Aspiration and Antiseptic Irrigation 
of the Knee Joint. 
HY f — 
THOS. W. HUNTINGTON. B. A.. M. I) 
Sacramento, Cal. 
SACRAMENTO, CALIFORNIA : 
Reprinted from the Occidental Medical Times, April, /Sgo. Reprinted from the Occidental Medical Times, April, 1890. 
ASPIRATION AND ANTISEPTIC IRRIGATION OF THE 
KNEE JOINT. 
By Tuos. W. Huntington, B. A., M. D., Surgeon Southern Pacific 
Company’s Hospital, Sacramento, Cal. 
Read before the Sacramento Society for Medical Improvement. 
Chronic synovitis of the knee joint with effusion, under various 
methods of treatment, has in many instances been attended by re- 
sults quite unsatisfactory both to the profession and to the patient. 
Counter irritation by iodine, blisters and other agents, compres- 
sion, rest in bed and various schemes, have been adopted to meet 
the exigencies of these cases. Acute forms of the disease, espec- 
ially those resulting from traumatisms, are, in a certain proportion 
of cases, amenable to the foregoing measures, but all surgeons now 
and then have exhausted their skill and patience and left the sub- 
jects little if any the better for their pains. The tendency in many 
instances is for the disease to become chronic. An effusion once es- 
tablished persists and there seems to be an inability on the part 
of joint structures to carry away the offending fluid. As a conse- 
quence, the joint becomes enfeebled and flaccid from long con- 
tinued tension; articular surfaces gradually undergo structural 
change; there is much pain and discomfort to the patient; move- 
ments of the joint are impeded and its integrity more or less 
permanently impaired. Finally, constant irritation results in sup- 
puration and total destruction of the articulation, conditions which 
render imperative, erasion, excision, or amputation. 
What is true of synovitis as a result of traumatism has greater 
weight in dealing with tuberculous synovitis. Here, although the 
conditions are somewhat different, disastrous consequences are real- 
ized with far greater certainty. While it is true that absolute 
rest during the earlier stages of tubercular joint affections may 
prevent progress and perfect a cure, as asserted by Howard Marsh, 
unfortunately resort to this measure is not had at the proper time 
in a large proportion of cases. As a matter of fact the attention 
of patients themselves is not forcibly called to the probability of 
danger until they have passed beyond the point where rest as a 
curative means is in any sense available. In dealing with the later 
stages of chronic synovitis of the knee joint where partial or ex- 2 
tensive disintegration of tissues has taken place, three alternatives 
are offered as a source of relief: (i) Amputation; (2) Excision; 
(3) Arthrectomy or, according to later nomenclature, erasion. 
The first is of course out of the question, except in those cases 
where not only the function of the joint, but the usefulness of the 
limb is wholly destroyed, and where danger to life is imminent. 
Between the two latter methods, a marked difference of opinion 
exists as to the better course. Excision and erasion each have 
their champions, equally respectable, and alike claiming that their 
own special procedure offers the greatest immunity from danger, 
and likelihood of radical cure. The weight ot evidence, however, 
goes to show that early excision obviates the necessity of later 
amputation; that an earlier erasion is productive of more rapid re- 
covery with greater utility as a final result. 
Later contributions to the treatment of chronic arthritis, either 
traumatic or tuberculous, furnish material for inference that each 
of these three alternatives may be superceded by the method 
known as antiseptic aspiration and irrigation. My attention was 
especially directed to this subject in May last by Dr. Maurice H. 
Richardson’s report of a series of cases successfully treated at the 
Massachusetts General Hospital. As the operation described by 
Dr. Richardson has but recently come into use in this country, 
the following report of cases may be of interest: 
Case I.—Mrs. A. G , age 40, housewife, was referred to me 
in July, 1889, by Dr. W. A. Briggs, of this city, with the follow- 
ing history: Several years ago had suffered from a chronic abscess, 
located in the muscles of the back. This, under the usual treat- 
ment, was cured. Six years ago left knee was injured by a fall; 
joint remained slightly sensitive for two years, then began to en- 
large perceptibly and became painful. Condition of joint has 
gradually grown worse. On examination, knee found to be ten- 
der and distended with fluid; locomotion impaired and movements 
imperfect. July 9th, assisted by Drs. W. A. Briggs and G. B. 
Somers, I aspirated the joint, removing two ounces of slightly 
turbid serum; I then injected the same amount of a five per cent, 
solution of carbolic acid, which in turn was reexhausted. The 
limb was then placed upon a posterior splint and slight pressure 
applied over the patella. On the following day there was slight 
elevation of temperature and considerable joint pain, the latter 
being relieved by removal of the pressure. On exposure of the 
part the articulation was found to have refilled with fluid. The 
splint was readjusted and by the second day the temperature was 
normal; no pain or discomfort. On the seventh day the fluid in 
the joint had almost disappeared, and at the end of the second 3 
week no fluid could be detected. The splint was removed, a plas- 
ter of Paris dressing applied, and patient allowed to go about on 
crutches. At the end of the fourth week the plaster dressing was 
removed. Movement of the joint, though slightly impaired, was 
painless. September 1st, eight weeks after the operation, patient 
was discharged well. At this time she could walk without 
crutches, and with a barely perceptible limp, the latter being due 
probably to protracted distension of the joint tissues. Patient was 
seen February 12th, and there has been no tendency up to the 
present time to relapse. 
Case II.—J. T , age 49, carpenter. On May 5, 1889, left 
knee was injured by a blow from a bar of iron, causing pain and 
swelling. Resumed work almost immediately, but as symptoms 
persisted, I was consulted July 12, 1889, about two months after 
receipt of injury. Treatment by rest, blisters and pressure was 
recommended, but without avail. Accordingly, on July 19th, 
I proceeded to aspirate and irrigate the joint, as in the preceding 
case. The following day the knee was greatly swollen and some- 
what tender; from this time, however, the symptoms rapidly sub- 
sided. August 10th.—Dressings were removed and excess of joint 
fluid found to have disappeared. There was, however, consider- 
able stiffness, requiring repeated efforts by passive motion for its 
relief. September 10th.—Patient discharged and resumed work. 
At this time the movements of the joint were perfect and size of 
limb normal. Up to February 10th, no tendency to relapse has 
been shown. 
Case III.—T. F , age 41, machinist. For eleven years has 
suffered, at varying intervals, from a painful affection of the left 
knee, which, during most of this period, has been slightly enlarged. 
On May 24, 1889, he fell from a horse, striking on the affected 
knee, causing a return of former trouble. June 3d.—Fluctuation 
in joint was apparent, accompanied by great pain, tenderness and 
heat. Resort was at once had to treatment by the irrigation 
method. About two ounces of bloody, sero-purulent fluid was 
withdrawn, and the joint thoroughly irrigated with a 3 per cent, 
carbolic acid solution. The case proceeded favorably, and at the end 
of a week no fluid could be detected. At the end of the second week, 
patient was allowed to go about on crutches. At the end of the 
fourth week there occurred a partial relapse, and the operation 
was repeated, the irrigation fluid employed being a five per cent 
carbolic acid solution. Subsequent to this there was no impedi- 
ment to recovery, and the patient was discharged cured July 26, 
1889. Function of joint unimpaired and locomotion perfect. 
Case IV.—J. D. H , age 52, railroad conductor. About 
sixteen months ago fell and injured left knee, since which time it 
has been noticeably enlarged and at times painful. On examina- 
tion, joint found to be greatly distended, partially flexed, immov- 
able, hot and painful. Fearing that suppuration was imminent I 4 
immediately resorted to treatment by aspiration and irrigation, as 
in the foregoing cases. Strength of irrigation fluid, three per cent. 
Amount of fluid removed, three and one half ounces. Micro- 
scopic examination revealed numerous pus cells and confirmed the 
early suspicion of impending suppurative disease. The following 
day, although the joint cavity had partially refilled, pain and heat 
had subsided and patient was resting comfortably. A plaster 
dressing was applied on January 2, 1890; this was removed Feb- 
ruary 17th. Owing to the urgency of the symptoms in this case, 
prolonged rest has been prescribed and the patient will be kept con- 
fined to his room several weeks longer. There is no excess of 
joint fluid and no symptoms tending to the discomfort of the 
patient. 
Case V.—E. J. R , age 17, machinist. About one year ago 
fell and injured left knee, which has been weak ever since. Five 
days previous to consultation first noticed that it was swollen. On 
examination knee found to be enlarged and fluctuating. Meas- 
ures 14inches in circumference; sound knee 13J4 inches. The 
joint was treated by the aspiration and irrigation method; i*4 
ounces of serous fluid being removed. The limb was placed on a 
posterior ham splint with a slight compress over the patella, and 
bandaged from the toe up. December 7th, five days after operation, 
splint removed; no pain or tenderness in the joint and no excess of 
fluid could be detected. Circumference of affected knee, 13 
inches; sound knee, 13k; inches. Patient allowed to move about the 
house and two days later discharged, cured. February 15th, I learn 
that the joint is in perfect condition. 
The various steps in the operation may be described as follows: 
The affected limb should be subjected to a careful antiseptic bath. 
The point of selection for puncture is at the upper external angle 
of the patella as the joint covering is thinner here than elsewhere. 
An aspirator needle of large size should be selected to avoid clog- 
ing during the act of exhausting the injection fluid which is ren- 
dered flocculent by coagula. The John Smith aspirator is especially 
adapted to this purpose, it being provided with an arrangement 
for injection as well as for exhaust. With this apparatus the 
operator should become thoroughly familiar before attempting its 
use. The aspirator having been prepared as an exhaust pump, 
the needle is thrust into the joint cavity, and the fluid removed at 
once. The instrument is then reversed, the flask is two-thirds 
filled with a five per cent, carbolic acid solution, and inverted. 
An assistant should then hold the cork firmly in place, while the 
air over the fluid is condensed by working the pump. The stop- 
cock between the flask and the knee joint is now opened, and the 
joint cavity is allowed to become well distended with the acid solu- 5 
tion. A special precaution in this step is to have such an amount 
of solution in the flask that the latter need not be entirely emptied 
in filling the cavity, otherwise compressed air will be allowed to 
escape into the joint, which, in a measure, enhances the risk to 
the patient. The irrigation may be repeated two or three times, 
or until the return fluid is clear. The needle is then withdrawn, 
an antiseptic dressing applied to the puncture, and the limb laid 
upon a posterior splint, and bandaged lightly. On the day fol- 
lowing the operation the joint will be found to have refilled with 
fluid. This, however, is gradually reabsorbed and at the expira- 
tion of front three to six weeks the limb is usually fit to use. 
A few remarks upon the proper attitude of the surgeon in 
adopting a given line of action will be in place, as suggested by 
the subject chosen for discussion this evening. These comments, 
while but reflexes of warnings and maxims without number, from 
the most earnest advocates of a high standard of excellence in 
surgery, as regards technique of operation, efficiency in after 
treatment and the attainment of final success, have been accentu- 
ated by personal observation and emphasized by practical exper- 
ience. 
The rapid, almost bewildering progress in the art of surgery 
during the past decade, has proportionately added to the duties 
and responsibilities of the surgeon. Methods of procedure that 
were formerly suggested as a last and lamentable resort, in the 
light of modern pathology and with the immunity afforded by 
asepsis, are recognized as offering the brightest possibilities to the 
operator and the most perfect relief to the afflicted. 
Foremost among these recently imposed duties is that of early 
and positive diagnosis, a necessity in every instance, but irrecon- 
cilably imperative in a very large class of pathological conditions. 
This fact failed of adequate appreciation, until it had become 
axiomatic; that it is often possible to avert disaster and save 
human life by a resort to operative measures in the incipiency of 
disease. The work of clearing away a doubt, of confirming a 
vague suspicion, or of demonstrating what has risen to the dignity 
of an opinion, has been in the main so simplified, that henceforth 
groping hesitancy must stand as the exponent of recklessness, 
incompetence or neglect. The contents of a cavity, though it be 
deeply seated or contiguous to important structures, are easily 
accessible for ocular or technical examination. Abdominal and 
joint incisions for purposes of exploration are of daily occurrence, 6 
and in skilled hands are devoid of risk; and fragmentary portions 
of abnormal growths may be chipped off, and their nature deter- 
mined beyond peradventure, through the agency of the micro- 
scope. Hence it may be truly said that with these sources of 
information, reinforced by the ordinary methods of physical 
examination, the judgment of the modern surgeon may be, and 
in a fair proportion of cases should be, infallible. 
But an early diagnosis, be it an evidence of never so much 
dexterity and acuteness on the part of the observer, reflects littlb 
credit upon the profession, and offers even less measure of relief 
to the patient in the absence of its legitimate correlative, thorough- 
going and rational methods of treatment. Accuracy, prompti- 
tude and courage are the requisites of the present time. But little 
latitude is accorded the surgeon in deciding whether undue ten- 
sion shall be relieved, whether a breast which is the seat of a 
suspicious looking growth shall be amputated, or whether a 
herniotomy or a laparotomy shall be undertaken in hope of 
averting impending peril. In these, as in nearly every exigency 
requiring operative interference, the words of Lawson Tait should 
be kept well in mind: “Early operations mean successful opera- 
tions.” In fact the policy of'former years has been reversed and 
the injunction to proceed at once and radically is an accredited 
surgical aphorism. 
Nor is it in operative cases alone that promptness is an efficient 
weapon in the surgeon’s hands. For example, a large number of 
joint affections, whether traumatic, tuberculous or specific, are 
thoroughly amenable to appropriate measures, if skilfully and 
persistently employed. Here he will find a field for display, not 
only of his skill, but of his conscientious devotion to duty, and to 
this point attention cannot be directed with too much emphasis. 
To paint, or poultice, or blister a joint, which is the suspected seat 
of progressive disease, as a substitute for the more sensible and 
only rational plan of rest or extension, or of both combined, is 
wrong in theory, and disastrous in practice. In carrying out a 
correct policy in such a case, impediments will often be encoun- 
tered. Be they in the shape of unreasonable and unyielding ob- 
jections on the part of patient or friends who ignorantly plead 
for delay or temporizing treatment, withdrawal from the case, 
positive and unconditional, is an open avenue of escape from 
responsibility. But if poverty be the obstacle, and the already 
overburdened practitioner feels that he can ill afford the demand 7 
for unrequited time and labor, the situation is quite different, 
though not hopeless. Such cases rightly belong to the proper 
institutions, or to the younger, less busy and perhaps more am- 
bitious members of the profession, and to these they may properly 
be consigned. 
A tolerably fair index to the quality of work that may be ex- 
pected from an operator, is to be found in the completeness of his 
preparation when approaching any undertaking. Perfect system 
in the arrangement of preliminaries is a leading factor in the econ- 
omy of energy, patience and time, and what is even more impor- 
tant, contributes greatly to the comfort and safety of the patient. 
Too frequently there is observed neglect of these steps, that to 
say the least, is discreditable. At a critical period in an operation 
absence of an essential instrument or appliance occasions an em- 
barassing delay, or necessitates the employment of an inferior 
article. A common illustration of this error is the omission of 
drainage tubing from the surgeon’s outfit. The usual makeshift 
is a gum elastic catheter, which in point of size and antiseptic 
preparation, is more than probably illy adapted and wholly unsafe 
for use. Again, a bed, soiled and disarranged, has been used as 
a ghastly substitute for a suitable operating table. To one who 
has used, and who therefore appreciates the value of a thoroughly 
equipped irrigator, it is amazing that this simple, yet invaluable 
contrivance is not more generally employed. It is difficult to con- 
ceive of more unmistakable evidence of slovenliness on the part 
of an operator, than the presence of a hand-bowl with its contents 
of bloody opaque fluid, to which resort is had in the sponging of 
a wound. The fluid at the outset may have been aseptic or anti- 
septic, but after one or two rinsings of a sponge, it will completely 
have lost its identity as such. In consequence of careless indiffer- 
ence to details, an operation has now and then gone wrong, has 
fallen short of perfect success, or failed deplorably, and anticipated 
triumphs have found fruition in calamity. 
The special features of recent operative methods are designated, 
in the main, by two words—cleanliness and thoroughness. The 
former suggests all the safeguards of asepsis and antisepsis. 
Championiere closes a report of four hundred and sixty-three suc- 
cessful capital operations, done under most unfavorable surround- 
ings, in sheds and barracks, with these significant words: “Splendor 
of means and luxury of antiseptic material are of little moment, 
while the surgeon’s faith in the antiseptic method is the whole of 8 
it.” The latter, however, in this connection is infinitely more 
complex and comprehensive. Thoroughness exacts unwearying 
zeal and absolute singleness of purpose in the attainment of an 
end. It implies precision, painstaking, patience. It absolves the 
operator from restraint and begets boldness, which is curbed only 
by sound judgment. It sacrifices brilliancy to efficiency, rapidity 
of execution to the veriest plodding in the interest of accuracy and 
completeness. Independent of professional attainment, special 
skill and wide experience, which must ever remain variable quan- 
tities, the presence or absence of these attributes determines beyond 
question the value of the personal equation, a most important 
factor in the estimation of risk attending an operation. Says Mr. 
Keetley: “Let us never forget to distinguish between the dangers 
of an operation, and of the particular operator who does it.” 
Certain it is that he who fails to recognize the intimate relation 
which scrupulous cleanliness and conscientious thoroughness bear 
to success in the practice of surgery, has grossly misinterpreted the 
spirit and teaching of his age. 
426y2 J street.