THE NECROBIOTIC NODULES RHEUMATOID ARTHRITIS · the necrobiotic nodules of rheumatoid arthritis case in which the scalp, abdominal wall (involving striped muscle), larynx, pericardium

THE NECROBIOTIC NODULES OFRHEUMATOID ARTHRITIS

CASE IN WHICH THE SCALP, ABDOMINAL WALL (INVOLVINGSTRIPED MUSCLE), LARYNX, PERICARDIUM (INVOLVING MYOCARDIUJM),PLEURAE (INVOLVING LUNGS), AND PERITONEUM WERE AFFECTED

BY

RONALD W. RAVEN, F. PARKES WEBER, and L. WOODHOUSE PRICE

Much has been written about the nodules ofrheumatoid arthritis, which, though present in lessthan a quarter of the patients, ma) nevertheless beregarded as constituting an important, if not themost important, feature from the pathologicalpoint of view. Collins (1937) and others, includingParkes Weber (1943, 1944), Kersley and others(1946) have shown that the characteristic sub-cutaneous nodules consist of ioci of fibrinoiddegeneration and necrosis, surrounded by a borderof tissue reaction, notably by a palisade-like radiatearrangement of fibroblasts. Somewhat similarmicroscopic appearances have been described inpathological conditions of a different nature(granuloma annulare, necrobiosis lipoidica), buteven if the histological features of the nodules ofrheumatoid arthritis were absolutely pathogno-monic, one would still be far from the discovery ofthe essential pathogenic agent.

Allison and Ghormley (1931) made a great pointof what they called " focal collections of lympho-cytes'" in the synovial membrane of joints beingalmost pathognomonic of " proliferative arthritisof uncertain origin "-that is to say. of rheumatoidarthritis. But if one looks at their illustrations(for instance, p. 147, fig. 4; p. 169, fig. 3; andPlate VIII) one recognizes the presence (in these" focal collections ") of so-called " germ-centres "of Flemming. Now, surely such lymphadenoidfoci with typical " germ-centres " can hardly be.considered as pathognomonic of any special disease.Apart from their conspicuous presence in normallymphadenoid tissue (lymph glands, tonsils, thewalls of the vermiform appendix and intestines, theMalpighian corpuscles of the spleen), they form aspecial feature in so-called lymphadenoid goitres,and are also not rarely found in thyroids frompatients with Graves' disease. One of us (Parkes

F 6

Weber) has seen them in abnormal salivary glands.They constitute a conspicuous feature of cutaneouslymphocytomata (Epstein, 1935), and may be foundin various other pathological conditions (ParkesWeber, 1947).

Similarly, there is nothing absolutely patho-gnomonic in the painless lymphadenopathy of thesuperficial lymph-glands, which is present duringactive periods in many cases of rheumatoid arthritis,though seldom noticed by the patients themselvesand often not looked for by the examining doctor.It is " non-specific follicular lymphadenopathy "of toxic or infective origin, with marked enlargementof the " germ-centres " of Flemming (not to be con-fused with " follicular lymphoblastoma " of neo-plastic nature), and tends to disappear when thepatient's general and articular condition improvesand the disease becomes quiescent (Parkes Weber,1947, p. 38. case 4). Rochu (1946) thinks thatthis lymphadenopathy, together with the articularchanges and occasional splenomegaly, indicates thatwhat we in England call rheumatoid arthritis-which cannot be separated from the Chauffard-Still-Felty syndrome-is much more than a jointdisease and that the reticulo-endothelial system isobviously involved.As to possible pathogenic relationship between

rheumatoid arthritis and rheumatic fever andbetween their respective nodules (cf. Bennett andothers, 1940), there has been much discussion.Most of those who have studied the question -apparently have come to the conclusion that the twodiseases are clinically distinct and probably notdue to the same (still unknown) pathogenic agent.Dawson (1933), however, in his " Comparativestudy of Subcutaneous Nodules in Rheumatic Feverand Rheumatoid Arthritis " wrote: " These studies

. .lend further support to the conception that53

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ANNALS OF THE RHEUMATIC DISEASES

rheumatic fever and rheumatoid arthritis are inti-mately related and possibly different responses ofaffected individuals to the same aetiological agent."

In rheumatic fever the nodules mostly remainsmall and soon disappear. Small nodules in rheu-matoid arthritis also sometimes disappear rapidly,but most of the nodules, especially the larger ones,become chronic and are only slowly, if at all,-absorbed-doubtless owing to the formation of thecharacteristic necrotic foci surrounded by chronicreactive inflammatory and firm fibrous tissue.Fresh nodules may appear-a sign of renewedactivity-even in old quiescent and apparently"burnt-out " cases.

Case ReportHistory.-The patient, a woman, aged 62, was admitted

to the Royal Cancer Hospital under one of us (R. W.Raven) on March 14, 1947, on account of increasingdifficulty in breathing. This commenced about January,1946, and steadily progressed with increasing inspiratorystridor. Eventually the patient was suffering frombreathlessness whilst at rest.

In April, 1946, there was onset of dysphagia, withspecial difficulty in the swallowing of fluids, which wereoften regurgitated. There was also progressive loss ofvoice, which became more and more indistinct and of acroaking character.

In December, 1946, the patient noticed the appearanceof multiple lumps on her head. Whilst under observa-tion similar lumps developed over the abdomen. Therewere also nodules on the elbow-joints and hands, someof which probably dated from the commencement ofrheumatoid arthritis in 1916.From October, 1946, there wa$ increasing difficulty in

vision, associated with gross conjunctivitis, which laterprogressed until, by the middle of March, 1947, shecould only vaguely appreciate any object. There wasmarked loss of weight and energy, and the appetite waspoor. No symptoms related to the colon or gastro-intestinal tract were noted.The patient had no children, but had had five mis-

carriages. She had had rheumatic fever in 1905, andin 1916 showed the onset of progressive chronic rheu-matoid arthritis.

Condition on Examination.-Arthritic changes in-volved the joints of the arms and legs, with grossdeformity. The patient was noticed to breathe with amarked inspiratory stridor, with all the accessory respira-tory muscles in-action. There was obvious great loss ofweight.Numerous nodules were present in the subcutaneous

tissues of the scalp, some of which were attached to theskin and some attached deeply to the epicranial apo-neurosis. The nodules were most marked on the fore-head, but were scattered throughout the scalp. Theyvaried in size from 1 cm. to 3 cm. in diameter.The conjunctivae were pale, and there was an exten-

sive ulcerative scleritis with corneal involvement which, in

the left eye especially, had the clinical appearance of aMooren's ulcer.There were numerous hard nodules about the elbow

joints, attached to the skin, and on the left side ulcerated.*The subcutaneous tissue of the abdomen showed

multiple scattered nodules, whereas none was seen overthe chest.There was a painless lymphadenopathy of the super-

ficial lymph-glands, such as is often present during theactive stages of rheumatoid arthritis (see above).

There was a patch of dry gangrene on the tip of theright great toe, and no pulsation could be felt in eitherarteria dorsalis pedis.

Radiographic Investigations.-Radiographs of thechest showed bronchitic changes in the lungs and somecardiac enlargement. No abnormality detected onradiographic examination of the skull.

There were advanced changes of rheumatoid arthritisin all the joints, with marked osteoporosis and skeletaldeformity. A radiograph of the larynx showed a pro-jection from the posterior wall at the level of the epiglottis.

Haematology.-There were 4,660,000 red blood cellsand 8,000 white blood cells per c.mm. The Hb was75 per cent.; Wassermann and Kahn reactions werenegative. The erythrocyte sedimentation rate was40 mm. in one hour (Westergren).Blood urea, blood uric acid, serum calcium, serum

inorganic phosphorus, and serum phosphatase were allwithin normal limits. There was nothing abnormal inthe urine.Progress.-The patient developed signs of pneumonia.

Her condition deteriorated, and she died on March 30,1947.This patient had been seen by one of us (F. Parkes

Weber), who agreed that the case was one of advancedchronic nodular necrobiosis of the rheumatoid arthritistype. The biopsy tissue (see below) had been foundsuperficially to resemble that of a gumma.

Post-mortem ReportExternal Examination.-The body was that of a poorly

developed, poorly nourished, and extremely deformedwoman of about 60 years of age. A small surgical in-cision was seen on the anterior aspect of the right temple.In the left temporal region were three or four small, firm,circumscribed subcutaneous nodules. They did notfluctuate, and were not attached to the overlying skin.A number of smaller nodules were seen and felt beneaththe skin round the elbow and wrist joints and in theanterior abdominal wall. The degree of joint deformitywas considerable, and the wrists and hands displayed anexaggerated ulnar deviation with wasting of the inter-osseous muscles, presenting a picture of advancedrheumatoid arthritis. In the legs it was hardly possibleto move the ankle joints, and the left tibia showed analmost complete backward dislocation.

internal Examination.-The scalp showed no abnor-mality, apart from that already mentioned, and the skullappeared to be of normal thickness. The brain was

* One ofus (F. Parkes Weber) has since heard of two (unpublished)cases with ulcerated nodules of the rheumatoid arthritis type.

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NECROBIOTIC NODULES OF RHEUMATOID ARTHRITIS

normal in appearance. There was no meningitis orflattening of the cerebral convolutions. The ventriclescontained a normal amount of cerebrospinal fluid, andthe arteries at the base of the brain did not present anygross evidence of atheroma.The mouth was edentulous and the tongue, larynx,

pharynx, thyroid, and trachea presented no obviousmacroscopic evidence of pathological change, exceptinga few small submucous nodular thickenings in the regionof the glottis, particularly one on the epiglottis.The left lung was adherent at its apex. It was partly

collapsed by a left basal effusion and the visceral pleurawas covered by a fairly thick fibrinous exudate. The cutsurface of this lung showed the characteristic appearanceof collapse, and there was some evidence of bronchitis.Pulmonary emboli were not found.The right lung was also adherent to the parietal

pleura and a small amount of turbid fluid was found atits base. This lung also was covered by fibrinous exudatewhich had involved the mediastinum and pericardium;on the left side the diaphragm and the splenic capsulewere involved, producing an obvious perisplenitis.The pericardium was adherent over the anterior sur-

face of the heart; and, on forcible removal, both visceraland (to a less extent) parietal pericardia were found to bestudded with raised, whitish firm nodules of 1 to 10 mm.in diameter. There was apparently no calcification.The heart was normal in size and it showed some dilata-tion of the left auricle with a moderate degree of mitralstenosis. On the endocardial surface of the left auriclethere were some nodules of a similar nature to thosefound on the pericardium, although the process in thisinstance appeared to be of a minor degree. Furtherdissection of the heart was not done, with a view to pre-

serving it as a museum specimen, but what could be seenof the aorta and aortic valve did not show any obviousevidence of syphilitic aortitis. The heart muscle, in sofar as it was examined, did not appear macroscopicallygrossly abnormal.The diaphragm was thickened by a fibrinous exudate

which, although penetrating on the left side to involve thespleen, had not produced on the right side any noticeableperi-hepatitis.The liver was normal in size. Its cut surface did not

present any abnormal features and the gall-bladder con-

tained about 3 c.cm. of bile. Gall-stones were notfound. The bile-ducts were patent. The gastro-intestinal tract appeared normal thtoughout. Theadrenals were normal.The kidneys were normal in size and the renal pelves

showed no evidence of pyelitis; the capsules were easilystripped off, showing some degree of granulation of thekidney cortex. The ureters and urinary bladder appearednormal.The uterus and ovaries, together with their ligaments,

did not show any abnormal features.Cause of Death.-The cardiac condition was thought

to have been the cause of death.Summary ofNaked-Eye Pathological Findings.-Naked-

eye pathological examination showed pericarditis,endocarditis, and mediastinitis; bilateral pleural effu-sion; perisplenitis; and rheumatoid arthritis.

Histological ExaminationLung and Pleura.-The latter showed fibrous thicken-

ing, in which there were several areas of necrosis of vary-ing size from about O-1 mm. up to 5 mm. These showedsome peripheral palisading of nuclei, but in general theappearances were not so characteristic as in the nodulesin the heart muscle. Giant cells were inconspicuous.

In sections stained with Orcein much fragmentation ofelastic fibres by the necrotic process was discernible.

Rectus Abdominis Muscle.-This showed very clearlydemarcated necrobiotic nodules. Muscle bundles wereseparated, and in several instances the sarcolemma sheathwas either destroyed or invaded by proliferating cells.

Heart Muscle.-Sections stained with Van Giesonshowed interstitial fibrosis of the muscle fibres, partlyin association with necrobiotic nodules, but more fre-quently remote from the immediate vicinity of suchnodules. In addition there was some deposition ofcalcium salts. The nodules in the heart muscle weresharply demarcated and of characteristic appearance,the peripheral zone of radiating fibroblasts being parti-cularly clear.A careful search of the heart muscle remote from the

necrobiotic nodules failed to reveal any characteristicAschoff's nodes in the perivascular zones.

Spleen.-The splenic pulp was markedly congested,and the arterioles showed well-marked hyaline degenera-tion of their medial coats. Some perivascular fibrosiswas present, and slight atheromatous changes were seen.A notable feature was the presence of multiple confluentareas of necrobiosis in the thickened capsule. Thesepresented the characteristic morphology of the necro-biotic nodules of rheumatoid arthritis, though giant cellswere inconspicuous. The Malpighian bodies wereprominent.Liver.-Brown atrophy was present, and there was a

mild degree of cloudy swelling. Certain areas showedcongestion, but there was no gross pathological change.No fibrosis was discernible other than a mild degree incertain portal areas.Kidney.-The cortex showed patches of fibrosis and

lymphocytic infiltration associated with glomerularsclerosis and arteriolar sclerosis. The renal tubulesshowed well-marked stellate lumina produced by cloudyswelling.

Brain and Pituitary.-These showed no gross patho-logical change.

Larynx: Epiglottic Nodule.-The sagittal section inthe midline was passed through the epiglottis and baseof the tongue.

Microscopic examination showed multiple foci ofnecrobiosis in the sub-epithelial zones of the epiglottis,and also in the musculature of the tongue. These focipresented the characteristic histological picture asdescribed in the note on the general histology of thesenodules (see further on). Several areas showed hyalinedegeneration. Nuclear hyperchromia and pyknosiswere well marked. Nuclear palisading was present,and giant cells of the Touton type were frequent. Thecbaracteristic lesions were well marked among mucin-secreting accessory salivary glands. The involved tongue

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66 ANNALS OF THE RHEUMATIC DISEASES

musculature showed interstitial fibrosis, atrophy, andhyaline change.Nodule from the Forehead.-A nodule from the fore-

head (biopsy) showed necrobiotic foci surrounded byreactive cellular areas, containing multi-nuclear giantcells (some of Touton type).

Histology of the Nodules.-Characteristically thechange was multifocal. Typical lesions from the heartmuscle showed numerous minute foci of necrosis. Thesewere approximately 0 5 x I mm. in diameter. The centralzone showed pyknosis, karyorrhexis, karyolysis, and afine powdery deposition of calcium salts.Extemal to this there was a narrow zone where all

structure was lost and which remained almost unstainedby eosin. Immediately external to this structurelesszone there was some cellular concentration which tendedto show palisading of the nuclei and which gave thegeneral effect of cells radiating centrifugally from thecentral necrotic area. The cells concemed comprisedlymphocytes, plasma cells, histiocytes, and small multi-nucleated giant cells. Some of the latter were of Toutonform with a more or less complete peripheral ring ofhyperchromic nuclei; others bore a slight resemblanceto the tuberculous giant cell.

These centres of necrobiosis were in some cases iso-lated and occurred in small groups, each separated fromits neighbour by normal adipose or muscular tissue. Inother instances the necrotic foci became confluent,giving rise to elongated and tortuous masses whichpresented the characteristic histological features fromwithin outwards, as above described.We are greatly indebted to Professor D. S. Russell for

the following report." The specimens received had been fixed in formal-

dehyde and consisted of (1) a portion of heart muscle,with pericardium, measuring 2-8 x 11 x 1 cm. The peri-carIdlum was expanded by two opaque greyish-whitefirm nodules, the larger of which measured 0 7 cm. Themuscle showed no naked-eye changes. (2) A portion ofskin and subcutaneous tissues, from the elbow, measuring3-2 x 1-4 x 1 cm. Beneath the skin lay a nodular mass,1-4 cm. in diameter, of firm opaque greyish-white tissueof tough, somewhat fibrous consistency.One half of each specimen was embedded in paraffin

wax; frozen sections were prepared from the remainderand were stained with Sudan III. Unstained frozensections were mounted for examination with polarizedlight.

Microscopic Examination(1) Heart.-The visceral pericardium is everywhere

thickened by a slight increase of collagenous fibres,sparse infiltration with small lymphocytes and plasmacells, and an increase in small blood vessels which are

engorged. There is great focal expansion of this layerby three nodules. The largest shows a large centralacellular.area of serpiginous outline; much of it appearsfibrinoid, but in places, especially towards the periphery,there are many delicate collagenous fibres, and in placesill-defined granular areas packed with fragmentedleucocytes. This acellular central area is surrounded bya dense zone of short spindle, and angular, polymorphic

cells with round, oval, rod, or occasionally lobed,nuclei and abundant basophil cytoplasm. These cellsare often arranged as a palisade, their long axes radiatingtowards the central area. Small multinucleated giantcells are occasionally present. There are no foam cells.The cells are supported by delicate collagen fibres, whichin places coalesce to form small hyaline foci. At theperiphery of the nodule is an indefinite zone of infiltra-tion with small round cells blending with that in theremainder of the pericardium.

Frozen sections stained for fat show sparse, fineextra-cellular granules throughout the central necroticarea. Intra-cellular droplets of larger size are numerouswithin the cells immediately surrounding the necrosis,thereby rendering the zone conspicuous under low powersof the microscope. None is to be found in the peripheryof the nodule.With polarized light some of the intracellular Sudano-

phil material appears doubly refractive, but the centralextra-cellular granules are isotropic.The myocardium shows, in the interstitial tissue at the

extreme edge ofthe block, a nodule resembling the largestfocus in the pericardium. It is almost completely sur-rounded by bundles of muscle fibres, but, from thecurvature of the section, it must lie close beneath thepericardium. The muscle is normal, apart from granulesof lipofuscin at the poles of the fibre nuclei.

(2) The subcutaneous lesion from the elbow expands thedermis and is composed of aggregated nodules of varyingsize separated by narrow strands of connective tissue.The largest nodules, measuring up to 8 mm., are centraland are composed almost entirely of hyaline collagenoustissue. Many areas are devoid of cells; elsewheresparse fibroblasts separate the fibres. Near the centresof these larger nodules there are, however, a few ill-defined aceilular fibrinoid foci occasionally containingangular spaces. The margins of these foci contain deli-cate collagenous fibres.

Eight smaller nodules, occupying the periphery of theconglomerate mass, are lenticular and are far more cellu-lar. Though all are rich in collagen, the fibres are moredelicate. Central necrosis of a fibrinoid character isvisible in six, and the general appearances in these areclosely similar to those already noted in the pericardium.Several giant cells of Touton type are present in one ofthe remaining nodules, and in the compressed adjacenttissues of the dermis, which show a diffuse, mainly peri-vascular infiltration with lymphocytes, plasma cells, andlarge mononuclear cells. A few of the giant cells un-associated with nodules are conspicuously foamy, but apartfrom these no foam cells are present. The infiltrationextends about the appendages to the deep borders of theoverlying epidermis. The walls of blood vessels areunaltered.

In frozen sections the large hyaline nodules are for themost part devoid of Sudanophil material, but finely-granular aggregates occupy areas corresponding to thenecrotic fibrinoid foci; they are associated with large,unstained acicular and rhomboid cholesterol crystals.In the smaller nodules the amount and distribution ofSudanophil lipoid corresponds to that already describedfor the pericardium.

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NECROBIOTIC NODULES OF RHEUMA TOID ARTHRITIS 67

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FIG. 9.-Nodules on the patient's forehead.FIG. 10.-Nodules on the patient's abdomen.

FIG. 11.-Showing nodules on patient's right elbow and deformity of wrist.

FIG. 12.-Showing gross deformity of patient's left hand and wrist.

IFIG. 13.-Radiograph showing gross deformity of left hand and wrist with osteoporosis.

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With polarized light there is abundant doubly refrac-tive lipoid in the areas where crystals are present. Un-fortunately few of the smaller peripheral nodules arerepresented; in those present the amount of doublyrefractive lipoid appears somewhat greater than in thepericardial nodule."

DiscussionA case like our present one, in which the main

feature during the latter part of the patient's lifeconsisted in the almost universally distributed (bothsuperficial and visceral) characteristic nodules ofthe rheumatoid arthritis type, makes one wonderwhether rheumatoid arthritis should not be classifiedwith the infective granulomata, together with tuber-culosis, syphilis, and lepra, though the infectiveagent still remains unknown. A varying allergic-like reaction towards the infective agent (whateverit may be) almost certainly plays an importantpart in the symptomatology.

In regard to the involvement (in the present case)both of skeletal striped muscle (abdominal wall)and of heart muscle, it is interesting to study thepaper by Steiner and others (1946) on " Lesions ofSkeletal Muscles in Rheumatoid Arthritis". Theseauthors describe a condition of " nodular poly-myositis" in cases of rheumatoid arthritis, which,together with a kind of perineuritis, constitutes,they claim, an essential lesion in rheumatoid arthritis,for which they propose the term " nodular neuro-myositis". The size of the nodules varied fromthose easily seen by naked-eye inspection instained sections to very small (microscopic) ones." Lymphocytes and plasma cells were abundant,mast cells occasional, and polymorphonuclear cellsand eosinophils rare or absent." All the variouslesions of rheumatoid arthritis they regard as ofan inflammatory and granulomatous nature. Themuscular lesions, they find, differ from those foundin other diseases. They obviously differ in degreefrom the relatively gross necrobiotic nodules in ourcaseAs to the pericardial and heart lesions in the pre-

sent case, one may remember that clinical signs ofheart involvement of some kind are found in a greatmany cases of rheumatoid arthritis at variousperiods of the disease. Feiring (1945) reported anincidence of 29 per cent. (" carditis ") in twenty-seven cases of rheumatoid arthritis. It may beremembered that in Still's disease, which is an in-fantile or juvenile type of rheumatoid arthritis,Still himself reported the occurrence of pericarditis.

Incidentally, our case illustrates a point urged bySteiner and others (1946), namely, that in oldquiescent and apparently "burnt-out " cases ofrheumatoid arthritis one can never be sure that the

disease may not burst out again with renewedvirulence.One may ask whether a case like the present may

be related to certain rare conditions classed asexamples of " disseminated lupus erythematosus ",a disease, according to Baehr and Pollack (1947),expressing itself morphologically as a fibrinoiddegeneration of the collagen of the connective tissues.This, they say, " is but the structural symptom of thedisease, whose essential nature is yet to be dis-closed ". These authors speak of areas of fibrinoiddegeneration in the subendothelial connective tissueof the epicardium, which are responsible for peri-carditis; of the pleura, responsible for pleuritis;of the peritoneum, responsible for peri-splenitis orperi-hepatitis. In our present case we found noverrucose endocardial lesions of the so-called Lib-man type, nor the vascular lesions mentioned bythese authors. Clinically, indeed, commencingdry gangrene of the right big toe was noted, butunfortunately the corresponding blood vessels werenot examined post mortem.

Finally. in regard to lipoidal changes connectedwith the nodules, a lipoidosis of some kind mayundoubtedly be associated with symptoms andlesions of rheumatoid arthritis. As in the presentcase and cases described by Fletcher (1946), andKersley and others (1946), there may be, and prob-ably usually is, lipoid material present in thenecrobiotic nodules of rheumatoid arthritis type;Professor Russell is convinced that the sudanophilsubstances present in the nodules of our cases areno greater in amount, nor different in character,from what one might expect in such lesions withcentral necrosis. Secondly, there are rare caseswhich may be termed " lipoid rheumatism " or" xanthomatous rheumatism " (Parkes Weber andFreudenthal, 1937; Parkes Weber, 1943, and 1948;Layani, 1939; Layani and others, 1939). Grahamand Stansfeld (1946) described an exceedinglypuzzling case as one of " A Hitherto UndescribedLipoidosis simulating Rheumatoid Arthritis

Addendum: January, 1948Since this paper was completed, one of us (F. Parkes

Weber), through the kindness of Dr. G. B. Dowling, hasseen a middle-aged man with a typical nodular lesionover the left ulna, near the elbow, of the rheumatoidarthritis type. The patient likewise had a ringed swellingresembling granuloma annulare over the knuckle of theright index finger. This, like the elbow lesion, hadgradually developed during the last two years. Bothlesions were subcutaneous and situated over prominentbones, and both felt to palpation as if they consisted ofmultiple small nodules, each nodule probably represent-ing a minute necrobiotic focus surrounded by an area of

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CORRECHON

The paragaph after the summary does not belong to this paper. Thefollowing is to be substituted:We have unfortunately overlooked the mention of a similar case of

widely disseminated rheumatoid arthritis nodules with pericardial andpleural involvement (Bennett and others, loc. cit.).

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CORRECTION

The paragraph after the summary does not belong to this paper. Thefollowing is to be substituted:We have unfortunately overlooked the mention of a similar case of

widely disseminated rheumatoid arthritis nodules with pericardial andpleural involvement (Bennett and others, loc. cit.).

Documents

THE NECROBIOTIC NODULES RHEUMATOID ARTHRITIS · the necrobiotic nodules of rheumatoid arthritis case in which the scalp, abdominal wall (involving striped muscle), larynx, pericardium