It seems to have started, as many things medicinal do, with Hippocrates. We may not understand precisely why, some 2000 years ago, the great Greek physician chose to insert the bladder of a pig into a patient’s chest and then inflate this porcine balloon. But it may have had something to do with tuberculosis and with the phenomenon of “pulmonary collapse,” which has had a surprisingly long and fruitful run in the annals of medical history. The tuberculosis bacterium has long been a worthy foe to physicians and patients, hardy and defiant in the face of many unusual therapies that the medical establishment has flung at it over the past two millennia. TB was the leading cause of death in the late nineteenth century (1). This was the time of the Great White Plague, an enduring multi-century epidemic across Europe that killed millions by means of an airborne affliction to which all social classes were susceptible.
A normal x-ray of the chest. Image: Zhang zhugang. Click for source. Treatment of the infection at that time largely relied on what was considered to be the powerful curative effects of rest and relaxation, something that could be sought at sanitariums. From these high altitude sanitariums to leeching to radiation therapy, however, our attempts to control and treat tuberculosis were more or less futile until the discovery of effective antibiotics in the mid-twentieth century. The playwright George Bernard Shaw points to the desperate, creative, and desperately creative array of failed treatments for TB in his 1906 play "A Doctor’s Dilemma," where he excoriated the early 20th century medical industry's management of tuberculosis as a "a huge commercial system of quackery and poison.” But just as tuberculosis was percolating through nineteenth century Europe, the field of surgery was making enormous headway, bolstered by advances in anesthesiology and decreasing rates of mortality. As a form of medicine that is “defined by its authority to cure by means of bodily invasion,” it was surely just a matter of time before surgical intervention was applied to our struggle to a microscopic invader of the body (2). In 1891, the French surgeon Théodore Tuffier pioneered the first surgical procedure targeting tuberculosis. "Plombage thoracoplasty” consisted of excising a chunk of the fourth rib in the back, deflating the lung, and then inserting into the upper thoracic cavity a foreign, inert material, a so-called “plombe” named after the lead bullets that were initially used. The goal? To deliberately collapse and compress a lobe of lung, and with it, its nidus of festering infection. An assortment of “filler” materials were used as as the procedure gained headway, including animal fat, solid paraffin wax, bone, olive oil, silk and gauze (3). In the 1940s, smooth, unyielding lucite became the material of choice to craft these 4-cm wide spheres. “These spheres were supposed to be non-irritating to adjacent tissue, non-carcinogenic and non- antigenic, insoluble, slightly resistant to Roentgen rays, round and easily fitted into any space, lightweight to prevent erosion or migration, and able to float (in case fluid developed)(4). ” The therapy relied on the presumption that a collapse of the bacteria-ridden cavities of the lung would accelerate healing by reducing the oxygen tension in the lungs, thereby inflicting an inhospitable environment for the oxygen-loving microbe (5). Collapse of the lung also allowed for a renewed and reinvigorated attack of the immune system, resulting “in the formation of considerable connective tissue, with encapsulation of the disease focus. Within weeks, this resulted in a decrease in sputum production, a reduced number of tubercle bacilli in sputum, and a general containment of the infection (4).”
A chest x-ray of a patient with tuberculosis in 1972. Image: CDC. Just as the sanitariums allowed for a restorative respite from illness and pollution for the whole of the afflicted body, plombage therapy was a form of enforced rest for the afflicted lung. There is little data on how prevalent the operation was; however, surgery did become a mainstay of tuberculosis treatment from either plombage, lung deflation (known as pneumothorax), or simply surgical resection of a diseased lobe. One surgeon estimated that a third of patients hospitalized for tuberculosis infection in the nineteenth century received plombage therapy (4). In a 1957 article, one surgeon wrote of completing 400 operations between 1950 and 1955 (6). Within the United Kingdom, at least 450 individuals received plombage (7). What we do know is that it appeared to be moderately successful: in over 50% of patients that received collapse therapy, their sputum tested negative for the bacterium, compared to just 14% of patients confined to bed rest (8). What little is known about plombage therapy is largely due to case histories of patients seeking medical care for complications from the surgery decades after their therapy. And, as you can image, there were myriad long-term effects to filling one's lungs up with ping pong balls and bits of wax. The literature is riddled with case studies of patients presenting with major airway obstruction, organ damage, pneumonia, abscesses, and even cases of malignancy caused by long-term irritation and inflammation of the plombe. All cases are variants of the same clinical presentation: an elderly patient complaining of shortness of breath, of vague pain and of malaise. An x-ray reveals a complete surprise to the attending physician, an anomaly wildly beyond the expectations of the typical anatomical variant: dozens of balls in the thorax. The patient, upon hearing of this shocking and unexpected discovery, suddenly recalls receiving what was considered the treatment de rigueur for tuberculosis just half a century ago, one that involved the very reasonable-sounding insertion of plastic balls into one's thoracic cavity. In some patients, the plombe migrated to unwanted regions of the body to compress on vital nerves, the esophagus, vocal cords, spine, and the heart. In one 80-year old Australian patient, the plombe emigrated up and out of the chest, squeezing between the clavicles (4). He originally presented with a complaint of fever and shoulder swelling and originally reported no history of “major medical or surgical illness,” forgetting that 23 lucite balls had been placed in his left thorax to compress his left lung in 1950. Many of the spheres were broken and a few were filled with pus. The therapy apparently had done the trick though: he tested negative for tuberculosis. In the case of one American gentleman, erosions into his esophagus formed a passageway from his lung into his gut, allowing for one plombe to escape and journey through his stomach, duodenum, and finally to his jejunum (9). In 2013, a 72-year old man from Shanghai, China visited physicians with the complaint of fever and right-sided chest pain; eighteen plombe were retrieved from a pus-filled pocket of infection. He had undergone plombage in 1959 (10). By the 1950s, the surgical approach of plombage was quickly swept under the rug by the successful advent of antibiotics. Plombage therapy was eventually abandoned following the discovery of the antibiotic streptomycin in 1945, and then by isoniazid, an antibiotic that is now a pillar of tuberculosis therapy. But prior to the era of antibiotics, surgery was the go-to strategy for an incurable scourge. Though it remains an arcane and often overlooked chapter in the long history of tuberculosis, this aggressive intervention paved the way for the speciality of thoracic surgery. Images Unfortunately, many of the clinical images of patients with plombage have copyright restrictions. Please check out these sites to see some x-rays and MRIs of plombage therapy. You won't regret it. "Plombage" at Radiopaedia.org"Infection 57 Years after Plombage" at the New England Journal of Medicine"Plombage Cavities" at the New England Journal of Medicine "Lucite-Ball Plombage" at the New England Journal of MedicineResources George Orwell, author of 1984, received pulmonary collapse therapy in 1947. Read about his long battle with various respiratory diseases and tuberculosis in this article, which proposes an syndromic disease underlying his assorted illnesses. References 1) D Wlodarczyk (1999) Contagion and Confinement: Controlling tuberculosis along the Skid Road. N Engl J Med 341: 459-460 2) A Gawande (2012) Two Hundred Years of Surgery. N Engl J Med366: 1716-1723 3) HE Walkup et al. (1949) Extrapleural pneumonolysis with plombage. Am J Surg. 78: 245-50 4) S Yadav et al. (2010) Late extrusion of pulmonary plombage outside the thoracic cavity. Interact Cardiovasc Thorac Surg. 10(5) :808-10 5) MK Leonard et al. (2006) Man with syncopal episodes and abnormal chest radiograph findings. Plombage therapy. Clin Infect Dis.42(12): 1755, 1800-2 6) H Joly et al. (1957) Plombage in the surgical treatment of pulmonary tuberculosis; a study of 400 cases. J Thorac Surg. 34(1): 36-48 7) MP Shepherd (1985 Plombage in the 1980s. Thorax.40: 328-340 8) J Alexander. (1937) The collapse therapy of pulmonary tuberculosis. Springfield IL: Charles C. Thomas. 9) MD Horowitz et al. (1992) Late complications of plombage.
Ann Thorac Surg.
53(5): 803-6 10) D Xie et al. (2013) Thoracic wall abscess as a late complication of extrapleural plombage. Ann Thorac Surg. 96(4): e107
