Necrobiotic nodules of rheumatoid arthritis type with lipoid deposition.

The incidence and structure of subcutaneous nodules in rheumatic fever and rheumatoid arthritis have been the subject of research for many years. In 1937 Collins published a paper on the subcutaneous nodule in rheumatoid arthritis, and in 1939 he reviewed in these Annals some of the work on the pathology of rheumatic fever and rheumatoid arthritis. He mentions the basic pattern of tissue change as coming under four heads-exudation, mesenchymal proliferation, connective tissue degeneration, and leucocytic infiltration. He remarks that this general pattern is an elementary one and cannot be regarded as specific, but that generally speaking it makes up a histological picture characteristic of rheumatism. To the connective tissue degeneration the name of " fibrinoid " degeneration has been given. This change is also part of the Arthus phenomenon, and is regarded as a basic type of tissue reaction in states of hypersensitivity. He also mentions the vascular lesions commonly found in rheumatic fever but only in the joints and subcutaneous nodules in arthritis. It seems now to be generally agreed that the typical subcutaneous nodules of rheumatoid arthritis all have a similar structure. This structure consists generally of a central area of fibrinoid degeneration and necrosis, surrounded by a cellular band, the most noticeable feature of this surround being a palisade arrangement of fibroblasts. The case to be described in this article falls only partly into this category, and it should be mentioned that Parkes Weber published a somewhat similar case, though differing in several features, in the Annals of 1944.