Child Abuse & Neglect 32 (2008) 920–924

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Child Abuse & Neglect

Brief Communication

100 years of lost opportunity. Missed descriptions of childabuse in the 19th century and beyond

A.N. Williams ∗, N.K. GriffinDepartment of Paediatrics, Northampton General Hospital, Billing Road, Northampton, United Kingdom NN1 5BD

a r t i c l e i n f o

Article history:Received 26 April 2004Received in revised form 14 November 2007Accepted 8 December 2007Available online 5 November 2008

Keywords:Child abuse historyAmbroise TardieuSamuel WestNon-accidental injury

Introduction

The purpose of this short article is to explore 19th century cases of likely or certain child abuse which were either notconsidered as such at the time, or if confirmed, sadly forgotten until the rediscovery of child abuse as a serious paediatriccondition in the latter half of the 20th century. The 19th century marked the dawn of industrialization upon the world, andthe effects of this upon society and its attitudes during this period were dramatic. The great French novelist Victor Hugo saw“the three problems of the age – the degradation of man by poverty, the ruin of woman by starvation and the dwarfing ofchildhood by physical and spiritual night” (Hugo, 1998).

In the early 19th century conditions for families and children were very hard indeed with child labor having a highprevalence. Although child labor is now considered to be abhorrent, as Heywood (2005) pointed out, the issue is not so clear-cut: “The costs of working at a tender age had to be set against the benefits of earning a wage and combating the debilitatingeffects of poverty.” In 1828, Villermé had already recognized the multitude of interacting factors which contributed to theexcess mortality and morbidity of children from poorer backgrounds.

“I do not seek to establish whether the poor succumb most readily to their lack of nourishment; to the poor quality oftheir food; to their excessive work; to the bad air; to illness brought on by their trades, humidity, unhealthy lodgings,squalor or overcrowding; to the anxiety of being unable to raise a family; or even to the intemperate habits commonamongst them” (Villermé, 1828).

This multiple interaction demonstrates that progress in child health or child protection cannot be defined within thecontext of a single issue. Also, it needs to be emphasized that the grinding nature of poverty forces unpleasant and difficultchoices upon children and their families.

∗ Corresponding author.

0145-2134/$ – see front matter © 2008 Elsevier Ltd. All rights reserved.doi:10.1016/j.chiabu.2007.12.007

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Infanticide, the severest form of child abuse, has occurred throughout history and has been well described elsewhere(Langer, 1974; Smith, 1975a, 1975b). Child abuse too has long been noted outside the medical profession (Lynch, 1985).Indeed, the noted essayist Montaigne eloquently described its consequences in his essay “On Anger.” “Children are crippledand knocked stupid by such batterings: yet our judicial system takes no note of it, as though it were not the very limbs ofour state which are being put out of joint and maimed” (Montaigne, 1592). The English Parliament passed an Act in 1624“to prevent the murthering of bastard children” (Hoffer & Hull, 1981). However, the consequences of the physical abuseof children was only relatively recently recognized by the medical profession itself in the 20th century. It was with Kempe,Silverman, Steele, Droegemueller, and Silver (1962) and their seminal paper “The Battered Child Syndrome” that brought thiscondition not only to medical but also to public attention. However, the medical literature and popular fiction long beforethat time gave clear and unambiguous histories, which detailed abuse. Unfortunately, within the medical world a diseasedoes not exist until it is given a name (Asher, 1986).

The great novelists of the 19th century enlightened and educated society to the plight of children, single mothers, as wellas the poor and stirred society to make changes. Taking just one such example, Hugo’s “Les Miserables”—set in the early19th century, there is the description of Cosette, a neglected and abused orphan; “The whole person of this child, her gait,her attitude, the sound of her voice, the intervals between one word and another, her looks, her silence, her least motion,expressed and uttered a single idea: fear” (Hugo, 1998).

It is clear, however, that children who had suffered abuse through neglect were being seen by the medical services of thetime as the following case from the London Hospital, recorded in the 1832 Lancet, demonstrates:

“About nine o’clock on the evening of the 20th, a little child one year and three quarters old, was brought tothis hospital with the back part of the head, neck and arms very severely burned, from the clothes having caughtfire. Wine and laudanum were assiduously administered and linseed oil and turpentine were applied to the parts,but reaction was not restored. The little sufferer lingered till about three o’clock the following afternoon whenit died. The nurse says that the parents of this child lost another in the same ward about five months since bythe same means. Let us hope this is the last of the offspring whose safety appears to be so grossly neglected”(Burn, 1832).

The case is described merely under the heading of “Burn”. Deaths in childhood due to accidents are still a major cause inthe youngest age groups and neglect is an important contributing factor. Nowadays all child healthcare professionals wouldhope a more thorough investigation would be undertaken to ensure that there was no repetition.

Ambroise Tardieu

In 1860, Ambroise Tardieu (1818–1879), Professor of Legal Medicine at the University of Paris presented a long paperdescribing 32 cases of clear child abuse of whom 18 died (Roche, Fortin, Labbé, Brown, & Chadwick (2005); Tardieu, 1860).Tardieu gave a clear breakdown of the different violent methods used, the considerable variety of pathology seen and theparental denial and indifference to the suffering of their children. Tardieu described how recognition and interventionsuccessfully transformed these children:

“One important characteristic to be noted is the speed with which their facial expression changes as soon as the childrenare taken in by public charities or placed under legal protection, and are thus shielded from their daily torture. Thisgeneral change in their constitution is more or less profound, according to the severity and duration of the abuse”(Tardieu, 1860).

Tardieu’s paper, with its unambiguous, detailed descriptions and categorical conclusions of physical abuse being the causeof these injuries in children, made a challenge to society to do something urgently to prevent maltreatment. Unfortunately,it is one of the great tragedies of child health care that this pioneering work which was “the first in which the concept ofa battered child, as presented by Kempe and his colleagues 101 years later was clearly stated” remained in obscurity forover a century (Silverman, 1972). This condemned “child victims . . .to suffer abuse and neglect without the support of themedical community” during that time (Labbé, 2005). These points have been addressed elsewhere by Roche et al., 2005 andSilverman (1972). It is also pertinent to mention that later in 1873, Tardieu published “A Medico-Legal Study of AssaultsOn Decency,” which described French rape cases from 1859–1869. Of more than 11,000 victims, nearly 80% were children(Tardieu, 1873).

Samuel West and acute periostial swellings

In 1888, Samuel West presented a paper to the Medical Society of London entitled “Acute Periostial Swellings in SeveralYoung Infants of the Same Family Probably Rickety in Nature.” West wrote:

“A child, aged 5 weeks, was brought by its mother, with the statement that its left arm had “dropped.” A swelling,apparently periostial, occupied the middle third of the shaft of the humerus. It was exquisitely painful and tender. Themovements of the arm were perfect but the child kept the arm still on account of the pain which movement caused.Similar swellings were found on the right humerus and on the left femur. There were some slight bosses on the ribs,

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but no other signs of rickets and the child was well developed and well nourished and except for the pain and theswellings seemed in good health” (West, 1888).

West treated the child with cod liver oil, potassium iodide, and supplemented mother’s breast milk with cow’s milk. Westwrote:

“In a fortnight the pain had almost gone, and the swellings were smaller. In the course of three months they werehardly to be made out, and they ultimately entirely disappeared, leaving the bones straight. The patient was the fifthchild. The first swelling came on the ninth day, the second in the fourth week, the last two days before it came underobservation. . . Of the other children, the eldest was similarly affected at the age of a week. The second was never soaffected The third and also the fourth were both affected. The second case was seen in a child of the brother of thefather of the previous children. It was a girl infant aged three weeks and had developed a swelling of the left humerus aweek before being seen. The patient was the fourth child. The first had always been well. The second had both arms andlegs affected in the same way at the same age. That these were cases of early rickets, could not however be doubted,on account of the evidence of rickets in the family and the absence of any other assignable cause” (West, 1888).

Interestingly, although West offered a lively discussion about the etiology in these case reports (with the then recent workon intrauterine rickets being discussed at some length as well as the experience of similar cases being mentioned by thedoctors concerned), abuse by the parents or other carers was not mentioned as a possibility. This failure by West to mentionphysical abuse as a possible cause has been commented on by Smith (1975b) and Lynch (1985). Neither of these authors,however comments on the sentence which gives a possible cause: “The cases were doubtless peculiar, but the peculiarity wasdue to some very special personal or family idiosyncrasy of the subjects attacked” (West, 1888). Whether this final commentactually reflected that West knew or suspected the true cause of the problem one cannot definitively say.

Non-accidental head injury and “chronic pachymeningitis”

That head injury could have serious effects on adult and children was generally known. Thomas Willis (1621–1675)had eloquently described the sequelae of head injury. “Sometimes a great wound, or concussion of the Head, especiallywhich happens by falling headlong from an high place, brings a prejudice and weakness to the animal faculty, dulling theunderstanding. . .The disease raised through some evident Cause as by a hurt of the Head, if it persevers for some time, isafterward incurable” (Willis, 1685).

However, it took a long time for paediatric pathologists to link subdural haemorrhages with non-accidental head trauma.The classic example of the lack of recognition of trauma was “chronic pachymeningitis” which held sway from the end

of the 19th century until it began to be challenged in the 20th. Silverman (1972), commenting on the term “chronic pachy-meningitis” mentioned Tardieu and cites the posthumous 10th edition of Holt’s Diseases of Paediatrics in 1938. However,Holt’s first (1899) edition of this work contains the following descriptions of bleeding on or in between the membranes liningthe brain.

“Of chronic pachymeningitis or haematoma of the dura mater. . . its causes are for the most part unknown” “. . .It isnot very rare, being discovered at autopsy in children, chiefly cachectic infants who have died of other diseases” (Holt,1899).

Holt further defined those cases either with or without extensive haemorrhages and questioned whether the haemor-rhages were due to the convulsions or the other way round. He cited a case in the literature in which recurrences were seen.Holt also described his own personal experience:

“The infant was six months old, and the symptoms had existed for six days. The fontanel was bulging to a markeddegree, and the sagittal and coronal sutures were separated. A thin recent clot from one eighth to one fourth of aninch in thickness covered nearly the whole of the right hemisphere and part of the convexity of the left. The entiredura was lined both at its convexity and base by a pseudo-membrane of grayish color about one sixteenth of an inchin thickness. The brain was anemic” (Holt, 1899).

The difficulty of diagnosis (still very much a problem) was also emphasized: “Without large haemorrhages pachymeningi-tis interna can not be diagnosed: and it is impossible to differentiate the haemorrhagic cases from other varieties of meningealhaemorrhage” (Holt, 1899).

Discussion

Reviewing 19th century medical literature provides evidence of the clinical presentation of children who were probablyabused. Society continued to evolve as it became increasingly sensitized to the abuse of children and the need for childrento be protected, but this process was slow. The 1874 case of Mary Ellen Wilson in the United States (which contrary to mythdid not use animal cruelty legislation to protect Mary Ellen [Myers, 2004]) and the founding of the English Society for thePrevention of Cruelty to Children in Liverpool in 1883 and London in 1884 (the latter becoming the National Society for thePrevention of Cruelty to Children [NSPCC, 2000]) are notable benchmarks.

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Part of this process towards a meaningful and effective protection of children is society’s slowly changing attitudes towardsphysical punishment of children. An 1888 article in the British Medical Journal on “Corporal Punishment In ElementarySchools” is illustrative:

“Corporal punishment may produce some aches and pains, but it interferes with health less than confinement afterhours or deprivation of food. The teacher should not fear to do his duty, and the law should support him in doing it forthe child’s good and the maintenance of a wholesome discipline” (Corporal Punishment In Elementary Schools, 1888).

Of course, there have been immense changes in the relative importance of different pediatric pathologies over the lastcentury. In the 19th century, child mortality in particular was far higher due to infectious disease, poor sanitation and chronicmalnutrition. At the present time, within the developed world, infectious disease has now largely disappeared througheffective public health measures that include immunization. In the 19th century, on a background of high infant mortalitywithin a society with limited social services and not fully willing yet to recognize child abuse as a national problem, thethreshold for child protection questions to be asked leading to effective intervention was much higher than today.

It is clear to modern eyes that the children being presented in these case reports were subjected to abuse. Present daychild health care professionals will wonder how physicians during this period did not link the two but should not be too hastyin jumping to conclusions about the 19th century authors’ ignorance of these matters. Although X Rays were discovered byRoentgen at the end of the century, it was to be almost fifty years later, with the work of Caffey that radiology was used todescribe non-accidental injuries in children (Caffey, 1946). Within medicine it is true that conditions have to be defined as aclinical entity before the profession will recognize them and that this knowledge then has to be widely disseminated (Asher,1986). The final and most crucial part of all is the acceptance of the condition. An insight into this process regarding childabuse in the United Kingdom from the memoirs of the noted pathologist Professor Keith Simpson, who practiced during the1940s–1970s. Simpson (1996) wrote “the battered child syndrome is a relatively modern phenomenon.” Simpson describedthe contemporary attitude up to his involvement in several notable child abuse cases in the 1960s: “Nobody wanted tobelieve it, and seriously injured infants would frequently be treated in hospital and discharged back to the care of those whohad injured them.” Obviously the cases that reached his attention (and regarding which he did testify as being due to abuse)were the extreme end of this spectrum. Nevertheless, the fundamental problem of the identification of abused children andreturning them to such dangerous environments without any safeguards in place is not one that can be said to always havebeen satisfactorily resolved.

Conclusion

Child abuse is now recognized as a problem that all of society must address. In the 19th century, there were clear descrip-tions of child abuse, including its pathology and post mortem consequence. The great tragedy, beyond that to the innumerablechildren concerned, was the interval between Tardieu’s paper and when child abuse became recognized and accepted by themedical profession as a serious child health problem and a major challenge for society as a whole.

The historical literature on child abuse is still far from complete, as new sources arise from medical historians and thosewith an interest in the history of childhood. There is still a great deal of resistance to society’s acceptance of child abusein spite of the official medical recognition of this condition. Indeed, the existence of some aspects of child abuse, such asfactitious disorder by proxy for a psychiatric diagnosis applicable to the fabricator, is still continuously denied in somequarters, using medically preposterous alternative explanations (United Kingdom Department of Health, 2002). Ongoingchild health enquiries should remove any complacency and continually remind society and child health care professionalsthat children continue to suffer and die from abuse.

Acknowledgments

The authors thank Mrs. Joanne Williams for the translation of the Tardieu excerpt, the staff of the Cripps PostgraduateMedical Library for their kind assistance in researching this paper, and the Centre for the History of Medicine, BirminghamUniversity.

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