Widespread serous membrane involvement by rheumatoid nodules.

The characteristic cutaneous rheumatoid nodule, described fully by Collins (1937) and Bennett, Zeller, and Bauer (1940), is composed of a central area of fibrinoid necrosis around which develops an encircling corona of closely packed mesenchymal cells, the great majority of which appear to be fibroblasts (Collins, 1937), and external to this is a zone of inflammatory tissue. Lesions with similar histological features occur in the synovial membranes, and have been described involving serous membranes such as the pleura (Bennett et al., 1940; Baggenstoss and Rosenberg, 1943; Gruenwald, 1948), and Raven, Weber, and Price (1948), in whose case the peritoneum was also involved. Rheumatoid lesions have been known for some time to involve the pericardium (Baggenstoss and Rosenberg, 1944; Feiring, 1945; Clark and Bauer, 1947, 1948; Raven et al., 1948) the myocardium (Clark and Bauer, 1948), the ring and cusps of the mitral and aortic valves (Grzimek, 1932; Baggenstoss and Rosenberg, 1941; Bywaters, 1950; Sokoloff, 1953a), the aortic valve (Pirani and Bennett, 1951 ; Bauer, Clark, and Kfilka, 1951), and the tricuspid valve (Baggenstoss and Rosenberg, 1941; Gruenwald, 1948). Ellman (1947) and Ellman and Ball (1948) have described interstitial involvement of the lung in rheumatoid disease. It is therefore thought that the present case may be of interest as it illustrates the widespread clinical manifestations associated with rheumatoid lesions of the pericardium, myocardium, endocardium, all heart valves, sclera, visceral pleura, and dura mater. As far as can be ascertained involvement of the dura mater has not previously been recorded.