The first descriptions of therapeutic arthrocentesis: a historical note

F. J. Aceves-Avila1,2,, M. A. Delgadillo-Ruano2, C. Ramos-Remus1,2, A. Gómez-Vargas2 and S. Gutiérrez-Ureña2,3

1 Departamento de Reumatología, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara,
2 Unidad de Enfermedades Crónico-Degenerativas S.C. Guadalajara and
3 Unidad de Investigación en Reumatología, URHIA, Antiguo Hospital Civil de Guadalajara, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, México

Abstract

The existence of synovial fluid has been known since Hippocratic times. The abnormal accumulation of liquid inside the joints has been recognized as the proximal cause of rheumatic diseases since humoral theory was the dominant paradigm in Occidental medical culture. Although evacuating the excess of the abnormal humour was the target of all therapeutic measures taken during this era, no mention of arthrocentesis is found in Occidental medical texts until 1652. We present two earlier indications of arthrocentesis to treat abnormal accumulation of liquid inside the joints. One in the Codex Badianus, an Aztec manuscript written in the 16th century, and the other in the Tractado breve de medicina, published in Mexico in 1592.

KEY WORDS: Rheumatic diseases, History, Therapeutics, Arthrocentesis, Synovial fluid.

In the treatise ‘on joints’, the Corpus Hippocraticum is recognized as the first mention of the existence of liquid inside the joints [1]. As Greek medicine flourished in the Mediterranean zone, the humoral theory was the dominant paradigm in Occidental medicine. Under this theory, the human body was considered as a blend of at least four different humours: blood, phlegm, yellow bile and black bile. A healthy state was the equilibrium between the different humours, a eucrasy, and the disequilibrium was a diseased state, a discrasy. This disequilibrium could be an excess of a specific humour in all the body, or the accumulation of a specific humour in a closed compartment. Each humour was associated with one of the four basic elements. Blood represented air, yellow bile represented fire, black bile represented earth and phlegm represented water [2]. The influence of one predominated above the others to define the personality and the disease processes to which each person was exposed during his life [3]. The main therapies were directed to the redistribution or the elimination of the excessive humour through bloodletting, purging, vomiting or sweating.

Gout was recognized as an abnormal accumulation of one of the humours in the joints. All rheumatic diseases were classified as different kinds of gout [4]. The precise nature of this fluid was not known, although it was recognized that this abnormal accumulation was the cause of severe pain and permanent dysfunction. It could be due to any of the four humours, but the direct evacuation by puncture of swollen joints was not mentioned as a method to evacuate this abnormal accumulation [5, 6].

Paracelsus named the synovia in 1520, and wrote about the liquid inside the joints (aqua articulorum) in 1565, while explaining the causation of gout by tartarum, but without mention of direct evacuation to alleviate the symptoms of the disease [7, 8]. Surgeons, who were not originally included among physicians, seem to have named the fluid found in joints as synovial fluid. In 1691 Clopton Havers proposed that the primary function of the synovial fluid was joint lubrication [9].

Fabricius Hildanus (1560–1634), a surgeon, seems to have been the first to puncture a pyarthrosis due to a previous open wound in the knee [10]. He described how he entered an abscess that was visible through the open wound using a probe. Although the patient lived, he suffered ankylosis of the afflicted joint. This intervention, published after the death of the author, did not influence the management of similar cases in subsequent centuries. We have found no mention of therapeutic punctures in unwounded swollen joints. No major advance in therapeutic arthrocentesis is recorded until Jean Gay reported his experience after the intra-articular injection of medication in two patients in 1792, in France. After the evacuation of large quantities of colourless, transparent synovial fluid, he repeatedly injected two patients with medication, mostly composed spirituous liquors, over a few days, and reported important clinical improvement in both. Unfortunately, we are not aware of the later experiences of this physician, nor of the intellectual influences on which he based his decision to puncture the joint [11]. This did not become standard practice until the 20th century, although the precise time when the practice was accepted is not clear. Marañón mentions the intra-articular administration of iodide compounds to treat several chronic joint diseases without mentioning the specific technique [12]. In 1947 Von Reis and Swenson [12a] proposed the use of intra-articular osmic acid to produce a chemical synovectomy in rheumatoid arthritis and Hollander [13, 14] employed intra-articular hydrocortisone in rheumatic diseases. It has been since his publication that arthrocentesis has become a standard practice in rheumatology.

Alarcón-Segovia [15] reported how Mexican pre-Hispanic physicians used therapeutic arthrocentesis in swollen unwounded knees. Swollen knees were punctured with a thorn to relieve pain and restore function [16]. Fray Bernardino de Sahagún gathered this information through direct interviews with the surviving Aztec nobility in México city in the 16th century.

Another mention of an evacuating articular puncture is made in the Libellus de medicinalibus indorum herbis, also known as the Badianus manuscript, an Aztec manuscript written in 1552 and translated into Latin by Juan Badiano [17] (Fig. 1Go). He was a pure aboriginal who studied in the Colegio de Santiago de Tlatelolco, where Franciscan friars taught Latin after the Spanish conquest [18]. Originally written as a gift for King Charles V of Spain, it was presented to Prince Philip, the future Philip II of Spain. Not intended as a medical text, it is a sort of catalogue registering some of the herbal remedies and therapeutic measures employed in Aztec medical practice. Rediscovered in 1929 in the Vatican Library [19], it was finally published in 1939 [17, 20, 21]. In Chapter 9 (Fig. 1Go), while talking about joint diseases, it mentions that the rigid joint must be punctured with the bone of an eagle or a lion, after which a cataplasm made with honey and several herbs and insects should be applied. It also states that the puncture should not be performed if the joint is not severely painful.



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FIG. 1. Page of the Codex Badianus on which arthrocentesis is mentioned. On it we can also see the herbs recommended to treat swollen joints.

 
Contra el dolor de las articulaciones prepárese una cataplasma de estas hierbas: cuauhtzitzicaztli, tetzitzicaztli, colotzitzicaztli, patlahuac, tzitzicaztli, y xiuhtlemaitl. También viborillas, escorpiones, cienpiés, y todo se muele y cuece en agua. Además, la parte que está entorpecida por la rigidez tiene que ser punzada con un hueso de águila o de león, y luego poner la cataplasma dicha, mezclada con miel. Cuando el artrítico, o paciente de dolor articular, no siente tan gran dolencia, no hay necesidad de punzarle la parte enferma.

These descriptions were made when no important exchange theories and treatments had occurred between European and Nahuatl physicians. So, it seems that the presence of synovial fluid was recorded independently in both continents. The different terms employed to compare the colour and consistency of synovial fluid in both continents supports this. European surgeons compared it egg yolk, while in Nahuatl descriptions it is mentioned as the fluid obtained from cactus. Hens came to México with the Spanish conquest [22].

Fray Agustín Farfán published the second edition of the Tractado breve de medicina in 1592, in México (Fig. 2Go) [23]. In the second book he describes for the first time in an Occidental medical text, the precise indications and benefits of performing an arthrocentesis in swollen knees. In brief, he mentions that knee swelling is frequent, painful and disabling. In accordance with the humoral theory, he first suggests the use of cathartics and poultices. Should they be ineffective, then the swelling will increase. Then, before a spontaneous opening, he suggests an evacuating procedure by puncturing the lowest point of the swollen knee with a thin cautery and immediately evacuating the contents in a gentle manner.



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FIG. 2. Tractado breve de medicina, by Fray Agustín Farfán.

 
Muchas veces he visto unas hinchazones, que se hacen en las rodillas, y estas son muy penosas, y causan muy gran dolor. ... Si viniere la hinchazón a madurar, como las he visto muchas veces, y aunque por estar en juntura son peligrosas todas las hinchazones que se abren, sanan, si con cuidado las curan, hagan la cura de esta manera; abran la con cauterio sutil, por la parte más baja y no aguarden a que del todo esté tan madura, que la materia vaya comiendo la carne buena. Saquen (sin lastimar) de una vez la materia, y no la dejen para otro día...

In case of an increase in pain or should there be fever, the third line of treatment was bleeding the patient on the arm, on the same side as the swollen joint. Although rheumatic conditions are mentioned several times, including joint swelling and disability, we have found no similar prescription in several medical texts published in Mexico at the same time [24, 25]. Unfortunately, it seems that the utility of this therapeutic approach was not recognized, as no further mention is found in medical books published in Mexico in subsequent centuries [2628].

Of the mentioned texts written in the New World, only Farfán's book had an extensive distribution. Sahagún's writings were not published until 1829 [29] and we have already mentioned a brief history of Codex Badiano. Unfortunately, medical books written in languages other than those of current use in central Europe were seldom employed as reference in mainstream medical theories. This is one thing that the modern globalization process must change. Hollander's publications received attention due to the conjunction of a new effective pharmacological compound and a ‘new’ technique of administration. Why arthrocentesis was not included in the therapeutic armamentum of physicians and surgeons until the 20th century should be an interesting example for the sociologists of science to investigate.

Notes

Correspondence to: F. J. Aceves-Avila. E-mail: fjaceves{at}megared.net.mx Back

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Accepted 8 October 2001