July 4, 2011

Dear Cyndy,

After I received your inquiry about intraarticular steroid injections, I searched the Internet on the subject of complications from this surgical procedure, and, somewhat impulsively, forwarded to you the relevant URL. As with all medical advice, it would be foolish of me to express an opinion about the therapy of _your_ knee, unless I were in fact responsible for the treatment, and even then, not until I had obtained a history, performed a physical examination, and obtained a report of the X-ray findings. All I can responsibly say is that intraarticular injections are surgical procedures with uncertain consequences of benefit and harm; and that before submitting to such an operation, you should obtain Victoria's advice and consent.

My own view on the subject, without reference to any particular patient, is that the rationale of intraarticular injections of steroids for non-inflammatory "degenerative joint disease" as opposed to inflammatory rheumatoid arthritis is uncertain at best. Inasmuch as symptoms fluctuate, the benefit is difficult to assess, and complications would tend to be masked by the underlying pathology. It is not at all clear how much of the purported benefit would be pharmacologic consequence of the steroid, as opposed to a non-specific acupuncture effect simply from local stimulation by needle puncture.

I would distinguish between arthritis induced limitation of motion which I would try to treat with exercise and/or physical therapy, and pain. Although pain is "caused" by peripheral disease, as of a joint, it is "experienced" centrally, in the nervous system, where its intensity is modulated by poorly defined chemical substances called "endorphins".  When pain in a joint fluctuates, (or improves after intraarticular injection) such fluctuation or improvement may be consequence of enhanced endorphin activity in the brain or the spinal cord rather than of changing disease in the affected organ.

A relevant experience of my own occurred four nights ago, after I had decided to celebrate a strenuous afternoon of house-painting with two 12 oz. bottles of beer at bedtime. Whether propter hoc or only post hoc, I can't say with certainty, but pain in my arthritic right hip which had dutifully acquiesced to several hours on the ladder, kept me awake most of the night, only to disappear with the morning light, once the alcohol had been metabolized. My interpretation is not that the alcohol seeped down into the hip joint to cause it to ache, but rather that the unaccustomed alcohol had somehow interfered with the endorphins' normal suppression of pain. That's merely a guess; I can't prove it, but I'm not going to repeat the experiment. My point: chronic pain is a mental, not a mechanical phenomenon, and can seldom be alleviated by purely mechanical means.

You asked about Benjamin and Leah. We see very little of them.  Benjamin, now 18 years old, an excellent trumpeter, though less inspired than his older brother, has been admitted to Dartmouth to which he was attracted less by its scholarly renown than by its proximity to skiing in the White Mountains. He has been a less than ardent student, but is wonderfully intelligent and touchingly sympathetic to all living creatures from Leah's rabbit on up. His ardor for sports has been dampened somewhat by the circumstance that various coaches deemed him too refined and too intellectual to permit him as active a role in the games as he wished.  His girl friend jilted him a year ago and taught him a lesson which he seems to have taken to heart.  He spends much of his time with "friends" who seem proper and respectable, but are not well known to the family.

Leah, now 16 years old, seems always to have been to tallest, most competent and most self assured member of her class of schoolmates from kindergarten to high school, where she is now a sophomore.  They voted her the girl most likely to succeed Barack Obama.  This eminence is attributable in part to the calendar, in that she was born 15 days too late to be enrolled with children more nearly her age. Margaret, reading over my shoulder, adds that Leah's prominence is also a reflection of her flaming red hair. Margaret also notes that of the four, Leah was the most interested in her grandparents, until the day that she was given a cell phone, which changed her life. Until about a year ago, Leah's passion was horseback riding, in which her parents, - wisely I believe - indulged her by ferrying her to a Concord farm at very regular intervals. You will agree that at age 15, a passion for horses is much to be preferred to a passion for boys. Next, Leah took up fencing, but only briefly, and has of late devoted her not inconsiderable energies to sculling on the Charles. Leah's most impressive achievement is her virtuosity on the French Horn, which she plays with much assurance and empathy. Not long ago she performed in Beethoven's 7th, in Sanders Theatre, whether with the Boston Youth Symphony or the Harvard Radcliffe Orchestra, I'm not sure.  Nathaniel, who is now the family expert in such matters, has pronounced her at the threshold of a soloist career, - the name that was dropped was of Dennis Brain.  Her academic work is first rate.  She'll have no trouble finding a college.  My only concern for Leah is Herodotus' misgivings about Polykrates, that supremely fortunate King of Samos, echoed in Schiller's poem "Der Ring des Polykrates," (the first poem I learned by heart):

Mir grauet vor der Goetter Neide
Des Lebens ungemischte Freude
Ward keinem Irdischen zu Teil.

(I dread the envy of the gods, 
Life's unmixed bliss
Will be imparted to no mortal.)

You and Ned stay well, and beware of men (and women) in white coats.

Jochen

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