Biomedical Ephemera, or: A Frog for Your Boils

Intracranial aspiration in cerebro-spinal meningitis of the infant

For many decades, the anterior fontanelle of the infant was used as an alternative access point for emergency care (such as emergency rehydration), when a suitable vein could not be located. It was also used as a puncture site to drain the pus from cerebrospinal meningitis.

While intraosseous (IO) injection is now the alternative access point used in most practices, relieving cranial pressure due to meningitis or encephalitis is still occasionally done through the anterior fontanelle, if it has not yet closed.

In adults and babies whose fontanelles have closed - almost all by 18 months of age - the most common way to relieve intracranial pressure is through an emergency burr hole (a hand-drilled hole surprisingly akin to trepanation) or, in cases at more equipped facilities, craniotomy (creating a temporary hole) or craniostomy (creating a permanent hole).

Diseases of Infancy and Childhood. Louis Fischer, 1917.

Subperiosteal Hemorrhage in the Pediatric Femur

Left: "Fresh" subperiosteal hemorrhage, as seen in x-ray of 9-month old infant. Right: Result of subperiosteal hemorrhage, as seen in femur split down the anteroposterior plane. Fracture can be seen about a quarter-length down from the head, displacing the epiphysis (the rounded head of the femur that is supposed to articulate with the hip). There is a large separation of the periosteum from the upper half of the bone, with new bone formed between the shaft and periosteum, due to a pre-existing subperiosteal hemorrhage.

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In scurvy, creation of collagen and capillaries (which rely heavily on ascorbic acid, aka vitamin C) are both impaired, leading to poor wound healing, fragile capillaries and capillary beds (such as in the periosteum, which supplies nutrients to the bones), and structurally unsound bone growth. When these are combined, fractures and subperiosteal hemorrhages are inevitable, and in children, this leads to great bone deformation that affects them for the rest of their lives.

While adults may suffer many of the same symptoms of scurvy, the fact that their bones already have the support structure and are slow-growing in general, means that they're at a much lower risk for subperiosteal hemorrhage causing extraneous bone growth. Though adult bones are weakened, that generally leads to breaks straight through the shaft, rather than internal fractures.

Diseases of Infancy and Childhood. Louis Fischer, 1917.

Cerebrospinal meningitis due to influenzavirus

This 4-month-old was suspected to have developed meningitis due to the influenza “bacillus” (now known to be influenzavirus) crossing into the brain either by the frontal sinus (which is thin to begin with, but extremely delicate in young children), or through the nasopharyngeal lymph channels near the base of the brain. 

The brain was found to be partially covered in a muco-purulent exudate, with a large necrotic patch in the right frontal lobe. The infant had several seizures during the course of the illness, but it was suspected that they were febrile seizures (caused by high fever and not uncommon in babies), and unrelated to the necrosis of the frontal lobe. The bacterial infiltration of the cortex was suspected to have blocked one or more blood vessels, causing a stroke.

Influenza may not be killing off 5% of our population every year like it did in 1918 (which was after this case and, interestingly, spared the frail and killed the healthy), but it's still a fatal disease to many infants and elderly patients. And really, even the healthiest person can come down with really awful complications from the yearly flu virus. It just happens to be much more prevalent in those whose bodies are not fully capable of fighting off infection.

So if you've had the flu recently, and felt awful and unable to breathe and your body hurt like you had been sleeping on a bed of lumpy rocks, you probably can see where bad complications can come from. But if you never get the flu or haven't had it in ages, don't think it's just some little thing, or just like a bad cold or something. It's something that's actually worth going out of your way to protect yourself (and those around you) from!

Diseases of Infancy and Childhood. Louis Fischer, 1917.

Unusually Severe Desquamation

Desquamation (from the Latin desquamare - to scrape scales off a fish) is simply the peeling or shedding of the outermost layer of the skin. It happens to everyone when skin cells are replaced every 14 days or so, but the cells are generally unnoticeable, as they don't shed in large sheets. 

When skin is damaged or burned, like in a sunburn, desquamation becomes more noticeable and occurs in sheets and flakes. Some of the diseases that commonly afflicted kids, like measles and scarlet fever, caused significant damage to the epidermis, causing (sometimes very significant) desquamation after the rash dissipated. 

This child had scarlet fever with a markedly more severe rash than most, but with other symptoms within the average range. 

Diseases of Infancy and Childhood. Louis Fischer, 1917.

Nutritional Disorders: Rickets

One of the characteristic symptoms of rickets in infants and younger children is the "beading" of the costochondral joints. This is caused due to a deficiency of available calcium (either because of a lack of vitamin D to process the calcium, or a primary deficiency of calcium), leading to a lack of joint mineralization. This causes the costochondral joint cartilage to become overgrown to make up for it.

Diseases of Infancy and Childhood: Their Dietetic, Hygienic, and Medical Treatment. Louis Fischer, 1917.

EAT YO ORANGES, GUYS.

Diseases of Infancy and Childhood. Louis Fischer, 1912.

From Louis Fischer's 1912 Diseases of Infancy and Childhood. I find this concept of scrunching up a baby for artificial respiration terribly fascinating.

Diphtheria case study in Diseases of Infancy and Childhood by Louis Fischer, M.D., 1917.

Diphtheria is known for creating a slimy/sticky/smelly exudate in the throat and mouth, but there are quite a few variations on its etiology and presentation.

A. Common type of diphtheria. Child three years old, seen on fourth day of illness. Exudate covering pharynx, tonsils, and uvula. Received 16,000 units of antitoxin. Throat clear on sixth day. Discharged cured.

B. Follicular type of diphtheria. Child seven years old, seen on second day of illness. The membrane involved the lacunae of the tonsils. Resembles follicular tonsillitis. Received 6,000 units of antitoxin total.

C. Hemorrhagic type of diphtheria. Child seven-and-a-half years old, seen on sixth day of illness. Tonsillar and post-pharyngeal exudate. Severe nasal and post-pharyngeal hemorrhages during exfoliation of membrane. Received in all 15,000 units of antitoxin. Throat clear on ninth day of illness. Myocarditis developed. Case discharged cured four weeks after admission. 

D. Septic type of diphtheria. Child eight years old, seen on fifth day of illness. The pseudo-membrane in this case covered the hard palate and extended in one large mass down the pharynx, completely hiding the tonsils.

Diseases of Infancy and Childhood. Louis Fischer, M.D., 1917.

Noma, also known as cancrum oris or gangrenous stomatitis. Used to sometimes present itself after serious infections like scarlet fever, chicken pox, measles, or TB. More likely to occur if the patient is malnourished or immunodeficient, and was observed in the Nazi concentration camps (Josef Mengele is actually the one that found out a lot of what we know about the disease progression and mechanism). Still occurs in places like Cambodia, Ethiopia, and Nigeria, but is extremely rare in industrialized nations.

Usually found in kids 2-6 years old. Starts with a low fever and swelling in the cheek for one to two days, then suddenly progresses to the gangrenous phase. Gangrenous regions form from the oral cavity, extending to the lips, cheeks, and sometimes maxillary and mandibular bones. Progresses extremely quickly and tissue destruction in necrotic zones can result in the loss of the jaw and cheekbones. Most children die of septicemia during this phase. 

Disease can be halted with IV antibiotics and improved nutrition, but full recovery can take up to a year. Without treatment, mortality approaches 100%. Even with treatment, mortality is around 60%, due to the rapid progression of the disease.