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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.


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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