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 {423} 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.