Complications often occur in these cases. Abscesses may form in various parts of the body ; gangrenous sloughing may attack the skin ; pneumonia may occur ; or the inflammation may pass directly to the peri toneum through the recently healed umbilicus, or to the larynx and throat. Au infant under six months old was brought to St. Thomas' Hospital and admitted, under Mr. Croft, for erysipelas following vaccination. When seen, the whole cervical region and part of the chest were the seat of oede matous erysipelas, and there was great dyspnoea without symptoms of croup. The child was placed in a warm bath and a dose of ipecacuanha wine was given to produce vomiting. These measures relieved the child for a time, but in the evening the dyspncea returned with such intensity that tracheotomy was performed by the Surgical Registrar. After the op eration the infant coughed up small pieces of cartilage—probably from the rings of the trachea. Eventually he recovered.
Whether the disease be idiopathic or arise from traumatic causes its gravity appears to be the same. In the first case the appearance of the special symptoms is often preceded by signs of derangement or sluggish ness of the digestive organs. In Mr. Strugnell's case, before referred to, an infant of eight weeks old had been a fairly healthy child, but for ten days or so had been passing very firm, pale, pasty-looking motions. The child was suddenly taken with severe symptoms, and when first seen was lying with his head thrown back and his thumbs twisted inwards upon his palms, but there was no retraction of the abdomen or strabismus. The pupils were equal and acted to light, the pulse was rapid, the temper ature was normal. On examination slight oedema of the scalp was noticed on the occipital bone, but there was no redness. On the next day the cedematous part was red. On the third day the cerebral symptoms had subsided ; but the erysipelas had spread to the forehead and down the back of the neck. Afterwards it extended over the face, arms, and trunk. A vesicle the size of a filbert and filled with clear serum formed over the left elbow, and another appeared a little later on the thigh. As the dis ease advanced, the abdomen became distended and tympanitic, and the breathing oppressed. No mischief was discovered in the chest. The child sank and died on the seventh day.
In this case the early cerebral symptoms (retraction of the head and twisting in of the thumbs) were probably symptomatic of the general dis ease and not of any special intra-cranial complication. They were of short
duration and quickly disappeared when the skin affection became marked. The tympanites and embarrassment of breathing were, no doubt, due to the occurrence of peritonitis. Premonitory symptoms, such as were found in the above instance, are not common. Usually the first indication of ill health is the occurrence of the cutaneous redness and swelling.
In traumatic cases the duration of the disease is often considerable. The illness may last two or three weeks, or even longer. Recovery is not a frequent termination, and usually death is brought about by one of the many complications to which these cases are liable. If none of these occur, the case may end favourably, even although the erysipelas has spread ex tensively and involved the greater part of the surface of the body. The subsidence of the cutaneous inflammation is followed by desquamation of the epithelium in the portions of skin affected.
Diagnosis.—The nature of the disease can scarcely be misapprehended. A patch on the skin of bright redness, which feels brawny to the touch and is perhaps cedematous, spreads continuously over the surface, and is bounded by a well-defined margin—these local symptoms combined with the severe general disturbance and high fever, make the diagnosis of erysipelas an easy matter.
Prognosis.—When erysipelas occurs in an infant of a week or fortnight old, as a result of puerperal infection, the prognosis is most serious. Very few of these cases recover, although Trousseau has stated that in cases where abscesses have formed extensively, and in these cases only, he has known life to be saved. Consequently he regarded the occurrence of ab scesses as by no means an unfavourable symptom.
When the disease arises as a result of other causes the child's pros pects are more hopeful, and are brighter in proportion to his age, his general strength, and the healthfulness of his surroundings. Of forty three cases collected by Dr. Lewis Smith eighteen recovered ; but of the cases of recovery in only one was the child younger than three mouths. If the disease attack an infant during the first two or three weeks after birth, death is almost certain. After the age of six months the proportion of recoveries is greater than that of the deaths.
In all cases the occurrence of a serious complication greatly reduces the child's chances of escape, and if peritonitis occur, we can have little hope of a favourable issue.