Befuddlement that has enveloped the matter of melanomas in children for nearly 100 years stems directly from confusion about the subject that began with Darier and Civatte¹²³ and was sustained by Pack, Spitz, and Allen and Spitz,^2,3,5,7–10 and from efforts of Allen for more than 40 years to rewrite the history of it in such a way that he and Spitz would emerge heroic by virtue of having understood from the outset that what came to be designated Spitz's nevus really was a nevus rather than the malignant melanoma that Spitz insisted repeatedly that it is, and from lack of workable criteria from the very beginning for diagnosis histopathologically of melanoma and of nevi of various kinds, among them that nevus called by Spitz, bewilderingly, "juvenile melanoma."^12,18,46 That lack of knowledge coupled with lack of candor in acknowledging error in diagnosis histopathologically and in perception conceptually, lack of collegial exchange of ideas, and lack of critical, incisive thought about these issues and many more that derive from them, made for a situation in which mysticism triumphed over rationality, a circumstance in regard to Spitz's nevus and to melanoma in prepubescent children that obtains in some quarters to this day. That these failures have been inherent in nearly every article written during the past more than 60 years about the subject of true melanomas in children is apparent in even a casual reading, let alone when an effort is made to probe profoundly. The irrationality reached its apogee with the pronouncement of a malignant Spitz's nevus and a metastasizing Spitz's nevus. By reviewing briefly now the most noteworthy events during the last three score decades, insight may be gained into how the matter of melanoma in young children became such a muddle.

Because Pack, a cancer surgeon at Memorial Hospital in the 1930s and 1940s with no firsthand knowledge of histopathology, was at a loss in coming to grips with the dilemma posed by the seeming contradiction of sections of tissue that showed changes which Stewart, his pathologist at Memorial Hospital, diagnosed as those of malignant melanoma on one hand and the benign biologic behavior of those neoplasms on the other, he chose to name them prepubertal melanomas and to assume that the benign behavior of them was related to no flow of sex hormones before puberty. Spitz, working at the same hospital and in the same department as Stewart, but conducting her professional life independent of both Pack and Stewart, studied the same neoplasm as they and in 1948 termed it melanoma of childhood and juvenile melanoma, insisting, without equivocation, that it was a true melanoma indistinguishable from malignant melanoma in adults.

Neither Pack nor Spitz was aware that Darier and A. Civatte had grappled with the same problem in 1910 in the form of a red papule on the nose of an 8-month-old that showed histopathologic features of a "nevo-carcinoma" but displayed the behavior biologically of a nevus.

Although Pack and Spitz (as well as Spitz's husband, Arthur Allen) were studying with intensity the same subject, that is, "melanoma" in children, in the same hospital, that is, Memorial, they did not collaborate with one another as evidenced by statements to that effect by colleagues there contemporaneous with them, as well as by the fact that their names do not appear together as authors of a single one of their several publications about the matter. Even more remarkable is that neither Pack nor Spitz referred to the other by name or made reference to one another in articles authored by them about the issue. The reasons for the distance between them are not known for sure, but it may be inferred that among them were considerations as disparate as personality, religion, sex, and specialty in medicine. Not to be neglected was the influence on Spitz of Allen, who, as everyone who interacted with him professionally attests, was an extremely difficult man given to adversarial relationships both with colleagues and with the truth. Had Pack and Spitz worked together on the problem of proliferations of melanocytes in children, and neoplasms in particular, of juvenile (prepubertal) melanoma and of malignant melanoma, it is possible that those neoplasms could have been elucidated in the best tradition of surgical pathology in which the surgeon, in this instance Pack, came to clarify the nature of a neoplastic process by virtue of careful clinico-pathologic correlation. Had the pathologist, in this instance Spitz, joined with Pack in actually seeing patients with juvenile melanoma, it is possible that by virtue of careful patho-clinical correlation the enigma could have been resolved by them, then and there. Had either Pack or Spitz been a dermatologist and thereby conversant with the "gross pathology" in vivo, the benign nature of the neoplasm under discussion would have been obvious. The clinical lesions pictured by Spitz in her seminal article of 1948 are clearly nevi and not melanomas. But none of that was to be, and Pack and Spitz, laboring separately, came to wrong conclusions which bedevil students to this day.