Matthew Scott can barely do up his own buttons. When he types, he clutches a pen in his left hand to tap at the keys. He cannot tell a puff of cotton from a ball of twine by touch. His left hand is mottled with age spots that his right will not see for another 20 years, and every day he takes a handful of pills that may shorten his life, or invite serious illness. But he says he feels whole.
On January 24 1999, a team of surgeons in Louisville, Kentucky fused bone, nerve, artery and vein and attached a hand from a corpse to Scott's left wrist, performing the world's first successful hand transplant. Then and now, it was a medically and ethically controversial procedure. Scott had been living for more than a decade with a prosthetic hand, after losing his limb in a fireworks accident. Within most of the scientific establishment, it was unthinkable to subject a patient to the risks of surgery and an indefinite future on immuno-suppressant drugs - all for the sake of a relative non-essential such as a hand.
The debate was re-opened recently when Scott marked the fifth anniversary of his surgery, attaining a medical milestone that puts pressure on the scientific establishment to re-examine the future of transplant surgery. Promoters of the pioneering field of surgery argue that Scott's survival without serious illness or infection should advance the day when such operations would be widely viewed as routine procedures.
Critics argue that there have been too few operations like Scott's to gauge their success, and that it is too soon to assess the long-term effects of transplant surgery. However, the experience of Scott, and other recipients of hand transplants, may lead the medical community to review its attitude towards an entire field of medicine. "It's a probability marker. The fact that he has made five years shows us that it is possible to achieve this length of time with a hand," says Warren Breidenbach, who led the team of experts at the Jewish hospital in Louisville, which pioneered the surgery. "It also implies that he has a considerable length of time in front of him that he will keep it."
Since Scott's surgery, hand transplants have been performed in Belgium, Italy, France and China. In Germany, doctors have harvested portions of the knee from cadavers for transplant into living humans. Meanwhile, in America, researchers have recorded some success on rats in carrying out face transplants.
For doctors seeking to expand the area of transplants beyond vital organs such as kidneys, Scott's survival is proof that advances in drug therapy have markedly reduced the risk that a patient will reject a limb from an unrelated donor.
Those advances go to the heart of one of the main doubts about such surgery. The immunosuppressant drugs that must be taken can open up new pathways to illness and death by causing tumours and leaving the body vulnerable to infection - and a heart or kidney are essential to human life whereas a hand is not. There had been discomfort about subjecting patients to high levels of risk, not only during surgery but throughout their lives when they must take a regimen of anti-rejection drugs. Such drugs increase the risk of illnessess such as diabetes or hypertension. They also shorten lives.
However, proponents of such surgery argue that Scott's survival indicates that such risks fall within acceptable margins. "It is telling us is that the old concept that skin was highly rejected and could not be transplanted is now incorrect," says Breidenbach. "It is still true that skin promotes more response against it than muscle or kidney but the immunosuppression is so good nowadays that we can use the same level that was used for a kidney transplant to do a hand transplant. So the drugs are good enough today to keep skin and other soft-tissue structures alive for the same risk as kidney transplant."
To date, however, only 23 hand transplants have been performed on 18 people. That is far fewer than were anticipated by Breidenbach five years ago. It also suggests that the pioneers of such procedures have been unable to entirely overcome scepticism within the medical establishment.
The beginnings of hand transplant surgery were hardly auspicious. A few months before Breidenbach assembled his team in Kentucky, doctors in France pioneered the first hand transplant on a New Zealander, Clint Hallam. In February 2001, he asked for the alien hand to be amputated, saying that he had never felt it was truly his own. Since then, only one other transplant recipient has had the surgery reversed. No patient has suffered serious infection or tumour, or loss of life.
Even so, doctors have been unable to demonstrate that the benefits of surgery outweigh the medical or financial risks. Although medical centres such as Louisville's Jewish hospital are prepared to offer the operation free of charge, transplant recipients must commit to a lifelong regime of immunosuppressant drugs which can cost as much as $15,000 (£7,935) a year.
For Scott, there are no such doubts. He is convinced that his transplant was entirely worth any risks of disease he may encounter in the future, or the discomforts to date.
Scott learned to use his prosthesis after losing his hand in 1985. Born left-handed, he learned how to write with his right hand. He reconciled himself to the limited functioning of the artificial limb.
However, he says he never felt truly himself, and when he heard that doctors at Louisville were contemplating the experimental procedure, he knew that he wanted to go ahead. "Don't get me wrong. Living with a prosthesis is an absolutely acceptable way to exist. I just wanted something better - flesh and bone and muscle and tendon, as opposed to plastic, latex and a battery."
The first year after his surgery was far from easy. Scott suffered nauseau and stomach upsets, and a number of "rejection episodes" when his body rebelled against the transplant. These eased over time, but he still takes six to seven anti-rejection pills a day. However, he believes the pay-offs have been immense. Although the transplanted hand is more mobile than the prosthesis, enabling him to play football or move furniture, the greatest benefit has been psychological. "Next to our voices, our hands are probably the most expressive things. So much is conveyed in a touch of a hand, and so much in the way we use our hands."
The proponents of this kind of surgery believe that the time is coming when the realm of transplant surgery is expanded to give new limbs capable of growing to children who suffer catastrophic accidents, or faces to the survivors of horrific fires.
"I would say that we are probably going to see face transplantation within a year to five years," says Breidenbach. "There are some ethical issues, and some medical issues that need to be very carefully thought through, but I do think that in a highly selected patient with the right indications, and with the right exit strategy, that it is possible that it could be done now."
