Robert M. Stecher

Heberden Oration Heberden's Nodes. a Clinical Description of Osteo-Arthritis of the Finger Joints

It is indeed a great honour to be invited to deliver the Heberden Oration and to thus be linked with such medical scholars as have appeared in this role in the past. It is hoped that they will not feel uneasy at being forced thus to be associated so intimately with me! It is indeed a happy occasion to be invited to talk to the Heberden Society which includes among its membership so many close friends. It was my pleasure to be a dinner guest at a meeting of the Society in 1947, when Dr. Copeman was President. Above all, it moves me deeply to have this opportunity to pay my respects to the man you have chosen as your patron, William Heberden, after whom your Society has been named. I, too, quite independently, chose him as my patron over 15 years ago when starting to study Heberdens nodes. My attempt to answer a simple question, which I thought might take several months, started me on a quest which is still continuing. My talk to-day is about what Heberden called digitorum nodi, which have come to be known throughout the world as Heberdens nodes. During his lifetime Heberden was a leading clinician, a successful practitioner, an author, and an essayist. He was the first to study and describe angina pectoris. His commentaries on disease, which were written in Latin, were translated into English and published posthumously. So far as I can find what he wrote amounted to 79 words in English about enlargement of the fingers (Heberden, 1803):

Anatomical Variations of the Spine in the Horse

The vertebral counts of the thoracic, lumbar and sacral spines of 190 horses and of the sacral and lumbar spines of 256 horses and classified into 9 species are given and the variations are shown. The cervical spine always had 7 vertebrae. While 18 is the usual number of thoracic vertebrae, 17 were found in 18 and 19 in 11 of 190 specimens. Nineteen thoracic vertebrae were found in only 11 of the specimens but of these 11 instances, 9 occurred among 32 spines of the Prjevalsky horse. The domestic horse, Shetland pony, zebras, Arabian horses and hybrids normally have 6 lumbar vertebrae, the donkeys and hemiones have 5 but exceptions were found in all classes. The Prjevalsky horse has 5, or 6 equally divided. It may be proper to think of the Prjevalsky horse as having normally 6 lumbar vertebrae with a high incidence of dorsalization of L1. The sacra usually have 5 vertebrae, this number having been counted 176 times, but 4 vertebrae were counted 49 times and 6 vertebrae 9 times. Caudal vertebrae are often fused with the sacrum making a single functional unit. If such fused caudal vertebrae and transitional sacro-caudal vertebrae are counted as parts of the sacra, of 52 horses with 5 lumbar vertebrae, 2 had 4, 30 had 5, 16 had 6 and 4 had 7 sacral segments; of 180 horses with 6 lumbar vertebrae, 18 had 4, 110 had 5, 44 had 6 and 8 had 7 sacral segments. Horses with 5 lumbar vertebrae had longer sacra, average 5.41, than horses with 6 lumbar vertebrae, average 5.23. The shortest sacra were found in Shetland ponies, horses, Arabians and Prjevalsky horses. The longest sacra were found in Grevy zebras, zebras, donkeys and hemiones. Variation in one portion of the spine results in compensating changes in the neighboring areas.

Heberden's Nodes: The Clinical Characteristic Of Osteo-Arthritis Of The Fingers

William Heberden was a prominent English physician of the eighteenth century whose name is associated with several diseases. His most important contribution was read at the Royal College of Physicians on July 21, 1768, and was printed in the Medical Transactions in 1772. This description of angina pectoris was of itself of sufficient importance to assure him of lasting fame. He later published a book in which he described enlargement of the fingers, a condition with which his name has since been uninterruptedly associated. The disease itself is benign and insignificant but references have been made to Heberdens nodes in nearly every study on arthritis which has appeared subsequently. His name has been so intimately associated with arthritis that he has become the patron saint of an organization devoted to the study ofjoint disease, an association called by his name, the Heberden Society. The present paper, devoted to this form of arthritis named for him, is a review and summary of studieson Heberdens nodes which have previously been reported in detail. Heberdens original description is so short that it is reprinted in full (Heberden, W., Jun., 1803): *

Ankylosis of the finger joints in rheumatoid arthritis.

The ordinary manifestations of rheumatoid arthritis are well known and readily recognized. They are subject to wide variations and, as they deviate farther from the conventional picture, diagnosis becomes difficult, doubtful, or even impossible. The aetiology is unknown and proof of diagnosis is lacking. Even the proposed diagnostic criteria for rheumatoid arthritis (Ropes, Bennett, Cobb, Jacox, and Jessar, 1957) have not completely eliminated the difficulty, although they have made greater uniformity of classification possible. Under such circumstances, doubtful cases conforming to some diagnostic criteria but not to others are of considerable interest and often worthy of detailed study. Bony ankylosis of joints is a characteristic result of rheumatoid arthritis in a small proportion of cases, but it is non-specific for the disease. Several cases in which ankylosis of the finger joints has occurred or has been an outstanding feature have been observed which seem worthy of further attention and will be described here. In two such cases, ankylosis of the interphalangeal joints of the fingers were observed in long-standing, generalized, and severely crippling rheumatoid arthritis. These cases are described briefly for comparison. Two other cases, however, have been followed for several years, one through a period of soft tissue inflammation and bone destruction, progressing into ankylosis. The trouble with the fingers has been the outstanding complaint. No other joints have been involved, general health has not been impaired, and since the inflammation has subsided, immobility of the fingers has been the only complaint.

Cortisone in the Treatment of Degenerative Joint Disease of the Hip

Degenerative joint disease of the hip, often called osteo-arthritis, or malum coxae senilis, a clinical condition known for the pain and deformity it causes, is the most disabling form of degenerative joint disease. The cause of the condition is unknown; trauma, an old dislocation of the hip, a slipped epiphysis, Legg-Perthes disease, and senescent degenerative changes have all been suggested (Steindler, 1951) as the most likely factors in its formation. The pathology comprises fibrillation, erosion, and eburnation of the articulating cartilage and the production of exostoses of bone. The femoral head may show variable degrees of flattening, and cystic changes may be localized in it as well as in the acetabulum. Sclerosis of the acetabular rim is also seen. Later fibrosis of the joint capsule and peri-articular tissue may also occur and lead to further restriction of joint mobility. Because of the dramatic effects of cortisone in rheumatoid arthritis, its use experimentally in malum coxae senilis seemed worthwhile even though the pathology of the latter disease differs markedly from that of rheumatoid arthritis. This series of experiments was also prompted by the differences in clinical results following treatment of degenerative joint disease (including malum coxae senilis) with ACTH and cortisone as reported in the literature. Hench and others (1950) reported a patient with degenerative joint disease of one knee who received cortisone for the treatment of leukaemia cutis, and noted relief of pain and stiffness of the involved knee. Boots and others (1951) reported the treatment of eleven patients with malum coxae senilis; they observed subjective improvement in ten patients and increased range of motion in all patients. Brown and others (1951) reported their observations after treating eight patients with malum coxae senilis; two were improved, while six obtained neither subjective nor objective benefit. Thorn and others (1951) described alleviation of symptoms in a patient treated with ACTH who had generalized degenerative joint disease with involvement of both hips. Dale (1950a, b) reported treating two cases of osteo-arthritis who experienced dramatic relief of symptoms. These published reports suggest the need of a controlled study in the therapeutic evaluation of this condition.