ERYTHEMA INDURATUM¹

Synonyms.—Erythema induratum scrofulosorum; Erythème induré des scrof-
uleux (Bazin); Erythème noueux chronique des membres inférieurs (Besnier).

Definition.—A sluggish chronic disease, usually of the leg, char­
acterized by the more or less continuous formation of subcutaneous
nodules, which enlarge to variable size, become purplish or purplish red
in color, and terminate after long duration in absorption or necrosis.

Symptoms.—The disease, first clearly described by Bazin, and
later by Besnier, Feulard, Colcott Fox, J. C. White, and others, is
usually slow and insidious in its appearance, presenting a symptoma­
tology resembling both erythema nodosum and syphilitic gummata.
Several or more nodules are usually found about the legs, and, most
frequently, on the lower calf region, and, as a rule, at the sides and
slightly posteriorly. They have been, however, observed on the entire
leg region, and also on the lower part of the thigh. The lesions are first
not perceptible to the eye, but are felt on palpation as deep-seated, hard,
indurated, pea-sized nodules. Gradually in the course of days or weeks
enlargement ensues, and they reach the size of a small or large cherry or

¹ Literature: Bazin, Léçons sur la scrofule, second edit., 1861, p. 146; Besnier,
Annales, 1889, p. 25 (case demonstration); Feulard, ibid., p. 206; Colcott Fox, West­
minster Hosp. Reps., 1888, p. 144; and Brit. Jour. Derm., 1893, pp. 225 and 293 (with
colored plate and report of 9 cases—a clear clinical presentation and review and refer­
ences to literature of the disease); also ibid., 1896, p. 178 (case with associated angio-
keratoma); Patteson, ibid., p. 338; Hutchinson (a number of suggestive cases), Archives
of Surgery, 1893-94, vol. v, pp. 31 and 98; Crocker, Diseases of Skin, second edit., 1893,
p. 107 (refers to cases with arm lesions); J. C. White, Jour: Cutan. Dis., 1894, p. 471
(4 cases, 1 a boy aged twelve); Thibiérge, Semaine Méd., 1895, p. 545; Pringle, Brit.
Jour. Derm., 1896, p. 96 (male subject); Méneau, Jour, de Méd. de Bordeaux, 1896,
vol. xxvi, p. 105 (case demonstration); Truchi, These, Toulouse, 1898, brief abstract in
Annales, 1898, p. 1034 (histologic examination); Mackenzie (case demonstration),
Brit. Jour. Derm., 1897, p. 79; Audry, Annales, 1898, p. 209 (histologic examination,
and animal inoculation—negative); Leredde, ibid., p. 893 (histologic examination);
Dade, Jour. Cutan. Dis., 1899, p. 306 (full clinical report of a case, with histologic ex­
amination by Ewing); Johnston, ibid., p. 312 (with associated necrotic granulomata;
histologic examination; review of subject and allied cases, with bibliography); also
Philadelphia Monthly Med. Jour., Feb., 1899; Bronson, Jour. Cutan. Dis., 1899, P.
240 (case demonstration); Abraham, Brit. Jour. Derm., 1899, p. 206 (demonstration—
doubtful case—with discussion); Thibiérge and Ravaut, “Etude sur les lésions et la
nature de l‘érythème induré,” Annales, 1899, p. 513 (report of 3 cases, with 4 colored
histologic cuts; review of the subject and references); see also a suggestive paper by
Macleod and Ormsby, “Report on the Histopathology of Two Cases of Cutaneous
Tuberculides, in One of which Tubercle Bacilli were Found,” Brit. Jour. Derm.,
1901, p. 367 (with 2 histologic cuts, review, and references); Whitfield's (Brit. Jour.
Derm., 1901, p. 386, and 1905, p. 241, and on “Multiple Inflammatory Nodules of
the Hypoderm,” ibid., 1909, p. 1, with several case and histologic illustrations and
review of the subject) investigations led him to conclude that there are two types—
one being of a tuberculous nature, occurring almost entirely in young girls; the other
occurring in middle-aged women of poor circulation, having nothing to do with the
tuberculous process, and which might be called by Philippson‘s name of “phlebitis
nodularis necrotisans”; Thibiérge and Gastonel, Annales, 1909, p. 310 (reaction and
improvement from tuberculin injections); Thibiérge and Weissenbach, Bull, et Mem.
d. I. Soc. med. des Hop. (seance des March 11, 1911).

166                                      INFLAMMATIONS

even as large as a walnut; the skin during this enlargement becomes at
first a pale purplish red, later darker in tinge, and finally a dull viola­
ceous. The formations are still noted to be somewhat hard or slightly
doughy, but when of large size lose their well-defined character and seem
to fuse with surrounding infiltrated tissue. They may continue at this
stage for some time, and then gradually soften and disappear by absorp­
tion, with slight desquamation and sometimes atrophy, or undergo
necrosis and result in a punched-out, somewhat deep, sluggish-looking,
irregular ulcer. Exceptionally, as in the cases of Burns¹ and W. Pick,²
there is very little or no disposition to ulceration, and the condition
is suggestive of a chronic erythema nodosum, under which title Pick
places his case. Both terminations are usual in an average case, a few
lesions disappearing, the larger number breaking down. Some lesions
remain small and scarcely recognizable, except by palpation. There is
never distinct abscess formation, but slight softening takes place, the
skin becomes necrotic at one point, and there may be a slight, sero-
purulent discharge, followed by gradual necrosis of the whole nodule;
or this latter takes place en masse, without previous spot necrosis.
Occasionally the nodule necroses first at several points, and then rapidly
or gradually in its whole mass, the surface breaking down at first, and
the deeper parts, quickly or slowly afterward. In some cases several
nodes may be in close proximity, and as they grow practically fuse
together, although to the sight and to touch there usually remains an ill-
defined outline of the several lesions composing the mass. In these cases
there may be a noticeable surrounding sluggishly inflammatory infiltra­
tion.

The ulcers, the maturing nodes, and the atrophic depressed areas
left from absorbed lesions are surrounded by deep, dark red, or purplish
areola. This dark color remains for some time subsequently to healing.
Some of the ulcers may gradually heal, others remain open and sluggish,
with a slight seropurulent or watery discharge; if several are in close
proximity, there may result an irregular, ulcerated area, with here and
there a “bridge” of purplish colored infiltrated skin and tissue; in such
cases the consequent scarring is usually pronounced. A variable de­
gree of edema of a doughy or inelastic character is sometimes noted,
which is occasionally followed by slight tissue hypertrophy.

The disease is almost invariably limited to the parts named, al­
though Bazin, Crocker, Pringle, and Colcott Fox have exceptionally
observed lesions elsewhere as well, more especially, however, on the
arms. Johnston and DuCastel have each observed a case with char­
acteristic nodes upon the legs and suggestive necrotic tuberculous look­
ing lesions on other parts. It is slow and persistent, and more pro­
nounced in its expression in the cold season. As a rule, the lesions are
not painful except upon pressure—certainly not painful to a marked
degree.

Etiology and Pathology.—The disease is met with almost
exclusively in girls and women between the ages of twelve and thirty,

¹ Burns, Boston Derm. Soc. Trans., Jour. Cutan. Dis., 1905, p. 177.

² Pick, Archiv, 1904, vol. lxxii, p. 360 (1 plate).

ERYTHEMA INDURATUM

167

and especially among those whose occupation keeps them on their feet.¹
It is a rare malady, and particularly among the well-to-do classes.

The nature of the disease is obscure. It is not a thrombosis nor a
phlebitis, as the characteristic symptoms of these conditions are lacking;
nor is it connected with syphilis in any way, although the clinical picture
is extremely suggestive. There are often associated symptoms, past or
present, of a scrofulous diathesis; this has been noticeably so in the cases
under my observation. In fact, its tuberculous origin is more in accord
with the clinical data.²

Histologic and bacteriologic investigations led Audry and Truchi
to conclude that it is not tuberculous, but a manifestation of a nature
similar to erythema nodosum. Johnston, although believing that it is
an expression of tuberculous disease, could not corroborate it by histo-
logic findings. On the other hand, Thibiérge and Ravaut‘s studies
place it among the cutaneous manifestations of tuberculous infection.
They found in all three cases examined by them that the vascular chan­
nels were chiefly affected with inflammatory and degenerative changes,
and there was a large number of giant-cells; moreover, they succeeded,
by experimental animal inoculation, in producing a general tuberculosis.
Leredde, who also examined a case histologically, compares the lesion
to a necrotic tuberculid. The bacillus has, however, never been found,
although as yet the examinations have been meager. It is not improb­
able, as contended by Whitfield, that there are two classes of cases
scarcely, if at all, positively clinically distinguishable, one of which be­
longs under tuberculosis; the other, more acutely inflammatory, but of
obscure origin and nature.

Diagnosis.—Erythema nodosum and syphilitic gummata are to
be excluded. The acute character of the former, its surface involve­
ment in the very earliest stage, some lesions remaining small and surface
lesions throughout; the bright pink or red color, with the gradual change
of color often observed; the painful and tender character of the nodes,
and its usually occupying preferably the tibial surface; the absence of
tendency to break down, and its course—are all different from the
symptoms of erythema induratum. The nodes in erythema nodosum,
it is true, are often suggestive of softening, but this never ensues, a few
cases of ulcerative ending are on record, but one may ask, in view of its
resemblance to erythema induratum, whether it was not confused with
this latter disease.

¹ Hirsch, Arch. Derm., 1905, vol. lxxv, pp. 56 and 181, shows in a review-summary of
80 collected cases that only 11 were males; as to age, there were 18 under twenty, 18
between twenty and thirty, 11 between thirty and forty, 5 between forty and fifty, 1
between fifty and sixty, and 1 at sixty-eight; in 30 of the cases there were other evi­
dences of tuberculosis.

²Harttung and Alexander‘s case, Archiv, April, 1902, vol. lx, p. 39 (clinical and
histologic, with 2 colored histologic plates, and full bibliography), died of pleuropneu-
monia—the autopsy showed pulmonary tuberculosis; second paper, ibid., 1905, vol.
1xxi, p. 385 (5 cases, 1 doubtful): there were histologically two groups—those showing
tuberculous changes and those showing inflammatory changes; Thomas, Rev. gen. de
din. et thér., Jan. 24, 1903, p. 49, case with scrofulous symptoms and pleuropneumonia;
Söllner, Monatshefte, 1903, vol. xxxvii, p. 545, has reported a case in which there was
an association with both lichen scrofulosorum and pulmonary tuberculosis; Alexander,
Berlin, klin. Woch., 1904, vol. lxi, p. 897, an association with folliclis.

168

INFLAMMATIONS

The clinical expression of the ulcers is strikingly like syphilis, but
gummata are usually rapid, remain rather sharply circumscribed, are
generally more painful and inflammatory and suppurate, and are mark­
edly purulent; in erythema induratum the destruction of tissue results
from necrosis rather than from suppuration. Moreover, syphilitic
gummata are rarely numerous, and rarely on both legs. Further,
syphilitic lesions yield rapidly, as a rule, to antisyphilitic remedies—
erythema induratum, on the contrary, not only is uninfluenced but
often aggravated by such treatment.

Prognosis and Treatment.—The disease is persistent and
obstinate, but with the patient's co-operation the results are satisfac­
tory. The constitutional treatment of most value is that based upon
the assumption that the disease is scrofulous. Cod-liver oil, iron,
quinin, strychnin, and phosphorus, with full nutritious diet, are the
remedies indicated, cod-liver oil being the most useful. Rest, with the
leg in a recumbent or supported posture, is of great importance. Anti­
septic applications of boric acid, hydrogen dioxid, and resorcin are espe­
cially valuable. An ointment of resorcin, 5 to 10 per cent. strength,
made up with Lassar's paste (see Eczema), is a useful application. The
plan I have found most satisfactory when patients cannot give the time
to absolute or even relative rest is to wash daily the ulcers, and also the
general leg surface, with a saturated solution of boric acid containing 3
to 10 grains (0.2-0.65 gm.) of resorcin to the ounce (32 gm.), dressing
the ulcers with a powder of boric acid or with the foregoing paste, and
putting on a roller-bandage. As soon as a clean condition of the ulcers
is established and they are looking less active, which usually ensue in
from ten days to a few weeks, this treatment, provided the ulcers are
not numerous, is somewhat changed; the preliminary washing of the
entire leg is the same, but the ulcers are sprayed with hydrogen dioxid,
and then a gelatin dressing of zinc oxid and ichthyol (see Eczema for
formula) is put on, leaving a “window” over each ulcer. The ulcers
are then dressed with the powder or ointment as above and changed
daily. The gelatin dressing is renewed every three or four days. If
the ulcers are numerous, this gelatin bandage treatment is not feasible
until the smaller have been healed and but several remain. Whitfield
and Thibiérge have both had a good result from treatment with injections
of tuberculin.

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