Section 25. Artifacts

The physical abuse of children accounts for many deaths each year in the United States. Physicians who care for children must acquaint themselves with the signs of battering, sexual abuse, and nutritional deprivation. For the protection of children, the laws in all states require the reporting of all cases of suspected child abuse. Illustrated here are typical loop marks in a child who was struck with a doubled-over rope or electrical cord. The presence of ecchymoses or scars on the lower back or buttocks is almost always the result of physical abuse. Slap marks, human bites, and lash marks each leave bruises of a distinctive shape and distribution. The presence of bruises of this sort is the evidence of force used without restraint and is a definite sign of child abuse.

Ten percent of the cases of physical abuse in children involve the deliberate infliction of burns as a form of punishment. Cigarette burns, which appear as uniform round erosions, are often located on the palms and soles. Second-degree burns may also occur when a child is held against a radiator or hot plate. Illustrated here are two burns that resulted from forcible immersion in hot water. Symmetrical blistering of the perineum (Fig. 25-3) is the evidence of a child being lowered into a hot bath. Figure 25-4 is illustrative of forcible immersion of a hand. In general, the presence of an injury for which the history seems implausible should alert the physician to the possibility of child abuse. A delay in seeking medical assistance for the care of an injury should also cause concern.

Injuries to the skin that are induced by the patient or another individual are termed factitial dermatitis. This entity, when it occurs in childhood, may be related to a variety of emotional disturbances in either parent or child. The lesions in Fig. 25-5 are self-inflicted wounds caused by bites. Some are scars and others are inflammatory lesions. The distribution and morphology of lesions of this type are not consistent with any known cutaneous disease, and there is usually no credible history for their development. Other methods of inducing self-injury include scratching, picking, and gouging. The hypertrichosis in Fig. 25-6 resulted from repeated biting on the skin in a child with severe mental retardation. Self-mutilation of this type is also seen in the Lesch-Nyhan syndrome.

Figure 25-7 shows ecthymatous lesions that might have been produced by fingernails. Figure 25-8 shows the sort of lesions caused by caustic chemicals. Self-induced injury of this sort is associated with a wide range of emotional disturbances or psychiatric disease. Healing of lesions can sometimes be facilitated by occlusion of the area of skin that is being repeatedly injured. Psychiatric referral is often of value. A particular cause of factitial dermatitis in children is termed Munchausen syndrome by proxy. In this condition, a disturbed parent attempts to create the appearance of illness in a child. The presence of this syndrome signals a high level of physical danger for the child, and cases of this sort must be promptly reported to social service agencies as a form of child abuse.

The presence of a localized purpuric eruption in the circumoral area may not indicate a serious disease. This condition is caused by sucking on a glass or cup, creating a negative pressure around the mouth, resulting in the presence of purpura.

This method has been used in traditional Chinese medicine for a long time. A vacuum is created in a glass cup by placing a small amount of alcohol at the bottom of the cup, then lighting it and immediately placing it on to the skin. The suction created results in a circular area of purpura that is sharply demarcated.

Infants and toddlers ingesting senna based laxatives may rarely develop a burn-like eruption on the buttocks. The eruption tends to occur after the buttock has been exposed to a loose stool for a few hours in a patient given a senna-containing laxative. It is important to differentiate this from a scald from hot water immersion as seen in Fig. 25-3.

The word ainhum means “to saw.” True ainhum is limited geographically to Africa and usually presents as a groove encircling the small toe. Pseudoainhum refers to a condition that is clinically similar but caused by a wide variety of disease processes. In children, congenital constricting bands may be a cause. More commonly, pseudoainhum occurs as an artifact from the wind of a cord or a long hair buried around a digit. In this illustration, the third toe is affected by a groove whose cause was indeed a buried hair.

Stigmata caused by certain operations in occupations and avocations are characteristic. The bump on the radial aspect of the middle finger of a scribe and the callused fingertips of a violinist are examples. The illustration here is of punctate and ecchymotic hemorrhages in a heel of a basketball player. There is something about basketball playing in its jumps, twists, and turns that promotes this type of lesion. Its only significance is that it should not be mistaken for malignant melanoma.

The deposition into skin of inert materials that produce colored effects may be accidental or premeditated. The usual material that enters the skin accidentally is carbon from mischance, such as fire blast, abrasion on dirty surfaces, and stabs of sharp pencils. Figure 25-14 shows a stripe of blue color resulting from an incised wound incurred in a fall on a tarred pavement. Figure 25-15 is a conventional tattoo placed by a tattoo artist. The pigments used by tattooists to produce colors are carbon for blue and black, cinnabar or cochineal for red, cadmium salts for yellow, and cobalt salts for green. These materials are inert, but on occasion granulomas (Fig. 25-15) develop, especially from cinnabar. The color produced by carbon is black if placed superficially and progressively dark to light blue the deeper it is placed. The use of lasers for removal can be quite successful.