After birth, the 'umbilical cord is the most frequent point of entry for sepsis. Infection, moreover, takes place usually before the separa tion of the cord. After separation of the cord the navel wound, for rea sons given in the chapter on diseases of the navel, often furnishes the gateway for local and general infection. Next in frequency as an en trance port for infection conies the skin, its physiological peculiarities in the newborn, the many traumata to which it is exposed and which so often lead to superficial diseases (eczema, furunculosis) predisposing it to septic infection.
Fissures, slight tears, superficial abrasions of the epithelium, such as are caused by mechanical cleansing, decubitus on the heel or above the internal malleoli or over the sacrum, such as often develop in chil dren suffering from disturbances of nutrition, are convenient gateways for the entrance of the virus. The mucosa of the oral cavity is very often the starting point of sepsis (Epstein). The physiological shed ding of the niucosa in the newborn, mechanical abrasions due to cleans ing of the mouth, fissures of the mucosa, the so-called liednar's aphthie, septic pseudodiphtheritic inflammation of the oral mucosa (Epstein), thrush, and the various forms of stomatitis and gingivitis can all lead to sepsis. The pharyngeal and nasal mucous membranes, as a. rule only when locally diseased, are also at times the starting point. of general infection. It is worthy of note that the tonsils have only in the rarest instances been considered the entrance for general septic infection. In very rare instances sepsis arises from the conjunctiva and that too, only when it is the site of some inflammation, gonococcus or other.
The ear, which is a frequent site of local disease in the infant, can also be the source of a sepsis prone to have the clinical picture of puru lent meningitis (Scherer).
The niucosa of the gastro-intestinal tract has been regarded by many as the starting point of septic processes. Sevestre and others have con sidered the inflamed intestine to be the point of entry and Czerny and Moser have held gastro-enteritis to be the primary focus of a general sepsis. Proof however, has not yet been adduced and only the few well established cases in which the intestinal streptococci of Escherich have lead to sepsis serve as a foundation for the opinion that. the newborn and young child can be infected with sepsis starting from the injured intestinal niucosa.
Very much more importance must be attributed to the lungs than to the gastrointestinal tract, as furnishing the primary focus of sepsis (Fisch]).
Tt is usually either a bronchitis with necrosis of the epithelium or else more or less extensive inflammatory foci, from which the infection spreads by way of the lymphatics (Fisch]).
In some cases the infection can be referred to injury at birth; namely, when the injury has led to local inflammation. In other cases the skin is the gateway for the entrance of the infection; and diseases of the skin often furnish the chance for septic infection.
In relatively infrequent instances local infections of the vulva, more frequently diseases of the bladder, and cystitis, by extension to the upper urinary tract, can give rise to septic infection (Eschcrich, Trumpp). It is worthy of note that this mode of infection (cystitis) is ahnost without exception confined to female infants.
In many cases the starting point of the sepsis remains unknown: we may, therefore, speak of a cryptogenic sepsis.
Clinical Picture.—Sepsis occurs in various forms in the infant, dependent on the origin of the infection, the age of the child and the virulence of the bacteria.
We must first note that there are many cases which run their course practically without symptoms. With or without a demonstrable primary disease, while apparently well, the child goes into sudden collapse and dies, the temperature falling rapidly. In such cases the diagnosis of a general infection can only be suspected, though somewhat more strongly when the newborn is premature. In other cases, however, the course of the disease is stormy, with a high fever, vomiting and severe diar rhcea, so that the sepsis runs its course under the clinical picture of an acute gastro-enteritis (v. Ritter, Epstein). In a third group of infants, we have fever, ashen gray pallor of the skin, Inumorrhages in the skin and organs, severe inflammatory signs at the navel, on the skin, in the lungs. gastrointestinal or urinary tract. Added to these there arc se vere disturbances of the central nervous system which can also quite dominate the picture, so that the disease can simulate severe intoxica tion or meningeal disease. In other cases purulent metastases form the salient features of the disease or else—and especially in asylums—pul monary symptoms are so prominent that the disease runs a course under the clinical picture of a pneumonia. Of special importance are the cases in which hemorrhages into the skin or internal organs form the most salient and often the only symptom of septic disease. A number of cases which run their course under the picture of melama must be classed with sepsis. Other cases are classified under the heading of "umbilical haemorrhages" because the bleeding from the navel is the dominating and perhaps the only symptom and because no proof of sepsis is sought for or furnished either during life or at necropsy.