by Gilberto Gonzalez, M.D.
Dr. Gonzalez is a retired general surgeon. He trained at Mercy Hospital in Chicago for three years, the Municipal Tuberculosis Sanitarium for one year (1961-62) and two years at the University of Iowa. He practiced in Bismarck, ND, for 31 years and retired in 1995.
What you will read is an account of my experience at the Municipal Tuberculosis Sanitarium. It is not a scientific paper, in fact, I purposely kept is as non technical as possible. I am thankful that some of you posted your experience of living so close to the “forbidden place” Now you will know what transpired inside.
The working conditions of the Municipal Tuberculosis Sanitarium eased the bad memories of a pyramidal system at Mercy hospital that had denied me a Senior Resident position, and which eventually would cost me two more years of additional training. However, looking back, I am glad it happened that way. Incidentally, the pyramidal system in surgical residencies was phased out by the 80s.
I started a residency in thoracic surgery at the Municipal Tuberculosis Sanitarium of Chicago on July 1, 1961. The Sanitarium was one of the largest in the nation and one of the largest tuberculosis hospitals in the world. It occupied a large compound of 160 acres, where 1,500 patients received treatment for tuberculosis. It was located on Pulaski, Peterson Ave. and Byrn Mawr about ten miles out of downtown Chicago, few blocks off the Lawrence exit of the newly inaugurated Eden Express Way. The Sanitarium served the public from 1915 until its closure in the early 70s.
A tall iron fence surrounded the compound, leaving only one guarded entrance. The fence was a deterrence; however, it would not have been sufficient to hold someone bound to escape, yet I do not remember to have heard of any escape attempt. I believe the patients realized that they were there for two reasons: to get adequate treatment, and through their isolation, to contribute to the fight against the spread of the disease.
The resident’s quarters were located about one block from the main hospital. A tunnel connected both buildings, and a large cafeteria, that fed hundreds of hospital personnel, was located next to the resident’s quarters. Each resident had his own room, and we all shared a common recreation room, which had a television set and ping pong table. The unmarried residents lived in campus, but those who were married stayed overnight only when being on call.
As a City of Chicago employee, the residents had the privilege of working only eight hours a day, something unthinkable on any other hospital other than a city hospital. We received a monthly salary of $300.00; a small fortune in comparison to what I made at Mercy Hospital. (My salary at Mercy Hospital was $100.00 a month with yearly increments of $50.00 a month for the subsequent three years I spent there).
All the residents donned the hospital attire in the resident’s quarters and walked the tunnel that connected it to the Sanitarium. Approaching the other end of the tunnel, each one instinctively tied the mask’s strings, for it was mandatory to wear a mask at all time while in the sanitarium. Tuberculosis spreads through airborne droplets from sneezing, coughing or talking, and since we were in direct contact with the patients, the potential for contracting the disease was real.
The operating rooms were equipped with ultra violet lights, which were on all the time. Ultraviolet light was supposed to kill the tuberculosis bacillus, and its use was a common practice in institutions such as the Sanitarium, although its value was controversial and some institutions did not use it any more. Since the operating room attire covered practically every part of our body except our eyes, we were speared a suntan.
A chest X-ray and a tuberculin skin test was a requisite for every one working at the M.T.S. As expected, I tested positive to the tuberculin skin test. (It may surprise you to know that almost 50% of the general population tested positive to the tuberculin skin test at that time). Likewise, my chest X-ray showed the same lesion that gave me problems in Laredo, Texas when I entered this country in 1954. The Chief of Surgery, Dr. Lees, and the radiologist were concerned about my chest X-ray, and for a moment, they made me feel like a patient instead of a member of the medical staff. Fortunately, I kept the X-ray taken in Monterrey in 1954, and with it, I proved that the lesion had not changed, and that was the end of it. I have already alluded to this before. See page twenty-two for more details.
Let me expand a little the significance of a positive skin test, so you have a clear understanding of what went on. If 50% of the population reacted positive to the test, it means that all of them have been exposed and infected with tuberculosis. However, only a small percentage of the exposed population developed a full-blown case of pulmonary tuberculosis. Among the group that did not developed the disease, some developed minimal symptoms while the immune system attack the bacillus and literally walls it off; leaving in the process a scar (as in my case.) While others did not develop any clinical manifestation of the disease, but the exposure to it caused them to test positive to a tuberculin test. Theoretically, 10 % of those individuals in my group may develop tuberculosis years later, and for that reason, a prophylactic treatment with isoniazid for six months to a year is indicated. However, at that time we did not follow that routine; therefore, I was not get any prophylactive treatment.
Years later, when I was 60 years old, a pulmonologist insisted that I be treated prophylactically with isoniazid; therefore, I started the treatment. Within few weeks, I developed severe side effects to isniazid; namely, painful arthritis of my elbows and hands and I had to discontinue the treatment, therefore, my condition is monitored with a yearly chest X-ray.
Contracting the disease became real to one colleague resident in surgery when his skin test converted to positive while working at the M.T.S., for that reason, he had to receive prophylactic therapy. Dr. Lees used to say that it was easier to contract the disease in the outside world, than it was to get it at the Sanitarium by saying: “Here you know everybody has it and you take precautions, outside you don’t know if the person you are talking to, or riding the bus next to has it or not.” Although he might have been right saying it, one of our colleagues had proved him wrong, and that was more than a reason never to take any chances.
Nowadays, it is hard to imagine a similar situation. Then, a suspicious chest X-ray, and the confirmation of the diagnosis of tuberculosis by laboratory means, render the patient unfit to live in the society he or she knew, and confinement to a tuberculosis sanitarium was the norm; the individual rights subordinated to the well-being of society. In addition, a blood test to rule out venereal diseases was mandatory before obtaining a marriage license in all states, now only six states continue that practice.
Could the same public health measures, adopted then, been possible in the mid 80s to control the AIDS epidemic, particularly when the origin and the treatment of the disease were unknown? Would it not have violating the right of privacy of the many? Yes! However, how many would have been spared suffering and death by its adoption? The measure would have been anathema to a social group directly affected by AIDS; however, before 1970, tuberculosis patients did not have any choice.
A positive sputum test for tuberculosis corroborated the diagnosis. In the same manner, a negative sputum test after months or years of treatment was a requisite for the discharged from the Sanitarium. It took a long time for the sputum test to convert from positive to negative, and the discharge hinged upon providing six consecutive monthly negative sputum tests. Many patients sputum test never reverted to negative and never got out. I recall a patient that had been there since 1931, which is the year I was born.
The treatment was very standardized, and it progressed from one regime to the next according to the patient’s response. The results were not spectacular, since we really did not have good drugs to treat the disease at that time, and the ones we had: streptomycin, para amimo salicylic acid, and isoniazid had unpleasant side effects. We used other drugs when the ones I mentioned were no longer effective, but they were not any better and the side effects were more serious.
If we consider that para amino salicylic acid and streptomycin were discovered in the 40s and that isoniazid was discovered in the early 50s, we realize how rudimentary the treatment of tuberculosis was in the past. Tuberculosis was the leading cause of death in the western world, and was considered incurable before isolation and therapeutic intervention took place.
By the early 60s, which is the period I am writing about, the mortality due to tuberculosis markedly diminished. The combination of case finding, isolation, the use of three drugs above mentioned, and better standard of living all contributed to the decline. Yet, tuberculosis was still around and the patient’s population of the M.T.S. proved it. Some patients developed pulmonary cavities. These patients were at a disadvantage because it was difficult for the sputum to revert to negative, since the cavity made it difficult to exterminate the bacillus and the prolonged treatment predisposed them to develope drug resistant disease. For that reason, they underwent invasive procedures whose aim was to collapse the cavity or to remove the diseased part. I will enumerate the procedures we used.
Pneumoperitoneum consisted in injecting several liters of air in the abdominal cavity. The air created an increased pressure of the abdomen, which pushed the diaphragm upward; therefore, it compressed the lung and led to the collapse of the tuberculosis cavity. It was a well-known fact that pregnant women suffering from tuberculosis experienced sometimes a favorable regression of the disease. Therefore, it was logical to think that the elevation of the diaphragm, secondary to an increased abdominal pressure by an expanding uterus, was responsible for obliterating the cavitary disease. That is why, the use of injected air into the peritoneal cavity, to mimic what pregnancy did normally became a tool to treat tuberculosis from the early 20s on. Additional elevation of the diaphragm was obtained by crushing the phrenic nerve (the nerve that supplies the diaphragm) rendering that side of the diaphragm paralyzed. The phrenic nerve is easily found in the neck, and crushing was done with a simple clamp. We monitor the elevation of the diaphragm with fluoroscopy; a devise that projects the X-ray image onto a screen in front of the patient, and we gave the patient a refill of air accordingly.
Naturally, we protected ourselves by wearing a lead apron and lead gloves while performing the procedure, and performed the procedure as quickly as possible to minimize exposing the patient to unnecessary radiation. Air injected directly into the chest cavity (pneumothorax) used in the past to collapse the lung, was no longer used when I was a resident at the Sanitarium, for its effectiveness came into question.
In 1883, Dr. H.M.Block, a surgeon in Dazing, East Prussia, now Gdansk, Poland, performed the first pulmonary resection. As one would expect, soon after he opened the chest, the atmospheric pressure not only collapse the lung he was operating on, but also put pressure on the opposite lung, and without the means to counteract the atmospheric pressure the patient’s vital signs gradually decline and the patient died.His colleagues severely criticized Dr. Block and admonished all other doctors never to repeat such a procedure. This unfortunate outcome retarded the development of chest surgery for half of century. The story has a more tragic end, for not only was the patient a relative of Dr. Block, but he committed suicide after his failed procedure. I hope that it is the only time an operation carries 200% mortality.
The first resection of the lung was performed 50 years later in 1933, when new anesthesia methods allowed the surgeon to open the chest without having to worry about ventilating the contra lateral lung. Two years before, the first lobectomy was performed, and in 1939 the first segmentectomy. As you can see, thoracic surgery evolved very late, the amazing thing is that now pulmonary surgery as well as cardiac surgery have progressed so rapidly.
When a surgical resection of the diseased lung was required, we tried to preserve as much functioning lung tissue as possible; therefore, we removed only the involved segment (segmentectomy or the entire lobe (lobectomy). Occasionally the entire lung (pneumonectomy) was removed, but that was seldom done for tuberculosis. Segmentectomy, seemingly a lesser procedure, required a more challenging technique, one that really put to test the surgical skills, although once mastered it appeared like a simple procedure.
Without attempting to give you a lesson on anatomy, I like to point some details that will help you understand the new terminology. The right lung has three lobes (upper, middle and lower lobes); each lobe is separated by a well-defined groove. Conversely, the upper and middle lobes of the left lung are fussed into one single lobe (upper lobe); the lower lobes of both lungs are for our purpose almost identical. Each lobe is divided into segments: the right upper lobe has three segments; the middle lobe has two and the lower lobes have five. The segmental anatomy of the left lung is different from the right lung, but for our purpose, there is no reason to go into more details.
Notice the groves that separate the three lobes of the right lung, and how on the left lung, the segments # 3and 4 are fussed together with # 2. The segment # 10 cannot be seen on right side side, for they are located on the other side of the lung, and on the left, segments #7 and eight are fussed into one, so there are only 8 segments.
There is nothing on the surface of the lung to reveal the boundary of each segment. The boundary is found by knowing the anatomy and feeling the plane between the segments during the operation. Therefore, it is possible to remove the diseased segment (segmentectomy) without compromising the blood supply to the remaining lung, and segmentectomy was the procedure of choice when feasible, otherwise the entire lobe (lobotomy) was removed. Segmentectomy is an operation no longer done nowadays, for its use applied only to tuberculosis patients; however, knowing the technique may become handy on the most unexpected circumstances. Occasionally, the entire lung (pneumonectomy) was removed; however, that was too radical a procedure on patients that have also disease in the remaining lung, and we avoided it as much as we could.
I do not want to mislead my readers into thinking that segmentectomy is an operation of the past. On the contrary, some institutions still use it to treat very early lung cancers; however, I question the nomenclature. Segmentectomy, the way we did it, followed anatomical planes between the segments. However if a surgeon uses a stapling devise (we did not have stapling devises at that time) to remove a portion of the lung, he or she cannot call it a segmentectomy, what he or she is doing is a wedge excision and that is different from a true segmentectomy.
Older patients, whose disease did not extend beyond the upper lobe and who might have not tolerated invasive procedures such as the one I described before, were candidates to have an operation called: Extraperiosteal Thoracoplasty with Paraffin Plombage. The name of the procedure may sound to you too technical, but in reality describes exactly what we did. We removed an inch of the third and fourth ribs, between the spine and the shoulder blade. Thorough that small window, and using the proper instruments, we dissected the periosteum (the tough membrane that covers every bone in the body), off the inner aspect of the first five ribs. This allowed us to create a space between the underlying lung and the ribs, which we filled with sterile paraffin.
At the end of the procedure, the entire space formerly occupied by the upper lobe collapsed under the paraffin pack; therefore, the cavity became obliterated. Some other institutions used Lucite balls, which were small plastic balls similar to pig pong balls, but at the Sanitarium, we always used paraffin.
Four percent of the patients who underwent segmentectomy, lobetomy or pneumonectomy for tuberculosis developed a leak at the site of the bronchial stump (where the bronchus was severed and sawn shot.) This complication, which is seldom seen on a nontuberculous patient, was a devastating event on our patients. The leak never healed, and the insertion of a rubber tube in the chest was necessary to let the air flow in and out of the chest, sometimes with a whistling sound.
When this complication occurred after a pneumonectomy, the entire chest cavity, formerly occupied by the lung, became infected and filled with pus. To correct that, the patient underwent either an open drainage (removal of a short segment of the lowermost ribs to let the infected chest cavity drain by gravity). However, that did not take care of the leak. To do so, patients underwent an extremely radical procedure called, “Conventional Thoracoplasty.” It consisted on removing the first seven or eight ribs completely, from front to back, in order to allow the entire chest wall to collapse toward the middle of the body. It was a very traumatic and deforming procedure, which we infrequently performed at the sanitarium. Conventional thoracoplasty was a last resort procedure.
Generally, the patient was already too weak due to not only the disease itself, but also the chronic infection that invariable followed a bronchial fistula. The procedure required a surgeon who could perform the operation fast, for that reason, the chief or the assistant chief performed the few conventional thoracoplasties that I witness. I never forget how Dr. Fox stripped the periosteum of a rib with a single swipe of the instrument, above and below the rib, and cut both ends of the rib with an amazing dexterity while saying, “This instruments have been here many times and they know where to go.” In some institutions, the procedure was done on two stages to minimize the trauma and stress of such radical procedure, but as I have explained before, the chief or his assistant could perform the procedure with an amazing dexterity in a short time, therefore, the one stage procedure was the procedure of choice at the Sanitarium.
About ten years after I started to work in Bismarck (1974), I saw one of the most unusual tuberculosis patients that I had ever seen. A man about 55 years of age came to my office accompanied by his wife. He was emaciated, his voice was weak and there was a peculiar odor about him―-like rotten meat. He coughed intermittently and when he did, a gurgling sound came out of his left chest. Almost apologetically, he undressed above his waist. A diaper covered a large hole on his left chest through which foul smelling secretions pour out. Removing the diaper exposed a hole the size of a clench fist on the left chest wall through which one could see his beating heart, and a leak at the site of the bronchial stump through which air escaped with a gurgling sound.
Many years before, he underwent a left pneumonectomy for pulmonary tuberculosis (removal of the left lung.) Unfortunately, he developed a leak at the site of the bronchial stump, and the chest cavity had to be drained. To do that a large segment of several of the lower ribs was removed. The procedure accomplished its aim; however, the result was a huge hole on the chest wall and a fistula that never healed.
At the M.T.S., he would have been a candidate for a conventional thoracoplasty, but no doctor had recommended any thing like that in the Sanitarium where his operation took place on. As I said before, I did not have any practical experience with this procedure, but I knew where he could get help. Therefore, I sent him to Dr. Payne, a prominent chest surgeon at the Mayo Clinic, who performed the operation successfully. After the operation, he gained weight, his fistula healed and he ceased to be a medical curiosity. He lived to an old age having the distinction of being one of the last examples of a bygone era.
Patients who underwent a surgical procedure underwent a bronchoscopy (visual inspection of the bronchial tree), to rule out tuberculosis of the bronchus, which would have contraindicated the operation. We did not have flexible fiber optic bronchoscope at that time; therefore, we used a rigid tube with a light at the end. During the bronchoscopy, the patient breathed and coughed through the tube; therefore, we protected ourselves with a clear plastic shield similar to the one used by a welder.
Dr. Lees was an artist using the rigid bronchoscope, for he could introduce the instrument in the trachea with an amazing dexterity, and do a complete inspection of the trachea and bronchus, with the speed and assurance of one that had done it thousands of times. Introducing a rigid tube into the patient’s trachea required another doctor to hold the patient’s head and neck in a position similar to that of a sword sallower when performing his act and any deviation from a perfect hold rendered the procedure more difficult if not impossible to do.
The rigid bronchoscope allowed us to inspect the inner lining of the trachea and bronchus and to inspect the takeoff of the segmental branches. To look into the segmental branches, we introduced a right angle scope through the lumen of the bronchoscope, but even that had its limitations. We used a diluted solution of cocaine to anesthetize the larynx and trachea before introducing the bronchoscope. Dr. Lees purposely did not allow the use a high concentration of cocaine, which would have made the procedure easier even for a rough operator; instead, the diluted concentration of cocaine forced us to be very gentle, otherwise, the patient started to cough, making it impossible to complete the procedure.
We performed the bronchoscopies once a week. Usually we had about twenty patients in the schedule, and since we were only four residents performing the procedure, we really mastered the technique in a short time. At the time, nobody foresaw that one day, things will be different when the flexible fiber optic bronchoscope became available, for it made the procedure infinitely easier for the patient and the doctor performing it.
Dr. Lees and Dr. Fox’s office connected to the operating room by one door. They were always aware of what was going in the operating room, and instantly available if we run into any troubles. However, one day it did not happened that way. That day, I was performing a pneumonectomy (removal of the entire lung). During this procedure, there are only three structures to take care: the bronchus, the pulmonary artery and the pulmonary vein. I had tied the pulmonary artery already and had dissected the pulmonary vein all the way around, tied it twice and severed it; but not before noticing that the tissues were not as thin and pliable as usual; probably due to a previous pleural effusion. Then I severed the bronchus and closed the stump shot, after that, I remove the lung from the chest cavity.
Suddenly, right in front of my eyes, I saw how the ligatures of the pulmonary vein started to slip off, and in no time, the chest became a deep well filling up with blood fast. This profuse bleeding can lead to rapid exsanguinations, for the pulmonary vein has the diameter of an index finger. Immediately I put a finger at the source of the bleeding and suctioned off the blood to give me an idea where to replace the clamp, I gradually made a series of maneuvers, and I was able to put a clamp on the severed vein. For a moment, the situation was under control. By that time, a nurse had summoned Dr, Lees and Dr, Fox, but they were not instantly available since they were in the dinning room at that time (one block away). As I was cleaning up after successfully sawing the end of the vein, Dr. Lees opened the door that connected his office to the operating room and calmly he asked, “Everything alright?” “Yes Sir, I said.” To which he added, “Welcome to the club.” It was my rite of passage; and one that he had already gone through.
We had a lot of responsibility in the operating room, for all the residents were not novice. We had at least three years training in general surgery (four in my case) before coming to the Sanitarium. We generally operated two patients a day except the days we performed the bronchoscopies. I do not recall any death in the operating room, and the postoperative care was excellent; the chief would have not accepted sloppy work.
One day Dr. Lees informed us that we were going to have several doctors from Mexico visiting the Sanitarium, and since I was the only Spanish-speaking resident, he asked me to take care of them. I was much surprised to see among them, Dr. Antonio Elizondo, who was my medical school professor of pulmonary diseases. After our encounter, we talked about the way we managed our patients at the Sanitarium, and among other things, I talked with Dr. Elizondo about my prospects of coming back to Monterrey to work for the Social Security System in Mexico. Dr. Elizondo was the director of one of the large Hospital of the Social Security in Monterrey, and I thought that he was in the position to offer me a place in the system. He told me to contact him before I finished my training, and I will write more about this at the proper time.
The directors of other institutions dedicated to the care of tuberculosis patients, were frequent visitors at the Municipal Tuberculosis Sanitarium, for there was a very close camaraderie among them. They came to attend a weekly conference where we discussed the patient’s history, reviewed the X-rays and proposed the treatment. The residents were in charge of collecting and presenting all the data, and responsible for carrying out the recommendations coming out of conference.
During one of those gatherings, a new patient was admitted to my ward, and the chief asked me examine her and prepare a written history and physical examination. Upon reviewing the chest X-ray film, I became suspicious that the patient might not have tuberculosis, for the lesion in question had some peculiarities that had eluded the radiologist. I had come across a similar lesion while I reviewed the X-ray collection of St. Anthony Hospital in Rockford, IL, and I believed that this patient’s problem was not tuberculosis but an arterio-venous fistula of the lung; it is to say a direct connection between an artery and a vein in a small part of the lung. Examination of the patient corroborated my diagnosis, for I was able to hear with my stethoscope, the sound of the blood rushing from a high-pressure artery, into a low-pressure vein.
It was indeed a very rare case. Many doctors go through the entire career, without seeing one, let alone diagnosing one. After examining the patient, I wrote the history and brought it to Dr. Lees. When he came to the end, and read my diagnosis, he threw the paper on his desk with disdain saying, “Nobody makes a diagnosis like that clinically,” meaning without special studies. “I did not know that.” I said, while one of the visiting doctors, more inquisitive, personally went to examine the patient. When he came back, he was shaking his head saying, “He got it.” Reviewing the collection of interesting films at the M.T.S., I found no similar case, and the radiologist and Dr. Lees had never seen one like that either. Obviously the patient did not have tuberculosis; therefore, she was discharged the same day.
I mention this particular case to illustrate how paranoid the medical community was about tuberculosis at that time. The slightest suspicious shadow on a chest Xray was sufficient to presume tuberculosis, with a predictable result: sputum testing, prolonged confinement in a tuberculosis sanitarium, intake of many drugs, uncertain response to therapy, painful surgical procedures and In my case, it almost denied my entry into this country.
On the late 60s, two new drugs came in the market that revolutionized the treatment of tuberculosis; namely, Ethambutal and Rifampin. These two drugs, in combination with isoniazid, were very effective in reverting the patient’s sputum to negative in a short time; therefore, they did not have to be treated in a hospital; instead, they received treatment at home. So successful was the new treatment that the Municipal Tuberculosis Sanitarium and similar institutions around the world closed their doors several years later.
Now, few people may remember what happened there, and tuberculosis is fading from memory at least in developed countries. However, tuberculosis disappearance may be more illusory than real. It has always been prevalent in third world countries, and it is still seen in developed countries, and its rampant return worldwide, in a more virulent form, is not only possible, but it is happening now.
With the emergence of AIDS in the mid 80s, tuberculosis became prevalent among an imuno-suppressed population; therefore, a more virulent form of tuberculosis emerged, which is resistant to the drugs available today, and a new public health hazard may be in our midst. I hope the world will be prepared to fight it aggressively, so scenes recorded in this chapter will not repeat, and that I can safely say that I was part of the last generation of doctors that saw the terrible toll that tuberculosis inflicted upon humanity. I hope also that its control extends to all parts of the world; something similar to what is happening to polio control nowadays.
Editor’s note: In the text there are references to illustrations, but unfortunately I wasn’t able to upload those images.
