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Inflammatory joint conditions as affected by menstruation
INFLAMMATORY
JOINT CONDITIONS AS AFFECTED BY MENSTRUATION* J.
T.
RUGH,
M.D.
PHILADELPHIA
0
of the interesting phases of the practice of medicine Iies in discoveries which substantiate and verify the foIkIore and superstitious beIiefs Research is conof past generations. stantIy uncovering a physioIogica1, chemicaI or anatomical basis for what was once considered a supernatura1 phenomenon or accepted as a fact because substantiated by years or centuries of common beIief. Whatever the basis or origin may have been, observation and experience were the two empiric educationa standards which formuIated them and the accuracy and verity of the beliefs depended entireIy upon the reIative persona1 reIiabiIity of the observer. However, time, imagination and superstition added credence to an erstwhiIe suspicion unti1 fInaIIy it became an accepted truth to be handed down from generation to generation by oId men’s or oId women’s taIes and so to become a part of the Iiterature and credo of the community and nation. Such has been the case regarding menstruation in the femaIe. BibIicaI and medica records are repIete with mysterious taIes and observations regarding the vagaries and injurious effects of this norma physioIogica1 function of the femaIe, not only as concerns the woman herseIf but aIso as affecting other individuaIs and objects. Outstanding have been the beIiefs as to the injurious effects which the menstruating woman may exert upon the growth of ffowers and pIants, the baking of bread and, among some wiId tribes, upon other members of the community. Many curious comphcations occurring in NE
the individual herseIf have been reported in medica Iiterature in the past two centuries and they have been accepted as observed facts without any proved etioIogy. The most common of these complications has been hemorrhage in various parts of the body, anywhere between the eyes and ears and the toes. Vicarious menstruation is an accepted though unexpIained occurrence. It may manifest itseIf in many different ways but seems to occur more frequentIy as hemorrhage into a part of the body affected by disease or in which structura1 change has occurred by reason of injury of some character. The most common of these is the hemorrhage in tubercuIous women but it may aIso occur into the stomach, boweIs, or ot,her viscera. Hemorrhage into the knee joint has been mentioned once in Iiterature’ but in this case, there were aIso effusions into other cavities of the body though the knee was the onIy one which contained bIood. The writer has had 3 cases of exaggeration of joint conditions during menstruation, two invoIving the knee and one the wrist and the rarity of the occurrence in these parts prompts this report and a search for a possibIe expIanation of the phenomenon. CASE I. Mrs. E. R. was first seen.in June, 1916 when thirty-three years of age. She compIained of troubIe in her Ieft knee, of seven or eight years’ standing. There was some sweIIing present with stiffness and pain and these were always more pronounced before and during menstruation. On each side of the
1Ephemerides,
Acad. Nat. Curios., l~rz.
* Read at the combined meeting of the Orthopedic Section of the New York Academy of Medicine and the PhiladeIphia Orthopedic CIub held in New York. 126
Nra
SWCIES VOL.
XXV,
No.
I
Rugh-Joint
pateIIa and patelIar tendon could be feIt some thickened bodies which sIipped beneath the fingers. There was considerable distention and fluctuation in the upper cuI-de-sac and baIIotment of the patefIa. Motion was not so free as in the other knee and when the Ieg was heId in one position for a whiIe, a change of position always caused pain. X-rays made at this time showed no changes in the bony parts but some cloudiness in the entire joint. A diagnosis of chronic viIIous arthritis was made and operation advised but refused. LocaI treatment was then instituted and the patient consuItec1 another orthopedic surgeon who treated her unti1 June, 1919, when she again came under my care. Operation was again advised and accepted and on June 7, the joint was opened. When the thickened synovia1 sac was reached, it presented a brownish coffee or chocoIate coIor and had the typica appearance of the hemophifiac joint. When this was opened, there escaped about 300 C.C. of bloody fluid, but free from clots. The entire joint surface had the same brownish coIor and the articular edges were extensiveIy fringed with hypertrophic viIIi. The fat pads were enfarged and discoIored and had the patient been a maIe, the situation wouIc1 have been a most disconcerting one. The \-ilfi were thoroughIy removed as we11 as the fat pads and numerous thickened masses on the outer synovia1 wafIs. BIeeding was easiIy controffed and the joint was closed. No fixation of the part was used and the patient left the hospital in twefve days in quite good condition. Inquiry directfy after the operation showed that she had ceased menstruating the day fIefore the operation and as she had afways had an exacerbation of the condition at that time, it \vas considered a case of vicarious menstruation into a joint affected by viIIous arthritis. Some of the tissue was sent to the laboratory and the following report was returned: “The tissues are of a yellowish color which extends throughout the section. The tissue shows a rather Iarge amount of fibrous tissue, between the fibrils of which are many cells. The fibrous tissue is old, rather dense and stains weI1. The tissue is very ceIfufar, the cells being mostly mononuclear, either round or spindle-shaped. Many spaces appear throughout the tissue; some are empty, others are filfed with ceIfs which are giant cells. The fatter contain from tw.0 to six nuclei and are centrally placed. It is
Conditions our opinion that this tissue is infIammatory but by some observers might be regarded as a sarcoma, probabIy of the giant ceI1 \.ariety. There is no suggestion of tuberculosis; neither in the tissue or in the joint fluid coufcf any tubercIe bacilli be found. Diagnosis: Chronic inflammatory tissue.” It was a IittIe surprising that the laboratory examination did not reveal any hemorrhagic infiItration in the removed tissue as such a “hemorrhage is frequentIS associated with the presence of pigment in the matrix of the cartiIage and fibrous tissue as we11 as in the capsule of the norma cartiIage ceII.“r When the patient was questioned as to the exacerbations during her pregnancies, she stated that there were none but that the joint remained in about the same condition as obtained between the menstrual periods. She made a good recol-ery and resumed her work as a housewife, with very Iittfe trouble from her knee ancI no disturbance during her menstruations for about two years. At this time, she was doing housecleaning and was on her knees and cIimbing stepIadders and doing very hard work when, at her period, the swelling recurred. I saw her again in June, 1930 ant1 found the joint tissues much thickened, motion restricted and considerable soreness present. Because of the profound changes in the synovial membrane and the progressive disability in the joint, compIete syno\‘ectomy \vas advised but has not yet been accepted. A recent communication from her shows the knee condition to be practically unchanged from what it was three years ago. She gets about with moderate comfort but at each menstrua1 period there is increase in the swelfing and discomfort but subsidence of much of the swelling after cessation of the menstrual flow. CASE II. Miss 31. W’., aged twenty-one years, a coIIege girl, referred by Dr. Francis J. Dever of BethIehem, Pa., for knee troubIe and first seen in August, 1930. She complained of tenderness and slight swelling of the right knee for seven years and that it was growing worse. Th e patient stated that the trouble first deveIoped after a fall seven years ago byhen the knee was “knocked out of place,” and she was confmed to bed for three months following this injury. There was restriction of motion and discomfort which de\-eloped into pain following
128
American
JournaI
of Surgery
Rugh---Joint
sports and unusuaI use. Her genera1 heaIth was exceIIent and there was no history of any contributory infective process. The synovia1 sac was thickened, the infrapateIIar fat-pads were hypertrophied and there was some increase in the joint ffuid but not to the point of distension. A diagnosis of chronic synovitis with sIight infXtration of the synovia1 sac and hypertrophy of the infrapateIIar fat-pads was made and IocaI measures, such as heat, contrast baths, gentIe massage and wearing a compression bandage were used for severa months but without reIief. About October I, a ceIIuIoid Iegging was appIied and worn constantIy unti1 June, 193 I, with great comfort and reIief from pain, but no appreciabIe change in the joint appearance. At this time arthrotomy was advised and on June 13, she entered the Methodist HospitaI for operation. The joint was opened by a latera incision and when the synovia1 sac was reached, it was found to be somewhat yeIIowish in coIor and much thickened. When opened, there escaped about 35 C.C. of ffuid, more yeIIow than norma but containing no Iymph ffakes or other abnormal substance. When the joint was exposed wideIy, the synovia1 surface was found covered by a dirty grayish membrane which Iooked much Iike that seen in diphtheritic throats. This was easiIy removed with gauze on the finger and beneath it, the synovia1 membrane was of norma coIor though thickened. The possibiIity of another case with menstrua1 compIication at once occurred to us but the operation was compIeted by removing synovia1 fringes and the hypertrophied fatpads. The rest of the joint being of good appearance, the incision was cIosed. As soon as the patient recovered from the anesthetic, she was questioned as to any changes in or effects upon the joint during menstruation and she promptIy said “Yes, it is aIways much more sore and swoIIen at that time.” Her Iast period ceased about tweIve days prior to the operation so that the exudate or deposit was evidentIy due to hemorrhage at that time. UnfortunateIy none of this membrane was sent to the Iaboratory so that its composition is unknown, though macroscopicaIIy it was a fibrous exudate or deposit. Her recovery was uneventfu1 and at her next period, there was no evidence of joint sweIIing or IocaI reaction. She was again seen five months Iater and there was perfect comfort in the joint with no evi-
Conditions
JULY,1934
dence of any disturbance at the monthIy periods. On October 29, 1933, a Ietter was received stating that a few days previousIy, just at the cIose of her period, her knee began suddenIy to sweI1 and increased to nearIy twice its norma size and remained so in spite of IocaI treatments. AIso she had just returned from the Chicago Fair where she had done a great dea1 of waIking. This would indicate that the primary inffammatory condition has Ieft her with a vuInerabIe knee and that she wiI1 probabIy be permanentIy in danger of these periodic outbreaks. A rather extensive synovectomy wiI1 be advised if the troubIe continues as it is beIieved that compIete reIief cannot be secured without such an operation. CASE III. Miss J. de G., aged eighteen years, a heaIthy schoo1 gir1, referred by Dr. John MuIrenan, on account of sweIIing and discomfort in her right wrist. This first began when she was about fourteen years of age and has not invoIved any other joints. There was no history of injury or other etioIogic factor beyond numerous attacks of sore throat. She had matured at eIeven years of age and her menstrua1 history was perfectIy normaI. The reaction in the wrist was quite sIight for about one year and then became of sufficient severity to send her to her physician who diagnosed synovitis of probabIe toxic origin and advised remova of the diseased tonsiIs. This, however, was not done and the discomfort and sweIIing continued. The doctor then noted that the symptoms were aIways aggravated during menstruation. I saw her with him and concurred in his diagnosis of toxic synovitis which was increased at or by the monthIy periods. Ordinary care and genera1 hygienic treatment were used and after a year, the condition subsided and has now been quiescent for a year. This patient was recentIy examined and there was no evidence of any pathoIogic or functiona changes present in the wrist, either cIinicaIIy or by x-rays. A differentia1 bIoodcount showed a miId Ieucocytosis which is strongIy indicative of the constitutiona toxemia, having its origin in her tonsiIs which have not yet been removed. It wiI1 be of great interest to watch her further progress and note the possibIe persistence of the menstrua1 upheava1 upon the invoIved joint. NaturaIIy, the wrist is not exposed to the same degree of trauma as is the knee and this is proba-
Rugh-Joint I>Iy a large factor symptoms.
in the subsidence
of the
During the menstrua1 cycIe, there is marked constitutiona activity invoIving many organs so that the function must be Iooked upon as constitutiona rather than mereIy peIvic. There is commonIy a sIight rise in bIood-pressure foIIowed by a corresponding Iowering shortIy before the flow. The temperature is practicaIIy unchanged except in the presence of tubercuIosis. The nervous system becomes more sensitive as shown in the menta1 excitability and genera1 nerve irritabiIity and their Iessening after the Aow has become estabIished. Different individuaIs react differentIy and the particuIar systems or structures invoIved and the severity of the manifestations appear to depend greatIy upon the inherent strength or weakness of these parts. PhysioIogists are now endeavoring to determine the factors concerned with the estabIishment and continuance of menstruation, beIieving that if these are discovered, it wiI1 be possibIe to expIain and to more satisfactoriIy dea1 with the complications. There are practicaIIy three theories concerning this phenomenon and these may be either separateIy or coIIectiveIy concerned with the function. The first one is that menstruation is a cycIe or habit pecuIiar to the femaIe and which is coincident with or constitutes puberty and continues, unIess interrupted by pregnancy or disease, unti1 forty-five or fifty years of age and then ceases; that it is nature’s provision for the continuation of the species as without it, Iibido is absent, in the Iower animaIs, and especiaIIy there wouId be no union and procreation. This is mereIy a statement of fact and does not offer an expIanation of the phenomenon. The second theory premises that the ductIess gIands, chiefly the pituitary, the thyroid and the adrenaIs, are the actuating factors in the upheava1 and that the pituitary is the dominating factor in the function, or as expressed by a recent
Conditions writer, “the pituitary is the leader of the orchestra.” The third theory is that the ovary or its corpus Iuteum is or provides the actuating force of the function and that whiIe this structure is undoubtedIy aItered and influenced by the ductIess gIand secretions, yet it suppIies the A-ital substance or stimulus which, through the somatic and sympathetic nerve systems, produces the constitutional disturbances characteristic of this function. The researches of Macht, of Johns Hopkins, wiI1, if substantiated, throw Iight upon many of these curious observations. He ascribed many of these phenomena to a substance he caIIed menotoxin and which he found present in practically every secretion and excretion of the body. The bIood, red bIood-ceIIs, urine, sweat, tears, saliva and even the breath contained this active principIe which markedIy retarded pIant growth and Iife. Its inhibitive or retarding effects upon certain types of pIant Iife (Lupinus aIbus) presented a quite constant percentage and if his deductions prove correct, a credible expIanation wiI1 have been provided for former suspicions and Iegends regarding this function. One of his most striking experiments was made with yeast. Two pieces of equa1 size were given to women, one menstruating and the other normal. Th e yeast was kneaded by each with sugar and water in the paIm of the hand for about five minutes and the masses were then pIaced in two fermentation tubes and these pIaced in an incubator. In due time, there was a Iarge amount of gas formed in the tube containing the yeast kneaded by the norma woman whiIe the other one showed scarceIS any fermentative reaction. This observation was in entire accord with the experiments upon pIant growth, flowers, etc. and wouId afford an expIanation of the faiIures noted in the baking of bread. Patzschke and Labhardt and HGssy have aIso found this substance to possess a marked stimuIative action upon the heart and vaso-
‘30
American
Journal
of Surgery
Rugh-Joint
constrictor tissues but the eIement of ductless gland secretions, which are recognized as being eIaborated in very greatly increased amounts at this period, may aIso have been the factor in the cardiac and vasoconstrictor effects noted by these investigators. Many surgeons have reported hemorrhage from scars, uIcers, wounds and sinuses during this period and the writer had one case in which a sinus near a quiescent tuberculous hip became active and discharged bIoody pus reguIarIy during the menstrua1 periods for nearIy a year. Hunner’ states: “It is we11 recognized by abdomina1 surgeons that symptoms of any organic abdominal Iesion are IikeIy to be exaggerated from the increased congestion at this period. Chronic appendicitis is a cIassic exampIe of this 1 CUrtiS'
SySteIYl, p. 725.
Conditions
JULY, 1934
influence as is aIso bIeeding from the stomach or lower boweI.” May it not be possibIe that this menotoxin described by Macht may be in part responsibIe for these aberrant manifestations and that, through its cardiac and vascuIar stimuIation, it may inAuence tissues which are aIready devitaIized or of much Iower vitaIity because of infection, inflammation or injury? So IittIe is known of the actual character of these biochemica1 products that the scientific mind has unIimited and unrestricted scope in its search for the unexpIained though interesting phenomena of human Iife and its functions. These laboratory observations certainIy open a fieId for investigation which may prove to be of greater importance and vaIue to the orthopedic surgeon than has hitherto been suspected.
JOINT CONDITIONS AS AFFECTED BY MENSTRUATION* J.
T.
RUGH,
M.D.
PHILADELPHIA
0
of the interesting phases of the practice of medicine Iies in discoveries which substantiate and verify the foIkIore and superstitious beIiefs Research is conof past generations. stantIy uncovering a physioIogica1, chemicaI or anatomical basis for what was once considered a supernatura1 phenomenon or accepted as a fact because substantiated by years or centuries of common beIief. Whatever the basis or origin may have been, observation and experience were the two empiric educationa standards which formuIated them and the accuracy and verity of the beliefs depended entireIy upon the reIative persona1 reIiabiIity of the observer. However, time, imagination and superstition added credence to an erstwhiIe suspicion unti1 fInaIIy it became an accepted truth to be handed down from generation to generation by oId men’s or oId women’s taIes and so to become a part of the Iiterature and credo of the community and nation. Such has been the case regarding menstruation in the femaIe. BibIicaI and medica records are repIete with mysterious taIes and observations regarding the vagaries and injurious effects of this norma physioIogica1 function of the femaIe, not only as concerns the woman herseIf but aIso as affecting other individuaIs and objects. Outstanding have been the beIiefs as to the injurious effects which the menstruating woman may exert upon the growth of ffowers and pIants, the baking of bread and, among some wiId tribes, upon other members of the community. Many curious comphcations occurring in NE
the individual herseIf have been reported in medica Iiterature in the past two centuries and they have been accepted as observed facts without any proved etioIogy. The most common of these complications has been hemorrhage in various parts of the body, anywhere between the eyes and ears and the toes. Vicarious menstruation is an accepted though unexpIained occurrence. It may manifest itseIf in many different ways but seems to occur more frequentIy as hemorrhage into a part of the body affected by disease or in which structura1 change has occurred by reason of injury of some character. The most common of these is the hemorrhage in tubercuIous women but it may aIso occur into the stomach, boweIs, or ot,her viscera. Hemorrhage into the knee joint has been mentioned once in Iiterature’ but in this case, there were aIso effusions into other cavities of the body though the knee was the onIy one which contained bIood. The writer has had 3 cases of exaggeration of joint conditions during menstruation, two invoIving the knee and one the wrist and the rarity of the occurrence in these parts prompts this report and a search for a possibIe expIanation of the phenomenon. CASE I. Mrs. E. R. was first seen.in June, 1916 when thirty-three years of age. She compIained of troubIe in her Ieft knee, of seven or eight years’ standing. There was some sweIIing present with stiffness and pain and these were always more pronounced before and during menstruation. On each side of the
1Ephemerides,
Acad. Nat. Curios., l~rz.
* Read at the combined meeting of the Orthopedic Section of the New York Academy of Medicine and the PhiladeIphia Orthopedic CIub held in New York. 126
Nra
SWCIES VOL.
XXV,
No.
I
Rugh-Joint
pateIIa and patelIar tendon could be feIt some thickened bodies which sIipped beneath the fingers. There was considerable distention and fluctuation in the upper cuI-de-sac and baIIotment of the patefIa. Motion was not so free as in the other knee and when the Ieg was heId in one position for a whiIe, a change of position always caused pain. X-rays made at this time showed no changes in the bony parts but some cloudiness in the entire joint. A diagnosis of chronic viIIous arthritis was made and operation advised but refused. LocaI treatment was then instituted and the patient consuItec1 another orthopedic surgeon who treated her unti1 June, 1919, when she again came under my care. Operation was again advised and accepted and on June 7, the joint was opened. When the thickened synovia1 sac was reached, it presented a brownish coffee or chocoIate coIor and had the typica appearance of the hemophifiac joint. When this was opened, there escaped about 300 C.C. of bloody fluid, but free from clots. The entire joint surface had the same brownish coIor and the articular edges were extensiveIy fringed with hypertrophic viIIi. The fat pads were enfarged and discoIored and had the patient been a maIe, the situation wouIc1 have been a most disconcerting one. The \-ilfi were thoroughIy removed as we11 as the fat pads and numerous thickened masses on the outer synovia1 wafIs. BIeeding was easiIy controffed and the joint was closed. No fixation of the part was used and the patient left the hospital in twefve days in quite good condition. Inquiry directfy after the operation showed that she had ceased menstruating the day fIefore the operation and as she had afways had an exacerbation of the condition at that time, it \vas considered a case of vicarious menstruation into a joint affected by viIIous arthritis. Some of the tissue was sent to the laboratory and the following report was returned: “The tissues are of a yellowish color which extends throughout the section. The tissue shows a rather Iarge amount of fibrous tissue, between the fibrils of which are many cells. The fibrous tissue is old, rather dense and stains weI1. The tissue is very ceIfufar, the cells being mostly mononuclear, either round or spindle-shaped. Many spaces appear throughout the tissue; some are empty, others are filfed with ceIfs which are giant cells. The fatter contain from tw.0 to six nuclei and are centrally placed. It is
Conditions our opinion that this tissue is infIammatory but by some observers might be regarded as a sarcoma, probabIy of the giant ceI1 \.ariety. There is no suggestion of tuberculosis; neither in the tissue or in the joint fluid coufcf any tubercIe bacilli be found. Diagnosis: Chronic inflammatory tissue.” It was a IittIe surprising that the laboratory examination did not reveal any hemorrhagic infiItration in the removed tissue as such a “hemorrhage is frequentIS associated with the presence of pigment in the matrix of the cartiIage and fibrous tissue as we11 as in the capsule of the norma cartiIage ceII.“r When the patient was questioned as to the exacerbations during her pregnancies, she stated that there were none but that the joint remained in about the same condition as obtained between the menstrual periods. She made a good recol-ery and resumed her work as a housewife, with very Iittfe trouble from her knee ancI no disturbance during her menstruations for about two years. At this time, she was doing housecleaning and was on her knees and cIimbing stepIadders and doing very hard work when, at her period, the swelling recurred. I saw her again in June, 1930 ant1 found the joint tissues much thickened, motion restricted and considerable soreness present. Because of the profound changes in the synovial membrane and the progressive disability in the joint, compIete syno\‘ectomy \vas advised but has not yet been accepted. A recent communication from her shows the knee condition to be practically unchanged from what it was three years ago. She gets about with moderate comfort but at each menstrua1 period there is increase in the swelfing and discomfort but subsidence of much of the swelling after cessation of the menstrual flow. CASE II. Miss 31. W’., aged twenty-one years, a coIIege girl, referred by Dr. Francis J. Dever of BethIehem, Pa., for knee troubIe and first seen in August, 1930. She complained of tenderness and slight swelling of the right knee for seven years and that it was growing worse. Th e patient stated that the trouble first deveIoped after a fall seven years ago byhen the knee was “knocked out of place,” and she was confmed to bed for three months following this injury. There was restriction of motion and discomfort which de\-eloped into pain following
128
American
JournaI
of Surgery
Rugh---Joint
sports and unusuaI use. Her genera1 heaIth was exceIIent and there was no history of any contributory infective process. The synovia1 sac was thickened, the infrapateIIar fat-pads were hypertrophied and there was some increase in the joint ffuid but not to the point of distension. A diagnosis of chronic synovitis with sIight infXtration of the synovia1 sac and hypertrophy of the infrapateIIar fat-pads was made and IocaI measures, such as heat, contrast baths, gentIe massage and wearing a compression bandage were used for severa months but without reIief. About October I, a ceIIuIoid Iegging was appIied and worn constantIy unti1 June, 193 I, with great comfort and reIief from pain, but no appreciabIe change in the joint appearance. At this time arthrotomy was advised and on June 13, she entered the Methodist HospitaI for operation. The joint was opened by a latera incision and when the synovia1 sac was reached, it was found to be somewhat yeIIowish in coIor and much thickened. When opened, there escaped about 35 C.C. of ffuid, more yeIIow than norma but containing no Iymph ffakes or other abnormal substance. When the joint was exposed wideIy, the synovia1 surface was found covered by a dirty grayish membrane which Iooked much Iike that seen in diphtheritic throats. This was easiIy removed with gauze on the finger and beneath it, the synovia1 membrane was of norma coIor though thickened. The possibiIity of another case with menstrua1 compIication at once occurred to us but the operation was compIeted by removing synovia1 fringes and the hypertrophied fatpads. The rest of the joint being of good appearance, the incision was cIosed. As soon as the patient recovered from the anesthetic, she was questioned as to any changes in or effects upon the joint during menstruation and she promptIy said “Yes, it is aIways much more sore and swoIIen at that time.” Her Iast period ceased about tweIve days prior to the operation so that the exudate or deposit was evidentIy due to hemorrhage at that time. UnfortunateIy none of this membrane was sent to the Iaboratory so that its composition is unknown, though macroscopicaIIy it was a fibrous exudate or deposit. Her recovery was uneventfu1 and at her next period, there was no evidence of joint sweIIing or IocaI reaction. She was again seen five months Iater and there was perfect comfort in the joint with no evi-
Conditions
JULY,1934
dence of any disturbance at the monthIy periods. On October 29, 1933, a Ietter was received stating that a few days previousIy, just at the cIose of her period, her knee began suddenIy to sweI1 and increased to nearIy twice its norma size and remained so in spite of IocaI treatments. AIso she had just returned from the Chicago Fair where she had done a great dea1 of waIking. This would indicate that the primary inffammatory condition has Ieft her with a vuInerabIe knee and that she wiI1 probabIy be permanentIy in danger of these periodic outbreaks. A rather extensive synovectomy wiI1 be advised if the troubIe continues as it is beIieved that compIete reIief cannot be secured without such an operation. CASE III. Miss J. de G., aged eighteen years, a heaIthy schoo1 gir1, referred by Dr. John MuIrenan, on account of sweIIing and discomfort in her right wrist. This first began when she was about fourteen years of age and has not invoIved any other joints. There was no history of injury or other etioIogic factor beyond numerous attacks of sore throat. She had matured at eIeven years of age and her menstrua1 history was perfectIy normaI. The reaction in the wrist was quite sIight for about one year and then became of sufficient severity to send her to her physician who diagnosed synovitis of probabIe toxic origin and advised remova of the diseased tonsiIs. This, however, was not done and the discomfort and sweIIing continued. The doctor then noted that the symptoms were aIways aggravated during menstruation. I saw her with him and concurred in his diagnosis of toxic synovitis which was increased at or by the monthIy periods. Ordinary care and genera1 hygienic treatment were used and after a year, the condition subsided and has now been quiescent for a year. This patient was recentIy examined and there was no evidence of any pathoIogic or functiona changes present in the wrist, either cIinicaIIy or by x-rays. A differentia1 bIoodcount showed a miId Ieucocytosis which is strongIy indicative of the constitutiona toxemia, having its origin in her tonsiIs which have not yet been removed. It wiI1 be of great interest to watch her further progress and note the possibIe persistence of the menstrua1 upheava1 upon the invoIved joint. NaturaIIy, the wrist is not exposed to the same degree of trauma as is the knee and this is proba-
Rugh-Joint I>Iy a large factor symptoms.
in the subsidence
of the
During the menstrua1 cycIe, there is marked constitutiona activity invoIving many organs so that the function must be Iooked upon as constitutiona rather than mereIy peIvic. There is commonIy a sIight rise in bIood-pressure foIIowed by a corresponding Iowering shortIy before the flow. The temperature is practicaIIy unchanged except in the presence of tubercuIosis. The nervous system becomes more sensitive as shown in the menta1 excitability and genera1 nerve irritabiIity and their Iessening after the Aow has become estabIished. Different individuaIs react differentIy and the particuIar systems or structures invoIved and the severity of the manifestations appear to depend greatIy upon the inherent strength or weakness of these parts. PhysioIogists are now endeavoring to determine the factors concerned with the estabIishment and continuance of menstruation, beIieving that if these are discovered, it wiI1 be possibIe to expIain and to more satisfactoriIy dea1 with the complications. There are practicaIIy three theories concerning this phenomenon and these may be either separateIy or coIIectiveIy concerned with the function. The first one is that menstruation is a cycIe or habit pecuIiar to the femaIe and which is coincident with or constitutes puberty and continues, unIess interrupted by pregnancy or disease, unti1 forty-five or fifty years of age and then ceases; that it is nature’s provision for the continuation of the species as without it, Iibido is absent, in the Iower animaIs, and especiaIIy there wouId be no union and procreation. This is mereIy a statement of fact and does not offer an expIanation of the phenomenon. The second theory premises that the ductIess gIands, chiefly the pituitary, the thyroid and the adrenaIs, are the actuating factors in the upheava1 and that the pituitary is the dominating factor in the function, or as expressed by a recent
Conditions writer, “the pituitary is the leader of the orchestra.” The third theory is that the ovary or its corpus Iuteum is or provides the actuating force of the function and that whiIe this structure is undoubtedIy aItered and influenced by the ductIess gIand secretions, yet it suppIies the A-ital substance or stimulus which, through the somatic and sympathetic nerve systems, produces the constitutional disturbances characteristic of this function. The researches of Macht, of Johns Hopkins, wiI1, if substantiated, throw Iight upon many of these curious observations. He ascribed many of these phenomena to a substance he caIIed menotoxin and which he found present in practically every secretion and excretion of the body. The bIood, red bIood-ceIIs, urine, sweat, tears, saliva and even the breath contained this active principIe which markedIy retarded pIant growth and Iife. Its inhibitive or retarding effects upon certain types of pIant Iife (Lupinus aIbus) presented a quite constant percentage and if his deductions prove correct, a credible expIanation wiI1 have been provided for former suspicions and Iegends regarding this function. One of his most striking experiments was made with yeast. Two pieces of equa1 size were given to women, one menstruating and the other normal. Th e yeast was kneaded by each with sugar and water in the paIm of the hand for about five minutes and the masses were then pIaced in two fermentation tubes and these pIaced in an incubator. In due time, there was a Iarge amount of gas formed in the tube containing the yeast kneaded by the norma woman whiIe the other one showed scarceIS any fermentative reaction. This observation was in entire accord with the experiments upon pIant growth, flowers, etc. and wouId afford an expIanation of the faiIures noted in the baking of bread. Patzschke and Labhardt and HGssy have aIso found this substance to possess a marked stimuIative action upon the heart and vaso-
‘30
American
Journal
of Surgery
Rugh-Joint
constrictor tissues but the eIement of ductless gland secretions, which are recognized as being eIaborated in very greatly increased amounts at this period, may aIso have been the factor in the cardiac and vasoconstrictor effects noted by these investigators. Many surgeons have reported hemorrhage from scars, uIcers, wounds and sinuses during this period and the writer had one case in which a sinus near a quiescent tuberculous hip became active and discharged bIoody pus reguIarIy during the menstrua1 periods for nearIy a year. Hunner’ states: “It is we11 recognized by abdomina1 surgeons that symptoms of any organic abdominal Iesion are IikeIy to be exaggerated from the increased congestion at this period. Chronic appendicitis is a cIassic exampIe of this 1 CUrtiS'
SySteIYl, p. 725.
Conditions
JULY, 1934
influence as is aIso bIeeding from the stomach or lower boweI.” May it not be possibIe that this menotoxin described by Macht may be in part responsibIe for these aberrant manifestations and that, through its cardiac and vascuIar stimuIation, it may inAuence tissues which are aIready devitaIized or of much Iower vitaIity because of infection, inflammation or injury? So IittIe is known of the actual character of these biochemica1 products that the scientific mind has unIimited and unrestricted scope in its search for the unexpIained though interesting phenomena of human Iife and its functions. These laboratory observations certainIy open a fieId for investigation which may prove to be of greater importance and vaIue to the orthopedic surgeon than has hitherto been suspected.