4. The mucous membrane of the mouth is very often loosened, espe cially in young infants, and not rarely covered with hremorrhages. Fissures in the corners of the mouth, catarrhal inflammations with or without thrush, processes leading to necrosis of the mucosa, which are sometimes followed by necrosis of the jaw-bones; inflammations and suppurations of the salivary glands (especially the parotid) which on pressure fill the mouth with pus; all these are among the most frequent occurrences. Catarrhal rhinitis sometimes causes profuse purulent dis charge with the formation of fissures on the aloe nasi and more rarely severe epistaxis. In some cases the fissures or the inflamed or necrotic mucous membranes bleed, thus at times leading to the diagnosis of mehena.
5. The eyes are not usually involved in the systemic infection. Retinal hemorrhages have been found repeatedly in the newborn and are of value diagnostically. Hremorrhages from the lids, at times uncon trollable, are, according to Ritter, of septic origin in the majority of instances in which there is no primary local disease (blennorrlicea, etc.). Otitis media occurs very often; but extension of the process to the bones, sinuses, brain or meninges belongs to the rarest complications.
6. The respiratory organs are most severely involved in the symp tom-complex of sepsis. Even in uncomplicated cases dyspncea with very rapid breathing is present as an index of a severe intoxication. Bronchitis and pneumonia, which are only demonstrable when some what extensive; multiple abscesses of the lungs, clinically not demon strable; serofibrinous and purulent pleurisies, all belong to the most frequent occurrences. When they form the only salient clinical feature the disease is termed "septic infection with pulmonary symptoms" (Fischl).
7. Pericarditis occurs quite often, as an involvement of the circu latory apparatus., in consequence of the general infection. It usually arises by extension from the pleura, or more rarely from the medias tinum. Endocarditis has been observed several times, on the whole, however, rarely. In the diagnosis of this complication in infants we often encounter insurmountable difficulties (Finkelstein). The behavior of the pulse is in no way characteristic. Just as in all severe diseases of the infant, cardiac weakness easily conies on and either leads acutely to death or else persists for days, accompanied by a subnormal body temperature.
S. The gastro-intestinal canal is very often involved in the clinical picture of sepsis. Vomiting and diarrhoea are at times the only, often the most striking symptoms. The sepsis not uncommonly runs its course from the very beginning under the clinical picture of a gastro intestinal catarrh; more frequently, however, severe diarrhceas occur during the course of sepsis, and, what is worthy of note, in artificially fed as well as breast-fed infants (Ritter el al.).
The vomitus is bile stained in some instances, in others it is col ored from blood-red to brownish, the stools are fluid or soft, yellow or green and often there is an admixture of blood, brown or blackish brown in color, rarely dark red (inelfena). The abdomen is distended very frequently and the peristalic action very lively; at times intestinal paralysis with tremendous distention of the abdomen occurs, pushing up the diaphragm and causing dyspncea; purulent peritonitis occurs very often, especially in cases of umbilical sepsis. Recognition of the peritonitis, however, is difficult; fluid exudate is usually not present in demonstrable quantities. The presence of considerable tenderness over the abdomen may be considered as evidence of peritonitis.
9. The spleen is frequently enlarged, but the swelling is of no value diagnostically, as it occurs in the nursling in so many other conditions.
10. The liver seldom shows any clinical signs except the icterus, the import of which has already been discussed. The edge of the liver is palpable in the healthy nursling when the abdomen is free from disten tion; therefore, the fact that the liver is palpable should be used cau tiously for diagnostic purposes.
11. The urine usually contains albumin, rarely sugar (milk-sugar). The albuminuria is either an expression of a toxic degeneration of the kidneys or of a true, rarely hemorrhagic, nephritis or a pyelocystitis. In children of the first weeks of life who have had icterus, bile-pigment is often found in the urine (see chapter on icterus neonatorum). In many cases hmmoglobin in solution and in pigment granules has been found (Winekel's disease). The urinary sediment should be examined in every case and gives findings corresponding to the involvement: hya line, epithelial or granular casts, casts of blood corpuscles, pus cells, either isolated or in clumps, epithelial cells and leucocytes.