A Lung and a Larynx

Although the transplanting of a human heart is the most dramatic feat of today's surgery, it is not the most difficult. From the technical standpoint, implantation of a new lung is more delicate and complex. And it carries an even greater risk of failure because the basic function of the lung is to inhale air from outside the body, thus exposing it to infection by airborne microbes. Of ten human-lung transplants previously reported, most have failed within a few days, and all in less than a month.

Good Tissue Match. Last week surgeons were astonished to learn that in the grimy Belgian city of Ghent (pop. 235,000), a lung transplant had been performed in utmost secrecy more than three months ago and the recipient was still doing well. Alois Vereecken, 23, a metalworker, received the lung from an unidentified donor on Nov. 14 at the hands of a five-man surgery team headed by Professor Fritz Derom. Patient Vereecken had developed severe silicosis in both lungs.

Vereecken has remained in a sterile isolation room at Ghent University Clinic, where for weeks he has been reading, watching TV and doing some wicker work. What is most striking, considering the radical nature of his operation, is that he has been able to get up and walk around his room. His most serious recent complaint has been stomach distress brought on by the heavy doses of drugs that he must take to suppress the immune mechanism by which his system might try to reject the graft. Derom ascribes the long survival of the graft to the unusually good match between the tissue and cell types of the donor and recipient, as well as to Vereecken's youth and will to live.

The lung transplant was disclosed almost incidentally during a buzz of excitement over another Ghent operation, believed to be the world's first transplant of a larynx. Jean-Baptiste Borremans,-62, a rural policeman, had been complaining for a year of discomfort in his throat, and he became progressively more gravel-voiced. While he was under observation at the University Clinic, says Mme. Borremans, "the doctors decided to operate, but there was no question of a transplant. It was the morning after the operation when I went with our two grown children to see him that I was told Jean had had the transplant."

The larynx, protected by the Adam's apple, is an organ with three important functions. The valve-like flap at its top, the epiglottis, must close when anything is being swallowed, to keep food or drink from going into the larynx or down the windpipe. With the valve open, the larynx is part of the airway to the lungs. Within it are two folds, the vocal cords, which vibrate when air is exhaled. The vibration of the cords generates the basic sound that is modified by various mouth structures to produce speech.

Burp Speech. Normal speech is impossible without a larynx, but thousands of patients who have had their larynxes removed because of cancer learn to speak by swallowing air and expelling it while they vibrate their gullet muscles. In this esophageal or "burp" speech, the esophagus (gullet) substitutes for the windpipe. Although the Ghent surgery team headed by Professor Paul Kluyskens would say only that Borremans' larynx had to be removed, his complaint was almost certainly cancer. Knowing that many laryngectomy patients fail to learn esophageal speech, Kluyskens decided that a new larynx would offer Borremans a great advantage. If the transplant took, he should be able to speak almost normally, although in a monotone.

The larynx, also from an unnamed donor, was transplanted in a four-hour operation. To what extent Kluyskens tried to attach the recipient's laryngeal nerves to those in the graft, or to what extent he succeeded, was unclear. On this depends the ability of the larynx to function more or less like Borremans' own. Last week one of his doctors described Borremans' breathing as perfect, and added: "His voice already exists." He was still being fed artificially.

Some U.S. physicians questioned whether the larynx transplant was ethical. It exposed Borremans to additional surgical hazards, not to mention the perils of immunosuppressive drugs. All that was necessary, in their view, was a simple laryngectomy.

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