CMC - Day Eight

As she began a patient visit this morning with a young Bengali family, Beryl, one of my favorite interns on the team, advised that when interviewing families, one ask what is the primary purpose for their visit to CMC. It is likely to tell one about the urgency of a child's presentation. In the case of this family, the grandfather was here receiving treatment for some ailment or another. They had brought their daughter in out of convenience. Cute as a button - cute being the 5th vital sign in kids, along with temperature, blood pressure, pulse and respiratory rate - with short black hair, wide brown eyes, and lips pursed in shyness, this young lady looked very healthy. Her chief complaint was actually not hers at all; her parents were concerned about her hyperpigmented tongue. I ask you to understand the word hyperpigmentation in the lightest sense possible. Her tongue appeared only slightly darker than the child that had come before her and she exhibited none of the greyish to black (or even hairy) hyperpigmentation that can be seen in Addison's disease (or, for medical folks: Peutz-Jeghers syndrome, melanoma, amalgam tattoo, toxic reactions to various metals, hemochromatosis, pernicious anemia, scleroderma, Laugier-Hunziker syndrome), or that present as a rare side effect of using certain medications, among them antimilarials, minocycline (for acne), and doxorubicin (for anticancer activity.) In truth, her parents complaint was more cosmetic than medical. Beryl seemed to think that it had something to do with the girls marital eligibility some day. One might be tempted to think that in a country where a family is so much more likely to struggle for the basic things in life that such superficial concerns would be a trifle.

Not so. In India, as in most countries of the world where skin is naturally darker, one finds an assortment of skin-bleaching products on the shelves of even the smallest corner stores. They are advertised extensively, in newspapers, tabloids, billboards. In matters of the skin, is the grass always greener? A few weeks ago i wrote to a new friend, Elizabeth of Uganda, a woman with the most stunning ebony skin, and told her of plans to head to the beach - must tread carefully here as my dermatologist is recieving these dispatches. "Wish you luck with your tanning," she wrote back. "Isn't it amazing? The whites want to be dark so they tan themselves and the blacks want to be light so they bleach themselves! Why we werent given the choice i don't understand. It would make for an easier life. One day white and one day black." I love this idea; it had never before occurred to me. I'm not so sure it would solve any problems, though. Surely skin color would be subject to the same fads that present themselves in all the other areas of our lives in which we have choices. Such a thing might have the positive effect of teaching us all how unimportant skin color really is when it comes down to it. As an aside, in the west the most successful medical students often go on to choose careers like dermatology, which offers good medicine, great hours and a grand income. I mentioned this to the residents over coffee the other day, and to their surprise. In India, despite all this concern about the skin, i'm happy to report that the most competitive fields are in primary care.

We heard an interesting lecture today from the developmental pediatrics team on a condition called Hemiconvulsion, Hemiplegia, and Epilepsy (HHE). This rare phenomena has two types, distinguished by their mechanism of onset. Type I comes about in most cases following an infection in the central nervous system - meningitis or encephalitis - and Type II is called idiopathic because it seems to originate without a cause (but is often referred to as an atypical febrile seizure). The course of illness goes something like this: children usually under the age of four develop a prolonged seizure either as a result of illness or not. This seizure causes damage to the brain tissue which leads in some time to either a flaccid, spastic, or flaccid then spastic paralysis on one side of the body (hemiplegia). Most often it resolves, at least in part; sometimes it does not. In a period that varies in time (in the largest observational studies) from 1.5 to 12 years, children experience the onset of epilepsy. The lecturer raised an interesting point, one that exceeds most peoples understanding of epilepsy: seizures are only one symptom of epilepsy. Many of the children identified with HHE have epileptic seizures only rarely. Depending on where the initial damage took place in the brain, children's motor skills, spatial awareness, verbal fluency, and behavior could, and are, affected. The children identified in the department at CMC presented with rather severe behavioral problems. Now for the treatment: hemispherectomy. That is, they take out the part of the brain that is affected. What has been shown is that not only has seizure activity been eliminated or improved in most cases, behavioral problems have also improved. (for those interested in the article, the reference is: Devlin et al. Clinical outcomes of hemispherectomy for epilepsy in childhood and adolescence. Brain, Vol. 126, No. 3, 556-566, March 2003. you can google it.) Now, what some were wondering, myself among them, was if the children's behavior improved for some other reason than the removal of bad brain tissue. Perhaps the recognized punishment of having part of one's brain removed was enough to get kids to shape up. Take note: the threat of such an operation might be an effective parenting tool in times of bad behavior. In all seriousness, it's a remarkable procedure, one performed with great awareness about what parts of the brain are affected adversely and which are not. With imaging techniques becoming more and more sophisticated by the day -

Medicine is exciting because it concerns itself with the skin, the mind, and everything in between. As the young child with the slighly more purple tongue was being examined, on the chair next to her (remember that there are often two exams going on in the same room at the same time by two different doctors) was a young girl with a cleft lip and palate. She was cute too, a happy and playful child. She had come to CMC for surgery to correct the split in the roof of her mouth and lip, surgery which had been delayed because she had developed a cold. As we examined the child with the cleft lip i noticed that the mother of the other girl kept looking over to watch the former. She could hardly take her eyes of the little one. I wonder if seeing this child with this obvious deformity, correctable though it is, made her think about the complaint she had for her own daughter. I wonder if it made her grateful for what she had.

I'm grateful to be in India and grateful to have friends like you.

justin


ps. As i write, a young physician in the computer room in front of me is surreptitiously surfing the web for photos of his favorite female Tamil film stars, most of whom have fairer skin. It's a funny site and one i see almost everyday. Young male students and doctors gaze at their computer screens, ready, when someone walks by, to pull up another page that would make it appear that they are actually working.