|Year : 2017 | Volume
| Issue : 2 | Page : 97-110
Homicidal abuse of young children: A historical perspective
Rudy J Castellani1, Joyce L deJong1, Carl J Schmidt2
1 Department of Pathology, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
2 Department of Pathology, Wayne County Medical Examiner, University of Michigan, Detroit, MI, USA
|Date of Web Publication||30-Jun-2017|
Rudy J Castellani
Department of Pathology, Western Michigan University Homer Stryker M.D. School of Medicine, 300 Portage Street, Kalamazoo, MI 49007
Source of Support: None, Conflict of Interest: None
The past 50 years has seen a heightened awareness of abusive injury patterns and increased concern for the plight of children victimized by their caregivers. Murder of the young, however, has been embedded in society since the beginning of recorded time. Indeed, nature provides abundant examples of infanticide in lower animals, raising the question of whether exploitation, apathy, and violence toward children are on some level evolutionarily conserved. In human antiquity, selective killing of females, the illegitimate, and the malformed, killing by ritualistic sacrifice or to conserve resources was carried out with impunity. The middle ages and later saw a decline in these practices albeit limited. One hundred years into the industrial revolution, with harsh child labor in public view, legal remedies were sought to protect children but with little effect. The domestic abuse of children was not addressed until a pivotal 19th-century case, in which the rights of animals were invoked to intervene on behalf of a child. In the 20th century, physicians began to look closely at anatomical findings; patterns due to trauma, especially inflicted trauma, began to emerge. “Battered child syndrome” was followed by “shaken baby syndrome,” the latter prompted by the recurrent findings of subdural hematoma, retinal hemorrhages, and brain injury with the absence of impact injuries and no plausible accidental or natural disease explanation. In the 21st century, high-quality studies and an emphasis on evidenced-based medicine substantiated the existence of injury patterns resulting from homicidal violence. However, progress has been uneven. A case of child abuse that reached the US Supreme Court resulted in an ill-cited dissent that seems to have amplified an already toxic medicolegal environment, perhaps unjustifiably. The difficulties in balancing the welfare of society with that of caregivers in the aftermath of homicidal abuse will no doubt continue.
Keywords: Abusive head trauma, child abuse, homicide, infanticide
|How to cite this article:|
Castellani RJ, deJong JL, Schmidt CJ. Homicidal abuse of young children: A historical perspective. J Forensic Sci Med 2017;3:97-110
| Infanticide in Lower Animals: Conserved Trait Versus Social Pathology|| |
From an evolutionary standpoint, it is of some passing interest that killing of the young is a conserved trait in many species albeit with multiple precipitating factors. Theories attempting to explain this trait encompass exploitation, resource competition, parental manipulation, social pathology, and sexual competition, some of which may be inapplicable to humans. Nevertheless, the abundance of examples of infanticide provided by nature suggests that a decrease in infant survivorship may be fundamentally adaptive for the species as a whole to benefit  and raises the question of whether a level of indifference to the suffering and death of children is encoded in the human genome.
Infanticide by males is particularly widespread, being documented in insects, amphibians, birds, rodents, carnivores, primates, and other mammals. On the other hand, whether infanticide in a given species reflects pressure for infanticide per se, or instead is a by-product of other conserved behaviors, seems to depend on the factors that precipitate it and continues to be a matter of some debate. Sexual competition may mandate infanticide as a prerequisite for species survival if the overall natural force is the propagation of genetic material. Infanticide out of social pathology is, in contrast, a probabilistic event, as a by-product of other behaviors or as a tolerable (in terms of species survival) aberration.
Perhaps the most intuitively obvious adaptive killing relates to resource competition. Among wild dogs, for example, a dominant female may kill the pups born to a subordinate pack member. Mother's milk has also been implicated in infanticide by female elephant seals who attack and kill pups who become separated from their mothers. A nursing gull may devour a strange chick if discovered without a parent. Among ground squirrels of the high California Sierras, infanticide by females, usually only distantly related, is the leading cause of mortality. There are many other examples.
The influence of adult gender and infant legitimacy on infanticide in primate species, apparently as a function of sexual competition, is well documented., This sexual selection model goes back to Darwin, later refined by Trivers  and predicts that infant killing will be directed at unrelated offspring to eradicate competing genetic material. There is also a positive correlate between age at infant death and interbirth interval, increasing the infanticidal male's own opportunities to breed., Infanticide in this manner is particularly well studied in the Hanuman langur (Presbytis entellus), a member of Asian and African colobine monkeys. Upon usurping the authority of a herd leader, the new male Hanuman langur herd leader will kill any infant born from intercourse with the former herd leader. DNA analyses support the lack of genetic relationship between the infanticidal male and infant, supporting the sexual selection hypothesis that infanticide is an evolved, adaptive male reproductive tactic. Similar behaviors have been observed in the Great Apes and multiple other primate species., Bias toward, and protection of, offspring of the paternal male in chimpanzees is also noteworthy. While cannibalism is sometimes also observed in association with primate infant killing, this appears to be a result of collateral violence in aggressive species, rather than pressure for an energy source.,,
Clearly, the biological underpinnings for such behaviors are complex and extrapolation to human behavior conjectural at best. Nonetheless, it is tempting to speculate that the disproportionate physical abuse and killing of human infants and toddlers by nonpaternal males and boyfriends specifically [16-18] may be an aberrant but vestigial recall to the herd leader mentality. The fact that mothers of murdered young children often defend and support the boyfriend after the fact and may continue to have children with the perpetrator seems to parallel the finding in great apes and langurs where females whose infants were killed may be observed copulating with the nonpaternal infanticidal male. Ultimately, illegitimacy of infants, or the possession of genetic material from an unaccounted for male, carries with it a finite risk of premature death across multiple advanced species including humans.
| Killing of Young Children in History|| |
The murder of infants and young children before their achieving self-awareness is synonymous with human existence. Whether out of convenience, survival necessity, ritualistic sacrifice, psychosis or other mental illness, or uncontrolled violence, and whether by omission or commission, the threshold for extinguishing a young life is historically surprisingly low, suggesting a level of indifference. Infanticide rates of up to 50% are evident from the human prehistoric record as well as records from more recent agrarian cultures. In every ancient society for which records exist, infanticide was practiced and culturally accepted.
Infanticide in antiquity was not limited to eastern civilization as sometimes asserted. Sufficient records in the West exist to conclude that infanticide of both legitimate and illegitimate children was as widespread and culturally accepted as it was in the east. Any child that was not of a desired size and shape, cried too much or too little, or did not conform to writings on “How to Recognize the Newborn That is Worth Rearing” (on the basis of a scoring system similar to APGAR proposed by the Greek physician Soranus in the 2nd century AD ) was generally killed. Firstborns were allowed to live for the most part, especially if males. Indeed, selective female killing has been practiced from prehistoric times until the present, a phenomenon that appears to be uniquely human. A sex ratio of 148 to 100 in favor of men has been noted, for example, among Pithecanthropines and Mesolithic peoples. Out of 79 families who gained Milesian citizenship in 228–220 BC, there were 118 sons and 28 daughters. Of 600 families from 2nd-century inscriptions at Delphi, 1% raised two daughters. As instructed by Hilarion to his wife Alis: “If as may well happen you give birth to a child, if it is a boy let it live; if it is a girl, expose it.” Today, countries such as China and India have an unbalanced male: female ratio due to the preference for male firstborns in many societies.
Methods of disposal were lurid and inhumane by any recognizable standard today. Children were thrown into rivers, dung heaps, and trenches, “potted” in jars until death by starvation and exposed on any hill and roadside. Exposure to Romans, or expositio, was an acceptable method for disposing of unwanted children. Since it was not a formal process, few official records exist although it can be inferred from the demand for foundling wet nurses that exposure was widespread. Those who survived faced the near inevitability of slavery.
As Langer notes in his essay infanticide: A historical survey – “Infanticide has, from time immemorial, been the accepted procedure for disposing not only of the sickly infants but also of all such newborns who might strain the resources of the individual family or larger community.” Obladen likewise points out that undesired infants in antiquity included the “legitimate of the poor, the illegitimate of the rich, malformed of all, females in mandatory dowry cultures, twins, and premature infants.” Until the 4th century AD, neither law nor public opinion expressed anything untoward about infanticide in Greece or Rome. Aristotle once wrote:
”As to exposing or rearing the children born, let there be a law that no deformed child shall be reared; but on the ground of a number of children, if the regular customs hinder any of those born being exposed, there must be a limit filed to the procreation of offspring.”
Hellenistic Greeks usually did not rear more than one girl. Roman “Patria Potestas” included the father's right to kill his children-“jus vitae ac necis.” This right was most often invoked with an abundance of female children, physical malformation, suspected maternal adultery, and birth on “fateful days” as defined by religion or superstition. Ritualistic sacrifice of children was also widely practiced in antiquity. Julianus was said to have “killed many boys as a magic rite.” Suetonius the historian wrote that because of a portent, the Senate “decreed that no male born that year should be reared.” Pliny the Elder spoke of men who “seek to secure the leg marrow and the brain of infants.” Particularly, common was the killing of children of enemies at war. The children of nobility thus not only witnessed the killing of the enemies' children but also lived under the constant threat of being killed themselves, should the fortunes of battle favor the other side.
Despite the embedded cultural acceptance of the homicide of the young child, the Greeks and Romans were on the humane end of the spectrum for their time. Several Germanic tribes openly practiced sacrificial infanticide including Frisians and Visigoths. As described by Plutarch, the Carthaginian child sacrifice was noteworthy:
”With full knowledge and understanding they themselves offered up their own children, and those who had no children would buy little ones from poor people and cut their throats as if they were so many lambs or young birds; meanwhile, the mother stood by without a tear or moan; but should she utter a single moan or let fall a single tear, she had to forfeit the money, and her child was sacrificed nevertheless; and the whole area before the statue was filled with a loud noise of flutes and drums so that the cries of wailing should not reach the ears of the people.”
Child sacrifice was practiced by groups such as the Irish Celts, Gauls, Scandinavians, Egyptians, Phoenicians, Moabites, Ammonites, and in certain periods, the Israelites. Archeologists have dug up thousands of bones of sacrificed children, often with inscriptions identifying them as firstborn of noble families. Infants have been embedded in the walls of buildings for ritualistic purposes as early as 7000 BC Jericho, and as late as 1843 Germany. The seemingly innocuous childhood game, “London Bridges Falling Down” is said to have its historical roots in the acting out of child sacrifice to a river goddess. The sacrificial burying of the child into the bridge's foundation was required for its structural integrity, lest it collapses and falls like the child at the end of the song.
Misunderstandings about developmental biology led to brutal Darwinesque experiments in some societies. Ancient Germans would plunge newborns into an icy river, not only to test the child but also determine its robustness of constitution. North American Indians threw newborns into a pool of water and saved it only if it managed to cry at the surface. In British New Guinea, an infant would be taken to the banks of the stream and moisten the infants' lips with water. If the infant did not take the water, it was thrown into the river and drowned.
The middle ages saw an increasingly Christian influence with concern for the souls of those not yet baptized, and thus a broader condemnation of infanticide as a crime against Providence. Its continued practice, however, was empirically evident in unnaturally high male: female ratios (up to 172 to 100 in 1391 AD) across cultures and the establishment of foundling hospitals. In addition, although secular laws against infanticide began to appear, religious and societal condemnation of women with illegitimate children still held the latter as undesirable, which likely added to the evidence of infanticide not otherwise apparent in simple sex ratios. Interestingly, middle-aged crises, and especially wars and the Great Plague of 1348, led government leaders to rethink statutory protections in favor of infants, suggesting that pragmatic concerns were more influential than religious or moral imperatives.
More modern times and more enlightened thought saw paradoxically less harsh treatment of infanticide, with more empathy for social circumstances and mental illness, and increasing philosophical assertions that self-awareness was required for personhood. Malformed, premature, and disabled infants again still were considered to have a reduced right to live. In June of 1863 in Great Britain, the Morning Star asserted that infanticide was a “national institution.” In the US, infanticide has never been recognized as a separate entity from homicide although when slavery was prevalent, an infant mortality rate of 50% was considered normal, perhaps reflecting an undetected practice. In 19th century Asia, continued infanticide was axiomatic in the absence of infanticide laws and the dowry system. As reported by Traveller John Barrow, the police in Peking employed persons to go on early morning rounds and “pick up such bodies of infants as may have been thrown out into the streets in the course of the night.”,
Selective female infanticide was still so common in 19th century India, especially the throwing of female infants into the Ganges River, that the government was compelled to pass the Infanticidal Act in 1875. Increased awareness of this practice saw a trend toward normalizing of sex ratios in the second half of the 20th century although this appears to have been turned back by the outlawed practice of selective female abortion, facilitated by sex-specific antenatal ultrasound. Nobel laureate Amartya Sen estimated in 1992 that there were 100 million “missing” women  (not all accounted for by abortion), the large majority from Asia. In the US, there is a decrease in the infant homicide rate where there are unintended pregnancy rates that are close to 50% although child death by maltreatment in the US is high by comparison with other countries.
Brutality to young children throughout history was by no means restricted to neonates or selected cultural or individual aberrations. Indeed, one is hard-pressed to find any written expression of empathy toward children before the 18th century. It should also be noted that “infancy” in antiquity and even later extended from birth until about 7 years of age. As Lloyd deMause concluded: “The history of childhood is a nightmare from which we have only recently begun to awaken.” In a world preoccupied with warfare, political upheavals, and artistic expressions of adults, the plight of children is virtually unrecorded. The severity of discipline in children of antiquity is only obliquely inferred by references made to shackles, handcuffs, gags, and extended times locked in wood blocks. The Spartans described bloody flagellation contests for purposes of sport, which involved whipping youths to death. One Anglo-Saxon custom described the use of children as witnesses to official proceedings or ceremonies, who “then and there were flogged with unusual severity; which it was supposed would give additional weight to any evidence of the proceedings they might afterward furnish.”
The childhood of Louis XIII was among the rare detailed accounts in the Renaissance documenting regular whippings even among the privileged. Before age two, he reportedly knew not to cry when threatened with the sight of his father's whip. As king, he still awoke at night in terror, in anticipation of his morning whipping. Susannah Wesley noted that her children “When turned a year old (and some before), they were taught to fear the rod and cry softly.” Giovanni Dominici advised to give babies “frequent yet not severe whippings….” Until surprisingly recently, the medieval law applied: “If one beats a child until it bleeds, then it will remember – but if one beats it to death, the law applies.” Thus, century after century, battered children grew up, and in turn battered their own children.
The experience of the peasantry and the proletariat class is even more sparse in the historical record and instead has to be pieced together through inferences from works of art or poetry. Perhaps a surrogate of the physical abuse that was undoubtedly present in private was the public tolerance of exploitation in the form of sexual abuse. The Greeks and Romans, otherwise islands of cultural enlightenment, had a sexual affinity (by modern standards) for children and especially boys. Boy brothels flourished in every city. The renting of boys for sexual services was available in Athens. Sodomy was the favored sexual use for children. Castrated boys, rendered tamer and more docile through castration, were particularly desirable “voluptates” in imperial Rome. Infants were often thus castrated for later use in brothels by men with an eye for buggering. These men were apparently present in sufficient numbers to justify the practice. A standard infant castration procedure was described by Paulus Aegineta:
”Since we are sometimes compelled against our will by persons of high rank to perform the operation… by compression it is thus performed; children, still of a tender age, are placed in a vessel of hot water, and then when the parts are softened in the bath, the testicles are to be squeezed with the fingers until they disappear.”
In the post-Renaissance West, physical abuse of children was in plain view, suggesting either a level of tolerance or desensitization. The many implements used to batter children even in the late 19th century were cataloged and included “boots, crockery, pans, shovels, straps, ropes, thongs, pokers, fire, and boiling water.” Cataloged as well was a horrifying level of neglect, describing children as “miserable, vermin infested, filthy, shivering, ragged, night naked, pale, puny, limp, feeble, faint, dizzy, famished, and dying.” Children were routinely put out to beg, with a pitiable appearance enhanced by emaciation, pallor, and often, untreated illness, the consequences of the practices of those responsible for their care. Children were often held captive by idle vagrants. Little girls were regularly victimized by sexual abuse. Circuses and traveling shows often put children on display as monstrosities and exploited them in all manner of unfathomable abuse. The fact that much of the work of the world was done by children, starting at age 4 or 5, speaks to the reality that children have been the implements of adult needs throughout history.
When a child reached the age of 7 years during the days of the early industrial revolution, infancy was over but so was childhood. Sons of nobility were apprenticed to the households of higher station, which could involve learning the art of warfare, lumber, farm labor, weaving, clerking, or stonecraft, among others. As such, they were dependent entirely on their master and that master's manner of dealing with children. This could range from the benignity of the kind hearted to torment and torture. There were no statutory prohibitions against physical abuse until the 19th century, short of murder, and even in the case of murder, statutory remedies were few and ineffective. Inquests of physically brutalized children tended to be explained away, in a manner similar to that described by Dickens:
”Occasionally, when there was some more than usual interesting inquest upon a Parish child who had been overlooked in turn up a bedstead, or inadvertently scalded to death when there happened to be a washing… the jury would take it into their heads to ask troublesome questions, or the parishioners would rebelliously affix their signatures to a remonstrance. However, the impertinences were speedily checked by the evidence of the surgeon, and the testimony of the beadle; the former of whom had always opened the body and found nothing inside (which was very probable indeed), and the latter of whom invariably swore whatever the Parish wanted.”
Culturally accepted child labor through the 19th century merged imperceptibly with abuse. Harsh child labor in continental viticulture over protracted periods, for example, led to physical deformities, and yet specific laws prohibiting the injurious work lagged the formal recognition of the abuse by more than a century. Early guilds regulated the work of children, not out of compassion but the need for competitive pricing. A “dull dejection” was described among 4–10 years old in cotton mills, which was tolerated as long as it did not impact productivity. “Sherrington's daughter,” a mechanical device that forced the head of children between their knees until blood was produced from the nose and ears, was used in the mills to discourage idleness. Chimney sweeps were a particularly sad lot, covered in soot, and emaciated by design to facilitate their work. The diffusion of soot into their inner clothing as they worked produced chronic scrotal irritation, and in some cases, squamous cell carcinoma of the scrotum, the first cancer known to be caused by environmental exposure.
Untimely death of infants and children from abuse and neglect was neither surprising nor unusual, even in relatively recent times. In 1873, over 1300 infants were found abandoned, and over 122 infants were found dead in the streets and alleys of New York City. Ninety percent of abandoned children died of malnutrition. Removal to private homes, i.e., foster care, often subjected children to further abuse. Eighty percent of illegitimate children put out to nurse in London during the 19th century did not survive. In Germany, 31% of illegitimate children died under foster care in 1881, reportedly from natural causes but more likely from exposure and inflicted violence. The Pennsylvania Society to Protect Children from Cruelty estimated in 1882 that about 700 infants in Philadelphia died annually from abuse and neglect.
In 1896, the British Medical Journal published an article entitled “Report on the Baby Farming System and its Evils,” indicating the on-going practice of accepting custody of an infant, usually illegitimate, in exchange for payment. It was noted that “baby farming” and “child murder” were frequently “convertible terms.” Since the payment was less than the cost of raising a child, a dead child was more profitable. This led to neglect or outright murder, for which a number of women were hanged in the late 19th century and early 20th century. Hilda Nilsson, euphemistically referred to in Swedish as “änglamakerska” or “angel maker,” accepted for payment and subsequently murdered eight children. She committed suicide by hanging after being sentenced to death, not realizing that her death sentence was commuted to life imprisonment the day she died.
An ignominious and yet pivotal case of physical abuse was that of Mary Ellen Wilson in 1874. Mary Ellen was boarded after the death of her father in the Civil War and the inability of her mother to provide care. She eventually found herself in a foster home where, over the course of years, she was beaten, cut, starved, closeted, burned, and sexually abused. A Methodist missionary discovered the abuse, and after attempts at intervention failed, she sought the help of Henry Bergh, founder and president of the New York Society for the Prevention of Cruelty to Animals (founded in 1866). Bergh pursued the case to the New York State Supreme Court and argued, “The child is an animal. If there is no justice for it as a human being, it shall at least have the rights of the stray cur in the street.” Mary Ellen's own statement (collective responses to questions posed by the court) describes the social pathology and helplessness of her ordeal better than any author:
”My father and mother are both dead. I don't know how old I am. I have no recollection of a time when I did not live with the Connollys. I call Mrs. Connolly mamma. I have never had but one pair of shoes, but I cannot recollect when that was. I have had no shoes or stockings on this Winter. I have never been allowed to go out of the room where the Connollys were, except in the night time, and then only in the yard. I have never had on a particle of flannel. My bed at night has been only a piece of carpet stretched on the floor underneath a window, and I sleep in my little undergarments, with a quilt over me. I am never allowed to play with any children or to have any company whatever. Mamma (Mrs. Connolly) has been in the habit of whipping and beating me almost every day. She used to whip me with a twisted whip – a rawhide. The whip always left a black and blue mark on my body. I have now the black and blue marks on my head which were made by Mamma, and also a cut on the left side of my forehead which was made by a pair of scissors (scissors produced in court). She struck me with scissors and cut me. I have no recollection of ever having been kissed by anyone – have never been kissed by mamma. I have never been taken on mamma's lap and caressed or petted. I have never dared to speak to anybody because if I did I would get whipped. I have never had, to my recollection, any more clothing than I have at present – a calico dress and skirt. I have seen stockings and other clothes in our room but was not allowed to put them on. Whenever mamma went out, I was locked up in the bedroom. I do not know for what I was whipped – mamma never said anything to me when she whipped me. I do not want to go back to live with mamma because she beats me so. I have no recollection of ever being on the street in my life.”
Mary Ellen was then taken out of the custody of her abuser by order of the New York Supreme Court, and a broader public consciousness followed including the founding of The Society for Prevention of Cruelty to Children. While the cruelty to Mary Ellen can only be regarded as aberrant, it is worth noting that no meaningful statutory protection for children existed as recent as the late 19th century. The need to invoke the rights of animals to intervene on behalf of a child, and that the founding of an advocacy society for animals occurred 8 years before the establishment of one to protect children speaks to a level of societal disregard for child welfare.
Perhaps most remarkable about the history of child maltreatment is the level of concern for infants and children in the past 50 years. While atrocities have always existed, ritualistic infanticide, selective killing of female infants and the malformed, killing of the illegitimate, and physical abuse in the form of child labor are less common in recent decades and seems to parallel decreasing tendency toward violence in human society as a whole. As culturally driven abuse and homicide have receded, however, physical abuse out of aberrant social pathology seems to have been unmasked. As noted by Eisenberg, “Child abuse thrives in the shadows of secrecy and privacy. It lives by inattention.” In the case of homicidal abuse, deviant acts are now more often brought out of the shadows although recognition is incomplete to this day.
| Recognition of Abuse by Physicians|| |
Given that traumatic injuries from physical abuse are frequently internal, and that medical science was dominated by humoral theory until the mid-19th century (notwithstanding earlier efforts by Vesalius [1514–1564] and Morgagni [1682–1771], for example), it stands to reason that physicians would be slow in recognizing abuse. Auguste Ambrose Tardieu (1818–1879) was an exception. Tardieu described in copious detail the cardinal manifestations of child abuse as accepted today including the lack of external evidence of impact.
”In these cases, one may find no lesion within the viscera to explain the cause of death, which event may then be the result of nervous agitation…. There also occur visible lesions to the brain, especially in very young infants submitted to such abuse. I have discovered effusions of blood on the surface of the brain, manifestly the results of blows to the head, as well as to other parts of the body.”
In addition to his observations on child abuse, Tardieu described sexual abuse and articulated major deficiencies in French child labor laws, which led to the enactment of new laws aimed at child protection. Still, his attempts to reach a more enlightened medical audience, including the republishing in 1879 an article on abuse that was published in 1860, were futile. His comments nevertheless capture the essence of homicidal abuse:
”From the earliest days of their lives, such piteous defenseless beings are destined each day, each hour even, for the cruelest of abuse, are submitted to harsh deprivations, their lives hardly begun are already a martyrdom, such torment, such physical tortures, from which the imagination recoils lay waste their bodies, extinguishes the first awakening of their minds and cuts short their very li ves. These stories become even more unbelievable because their tormentors are often the very ones who gave them life in the first place.”
Rudolf Virchow, the undisputed leader of pathology and medicine of his era and a transformative figure in the establishment of the cellular basis of disease, may have delayed understanding of the pathophysiology of subdural hemorrhage, and perhaps by extension abusive head trauma, for decades. While Virchow accurately described subdural neomembranes, the often cryptic clinical presentation in adults prompted his “pachymeningitis hemorrhagica interna” concept, which placed hemorrhage secondary to an ill-defined inflammatory etiology. Some of his contemporaries and late 19th century scholars differed from the primary inflammation theory including Hewett (1845), Huegenin (1877), Lewis (1889), and Doehle (1890), but all lacked the gravitas to supplant Virchow's theory.
Wiglesworth objected to Virchow's inflammatory hypothesis in 1892 and detailed his rationale, while tacitly lamenting authority by prestige – “Virchow lent the weight of his authority to the inflammatory doctrine, and it is mainly to the writings of that eminent pathologist that we are indebted for the predominance of the inflammatory theory which at one time was almost universally accepted.” More vocal and definitive, however, was William Trotter, who was not only a classically trained neurosurgeon, but also a student of social psychology and the phenomenon of the herd mentality. He viewed those adhering to Virchow's primary meningitis theory as one such herd. In a clinical study of four adult patients with chronic subdural hematoma, published in 1914, Trotter concluded:
”(1) That internal hemorrhagic pachymeningitis is a term which involves an unjustified hypothesis and should be discarded in favor of some such term as chronic subdural hematoma; (2) that apart from some cases occurring in diseases which cause a strong tendency to spontaneous hemorrhage and possibly, including them, hemorrhagic pachymeningitis is almost, if not quite invariably, a true traumatic hemorrhage coming from veins torn in their course between the brain and a dural sinus.”
Trotter thus provided insight into one of the cardinal manifestations of abusive head trauma although it was several decades before a traumatic etiology in young children was both accepted and linked to physical abuse. Putnam and Cushing (1925), in their lengthy discussion of subdural hemorrhage and associated reactive processes, accepted broad etiologic possibilities, influenced again by the heterogeneous presentation in adults, the frequency of association with alcoholism, and dynamic histologic reaction in the subdural compartment.
”Pachymeningitis” in children specifically was reported by Doehle in 1890 in 14.1% of 269 autopsies in children under 1 year of age. Additional cases in children in the late 19th and early 20th century were reported by Sutherland, Herter, Finkelstein, Misch, Goppert, Hahn, Ingalls, Meigs, Rosenberg, Hada, Wohlwill, Gordon, Feer, Burhans and Gerstenberger, Debre and Semelaign, Kernbach, Fisi, and Glauber, and Sherwood, among others. Noted among these cases were retinal hemorrhages, a variety of infections, rickets, scurvy, and increased head circumference, which were generally interpreted as comorbidities.
Herter's report in 1898 is of note  in that rickets and congenital syphilis were said to be present in a significant minority of cases in the literature at that time and poor nourishment and cachexia in the majority cases. Scurvy was noted in his case material, although he also commented on trauma and its implications, making reference to Doehle's earlier report of a case of internal pachymeningitis caused by a short distance fall:
”One other aspect of internal pachymeningitis in children deserves mention. It is probable that relatively slight traumatisms to the head may occasion the rupture of vessels in a highly vascular membrane. This fact gives these cases a certain medicolegal importance. Doehle reports the case of a careless mother who allowed her apparently healthy infant fall out of bed. The child was found comatose and died. The autopsy showed that the child had a hemorrhage from a subdural membrane. The question of the influence of trauma may thus arise.”
The series of five cases reported by Burhans and Gersteberger in 1923 was noteworthy in several respects. They mentioned that “the acute infections, syphilis, tuberculosis, and trauma are perhaps most frequently given as the primary etiologic factors” and that “so-called 'hemorrhagic diathesis group' including scurvy, leukemia, pernicious anemia, purpura, and hemorrhagic disease of the newborn are often blamed,” but that “in reading the reports of various authors, we find that in a majority, no definite etiology could be assigned,” and that “the most characteristic finding is the retinal hemorrhage, which is present in a majority of cases and is certainly rare in other conditions of later infancy.” Four out of their five cases had retinal hemorrhages. The one case that lacked retinal hemorrhages was a 4 month old who was thrown from an automobile. They go on to say that “Many of the infants who live through the attack carry a permanent disability such as chronic hydrocephalus, imbecility, blindness, deafness, paralysis, spasticity, or speech defect.”
In a similar vein, Sherwood provided detailed descriptions of infantile chronic subdural hematoma in nine patients, four of whom had retinal hemorrhage, and one of whom had an unexplained fracture of the radius. Sherwood also noted possible social pathology:
”Five of the nine patients had rather dubious home conditions, being cared for by the state, by foster mothers or by charitable institutions. This fact made the histories less valuable and also brought up the question of possible trauma occurring with no admission of it being made.”
It is, therefore, possible and even likely that selected physicians in addition to Tardieu understood the abusive nature of subdural hematoma of infancy in some of the early cases. The mention of medicolegal implications also suggests that they understood the potential for adversity in the diagnosis of trauma and may have raised the threshold for diagnosis accordingly.
The extent to which early subdural hematoma theories were influenced by an era of widespread infection before the advent of antibiotics and widespread nutritional deficiency remains an unanswered question, although it likely played a role. It can be gleaned from the numerous case reports that physicians struggled with correlation versus causation. The likelihood of polyabuse, i.e. neglect and physical abuse causing natural disease and traumatic lesions, respectively, appears only with the benefit of hindsight. It is also interesting to note the alternative theories from the early 20th century that still appear today, such as scurvy, rickets, infection, birth injuries, and bleeding diatheses not otherwise specified. Ingalls was particularly vocal in support of role for scurvy, influenced by the poor nutritional state of infants in the case material. He cited Herter's cases, although Sherwood earlier pointed out that Herter “did not prove that this was more than a coincidence.” Ingraham and Heyl (1939), neurosurgeons at Children's Hospital in Boston, also disputed nutritional deficiency and infection in the analysis of 11 cases of infantile subdural hematoma:
”We realize that the illegitimate infant, or the one given poor general care, may well have a deficient diet and also be more frequently exposed to trauma than is the child living in ideal conditions, but we feel certain that these elements, although they may commonly be present, are not essential in the causation of the disease. Trauma has been a more constant feature in the history of our cases although it has not been present in all.”
They also noted that an increase in the incidence of infantile subdural hematoma occurred in the face of improved nutrition in the general population, which again argued against a metabolic etiology and in favor of trauma.
A follow-up study by Ingraham and Matson extending their series of infantile subdural hematoma to 98 cases  warrants some elaboration, as it raised a number of issues relevant to abuse head trauma that have since been verified. These include the frequency of convulsions and vomiting at presentation, the frequency of comorbid nutritional deficiency and infection, retinal hemorrhage in some cases, the poor outcome with tendency for cerebral atrophy and mental retardation, frequent enlargement of the head and especially biparietal diameter, and poor correlation between degree of organization of the subdural collection and presenting clinical symptoms. The challenging clinical diagnosis was emphasized in that “the frequency with which subdural hematoma is found in infancy is largely proportional to the intensity with which it is sought.” Unreliability of clinical history was also commented upon:
”We should like to emphasize again, however, the inadequacy of the history in many of these infants. Due to this, the absence of a history of trauma should never influence the diagnosis against subdural hematoma.”
In short, the totality of the cases of infantile subdural hematoma from the late 19th and early 20th century contain essentially all aspects of the framework for abusive head trauma as it is understood today. Mixed acute and chronic subdural hematoma (to this day absent in confirmed accidental scenarios), traumatic origin of subdural bleeding, retinal hemorrhages, comorbid fractures, high frequency of seizures, high morbidity and mortality, suboptimal social circumstances, absence of a plausible explanation for the severity of the lesions and acute collapse, unreliability of clinical history, and indeed, potential for medicolegal acrimony are all described. The words of Harvey Cushing aptly describe the sentiment while examining case material from the early 20th century:
”It consequently has been a surprise and the source of some mortification to find how many examples are buried under various titles in our past case histories.”
In 1946, John Caffey reported a seminal series of six cases of infantile subdural hematoma, in which 23 long bone fractures of various stages of healing were also identified. Neither the fractures nor the subdural hemorrhages had an explanation provided by the caretaker. Caffey concluded that this lack of history could be explained by “assuming that sometimes lay observers do not properly evaluate ordinary but causally significant accidents, especially falls on the head and that other important traumatic episodes pass unnoticed or are forgotten by the time delayed cranial symptoms appear.” He further opined that injuries “may be denied by mothers and nurses because injury to an infant implies negligence on the part of its caretaker.” This was the first suggestion, albeit tepid, that the combination of long bone fractures and subdural hematoma was a traumatic and possibly inflicted pattern. Silverman would later comment that Caffey was convinced that all cases in this first series indicated physical abuse but held back in his narrative for fear of a backlash since the idea of such physical or homicidal abuse was considered preposterous in the US at that time.
Smith (1950) was the first to demonstrate a skull fracture in addition to the long bone fracture in the subdural hematoma/fracture pattern in an infant. His case was interesting in that the initial clinical diagnosis for the injury complex in his case was scurvy including treatment with large doses of Vitamin C and D. New fractures appeared, however, despite oral and parenteral Vitamin C therapy. The recurrent theme of unhelpful clinical history was commented upon:
”No history of trauma was elicited in this case. However, the patient had made a long trip by train and had been handled by sitters and relatives. Under these circumstances, trauma is often denied. Very often the diagnosis of subdural hematoma is extremely difficult to make and as in the case reported, the history and physical findings are often of no value in establishing that diagnosis.”
Silverman pointed out in 1953 that subdural hematoma and bony changes were the results of severe, recurrent trauma. He described three cases between the ages of 2 and 7 months. All had healing metaphyseal fractures. Subdural hemorrhage was suspected in two of the three cases although the report focused on the “bizarre” radiographic findings. Despite the small case numbers, Silverman's report touched on numerous issues that come up today with respect to abusive head trauma. The history of trauma varied from no history, to “not acting right,” to trivial trauma, to trauma implicating “rough play,” to accidents attributed to siblings and other children, to “violent shaking” as part of complex accidental action sequences described by caregivers, and to parental resuscitation attempts. He noted the contrast in behavior between parents of children who sustained clearly accidental trauma (being “deeply and immediately concerned”) and that of physically abusive parents who delayed health care and provided changing stories only after questions were raised by the radiologic studies. Recalcitrant parents were commented upon. A number of metabolic diseases were considered in the differential diagnosis including rickets, scurvy, osteogenesis imperfecta, and nutritional deficiency secondary to celiac disease, all carefully excluded on the basis of clinical and radiographic findings. Polyostotic infection, including tuberculosis and syphilis, was considered and excluded. The issue of trivializing injury severity on the basis of unknown illnesses that “predispose some children more than others to disease of this type” was raised, but he thought that such theorizing served “merely to cloud the issue.” Interestingly, suggestions of trauma were strongly resisted by consulting pediatricians and orthopedic surgeons, which he attributed to the delay in the appearance of healing by X-ray, and therefore the lack of acute trauma history in the clinical presentation.
In retrospect, the impact of Silverman's report was probably lessened by the minimal discussion of brain injury, and the tension of conflicting interests as he attempted to walk the tightrope between concern for the infant and empathy for the caregivers. In his introductory comments, Silverman clearly identifies the existence of inflicted trauma and its recognition on X-ray:
”It is often not appreciated that many individuals responsible for the care of infants and children (who cannot give a history of their own) may permit trauma and be aware of it, may recognize trauma but forget or be recalcitrant to admit it, or may deliberately injure the child and deny it….”
He further comments on the substantial emotional impact on families with the pursuit of such alternative diagnoses such as osteomyelitis, neoplasm, tuberculosis, and syphilis, and that “the injury incurred is of no consequence compared to the possible sequelae to the injury, from which the child may have been saved.” Silverman's concluding remarks, however, euphemistically described the X-ray findings as “unrecognized skeletal trauma” and ultimately biased his analysis in favor of the parents:
”It is of the greatest importance not to overwhelm those responsible for the care of the infant with feelings of guilt. The relief of emotional tension which follows the admission of previously withheld suspicions concerning the nature of the child's condition has been gratifying to see.”
In 1955, Woolley and Evans were seemingly convinced of physical abuse in their description of 12 children with unexplained fractures, many with subdural hematoma, and were the first to recommend removal of the injured children from their homes for what they euphemistically described as “undesirable vectors of force” visited upon the young children. Adelson in 1961 raised the issue of child homicide in a somewhat heterogeneous group of victims, perpetrators, and homicidal mechanisms and touched on several points of on-going relevance. He noted that “it is probable that some deaths in childhood ascribed to accidents are really homicides, but the absence of witnesses is an insurmountable obstacle to the prosecution.” He also correctly pointed out:
”The fact that the victims are often so young that they cannot communicate puts the investigating officials under a serious handicap. With relatively slight or absent external evidence of injury, combined with failure or unwillingness of the responsible adults to volunteer what had occurred, many nontraumatic diagnoses were entertained by the attending physicians as explanations for the presenting clinical syndromes, which were often quite bizarre.”
In 1962, Kempe et al. took the gloves off, as it were, and stated the problem in unambiguous terms. The report of two prototypical cases was described, and the condition was aptly named “battered child syndrome.” The authors made reference to subdural hematoma, diagnostic bone lesions, parental assault, social and psychiatric pathology, and poor outcome. Kempe et al. concluded:
”Although the findings are quite variable, the syndrome should be considered in any child exhibiting evidence of possible trauma or neglect (fracture of any bone, subdural hematoma, multiple soft tissue injuries, poor skin hygiene, or malnutrition) or where there is a marked discrepancy between the clinical findings and the historical data as supplied by the parents.”
Kempe also brought physicians into the discussion, noting a tendency to deny or protest the possibility of abuse, and a pervasive inability to function in the best interests of the battered child:
”… physicians have great difficulty both in believing that could have parents attacked their children and in undertaking the essential questioning of parents on this subject. Many physicians find it hard to believe that such an attack could have occurred and they attempt to obliterate such suspicions from their minds, even in the face of obvious circumstantial evidence. The reason for this is not clearly understood….”
Unlike Silverman who concluded with an appeal to assuage parental guilt, Kempe concluded squarely on behalf of the abused child.
”All too often, despite the apparent cooperativeness of the parents and their apparent desire to have the child with them, the child returns to his home only to be assaulted again and suffer permanent brain damage or death. Therefore, the bias should be in favor of the child's safety; everything should be done to prevent repeated trauma, and the physician should not be satisfied to return the child to an environment where even a moderate risk of repetition exists…. Above all, the physician's duty and responsibility to the child requires a full evaluation of the problem and a guarantee that the expected repetition of trauma will not be permitted to occur.”
Of all literature to date, Kempe's 1962 paper appears to have had the greatest impact on bringing physical abuse of children into mainstream medicine, raising the awareness of abusive head trauma and its often obscure systemic manifestations. Noteworthy, for example, is that battered child syndrome was diagnosed in 260 patients at Children's Hospital of Michigan in 1975, compared to only one patient in 1964.
In 1971, Guthkelch expounded on the concept of whiplash in young children during the course of physical abuse, and vulnerability owing to “the relatively large head and puny neck muscles of the infant.” He cited work by Ommaya and Yarnell suggesting that rotation without impact was sufficient to cause subdural hemorrhage  and noted that abusive subdural hemorrhage could occur in the absence of external signs of impact.
Shortly, thereafter, Caffey introduced the term “whiplash shaken infant syndrome,” highlighting a number of cases with admissions to shaking including the accounts of the Virginia Jaspers cases. Somewhat unlike the historical case material on abusive homicide, Ms. Jaspers inflicted injuries and death upon infants of the upper middle-class strata near New Haven, Connecticut. As an infant–nurse with an erstwhile reputation for being “extravagantly kind” in her work with upper middle-class families, she had the full confidence of parents and pediatricians. In one case, she was invited back to care for a couple's second child, after shaking the first child to death. After a period of years evading authorities, she eventually admitted to violently shaking a number of infants, killing three, maiming two, and significantly injuring ten others, saying that “it was all uncontrollable. I didn't know why I did it. Children sometimes get on my nerves.”
Caffey presented case histories from 14 additional young children between the ages of 3 weeks and 4 years generally with histories supportive of shaking, with or without impact, with or without subdural hemorrhage, and often with metaphyseal fractures. The term “shaken baby syndrome,” now embedded in the medical lexicon, emphasizes internal injury as a result of inflicted mechanical force, which has since served to heighten the awareness of abusive acts in the absence of external evidence of trauma, an issue that had clearly plagued the identification of abusive homicide for centuries.
The clinical and anatomic diagnosis of a specific mechanism (shaking) for injuries that are almost never witnessed naturally inspires biomechanical modeling studies and alternative theories. Among the more influential of such studies of the late 20th century was that of Duhaime et al. in 1987, where the authors combined clinicopathological analysis of abusive head trauma patients with mathematical modeling of “Just Born” dolls subjected to shaking with and without impact. Noteworthy was that impact increased the translational acceleration measurements by nearly 50-fold. Impacts on a padded surface showed less acceleration compared to a metal bar but were still 40-fold higher than the no impact group. The authors concluded that shaking alone would likely not reach the biomechanical threshold for diffuse axonal injury or subdural hemorrhage and suggested a “shaken-impact” model for abusive head trauma.
The study by Duhaime et al. makes intuitive sense although the applicability of the model to in vivo biology is unclear. Jenny et al. recently demonstrated that rotational accelerations in the range of subdural hemorrhage thresholds were possible with manual shaking alone, using an improved biofidelic anthropomorphic test device (infant surrogate). Others have commented on the discrepancy between biomechanical data and the clinical reality., At present, mathematical “proof” is nonexistent, as either argument may be satisfied based on one's choice of experimental construct. An untenable interpretation of the Duhaime et al. data – that absence of physical evidence of impact precludes abuse (i.e., indicates natural disease or trivial trauma) – unfortunately seems to have followed the study despite the fact that physicians to this day confront abusive injury patterns – subdural and retinal hemorrhages, seizures, apnea, collapse, with no evidence of impact, no natural disease explanation, and no trauma history provided by caregivers. Indeed, absence of impact has been shown to favor abuse over accidents in high-quality studies.,
| Recognition of Abuse by Physicians|| |
Child abuse in the 21st century. Closer attention to the precepts of evidence-based medicine, i.e. study design and quality of evidence, has characterized the medical literature of the 21st century. This has been facilitated by the computer revolution, in which massive amounts of data within and between studies can be statistically analyzed with relative ease. Systematic reviews and meta-analyses, the publication of higher evidence quality based on the precepts of the evidence-based medicine, are now common. In the child abuse literature, a number of high quality-of-evidence studies including systematic reviews have appeared in recent years, all of which substantiate the concepts first articulated by Tardieu in 1860.[79-85] Armed with the data presently available, physicians are able to identify abusive head trauma patterns with a high degree of specificity. Among the features are subdural hematoma (acute, chronic, or both), [Figure 1], retinal hemorrhages (especially severe retinal hemorrhages extending to the ora serrata), [Figure 2], acute encephalopathy, apnea,, unexplained extremity and rib fractures,, and a history of no trauma or inconsequential injury.
|Figure 1: Acute subdural hematoma and acute subarachnoid hemorrhage in homicidal abusive head trauma. Child abuse is the most common cause of subdural hematoma in children under the age of two|
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|Figure 2: Severe ocular hemorrhage, including extensive intraretinal hemorrhage, subinternal limiting membrane hemorrhage, vitreous hemorrhage, and peripapillary intrascleral hemorrhage, and perimacular folds, in homicidal abusive head trauma. This pattern and extent of ocular trauma is highly specific for child abuse|
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However, the modern era is not without complications. Sophisticated imaging techniques have added to the complexity of the clinical evaluation during life. Computed tomography, magnetic resonance imaging examination, and skeletal surveys have facilitated diagnostic certainty on the one hand and have provided a forum for diverging opinions on the other. Similarly, modern molecular biology has permitted greater confidence in the exclusion of rare metabolic diseases as putative abuse mimics  but raises the specter of misdiagnosis if a condition diagnosable by genetic testing is not considered with the primary interpretation.
While the concept of the child abuse mimic has obvious importance in case interpretation, it should be noted that individual mimics are difficult to study in the form of a clinical study, i.e., from the standpoint of evidence-based medicine because of their rarity. Examples of some conditions that have been raised as mimics of one or more features of physical abuse include: glutaric aciduria Type 1, Menkes kinky hair disease, osteogenesis imperfecta, Ehlers–Danlos syndrome, benign enlargement of the subarachnoid space, vitamin deficiencies including Vitamin D (rickets), Vitamin C (scurvy), and Vitamin K, venous sinus thrombosis, congenital syphilis, various bleeding disorders including hemophilia, von Willebrand disease, and thrombocytopenia, hypersensitivity vasculitis, Mongolian spots, and folk remedies.
The current literature surrounding mimics, and especially rickets, is interesting from a historical standpoint, in that comorbid rickets were common in the infantile subdural hematoma case material from the early 20th century in the absence of a clear understanding of the etiology yet was not given serious consideration as an etiology for the intracranial findings even then. Rickets continues to appear in the literature as a theoretical differential diagnosis for physical abuse although clinical studies are again lacking, and differences in interpretation raise the issue of misdiagnosis of rickets, as much as rickets raise the issue of misdiagnosis of abuse.
The relevance of the various mimics that appear in modern literature naturally depends on the abuse manifestations in question, for example, subdural hemorrhages, fractures, or cutaneous bruising. In one clinical study, mistaken diagnoses of abuse related only to cutaneous lesions and bone injury. Unexplained subdural hemorrhages mimicking abuse are generally limited to case reports of rare diseases and opinion articles of unsubstantiated concepts such as “chronic rebleed” and “temporary brittle bone disease.”[104-106] Conditions mimicking retinal hemorrhage of abuse are few in the setting of pediatric trauma, especially if retinal hemorrhages are severe  although sepsis, severe coagulopathy, cardiopulmonary resuscitation with chest compression, and increased intracranial pressure  are sometimes discussed, despite little overlap with the severity seen in abuse in clinical studies. Birth-related subdural hemorrhage may be suggested, as it was a century ago although modern technology now indicates that when present at birth, such hemorrhage is limited in extent, is asymptomatic, and clears within a short period of time, notwithstanding the rare, isolated case descriptions of subdural collections following unusually traumatic deliveries. Evanescent birth-related retinal hemorrhages are also described.
Less studied from the standpoint of mimics, even today, is the relevance of the various mimics to a young child who acutely collapses or is found dead. As the outcome in subdural hematoma, even in adults, is related more to damage to the underlying brain than the accumulating blood, such things as vitamin deficiency, bleeding diathesis, osteogenesis imperfecta, and chronic fluid collections have difficulty explaining the acute parenchymal brain injury that underlies the bad outcome. Despite the major advances of the 21st century, very little is known about the pathophysiology of brain damage per se and mechanisms of brain swelling in homicidal abuse.
Ironically, the challenges of abusive head trauma seem to have intensified in recent years, owing in part to a dissenting opinion from the US Supreme Court  over a case of abusive head trauma which resulted in the conviction of a grandmother accused of abusing a grandchild. Among the justifications for the dissent was that “doubt has increased in the medical community “over whether infants can be fatally injured through shaking alone.” The court seemed to have mistaken a theoretical debate over the shaking mechanism for doubts about whether infants can be fatally injured without evidence of impact. While such theoretical debates are ongoing, the lack of scientific robustness of the dissent was striking, in that the only medical literature cited in support of the dissent were opinion articles.,,,,,, Moreno and Holmgren, in their law review critique of the dissenting opinion, articulate a contrary point of view:
”It is enough to note here that the dissenters base their conclusion on a handful of papers: (1) written by a tiny group of 'mercenary scientists' whose regular testimony as defense-retained witnesses in child abuse and child homicide cases undermines the objectivity, legitimacy, and validity of their work; (2) that contain little original research and instead reflect manipulation of data and statistical methods, (i.e. opinion pieces, nonrandomized retrospective case series/reports, scientifically unsubstantiated opinions of other 'mercenary' witnesses, and mischaracterizations of earlier AHT/SBS research); (3) written not for academic and research purposes, but for use in legal proceedings; and (4) riddled with blatant methodological flaws and discredited by pediatric expert medical research and peer-reviewed scientific publications in a wide range of fields.”
The Supreme Court dissent was not lost on the legal community or the media, however, as rhetorical calls to “put science on trial” are now heard with regularity. Of concern for the foreseeable future may be the chilling effect of an increasingly hostile environment on the willingness of practitioners experienced in the diagnosis of child abuse to offer an objective interpretation. This is despite the controversy being media- and courtroom-driven, according to the American Academy of Pediatrics, rather a legitimate medical debate [Figure 3].
| Conclusion|| |
The historical record makes it clear that abusive homicide is synonymous with human existence and that abusive and homicidal acts against young children have been tolerated throughout history. Whether this reflects a conserved biological tendency or a manifestation of social pathology is unclear although the reality of the pervasiveness of homicidal abuse in recorded human history is difficult to deny. On the other hand, an inflection point seems to have been reached in the middle of the last century, with the initial characterization of abusive injury patterns that are now recognized and described in copious detail. This has led to a heightened awareness of the plight of children behind closed doors, and the implementation of government agencies that monitor child welfare when the issue of abuse is brought to medical attention. The problem of homicidal caregivers continues, however, and the challenges to medical professionals only seem to be growing. The increase in diagnostic certainty of abusive homicide in the 21st century is matched or exceeded by the backlash against the primary diagnostician, which may well be an atavistic reminder of an evolutionary trait that regards young children with indifference.
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[Figure 1], [Figure 2], [Figure 3]