1. Introduction: The Artificial Lung Collapse of Forlanini

In August 1882, a few months after Robert Koch published his groundbreaking discovery of the tuberculosis pathogen, the Italian doctor Carlo Forlanini (1847–1918) suggested an unorthodox method for defeating the deadly epidemic.Footnote ¹ Thus, the treatment method known as ‘artificial pneumothorax’ (PNX), was born. Also known as lung collapse therapy, artificial (or therapeutic) pneumothorax was unable to cure the disease completely, but it intervened in the disease process, slowing down its progression. Alongside X-ray therapy and surgical excision of tuberculosis lesions in the thorax (lobectomy), PNX was one of the most widely used treatments for pulmonary tuberculosis in the pre-antibiotic era. However, from its inception collapse therapy was highly controversial due to the frequent complications associated with its use. This professional discussion took a sinister turn in the Soviet Union under Stalin. Documents from Stalin’s personal estate reveal how uncertainties regarding the risks and side effects of artificial pneumothorax were intentionally manipulated, and illuminate how this treatment was used as an instrument of political denunciation in the 1930s.

In the mid-nineteenth century, some speculated that spontaneous pneumothorax could have a beneficial effect on the progression of tuberculosis. Such observations inspired experimentation by Forlanini, who was the first to artificially collapse the lungs for therapeutic purposes and to develop customised equipment for this purpose.Footnote ² To conduct artificial pneumothorax, filtered compressed air was pumped into the pleural space and the lungs were pressed firmly together. This allowed further progression of tuberculosis lesions to be prevented in certain circumstances.

Various hypotheses have been offered as to the causes of this favourable effect. It was believed that the temporary immobilisation of the lung and mechanical pressure permitted the draining and closure of tuberculosis cavities. Other proposed mechanisms included the reduced absorption of toxic metabolites of the pathogen and an increase in the body’s defences through the stimulation of lymphocytosis.Footnote ³ To penetrate and introduce air into the pleural space, a ‘pneumo device’ was used, which consisted of a hollow needle, hydraulic pump and pressure gauge (Figure 1).

Figure 1: Pneumo device (1920). Manufacturer: C. Stiefenhofer, Munich. Dimensions: height: 50cm (without handle), width: 35cm, depth: 13cm. Inv SO-87-335-20, Ingolstadt German Medical History Museum, photo by Michael Kowalski.

General disappointment about the failure of tuberculin as a cure for tuberculosis provided a boost to the development of Forlanini’s method at the beginning of the twentieth century.Footnote ⁴ Although PNX was associated with a high percentage of favourable outcomes (eg. substantial improvement of symptoms could often be observed within a few days of treatment), frequent complications frustrated its general acceptance. Because extensive experience and intuition were needed to determine whether a patient was indicated for PNX, Forlanini once described it as an ‘aristocratic therapy’.Footnote ⁵ During the 1910s and 1920s in Germany and the United Kingdom, most experts only recommended the so-called ‘gas chest treatment’ ‘as a last resort in apparently hopeless cases’ after all alternatives had been exhausted.Footnote ⁶

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 release from the pleura, pleural ruptures and dangerous infections would occur.Footnote ⁷ Pneumopleuritis was most feared, which, if it became septic, claimed patients’ lives.Footnote ⁸ Initially, there was no clear understanding of the frequency of pleurisy (10% to 70%, according to different observers), its cause or its prognosis. Most pulmonologists attributed pneumopleuritis to endogenous factors that could not be influenced by the clinician (eg. the tuberculosis pathogen itself). Some even reported the beneficial side effects of pleural effusions. However, other sceptics cited mechanical irritation, decreasing tissue resistance and secondary infection as complications of the therapy, stoking fears of its consequences.Footnote ⁹ As a result, use of artificial pneumothorax was widely disputed for some time.

2. The Pneumothorax Scandal

After 1917, tuberculosis (which was described by Karl Marx as ‘a living condition for capital’Footnote ¹⁰) became a heated political issue in Soviet Russia. While tuberculosis had previously been glorified as a ‘self-destructive soul fire’ and a ‘romantic disease’ by writers and artists in the early nineteenth century, by the beginning of the twentieth century it morphed across Europe into a ‘disease of the proletariat’ and scourge of the victims of exploitative capitalism.Footnote ¹¹ In Imperial Russia, the literary stereotype of political dissidents suffering from consumption emerged in this context.Footnote ¹² With the triumph of the dictatorship of the proletariat, the motif of the tuberculosis-stricken Bolshevik martyr emerged – that hollow-cheeked hero who burned up in the fire of revolution and ‘consumption’. In actual fact, many Bolshevik leaders had suffered from tuberculosis, including the ‘Knight of the Revolution’, Felix E. Dzerzhinsky (1877–1926); the ‘Storm Petrel of the Revolution’, Maxim Gorky (1868–1936) and the ‘father of Russian Marxism’, Georgi V. Plekhanov (1856–1918). ‘The proletarian disease’ was the headline of the antituberculosis pamphlet by the first People’s Commissar of Public Health, Nikolai A. Semashko (1874–1949), which was published in 1920.Footnote ¹³ His deputy, Zinovij P. Solov’ev (1876–1928), compared the struggle against tuberculosis with a battle against the White Army.Footnote ¹⁴ These heroic connotations found artistic expression 1926, when the classic film The Mother featured the actor Nikolay P. Batalov (1899–1937), who had suffered from severe tuberculosis, in the starring role of the revolutionary leader Pavel.Footnote ¹⁵

But naturally, the struggle against tuberculosis was much more than metaphorical. Tuberculosis was a common cause of death among adults during the 1920s.Footnote ¹⁶ It is hardly surprising, then, that the disease stood at the centre of the Soviet Union’s early public health programme, embedded in the bio-political project to create the New Soviet Man.Footnote ¹⁷ From the very beginning, victory over tuberculosis was an inherent part of the promise of Communism. However, as the political situation grew more tense following the abandonment of the New Economic Policy (NEP) in 1929–30, calls grew loud to eliminate the disease within two Five Year Plans. In this context, the Communist leadership strove to end the egalitarian health care policies of the 1920s and provide privileged treatment to the proletariat – and not just in the effort to battle tuberculosis.Footnote ¹⁸

Correspondingly great were the political expectations placed upon Professor Volf S. Kholtsman [Holzman] (1886–1941), who during period of political change (Stalin’s ‘Great Break’ 1929–30) became the director of the Moscow Oblast Tuberculosis Institute (MOTI). Kholtsman was a central figure among Soviet ‘phthisiatrists’ during the 1930s. Kholtsman had studied medicine at Moscow University, where he graduated in 1911. He began his medical work as a doctor of the Moscow University Clinic before moving to tuberculosis sanatorium ‘Vysokie gory’ in 1916, where he remained as a Deputy Chief Physician until 1928. The first purge at the Moscow Department of Public Health in 1928–9 was a considerable boon to Kholtsman’s career. By 1935 he was the head of both of Moscow’s large tuberculosis institutes: the MOTI and CTI (Central Tuberculosis Institute). Yet he was unable to maintain this position of ascendancy for very long – the Soviet secret police arrested him in 1939 (Figure 2).Footnote ¹⁹

Figure 2: V.S. Kholtsman, Photo, NKVD investigation file (FSB Central Archive), Source: Sakharov-Center, Martirolog rasstreljanych v Moskve I Moskovskoj oblasti, accessed 12 February 2014, http://www.sakharov-center.ru/asfcd/martirolog/?t=page&id=14879.

For decades the fate of this leading Soviet lung doctor remained unknown.Footnote ²⁰ Only with the opening and researching of Soviet archives have new sources shed light onto his death. Such sources include Stalin’s so-called ‘shooting lists’ which, after decades of strict secrecy, were published by the human rights organisation ‘Memorial’. Most recently, the Archive of the President of the Russian Federation published the ‘shooting lists’ in an updated and expanded version on the sixtieth anniversary of Stalin’s death in March 2013. Kholtsman’s name is among the several thousand individuals identified for execution in these lists, which were usually signed by Stalin personally. As revealed by other contemporary sources, including documents from the Russian State Archive of Social–Political History (RGASPI), artificial pneumothorax played a role in his tragic fate.

The response to PNX at the beginning of the 1920s in Soviet Russia was more open-minded than, for example, in Germany.Footnote ²¹ In Russia the method was applied for the first time as early as 1910 by Arkadij N. Rubel (1867–1937).Footnote ²² In 1912 he wrote the very first monograph on this issue and contributed significantly to its popularisation after the October Revolution.Footnote ²³ Kholtsman was among those lung doctors who campaigned for the widespread introduction of PNX, including double-sided lung collapse, for the treatment of tuberculosis as a standard method, and considered the complication rates acceptable.Footnote ²⁴ But precisely on this controversially discussed issue of side effects and risks, he made himself vulnerable after Stalin had proclaimed his ‘theory on the aggravation of the class struggle’ in 1929. In the same year, a young doctor named Ilja A. Slobodjanik appeared at Kholtsman’s door with a transfer order from the Moscow health authority, introducing himself as Kholtsman’s new colleague. Slobodjanik claimed to have connections. In fact, he had been able to make contacts with important party functionaries through his previous work at the Karl Liebknecht tuberculosis sanatorium near Moscow, a luxury sanatorium for Bolshevik luminaries.Footnote ²⁵ Slobodjanik seemed to perfectly embody the contemporary goals of Bolshevik social and educational policy. His rise was perhaps also abetted by the broader effort underway to identify ‘natural talents’ among working-class and farming families. Such ‘talents’, labelled vydvizhentsy (‘promotees’), were to offer a counterpoint to old specialists (specy), bringing fresh ideas and innovation.Footnote ²⁶ One of the most prominent individuals to profit from this policy of encouraging young talent was Trofim D. Lysenko (1898–1976), a representative of Michurin agrobiology who was celebrated by the Soviet press as a ‘barefoot professor’. Lysenko demonised genetics as ‘bourgeois pseudoscience’ and his rise led to a multi-decade moratorium on Soviet genetic research.Footnote ²⁷ Looking on Slobodjanik’s career it might be assumed that an attempt was made, as so often in the Soviet Union, to manufacture a hero in the public eye – only in this instance in the field of phthisiology.

Even early in his career as a sanatorium physician Slobodjanik was a lively inventor, initially focusing on household and medical appliances (eg. a furnace for the burning of infectious sputum).Footnote ²⁸ He touted supposed ‘miracle’ cures for tuberculosis, made from specially developed adonis and yarrow extracts, but was convicted of fraud and plagiarism. Although he was exposed as a plagiarist, as a hopeful vydvizhenets and unorthodox inventor he was defended by the Rabkrin (Workers’ and Peasants’ Inspectorate) and got a second chance.Footnote ²⁹ Yet once at the Tuberculosis Institute, Slobodjanik quickly became an epicentre of controversy when he claimed to have revolutionised the apparatus for administering PNX by equipping it with special oil filters.Footnote ³⁰

Ironically, this technical improvement was soon overlaid with ideological connotations. From 1930 onwards a mass public health campaign for ‘cleanliness’, labelled sanminimum (minimum sanitation), had been underway all over Soviet Russia.Footnote ³¹ In what would appear to be a blatant effort to benefit from the much celebrated ‘storm for sanminimum’ during the First Five-Year Plan, in March 1932 Slobodjanik reported on the supposed ignorance and neglect of basic sanitary standards at the Tuberculosis Institute in the newspaper Izvestija, the official Organ of the Presidium of the Supreme Soviet, in an article titled ‘Into the fight against the routine in tuberculosis therapy’.Footnote ³² Although Kholtsman considered pneumopleuritis to be an endogenous and unavoidable complication in PNX,Footnote ³³ Slobodjanik accused him of not wanting to do anything about this problem. Pneumopleuritis occurred in far more than 50% of PNX treatments, Slobodjanik claimed, of which almost half ended in septic form, which had a 50% mortality rate. The article asserted that Kholtsman concealed this risk and watched quietly as honoured Old Bolsheviks died from complications.Footnote ³⁴

Pneumopleuritis arose from the compression therapy itself, Slobodjanik argued, asserting that while the lung tissue is destroyed by a severe increase in intrapleural pressure, the pneumo apparatus acts like a bacterial dispenser, pressing airborne germs into the fresh wounds inside. Slobodjanik claimed to have analysed airborne germs in the treatment rooms of the Institute of Tuberculosis and to have found countless staphylococci and moulds. Slobodjanik claimed that by ignoring these evident facts and denying the cause of iatrogenic infection, experts in the field did not uphold the most elementary standards of asepsis. Slobodjanik maintained that his newly developed hygienic device (Figure 3), with its special bactericidal oil filter of camphor, menthol, and thymol, could kill germs and lower the pleuritis rate to just 2%.Footnote ³⁵ Riding on the wave of the ideological campaign for ‘cleanliness’, Slobodjanik apparently wanted to draw on the old conflict between the advocates and opponents of antisepsis and asepsis while stylising himself as a Russian Semmelweis – the famous ‘saviour of mothers’ from Vienna who branded all gynaecological experts as ‘murderers’ because they disputed the contagious origin of childbed fever. The fact that this association was still possible and plausible eighty years later, during the 1930s may seem surprising. To explain this, it must be mentioned that collapse therapy, which originally fell into the sphere of competence of surgeons, became the domain of ‘phthisiatrists’ in the 1920s. But this sort of physician, Slobodjanik argued, in contrast to surgeons, did not take the principles of asepsis seriously.Footnote ³⁶

Figure 3: Slobodjanik’s pneumo device (1932). Pnevmoapparat d-ra I.A. Slobodjanika. Izdanie vsesojuznogo ob” edinenija točnoj industrii. Moscow 1932.

What began as a technical debate with political accusations in 1932 led to the veritable political destruction of the renowned Institute Director by 1935. Alexander S. Serafimovich (1863–1949), a ‘classic’ writer of socialist realism during his lifetime, added new momentum to the debate. The subject of tuberculosis was a personal one for Serafimovich. After he was implicated, along with Lenin’s brother Alexander, in an assassination attempt against the Tsar in 1887, he was sent into exile and became ill with tuberculosis. In his article ‘A crime of the physician’ published in the newspaper Pravda, Serafimovich attacked Professor Kholtsman as a former Menshevik party member who systematically covered up fatal medical errors.Footnote ³⁷

The timing was catastrophic: in the summer of 1935, the three-act drama Platon Krechet written by famous Soviet dramatist Alexander E. Korneychuk (1905–72) hit the stages of the Soviet Union. The piece was about the struggle of a talented young surgeon named Krechet against bureaucracy and hypocrisy in medicine, embodied by the clinic Director Arkadij, who hid his true face behind politically convenient rhetoric about the ‘dialectical method of tuberculosis healing’. Meanwhile, he sent innumerable patients home, deeming them incurable, instead of fighting to the very last for their health.Footnote ³⁸ On 13 June 1935, after a successful performance of the play at the Gorky Moscow Art Theatre (MChAt), a review of the play in Pravda tersely said: ‘These people must be unmasked and relentlessly beaten’.Footnote ³⁹ In the same issue, Pravda reported extensively on the alleged crimes of Kholtsman.Footnote ⁴⁰

A document from Stalin’s private estate held at the Russian State Archive of Socio-Political History (RGASPI) shows that the campaign against Kholtsman was approved by the highest authority. Serafimovich addressed a personal letter to Stalin on 16 May 1935, before he sent his denunciatory article to the newspaper.Footnote ⁴¹ In it, he vilified in drastic words the clique of ‘Kholtsmanists’, whose tentacles even reached to the ‘opportunist’ Nikolai I. Bukharin (1888–1938).Footnote ⁴² Honourable comrades, he stated, were continuously mistreated at the Institute of Tuberculosis or sent home to die. They all would have died, Serafimovich asserted, without Slobodjanik’s intervention at the last minute:

Serafimovich’s request was obviously granted, although his Pravda article used less acerbic language than his letter.Footnote ⁴⁴ In summer 1935 there was supposedly political interest in continuing this public debate. Kholtsman was granted a chance to respond to Serafimovich’s attacks in the same newspaper. The ‘phthisiatrist’ published a comprehensive rebuttal, half of which discussed the aetiology and pathogenesis of pneumopleuritis. Overloaded with specialist terminology, the article was incomprehensible to lay readers. Kholtsman denied the high PNX complication rates cited by SlobodjanikFootnote ⁴⁵ and claimed that his opponents would be responsible for the negative consequences to public health resulting from this professional debate being carried out in newspapers. Indeed, tens of thousands of frightened tuberculosis patients lost confidence in the medicine and PNX, and thus avoided receiving beneficial treatment.Footnote ⁴⁶

Yet Kholtsman underestimated the extent to which a general mistrust of medicine had become prevalent. Serafimovič had stated that Slobodjanik’s main contribution lay in ‘shaking the confidence placed in doctors’. He didn’t just portray him as a selfless fighter for the sanminimum, but also as someone who encouraged patients to mistrust doctors and to demand that they wash their hands. In this way, he was advocate of a radical reversal in the traditional doctor–patient relationship.Footnote ⁴⁷ Accordingly, the main target of the writer was ‘the horrible principle of “medical confidentiality”, of the “medical ethics” that previously prevailed among bourgeois doctors and still holds sway abroad today, a “medical ethics” that turns the doctor into a sorcerer’.Footnote ⁴⁸

The deeper meaning of this rhetoric first becomes clear within the context of the tensions that prevailed in the field of medicine in the early Soviet Union. After the October revolution, the doctor, like the priest, was often portrayed as a representative of the bourgeois milieu or, alternatively, as an agent of the czar’s political apparatus of oppression. Accordingly, a logical extension of the overthrow of the state was to usher in a revolution in the field of medicine. In the mid-1920s there were mass protests against the medical profession, and doctors were even assaulted and murdered.Footnote ⁴⁹ Collective resentment against ‘medical augurs’ led to the demand, that ‘Soviet doctors perform their work transparently under the glass bell jar of the worker and farmer movement’.Footnote ⁵⁰ After the ‘great upheaval’, uncontrolled violence ‘from below’ against medical professionals declined sharply. Yet ‘from above’ the field of medicine was declared a sphere of activity in which the threat of sabotage was particularly high.Footnote ⁵¹ During the Stalinist purges of the 1930s and again in 1952–3, the doctor was portrayed as a perfidious ‘mixer of poisons’ who sought to murder the New Soviet Man.Footnote ⁵²

In 1935–6 there was a pause in the Stalinist terror. Kholtsman was left temporarily in his position as Director of the CTI. Yet after 1936, the campaign to generate resentment towards doctors continued. Allegations peaked during the show trial against the so-called ‘Bloc of Rightists and Trotskyites’ in March 1938, as several Kremlin physicians were accused of having insidiously eliminated reliable party members. Lev G. Levin (1870–1938), head physician of a Sanitary-Clinical Department of the Kremlin – responsible for health care for political elites – had supposedly ‘collaborated’ with the renowned professor Dmitri D. Pletnev (1871–1941) at the behest of the ‘traitor’ Genrikh G. Yagoda (1891–1938) in order to assassinate old Bolsheviks. Difficult heart or lung conditions that led to the death of the patient were thus ‘exposed’ as incidents of ‘slow murder’, as treatment methods known to be improper had ostensibly been used. At the show trail, the public learned a number of disturbing facts: not sickness, but mistreatment at the hands of perfidious ‘mixers of poison in white smocks’ had led to the untimely death of a number of prominent figures, including OGPU head Vyacheslav R. Menzhinsky (10 May 1934), the chairman of the Government Supervisory Commission Valerian V. Kuybyshev (25 January 1935), and the great proletariat writer Maxim Gorky (18 June 1936).Footnote ⁵³ Entire newspaper pages were devoted to the publication of collective letters of protest and resolutions, all of which made similar calls, including ‘No pardon for murderous doctors’, ‘Fascist dogs up against the wall’, and ‘Die you beasts!’Footnote ⁵⁴ In his poem ‘Death to the Traitors’, the rising propaganda poet Sergey A. Vasiljev (1911–75) showcases a flair of demagogy in describing his impressions of the courtroom:

In his indictment, which called for special vigilance in dealing with physicians, chief prosecutor Andrey J. Vyshinsky (1883–1954) warned that:

A feverish search for other, as yet undiscovered ‘murderers in white coats’ began, until finally it was Professor Kholtsman’s turn. On 4 June 1939, he was arrested as a spy, accused for providing secret data about the health care of the Red Army to the German intelligence service. On 30 July 1941, he was executed. A direct connection to the case against the ‘Right-Trotskyist bloc’ was constructed in a memorandum that has survived along with the shooting list of 6 September 1940. According to it, Kholtsman allegedly murdered prominent pulmonary patients on behalf of the Kremlin doctor, Lev G. Levin, who had already been executed.Footnote ⁵⁷ Stalin’s private secretary Ivan P. Tovstucha (1889–1935) was one of Kholtsman’s alleged victims. In a historical irony, Tovstucha was one of Stalin’s most faithful paladins, and was entrusted with compiling Stalin’s shooting lists.Footnote ⁵⁸