days later.

A mother comforts her child after his operation.

Working Hands team and local doctors in the middle of a procedure in Lalgadh hospital.

The art of surgery: life drawing and leprosy

A decade of deadlock over Alzheimer"s treatment may be drawing to a close

When Terry Pratchett was diagnosed with Alzheimer’s he recalled his wife’s relief that he hadn’t got a brain tumour. “All I could think then was, ‘I know three people who have got better after having a brain tumour. I haven’t heard of anyone who’s got better from Alzheimer’s,’” the late author wrote in 2008.

Nearly a decade on, not much has changed for people facing a new diagnosis of Alzheimer’s. Unlike patients with heart disease, cancer or diabetes, there is no well-trodden medical track to follow and no treatments that can slow the disease’s devastating progress.

Between 2002 and 2012, 99.6% of drugs studies aimed at preventing, curing or improving Alzheimer’s symptoms were either halted or discontinued. The consistent failure of trials, at vast financial cost to drugs companies, caused many to shut down dementia programmes as a result.

The latest trial results from Merck, together with other drugs in the final stage of development, provide hope that the years of deadlock may be drawing to a close.

The Merck trial may be preliminary, in the clinical sense, but it represents an entire career’s work for some of the scientists involved. “We’re 16 years into the program,” said Matt Kennedy, the neuroscience director at Merck who led the research. “It’s a good example of how long it takes.”

How BACE1 blocking drug could reduce toxic proteins in Alzheimer’s patients.

The first challenge scientists faced was creating a compound that would get through the blood-brain barrier, without also causing toxic side-effects or damaging healthy structures in the brain. Simply optimising the structure of the compound to do this took a decade, Kennedy said.

The latest results appear to show that the scientists got this bit right – the drug appeared to have few side-effects and it substantially lowered levels of toxic amyloid compounds.

The real question, which the next phase of the trial should answer, is whether the formation of plaques are a root cause of the disease or simply a visible symptom. Previous drugs aimed at clearing abnormal tangles of proteins from the brain have not been successful, and some argue that by the time the plaques are present irreparable brain damage may have already occurred.

It is possible that previous drugs based on the so-called amyloid hypothesis, were given to patients whose disease was too far advanced for them to benefit. Merck hopes that its drug, which acts at an earlier stage in the disease process by shutting down the production of the misshapen proteins rather than clearing them once they appear, will fare better.

There is no guarantee that the drug will ultimately make it to market, but in a field that has seen such scant progress, the fact that a major clinical trial is underway is welcome news.

Professor John Hardy, a neuroscientist at University College London and pioneer in the study of Alzheimer’s disease, said: “Conveying some excitement isn’t the wrong thing to do in this case.”

A decade of deadlock over Alzheimer"s treatment may be drawing to a close