Wednesday, January 27, 2016

Chest CT Mystery Solved: Plombage Treatment for Consumptives

Before the advent of antibiotics, TB was treated by isolating the patient  consumptive from the rest of society in sanitariums.  Almost every county in the country had a sanitarium where the treatment consisted primarily of rest and relaxation. Despite the resources invested in sanitariums, they were certainly not curative. A cure would have to wait until the mid 1940s when streptomycin was discovered. It always made me realize the limits of hospitals when the cure to the problem came from outside the sanitariums.

There was even a surgical procedure to relax the lungs called "plombage." The rationale for this procedure was to force rest on a lung infected with TB. To facilitate this, the chest was opened and a lung was collapsed by packing the chest with wax, olive oil, or small Lucite balls. The CT scan in the previous post shows a chest cavity packed with Lucite balls which are actually about 2/3rds the diameter of a ping pong ball. Lucite was thought to be a good space occupying material as it was inert and light weight. I was never involved in the initiation of this procedure, but did many cases where the Lucite balls or paraffin wax packing  was removed from a chest. It seemed like our hospital was the Cook County Center of Excellence for plombage packing removal-we did a lot of them.  The last of the plombage procedure was done in the late 1940's so I doubt anyone is walking around with Lucite balls or wax packed in their chest today.

Before the start of a thoracotomy to remove the plombage packing, Dr. Particular, our chest surgeon  always asked the scrub nurse to autoclave a tablespoon with the rest of chest  instruments. The concave surface of a tablespoon perfectly mated with the curvature of the Lucite plastic balls. After residing in someone's chest, these balls were very slippery and difficult to get a handle on. Dr. Particular could quickly coral them with his tablespoon technique.  He would slide the tablespoon under the ball and stabilize it with his index finger and yank it out. The tablespoons could also be used to dig out the paraffin wax that was also used as packing. I saw one case in which both wax and Lucite balls were used. I guess this further proves the old adage that when there is more than one treatment for a problem-none of them are effective.

Plombage balls looking somewhat worse for the wear after removal from some poor soul's chest cavity. Paraffin was also used as chest packing and it always reminded me of scooping ice cream when it was removed with a tablespoon.

The theory behind plombage was that resting an infected lobe of the lung would be curative. Dr. Particular always said this theory was not true, but collapsing the lung tissue and depriving it of oxygen might have been helpful because the tubercle bacillus was aerobic. Dr. Particular always seemed sympathetic to the patients that had plombage because he always bellowed out during the removal part of the surgery, "finally we are being of service to this patient."

After surviving the initial plombage procedure without hemorrhage or infection, patients faced long term risks. The most common long term complication was fistualization involving bronchus, esophagus or migration to the skin.

Usually when a surgeon asks his scrub nurse to autoclave an unusual or eclectic item, the prognosis is not great. I think I might have mentioned this in a previous post "What's the Prognosis Doc?" I have been asked by surgeons to autoclave buttons, paper clips, toothpicks, and even an automotive drum brake adjusting tool. Happily, the plombage patients usually did very well after having the space occupying material removed from their chest. It always felt good when you fixed something or corrected a problem.

I wonder what current treatments will seem crude and even barbaric in the future. Maybe with the advances in immunotherapy, toxic chemotherapy will look primitive. The current treatment of mental illness is not really curative. Some of the psychotropics are akin to weeding a garden with a hand grenade, but that's another story.

Congratulations to OldDoc who correctly figured out the chest CT mystery. Thanks to all of you for reading my ramblings and I appreciate the privilege of sharing your time with my foolishness.


  1. Congratulations, OldDoc! Very cool stories ~ I'm still waiting the the invention of the Tricorder analyzers ala Star Wars (the original series)

  2. Once again, you have led me down memory lane. I never saw or heard of plombage, but I have autoclaved a tablespoon to remove another kind of packing, or rather impaction. Do they ever disimpact in the OR these days? I doubt it.

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