21-year-old student from Pune and the curious case of her changing hands | Hacker News Reader

21-year-old student from Pune and the curious case of her changing hands

indianexpress.com

221 pointsrchaudhary79 comments

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Wow.. Wow wow wow. I had no idea this was even remotely possible...

I would never have imagine that the nervous system alone would be able to adjust. This is incredible.

I'm really curious now if there have been other transplants like this before with similar results?

> The nerve begins to send signals, it is called reinnervation, and the muscles function according to body needs.

Also, is this just letting the body 're-connect' or is this some specific medical process to achieve ?

Either way this is incredible!

Are you talking about the general case of attaching nerves or the specific case of the physiological changes here?

From the article they seemed to be describing well known phenomena regarding peripheral nerves. The myelin sheath can survive detachment, the nerve does not. With finger re-attachment, a very talented surgeon reattaches the sheathes, and new nerves grow down the channel, at a rate of about an inch a month (mentioned in passing in the article). So for a finger, with some luck you should be able to feel your fingertips in a few months. The arms would have taken a year or more. (I can't imagine what that feels like, emotionally).

There's also a lot of plasticity in the brain. I'd heard of cases where a badly seared finger has a patch of skin grafted from the side of another finger to restore tactile function. They move the skin patch with the nerves still attached, and at first your brain tells you that the side of your finger is being touched. With rehab your brain eventually believes that the sensation now happening to your thumb actually occured on your thumb.

But she would have had to do this for the whole lower arm, twice.

Again.. I am blown away.

> well known phenomena regarding peripheral nerves.

This for starters has my mind blown, but I was curious if they were using techniques that were enhancing that.

> new nerves grow down the channel, at a rate of about an inch a month

Again, amazing! I guess I just never appreciated how amazing the body really is. I always take it for granted of course, but the nervous system for me was always like a webbing, that if broken could never grow back.

Insane, thank you for the info! And again, credit to her and her physicians, nurses and donor. Amazing!

https://youtu.be/Nlreep7UDIc?t=171

We need more Simpsons & Futurama references in the world! Thanks for bringing a smile!

Does this same process not work for a severed spinal cord? Or would it just take a prohibitively long time? Or.. can severed spinal cords be repaired now?

I never quite understood this. I mostly remember that it was important to some people to distinguish between the peripheral and central nervous system when discussing how it behaves

https://en.m.wikipedia.org/wiki/Neuroregeneration has a bit, about the central nervous system being actively hostile to regrowth.

It also says I was off about the myelin sheath - it’s the next layer of tissue that surrounds the myelin sheath that survives. The sheath itself also begins to break down post-trauma, apparently.

Not the most credible evidence, but from some reading long ago I can't find. I think it has to do with the way spines break it damages the nerve endings. If you were to slice the spine with a sufficiently sharp blade I believe they would regrow.

I came to ask about this too - the nerves.

The article briefly explains how the doctors did the surgery - The hand of the donor was first attached by bone, then arteries, veins and tendon muscles before the skin was stitched to Shreya’s upper limb. But says nothing about the nerves. I had read that nerve damage is irreparable. Then there is the fact that that the human body also attacks transplanted organs.

So I am really curious what happens in such cases - will she ever have full nerve functions in the transplanted hand and will her body start rejecting her hand?

That is a curious omission. I think the wiki page I linked below or another doc I tried to find something more accurate (than my recollection of fifteen year old medical documentaries) said that the regrown nerves are often weaker. Something is better than nothing.

Now that you mention it, something about the article bothered me regarding rejection too. She said that they told her they had a blood type match to a donor. I was under the impression that there were much more precise tissue matching criteria that reduce the rate and chance of rejection. But second or third hand medical info can be pretty awful. She was likely much more focused on “I get to feed myself again” than medical accuracy.

That guy who got the first hand transplant, I hear they were removed again. I believe he said that they started to itch so bad when rejection started that he took the doctors’ advice.

> I'm really curious now if there have been other transplants like this before with similar results?

Sometimes the results are not so good:

https://time.com/4419959/double-hand-transplant-surgery/

This link describes a transplant patient who did not achieve a similar level of success.

However since his surgery dates back to the very early days of this medical procedure, I suspect over time the process has improved and current surgery patients end up with better outcomes.

For a moment I thought this was the guy I was thinking of, and was shocked I never heard he couldn’t use them. But the guy I’m thinking of had a drunken encounter with fireworks, not sepsis. I recall being mad that the first recipient was just some random fool instead of a wounded hero. But a fool is probably easier to talk into a crazily experimental procedure...

> Hand donations are rare, because few families are willing to donate limbs fearing disfiguration of the body even though a prosthetic limb is fitted to the donor’s body.

Can someone explain this? Is it an Indian thing?

If I died and donated my hands, I would be proud for them to be missing in the casket. I can only see because two people donated their corneas.

Lots of cultures have strongly-held mystical beliefs about dead bodies, going back thousands of years. There are plenty of famous examples, even, like the fights over Patroclus and Hector's dead bodies in the Iliad.

There is a stigma because some people believe your body needs to be whole during your last rites (Even though you cremate the body in the end if you're Hindu). This is pure superstition.

This is gradually changing with increasing education and awareness among people, making organ donations socially acceptable and something to be proud of.

> some people believe your body needs to be whole during your last rites (Even though you cremate the body in the end if you're Hindu). This is pure superstition

It's not just superstition, it's easily defeated with reason: If this were true, then every innocent person who has to suffer an amputation due to an accident would be unjustly disadvantaged.

It's similar to people who argue against gay marriage since kids aren't produced: This implies every heterosexual marriage without children is worthless

> it's easily defeated with reason: If this were true, then every innocent person who has to suffer an amputation due to an accident would be unjustly disadvantaged

How's that a defeat? Terrible things happen unjustly all the time.

Every innocent person who has to suffer an amputation due to an accident already is unjustly disadvantaged; it's not like this is an impossible state of affairs. (Just ask them whether they'd prefer to have their appendages back!)

Unless you believe there are no accidents.

Some Hindus bury, fyi

I know this is mentioned a lot but this is very rare, i would say < 5 % (anecdotal)

Buried if unmarried, cremated otherwise. I don't know if it's only our tradition.

nope... I know that some castes like Lingayats in Karnataka and Pisharody in Kerala bury all their dead. Probably there maybe more such castes in other parts of India.

Bhils in Sindh

Everything that you don’t agree with or don’t understand isn’t ‘pure superstition.’

Objectively, the funeral is really about the survivors and not the deceased. It’s sometime dressed up in religion so thoroughly that it’s hard to see, but it’s still there. If your perspective is that your loved one is “still with us” more concretely when some other person gets the gift of life from your tragedy, then that may be of great comfort. If not, then it might be more anxiety in an already very difficult situation. Look what they did to my boy.

The relative frequency of “nobody went to his funeral” vs “I missed my mother’s funeral and I’m a terrible person” story arcs in movies and tv seems to follow this pattern. Human interest stories about parents who still visit the recipient who got their motorcycle-riding son’s heart pop up at least once a year (please don’t ride motorcycles, kids).

I'd wager it is more than just an indian thing. Most cultures have the body be viewable by people for last rites before they are interred or cremated. But if any part or the whole body is going to be donated, the body has to be worked on right away or kept in the morgue, which is incompatible with a public viewing.

I speak from recent personal experience. My father (Indian/Hindu) passed away a few months ago. He had registered with a medical college "to use his body for science". He was a devout Hindu, which made this extremely unusual. And being an atheist and dispassionate about death myself, I was most chuffed and proud of him. When he passed away in the hospital, the med school sent their ambulance and transferred him to the school's morgue. That is when I was struck by how much the lack of last rites mean to people. Many friends and relatives were left feeling adrift, that they didn't have time to say bye. It was too sudden, even for me. You know there is no life in that body, but the thought of him as a cadaver, with med students using him to learn suturing or surgeries or whatever is deeply unsettling. We did have a memorial service later on which was cathartic for all, but it is not at all common in India.

For those of you who are reading this and are from Bangalore, I cannot recommend MS Ramaiah hospital highly enough. They showed such kindness and respect to us and to my father that I never felt my father was being "used". I recommend considering body donation for yourself and urging others to consider it. Registered donors get free medical checkups for life!

https://www.msrmc.ac.in/wp-content/uploads/2018/03/Donor_Pro...

When I was younger, I used to routinely joke on the internet that "I have three shades: White, off-white and lobster red." I didn't really tan. I mostly went from cadaverous white to badly sunburned.

I've taken a long strange journey of healing and one of the side effects is that I am now capable of tanning. So based on my experience, I will suggest that gut biome may be a factor here. It's less obvious than "female hormones" in a cross-gender transplant, but it more closely fits my experience of changes in skin function and color.

For background info to help you understand the context:

I have a form of cystic fibrosis, not diagnosed until my mid thirties. My maiden name is Irish in origin and discussion on CF lists years ago suggested that people with CF are "typically" very pale skinned with blonde hair. Irish families are the most likely to have more than one member with a diagnosis of CF and Irish people tend to be very pale and often don't tan well.

Thanks for sharing this story. I really like it. The change of color is one thing but it would be interesting to know how the brain rewrites its motor cortex to connect to the right peripheral nerves and to the muscles they connect to.

Change of color was one thing but the change of shape was very surprising. tl;dr: changes in color and shape may have been due to hormones being the first(?) male-to-female hand transplant, hand shape became more female.

They mentioned her losing 12kg after an infection. There could be more to it, but that is a significant loss that could explain much of it

I kinda suspect that gender reassignment patients and their doctors were not at all surprised by this change.

Is that necessarily needed? Couldn’t the nerves still control the same muscles?

My understanding was that the location and arrangement of peripheral nerves in the human body is not fixed. So which parts go where is not identical. But yes, supposedly you can relearn.

I cut the shit out of my thumb a few years ago and was relieved that I could still feel everything, except for one little spot below the cut (which also pooled blood for a while, both issues have resolved now) I’d heard that it’s a crap shoot whether you hit the nerve or not, and none of the three doctors I talked to disagreed with me.

Site is currently hosting UI-hijacking ads that kick in after 15 seconds or so. Flagged.

Agree. The story is good but this source is absolute trash.

This is why people use devices like PiHoles and adblock.

Wow I didn’t realize so few people had hand transplants. For numbers that low in the human experience, I like to compare with the number of people who’ve been to space.

At 200 transplants, that is twice as rare as going to space!

Ha! That's neat.

The technical part of hand transplants is hard; there’s a lot of nerves and muscles to connect. https://en.wikipedia.org/wiki/Hand_transplantation:

”The operation is quite extensive and typically lasts from 8 to 12 hours. By comparison, a typical heart transplant operation lasts 6 to 8 hours”.

Apart from that, there’s the psychological aspect. Recipients must accept their new hand as theirs. That can require extensive psychological support.

Then, there’s the ethical aspect. Unlike heart transplants, a hand transplant isn’t life-saving, but like it, it condemns patients to the life-long use of immunosuppressants, with the side effect of a weaker immune system. Prosthetics may be the better choice. It also is a lot cheaper. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3499956/ claims

”The lifetime cost of a single hand transplantation is approximately $528,293; on average 62% of this total is due to expensive immunosuppressive therapy and postoperative management.18 The lifetime cost for a single prosthetic adaptation is approximately $20,653

[…]

The quality-adjusted life years (QALYs) of prosthetic adaptation exceed those for hand transplantation, due to the complications of immunosuppression.”

Most of your comment makes sense to me, except this bit:

> Then, there’s the ethical aspect. Unlike heart transplants, a hand transplant isn’t life-saving, but like it, it condemns patients to the life-long use of immunosuppressants, with the side effect of a weaker immune system. Prosthetics may be the better choice.

Surely it's up to the transplant recipient to decide what will be best for them? I'm sure there are many people to whom the trade off will be worth it. How exactly do "ethics" come into play here?

I assume the doctors would make the patient aware the drugs that prevent rejection could compromise their immune system? I doubt many even get the opportunity with the prohibitive costs and difficulty of the surgery.

> Surely it's up to the transplant recipient to decide what will be best for them?

If they pay for it sure.

When society pays then no.

When society pays for things they have a right to pay when it statistically makes sense.

Just because someone has a feeling they are different doesn't mean society should take large amounts of communal money from the disability sector to give to them.

It can be (and in his case has been) argued that (some) patients do not know what will be best for them.

Patients typically are fairly shortly after traumatic injury, and don’t really know what either option entails.

Combine that with the Hippocratic oath or its modern equivalent, which requires doctors to do what’s in the best interest of the patient, and there’s a clear conflict.

(Couldn’t find an example directly related to this, but the general problem is https://en.wikipedia.org/wiki/Medical_ethics#Between_autonom...)

I think it can also be argued that prosthetics will keep on getting better. Although i wonder when they will overtake natural limbs in dexterity or compensate it with other features.

Yes, between immunosupressants, likely limited life time, limited functionality, I would be inclined to go with a prosthetic personally. Even though I think I would be fine pyschologically.

I think, hopefully I won't find out for sure!

I expect the fact that it was both hands may have played a role. I imagine that a prosthetic can be great as a supplement to a working hand, but that it would be difficult to manage with two of them.

Do you suppose that reconnecting at the elbow like they did reduces the number of nerves involved? I figured the nerve bundles would be larger higher up.

The photo shows her holding a pen. It's amazing that you can transplant something as complex as a hand and use it to manipulate something as delicately as writing.

The photo doesn't show her wrists very clearly, but not only has the color matched, but I don't see any scarring. I'm sure it's there, but even so... it's just stunning how good this is.

The hands were connected near the elbow. There's another picture further down.

It looks like the transplant attached the hands and forearms to the upper part of the recipients arm. She lost basically just below the elbow in the accident it seems.

Can any trans folk comment on if they've noticed significant changes in their hands in response to hormone treatment?

I know trans people whose hands are closer to the gender that their brains say that they are than their biological one.

However they also took hormones during puberty, so it is an open question whether this was the effect of hormones during development, or hormones after development.

Anecdotally, I feel like my hands have changed to be slimmer after 3.5 years of estrogen, but I haven't taken any measurements and don't have detailed photos of my hands before/after.

Not really. At least from personal anecdote, it seems more likely it's due to her losing a bunch of weight. Most of hand bulk is bone structure which is mostly static after puberty. The skin does definitely change though, and that plus the weight loss IMO explains everything.

Edit: For context, I started hormones a week before my 20th birthday, almost 13 years ago. Long enough ago that I've seen the full effects I'm going to, and it was after most of puberty.

I've been on hormones for nine years. None of the reported changes strike me as implausible. My skin became gradually softer, and my hairs finer and less pigmented over the first couple years of hormone therapy, and by about six and a half years in, some skeletal changes became evident.

I've noticed that folks' skin tone tends to darken and lighten about a shade on testosterone and estrogen, respectively. I did not personally notice pigmentation changes, but my skin was very light to begin with.

As for my hands, I can't make interesting specific comments; all these things seem to be systemic. I'm sure that the ratio of the lengths of my ring and index finger (a sexually dimorphic trait) did not change.

I have a vivid memory of looking at the back of my hands while driving and feeling intensely uncomfortable with my "man hands", just around the time I started hormones. That thought never crossed my mind again, though, after a short time I felt fine with them and haven't been bothered by them since. I suppose they must have changed enough to relieve my anxiety while I was distracted by other more dramatic effects.

So I assume she has to take immunosuppressants more/less for life, but then that leads to immunodeficiency too?

I would assume so. If we ever find a way to prevent our immune systems from attacking transplants it would be a major breakthrough, and organ transplants would last far longer for the recipient.

I wonder then how it works that some people are able to stop immunosuppressants and not experience rejection? Perhaps finding the fundamental basis for this and whether it's replicable just after transplant would have the potential to save an enormous amount of money, hassles and risks.

It's among the side-effects [0]. But it sees that the general understanding of the immune system gets better as well as therapies.

[0]: http://www.ectrx.org/forms/ectrxcontentshow.php?year=2019&vo...

Here's a video from the Institute where she underwent the transplantation.

https://m.youtube.com/watch?v=RjakQiWPDMk

Not sure why that should be surprise. Skin does not go light or dark randomly, it depends on the amount of melanin and other things body produces. If her natural skin is light, the skin of new hands lost all additional pigmentation over time and went to the body average levels.

The analyses and speculation in the article place too much emphasis on sex / gender and too little on general diversity of physical characteristics. But perhaps I am jumping to that conclusion because I regard India as having archaic, sexist modalities.

> I regard India as having archaic, sexist modalities.

Unlike USA?

> Hand donations are rare, because few families are willing to donate limbs fearing disfiguration of the body even though a prosthetic limb is fitted to the donor’s body.

In my opinion, this state of things is a strong argument for utilitarianism for organ transplantation[1].

For me, it is hard to find a measure in which an additional discomfort during a funeral[2] outweighs the discomfort of living with a life-altering disability (e.g. no hands) or well, dying (which affects their family members, friends, etc).

[1] I support an option that people may personally opt-out of the system, meaning that they don't agree for their own body to be donated (and agree they won't be a recipient).

[2] In many places closed-coffin funerals are a standard, regardless of the state of the deceased.

Opting out of the system would require to spend some time with the people these incredibly selfish people deny from a hope of a better life.

That would need to be a strict oup out system, no questions asked to anyone if no opt out.

Finally, the opt out system should be designed by the people who designed some gov sites (crazy captchas, scrollbar behaving erraticaly, confusing questions, pale on pale colors, internet explorer 6 required)

Genuinely blows my mind that hand transplants are possible.

The article is impossible to read on mobile because of ads. After a few seconds it redirects to some shady website.

wow. I feels like I should also donate my body. I am really proud of those doctor and wishing alot of happiness to that family who donated there child body. As an indian and hindu, I can feel how big this means.

Flagged: redirects to lottery won advert after a timeout on Android.

I got that too on Mac/Safari. Disabled JS and went back.

This is one of the coolest things I've seen in my entire life.

After reading, I feel the need to know how, when, and why he died.

"She came to know later that Sachin, a B.Com student from Ernakulam’s Rajagiri College, had been declared brain dead that day after being involved in a bike accident — and that his family had agreed to donate his hands and other organs."

I didnt know such surgeries could be performed in India. I didnt even know such surgeries were possible in the first place let alone being done in India

Interestingly, not only can such surgeries be performed in India but some kinds of surgeries have better outcomes in India for cheaper prices than in America. I believe it's some kinds of heart surgeries that I saw the stats for.

Surgeons who do lots of surgery are better than other surgeons who don't. This advantage dominates those of training, resources, years of experience, etc. It's no surprise that inexpensive surgeons in a populous nation would be the best.

practice makes perfect

India has some very good doctors and hospitals but are generally unviable financially for most of the population. Hypothetically, if the doctors and health staff lost to the West and Middle East over the last 50 years remained, it would have much stronger reputation for great doctors. But that’s again a what-if thing.

No one suspicious there is no footage of her gripping things?

This is amazing, totally amazing, but you are not in a Sci-Fi movie. Her hands are quite limited.

> Today, her handwriting almost matches her original

Here is footage of her writing, but you don't see her initially gripping the pen. Certainly her hand writing will have changed.

https://www.youtube.com/watch?v=SE1scH3riEc

I get in India life is tough for many people so the media does all these great glossy stories that border on lies, it seems built into the system, individual facts are not as important as the story. But it's not that simple.

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