SYMPTOMS. - Preceding the appear ance of the lesions of an erythema nodo sum there is usually general constitu tional disturbance. Chills, with an ele vation of temperature, or myalgic or rheumatic pains may be encountered. According to Duhring, cedema may be one of the first symptoms, while visceral involvement—with, later on, lesions of the heart and kidneys—may be present. For the most part, the nodes are localized upon the anterior surface of the shins, along the line of the tibias, and are ar ranged symmetrically. They are also ob served, in exceptional instances, upon other parts, the arms and face, and I have recently observed a case in which the lesions were situated upon the chest, along the line of the ribs, and upon the abdomen. Pospelow, quoted by Elliot, noted similar involvement of the mucous membranes of the mouth. These nodes appear rather suddenly, developing rapidly, and are of a light or rosy red color, but later become darker in ap pearance, of a bluish or of a purplish tint. Appearing either singly (usually) or in crops, the process may extend over a period of from one to five weeks (or longer), although each individual lesion lasts only about six or eight days. While disappearing they assume various colors, from a yellow to blue or purple, and closely resemble a bruise. During their height they have a tense and shiny look, and give to the touch an indistinct im pression of containing fluid. They rarely suppurate, absorption generally taking place, although this result has been ob served by Haisholt and others. Dilata tion of the capillaries has been observed by Lewin and Unna, while Van Harlin gen has noted lymphatic involvement.
Hemorrhage has, according to Demme, been observed in a case in which gan grene also took place. They are always painful and at first are firm to the touch, although they soon become softer, as they are disappearing. Some authors have described an ominous form of the affection in which tuberculosis is noted. Occasionally erythema nodosum and ery thema multiforme are co-existent, espe cially that variety of erythema multi forme in which papules arc the predomi nating manifestation.
—While with a careful survey of the lesions presented, as well as the concomitant phenomena, little cause may exist for error in diagnosing ery thema nodosum, some instances do occur in which difficulty may be experienced.
Contusions are likely to be single and do not present those deep nodular forma tions. The cause can generally be deter mined.
Syphilis.—The syphilitic gummata, especially the non-ulcerating variety, which often resemble erythema nodosum, are sharply defined, indolent, and occa sion no pain.
Erythema nodosum, a variety of poly morphous erythema, occurs frequently in the course of known infectious mala dies as a secondary affection. Primary erythema nodosum results probably from a latent infection. _ Cutaneous manifestations, reproducing with absolute fidelity the clinical type of erythema nodosum, are met with in the course of syphilis. This erythema may be due to a coincidence, and may result from some infection superadded to syphilis; but it is most frequently determined by syphilis itself.
There exists between syphilitic ery thema nodosuin and gummata of the skin and subcutaneous tissues a series of intermediate affections producing between these two kinds of lesions an insensible transition, and showing that between these two clinical types there is only a difference in intensity in the anatomo-pathological process. Beur mann and Claude (Antiales de Derm. et de Syph., No. 4, '91]).
Erysipelas generally presents a hard, though diffuse, inflammation, instead of a more circumscribed character of swell ing.
Erythema Indure des Serofuleux is not painful, is asymmetrical, of longer dura tion, and tends to ulceration; occurs in scrofulous subjects.
ETIOLOGY.—Erythema nodosum is an affection of early life, although instances in which it has affected varying ages have been recorded. Out of a total of 10S cases, S. Mackenzie found 14 under 10 years of age, 69 between 10 and 30, 15 between 30 and 40 years, and 10 over 40 years of age. Comby has presumably re corded the youngest, 14 months old. Most authors consider that the spring and autumn contribute the greatest number. Rheumatism accompanied many cases. Malaria was found to be a possible exciting cause by Boicesco.