Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

One can be fairly certain that infections existed in human beings from the first days of man's history.

To my knowledge, the earliest record of bacterial infection comes to us from approximately 5000 B.C!

In 1904 the bones of a Stone Age man were dug up from a neolithic burial ground near Heidelberg. His fourth and fifth vertebrae had collapsed and fused -typical signs of Pott's disease.

The Old Testament, which begins approximately 2000 B.C., has many references to disease and pestilence, ranging from the leprosy of Moses and Miriam to the boils of Job.

And as further indisputable evidence, a mummy of a priest of Amen belonging to the 21st Egyptian dynasty (about 1000 B.c.) was so well preserved that it not only clearly showed the kyphosis of Pott's disease but had a psoas abscess as well.

For thousands of years, until about 100 years ago, physicians had been diagnosing diseases and infectious disorders without knowing their actual causes.

Six hundred years after the priest of Amen died of tuberculosis, Hippocrates was describing numerous infections (many of them in children). Among these were inflammation of the umbilicus, discharging ears, acute tonsillitis, asthma, tuberculosis, and - in a beautiful description - an epidemic of mumps.

Numerous clinicians followed - from Galen in the second century to Sydenham in the 17th century - each describing diseases and commenting on treatment, but with wild guesses as to etiology.

Many of us today have often wondered how it was possible for intelligent human beings to ascribe epidemics, plagues, contagious diseases, and other infections to witches, evil eyes, bad air, sewer gas, immoral activities, or punishment from heaven - just to mention some of the most frequent of the supposed enologie factors.

But put yourselves in the place of these people of yesteryear, before the discovery of bacteria and viruses and their relation to disease. What would you have thought?

In the 17th century a Dutch naturalist and lens maker, Anton van Leeuwenhoek, perfected the microscope and in the course of his studies examined his own saliva. Although he saw many bacteria, he assumed these were of no medical significance since he felt perfectly well. He had discovered bacteria but did not realize their importance.

More than 200 years passed; then, one day in 1847, Ignaz Semmelweis concluded that there was something on the hands of examining physicians that caused puerperal fever. He did not know what it was, but when he had the physicians disinfect their hands in chlorine water, the cases of postpartum infection declined markedly.

It was Louis Pasteur, a French chemist, and Robert Koch, a German physician, who, in the 187Os and 188Os, finally discovered that bacteria caused infections. An exciting period followed. In rapid succession the bacterial causes of wound infections, relapsing fever, gonorrhea, typhoid fever, leprosy, erysipelas, cholera, diphtheria, pneumonia, tetanus, meningococcic meningitis, plague, and syphilis were determined. And although it took another 50 years to discover viruses, researchers and physicians realized that ultramicroscopic organisms had to be responsible for certain diseases that had incubation periods and signs and symptoms similar to those of some bacterial infections.

We all know the rest - antitoxins, immune globulins, toxoids, vaccines, and antibiotics. The causes of almost all infections and infectious diseases have been discovered, and most of them can usually be controlled.

But efforts at mass immunization are not completely successful, and we pediatricians meet occasional cases of rubella or measles with their sequelae. In addition, we still do not have immunization against hepatitis or meningococcus infections - and we are just beginning to discover the underlying factors in bodily…

One can be fairly certain that infections existed in human beings from the first days of man's history.

To my knowledge, the earliest record of bacterial infection comes to us from approximately 5000 B.C!

In 1904 the bones of a Stone Age man were dug up from a neolithic burial ground near Heidelberg. His fourth and fifth vertebrae had collapsed and fused -typical signs of Pott's disease.

The Old Testament, which begins approximately 2000 B.C., has many references to disease and pestilence, ranging from the leprosy of Moses and Miriam to the boils of Job.

And as further indisputable evidence, a mummy of a priest of Amen belonging to the 21st Egyptian dynasty (about 1000 B.c.) was so well preserved that it not only clearly showed the kyphosis of Pott's disease but had a psoas abscess as well.

For thousands of years, until about 100 years ago, physicians had been diagnosing diseases and infectious disorders without knowing their actual causes.

Six hundred years after the priest of Amen died of tuberculosis, Hippocrates was describing numerous infections (many of them in children). Among these were inflammation of the umbilicus, discharging ears, acute tonsillitis, asthma, tuberculosis, and - in a beautiful description - an epidemic of mumps.

Numerous clinicians followed - from Galen in the second century to Sydenham in the 17th century - each describing diseases and commenting on treatment, but with wild guesses as to etiology.

Many of us today have often wondered how it was possible for intelligent human beings to ascribe epidemics, plagues, contagious diseases, and other infections to witches, evil eyes, bad air, sewer gas, immoral activities, or punishment from heaven - just to mention some of the most frequent of the supposed enologie factors.

But put yourselves in the place of these people of yesteryear, before the discovery of bacteria and viruses and their relation to disease. What would you have thought?

In the 17th century a Dutch naturalist and lens maker, Anton van Leeuwenhoek, perfected the microscope and in the course of his studies examined his own saliva. Although he saw many bacteria, he assumed these were of no medical significance since he felt perfectly well. He had discovered bacteria but did not realize their importance.

More than 200 years passed; then, one day in 1847, Ignaz Semmelweis concluded that there was something on the hands of examining physicians that caused puerperal fever. He did not know what it was, but when he had the physicians disinfect their hands in chlorine water, the cases of postpartum infection declined markedly.

It was Louis Pasteur, a French chemist, and Robert Koch, a German physician, who, in the 187Os and 188Os, finally discovered that bacteria caused infections. An exciting period followed. In rapid succession the bacterial causes of wound infections, relapsing fever, gonorrhea, typhoid fever, leprosy, erysipelas, cholera, diphtheria, pneumonia, tetanus, meningococcic meningitis, plague, and syphilis were determined. And although it took another 50 years to discover viruses, researchers and physicians realized that ultramicroscopic organisms had to be responsible for certain diseases that had incubation periods and signs and symptoms similar to those of some bacterial infections.

We all know the rest - antitoxins, immune globulins, toxoids, vaccines, and antibiotics. The causes of almost all infections and infectious diseases have been discovered, and most of them can usually be controlled.

But efforts at mass immunization are not completely successful, and we pediatricians meet occasional cases of rubella or measles with their sequelae. In addition, we still do not have immunization against hepatitis or meningococcus infections - and we are just beginning to discover the underlying factors in bodily immunity.

This issue of PEDIATRIC ANNALS covers certain of the infectious disorders of infancy and childhood. The guest editor is Dr. Louis Z. Cooper, director of pediatrics at Roosevelt Hospital in New York and Professor of Pediatrics at Columbia University College of Physicians Oc Surgeons. Dr. Cooper is nationally known for his studies on rubella.

The first article in this symposium, "Congenital Rubella: The Teenage Years," is by Dr. Philip R. Ziring, clinical deputy director of the Willowbrook Developmental Center in New York. He reports on a study of hundreds of children born with congenital rubella in the epidemic of 1964-65 who have been followed since that time. Is the hearing loss progressive? What of those children with congenital cataract or glaucoma? Of those with cardiac or urogenital defects? As to endocrine disturbances, Dr. Ziring reports that these children are more likely to develop diabetes, and he quotes a study from Australia, where 20 per cent of older persons who had had rubella developed diabetes. In the neurologic area, seizure disorders have been appearing with increasing frequency among teenagers. Also reported is an increased tendency towards the development of autism. This is an interesting and important progress repon on a complex disease that affects so many organs and tissues of the child's body.

The second article deals with "The Role of Infection in Childhood Asthma" and was written by Dr. Herbert I. Cohen, chief of pediatrie allergy at Roosevelt Hospital and one of the most widely known pediatrie allergists in the New York area. In this article, Dr. Cohen discusses the current concepts regarding the relationship of infections to asthmatic attacks in younger children and in older children. He reports that on the basis of numerous studies, viruses and mycoplasma rather than bacteria are the principal infectious agents precipitating acute asthmatic attacks. This would seem to imply that bacterial vaccines, used so frequently in the prevention of asthma, are only very rarely indicated. Bronchiolitis is also considered in this article, and Dr. Cohen states that it is frequently an early or premonitory form of asthma, with as many as 30 to 50 per cent of children with this infection later developing bronchial asthma.

The following contribution, *The Management of Infections in the Hematologically Compromised Patient,'1 is by Dr. Marianne F. Schwob, pediatrie hematologist at Roosevelt Hospital. After emphasizing the extreme importance of preventing and treating infections in the long-term hematologie patient, Dr. Schwob presents a review of the body's normal defenses. This is followed by a discussion of disorders of nonspecific defenses, diseases of the reticuloendothelial system, and immunodeficiencies. The remainder of the article is devoted to the management of infections in these hematologically compromised children and presents a step-by-step approach to problems that must be considered by the pediatrician who cares for such patients. This is a valuable reference article for the practicing pediatrician and is an instructive review of the subject.

The fourth article deals with "Central Nervous System Infections: Long-Term Complications and Management." The author is Dr. Neil Lombardi, chief of child neurology at Roosevelt Hospital and Assistant Clinical Professor of Pediatrics and Neurology, Columbia College of Physicians & Surgeons. Dr. Lombardi emphasizes that infections of the nervous system often produce continuing and sometimes progressive symptoms. He points out that a great many of these children, even though they have been discharged as neurologically normal after having had bacterial meningitis, later develop permanent neurologic defects. Prenatal and postnatal neurologic infections are considered with their resulting physical, mental, and emotional sequelae. A follow-up plan is presented for children suffering from the effects of central nervous system infections. But, as Dr. Lombardi states, much as rehabilitation, education, and social support can help those who are handicapped neurologically, the most efficient approach to the problem is prevention through immunization.

The final article, "Tuberculosis in Children: Current Concepts," is by Dr. Anastasios A. Anastasiades, Associate Clinical Professor of Pediatrics at the College of Physicians & Surgeons and associate director of pediatrics at Roosevelt Hospital. Dr. Anastasiades spent some years with the late Dr. Edith Lincoln at her large children's tuberculosis service at Bellevue Hospital. We in the United States see very little tuberculosis in infants and children these days because of routine tuberculin testing, the use of isoniazid, and modern publichealth measures. It is hard to believe that 40 years ago about 20 per cent of the children in New York City had positive tuberculin tests. When it was first suggested that every child should be routinely tested, there were cries of dissent: "A positive test would frighten the parents."

This article by Dr. Anastasiades is very important, for there are still cases of childhood tuberculosis and a review of the subject is of great value. All angles are considered and the most modern concepts presented. This is a paper worth reading.

10.3928/0090-4481-19771201-03

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