Heberden's Nodes





The most familiar form is named Heberden's nodes, from the great

English physician who first made a special study of it. The affection

is characterized by an enlargement of the sides of the distal

phalanges with small, hard nodules, "little hard knobs", as Heberden

called them, developing at these points. They are more frequent in

women than in men. Evidently neither hard work nor exposure nor

excesses in eating or drinking occasions them. They occur in all

classes, the poor and rich, manual workers as well as professionals.

It is rare to find them on one hand alone, though it is not at all

rare to find them affecting solely the little fingers of each hand. I

have seen several cases where surgical intervention had been attempted

on one little finger because of the deformity produced when the node

originally appeared. When I asked if there was not some trace of a

similar condition on the other hand I was told there was not, yet I

have been able to show that the first signs, at least, of a

corresponding growth already existed on the little finger of the other

hand. In the two cases in which my attention was called to a slight

enlargement on one side before anything developed on the other, my

tentative prophecy that corresponding nodosities would grow on the

other side was fulfilled during the following years.



While this form of the disease is a true arthritis deformans it seems

to be entirely separate from the progressive forms which we shall

speak of later. The nodes increase in size and occasionally develop on

all of the fingers, but usually never spread beyond the phalangeal

joints. There is a tradition in the medical profession of

England, where this affection has been observed with care for some two

hundred years, that sufferers from these nodes commonly live to long

life. This is not founded on any theory, but is an actual observation.

There is also a tradition, though I cannot vouch for its truth, that

the people who are thus affected have some sort of immunity to

tuberculosis, or at least good resistive vitality against a rapidly

running tuberculous process.



I have had at least a score of Heberden's nodes cases under

observation for more than ten years and some of them for nearly twenty

years, and have been surprised at the slowness with which the process

develops. A year often makes no change in the size of the nodes, and I

have seen cases where after five years the photograph showed no

difference. The lesions are often exquisitely symmetrical so that the

question of the origin of the affection in the spinal cord constantly

crops up, for that is the symmetrical influence in the body. There

are, however, no other symptoms that point to involvement of the cord

in any way. Most of these patients have suffered more from worry about

it than from their affection. It is another case of "having many

troubles most of which never happen."



Some of my patients are physicians, and all of them have consulted

other, some many other, physicians. As a consequence, many of them

have taken to various diets, especially eliminating certain foods and

liquids with the idea that this might stop the progress of the

disease. I have never known any change of diet or any abstinence from

liquids or solids that seemed to make the slightest difference, though

I have seen a number of cases that were considerably worse than they

would have been if the diet had not been tinkered with to such an

extent as seriously to disturb nutrition.



The main disturbing feature of the affection is the dread of the

development of serious crippling conditions in the hands or in the

large joints.



As a rule, after a time the nodes cease to grow, and then a period of

remission sets in that lasts for many years and there may be no

recrudescence of the affection. This remission is delayed if the

patients allow themselves to run down in general health. It is

apparently hastened by getting the patients up to normal weight and

removing any factors that disturb their general health. If the

patients' minds are properly disposed, the neurotic symptoms that

sometimes develop as the result of over-solicitude about their

condition are done away with, the patients are more comfortable, and

even the progress of the disease is inhibited.





ACUTE PROGRESSIVE ARTHRITIS



The second variety of the affection is a general progressive arthritis

which usually begins with fever, redness, and swelling, involving

especially the smaller joints. The diagnosis of the disease can almost

be made on the fact that its favorite locations are the jaw and the

joints of the spine. It is a much more serious affection than

Heberden's nodes. In its beginning it often simulates acute

rheumatism. It occurs particularly in people who are run down for any

reason, in young women who have recently come to the country and are

working as domestics, in young men who have recently changed their

occupation from indoors to outdoors and are not used to the

inclemencies of the weather. On the other hand, it occurs rather often

in young persons of both sexes used to living and working out of

doors who take up an occupation in a damp interior.



The fever usually runs a lower course than that of genuine acute

articular rheumatism, the pain is not favorably affected by

salicylates, and the duration of the disease is generally longer. This

affection always leaves its marks on the joints and there are always

recurrences. It is, indeed, the confusion of this quite distinct

disease with acute articular rheumatism that has given the latter

affection the bad name it has in many minds as a producer of

deformities. Arthritis deformans or general progressive arthritis is

always a crippling disease; acute articular rheumatism has for its

surest diagnostic sign, when the complete history of the case is

known, the fact that it leaves no mark after it except, unfortunately,

that so often seen in the heart.





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