Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

About 15 years ago a large malpractice suit was filed against the medical center with which I am associated and against the obstetrician who had delivered an infant. The father had been told that the baby needed some resuscitation immediately after birth but that the newborn had quickly started breathing and was in excellent condition. When the infant was taken home, the father reported a large bruise in the upper buttock area - and his lawyer wrote a learned treatise on the needlessness of spanking a baby to stimulate respiration. Of course, the case never went to court; the suit was quickly withdrawn, and the "bruise" remained on the infant's buttocks for months before finally disappearing.

I've often wondered why some babies are born with these bluish Mongolian spots. It's easy to say that its a racial characteristic - but why is it a racial characteristic, what does this local area of pigment mean, and why does it disappear so soon?

The skin has always been a source of wonder to me. Once, as a thirdyear medical student, I wandered through the stalls of a secondhand medical bookstore several short blocks from the medical school. There, to my possibly morbid delight, I found a three-volume black leather-bound edition of a work called Dermachromes, by Professor Jacobs, dated 1905, with beautifully colored, lifelike pictures of dermatologie models in the Breslau Clinic. A note on the title page states that "the beautiful production of colors is an invention of Dr. Albert of Munich." The books are still in my library, the pictures as lifelike as ever - although the black leather binding shows signs of age.

As I went through the illustrations in these books, I realized then that in the human being, more so than any other animal in the world, the skin is a very important reflection of what is going on within the body. It can appear yellow, blue, pink, brown, or white - each color reflecting some underlying condition. It presents an amazing assortment of different responses to infectious diseases - and these differences are of significant diagnostic value. The rashes of measles, scarlatina, chickenpox, smallpox, meningococcemia, typhoid fever, rheumatic fever, and syphilis all differ.

One could go on and on about abnormal changes in the skin, such as congenital abnormalities and superficial reactions to viruses, bacteria, fungi, heat, cold, sunlight, and stranger reactions - among which are pityriasis rosea, erythema multifoime, and lupus erythematosus. It is interesting to note that reactions of the skin of infants and children have drawn the attention of physicians for many centuries. Note a statement by Paul of Aegina (a.d. 625-690), who wrote:

Whatever eruptions appear upon the skin of a child are to be encouraged, in the first place; but when the eruption is properly come out, it may be cured by putting the child into baths, of lentisk, or roses, and then anointing with oil of roses or lentisk or with a cerate containing ceruse. And its body may be gently rubbed with nitre; but it will not bear hard friction.

Even pediatric dermatology is not as recent a specialty as many of us may imagine. Among the volumes in my library is one published in 1893 - Diseases of the Skin with Spedai Reference to the Skin Eruptions of Children, by H. Radcliffe Crocker, M.D., "Physician to the East London Hospital for Children."

Today, as in the past, the knowledge of skin abnormalities of infants and children is oí great importance to all practicing pediatricians, and it is to this interest that the present issue of PEDIATRIC ANNALS is…

About 15 years ago a large malpractice suit was filed against the medical center with which I am associated and against the obstetrician who had delivered an infant. The father had been told that the baby needed some resuscitation immediately after birth but that the newborn had quickly started breathing and was in excellent condition. When the infant was taken home, the father reported a large bruise in the upper buttock area - and his lawyer wrote a learned treatise on the needlessness of spanking a baby to stimulate respiration. Of course, the case never went to court; the suit was quickly withdrawn, and the "bruise" remained on the infant's buttocks for months before finally disappearing.

I've often wondered why some babies are born with these bluish Mongolian spots. It's easy to say that its a racial characteristic - but why is it a racial characteristic, what does this local area of pigment mean, and why does it disappear so soon?

The skin has always been a source of wonder to me. Once, as a thirdyear medical student, I wandered through the stalls of a secondhand medical bookstore several short blocks from the medical school. There, to my possibly morbid delight, I found a three-volume black leather-bound edition of a work called Dermachromes, by Professor Jacobs, dated 1905, with beautifully colored, lifelike pictures of dermatologie models in the Breslau Clinic. A note on the title page states that "the beautiful production of colors is an invention of Dr. Albert of Munich." The books are still in my library, the pictures as lifelike as ever - although the black leather binding shows signs of age.

As I went through the illustrations in these books, I realized then that in the human being, more so than any other animal in the world, the skin is a very important reflection of what is going on within the body. It can appear yellow, blue, pink, brown, or white - each color reflecting some underlying condition. It presents an amazing assortment of different responses to infectious diseases - and these differences are of significant diagnostic value. The rashes of measles, scarlatina, chickenpox, smallpox, meningococcemia, typhoid fever, rheumatic fever, and syphilis all differ.

One could go on and on about abnormal changes in the skin, such as congenital abnormalities and superficial reactions to viruses, bacteria, fungi, heat, cold, sunlight, and stranger reactions - among which are pityriasis rosea, erythema multifoime, and lupus erythematosus. It is interesting to note that reactions of the skin of infants and children have drawn the attention of physicians for many centuries. Note a statement by Paul of Aegina (a.d. 625-690), who wrote:

Whatever eruptions appear upon the skin of a child are to be encouraged, in the first place; but when the eruption is properly come out, it may be cured by putting the child into baths, of lentisk, or roses, and then anointing with oil of roses or lentisk or with a cerate containing ceruse. And its body may be gently rubbed with nitre; but it will not bear hard friction.

Even pediatric dermatology is not as recent a specialty as many of us may imagine. Among the volumes in my library is one published in 1893 - Diseases of the Skin with Spedai Reference to the Skin Eruptions of Children, by H. Radcliffe Crocker, M.D., "Physician to the East London Hospital for Children."

Today, as in the past, the knowledge of skin abnormalities of infants and children is oí great importance to all practicing pediatricians, and it is to this interest that the present issue of PEDIATRIC ANNALS is dedicated.

The Guest Editor for this month is Dr. Alvin H. Jacobs, Professor of Dermatology and Pediatrics at Stanford University School of Medicine. Dr. Jacobs is one of the outstanding pediatric educators in the field of dermatology. Many of us remember him from the seminars he has conducted at the annual conventions of the American Academy of Pediatrics, as well as by his written contributions on the subject.

The symposium is opened by an article on birthmarks. This includes not only those conditions seen at birth - such as hemangiomas, port-wine stains, giant nevi, and Mongolian spots - but also the pigmented nevi that appear between the second and sixth years. Freckles and café-au-lait spots are also discussed.

The next two articles deal with the common problem of atopic dermatitis and cover the present-day knowledge concerning its etiology as well as its clinical appearance and management.

In order follow discussions on acne vulgaris, warts, cutaneous infections including syphilis, and fungal infections of the skin.

The topics discussed are beautifully illustrated.

I believe you will agree with me that this is a well-organized and well-written symposium on the subject.

10.3928/0090-4481-19761201-03

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