Trauma Leads the Way

Let’s begin with Rolandus’s story from 1499. He needed more than a little persuasion to act! “Called to a citizen of Bologna on the sixth day after his wound, I found a portion of the lung issued between two ribs; the afflux of the spirits and humors had determined such a swelling of the part that it was not possible to reduce it (i.e., to return it into the chest). The compression exercised by the ribs, retained its nutriment from it, and it was so mortified that worms had developed in it. They had brought together the most skillful chirurgeons of Bologna, who, judging the death of the patient to be inevitable, had abandoned him. But I, yielding to his prayers, and to those of his parents and his friends, and having obtained the leave of the Bishop, the master, and the man himself, I yielded to the solicitation of about 30 of my pupils, and made an incision through the skin…Then with a cutting instrument I removed all the portion of the lung, level with my incision…” (After recovery, perhaps fearing a repeat of this experience, the patient hastily departed Bologna.)

Over time this scenario was repeated. These observed events were the result of trauma to victims who survived injuries severe enough to create chest wall defects that allowed the lung to partially escape the chest cavity through the tight gap between ribs. The subsequent compression by the rib cage on the protruding lung would be sufficient over time to occlude its blood supply. This inevitably caused necrosis of the herniated lung tissue which either sloughed off of its own accord or was amputated by a surgeon. These episodes were delivering messages important for the future of thoracic surgery. One was that removal of at least some amount of lung was legitimately possible from a technical perspective. Second, even though one would not expect the survivors of these injuries to be particularly spry, observation of the individual over time would have revealed that there was enough redundancy of total lung function that a person could lose some of their breathing capacity and yet continue with reasonable activity. Although most traumatic events of the magnitude Rolandus’ patient experienced must have been fatal, sporadic similar reports continued to appear over the following centuries.

The Next Step

The French surgeon Péan took the first step forward toward a planned lung resection in 1861. When removing a tumor of the chest wall he found it doing what cancers are notorious for and invading into and therefore firmly adherent to the underlying lung. He simply excised altogether the tumor, tissues of the chest wall, and, wanting a margin of normal tissue so that all tumor was removed, a bit of attached lung. A modern surgeon would anticipate this finding as cancer (from the Latin for crab) is so termed because of the natural growth of the tumor into neighboring structures in an irregular fashion so that a fanciful imagination sees it as resembling the outline of a crab.