**4. Disputes and Di**ff**usion**

A bad surprise caught Forlanini when, in 1906, he read an article by Ludolph Brauer of Marburg, published in an authoritative German journal, in which the invention of the method was attributed to the important American surgeon John Benjamin Murphy [25]. The latter had developed a version of the operation, presumably without knowing the work of the Italian, and had described it in 1898 at the meeting of the American Medical Association [26–28]. Murphy was the first to adopt the new x-ray technology (Wilhelm Roentgen had discovered x-ray in 1895) to control pneumothorax therapy results. Forlanini immediately reacted to Brauer's article and published in another authoritative German journal the results obtained by him in 25 cases of pulmonary tuberculosis, also to claim the priority of the invention [29]. Moreover he criticized Murphy's treatment modalities, as they involved an incision of the skin and the chest muscles (and not a single puncture as he did) and again the large amount of nitrogen introduced (1000–3000 mL) by the American surgeon, which led to excessive compression of the lung. Forlanini's article contributed to the diffusion of his invention in the German medical

world and therefore in transalpine Europe. From this moment on, Forlanini promoted the method, also with conferences for doctors. In 1906–1907, there was a technological development that made the apparatus more applicable, when Christian Saugman, of the Vejlefjord sanatorium in Denmark, perfected it by inserting in the pneumothorax instrument a water pressure monitor, which allowed a precise control of the gas introduced. Moreover, in 1912, Maurizio Ascoli proposed a partial collapse therapy that allowed a bilateral pneumothorax to treat cases of involvement of the two lungs in the pathological process.

On April 1912, Forlanini held a memorable lecture in Rome entitled "Artificial pneumothorax in the treatment of pulmonary phthisis", at the seventh international congress on tuberculosis [30]. The presentation obtained a great ovation and, after thirty years of studies on pneumothorax, Forlanini at last obtained full international recognition.

In England, the method was not used before 1911; subsequently, it achieved considerable success. In 1917, the doctor Clive Riviere wrote in his textbook "The pneumothorax treatment of pulmonary tuberculosis": "No more hopeful ray of sunshine has ever come to illuminate the dark kingdoms of disease than that introduced into the path of the consumptive through the discovery of artificial pneumothorax" [31]. Riviere confirmed this judgment ten years later in the "British Journal of Tuberculosis" [32]. Other British doctors expressed an overall positive opinion on the treatment [33–47], which was also applied to children [48]. Its level of popularization is also demonstrated by the fact that one of the important episodes in the novel "The Citadel" (1937) by the Scottish writer Archibald Joseph Cronin concerns precisely the description of an artificial pneumothorax operation. However, the spread of the method, after 1912, reached all European countries and, with some delay, also the United States. In Imperial Russia, the therapeutic pneumothorax was already used in 1910 by Arkadij N. Rubel who, two years later, published the first monograph on the topic, contributing to its knowledge in the country [18,49]. In the 1930s, in Stalinist Russia, the application of this method took on political connotations. The treatment was considered an "aristocratic therapy", therefore counter-revolutionary, and in the end the pneumothorax device was attacked by propaganda as a "killing machine". One of the leading Russian physicians advocating pneumothorax therapy, Volf S. Kholtsman, director of the Moscow Oblast Tuberculosis Institute, was arrested in 1939 during the Stalinist purges and then executed two years later.
