Tuberculosis is an ancient disease that long ago earned the appellation of ‘‘Captain Among these Men of Death.” It remained untreatable until the nineteenth century, when physicians and patients turned to spas or sanitaria offering regimens of rest, diet, and carefully supervised exercise.¹ The first sanatoria in North America opened in 1884 in Asheville, North Carolina and at Saranac Lake, New York.¹ Whether these changed the ultimate outcome for patients is not entirely clear, but at least some of those with minimal disease did recover. Overall, the cure rates in New York sanatoria did not differ greatly from spontaneous ones, and the prognosis for the patient with severe disease remained dismal.¹

It is within this context that the year 1882 qualifies as the Annus Mirabilis.^1-3 On March 24 of that year, Robert Koch announced he had isolated and identified Mycobacterium tuberculosis as the cause of tuberculosis.^1,2 His presentation at the Berlin Physiological Society has been described as the most dramatic moment in the history of medicine.² Paul Ehrlich (who would be awarded the Nobel Prize in Medicine in 1908) always remembered that evening as “the most important scientific experience of my life.”² Another event that year, surpassed in impact only by the much later discovery of streptomycin, was when Carlo Forlanini announced he had successfully treated tuberculosis by creating a “therapeutic” or “artificial pneumothorax.”^2-4

There had been earlier observations of patients with tuberculosis improving when they developed a pneumothorax, going back to Giorgio Baglivi, whose patient had sustained a sword wound in 1696.¹ In 1822, a British doctor, James Carson, after some experiments on rats, attempted to cure tuberculosis by inducing a pneumothorax in his patients but was not successful.² In 1834, F.H. Ramadge in London created a therapeutic pneumothorax and claimed to have cured his patient.^1,2 Other physicians in Europe likewise tried to cure tuberculosis by resting the lungs but none were successful until Forlanini.^2-4 However, as late as 1880, the French physicians Emile Toussaint and Hippolyte Hérard had noted that some of their patients improved after their lungs were collapsed by a spontaneous pneumothorax.²

Carlo Forlanini (1847–1918) was born in Milan and began his medical studies at the University of Pavia. In 1866 he interrupted his studies to fight under Garibaldi for the unification of Italy. Graduating in 1870, he worked in the department of chronic diseases at the Ospedale Maggiore in Milan, caring at first for patients with diseases of the eyes. Later he experimented with his brother to develop a cure for tuberculosis. Acting on the well-established concept that rest is essential in healing injured organs, he announced in 1882 that he had developed a technique of allowing the lungs to heal by insufflating nitrogen into the pleural cavity and creating an artificial pneumothorax. The procedure involved collapsing the lung by injecting air into the pleural cavity between the lung and the chest wall. By creating this artificial pneumothorax, the diseased lung was compressed, reducing its movement and giving it a chance to rest and heal.^1-4

A physician visiting Forlanini’s clinic a few years after its inception described it as small, having only twenty-five beds. On entering the laboratory he saw a strange apparatus, and on asking the professor about its use, was told, “It is for the evolution of nitrogen to inject into the pleural cavity, and compress the pulmonary parenchyma in unilateral tubercle of the lung.”⁵ “What results have you?” the visitor asked. “Guariscono tutti” (They all get well), he replied. When asked if he knew that his method was being practiced in America he replied, “No. I have practiced it for ten years, and they must have got it from me.”⁵

Despite initial skepticism from the medical community, Forlanini’s method gained acceptance over time. In the 1920s and 1930s, artificial pneumothorax was standard treatment for pulmonary tuberculosis in many parts of the world, remaining in use until the advent of effective antibiotic treatments in the mid-twentieth century. It reportedly was used in Chicago by the flamboyant surgeon JB Murphy.^2,5 It seems to have been moderately effective, but when performed on elderly patients or those with large chest cavities, artificial pneumothorax was associated with a worsening of symptoms. If the lung did not become detached from the pleura, the pleura would rupture and dangerous infections could occur.⁶

Forlanini’s contributions to medicine eventually extended beyond pneumothorax therapy. He invented a water manometer to measure pleural pressure and designed specialized needles for the procedure. He published many scientific papers detailing his research and clinical experiences, received several many honors during his life, was elected to the Royal Academy of Medicine of Turin, and became a member of the Italian senate.

After the introduction of streptomycin, the incidence of tuberculosis rapidly declined. During my internship in Sydney, Australia in the early 1950s, we still had a building devoted to its treatment, but increasingly it was being used for other chest diseases. There were still a few patients with old tuberculous empyema, and one was being drained under the supervision of an Irish nurse who to our amusement pronounced the name of the premier of New South Wales as it was written (CAHILL), whereas Australians pronounced it as a single sound, like CAAL. Later I treated a young English sailor who developed tuberculosis during one of his voyages. He almost rolled on the floor when I explained that this illness was caused by a “wag,” the then Australian term used for bacteria but having different connotations in the UK.

There was an unpleasant epilogue to artificial pneumothorax therapy during Stalin’s tyranny in the 1920s and 1930s. The Soviet government had made eliminating tuberculosis an important objective during its first two five-year plans, but if complications ⁶ ensued after treatment, it would execute the doctors on the pretext that they had assassinated Communist leaders on instructions from Western imperialists.⁶

References

1. Daniel, TM. The history of tuberculosis. Respiratory Medicine 2006;100:1862-70.
2. Mazzarello, P. A Physical Cure for Tuberculosis: Carlo Forlanini and the Invention of the Therapeutic Pneumothorax. Applied Sciences MDPI, April 30, 2020.
3. Ebstein E. Die Idee des künstlichen Pneumothorax und der Lungenchirurgie: Historische Bemerkungen. Archiv für Geschichte der Medizin. March 31, 1926;18(1):93-9.
4. Forlanini and Artificial Pneumothorax. BMJ March 2, 1929:410-1.
5. Tidey S. A visit to the hospital of San Giovanni al Turin. BMJ October 22, 1898:1287.
6. Polianski IJ. Bolshevik Disease and Stalinist Terror: On the Historical Casuistry of Artificial Pneumothorax. Med. Hist 2015;59(1):32-43.