Definition And Description

Quite different from the affection last described is the one to which the name of Erythema nodosum has been applied. This disease is characterized by an eruption of reddish and somewhat acuminate tumors from the size of a small cherry to that of an egg, and usually situated upon the lower extremity between the knee and ankle. The number of tumors varies. There may be but half a dozen of them when the affection is confined to the lower extremities, or two dozen or more when diffused over other regions as the abdomen and up-per extremities. Not unfrequently the affection is ushered in by slight fever, which subsides as the eruption develops. At first the swellings are a little painful and tender on pressure, with a feeling of tension in the affected parts. The color is at first a light red, as from an active hyper-etnia; it soon becomes darker, however, and assumes a purplish tinge which gives place to a yellowish green, that in time fades away with the diminution of the swelling in the course of ten days or two weeks. The appearance presented is very like that of a bump on the forehead, so common in childhood as the result of a slight blow. It is this aspect that has given it the name of Dermatitis contusiformis. The tumors may not all appear on the first day of the eruption, but may take two or three days before the crop is all out. As the first crop subsides, a second may appear, as in the case of erythema multiforme, and even a third or fourth. prolonging the affection in this way for six weeks or two months. A high degree of inflammatory action is not commonly met with, and resolution by gradual absorption is the usual termination; but suppuration and ulceration have been observed in scrofulous cases by Hardy. Purdon also records (123, June, '72) an instance of this.

Erythema nodosum is peculiarly an affection of young adults from the ages of twenty to thirty, and most observers have encountered it more frequently in the female sex. It is very frequently accompanied with menstrual derangements, and sometimes would seem to be connected with rheumatism.

Diagnosis

The features of the disease are so characteristic that no difficulty need be experienced in diagnosis. In its declining stages it might, from its aspect alone, be mistaken for multiple contusions, but the history of the case would eliminate any doubt on this score.

Prognosis

The prognosis is uniformly good, except in the rare cases in which suppuration ensues.

Etiology

The frequent occurrence of Erythema nodosum in connec-n with menstrual derangements may be purely accidental, or the former may stand in a causative relation to the latter. We are inclined to adopt the latter view, especially as we have met with a case in which the affection occurred within a few days after the patient had purposely stopped the menstrual flow by vaginal injections of cold water. Its connection with rheumatism has also been insisted on by some, and certainly requires further investigation. It is perhaps met with in persons of robust \\< but certainly occurs more frequently in those who are anaemic and debilitated.

Treatment

Hebba says that as the disease will get well of itself in time, there is no special necessity for prescribing any treatment whatever, but if the patient insists on something being done, cold or warm applications with, perhaps, the addition of a little Goulard's extract may be ordered. The question in treatment, however, is not as to whether a disease will terminate by spontaneous recovery, but whether its course may be shortened, and the pain or other inconveniences of its presence may be lessened. This, I believe, can be done in the affection under consideration. Seen at the commencement, if there be the slightest febrile action, of elevation of temperature, aconite in apyretic doses should be given and continued for at least a couple of days; later, iron in moderate quantities is of service, and, perhaps, also the mineral acids. Locally, I apply compresses of Hamamelis for the first few days, to be succeeded by Arnica (root) as the lesions begin to assume the appearance of a bruise. An elastic bandage materially hastens the resolution of the tumors.

Spender recommends (135, 4: 19) a combination of sulphate of iron with a dilute mineral acid and very mild saline purgatives. He thinks that quinine and strychnine do little good by themselves in this affection but may assist the hematic powers of iron. Locally, he supports the limb with a flannel bandage, applied with considerable pressure. This is employed for purposes of compression, as well as for its calorific properties. Every third or fourth day the bandage is removed, and the limb shampooed with a lather of soap and hot water. Salt-water bathing is also recommended.

Wilson says (T7, 128) that the affection requires antiphlogistic regimen, a brisk purgative of calomel and colocynth at the commencement, then tonics and the mineral acids. As a local application, the nitrate of silver has been recommended by Chapman (138, '37).