Editorials |

Out of the Pages of History FREE TO VIEW

Hans E. Einstein, MD, FCCP
Author and Funding Information

Affiliations: Bakersfield, CA 
 ,  Dr. Einstein is Professor of Clinical Medicine, Emeritus, Keck School of Medicine, University of Southern California

Correspondence to: Hans E. Einstein, MD, FCCP, PO Box 1888, Bakersfield, CA 93303-1888

Chest. 2001;120(3):696-697. doi:10.1378/chest.120.3.696
Text Size: A A A
Published online

The control and containment of tuberculosis in the industrialized world in the first half of the last century is one of the significant success stories of that time. This achievement was brought about by a number of factors—in particular, enlightened public health controls, the sanatorium movement (which isolated infectious cases from the community) and the overall rise in the standard of living in the industrialized areas. The treatment of the disease itself played a relatively minor role. The decline in morbidity and mortality from tuberculosis began long before effective antimicrobial therapy became available in the 1940s, and that availability caused only a very minor change in the already rapidly declining rates. Nevertheless, treatment was obviously of great importance to individual patients. No effective treatment had been available previously, and bed rest was practiced universally and relentlessly, based not so much on critical studies but rather as something to do when nothing else was available. The only aggressive interventional approaches of the day were those offered by collapse therapy, consisting of artificial pneumothorax, phrenic paralysis, plombages placed extrapropleurally, and pneumoperitoneum. This last was practiced widely but with questionable effectiveness. The article by Weissberg et al, in this issue of CHEST (see page 847), reviews a series of patients who were treated from the 1930s through the 1950s, who presented quite recently with residua of complications from the earlier procedures. This patient population came from Israel and represents a broadly based sampling from many areas and of multiple techniques. In this age of essentially nonsurgical drug treatment of tuberculosis, this study serves as a useful reminder of the significant successes many of these old procedures did indeed enjoy.

Collapse therapy was a daunting undertaking, demanding a high level of commitment from both patient and therapist. Artificial pneumothorax required frequent interventions, treatment frequently lasted for years, and ultimately, it could be successfully maintained in only 25% of patients, with tuberculous empyema developing in 20%. Surgical collapse of the chest wall by various techniques finally resulted, in the mid-1930s, in a general acceptance of John Alexander’s techniques of posterolateral rib resection, which was widely used with thousands of the procedures being done all over the world. This multistage approach had a 2% mortality rate and an 80% success rate. In an effort to mitigate the effects of this arduous surgical procedure and its severely disfiguring effects, various extrapleural plombage methods were developed, including the introduction of oil, air, paraffin, bone fragments, Lucite balls, or gauze into an extrapleural pocket. The use of these materials, which tended to move and become secondarily infected, was replaced by the arrival of resectional surgery under antimicrobial coverage, soon after World War II. Thoracoplasties were used only occasionally to obliterate residual spaces following extensive pulmonary resections, particularly pneumonectomies. The period of great activity in pulmonary collapse surgery also marked the evolution of cardiopulmonary physiologic studies. It was feared early on that many of the patients undergoing these procedures might end up with severe cardiopulmonary physiological derangement in later years. While a certain number of survivors, particularly the smokers, did, indeed, develop manifestations of pulmonary hypertension, this has not proven to be the large problem that was feared. Most of these patients lived long, productive lives, as indicated by the Weissberg and Weissberg series. The majority of them would have died absent these interventions. Even if not fully rehabilitated, these patients were often rendered noninfectious and thus could return to the community. Life-threatening bleeding frequently became manageable, and most important, many patients were kept alive for the later arrival of resectional surgery, which allowed them to become essentially cured. As the Weissbergs found, many of these patients, when they did receive resectional surgery, were no longer infective, as evidenced by negative tissue cultures. This was true even in the earlier cases in patients who had not received chemotherapy and was almost universally true in those who did. The fact that none of the patients in the present series harbored viable organisms is a further testimony to the effectiveness of the chemotherapy, an advantage that would not have ensued had not the interim collapse therapy allowed them to live into the antimicrobial era.

After the romanticism of Puccini and Voltaire, followed by the therapeutic attempts of Trudeau, leading to the realism of Orwell, and culminating finally in the triumphs of Alexander, Waksman, and Hinshaw, the control and hoped-for final conquest of tuberculosis is a metaphor for progress in medicine, from the purely empirical into the modern scientific, and now genomic, era.




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543