Carlo Forlanini

Carlo Forlanini was born in Milan on 11 June 1847, and was the eldest of four brothers and one sister.[2]

His father, Giuseppe Forlanini, was a physician, his mother died of pulmonary phthisis.

He was initially undecided whether to start a career in engineering or medicine but finally decided on the latter.

After high school studies, Forlanini enrolled in the medical faculty of the University of Pavia in 1864 as a pupil of the Borromeo College.[3] His medical studies at Pavia were temporarily interrupted in 1866 when he volunteered to serve under Garibaldi, in the battles of Monte Suello and Bezzecca. Back in Pavia he published his first scientific work in 1868 and linked himself to a fraternal friendship with Giulio Bizzozero and Camillo Golgi (1843-1926), who was later to achieve eminence as a histologist and received the Nobel Prize in 1906.

In 1870 he graduated in medicine under the guidance of the ophthalmologist Antonio Quaglino with a thesis about “Contribuzione alla teoria della Piogenesi”. After qualification, Forlanini was at first attracted towards the specialty of ophthalmology and in 1871 published a paper on inflammation of the lens, "Studio sperimentale sulla inflammazione del cristallino." In the same year he moved bak to Milan, where he worked in the Ospedale Maggiore for the next 13 years.[4] He worked in the departments of chronic diseases, eye diseases, and skin diseases, becoming the head of the skin department in 1881; but his interest in general medicine and especially in diseases of the lungs and tuberculosis remained his priority. During these years he started to conceive devices that could increase lung ventilation, helped by his younger brother, Enrico, a gifted engineer who was one of the pioneers of air flight.[5]

In 1875, Carlo Forlanini, founded the Pneumotherapy Society and with the help of his brother he founded also the Pneumatic Insitute of Milan and, from 1881, he was also chief physician for skin diseases. He later became assistant professor and chief physician to the medical wards, which included beds for tuberculous patients.

Meanwhile, he began a series of attempts to treat tuberculosis and lung diseases with forced respiratory movements and with aerotherapy to increase blood flow and air supply to the lung. With the scientific collaboration of his brother Enrico, he would also build some of the first hyperbaric chambers.

He observed some positive results in the treatment of pulmonary emphysema and also some mild improvement in phthisis. Soon, however, Forlanini began to develop opposite therapeutic considerations for pulmonary tuberculosis. It was not the respiratory act of advantage to the sick lung, but rest.[6]  

In 1882 he created the first artificial inter pleural pneumothorax by collapsing the lung and filling the pleural cavity with Nitrogen.[7]

In 1884 Forlanini began his university career at the University of Turin and obtained the position of “extraordinarius” professor of “Clinica medica preparatoria” (preparatory medical clinic). Soon he became full professor of special medical pathology.

He remained in Turin until 1889, then he returned to Pavia, first on a provisional teaching of special medical demonstrative pathology and, from 1900, at the age of 53, he obtained the chair of clinical medicine at Pavia.

Forlanini had a passion for teaching and prepared his lectures meticulously, making him a popular teacher. Among his students there were Umberto Carpi, Eugenio Morelli, and Scipione Riva-Rocci. Carpi and Morelli were later to make important contributions to the collapse therapy of pulmonary tuberculosis,[7] while Riva-Rocci achieved fame when he introduced the first practical sphygmomanometer in 1896.

Meanwhile, Forlanini made his operation practicing artificial pneumothorax. Presenting it with a report held on 2 April 1894[8] at the eleventh international medical congress of Rome and, the following year, with a lecture at the italian congress of internal medicine. However, the reaction by the medical community was not extremely positive and artificial pneumothorax found oppositions and objections.

Anyway, year by year Forlanini improved and promoted his method and, on April 1912, he held a famous lecture in Rome entitled “Artificial pneumothorax in the treatment of pulmonary phthisis” at the seventh international congress on tubercolosis. The presentation obtained a great ovation and, after thirty years of studies on pneumothorax, he finally obtained full international recognition.[9]

Forlanini had an attractive personality, was a good conversationalist, and was cultured in music and art. He was very much the beloved physician to his hospital patients and was content to pursue his researches without desire for personal aggrandisement.

In 1913 he was nominated senator of the kingdom member of the council of public education.[10][11]

His friend and fellow professor at the University of Pavia, Camillo Golgi (Nobel Prize winner for 1906), proposed him three times for the Nobel Prize with the motivation that the invention of pneumothorax was “of great benefit to humanity”. However, the Nobel Prize was not awarded in the years of the First World War between 1915 and 1918, and in this last year Forlanini died.

During the years of the First World his health gradually declined: Forlanini suffered from severe attacks of migraine, but his terminal illness was due to an abdominal malignancy, probably carcinoma of the pancreas. He died at Nervi, on the Ligurian Riviera, in his 71st year on 25 May 1918.

Today the "Carlo Forlanini Institute" in Rome, founded in 1934, is named in his honor.[12]

From the early stages of his career, Forlanini’s interest in tuberculosis has been a recurring factor in his professional and academic life, leading him to the invention of the artificial pneumothorax.

The idea that a pneumothorax might have been useful in treating phthisis pulmonalis was first proposed in 1771 by French librarian Edmong Claud Bourru, who at the time was working on a French translation of Gilchrist’s work “The Use of Sea Voyages in Medicine, Particularly in a Consumption and Observations on that Disease”.

It was, however, only fifty years later (in 1822) that British physician James Carson started conducting experiments on rabbits to study the impact and potential applications of the pneumothorax on rabbit activities. Despite the risk of complete collapse of the diseased lung, Carson thought the attempt at producing an artificial pneumothorax in humans was justified due to the disease’s death rate and how widespread it was. However, after a failed attempt at reproducing the experiment in a human subject the idea of collapsed therapy was abandoned and it would only resurface several years later.[13]

When Forlanini first started exploring the idea of using an artificial pneumothorax as a treatment for tuberculosis, he wasn’t aware of Carson’s experiments (his work remained unnoticed until 1909). His interest in the study of pulmonary diseases developed while he was working as a newly graduated medical student in the chronically ill division of the ospedale maggiore in Milan. During this years, he started to conceive devices with the objective to increase lung ventilation in people suffering from phthisis pulmonalis. In his effort to build said device, he was aided by his brother Enrico Forlanini (a skilled engineer and one of the pioneers of air flight). [14]

With the assistance of his brother, Carlo Forlanini designed and constructed a simple device capable of administering gases intrapleurally. The presence of gas in the intrapleural fluid caused the lung to collapse, therefore creating an artificial pneumothorax. After having built the device, Forlanini tried treating two cases of phthisis by inducing a pneumothorax in the two patients and obtained positive results.

The device used in the treatment, later referred to as “pneumo device”, consisted of a hollow needle, a hydraulic pump and a pressure gauge, as well as two nitrogen reservoirs. [15][2]

During his experiments, Forlanini noticed that the pleura bears the presence of air quite well, however oxygen was absorbed more quickly than other gases. This prompted him to use nitrogen, which had to be administered everyday in small quantities (if the gas was absorbed too quickly, the dose had to be increased). As the absorptive capacity of the pleura lessens over time, the interval between the injections could be lengthened after a few months.

In the year following his experiments (1895) Forlanini reported the successful outcome of his artificial pneumothorax in the journal “Gazzetta Medica di Torino”. However, the full report on his experiments and the extent of his research only came in 1906 (report based on 25 cases).

After 1895, Forlanini’s findings were mostly met with indifference in the Italian medical community (in some cases Italian physicians proved to be hostile towards the new technique). Despite this, Forlanini persevered in his research and perfected the artificial pneumothorax, granting him an even deeper understanding of the procedure itself. This allowed him to present an authoritative report on his artificial pneumothorax during the Seventh International Tuberculosis Congress in Rome (in 1912), for which he received great praise.

After 1912 Forlanini’s technique for artificial pneumothorax started spreading all over Europe and the United States, prompting many other physicians to adopt this technique.

Over the years, Forlanini’s technique was further developed and improved, therefore increasing the success rate of the procedure.

From 1912 to 1919, Forlanini was nominated at least 20 times for the Nobel Prize; all of his nominators were Italian professors of medicine.[16] They put forward several arguments to try to convince the prize jury why Forlanini should be seen as “the person who shall have made the most important discovery within the domain of physiology or medicine”.[16] Three of the nominations for Forlanini were submitted by his close friend Camillo Golgi (1843 to 1926) from Pavia, who, as a former Nobel Laureate (1906) had the right to propose a candidate each year (NA, yearbooks of 1912, 1917, 1919), he nominated Forlanini because he was convinced that the invention of pneumothorax was a turning point in the fight against tuberculosis .

Because at least some members of the Nobel committee saw great potential in PNX, Forlanini was viewed as one of the prime Nobel Prize candidates during 1913 and 1914.[17] But as a matter of facts, he never received the Prize. The prize Jury voted in favor of other candidates because they judged the PNX method neither original nor brilliant enough to warrant a Nobel Prize anche associated it with high risks for the patiences.

When Forlanini died in 1918, his many pupils and admirers, both Italian and foreign, wished to create a suitable living memorial to the master. A research fund for the study of tuberculosis was founded in his name shortly after his death.[18] Chiefly through the inspiration of his favorite pupil, Eugenio Morelli (1881-1968), the Carlo Forlanini Institute in Rome was founded in 1934. Morelli was the first director (1934-1945) and he was succeeded by his pupil Attilio Omedei- Zonini (1945–68), who was followed by a series of distinguished Italian physiologists.

The Hospital was used as a sanatorium, specifically opened for all those who suffered from tuberculosis. The building is in the middle of a 280,000 sq.m park because, before the discovery of anti-TB drugs with bactericidal and bacteriostatic activity, TB was treated with the rest in a hygienic and well ventilated place.[19] In order to contain the costs of health care, the company hospital S. Camillo-Forlanini decided to close the hospital Forlanini within December 31, 2008 and to transfer its assets and services to the S. Camillo.

In 2015 the hospital was closed definitely, its pneumatology departments  were merged with the San Camillo ones, while its thoracic surgery wards were included in the Spallanzani hospital. Nowadays “Carlo Forlanini Hospital” is located  in Piazza Carlo Forlanini 1 and it is part of the hospital organization San Camillo-Forlanini-Spallanzani.

• L'aeroterapia, Milano : Stab. Tip. Della Casa Edit. Dott. Francesco Vallardi, 1881 – Aerotherapy.
• La tecnica delle inalazioni medicamentose, Milano, Vallardi, 1883 – The technique of medicinal inhalation.
• Nuovi apparati pneumatici trasportabili, Milano : Dott. Leonardo Vallardi Edit., 1889 – A new transportable pneumatic apparatus.
• Storia di un caso di tisi polmonare curato colle iniezioni parenchimatose, Milano : L. Vallardi, 1889 – History of a case of pulmonary tuberculosis cured via parenchymatous injections.
• La cura della tisi polmonare col pneumotorace prodotto artificialmente, Pavia : Successori Marelli, 1907 – The cure of pulmonary tuberculosis using artificial pneumothorax.[20]
• 1875 Brevissimi cenni di aeroterapia e sullo Stabilimento Medico-pneumatica di Milano. Gazzetta Medica Italiana Lombardia. Serie VII: 6
• 1882 A contribuzione della terapia chirurgica nella tisi del polmone. Ablazione del polmone? Pneumotorace artificiale? Gazzetta degli Ospedale e della Cliniche di Milano
• 1894 Primi tentativi di pneumotorace artificiale della tisi pulmonare. Gazzetta Medica di Torino. 45:381-4, 401-3
• 1894 Su un caso di stenosi dell'arteria polmonare con persistenza del dotto di Botallo e di tisi polmonare
• 1895 Primo caso di tisi pulmonare monolaterale avanzata curato felicemente col pneumotorace artificiale. Gazzetta Medica di Torino 46:857
• 1897 Contributo allo studio del polso venoso presistolico
• 1897 Contributo alla terapia dell'empiema
• 1906 Zur Behandlung der Lungenschwindsucht durch künstlich erzeugten Pneumothorax. Deutsche Medizinishe Wochenschrift 32:1401-5
• 1908 Apparati e tecnica operativa dello pneumotorace artificiale
• 1909 Cenni storici e critici sul pneumotorace artificiale nella tisi pulmonare. In: Cappelli, ed. Scritti di Forlanini. Bologna, 1928:1013
• 1912 Il pneumotorace artificiale nella cura della tisi pulmonare. Atti de VII Congresso Internazionale Contra la Tubercolosi. Vol 3 Rome, 182.

• Armocida E , Martini M., Tuberculosis: a Timeless Challenge for Medicine, Journal of preventive medicine and Hygiene, 2020
• EDITORIAL, Carlo Forlanini — 1847–1918 In commemoration of the 100th anniversary of his birth, Chest Journal vol 14, 1948
• Frith J., History of Tuberculosis. Part 2 - the Sanatoria and the Discoveries of the Tubercle Bacillus, Journal of Military and Veterans’ Health, 2014
• Garbarino, M.C.; Cani, V.; Mazzarello, P. A century ago: Carlo Forlanini and the first successful treatment of tuberculosis. Lancet 11 August 2018
• Gerardo M., Balboni M.D., Forlanini’s artificial pneumothorax. A Study, Boston Medical and Surgical Journal, 1914
• Hansson, N.; Polianski, I.J. Therapeutic pneumothorax and the Nobel Prize. Ann. Thorac. Surg. 2015
• Loiacono S., Forlanini's original communication on artificial pneumothorax, Tubercle, 1934
• Martini M., Besozzi G, Barberis I, The never-ending story of the fight against tuberculosis: from Koch's bacillus to global control programs, Journal of preventive medicine and Hygiene, 2018
• Martini M., Gazzaniga V., Behzadifar M., Bragazzi N.L., Barberis I., The history of tuberculosis: the social role of sanatoria for the treatment of tuberculosis in Italy between the end of the 19th century and the middle of the 20th, Journal of preventive medicine and Hygiene, 2018
• Mazzarello, P., A Physical Cure for Tuberculosis: Carlo Forlanini and the Invention of Therapeutic Pneumothorax, Applied Sciences, 2020
• Papagiannis, A.; Lazaridis, G.; Zarogoulidis, K.; Papaiwannou, A.; Karavergou, A.; Lampaki, S.; Baka, S.; Mpoukovinas, I.; Karavasilis, V.; Kioumis, I.; et al. Pneumothorax: An up to date “Introduction”. Ann. Transl. Med. 2015
• Sakula, A. Carlo Forlanini, inventor of artificial pneumothorax for treatment of pulmonary tuberculosis. Thorax 1983
• Venanzetti M., Storia dell’ospedale San Camillo-Forlanini, in Salute e società-L’ospedale San Camillo-Forlanini: prospettive, opportunità, Anno XII - n. 2/2014, FrancoAngeli, Milano, 2014

Wikimedia Commons has media related to Carlo Forlanini.

• San Camillo-Forlanini-Spallanzani - Archivio Storico Portuense 2.0
• FORLANINI, Carlo in Dizionario Biografico
• Forlanini, Carlo in Pavia University History Museum website
• Forlanini, Carlo in Torino scienza website
• Mainardi G., Personaggi della Scienza, Carlo Forlanini in Pavia e dintorni website
• Discussioni del Senato del Regno, Indice Alfabetico ed Analitico, Atti Parlamentari Senato della Repubblica 1918-1919
• Senato della Repubblica, Scheda dell’Attività Parlamentare del Sen. Carlo Forlanini, 1913–18