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Our Surgical Heritage

"Empyemas" of the Thoracic Cavity in the Hippocratic Corpus

History of Medicine, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

^_* Address correspondence to Dr Christopoulou-Aletra, 73 Nikis Ave, Thessaloniki, 54622, Greece (Email: ealetra{at}hotmail.com; ealetra{at}med.auth.gr).

	Abstract

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Thoracic "empyemas" appear often in the Hippocratic Corpus and with detailed descriptions of their etiology and clinical manifestation. To find the precise thoracic location suffering from "empyema," the physician asks the patient to turn on one side and inspects there for pain. The Hippocratic physicians give a very detailed description of "empyemas" caused by "peripneumonia," which is an illness resembling today’s pneumonia. The proposed therapeutic method in this case, thoracostomy and drainage of the empyema, constitutes a cornerstone of our surgical heritage, appearing for the first time in the Hippocratic texts.

	Introduction

Top Abstract Introduction Thoracic "Empyema" Comment Acknowledgments References

 
The empirical medicine, mainly traumatology, present in the Homeric texts (eighth century BC), was discontinued till the fifth century BC when systematized medical texts start to appear bearing the name of Hippocrates (Hippocratic Corpus). Hippocrates, a descendant of Hercules and Asclepius, is said to have been born in 460 BC in the Greek island of Kos and died in Larisa (Thessaly) almost at the age of 100. Hippocrates is known as the founder of the medical School of Kos. The treatises of the Hippocratic Corpus continued to be composed till the second century BC.

The great leap forward to the development of Medicine was achieved through the Hippocratic writings. According to the great scholar and translator of the Hippocratic texts Émile Littré (1839–1861), the treatises come up to 71. The significant change, from the dominant religious and magical medicine that dominated at the time the entire ancient world, toward a more reason-orientated view of the disease occurs in these.

The theory of the four humors of the body (blood, phlegm, black bile, and yellow bile) is incorporated within the frame of a general rationalization; their balance ensures preservation of health. The disruption of this balance results in disease, and the role of the doctor is to restore it, by usually removing any such excess (purgation). The management is simple and aims to provoke vomiting, expectoration, urination, defecation, sweating, or blood letting. Additionally, some other practices are used, such as surgical procedures, cauterization, and use of medicaments. Prevention is repeatedly prompted in the Hippocratic Corpus, and it is achieved through diet, exercise, and avoidance of any kind of exaggerations in life style. Here we note another practical application of the ideals of the Greek classical era, where all aspects of life are governed by moderation "logos." In this sense of logic, all the known diseases are described, named, and their prognosis, symptoms, and treatment are given. Clinical examination and history taking are applied for the first time.

In the case of thoracic "empyema," clinical examination involve as diagnostic procedures the shaking of the patient to locate fluid accumulation in the cavities of the body and auscultation [1].

	Thoracic "Empyema"

Top Abstract Introduction Thoracic "Empyema" Comment Acknowledgments References

 
Terminology
The term "empyema" is a compound Greek word consisting of the prefix "en," meaning "in" or "within," and the stem "pyema," meaning "accumulation of pus." According to the Hippocratic texts, "empyemas" can be located in the thorax, the uterus, the bladder, the ear, and other parts of the body. Thoracic "empyemas" appear in the Corpusmore often and with more detailed descriptions than any other type of "empyema," referring either to the modern meaning of the term, namely, accumulation of pus into the pleural cavity, or to accumulation of pus in any part or organ of the body, namely, abscesses. Since the Hippocratic physicians ignored the anatomy of the thoracic organs, they were unable to distinguish between these two pathologic entities.

Etiology and Pathogenesis
According to the Hippocratic physicians, the thoracic "empyemas" are not primary diseases; rather, they are caused by the inability of physicians to cure other preexisting illnesses of the thorax. Their most common cause is entrance of foreign bodies into the lungs, either by inhalation or drinking. The authors claim that once the foreign bodies have entered the lungs, they can not be rejected; they remain there, causing accumulation and stagnation of fluid that turns into a "concretion," which results in sepsis and "empyemas" [2]. "Empyema" may also occur in patients after "peripneumonic affections" or "pleurisy" "because their chest is not cleared through expectoration within fourteen days" [3]. The empyema may rupture, leading the pus either inside or outside the thorax through the mouth. This rupture may occur either on the very first day of its formation, or within the next 14 days [4].

Symptoms and Signs
The symptoms signaling the beginning of accumulation of pus into the thorax are fever, rigor, and thoracic pain, which may be accompanied by a feeling of heaviness at the site of the chest, where pain is located. Patients with an already formed "empyema" usually suffer from the following: fever (mild during the day but higher at night), red eyes, "copious sweating," cough, bent nails of the hands, edemas in the lower extremities, anorexia, and blisters all over the body. In chronic empyemas, the above-mentioned symptoms are more severe. Newly formed empyemas can be recognized by the above-mentioned symptoms, "if at the same time there be some difficulty of breathing" [4]. Pain, followed by dyspnea, coughing, and increased expectoration may be considered as signs of rupture.

Thoracic "empyema," secondary to "peripneumonia" in particular, is accompanied by fever, dry cough, dyspnea, swelling of the feet, and curving of the nails of both hands and feet [5]. Patients with a chronic "empyema" usually suffer from fever, red eyes, "copious sweating," cough, bent nails of the hands and feet, edemas of the lower extremities, anorexia, and blisters all over the body.

Physical examination, including inspection, palpation, and auscultation, is applied for diagnosis and detection of the precise location of the "empyema" in the thorax. The typical percussion, which is a technique in today’s everyday practice, was not used in these cases; instead it used the shaking of the patient. "The physician asks the patient to sit on a chair and shakes him or her by the shoulders. By applying the ear, during a certain time, on the thoracic wall" the doctor can hear a typical rippling sound, similar to that produced by shaking a bottle half filled by fluid. This means presence of accumulated fluid into that hemithorax. If sound cannot be obtained by shaking, the physician inspects and palpates the patient’s thorax. The "empyema" is located on the side that is more swollen and painful [4]. The doctor also asks the patient to turn on one side; "and if one side be somewhat hotter than the other, ask the patient, while he is lying on the sound side, if he feels a weight hanging from the upper part. Should this be so, the empyema is one-sided, on whichever side the weight occurs" [4].

Prognosis
The prognosis depends on the presence and severity of symptoms and signs, such as the appearance of fever, and of characteristics of expectoration, which may contain either pus or bile. "Those chiefly recover who lose the fever on the same day after the gathering breaks, quickly recover their appetite, and are rid of thirst; when the bowels pass small, solid motions, and the pus evacuated is white, smooth, uniform in color, rid of phlegm and brought up without pain and coughing. These make the best and quickest recovery; the nearer the approximation to their symptoms the better. Those die who are not left on the same day by the fever, which seems to leave them and then appears again with renewal of heat; who are thirsty but have no appetite; whose bowels are loose, and who evacuate pus that is yellow and livid or full of phlegm and froth. Those who show these symptoms die" [4]. On the contrary, "Should, however, the abscessions disappear without the evacuation of sputum and while the fever lasts, the prognosis is bad, as there is a danger lest the patient become delirious and die. When empyema occurs as the result of peripneumonia, older patients are the more likely to die; with other kinds of empyema younger people more easily succumb" [4].

If "empyema" is the result of "peripneumonia" or "pleurisy" and is accompanied by a feeling of heaviness, complaints about the stomach, and discharge of yellow and malodorous stools, the patient usually dies on the 21st day; but if the patient survives after this day, he will finally recover [6]. The appearance of "empyemas" after the seventh day of "peripneumonia" or "pleurisy" is a good sign, as it diminishes the risk of death [6].

After surgical drainage, the prognosis depends on the macroscopic image of the drained pus. If the pus is white and clean and contains streaks of blood, the patient generally recovers. If the pus is yellowish, thick, and fetid, the patient usually dies.

Treatment
The Hippocratic physicians start treating "empyemas" with conservative methods such as providing medicaments and physiotherapy. The medicaments are mainly made of plants including ground cuckoo-pint root, radish skin, flower of copper, bitter pomegranate-peels, cyclamen, silphium, salt, honey, and oil. Physiotherapeutic measures include warm baths, "vapour-bath" consisting of equal amounts of water-parsnip juice, "Toronian wine," and goat’s or cow’s milk, which should be applied through the mouth, letting "the patient draw in the vapor through a reed," and shaking the patient by his or her shoulders to achieve eruption and expectoration of the pus [5]. If after all these efforts no obvious expectoration of pus occurs, this suggests that the abscess has ruptured into the thorax.

If the pus is accumulated into the thorax, and all other treating methods fail, thoracostomy and drainage are proposed. The surgical procedure is described with precision. The patient should first take hot baths and sit still on a chair. Someone else should hold his arms. As has already been mentioned, the physician should determine on which hemithorax the "empyema" is located, to perform the skin incision in the appropriate side; for this purpose, the doctor should shake the patient by his shoulders and listen to the sound of the liquid within. Then, the incision follows: "First, cut the skin between the ribs with a bellied scalpel; then wrap a lancet with a piece of cloth, leaving the point of the blade exposed a length equal to the nail of your thumb, and insert it. When you have removed as much pus as you think appropriate, plug the wound with a tent of raw linen, and tie it with a cord; draw off pus once a day; on the tenth day, draw all the pus, and plug the wound with linen. Then make an infusion of warm wine and oil with a tube, in order that the lung, accustomed to being soaked in pus, will not be suddenly dried out. When the pus is thin like water, sticky when touched with a finger, and small in amount, insert a hollow tin drainage tube. When the cavity is completely dried out, cut off the tube little by little, and let the ulcer unite before you remove the tube" [6]. The doctors use linen as tampons, cleaning the cavity and obstructing its closure. The drainage tube is removed only after thorough lavage of the cavity.

	Comment

Top Abstract Introduction Thoracic "Empyema" Comment Acknowledgments References

 
The Hippocratic physicians are the first to refer to "empyema." They are aware that accumulation of pus into the chest causes symptoms and possibly death and provide precise description of its manifestations, which may appear not only at the site of the pus collection but also at other, remote points in the body. These manifestations have been accepted in medical literature for centuries. Laennec, in his treatise concerning chest auscultation published in 1834 [7], in an attempt to differentiate between the diagnoses of hydrothorax and empyema, translates the original Hippocratic description of the so called "Hippocratic succussion sound." Most of the manifestations mentioned in the Hippocratic Corpus, for example, cough, fever, expectoration, chest pain, excessive sweating, weight loss, clubbing, and so forth, are recognized as diagnostic symptoms and signs of chronic suppurative diseases of the chest even today.

The treatment of "empyemas" concerns medication mainly made of plants, physiotherapy, and drainage [4]. Chemical examination of the plants reported in the Hippocratic Corpus shows that their choice was not made by chance. Most of them dispose expectorant, analgetic, antiinflammatory, and even antimicrobial properties. They start their treatment by using plants with expectorant properties, while their next choice is to "purge" the patient to achieve the balance of the body humors [1]. In the case the patient would not recover, the physicians should then use a plant with antimicrobial action such as radish. The final suggestion is a concoction of plants with different properties each (purgatives, expectorants, and astringents) [8–13].

If the conservative methods fail, the Hippocratic physicians proceed to surgical drainage following the well-known Hippocratic Aphorism: "those diseases that medicines do not cure are cured by the knife" [14]. Chest drainage is the greatest novelty in the management of thoracic empyema described with precision in the Hippocratic texts and is a cornerstone of our surgical heritage. The original Hippocratic technique of drainage is based on sound ground. For the next two millennia, no significant advances were made in that technique. Only vague reports of drainage for thoracic empyema exist, with an example of Ambroise Paré in the 17th century AC [15]. Practically, the Hippocratic technique is very similar to that in practice in modern medicine.

	Acknowledgments

Top Abstract Introduction Thoracic "Empyema" Comment Acknowledgments References

 
We would like to thank Prof Theodosios J. Dosios for his extensive suggestions.

	References

Top Abstract Introduction Thoracic "Empyema" Comment Acknowledgments References

 

1. Christopoulou-Aletra H. Introduction in the Hippocratic medicineThessaloniki, Greece: Siokis; 2002. pp. 17-2889–90.
2. Hippocrates. On the nature of bones. Vol 4. Athens, Greece: Kaktos; 1992. pp. 131-133.
3. Hippocrates. AphorismsIn: Jones WHS, editor. transl. Hippocrates. Vol 4. Cambridge, MA: Harvard University Press; 1992. pp. 159section 5.
4. Hippocrates. PrognosticIn: Jones WHS, editor. transl. Hippocrates. Vol 2. Cambridge, MA: Harvard University Press; 1992. pp. 31-41.
5. Hippocrates. On diseases IIIn: Potter P, editor. transl. Hippocrates. Vol 5. Cambridge, MA: Harvard University Press; 1988. pp. 271-275.
6. Hippocrates. On diseases IIIIn: Potter P, editor. transl. Hippocrates. Vol 6. Cambridge, MA: Harvard University Press; 1988. pp. 39-43.
7. Laennec RT. Mediate auscultation 1834. pp. 86Paris, France.
8. Chaumeton F-P. Flore médicaleParis, France: Panckoucke; 1814. pp. 137-139Vol 1.
9. Schauenberg P, Paris F. Compendium of medicinal plantsAthens, Greece: Giourdas; 1981. pp. 90310, 346.
10. Chaumeton F-P. Flore médicaleParis, France: Panckoucke; 1816. pp. 135-136Vol 3.
11. Galen. De simplicium medicamentorum temperamentis ac facultatibusIn: Galen, editor. Opera Omnia. Vol 12. Lipsiae: Libraria Car Cnoblochii; 1826. pp. 112-123.
12. Jouanna J. HippocratesAthens, Greece: Kardamitsa; 1998. pp. 212.
13. Galen. De alimentorum facultatibusIn: Galen, editor. Opera Omnia. Vol 6. Lipsiae: Libraria Car Cnoblochii; 1823. pp. 639.
14. Hippocrates. AphorismsIn: Jones WHS, editor. Hippocrates. Cambridge, MA: Harvard University Press; 1992. pp. 217.
15. Pare A. The works of that famous chirurgionLondon, United Kingdom: T Cotes & R Young; 1634. pp. 298-299.

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