Emergencies and acute diseases in the collected works of Hippocrates: observation, examination, prognosis, therapy.

The collected works οf Hippocrates include a wealth of references to emergencies and acute conditions; if the physician could treat these, he would be considered superior to his colleagues. Works most relevant to current Emergency Medicine are presented. They indicate Hippocrates' remarkable insight and attention to the value of close observation, meticulous clinical examination, and prognosis. Hippocrates and his followers disdained mystery and were not satisfied until they had discovered a rational cause to diseases. They assigned great significance to distressing signs and symptoms - the famous Hippocratic face, the breathing pattern, pain, seizures, opisthotonus - pointing to a fatal outcome, which they reported to their patient. The principles of treatment of emergencies, such as angina, haemorrhage, empyema, ileus, shoulder dislocations and head injuries, are astonishingly similar to the ones used nowadays.

Evarts Ambrose Graham (1883-1957), doyen of pulmonary surgeons.

Evarts Graham performed the first successful pneumonectomy in 1933. Evarts Ambrose Graham, the son of a Scotch Irish surgeon, was born on 19 March 1883. After early schooling in Chicago, he graduated at Princeton and returned to Chicago to study Medicine, taking his MD at Rush Medical College in 1907. The chemical aspects of pathological changes then occupied him fully until 1919, when he was appointed full-time professor of surgery at the Washington School of Medicine in St Louis. Visualisation of gallstones temporarily took his attention, but bronchogenic carcinoma was seldom far from his thoughts, and he recognised (too late to save himself) the causative association with cigarette smoking by 1950. He died on 4 March 1957.

Taming an old enemy: a profile of intracranial suppuration.

Intracranial suppurative disorders (ICSDs; brain abscess, empyema, and purulent ventriculitis), have been a scourge through the ages and attempts at curative surgery, as for cranial trauma, are considered to be one of the first true neurosurgical interventions performed. ICSDs, seen initially as a consequence of poor socioeconomic conditions and neglected otorhinogenic infections, predominantly manifest today as postsurgical complications, and/or in immunocompromised patients where they continue to result in significant neurologic morbidity and death. The reduction in the incidence of "old world" classic ICSDs can be attributed to the modernization of society, driven inter alia by a shift from an agricultural to an industrial economic society. It can also be coupled with pivotal achievements in public health and the dramatic developments in medicine in the 20th century. This trend was first noted in developed countries but now, with improved socioeconomic circumstances and globalization of medical technology, it is occurring in the developing regions of the world as well. Although ICSDs have undergone a metamorphosis in their clinical profile and despite their rarity in contemporary "developed world" neurosurgical practice, they still have undoubted potential for fatal consequences and continue to pose a significant challenge to the 21st-century neurosurgeon.

[Evarts A. Graham (1883-1957)--biography and medical achievements. His input into the knowledge of carcinogenic actions of tobacco]. / Evarts A. Graham (1883-1957)--biografia i osiagniecia medyczne. Wklad do wiedzy o rakotwórczym dzialaniu tytoniu.

Evarts Ambrose Graham (1883-1957) was one of the most prominent American surgeons of the 20th century. Some believe that he belonged, together with William Halsted and Harvey Cushing, to the three most respected American surgeons. Graham was mainly dedicated to thoraco-surgery. He proposed a new treatment for empyema of the chest, based on the physiological understanding of pleural mechanics. He introduced the cholecystography method for the visualization of gall bladder and performed the first total one-stage pneumonectomy. Moreover, he was actively engaged in the studies of carcinogenic influence of tobacco and an association between tobacco smoking and lung carcinoma.

Changing patterns of disease in Papua New Guinea over a period of 40 years from 1962. Pathology encountered in a stoneage culture by the first western-trained doctors who entered the country.

The diseases observed in Papua New Guinea coastal and highland people were described: segmental enteritis necroticans caused by the ingestion of pig meat contaminated with Clostridium welchii type C; chest empyemas caused by thoracostomies performed by village doctors because of ancient superstition; traumatic injuries; primary and secondary (lepromatous leprosy or tuberculosis) amylosis; slow prominent atherosclerosis and myocardial infarction.

Evarts Ambrose Graham, empyema, and the dawn of clinical understanding of negative intrapleural pressure.

The concept of negative intrapleural pressure is fairly new. Although the phenomenon had already been described, Wirz provided the first definitive analysis of its significance to the mechanics of breathing in 1923. By contrast, empyema has been known since antiquity; from the time of Hippocrates, treatment has consisted of open drainage. Open drainage was often successful and did not result in pneumothorax, because most cases of empyema were associated with adhesions and thickened visceral pleura that prevented the lung from collapsing. The epidemic of group A streptococcal pneumonia in military camps in 1917-1918 was associated with the rapid and early accumulation of empyema fluid and was the catalyst for renewed study of empyema. Use of open drainage to manage this illness resulted in a high immediate mortality rate, probably because patients developed pneumothorax. The work of Evarts Graham and the Empyema Commission married physiological understanding of pleural mechanics with rational clinical treatment and paved the way for further advances in thoracic surgery.

Historical developments in the management of empyema.

The diagnosis and treatment of empyema was first described by Hippocrates over 2000 years ago. Virtually nothing else pertaining to this disease was recorded until the early 18th century. Since that time, numerous treatments have been described including open and closed tube drainage, thoracentesis, and thoracoplasty.

At one time, operations outside the hospital were not uncommon.

Before World War II, it was not uncommon for a person with influenza caused by streptococcus to develop empyema. Retired surgeon Harry Morton recalls two well-known patients who had empyema-related operations outside the hospital.

Gotthard Bülau and closed water-seal drainage for empyema, 1875-1891.

Optimal treatment of pleural empyema remains controversial to the present day. In the preantibiotic era, surgical thinking favored early and aggressive drainage of closed-space infections, but the dynamics of the pleural space were poorly understood and open pneumothorax generally was considered the necessary price of surgical drainage. Against bitter opposition, revision of the dogma of early open drainage was achieved in 1918 by Evarts Graham and his associates on the US Army's Empyema Commission. Unacceptable mortality rates for early drainage were brought under control through a treatment program of repeated tapping, with surgical drainage only after loculation had occurred. Paradoxically, closed water-seal drainage for empyema had been used by a German internist, Gotthard Bülau, as early as 1875. His technique was published in 1891, 27 years before the report of the Empyema Commission. As a closed system, it would have been suited to empyema drainage in either the early diffuse or the loculated stages. Thoracotomy was not possible at the time, and Bülau probably could not foresee the future importance of his method to surgery.

Samuel Robinson, pioneer thoracic surgeon (1875-1947).

Sam Robinson was born in Augusta, ME, in 1875. A graduate of Harvard Medical School, and of the Massachusetts General Hospital (MGH), he worked in the laboratory of Walter Cannon. While a junior at MGH he spent four months abroad with Ferdinand Sauerbruch. He returned to Boston and remained there until 1912, performing his first successful lobectomy for bronchiectasis in 1909. He made important contributions to the management of pneumothorax during operation, notably Sam Robinson's box. In 1912 he moved to Clifton Springs, NY. From 1915 to 1917 he was the first Chief of Thoracic Surgery at the Mayo Clinic. Illness, probably bronchiectasis, led him to abandon academic thoracic surgery in 1918 and retire to Santa Barbara, CA, where he practiced general surgery until 1947. He was President of the Association for Thoracic Surgery in 1922. In addition to the use of positive pressure and early resections, his contributions include artificial pneumothorax for tuberculosis and management of acute and chronic empyema. His colorful writings provide a vivid picture of the early days of our specialty.