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Heberden S Nodes - Arthritis Deformans

joints, fingers, disease, seen, terminal, tendency, heberdens, chronic, instances and affected

HEBERDEN' S NODES - ARTHRITIS DEFORMANS.

When speaking of the differences in the clinical features of the more acute and chronic forms of arthritis deformans I pointed out that in the more chronic cases, such as are best seen among aged folk, there is much less swelling around the affected joints, and the outlines of the articular ends of the bones, which are deformed by lipping and by osteophy tic outgrowths, can be made out and even seen with great distinctness.

There is a subvariety of the polyarthritic form of the disease in which such chronic enlargements are limited to the terminal inter phalangeal joints, and the deformities so produced are universally described as Heberden's nodes, because it was Heberden who first described this condition. In his work published in 1805, which has been already referred to as containing one of the very earliest differ entiations of arthritis deformans from rheumatism and gout, this author wrote as follows : "I have never rightly understood the nature of the tumors attaining to the size of a pea, which are sometimes de veloped near the third joints of the fingers. They have certainly nothing in common with arthritis (gout), since they are met with in many persons to whom that disease is unknown. They remain throughout life, are devoid of all pain, and show no tendency to ulceration. The deformity is more conspicuous than the inconve nience that they cause, although the movement of the fingers is some what impeded by them." It is perfectly true that, as Heberden states, these nodes are often quite painless, and the patients are frequently more concerned by the disfigurement which they occasion than by any other trouble to which they give rise.

In many cases the development of Heberden's nodes appears to be nothing more than a senile change; and there is usually no ten dency to further extension of the disease. Sometimes they are met with in association with the local form of arthritis deformans in the hip or shoulder joints.

The nodes have their origin in osteophy tic outgrowths upon the articular ends of the bones, and the affected joints exhibit, as Char cot and others have shown, the ordinary changes which are produced by arthritis deformans. In the most typical cases two bony nodules are situated symmetrically upon the dorsal aspect of the terminal joint, one upon either side of the middle line, but where the morbid process is more active the swelling may be more uniform, and the entire joint may exhibit a fusiform enlargement.

Sometimes the nodes are greatly increased in size by small cystic swellings which may appear translucent when examined against the light, and which most probably consist of hernial bulgings of the synovial capsules of the joints. When the patients are led to punc ture these cysts, a clear viscid fluid exudes.

In some instances there is a marked lateral deflexion of the ter minal phalanges, and when this is the case the deflexion, unlike that of the fingers as a whole, is always toward the radial side.

The terminal joint of the thumb usually escapes even when all the fingers are affected.

The so frequent limitation of the disease to the terminal joints of the fingers may be regarded as a particular instance of a general law, to which, however, there are numerous exceptions, that arthritis de formans tends to begin peripherally.

Although seldom acutely painful these nodes may cause marked limitation of the movements of the affected joints, and thus greatly im pair the utility of the hands for any delicate movements. Like the other forms of multiple arthritis defornaans they are much more fre quently seen in women than in men.

Charcot found that Heberden's nodes were in a considerable num ber of instances associated with malignant growths, especially of the uterus. Seeing that there is certainly a connection between the ar ticular lesions and uterine disorders, it appears probable that malig nant disease may have some share in their causation, but there is little evidence of any connection between the disease under discussion and cancer y ad cancer, nor, as far as I am aware, has this point been dwelt upon by any other observer.

A far more complicated question is presented by the relationship of Heberden's nodes to gout. As we have seen, Heberden himself pronounced very emphatically, and probably too emphatically, against the existence of any such connection, but since his time a number of physicians, and among them Begbie, have maintained the opposite thesis. Sir Dyce Duckworth believes that in some instances the nodes are certainly of gouty origin, and Dr. Emil Pfeiffer," of Wiesbaden, while admitting that they are to be found in many per sons who have never suffered from actual articular gout, maintains that their presence always affords evidence of a gouty tendency, either inherited or acquired. This conclusion he bases upon the re sults of the application of his uric-acid filter test to the urine of the patients, a test the value of which for diagnostic purposes has been seriously questioned by Sir William Roberts and others.

Pfeiffer makes the further statement that in true arthritis defor mans the terminal joints of the fingers always escape, a statement which is certainly at variance with common experience.

Dr. Kent Spender, of Bath," strongly maintains the alternative. view, and although I have certainly seen cases in which the develop ment of Heberden's nodes has been associated with unquestionable evidences of a gouty tendency, I find it difficult to doubt that in the great majority of instances they are manifestations of an extremely chronic form of arthritis deformans.

They are perhaps most commonly met with in elderly women of the lower orders, who have spent a long life in more or less strenu ous manual labor, and it is not easy to imagine that in such cases there is constantly an underlying gouty tendency in view of the fact that the less questionable manifestations of that tendency are exceed ingly uncommon among such patients.