Reprinted from the 
University Medical Magazine, 
January, 1890. 
SUBCUTANEOUS RHEUMATIC NODULES. 
By William A. Edwards, M.D., 
San Diego, California. 
Fellow of the College of Physicians of Philadelphia; American Pediatric, and 
Pathological Societies; formerly Instructor in Clinical Medicine, 
University of Pennsylvania ; Physician to St. foseph's Hospital, 
and Associate Pathologist, Philadelphia Hospital, etc. Reprinted from the 
University Medical Magazine, 
January, 1890. 
subcutaneous rheumatic nodules. 
By William A. Edwards, M.D., 
San Diego, California. 
Fellow of the College of Physicians of Philadelphia; American Pediatric, and 
Pathological Societies; formerly Instrtictor in Clinical Medicine, 
University of Pennsylvania ; Physician to St. foseph's Hospital, 
and Associate Pathologist, Philadelphia Hospital, etc. 
Among the rare manifestations of rheumatism are to be classed the devel- 
opment of fibrous nodules in the subcutaneous tissues-rare, however, only in 
adults, as children seem to be peculiarly prone to their development. 
Some years ago the committee on the collective investigation of disease, of 
the Medical Society of the State of Pennsylvania, sent out two thousand in- 
quiries requesting information regarding rheumatism and its many and varied 
manifestations, and, as an illustration of the rarity of the condition that we 
are considering, but seven instances of the occurrence of rheumatic nodules were 
noted.1 In my own experience of over two thousand cases of rheumatism ob- 
served in the city of Philadelphia, I have never seen an illustration of it. 
The case which forms the text for this communication was admitted to the San Diego 
County Hospital, Sept. 1889,2 and has been rheumatic for many years. The nodules are 
four in number, and are situated as follows : one in close proximity to the second joint of 
middle finger of right hand, another just below the left internal malleolus, and one below 
the left elbow joint, and another three inches below it. They were slow in development, 
painless, but in two instances were in close proximity to painful joints, which were red, 
tender, and swollen. The nodosities were not at all tender, but were firm, elastic, movable 
and quite subcutan' us ; they were all about the size of the ordinary chestnut. There were 
no murmurs, dilatation nor hypertrophy ; the arteries were somewhat stiffened, but the man 
was qu Le 55 years old. 
A better description cannot be given than by quoting Howard's3 abstract of 
the statements of Barlow and Warner*: " The nodules may vary in number from 
one to fifty, and in size from that of a pin's head to the volume of an almond, and 
are subcutaneous, firm and elastic, painless, and freely movable. They are 
not usually attached to the skin, but to the tendons, deep fascia, peri- 
cranium, periosteum, etc.; the integument over them is free from heat, redness, 
and infiltration, although, exceptionally, tenderness on pressure and slight 
redness may exist over them. They are found most frequently on the back 
of the elbow, the malleoli, and margins of the patella, but occur occasionally on 
the extensor tendons of the hand and foot, the scapular spine and iliac crest, 
1 Report of Com. on Col. Investigation of Disease. Edwards, Soc. Trans. 1886. 
2 I am enabled to report the case through the courtesy of Dr. J, P. Lefevre, Physician to the Hospital. 
* Pepper's System of Mdicine, vol. ii. p. 43. 
4 Transactions International Medical Congress, Lond. vol. iv. pp. 116-128, 1881. 2 
EDWARDS, SUBCUTANEOUS RHEUMATIC NODUEES. 
the temporal ridge and superior occipital curved line, the ear, etc. These 
nodules occur singly or in clusters, and are often symmetrical ; they are very 
rapidly developed in crops or in succession, and last sometimes for a few hours, 
more frequently from three or four days to four or five months, or even eighteen 
to thirty months. The original formations may disappear, and be succeeded 
by fresh ones ; and sometimes when no longer perceptible by touch, they may 
be found post mortem. Their development is unattended by pyrexia, unless 
pleuritis, pericarditis, or other conditions coexist to which the pyrexia might 
be referred. These nodosities do not appear to suppurate or ossify, or become 
infiltrated with urate of soda, and, histologically, they resemble organizing granu- 
lative tissue. ' ' 
There can be no question of the intimate relation that these bodies bear to 
the rheumatic condition. Barlow and Warner1 found evidences of rheumatism 
in 25 out of 27 cases ; in all of the 27 cases the heart was affected, and 10 pre- 
sented chorea. Barlow,2 in a later communication, further remarks that there 
was some morbid condition in every one of the 27. The association of erythema 
marginatum and subcutaneous nodules has also been noticed, indeed it has been 
demonstrated that there is a certain histological relation between these nodular 
formations and the vegetative formations upon the cardiac valves in cases of 
rheumatic endocarditis. Recently Money has found in a case of rheumatic 
nodules, where there was extensive pericardial adhesion, a distinct node invad- 
ing the heart substance extending from the pericardium inwards. The pres- 
ence of these nodules and their association with rheumatism has also been noted 
by Hillier,3 Jaccoud,4 Froriep,5 Sauvage and Chomel,6 Troisier and Brock,7 
whose paper contains a short bibliography, Mackenzie and Dyce Duckworth8. 
has also observed two adult cases, in one of which the nodules were 
very numerous. 
The selective site of these nodules in the fibrous tissues, their constant as- 
sociation with rheumatic manifestations, particularly with heart disease, and 
furthermore their liability to spontaneous disappearance, and their tendency to 
recurrence and relapse, leave but little doubt of their true nature. Cheadle, 
in his most recent communication upon the subject already referred to, indeed, 
goes so far as to state that their chief association, in children at all events, is 
with endocarditis and pericarditis ; it is his experience that they seem to appear 
concurrently with the endocardial inflammation, and when they are numerous 
and recurrent are to be considered of grave import ; during the last few months 
he has observed " four cases in which plentiful and persistent evolution of nod- 
T Loc. cit. 
2 British Medical Journal, Sept. 15, 1883, p. 511. 
3 Cheadle, Keating, Hncyclop. vol. i. p. 801. 
4 Path. Interne, ii. p. 546, 1871. Howard, loc. cit. 
6 Die Rheumatische Schwiele, Weimar, 1843. 
6 Howard, Ibid. 
7 Rev. de Medicine, t. i. 297-308, 1881, 
8 Clin. Soc. Proceedings, Load. vol. xv. 1883 
Doc. cit. EDWARDS, SUBCUTANEOUS RHEUMATIC NODUEES. 
3 
ules in almost continuously successive crops has proceeded pari passu with pro- 
gressive endocarditis and pericarditis to a fatal issue. The eruption of subcu- 
taneous fibrous nodules, then, in any case, whether of recognized rheumatic 
arthritis or chorea or erythema marginatum, or appearing alone, must be re- 
garded not only as a sign of the existence of a rheumatism in some form, but 
also as gravely suggestive of the coexistence of endocarditis, and that a similar 
change to that observed in the fibrous tissues beneath the skin may be proceed- 
ing unseen in the cardiac valves." Histologically, these nodules consist of 
fibrous tissue, they may have abundant vessels or be slightly vascular, they 
rarely occur in the vicinity of a joint which is actively inflamed, or contains 
an effusion. 
The accompanying table will serve, in a concise manner, to illustrate the 
general characteristics of a rheumatic who presents the nodular formations ; it 
is compiled from my report to the State Society,1 but is unfortunately silent 
in four of the cases as to the condition of the heart. 
Addendum.-Just as this paper is finished, another case has come under 
my observation. 
Miss K. T., set. 27, a native of Ceylon, the daughter of English parents ; father was an 
officer in the English army, and died of dysentery in Ceylon ; mother died of phthisis. 
Patient came to San Diego two years ago, and to my private hospital, in June last, on ac- 
count of incipient phthisis and rheumatism ; four weeks ago patient had an attack of rheu- 
matic polyarthritis, confined to smaller joints, more particularly to both feet. A few days 
ago she called my attention to a subcutaneous nodule situated on the dorsal surface of the 
right hand, on the line of the tendon of the middle finger, and a similar growth in a like 
situation upon both of the feet. The growths partake of the general characteristics as de- 
scribed above ; they are, however, somewhat painful, particularly on pressure; the patient 
presents a well-marked history of hereditary rheumatism. 
1 Loc. cit. table of cases of subcutaneous rheumatic noduees. 
6 
3 
o 
M 
<D 
CD 
Age. 
Occupation. 
Temperate 
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h 
7 
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Atmospheric 
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Exposure 
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damp, 
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1885. 
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west. 
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Feb'y, 
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Feb. 10, 
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18 
Servant. 
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Juneis, 
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6 
Female 
45 
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Tem- 
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To 
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Mar. 25, 
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12 
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To 
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Oct. 7, 
1885. 
Oct. 8, 
1885. 
Severe. 
Many 
Fixed. 
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joint 
HEART AFFECTIONS. 
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